Advances in perioperative management drive paradigm shift in the ‘outpatient era’
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Optimization and pragmatic thinking can improve the patient experience and help surgeons transition from a “sick-patient” model to a “well-patient” model in the era of outpatient total hip and knee arthroplasty, according to a presenter.
“We now have a good understanding as an orthopedic community on the components of delivering safe and effective perioperative care and that allows us to do more patients as same-day surgery,” Mark W. Pagnano, MD, said in his presentation at the Current Concepts in Joint Replacement Meeting. “We’ve moved from that ‘sick-patient’ model to a ‘well-patient’ model today where we are expected to take patients, optimize them before surgery, perform an intervention and quickly return them to daily life,” he added.
Interventions for patients who require THA or TKA have changed throughout the years, Pagnano said. It was assumed that substantial resource allocation and increased hospital intervention would only improve patient outcomes and satisfaction. Now, patients who require THA or TKA in the well-patient model are treated as such. Interventions are made as efficient and minimally invasive as possible. Pragmatic thinking can also help surgeons stay ahead of predictable complications that impact recovery and increase costs. Surgeons should proactively address areas such as patients’ fluid or blood loss, pain and nausea.
Pagnano said that advances in multimodal pain protocols, blood management and early mobilization therapy have accounted for the greatest improvements in the patient experience in the last 10 years. Each patient is optimized preoperatively, treated with the latest advancements in perioperative medicine and placed on a postoperative multimodal pain regimen.
Multimodal pain protocols should include an NSAID, acetaminophen, an oral opioid and gabapentin for some patients, according to Pagnano. Surgeons should strive for regional anesthesia rather than general anesthesia and consider peripheral nerve blocks or periarticular local anesthetic cocktail injections. Surgeons should also stay on schedule for delivering postoperative medications, only use opioids for patients’ breakthrough pain and devise a proactive and reactive plan for follow-up, he added.
“The outpatient era is not coming; it’s here,” Pagnano said. “Every patient needs to be optimized no matter what setting they are having surgery, and it’s more now a question of who is not a candidate for outpatient or same-day surgery ... An organized set of prehospital, in-hospital and posthospital set of protocols are the prime drivers,” he added.
Perspective
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Pagnano highlights the essential components of all “state-of-the-art” joint replacement surgery programs that have enabled total hip and knee replacement procedures to be safely and successfully performed, for nearly all patients, in either an ambulatory or short hospital stay setting. Minimization of postoperative pain and the adverse effects of narcotic analgesics with preemptive multimodal pain management protocols, reduction in the negative physiologic effects of perioperative blood loss through the near universal use of tranexamic acid and early patient mobilization almost immediately after surgery are responsible for most of these effects. In addition to these changes in perioperative care contributing to this paradigm shift from an “illness” to a “wellness” model of health care, careful preoperative optimization of the patient, comprehensive patient and family education, establishment of appropriate patient expectations and creation of a culture that promotes improved health, rapid recovery and enhanced quality of life for our patients will become increasingly important as more joint replacement surgeries move to the outpatient setting.
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Pagnano MW, et al. Perioperative management in the era of outpatient arthroplasty. Presented at: Current Concepts in Joint Replacement Meeting; Dec. 7-10, 2022; Orlando (hybrid meeting).
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