1. Total Knee Arthroplasty (TKA)
Performance improvement project

2. Introduction Pain control after TKA can be very challenging
Inadequately controlled pain can cause slower mobilization and a delay in rehabilitation. (1)
This can also increase hospital length of stay (LOS), patient dissatisfaction, chronic pain syndrome and an increase in post operative complications. (2)

3. Hospital Course (Prior to ERAS) 2013-2016
Knee Surgery done under GA
(General Anesthesia)
Local infiltration of joint with Ropivacaine cocktail
49.25 mL Ropivacaine HCL mL Epinephrine
1 mL Ketorolac (30mg/mL)
0.8 mL Clonidine HCL mL Sodium Chloride
+/- Femoral Nerve Block (FNB) + Sciatic Nerve Block
PACU length of stay
>1 hr
Average Hospital length of stay(LOS)
3-5 days
Pain control with PCA dilaudid/morphine and other oral opioids
Inadequate pain relief
Increase in pain
POD #1 beginning at 24 hr

4. Expedited Recovery After Surgery (ERAS)
Accelerated care pathways delivered using an evidence based multidisciplinary approach, leading to reduced LOS, improved quality of treatment, and better outcomes throughout the hospital course
Multimodal Pain Management
IV fluid management
Decrease in perioperative Anesthesia drugs
Early mobilization
Decreased post operative nausea and vomiting (PONV)

5. Expedited Recovery After Surgery (ERAS)
GOALS
Efficient pain control after surgery
Decrease opioid consumption
Early mobilization
Decreased length of stay
Increased patient satisfaction

6. ERAS Dallas Veterans Affairs
Developed and Implemented ERAS for TKA using a team effort, multidisciplinary approach
Surgeons
Anesthesia
Day Surgery
PACU
4C Nursing
PT ,OT
Social Work
Home Health

7. ERAS Protocol Results Instituted full protocol July 2016
Continuously updated/changed protocol as needed
Better pain control than previous TKA surgeries for hours with
PCA
Pre Op PO pain medications
20mg po oxycodone, 650 mg po acetaminophen, 300mg po gabapentin
Post-Op PO pain medications
15mg po meloxicam, 20 mg po oxycodone on arrival to 4C, prior to working with KT/PT
Pain assessed q 4H
IV acetaminophen x3 doses , 300mg po gabapentin
Early mobilization
Cryotherapy (Polar Ice)
Crescendo Pain effect
Gradual increase in pain resulting in an abrupt onset of extreme pain
Intense pain that is difficult to get under control and manage
Occurs around 24h period
EBP to find a solution to crescendo pain

8. Research with Exparel Only 1 study done at VA facility using EXPAREL
Efficacy of Liposomal Bupivacaine Infiltration on the Management of Total Knee Arthroplasty (TKA)
2 yr Retrospective cohort study undergoing TKA at Indiana VA
199 patients

9. Results

10. What about Exparel? Let’s build on ERAS
Ropivicaine based cocktail – Pain relief for 9-12hrs
Unknown cost associated with this compounded mixture
Liposomal Bupivacaine (Exparel) Pain relief for hrs
Prolonged- release formulation indicated for infiltration into the surgical site for post surgical analgesia
IMPACTED BY INJECTION TECHNIQE (3)
The orthopedic surgeon received extensive training in cadaver lab to perfect infiltration technique
Multiple training seminars
Complete support during surgery to ensure injection success
14 injections ( 9- 10cc Pre-hardware and 5- 10cc Post Hardware =140 mL of pain control)
Results
Reduction in opioids in first 24 hours,
Decreased anti-emetic use
Improved post-operative pain control with NO reported crescendo pain
Institutional cost savings

11. Discovery What we found in 25/30 patients using ERAS with EXPAREL
**Update** ~200 patients with similar results
52% in LOS
SAIL metric
61% in Oxycodone use
National crisis with opioid addiction
Multiple patients on pain contracts
Historically, patient’s were sent home with 120 pain pills
Currently, patient’s sent home with 30 pain pills
To date, no request for more pain medication
Elimination of Dilaudid PCA ($350) savings (3)
Drastic reduction in IV Dilaudid for rescue
Decrease in PACU time

12. Statistics
Average cost for a hospital stay per night, according to Becker’s Hospital review was $1,760 in 2010
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13. Mean/Avg Cost Saving For Decreased LOS
Non- ERAS/ERAS
ERAS with EXPAREL
LOS
45.3 hours
Est. cost/Hour:
$ 83.41
Total cost per patient:
$ 3,778
LOS
21.7 hours
Est. cost/Hour:
$ 83.41
Total cost per patient:
$ 1,809
Institutional savings for Dallas VA:
$ 1,916 per patient

14. The Opioid Crisis Since 1999, rate of overdose deaths have quadrupled
More than 165,000 people have died from prescription opioid overdoses
On the average day in US
650,000 opioid Rx dispensed
3,900 people use for non-medical purpose
78 people die from overdose
Economic impact of crisis
55 Billion in health and social costs related to prescritp opioid abuse each year
20 Billion in Emergency Department and inpatient care for opioid poisonings
Source: IMS Health National Prescription Audit1 / SAMHSA National Survey on Drug Use and Health2 / CDC National Vital Statistics System3

15. Post op opioid consumption
The almost flat trend line of the Oxycodone use with EXPAREL suggest better pain management.

16. Decrease in Opioids Dallas VA
Cost savings
Decrease in overall consumption
Average opioid consumption during hospital stay
Non Exparel
Exparel
Reduction
Hydrocodone
40mg
10mg
75%
Oxycodone
65mg
25mg
61%
Dilaudid
5mg
0.2mg
96%
Morphine
39mg
100%

17. Overall results ERAS with EXPAREL
What we were trying to achieve
What we ACTUALLY achieved
Decrease in crescendo pain
↓ LOS
↓ Post-op pain
↓ PONV
Elimination of PCA
Elimination of IV rescue meds
↓ Opioid home
61% reduction
90 pills → 30 pills
↑ Patient satisfaction
↑ Increase employee satisfaction
↑ Increase Communication between teams
↑ Holistic approach to patient care

18. Other Considerations
Given the momentum and success, lets keep moving forward
On April 20, 2017, presented at the Dallas VA P & T committee meeting.
Continue use of Exparel on TKA’s
The use of Exparel has improved overall patient care/satisfaction
Telephone survey
Multiple Veterans with B TKA (With and without Exparel)
Cost Savings with decreased LOS, decrease in IV narcotics and elimination of PCAs
Currently: working on research project
IRB completed and data collected
Without EXPAREL
Re-evaluation of pain pill needs at discharge
We will need to add the PCA and IV rescue Dilaudid back in to the treatment plan
Decreases mobilization due to PCA infusion
Increases nausea/vomiting due to opioid use (Morphine)
Increase chances of constipation
Decreases patient satisfaction
Decreased employee satisfaction
Increased pain leads to unpleasant veteran
2 RN’s needed for PCA verification

19. References
1) Rostlund T, Kehlet H. High-dose local infiltration analgesia after hip and knee replacement: what is it, why does it work, and what are the future challenges? ActaOrthop 2007;78:159.
2) Perkins FM, Kehlet H. Chronic pain as an outcome of surgery: a review of predictive factors. Anesthesiology 2000;93:1123.
3)Dysart, S et al. A Randomized, Multicenter, Double-Blind Study of Local Infiltration Analgesia with Liposmal Bupivacaine for Postsurgical Pain Following Total Knee Arthroplassty: Rationale and Design of the PILLAR Trial.
4)Sakamoto, B et al. Efficacy of Liposomal Bupivacaine Infiltratrion on the Management of Total Knee Arthroplasty. Journal of American Medical Association 2016;