Total knee and Total Hip Replacement, a Fast Track Muhammad I Shaikh M.D.,Ph.D. Associate Professor of Anesthesiology, UCSF Outline of my talk Definition of Fast Track Principles of FT as applied to Orthopedics Multimodal analgesia Describe variety of regional and local block options employed in Fast track protocols Summarize our experience with FT in joint replacement surgery at UCSF Disclosures I have nothing to disclose What is Fast Track Arthroplasty? An evidence-based protocol designed to standardize medical care, improve outcome, lower healthcare cost and improve patient satisfaction. 1
Fast track requires the efforts of a multidisciplinary team - Surgeons - Anesthesiologists - Nursing Staff - Pain Service - Physical Therapy - Pharmacy - Social Services - Patients (no less important than the hospital team itself) KehletH, Andersen LO. Local infiltration analgesia in joint replacement:the evidence and recommendations for clinical practice. ActaAnaesthesiol Scand 2011;55:778-84 Goals of Fast Track Fewer complications A reduction in cost Less postoperative pain Reduction in the hospital length of stay Quicker return to work and normal activities Historical Background - Initial concepts from Colorectal surgery - Focus on elements within the three surgical phases - Preoperative strategies - Intraoperative strategies - Postoperative strategies Extend concept to orthopedics Early study of 220 fast-track hip/knee replacement : - reduced morbidity and mortality during hospitalization - reduced length of stay - elimination of delirium - significant cost-savings Henrik Kehlet, Douglas W. Wilmore. Evidence-Based Surgical Care and Evolution of Fast-Track Surgery.AnnSurg 2008;248:189-198 Henrik Kehlet, Jorgen B Dahl. Anesthesia, surgery, and challenges in postoperative recovery. Lancet 2003;363:1921-28 Malviya A, Martin K, Harper I, et al. Enhanced recovery program for hip and knee replacement reduces death rate. Acta Orthop 2011; 82: 577-81 Henrik Kehlet. Fast-Track hip and knee arthroplasty. The Lancet 2013; 381:May 11, 2013 Henrik Kehlet and KjeldSoballe. Fast-track hip and knee replacement-what are the issues.guest editorial. ActaOrthopaedica 2010;81(3):271-271 2
Fast-track hip and knee replacement goals - Enhanced patient information/communication - Optimize anesthetic technique (regional vs. GA), pain management, transfusion strategy and rehabilitation and physiotherapy - Fast track protocols can reduce duration of thromboprophylaxis, postoperative cognitive dysfunction, post-discharge pain, length of stay 1-2 days Henrik Kehlet and Kield Soballe. Fast-track hip and knee replacement. ActaOrthopaedica 2010;81:271 Preoperative Strategies Preoperative Optimization Challenge Elderly ASA II-III Significant co-morbitities HTN, obesity, diabetes, angina, previous MI, CAD with DES, COPD Malnutrition and poor general condition Alexander W Phillips, Alan F Horgan. Fast track surgery and preoperative optimization. Surgery Feb.2014;32(2):84-88 Aggressive Optimization PREOPERATIVE EVALUATION: - Evaluated in the preop clinic months in advance - Optimization involving discussion with PCPs, cardiologists, pulmonologists, pain management team - Preoperative education - Setting realistic goals at each aspect of their journey Intraoperative Strategies Focus on: Pain control (multimodal analgesics and regional anesthesia with blocks) Fluid balance Reduction in blood loss N/V control (regional anesthesia preferred) 3
Effort begins Day of Surgery Studies in Multimodal Pain Mgt Multimodal Approach to Pain Management - Reduce the amount of perioperative narcotics - Use different medication classes (work at different sites of action) - Prevent development of chronic pain - Improve pain relief - Improved physical therapy - Avoid N/V - 36 patients undergoing TKA randomized to receive either periarticular injection ( 30 cc 0.5% bupivacaine,10 mg MS, 15 mg ketorolac) plus multimodal analgesics (oxycodone, tramadol, ketorolac) or hydromorphone PCA alone - Multimodal group had lower VAS, fewer adverse effects, lower narcotic usage, higher satisfaction scores and earlier time to physical therapy Joseph D Lamplot, Eric R. Wagner, David W. Manning. Multimodal Pain Management in Total Knee Arthroplasty. A prospective Randomized Controlled Trial. The Journal of Arthroplasty 29(2014): 329-334 Studies in Multimodal Pain Mgt - 160 knee arthroplasty pts randomized to 4 groups Group A - ropivacaine, epi, ketorolac and clonidine; Group B - ropivacaine, epi and ketorolac; Group C - ropivacaine,epi and clonidine; Group D (control) - ropivacaine and epinephrine - Compared to control the groups receiving ketorolac and/or clonidine had significantly lower VAS Todd C Kelly, Mary J Adams, Brian D Mulliken, David F Dalury. Efficacy of Perioperative Analgesia Protocol with Periarticular Medication Injection in Total Knee Arthroplasty: A Randomized Double-Blinded Study. The Journal of Arthroplasty 28(2013): 1274-1277 UCSF Study (unpublished) Retrospective analysis of primary knee arthroplasties - 2012 Multimodal analgesia protocol introduced June 2012 Acetaminophen, celecoxib(celebrex) and gabapentin Initiated Pre-op and continued Post-op Pre-multimodal group - 96 pts; multimodal group - 81 pts. Femoral nerve catheter and intraoperative single shot spinal Post-operative opiates minimized 4
RESULTS - 7.5 hour earlier discharge in multimodal group - Significant difference in LOS with use of all three multimodal agents - Reduced (LOS) resulted in decreased hospital cost - Relevant factors not studied included effect of pain service & team attention on pain, elimination of routine PCA opioid use, focus on earlier mobilization and discharge. Multimodal Agents We Use Pre-op/post-op: - Acetaminophen 1000 mg po x 1 - Celecoxib(celebrex) 400 mg po x 1 - Gabapentin 600 mg po x 1 Cautions may need to limit - APAP (Hepatic); Celecoxib (CAD, GI, Renal); Gabapentin (Renal) Preoperative Regional Anesthesia Day of Surgery Knee Replacement: Femoral Catheters vs. Adductor Canal block Hip Replacement: Lumber Plexus Catheters (Repeat Hips) Bilateral Hip and Knee Replacements - Combined Spinal + Epidurals or - Bilateral Femoral or Adductor Canal Catheters (Knees) Issues with Femoral Catheters Time consuming Added cost Timing of VTE prophylaxis Slower recovery of LE (primarily quadriceps) function 5
Adductor Canal vs. Femoral Nerve Prospective double-blinded, randomized controlled trial Forty-six patients received ACB; 47 patients received FNB Quadriceps strength, pain score and opioid consumption were assessed on both legs and at 6, 8, 24 and 48 h post-block At 6-8 h post-anesthesia, ACB compared with FNB exhibited early sparing of quadricep strength, excellent analgesia and reduced opioid intake Adductor Canal vs. Femoral Nerve Retrospective cohort study of patients undergoing total knee 66 had an adductor canal block and 102 pts had FNC Intraoperatively all patients received GA Primary outcome - total ambulation distance on PODs 1 and 2 Total ambulation significantly greater in ACB pts compared to those receiving FNC David H Kim, Yi Lin, Enrique A Goytizolo, Richard L Kahn et al. Adductor Canal vs Femoral Nerve Block for Total Knee Arthroplasty. A Prospective, Randomized, Controlled Trial. Anesthesiology 2014; 120:540-50. Seshadri C Mudumbai, Edward Kim, Steven K. Howard, J Justin Worman, Nicholas Giori, Steven Woolson et al. Continuous Adductor Canal Blocks are Superior to Continuous Femoral Nerve Blocks in Promoting Early Ambulation after TKA. ClinOrthop Relat Res. 30 July 2013 Adductor Canal vs. Femoral nerve Other approaches to pain control Intra-op Peri-articular / Intra-articular Blocks 6
Periarticular injection Injection of cocktail of medications including local anesthetics, analgesics, epinephrine into surrounding soft tissues at the time of surgery. Periarticular Injection vs. FNC Multiple studies - one of more recent: Randomized parallel clinical trial compared two protocols of postoperative pain relief after TKA - 20 pts in each group received either FNC ( ropivacaine) or peri-/ intraarticular infiltration with ropivacaine/ketorolac/epinephrine - Pain intensity and morphine consumption determined hourly Pain intensity and total morphine use same in both groups Fatin Affas,Eva-Britt Nygards, Carl-Olav Stiller at.al. Pain Control after Total Knee Arthroplasty: a Randomized Trial Comparing Local Infiltration Anesthesia and Continuous Femoral Block. ActaOrthopaedica2011; 82(3):441-447 Periarticular injection vs. FNC Pain: similar pain scores/morphine use for PAI vs. FNC Function: Better quad function and earlier d/c with PAI. No difference in knee range of motion Other anecdotal benefits: no interference with postop anticoagulation therapy and no need for knee immobilizer Complications: No significant differences reported. No toxicity or medication related problems with PAI References: PAI vs Continuous Nerve Block Constant AB, Benjamin JS et al. Efficacy of Periarticular Multimodal Drug Injection in Total Knee Arthroplasty. The Journal of Bone and Joint Surgery, May 2006;88:959-963 - 64 patients randomized to receive periarticular injections (ropivacaine + ketorolac + epi + MS. Or NS in the control group All pts. Received MS PCA for 24 h Treament group: had higher VAS for satisfaction, Lower VAS for pain control, Less use of PCA for 24 h Carli F, Clemente A et al. Analgesia and functional outcome after total knee arthroplasty: periarticular infiltration vs continuous femoral nerve block. Br J Anaesthesia 105(2):185-95 - Randomized double blind study of 40 pts., who either received PAI injections or FNC - postoperatively all pt. received morphine PCA - Early functional capacity (1-3 days) was similar in two groups, however late (6 weeks later) was better in FNC 7
References: PAI vs Nerve blocks Appendix: Injection technique Fatin A, Eva-Britt N, Carl-Olav et al. Pain control after total knee arthroplasty: a randomized trial comparing local infiltration anesthesia and continuous femoral block. Acta Orthopaedica 2011;82(3):441-447 - Very similar to earlier studies - 40 pts., scheduled for TKA randomized to receive PAI or FNB before receiving spinals - All pts., received morphine PCA - Pain intensity at rest and movement was marginally lower in PAI group - Total morphine consumption was similar Ng Fu-Y, Fhkam, Ng JKF, Chiu KY et al. Multimodal periarticular injection Vs continuous femoral nerve block after total knee arthroplasty. A prospective, crossover, randomized clinical trial. The J of Arthroplasty, 2012;27(6):12341238 - Randomized, cross-over clinical of 16 pts., scheduled for bilateral TKA - First stage they receive FNB (R) or PAI (Ropi. + Epi + Triamcinolone) - Second stage cross over of the study to PAI and FNB - All pts. Received morphine PCA - No difference in pain score or morphine consumption Mixture: Ropivacaine: 0.5% available in OR pharmacy = 5mg/ml. 200 mg = 40 ml; 250 = 50 ml; 300 mg = 60 ml Epinephrine: 1:1000 dilution 3mL = 0.3mg Toradol: 30 mg in 1 ml Sterile saline added to make 120 ml solution Injection protocol: Lavage joint after all bony cuts made and implants trialed. Inject approximately 30 ml of solution into posterior capsule, staying away from midline (NV bundle) and from posterolateral (common peroneal n). -- Inject 40 ml quads, and subcutaneous tissue prior to closure Therefore based on clinical evidence our patients receive: Adductor Canal block with LA infusion catheter (preoperatively) OR Periarticular injections (intraoperatively) KehletH, Andersen LO. Local infiltration analgesia in joint replacement:the evidence and recommendations for clinical practice. ActaAnaesthesiolScand 2011;55:778-84 David H Kim, Enrique A Goytizolo, Richard L Kahn, Daniel B Maalouf, Asha Manohar et aladductor Canal Block versus Femoral Nerve Block for Total Knee Arthroplasty. A Prospective, Randomized, Controlled Trial. Anesthesiology 2014;120:540-50 Intraoperative Protocol Fluid Optimization - no consensus, generally 30 40 ml/kg total considered as optimal for these cases Regional with Deep Sedation - Spinal or combined spinal + epidural for bilateral knees or bilateral hips Reduce blood loss - Transexamic acid 10 mg/kg followed by 1 mg/kg/hr (unless contra-indicated) Control of Nausea/Vomiting - regional anesthesia with block, propofol infusion, minimize periop narcotics, adequate hydration 8
Post-operative Strategies Optimize Pain control Early PT Early Discharge planning Post-operative Management F/u by the pain management team maintain epidural or nerve catheter for 48 hrs. Continue multimodal non-opioid medications Acetaminophen 1 g po q 6 h Celebrex 200 mg po bid Gabapentin 300 mg po bid - PRN Medications: - Dilaudid 0.2 0.6 mg iv q 2h prn - Oxycodone 5 10 mg po q 3h prn Postoperative Management Physical therapy starting POD O Lovenox (SC) prophylactic dose In case of continued epidural heparin 5000U SQ /d Discharge home on 2 nd or 3 rd day Average length of stay in 2013 2014 UCSF 2013 (Jan Dec) Total Proc. 837 3.8 days 2014 2.8 days 9
Conclusions Fast-track Arthroplasty associated with - better pain control - earlier patients mobility - reduced length of hospital stay - greater patient satisfaction - cost effective 10