How Regional Anesthesia Fast-Tracks Surgery

Fast-track surgeries in orthopedics are more important now than ever with health systems looking to get patients up and moving quicker with less time spent in this hospital while also reducing costs.

Fast-track surgeries have the potential to get patients safely out of bed, drinking and eating faster.

Even complex surgeries like total joint replacement are being fast-tracked, and the anesthesia used during surgery plays an important role in how quickly a patient can get back on their feet post-surgery.

At his institution, Emory Healthcare, orthopedic surgeon Thomas L. Bradbury, M.D. says that one of the most important factors in a successful fast track joint arthroplasty surgery is patient preparation and engagement.

“Being able to walk four hours after total hip replacement is not so much about surgical technique or the type of implant used. I think we can all agree that the preoperative ambulatory experience is more important than what happens the day of surgery,” Bradbury said.

Patient Engagement

“Patient selection and their education on what to expect are key and then you can drive engagement in the process, and with that you are rewarded with patient safety and satisfaction which can occur in a short interval after surgery,” he said.

He added, “I think the single most important variable you can control when it comes to the length of stay is what you tell them. If you tell them there is a high chance they will go home the same day, as long as you are safely mobilized and are comfortable enough, there is a high chance your patient will be up and around that day if not the following day and I think that is very important.”

Bradbury explained that there are a lot of details that that go into getting a patient out of the hospital in one day.

He gave an example of the first patient of the day:

“It’s 6 am. He or she spends 30 minutes doing paperwork, 30 minutes getting ready and then back to preoperative holding. Then after their preoperative anesthesia evaluation, they are typically ready for surgery by 7:15 a.m.”

Most of primary arthroplasty cases are completed in an hour or less and then the patient spends 30 minutes to an hour in PACU (Post-Anesthesia Care Unit) before going to the floor. At that point the patient has four hours to demonstrate that he or she is safely mobilized and comfortable enough to go home in the afternoon.

Bradbury said that for all this to get done in such a short interval, team consistency is crucial. And the type of anesthesia the anesthesiologist uses is an integral part of that.

Choosing the Right Anesthesia

The primary anesthesia options include:

1. General

• General endotracheal anesthesia (GETA)
• Total intravenous anesthesia (TIVA)

2. Neuraxial/Regional

• Spinal
• Epidural
• Lumbar plexus in total hip arthroscopy
• Femoral nerve in total knee arthroscopy

According to Bradbury, if you can control these 6 variables—pain, PONV (nausea or vomiting after surgery), cognition, muscle weakness, urinary retention and orthostasis within 4 hours post op—you will win. Your patients will feel better and will be safe.

He said, “There is some data out there that can help us drive decision. Research has found higher occurrence of nausea and vomiting after total hip arthroplasty using general versus spinal anesthesia—1.5-2x increase risk of nausea with general anesthesia. And I think we can all agree that perioperative IV steroid use is making a place for itself in total joint replacement surgery. Best available data shows that it alleviates pain, alleviates nausea and there is no change in risk for PJI (periprosthetic joint infection).”

For Bradbury, cognition is his biggest pet peeve. He pointed to a study, “The Influence of Anesthesia and Pain Management on Cognition Dysfunction after Joint Arthroplasty” published online in Clinical Orthopaedics and Related Research in 2014 found that cognition dysfunction is more common with GETA in first week.

The researchers’ recommendations for using GETA is to optimize the depth of GETA, use non-opioid pain management and oral narcotics whenever possible. They also advise against the use of intravenous morphine and meperidine.

Spinal vs General

He said, “If you go to the recovery room, you can tell who has had a general, who has had a spinal. The spinal folks are sitting up and smiling, drinking ginger ale. While the general anesthetics are generally drooling over themselves or throwing up in a bucket. That has been my general experience. I am a big fan of being cognitive after surgery and this study supports that notion,” Bradbury said.

Orthostatic intolerance during early mobilization after fast-tracked hip arthroplasty is another important variable according to Bradbury.

This dangerous condition occurs when a patient experiences cerebral hypoperfusion upon standing. Symptoms include dizziness, nausea, blurred vision, diaphoresis and syncope.

Orthostatic intolerance during early mobilization after fast-tracked hip arthroplasty is unfortunately very common, 40% within 6 hours post op and 20% within 24 hours post op. It is associated with impaired cardiovascular orthostatic response; however, not associated with hemoglobin or opioid therapy so using orthostasis as an indicator for transfusion is probably a poor practice, according to Bradbury.

He said that while the precise pathophysiological mechanism is unknown it does appear to involve impaired reflex vasoconstriction and autoregulation of cerebral perfusion.

Regional vs General? Lidocaine vs Bupivacaine?

What about anesthesia effects beyond the day of surgery? Bradbury said there is a lot of data on this as well.

“Effects of Regional Versus General Anesthesia on Outcomes After Total Hip Arthroplasty” by Mohammad A. Helwani, M.D. and colleagues published in the Journal of Bone and Joint Surgery in February 2015 looked at the difference between general and regional anesthesia. The authors found that with regional anesthesia, surgical site infection, length of stay and cardiopulmonary complications as a whole were reduced.

In “Comparison between two different selective spinal anesthesia techniques in ambulatory knee arthroscopy as fast-track anesthesia” published in the January-April 2015 issue of Anesthesia, Essays & Researches, researchers reported a difference in motor block and sensory function between lidocaine and bupivacaine.

They found there was a significant different in the duration of the motor block between the two groups, with the lidocaine group having a substantially shorter duration of motor block (Group B: 136.5±11.2 minutes, Group L: 60.7 ± 9.6 minutes, p < 0.001).

The Devil in the Details

Bradbury said that when it comes to using spinal anesthesia, “the devil is in the details” and there are a lot of options available. He explained the approach they use at his institution.

“We have had a fair amount of success with safety and early mobilization with this cocktail and this requires a lot of corroboration with your anesthesiologist and it is of my opinion if you are an orthopedic surgeon you need to act like their anesthesiologist.”

“Although they are a good colleague they are not, at our institution, going on rounds. They really don’t know the effects of what they do the day of surgery, so you have to be intimately involved in this decision.”

He added, “A lot of times your anesthesiologist will say no when you ask for lidocaine because of transient neurologic symptoms (TNS) and I think this is a crock. I have not had any cases of this.”

Transient neurologic symptoms include bilateral sensations of paresthesia occurring within the first days after the operation, pain or dysesthesia or both occurring in the legs or buttocks after recovery from spinal anesthesia, and any type of bilateral or unilateral pain, numbness, or hyperalgesia in the back; or radiating pain to waist, buttock, hip or anterior or posterior regions of leg or thigh.

At Bradbury’s institution they have evolved over the years in their anesthesia technique. When he first started they used the traditional general anesthesia and then moved on to bupivacaine or mepivicaine spinal and now lidocaine spinal.

Lidocaine for Spinal?

So why lidocaine for spinal anesthesia?

According to Bradbury, it provides dense block, the duration of sensory block is perfect, and the duration of motor block is less dense and shorter than with bupivacaine. There is also less risk of urinary retention.

Their current protocol is lidocaine spinal for primary total knee arthroscopy and total hip arthroscopy, bupivacaine spinal for revision total knee arthroscopy because surgeons need a little more time, and general anesthesia for tough hip revisions or surgeries in the lateral, revision total hip arthroscopy, and total hip arthroscopy in lateral position.

Their lidocaine protocol is to give the patient 20mg MS Contin preoperatively and then in the operating room:

• Spinal
  • 100 mg of 2% isobaric plain lidocaine
  • No intrathecal narcotics
  • No epidural
• Decadron: 10mg IV
• Ketorolac: 15 mg-30 mg IV

Bradbury said, “And then in PACU we give the patient oxycodone 5mg postoperatively. This is our transition the last several years. With lidocaine we had much higher success rate with all the variables.”

Overall, he said, regional anesthetic techniques show advantages, and the specifics of regional techniques play a large role in day of surgery performance.

“When looking at the side effects profile at four hours for GETA vs bupivacaine vs lidocaine, lidocaine has the best success rates over all six variables (PONV, cognition, muscle weakness, urinary retention, pain, 0rthostasis).”

Meet Dr. Bradbury at the Upcoming ICJR South Hip and Knee Course

Bradbury’s research was originally presented at the International Congress for Joint Reconstruction’s 5th Annual South Hip and Knee Course, during “Fast-Track Anesthesia and Pain Management Protocols.”

Bradbury’s presentation on fast-track anesthesia is also on the agenda for the 6th Annual ICJR South Hip & Knee Course which will be held June 21-23, 2018 in Key Largo, Florida at the Ocean Reef Club.

The conference is designed for orthopedic surgeons and allied health professionals looking to learn the latest in orthopedic technology, surgical technique and optimum patient care. The course will include current controversies in total knee arthroplasty and total hip arthroplasty, enhanced recovery and outpatient arthroplasty, live surgery and perioperative patient management.

To register, click here: https://icjr.net/meeting/2018-6th-annual-icjr-southrlo-spring-hip-knee-course. To livestream the conference, click here: https://icjr.net/meeting/2018-6th-annual-icjr-south-hip-knee-courselivestream.