Perioperative medication management in orthopedic surgery
Authors:   , Wesselink Elsbeth Johanna 
Published: July 2024

In the preoperative phase of orthopedic surgery, having insight into the patient's home medication is important to the anesthesiologist and orthopedic surgeon. Therefore, medication reconciliation is conducted. Chapter 2 explores the frequency of alterations in home medication between the medication reconciliation process and the day of surgery. In 9.3% of the patients the medication error had potentially harmful consequences. Risk factors for changes included the use of ≥5 medications, cardiovascular disease, or asthma/COPD.
Knee arthroscopy is performed as an outpatient procedure; the surgery lasts approximately 20 minutes, and patients can be discharged on the same day. Chapter 3 describes the results of the SPACE study, in which prilocaine and chloroprocaine are compared in terms of the duration of motor and sensory block. One hundred and fifty patients were double-blind randomized to receive either 40 mg of prilocaine or 40 mg of chloroprocaine. The conclusion of this study was that patients who received chloroprocaine could be discharged 57 minutes earlier. In a follow-up study, the CORONA study, we investigated whether a lower dose of chloroprocaine would provide sufficient motor and sensory block for knee arthroscopy and the effect on the length of hospital stay. Chapter 4 presents the results of this multi-center dose-finding study. The effective dosage in 90% of the patients (ED90) was established at 27.8 mg. In a second cohort, the ED90 was validated in 50 patients, with 49 patients achieving successful anesthesia at this dosage. The median time to complete recovery of motor blockade was 60 minutes, and 90 minutes for the sensory block. The conclusion of this study was that a dosage of 28 mg chloroprocaine is effective for knee arthroscopy and results in rapid patient turnover.
After major orthopedic surgery, effective pain management is essential for recovery and quick mobilization. A well-known risk associated with a medical prescription for opioids is the potential development of dependence with prolonged use. In Chapter 5, we conducted a retrospective analysis of 386 total hip replacement patients who received postoperative opioid prescriptions. The percentage of patients with an active opioid prescription was reduced from 14.2% preoperatively to 2.6% postoperatively over a six-month period. Risk factors for prolonged opioid use included polypharmacy, a poor physical health, preoperative opioid use, and a longer stay in a rehabilitation center. We conclude that these risk factors can be identified preoperatively by the anesthesiologist and may lead to adjusted pain management or postoperative monitoring.
In the first two weeks after total hip or knee surgery, patients have an increased risk of falling due to reduced balance and loss of muscle mass. Preventing fall incidents is crucial, as a fracture following total hip or knee surgery is associated with increased morbidity and mortality. Chapter 6 describes a systematic review and meta-analysis we conducted to evaluate the risk of CNS medication use on postoperative fall incidents after total hip or knee surgery. In five studies, postoperative use of CNS medication was associated with fall incidents, with an almost 2-fold increased risk of falling.
After a more complex orthopedic procedure, patients may be postoperatively observed in the Intensive Care Unit (ICU). In the ICU the use of multiple drugs is common, increasing the likelihood of drug-drug interactions between two drugs. Chapter 7 describes the results of the SIMPLIFY study. Approximately half of the 103,871 intensive care unit patients were exposed to a potential medication interaction over a 7.5-year period, of which 38% were clinically relevant. This study demonstrates that ICU patients are often exposed to clinically relevant potential medication interactions, which can cause severe harm to the patient.