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Five-year follow-up to assess long-term sustainability of changing clinical practice regarding anesthesia and regional analgesia for lower extremity arthroplasty

대한마취과학회지 2020년 73권 5호 p.401 ~ 407
Tamboli Mallika, Leng Jody C., Hunter Oluwatobi O., Kou Alex, Mudumbai Seshadri C., Memtsoudis Stavros G., Walters Tessa L., Lochbaum Gregory Milo, Mariano Edward R.,
소속 상세정보
 ( Tamboli Mallika ) - Stanford University School of Medicine Department of Anesthesiology, Perioperative and Pain Medicine
 ( Leng Jody C. ) - Stanford University School of Medicine Department of Anesthesiology, Perioperative and Pain Medicine
 ( Hunter Oluwatobi O. ) - Veterans Affairs Palo Alto Health Care System Anesthesiology and Perioperative Care Service
 ( Kou Alex ) - Stanford University School of Medicine Department of Anesthesiology, Perioperative and Pain Medicine
 ( Mudumbai Seshadri C. ) - Stanford University School of Medicine Department of Anesthesiology, Perioperative and Pain Medicine
 ( Memtsoudis Stavros G. ) - Weill Cornell Medical College Department of Anesthesiology and Public Health
 ( Walters Tessa L. ) - Stanford University School of Medicine Department of Anesthesiology, Perioperative and Pain Medicine
 ( Lochbaum Gregory Milo ) - Stanford University School of Medicine Department of Anesthesiology, Perioperative and Pain Medicine
 ( Mariano Edward R. ) - Stanford University School of Medicine Department of Anesthesiology, Perioperative and Pain Medicine

Abstract


Background: Long-term and sustainable clinical practice changes in anesthesia procedures have not previously been reported. Therefore, we performed a 5-year audit following implementation of a clinical pathway change favoring spinal anesthesia for total knee arthroplasty (TKA). We similarly evaluated a parallel cohort of patients undergoing total hip arthroplasty (THA), who did not undergo a clinical pathway change, and studied utilization rates of continuous peripheral nerve block (CPNB).

Methods: We identified all primary unilateral TKA and THA cases completed from January 2013 through December 2018, thereby including clinical pathway change data from one-year pre-implementation to 5-years post-implementation. Our primary outcome was the overall application rate of spinal anesthesia. Secondary outcomes included CPNB utilization rate, 30-day postoperative complications, and resource utilization variables such as hospital readmission, emergency department visits, and blood transfusions.

Results: The sample included 1,859 cases, consisting of 1,250 TKAs and 609 THAs. During the initial year post-implementation, 174/221 (78.7%) TKAs received spinal anesthesia compared to 23/186 (12.4%) cases the year before implementation (P < 0.001). During the following 4-year period, 647/843 (77.2%) TKAs received spinal anesthesia (P = 0.532 vs. year 1). The number of THA cases receiving spinal anesthesia the year after implementation was 78/124 (62.9%), compared to 48/116 (41.4%) pre-implementation (P = 0.001); however, the rate decreased over the following 4-year period to 193/369 (52.3%) (P = 0.040 vs. year 1). CPNB use was high in both TKA and THA patient groups, and there were no differences in 30-day postoperative complications, hospital readmission, emergency department visits, or blood transfusions between patients who underwent spinal and general anesthesia in both TKA and THA groups.

Conclusions: A clinical pathway change promoting spinal anesthesia for TKA can be effectively implemented and sustained over a 5-year period.

키워드

Analgesia; Change implementation; Clinical pathway; Hip arthroplasty; Knee arthroplasty; Nerve block; Quality improvement; Regional anesthesia; Spinal anesthesia

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