Anesthesia providers are trying to keep pace with the shift of complex orthopedic cases to outpatient ORs by looking for new ways to mitigate complications, speed recoveries and minimize — or eliminate — the need to manage post-op pain with opioids. Those efforts include more targeted and effective regional blocks, a spinal anesthetic that wears off in less than an hour and, if you can believe it, sedation-free surgery performed on wide-awake patients. Let's take a closer look at those developments and a few other trends that can help your patients bounce back faster and move around sooner after some of surgery's most painful procedures.

1. Improved pre-op preparation

Experts are beginning to realize that anesthesia, in the broader sense, shouldn't start only after the patient is wheeled into the OR.

"We're trying to be total perioperative physicians, not just intraoperative physicians," says anesthesiologist Zachary Turnbull, MD, the medical director of performance improvement and the director of the Center for Perioperative Outcomes at New York's Weill-Cornell Medical College.

Experts are reassessing the hard-and-fast rule of fasting at midnight the night before surgery. New thinking on NPO involves having patients drink carbohydrate-rich supplements 2 to 3 hours before surgery. The developing concept is a definite satisfier for patients, who show up for surgery feeling comfortable and perhaps less anxious. They're also hydrated and nourished, and a growing body of research suggests patients who don't go NPO experience fewer post-op complications and recover faster.

"You want to consider what patients are doing at home," says Dr. Turnbull. "They have better outcomes if they eat well and are well hydrated, if they're exercising a little bit, if they're training for surgery and doing the right things for their body to recover from an insult. That lets us manage the intraoperative part in such a way that we maximize the post-op period and patient outcomes."

2. Maximized multimodal regimens

To get at the root of post-op pain, you should attack it with a multimodal approach (using 2 or more different methods or medications to manage pain) rather than using opioids alone, says Dr. Turnbull. Acetaminophen, COX-2 inhibitors and gabapentinoids are among the analgesics that address the "multitude of pathways" that can lead to pain. But here, too, there's a balancing act.

"With Gabapentin and pregabalin, for example, there's definitely a pain benefit, and they do reduce the need for opioids," says Dr. Turnbull. "But they also make a lot of people feel very sleepy. Again, it's finding that right point. Maybe it's the dose, or maybe it's the wrong medication altogether. Are we decreasing pain? Yes, but at what cost? That's how we're trying to thread the needle."

For total knees, general anesthesia has traditionally been the go-to approach. But multiple studies have clearly demonstrated the potential advantages of combining regional techniques with multimodal analgesia.

"A lot of people are investigating the best block for this type of procedure," says Dr. Turnbull. "When are patients able to get up and move, and how much pain are they having? Do they need supplemental blocks? I think it's an evolving question that the literature is still teasing out."

There is new thinking in regional anesthesia with the potential to move the needle:

• Periarticular injections. For total knees, a periarticular injection combined with an adductor canal block allows for a very rapid discharge and controls pain safely, says orthopedic surgeon R. Michael Meneghini, MD, director of the Indiana University Hip and Knee Center.

"The combination has really improved our ability to get patients out of the hospital quickly or to do them in a surgery center," he says.

The periarticular injection, directed at the local peripheral nerves around the knee, can be a combination of a "pretty inexpensive dosage of ropivacaine, clonidine and epinephrine that has really been shown to improve pain scores in multiple studies," says Dr. Meneghini, who adds that Exparel (liposomal bupivacaine), on the other hand, significantly increases costs without having a commensurate effect on pain.

• Adductor canal blocks. These blocks are increasingly preferred over femoral blocks for total knees because they allow for greater mobility after surgery. "They don't shut down your quadricep strength the way femoral blocks do," says Dr. Meneghini, "but you still have to pay attention, because they can have proximal spread and produce quad weakness. Patients can still be at a risk for falls."

Stavros G. Memtsoudis, MD, PhD, FCCP, echoes both the enthusiasm and the concern. With adductor canal blocks, "care needs to be taken to limit the volume of anesthetic, so as to not cause inadvertent upward spread, which can affect femoral nerve fibers and cause weakness," says Dr. Memtsoudis, a senior scientist and attending anesthesiologist at Weill Cornell's Hospital for Special Surgery in New York, N.Y. "But as a sensory block, it affects motor strength to a lesser degree than femoral blocks. And some motor dysfunction should always be expected with total knees."

The downside, he says, is that adductor canal blocks, along with requiring ultrasound guidance and some expertise to place, alleviate pain only in the anterior of the knee. "To address that problem, more and more anesthesiologists are combining them with IPACK (interspace between the popliteal artery and the capsule of the posterior knee) blocks," explains Dr. Memtsoudis. "That's another sensory block, and it's replaced the schiatic nerve block."

3. A fast-acting block

One of the challenges of anesthesia is getting patients back on their feet as quickly as possible. Help appears to be on the way in the form of a new spinal anesthetic called Clorotekal (chloroprocaine hydrochloride), which wears off in about 40 minutes. Clorotekal, which also has a quicker onset time and is associated with a lower urinary retention rate than other anesthetics, was unveiled this past spring at the American Society of Regional Anesthesia (ASRA) and Acute Pain Medicine's 43rd annual conference. In one study, patients given Clorotekal were reportedly ready to be discharged 150 minutes after being injected, beating bupivacaine study patients out the door by some 80 minutes.

4. Wide-awake hand surgery

Anesthesiologists can agree that less sedation is safer than more sedation, and that the safest sedation is no sedation, says Donald Lalonde, MD, the chief of plastic and reconstructive surgery ?at Dalhousie University in Saint John, New Brunswick, Canada. That philosophy inspired Dr. Lalonde to develop what he calls WALANT — "wide awake, local anesthesia, no tourniquet" — hand surgery.

The technique, which is used for wrist and hand procedures, uses lidocaine or epinephrine injected only at the areas of dissection. Among the advantages, says Dr. Lalonde, is patients can move their fingers on command while the surgery takes place.

"One of the most difficult problems in tendon transfer has always been the problem of getting the tension just right, not too tight or too loose," he explains. "Doing these operations while patients are wide awake has really improved our ability to do this."

Jodi L. Pelkey, BSN, RN, CNOR, an educator at the Flagstaff (Ariz.) Medical Center, helped set up a successful WALANT program after a surgical colleague proposed the idea. Now, she says, they have WALANT days roughly once a week at their affiliated ASC, during which they can do upwards of 15 patients with just one surgeon working because the procedure is very fast-paced.

The full numbing effect of the anesthetic typically takes 15 to 20 minutes to set in, so they use 2 ORs, and the surgeon moves back and forth at appropriate intervals. By the time one patient's surgery is complete, the next patient is ready to go.

"The surgical time doesn't change much, but we can get started quicker, and afterward we don't have to wait for the patient to be less sedated or to wake up from general anesthesia," says Ms. Pelkey. "Things move quickly on both ends of surgery."

There's also a cost savings, she says, because although supply costs are static, there's no anesthesia chart and less monitoring is needed.

"The other thing that's really great for the patients is that we don't have to tell them not to eat or drink, and we don't have to adjust their medication schedules," she adds. "We expect them to eat breakfast and we expect them to take their pills as they normally would."

The only caveat: Patient selection is key. "They have to be well prepped. They have to know they're going to be awake and are going to hear us, and that we expect them to speak up if they have any discomfort, because we'll take care of it," says Ms. Pelkey. "For patients who haven't seen the inside of an operating room before, it can be a little nerve-wracking."

But many patients do love the technique, insists Dr. Lalonde, who says patients can speak to the surgeon during the case and have their questions answered, and they don't have any tourniquet pain or nausea. They also don't have to make an unnecessary visit to a hospital for unnecessary X-rays or EKGs, and they don't have to take time out of work or get a babysitter to have unnecessary tests. And nobody needs to get admitted to a hospital for medical problems."

On the cusp

Dr. Turnbull says the goal of ambulatory anesthesia is to establish clinical pathways that minimize unnecessary variations and reduce costs with streamlined procedures and protocols.

"I think the culture of medicine is always hard to change," he says. "But anesthesia is undergoing its own cultural revolution."

Providers, however, want to see quality research before implementing new techniques to ensure that they're doing no harm. "I think we're headed in the right direction with a multi-pronged approach to a multifactorial problem," says Dr. Turn-bull. "I'm optimistic we'll get there." OSM