Introducing a day-case arthroplasty pathway significantly reduces overall length of stay

Aims Day-case arthroplasty is gaining popularity in Europe. We report outcomes from the first 12 months following implementation of a day-case pathway for unicompartmental knee arthroplasty (UKA) and total hip arthroplasty (THA) in an NHS hospital. Methods A total of 47 total hip arthroplasty (THA) and 24 unicompartmental knee arthroplasty (UKA) patients were selected for the day-case arthroplasty pathway, based on preoperative fitness and agreement to participate. Data were likewise collected for a matched control group (n = 58) who followed the standard pathway three months prior to the implementation of the day-case pathway. We report same-day discharge (SDD) success, reasons for delayed discharge, and patient-reported outcomes. Overall length of stay (LOS) for all lower limb arthroplasty was recorded to determine the wider impact of implementing a day-case pathway. Results Patients on the day-case pathway achieved SDD in 47% (22/47) of THAs and 67% (16/24) of UKAs. The most common reasons for failed SDD were nausea, hypotension, and pain, which were strongly associated with the use of fentanyl in the spinal anaesthetic. Complications and patient-reported outcomes were not significantly different between groups. Following the introduction of the day-case pathway, the mean LOS reduced significantly by 0.7, 0.6, and 0.5 days respectively in THA, UKA, and total knee arthroplasty cases (p < 0.001). Conclusion Day-case pathways are feasible in an NHS set-up with only small changes required. We do not recommend fentanyl in the spinal anaesthetic for day-case patients. An important benefit seen in our unit is the so-called ‘day-case effect’, with a significant reduction in mean LOS seen across all lower limb arthroplasty. Cite this article: Bone Jt Open 2021;2(11):900–908.

1299 Observational Study of The Use of Spinal Anaesthesia As an Alternative to General Anaesthetic For Ureteroscopy During The COVID-19 Pandemic

Introduction General anaesthetic has traditionally been felt to be more appropriate than spinal anaesthesia for patients undergoing ureteroscopy as it is difficult to achieve a suitably high block. During the COVID-19 pandemic, our centre moved elective operating to an alternative day-case surgical environment where the anaesthetic team performed predominantly spinal anaesthesia and were therefore very experienced with this modality. In view of concerns of COVID-19 transmission by aerosolisation during the intubation and extubation phases of general anaesthetic, spinal anaesthesia as an alternative first line modality was trialled with the option of converting to general anaesthesia if surgery could not be achieved safely and comfortably for the patient. Method During a three-month period, unless contraindicated, spinal anaesthesia was used as the first line anaesthetic for ureteroscopy cases. A retrospective study of outcomes was then undertaken. Results 44 patients were treated with a conversion rate to general anaesthetic of 9% (n = 4). There was a complication rate of 20% (n = 9); 4 partial procedures, 4 readmissions with symptomatic residual fragments or sepsis and 1 patient required post-operative overnight stay due to anaesthetic. Spinal anaesthetic time averaged 25minutes. Conclusions The global COVID-19 pandemic has led to change in practice and we have demonstrated that spinal anaesthesia is a valuable alternative to general anaesthetic in the majority of ureteroscopy cases. When undertaken by an experienced anaesthetic team, using this method does not significantly add to procedure time.

Is fascia iliaca compartment block or intravenous opioid analgesia better when positioning patients with fractured neck of femur for spinal anaesthesia?

Patients with a fractured neck of femur require effective analgesia to improve positioning before the administration of spinal anaesthetic. This article discusses the evidence to show whether fascia iliaca compartment block or intravenous opioid analgesia is preferable in this situation.

Neonatal Apgar Score Outcomes in Spinal Versus General Anaesthesia at the University Teaching Hospital (UTH), Lusaka.

Background: The knowledge gap was from the fact that the type of anaesthetic drug administered during caesarean section can have effects on neonatal outcome like low Apgar score with most hospitals in developed countries now using more modern inhalational anaesthetic agents with fewer or no cardio-respiratory depressant effects e.g. Isoflurane or Sevoflurane. However at UTH, halothane is still being used for maintenance of general anaesthesia despite well documented cardio-respiratory depressant effects with very limited research done on its effects on neonatal Apgar score. The Apgar score is a means of rapid evaluation of the physical condition of infants shortly after birth. Thus this study investigated the effects of general anaesthesia with halothane versus spinal anaesthesia on neonatal Apgar score. Objective and study design: With the view of determining the type of anaesthesia administered during caesarean section with the least effects on neonatal wellbeing shortly after birth, a prospective observational cohort study was conducted at the University Teaching Hospital between May 2015 and January 2016.The scientific objective was to determine the effects of general anaesthesia with halothane versus spinal anaesthesia on neonatal Apgar score. This study involved 70 neonates, 54 were born from mothers that had undergone caesarean section under spinal anaesthesia and 16 from mothers that had undergone general anaesthesia. The data was analysed using SPSS version 16.0. Inferential analysis was conducted using logistic regression. Results: 20 neonates out of 54 (37%) in the spinal anaesthetic group had an Apgar score less than 8 at 1 minute[Fig 1]. Out of the 16 neonates in the general anaesthesia group, 14 (87.5%) had Apgar score less than 8 at 1 minute[Fig 1]. One (1.9%) neonate had an Apgar score less than 8 at 5 minutes in the spinal anaesthesia group. While 4 (25%) neonates had Apgar score less than 8 in the GA group[Fig2] The logistic regression at 1 minute Showed that it is over 11 times more likely to get a low Apgar with a general anaesthetic as compared to a spinal anaesthetic (OR 11.9), [Table 3]. The Apgar score at 1 minute in the Spinal anaesthesia group was statistically significantly higher than the general anaesthesia group (p=0.002). The logistic regression at 5 minutes Showed that it is over 17 times more likely to get a low Apgar with a general anaesthetic as compared to a spinal anaesthetic (OR 17.7), [Table 4]. Further, the 5 minutes Apgar score in the spinal anaesthesia group was statistically significantly higher than the general anaesthesia group (p=0.014),[Table 4]. Conclusion: With the results pointing to the fact that there is significant difference in neonatal Apgar score outcomes in spinal versus general anaesthesia, the researcher therefore rejected the null hypothesis. It is therefore inferred that spinal anaesthesia method has better neonatal outcomes by Apgar score measure than general anaesthesia method.

The use of high-dose intrathecal diamorphine in laparoscopic bariatric surgery: a single-centre retrospective cohort study

Introduction: The use of intrathecal diamorphine is not commonplace in laparoscopic bariatric surgery. At our institution, a major UK bariatric centre, high-dose intrathecal diamorphine is routinely utilised. Methods: Data were analysed retrospectively. Fifty-three patients who had a spinal anaesthetic were matched against age, sex, body mass index and surgical procedure type to generate controls. Pain scores were recorded in the post-anaesthetic care unit on arrival, after 1 hour and on discharge to the ward. Post-operative nausea and vomiting; post-operative hypertension; pruritus; 24-hour morphine consumption and length of stay were measured. Results: Pain scores were better in the spinal anaesthetic group in all measured categories (p = 0.033, p < 0.01, p < 0.01); post-operative nausea and vomiting was less common in the spinal anaesthetic group (p < 0.01); post-operative hypertension was less common in the spinal anaesthetic group (p = 0.25); pruritus was more common in the spinal anaesthetic group (p < 0.01); morphine consumption was less common in the spinal anaesthetic group (p = 0.037). Length of hospital stay was reduced by 12.4 hours (p = 0.025). Conclusion: We propose that this is a practical and safe technique to adopt. A randomised-control trial will need to be conducted in order to find the most efficacious volume of local anaesthetic and dose of diamorphine

First Year Specialist Anaesthesia Training in Ireland: A Logbook Analysis

Objective:Acquisition of a new range of skills occurs during first year anaesthesia training. At present, no defined logbook targets exist for the Irish anaesthesia trainee.The aim of this study was to quantify the number of practical procedures performed and supervision required during first year anaesthesia training.Methods:A retrospective analysis of prospectively maintained logbooks of three first year anaesthesia trainees was performed.Results:In the first three months, mean numbers of cases were 224, enodotrachael tube (ETT) 64, laryngael mask airway (LMA) 55, spinal anaesthetic 12, arterial lines 9.5, central lines 0.5, peripheral nerve blockade (PNB) 2, epidurals 0. There was 91.5% direct supervision and 8.5% indirect supervision.In the final three months, mean numbers of cases were 205.5, ETT 28, LMA 35, spinals 50, arterial line insertions 4.5, central line insertions 1.5, PNB 3.5, epidurals 80. There was 68.5% direct supervision and 31.5% indirect supervision.Conclusions:Defined logbook targets are needed to quantify trainee progress.

Thromboembolic Diseases and the Use of Vena Cava Filters

Mr GW is a 77-year-old gentleman who is hoping to have a total knee replacement of his left knee. He underwent a knee replacement on the right in 2011 under spinal anaesthetic, where his postoperative period was complicated by a saddle pulmonary embolus (PE).