CODE speaking with Dr. Arnaldo Valedon, MD at the 4th Interdisciplinary Conference on Orthopedic Value Based Care 2020

Session Topics: 

  • ASC Accreditation panel 
  • Myth Busters in Anesthesia and Orthopedics

Interviewee:
Arnaldo Valedon, MD
Board Chair,
Accreditation Association for Ambulatory Healthcare (AAAHC)

Dr. Brian Cunningham:
Welcome to OVBC 2020. We’re lucky enough to be joined by Dr. Valedon. We just talked a little bit about ASC credentialing and that entire process and key and a significant portion of that is around making sure that the processes for the total joint movement to the outpatient setting have been well done. Let’s talk a little bit about some of your perspective on how you select patients for an outpatient setting for total joints?

Dr. Arnaldo Valedon:
A very interesting topic. And this is a topic that has been evolving honestly for the last 20 years, which is when we first heard of a wish to really decrease the hospital stay for total joints. So patient selection has really changed and has been refined over time. Currently, I got to say, the amount of work that has been done has been fantastic, and I think we have made great strides in really identifying some of the potential issues that would really decrease our success for patients. Again, we can define success in many different ways. We have heard today as a matter of fact about how that can be measured and many times it’s in the eye of the beholder, but certainly on the clinical side, we have some direct evidence that can lead us to better outcomes. Starting with a body mass index, again, this is a topic that has been looked at in depth. BMI, we know over 40, has been associated with lesser success and more complications than anything under 40, so that’s something that we’d like to take a look at.

Obstructive sleep apnea, as a matter of fact. It’s a huge topic that has been discussed both in the sleep medicine community as well as the anesthesia community. We really strongly need patients to be treated for sleep apnea to decrease complications. Smoking, directly related to successful total joints.

Any issues with coagulopathy, as an example, has also been this cost and there’s plenty of evidence on that end that it decreases success. And last but not least, hyperglycemia. So diabetes management.

We also know that typically hemoglobin of A1C, hemoglobin A1C over 7.0, some people use 6.8 which is a little more strict and can lead to decreased success in that population. So again, these are basic rules for which we have evidence in the population. Above and beyond that, there’s plenty of other comorbidities that need to be checked and optimized for success. Not only that, on the clinical side, we need first and foremost to have a motivated patient with the appropriate infrastructure at home for support. If we do not have any of those two, any comorbidity is going to be well-controlled, we’re not going to succeed.

So, a lot of work that really needs to be done in this area. We have been talking about enhanced recovery, of course, for these patients. In my mind, enhanced recovery, really has many other principles based on efficient outpatient perioperative management. So, we need more data when it comes to hips and nutrition, ahead of time. A lot more data that is needed. But it’s very interesting, the way we’re going at it, as well as all the developments with regional anesthesia as an example. We are, I mean, leap years ahead.

Dr. Brian Cunningham:
When you think about a total joint, as an orthopedic surgeon, I have a small brain, tell me, what’s the preferred anesthesia, all things being equal? Is it a spinal, is it sedation and regional? Is it general? Help me walk through your kind of preferred decision making in the outpatient setting.

Dr. Arnaldo Valedon:
So, very good question. And this is something that we face almost on a daily basis. Where we do know, and there’s plenty of evidence out there for this, is that a multimodal analgesic approach to total hips is what’s going to make us successful. What I mean by that is, that you really need to treat pain before it occurs and you need to be aggressive in treating post operative pain. So, and when you treat postoperative pain, again, there’s many different ways, many different paths that you can combat pain, if you will. So, that multimodal approach is really absolutely key for success. That being said, we’re dealing with the pain management, the anesthetic itself. In the interest of discussion, I can tell you that both work. Doing a spinal anesthetic is certainly very reasonable to do depending on the speed of the surgeon, depending on the complexity of the case, it’s the type of spinal that you can use and many people do.

General anesthesia of course, depending on the data that you look at, some of the data shows a very slight increase in complications in some studies, not in all. Personally, I strongly prefer to do general anesthesia because spinals can actually lead to some untoward complications that I’d rather not deal with. Urinary retention being one of them, number one. And number two, residual weakness when we get into recovery. So, if we’re really aiming for quick ambulation, and what I mean by that is within typically 30 minutes of getting into recovery, my enemy will be a residual weakness. So, we rather not deal with that on a potential fall or anything like that for the patients.

Dr. Brian Cunningham:
Now, do you rely on in your setting, or in your kind of a preferred situation, to have the surgeon using some type of local anesthetic delivery intracapsular around the soft tissues, that kind of-

Dr. Arnaldo Valedon:
Yes.

Dr. Brian Cunningham:
… especially if you’re going to prefer a general anesthetic, it would seem like the general anesthetic would allow early wake up and early mobility and the intraoperative anesthetic multimodal strategy would allow pain control. That seems like it would be a good partnership.

Dr. Arnaldo Valedon:
No doubt.

Dr. Brian Cunningham:
Okay.

Dr. Arnaldo Valedon:
Partnering with the surgeon for good pain control is absolutely essential in our practice. And again, not because I have any stock in the company or anything else, but certainly using slow release bupivacaine exparel has really changed our practice significantly. Now, the injection with the exparel again needs to be in a very specific way, it’s not just a periarticular injection. It really needs to be done in various specific sites for it to work, but it really, it works beautifully. The other thing as an example for total joints, sorry, for total knees rather, doing an iPACK Block has really also transformed our recovery from total knees.

Dr. Brian Cunningham:
Tell me a little bit more about that. What is the iPACK Block, specifically?

Dr. Arnaldo Valedon:
So, it is an injection or local anesthetic done on the ultrasound, inferior to the popliteal artery and behind the knee and above the knee capsule. So, it’s more of a field block if you will. So you’re good on the ultrasound, once the needle is being retracted, inject local anesthetic and you deposit the local anesthetic. Some of the potential downside, if you inject too much local anesthetic or if it spreads, you can have a foot drop. It’s temporary of course. But it is a fantastic, fantastic block until we’re done. Now overall, since we talked briefly about quality metrics and how we measure that, I’m a strong believer, A., you can only change what you can measure. So, what is success to me or to a surgeon or to a patient can look very different. Being able to get a patient home, for some, might be success. Not necessarily in our era today. You really need to have a long term view on how to get patients through. It could be 30 days, it could be, as a matter of fact, closer to 12 months for implants and that is data that needs to be reported.

So, in terms of quality metrics, again, we have several clinical metrics that we look at. But my point in bringing that up is that we must, absolutely must incorporate. Return to, A., daily activities or something that the patient wants. Otherwise it’s not as good.

Dr. Brian Cunningham:
Yeah. What are we doing? If we’re playing for the short run win and we’re doing worse for our patients in the long run, that’s obviously not what we want to do. Fantastic. Well, thank you so much. Thank you for stopping by. Incredible opportunity, great talk. Looking forward to seeing you some more.

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