Updated: 4/16/2020

THA Postoperative Inpatient Management

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https://upload.orthobullets.com/topic/422739/images/total_hip_inpatient_rehab_walker.jpg
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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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