How to _Get Ahead and Stay Ahead’ to Promote Rapid Recovery

    Dr. Mark Pagnano discusses protocols that can be put into place to help joint replacement patients progress faster through all phases of recovery to discharge.

    Over the past decade, there has been a shift in thinking about the total joint arthroplasty experience. No longer are these patients viewed as “sick”; they are “well patients” who require minimal hospital intervention to progress toward discharge.

    Key drivers of this paradigm shift, according to Mark W. Pagnano, MD, have been advances in blood management and advances pain management, and they are part of what he calls a “get ahead and stay ahead” philosophy that encompasses proactive management of fluids (including blood), pain, and nausea before, during, and after surgery.

    The goal is to help the patient progress faster through all phases of recovery to discharge, whether that discharge is the same day, 1 day later, or 2 days later.

    Dr. Pagnano spoke about the shift toward rapid recovery following total joint arthroplasty at ICJR’s Winter Hip & Knee Course in Vail, Colorado.

    Fluid Management

    Guidelines from the American Society of Anesthesiologists recommend allowing well patients who are undergoing elective total joint arthroplasty to drink clear liquids up until 2 hours before surgery, such as water, black coffee, and juices without pulp.

    Keeping these patients NPO after midnight does not make sense, Dr. Pagnano noted. A well-hydrated patient will have a more predictable response to anesthesia, will be less prone to hypotension during surgery, and will have less nausea and pain after the procedure, he said.

    Minimizing blood loss and blood transfusions is also a desirable outcome of fluid management. Transfusions are not only costly, but they also impeded rehabilitation and discharge from the hospital. And, they have a profound psychological impact on the patient, Dr. Pagnano said. The previously well patient is now a sick patient.

    Dr. Pagnano recommends that surgeons rethink their thought process regarding blood management: Think fluids first, red blood cells second – meaning that the symptoms surgeons typically associate with anemia might really be symptoms of a volume issue. As he noted, orthostatic hypotension, elevated heart rate, and low urine output generally respond to fluids, eliminating the need for transfusions.

    The use of tranexemic acid, which has been used at Mayo Clinic since 2000, also plays a role in minimizing transfusions. Mayo Clinic data from 2010 showed a reduction in the transfusions in total knee arthroplasty patients from 18% before the use of tranexemic acid to 2% with tranexemic acid. An even more dramatic reduction was seen in total hip arthroplasty patients, from 33% to 7%.

    Tranexemic acid is widely used by orthopaedic surgeons, Dr. Pagnano said, with the intravenous (IV) version the subject of greater study than the topical version. At Mayo Clinic, surgeons typically mix 1 gram of tranexameic acid with 50 mL of saline and infuse it over 10 minutes preoperatively at the time of prophylactic antibiotics. They repeat this dosage at wound closure.

    Pain Management

    The benefits of a multimodal pain management protocol have been well documented in the joint replacement literature. Staying ahead of the pain by addressing multiple pain pathways with multiple drugs can help limit the total analgesia requirement, Dr. Pagnano said, as well as minimize the use of IV opioids.

    At Mayo Clinic, surgeons typically prescribe a preoperative regimen of pain management drugs that includes acetaminophen, non-steroidal anti-inflammatory drugs, and tramadol or oral opioids; some patients also receive gabapentin and ketamine.

    Postoperative pain medications are given on a schedule, not PRN. As Dr. Pagnano said, pain can be predicted following joint replacement, so a predictable schedule of medications will stay ahead of the pain and minimize or eliminate breakthrough pain.

    Dr. Pagnano prefers to use regional anesthesia – specifically, a spinal block – for his patients rather than general anesthesia whenever possible. Because he knows his procedures will take about an hour, the anesthesiologists he works with can tailor the anesthetic dose to the length of surgery. They use what he described as an “arthroscopy-like” dose of the spinal anesthetic that wears off in the recovery room and allows earlier ambulation.

    Dr. Pagnano has also switched in the last 18 months from peripheral nerve blocks to periarticular anesthetic infiltration of the surgical site, noting that it is a simple, surgeon-directed approach that addresses pain at the source.

    Nausea Management

    Providing fluids and promoting hydration in the preoperative and intraoperative periods will go a long way toward reducing postoperative nausea, Dr. Pagnano said.

    In addition, he and his colleagues do a proactive nausea screening. If patients are found to be at high risk for postoperative nausea, they are preemptively treated with a steroid, such as dexamethasone, ondansetron, or a scopolamine patch. If a patient who was not on this protocol develops nausea after surgery, he or she receives a steroid plus IV fluids.

    Dr. Pagnano’s presentation can be found here.