Outpatient joint replacements wouldn't be possible without the efforts of your anesthesia team. They identify and manage comorbid conditions to ensure patients are primed for surgery. They implement fast-track anesthesia techniques to get patients up and moving minutes after leaving the OR and ready to head home hours later. They administer aggressive, multimodal pain management protocols to prepare patients mentally and physically for taking the initial steps toward recovery. There are countless ways anesthesiologists contribute to successful outpatient joint replacement programs, beginning with working hard to set up patients for smooth recoveries.

There's a lot of buzz surrounding the Enhanced Recovery After Surgery (ERAS) movement as it pertains to total joints, and rightly so. Joint replacements are perfectly suited for the bundled payment model in which insurers pay a single global fee to surgeon groups and surgical facilities to deliver an entire episode of care, beginning when cases are scheduled and ending 90 days after surgery. The basic concept of ERAS dovetails nicely with what it takes to manage patients during that period: a holistic, multidisciplinary approach from the preoperative phase straight through to recovery is paramount to a positive surgical outcome.

In the pre-op phase, anesthesiologists identify candidates for surgery and optimize comorbid conditions, including:

• Anemia. Hemoglobin levels lower than 13 g/dL are associated with an increased need for blood transfusions and can lead to a number of post-op complications that can delay ambulation and physical therapy. Anemia is easily treated pre-operatively with iron supplements and/or erythropoietin.
• Glycemic control. Elevated A1C is linked to a higher rate of surgical-related infection. In general, patients should have an A1C of < 8 mg/dL before surgery.
• NPO status. Some providers and patients think pre-op fasting means drinking or eating nothing after midnight the night before surgery. That shouldn't be the case. The American Society of Anesthesiologists recommends that patients should be allowed to drink water up to 2 hours before procedures. That's why I tell patients to drink 2 glasses of water before bed, and 2 glasses before they leave in the morning for surgery. This simple practice reduces PONV risk, improves IV starts and drastically improves outcomes.
• Frailty. Anesthesiologists assess total joint candidates to ensure they don't have frailty issues that will likely hinder their recoveries. With CMS expected to approve knee replacements performed in ASCs in the near future, it will be more important than ever for anesthesiologists to determine frailty levels in the pre-op consult phase.

When you're considering the factors that can potentially delay a patient's post-op recovery, intraoperative anesthesia should be near the top of the list. The drugs used and the depth of anesthesia the patient is under are of critical importance when it comes to anesthetizing patients for total knee and total hip procedures, after which patients must be up and moving as quickly as possible.

There are no clear complications associated with general anesthesia, although neuraxial anesthesia avoids the potential adverse effects — cardiopulmonary depression and residual muscle paralysis — associated with the drugs used to administer it. Still, general anesthesia is a better choice for outpatient total joints than spinal, which could delay post-op ambulation and discharge due to muscle weakness and postural hypotension.

PONV is a complication that anesthesiologists tackle with prophylactic multimodal antiemetic therapy. The combination of antiemetics depends on the patient's risk level. For example, a combination of IV dexamethasone 8 mg and ondansetron 4 mg works for most patients, but those at a very high risk of PONV may require additional antiemetics such as a preoperative transdermal scopolamine patch.

Intraoperative bleeding is controlled through the use of tranexamic acid (TXA), an antifibrinolytic agent that minimizes blood loss and the need for transfusions, both critical components of performing total joints in the outpatient setting. Common dosing (though there is variability) is 1 gm IV before incision followed by 1 gm at the end of surgery.

Outpatient joint replacement is a safe and effective procedure requiring a total team effort from a group of multidisciplinary providers. Anesthesiologists lead the way. Their abilities to identify candidates for surgery, administer general anesthesia with a minimal number of short-acting drugs at the lowest possible dose and manage pain with opioid-sparing techniques have been key to moving more cases to ambulatory ORs. OSM