MDNews - Greater Boston

COV ER FE AT UR E EARLY PARTICIPATION IN postoperative rehabilitation following total knee or hip replacement is critical to achieving optimal outcomes. But traditional opioid-based analgesic regimens often cause side effects, such as fatigue, nausea and vomit - ing, that prevent patients from engaging in postoperative rehabilitation quickly and effectively. Anesthesiologists at Saint Anne's Hospital have developed a comprehensive regimen for total hip and knee replacement procedures that reduces complications, such as bleeding, blood clots and infec - tions, and speeds recovery by reducing postoperative pain and anesthesia-related side effects. "We have to move away from opioids and focus on multiple strategies to achieve simi- lar if not superior pain control to facilitate rapid rehabilitation and reduced hospitaliza- tion," says Vijay Sudheendra, MD, Chair of Anesthesia for Saint Anne's Hospital and Medical Director for the hospital's Southern New England Surgery Center. "With that in mind, we've instituted a multimodal analgesic pathway that targets multiple receptors with lower doses of medications that work in synergy to achieve superior analgesia without side effects." The move from opioid-centered analge- sic plans not only reduces the complication rates associated with such strategies, but it also significantly reduces patients' pain levels once the medications wear off. Multimodal analgesia along with regional anesthesia gives providers the confidence to send patients home early — for some, the same day as surgery — knowing their pain will be controlled with an oral medication, such as Percocet. STAGED DELIVERY Targeting specific pain receptors with combination therapy not only provides acute pain relief, but renders a pain-free state for an extended period of time after surgery, says Dr. Sudheendra. The regimen initiates with intraoperative pain medication and neuraxial analgesia — a spinal anesthetic commonly used at Saint Anne's Hospital. Surgeons administer perioperative injections of a combination of medications around the joint, leaving patients with substantially less pain for 48 to 72 hours. Multimodal analgesic strategies used preoperatively can also be continued in the postoperative period for patients who need them, but often the perioperative injections sufficiently relieve postoperative pain so patients can begin rehabilitation. "Because this method eschews narcot- ics, we avoid the side effects from those medications that delay rehabilitation," explains Betty Medeiros-Beattie, MD, Associate Chief of Anesthesia at Saint Anne's Hospital. "If patients feel nauseated or are vomiting, they won't participate in therapy, and that delays the entire recovery process. With the new regimen we've developed, patients recover quickly from a spinal anesthetic and are ready to start working toward recovery." Traditional methods for total hip and knee replacement often result in blood loss that can cause postoperative anemia, leading to excessive fatigue. One of the medications used during surgery is an anti- fibrinolytic agent that reduces the need for perioperative blood transfusion. The multimodal and neuraxial anesthesia strategy also avoids femoral nerve blocks that could limit rehabilitation capabilities, adds Dr. Medeiros-Beattie. "Femoral nerve blocks caused quad- riceps weakness," she says. "Patients would participate in rehab, but not to the level that they do now. Our rehabilitation therapists are amazed by how much more patients are doing — how much farther they're walking, how they're able to walk up stairs more quickly — and the levels of satisfaction they report. Less pain results in motivated patients who aren't reluctant to engage in physical therapy and who return home faster." State-of-the-art Anesthesia Management Results in Less Pain, Plus Quicker Therapy and Recovery The Rapid Rehabilitation Model: 8 | Greater Boston MD NEWS ■ M D N E W S . CO M

• Cover