ENHANCED RECOVERY PROTOCOLS FOR KNEE REPLACEMENT Jeff Gadsden, MD, FRCPC, FANZCA Associate Professor Duke University Department of Anesthesiology Regional Anesthesia and Acute Pain Medicine
DISCLOSURES Pacira Pharmaceuticals B.Braun Medical Mallinckrodt Pharmaceuticals
OUTLINE Describe key elements of clinical pathways for total joint arthroplasty Discuss evidence for/against each of these
PROJECTED ANNUAL TOTAL HIP/ KNEE REPLACEMENTS, U.S. 1,500,000 1 TKA 1,200,000 900,000 600,000 1 THA 300,000 Revision TKA Revision THA 0 2005 2010 2015 2020 J Bone Joint Surg Am 2014;96:624
What s different about ERPs for Orthopedics?
Pain Muscle weakness Dizziness/orthostasis Acta Orthop 2011;82:679 Arch Orthop Trauma Surg 2010;130:263
PRE-OPERATIVE INTERVENTIONS
PREOPERATIVE VISIT ideally >4 weeks in advance Routine anesthetic evaluation/optimization Smoking cessation Discussion regarding pain expectations
PAIN CALIBRATION?
PREOPERATIVE VISIT ideally >4 weeks in advance Routine anesthetic evaluation/optimization Smoking cessation Discussion regarding pain expectations Preoperative hemoglobin optimization
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
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
PREOPERATIVE HOLDING AREA Initiate multimodal pain protocol acetaminophen 1 g q6h x 72 h celecoxib 200 mg bid x 72 h pregabalin 75-150 mg bid x 72 h
OPIOIDS
Opioid-related adverse events orthopedic surgical patients, n=402 Emesis 3 0.7 Confusion 3 1.1 Constipation 2.9 1.4 0 1 2 3 4 5 Mean days without adverse event Additional days with adverse event Pizzi et al. Pharmacotherapy 2012;32:502
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
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
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
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
But. Analgesia Mobility
n=191,000, multiple regression analysis risk factors for falls: age > 55 male general anesthesia (30% RR with neuraxial) Anesthesiology 2014;120:551
No quads weakness. RAPM 2013;38:321
Reg Anesth Pain Med 2013;38:526 Equivalent for opioid sparing & VAS Anesthesiology 2014;120:540
Local Infiltration Analgesia REPRODUCIBILITY??...supporting evidence for its use is currently limited. Anaesth Intens Care 2013;41:458
INTRA-OPERATIVE INTERVENTIONS
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
KETAMINE NMDA receptor antagonist 0.25-0.5 mg/kg bolus 30-40% reduction in Used systemically, epidurally, intra-articular +/- morphine use postoperatively 1.5-3 Regimen? mcg/kg/min Need infusion for infusion? More rapid 90 flexion Anesth Analg 2005;100:475 Anesth Analg 2009;109:1963
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
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 0.2% @ 6 ml/hr) ipack (20 ml 0.2% ropivacaine)
OUTCOMES
femoral catheter + PCA LIA + PCA LIA + multimodal Adductor canal + multimodal p value n 116 45 101 118 PT visits 4.83 4.71 4.55 3.21 <0.001 Mean VAS PACU 2.31 3.41 2.95 3.12 0.05 Mean VAS POD#0 3.94 4.21 4.68 3.79 0.028 Mean VAS POD#1 4.26 5.32 4.57 3.66 <0.001
femoral catheter + PCA LIA + PCA LIA + multimodal Adductor canal + multimodal p value n 116 45 101 118 Ambulation POD#1 (ft) 61.63 53.04 91.68 166.34 <0.001 24 hr morphine equivalent 65.7 61.1 38.3 30.8 <0.001 LOS 3.21 3.21 2.81 2.17 <0.001
SNF Home 100 p=0.013 80 60 40 20 0 fem cath + PCA LIA + PCA LIA + MM ACC + MM
FUTURE DIRECTIONS Proper analgesic/mobility balance--new agents/tech? Preop muscle strengthening Preoperative risk stratification for POCD Genotyping for high pain responders
THANK YOU.