Enhanced recovery for lower limb arthroplasty

Enhanced recovery for lower limb arthroplasty K Place MBChB FRCA NB Scott MBChB FRCS(Ed) FRCA Matrix reference 3A08 Key points Enhanced recovery is multidisciplinary standardized perioperative care aimed at early mobility, discharge, and return to normal life with both reduced morbidity and potentially mortality. The strategy has four strands: improving preoperative care, reducing the physical stress of the operation, decreasing postoperative discomfort, and improving postoperative mobility. The anaesthetist has a central role in enhanced recovery with access and influence on pre-, intra-, and postoperative care. Patients must play an active role in their own enhanced recovery. Audit and continued vigilance are required to maintain success in any multimodal multidisciplinary technique. K Place MBChB FRCA Consultant Anaesthetist Royal Berkshire Hospital NHS Foundation Trust London Road Reading RG1 5AN UK Tel: þ44 118 322 7068 Fax: þ44 118 322 7067 E-mail: kelly.place@royalberkshire.nhs.uk (for correspondence) NB Scott MBChB FRCS(Ed) FRCA Deputy Chief of Anaesthesia Hamad Medical Corporation PO Box 3050 Doha Qatar 95 Between April 2010 and April 2011, the NHS performed more than 140 000 knee and hip arthroplasties in England and Wales. An increasingly elderly population and increasing levels of obesity indicate that these numbers are likely to increase. Orthopaedic teams have looked at the lessons learned from fast track colorectal surgery and applied the principles to enhanced recovery for lower limb arthroplasty procedures. Enhanced recovery/fast-track surgery Fast-track surgery or more appropriately named enhanced recovery refers to a multidisciplinary, evidence-based, and procedure-specific strategy to surgery. Early work on enhanced recovery was pioneered by Henrik Kehlet, a Danish surgeon in 1990. The strategy has four strands: improving preoperative care, reducing the physical stress of the operation, and decreasing postoperative discomfort, thereby leading to improved postoperative mobility and earlier supported discharge. These are all targeted by the ERAS (enhanced recovery after surgery) team (anaesthetists, surgeons, physiotherapists, and nurses) allowing faster recovery with better outcomes. There are a number of potential advantages to this approach, including standardized care, earlier discharge, increased patient satisfaction, and reduced morbidity and potentially mortality. 1 In the UK, a nationwide ERAS network has developed with workshops and online forums. Flagship centres have government support to provide observational visits and follow-up support to allow other centres to set up their own enhanced recovery programmes. The recent publication from the Department of Health Delivering Enhanced Recovery provides a basis for these processes. 2 However, there is no single protocol for all hospitals and each centre must develop its own ERAS programme based on its own strengths and limitations. The Golden Jubilee Hospital uses the CALEDonian technique (Clinical Attitude Leading to Early Discharge). This is detailed in Table 1. Patient selection Patient selection for an enhanced recovery programme should include patients with fully optimized, well-controlled systemic disease who are motivated to complete the programme. Individual trusts have developed inclusion criteria, but the variety of patients suitable for enhanced recovery is ever-increasing. There will always be patients who may not be appropriate and require a different approach. Examples include opioid-dependent patients with potentially difficult analgesia requirements or surgically challenging revision arthroplasties. While a protocol-led anaesthetic plan may not be appropriate in these patients, early mobility and team work can still be applied. Factors associated with increased length of stay in a series of more than 700 unselected enhanced recovery arthroplasties 3 have included increasing age, female sex, unmarried/single patients, and increasing ASA, indicating that social circumstances and home support networks may also have a role to play. Operation dates may also affect discharge as patients receiving operations at the end of the week often failed to meet a 3 day discharge time due to reduced personnel and physiotherapy input at the weekend. The use of preoperative walking aids increased length of stay as did the need for blood transfusion. These can all be identified as possible preoperative target areas. Preoperative preparation Preoperative preparation begins at booking. Patient education, and more importantly engagement, is vital to successful enhanced recovery. Joint schools before admission have proved a good forum to manage patient expectation. Joint schools are interactive multidisciplinary educational sessions focusing on preoperative assessment, expectation, and recovery before surgery. doi:10.1093/bjaceaccp/mkt037 Advance Access publication 9 March, 2014 Continuing Education in Anaesthesia, Critical Care & Pain Volume 14 Number 3 2014 & The Author [2014]. Published by Oxford University Press on behalf of the British Journal of Anaesthesia. All rights reserved. For Permissions, please email: journals.permissions@oup.com

Table 1 CALEDonian technique (Clinical Attitude Leading to Early Discharge) Knee arthoplasty Hip arthroplasty Preop medication p.o. Gabapentin 300 mg, paracetamol 1 g, ibuprofen 400 mg, temazepam 10 mg, dexamethasone 8 mg 10 p.m. night before surgery and repeated 2 h before surgery However, contrary to popular opinion, patient education has little effect on length of stay after arthroplasty, pain, or postoperative function. 5 There is evidence that it may reduce patient anxiety in patient groups who require extra support or do not mobilize well. In these groups, it may improve recovery. Optimization of anaemia before operation can reduce postoperative morbidity and mortality and this can be done in the general practice setting. Anaesthetic preoperative assessment is a growing speciality in its own right. The anaesthetists role is central to enhanced recovery with clear access to pre-, intra-, and postoperative care, which, if balanced can allow early mobility. Preoperative clinics are now working alongside general practice in some centres to identify anaemic patients, investigate, and treat them appropriately before surgery. Co-existing co-morbidities such as hypertension and diabetes can also be optimized in the community and perioperative plans established before admission. Good community relations are also required after operation with some centres using community-based enhanced recovery nurses to identify and treat postoperative complications. Patient admission The majority of arthroplasty patients are admitted on the morning of surgery. Current studies indicate that enhanced recovery is most successful if carried out in designated areas or wards. Designated enhanced recovery areas aid standardized care, staff training, and a team approach. Premedication is given to all patients (Table 1). Premedication is given with a view to reducing the stress response of surgery, opioid requirements, and improving analgesia. In order to achieve this, multimodal analgesia is advocated, including the use of non-steroidal anti-inflammatory drugs (NSAIDs), paracetamol, and gabapentin. NSAIDs are used, provided that contraindications are not present (i.e. renal impairment, allergy, and gastrointestinal intolerance), prescribed for a short course only with regular review in the elderly population. Other premedicant agents target the reduction in the stress response to surgery, that is, clonidine (a central Gabapentin 300 mg, paracetamol 1 g, ibuprofen 200 mg, temazepam 10 mg, dexamethasone 8 mg 10 p.m. night before surgery and repeated 2 h before surgery Intraoperative analgesia Ketamine 25 50 mg i.v. intraop Ketamine 25 50 mg i.v. intraop Intraoperative fluid 500 1000 ml crystalloid 1000 1500 ml crystalloid Tranexamic acid 2.5 g after tourniquet release 2.5 g intraop Local anaesthetic Ropivacaine 2mg ml 21. Catheter placed in posterior compartment Ropivacaine 2 mg ml 21 around hip joint infiltration-surgery 4 of knee Postoperative analgesia Ropivacaine 2 mg ml 21 via wound catheter, 6 h post surgery, 10 p.m., 8 a.m. day 1 postop No wound catheter Oral postoperative multimodal analgesia Oxycodone modified release 5 20 mg b.d. and p.r.n. for 24 48 h; oxycodone immediate release (oxynorm) p.r.n. for 24 48 h; gabapentin 300 mg b.d. 5 days; paracetamol 1 g q.d.s.; ibuprofen 400 mg t.d.s. Oxycodone modified release 5 20 mg b.d. and oxycodone immediate release (oxynorm) p.r.n. for 24 48 h; gabapentin 300 mg b.d. 5 days; paracetamol 1 g q.d.s.; ibuprofen 400 mg t.d.s. Mobilization Day 0: mobilize to toilet; day 1: full mobilization Day 0: mobilize to toilet; day 1: full mobilization a2-agonist prescribed to patients who are not already taking b-blockers) and dexamethasone which has added advantage of reducing postoperative nausea and vomiting (PONV). 6 Minimizing fasting times and maintaining nutrition have been shown to reduce postoperative pain, nausea, perioperative insulin resistance, muscle catabolism, and in some small studies anxiety. The benefits of minimal starvation and the use of carbohydrate drinks are already well established in fast-track colorectal surgery. Anaesthetic technique Traditionally, anaesthetic approaches to hip and knee arthroplasty have been varied with debate over the relative advantages of regional vs general anaesthesia. Consensus has been difficult with anaesthetic websites such as the PROSPECT group (http://www.postoppain.org/ accessed October 2012) ( procedure-specific postoperative pain management) trying to produce evidence-based best practice anaesthetic techniques for a range of common surgical procedures. Historically, analgesia was the primary outcome aim for most procedures for the anaesthetist with mobility a secondary outcome. Now there is increasing emphasis on more appropriate techniques to facilitate enhanced and early mobility. There are a number of techniques that can be used as part of an enhanced recovery programme both alone or in combination. Central neuraxial blocks Spinal or epidural analgesia has commonly been used for joint arthroplasties. They can be used for anaesthesia alone (see below) or used with the addition of opioid either as a bolus or infusion for postoperative analgesia. Systematic reviews indicate that neuraxial and regional techniques can still confer reduced postoperative pain, morphine consumption, and nausea and vomiting while in the case of knee arthroplasty, potentially reduced length of stay. 7 While infiltration with or without a regional block can be used for postoperative analgesia, the patient will still require another form of anaesthesia for the procedure. Although general anaesthesia can 96 Continuing Education in Anaesthesia, Critical Care & Pain j Volume 14 Number 3 2014

be applied at our institution, a non-opioid low-dose spinal with an intraoperative target-controlled propofol infusion for sedation is used. Care must be taken to reduce PONV to a minimum with appropriate prophylaxis and treatment of high-risk groups. Postoperative analgesic techniques Local infiltration A local infiltration technique, as described in Table 1, is used in our institution. The use of widespread local anaesthetic infiltration originally described by Kerr and Kohan 8 is gaining popularity. Combined field and intra-articular infiltration is potentially an easier technical skill to acquire, with reduced risk of nerve injury and minimal motor block when compared with peripheral nerve block. Large volumes are used for knee replacement in order to ensure effective infiltration of all layers in the wound, namely the posterior capsule and femur, anterior capsule, quads, collateras, anterior femur and subcutaneous tissues. Although limited data suggest that toxic plasma levels are not acheived, the anaesthetist must be constantly vigilant against the possibility of both the surgeon exceeding the maximum recommended dose and an accidental intravascular injection of local anaesthetic. If adrenaline is used with the local anaesthetic, accidental intravascular injection may result in techycardia and hypertension. In the Kerr and Kohan paper, 8 this dose was reduced to a maximum of 250 mg ropivacaine for patients,55 kg,.85 yr, ASA III IV, or patients with previously reduced tolerance to local anaesthetics. One study looking at ropivacaine concentrations using an infiltration technique and a redivac drain found local anaesthetic concentrations below that which would be considered toxic, even after reinfusion of drain contents; 9 however, further pharmacokinetic research in this setting is required. Chondrolysis has recently been reported in association with intra-articular injection but is not an issue for THR and TKR where joint cartilage is removed. Meticulous technique training and continued audit is essential for success. Single injections have limited duration. Intermittent top-up injections and continuous infusions through intra-articular catheters have successfully been used in a number of centres for TKR. Evidence on the use of intermittent doses vs continuous infusion remain confusing with lack of standardization and inappropriate control groups. 10 Having originally used catheter top-ups for THR, we now successfully use a single perioperative local anaesthetic infiltration. Rather than catheters being ineffective in THR, this probably demonstrates that a THR is less painful after operation in comparison with a TKR. Additives to the local anaesthetic infiltration include NSAIDs (ketorolac 30 mg) plus epinephrine 0.5 mg to prevent reabsorption and extend the duration of analgesia. The available literature indicates that overall pain scores are reduced in infiltration groups in a number of trials. However, some reviews have again been criticized due to lack of adequate control group or the use of patient-controlled anaesthetics or saline groups rather than other more efficacious regional anaesthetic techniques. 6 Evidence examining the individual contribution of each agent within the local anaesthetic mixture are few: one small study indicating that locally applied NSAID (ketorolac) may be more effective than systemic administration. After some episodes of hypertension on deflation of the tourniquet, our institution now omits the epinephrine in the mixture; NSAIDs are administered systemically. Surgical technique using smaller incisions and shortened tourniquet times in the case of total knee replacement is also important in reducing postoperative swelling and pain. Infiltration analgesia with regional nerve block Some centres have adopted a combination of surgically placed posterior compartment local infiltration and a femoral nerve block for cases of knee arthroplasty. The concentration of local anaesthetic in the femoral nerve block has been reduced over time in an attempt to minimize motor block, with some studies achieving analgesia with concentrations as low as levobupivacaine 0.24 mg ml 21. 11 With any femoral nerve block, there exists the danger of motor block leading to delayed mobility or reduced proprioception leading to falls. 12 The risks can be reduced with lower concentrations, physio-aided mobilization, and splints. Recent literature indicates that there is increasing interest in the use of single-shot or continuous femoral nerve blocks for TKR in particular with a view to short and potentially long-term functional mobility. 13 While sciatic nerve block in combination with a femoral nerve block can provide excellent analgesia, the accompanying motor block and foot drop has excluded its use in an enhanced recovery setting. Intraoperative Once spinal anaesthesia and sedation is established, a single intraoperative dose of ketamine is given to reduce postoperative morphine consumption and PONV. 14 In line with enabling early mobility, the use of urinary catheters is best avoided. With an opioid-free spinal anaesthetic, our catheterization rate is 7% in a series of more than 5000 joints. With the use of tranexamic acid, the need for surgical drains in TKR has also stopped, facilitating early mobilization. Tranexamic acid Tranexamic acid is an antifibrinolytic that has been shown to reduce blood loss in both cardiac and orthopaedic surgery. Reducing blood loss has obvious advantages including less postoperative anaemia and less need for postoperative drains which are all potential barriers to mobilization. Reduced transfusion requirements results in fewer associated complications including immunosuppression and infection. 15 The dose of tranexamic acid used vary from 10 mg to 15 mg kg 21, given before release of the tourniquet in TKR. A recent audit confirms that our transfusion rate with tranexamic acid for TKR and THR is 1% with only one patient in a consecutive series of 1089 patients requiring a blood transfusion. Recently, concern over potential prothrombotic effects of tranexamic acid in trauma patients stresses the need for caution in high-risk groups. 16 However, although we have used tranexamic acid in nearly 5000 TKR and THR Continuing Education in Anaesthesia, Critical Care & Pain j Volume 14 Number 3 2014 97

patients with no increase in thromboembolic complications, further research is required. Recovery: the cryocuff In the recovery room, we apply a cryocuff to the operative leg (Fig. 1). A cryocuff is an ice-filled cuff that can be applied to the knee to provide both cold and pressure to the arthroplasty. Theoretically, this may provide cryoanalgesia, prevent local anaesthetic absorption, reduce inflammation or swelling, and finally, provide physical support to the joint. A prospective randomized study in TKR with or without compression bandages for the first 24 h indicated similar opiate requirements but reduced pain scores at rest and movement in the bandage group. 17 On return to the ward, the patients are mobilized to and from the toilet as soon as possible with a physiotherapy visit on the day of surgery. Perioperative fluid management The debate over perioperative fluid balance continues with regard to type and amount. Inadequate fluid replacement may cause postural hypotension, renal impairment, and PONV while an excessively liberal use of fluids increases the risk of tissue oedema and in extreme cardiac failure and respiratory distress. Goal-directed therapy is well established in ERAS for colorectal surgery 18 and is now a CQUIN target for some surgical procedures. It remains unclear whether it is necessary in lower limb arthroplasty. In TKR, fluid and blood losses are very low (operation under tourniquet and tranexamic acid). Further research to establish any benefits of cardiac output monitoring is required in an orthopaedic fast-track setting. An awake patient with a spinal anaesthetic would preclude techniques such as the oesophageal Doppler. Further interventions such as an arterial line would be required if arterial waveform cardiac output techniques such as LidCO is to be considered. The drip stand is a major deterrent to mobility for elderly arthritic and frail patients, especially those with other co-morbidities. Kehlet advocates a restrictive fluid regime over the 24 h postoperative period (,2 litre) as opposed to a liberal regime (4 5 litre) in TKR but emphasizes the need not to dehydrate patients. THR patients lose more blood intraoperatively than TKR patients and therefore i.v. fluids are continued until the patient is able to drink adequate oral volumes. Failed analgesia or mobilization A motivated and successful ERAS team can achieve routine mobilization on the operative day. Multimodal postoperative analgesia is detailed in Table 1. Full commitment from all members of the enhanced recovery team including physiotherapists, ward nurses, doctors, and the patients is required; however, there are cases where this may not be possible. It is important with any enhanced recovery protocol to have a secondary plan if there is failure at any stage. At our centre, if patients experience pain despite local anaesthetic top-ups for TKR, a rescue femoral nerve block or an epidural is sited, provided there are no contraindications. In the case of failed local anaesthetic infiltration for a THR, an epidural is sited or rescue opioid analgesia given. Each centre will need to devise a backup plan to identify and treat these patients promptly. Failure of one analgesic technique and conversion to another should not prevent attempts at early mobilization once comfortable. Postural hypotension is another barrier to mobilization in some groups; the incidence can be as high as 42% at 6 h after operation in THR; 19 exact mechanisms and predictors remain unclear. However, it would seem sensible to exclude PONV, anaemia, dehydration, and cardiac causes after which 15 30 mg of oral ephedrine can be used pre-emptively before further attempts at mobilization. Fig 1 Cyrocuff. Audit With any new technique, it is of paramount importance to determine its efficacy, efficiency, and effectiveness. The ideal investigation is the prospective randomized controlled clinical trial, but this is difficult for many busy NHS units that do not have research facilities. However, centres should be encouraged to present any findings that may prove useful to the future development of ERAS programmes. With a multimodal multidisciplinary technique, there are numerous stages at which complications and failure may occur. Thus, carefully 98 Continuing Education in Anaesthesia, Critical Care & Pain j Volume 14 Number 3 2014

performed clinical audit also allows further modification and improvement to existing practice. Patient diaries detailing daily goals, progress, and feelings have proved useful not only for patient experience and feedback but as motivators. Declaration of interest None declared. References 1. Malviya A, Martin K, Harper I et al. Enhanced recovery program for hip and knee replacement reduces death rate: a study of 4,500 consecutive primary hip and knee replacements. Acta Orthop 2011; 82: 577 81 2. Department of Health. Delivering enhanced recovery, helping patients to get better sooner after surgery, March 31, 2010. Available from www.dh. gov.uk (accessed 16 April 2010) 3. Husted H, Helm G, Jacobsen S. Predictors of length of stay and patient satisfaction after hip and knee replacement surgery fast track experience in 712 patients. Acta Orthop 2008; 79: 168 73 4. McDonald DA, Siegmeth R, Deakin AH, Kinninmonth AWG, Scott NB. An enhanced recovery programme for primary total knee arthroplasty in the United Kingdom- follow up at one year. The Knee 2012; 19: 525 9 5. McDonald S, Hetrick S, Green S. Preoperative education for hip or knee replacement. Cochrane Database of Syst Rev 2004; 1 6. Fawcett WJ, Mythen M, Scott M. Enhanced recovery: more than reducing length of stay? Br J Anaesth 2012; 109: 671 4 7. Macfarlane AJ, Govindarajulu AP, Chan V, Brull R. Does regional anaesthesia improve outcome after total hip arthroplasty? A systematic review. Anaesthesia 2009; 103: 335 45 8. Kerr D, Kohan L. Local infiltration analgesia: a technique for the control of acute postoperative pain following knee and hip surgery a case study of 325 patients. Acta Orthop 2008; 79: 174 83 9. Parker DA, Collican MR, Mather LE, Graham DA, DeWall MJ. Safety of combined use of local anaesthetic infiltration and reinfusion drains in total knee arthroplasty. J Arthroplasty 2009; 24: 918 24 10. Gibbs DMR, Green TP, Esler CN. The local infiltration of analgesia following total knee replacement: a review of current literature. J Bone Joint Surg Br 2012; 94: 1154 11. Macleod GA, Dale J, Robinson D et al. Determination of the EC 50 of levobupivavcaine for femoral and sciatic perineural infusion after total knee arthroplasty. Br J Anaesth 2009; 102: 528 33 12. Sharma S, Lorio R, Specht L, Lepie S, Healy W. Complications of femoral nerve block for total knee arthroplasty. Clin Orthop Relat Res 2010; 468: 135 40 13. Carli F, Clemente A, Asenjo J et al. Analgesia and functional outcome after total knee arthroplasty: periarticular infiltration vs continuous femoral nerve block. Br J Anaesth 2010; 105: 185 95 14. Bell RF, Dahl JB, Moore RA, Kalso E. Peri-operative ketamine for acute post-operative pain: a quantitative and qualitative systematic review (Cochrane review). Acta Anaesthesiol Scand 2005; 49: 1405 28 15. Foss N, Kristensen M, Kehlet H. Anaemia impedes functional mobility after hip fracture surgery. Age Ageing 2008; 37: 173 8 16. Zuttery P, Miquet M, Quenet S et al. Tranexamic acid in hip fracture surgery: a randomised controlled trial. Br J Anaesth 2010; 104: 23 30 17. Anderson L, Husted H, Otte K, Kristensen B, Kehlet H. A compression bandage improves local infiltration analgesia in total knee arthroplasty. Acta Orthop 2008; 79: 806 11 18. Noblett S, Snowden C, Shenten B, Horgan A. Randomised clinical trial assessing the effect of Doppler-optimised fluid management on outcome after elective colo-rectal resection. Br J Surg 2006; 93: 1069 76 19. Jans O, Bundgaard-Neilsen M, Solgaard S, Johansson P, Kehlet H. Orthostatic intolerance during early mobilization after fast-track hip arthroplasty. Br J Anaesth 2012; 108: 436 43 Please see multiple choice questions 1 4. Continuing Education in Anaesthesia, Critical Care & Pain j Volume 14 Number 3 2014 99