Enhanced Recovery in Total Joint Arthroplasty: We Must Evolve Staci D. Ridner, M.D. American Anesthesiology of Tennessee Chattanooga, Tennessee February 4, 2017
Total Joint Arthroplasty ✤ Currently, 1 million total joints per year in US ✤ Aging population, yet expectation to remain active ✤ 2030 projections: 3.4 million TKA/yr = 673% increase* ✤ Creates an opportunity to drastically affect cost and streamline procedures. S. Kurtz et al, J Bone Jt Surg Am 2007;89(4):780
Follow the Money ✤ Triple Aim: Improve US healthcare by: 1) improving patient experience; 2) improving population health; 3) reducing cost. ✤ Enhanced Recovery programs can greatly reduce the healthcare cost associated with various procedures by decreasing LOS without increasing readmission rates.
ERAS for Colorectal ✤ Implemented an ERAS protocol for colorectal surgery ✤ Through multi-modal analgesia (2 or more analgesic modalities with different mechanisms of action), limited iv fluid administration, limited narcotic use, regional anesthesia techniques for post-operative pain, early ambulation, and decreased fasting times, LOS has dramatically decreased. ✤ Mean of approximately 8.4 days to 4.7 days.
✤ LOS (Length of Stay) translates into money spent/money saved. In 1974, LOS for TKA was 23 days. ✤ In Arthroplasty Today, in 2015, Barad et. al implemented fast-track TKA protocol. ✤ Average LOS decreased 2.0 days to 1.3 days and increased the rate of patients discharged to home with outpatient PT or home health (59%-99%). ✤ No increase in readmission rate. ✤ LOS difference created a savings of $3,245.00 per patient (comparing 2009 cost numbers to 2014 cost numbers) ✤ Applied to only 1000 patients, that is a savings of $3,245,000 per year. (3.48 million TKAs projected for 2030) S.J. Barad, et al., Arthroplasty Today (2015), http://dx./doi/org/10.1016/j.artd.2015.08.003
Anatomy of Enhanced Recovery ✤ Requires cooperation of multiple care teams including surgeons, anesthesiologists, physical therapists, nurses, social workers/discharge planners and patients and their families. ✤ Surgery Clinic: Education classes to manage expectations, d/c planning ✤ Preoperative management: reduced fasting times, multimodal analgesia, PONV prophylaxis, regional anesthesia ✤ Intraoperative: choice of anesthetic, fluid management, active warming, and blood loss management, antibiotic prophylaxis ✤ Postoperative: Continuous regional anesthesia, PT POD 0/early ambulation, scheduled multimodal oral analgesia, discharge planning Adapted from D.B. Auyong et al. The Journal of Arthroplasty 30 (2015) 1705-1709.
Evidence for Enhanced Recovery ✤ Review Article 2014 Journal of Orthopedic Surgery. ✤ Marinus et al review 22 studies of ER pathways for THA and TKA ✤ Review pre, intra, and postoperative interventions ✤ Takes each component proposed in various studies and rates the evidence as “strong, good, unclear, and none”then propose a regimen for ER. Marines et al., J Orth Surg 2014; 22(3):383-92
✤ Preop: Education, d/c planning, nutrition screening, premedication ✤ Intraop: Spinal + regional or local, liberal IV fluid, antibiotic x 24 hrs, Tranexamic acid, Avoidance of drains ✤ Postop: Early ambulation, early PT, ASA, stockings & SCDs, multimodal opioid-sparing analgesia
Results of Enhanced Recovery ✤ Decreased LOS ✤ Decreased need for transfusion ✤ Lower pain scores ✤ Less opioid-induced adverse events ✤ Less postoperative delirium ✤ Less skilled nursing at time of discharge ✤ Earlier ambulation ✤ Reduced fasting times ✤ Less PONV
Enhanced Recovery for THA & TKA ✤ Malviya, et al. retrospectively evaluated 4500 consecutive unselected lower joint replacements. 3,000 via traditional protocol; 1500 ER protocol. ✤ ER group experienced reduction in 30-day death rate & 90-day death rate, decreased LOS (6 vs. 3), decreased blood transfusion requirement, and unchanged re-admission rate. A. Malviya et al. Acta Orthop 2011 Oct; 82(5): 577-581
Total Joint Arthroplasty in American Anesthesiology of TN ✤ We cover 3 hospitals that perform total joint replacements; the largest is a 365 bed facility performing 1946 joint replacements cases in 2016 & 2237 implants. ✤ Total Shoulder Arthroplasty ✤ Total Elbow Arthroplasty ✤ Total Knee Arthroplasty ✤ Total Hip Arthroplasty
Patient Population ✤ Increasing age ✤ Increasing co-morbidities ✤ Numerous bilateral procedures ✤ Severe systemic illnesses ✤ Questionable rehabilitation potential ✤ Cultural barriers to regional/neuraxial anesthesia
Total Shoulder Arthroplasty
Total Shoulder Anesthesia ✤ PONV Prophylaxis in preoperative and intraoperative areas ✤ Multi-modal analgesia where appropriate ✤ Sitting procedure in beach-chair position; extensive co-morbidities may get invasive hemodynamic monitoring. ✤ Ultrasound-guided ISB with catheter placed in pre-operative area. On-Q pump ordered and connected in PACU. Patient has a dense block prior to induction of general anesthesia. Excellent analgesia is maintained for 2-3 days. ✤ Most patients are discharged home POD 1/ POD 2.
✤ Selection criteria for ISB is fairly liberal in this setting ✤ Rarely, ISB is deferred. Mainly in the setting of severe pulmonary disease or mechanical valves/need for extensive anti-coagulation, existing neuropathy, or patient refusal.
Evidence for ISB with Catheter • Many studies suggest improved outcomes for shoulder patients who receive continuous peripheral nerve catheters after ISB • Mariano et al (2009) randomized 30 patients to 30 mL ISB with catheters — half of patients received NS and half 0.2% ropivicaine. Catheter group had decreased pain, decreased oral opioid use, decreased sleep disturbance, & increased patient satisfaction. • Fredrickson et al, Kean et al, and Ilfed et al all had similar results with varying study modalities. Mariano et al. Anesth. Analg. 2009 May; 108(5):1688-94
✤ Initial dose of 10-15 mL of 0.5% Ropivacaine ✤ Pump delivers 5 mL/hr of 0.2% Ropivacaine with a PCA button that delivers a 5 mL demand with a 10 mL 1 hour lock out. ✤ Patients remove the catheter at home. ✤ Pain nurse rounds on patient in hospital and patients are supplied with an anesthesia number to call if any problems arise upon discharge.
Total Hip Arthroplasty
Total Hip Arthroplasty on the Rise ✤ In a 2015, multiple sources cited the US National Center for Health Statistics report indicating a 92% increase in THA from 2000-2010 from 138,700 to 310,800. ✤ Additionally, younger patients are more commonly undergoing this procedure with a 205% increase in patients age 45-54.
Enhanced Recovery for THA ✤ Postoperative pain management is complicated due to intricate innervation of the hip joint from both the lumbar and sacral plexus. ✤ Several studies have shown decreased cost and improved recovery using spinal anesthesia vs general anesthesia.
Spinal vs General for THA ✤ Basques et al (2015) showed decreased cost per case in the spinal group vs general group (small study). GA group also had higher PACU pain scores and increased requirement for analgesics. ✤ A meta-analysis by Mauermann et al (2006) revealed decrease in DVT, PE, surgical time, and blood transfusion ✤ A Yale study identified almost 21,000 patients from the ACS-NSQIP database with 61% GA and 39% RA. GA had longer operative and PACU times, prolonged ventilator use, and increased risk of cardiac arrest, blood transfusion, stroke, and unplanned intubation. Adapted from Ko and Chen. Ann Transl Med. 2015 Jul; 3(12): 162.
THA with American Anesthesiology of Tennessee ✤ Preoperative: Antibiotic prophylaxis 1 hour prior to incision, oral cocktail (see TKA protocol), PONV prophylaxis per AA. ✤ Intraoperative: Spinal vs General (This determination is patient and surgeon specific), dexamethasone 8mg iv, +/- transexemic acid, intra-articular injection by surgeon at close of case (see TKA protocol) ✤ Postoperative: DVT prophylaxis per surgeon, all pain meds written by surgeon including PCA for 1st 24 hours with scheduled multi-modal po medications.
Total Knee Arthroplasty
There is more than 1 way to skin a cat!! Date
Anatomy of the Knee • Knee joint is supplied by 4 different nerves: • Anteriorly — Femoral Nerve • Posteriorly — Sciatic Nerve • Medially — Obturator Nerve • Laterally — Lateral Femoral Cutaneous Nerve
Innervation of the Knee Anterior
Innervation of the Knee Posterior
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