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Haslam N, Halvey E, Scott C. Perioperative care of patients undergoing total hip arthroplasty. BJA Educ 2024; 24:183-190. [PMID: 38764444 PMCID: PMC11096433 DOI: 10.1016/j.bjae.2024.03.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/11/2024] [Indexed: 05/21/2024] Open
Affiliation(s)
- N. Haslam
- South Tyneside and Sunderland NHS Foundation Trust, Sunderland, UK
| | - E. Halvey
- Sir Charles Gairdner Hospital, Perth, WA, Australia
| | - C. Scott
- Royal Infirmary of Edinburgh, Edinburgh, UK
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Pitaro NL, Herrera MM, Stern BZ, Russo DA, McLaughlin JA, Chen DD, Moucha CS, Hayden BL, Poeran J. Synthesis of 'joint class' curricula at high volume joint replacement centres and a preliminary model for development and evaluation. J Eval Clin Pract 2024; 30:46-59. [PMID: 37211660 DOI: 10.1111/jep.13865] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/05/2023] [Revised: 05/02/2023] [Accepted: 05/04/2023] [Indexed: 05/23/2023]
Abstract
RATIONALE Preoperative patient education through 'joint class' has potential to improve quality of care for total joint replacement (TJR). However, no formal guidance exists regarding curriculum content, potentially resulting in inter-institutional variation. OBJECTIVE We aimed to (a) synthesize curriculum components of 'joint classes' across high-volume institutions and (b) develop a preliminary theory of change model for development and evaluation guided by the existing curricula and related literature. METHODS We reviewed 'joint class' curricula from the websites of the 10 highest-volume TJR centres (by average annual 2017-2019 volume) that publicly disclosed this information. Two reviewers qualitatively compared available content and noted common categories, which were synthesized into key domains across institutions. We then reviewed the PubMed database for literature on pre-TJR patient education and education needs in the past 10 years. Drawing on our curriculum synthesis and related literature, we proposed a theory of change model: hypothesized mechanisms through which 'joint class' confers benefits to patients and health systems. RESULTS We identified 30 categories in our review of existing class content, which we synthesized into seven key domains: (I) Practical Elements, (II) Logistics, (III) Medical Information, (IV) Modifiable Risk Factors, (V) Expected Outcomes, (VI) Patient Role in Recovery and (VII) Enhanced Education. Variation across institutions was noted. Our preliminary model based on the curriculum synthesis and related literature on the impact of 'joint class' includes three levels: (1) Practical Elements ('joint class' accessibility and information quality), (2) Class Goals (increased health literacy, increased adherence, risk mitigation, realistic expectations, and reduced anxiety) and (3) Target Outcomes (improved clinical outcomes, positive patient experience and increased patient satisfaction). CONCLUSION Our synthesis identified core common topics included in pre-TJR education but also highlighted variation across institutions, supporting opportunities for standardization. Clinicians and researchers can use our preliminary model to systematically develop and evaluate 'joint classes,' with the goal of establishing a standard of care for TJR preoperative education.
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Affiliation(s)
- Nicholas L Pitaro
- Leni and Peter W. May Department of Orthopaedic Surgery, Icahn School of Medicine at Mount Sinai, New York City, New York, USA
| | - Michael M Herrera
- Leni and Peter W. May Department of Orthopaedic Surgery, Icahn School of Medicine at Mount Sinai, New York City, New York, USA
| | - Brocha Z Stern
- Leni and Peter W. May Department of Orthopaedic Surgery, Icahn School of Medicine at Mount Sinai, New York City, New York, USA
- Department of Population Science and Policy, Icahn School of Medicine at Mount Sinai, Institute for Healthcare Delivery Science, New York City, New York, USA
| | - Donna A Russo
- Leni and Peter W. May Department of Orthopaedic Surgery, Icahn School of Medicine at Mount Sinai, New York City, New York, USA
| | - Jonathan A McLaughlin
- Leni and Peter W. May Department of Orthopaedic Surgery, Icahn School of Medicine at Mount Sinai, New York City, New York, USA
| | - Darwin D Chen
- Leni and Peter W. May Department of Orthopaedic Surgery, Icahn School of Medicine at Mount Sinai, New York City, New York, USA
| | - Calin S Moucha
- Leni and Peter W. May Department of Orthopaedic Surgery, Icahn School of Medicine at Mount Sinai, New York City, New York, USA
| | - Brett L Hayden
- Leni and Peter W. May Department of Orthopaedic Surgery, Icahn School of Medicine at Mount Sinai, New York City, New York, USA
| | - Jashvant Poeran
- Leni and Peter W. May Department of Orthopaedic Surgery, Icahn School of Medicine at Mount Sinai, New York City, New York, USA
- Department of Population Science and Policy, Icahn School of Medicine at Mount Sinai, Institute for Healthcare Delivery Science, New York City, New York, USA
- Department of Medicine, Icahn School of Medicine at Mount Sinai, New York City, New York, USA
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Cheng SI, Swamidoss CP, Soffin EM. Perioperative Acupuncture: A Novel and Necessary Addition to ERAS Pathways for Total Joint Arthroplasty. HSS J 2024; 20:122-125. [PMID: 38356751 PMCID: PMC10863582 DOI: 10.1177/15563316231204308] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/20/2023] [Accepted: 06/22/2023] [Indexed: 02/16/2024]
Affiliation(s)
- Stephanie I Cheng
- Department of Anesthesiology, Critical Care & Pain Management, Hospital for Special Surgery, New York, NY, USA
- Department of Anesthesiology, New York-Presbyterian Hospital, Weill Cornell Medicine, New York, NY, USA
| | - Cephas P Swamidoss
- Department of Anesthesiology, Critical Care & Pain Management, Hospital for Special Surgery, New York, NY, USA
- Department of Anesthesiology, New York-Presbyterian Hospital, Weill Cornell Medicine, New York, NY, USA
| | - Ellen M Soffin
- Department of Anesthesiology, Critical Care & Pain Management, Hospital for Special Surgery, New York, NY, USA
- Department of Anesthesiology, New York-Presbyterian Hospital, Weill Cornell Medicine, New York, NY, USA
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Hu J, Wang Q, Hu J, Kang P, Yang J. Efficacy of Ultrasound-Guided Pericapsular Nerve Group (PENG) Block Combined With Local Infiltration Analgesia on Postoperative Pain After Total Hip Arthroplasty: A Prospective, Double-Blind, Randomized Controlled Trial. J Arthroplasty 2022; 38:1096-1103. [PMID: 36529195 DOI: 10.1016/j.arth.2022.12.023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/21/2022] [Revised: 12/02/2022] [Accepted: 12/12/2022] [Indexed: 12/23/2022] Open
Abstract
BACKGROUND This study examined whether pericapsular nerve group (PENG) block combined with local infiltration analgesia (LIA) could improve pain management and functional recovery after total hip arthroplasty. METHODS All patients were randomly assigned to receive PENG block combined with LIA (PENG group) or sham PENG block and LIA (Sham group). The primary outcome was cumulative morphine consumption within 24 hours after surgery. Secondary outcomes were pain scores on a visual analog scale (VAS); time to first rescue analgesia; cumulative morphine consumption during hospitalization; intraoperative consumption of opioids; postoperative recovery; and postoperative complications. RESULTS PENG patients consumed significantly less morphine within the first 24 hours and throughout hospitalization and smaller amounts of intraoperative opioids. There were significantly lower pain scores at rest and during motion within 24 hours in PENG patients. PENG patients took significantly longer until the first rescue analgesia and showed significantly better postoperative rehabilitation. However, the absolute change in morphine consumption and VAS scores did not exceed the reported minimal clinically important differences (morphine consumption: 10 mg; VAS scores: 1.5 at rest and 1.8 during movement). The two groups showed no difference in quadriceps muscle strength and postoperative complications. CONCLUSION PENG block combined with LIA could improve postoperative pain relief, reduce opioid use, and enhance recovery in total hip arthroplasty patients, without weakening the quadriceps muscle strength. This work justifies further trials to examine the safety and efficacy of this block and to explore maximal effective volume of local anesthetic for motor-sparing PENG block.
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Affiliation(s)
- Jian Hu
- Department of Anesthesiology and National Clinical Research Center for Geriatrics, West China Hospital of Sichuan University, Sichuan Province, Chengdu, China
| | - Qiuru Wang
- Department of Orthopedic Surgery, West China Hospital, Sichuan University, Chengdu, China
| | - Jie Hu
- Department of Anesthesiology and National Clinical Research Center for Geriatrics, West China Hospital of Sichuan University, Sichuan Province, Chengdu, China
| | - Pengde Kang
- Department of Orthopedic Surgery, West China Hospital, Sichuan University, Chengdu, China
| | - Jing Yang
- Department of Anesthesiology and National Clinical Research Center for Geriatrics, West China Hospital of Sichuan University, Sichuan Province, Chengdu, China
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Somoza-Fernández B, Ribed-Sánchez A, Martín-Lozano S, de Vega-San Vicente FM, Menéndez-Tarín R, Giménez-Manzorro Á, Sanz-Ruiz P, Garutti-Martínez I, Herranz-Alonso A, Vaquero-Martín J, Sanjurjo-Sáez M. Implementation of an enhanced recovery after surgery program including a patient school: Impact on quality of life results. Injury 2022; 53:3987-3992. [PMID: 36244831 DOI: 10.1016/j.injury.2022.09.063] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/12/2022] [Revised: 09/29/2022] [Accepted: 09/30/2022] [Indexed: 02/02/2023]
Abstract
INTRODUCTION Enhanced Recovery After Surgery (ERAS) protocols and educational programmes have been shown to accelerate orthopaedic surgery recovery with fewer complications, and improve patient-reported outcomes (PROs) for different types of surgery. The objective was to evaluate the impact of an ERAS programme including a patient school on health outcomes and PROs for Total Knee Replacement (TKR) surgery. MATERIAL AND METHODS A multidisciplinary group created the programme and the patient school (preoperative consultations where the patients' surgical processes are explained and are also given instructions for an appropriate perioperative care management). An observational, prospective study was conducted on all patients operated for TKR from March 2021 to March 2022. Main health outcomes were: hospital stay length, surgical complications and surgery cancellations due to a wrong preoperative medication management. PROs evaluated were: patient satisfaction with pain management, the school, and quality of life before and after surgery (EQ-5D). RESULTS One hundred thirty-three patients were included. Median hospital stay length was 3 days (IQR 3-5). Rate of surgical complications was 25.6%. No surgery was cancelled. Patient satisfaction rates with pain management and with the school were 8.10/10 and 9.89/10, respectively. Concerning quality of life, mean improvement in mobility and knee pain after the surgery was 0.66 (p < 0.05) and 0.84 (p < 0.05), respectively. CONCLUSIONS The ERAS programme including a patient school was highly successful with a fast recovery, a short hospital stay length, no surgery cancellations, and improved PROs.
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Affiliation(s)
- B Somoza-Fernández
- Pharmacy Department, Hospital General Universitario Gregorio Marañón, Instituto de Investigación Sanitaria Gregorio Marañón (IiSGM), Doctor Esquerdo Street, 46, Madrid 28007, Spain.
| | - A Ribed-Sánchez
- Pharmacy Department, Hospital General Universitario Gregorio Marañón, Instituto de Investigación Sanitaria Gregorio Marañón (IiSGM), Doctor Esquerdo Street, 46, Madrid 28007, Spain
| | - S Martín-Lozano
- Traumatology and Orthopaedic Surgery Department, Hospital General Universitario Gregorio Marañón, Instituto de Investigación Sanitaria Gregorio Marañón (IiSGM), Doctor Esquerdo Street, 46, Madrid 28007, Spain
| | - F M de Vega-San Vicente
- Traumatology and Orthopaedic Surgery Department, Hospital General Universitario Gregorio Marañón, Instituto de Investigación Sanitaria Gregorio Marañón (IiSGM), Doctor Esquerdo Street, 46, Madrid 28007, Spain
| | - R Menéndez-Tarín
- Traumatology and Orthopaedic Surgery Department, Hospital General Universitario Gregorio Marañón, Instituto de Investigación Sanitaria Gregorio Marañón (IiSGM), Doctor Esquerdo Street, 46, Madrid 28007, Spain
| | - Á Giménez-Manzorro
- Pharmacy Department, Hospital General Universitario Gregorio Marañón, Instituto de Investigación Sanitaria Gregorio Marañón (IiSGM), Doctor Esquerdo Street, 46, Madrid 28007, Spain
| | - P Sanz-Ruiz
- Traumatology and Orthopaedic Surgery Department, Hospital General Universitario Gregorio Marañón, Instituto de Investigación Sanitaria Gregorio Marañón (IiSGM), Doctor Esquerdo Street, 46, Madrid 28007, Spain
| | - I Garutti-Martínez
- Anesthesiology and Resuscitation Department, Hospital General Universitario Gregorio Marañón, Instituto de Investigación Sanitaria Gregorio Marañón (IiSGM), Doctor Esquerdo Street, 46, Madrid 28007, Spain
| | - A Herranz-Alonso
- Pharmacy Department, Hospital General Universitario Gregorio Marañón, Instituto de Investigación Sanitaria Gregorio Marañón (IiSGM), Doctor Esquerdo Street, 46, Madrid 28007, Spain
| | - J Vaquero-Martín
- Traumatology and Orthopaedic Surgery Department, Hospital General Universitario Gregorio Marañón, Instituto de Investigación Sanitaria Gregorio Marañón (IiSGM), Doctor Esquerdo Street, 46, Madrid 28007, Spain
| | - M Sanjurjo-Sáez
- Pharmacy Department, Hospital General Universitario Gregorio Marañón, Instituto de Investigación Sanitaria Gregorio Marañón (IiSGM), Doctor Esquerdo Street, 46, Madrid 28007, Spain
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Alfitian J, Scheyerer MJ, Rohde A, Schick V, Kammerer T, Schier R. Omission of tranexamic acid does not increase the amount of perioperative blood transfusions in patients undergoing one-level spinal fusion surgery: a retrospective propensity score-matched noninferiority study. Arch Orthop Trauma Surg 2022; 143:2943-2950. [PMID: 35708870 DOI: 10.1007/s00402-022-04494-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/11/2021] [Accepted: 05/18/2022] [Indexed: 11/26/2022]
Abstract
INTRODUCTION Application of tranexamic acid (TXA) in spine surgery is very frequent even without signs of hyperfibrinolysis, although its beneficial blood-saving effects are offset by harmful adverse events such as thromboembolic incidents. Thus, we investigated whether in relatively less invasive spinal procedures such as one-level posterior spinal fusion, omission of TXA affects the requirement for blood transfusions. METHODS We conducted a retrospective propensity score-matched noninferiority study with 212 patients who underwent one-level posterior spine fusion and who were stratified according to whether they received TXA intraoperatively at our tertiary care center. The primary endpoint was the volume of transfused packed red cells. Testing for noninferiority or equivalence was performed by two one-sided testing procedure (TOST) with a priori defined noninferiority margins ([Formula: see text]). RESULTS After propensity score matching a total of five patients (11.6%) treated with TXA were transfused compared with five patients (11.6%) who did not receive TXA. The majority of patients (51.2%) had a risk-increasing condition. The risk difference (no TXA-TXA) of intraoperative transfusion was - 4.7% (CI 90% - 13.62 to 4.32%), and omitting TXA was noninferior ([Formula: see text] = [Formula: see text] 10%). The mean intergroup difference in transfused volume (no TXA-TXA) was - 23.26 ml intraoperatively (CI 90% - 69.34 to 22.83 ml) and - 46.51 ml overall (CI 90% - 181.12 to 88.1 ml), respectively, suggesting equivalence of TXA omission ([Formula: see text] = [Formula: see text] 300 ml). The hemoglobin decline between both groups was also equivalent (with [Formula: see text] = [Formula: see text] 1 g/dl) both on the first postoperative day ([Formula: see text] Hb = 0.02 g/dl, CI 90% - 0.53 to 0.56 g/dl) and at discharge ([Formula: see text] Hb = - 0.29 g/dl, CI 90% - 0.89 to 0.31 g/dl). CONCLUSION We demonstrated that requirement of transfusion is rare among one-level fusion surgery and the omission of TXA is noninferior with regard to blood transfusion in high-risk patients undergoing this procedure. Therefore, the prophylactic use of TXA cannot be recommended here, suggesting to focus on alternative blood conservation strategies, if necessary.
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Affiliation(s)
- Jonas Alfitian
- University of Cologne, Faculty of Medicine and University Hospital Cologne, Department of Anaesthesiology and Intensive Care Medicine, Kerpener Str. 62, 50937, Cologne, Germany.
| | - Max Joseph Scheyerer
- University of Cologne, Faculty of Medicine and University Hospital Cologne, Department of Orthopaedics and Trauma Surgery, Kerpener Str. 62, 50937, Cologne, Germany
| | - Axel Rohde
- University of Cologne, Faculty of Medicine and University Hospital Cologne, Department of Orthopaedics and Trauma Surgery, Kerpener Str. 62, 50937, Cologne, Germany
| | - Volker Schick
- University of Cologne, Faculty of Medicine and University Hospital Cologne, Department of Anaesthesiology and Intensive Care Medicine, Kerpener Str. 62, 50937, Cologne, Germany
| | - Tobias Kammerer
- University of Cologne, Faculty of Medicine and University Hospital Cologne, Department of Anaesthesiology and Intensive Care Medicine, Kerpener Str. 62, 50937, Cologne, Germany
| | - Robert Schier
- University of Cologne, Faculty of Medicine and University Hospital Cologne, Department of Anaesthesiology and Intensive Care Medicine, Kerpener Str. 62, 50937, Cologne, Germany
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Soffin EM, Wainwright TW. Hip and Knee Arthroplasty. Anesthesiol Clin 2022; 40:73-90. [PMID: 35236584 DOI: 10.1016/j.anclin.2021.11.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/14/2023]
Abstract
Variation in care is associated with variation in outcomes after total joint arthroplasty (TJA). Accordingly, much research into enhanced recovery efficacy for TJA has been devoted to linking standardization with better outcomes. This article focuses on recent advances suggesting that variation within a set of core protocol elements may be less important than providing the core elements within enhanced recovery pathways for TJA. Provided the core elements are associated with benefits for patients and health care system outcomes, variation in the details of their provision may contribute to a pathway's success. This article provides an updated review of the literature.
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Affiliation(s)
- Ellen M Soffin
- Department of Anesthesiology, Critical Care & Pain Management, Hospital for Special Surgery, 535 East 70th Street, New York, NY 10021, USA.
| | - Thomas W Wainwright
- Orthopaedic Research Institute, Bournemouth University, 89 Holdenhurst Road, Bournemouth, Dorset BH8 8FT, UK
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Fan J, Lv Y, Xu X, Zhou F, Zhang Z, Tian Y, Ji H, Guo Y, Yang Z, Hou G. The Efficacy of Multidisciplinary Team Co-Management Program for Elderly Patients With Intertrochanteric Fractures: A Retrospective Study. Front Surg 2022; 8:816763. [PMID: 35284470 PMCID: PMC8907576 DOI: 10.3389/fsurg.2021.816763] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2021] [Accepted: 12/28/2021] [Indexed: 11/13/2022] Open
Abstract
BackgroundIntertrochanteric fractures increased quickly in past decades owing to the increasing number of aging population. Recently, geriatric co-management was rapidly emerging as a favored clinical care model for older patients with hip fractures. The purpose of this study was to assess the efficacy of a multidisciplinary team (MDT) co-management program in elderly patients with intertrochanteric fractures.MethodsIn this retrospective study, patients were divided into MDT group and traditional orthopedic care (TOC) group according to the healthcare model applied. 249 patients were included in the TOC group from January 2014 to December 2016 and 241 patients were included in the MDT group from January 2017 to December 2019. Baseline data, peri-operative data, and postoperative complications were collected and analyzed using SPSS 21.0.ResultsNo significant differences were observed between the two groups in terms of patient baseline characteristics. Patients in the MDT group had significantly lower time from admission to surgery and length-of-stay (LOS) compared with those in the TOC group. Furthermore, the proportion of patients receiving surgery within 24 h (61.4 vs. 34.9%, p < 0.001) and 48 h (80.9 vs. 63.5%, p < 0.001) after admission to the ward was significantly higher in the MDT group compared with those in the TOC group. In addition, patients in the MDT group had significantly lower proportion of postoperative complications (25.3 vs. 44.2%, p < 0.001), deep vein thrombosis (7.9 vs. 12.9%, p = 0.049), pneumonia (3.8 vs. 8.0%, p = 0.045) and delirium (4.1 vs. 9.2%, p = 0.025) compared with those in the TOC group. However, no significant changes were found for in-hospital and 30-day mortality.ConclusionThe MDT co-management could significantly shorten the time from admission to surgery, LOS, and reduce the postoperative complications for elderly patients with intertrochanteric fractures. Further research was needed to evaluate the impact of this model on patient health outcomes.
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Affiliation(s)
- Jixing Fan
- Department of Orthopedics, Peking University Third Hospital, Beijing, China
- Engineering Research Center of Bone and Joint Precision Medicine, Ministry of Education, Beijing, China
| | - Yang Lv
- Department of Orthopedics, Peking University Third Hospital, Beijing, China
- Engineering Research Center of Bone and Joint Precision Medicine, Ministry of Education, Beijing, China
| | - Xiangyu Xu
- Department of Orthopedics, Peking University Third Hospital, Beijing, China
- Engineering Research Center of Bone and Joint Precision Medicine, Ministry of Education, Beijing, China
| | - Fang Zhou
- Department of Orthopedics, Peking University Third Hospital, Beijing, China
- Engineering Research Center of Bone and Joint Precision Medicine, Ministry of Education, Beijing, China
- *Correspondence: Fang Zhou
| | - Zhishan Zhang
- Department of Orthopedics, Peking University Third Hospital, Beijing, China
- Engineering Research Center of Bone and Joint Precision Medicine, Ministry of Education, Beijing, China
| | - Yun Tian
- Department of Orthopedics, Peking University Third Hospital, Beijing, China
- Engineering Research Center of Bone and Joint Precision Medicine, Ministry of Education, Beijing, China
| | - Hongquan Ji
- Department of Orthopedics, Peking University Third Hospital, Beijing, China
- Engineering Research Center of Bone and Joint Precision Medicine, Ministry of Education, Beijing, China
| | - Yan Guo
- Department of Orthopedics, Peking University Third Hospital, Beijing, China
- Engineering Research Center of Bone and Joint Precision Medicine, Ministry of Education, Beijing, China
| | - Zhongwei Yang
- Department of Orthopedics, Peking University Third Hospital, Beijing, China
- Engineering Research Center of Bone and Joint Precision Medicine, Ministry of Education, Beijing, China
| | - Guojin Hou
- Department of Orthopedics, Peking University Third Hospital, Beijing, China
- Engineering Research Center of Bone and Joint Precision Medicine, Ministry of Education, Beijing, China
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Update on current enhanced recovery after surgery (ERAS) pathways for hip and knee arthroplasty. CURRENT ORTHOPAEDIC PRACTICE 2022. [DOI: 10.1097/bco.0000000000001095] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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10
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Morrell AT, Layon DR, Scott MJ, Kates SL, Golladay GJ, Patel NK. Enhanced Recovery After Primary Total Hip and Knee Arthroplasty: A Systematic Review. J Bone Joint Surg Am 2021; 103:1938-1947. [PMID: 34166275 DOI: 10.2106/jbjs.20.02169] [Citation(s) in RCA: 65] [Impact Index Per Article: 21.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND Enhanced Recovery After Surgery (ERAS) has become increasingly implemented to reduce costs, to increase efficiency, and to optimize patient outcomes after a surgical procedure. This study aimed to systematically review the effect of ERAS after primary elective total hip arthroplasty (THA) or total knee arthroplasty (TKA) on hospital length of stay, total procedure-related morbidity, and readmission. METHODS A systematic review was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines and with guidance from the Cochrane Handbook for Systematic Reviews of Interventions. MEDLINE, Embase, and Cochrane databases were searched from inception (1946 for MEDLINE and 1974 for Embase; Cochrane is a composite of multiple databases and thus does not report a standard inception date) until January 15, 2020. Prospective nonrandomized cohort studies and randomized controlled trials comparing adult patients undergoing elective primary THA or TKA with ERAS or traditional protocols were included. Articles examining outpatient, nonelective, or revision surgical procedures were excluded. Two reviewers independently assessed the risk of bias and extracted data. The primary outcome was length of stay. The secondary outcomes included total procedure-related morbidity and readmission. RESULTS Of the 1,018 references identified (1,017 identified through an electronic search and 1 identified through a manual search), 9 individual studies met inclusion criteria. Data were reported from 7,789 participants, with 2,428 receiving ERAS and 5,361 receiving traditional care. Narrative synthesis was performed instead of meta-analysis, given the presence of moderate to high risk of bias, wide variation of ERAS interventions, and inconsistent methods for assessing and reporting outcomes among included studies. Adherence to ERAS protocols consistently reduced hospital length of stay. Few studies demonstrated reduced total procedure-related morbidity, and there was no significant effect on readmission rates. CONCLUSIONS ERAS likely reduced the length of stay after primary elective THA and TKA, with a more pronounced effect in selected healthier patient populations. We found minimal to no impact on perioperative morbidity or readmission. The quality of existing evidence was limited because of study heterogeneity and a significant risk of bias. Further high-quality research is needed to definitively assess the impact of ERAS on total joint arthroplasty. LEVEL OF EVIDENCE Therapeutic Level II. See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Aidan T Morrell
- School of Medicine, Virginia Commonwealth University, Richmond, Virginia
| | - Daniel R Layon
- Department of Orthopaedic Surgery, Virginia Commonwealth University, Richmond, Virginia
| | - Michael J Scott
- Department of Anesthesiology and Critical Care, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Stephen L Kates
- Department of Orthopaedic Surgery, Virginia Commonwealth University, Richmond, Virginia
| | - Gregory J Golladay
- Department of Orthopaedic Surgery, Virginia Commonwealth University, Richmond, Virginia
| | - Nirav K Patel
- Department of Orthopaedic Surgery, Virginia Commonwealth University, Richmond, Virginia
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Duojun W, Hui Z, Zaijun L, Yuxiang G, Haihong C. Enhanced recovery after surgery pathway reduces the length of hospital stay without additional complications in lumbar disc herniation treated by percutaneous endoscopic transforaminal discectomy. J Orthop Surg Res 2021; 16:461. [PMID: 34273984 PMCID: PMC8285793 DOI: 10.1186/s13018-021-02606-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/05/2021] [Accepted: 07/08/2021] [Indexed: 12/20/2022] Open
Abstract
Background Enhanced recovery after surgery (ERAS) pathway in spine surgery is increasingly popular which can reduce the length of hospital stay (LOS). However, there are few studies on the safety and effectiveness of ERAS pathway in the treatment of single-level lumbar disc herniation (LDH) by percutaneous endoscopic transforaminal discectomy (PETD). The aim of this study was to investigate whether ERAS can reduce LOS of patients with single segment LDH treated by PETD. Methods We reviewed the outcomes of all LDH patients (L4/5) who had been treated with PETD at our institution. Quasi-experimental study was adopted between patients treated in an ERAS after PETD with those rehabilitated on a traditional pathway. The two groups were analyzed for LOS, operation time, complications, visual analog scale (VAS), Oswestry Dysfunction Index (ODI), hospitalization expenses (HE), and improved MacNab efficacy assessment criteria (MacNab). Results A total of 120 single segment LDH patients (ERAS pathway 60 cases, traditional care pathway 60 cases) who were selected from January 2019 to January 2021 met the inclusion criteria. There was a significant difference in mean LOS postoperative VAS scores and ODI on the 3rd day after surgery between the two groups (P < 0.05). The incidence of complications and HE were similar in the two groups (P > 0.05). The mean LOS decreased from 3.47 ± 1.14 days to 5.65 ± 1.39 days after application of ERAS pathway (P < 0.05). Conclusions The ERAS pathway reduced LOS without resulting in additional complications after PETD. These findings support the application of the perioperative ERAS pathway in the treatment of single-level LDH with PETD. Level of evidence Level IV, therapeutic
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Affiliation(s)
- Wang Duojun
- Department of Spine Surgery, Shidong Hospital, Yangpu District, Shidong Hospital Affiliated to University of Shanghai for Science and Technology, 999 Shiguang Road, Shanghai, 200438, People's Republic of China
| | - Zhang Hui
- Department of Spine Surgery, Shidong Hospital, Yangpu District, Shidong Hospital Affiliated to University of Shanghai for Science and Technology, 999 Shiguang Road, Shanghai, 200438, People's Republic of China
| | - Lin Zaijun
- Department of Spine Surgery, Shidong Hospital, Yangpu District, Shidong Hospital Affiliated to University of Shanghai for Science and Technology, 999 Shiguang Road, Shanghai, 200438, People's Republic of China
| | - Ge Yuxiang
- Department of Orthopaedic Surgery, Minhang Hospital, Fudan University, 170 Xin Song Road, Shanghai, People's Republic of China.
| | - Chen Haihong
- Department of Orthopaedic Surgery, Minhang Hospital, Fudan University, 170 Xin Song Road, Shanghai, People's Republic of China.
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12
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Morrell AT, Kates SL, Lahaye LA, Layon DR, Patel NK, Scott MJ, Golladay GJ. Enhanced Recovery After Surgery: An Orthopedic Perspective. Arthroplast Today 2021; 9:98-100. [PMID: 34136612 PMCID: PMC8181632 DOI: 10.1016/j.artd.2021.04.019] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Key Words] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/15/2021] [Revised: 04/21/2021] [Accepted: 04/25/2021] [Indexed: 12/14/2022] Open
Affiliation(s)
- Aidan T Morrell
- School of Medicine, Virginia Commonwealth University, Richmond, VA, USA
| | - Stephen L Kates
- Department of Orthopaedic Surgery, Virginia Commonwealth University, Richmond, VA, USA
| | - Laura A Lahaye
- Department of Anesthesiology, Virginia Commonwealth University, Richmond, VA, USA
| | - Daniel R Layon
- Department of Orthopaedic Surgery, Virginia Commonwealth University, Richmond, VA, USA
| | - Nirav K Patel
- Department of Orthopaedic Surgery, Virginia Commonwealth University, Richmond, VA, USA
| | - Michael J Scott
- Department of Anesthesiology and Critical Care, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Gregory J Golladay
- Department of Orthopaedic Surgery, Virginia Commonwealth University, Richmond, VA, USA
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13
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Anger M, Valovska T, Beloeil H, Lirk P, Joshi GP, Van de Velde M, Raeder J. PROSPECT guideline for total hip arthroplasty: a systematic review and procedure-specific postoperative pain management recommendations. Anaesthesia 2021; 76:1082-1097. [PMID: 34015859 DOI: 10.1111/anae.15498] [Citation(s) in RCA: 100] [Impact Index Per Article: 33.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/03/2021] [Indexed: 12/11/2022]
Abstract
The aim of this systematic review was to develop recommendations for the management of postoperative pain after primary elective total hip arthroplasty, updating the previous procedure-specific postoperative pain management (PROSPECT) guidelines published in 2005 and updated in July 2010. Randomised controlled trials and meta-analyses published between July 2010 and December 2019 assessing postoperative pain using analgesic, anaesthetic, surgical or other interventions were identified from MEDLINE, Embase and Cochrane databases. Five hundred and twenty studies were initially identified, of which 108 randomised trials and 21 meta-analyses met the inclusion criteria. Peri-operative interventions that improved postoperative pain include: paracetamol; cyclo-oxygenase-2-selective inhibitors; non-steroidal anti-inflammatory drugs; and intravenous dexamethasone. In addition, peripheral nerve blocks (femoral nerve block; lumbar plexus block; fascia iliaca block), single-shot local infiltration analgesia, intrathecal morphine and epidural analgesia also improved pain. Limited or inconsistent evidence was found for all other approaches evaluated. Surgical and anaesthetic techniques appear to have a minor impact on postoperative pain, and thus their choice should be based on criteria other than pain. In summary, the analgesic regimen for total hip arthroplasty should include pre-operative or intra-operative paracetamol and cyclo-oxygenase-2-selective inhibitors or non-steroidal anti-inflammatory drugs, continued postoperatively with opioids used as rescue analgesics. In addition, intra-operative intravenous dexamethasone 8-10 mg is recommended. Regional analgesic techniques such as fascia iliaca block or local infiltration analgesia are recommended, especially if there are contra-indications to basic analgesics and/or in patients with high expected postoperative pain. Epidural analgesia, femoral nerve block, lumbar plexus block and gabapentinoid administration are not recommended as the adverse effects outweigh the benefits. Although intrathecal morphine 0.1 mg can be used, the PROSPECT group emphasises the risks and side-effects associated with its use and provides evidence that adequate analgesia may be achieved with basic analgesics and regional techniques without intrathecal morphine.
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Affiliation(s)
- M Anger
- Service d'Anesthésie Réanimation et Médecine Péri-opératoire, CHU Rennes, Université Rennes, Rennes, France
| | - T Valovska
- Service d'Anesthésie Réanimation et Médecine Péri-opératoire, CHU Rennes, Université Rennes, Rennes, France
| | - H Beloeil
- Department of Anesthesiology, Henry Ford Health Systems, Wayne State School of Medicine, Detroit, MI, USA
| | - P Lirk
- Department of Anesthesiology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - G P Joshi
- Department of Anesthesiology and Pain Management, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - M Van de Velde
- Department of Cardiovascular Sciences, Katholieke Universiteit Leuven, Leuven, Belgium.,Department of Anaesthesiology, UZLeuven, Leuven, Belgium
| | - J Raeder
- Department of Anaesthesiology, Oslo University Hospital, Oslo, Norway.,Division of Clinical Medicine, Medical Faculty, University of Oslo, Oslo, Norway
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14
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Kelleher DC, Lippell R, Lui B, Ma X, Tedore T, Weinberg R, White RS. Hospital safety-net burden is associated with increased inpatient mortality after elective total knee arthroplasty: a retrospective multistate review, 2007-2018. Reg Anesth Pain Med 2021; 46:663-670. [PMID: 33990442 DOI: 10.1136/rapm-2020-101731] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2020] [Revised: 04/22/2021] [Accepted: 04/25/2021] [Indexed: 11/03/2022]
Abstract
BACKGROUND Total knee arthroplasty (TKA) is among the most common surgical procedures performed in the USA and comprises an outsized proportion of Medicare expenditures. Previous work-associated higher safety-net burden hospitals with increased morbidity and in-hospital mortality following total hip arthroplasty. Here, we examine the association of safety-net burden on postoperative outcomes after TKA. METHODS We retrospectively analyzed 1 141 587 patients aged ≥18 years undergoing isolated elective TKA using data from the State Inpatient Databases for Florida, Kentucky, Maryland, New York and Washington from 2007 through 2018. Hospitals were grouped into tertiles by safety-net burden status, defined by the proportion of inpatient cases billed to Medicaid or unpaid (low: 0%-16.83%, medium: 16.84%-30.45%, high: ≥30.45%). Using generalized estimating equation models, we assessed the association of hospital safety-net burden status on in-hospital mortality, patient complications and length of stay (LOS). We also analyzed outcomes by anesthesia type in New York State (NYS), the only state with this data. RESULTS Most TKA procedures were performed at medium safety-net burden hospitals (n=6 16 915, 54%), while high-burden hospitals performed the fewest (n=2 04 784, 17.9%). Overall in-patient mortality was low (0.056%), however, patients undergoing TKA at medium-burden hospitals were 40% more likely to die when compared with patients at low-burden hospitals (low: 0.043% vs medium: 0.061%, adjusted OR (aOR): 1.40, 95% CI 1.09 to 1.79, p=0.008). Patients who underwent TKA at medium or high safety-net burden hospitals were more likely to experience intraoperative complications (low: 0.2% vs medium: 0.3%, aOR: 1.94, 95% CI 1.34 to 2.83, p<0.001; low: 0.2% vs high: 0.4%, aOR: 1.91, 95% CI 1.35 to 2.72, p<0.001). There were no statistically significant differences in other postoperative complications or LOS between the different safety-net levels. In NYS, TKA performed at high safety-net burden hospitals was more likely to use general rather than regional anesthesia (low: 26.7% vs high: 59.5%, aOR: 4.04, 95% CI 1.05 to 15.5, p=0.042). CONCLUSIONS Patients undergoing TKA at higher safety-net burden hospitals are associated with higher odds of in-patient mortality than those at low safety-net burden hospitals. The source of this mortality differential is unknown but could be related to the increased risk of intraoperative complications at higher burden centers.
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Affiliation(s)
| | - Ryan Lippell
- Department of Anesthesiology, Weill Cornell Medicine, New York, New York, USA
| | - Briana Lui
- Department of Anesthesiology, Weill Cornell Medicine, New York, New York, USA
| | - Xiaoyue Ma
- Population Health Sciences, Weill Cornell Medicine, New York, New York, USA
| | - Tiffany Tedore
- Department of Anesthesiology, Weill Cornell Medicine, New York, New York, USA
| | - Roniel Weinberg
- Department of Anesthesiology, Weill Cornell Medicine, New York, New York, USA
| | - Robert S White
- Department of Anesthesiology, Weill Cornell Medicine, New York, New York, USA
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15
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Early postoperative recovery after peri-acetabular osteotomy: A double-blind, randomised single-centre trial of 48 vs. 8 mg dexamethasone. Eur J Anaesthesiol 2021; 38:S41-S49. [PMID: 33399374 DOI: 10.1097/eja.0000000000001410] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Peri-acetabular osteotomy is the joint-preserving treatment of choice in young adults with hip dysplasia but is associated with intense pain and high opioid consumption postoperatively. OBJECTIVES To investigate whether 48 mg of pre-operative dexamethasone was superior to a standard dose of 8 mg on reducing pain in the immediate postoperative phase. DESIGN A randomised, double-blind trial. SETTING Single-centre, primary facility. May 2017 to August 2019. PATIENTS At least 18 years undergoing peri-acetabular osteotomy. INTERVENTIONS Patients were randomised 1 : 1 to 48 or 8 mg dexamethasone intravenous (i.v.) as a single pre-operative injection. All patients received a standardised peri-operative protocol, including pre-operative acetaminophen and gabapentin, total i.v. anaesthesia and local anaesthetic catheter based wound administration. MAIN OUTCOME MEASURE Number of patients with moderate/severe pain [>3 on a numeric rating scale (NRS)] in the immediate postoperative phase. RESULTS Sixty-four patients (32 in each group) were included, and their data analysed. At some point from tracheal extubation until transfer to the ward, the NRS was more than 3 in 75% (24/32) of the 48 mg group and in 66% (21/32) in the 8 mg group, odds ratio 1.571 (95% CI, 0.552 to 4.64), P = 0.585. Patients in the 48 mg group received less opioid [cumulative rescue analgesics, oral morphine equivalents (OMEQ)] during postoperative days 0-4: median [IQR] OMEQ was 36 [15 to 85] mg vs. 79 [36 to 154] mg in the 48 and 8 mg group, respectively, P = 0.034. There were no statistically significant differences regarding complications, rate of infections or readmissions. CONCLUSION Forty-eight milligram of dexamethasone did not reduce pain in the immediate postoperative phase compared with an 8 mg dose. We observed insignificantly lower pain scores and significantly lower cumulated opioid requirements in the 48 mg group during the first four postoperative days. TRIAL REGISTRATION Clinicaltrials.gov, NCT03161938, EudraCT (2017-000544-1).
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16
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Aletto C, Aicale R, Pezzuti G, Bruno F, Maffulli N. Impact of an orthogeriatrician on length of stay of elderly patient with hip fracture. Osteoporos Int 2020; 31:2161-2166. [PMID: 32572520 DOI: 10.1007/s00198-020-05510-0] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/14/2020] [Accepted: 06/16/2020] [Indexed: 12/16/2022]
Abstract
UNLABELLED Hip fracture patients are complex, and orthopaedic management is limited to the surgery phase. To provide better evaluation pre-operatively and an optimal level of post-operative care, an orthogeriatrician was introduced in the orthopaedic team. This ensured that time to surgery from admission consistently was below 48 h, decreasing hospitalization time after surgery and total length of stay. INTRODUCTION Hip fractures are a major health issue in elderly and frail patient. The integration of orthogeriatric care within the orthopaedic team could be useful to optimize the clinical conditions of these patients in perioperative phases and stabilize them after surgery, reducing hospital length of stay. The present study evaluates the role of an orthogeriatrician in the management of patients with a hip fracture. MATERIALS AND METHODS Data about patients admitted and operated from February to September 2018 and from February to September 2019 were collected from the San Giovanni di Dio e Ruggi d'Aragona Hospital of Salerno database. A total of 352 patients were identified and divided in two groups according to the year in which the orthogeriatrician was working in Orthopaedic Department. Records regarding age, sex, side and type of fracture, time of admission, day of surgery and discharge were collected and length of stay, days from the admission to surgery and days from surgery to discharge were calculated. RESULTS There were no statistically significant differences in the pre-surgery phases of both groups, and all patients were operated at a mean of 2.1 days ± 1.8 SD from admission (p > 0.05). No statistically significant difference between demographic data in both groups (p > 0.01) was observed. There was, however, statistically significant reduction of hospitalization time after surgery and total LOS from 2018 to 2019 (p < 0.01). CONCLUSION An Orthogeriatric doctor in an Orthopaedic and Traumatology Department may lead a multidisciplinary approach to manage elderly patients with hip fractures, ensuring that the time to surgery from admission is less than 48 h, and reducing hospitalization time after surgery and total length of stay.
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Affiliation(s)
- C Aletto
- Department of Musculoskeletal Disorders, Faculty of Medicine and Surgery, University of Salerno, 84084, Baronissi, Italy
- Clinica Ortopedica, Ospedale San Giovanni di Dio e Ruggi D'Aragona, 84131, Salerno, Italy
| | - R Aicale
- Department of Musculoskeletal Disorders, Faculty of Medicine and Surgery, University of Salerno, 84084, Baronissi, Italy
- Clinica Ortopedica, Ospedale San Giovanni di Dio e Ruggi D'Aragona, 84131, Salerno, Italy
| | - G Pezzuti
- Clinica Ortopedica, Ospedale San Giovanni di Dio e Ruggi D'Aragona, 84131, Salerno, Italy
| | - F Bruno
- Clinica Ortopedica, Ospedale San Giovanni di Dio e Ruggi D'Aragona, 84131, Salerno, Italy
| | - N Maffulli
- Department of Musculoskeletal Disorders, Faculty of Medicine and Surgery, University of Salerno, 84084, Baronissi, Italy.
- Clinica Ortopedica, Ospedale San Giovanni di Dio e Ruggi D'Aragona, 84131, Salerno, Italy.
- Queen Mary University of London, Barts and the London School of Medicine and Dentistry, Centre for Sports and Exercise Medicine, Mile End Hospital, 275 Bancroft Road, London, E1 4DG, England.
- Faculty of Medicine, School of Pharmacy and Bioengineering, Guy Hilton Research Centre, Keele University, Thornburrow Drive, Hartshill, Stoke-on-Trent, ST4 7QB, England.
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17
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Wu CL, Jules-Elysee KM, Kirksey MA, Liguori GA. Perioperative Nonsteroidal Anti-Inflammatory Agents in the COVID-19 Orthopedic Patient. HSS J 2020; 16:97-101. [PMID: 32952464 PMCID: PMC7489195 DOI: 10.1007/s11420-020-09783-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/27/2020] [Accepted: 07/23/2020] [Indexed: 02/07/2023]
Abstract
BACKGROUND SARS-CoV-2 infection can cause serious complications beyond lung injury and respiratory failure, including sepsis, cardiovascular injury, renal failure, coagulation abnormalities, and neurologic injury. Widely used medications such as nonsteroidal anti-inflammatory drugs (NSAIDs) have been flagged as having the potential to cause harm in the context of COVID-19. It is unknown if the benefits of NSAID use in the orthopedic population will outweigh the potential risks of increased morbidity in COVID-19 orthopedic patients. METHODS We conducted a narrative review of the use of NSAIDs in the orthopedic patient with COVID-19, focusing on the effects of NSAIDs on the inflammatory process, the role of NSAIDs in orthopedics, and the associations between NSAID use and complications of pneumonia. RESULTS We found that it may be appropriate to consider NSAID use in otherwise healthy orthopedic patients with COVID-19 and significant pain. CONCLUSIONS In this context, we recommend that NSAIDs be used at the lowest effective dose for the shortest duration possible in orthopedic patients with COVID-19. However, pending further data and based on the concerns outlined in this review, we recommend avoiding NSAIDs in orthopedic patients with significant comorbidities and those who are undergoing major orthopedic surgery.
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Affiliation(s)
- Christopher L. Wu
- Department of Anesthesiology Critical Care & Pain Management, Hospital for Special Surgery, 535 East 70th St, New York, NY 10021 USA
- Department of Anesthesiology, Weill Cornell Medicine, New York, NY USA
| | - Kethy M. Jules-Elysee
- Department of Anesthesiology Critical Care & Pain Management, Hospital for Special Surgery, 535 East 70th St, New York, NY 10021 USA
- Department of Anesthesiology, Weill Cornell Medicine, New York, NY USA
| | - Meghan A. Kirksey
- Department of Anesthesiology Critical Care & Pain Management, Hospital for Special Surgery, 535 East 70th St, New York, NY 10021 USA
- Department of Anesthesiology, Weill Cornell Medicine, New York, NY USA
| | - Gregory A. Liguori
- Department of Anesthesiology Critical Care & Pain Management, Hospital for Special Surgery, 535 East 70th St, New York, NY 10021 USA
- Department of Anesthesiology, Weill Cornell Medicine, New York, NY USA
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18
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Fischer MO, Lemoine S, Tavernier B, Bouchakour CE, Colas V, Houard M, Greub W, Daccache G, Hulet C, Compère V, Taing D, Lorne E, Parienti JJ, Hanouz JL. Individualized Fluid Management Using the Pleth Variability Index: A Randomized Clinical Trial. Anesthesiology 2020; 133:31-40. [PMID: 32205547 DOI: 10.1097/aln.0000000000003260] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
BACKGROUND The present trial was designed to assess whether individualized strategies of fluid administration using a noninvasive plethysmographic variability index could reduce the postoperative hospital length of stay and morbidity after intermediate-risk surgery. METHODS This was a multicenter, randomized, nonblinded parallel-group clinical trial conducted in five hospitals. Adult patients in sinus rhythm having elective orthopedic surgery (knee or hip arthroplasty) under general anesthesia were enrolled. Individualized hemodynamic management aimed to achieve a plethysmographic variability index under 13%, and the standard management strategy aimed to maintain a mean arterial pressure above 65 mmHg during general anesthesia. The primary outcome was the postoperative hospital length of stay decided by surgeons blinded to the group allocation of the patient. RESULTS In total, 447 patients were randomized, and 438 were included in the analysis. The mean hospital length of stay ± SD was 6 ± 3 days for the plethysmographic variability index group and 6 ± 3 days for the control group (adjusted difference, 0.0 days; 95% CI, -0.6 to 0.5; P = 0.860); the theoretical postoperative hospital length of stay was 4 ± 2 days for the plethysmographic variability index group and 4 ± 1 days for the control group (P = 0.238). In the plethysmographic variability index and control groups, serious postoperative cardiac complications occurred in 3 of 217 (1%) and 2 of 224 (1%) patients (P = 0.681), acute postoperative renal failure occurred in 9 (4%) and 8 (4%) patients (P = 0.808), the troponin Ic concentration was more than 0.06 μg/l within 5 days postoperatively for 6 (3%) and 5 (2%) patients (P = 0.768), and the postoperative arterial lactate measurements were 1.44 ± 1.01 and 1.43 ± 0.95 mmol/l (P = 0.974), respectively. CONCLUSIONS Among intermediate-risk patients having orthopedic surgery with general anesthesia, fluid administration guided by the plethysmographic variability index did not shorten the duration of hospitalization or reduce complications.
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Affiliation(s)
- Marc-Olivier Fischer
- From the Anesthesiology and Critical Care Medicine Department (M.-O.F., S.L., W.G., G.D., J.-L.H.) the INSERM COMETE 1075 Unit, Orthopedic Department, (C.H.) the Biostatistics Department (J.-J.P.), Normandy University, Caen University Hospital, Caen, France Anesthesiology and Critical Care Medicine Department, Lille University Hospital, Lille, France (B.T., M.H.) Anesthesiology and Intensive Care Medicine Department, Hospital of Catholic Institute of Lille, Saint Philibert Hospital, Lomme, France (C.-E.B., V.C.) Anesthesiology and Critical Care Medicine Department, Rouen University Hospital, Charles Nicolle Hospital, Rouen, France (V.C.) Anesthesiology and Critical Care Department, Amiens University Hospital, Amiens, France (D.T., E.L.) Research Unit on Simplified Care of Complex Surgical Patients, Jules Verne University of Picardy, Amiens, France (E.L.). Caen University Hospital, Caen, France Caen University Hospital, Caen, France Amiens Picardie University Hospital, Amiens, France Amiens Picardie University Hospital, Amiens, France Lille University Hospital, Lille, France Lille University Hospital, Lille, France Hospital of Catholic Institute of Lille, Lomme, France Clinical Research Department, Caen University Hospital Clinical Research Department, Caen University Hospital Clinical Research Department, Caen University Hospital Clinical Research Department, Hospital of Catholic Institute of Lille Clinical Research Department, Lille University Hospital Clinical Research Department, Lille University Hospital Clinical Research Department, Amiens Picardie University Hospital
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Bekeris J, Fiasconaro M, Della Valle AG, Liu J, Shanaghan KA, Poeran J, Wilson LA, Memtsoudis SG. Modifiable Analgesia-/Anesthesia-Related Factors and Risk of Severe Gastrointestinal Complications After Lower Extremity Total Joint Arthroplasty: A Nationwide Analysis. J Arthroplasty 2020; 35:2624-2630.e2. [PMID: 32376164 DOI: 10.1016/j.arth.2020.04.008] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/07/2019] [Revised: 02/19/2020] [Accepted: 04/05/2020] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND Severe gastrointestinal (GI) complications after elective hip and knee arthroplasty (THA/TKA) are rare. Some of them can be life-threatening and/or require emergency abdominal surgery. We studied the epidemiology of severe GI complications after THA/TKA and associations with anesthesia- and/or analgesia-related factors. METHODS We included 591,865 THA and 1,139,616 TKA cases (Premier Healthcare claims database; 2006-2016). Main outcomes were GI complications and related emergency surgeries within 30 days after THA/TKA. Anesthesia- and analgesia-related factors were anesthesia type (neuraxial, general), use of peripheral nerve block, patient-controlled analgesia, nonopioid analgesics (acetaminophen, gabapentin/pregabalin, nonsteroidal anti-inflammatory drugs, cyclooxygenase-2 inhibitors, ketamine), and opioids (in oral morphine equivalents, categorized into low, medium, and high use based on the interquartile range). Mixed-effects models measured associations between anesthesia- and analgesia-related factors and outcomes, which were reported using odds ratios (ORs) and 95% confidence intervals (CIs). RESULTS Among THA patients, GI complications were observed in 1.03% (n = 6103), with 0.08% (n = 450) requiring emergency surgery; this was 0.79% (n = 8971) and 0.05% (n = 540), respectively, for TKA patients. After adjustment for relevant covariates (including opioid use), almost all anesthesia-/analgesia-related factors were associated with significantly decreased odds of GI complications, specifically use of cyclooxygenase-2 inhibitors (OR 0.72 CI 0.67-0.76/OR 0.82 CI 0.78-0.86), nonsteroidal anti-inflammatory drugs (OR 0.81 CI 0.77-0.85/OR 0.90 CI 0.86-0.94), and peripheral nerve blocks (OR 0.77 CI 0.69-0.87/OR 0.91 CI 0.85-0.97); all for THA and TKA, respectively (all P < .01). CONCLUSION Rare, but devastating, acute GI complications (requiring surgery) after THA/TKA may be positively impacted by a variety of modifiable anesthesia-/analgesia-related interventions.
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Affiliation(s)
- Janis Bekeris
- Department of Anesthesiology, Critical Care and Pain Management, Hospital for Special Surgery, New York City, NY; Department of Anesthesiology, Perioperative Medicine and Intensive Care Medicine, Paracelsus Medizinische Privatuniversitat, Salzburg, Austria
| | - Megan Fiasconaro
- Department of Anesthesiology, Critical Care and Pain Management, Hospital for Special Surgery, New York City, NY
| | | | - Jiabin Liu
- Department of Anesthesiology, Critical Care and Pain Management, Hospital for Special Surgery, New York City, NY; Department of Anesthesiology, Weill Cornell Medicine, New York, NY
| | - Kate Anne Shanaghan
- Department of Orthopedic Surgery, Hospital for Special Surgery, New York City, NY
| | - Jashvant Poeran
- Department of Population Health Science and Policy, Institute for Healthcare Delivery Science, Icahn School of Medicine at Mount Sinai, New York City, NY; Department of Orthopedics, Icahn School of Medicine at Mount Sinai, New York City, NY
| | - Lauren A Wilson
- Department of Anesthesiology, Critical Care and Pain Management, Hospital for Special Surgery, New York City, NY
| | - Stavros G Memtsoudis
- Department of Anesthesiology, Critical Care and Pain Management, Hospital for Special Surgery, New York City, NY; Department of Anesthesiology, Perioperative Medicine and Intensive Care Medicine, Paracelsus Medizinische Privatuniversitat, Salzburg, Austria; Department of Orthopedic Surgery, Hospital for Special Surgery, New York City, NY; Department of Health Policy and Research, Weill Cornell Medical College, New York, NY
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20
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Kehlet H. LIA in arthroplasty - the history of a single-center observational study leading to implementation in general clinical practice. Acta Orthop 2020; 91:224-225. [PMID: 32406292 PMCID: PMC8023944 DOI: 10.1080/17453674.2020.1763563] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023] Open
Affiliation(s)
- Henrik Kehlet
- Rigshospitalet, Section of Surgical Pathophysiology, Copenhagen, Denmark,E-mail:
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21
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Kehlet H, Memtsoudis SG. ERAS guidelines for hip and knee replacement - need for reanalysis of evidence and recommendations? Acta Orthop 2020; 91:243-245. [PMID: 32077358 PMCID: PMC8023927 DOI: 10.1080/17453674.2020.1728920] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023] Open
Affiliation(s)
- Henrik Kehlet
- Rigshospitalet, Section of Surgical Pathophysiology, Copenhagen, Denmark; ,E-mail:
| | - Stavros G Memtsoudis
- Department of Anesthesiology, Critical Care, and Pain Management, Hospital for Special Surgery, New York, USADepartment of Healthcare Policy and Research, Weill Cornell Medical College, New York, USADepartment of Anesthesiology, Perioperative Medicine and Intensive Care Medicine, Paracelsus Medical University, Salzburg, Austria
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22
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Memtsoudis SG, Fiasconaro M, Soffin EM, Liu J, Wilson LA, Poeran J, Bekeris J, Kehlet H. Enhanced recovery after surgery components and perioperative outcomes: a nationwide observational study. Br J Anaesth 2020; 124:638-647. [DOI: 10.1016/j.bja.2020.01.017] [Citation(s) in RCA: 41] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2019] [Revised: 01/10/2020] [Accepted: 01/15/2020] [Indexed: 11/16/2022] Open
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23
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Soffin EM, Wetmore DS, Barber LA, Vaishnav AS, Beckman JD, Albert TJ, Gang CH, Qureshi SA. An enhanced recovery after surgery pathway: association with rapid discharge and minimal complications after anterior cervical spine surgery. Neurosurg Focus 2020; 46:E9. [PMID: 30933926 DOI: 10.3171/2019.1.focus18643] [Citation(s) in RCA: 53] [Impact Index Per Article: 13.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2018] [Accepted: 01/23/2019] [Indexed: 12/29/2022]
Abstract
OBJECTIVEEnhanced recovery after surgery (ERAS) pathways are associated with improved outcomes, lower morbidity and complications, and higher patient satisfaction in multiple surgical subspecialties. Despite these gains, there are few data to guide the application of ERAS concepts to spine surgery. The authors report the development and implementation of the first ERAS pathway for patients undergoing anterior cervical discectomy and fusion (ACDF) and cervical disc arthroplasty (CDA).METHODSThis was a retrospective cohort study of prospectively collected data. The authors created a multidisciplinary pathway based on best available evidence for interventions that positively influence outcomes after anterior cervical spine surgery. Patients were followed prospectively up to postoperative day 90. Patient data were collected via electronic medical record review and included demographics, comorbidities, baseline and perioperative opioid use, postoperative complications, and length of hospital stay (LOS). ERAS process measures and compliance with pathway elements were also tracked.RESULTSThirty-three patients were cared for under the pathway (n = 25 ACDF; n = 8 CDA). The median LOS was 416 minutes (interquartile range [IQR] 210-1643 minutes). Eight patients required an extended stay-longer than 23 hours. Reasons for extended admission included pain (n = 4), dyspnea (n = 1), hypoxia (n = 1), hypertension (n = 1), and dysphagia (n = 1). The median LOS for the 8 patients who required extended monitoring prior to discharge was 1585 minutes (IQR 1423-1713 minutes). Overall pathway compliance with included process measures was 85.6%. The median number of ERAS process elements delivered to each patient was 18. There was no strong association between LOS and number of ERAS process elements provided (Pearson's r = -0.20). Twelve percent of the cohort was opioid tolerant on the day of surgery. There were no significant differences between total intraoperatively or postanesthesia care unit-administered opioid, or LOS, between opioid-tolerant and opioid-naïve patients. There were no complications requiring readmission.CONCLUSIONSAn ERAS pathway for anterior cervical spine surgery facilitates safe, prompt discharge. The ERAS pathway was associated with minimal complications, and no readmissions within 90 days of surgery. Pain and respiratory compromise were both linked with extended LOS in this cohort. Further prospective studies are needed to confirm the potential benefits of ERAS for anterior cervical spine surgery, including longer-term complications, cost, and functional outcomes.
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Affiliation(s)
- Ellen M Soffin
- 1Department of Anesthesiology, Critical Care & Pain Management, Hospital for Special Surgery.,2Department of Anesthesiology, Weill Cornell Medicine
| | - Douglas S Wetmore
- 1Department of Anesthesiology, Critical Care & Pain Management, Hospital for Special Surgery.,2Department of Anesthesiology, Weill Cornell Medicine
| | - Lauren A Barber
- 3Department of Orthopaedic Surgery, Hospital for Special Surgery; and
| | - Avani S Vaishnav
- 3Department of Orthopaedic Surgery, Hospital for Special Surgery; and
| | - James D Beckman
- 1Department of Anesthesiology, Critical Care & Pain Management, Hospital for Special Surgery.,2Department of Anesthesiology, Weill Cornell Medicine
| | - Todd J Albert
- 3Department of Orthopaedic Surgery, Hospital for Special Surgery; and.,4Department of Orthopaedic Surgery, Weill Cornell Medicine, New York, New York
| | - Catherine H Gang
- 3Department of Orthopaedic Surgery, Hospital for Special Surgery; and
| | - Sheeraz A Qureshi
- 3Department of Orthopaedic Surgery, Hospital for Special Surgery; and.,4Department of Orthopaedic Surgery, Weill Cornell Medicine, New York, New York
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PENG block and LIA as a possible anesthesia technique for total hip arthroplasty. J Anesth 2020; 34:472-475. [DOI: 10.1007/s00540-020-02768-w] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2019] [Accepted: 03/21/2020] [Indexed: 10/24/2022]
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Huang M, Brusko GD, Borowsky PA, Kolcun JPG, Heger JA, Epstein RH, Grossman J, Wang MY. The University of Miami spine surgery ERAS protocol: a review of our journey. JOURNAL OF SPINE SURGERY 2020; 6:S29-S34. [PMID: 32195411 DOI: 10.21037/jss.2019.11.10] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Affiliation(s)
- Meng Huang
- Department of Neurosurgery, University of Miami Miller School of Medicine, Miami, FL, USA
| | - G Damian Brusko
- Department of Neurosurgery, University of Miami Miller School of Medicine, Miami, FL, USA
| | - Peter A Borowsky
- Department of Neurosurgery, University of Miami Miller School of Medicine, Miami, FL, USA
| | - John Paul G Kolcun
- Department of Neurosurgery, University of Miami Miller School of Medicine, Miami, FL, USA
| | - Julie A Heger
- Department of Neurosurgery, University of Miami Miller School of Medicine, Miami, FL, USA
| | - Richard H Epstein
- Department of Anesthesiology, University of Miami Miller School of Medicine, Miami, FL, USA
| | - Jay Grossman
- Department of Anesthesiology, University of Miami Miller School of Medicine, Miami, FL, USA
| | - Michael Y Wang
- Department of Neurosurgery, University of Miami Miller School of Medicine, Miami, FL, USA
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Licina A, Silvers A, Laughlin H, Russell J, Wan C. Proposed pathway for patients undergoing enhanced recovery after spinal surgery: protocol for a systematic review. Syst Rev 2020; 9:39. [PMID: 32085813 PMCID: PMC7035675 DOI: 10.1186/s13643-020-1283-2] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/02/2020] [Accepted: 01/22/2020] [Indexed: 12/11/2022] Open
Abstract
BACKGROUND The best evidence-enhanced recovery care pathway is yet to be defined for patients undergoing spinal surgery. Minimally invasive surgery, multimodal analgesia, early mobilization, and early postoperative nutrition have been considered as critical components of enhanced recovery in spinal surgery (ERSS). The objective of this study will be to synthesize the evidence underpinning individual components of a proposed multidisciplinary enhanced recovery pathway for patients undergoing spinal surgery. METHODS This is the study protocol for a systematic review of complex interventions. Our team identified 22 individual care components of a proposed pathway based on clinical practice guidelines and published reviews. We will include systematic reviews and meta-analysis, randomized controlled trials, non-randomized controlled trials, and observational studies in adults or pediatric patients evaluating any one of the pre-determined care components. Our primary outcomes will be all-cause mortality, morbidity outcomes (e.g., pulmonary, cardiac, renal, surgical complications), patient-reported outcomes and experiences (e.g., pain, quality of care experience), and health services outcomes (e.g., length of stay and costs). We will search the following databases (1990 onwards) MEDLINE, EMBASE, and Cochrane Library (Cochrane Database of Systematic Reviews and CENTRAL). Two reviewers will independently screen all citations, full-text articles, and abstract data. Potential conflicts will be resolved through discussion. The risk of bias for individual studies will be appraised using appropriate tools. A narrative synthesis will be provided with the information presented in the text and tables to summarize and explain the characteristics and findings of the included studies. Due to clinical and methodological heterogeneity, we do not anticipate to conduct meta-analyses. Confidence in cumulative evidence for each component of care will be classified according to the GRADE system. DISCUSSION This systematic review will identify, evaluate, and integrate the evidence underpinning individual components of a pathway for patients undergoing spinal surgery. The formation of an evidence-based pathway will allow for the standardization of clinical care delivery within the context of enhanced recovery in spinal surgery. SYSTEMATIC REVIEW REGISTRATION PROSPERO CRD42019135289.
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Affiliation(s)
- Ana Licina
- Austin Health, 145 Studley Road, Heidelberg, Victoria 3084 Australia
| | | | - Harry Laughlin
- Austin Health, 145 Studley Road, Heidelberg, Victoria 3084 Australia
| | - Jeremy Russell
- Austin Health, 145 Studley Road, Heidelberg, Victoria 3084 Australia
| | - Crispin Wan
- St Vincent’s Health, 41 Victoria Parade, Fitzroy, Victoria 3065 Australia
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Weyker PD, Webb CAJ. Establishing a patient centered, outpatient total joint home recovery program within an integrated healthcare system. Pain Manag 2019; 10:23-41. [PMID: 31852383 DOI: 10.2217/pmt-2019-0040] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Outpatient total joint home recovery (HR) is a rapidly growing initiative being developed and employed at high volume orthopedic centers. Minimally invasive surgery, improved pain control and home health services have made HR possible. Multidisciplinary teams with members ranging from surgeons and anesthesiologists to hospital administrators, physical therapists, nurses and research analysts are necessary for success. Eligibility criteria for outpatient total joint arthroplasty will vary between medical centers. Surgeon preference in addition to medical comorbidities, social support, preoperative patient mobility and safety of the HR location are all factors to consider when selecting patients for outpatient total joint HR. As additional knowledge is gained, the next steps will be to establish 'best practices' and speciality society-endorsed guidelines for patients undergoing outpatient total joint arthroplasty.
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Affiliation(s)
- Paul David Weyker
- Department of Anesthesia & Perioperative Medicine, The Permanente Medical Group of Northern California, South San Francisco, CA 94080, USA.,Department of Clinical Sciences, Kaiser Permanente School of Medicine, Pasadena, CA 91101, USA
| | - Christopher Allen-John Webb
- Department of Clinical Sciences, Kaiser Permanente School of Medicine, Pasadena, CA 91101, USA.,Department of Anesthesia & Perioperative Medicine, The Permanente Medical Group of Northern California, South San Francisco, CA 94080, USA.,Department of Anesthesia & Perioperative Care, University of California San Francisco, San Francisco, CA 94143, USA
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Soffin EM, Wick E, Kates S, Wu CL. In Response. Anesth Analg 2019; 128:e52-e53. [PMID: 30320648 DOI: 10.1213/ane.0000000000003868] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Affiliation(s)
- Ellen M Soffin
- Department of Anesthesiology, Critical Care and Pain Management, Hospital for Special Surgery, New York, New York, Armstrong Institute for Patient Safety and Quality, Johns Hopkins University, Baltimore, Maryland Department of Orthopeadic Surgery, Virginia Commonwealth University School of Medicine, Richmond, Virginia Department of Anesthesiology, Critical Care and Pain Management, Hospital for Special Surgery, New York, New York
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Kehlet H, Joshi GP. Anesthesia in Enhanced Recovery Pathways for Hip and Knee Arthroplasty: Where Is the Evidence? Anesth Analg 2019; 128:e52. [PMID: 30320647 DOI: 10.1213/ane.0000000000003867] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Affiliation(s)
- Henrik Kehlet
- Rigshospitalet, Section of Surgical Pathophysiology, Copenhagen, Denmark, Department of Anesthesia, University of Texas Southwestern Medical Center, Dallas, Texas
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Tan NL, Gotmaker R, Barrington MJ. Impact of Local Infiltration Analgesia on the Quality of Recovery After Anterior Total Hip Arthroplasty: A Randomized, Triple-Blind, Placebo-Controlled Trial. Anesth Analg 2019; 129:1715-1722. [PMID: 31743193 DOI: 10.1213/ane.0000000000004255] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND Local infiltration analgesia (LIA) is commonly used in anterior total hip arthroplasty (THA) surgery; however, evidence for its efficacy is lacking. We hypothesized that LIA with 0.2% ropivacaine when compared with injection of placebo (0.9% saline) would improve patient quality of recovery on postoperative day (POD) 1, as measured by the Quality of Recovery-15 (QoR-15) score. METHODS Patients scheduled to have a primary unilateral anterior THA with a single surgeon in a tertiary level metropolitan hospital were randomized to receive LIA with either 2.5 mL/kg of 0.2% ropivacaine or 0.9% saline as placebo. Patients and clinical and study personnel were blinded to group allocation. Perioperative care was standardized and this included spinal anesthesia and oral multimodal analgesia. The primary outcome was a multidimensional (pain, physical comfort, physical independence, emotions, and psychological support) patient-reported quality of recovery scale, QoR-15, measured on POD 1. RESULTS One hundred sixty patients were randomized; 6 patients were withdrawn after randomization and 2 patients had incomplete outcome data. The intention-to-treat analysis included 152 patients. The median (interquartile range [IQR]) QoR-15 score on POD 1 of the ropivacaine group was 119.5 (102-124), compared with the placebo group which had a median (IQR) of 115 (98-126). The median difference of 2 (95% confidence interval [CI], -4 to 7; P = .56) was not statistically or clinically significant. An as-per-protocol sensitivity analysis of 146 patients who received spinal anesthesia without general anesthesia, and the allocated intervention, also showed no evidence of a significant difference between groups. Secondary outcomes (worst pain numerical rating scale at rest and with movement on POD 1, opioid consumption on PODs 1 and 2, mobilization on POD 1, Brief Pain Inventory severity and interference on POD 90, and length of stay) were similar in both groups. CONCLUSIONS LIA with 0.2% ropivacaine when compared with 0.9% saline as placebo did not improve quality of recovery 1 day after anterior THA.
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Affiliation(s)
- Nicole L Tan
- From the Department of Anaesthesia, Critical Care Institute, Epworth HealthCare, Melbourne, Australia
- Department of Medicine and Radiology, Faculty of Medicine, Dentistry and Health Sciences, University of Melbourne, Australia
| | - Robert Gotmaker
- Department of Anaesthesia and Acute Pain Medicine, St Vincent's Hospital, Melbourne, Australia
| | - Michael J Barrington
- Department of Anaesthesia and Acute Pain Medicine, St Vincent's Hospital, Melbourne, Australia
- Department of Medicine and Radiology, Melbourne Medical School, Faculty of Medicine, Dentistry and Health Sciences, University of Melbourne, Australia
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Kang Y, Liu J, Chen H, Ding W, Chen J, Zhao B, Yin X. Enhanced recovery after surgery (ERAS) in elective intertrochanteric fracture patients result in reduced length of hospital stay (LOS) without compromising functional outcome. J Orthop Surg Res 2019; 14:209. [PMID: 31288824 PMCID: PMC6617739 DOI: 10.1186/s13018-019-1238-2] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/05/2018] [Accepted: 06/12/2019] [Indexed: 01/14/2023] Open
Abstract
Background Enhanced recovery after surgery (ERAS) has rapidly gained popularity among hip or knee arthroplasty area which can decrease hospital length of stay (LOS). However, limited data exist regarding its safety and efficacy among intertrochanteric fracture patients. The purpose of this study was to determine if LOS associated with intertrochanteric fracture patients can be improved following an existing orthopedic ERAS procedure. Methods We reviewed the outcomes of all patients who had been treated with the PFNA intramedullary fixation at our institution. Open fractures, metastatic pathological fractures, patients unable to walk independently before fracture and patients with Alzheimer's disease were excluded. A quasi-experimental study was adopted between patients treated in an ERAS after intramedullary fixation with those rehabilitated on a traditional pathway. Clinical and demographic data were collected among the two pathway cohorts including LOS, Harris hip scores (HHS), visual analog scale (VAS), and activity of daily living scale (ADL). Results A total of 100 intertrochanteric fracture patients (ERAS pathway 50 cases, traditional care pathway 50 cases) were selected between January 2016 and December 2017 met the inclusion criteria. ERAS procedure was associated with shorter LOS, lower postoperative VAS scores, reduced opioid consumption, earlier mobilization, significant improvement in the mean HHS scores at 3 months postoperatively, lower risk of complications, lower rates of readmission, and reoperation and higher likelihood of being discharged home. The mean LOS decreased from 8.21 ± 0.83 days to 5.82 ± 0.64 days after implementation of the evidence-based orthopedic ERAS pathway (p < 0.05). Conclusions This series of intertrochanteric fracture patients treated with the orthopedic ERAS procedure demonstrated that the procedure is capable of reducing LOS and preserving hip function without compromising functional outcome. This improvement was possible without a concomitant increase in postoperative complications and readmission rates. Level of Evidence Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Yan Kang
- Orthopaedic Department, Minhang Center Hospital, Fudan University, 170 Xin Song Road, Shanghai, People's Republic of China
| | - Jianxing Liu
- Orthopaedic Department, Minhang Center Hospital, Fudan University, 170 Xin Song Road, Shanghai, People's Republic of China
| | - Haihong Chen
- Orthopaedic Department, Minhang Center Hospital, Fudan University, 170 Xin Song Road, Shanghai, People's Republic of China
| | - Wang Ding
- Orthopaedic Department, Minhang Center Hospital, Fudan University, 170 Xin Song Road, Shanghai, People's Republic of China
| | - Jianqing Chen
- Orthopaedic Department, Minhang Center Hospital, Fudan University, 170 Xin Song Road, Shanghai, People's Republic of China
| | - Bin Zhao
- Orthopaedic Department, Minhang Center Hospital, Fudan University, 170 Xin Song Road, Shanghai, People's Republic of China
| | - Xiaofan Yin
- Orthopaedic Department, Minhang Center Hospital, Fudan University, 170 Xin Song Road, Shanghai, People's Republic of China.
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MESH Headings
- Aged
- Arthroplasty, Replacement, Hip/adverse effects
- Arthroplasty, Replacement, Hip/methods
- Arthroplasty, Replacement, Hip/rehabilitation
- Arthroplasty, Replacement, Knee/adverse effects
- Arthroplasty, Replacement, Knee/methods
- Arthroplasty, Replacement, Knee/rehabilitation
- Humans
- Length of Stay
- Multiple Chronic Conditions
- Patient Care Management/methods
- Patient Care Planning
- Postoperative Complications/classification
- Postoperative Complications/etiology
- Postoperative Complications/therapy
- Prognosis
- Rehabilitation/methods
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Affiliation(s)
| | - Henrik Kehlet
- Section of Surgical Pathophysiology, Rigshospitalet, Copenhagen University, Denmark and The Lundbeck
- Foundation Centre for Fast-track Hip and Knee replacement, Copenhagen, Denmark
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