Blood Pressure and Early Mobilization After Total Hip and Knee Replacements

Abstract

Background: Early mobilization is an important therapeutic goal after total knee replacement and total hip replacement. Orthostatic hypotension and orthostatic intolerance can impede mobilization. Midodrine hydrochloride, an orally administered vasoconstrictor, may improve blood pressure and diminish the prevalence of adverse mobilization events. Methods: We conducted a pilot change-of-practice study. Two cohorts, each comprising 10 patients managed with total knee replacement and 10 patients managed with total hip replacement, were managed with blood pressure-adjusted midodrine, which was administered 3 times daily for the first 72 hours postoperatively at either a low dose (2.5 or 5 mg) or a higher dose (5 or 10 mg). These patients were then matched with an equivalent preintervention cohort of patients. Results: The midodrine protocol was instituted effectively and with high compliance. Hypotension was uncommon across all groups, with the mean lowest systolic blood pressure ranging from 110 to 121 mm Hg. Moreover, adverse mobilization events were uncommon across all groups (prevalence, 9.6% in the control group, 5.6% in the low-dose group, and 2.9% in the high-dose group) (p = 0.046 for the high-dose group versus the control group). A midodrine dose of 10 mg generated a significant mean dose-related systolic blood pressure increase of 14 mm Hg at 2 hours after administration (p < 0.001). There were no significant differences between the groups in terms of mean systolic blood pressure, biochemical markers, or intravenous therapy administration. Conclusions: A dose of 10 mg was found to achieve a significant systolic blood pressure response at 2 hours after administration and, in patients who received higher-dose midodrine, adverse mobilization events appeared less common. Additional investigation with a blinded randomized controlled trial, utilizing 10 mg of midodrine 2 hours before mobilization, would be needed to confirm the efficacy of midodrine therapy. Level of Evidence: Therapeutic Level III . See Instructions for Authors for a complete description of levels of evidence.

Ambulatory total hip arthroplasty: Causes for failure to launch and associated risk factors

“… 39 , 41 Preliminary data suggests using low doses of ⍺ 1 -drenoreceptor agonist may reduce orthostatic intolerance. 42 , 43 In addition, reports from the anaesthesia and general surgery literature suggest the use of preoperative complex carbohydrate drinks reduces postoperative insulin resistance, positively impacting lean body mass and muscle function, and decreasing incidence of PONV. 44 - 48 However, there is lack of data suggesting the same benefits are translated to the arthroplasty population.…”

Postoperative hypotension following acute hip fracture surgery is a predictor of 30-day mortality

“…34 It has been suggested that a systemic inflammatory response syndrome state postoperatively, with associated increases in inflammatory markers and vasodilation, can play a role in the development of postoperative hypotension. 37 The results of our study provide an additional parameter for surgeons and clinicians to promptly identify and highlight patients most at risk of increased mortality in the immediate postoperative period, and therefore will be able to personalize and monitor their care during their inpatient stay. This further highlights the requirement for individualized circulatory management with early intervention, such as inotropic or vasopressor support, for this modifiable risk factor in order to improve morbidity and mortality.…”

“…34 It has been suggested that a systemic inflammatory response syndrome state postoperatively, with associated increases in inflammatory markers and vasodilation, can play a role in the development of postoperative hypotension. 37…”

Post-Operative Remote Monitoring for Same-Day Discharge Elective Orthopedic Surgery: A Pilot Study

“…While both aggressive perioperative volume repletion and the increased use of tranexamic acid to limit blood loss are now standard practice [ 24 , 25 , 26 ], hypotension remains a common cause of rapid discharge failure and complications such as fainting and falls resulting in peri-prosthetic fractures [ 17 ]. The only other pilot study in this space, to our knowledge, found improved BP management and mobilization using midodrine hydrochloride, an orally administered vasoconstrictor [ 27 ]. In our study, however, we capitalize on non-pharmacological management, utilizing an inexpensive, straightforward means of decreasing risk of adverse consequences via an outpatient hydration protocol.…”