Outpatient total joints

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caligas

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anybody doing these? Supposedly coming down the pipe for us (for very select patients that are able to meet all the discharge criteria).
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caligas said:
anybody doing these? Supposedly coming down the pipe for us (for very select patients that are able to meet all the discharge criteria).
Click to expand...

As a guy who has had two of them, No Way in Hell would I have one as an outpt.
Just because one can do something, doesn't mean that one should do something.
 
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caligas said:
anybody doing these? Supposedly coming down the pipe for us (for very select patients that are able to meet all the discharge criteria).
Click to expand...

we do some carefully selected total hips and knees in outpatient setting, but with overnight stay for observation before sending home in the morning. Basically healthy motivated patients where they can get home PT set up to start on POD #1.
 
Mman said:
we do some carefully selected total hips and knees in outpatient setting, but with overnight stay for observation before sending home in the morning. Basically healthy motivated patients where they can get home PT set up to start on POD #1.
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That doesn't sound like outpatient
 
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leaverus said:
That doesn't sound like outpatient
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Technically it is "observation" which is not an admission.
The key with all of this is preoperative teaching, and home followup.

For the motivated, intelligent, healthy patient, the actual hospital doesnt really add all that much to their care other than being a lot more convenient for getting all the pieces in place. Look at how often these patients are having any sort of intervention on the floor postop. The biggest questions are pain control and mobilization.

Must have motivated patients that are pretty savvy and healthy though, it would be a disaster to send the vast majority of the patients we see for joints home. Most of mine would fall on their way outside to smoke because their hands were too full of beer and cheese to use their crutches.


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leaverus said:
That doesn't sound like outpatient
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It's not outpatient, but it's also not getting admitted. They certainly aren't d/c'ing home from PACU. It's a free standing facility with no physician in house overnight so it's just observation til the morning when they get discharged.
 
Caveat emptor. Private orthos just want to take these to their centers, and leave the hospital anesthesiologists to figure out all the kinks in the system. Just watch. They have no problem taking food off your plate.
 
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I've done a few true outpt TSA's, but it's not the norm. Have yet to see anyone book a total hip or knee as an outpatient case.
 
Have not done a total joint in a surgicenter setting before but I know of a couple places in my area that do them. pretty ballsy if you ask me.
 
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We do them in selected patients. Both GA and spinal. Surgeon injecting TKA solution - has decadron, bupi and something else that I'm blanking on right now. They get preop tylenol, ditropan and celebrex. Used to give gabapentin but no longer. Everyone gets PONV prophylaxis and an IVF bolus (these are all otherwise healthy people - no significant cardiac or renal disease).

Biggest problem we have had is urinary retention. Honestly, preop teaching and prep is the only way to make this work.
 
loveumms said:
Biggest problem we have had is urinary retention. Honestly, preop teaching and prep is the only way to make this work.
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What's in your spinal cocktail? There's a literature quoted rate of 30% retention with duramorph, though we routinely give 0.1mg and haven't had any issue. Patient's are getting foley's during the case either.
 
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facted said:
What's in your spinal cocktail? There's a literature quoted rate of 30% retention with duramorph, though we routinely give 0.1mg and haven't had any issue. Patient's are getting foley's during the case either.
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I had a spinal for one and a general (LMA) for the other with fem/sciatic both times. No problem with retention with the spinal, had to be in and out cathed for the general. Go figure.
Avoiding spinal isn't a guarantee against retention.
Also, fem/sciatic blocks didn't affect my mobility enough to mention.
 
facted said:
What's in your spinal cocktail? There's a literature quoted rate of 30% retention with duramorph, though we routinely give 0.1mg and haven't had any issue. Patient's are getting foley's during the case either.
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Never any opiates b/c worried about respiratory depression. Straight local and then nerve block post op.

Bladder scan in PACU if not voided within certain time frame (can't remember what it is off the top of my head). Then straight cath if >800ml. Otherwise fluids and ambulation to try and get them to void.
 
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Any thoughts on outpatient total shoulders at an ASC? It seems like most of these patients are elderly. In the hospital setting we do them with GA plus ISB.
 
kmurp said:
Any thoughts on outpatient total shoulders at an ASC? It seems like most of these patients are elderly. In the hospital setting we do them with GA plus ISB.
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We do them at our surg center, same GA + ISB. Patients have the option to return in the morning for a quick reblock, and we often add some precedex or decadron to the block for Friday cases so they're covered for the weekend.
 
Dejavu said:
As a guy who has had two of them, No Way in Hell would I have one as an outpt.
Just because one can do something, doesn't mean that one should do something.
Click to expand...
I had my THA done as an outpt last year. It was great. Wouldn’t want it any other way now.
 
I’ve done two outpt THA’s this year. Pts seem to like it. It’s new for our facility.
 
I also did a couple uni knees over 15yrs ago as outpts. Not sure how they went though. I don’t think uni’s are even that popular. I wouldn’t have one.
 
We're doing the majority of our TKAs/THAs as outpatients at one of our three hospitals. Strict protocols, careful patient selection, home PT. Legitimate outpatient - out the door 4-6 hrs postop. Virtually all SAB with an adductor canal block added for the knees. Multimodal analgesics (ketamine, gaba, dexamethasone, IV acetominophen, ketorolac, etc.) with no narcotics. I was a huge skeptic but hard to argue with the results.
 
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jwk said:
We're doing the majority of our TKAs/THAs as outpatients at one of our three hospitals. Strict protocols, careful patient selection, home PT. Legitimate outpatient - out the door 4-6 hrs postop. Virtually all SAB with an adductor canal block added for the knees. Multimodal analgesics (ketamine, gaba, dexamethasone, IV acetominophen, ketorolac, etc.) with no narcotics. I was a huge skeptic but hard to argue with the results.
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How much ketamine?
How are you giving it?
Are these pts on other sedatives (propofol infusion) during the surgery and you add some ketamine to it?
 
We do them for very select patients. For knees our cocktail involves spinal (ropi 17.5 mg, 25 mcg fentanyl) + adductor (bupi, clonidine, Dex, buprenorphine, and epi) + ropi sciatic block.

We had been placing adductor canal catheters but the surgeons were sending them home the next day and only get 20-24 hours out of the infusion.

A single shot adductor with the Adjuvants above lasts a whole lot longer than that.

Most of our knees and hips stay one night... Though we hear it is going to be more common coming down the pipe, too.

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The Physician Philosopher said:
We do them for very select patients. For knees our cocktail involves spinal (ropi 17.5 mg, 25 mcg fentanyl) + adductor (bupi, clonidine, Dex, buprenorphine, and epi) + ropi sciatic block.

We had been placing adductor canal catheters but the surgeons were sending them home the next day and only get 20-24 hours out of the infusion.

A single shot adductor with the Adjuvants above lasts a whole lot longer than that.

Most of our knees and hips stay one night... Though we hear it is going to be more common coming down the pipe, too.

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Click to expand...

we are doing THAs and TKAs in surgicenters and pts go home in 4hrs or so after surgery, spinal, propofol infusion, adductor block
 
Noyac said:
How much ketamine?
How are you giving it?
Are these pts on other sedatives (propofol infusion) during the surgery and you add some ketamine to it?
Click to expand...
0.5mg/kg, usually 10mg with midaz 2mg for SAB and block, then the balance once we get to the OR, arbitrary max of 50mg. Propofol infusion 25-100mcg/kg/min.
 
jwk said:
0.5mg/kg, usually 10mg with midaz 2mg for SAB and block, then the balance once we get to the OR, arbitrary max of 50mg. Propofol infusion 25-100mcg/kg/min.
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Twice lately I’ve had some real healthy relatively young pts that got <50mg that took at least 4hrs post-op to clear their head. That’s not cool especially when you are trying send them home.
 
:bored:You got me all wrong Salty, I use US. I just don’t need it.
 
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As a wise old anesthesiologist once said:

“Poor studies drive me nutz.”
 
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facted said:
30 pts in the ACB group... And somehow they have a defecit compared to Femoral block group?

What's the mechanism there? This is statistical noise.
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Guys.. the journal it is published in has an impact factor of 0.26

I have literally never seen one that low. I felt bad having to submit a manuscript to a journal with an impact factor of 1.5

This is beyond garbage and was published as such.

Screenshot_20180319-191928.jpg


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facted said:
30 pts in the ACB group... And somehow they have a defecit compared to Femoral block group?

What's the mechanism there? This is statistical noise.
Click to expand...


In the discussion, the authors speculate that the smaller caliber of the nerve to the vastus makes it more susceptible to local anesthetic neurotoxicity. Also the results were the opposite of the working hypothesis of the study and a surprise to the authors.
 
nimbus said:
In the discussion, the authors speculate that the smaller caliber of the nerve to the vastus makes it more susceptible to local anesthetic neurotoxicity. Also the results were the opposite of the working hypothesis of the study and a surprise to the authors.
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Guys... It's a bad publication in a terrible journal.


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The Physician Philosopher said:
Guys... It's a bad publication in a terrible journal.


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Click to expand...


Do you have a specific critique besides the publication in a low impact journal? Is it the low n?

The topic of persistent weakness after peripheral nerve block is worth investigation, especially in the setting of a sports medicine heavy practice. It matters to these patients and they should be informed.
 
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nimbus said:
Do you have a specific critique besides the publication in a low impact journal? Is it the low n?

The topic of persistent weakness after peripheral nerve block is worth investigation, especially in the setting of a sports medicine heavy practice. It matters to these patients and they should be informed.
Click to expand...

Where do I begin?

1) There is no description of adductor canal blockade versus femoral blockade. For this (single) institution, where does the femoral triangle end and the adductor canal start? I can tell you what I think, but the authors of this paper certainly don't. They even state in their own paper "Adoni et al1 demonstrated a 36% decrease in short-term vastus medialis strength in patients who underwent “typical” ACB but no strength reduction in patients who received a more distal saphenous nerve block. "

2) Bias is also huge. Retrospective. How did they recruit patients? ("Hey, we are doing a study on people to make sure muscle strength isn't diminished after the nerve blocks we perform?")

3) Why does 6 months matter more than 4 months? 2 months? 9 months? a year? seems like a randomly chosen time point.

4) What is the clinical significance (for athetes or otherwise) for having this difference at 240 degrees instead of 60?

I could go on...but it's published in a journal with an impact factor of less than 0.3.... which means they submitted to a bunch of other journals that rejected them until they found this one...
 
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So is there an agreement on where in the thigh to do the adductor canal block? I get the sense from reading that lower in the thigh, one could miss the nerve to the vastus and get less good pain control. Higher in the thigh, at the top of the canal or even in the femoral triangle might be better.
 
jwk said:
0.5mg/kg, usually 10mg with midaz 2mg for SAB and block, then the balance once we get to the OR, arbitrary max of 50mg. Propofol infusion 25-100mcg/kg/min.
Click to expand...

Man that much prop seems a lot like room air general
 
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kmurp said:
So is there an agreement on where in the thigh to do the adductor canal block? I get the sense from reading that lower in the thigh, one could miss the nerve to the vastus and get less good pain control. Higher in the thigh, at the top of the canal or even in the femoral triangle might be better.
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The answer is no.

Some say that where the adductor long ends is the start of true adductor canal. You are right in that the further distal you go the less likely you are to block the nerve to the vastus medialis. That said, there is less likely quad weakness there, too.

So, I go as distal as I can where the superficial femoral artery is still underneath the sartorius. Good results with analgesia while sparing the quad.

TPP

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kmurp said:
So is there an agreement on where in the thigh to do the adductor canal block? I get the sense from reading that lower in the thigh, one could miss the nerve to the vastus and get less good pain control. Higher in the thigh, at the top of the canal or even in the femoral triangle might be better.
Click to expand...

1/2 way from ASIS to proximal edge of the patella. Then scan a few cm each way until you get a clear view of the nerve.
 
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