San Antonio—A high-volume community hospital has succeeded with routine same-day discharge for knee and hip replacements by using a multimodal analgesia protocol (MMAP). Researchers from Northside Hospital, in Atlanta, reported that their MMAP relies on opioids for analgesia only on an as-needed basis.

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In 2017, the researchers performed more than 2,000 joint replacements on patients, 85% of whom were discharged within eight hours or less, and 75% in four hours or less. Opioids were avoided in about 70% of patients who were not already taking narcotics long-term.

They attributed the success of their program to three key factors: the surgeon–anesthesiologist partnership; full institutional support; and the use of a strict MMAP that incorporates routine preoperative spinal anesthesia and relies on opioids for PRN use only (Table).

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Table. MMAP for Joint Replacements at Northside Hospital, 2017
Preoperative
  • Pregabalin 150 mg PO
  • Spinal anesthesia: isobaric mepivacaine 40-60 mg
  • Adductor canal block: 15 mL bupivacaine 0.5% (with ultrasound guidance)
Intraoperative
  • Preoperative and intraoperative narcotics specifically excluded unless the patient has been on long-term opioid therapy
  • Acetaminophen 1,000 mg IV
  • Dexamethasone 0.15 mg/kg IV
  • Ketorolac 30 mg IV and
  • Ketamine 0.5 mg/kg IV
  • Periarticular injection performed by the surgeon, typically:
    • 30 mL of bupivacaine 0.5% with epinephrine 1:200,000
    • 30 mg ketorolac and 80 mg methylprednisolone
Postoperative
  • In the PACU: fentanyl 25-100 mcg for pain greater than “tolerable”
  • Patients discharged from an extended recovery area after a second dose of acetaminophen IV and evaluation by a physical therapist
At Home
  • Acetaminophen 1,000 mg PO three times daily ATC
  • Ibuprofen 800 mg PO three times daily ATC
  • Oxycodone 5 mg PO PRN
ATC, around the clock; PO, orally; PRN, as needed

Proving the Same-Day Model

Mark Hamilton, MD, an anesthesiologist at Northside Hospital and the study’s first author, said the study, which was presented at the 2018 annual pain medicine meeting of the American Society of Regional Anesthesia and Pain Medicine (abstract 6038), was prompted by colleagues at conferences who had expressed skepticism that routine same-day discharge for joint replacements using an opioid-sparing protocol was feasible. The research began as a pilot study with two surgeons in 2015, and was expanded to include all 10 orthopedic surgeons at the hospital in 2017.

“We wanted to pull our data to show that this can be done routinely,” Dr. Hamilton said. “I think part of the problem is that it’s not the paradigm, and so people think it’s impossible. When we began to work on the program several years ago, I thought it was impossible.”

Dr. Hamilton emphasized the necessity of a committed multidisciplinary team led by a strong anesthesiologist–surgeon partnership.

“Surgeons, anesthesia, physical therapy, business, the admissions people, preoperative and postoperative nurses—everyone has to be invested in making routine same-day discharge a reality,” he said. “That means following the data and refining protocols to control pain and eliminate side effects that would prevent discharge. That’s where everybody has to start.

“The third piece, after you have a truly multidisciplinary team and the belief in this paradigm shift, is patient education,” Dr. Hamilton said. “It’s vital to get the patients onboard with their pain control plan, and get their families onboard, so they’re not afraid and know what to expect.”

Dr. Hamilton added that the protocol is subject to ongoing revision in response to evidence. “We continually evaluate our outcomes and look for improvements. For example, in mid-2018, after an evaluation, we added iPACK [interspace between the popliteal artery and capsule of the posterior knee] blocks to our standard protocol for knee replacements. This required an adjustment of our local anesthetic doses for our other combined injections.”

Emily Lin, MD, MS, a regional anesthesiologist at Memorial Sloan Kettering Cancer Center in New York City, who was not involved with the study, called the findings “compelling. Performing joint replacements on an outpatient basis is an exciting yet relatively new phenomenon. While some centers are able to provide same-day care, there are few that do so with great numbers,” she said. “With such a high percentage of reported same-day discharges and minimal readmissions for pain, that may be enough reason for those with a robust joint replacement service to consider implementing a similar analgesic regimen.”

Dr. Lin added that the findings have implications well beyond joint replacement. “Regardless of area of practice, this study reiterates the importance of implementing multimodal analgesic regimens to minimize opioid consumption,” she said.

“This is happening throughout the anesthesia world, and it’s necessary,” Dr. Hamilton agreed. “There’s a push throughout the anesthesia world for opiate-free analgesia. This is the new frontier.”

—Ajai Raj

Dr. Hamilton reported no relevant financial disclosures.