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Adherence to a Multimodal Analgesic Clinical Pathway: A Within-Group Comparison of Staged Bilateral Knee Arthroplasty Patients
  1. Rachel C. Steckelberg, MD, MPH*,
  2. Natasha Funck, MD*,,
  3. T. Edward Kim, MD*,,
  4. Tessa L. Walters, MD*,,
  5. Gregory Milo Lochbaum, MD*,,
  6. Stavros G. Memtsoudis, MD, PhD,§,
  7. Nicholas J. Giori, MD, PhD,**,
  8. Pier F. Indelli, MD, PhD,**,
  9. Lorrie J. Graham, BS and
  10. Edward R. Mariano, MD, MAS*,
  1. *Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine
  2. Anesthesiology and Perioperative Care Service, Veterans Affairs Palo Alto Health Care System, Palo Alto, CA
  3. Departments of Anesthesiology and Public Health, Weill Cornell Medical College
  4. §Department of Anesthesiology, Hospital for Special Surgery, New York, NY
  5. Department of Orthopaedic Surgery, Stanford University School of Medicine, Stanford
  6. **Orthopaedic Surgery Section, Surgical Service, Veterans Affairs Palo Alto Health Care System, Palo Alto, CA
  1. correspondence: Edward R. Mariano, MD, MAS, Anesthesiology and Perioperative Care Service, VA Palo Alto Health Care System, 3801 Miranda Ave (112A), Palo Alto, CA 94304 (e-mail: emariano{at}


Background and Objectives Multimodal analgesic clinical pathways for joint replacement patients often include perineural catheters, but long-term adherence to these pathways has not yet been investigated. Our primary aim was to determine adherence rate to a knee arthroplasty clinical pathway for patients undergoing staged bilateral procedures.

Methods This study was performed at a hospital with a Perioperative Surgical Home program and knee arthroplasty clinical pathway using multimodal analgesia and adductor canal catheters. Data were examined for all orthopedic surgery patients over a 4-year period. We included patients who had staged bilateral knee arthroplasty electively scheduled on 2 separate dates. The primary outcome was rate of adductor canal catheter utilization as a measure of adherence to the clinical pathway. Other outcomes included rates of neuraxial anesthesia and minor and major perioperative complications.

Results We analyzed data for 103 unique patients. The interval between surgeries was a median of 261 days (10th–90th percentile, 138–534 days). All 103 patients had adductor canal catheters for both the first and second surgeries (P > 0.999). Forty-one percent of patients had the same surgeon for both surgeries, but only 2% had the same anesthesiologist (P < 0.001). From the first to the second surgery, utilization of neuraxial anesthesia increased from 51% to 68%, respectively (P = 0.005). There were no differences in minor or major complications.

Conclusions For staged bilateral knee arthroplasty patients, 100% clinical pathway adherence including perineural catheters and multimodal analgesia is feasible despite multiple variables. We believe that patient-centered acute pain management requires consistent and reliable delivery of care.

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  • The authors declare no conflict of interest.

    E.R.M. has received unrestricted educational program funding paid to his institution from Halyard Health (Alpharetta, Georgia) and B.Braun (Bethlehem, Pennsylvania). These companies had no input into any aspect of the present study design and implementation; data collection, analysis, and interpretation; or manuscript preparation.

    The work has been submitted for partial presentation at the 42nd Annual Regional Anesthesiology and Acute Pain Medicine Meeting, April 6 to 8, 2017, San Francisco, California.

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