Surgeons leverage resources to make outpatient surgery safer

Experienced outpatient surgeons can help others implement outpatient programs.

Keeping patients safe during and after orthopedic outpatient surgery of all types — arthroscopy, joint replacement, hand, spine and other procedures —will be of ongoing concern as the frequency with which these procedures are performed increases and anesthesia and surgical protocols evolve. The American Academy of Orthopaedic Surgeons stated in a position statement that with the continued advancement of medical technology comes more opportunities for outpatient surgery to be utilized. However, lingering concerns about the safety of outpatient orthopedic surgery remain.

“It is all about appropriate planning. If there is a question, I think we, as surgeons, have to be able to not hesitate to get further input to see if other people involved think it is safe,” Thomas M. DeBerardino, MD, professor of orthopedic surgery at the Baylor College of Medicine and Orthopedics Today Board Member, told Orthopedics Today.

Although orthopedic surgeons typically do not expect to encounter problems during outpatient surgery, he said it is important to run “through the scenarios and [see] if the system of the local outpatient surgery center can handle” any problem that may occur.

Source: Sandra Giunta

Procedures that leverage technology

Outpatient surgery should be avoided in patients with organ failure or advanced cardiac disease, several sources who spoke with Orthopedics Today said. However, surgeons should not limit which patients should undergo outpatient surgery, but, instead, should simply be more selective of which procedures are performed in any outpatient setting, they said.

Outpatient spine procedures are now limited to smaller operations, such as vertebroplasty, microdiscectomy and anterior cervical discectomy and fusion, and are performed in the healthiest, youngest patients, according to Michael Y. Wang, MD. However, by leveraging multiple technologies, Wang said he and his colleagues have been able to perform more complex surgeries, such as lumbar spine fusions, through their awake spinal fusion program.

“We are trying to leverage technology as opposed to cherry picking the best cases and that is a big departure from what normally happens,” Wang, professor of neurological surgery at the University of Miami, told Orthopedics Today. “It is in response to the health care system, in response to the potential restriction and resources for spine surgery,” he said.

Adolph V. Lombardi Jr., MD, FACS, who operates at a surgical center at which 7,500 outpatient total joint replacement procedures were performed between 2013 and 2018, said surgeons at the center perform outpatient total hip replacements, total knee replacements and partial knee replacements in about equal numbers, and they have also completed a number of outpatient revision THRs and TKRs.

Similarly, DeBerardino, who specializes in arthroscopy and sports medicine surgery, has done nearly every type of arthroscopy surgery he performs in an outpatient setting.

“There are none that I would not do or have not done or could not do and do not plan to do in the future,” DeBerardino said.

With the advancements in and increased use of what is known as wide-awake local anesthesia no-tourniquet (WALANT) hand surgery, a large variety of the most common hand surgeries can be performed outpatient without general or regional anesthesia, such as carpal tunnel release surgery, trigger finger release surgery, Dupuytren’s release surgery and finger and wrist mass excision, according to Asif M. Ilyas, MD.

In addition to those procedures, “there are many more that can be performed wide-awake, including just about any procedure of the fingers ... and most procedures of the hand and wrist, as well,” Ilyas, who is program director of hand surgery fellowship and professor of orthopedic surgery at Rothman Orthopaedic Institute at Jefferson, told Orthopedics Today.

Randall W. Culp, MD, partner at the Philadelphia Hand to Shoulder Center and professor of orthopedic hand and microsurgery at Thomas Jefferson University, said there are certain microvascular cases, free tissue transfers and toe transfers that are not amenable to WALANT.

“I think that some lengthy procedures, when the patient is wide-awake for more than a few hours, are not necessarily candidates for WALANT,” Culp, who is an Orthopedics Today Editorial Board Member, said.

Surgeons who are unsure whether a patient should undergo outpatient surgery should consult their anesthesia colleagues, sources said.

According to DeBerardino, patients with an American Society of Anesthesiologist (ASA) score of 1 or 2 can safely undergo surgery in an outpatient setting, but outpatient surgery should be avoided in patients with an ASA score of 4. For patients with an ASA score of 3, surgeons should have the anesthesia team perform a quick, cursory medical review to confirm the “patient is ready and safe and able to proceed with an outpatient surgical intervention,” DeBerardino said.

“When they are more complicated and involved patients, the biggest safety net is to have them preemptively go visit with the anesthesia team,” he said.

DeBerardino continued, “Only through the eyes of a subspecialist, like an anesthesiologist, would they be able to tell anesthesia was safe.”

Efforts to reduce complications

Preoperatively optimizing patients can help reduce complications in outpatient surgery, according to Lombardi.

DeBerardino noted patients should receive detailed written instructions, as well as have a face-to-face discussion with someone from the surgical team about what to expect regarding the operation and postoperative care.

“There is a discussion with the patient at the time of initial evaluation. There are educational materials that are provided to the patient in the form of written materials and they also receive a formal preoperative physical therapy evaluation and instruction,” Lombardi, president of Joint Implant Surgeons, told Orthopedics Today.

Prior to when any outpatient surgery gets underway, implementation of a surgical timeout will help confirm patient and procedure information with everyone involved in the patient’s surgical care, and can help avoid mistakes, Ilyas said.

“It is a time where you empower everyone on the team to be able to pull the emergency brake on the train if they think anything’s amiss: room setup wrong, wrong limb was prepped and draped,” DeBerardino said. “It happens mostly in outpatient settings because of the fast pace, so that is a huge thing with patient safety.”

During outpatient arthroscopy surgery, he said adequate visualization is important for quicker, more efficient surgery and greater patient safety, he noted, saying the advent of ultra-high definition or 4K technology has improved visualization during arthroscopic surgery to the surgeon’s and patient’s benefit.

“It is all about 4K technology, the highest definition that we have in the medical field,” DeBerardino said. “It is a safety and efficiency builder because if we can see better, we can do things safer and more efficiently. That means less OR time and OR time is related to risk of infection and complications, so anything we can do safely, quicker is better than slower and less safe.”

Changes with anesthesia

DeBerardino added surgeons also need to be sure they are providing patients with adequate multimodal pain management to avoid postoperative ER visits.

“We need to make sure to avoid bounce backs or visits to the ER [and] inadvertent phone calls [from patients] for not understanding how to control their pain,” he said. “[Also] that we have adequately covered all the different options available to us in 2019, whether it is regional blocks with our anesthesia partners, intra-articular pain medications, adjuvant pain therapy, preoperative and perioperative multimodal pain management. It could be IV Tylenol or some of these long-acting injections that we can inject in and around the surgery site.”

According to Lombardi, patients undergoing outpatient TJR receive anesthesia through a multimodal pain approach similar to what is used for inpatient surgery.

“A typical knee patient will receive an adductor canal block and an [injection between the popliteal artery and posterior compartment of the knee] iPACK block in the interspace between the popliteal artery and the posterior capsule, so we can minimize the amounts of narcotics,” Lombardi said.

Patients will receive perioperative antibiotics, tranexamic acid and dexamethasone. Patients with a normal kidney status who are not allergic to sulfa will also receive Celebrex (celecoxib, Pfizer), he said.

For outpatient spine surgery, Wang noted surgeons should have as small of an anesthetic footprint as possible. That strategy can be an issue “as spine surgeries are typically painful,” he said.

“What we rely heavily on are two things: one is minimally invasive techniques and the second is using Exparel, which is the long-acting regional anesthetic,” Wang said.

Alok D. Sharan, MD, MHCDS, co-director of the WestMed Spine Center in Yonkers, New York, said for years he and his colleagues performed laminectomies and other small cases with the patients under spinal anesthesia, which proved to reduce the risk of delirium in elderly patients.

“As we became comfortable with doing lumbar cases under spinal anesthesia, we moved then to doing our spinal fusions under spinal anesthesia, which was a big stepping stone for us,” Sharan said. “That worked out well because, by avoiding general anesthesia and the nausea and vomiting associated with it ... we were able to mobilize our patients better.”

Using spinal anesthesia enabled them to reduce patients’ length of stay from 1.4 days to 1.1 days, Sharan said, adding that they then began using regional blocks in the spinal fusion cases, which further reduced the length of stay to 0.8 days.

Sharan and colleagues are using Exparel (bupivacaine liposome injectable suspension, Pacira Pharmaceuticals) for a novel regional block, which has reduced the amount of pain patients experience, he said, noting many patients are off narcotic pain medications by 1 week after fusion.

“Currently, we have a 40% outpatient discharge rate for our lumbar fusions, so 40% of the patients who undergo lumbar fusion with us go home the same day,” Sharan said. “What we found out is that by reducing the general anesthesia, by doing proper anesthesia protocol through adding a regional block, all these things have been able to enable us to do outpatient spine surgery safely.”

Role of lidocaine, epinephrine

One advantage of WALANT is it uses lidocaine and epinephrine as an anesthetic and for hemostasis. Culp told Orthopedics Today these drugs are safe and are typically cheaper than general anesthesia.

When administered, lidocaine is buffered with bicarbonate, which decreases the burning and discomfort patients feel with the infiltration of the anesthetic, while epinephrine creates a bloodless or near-bloodless surgical field, according to Ilyas.

“What that does then is, if you do not have blood in the field, you do not need to have a tourniquet, and if you do not have a tourniquet, you do not need to have sedation to manage tourniquet pain,” Ilyas said. “In addition, if you have a well-blocked surgical field, there is no need to have additional general anesthesia ... because [the patient is] already numb at the site.”

Lidocaine and epinephrine are also advantageous in that they allow surgeons to immediately document the success of a flexor tendon or extensor tendon repair and tendon transfer, according to Culp.

“One of the issues with tendon transfer is that it is sometimes difficult to ascertain the exact, correct tension, but if the patient is wide awake, you can test it immediately,” he said.

Despite precautions taken, a risk that a complication will occur is part of the reality of outpatient surgery. For example, although rare, epinephrine used during WALANT may cause ischemia or vasoconstriction, Ilyas said.

Patients may also experience vasovagal, or loss of consciousness, from the injection, Culp said.

If that occurs, “if the procedure is being done in a sitting position, the patient can merely lie down” Culp said. “That would increase blood flow to the brain and the vasovagal goes away.”

He added, “If the patient is lying down and they get a vasovagal event, you can flex their hips and knees to get more blood flow to the brain.”

Hematoma formation is among the most significant complications that can occur in outpatient spine surgery, according to Wang.

“That can lead to paralysis or death in [anterior cervical discectomy and fusion] ACDF,” Wang said. “The surgeon has to be absolutely meticulous in terms of the care and attention to prevent a hematoma formation after surgery.”

Lombardi said excess bleeding, urinary retention and low oxygen saturations are complications that can occur in outpatient TJR. Increasing the patient’s mobility postoperatively can help keep patients healthy, allow them to go home quicker and help decrease the risk of infection, Lombardi said.

“Getting them up rapidly, moving them so they do not get a blood clot, they do not get pneumonia and they do not have urinary retention because they are up moving. They do not get slow bowels or irritable bowel syndrome or any issues like that because they are back and up in the home environment,” he said.

Implementation of outpatient surgery

Sources who spoke with Orthopedics Today believe outpatient surgery is the future for many orthopedic procedures and encourage orthopedic surgeons to begin implementing outpatient surgery in their daily practice.

“I think every surgeon should first work in a hospital and then, when they are doing cases in the hospital, discharge patients home the same day from the hospital,” Sharan said. “What that would do is help surgeons understand what kind of criteria they have for determining who can be done as an outpatient.”

Wang noted implementation should be done through a methodical and stepwise approach, beginning with manageable, small cases in preselected “young, non-obese, compliant patients who have the financial and social resources to be cared for” following outpatient surgery.

Lombardi said surgeons who want to perform outpatient surgery should find a partner with experience in outpatient surgery or visit a center with a tremendous amount of experience, he said. “Spend the day with your entire staff. You need to bring your anesthesiologists, your nurses, your [physician assistants] PAs and see how the program runs, so you can learn how to do it.”

Even with advice in-hand from someone who is experienced in outpatient surgery, Sharan said orthopedic surgeons must take their own practice and location into consideration before deciding on how to proceed.

“Every surgeon has to start thinking about their own inclusion/exclusion criteria for who should be considered outpatient vs. inpatient,” Sharan said. “In New York City, the practice environment is different than a rural area. I think it is important that surgeons have their own criteria.” – by Casey Tingle

• Reference:
• Position statements: Ambulatory Surgical Centers. Available at: https://aaos.org/About/Statements/Position/?ssopc=1. Accessed March 6, 2019.

• For more information:
• Randall W. Culp, MD, can be reached at 672 S. River St., Suite 217, Wilkes Barre, PA 18705; email: ddesanto@handcenters.org.
• Thomas M. DeBerardino, MD, can be reached at Christus Santa Rosa NW, Tower I, 2829 Babcock Road, #700, San Antonio, TX 78229; email: tdeberardino@tsaog.com.
• Asif M. Ilyas, MD, can be reached at 825 Old Lancaster Road, Bryn Mawr, PA 19010; email: asif.ilyas@rothmanortho.com.
• Adolph V. Lombardi Jr., MD, FACS, can be reached at 7277 Smith’s Mill Road, #200, New Albany, OH 43054; email: lombardiav@joint-surgeons.com.
• Alok D. Sharan, MD, MHCDS, can be reached at 171 Huguenot St., New Rochelle, NY 10801; email: aloksharan75@gmail.com.
• Michael Y. Wang, MD, can be reached at 1600 NW 10th Ave., #1140, Miami, FL 33136; email: mwang2@med.miami.edu.

Disclosures: Lombardi reports he is an owner of White Fence Surgical Suites. Wang reports he is a consultant for DePuy Synthes Spine. Culp, DeBerardino, Ilyas and Sharan report no relevant financial disclosures.

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