With collaboration among anesthesiologists, surgeons, hospitalists and physical therapists, the vast majority of joint replacement surgeries at UCLA are now being done with regional rather than general anesthesia.
The new approach has led to a host of desired outcomes: decreased length of hospital stay for patients, reduced opioid narcotic use for pain relief, faster recovery, less need to visit rehabilitation facilities and greater overall patient satisfaction.
“The traditional approach to joint replacement surgeries around the world has been that patients are put to sleep, they get a breathing tube, their joint is replaced, and then they spend several days in the hospital before going home,” says Natale Naim, MD, associate clinical professor in the Department of Anesthesiology and Perioperative Medicine at UCLA and a leader of the effort. “Particularly given that this is a surgery that is common in our older patient population, there has been a great deal of concern about the risks associated with general anesthesia among both patients and their families.
“Although we know it is safe overall, it’s also clear that there are better ways to prevent pain and keep patients off opioids and the risks associated with them. Even more importantly, we want to get patients home sooner, especially in COVID-19 times. With the new approach, instead of five days in the hospital, patients can go home within six hours,” Dr. Naim says.
Patients having joint replacement surgery at UCLA are now given a series of regional anesthesia nerve blocks — a process, Dr. Naim tells patients, that is analogous to getting their tooth numbed at the dentist. “We are essentially numbing up their joints so that only part of the body is being anesthetized,” she says. “We focus the anesthetic exactly where the surgery is, leaving the rest of the body alone — and any time we don’t have to take over the patient’s heart and lungs, there is less risk involved.” Patients are then discharged from the hospital with a nerve catheter — a portable anesthetic pump that continues to deliver the local anesthesia to the new joint around the clock for four days after the surgery, at which time the patient can pull the device out at home. UCLA Health first adopted the take-home nerve catheter approach in 2014, and Dr. Naim estimates that across all surgical services it is used in approximately 1,500 procedures per year, significantly more than at most other medical centers.
The current protocols for patients undergoing joint replacement surgery at UCLA were developed through intense collaboration among anesthesiologists, surgeons and others involved in the treatment of these patients. “We met weekly for years and continue to meet on a monthly basis,” Dr. Naim says. “Because most of these surgeries tend to be similar, from both an orthopaedic and anesthetic standpoint, they really lend themselves to standardization. Whenever we are able to do that in medicine, we are likely to see greater efficiency and better outcomes.”
The shift to regional anesthesia has made joint replacement a much more appealing option. “Orthopaedic surgeons are very happy with this development, not only because it addresses the concern about opioids, but also because it is making their patients much happier,” Dr. Naim says. “One surgeon told me that joint replacement surgery used to be a much bigger deal in a patient’s life — patients would talk about how it made things better in the long run, but they had to go through a difficult recovery. Now, it’s become more like a blip on the radar that they barely remember once it’s behind them. This is helping patients get back to their lives much more quickly.”