LAS VEGAS -- Knee replacement patients spent fewer days in the hospital and had improved pain scores after new protocol eliminated motor nerve blocks and reduced opioid medication use, researchers reported here.
After introducing a "rapid recovery" protocol, total knee replacement patients spent an average of 1.5 fewer days in the hospital, reported pain scores 1.6 points lower on a standard 10-point scale, and 26% fewer transfers to skilled nursing facilities, compared with pre-protocol patients, according to , of Cuyuna Regional Medical Center in Crosby, Minn., and colleagues.
Action Points
- This study was published as an abstract and presented at a conference. These data and conclusions should be considered to be preliminary until published in a peer-reviewed journal.
"Data demonstrates the positive impact and advantages of an easily translatable rapid recovery protocol using non-opioid medicines and motor sparing nerve blocks," Severson said in a presentation at the annual meeting of the .
"Patients were able to discharge on day 1, pain scores were markedly better, and the overall healthcare costs can be diminished due to shorter length of hospitalization and less need for skilled nursing facilities," Severson added.
A single surgeon performed 50 surgeries before and 50 surgeries after the implementation of the rapid recovery protocol for total knee arthroplasty patients. A medial parapatellar approach with standard length incision was used in each case, and no changes were made in the surgical techniques between pre- and post-protocol patients.
Patients in the pre-protocol group averaged 69 years of age, and those in the post-protocol group averaged 67 years of age.
No patients were excluded from the study.
Prior to the new protocol, patients were given multi-modal analgesia prior to surgery: a peripheral femoral nerve block consisting of a bolus 0.2% ropivacaine 20 mL followed by IV infusion 0.1% ropivacaine 8 mL/hr; and perioperative narcotic pain medications of 10 mg of OxyContin for patients under 80 years, or 150 mg of pregabalin (Lyrica) for patients 70 and older, or 75 mg pregabalin for patients under 70 years; plus 325 mg aspirin.
During surgery, patients were given an IV infusion of 1 g of tranexamic acid prior to incision and again during closure, and fentanyl and/or hydromorphone titrated to achieve the desired analgesic effect.
The femoral nerve catheter continued until the evening of day 1. Tramadol was given every 6 hours, oral opioids were available every 3 hours, and rescue IV opioids were given for severe pain. Physical therapy was scheduled to begin on post-operative day 1.
With the new rapid recovery protocol, patients were given a single-shot, motor-blocking preoperative adductor canal block of 20 mL of 0.5% ropivacaine, 50 mcg clonidine, and 1:400,000 epinephrine.
During surgery, patients received a long-acting local analgesic of 20 mL 0.25% bupivacaine liposome injectable suspension, and 1:400,000 epinephrine, an IV with 1 g of tranexamic acid, and opioid titration, 1,000 mcg acetaminophen every 0.8 hours for three doses (first dose given after the implant was placed), 30 mg or 15 mg (based on age) IV ketorolac 0.6 hours for four doses (first dose during closure), and 266 mg liposomal bupivacaine (20 mL diluted with 20 mL saline) injected into the posterior capsule midway through the procedure and subcutaneously prior to closure.
Postoperative IV acetaminophen and ketorolac tromethamine were given for 24 hours, but narcotics were only given for breakthrough pain.
After 24 hours, acetaminophen/ketorolac medications were transitioned from IV to oral doses.
For mild pain, patients were given tramadol, for moderate pain, oral opioids and tramadol were administered, and rescue IV opioids were additionally available for severe pain.
With no femoral nerve block-associated motor weakness, patients in the protocol group were able to begin physical therapy the day of surgery, compared with day 1 for patients in the pre-protocol group.
On average, patients in the rapid recovery protocol group were discharged after 1.7 days compared with 3.2 days for patients in the pre-protocol group (P<0.001).
Postoperative pain scores on the day after surgery averaged 3.2 out of 10 for patients on the new protocol compared with 4.8 out of 10 for patients in the pre-protocol group (P<0.002).
In the pre-protocol group, patients used 31.47 mg of opioids in the first 24 hours compared with 20.65 mg in the rapid recovery protocol group (P<0.001).
Discharges to skilled nursing facilities were more common in the pre-protocol group than the protocol group, 34% versus 8%, respectively (P not reported).
Readmission rates were identical, as one patient in the pre-protocol group returned for constipation and one patient in the protocol group returned for wound dehiscence.
The authors reported similar complication rates between groups.
In the pre-protocol group, one pulmonary embolism and two cases of pneumonia were reported. In the protocol group, one case of nausea and one instance of urinary retention were reported (P=0.446).
"Collaboration among surgeons, anesthesiologists, physical therapists, and nurses are essential for success," Severson said.
Disclosures
Gujer reported a financial relationship with Pacira. None of the other authors reported relevant financial relationships with industry.
Primary Source
American Academy of Orthopaedic Surgeons
Atchison F, et al "Rapid recovery protocol in total knee arthroplasty" AAOS 2015; Paper 072.