The intra-operative care processes•   The anaesthstic•   Surgical factors•   Blood loss•   Traditions                     ...
The aim is to minimise the stress response andenable a quick return function                                          @off...
So what is the surgical stress response?• Designed to ‘protect’ injured organism by promotingcatabolism in the absence of ...
The Surgical Stress Response• Activation of sympathetic nervous system• ↑catabolic & ↓anabolic hormones• Hypermetabolism &...
What is the ideal anaestheticapproach to minimise the effectof the surgical stress response?                              ...
Firstly, Consider our patientpopulation•   Elderly with osteo / rheumatoid arthritis•   Associated co-morbidities e.g. IHD...
Secondly, what are the aims ofanaesthesia• Patient safety & reduced morbidity• Create ideal operating conditions e.g. redu...
Anaesthetic goals for optimal rehabilitationas part of an enhanced recovery pathway •   Patient should be co-operative •  ...
Start by choosing type of Anaesthesia• GA – induction agent, muscle relaxant, opioid, inhalational  agent.  Advantages: si...
Regional Anaesthesia• Acute Normovolaemic Haemodilution     - sympathetic blockade, ↑ venous capacitance reservoir,       ...
What are the strategies to reducefatigue?•   Reduce the stress response by using RA•   Prevent hypoxaemia•   Control pain ...
What are the strategies to reduce post-opconfusion/delirium?•   Prevent prolonged anaesthesia/surgery•   Avoid benzodiazep...
What are the anaesthetic strategiesto help with DVT prophylaxis?• Major surgery is associated with hyper-  coagulation• RA...
Summary• RA +/- light GA or sedation, the team approach and  attention to detail results in:-    - Patient safety & reduce...
What type of RegionalAnaesthetic do the topperforming units use?                           @officialERblog                ...
Earlier slide - National TKR (HO4) length of stay data           2011/12-Q3 (Min 30 procedures)                 Different ...
How did we persuade 50anaesthetists to change practice  to a standardised approach?                                @offici...
Aim – A standardised RA approach forevery patient Webster R, Craig J, Smith I Richards G, Swan J (2009) Use of audit to as...
Result – A standardised anaesthetic and   analgesic pathwayWainwright T, Craig J, Swan J, Olyslaegers C, Miles K, Fick D, ...
Continued refinement and developmentof technique based on audit results                                   @officialERblog ...
Why is it difficult to determine what the best anaesthetic         technique is?    Local infiltration as an example      ...
@officialERblogenhancedrecoveryblog.com
Local infiltration• Offers a Safe and effective opioid-sparing analgesic regimen  whilst avoiding the potential complicati...
Growing evidence to support the useof local infiltration techniques.•   Search terms “hip replacement”, “hip arthroplasty”...
Single Dose or ContinuousInfusion?•   Busch et al. observed good outcomes using the single infiltration    technique but o...
What Is the Optimal Infiltration Site?•   Andersen et al. observed no difference between the use of intracapsular    cathe...
What Is the Most Effective Dose?•   Ropivacaine instead of bupivacaine enables larger doses whilst minimising    the risk ...
Local Infiltration versus Epidural•   Epidural analgesia is effective at providing predictable and reliable pain    relief...
Local Infiltration versus PeripheralNerve Block•   In many institutions FNB forms part of the standard postoperative pain ...
Summary• Evidence to support the use for TKR but its role in  THR less compelling• However, many unanswered questions• Opt...
What about surgical technique?                               @officialERblog                      enhancedrecoveryblog.com
The surgical evidence base• Hip and Knee Replacement are already very  successful operations                              ...
What is the role of minimally invasive surgery in a fast-track hip and knee replacement pathway?Lloyd J, Wainwright T, Mid...
History and Evolution – What is the role of MISin a THR/TKR enhanced recovery pathway?• Minimally invasive total hip repla...
What is the role of MIS in a THR/TKR enhancedrecovery pathway?• Initial reports suggested dramatic reductions  in LOS• Sub...
Conclusion - What is the role of MIS in aTHR/TKR enhanced recovery pathway?  Providing the surgery is well done, it does n...
Is prosthesis important?                            @officialERblog                   enhancedrecoveryblog.com
New prosthesis which saves 25%operative time                         Operative time data for differing THR types          ...
Choice of hip replacement reducesoperative time                             Operative time data for differing THR types   ...
What else can reduce surgical           time?                              @officialERblog                     enhancedrec...
Reducing variation in theatre processes Patient                         Patient returnsadmitted                           ...
Promoting teamwork in theatre                               @officialERblog                      enhancedrecoveryblog.com
Standardised theatre set up                                 @officialERblog                        enhancedrecoveryblog.com
Every step always identical – Alsohelps to guide practice                                    @officialERblog              ...
Prepare two days   in advance                @officialERblog       enhancedrecoveryblog.com
Standardise prosthesis                                  @officialERblog                         enhancedrecoveryblog.com
Results - Artificial variation isremoved and increased teamwork      07:00      05:48      04:36      03:24      02:12    ...
Results - Artificial variation is removedand increased teamwork          04:00          04:00          03:31          03:3...
Why may reducing surgical time  be of benefit in enhanced          recovery?                              @officialERblog ...
Example - Hip Revision SurgeryEnhanced Recovery•   Number: 177 cases,              Year     No of cases    from April 1999...
Hip Revision Surgery 2• Duration of Surgery:  – Median 180 mins (Range 60-360 mins)• Blood Loss:  – Median 1050 mls (Range...
@officialERblogenhancedrecoveryblog.com
@officialERblogenhancedrecoveryblog.com
Results: Descriptive• No Mortality up to Discharge• 4 HDU/ ITU Admissions   –   VF/VT 4 days post-op , to ITU   –   Cardia...
Results: Binary Logististic Analysis• Variables assessed with respect to Blood Loss  – Age  – Sex  – Type of Anaesthesia  ...
Results: Binary Logistic Regression2 Factors were to have a highly statistically  significantly effect on Blood Loss  – Du...
@officialERblogenhancedrecoveryblog.com
@officialERblogenhancedrecoveryblog.com
Massive Blood Loss and Length ofSurgery• Probability of massive transfusion   – Increases by 3% / min of excess surgical t...
What else can prevent blood           loss?                             @officialERblog                    enhancedrecover...
Reducing blood loss• THR and TKR is associated with significant blood loss• Blood transfusion used to treat the blood loss...
Tranexamic acid• Intra - operative Tranexamic acid reduces  postoperative and total blood loss and the  need for blood tra...
Rationale behind tranexamic acidprotocol to help reduce blood loss•   3 antifibrinolytics have been used in orthopaedic su...
Rationale behind tranexamic acidprotocol to help reduce blood loss•   Medline search provided 189 studies, refined to incl...
A tranexamic acid protocol to helpreduce blood lossTranexamic acid - 15 mg/kg iv slow injection at beginning of anaesthesi...
The use of drains (1)• Intra-articular drains should be avoided• Shown to increase need for blood transfusion,  have no si...
The use of drains (2)• If they are used by your surgeons, take them  down early.• 90% of drainage occurs in first 12 hours...
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Enhanced Recovery Masterclass Intra-op

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  • We have established that RA is better than GA – so what is the best type of Ra to use?
  • If you look at the tope performers – they use a slightly different cocktail? Why? Isn’t there a best option to use? We will come to that in a moment. What’s clear however, is that the top units have standardised. This is this is important. Standardisation allows the management of expectation, predictability, optimal analgesia post-op, rehab efforts can be timed Basket: HRGs (v3.5) - ALL | Outcome group: Length of stay First / Last: 2011/12-Q1 to 2011/12-Q1 | Admission type: Elective | Chapter: H Musculoskeletal System | HRG: H04 Primary Knee Replacement Superspells: 17,950 | Spells: 17,955 | Episodes: 18,542 Less than 30 procedures removed.
  • Looking at temperature, analgesic use, pain scores, PONV You can’t stop them now. Continual refinement of their anaesthetic
  • LIS is becoming very popoular Looking at the literature in this areas also highlights why it’s difficult to make conclusions from the literature about the best approach
  • MIS use in other ER surgical disciplines – but what’s it’s role in ortho when are techniques are already so good.
  • History and Evolution   The initial driving force behind minimally invasive joint surgery was cosmesis, reducing the length of the scar to less than 10-12cm for hips and less than 14cm for knees (4). As with most new technology there is the initial unbridled enthusiasm, then critical appraisal followed by a refining or discarding of the process. This holds true for MIS.   Minimally invasive total hip replacement surgery (MISTHR) has been around for thirty years. Various approaches have been described but they are essentially modifications of the standard posterior, lateral, anterolateral or anterior approaches. Some of the first advocates were Light and Keggi who used a direct anterior approach via a curved transverse skin incision (5). Over three years they reported on a series of 104 patients. They described reductions in blood loss, improved levels of comfort, faster recovery and shorter hospital stays. These improvements were thought to be partly due to the preservation of the hip abductors.   The anterior incision continued to reduce in size over the years and in the last decade there have been encouraging reports of good outcomes including: reduced dislocation rates, favourable component positioning and restoration of leg lengths (6,7). A special traction table is often required to improve visualisation for this approach (8).   Bertin and Rottinger reported on a modified mini-incision anterolateral approach utilising the muscle interval between the abductors and tensor fascia lata (9). Again, with this approach there have been reports of reduced blood loss and length of hospital stay (10).   The double-incision approach is an adaptation of the posterior Moore and the anterior Smith Peterson approaches (11,12). In 2004 Irving advocated the approach as limiting soft tissue trauma and facilitating faster rehabilitation (13). Berger pioneered a two-incision fluoroscopy assisted approach for THR (14). Again, rapid recovery, 85% first day discharges and only a 1% complication rate were reported on the first 100 cases. It is worth noting that extensive cadaveric training had been undertaken along with careful patient selection. Also, the definition of hospital discharge differs between countries.   Both the lateral (Hardinge) and posterior approaches have evolved to incorporate smaller incisions and subsequently less soft tissue trauma over the decades. There are variations on which precise muscles are released including the piriformis, quadratus femoris and gluteus maximus. Many surgeons report favourable outcomes and early discharge using these techniques (15-16).   MIS of the knee evolved in the 1990s for unicondylar arthroplasty. The MIS principles were applied to total knee arthroplasty in an effort to enhance recovery by reducing quadriceps muscle strength loss, improving earlier return of function and reducing hospital length of stay.   Five minimally invasive approaches have been described for total knee arthroplasty (MISTKA). They are mini-medial parapatellar, quadriceps muscle sparing, mini-midvastus, mini-subvastus and direct lateral. Following the initial interest in MIS there were a flurry of encouraging surgeon reported case series (6,7,9,10,13-18). It became apparent that not only was the scar smaller but there may also be potential benefits of a reduction in soft tissue trauma, shorter intra-operative time, less blood loss, less post-operative pain, faster rehabilitation and earlier hospital discharge. Over the next few years study designs improved but it took a few more years for any level I evidence studies to emerge. Recent Times   Any early theories that scar size alone equates to early recovery have not been sufficiently validated by subsequent, better-designed studies, although, some advocates still remain (19-22). The benefits associated with MIS are believed to be due to the multi-modal nature of the MIS pathways. The earlier case series often involved careful patient selection and also pathways with fast-track characteristics such as goal setting and more aggressive rehabilitation. These independent variables along with improved pain control have been shown to shorten recovery following hip arthroplasty surgery (23-25). The MISTKA techniques have been shown in various studies and meta-analyses to result in significantly less pain within the first 24 hours post-operation, when compared to standard knee approaches. There is also a general trend towards lower blood loss (26).
  • Comparing MIS Techniques   The various types of MIS have spawned debate over which technique is the most advantageous in accelerating recovery. In 2010, Popischill investigated the effects of the MISTHA lateral approach verses a traditional transgluteal approach on gait analysis. No difference was identified (27). In 2006 Bennett verified similar gait kinematic findings, and in 2007, he showed no difference in immediate post-operative walking ability after MIS compared with standard incision hip arthroplasty (28,29). Oganda and Lawlor published two papers in 2005 showing no enhancement in early walking ability or functional outcome by 6 weeks when comparing a MIS posterior approach with a standard posterior approach (20,30).   Interestingly, Pagnano reported a slower recovery in patients undergoing MIS in a well designed randomised clinical trial (31).   In the knee, only two studies have critically examined early hospital discharge. The verdict was inconclusive on whether MIS alone is directly responsible for early discharge (32,33). As is consistent with the research on fast-track surgery it is proposed that early physiotherapy and improved anaesthesia probably play a more significant role (34-36).   The MISTKA technique tends to allow significantly faster recovery times when it comes to regaining early range of motion. However, by the mid to long-term this initial advantage is lost when compared to standard approaches. This is borne out by knee scores failing to show any difference between the two procedures (26).   Some surgeons have tried to compare the various MIS approaches in order to determine which is best. Leuites compared the immediate post-operative advantages between a MIS Watson Jones approach and a MIS posterior approach. The posterior approach offered a significant advantage in functional ability, symmetry indices of stance, loading rates and single limb stance within the first 6 weeks. However, by 13 weeks the results were the same (37). In a small study, the MIS Watson Jones approach was favoured over the lateral transgluteal approach with regard to function, gait and Harris hip score at 6 and 12 weeks post-operation (38). In 2004, a similar study by the same author comparing the MIS anterior approach with a standard transgluteal lateral approach only found short term advantages of improved mobilisation, pain, gait and Harris hip scores at 3 and 10 days post op. By 6 weeks any difference had normalised (39).   Meneghini recently showed no difference between three MISTHR approaches with regard to discharge, functional recovery or outcomes scores over the first year. An aggressive rapid rehabilitation protocol was used in all cases and most patients were reportedly discharged a day post surgery (40).   Goebel found an initial reduction in pain levels after MIS anterior approach compared to a lateral approach (41). There was also an improvement in time to attain range of movement and shorter hospital stay. However, greater levels of pain reported at physiotherapy sessions 3 and 6-9 days post-operation accompanied this.   There are very few studies comparing two independent MISTKA approaches. The randomised study by Bonutti compared the MIS subvastus and mid-vastus approaches in patients undergoing bilateral TKA (42). They failed to demonstrate a difference. Aglietti compared the MIS quadriceps sparing and subvastus approaches in a randomised unilateral TKA study (43). They reported earlier straight leg raising ability in the subvastus group but otherwise no other difference was demonstrated. Chin randomised patients into three groups comparing radiographic outcomes between the standard parapatellar, MIS mid-vastus and the direct lateral approaches (44). The lateral approach had a higher likelihood of implant mal-alignment. Otherwise no difference was noted. More recently, Niki compared a MIS lateral subvastus approach for valgus knees with a MIS medial approach. There was no clear difference except for lower visual analogue pain scores in the first week and lower myoglobin levels (45).
  • Conclusion   MIS has driven the development and refinement of improved and less invasive surgical instrumentation. The introduction of MIS in hip and knee arthroplasty has also been accompanied by improvements to clinical pathways and the adoption of fast-track protocols. In addition to the MIS literature, accounts of fast-track pathways using conventional surgical techniques have achieved similar reductions in length of hospital stay and speed of recovery. Therefore, at present, there are too many confounding factors to convincingly show that MIS in isolation results in accelerated recovery for patients when compared to conventional surgery. In addition, MIS has failed to show, biochemically, any significant reduction in soft tissue trauma when compared to conventional arthroplasty surgery.   Several issues therefore remain. MISTHR and MISTKA will always be popular with the media and certain patients. However, unlike general and endoscopic surgery, in isolation, there are few proven advantages of MIS over conventional arthroplasty surgery, particularly in the hands of the low to medium volume surgeon. Therefore, the optimal incision size should be dictated by a combination of patient habitus, surgeon experience and implant instrumentation. Only time and registry data will reveal whether implant longevity has been compromised by incision size.   The MIS literature whilst not being conclusive in helping us to decide whether MIS is advantageous over conventional surgical techniques, does confirm the value of fast-track pathways in accelerating patient recovery. Optimised preoperative preparation, anaesthesia, analgesia and rehabilitation are certainly aspects of the MIS pathways described in the literature that are here to stay.
  • Rob you add in here or delete slide depending on how you want to end it.
  • Less theatre time – equals less anaesthetic and less blood loss Minimises the surgical stress response
  • Fall from 220 to 170 over the 5 years
  • 19, CF?VT 4 days postop going to ITU: 22, Cardiac arrest intra-op going to ITU: 103, Resp depression with PCA so HDU 24hrs; 112, ?MI to ITU
  • Tranexamic acid can cause nausea, vomiting and diarrhoea in a dose dependant manner. It may cause dizziness and hypotension on fast intravenous injection. It may rarely cause disturbances in colour vision.   Contraindications include history of myocardial infarction, angina, stroke, deep vein thrombosis, pulmonary embolus, warfarin use, bleeding diathesis, pregnancy and allergy to tranexamic acid. Renal failure with a creatinine of over 250 is a relative contraindication. The studies do not show an increase incidence of renal failure but tranexamic acid is cleared by the kidneys.
  • Enhanced Recovery Masterclass Intra-op

    1. 1. The intra-operative care processes• The anaesthstic• Surgical factors• Blood loss• Traditions @officialERblog enhancedrecoveryblog.com
    2. 2. The aim is to minimise the stress response andenable a quick return function @officialERblog enhancedrecoveryblog.com
    3. 3. So what is the surgical stress response?• Designed to ‘protect’ injured organism by promotingcatabolism in the absence of food• However, this is now redundant in modern electivesurgery• Instead it delays post-operative recovery @officialERblog enhancedrecoveryblog.com
    4. 4. The Surgical Stress Response• Activation of sympathetic nervous system• ↑catabolic & ↓anabolic hormones• Hypermetabolism & ↑protein breakdown Negative effects of stress response:- - ↑pain, ↑fatigue - Prolongs recovery - ↓splanchnic perfusion, ↓bowel function - Immunosuppression @officialERblog enhancedrecoveryblog.com
    5. 5. What is the ideal anaestheticapproach to minimise the effectof the surgical stress response? @officialERblog enhancedrecoveryblog.com
    6. 6. Firstly, Consider our patientpopulation• Elderly with osteo / rheumatoid arthritis• Associated co-morbidities e.g. IHD, CVD• Frail and prone to post-op confusion• Multi-organ dysfunction• Poly-pharmacy @officialERblog enhancedrecoveryblog.com
    7. 7. Secondly, what are the aims ofanaesthesia• Patient safety & reduced morbidity• Create ideal operating conditions e.g. reduced bleeding• Haemodynamic stability• Provide conditions conducive for efficient rehabilitation @officialERblog enhancedrecoveryblog.com
    8. 8. Anaesthetic goals for optimal rehabilitationas part of an enhanced recovery pathway • Patient should be co-operative • Patient should be pain free • Fatigue should be minimised • Reduce catabolic muscular breakdown • Patient should be ready for early mobilisation @officialERblog enhancedrecoveryblog.com
    9. 9. Start by choosing type of Anaesthesia• GA – induction agent, muscle relaxant, opioid, inhalational agent. Advantages: simple technique Disadvantages: unstable haemodynamics, ↑bleeding, poor pain control, ↑ PONV, ↑stress response• RA e.g. spinal/epidural/CSE with light GA/sedation Advantages: ↓stress response, ↓bleeding, CVS stability, good pain relief, ↓DVT risk Disadvantages: invasive procedure, potential initial CVS instability @officialERblog enhancedrecoveryblog.com
    10. 10. Regional Anaesthesia• Acute Normovolaemic Haemodilution - sympathetic blockade, ↑ venous capacitance reservoir, relative ‘hypovolaemia’, allows volume expansion• Hypotensive anaesthesia - RA enables hypotension – MAP 55-70 mmHg - decreased blood loss, dry surgical field and improves bone/cement integrity• ↑ Venous drainage - superior operation site allows natural drainage• DVT prophylaxis - ↑blood flow, ↓platelet activity and ↑fibrinolytic activity @officialERblog enhancedrecoveryblog.com
    11. 11. What are the strategies to reducefatigue?• Reduce the stress response by using RA• Prevent hypoxaemia• Control pain & prevent nausea and vomiting• Encourage nutritional intake• Prevent and correct anaemia @officialERblog enhancedrecoveryblog.com
    12. 12. What are the strategies to reduce post-opconfusion/delirium?• Prevent prolonged anaesthesia/surgery• Avoid benzodiazepines• Avoid certain drugs e.g. opioids, hyoscine• Prevent hypoxaemia• Prevent and correct hyponatraemia @officialERblog enhancedrecoveryblog.com
    13. 13. What are the anaesthetic strategiesto help with DVT prophylaxis?• Major surgery is associated with hyper- coagulation• RA decreases the hypercoagulation state by:- - ↑blood flow to splanchnic / peripheral vessels - ↑fibrinolytic activity and ↓platelet aggregation - Haemostasis in major orthopaedic surgery under RA. Platelet mediated haemostasis ↓39%, Clotting time ↓21% and thrombus formation ↓10%. Hollmann et al, Reg Anaesth and Pain Med 2001;26:215-22 @officialERblog enhancedrecoveryblog.com
    14. 14. Summary• RA +/- light GA or sedation, the team approach and attention to detail results in:- - Patient safety & reduced morbidity - Ideal operating conditions - Haemodynamic stability - Provide conditions for early mobilisaiton and good post- op recovery and rehabilitation @officialERblog enhancedrecoveryblog.com
    15. 15. What type of RegionalAnaesthetic do the topperforming units use? @officialERblog enhancedrecoveryblog.com
    16. 16. Earlier slide - National TKR (HO4) length of stay data 2011/12-Q3 (Min 30 procedures) Different anaesthetics are used But, the common theme is a standardised approach within each unit @officialERblog enhancedrecoveryblog.com
    17. 17. How did we persuade 50anaesthetists to change practice to a standardised approach? @officialERblog enhancedrecoveryblog.com
    18. 18. Aim – A standardised RA approach forevery patient Webster R, Craig J, Smith I Richards G, Swan J (2009) Use of audit to assist development of an analgesia pathway for fast track primary total knee replacement. Anaesthesia and Intensive Care 37(4): 662 @officialERblog enhancedrecoveryblog.com
    19. 19. Result – A standardised anaesthetic and analgesic pathwayWainwright T, Craig J, Swan J, Olyslaegers C, Miles K, Fick D, Middleton R (2008) A standardised analgesic ladder canreduce pain and accelerate rehabilitation after TKR. The Chartered Society of Physiotherapy Annual Congress, Manchester @officialERblog enhancedrecoveryblog.com
    20. 20. Continued refinement and developmentof technique based on audit results @officialERblog enhancedrecoveryblog.com
    21. 21. Why is it difficult to determine what the best anaesthetic technique is? Local infiltration as an example @officialERblog enhancedrecoveryblog.com
    22. 22. @officialERblogenhancedrecoveryblog.com
    23. 23. Local infiltration• Offers a Safe and effective opioid-sparing analgesic regimen whilst avoiding the potential complications of peripheral nerve blocks.• Technique developed in part by Kohan and Kerr in Sydney, Australia, and involves the infiltration of the surgical site with a high volume of a long-acting local anaesthetic agent (+/− analgesic agents) with adrenaline.• Seems logical to block the pain signal at the site of nociceptive stimulus (surgical site). Technique has the additional benefits of being simple with a low side effect profile. @officialERblog enhancedrecoveryblog.com
    24. 24. Growing evidence to support the useof local infiltration techniques.• Search terms “hip replacement”, “hip arthroplasty”, “knee replacement”, “knee arthroplasty”, and “local anaesthetic”.• Most studies observed a reduction in early postoperative pain and opiate use, along with reduced length of stay, without an increased risk of complications.• Most studies use a multimodal infiltration approach in which the use of a high volume of long-acting local anaesthetic agent, typically combined with analgesics (NSAIDs and/or opiates) and adrenaline.• Adrenaline is thought to improve the efficacy of the local anaesthetic and reduces the toxicity, by helping to keep it localised to the injection site. @officialERblog enhancedrecoveryblog.com
    25. 25. Single Dose or ContinuousInfusion?• Busch et al. observed good outcomes using the single infiltration technique but other studies have not supported this.• Concerns regarding the length of duration of action have resulted in the use of continuous intra-articular infusions.• There are now a number of RCT’S supporting the use of the high-volume infiltration combined with intra-articular infusion or further bolus dose• However not all studies support the use of additional bolus doses or infusions.• Studies are hard to compare. They use either bupivacaine or ropivacaine and use differnet multi-modal approaches (making synergistic actions hard to account for) @officialERblog enhancedrecoveryblog.com
    26. 26. What Is the Optimal Infiltration Site?• Andersen et al. observed no difference between the use of intracapsular catheters or intra-articular catheters in TKR with ropivacaine infusion.• In a randomised, placebo-controlled, double-blind trial investigating the role of subcutaneous wound infiltration (all patients received high volume local infiltration to the deeper layers), the same authors reported a significant reduction in both static and dynamic pain scores at 24 hours in the group that received intra-operative subcutaneous infiltration.• However, bolus administration through a subcutaneously placed catheter at 24 hours was ineffective.• These observations support previously published observations of a tendency (not statistically significant) towards improved pain relief with the addition of local anesthetic in the extra-articular wound space but it is not conclusive @officialERblog enhancedrecoveryblog.com
    27. 27. What Is the Most Effective Dose?• Ropivacaine instead of bupivacaine enables larger doses whilst minimising the risk of toxicity.• Adding adrenaline enables higher doses and may also potentiate the duration of action of the local anaesthetic by slowing its release into the vascular system.• 2 studies measured plasma ropivacaine levels and all patients remained below toxic levels.• No studies looked at the optimal doses for infiltration or infusion/bolus.• In general, all of the studies identified adopted a standardised LIA regimen for all patients rather than tailoring doses to individual weights.• It is possible that by matching ropivacaine dose to the individual a better response can be achieved. In addition, in the future the use of sustained- release local anaesthetics may negate the need for intra-articular catheters @officialERblog enhancedrecoveryblog.com
    28. 28. Local Infiltration versus Epidural• Epidural analgesia is effective at providing predictable and reliable pain relief. However, it is technically demanding and time-consuming and may cause an array of side effects including urinary retention, hypotension, headache, motor blockade, and nausea, all of which may result in delayed mobilisation.• Local infiltration techniques are inexpensive and relatively easier to perform, and have few side effects.• Studies have compared the use of local infiltration techniques to epidural infusion. All support local infiltration showing equal or better pain relief, earlier mobilisation, and reduced length of stay when compared to epidural infusion.• However, as there is no clearly defined gold standard epidural regimen, these results should be interpreted with caution. @officialERblog enhancedrecoveryblog.com
    29. 29. Local Infiltration versus PeripheralNerve Block• In many institutions FNB forms part of the standard postoperative pain relief protocols following total knee arthroplasty.• Little published in the literature comparing these two analgesic modalities.• Toftdahl et al. observed lower pain scores and opioid consumption with earlier mobilisation with inta-articular infiltration in their randomized trial• But Carli et al. observed the opposite, concluding that femoral nerve block was the most effective modality.• Affas et al. observed no significant difference in either pain intensity in the first 24 hours, or opiate consumption.• As with the studies on epidural anaesthesia what constitutes a standard femoral nerve block varies between studies making comparisons difficult. @officialERblog enhancedrecoveryblog.com
    30. 30. Summary• Evidence to support the use for TKR but its role in THR less compelling• However, many unanswered questions• Optimal study design not used - More cohort studies than RCT’s• Meta-analysis is difficult - Different concentrations and volumes of drug, used with different outcome measures, and as part of different multi-modal regimes• We need standardisation of outcome measures @officialERblog enhancedrecoveryblog.com
    31. 31. What about surgical technique? @officialERblog enhancedrecoveryblog.com
    32. 32. The surgical evidence base• Hip and Knee Replacement are already very successful operations @officialERblog enhancedrecoveryblog.com
    33. 33. What is the role of minimally invasive surgery in a fast-track hip and knee replacement pathway?Lloyd J, Wainwright T, Middleton R (2012) What is the role of minimally invasivesurgery in a fast-track hip and knee replacement pathway? Annals of the RoyalCollege of Surgeons. In press. @officialERblog enhancedrecoveryblog.com
    34. 34. History and Evolution – What is the role of MISin a THR/TKR enhanced recovery pathway?• Minimally invasive total hip replacement surgery (MISTHR) has been around for thirty years• MIS of the knee evolved in the 1990s for unicondylar arthroplasty• Following the initial interest in MIS there were a flurry of encouraging surgeon reported case series @officialERblog enhancedrecoveryblog.com
    35. 35. What is the role of MIS in a THR/TKR enhancedrecovery pathway?• Initial reports suggested dramatic reductions in LOS• Subsequent papers show no causal effect between MIS and LOS• Increase in complications with some MIS approaches @officialERblog enhancedrecoveryblog.com
    36. 36. Conclusion - What is the role of MIS in aTHR/TKR enhanced recovery pathway? Providing the surgery is well done, it does not seem to matter with regards to LOS: – Which approach was used – Length of incision – MIS or not Ogonda et al. J Bone Joint Surg 2005;87:701-6 Chimento et al. J Arthroplasty 2005;20:139-44 Wright et al. J Arthroplasty 2004;19:538-45 Woolson et al. J Bone Joint Surg 2004;86:1353-8 De Beer et al. J Arthroplasty 2004;19:945-50 @officialERblog enhancedrecoveryblog.com
    37. 37. Is prosthesis important? @officialERblog enhancedrecoveryblog.com
    38. 38. New prosthesis which saves 25%operative time Operative time data for differing THR types 250 Reduced operating time and 200 therefore enhanced recovery due to reduced operative stress. And the potential to 150 increase throughput.time (minutes) Low risk - Long term 100 prosthesis results already known to be good. 50 0 Uncemented Cemented Hybrid @officialERblog enhancedrecoveryblog.com
    39. 39. Choice of hip replacement reducesoperative time Operative time data for differing THR types 250 200 150 time (minutes) 100 50 0 Uncemented Cemented Hybrid @officialERblog enhancedrecoveryblog.com
    40. 40. What else can reduce surgical time? @officialERblog enhancedrecoveryblog.com
    41. 41. Reducing variation in theatre processes Patient Patient returnsadmitted to ward @officialERblog enhancedrecoveryblog.com
    42. 42. Promoting teamwork in theatre @officialERblog enhancedrecoveryblog.com
    43. 43. Standardised theatre set up @officialERblog enhancedrecoveryblog.com
    44. 44. Every step always identical – Alsohelps to guide practice @officialERblog enhancedrecoveryblog.com
    45. 45. Prepare two days in advance @officialERblog enhancedrecoveryblog.com
    46. 46. Standardise prosthesis @officialERblog enhancedrecoveryblog.com
    47. 47. Results - Artificial variation isremoved and increased teamwork 07:00 05:48 04:36 03:24 02:12 01:00 Theatre pathway introduced resulting in dramatic reduction of case time variability for THR and TKR @officialERblog enhancedrecoveryblog.com
    48. 48. Results - Artificial variation is removedand increased teamwork 04:00 04:00 03:31 03:31 03:02 03:02 02:33 02:33 02:04 02:04 01:36 01:36 01:07 01:07 00:38 00:38 00:09 00:09 Natural variation is still present but theremoval of artificial variability makes case times more predictable @officialERblog enhancedrecoveryblog.com
    49. 49. Why may reducing surgical time be of benefit in enhanced recovery? @officialERblog enhancedrecoveryblog.com
    50. 50. Example - Hip Revision SurgeryEnhanced Recovery• Number: 177 cases, Year No of cases from April 1999 to Sept 2004 1999 31• Age: Median 75 Range 45-95 2000 31 2001 27• Sex: M:F = 79:98 2002 26• Anaesthesia: 2003 35 GA & Regional 165 GA only 12 2004 27 @officialERblog enhancedrecoveryblog.com
    51. 51. Hip Revision Surgery 2• Duration of Surgery: – Median 180 mins (Range 60-360 mins)• Blood Loss: – Median 1050 mls (Range 200-4500 mls)• Blood Transfusion: – Median 4 units (Range 0-12 units) @officialERblog enhancedrecoveryblog.com
    52. 52. @officialERblogenhancedrecoveryblog.com
    53. 53. @officialERblogenhancedrecoveryblog.com
    54. 54. Results: Descriptive• No Mortality up to Discharge• 4 HDU/ ITU Admissions – VF/VT 4 days post-op , to ITU – Cardiac Arrest intra-op, to ITU – Respiratory Depression with PCA post-op, to HDU – Semi-arrest intra-op, to ITU• Orthopaedic Complications of note – 1 dislocation in post-op period – 1 peri-prosthetic fracture following a fall @officialERblog enhancedrecoveryblog.com
    55. 55. Results: Binary Logististic Analysis• Variables assessed with respect to Blood Loss – Age – Sex – Type of Anaesthesia – Year of Surgery – Duration of Surgery – Preop HB – Side of Operation @officialERblog enhancedrecoveryblog.com
    56. 56. Results: Binary Logistic Regression2 Factors were to have a highly statistically significantly effect on Blood Loss – Duration of the operation (Odds Ratio 1.03, CI 1.02-1.05, P<0.0001) – Year of the Surgery (Odds Ratio 0.70, CI 0.54-0.90, P=0.007)No other factors were found to be significant @officialERblog enhancedrecoveryblog.com
    57. 57. @officialERblogenhancedrecoveryblog.com
    58. 58. @officialERblogenhancedrecoveryblog.com
    59. 59. Massive Blood Loss and Length ofSurgery• Probability of massive transfusion – Increases by 3% / min of excess surgical time• Median operative time – After 2 years there is a 40 min fall, which is sustained• This 40 min of surgical time increases the risk of massive haemorrhage by a factor of x3 @officialERblog enhancedrecoveryblog.com
    60. 60. What else can prevent blood loss? @officialERblog enhancedrecoveryblog.com
    61. 61. Reducing blood loss• THR and TKR is associated with significant blood loss• Blood transfusion used to treat the blood loss carries significant risks including transfusion reaction, disease transmission, coagulopathy, renal failure and death.• Various methods are reported to reduce blood loss after TKA such as hypotensive anaesthesia, compression bandaging and cryotherapy and antifibrinolytics. @officialERblog enhancedrecoveryblog.com
    62. 62. Tranexamic acid• Intra - operative Tranexamic acid reduces postoperative and total blood loss and the need for blood transfusion. Husted et al. Acta Orthop Scand 2003;74(6):665-9 @officialERblog enhancedrecoveryblog.com
    63. 63. Rationale behind tranexamic acidprotocol to help reduce blood loss• 3 antifibrinolytics have been used in orthopaedic surgery Aprotinin, Epsilon Aminocaproic Acid (EACA) and Tranexamic acid.• Aprotinin withdrawn from use after trials showed increased mortality• EACA less effective than Tranexamic acid at reducing transfusion need post operatively.• Tranexamic acid is a synthetic lysine derivative that acts on the fibrinolytic system. It stops the breakdown of fibrin clot by inhibiting activation of plasminogen, plasmin and tissue plasminogen activator.• Tranexamic acid inhibits clot lysis more efficiently when administered before clot formation than after the fibrin clot is formed. This may explain why Tranexamic acid is less effective when administered at the end of surgery. It has a 2 hour plasma half life and a 500mg ampoule for iv injection costs £1.55. @officialERblog enhancedrecoveryblog.com
    64. 64. Rationale behind tranexamic acidprotocol to help reduce blood loss• Medline search provided 189 studies, refined to include 31 RCT’s in adult humans. 1966 – 2011. MeSH terms used for initial search: Knee, Hip, Antifibrinolytics, Tranexamic acid, Cyklokapron.• A variety of dosing regimes were used in the trials.• Doses ranged from 10 mg/kg to 150mg/kg in single and multiple injections and infusions. A recent paper failed to show a reduction in blood loss during TKA at 10mg/kg dose. No additional benefit was found with additional doses in the Cochrane review.• Many studies have looked for an increased risk of deep vein thrombosis and pulmonary embolus. Well constructed randomised controlled trials using venography have failed to show an increased rate of thrombosis. The risk of pulmonary embolus, death, stroke and myocardial infarction is not increased.• Cochrane 2011 showed 51% decreased transfusion rate and an average 446mls reduction in blood loss @officialERblog enhancedrecoveryblog.com
    65. 65. A tranexamic acid protocol to helpreduce blood lossTranexamic acid - 15 mg/kg iv slow injection at beginning of anaesthesia• Potential side effects - Nausea, Vomiting, Hypotension• Contraindications – Bleeding diathesis, Pregnancy, Renal failure with creatinine > 250 – Allergy to Tranexamic acid• No increased risk of Death/CVA/MI/DVT/PE/Renal failure @officialERblog enhancedrecoveryblog.com
    66. 66. The use of drains (1)• Intra-articular drains should be avoided• Shown to increase need for blood transfusion, have no significant effect on the occurrence of wound infecitons, hematomas, wound healing, limb swelling, DVT, or LOS• No study has shown a positive effect on blood loss and several have shown greater blood loss with a drain @officialERblog enhancedrecoveryblog.com
    67. 67. The use of drains (2)• If they are used by your surgeons, take them down early.• 90% of drainage occurs in first 12 hours• 97% of drainage occurs in first 24 hours• They limit early mobilisation and increase the “medicalisation” of patients post-opZamora-Navas, Acta Orthop Belg 1999Esler, J Bone Joint Surg 2003Parker, J Bone Joint Surg 2004 @officialERblog enhancedrecoveryblog.com
    68. 68. End

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