Enhanced Recovery in Total Joint Arthroplasty: We Must Evolve Staci - - PowerPoint PPT Presentation

February 4, 2017

Enhanced Recovery in Total Joint Arthroplasty: We Must Evolve

Staci D. Ridner, M.D. American Anesthesiology of Tennessee Chattanooga, Tennessee

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

• f Tennessee

✤ Preoperative: Antibiotic prophylaxis 1 hour prior to incision,

• ral 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

• f 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

Date

There is more than 1 way to skin a cat!!

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

Enhanced Recovery in TKA

✤ Preoperative, Intraoperative, and Postoperative considerations. ✤ The goal is to achieve an anesthetic that provides adequate analgesia for this very

painful procedure and even more painful recovery with minimal side effects.

✤ Considering PT staffing and preference are very important in order to reduce

“NEVER EVENTS” aka FALLS. Falls are associated with major cardiac, pulmonary, thromboembolic events, and higher 30 day mortality.

✤ Multiple authors have proposed various regimens and a significant transition has

• ccurred over the past several years. These range from general anesthesia with

IV PCA, to epidural/CSE, to various modalities for intraoperative management with FNB vs ACB vs intra-articular injections for postoperative pain.

✤ The perfect recipe? The answer in evolving.

FNB vs ACB

✤ Kim et al evaluated FNB vs ACB for TKA ✤ 6-8 hrs postoperative - ACB spared the quadriceps and was not

inferior in providing analgesia or in limiting opioid consumption.

✤ No difference existed between the 2 groups at 24 and 48 hrs.

(n=93)

✤ These patients also received a combined spinal/epidural and no

peripheral nerve catheter.

Kim et al. Anesthesiology 2014 March, Vol. 120, 540-550.

ACB Effect on Pain & Ambulation vs Placebo

✤ Jenstrup et al randomized 75 patients to to double-

blind placebo-controlled randomized trial to continuous AC catheter with intermittent boluses vs placebo.

✤ ACB significantly decreased morphine consumption

and pain on 45 degree flexion and enhanced ambulation ability as per the TUG test.

M.T. Jenstrup et al., Acta Anesth Scand 2012 March, 56(3): 357-364.

Modality Choice on Early Ambulation

✤ A. Perlas et al retrospectively evaluated 298 TKA patients comparing

local infiltration vs. ACB + local infiltration vs 48 hour continuous FNB all under spinal anesthesia as the primary anesthetic.

✤ Local infiltration and local + ACB patients ambulated longer distances

• n POD1 than FNB.

✤ Local +/- ACB lower pain scores at rest and during movement for the

first 24 hours, and lower opioid consumption.

✤ Local +ACB patients also had improved early ambulation benchmarks

and higher rate of discharge to home

• A. Perlas et al. Reg Anesth & Pain Med July/Aug 2013; 38(4): 334-339.

TKA Protocol in American Anesthesiology of Tennessee

✤ Rapidly evolving changes within the department

requiring extensive collaboration with preoperative staff, OR staff, surgeons, anesthesiologists, CRNAs, physical therapists, pharmacy staff, and patients.

✤ These changes have required a massive paradigm and

culture shift.

Preoperative for TKA

✤ Antibiotic Prophylaxis - 1 hour prior to incision ✤ P.O. Cocktail: Acetaminophen 1000 mg, Oxycodone ER 20 mg for < 65 yrs

• ld/10 mg for > 65 yrs old, Celebrex 200 mg (except with sulfur allergy or

creatinine > 1.4

✤ Some AA may add gabapentin, po clonidine, or iv ketamine depending on

patients history.

✤ PONV prophylaxis per AA ✤ Discussion of primary anesthetic with patient. ✤ Ultrasound-guided ACB block for single or bilateral TKA

Adductor Canal Block

✤ Is this adequate coverage for the knee? ✤ Primarily a sensory block, but may weaken vastus

medialis if performed high enough in the canal.

✤ Performed at the level of the mid-thigh, several nerves

can be captured: saphenous nerve, vastus medialis nerve, medial femoral cutaneous nerves, articular branches of obturator nerve, and medial retinacular nerve.

Adductor Canal Block

✤ Locate the superficial femoral artery traveling under the sartorius

muscle.

✤ Inject just above or around the SFA ensuring the needle has completely

traversed the sartorius muscle.

✤ Deposit 20 mL of 0.5% ropivacaine for a single knee or 15 mL of 0.5%

ropivacaine on each side. Many use dextrose or saline in a separate syringe to ensure proper needle placement and injection location.

✤ Aspirate prior to injecting local. Steep learning curve. Easy to get into

the accompanying vein or the SFA when initially learning this block.

Intraoperative TKA

✤ Spinal vs General anesthesia for unilateral or bilateral depending on

surgeon.

✤ If spinal, we run propofol for patient comfort. ✤ If general, we use LMA if not contraindicated. ✤ Surgeon injects in the joint space itself at the end of surgery: 50 mL 0.5%

Ropivacaine, 10 mg Astramorph PF, 30 mg ketorolac, 0.2 mg epinephrine, 30 mL 0.9% NaCl (total of 93 mL)

✤ Same local injection used for THA minus the saline. ✤ Surgeon variability with injection technique MAY affect the efficacy.

Postoperative TKA

✤ PT is happy with this regimen. No quadriceps

weakness/buckling which is important with an understaffed department and larger patients.

✤ Surgeons write postoperative orders for home meds,

celebrex, iv antibiotics, pepcid, FeSO4, Colace, MVI, SSI, anticoagulation, PCA (rarely indicated), zofran/ marinol, ambien, benadryl, tylenol, ketorolac with creatinine parameters, and po pain medication regimen.

Considerations as we Approach ER for TJA

✤ Catheter for TKA? ✤ More scheduled/regimented po multi-modal pain regimen? ✤ Addition of gabapentin? ✤ Continued protocol merger for surgeons with variability. ✤ Entrenched cultural considerations. ✤ Billing issues/barriers to evaluate true LOS numbers.

Be a Leader

✤ Change is never easy. Barriers will exist and there will be some trial and error. ✤ As anesthesiologists, we can be leaders in introducing new regional techniques

to our surgeons then using that trust to springboard into ER protocols.

✤ We are currently working on ER for orthopedics and for breast. We are also

continuously evaluating the current ERAS protocol for colorectal surgery.

✤ The facilities and hospitals we serve will quickly support these programs once

we educate them regarding the money saved as we face new regulations and payment in healthcare.

✤ More importantly, we can drastically affect the patient experience and patient

• utcomes.

Thank you and Good Luck!!