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Early Discharge : Same day or overnight surgery for THR or TKR

Early Discharge : Same day or overnight surgery for THR or TKR. H Yang Professor & Chair Department of Anesthesia. Objectives. To understand the theory and organization behind early discharge after TKR To understand some of the potential concerns of early discharge

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Early Discharge : Same day or overnight surgery for THR or TKR

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  1. Early Discharge: Same day or overnight surgery for THR or TKR H Yang Professor & Chair Department of Anesthesia

  2. Objectives • To understand the theory and organization behind early discharge after TKR • To understand some of the potential concerns of early discharge • To understand the limitations of current risk stratification methodology • To understand the remote patient monitoring system

  3. It takes a Team! • Susan Madden BScN MEd APN • Geoffrey Dervin. MD MSc, FRCSC Orthopedic Surgeon • Alan Lane, MD, FFARCSI Anӕsthetist • Holly Evans, MD, FRCPC Anesthesiologist • Timelines • Pathway implemented 2008 • Pathway revised 2011

  4. It takes a Team! • Fred Beauchemin, Tina Alverez West, Lynn Cuerrier, Physiotherapist; • Ray Vallee, Kevin Babulic & Lila Brooks, CCCAC; • Sonia Mathieu, SDCU RN • Barb d’Entremont, Clinical Pathway Coordinator; • Barb Crawford Newton, Kirsten Dupuis, Jackie Mace Orthopedic Nurse Manager; • Dr Peter Thurston, Orthopedic Surgeon • Sarah Plamondon, Kyle Kemp, Orthopedic Research team

  5. Inclusion Criteria • City of Ottawa • ASA 1 & 2 • Accept same day discharge • Motivated • Good understanding of care concepts • anticoagulant self-injections, multimodal analgesia, continuous nerve block: effects, limitations, care of numb extremity, Quad weakness, ambulatory pump function • Appropriate resources at home (responsible care giver, for 3-4 days limited stairs ~ 5, bathroom / bed on same level)

  6. Exclusion Criteria • ASA III – V • Chronic pain or opioid consumption • Residence outside the catchment area of home care services

  7. Multimodal Analgesia • Spinal without long acting opiods • Peri-articular local anesthetic injections • Acetaminophen 975 mg 2 hrspre-op; then 650 mg PO Q4H while awake • Celecoxib400 mg PO 2 hrs pre-op; then 200 mg Q12H for 2 weeks • Pregabalin 50 – 75 mg PO 2 hrspre-op; then 50 mg Q8H for 10 days ; 50 mg taken HS before surgery • Hydromorphone 1 – 2 mg po q4h prn

  8. Potential Gaps in Early Discharge • 45.8% of PMI occurs after POD 2 • Postop pneumonia defined at 48 hrs postop • Fatal PE peaks between POD 3 – 7 • In major arthroplasty • 3.1% PMI, CVA, rhythm irregularities, DVT, others • 43% have 1 – 2 of the 4 factors for metabolic syndrome

  9. Periopβ-blocker & mortality after major non-cardiac surgery (Propensity Analysis) • Retrospective cohort of patients undergoing major non-cardiac surgery in 329 hospitals in 2000 & 2001 • 782969 patients, 663635 without contraindications to β-blockers • 13454 mortality (2%) • Number of RCRI factors • 0: 313969 • 1: 76983 • 3: 15655 • ≥ 4: 1416

  10. 541297 (did not receive -blockers) 10771 (1.98%) RCRI Factors ≤ 1 RCRI Factors ≥ 2 2328 (4.23%) 8443 (1.73%) 78% of all mortality 22 % of all mortality Perioperative Mortality Lindenauer et al. NEJM 2005; 353:349 - 61

  11. Database Results • HHSC Chart Audit 1996 – 1997 elective THR & TKR • 679 charts • 38/49 (77.5%) cardiac complications in Detsky 0 or 5 • LHSC Referral Consults • 2035 patients • 95/130 (73.0%) of MI, unstable angina, CHF, or death in Detsky stratum 1 • TOH 2002 – 2006 elective THR & TKR • 5158 patients in Data Warehouse

  12. PMI (n=77) No PMI (n=5081) OR Class I 28 (36.4%) 4502 (88.6%) Class II 32 (41.6%) 502 (9.9%) 10 (6.1–17) Class III 15 (19.5%) 63 (1.2%) 38 (19–75) Class IV 2 (2.6%) 14 (0.3%) 23 (5.0–106) Effect of β-blockers in Postop Hip & Knee Replacements Anesthesiology 2009; 111(4): 690-4

  13. Transition Points • 46% of medication errors at admission or discharge • 23% medicine patients experienced at least 1 adverse event after discharge • Adverse drug events 72% • Therapeutic errors 16% • Nosocomial infections 11%

  14. Summary • Early Discharge • after TKR is reality • after THR is imminent • Multi-disciplinary team work essential • MIS & multimodal analgesia • Potential Gaps • Timing of complications • Limitations of risk stratification tools • Remote Monitoring • NIBP, SpO2, HR, BS, pain, activity advice • Real-time remote support • Smooth post-discharge transition

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