#27 – Total knee arthroplasty in the COVID-19 era with Adam Rana, MD & Ryan Mountjoy, MD

This episode outlines the overnight transition to same-day surgery & discharge for total knee patients at Maine Medical Center. Surgeon Adam Rana, MD was informed on a Tuesday afternoon in December 2020 that elective cases requiring overnight hospital stays were being canceled effective immediately. He reached out to physician anesthesiologist Ryan Mountjoy, MD, along with others, and the very next day they implemented a new anesthesia plan that got patients discharged safely the same-day of surgery. These patients experienced equivalent pain scores post-operatively while remarkably requiring less opioid refills. The length of stay was slashed from 42 hours to 12 hours. These physicians, along with physician anesthesiology resident and lead author Derek Bunch, DO and others, have submitted this story as a proof of concept for the American Society of Regional Anesthesia and Pain Medicine (ASRA) and will present this story at other national anesthesia and surgical meetings. Dr Bunch was unfortunately unable to join us on the podcast due to working overnight call during the wee-hours of the morning when we recorded this episode but hopefully he’ll agree to come on the show in the future to talk about this or other regional anesthesia topics as he prepares to head off for his regional fellowship later this summer. Dr Bunch’s write up is provided below courtesy of the authors with select table data following: The introduction of a multimodal clinical pathway for outpatient total knee arthroplasty in the COVID-19 era.Download Table 1: Pre and Post Surgical Medications Night PriorMorning ofDischargeCelecoxib 200 mgCelecoxib 200 mgCelecoxib 200 mg BID x 3d, then daily until complete (disp #14)Pregabalin 50 mg  Acetaminophen 1000 mgPregabalin 50 mg BID x 3d, then nightly until complete (disp #14)Acetaminophen 1000 mg Acetaminophen 1000 mg TID  Oxycodone 5mg 1-2 tab q 4h PRN (disp #42)Patients received oral analgesics before and after total knee arthroplasty as part of a multi-modal pain management plan. Table 2: Anesthesia Protocols Previous anesthesia protocolNew anesthesia protocol 0.5 or 0.75% bupivicaine spinalSpinal 60mg 2% mepivicainePostoperative adductor canal 20cc 0.5% ropivacainePreop adductor canal with 10cc 0.5% bupivicaine, 10cc 13.3% liposomal bupivicaine Preop iPACK block 20cc 0.2% ropivacainePosterior injection by surgeon (bupivacaine 120mg, epinephrine 300mcg, morphine 8mg)Posterior injection by surgeon (bupivacaine 50mg, epinephrine 100mcg)Propofol sedationPropofol sedationTable 2 highlights the differences between the standard practice and the new anesthesia protocol for same-day discharge for total knee arthroplasty at Maine Medical Center. Table 3: Demographics and Outcomes  Next day kneeSame day KneeNumber of patients4849Average LOS (hrs)4212Number of patients needing IV hydromorphone post op1511Number of patients needing oral opioids post op4132Average pain score in hospital3.93.8Average pain score at 2 weeks3.33Number of patients filling narcotics following surgery2520Total number of narcotics refills following surgery4927Table 3 highlights preliminary data comparing a cohort of patients from one year prior to the study period when patients were shifted to same-day discharge from total knee surgery. “Average age was 63 for both groups and average ASA scores were comparable (2.3 for next day knee patients and 2.2 for same day knee patients).” D. Bunch. Dr Adam Rana’s bio as quoted from his website: “Dr. Adam Rana is a Board Certified, Fellowship-Trained Orthopedic Surgeon who specializes in minimally invasive hip and knee replacement surgery with specific training in the anterolateral muscle sparring approach to the hip, custom partial and total knee replacement surgery as well as revision hip and knee replacement surgery… Dr. Rana earned his Bachelor’s degree with Honors in Economics and Biology from Colby College where he graduated Cum Laude. While at Colby, Dr. Rana spent two summers in Minneapolis, MN at the Hennepin County Orthopedic Biomechanics Laboratory… [and] was actively involved in research projects relating to biomechanics in hip and knee replacement systems.” He attended SUNY Downstate Medical Center for medical school and “subsequently completed his Orthopedic Surgical Residency at the Boston Medical Center… After residency, he completed a fellowship in Adult Reconstruction, Arthritis, and Joint Replacement Surgery at the Hospital for Special Surgery (HSS) in New York City.” Dr Rana is widely published in peer-reviewed journals as well as medical text chapters and frequently presents on orthopedic surgery at state and national meetings. He is actively involved in the American Academy of Orthopedic Surgeons, the American Association of Hip and Knee Surgeons and the New England and Maine Orthopedic Associations. He currently serves as the director of the Joint Replacement Center at Maine Medical Center. You may remember Dr Ryan Mountjoy, MD, who joined us for episode 11 of Anesthesia Guidebook to talk about the use of cognitive aids in emergencies. He is a board-certified physician anesthesiologist with Spectrum Healthcare Partners in Portland, Maine.  He is the Co-Director of Orthopedic Trauma and Total Joint Anesthesia and the Co-Director of Regional Anesthesia and Acute Pain Medicine at Maine Medical Center and the Site Chief of Anesthesia at MaineHealth’s Scarborough Surgery Center.  He completed his anesthesia residency at Stanford University and then pursued a Regional and Ambulatory Anesthesia fellowship at Duke University, where he worked prior to moving to Maine.  References Hussain, N., Brull, R., Sheehy, B., Essandoh, M. K., Stahl, D. L., Weaver, T. E., & Abdallah, F. W. (2021). Perineural Liposomal Bupivacaine Is Not Superior to Nonliposomal Bupivacaine for Peripheral Nerve Block AnalgesiaA Systematic Review and Meta-analysis. Anesthesiology, 134(2), 147-164.