Enhanced Recovery from Total Knee Arthroplasty. Danielle Stahla, BSN January 27, 2016

Transcription

1 Enhanced Recovery from Total Knee Arthroplasty Danielle Stahla, BSN January 27, 2016

2 Indications for TKA

3 Goals of Total Knee Replacement Surgery Decrease pain Improve muscle strength Increase range of motion Return to normal biomechanics Improve quality of life and function

4 Total Knee Timeline Traditional Recovery Enhanced Recovery Outpatient Surgery

5 OUTPATIENT TOTAL KNEE ARTHROPLASTY Practice began in Europe Rarely done in US Few patients meet criteria Differs from ENHANCED RECOVERY

6 ENHANCED RECOVERY

7 Pre-admission Preparation for Enhanced Recovery from Total Knee Arthroplasty

8 Preparing the Home Move frequently needed items to a handy location Remove throw rugs and obstacles to walking Safe seating area Prepare food and store in the freezer Friend/ Family to stay

9 Preparation of the Home - ADLs Raised toilet seat Shower chair Walker / cane Bed at safe, appropriate height Reacher Long shoehorn

10 Patient Preparation Prior to Admission Discontinue NSAIDs 5 to 10 days prior to admission depending upon the class of NSAID Stop smoking and alcohol consumption 7 to 10 days prior to admission Preop skin preparation as directed PREOP TESTING: Labs, dental, cardiac, possible urinary evaluation

11 Packing a bag for the Hospital Educational materials given by the surgeon s office Comfortable loose clothes and pajamas Flat, well-fitting, non-slip walking shoes or sneakers Medications Glasses, hearing aide, any normally needed assistive devices

12 Preparing to Return Home (done prior to admission) Know anticipated date to return home Inform family and friends of date to return home Arrange for a ride home Purchase or borrow needed equipment Prepare the home for safety Have needed medication at home, or arrange to have it picked up by someone, or delivered to home

13 Enhanced Recovery Perioperative

14 Principles of Enhanced Recovery Minimizing physiologic stress Modern joint replacement devices and techniques Anesthesia Less use of regional blocks Local anesthesia at surgical site Less use of catheters Less use of PCA Prevent complications SCDs Reinfusion device Incentive spirometry Monitor I & O Early dangling at bedside, early ambulation Early PT

15 Surgical Techniques Traditional Total Knee Unicompartmental Arthroplasty Minimally Invasive Total Knee Arthroplasty

16 Traditional Total Knee

17 Unicompartmental Knee Arthroplasty

18 Minimally Invasive Total Knee Arthroplasty

19 Pain Control PERIOPERATIVE CARE (Multimodal Anesthesia) Local anesthetic to joint Anti-inflammatories (COX-2 inhibitor) Oral pain medication Anti-inflammatories NURSING UNIT CARE Pain scale Cold therapy Positioning Ambulation Exercise PT Patient teaching

20 Spinal Anesthesia Advantages with Total Knee Arthroplasty Reduced blood loss Fewer transfusions Fewer DVTs Excellent pain relief in the immediate postop period More advantages Less risk of post-op pneumonia Need for less analgesia post-operatively Quicker return of oral intake Less confusion in elderly

21 Pain Control for Enhanced Recovery Pain control is a key to enhanced recovery Pain must be controlled for early ambulation Pain interferes with completing exercises Pain slows wound healing Pain slows return to normal oral intake

22 Prevention of Severe Postop Pain Severe postoperative pain has been associated with: ischemic cardiac events and myocardial insufficiency decreased pulmonary function gastrointestinal complications thrombus formation increase in stress hormone sleep disorders hypoventilation Korean Knee Society (2012). Guidelines for the management of postoperative pain after total knee arthroplasty. Knee Surgery and Related Research, 24(4),

23 Preventing DVTs Sequential compression devices Pharmacotherapy Early ambulation Positioning the knee, safe use of pillows

24 Preventing Complications Prevention of postop anemia Preop lab tests Postop treatments Blood transfusions Prevention of postop pneumonia Incentive spirometry Cough and deep breathe

25 Preventing Infection Prevention of hospitalacquired UTI I & O, monitor intake Early dangling, early ambulation to bathroom Early removal of urinary catheter Prevention of wound infection- 7S bundle Safety Screen Showers Skin Prep Sutures Solution Skin Closure

26 ENHANCED RECOVERY DISCHARGE PLAN

27 Discharge Criteria Pain controlled with oral medications DISCHARGE DESTINATION Able to ambulate with a mobility aide (walker or cane) Able to perform exercises BM Home Home Healthcare Swingbed/ Rehab No sign of complications

28 Discharge Planning Assure that all devices purchased and in place in the home (tub bench, toilet riser) Assure that patient has reacher, sock aid, shoe horn, walker, cane, other needed equipment Is someone available to be home with the patient, at least for a few days? Will the patient need Home Health assistance for bathing, dressing, meal prep, PT/OT?

29 Discharge Planning Rx: has all medications, or arrangements made for delivery or pickup Medication teaching completed Follow up appointment with surgeon If Home Health needed, Home Health admission visit scheduled Instructions for showering, exercises, diet, pain control, when to call the surgeon if difficulties occur

30 Postoperative Home Routine Dressing Wear loose-fitting clothing. Sit in a chair or on the side of the bed when you are getting dressed. Dress the operated leg first and undress the operated leg last. Use a long-handled shoehorn and/or sock aid.

31 Postoperative Home Routine Self Monitoring chest pain calf pain or swelling shortness of breath fever or chills nausea or vomiting bleeding any unusual discharge or bad smell from the dressing

32 Postoperative Home Routine Diet and exercise Diet and exercise Drink plenty of fluids Perform home exercises Eat regularly Attend Physical Therapy Eat healthy Use mobility aide per PT Take pain medication with food

33 Postoperative Home Routine Household tasks Laundry Tips Patients are likely to find household tasks difficult Expect to ask family and friends to help with chores Wash small loads of clothes Adjust the clothesline or use drying frame

34 Postoperative Home Routine Meal preparation Avoid lifting heavy pans. Slide them across the counter. Set up kitchen so needed items are shoulder to waist height Use small cart for heavy items Sit on a stool while preparing food, washing up and using the stove top Avoid using the oven if it is not at waist height Small items can be carried in an apron with pockets Frozen meals/ meal delivery service

35 HOME EXERCISE ROUTINE

36 Home Exercises - Stretching Rest postures to promote healing 1.Vary knee position at rest. 2.Rest with legs elevated while applying an ice pack to reduce knee swelling. 3.Rest with knee bent. 4.Rest with knee fully straight either with a towel rolled under the heel or with the foot resting on a stool about fifteen minutes every hour. Start with a comfortable period of time and slowly increase to fifteen minutes.

37 Home Exercises ANKLE PUMPS: recommended 20x / hour STATIC QUAD: pull toes up while pushing thigh down, count to five 5 to 10 times, 3 x per day

38 Home Exercises STATIC GLUTES (squeeze buttocks muscles while counting to five) Repeat 5 to 10 times, 3 to 5 times daily HEEL SLIDES (bend knee and pull heel toward buttocks, hold 5 seconds) Repeat 5-10x, 3-5x/day

39 Home Exercises INNER RANGE QUADS Place a rolled towel under your knee. Raise the lower part of your leg until your knee is straight. Hold for five seconds. Repeat five to ten times. Do 3 to 5 sessions each day. STRAIGHT LEG RAISE Bend up-operated knee to brace you, as you life the operated leg up about ten inches off the bed. Hold for 5 second, slowly relax. Repeat 5-10 times, do 3-5 times daily.

40 Home Exercises KNEE EXTENSION--SITTING Straighten operated leg and hold for 5 seconds. Repeat 5-10 times, 3-5 times daily KNEE FLEXION SITTING Bend operated knee as far as able. Hold 5 seconds. Repeat 5-10 times, 3-5 times daily

41 Home Exercises HAMSTRING STRETCH Place operated leg straight out. Sit tall and reach for toes of operated leg. Hold seconds. Repeat 3 times, 3x daily CALF STRETCH Holding on chair or counter, place operated leg behind you with knee straight and heel on floor. Bend other knee, stretch calf. Hold seconds. Repeat 3 times, 3 x daily

42 Home Exercises LUNGES Place operated leg on a step. Use handrail as needed. Lunge forward to bend knee. Hold 10 seconds, relax. Repeat 10x, 3 x daily SQUATS Using solid support, slowly squat down, sinking weight onto heels. Hold 10 seconds, then relax. Repeat 10x, 3 x daily

43 Home Exercises HAMSTRING CURLS Bend operated knee to lift heel toward bottom. Hold 5 seconds, relax. Repeat 10x, 3x daily PATELLA MOBILIZATION Gently move kneecap from side to side. Move 10 times, 3 x daily.

44 OUTCOMES ENHANCED RECOVERY

45 Research on Enhanced Recovery Malviya, Martin, Harper, Muller, Emmerson et al. (2011). Enhanced recovery program for hip and knee replacement reduces death rate. Acta Orthopaedica 2011; 82 (5): DOI / Methodology: 4,500 consecutive admissions for elective total joint hip or knee replacements. 3,000 underwent a traditional protocol and 1,500 underwent an enhanced recovery protocol involving behavioral, pharmacological and procedural modifications.

46 Comparison Traditional Group and Enhanced Recovery Group (Malviya, Martin, Harper, Muller, Emmerson et al.)

47 Outcomes Malviya, Martin, Harper, Muller, Emmerson et al. Measure Deaths (30-day) P=0.02 Traditional Practice Enhanced Recovery P value 0.5% 0.1% 0.02 Deaths (90-day) P= % 0.2% 0.01 Length of Stay 6 3 <0.001

48 Comparison of Complications (Malviya, Martin, Harper, Muller, Emmerson et al.)

49 Research on Enhanced Recovery Ibrahim, Alazzawi, Nizam & Haddad. (2013). An evidencebased review of enhanced recovery interventions in knee replacement surgery. Annals of the Royal College of Surgeons of England. 95, doi / X Methodology: Literature review using 37 articles from MEDLINE, Embase, and The Cochrane Library.

50 Factors that Increased LOS (Ibrahim, Alazzawi, Nizam & Haddad) Factor Low BMI in elderly patients Obesity Low albumin and transferrin levels Low preoperative hemoglobin Finding Increased LOS Increased operating room time; increased complications, increased LOS Malnutrition, increased LOS Increased LOS for knee replacement; low 1 st postoperative hemoglobin level correlated with increased length of stay Mobilization on postop Day 1 Mean increased LOS of 69 hours versus mobilization on Day 0

51 Factors that Reduced LOS (Ibrahim, Alazzawi, Nizam & Haddad) Factor Finding Mobilized on Day of Surgery 95% mobilized Day 0, decreased LOS by 2 days (4 days versus 6 days) Preoperative Education Preoperative PT Cox-2 inhibitors pre-op and post-op Local infiltration anesthesia Canadian study showed mean reduction in LOS of 69 hours with Day 0 mobilization Associated with reduction of LOS by 1 day At-risk patients identified and received preop PT able to follow Enhanced Recovery pathway Significant association with decreased LOS Reduced pain, reduced use of opioids, able to mobilize patient Day 0

52 QUESTIONS?