The Outpatient Knee Replacement Program at Orlando Orthopaedic Center. Jeffrey P. Rosen, MD

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1 The Outpatient Knee Replacement Program at Orlando Orthopaedic Center Jeffrey P. Rosen, MD

2 Anesthesia Pain Management Post-Op / Discharge Protocols

3 The Orlando Orthopaedic Center Joint Replacement Team Jeffrey P. Rosen, MD Eric Bonenberger, MD Sam Blick, MD Bryan Reuss, MD Bradd Burkhart, MD Travis VanDyke, MD

4 Over 350,000 Knee Replacements are done each year in the United States Traditionally an inpatient procedure 3-5 day hospital stay Newer techniques have made this a safe procedure in the outpatient / 23 hour stay setting in a select group of patients

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6 Why Outpatient Joint Replacement: Quicker Recovery Improved Patient Satisfaction Less Risk of Infection and other complications Less Cost the entire episode of care can be effectively completed at about one-half the cost of traditional inpatient surgery

7 Why Outpatient Joint Replacement: u u u Despite hospitals diligent efforts to prevent them, hospital acquired infections remain a significant risk to inpatient care. While infections can occur in an outpatient setting, they are much less common and much less serious than in a hospital inpatient setting. Innovative anesthesia and pain management protocols have led to significant reductions in post-operative complications

8 THE ONE FACTOR THAT CORRELATES MORE THAN ANY OTHER SINGLE FACTOR WITH REGARD TO INFECTION RATE IN SURGICAL PATIENTS IS HOSPITAL LENGTH OF STAY!!

9 Important Aspects of the Outpatient Program Patient Selection Patient Education Less Invasive Surgical Approaches Anesthesia Protocols Multimodal Pain Management Home Care Nursing and Physical Therapy

10 The Critically Important Aspect of the Outpatient Knee Replacement Program is to Assure the Patient and their Family that This is a SAFE alternative to Inpatient Surgery and that it allows a quicker recovery with higher patient satisfaction It is Important that the Patient and their Family know that there is a comprehensive plan of care that includes all aspects of their recovery

11 The Outpatient Total Knee Program at Orlando Orthopaedic Center Patient Selection for Same Day Discharge: Not all patients are candidates for this program no compromises will be made with regard to patient safety or risk ASA I or II BMI 35 or less No cardiac or pulmonary risk factors No history of blood clots All receive medical clearance Age relative factor

12 Patient Education: The Patient s Guide.. a step-by-step, day-by-day roadmap that guides the patient and family through the entire process One-on-one pre-op patient education Pre-Op Class

13 The Outpatient Total Knee Program at Orlando Orthopaedic Center Anesthesia:

14 Spinal Anesthesia Indications Any Surgical Procedure Below the Umbilicus Contraindications Patient Refusal Infection Severe Neurologic Disease Hypovolemia Coagulopathy Spinal Pathology prior spinal surgery

15 The Benefits of Spinal Anesthesia Compared with General Endotracheal Anesthesia Lower Pain Scores (VAS and verbal rating scores) Less Time spent in post-anesthesia recovery unit Longer time to first anesthetic request Fewer requests for rescue anesthesia and lower doses Less nursing time and lower nursing dependency Reduced opioid-based side effects Drowsiness/dysphoria Respiratory Depression Nausea / vomiting Ileus Reduced Thrombogenesis Reduced Blood Loss

16 The Benefits of Spinal Anesthesia Compared with General Endotracheal Anesthesia Increased Patient Satisfaction Scores Avoidance of Airway Manipulation Decreased Stress Response Improved Bowel motility Faster turnover Earlier discharge home from outpatient surgery Reduced unplanned admissions from outpatient surgery

17 Anesthesia: Minimize Narcotic Medications during surgery Femoral / adductor nerve block Exparel Ofirmev, Decadron, Toradol, Celebrex, Gabapentin

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19 The Outpatient Total Knee Program at Orlando Orthopaedic Center

20 Exparel Lysosomal Bupivicaine

21 Toradol (Ketorolac) Non Steroidal Anti-Inflammatory Reduces the production of prostaglandin the body s main mediator of pain and inflammation 30 mg. IV in pre-op

22 Prevention of Post-operative Nausea

23 The Key to the Success of the Outpatient Program has been Effective Pain Management Negative Clinical Outcomes of ineffective Postoperative Pain Control Deep Vein Trhombosis Pulmonary Embolism Coronary Ischemia and myocardial infarction Pneumonia Poor Wound Healing delayed recovery Insomnia Demoralization Chronic Pain

24 Post-operative Multi-modal Pain Management Nerve Block at surgery Exparel Opioids but in reduced dosages Ofirmev COX-2 NSAIDS Gabapentin

25 Goal Reduction in Opioid Use Respiratory depression Excessive sedation Nausea, Vomiting, Constipation, Ileus Urinary retention Pruritis Chest wall rigidity Cognitive impairment Seizures

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28 Cox-2 NSAIDs Role in Post-Operative Pain Management Cox-2 specific inhibitors (Celebrex) are safe in the perioperative period due to: Ability to suppress inflammatory response Lack of platelet inhibition Minimal Interaction with anticoagulants No adverse effect on healing No adverse effect on bone growth

29 Gabapentin (Neurontin) γ-aminobutyric acid (GABA) is the chief inhibitory neurotransmitter in the mammalian central nervous system. It plays the principal role in reducing neuronal excitability throughout the nervous system. In humans, GABA is also directly responsible for the regulation of muscle tone. Gabapentin GABA anaolgue reduces the magnitude of noxious nerve stimuli to the CNS

30 Multimodal Pain Management Improved Pain Scores Reduced Opoid Use Rapid Mobilization Lower Rate of Post-operative Complications Patients are comfortable when they leave the outpatient surgery center and pain at home is moderate and easily managed Lower Incidence of Blood Clots No increase in bleeding with COX-2 NSAIDs

31 Pain Management - Summary u Pre-op: Night Before Surgery: Celebrex + Gabapentin Morning of Surgery: Oral Celebrex + Gabapentin IV Toradol, Decadron, Ofirmev Nerve Block u Intra-Operative: Spinal Anesthesia Exparel

32 Pain Management - Summary u Post-op: Ofirmev 1 dose at 6 hrs post op Celebrex 200 mg daily x 14 days Gabapentin 300 mg po bid x 7 days Zofran 4 mg po q 6h prn nausea Oral pain meds Dilaudid 4 mg po q 6h x 24 hrs, then prn Transition to hydrocodone / tramadol

33 DVT prophylaxis Enteric Coated Aspirin 325 po bid x 4-6 weeks Begin 8-12 hours post-op

34 Home Care Following Discharge The Patient s Guide.. specific day-by-day instructions / roadmap includes all aspects of post-op care Home nursing care / home physical therapy Appropriate home equipment CPM machine, walker, crutches, cold-therapy unit, bedside commode

35 Home Care Following Discharge There are some aspects of care that we ask family members to participate in, but these are not complex or overwhelming they include such activities as assisting with bathing and hygeine, some dressing changes It is critically important for the patient and their family to know that adequate home support will be provided and all of their home care needs will be met. A physician is on call and available 24 hours per day 7 days a week if any concerns or problems arise

36 Patient Care Pathway: Discharge Criteria Post-op Assessment at 6 hrs post-op: Adequate pain control Clean Dry Dressing no evidence of bleeding Cleared by PT Able to void Patient and family comfortable with discharge plan

37 OUTPATIENT JOINT REPLACEMENT A safe and innovative program to allow patients to reclaim their quality of life Less Risk Less Cost Better Results Quicker Recovery

38 The Outpatient Total Knee Program at Orlando Orthopaedic Center