Short Stay Knee Arthroplasty

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For this #RAUK21 clinical symposium presentation, I present anesthesia and pain management considerations for short-stay knee arthroplasty including patient selection criteria, intraoperative anesthetic technique, multimodal analgesia, and nerve block options.

Saúde e medicina

Short-stay knee arthroplasty
Edward R. Mariano, M.D., M.A.S.
Professor of Anesthesiology, Perioperative & Pain Medicine
Stanford University School of Medicine
Chief, Anesthesiology and Perioperative Care
Veterans Affairs Palo Alto Health Care System
@EMARIANOMD

@EMARIANOMD
Kurtz S, et al. JBJS 2007
Arthroplasties are increasing

@EMARIANOMD
Arthroplasties are expensive

@EMARIANOMD
Short-stay may cut costs
Tse et al. J Anesth 2017

@EMARIANOMD
Same-day knee arthroplasty cost controversy

@EMARIANOMD
Recommendations
Memtsoudis, et al. BJA 2019
• Neuraxial anaesthesia is an
“opioid-free” option
• No neuraxial opioids in our
practice

@EMARIANOMD
Start with multimodal analgesia
Class Mechanism of Action Options Frequency Considerations
Nonpharmacologic Variable Patient Education
Compression
Cryotherapy
Acupuncture
Electrical Stimulation
Routine No clear guidelines
NSAIDs Nonselective COX-1,2
inhibition
Selective COX-2 inhibition
Ketorolac
Ibuprofen
Celecoxib
Routine Renal insufficiency,
gastric ulcers, platelet
dysfunction,
cardiovascular disease
Acetaminophen Central prostaglandin
synthesis inhibition
Acetaminophen
(Paracetamol)
Routine Hepatic dysfunction
Gabapentinoids Binding to alpha-2-delta
subunits of voltage-
dependent calcium channels
Gabapentin
Pregabalin
If indicated Renal impairment
NMDA Antagonists N-methyl-D-aspartate
blockade
Ketamine
Magnesium
If indicated Severe psychiatric
disorders, raised
intracranial or
intraocular pressure
(ketamine only)
Local and Regional
Analgesia
Sodium channel blockade Spinal/Epidural
Lumbar Plexus ± Sacral Plexus
Femoral Nerve ± Sciatic Nerve
Femoral Nerve ± LIA
Adductor Canal ± LIA
Adductor Canal ± IPACK
LIA Only
Routine Allergy to local
anesthetic, site
infection, available
resources and training
level of staff
NSAIDs = nonsteroidal anti-inflammatory drugs; NMDA = N-methyl-D-aspartate; LIA = local infiltration analgesia;
IPACK = infiltration between the popliteal artery and capsule of the knee
Kandarian, Elkassabany, Tamboli, Mariano. Best Pract 2019

@EMARIANOMD
So many options
Kandarian, Elkassabany, Tamboli, Mariano. Best Pract 2019
or genicular
nerve blocks
or genicular
nerve blocks

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Short Stay Knee Arthroplasty

1. Short-stay knee arthroplasty Edward R. Mariano, M.D., M.A.S. Professor of Anesthesiology, Perioperative & Pain Medicine Stanford University School of Medicine Chief, Anesthesiology and Perioperative Care Veterans Affairs Palo Alto Health Care System @EMARIANOMD

2. @EMARIANOMD Disclosures  None

3. @EMARIANOMD Kurtz S, et al. JBJS 2007 Arthroplasties are increasing

4. @EMARIANOMD Arthroplasties are expensive

5. @EMARIANOMD Short-stay may cut costs Tse et al. J Anesth 2017

6. @EMARIANOMD Same-day knee arthroplasty cost controversy

7. @EMARIANOMD

8. @EMARIANOMD

9. @EMARIANOMD Is our patient a candidate?

10. @EMARIANOMD

11. @EMARIANOMD Memtsoudis, et al. BJA 2019

12. @EMARIANOMD Recommendations Memtsoudis, et al. BJA 2019 • Neuraxial anaesthesia is an “opioid-free” option • No neuraxial opioids in our practice

13. @EMARIANOMD Start with multimodal analgesia Class Mechanism of Action Options Frequency Considerations Nonpharmacologic Variable Patient Education Compression Cryotherapy Acupuncture Electrical Stimulation Routine No clear guidelines NSAIDs Nonselective COX-1,2 inhibition Selective COX-2 inhibition Ketorolac Ibuprofen Celecoxib Routine Renal insufficiency, gastric ulcers, platelet dysfunction, cardiovascular disease Acetaminophen Central prostaglandin synthesis inhibition Acetaminophen (Paracetamol) Routine Hepatic dysfunction Gabapentinoids Binding to alpha-2-delta subunits of voltage- dependent calcium channels Gabapentin Pregabalin If indicated Renal impairment NMDA Antagonists N-methyl-D-aspartate blockade Ketamine Magnesium If indicated Severe psychiatric disorders, raised intracranial or intraocular pressure (ketamine only) Local and Regional Analgesia Sodium channel blockade Spinal/Epidural Lumbar Plexus ± Sacral Plexus Femoral Nerve ± Sciatic Nerve Femoral Nerve ± LIA Adductor Canal ± LIA Adductor Canal ± IPACK LIA Only Routine Allergy to local anesthetic, site infection, available resources and training level of staff NSAIDs = nonsteroidal anti-inflammatory drugs; NMDA = N-methyl-D-aspartate; LIA = local infiltration analgesia; IPACK = infiltration between the popliteal artery and capsule of the knee Kandarian, Elkassabany, Tamboli, Mariano. Best Pract 2019

14. @EMARIANOMD

15. @EMARIANOMD So many options Kandarian, Elkassabany, Tamboli, Mariano. Best Pract 2019 or genicular nerve blocks or genicular nerve blocks

16. @EMARIANOMD So many options Kandarian, Elkassabany, Tamboli, Mariano. Best Pract 2019 or genicular nerve blocks or genicular nerve blocks

Short Stay Knee Arthroplasty

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