Transcript Accelerated Recovery Technique”

“Accelerated Recovery Technique”
A unique way to decrease pain and blood loss for Total
Joint Replacement
H. Morton Bertram III, M.D.
Naples, Florida
It all starts with the wound
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Having the chance to work at the
NEBH was one of the best things that
ever happened to me
Working with Dr. Scott I was
impressed by the extreme importance
of the wound closure, and how much
attention to detail it received with the
“Scott Knot”
Wound Principles
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I enjoyed sewing, and still do, using the
mattress stitch for closures
I confess to backsliding after a few years to
using staples, however would still use the
stitch for revision knees or at risk wounds
I did however start using subcuticular
closures for THR in 2002, just not TKRsdon’t ask why
Platelet gel
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I started using Platelet gel or “PRP” in
or around 1999, with one goal in
mind-to improve my “Primary Wound
Healing”.
My goal was simply to have no
drainage once the patient left the
operating room, and avoid the use of
a drain
PRP
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Platelet gel allowed me to do that, and
it had an unanticipated consequencesignificantly decreased rate of
transfusions.
7 years go by……19992006
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After 7 years, of doing well with my
low rate of blood utilization ( lowest of
any surgeon of any specialty at our
hospital), I was still very unhappy with
the pain our patients were having
post-operatively
Minimally Invasive Craze
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About this time, the
concept of “Minimally
Invasive Surgery” came into
popularity in my part of the
country, and patients would
“shop” for our services.
I did not buy into that
whole concept, and the
lectures I attended seemed
to gloss over the concept of
pain management
“ Oh by the way” here is
what I am doing for pain
management of these
patients
Depressed
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So at this point, I was pretty sure I was
never going to learn how to do a THR or
TKR through a 5 cm incision, and I was
never going to get those patients to walk
down the hall the day of surgery like I was
seeing on all those videos.
So for the first time in my career, I felt
pretty inadequate, and quite frankly
depressed about it.
That is when I got it
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It was the pain management, not the
surgery responsible for these
incredible results.
However, I could get no help from my
Anesthesia staff, and no one seemed
interested in helping me to figure it
out.
“It’s supposed to hurt a lot”
Dr. Carl Highenboten
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About this time, I got a call from this doctor
in Dallas, he was doing about 400 TKR/year
He wanted to know about our use of PRP,
and I told him all I knew about that.
I asked him about pain management, and
what he was doing
He told me about Duramorph spinals in
combination with Peri-articular injections,
and subcuticular closures, with Dermabond
So I combined the two
modalities
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PRP, and
Duramorph spinals
( 0.1-0.2 mg
doses), with Periarticular injections
with Marcaine,
Subcuticular closure
with Dermabond,
and immediate
cryotherapy
The Results were
shocking!!!
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We noticed right away a long pain free
interval, usually about 24 hours, the
Duramorph giving excellent sensory
blockade but no motor blockade
Transitioned into p.o. meds for pain
Low transfusion rates
Not much swelling
Typical Day of Surgery
ROM
The Evolution
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At this point we are on our 4th iteration of
this technique
Have changed the sequence and location of
the injections
Use the PRP differently for Hips and Knees
Added immediate, Pre-emptive Compression
Therapy
Changed the local to Ropivacaine 0.2%
(safer profile)
Ropivacaine
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Much safer profile than Marcaine
Does not bind to the fat receptors in the heart or
the brain
Almost can not give a toxic dose of this medication
We usually use 100-120 cc of 0.2% combined with
5 mg Duramorph and 0.2cc Epi @ 1:1000
concentration
Studies have been done using regional anesthesia
and with 300-400 mg doses, no toxicity seen
Sequence of Injection
TKR
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4 different Aliquots
1st- a field block superior to the
incision-30cc
2nd- posterior capsule, laterally, LCL,
medially, MCL -30 cc
3rd – VMO muscle and Quad tendon30cc
4th- Superior synovium with remainder
Sequence of Injection
THR
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1st – 30 cc in a horseshoe around
incision
2nd – 10 cc in External Rotators
3rd – 30 cc in deep capsule, posterior,
inferior and anterior
4th – 30 cc in deep fascia
Current Goals
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“Primary Wound Healing”- no drainage after the
first dressing change
Avoid Blood Transfusions-Goal is 0%, (currently 35% for TKR and 8-10% for THR)
Avoid intravenous narcotics- our “ART” patients
need narcotics 1.5% of the time
Avoid Edema that interferes with recovery of
function
Greater than 98% patient satisfaction with the
process
Results & Observations
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Hospital Data
A report given to us looked at selected
quarter from 2005 & 2007
ART program started in March of
2006, suspended by Anesthesia, to
“study the safety”, then restarted in
Late 2006.
Compare 2005 & 2007
THR
TKR
Cases ALOS
Expected
Total
100
3.41
4.61
2007
68
3.25
4.62
2005
32
3.75
4.60
Total
106
3.25
3.96
2007
68
2.76
3.68
2005
38
4.13
4.46
LOS
Decrease
with ART
5%
33%
Complication Rate
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Q 1,2 of 2005 and Q 1,2 of 2007
Total 206 cases- complication rate 0.97%
(Expected was 2.93%)
2007 136 cases- complication rate 0.74%
(Expected was 3.34%)
2005 70 cases- complication rate 1.43%
(Expected was 2.13%)
So my profile was better by 50% with a
higher expected rate for the 2007 patients
Lowest complication rate
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In this review of 1616 cases and 8
surgeons, I had the lowest rate for
anyone doing at least 100 cases, using
the ART technique
Transfusion Rates with
ART last 1011 cases
Year
TKR
Transfusion Rate %
2007
123
8
2008
152
3.3
2009
175
2
450
4.40%
2007
100
10
2008
87
11.5
2009
84
8
271
9.90%
Total Cases
Year
THR
Total Cases
Bilateral TKR
12 of 61
19.60%
Biltateral THR
5 of 11
45.50%
Revision TKR
1 of 29
3.40%
Revision THR
5 of 34
14.70%
Pierson-JBJS 2004
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Algorithm using Procrit for high risk of
transfusion ( predicted Hgb < 7.0 )
assuming Hgb drop of 4 + or – 1 for
THR and 3 + or – 1 for TKR
Transfusion trigger of 7.0
We used no Procrit and trigger of 8.0
CareTenders HHC Data
2009
THR
Avg LOS
ICDs
Avg Age
States below 850
33.1
5.6
75.1
Dr. Bertram
36
15.4
4.8
72.3
2009
TKR
Avg LOS
ICDs
Avg Age
States below 1706
24.5
5.5
72.9
Dr. Bertram
14.0
4.8
73.2
113
Data from states of AL, FL, IL ,
IN, KY, MA, MO, OH
CareTenders HHC Data
2009
THR
Avg LOS
ICDs
Avg Age
States below 850
33.1
5.6
75.1
Dr. Bertram
36
15.4
4.8
72.3
2009
TKR
Avg LOS
ICDs
Avg Age
States below 1706
24.5
5.5
72.9
Dr. Bertram
14.0
4.8
73.2
113
Data from states of AL, FL, IL ,
IN, KY, MA, MO, OH
CareTenders HHC
Rehospitalizations
2009
Number TKR
Re-Hosp Rate
States
1671
3.0%
Dr. Bertram
114
1.7%
Number THR
Re-Hosp Rate
States
783
4.3%
Dr. Bertram
38
0%
CareTenders ER Visits
2009
Number TKR
Re-Hosp Rate
States
1630
5.3%
Dr. Bertram
111
4.3%
Number THR
Re-Hosp Rate
States
774
5.4%
Dr. Bertram
38
0%
NCH ADE data ( Adverse
Drug Events)
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Last 3 years, post-op oversedation events
have decreased by 63%
This includes all general surgery patients as
well
For the TJR receiving a Duramorph spinal,
NO oversedation events in the last 12
months
For this review of 2007-2009 for my
patients, NO oversedation events in over
1000 cases
Spinal Anesthesia
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Review of 2007-2009
Spinal Anesthesia 90% of patients
overall for my TJR
98.5% of those patients with
Duramorph Spinal received only p.o.
meds post operatively ( this includes
Bilateral TKR patients !!!!)
This is reason for low incidence of ADE
Concluding Statements
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Imperative we provide “Primary Wound Healing”
Stitches versus Staples
BMJ 2010 “Sutures versus Staples for skin closure
in orthopaedic surgery: meta-analysis. Smith et.al.
Risk of superficial wound infection was over 3 times
greater after staple closure, and with hip surgery
over 4 times greater
Each day of wound drainage increases our infection
rate by 40% per day.
Primary Wound Healing
Blood Transfusions
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We must avoid blood transfusions at all
costs.
Blood transfusions associate with higher risk
of infection, overall mortality & increased
length of stay
Med Par Data 2008: Average per surgery
costs were $3,000 higher in TKR, and
$2,000 higher in THR when a blood
transfusion was given
PRP
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In my hand, and
the way I do the
surgery, PRP has
significantly
improved my
outcomes, and
decreased the
complication rates
for my patients
Myeloperoxidase
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Elicited by the
platelets when
thrombin
activates them
Shown in vivo to
kill Staph aureus
Spinal Anesthesia
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Spinal Anesthesia should be done for TJR whenever
possible.
Neuraxial Anesthesia and Surgical Site
Infection, Anesthesiology 2010; 113:265–7
All wounds become contaminated, and the
development of infection is in large degree
determined by the host defense mechanisms.
Oxidative killing by neutrophils is the most
important defense mechanism
Oxidative killing is a function of local tissue
oxygenation, which is improved by spinal
anesthesia
Chang Article
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Anesthesiology: August 2010- Volume
113-Issue 2-pp279-284 “Anesthetic
Management and Surgical Site
Infections in Total Hip or Knee
Replacement: A Population based
Study”
Risk for infection was 2.21 times
higher for patients receiving general
anesthesia compared with regional
anesthesia
Afferent inputs
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General anesthesia does not block the
affferent input to the brain, and
results in a higher stress response,
releasing catecholamines, impairing
tissue perfusion, decreasing oxygen
tension
Volatile anesthetics impair neutrophil,
macrophage, T-cell and natural killer
cell functions, diminishing host
defense.
Spinal Anesthesia
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The mechanism is that spinal anesthesia is
associated with less release of vasoconstrictors and
norepinephrine, which cause decrease in tissue
oxygen levels.
The pain relief that patients receive after spinal
helps by blocking the autonomic response
Severe surgical pain decreases tissue oxygenation
by 15 mm Hg. “Postoperative pain and
subcutaneous oxygen tension” THE LANCET • Vol
354 • July 3, 1999
Hopf in Arch Surg 1997 “Wound tissue oxygenation
tension predicts the risk of wound infection in
surgical patients”
Pre-emptive Edema
Control
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The use of an
immediate Grade I
compression Jobst
type stocking
reduces swelling,
edema, and
improves function
earlier in the course
of recovery
Case example-Videos
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Revision TKR one day post op
Primary TKR compares ART technique
to “MIS” TKR done 6 months earlier by
different surgeon
I would like to close by saying that
I believe the next advances in Total
Joint Replacement Surgery will
come in the areas of Pain
Management, and Blood
conservation. This will result in the
best outcomes we have ever
enjoyed in our surgical lifetimes.
Our goal is no intravenous
narcotics, and no need for blood
transfusions, with absolute
“Primary Wound Healing”.
Thanks for having me, I
enjoyed my whirlwind here
in Boston and would like to
challenge these minds here
today, to take this concept
and make it better.