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Dr Matthew Checketts, NHS Tayside [PDF - 6Mb] - 18 Weeks

Dr Matthew Checketts, NHS Tayside [PDF - 6Mb] - 18 Weeks

Dr Matthew Checketts, NHS Tayside [PDF - 6Mb] - 18 Weeks

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Anaesthesia forEnhanced RecoveryArthroplasty<strong>Dr</strong> M.R.<strong>Checketts</strong>, Dundee


ObjectivesMobilisationAnalgesia


<strong>18</strong>/10/11GPReferral• Optimise• Health Improvement• Patient Info• Start d/c planEnhanced Recovery MapPACPre‐Operative• <strong>Dr</strong>ink until2hr before• Short Fast• StartGabapentinIntra‐OperativeFast offsetGA/RA• walk on day ofsurgery• oral hydration &nourishment• Stop IV fluids inrecovery•No wound drains•No Catheters•Regular oral analgesia•minimum opioidsPost‐Operative DX on planned day Increase therapy support telephone follow upFollow‐up12


Enhanced Recovery• Empowers the patient to lead their rehab• Facilitates early mobility• Provides effective analgesia• Reduced side effects• Reduces Hospital LoS• reduced HAI? Patients happy, £250per day saved• Reduces Mortality


• Gabapentin 300mg bdERA Package• Tranexamic Acid 15mg/kg• Spinal anaesthesia 10mg LB, no opioid• Local Anaesthetic Infiltration (LIA)• 150 ml 0.2% Ropivacaine• LA infusion for 24 hrs (for TKR only)• 10 ml/hr 0.2% Ropi via elastomeric ball• No routine catheter or postop iv fluids• Oxycontin/Paracetamol/NSAIDs8


Analgesia facilitates mobilisation• TKR• LIA• 1700 hrs• 4 hrs postopQuickTime and aH.264 decompressorare needed to see this picture.


•THR patient 75 minutesafter end of surgeryTHRQuickTime and aH.264 decompressorare needed to see this picture.


• 1081 patients•••LoS reduced from 6 to 4 daysTransfusion only 0.6%Urinary catheter from 35% to 7%


Pain scoresDay 0 Day 1 Day 2


Pre-Assess. Clinic• Identify risk factors• Ensure co-morbidities are “optimised”• Detect & treat Anaemia• Health Improvement• Patient Information


• ParacetamolMy Recipe• Gabapentin 300mg bd• Dexamethasone 8mg• Ketamine 0.5mg/kg• NSAIDs if no contra-indication• Tranexamic Acid• Spinal anaesthesia 10mg LB, no opioid• Local Infiltration Analgesia (LIA)• LA infusion for 24 hrs (TKR only) -10ml/hr 0.2% Ropivacaine• No routine catheter or postop iv fluids• Multimodal analgesia 8


Multi-modalanalgesiaGabapentinoidsminimalOpioidsketamine,steroidsNSAIDs& Cox2sParacetamolLAs


Gabapentin & Pregabalin• anti-allodynic• anti-hyperalgesic• reduction of central sensitisation• opioid sparing (~30mg -dependent)not doseAnesth Analg 2007;104:1545-56


•Reduced pain scores•Reduced morphine consumption•Reduced opioid side effects•Increased sedation in some•Optimal dose & duration not definedyet


Gabapentin, NSAIDs & Ketamine are opioid sparing andreduce opioid side-effects (Level 1)


GlucocorticoidsDexamethasone reduces postoperative pain, PONV &fatigue (level 1)


• Less pain on walking up to 32hrs• Lower rescue oxycodone analgesia• Less fatigue• No complications


• 3449 patients (gynae)• No increase rate of SSI if receiveddexamethasone


Opioid sparing effect, anti-hyperalgesic, preventativeanalgesia


Spinal AnaesthesiaDose?• ED50 for LB for LL surgery is 5.7mg• 15mg LB gives ~ 3-4 hrs surgicalanaesthesia• takes ~ 6 hrs to completely regress• 10 mg LB gives ~ 2 hrs surgicalanaesthesia• takes ~ 3-4 hrs to regressLee YY, Anesth Analg 2009;109:1331–4


Spinal Anaesthesiadose response?Bupivacaineminsless hypotension if


Bupivacaine dose -response per mgLui S, Anesth. 1996;85:729-36


Doses for ERA?• THR -• TKR -7.5-10mg LB, or 60mg Prilocaine5-10mg LB or 40-60mg Prilocaine


Intrathecal Morphine%Raffaeli W EJA 2006, 23:7:605-10


• Clinically significant nausea & vomiting, pruritisand urinary retention14


Dundee ERA Pilot 2010Urinary Catheter Rate%


PCA mgmorphineused


Is Femoral Nerve Block Useful inTKR• Analgesia for the wound but not the knee• All intra-articular structures innervated bybranches of the tibial nerve (ie not blocked by FNB)• Posterior knee pain is main problem• No evidence that cFNB better than ssFNB*


PNB = motor block = No Cigar!• Unhappy patients,nurses, physios &surgeons• Can very low LAconcentration sparequadriceps function?


Best Motor Score in 36hr


low dose blocks?• “despite the use of ultra-lowconcentrations of LB, mild motor block -manifest as impaired SLR or inability todorsiflex - still occurred in the majority ofpatients, and prevented early mobilization.Furthermore,patients felt that movementwas restricted by the weight of the blockedleg”


Charous MT -Anesthesiology 2011FNB: Quads power reduced by84%5ml/hr 0.1% Ropi


Need knee brace withFNBQuickTime and aH.264 decompressorare needed to see this picture.


• pooled data from 3 RCTs• 7 falls in 6 patients with cFNB or cLPB(n=85)• 0 falls in placebo group (n=86)• “our analysis suggests that there is a causalrelationship between cPNB and risk offalling..”Anesth Analg 2010;111:1552-4


• 10<strong>18</strong> patients• 709 had ss FNB• 12 falls (1.7%)• 3 re-operation (0.4%)• 5 femoral neuritis (0.7%)


So...• Spinal opioids make you sick & need acatheter• Nerve blocks paralyse quads, may notprovide great analgesia, make walkingdifficult and increase risk of falls• Neither technique compatible with earlymobilisation• Alternative?


L I A


LocalInfiltrationAnalgesia


Analgesiain thehandsof thesurgeon


[Ropi] after 250mg LIAStringer et al The Journal of Arthroplasty Vol. 22 No. 6 2007TKRTHRRopi toxic effects don’t appear below 2-3 mic/ml


3day reduction in LOS


Day 0 Day 1


%Dundee ERA Project - 1st walk


ERA home 2-3 days sooner than Traditional (SAB +/-cFNB)%


How do we reduce bleeding ?


Tranexamic acid


• Cochrane 2009 issue 4• >200 trials - cardiac, ortho, vascularmainly• Tranexamic acid reduces bleeding by ~30%• No increased VTE risk


Dundee ERA 2010Blood Transfusion%32


Transfusion risk factor for wound infectionSlappendel R 2000 n=982%33


still don’t


QuickTime and aMotion JPEG OpenDML decompressorare needed to see this picture.


Traditionaln=3000ERAn=1500Death -30d 15 (0.5%) 1 (0.1%)Death - 90d 25 (0.8%) 3 (0.2%)


Low VTE rate1977 patientsERA patientsRCTs with prolongedprophylaxisDVT 0.56% 0.3-3.0%PE 0.3% 0.25-1.1%Death 0.16% 0.2-0.9%Husted H Acta Orthop 2010


•http://gallery.me.com/matthew_checketts#gallery•ER Scotland•www.<strong>18</strong>weeks.scot.nhs.uk/service-redesign-andtransformation/enhanced-recovery•ER England & Wales•www.dh.gov.uk/en/Healthcare/Electivecare/Enhancedrecovery/index.htm•http://www.enhancedrecoveryblog.com

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