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Updated: Jun 10 2021

THA Postoperative Inpatient Management

  • Introduction
    • Postoperative inpatient management requires a coordinated effort from
      • physician (orthopedic surgeon +/- hospitalist)
      • physical therapist
      • occupational therapist
      • case manager
      • nursing staff
      • patient and patient's family
    • Care can be broken down into different phases including
      • preoperative teaching
      • inpatient acute care (hospital) - this topic
      • inpatient extended care (rehab/SNF)
      • outpatient home care
  • Inpatient Acute Care (Hospital)
    • Pain management
      • preoperative
        • NSAIDS and Acetaminphen are commonly given immediately before procedure to reduce postoperative pain
        • Some use Gabapentin and opiods but the data to support this is not as robust
      • intraoperative
        • regional anesthesia (spinal and/or epidural)
          • preferred over general anesthesia
        • periarticular multimodal drug injection
          • decrease postoperative pain with minimal risks
      • postoperative
        • multimodal oral drug therapy
          • gold standard
    • Medical management
      • surgical stress response can lead to exacerbation of underlying medical conditions
      • these conditions may require consultation with a hospitalist for workup and treatment
        • hypertension
          • defined as >140/90mm Hg however no set threshold for treatment
          • evaluate for reversible causes (missed medication, pain or anxiety, constipation, etc)
          • consider increasing home dose, IV antihypertensives (HTN emergency), or oral antihypertensives (preferred)
        • hypotension
          • defined as systolic BP <90 or drop in SBP by 40 from baseline
          • most common cause is intravascular volume depletion
          • treatment should include holding antihypertensives, IV fluid administration, +/- further testing (CBC/BMP, EKG, troponins, CXR, CTPE)
        • hypoxia
          • a combination of decreased cardiac output and oxygen tissue uptake results in hypoxia
          • all patients should be encouraged to use incentive spirometry or other pulmonary hygiene
          • may be a sign of acute cardiac ischemia, exacerbation of COPD/asthma, heart failure exacerbation, or PE
          • oxygen supplementation to keep O2 saturation >90% with those patients with an inability to maintain O2 saturation and respiratory distress should be taken to an intensive care unit
        • decreased urine output
          • most common causes are hypovolemia, urinary retention and acute kidney injury (AKI)
            • urinary retention
              • bladder dysfunction or urethral obstruction
            • acute kidney injury
              • prerenal (hypovolemia/hypotension), intrinsic, postrenal (urinary tract obstruction)
          • treatment for urinary retention includes straight cath, minimize anticholinergic/opioids, and consider tamsulosin
          • treatment for AKI includes correcting reversible cause, maintaining euvolemia, and remove nephrotoxics agents, renal dosing of other medications
        • altered mental status
          • mental status change that may wax and wane
          • identify underlying causes based on physical exam, laboratory values, and medication review
          • reorient and normalize sleep wake-cycle
        • chest pain
          • differential can include angina (myocardial ischemia), pleuritic chest pain, dyspepsia (epigastric discomfort), or chest wall pain
          • if cardiac origin is suspected check troponins and EKG
          • treatment can include immediate aspirin and cardiology eval (myocardial ischemia), NSAIDs (pleuritic or chest wall pain), or antiacid/PPI (dyspepsia)
        • nausea, vomiting, and abdominal pain
          • postoperative nausea and vomiting (PONV) is a side effect of opiates and anesthetic agents
          • treatment includes antiemetics, hydration, and electrolyte replacement
          • ileus may require placement of a nasogastric tube
          • Ogilvie's syndrome results in colonic obstruction without underlying mechanical cause and is a scenario where laxatives may make symptoms worse
        • postoperative fever
          • cytokine-mediated fever commonly occurs from surgical inflammation from orthopedic surgery on day 1-2
          • fevers after POD#3 have numerous causes broadly classified as infectious (UTI, cellulitis, pneumonia, C. diff, etc) or noninfectious (PE, withdrawal, transfusion reaction, medication reaction, etc)
          • observation is appropriate up to POD#2 if patients appear well
          • empiric antibiotics should be reserved for those patients who upon focused investigation have an infectious source of postoperative fever
    • Physical therapy
      • should start the day of surgery
        • decrease LOS
        • reduces pain and improves function
      • exercises
        • bed supported ROM exercises - ankle pumps, knee bends, glut sets, quad contractions, hip abduction, straight-leg raise
        • sit to edge of bed, sit in a chair, standing with a walker, gait training
        • stairs (up with the good, down with the bad)
          • going up should lead with nonoperative leg
          • going down should lead with operative leg
        • ambulation
          • walkers should be used in the immediate postoperative period
    • Occupational therapy
      • activities of daily living should be assisted by devices such as raised toilet seats, shower seats, and raised sitting chairs
    • goals of therapy
      • sitting upright -->
      • gait training, ambulation with walker, out of bed to chair -->
      • transfers, gait normalization -->
      • independence
    • Discharge home criteria
      • independent ambulation with assistive device (50-100ft)
      • independent transfers
      • independent ADLs
      • 2 stairs with supervision
      • follows dislocation precautions if present
      • appropriate home assistance (spouse, family, visiting nurses)
  • Inpatient Extended Care (Rehab)
    • Earlier discharge to rehab from hospital associated with improved outcomes
    • Discharge criteria to home similar to those in hospital
    • Levels of rehab include inpatient rehab and skilled nursing facility(SNF) or subacute rehab (SAR)
    • SNF/SAR
      • those patients who do not meet the above discharge criteria and do not qualify for inpatient rehab
      • considered a complement to acute care hospital and more cost-effective than inpatient rehab
    • inpatient rehab
      • for total joint arthroplasty patients must be able to participate in 3 hours of therapy/day and be >85 yo, BMI >50, or have undergone bilateral total joint arthroplasty
      • intensive rehabilitation services
      • rarely utilized following total joint arthroplasty
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