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Adherence to a Multimodal Analgesia Clinical Pathway: a Within-Group Comparison of Staged Bilateral Knee Replacement Patients
Sat, April 8, 3:00-4:30 pm
Salon 6

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Title: Adherence to a Multimodal Analgesia Clinical Pathway: a Within-Group Comparison of Staged Bilateral Knee Replacement Patients

Authors: Rachel C. Steckelberg, MD, MPH1,2, Natasha Funck, MD1,2, T. Edward Kim, MD1,2, Tessa L. Walters, MD1,2, Gregory M. Lochbaum, MD1,2, Stavros G. Memtsoudis, MD, PhD3,4, Lorrie Graham2, Edward R. Mariano, MD, MAS (Clinical Research) 1,2

1 Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine; Stanford, CA

2 Anesthesiology and Perioperative Care Service, Veterans Affairs Palo Alto Health Care System; Palo Alto, CA

3 Departments of Anesthesiology and Public Health, Weill Cornell Medical College; New York, NY

4 Department of Anesthesiology, Hospital for Special Surgery; New York, NY



Introduction: Continuous peripheral nerve block (CPNB) techniques decrease opioid consumption, time to achieve discharge criteria, and postoperative adverse events, and clinical pathways for patients having joint replacement surgeries which include CPNB demonstrate improved outcomes. However, adherence to these clinical pathways has not yet been investigated. The primary aim of this study is to determine the adherence rate to a clinical pathway for patients undergoing staged bilateral total knee arthroplasty (TKA) incorporating CPNB, and to test the difference in adherence rate for each of the staged surgeries.

Materials and Methods: This retrospective cohort study was performed at a university-affiliated, tertiary VA medical center with a Perioperative Surgical Home (PSH) program5 and an established TKA clinical pathway employing multimodal analgesia and preoperative adductor canal catheter (ACC) placement. Administrative, preoperative, intraoperative, and postoperative data from the PSH database were initially examined for all patients over a 4-year period who underwent more than one major lower extremity joint surgery at our facility. The primary outcome was the rate of ACC utilization as a measure of adherence to the clinical pathway. Other outcomes included rates of neuraxial anesthesia and minor and major complications in the perioperative period. 

Results: This retrospective cohort study was reviewed and approved with waiver of informed consent by our affiliated univer- sity’s institutional review board and local Veterans Affairs (VA) Research Committee. The final study cohort consisted of 103 unique patients who underwent staged bilateral TKA (Figure 1). The mean number of days between staged surgeries for all patients (n=103) was 323.6 days (+/- 199.5 days). All patients (103/103) had an ACC placed preoperatively for both the first (100% adherence) and second (100% adherence) TKA surgeries (p>0.999). Forty-one percent of patients had the same surgeon for both surgeries but only 2% had the same anesthesiologist (p<0.001). In terms of intraoperative anesthetic technique, 53/103 (51%) had neuraxial anesthesia for the first surgery compared to 70/103 (68%) for the second surgery:  43 patients had neuraxial anesthesia for both surgeries; 10 had neuraxial anesthesia the first time and changed to general anesthesia the second time; 27 had general anesthesia the first time and changed to neuraxial anesthesia the second time; and 23 had general anesthesia for both surgeries (p=0.005).

Discussion: We demonstrate a 100% adherence rate for a TKA clinical pathway incorporating ACC placement for postoperative pain control within a cohort of patients having staged bilateral TKA surgeries at a VA hospital with a PSH. Despite having a variable interval between surgeries, different surgeons, and different anesthesiologists involved, each patient received an ACC for both TKA procedures. We believe that patients scheduled for TKA surgery, especially those who have had the surgery previously, should not have to wonder what kind of pain relief will be offered, and the pain management plan should not vary based on which anesthesiologist is assigned, which surgeon is operating, or what time of day or day of the week the surgery is scheduled.


1. Hebl JR, Dilger JA, Byer DE, Kopp SL, Stevens SR, Pagnano MW, Hanssen AD, Horlocker TT. A pre-emptive multimodal pathway featuring peripheral nerve block improves perioperative outcomes after major orthopedic surgery. Reg Anesth Pain Med. 2008;33:510–517. 

2. Barbieri A, Vanhaecht K, Van Herck P, Sermeus W, Faggiano F, Marchisio S, Panella M. Effects of clinical pathways in the joint replacement: a meta-analysis. BMC Med. 2009;7:32.

3. Mudumbai SC, et al. The Perioperative Surgical Home model facilitates change implementation in anesthetic technique within a clinical pathway for total knee arthroplasty. Healthcare (2016), http://dx.doi.org/10.1016/j.hjdsi.2016.03.002i Article in press.

4. Ilfeld BM. Continuous peripheral nerve blocks: a review of the published evidence. Anesth Analg. 2011;113:904–925.

5. Mariano ER, Walters TL, Kim TE, Kain ZN. Why the Perioperative Surgical Home makes sense for veterans affairs health care. Anesth Analg. 2015;120:1163–1166.

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