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Short Stay Knee Arthroplasty

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Edward R. Mariano, MD
Edward R. Mariano, MD

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.

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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 Disclosures  None
@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
@EMARIANOMD
@EMARIANOMD Is our patient a candidate?
@EMARIANOMD
@EMARIANOMD Memtsoudis, et al. BJA 2019
@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
@EMARIANOMD So many options Kandarian, Elkassabany, Tamboli, Mariano. Best Pract 2019 or genicular nerve blocks or genicular nerve blocks
@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
  • 3. @EMARIANOMD Kurtz S, et al. JBJS 2007 Arthroplasties are increasing
  • 5. @EMARIANOMD Short-stay may cut costs Tse et al. J Anesth 2017
  • 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
  • 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