BACKGROUND:Gabapentinoids have been widely incorporated into enhanced recovery after surgery (ERAS) pathways for total joint arthroplasty despite limited evidence of benefit and increasing concern for adverse hemodynamic effects. In response to frequent postoperative hypotension observed on inpatient units, a multidisciplinary team initiated a quality improvement effort to remove routine gabapentinoids from an orthopedic ERAS pathway. METHODS:This initiative was conducted at a tertiary academic medical center as part of ongoing medication safety monitoring within an established ERAS program. Routine perioperative gabapentinoids were removed from the orthopedic ERAS pathway following multidisciplinary review, education, and correction of an electronic order set autoselection defect. Outcomes were monitored using routinely collected clinical data from adult patients undergoing primary or revision total hip or knee arthroplasty. The primary outcome was postoperative hypotension occurring from postoperative day 1 to discharge. Gabapentinoid exposure rates and patient and procedural characteristics were tracked to contextualize changes over time. RESULTS:A total of 1246 total joint arthroplasty cases were included during the quality monitoring period. Following pathway modification, gabapentinoid exposure decreased from 532 of 589 (90.3%) to 102 of 543 (18.8%) (P < .0001). This change was accompanied by a descriptive decrease in postoperative hypotension from 59 of 589 (10.0%) to 36 of 543 (6.6%) with P values reported descriptively. Patient demographics, procedure types, and anesthesia distributions remained similar across monitoring periods, suggesting that observed changes were temporally associated with pathway modification rather than shifts in case mix. CONCLUSIONS:Eliminating routine gabapentinoids from a total joint arthroplasty ERAS pathway was associated with lower observed rates of postoperative hypotension and substantially lower gabapentinoid exposure. This quality improvement initiative demonstrates how multidisciplinary review, electronic order set evaluation, and structured monitoring can support safer medication use and improve the reliability of perioperative care pathways.

Dear Dr Bhakta and Dr Harmon:\n\nWe thank you both for taking the time to read our article, ‘Music versus midazolam during preoperative nerve block placements: a prospective randomized controlled study’ which was recently published in the journal, Regional Anesthesia \u0026 Pain Medicine in June 2019.[

Background and objectives Peripheral nerve blocks have been integrated into most multimodal analgesia protocols for total knee arthroplasty (TKA). The adductor canal block (ACB) has gained popularity because of its quadriceps muscle sparing. Similarly, local anesthetic injection between the popliteal artery and the posterior capsule of the knee, IPACK block, has been described to provide analgesia to the posterior capsule of the knee with motor-sparing qualities. This prospective randomized controlled trial aimed to assess the analgesic efficacy of adding the IPACK block to our current multimodal analgesic regimen, including the ACB, in patients undergoing primary TKA. Methods 119 patients were randomized to receive either an IPACK or a sham block in addition to multimodal analgesia and an ACB. We were set to assess pain in the back of the knee 6 hours after surgery. Other end points included quality of recovery after surgery, pain scores, opioid requirements, and functional measures. Results Patients who received the IPACK block had less pain in the back of the knee 6 hours after surgery when compared with the sham block: 21.7% vs 45.8%, p<0.01. There was marginal improvement in other pain measures in the first 24 hours after surgery. However, opioid requirements, quality of recovery and functional measures were similar between the two groups. Conclusion The IPACK block reduced the incidence of posterior knee pain 6 hours postoperatively.

Background and objectivesMusic medicine is a non-pharmacologic intervention that is virtually harm-free, relatively inexpensive and has been shown to significantly decrease preoperative anxiety. In this study we aim to compare the use of music to midazolam as a preoperative anxiolytic prior to the administration of an ultrasound-guided single-injection peripheral nerve block.MethodsIn this randomized controlled study we compared the anxiolytic effects of intravenous midazolam (1–2 mg) with noise-canceling headphone-delivered music medicine. All patients received a preoperative ultrasound-guided single-injection peripheral nerve block indicated for a primary regional anesthetic or postoperative analgesia.ResultsThe change in the State Trait Anxiety Inventory-6 (STAI-6) anxiety scores from after to before the procedure were similar in both groups (music group −1.6 (SD 10.7); midazolam group −4.2 (SD 11); p=0.14; mean difference between groups −2.5 (95% CI −5.9 to 0.9), p=0.1). Patient satisfaction scores with their procedure experience were higher in the midazolam group (p=0.01); however, there were no differences in physician satisfaction scores of their procedure experience between groups (p=0.07). Both patient and physician perceptions on difficulties in communication were higher in the music group than in the midazolam group (p=0.005 and p=0.0007, respectively).ConclusionsMusic medicine may be offered as an alternative to midazolam administration prior to peripheral regional anesthesia. However, further studies are warranted to evaluate whether or not the type of music, as well as how it is delivered, offers advantages over midazolam that outweigh the increase in communication barriers.Clinical trial registryClinicaltrials.gov #NCT03069677

BACKGROUND: Adductor canal block (ACB) has emerged as an appealing alternative to femoral nerve block (FNB) that produces a predominantly sensory nerve block by anesthetizing the saphenous nerve. Studies have shown greater quadriceps strength preservation with ACB compared with FNB, but no advantage has yet been shown in terms of fall risk. The Tinetti scale is used by physical therapists to assess gait and balance, and total score can estimate a patient’s fall risk. We designed this study to test the primary hypothesis that FNB results in a greater proportion of “high fall risk” patients postoperatively using the Tinetti score compared with ACB. METHODS: After institutional review board approval, informed written consent to participate in the study was obtained. Patients undergoing primary unilateral total knee arthroplasty were eligible for enrollment in this double-blind, randomized trial. Patients received either an ACB or FNB (20 mL of 0.5% ropivacaine) with catheter placement (8 mL/h of 0.2% ropivacaine) in the setting of multimodal analgesia. Continuous infusion was stopped in the morning of postoperative day (POD)1 before starting physical therapy (PT). On POD1, PT assessed the primary outcome using the Tinetti score for gait and balance. Patients were considered to be at high risk of falling if they scored <19. Secondary outcomes included manual muscle testing of the quadriceps muscle strength, Timed Up and Go (TUG) test, and ambulation distance on POD1 and POD2. The quality of postoperative analgesia and the quality of recovery were assessed with American Pain Society Patient Outcome Questionnaire Revised and Quality of Recovery-9 questionnaire, respectively. RESULTS: Sixty-two patients were enrolled in the study (31 ACB and 31 FNB). No difference was found in the proportion of “high fall risk” patients on POD1 (21/31 in the ACB group versus 24/31 in the FNB group [ P = 0.7]; relative risk, 1.14 [95% confidence interval, 0.84–1.56]) or POD2 (7/31 in the ACB versus 14/31 in the FNB group [ P = 0.06]; relative risk, 2.0 [95% confidence interval, 0.94–4.27]). The average distance of ambulation during PT and time to up and go were similar on POD1 and POD2. Manual muscle testing grades were significantly higher on POD1 in the ACB group when compared with that in the FNB ( P = 0.001) (Wilcoxon-Mann-Whitney odds, 2.25 [95% confidence interval, 1.35–4.26]). There were no other differences in postoperative outcomes. CONCLUSIONS: ACB results in greater preservation of quadriceps muscle strength. Although we did not detect a significant reduction in fall risk when compared with FNB, based on the upper limit of the relative risk, it may very well be present. Further study is needed with a larger sample size.