Anesthetic Considerations for Ambulatory Hip & Knee Arthroplasty
The demand to perform total joint arthroplasties (TJA) on an outpatient basis has increased significantly over the past decade as a result of increasing health care costs and the push toward a more efficient and cost-effective healthcare system. Current projections state that arthroplasties will increase 673% to approximately 3.48 million procedures by 2030 (2,5). Total hip and total knee replacements are the two most commonly performed surgeries in the United States, making them a prime target for cost control and risk mitigation. Since the most effective ways of decreasing cost were shown to be limiting length of stay and preventing complications and readmissions, surgeons and anesthesiologists have been engaged in continuous analysis and modification of the perioperative approaches to care (5). Surgeons have improved their anatomical approaches and surgical tools and techniques to limit tissue trauma, pain, infection, and blood loss to the degree possible. Preoperative education and optimization have also been improved, as have anesthetic techniques to provide for the enhanced recovery required by this accelerated pathway. Indeed, studies have shown that patients also share this desire to recover at home when their chief postoperative concerns, fear of uncontrolled pain and dependency, are addressed. Similarly, surveys indicate 96% of patients would undergo another outpatient arthroplasty based on prior experience (1,7). Effective physical therapy, multimodal analgesic protocols, and muscle-sparing regional anesthetic techniques have served patients well in addressing these concerns. Anesthesiologists have also begun to play a more active role in ensuring these patients are able to ambulate and function postoperatively given the potential for regional and neuraxial techniques to impact motor function, however general anesthesia is known to pose a significantly higher fall risk when the central effect of opioids is relied upon for analgesia (3,5). Patient satisfaction surveys are revealing higher satisfaction at time of discharge for ambulatory arthroplasty and the cost of performing these surgeries has decreased by an estimated $4000 to $8,570 depending on the specific procedure (5).
A 2018 study on postoperative outcomes found 30-day readmission after TJA were mostly due to infection, which is often considered a surgical concern but the patient’s preoperative status and fitness for outpatient surgery also impact this outcome. Length of stay and duration of procedure are associated with increased surgical infections, both of which are impacted negatively by patient comorbidities such as diabetes and obesity. Other major risk factors for surgical site infection (SSI) include, drug/alcohol abuse, corticosteroid use, anemia, malnutrition, chronic liver disease, post-traumatic arthritis, prior surgery, and greater severity of comorbidities. It is also recommended that all patients are routinely screened for methicillin-resistant Staphylococcus aureus via nasal swab and decolonization as indicated (5,6).
One of the primary determinants of success for outpatient arthroplasty is patient selection. Proper selection is known to minimize the risk of adverse events and readmissions in the perioperative period. Regarding age, patients above 75 are at increased risk of falls, uncontrolled pain, stiffness, urinary retention, and readmission within one year. Younger patients with lower BMI were noted to have significantly fewer postoperative complications. While stating an exact age threshold to ensure safety for outpatient TJA is challenging, consideration should be given to the impact of frailty in patients of advanced age (5,7). Another study looking specifically at acute postoperative urinary retention (POUR) did not find age to be a significant factor, but rather male gender and the use of neostigmine and/or glycopyrrolate were noted to increase POUR by 34%. History of a POUR, absence of an indwelling catheter, and fentanyl use in spinals were also associated with acute POUR after ambulatory surgery. A separate study found indwelling catheters, when removed within 48 hours, were associated with less POUR and equivalent rates of infection when compared to intermittent catheterization (6). Simultaneous bilateral arthroplasty, arthroplasty for fracture treatment, and surgeries of significant complexity (revision arthroplasty, bone loss, intraoperative fracture, etc.) should be performed exclusively on an inpatient basis. Uncontrolled diabetics are at significant risk of perioperative stroke, ileus, hemorrhage, and mortality and should be scheduled early in the day to avoid prolonged fasting and poor glycemic control. Patients with at least moderate kidney disease are also known to have twice the mortality risk, although there are no recommendations to exclude them from ambulatory surgery on this basis alone (5). Patient compliance is key in ambulatory cases, as only 20% of patients were found to be compliant with recommendations for deep venous thrombosis (DVT) prophylaxis after same-day TJA surgery. The peak incidence of postoperative DVT occurs on day 16, indicating the need for close follow-up with a provider to ensure compliance with the prescribed anticoagulation regimen during this phase.
Regarding methods of anesthesia and analgesia, a shorter stay itself is associated with less pain and stiffness, meaning any measure that can safely shorten length of stay will potentially improve pain outcomes (7). Again, general anesthesia is associated with more central sedative effects, predisposing patients to falls, poor performance in physical therapy, postoperative delirium and cognitive decline, and inadequate analgesia. One study found 76% of patients experiencing a fall had received GA, compared with 11% neuraxial (5). Neuraxial techniques are also associated with decreased 30-day mortality, transfusion requirements, and superficial infections (3). Multiple methods of local and regional anesthesia have been studied, ranging from periarticular injection to peripheral nerve blocks and continuous catheters which are also useful in the ambulatory setting. In general, regional techniques are known to decrease opioid requirements and the incidence of related adverse effects such as ileus, urinary retention, respiratory depression, and nausea/vomiting, all of which commonly prolong recovery and delay discharge after surgery. Liposomal bupivacaine showed promise initially but has not been shown superior to ropivacaine and comes at a significantly higher cost (5,6). Muscle-sparing peripheral nerve blocks have been described such as the interspace between popliteal artery and posterior capsule of the knee (IPACK) and adductor canal blocks. Previously, the femoral and sciatic nerves were blocked non-selectively, however more aggressive approaches to physical therapy have necessitated the use of techniques that do not cause quadriceps weakness, foot drop, or other difficulties in ambulating in the immediate postoperative period. Several studies have shown equivalent analgesia with adductor canal blocks along with improved participation in physical therapy in the first two days after surgery and decreased length of stay, when compared to combined sciatic and femoral blocks. It is important to consider that quadriceps function can also be affected by the surgery itself, should postoperative mobility issues arise in the setting of a muscle-sparing nerve block. Continuous adductor canal catheters are now being investigated as the potential next step in analgesic protocol development for total knee replacement. Multimodal analgesics (acetaminophen, gabapentin, celecoxib, etc.) have proven to be a useful adjunct to regional/neuraxial techniques and are more effective if given preemptively rather than as needed postoperatively (3).
In conclusion, ambulatory arthroplasties have increased in popularity and will be one of the most commonly performed procedures in the near future. Thorough preoperative evaluation of these patients is essential to ensure appropriate screening of candidates for this surgery and to prevent costly complications and readmissions associated with poor patient selection. Effective communication and coordination of care amongst a multi-disciplinary team also ensures preoperative evaluation and education, intraoperative care, and postoperative physical therapy and follow-up are being optimized. Recommendations for intraoperative management include, use of neuraxial and muscle-sparing regional techniques, preemptive administration of multimodal analgesics, and tailoring of anesthetic plan to emphasize prevention of postoperative nausea and vomiting, postoperative urinary retention, muscle weakness, balance issues, ileus, and over sedation. As approaches to the prevention of perioperative complications continue to evolve, more patients will be considered for same-day arthroplasty, however certain patients should always be done on an inpatient basis, including those undergoing concomitant bilateral arthroplasty, post-traumatic arthroplasty, revision arthroplasty, frail elderly patients, and patients with severe, uncontrolled comorbidities. Patients in whom poor compliance with postoperative recommendations is anticipated should also be considered at higher risk for infection and venous thromboembolism and may benefit from inpatient admission. While all unexpected admissions cannot be avoided, a well-designed anesthetic plan that optimizes analgesia and mobility, limits opioid intake, and minimizes adverse side effects and complications will ensure patients have the best chance of same-day discharge after arthroplasty.Page Break
References
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