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ERAS for Hip and Knee (THA and TKA) Arthroplasty – a Need to Look Beyond LOS

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ERAS for Hip and Knee (THA and TKA) Arthroplasty – a Need to Look Beyond LOS ASERalert November 2016 | Volume 1, Issue 1 ERAS for Hip and Knee (THA and TKA) Arthroplasty – A Need to Look Beyond LOS OFFICIAL also in this issue PUBLICATION OF ERAS for Total Enhanced ERAS for Spine Joint Arthroplasty: Recovery for Surgery: A New Past, Present and Orthopedic Frontier ASER ALERT • VOLUME 1, ISSUE 1 • aserhq.org Future Surgery 1 ANNUAL CONGRESS OF ENHANCED RECOVERY AND 2017 PERIOPERATIVE MEDICINE APRIL 27TH-29TH, 2017 HYATT REGENCY WASHINGTON ON CAPITOL HILL 400 NEW JERSEY AVE NW, WASHINGTON, D.C. 20001 For more information please visit www.aserhq.org 2 ASER ALERT • VOLUME 1, ISSUE 1 • aserhq.org Board of Directors President’s Message Officers By Tong J (TJ) Gan, MD, MHS, FRCA, President President Tong J (TJ) Gan, MD, MHS, FRCA President-Elect Julie Thacker, MD t is my great pleasure to announce Vice-President the inaugural issue of the ASER Timothy Miller MB, ChB, FRCA Newsletter. Founded in 2014, Treasurer ASER is a multi-specialty nonprofit Roy Soto, MD Iorganization with an international Secretary membership and is dedicated to the Stefan D. Holubar MD, MS, FACS, FASCRS practice of enhanced recovery in the perioperative patient through education Directors and research. We are experiencing a period of tremendous expansion and Keith A. (Tony) Jones, MD growth, as is evidenced by the great Anthony Senagore, MD interest to implement the enhanced Maxime Cannesson, MD, PhD recovery pathway in hospitals around Terrence Loftus, MD, MBA, FACS the country. Andrew Shaw MB, FRCA, FFICM, FCCM Desiree Chappel, CRNA The ASER Mission is to advance the practice of perioperative enhanced recovery and to contribute to its pathways. It serves as a forum for Newsletter Committee growth and influences, by fostering communication of the many activities of Thomas Hopkins, MD: Chair and encouraging research, education, the society. Lyla Hance, MPH: Co-Chair public policies, programs and scientific I would like to thank Dr. Thomas Jeffrey Huang, MD progress. Hopkins, Lyla Hance and their Uday Jain, MD, PhD We have achieved much over the past committee for editing the newsletter Amy McCutchan, MD 2 years, including: and those who generously donated Asha Naik, FRCA their time to contribute to this edition. Christina Solis, MHA • Annual ASER/EBPOM Congress Matthias Stopfkuchen-Evans, MD We want this newsletter to be valuable • ASER website for you, so please share your feedback and suggestions to help us improve. • ASER manual of Enhanced About ASER Please forward it to friends and Recovery for Major Abdominopelvic ASER is a nonprofit organization with an international colleagues who you think will benefit membership, which is dedicated to thepractice Surgery from this newsletter. n of enhanced recovery in the perioperative patient through education and research. ASER’s mission is • Enhanced Recovery Implementation to advance the practice of perioperative enhanced Enjoy reading. Guide recovery, to contribute to its growth and influences, by fostering and encouraging research, education, Tong J (TJ) Gan, MD, MHS, FRCA • Regional Leadership forums public policies, programs and scientific progress. President • Perioperative Medicine as the official American Society for Enhanced society journal Recovery Administrative Office American Society for Enhanced Recovery This newsletter aims to share Professor and Chairman 6737 W Washington St. | Ste. 4210 Milwaukee, WI 53214 information, best practices, sample Department of Anesthesiology protocols and members’ experiences Stony Brook University 414-389-8610 | [email protected] in implementing enhanced recovery [email protected] ASER ALERT • VOLUME 1, ISSUE 1 • aserhq.org 3 ERAS for Hip & Knee (THA & TKA) Arthroplasty – A Need To Look Beyond LOS feature By Henrik Kehlet, Prof. MD, PhD RAS programs in total joint eliminate this problem. Although it arthroplasty have been is well-established that preoperative introduced worldwide in many The optimal anemia should be diagnosed centers with documented and treated, more focus on post- Esuccess and reduced length of technique of discharge anemia should be made, stay (LOS) and morbidity. However, since it may impair rehabilitation and despite the achieved success, increase risk of organ dysfunction, several challenges lie ahead. First of rehabilitation but so far with sparse available all “what is the optimal LOS?”, since data. Further data are required on there is a lack of documentation on needs thromboembolic complications and the economic and safety aspects of need for prophylaxis, since early same-day discharge vs next day in mobilization with ERAS may reduce a general THA and TKA population evaluation... the risk. Importantly, readmissions vs the proportion of selected suitable and discharge destination must be patients. Although overall morbidity is studies are required to preoperatively clarified due to a huge discrepancy reduced by ERAS, further studies on predict high-pain responders in between individual institutions and the relative importance of conventional subpopulations such as pain countries and where readmission to risk factors needs to be clarified, since catastrophizers, preoperative opioid “own institution” is insufficient because recent data question the relevance users and other pain “sensitized” some patients may be readmitted from standard risk assessment patients. Also, more data are required to other institutions. Also, discharge within traditional care. Still, a major on the otherwise documented risk of destination, which has major problem is the need to improve postoperative delirium especially with economic implications, needs further pain management after discharge in opioid-based pain management, but evaluation, since discharge to a relation to patient activity and optimal where a fully implemented opioid- “nursing care facility” or “rehabilitation” rehabilitation. In this context, further sparing ERAS program may almost institution is variable, and in some 4 ASER ALERT • VOLUME 1, ISSUE 1 • aserhq.org countries standard practice is In summary, despite an obvious total knee arthroplasty: are we there yet? Bone Joint J 2015; 97-B:3-9. discharge to home instead. success of ERAS in THA and THA to reduce LOS and morbidity, several Jans O, Kehlet H. Postoperative orthostatic The optimal technique of rehabilitation intolerance: a common perioperative problem with few challenges lie ahead to improve post- available solutions. Can J Anaesth 2016 (Epub). needs evaluation, since present discharge recovery. n data even with immediate strength Jorgensen CC, Petersen MA, Kehlet H. Preoperative prediction of potentially preventable morbidity after training have been disappointing and References fast-track hip and knee arthroplasty: a detailed descriptive cohort study. BMJ Open 2016; where all data have documented Aasvang EK, Luna IE, Kehlet H. Challenges in 6:e009813. a reduction of muscle function for postdischarge function and recovery: the case of fast- track hip and knee arthroplasty. Br J Anaesth 2015; Kehlet H, Jorgensen CC. Rapid Recovery After several weeks postoperatively. 115:861-866.Cyriac J, Garson L, Schwarzkopf R, Ahn Hip and Knee Arthroplasty--A Transatlantic Gap? J Although patient-reported outcomes K, Rinehart J, Vakharia S, Cannesson M, Kain Z. Total Arthroplasty 2015; 30:2380. joint replacement perioperative surgical home program: are fashionable and important, 2-year follow-up. Anesth Analg 2016; 123:51-62. Kehlet H, Jorgensen CC. Advancing surgical further studies to compare these with outcomes research and quality improvement within Artz N, Elvers KT, Lowe CM, Sackley C, Jepson P, an enhanced recovery program framework. Ann Surg objectively measured function and Beswick AD. Effectiveness of physiotherapy exercise 2016; 264:237-238. activity are required, since initial data following total knee replacement: systematic review and meta-analysis. BMC Musculoskelet Disord 2015; Kjellberg J, Kehlet H. A nationwide analysis of are disappointing and showing a gap 16:15. socioeconomic outcomes after hip and knee between the positive patient-reported replacement. Dan Med J 2016; 63:A5257.Pitter Cyriac J, Garson L, Schwarzkopf R, Ahn K, Rinehart FT, Jorgensen CC, Lindberg-Larsen M, Kehlet H. outcomes vs the rather disappointing J, Vakharia S, Cannesson M, Kain Z. Total joint Postoperative morbidity and discharge destinations objective recovery data. Finally, a replacement perioperative surgical home program: after fast-track hip and knee arthroplasty in patients 2-year follow-up. Anesth Analg 2016; 123:51- older than 85 years. Anesth Analg 2016; 122:1807- very large number of publications 62. 1815. on ERAS cohorts often has an Fragiadakis GK, Gaudilliere B, Ganio EA, Aghaeepour Pitter FT, Jorgensen CC, Lindberg-Larsen M, Kehlet insufficient interpretation compared N, Tingle M, Nolan GP, Angst MS. Patient-specific H. Postoperative morbidity and discharge destinations immune states before surgery are strong correlates of after fast-track hip and knee arthroplasty in patients with global literature, and a lack of surgical recovery. Anesthesiology 2015; 123:1241- older than 85 years. Anesth Analg 2016; 122:1807- balanced discussion on international 1255. 1815. experiences and consequences in Hossain FS, Konan S, Patel S, Rodriguez-Merchan Thienpont E, Lavand’homme P, Kehlet H. The different health care systems. EC, Haddad FS. The assessment of outcome after constraints on day-case total knee arthroplasty: the fastest fast track. Bone Joint J 2015; 97-B:40-44. FASTER RECOVERY, FEWER COMPLICATIONS, PROMOTING
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