ENHANCED RECOVERY PROTOCOLS FOR KNEE REPLACEMENT

Transcription

1 ENHANCED RECOVERY PROTOCOLS FOR KNEE REPLACEMENT Jeff Gadsden, MD, FRCPC, FANZCA Associate Professor Duke University Department of Anesthesiology Regional Anesthesia and Acute Pain Medicine

2 DISCLOSURES Pacira Pharmaceuticals B.Braun Medical Mallinckrodt Pharmaceuticals

3 OUTLINE Describe key elements of clinical pathways for total joint arthroplasty Discuss evidence for/against each of these

4 PROJECTED ANNUAL TOTAL HIP/ KNEE REPLACEMENTS, U.S. 1,500,000 1 TKA 1,200, , ,000 1 THA 300,000 Revision TKA Revision THA J Bone Joint Surg Am 2014;96:624

5 What s different about ERPs for Orthopedics?

6 Pain Muscle weakness Dizziness/orthostasis Acta Orthop 2011;82:679 Arch Orthop Trauma Surg 2010;130:263

7 PRE-OPERATIVE INTERVENTIONS

8 PREOPERATIVE VISIT ideally >4 weeks in advance Routine anesthetic evaluation/optimization Smoking cessation Discussion regarding pain expectations

9 PAIN CALIBRATION?

10 PREOPERATIVE VISIT ideally >4 weeks in advance Routine anesthetic evaluation/optimization Smoking cessation Discussion regarding pain expectations Preoperative hemoglobin optimization

11 HEMOGLOBIN OPTIMIZATION Iron Anemia: supplementation/erythropoietin both: correct anemia decrease transfusion requirement def n heterogenous, but typically <12 (F), <13 (M) decrease independent LOS predictor & readmission of increased mortality, (UK data) infection, LOS, transfusion Ann R Coll Surg Engl 2016 [epub] Transfusion 2016;56:297 Anesthesiology 2009;110:574 Anesthesiology 2010;113:482 J Knee Surg 2013;26:373

12 JOINT CLASS Multidisciplinary preop education session Expectations, goals for postop Prehab physiotherapy, practice exercises Conflicting data re: effect on LOS J Arthroplasty 2010;25:547 Cochrane Database Syst Rev 2004;1:CD003526

13 PREOPERATIVE HOLDING AREA Initiate multimodal pain protocol acetaminophen 1 g q6h x 72 h celecoxib 200 mg bid x 72 h pregabalin mg bid x 72 h

14 OPIOIDS

15 Opioid-related adverse events orthopedic surgical patients, n=402 Emesis Confusion Constipation Mean days without adverse event Additional days with adverse event Pizzi et al. Pharmacotherapy 2012;32:502

16 ACETAMINOPHEN 33-55% reduction in morphine use Mechanism? COX +/- postoperatively cannabinoid agonism after TKA/THA 1000 mg q6h Extremely good safety profile Significantly PONV Twice as likely to report excellent satisfaction vs placebo Anesthesiology 2005;102:822 Viscusi, et al. AAPM Annual Meeting, 2008, Orlando FL J Healthc Qual 2014 [epub] Pain 2013;154:677

17 NSAIDS/COX-2 INHIBITORS Inhibit prostaglandin synthesis in both spinal cord 30 AND mg periphery ketorolac 600 mg ibuprofen 33-40% reduction in Decreased hyperalgesic state morphine use 90 mg etoricoxib postoperatively after joint 400 Side mg effects celecoxib of non-selective agents replacement J Arthroplasty 2012;27:1033 BMC Musculoskelet Disord 2013;14:300 Anesth Analg 2008;107:2025

18 GABAPENTINOIDS voltage gated calcium channel 49% blockers reduction in morphine Pregabalin (usually 150 mg use postoperatively used twice to daily) treat neuropathic pain states side effect...dizziness, sedation incidence of neuropathic pain at 3 & 6 months post TKA Br J Anesth 2008;101:535 Anesth Analg 2010;110:199 RAPM 2010;35:535

19 PREOPERATIVE HOLDING AREA Initiate multimodal pain protocol acetaminophen 1 g q6h x 72 h celecoxib 200 mg bid x 72 h pregabalin 150 mg bid x 72 h Preoperative nerve blocks

20 But. Analgesia Mobility

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22 n=191,000, multiple regression analysis risk factors for falls: age > 55 male general anesthesia (30% RR with neuraxial) Anesthesiology 2014;120:551

23 No quads weakness. RAPM 2013;38:321

24 Reg Anesth Pain Med 2013;38:526 Equivalent for opioid sparing & VAS Anesthesiology 2014;120:540

25 Local Infiltration Analgesia REPRODUCIBILITY??...supporting evidence for its use is currently limited. Anaesth Intens Care 2013;41:458

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28 INTRA-OPERATIVE INTERVENTIONS

29 HEMOGLOBIN OPTIMIZATION Tranexamic Acid transfusion rate significantly Inexpensive/cost-effective Excellent safety profile J Arthroplasty 2016;31:579 J Arthoplasty 2015;30:365 Bone Joint J 2014;96:1005 Knee Surg Sports Traumatol Arthrosc 2012;20:1742

30 KETAMINE NMDA receptor antagonist mg/kg bolus 30-40% reduction in Used systemically, epidurally, intra-articular +/- morphine use postoperatively Regimen? mcg/kg/min Need infusion for infusion? More rapid 90 flexion Anesth Analg 2005;100:475 Anesth Analg 2009;109:1963

31 J Arthroplasty 2013;28 Suppl 1:11-17 Group 1 Group 2 Group 3 Placebo 10 mg dex 10 mg dex + 10 mg dex at 24 h LOS: 3.97 days LOS: 3.0 days LOS: 2.57 days

32 SUMMARY: OUR PROTOCOL Set the expectations early and reinforce Periop oral multimodal (acetaminophen/pregabalin/celexocib) x 1 week Intraoperative ketamine, TXA, dexamethasone Adductor canal catheter x 4 d (ropivacaine 6 ml/hr) ipack (20 ml 0.2% ropivacaine)

33 OUTCOMES

34 femoral catheter + PCA LIA + PCA LIA + multimodal Adductor canal + multimodal p value n PT visits <0.001 Mean VAS PACU Mean VAS POD# Mean VAS POD# <0.001

35 femoral catheter + PCA LIA + PCA LIA + multimodal Adductor canal + multimodal p value n Ambulation POD#1 (ft) < hr morphine equivalent <0.001 LOS <0.001

36 SNF Home 100 p= fem cath + PCA LIA + PCA LIA + MM ACC + MM

37 FUTURE DIRECTIONS Proper analgesic/mobility balance--new agents/tech? Preop muscle strengthening Preoperative risk stratification for POCD Genotyping for high pain responders

38 THANK YOU.