Multimodal Clinical Pathway With Adductor Canal Block Decreases Hospital Length of Stay, Improves Pain Control, and Reduces Opioid Consumption in Total Knee Arthroplasty Patients: A Retrospective Review

Ellis, Terry A.; Hammoud, Hassan; Merced, Philip Dela; Nooli, Nishankkumar P.; Ghoddoussi, Farhad; Kong, Joshua; Krishnan, Sandeep

doi:10.1016/j.arth.2018.03.053

Cited by 32 publications

(16 citation statements)

References 33 publications

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“…Cryotherapy has been shown to reduce postoperative pain and opioid requirements, with no to minimal side effects, which can include discomfort, local skin reactions, or coldrelated injuries, including case reports of frostbite that required debridement [50e53]. Furthermore, multimodal pain control strategies with a peripheral nerve block as the emphasis of pain control decreased opioid use and LOS [54]. Preoperative and postoperative opioid education has also been shown to be effective in reducing postoperative opioid use for a number of orthopedic procedures [55e57], in addition to the implementation of a hospital-wide opioid prescription protocol [58].…”

Section: Modifiable Risk Factorsmentioning

confidence: 99%

Modifiable, Postoperative Risk Factors for Delayed Discharge Following Total Knee Arthroplasty: The Influence of Hypotension and Opioid Use

Anastasio

Farley

Boden

et al. 2020

The Journal of Arthroplasty

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Keywords:total knee arthroplasty opioid hypotension modifiable risk factors length of stay anemia a b s t r a c t Background: We sought to identify independent modifiable risk factors for delayed discharge after total knee arthroplasty (TKA) that have been previously underrepresented in the literature, particularly postoperative opioid use, postoperative laboratory abnormalities, and the frequency of hypotensive events. Methods: Data from 1033 patients undergoing TKA for primary osteoarthritis of the knee between June 2012 and August 2014 at an academic orthopedic specialty hospital were reviewed. Patient demographics, comorbidities, inpatient opioid medication, postoperative hypotensive events, and abnormalities in laboratory values, all occurring on postoperative day 0 or 1, were collected. Multivariate logistic regression analysis was performed to identify independent risk factors for a prolonged length of stay (LOS) >3 days. Results: The average age of patients undergoing primary TKA in our cohort was 65.9 (standard deviation, 9.1) years, and 61.7% were women. The mean LOS for all patients was 2.64 days (standard deviation, 1.14; range, 1-9). And 15.3% of patients had a LOS >3 days. On multivariate logistic regression analysis, nonmodifiable risk factors associated with a prolonged LOS included nonwhite race (odds ratio [OR], 2.01), single marital status (OR, 1.53), and increasing age (OR, 1.47). Modifiable risk factors included every 5 postoperative hypotensive events (OR, 1.31), 10-mg increases in oral morphine equivalent consumption (OR, 1.04), and postoperative laboratory abnormalities (hypocalcemia: OR, 2.15; low hemoglobin: OR, 2.63). Conclusion: This study identifies potentially modifiable factors that are associated with increased LOS after TKA. Doubling down on efforts to control the narcotic use and to use opioid alternatives when possible will likely have efficacy in reducing LOS. Attempts should be made to correct laboratory abnormalities and to be cognizant of patient opioid use, age, and race when considering potential avenues to reduce LOS.

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Section: Modifiable Risk Factorsmentioning

confidence: 99%

Modifiable, Postoperative Risk Factors for Delayed Discharge Following Total Knee Arthroplasty: The Influence of Hypotension and Opioid Use

Anastasio

Farley

Boden

et al. 2020

The Journal of Arthroplasty

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“…1516171819 Second, a focus on the utilization on non-narcotic analgesia perioperatively has been endorsed as a strategy to reduce opioid exposure, ostensibly reducing the risk of chronic opioid use. 20-22 Finally, the overprescription of opioid medications after discharge has been identified as a target for intervention. 20,22,23…”

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confidence: 99%

A Goal-directed Quality Improvement Initiative to Reduce Opioid Prescriptions After Orthopaedic Procedures

et al. 2019

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Introduction:Orthopaedic surgeons are increasingly aware of deleterious effects of the opioid epidemic and the association between overprescription and diversion toward nonmedical opioid use or substance abuse. Opiate prescriptions at the time of hospital discharge have been identified as target for intervention. This study describes the successful outcome of a goal-directed intervention aimed at decreasing opioid overprescription by providing routine feedback to providers regarding their prescribing patterns.Methods:The amount of opioid medications, quantified as oral morphine equivalents (OMEs), provided to opioid-naive adult patients on discharge after orthopaedic surgery was prospectively collected. As part of an institutional quality improvement initiative, medical providers received reports every 2 months detailing median discharge OMEs prescribed, trended over time. After 6 months, a retrospective comparison was done between preintervention and intervention patient cohorts.Results:There were 401 patients in the preintervention cohort and 429 patients in the intervention cohort. Both groups were similar in regard to age, sex, rates of depression, surgical time, length of stay, orthopaedic subspecialty, and inpatient opioid requirement before discharge. Patients in the intervention cohort were prescribed markedly fewer opioid medications by 25%, equivalent to 20 tablets of 5-mg oxycodone IR (450 versus 600 OMEs, P < 0.001). Despite these opioid medications, opioid refill rates during the first 90 days after discharge did not markedly change between groups.Discussion:It is critical to judiciously treat postoperative pain while avoiding opioid overprescription. This study demonstrated the outcome of a goal-directed initiative to decrease overprescription of opioid medications. The initiative reduced discharge opioid prescriptions yet did not increase the risk of requiring a prescription refill in the postoperative period. This indicates that such an approach can result in opioid reduction, while still providing appropriate care and pain control for patients.

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“…The ACB has gained recent popularity as an effective alternative to periarticular injections alone, with several studies showing equivalent pain relief [11,13]. The adductor catheter is directed at the saphenous nerve, which predominately innervates the anterior knee, leaving the posterior knee uncovered.…”

Section: Discussionmentioning

confidence: 99%

“…The adductor canal block (ACB) is a relatively new peripheral nerve block that works on the saphenous nerve in the adductor canal. This has the benefit of controlling anterior knee pain without weakening the quadriceps muscle [10][11][12][13]. Previous studies have evaluated pain control with periarticular injections alone compared to peripheral nerve blocks alone [14].…”

Section: Introductionmentioning

confidence: 99%

A Collaborative Approach to Pain Control Reduces In-hospital Opioid Use and Improves Range of Motion following Total Knee Arthroplasty

Roberts

Foster

Shi

et al. 2019

Cureus

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Introduction: Opioid pain medications are commonly prescribed following orthopedic procedures, with overprescribing of these pain medications implicated as a driver of the current opioid epidemic. In an effort to reduce reliance on opioid pain medications, surgeons are relying on periarticular injections or peripheral nerve blocks. The purpose of this study was to compare numerical rating scale (NRS) pain scores and oral morphine equivalents (OMEs) in patients who underwent primary total knee arthroplasty (TKA) with a periarticular injection alone to those who underwent a collaborative approach with a periarticular injection in the posterior tissue and an adductor canal catheter for anterior knee analgesia. Methods: In this study, 236 patients underwent a primary TKA between December 2017 and April 2018. Forty patients received an adductor canal catheter and 196 underwent a periarticular injection alone. Results: We found no difference in patient demographics between the cohorts (p>0.05). The patients that underwent the collaborative approach with a periarticular injection and adductor canal catheter had lower NRS pain scores on post-operative day 0, 1, and 2 (all P≤0.033). These patients demonstrated a reduction of 43% in opioid consumption during the hospitalization (P<0.001). These patients also demonstrated improved range of motion (ROM) (96 vs. 92 degrees) on the day of discharge (P=0.013). Conclusion: This study provides strong evidence that in patients undergoing TKA, the collaborative approach with the adductor canal catheter and periarticular injection is associated with lower post-operative pain scores, fewer total OMEs per hospital day, and a greater ROM arc prior to discharge compared to patients receiving a periarticular injection alone.

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Multimodal Clinical Pathway With Adductor Canal Block Decreases Hospital Length of Stay, Improves Pain Control, and Reduces Opioid Consumption in Total Knee Arthroplasty Patients: A Retrospective Review

Cited by 32 publications

References 33 publications

Modifiable, Postoperative Risk Factors for Delayed Discharge Following Total Knee Arthroplasty: The Influence of Hypotension and Opioid Use

Modifiable, Postoperative Risk Factors for Delayed Discharge Following Total Knee Arthroplasty: The Influence of Hypotension and Opioid Use

A Goal-directed Quality Improvement Initiative to Reduce Opioid Prescriptions After Orthopaedic Procedures

A Collaborative Approach to Pain Control Reduces In-hospital Opioid Use and Improves Range of Motion following Total Knee Arthroplasty

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