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The Shift to Outpatient Total Joint Replacements

By Roger Massengale, General Manager, Acute Pain, Halyard Health | March 15, 2017

As physicians look to shift patients to a same-day surgical option, technology addresses pain management.

The drive to perform total joint replacement procedures on an outpatient basis continues to increase. Same-day orthopedic surgery allows patients to recover in the comfort of their own homes, rather than in a hospital bed, and provides multiple benefits to patients for improved recovery. By enabling patients to recover at home, the potential risk of hospital-acquired infections is decreased.1 In addition, the home environment enables patients to recover away from the disruption and restrictive beds of the hospital environment, which can cause long term sleep deprivation and, in turn, slow down the recovery process.1
One of the most challenging factors clinicians must take into account when performing outpatient total joint procedures is post-operative pain.2 More than 73 million surgical procedures are performed in the U.S. each year, and up to 75 percent of patients may experience pain after surgery.3 Post-operative pain can have a significant impact on patient recovery, yet inadequate pain management is common and can result in negative clinical outcomes, such as deep vein thrombosis, pulmonary embolism, coronary ischemia, myocardial infarction, pneumonia, poor wound healing, insomnia, and demoralization.3 New techniques and approaches like continuous peripheral nerve blocks (CPNBs) are playing a significant role in making post-operative pain more manageable. CPNBs have been successfully introduced in the ambulatory setting to provide on-going analgesia at home.4

Roger Massengale, General Manager, Acute Pain, Halyard Health
Unlike short-duration, single-shot nerve blocks, which can cause rebound pain at 24 hours after surgery,5 CPNBs allow patients to experience continuous extended pain relief for days in the outpatient setting, which can then be titrated to their needs via a portable post-operative pain pump.6 CPNBs can also help patients ambulate faster and improve their range of motion more quickly.4 Further, CPNBs have been shown to reduce the need for opioids,7 which can have negative side effects including nausea, vomiting, and drowsiness.8
In advance of scheduling an outpatient total joint procedure, physicians should meet with patients and their families to determine if same-day surgery is appropriate for them. Ideal patients should be free of major cardiac or pulmonary comorbidities.9 Physicians should also ensure that patients have assistance at home, as both patients and their caretakers need to execute a coordinated discharge plan in order to achieve an effective at-home recovery.
Through careful planning and effective pain management techniques such as CPNBs, physicians can successfully perform same-day total joint procedures that improve the patient experience, increase satisfaction, and speed recovery.
1 Healing at Home: The Impact & Reduced Risks of Recovering at Home [Internet]. Sound Options. Sound Options Inc.; [cited 2016 Dec 12]. Available from:
2 Chan EY, Blyth FM, Nairn L, Fransen M. Acute postoperative pain following hospital discharge after total knee arthroplasty." Osteoarthritis and Cartilage. 2013;21: 1257-263.
3 Apfelbaum JL, Chen C, Mehta SS, Gan TJ. Postoperative pain experience: results from a national survey suggest postoperative pain continues to be undermanaged. Anesthesia & Analgesia. August 2003;97(2):534-40.
4 Aguirre J, Del Moral A, Cobo I, Borgeat A, Blumenthal S. The role of continuous peripheral nerve blocks. Anesthesiol Res Pract. 2012;2012:560879.
5 Abdallah FW, Halpern SH, Aoyama K, Brull R. Will the real benefits of single-shot interscalene block please stand up? A systematic review and meta-analysis. Pain Medicine. May 2015;120(5): 1114-1129.
6 Visoiu M, Joy LN, Grudziak JS, Chelly JE. The effectiveness of ambulatory continuous peripheral nerve blocks for postoperative pain management in children and adolescents. Pediatric Anesthesia. 2014; 24 (11): 1141–1148.
7 Klein SM, Grant SA, Greengrass RA, Nielsen KC, Speer KP, White W, Warner DS, Steele SM. Interscalene brachial plexus block with a continuous catheter insertion system and a disposable infusion pump. Anesth Analg. Dec 2000;91(6):1473-8.
8 Dowell D, Haegerich TM, Chou R. CDC Guideline for Prescribing Opioids for Chronic Pain—United States, 2016. JAMA. 2016;315(15):1624-1645.
9 Romero A, Joshi GP. Adult patient for ambulatory surgery: are there any limits? American Society of Anesthesiologists. 2014; 78(9):18-20.

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