Total Joint Replacements (TJRs) are being done with increasing frequency in the outpatient setting. At our facility, we historically performed every TJR under spinal anesthesia and were very successful with this approach. However, our surgical team began to discuss alternatives as the practice became busier and successive TJRs were planned to be performed on the same days. The main obstacle we could foresee in continuing with spinal anesthesia was the required length of stay in the post anesthesia care unit (PACU). While data shows that there is slightly less bleeding and less nausea and vomiting with spinal anesthesia versus general anesthesia, the logistics of longer stays and extra PACU nurses needed for extended care were valid concerns in the spinal anesthetic cohort.
After we had performed about fifty TJRs under spinal anesthesia, our anesthesia team decided to alter our protocol to include general anesthesia with a Laryngeal Mask Airway (LMA) to replace the previous spinal anesthetic technique. We still performed the same exact protocol for the remainder of the procedure, including an adductor canal block and iPACK (injection between the popliteal artery and capsule of the knee) to provide good sensory pain relief. The objective was to maintain motor function, allowing for early ambulation and physical therapy prior to discharge.
Our team has now performed approximately 50 TJRs under general anesthesia. The lessons that we have learned in our general anesthetic cohort are: 1) the patient is ready for ambulation and physical therapy earlier, and 2) we have seen more nausea in PACU. These were both expected results. For about seventy-five percent of our patients, their discharge from PACU has been accelerated in the general anesthetic versus the spinal anesthetic cohort. The other 25% could have done better with a spinal anesthetic, as PONV is a minor complication that leaves a lasting impression on a patient having a major surgery. Many have said they would rather be in more pain and less nauseated, if given the option. In their cases, a more rigorous selection process to decide if they would be a good candidate for general anesthesia could have resulted in a better overall experience.
We have settled into doing the majority of our TJRs under general anesthesia in the last couple of months, but also consider spinal anesthesia in patients that are not appropriate candidates for general anesthesia. The pain scores remain remarkably similar between the two anesthesia modalities and the overall patient experiences are very similar in both cohorts. We have learned that there are exceptions to any rule, and one size does not fit all when deciding on the best or most time-efficient anesthetic technique. Each technique has advantages and disadvantages, so making sure the patient is an appropriate candidate for the technique chosen is of utmost importance. Flexibility on your part as the anesthesia provider can result in a better overall patient experience.
Anesthesia providers of DPI Anesthesia always prioritize patient safety and the patient experience. Although we recognize the need for efficiency—especially in the outpatient setting—our providers will ultimately choose the safest, most comfortable and least risky anesthesia modality for each patient. Being open-minded to new ways of performing routine cases is also important in discovering new efficiencies. Thinking critically, comparing data and tweaking protocols in the pursuit of clinical excellence are important aspects of being mindful partners to our clients.
If your outpatient surgery facility needs the benefit of a fresh perspective, contact us directly at 800.454.9902. DPI Anesthesia has been working together with ASCs for decades to help them become more proficient and profitable.