Risk factors of opioid use associated with an enhanced-recovery programme after total knee arthroplasty

Background Characterizing the impacts of postoperative opioid use on total knee arthroplasty (TKA) patients may help optimize the pain management after TKA. The aim of the study is to examine the prevalence and risk factors for opioid use with an enhanced-recovery programme after primary TKA. Methods We identified 361 patients undergoing TKA, and separated those on the basis of whether to receive opioid use after surgery. Themultivariate logistic regression model was used to identify independent risk factors for opioid use after primary TKA. Length of stay (LOS) and postoperative complications were also recorded and compared. Results The prevalence of opioid use after primary TKA was 23.0%. The significant risk factor was the longer operative time (OR [odds ratio] = 1.017, 95% CI [confidence interval] = 1.001 to 1.032, p = 0.034) and the protective factor was the utilization of tranexamic acid(OR= 0.355, 95% CI = 0.161 to 0.780, p = 0.010). In addition, the LOS was longer in opioid group (p < 0.05). Conclusion Considering the adverse health effects of opioid use, strategies need to be developed to prevent persistent opioid use after TKA. Reducing operative time and the application of tranexamic acid could lower the risk of opioid use with an enhanced-recovery programme after primary TKA.

Limited impact of a top-down approach to improve enhanced recovery programme in French university hospitals: a before-after retrospective survey

Background Enhanced recovery programme (ERP) after surgery needs development in Assistance Publique Hôpitaux de Paris (APHP). Methods A retrospective before-and-after study was performed in 2015 and 2017 on three surgical models (total knee arthroplasty (TKA), colectomy and hysterectomy) in 17 hospitals including 29 surgical departments. Data were collected in one control intervention (total hip arthroplasty (THA), gastrectomy and ovariectomy). In 2016, Massive Open Online Course on ERP and a day meeting information were developed by APHP. A national update on ERP was also organized by HAS and a regional professional partnership programme was started. Primary outcomes were length of stay (LOS) and complications after surgery. Data on ERP items were collected in the patients’ chart and in anaesthetist and surgeon interview. Seventy percent application rate reflects application of ERP procedure. Results 1321 patient’s files were analysed (812 in 2015 and 509 in 2017). The LOS (mean (SD)) is reduced by 1.6 day for TKA (2015, 8.7 (6.7) versus 7.1 (3.4) in 2017; p<0.001) but stable for colectomy and hysterectomy. Incidence of severe complications after surgery is unchanged in all types of surgical models. For TKA and hysterectomy respectively applied items of ERP (i.e. >70% application) increased respectively from 5 to 7 out of 17 and 16 in 2015 and 2017. For colectomy, they were stable at 6 out of 21 in 2015 and 2017. The mean application rates of ERP items stayed below 50% in all cases in 2017. The LOS was negatively correlated with ERP items’ application when data collected in 2015 and 2017 were analysed together. Conclusion ERP application did not significantly improved between 2015 and 2017 for three surgical models after an institutional information and diffusion of recommendations in 29 surgical departments of seventeen French University hospitals underlining the limit of a top-down approach.

Enhanced recovery after laryngectomy: A feasibility study in 25 patients

Purpose To describe the development and implementation of an enhanced recovery programme for patients undergoing total laryngectomy. Methods A feasibility study set in a tertiary head and neck unit in London, United Kingdom. The programme was developed based on Enhanced Recovery After Surgery (ERAS) Society guidelines for head and neck cancer surgery and local expert group consensus. An ERAS ‘booklet’ was devised which accompanied all laryngectomy patients during their inpatient stay. Contributors included otolaryngologists, anaesthetists, dieticians, physiotherapists, speech and language therapists and nurses. A 12-month pilot study was undertaken. The main outcome measures were feasibility and adherence. Results An enhanced recovery programme for 25 people undergoing total laryngectomy was successfully piloted in a tertiary referral head and neck unit. Median length of stay was reduced in the post-ERAS group by 1.5 days. No statistically significant difference in length of stay, time to first gastrografin swallow, rate of fistula nor postoperative normalcy of eating between the pre and post-ERAS patients who underwent laryngectomy was observed. Clavien-Dindo-grouped complication rates were significantly higher in the post-ERAS group. Conclusion This enhanced recovery programme for patients undergoing laryngectomy is the first of its kind in the literature. Implementation has been demonstrated feasible. Further longitudinal studies are required to reliably inform us on ERAS programmes’ effects on laryngectomy outcomes.

565 Outcome of Enhanced Recovery Programme in Lower Limb Arthroplasties

Background Enhanced Recovery Programme(ERP) is structured process of patient education, appropriate analgesia and early mobilisation. ERP was introduced to address, demand for surgical beds and cancellation of orthopaedic procedures. Objectives of this study were to evaluate efficacy and safety of ERP. Method This was prospective study, over three months. Included, all lower limb arthroplasty patients eligible for ERP(all primary arthroplasty patient with lower anaesthetic risk). Pre-medication, intra-operative local anaesthetics infiltration, same day post-operative radiograph, combinations of analgesics, early mobilisation, and discharge back to the usual place of abode. Results 201 patients, mean age was 71 years (42-87), 22 ASA (American Society of Anaesthesia) 1, 147 ASA 2 and 23 ASA 3 patients. Performed 121 total knee replacements and 80 total hip replacements. Average duration of weight bearing was1.04 days. Mean date of discharge was 1.37days (0-5). 8 patients were re-admitted (0.039%), they were, one with surgical site infection, another one for manipulation, 5 patients, suspected deep vein thrombosis (DVT) (all were excluded DVT). There was no failed discharge. Conclusions ERP is very safe and effective way of increasing performance of hip and knee arthroplasties by optimising availability of ring-fencing surgical beds and reducing the hospital stay.

Risk Factors of Opioid use Associated with an Enhanced-Recovery Programme after Total Knee Arthroplasty

Background: The relationship between total knee arthroplasty (TKA) and postoperative opioid use is poorly studied. The aim of the study is to examine the prevalence and risk factors for opioid use with an enhanced-recovery programme after primary TKA.Methods: We identified 361 patients undergoing TKA, and separated those on the basis of whether to receive opioid use after surgery. Multivariate logistic regression model was used to identify independent risk factors for opioid use after primary TKA. Length of stay (LOS) and postoperative complications were recorded and compared.Results: The prevalence of opioid use after primary TKA was 23.0%. Significant risk factor were more operative time (OR [odds ratio] = 1.017, 95% CI [confidence interval] = 1.001 to 1.032, p = 0.034) and protective factor was tranexamic acid use (OR= 0.355, 95% CI = 0.161 to 0.780, p = 0.010). In addition, the LOS was longer in opioid group (p < 0.05).Conclusion: Considering the adverse health effects of opioid use, strategies need to be developed to prevent persistent opioid use. Reducing operative time and application of tranexamic acid could lower the risk of opioid use with an enhanced-recovery programme after primary TKA.