WARP for Primary Hip and Knee Arthroplasty Patients

Guideline 576FM.1.1 1 of 24 Uncontrolled if printed

576FM.1.1 WYCOMBE ARTHROPLASTY RAPID-RECOVERY PATHWAY (WARP®) FOR PRIMARY HIP AND KNEE ARTHROPLASTY PATIENTS

1. INTRODUCTION ........................................................................................................ 2 2. ORTHOPAEDIC REVIEW IN OUTPATIENTS ............................................................ 2

2.1 Patient education and counselling ........................................................................... 3 2.2 Listing the patient for surgery and preparation......................................................... 3

3. THE RAPID RECOVERY NURSE .............................................................................. 4 4. PRE-OPERATIVE EDUCATION GROUP (JOINT SCHOOL) ...................................... 4

4.1 Key outcomes of Joint School ................................................................................. 4 4.2 Checklist for completion of Joint School .................................................................. 5

5. PRE-OPERATIVE ASSESSMENT AND PREPARATION ........................................... 5 5.1 Anaemia .................................................................................................................. 5 5.2 Diabetic management ............................................................................................. 5 5.3 Pain control ............................................................................................................. 5 5.4 Infection control ....................................................................................................... 6 5.5 Medication checking ................................................................................................ 6 5.6 Consent Clinic ......................................................................................................... 6

6. THE DAY OF SURGERY ............................................................................................ 7 7. ANAESTHETIC GUIDELINE....................................................................................... 7

7.1 Spinal and sedation ................................................................................................. 7 7.2 General anaesthesia +/- nerve block ....................................................................... 8 7.3 Co-ordination between teams (anaesthetic, scrub and surgical) .............................. 8 7.4 Antiemesis .............................................................................................................. 8 7.5 Antibiotic prophylaxis ............................................................................................... 8 7.6 Tranexamic acid (TXA) ............................................................................................ 8 7.7 Other ....................................................................................................................... 8 7.8 Post-operative medication whilst in hospital ............................................................ 8 7.9 Venous thromboembolism prophylaxis .................................................................... 9

8. SURGICAL TECHNIQUE AND JOINT REPLACEMENT PROSTHESES ................... 9 8.1 Intraoperative local anaesthetic infiltration ..............................................................10

9. POST-OPERATIVE MANAGEMENT – THE 3 PHASES OF RAPID RECOVERY .....10 9.1 PHASE 1 of Rapid Recovery: In Recovery ............................................................10 9.2 PHASE 2 of Rapid Recovery: In Ward 12B ............................................................10 9.3 PHASE 3 of Rapid Recovery: Discharge criteria ....................................................12

10. FOLLOW UP PROCEDURES ....................................................................................13 10.1 Wound care ............................................................................................................13 10.2 Pain management and other prescriptions on discharge ........................................13 10.3 Therapy on discharge .............................................................................................14 10.4 Follow-up appointments .........................................................................................14

11. RELATED BHT GUIDELINES ....................................................................................14 12. REFERENCES ..........................................................................................................15 13. ACKNOWLEDGMENTS ............................................................................................16 Appendix 1: Complete Pathway Flowchart ..........................................................................17 Appendix 2: Anaesthetic Pathway Flowchart .......................................................................18 Appendix 3: Criteria-Led Discharge List ..............................................................................19 Appendix 4: Medication To Take Home ...............................................................................20 Appendix 5: Patient Medication Diary (Codeine) ..................................................................21 Appendix 6: Patient Medication Diary (Tramadol) ................................................................22 Appendix 7: Post-operative Medication Information .............................................................23 Appendix 8: Virtual Follow-up Proforma ..............................................................................24


1. INTRODUCTION The Enhanced Recovery Programme has come a long way over the years, constantly evolving and improving as more and more components are implemented. The redesign of the Trust’s current Enhanced Recovery Pathway for elective primary arthroplasty was a work in progress to address the shortfalls highlighted by the Get It Right First Time (GIRFT) workstream. The process was accelerated by the COVID-19 Pandemic, which resulted in longer waiting lists and need for more complicated and laborious processes to maintain safety of staff and patients. Fuelled by the national GIRFT NHS improvement programme there was a great opportunity for rapid collaborative changes and innovations amongst the teams to help improve patient care and satisfaction, further reduce in-hospital length of stay, enhance efficiency, and improve safety. The need for changing our current practice prompted a review of every stage of how the service is delivering care. Effective multidisciplinary team collaboration and communication amongst all stakeholders led to the development of Wycombe Arthroplasty Rapid-recovery Pathway (WARP®). The redesigned WARP® is applicable to ALL patients for elective primary arthroplasty. Surgical and anaesthetic procedures, post-operative care and follow up, as well as other parts of the pathway, are standardised as much as possible so that the whole process is predictably reproducible and becomes familiar to the whole staff involved over a short period of time. This process results in shortening the operative time and hence the surgical stress and blood loss. The redesigned WARP® incorporates the latest evidence-based innovations and best practices shared nationally on GIRFT forums and on Enhanced Recovery Workshops. The aim of this pathway is to reduce the stress caused by the anaesthetic and surgery and by doing so to attenuate the trauma-induced physiological responses. The undisputable benefits are accelerated recovery, reduction of morbidity, and improved patient satisfaction. The patient-tailored, pre-emptive, multimodal analgesia allows quicker, more comfortable, and more productive post-operative mobilisation. As a result, less in-hospital physiotherapy sessions are required before patients are safely discharged. The redesigned WARP® helps to create a more robust framework, facilitates a quicker recovery and aids to a significant reduction in length of in-hospital stay helping the Trust to match the national top decile of performance metrics. A selected cohort of patients will be suitable for day-case surgery which is a great quality improvement for the patient as well as financial gain for the Trust. There are many opportunities for patient selection based on robust evidence-based criteria: Outpatient clinic, Preassessment Clinic, Consenting Clinic. The selected eligible patients are educated accordingly, an individually tailored management plan is made, and the multi-disciplinary team works closely with them throughout their journey to ensure excellent standards of patient-centered care. 2. ORTHOPAEDIC REVIEW IN OUTPATIENTS

• Review medical history and imaging. • Assess severity of pain and impact on the patient’s function, quality of life, occupation

and leisure activities. • Physical examination in deformity, range of motion, effusions, tenderness, gait/

description as per FRCS (Orth) guidelines. • Discuss risk and benefits of surgery and conservative treatment. • Confirm if patient understands options and how they wish to proceed. • Assess pre-existing pain score at rest and movement (no pain, mild, moderate to

severe). • Identify high risk patients based on age and comorbidities for comprehensive geriatric

assessment and more in-depth shared decision-making consultation involving the anaesthetic team before finalising decision for surgery in this group of patients.


• Identify candidates for day-case joint replacement using selection criteria:

o Straightforward surgery expected o Age <75 o BMI <30 o ASA 1 or 2 o No complex pain issues – not on increased opioids already o No severe/unstable cardiovascular or pulmonary disease o Motivated patient – support at home for 5 - 7 days

• Discuss in detail about WARP® and expectations around length of stay, recovery time and support required with time for questions. Such discussion is of paramount importance especially for day-case candidates and all team members should spend extra time to explain every step of the Rapid Recovery Pathway, to set all expectations right and to ensure that patients feel confident and safe to be discharged on the day of surgery.

2.1 Patient education and counselling

• Educating patients before surgery leads to reduction in length of stay and has a beneficial effect on their anxiety. This process starts in the Outpatient Clinic and should be carried throughout the care process.

• Emphasis should be given to WARP® and its potential benefits from a stress-free anesthesia and surgery, combined with pre-emptive multimodal analgesia. This process will allow early mobilisation, significant reduction in expected length of stay and improved patient experience.

• The expected length of stay should be specifically discussed and recorded in their consultation summary. This discussion is of paramount importance especially for day-case candidates and all team members should spend extra time to explain every step of the Rapid Recovery Pathway, to set all expectations right and to ensure that patients feel confident and safe to be discharged on the day of surgery.

• It is important to make patients feel that their care is individualised. The potential date of surgery and likely discharge would preferably be mutually agreed upon at the time of listing patients for surgery in the outpatient clinics. Patients should have single point of contact (Booking Team) to advise of illness or reason for delay or cancellation so others can take the operation slot.

• The feeling of individualised care should also be re-enforced in the meetings with physiotherapists and occupational therapists in the pre-operative education group. This enables patients to take responsibility for participation in their recovery after surgery.

• Provide the patient with all relevant information and advice, reiterating GP advice around smoking cessation, weight loss, alcohol consumption and exercise.

• In some cases, a dietetic review may be needed to achieve adequate nutritional status.

2.2 Listing the patient for surgery and preparation When a patient is listed for surgery the action should generate the following:

• Referral to ‘Joint School’. • Triage pre-assessment and referral to pre-operative assessment. • Wait listing of the patient. • Order for phases 1, 2 and 3 of nursing, medical inpatient and therapies care. • Order day 1 and day 4 virtual follow up (f/up) (if applicable), 2-week therapy f/up, 6-

week surgical f/up, and 6 months PROMs.


3. THE RAPID RECOVERY NURSE The role of the Rapid Recovery Nurse is of paramount importance in the Pathway. He/she works closely with the multi-disciplinary team and the patients to empower all involved to provide excellent standards of patient centered care. The Rapid Recovery Nurse acts also as a point of contact for patients throughout their joint replacement journey. Engagement with the patient through education and motivation are key in gaining patient compliance. The Rapid Recovery Nurse attends the patient education group (Joint School), visits the ward regularly to see both staff and patients, and offers support and advice once patients are discharged. The main roles of the Rapid Recovery Nurse include:

• Patient support and education throughout the pathway (pre-operative-assessment, Joint School, Surgical Admission Unit, Ward 12B, post-operative virtual follow-up).

• 1st point of contact for patients if concerns. • Pathway implementation and development. • Data collection and audit. • Staff education, training and project management.

4. PRE-OPERATIVE EDUCATION GROUP (JOINT SCHOOL)

• Attendance at Joint School is a required step prior to surgery and should be documented. Patients attend 4 - 8 weeks prior to surgery either face-to-face or virtually (MS Teams).

• The following teams should be represented to give advice and information: o Physio +/- occupational therapy team o The nurse specialists who will look after the patient o Pain management team

• The process highlights the principles of rapid recovery to the staff regularly. • The patient’s care needs post discharge are highlighted and any supportive

equipment the patient may need on discharge is identified, supplied and fitted before the patient’s admission (wherever possible).

• Patients should aim to bring their support person with them. 4.1 Key outcomes of Joint School

• Highlight the importance of following all guidance from POA, joint school, surgeon and other members of the hospital team to ensure optimal recovery, improved pain management, earlier mobilisation and improved outcomes.

• Overview of surgical procedure - benefits, symptom management, risks and complications.

• Set expectations around pain management. Information about benefits of short-acting spinal anaesthetic technique. Early mobilisation and length of stay for optimal patient-reported outcome measures and to avoid dissatisfaction from unmet expectations.

• Detailed Information on WARP® and how this will allow early mobilisation, significant reduction in expected length of stay and improved patient experience.

• Day-case arthroplasty should also be discussed as a safe option for a selected cohort of patients. Every effort should be made to ensure patients feel confident and safe to be discharged on the day of surgery.

• Preparation for hospital stay including what to bring (named toiletries, 2 sets of loose day and night clothes and appropriate footwear that can fit into a locker), what to expect the night before and morning of surgery (showering) and other advice (exercise in hospital, medication, visiting times).

• Discharge planning should start at pre-assessment and in joint school. This process will avoid unnecessary readmissions in the early post-operative days.

• Highlight the need to prepare discharge destination for safety, ease and comfort following discharge (stock up on meals to avoid errands during recovery, ensure home is cleaned prior to surgery, store items you need to access to avoid bending or reaching).


4.2 Checklist for completion of Joint School • Safety advice given regarding home environment. • Identify if patient has had a fall in the previous 12 months and refer to MUDAS if

required. • Check all patients are issued with a THR/TKR booklet in clinic that gives them an

overview of their prospective admission and recovery, as well as a brief introduction about the hospital/unit.

• Note any equipment needs that should be addressed pre-operatively. • Special information on day-case arthroplasty is provided to potential candidates. • Smoking cessation: local audits suggest that 10% of patients smoke. These patients

should receive a brief intervention from their surgeon about the benefits of smoking cessation and again be offered referral into a smoking cessation service.

5. PRE-OPERATIVE ASSESSMENT AND PREPARATION

• The process of determining a patient’s anaesthetic fitness for surgery starts in the outpatient clinic. The aim is to optimise patients for surgery and to avoid cancellations on the day of surgery that lead to negative patient experience and financial loss.

• Pre-operative assessment should be complete within a minimum 6 weeks of surgery and a pool of pre-assessed patients should be available to fill last-minute cancellations. Ideally pre-operative assessment should be done early in the pathway to allow time for risk modification and comorbidity optimisation.

• The preoperative assessment fitness slip should be available in the clinical notes (Evolve) promptly to allow patients to be assessed on multiple sites within the Trust prior to their surgery.

5.1 Anaemia

• Patients should be screened for iron deficiency anaemia. Haemoglobin (Hb) <13 (international consensus statement though local protocols Hb levels are often HB <12 (female) or <13 (male)) are treated preoperatively with oral or IV iron to reduce the need for perioperative blood transfusion.

• It is substandard clinical practice to proceed with elective surgery with iron deficiency anaemia and carries significant clinical risk. Pathways should be in place to refer back to GP or colorectal teams for urgent investigation of severe unexplained IDA.

5.2 Diabetic management

• Guidelines for managing diabetic patients should be in place based around the development of a diabetic perioperative team as detailed in the NCEPOD diabetic report recommendations. Ideally target HbA1c <69mmol/l. Recommendations include:

o Multi-disciplinary management. o Pre-operative assessment of diabetes control and effective management and

control. o Clinical lead for perioperative diabetes care. o Standardised referral process for elective surgery including HbA1c within 3/12

of surgery. o Close peri-operative monitoring. o Safe handover of patients from theatre recovery to ward staff.

5.3 Pain control

• The Pain Team should be part of the pre-assessment clinic and a proper programme should be set up for opiate reduction or change to other pain regimes prior to surgery to avoid issues peri-operatively.

• Patients on long standing opiate therapy for chronic pain should be highlighted at pre-operative assessment and a plan should be documented. Day-case arthroplasty


should be avoided in such patients as their post-operative pain management is usually challenging.

5.4 Infection control • Skin examination on surgical site. • MRSA and MSSA screening:

o Using a single swab which is tested for both MRSA and MSSA. Patients with +MSSA require 5 days treatment and clear result for 3 weeks after.

• Advice provided includes: o Showering on the night before and morning of surgery. o Use of Clinell® wipes or antimicrobial body wash before surgery. o Remove nail varnish, avoid shaving, apply nasal gel twice daily from day

before surgery. • COVID-19 screening:

o A swab test is performed 3 days prior to surgery. Patients and their household are requested to isolate following this until the day of surgery.

5.5 Medication checking

• Follow BHT guidelines on how medications should be administered or omitted in the peri-operative period and inform peri-operative management of many common medications (e.g. statins, ACE inhibitors, aspirin, oral anticoagulants).

• Patients, their medication, and the proposed surgery, should be considered in a holistic manner with risks and benefits considered for each case. If there is any doubt about the peri-operative management of any medication, advice should be sought from a senior member of the anaesthetic, surgical, specialty team or pharmacy (medicines resource centre) as appropriate. This advice, when appropriately documented, will then supersede the management outlined in this guideline.

• Patients ideally are seen by the clinical pharmacy team who will obtain a full medication history at pre-operative assessment.

• Patients are provided with advice on any medication that may need withholding pre-operatively.

• Continue any long-term analgesia including opioids and anti-hypertensives but not blood thinners unless stated.

• All patients should be encouraged to reduce their opioid intake prior to surgery to allow for safer and more effective post-operative analgesia.

• Follow post-operative analgesia protocol – make sure patients have their own supply of over the counter pain medication (paracetamol +/- ibuprofen) for when they go home.

• Patients receive verbal counselling on the medication usually started post-operatively, as well as a written Patient Post-operative Medication Information Leaflet.

5.6 Consent Clinic

• There should be (virtual) consent clinics in place at around the time of the pre-operative assessment. It is not acceptable to formally obtain consent for planned elective surgery on the day of admission. Signing of a formal document, whilst necessary, is not evidence of adequate consent. Consenting is a process which continues throughout care.

• The implication of this is that the patient undergoing planned surgery should have the opportunity to reflect on that planned surgery and may need to ask further questions at an additional time. This may be particularly necessary when there is a significant delay prior to surgery or when there is a need to clarify the surgical plan, for example when the patient is placed on a list for surgery by a practitioner who is not able to undertake the surgery. It is expected that after this consent stage patients will stay with a specific surgical team throughout their onward care.


6. THE DAY OF SURGERY • All patients are admitted for surgery to the Surgical Admissions Unit (SAU) of

Wycombe Hospital on the day of surgery. Patients are admitted at 07.30 if on a morning list and at 11.30 if on an afternoon list. This helps minimise pre-operative fasting and reduce patient anxiety. The pre-operative fasting times are actively managed to reduce undue physiological stresses. The policy is to stop taking solid food 6 hours prior to surgery but continue with clear fluids up to 2 hours prior to surgery.

• Patients listed for a day case joint replacement should be first or second on a morning list.

• The consent form signed at the time of the consent clinic is confirmed on the day of surgery by the operating surgeon. The operating surgeon should verify the surgical site marking using indelible marker pens.

• National Joint Registry should be discussed with the patient and consent obtained for full patient details to be added to the Joint Registry.

• Confirm patient understanding of post-operative pain management, ambulation and carer role (nurse, surgeon and anaesthetist).

• Ensure patients are not cold – prewarm if necessary (nurse). There is good evidence that pre-warming patients results in reducing the risk of hypothermia, which could result in coagulopathy with increased risk of transfusion, cardiac dysfunction and risk of infection.

• Verify medical history and clearance for surgery (nurse, surgeon). • Prescribe necessary pre-operative medications (anaesthetist):

o Oxycodone MR 10mg tablet po (5 mg if patient <50 kg or >75 years old) o Paracetamol 1 g tablet po o Lansoprazole 15 mg capsule po

• VTE risk assessment completed (any doctor). • For day-cases, prescribe take home medication (TTO) at SAU so that Pharmacy can

dispense in time – use Outpatient Prescription Form for day-case: o Paracetamol 1 g tablet QDS o Oxycodone MR 10 mg tablet BD (5 mg if patient <50 kg or >75 years old)

FOR 3 DAYS ONLY (1st dose in SAU, 5 more doses in TTO), then step down to:

o Codeine phosphate 30 – 60 mg tablet QDS (use tramadol 50 – 100 mg capsules TDS if codeine intolerance)

o Ibuprofen 400 mg tablet TDS (if no contraindication) o Lansoprazole 15 mg capsule OD (whilst on ibuprofen) o Movicol 1 sachet BD (max 4 daily PRN) o Oxycodone IR liquid (1 mg/1 ml solution) 5 mg 4 hourly PRN (50 ml bottle) o Ondansetron 4 mg tablet TDS PRN o Weight-based dalteparin injection SC or rivaroxaban 10 mg tablet OD

(28 days for hips, 14 days for knees)

7. ANAESTHETIC GUIDELINE First line recommendation is short-acting no-opioid spinal (rather than general anaesthesia (GA)) for elective primary arthroplasty where possible. 7.1 Spinal and sedation

• Spinal anaesthesia with 0.25% plain bupivacaine 3 - 4 ml. o Avoid using opioids in the spinal as this helps to reduce side-effects (nausea,

vomiting, urinary retention). If required, it is recommended to add 10 – 15 mcg of fentanyl instead of long-acting opioids.

• Sedation with short-acting sedative (e.g. propofol), avoid midazolam If the patient is unable to tolerate spinal anaesthetic or specifically requests GA, then general anaesthetic +/- regional technique is acceptable:


7.2 General anaesthesia +/- nerve block • General anaesthesia (avoid long-acting opioids). • Nerve block with 0.25% bupivacaine using US-guided technique to improve block

quality and reduce the volume of local anaesthetic required. o THR: Lumbar plexus block (20 - 25 mL) o UKR/TKR: Adductor canal block (20 - 25 mL) o Avoid femoral nerve motor block as it prevents post-operative mobilisation

• If a nerve block is performed, the need for local infiltration should be discussed between the anaesthetic and surgical teams and the volume of local infiltration should be tailored.

7.3 Co-ordination between teams (anaesthetic, scrub and surgical)

• Essential to improve efficiency. • Scrub team starts opening sets whilst patient in anaesthetic room for preparation. • Once sets are open and checked, scrub team gives green light to anaesthetic team to

commence anaesthesia. • Once anaesthetic is complete, surgeon is notified to position patient in the

anaesthetic room whilst assistant is scrubbed. • Once patient in Theatre and checks completed, assistant is prepping and draping

with scrub nurse whilst surgeon is scrubbing.

7.4 Antiemesis • Dexamethasone IV 3.3 - 6.6 mg • Ondansetron IV 4 mg

7.5 Antibiotic prophylaxis

• Teicoplanin IV 800 mg • Gentamicin IV 3 mg/kg

Antibiotics are put in separate 100 ml bags of normal saline and given 30 minutes prior to incision. Further postoperative antibiotics are not required (in line with BHT Guideline). 7.6 Tranexamic acid (TXA) As part of the blood management programme patients receive a combination dose of tranexamic acid with a maximum combined dose of 3 g:

• 1 g IV on induction (30 minutes prior to incision) • 1 g IV/intra-articular prior to closure

7.7 Other

• Hartmann’s solution: 1000 – 1500 ml IV. Avoid post-operative IV fluids, instead encourage oral intake in recovery. Unnecessary IV access should be removed as soon as possible.

• Consider ketamine IV 0.5 mg/kg at induction for patients with chronic pain issues. • No urinary catheter is required routinely.

7.8 Post-operative medication whilst in hospital (to be prescribed intraoperatively

by anaesthetist) • Paracetamol 1 g tablet po QDS • Ibuprofen 400 mg tablet po TDS (if no contraindications) • Oxycodone MR 10 mg tablet po BD (5 mg if patient <50 kg or >75 years old)

prescribed for 20:00 • Movicol 1 sachet BD (max 4 daily PRN) • Ondansetron 4 – 8 mg po/iv PRN max TDS • Oxycodone IR liquid 5 mg po for breakthrough pain (max 20 mg in 24 hours) • VTE prophylaxis to commence 6 – 12 hours post op (unless contraindicated)


Day 0 medication should be tailored to the timing of the operation. Therefore, it should be prescribed on the front page of the drug chart as stat doses to avoid confusion with regular medication timings. 7.9 Venous thromboembolism prophylaxis

• Offer VTE prophylaxis to patients undergoing elective hip or knee replacement surgery whose risk of VTE outweighs their risk of bleeding in line with BHT Guidelines (see guideline 733FM). Choose from below:

o Weight-based dalteparin SC o Rivaroxaban 10 mg tablet orally once daily

• Duration of chemical VTE prophylaxis should be: o 28 days for hip replacement surgery o 14 days for knee replacement surgery

• Offer IPC when pharmacological thromboprophylaxis is contraindicated. Continue until the patient is mobile.

• Offer anti-embolism stockings for 6 weeks or until the patient no longer has reduced mobility compared to their usual state.

• Patients normally on warfarin can restart their tablets on day 1. Bridging is required until INR becomes therapeutic – patient’s GP or Warfarin Clinic needs to be made aware and follow this up. Patients normally on NOAC do not require further chemical VTE prophylaxis.

• Any surgery performed in patients with previous history of VTE and not already taking long term anticoagulation: Prescribe 6 weeks of pharmacological and mechanical thromboprophylaxis, or follow local guidance for extended thromboprophylaxis, whichever is the longest option, providing the VTE risk outweighs the bleeding risk.

8. SURGICAL TECHNIQUE AND JOINT REPLACEMENT PROSTHESES • The goal in the intraoperative phase is to reduce the physical stress of the surgery

with minimally invasive surgical technique, respect to soft tissues, adequate haemostasis and watertight wound closure.

• The use of a wound drain should be avoided if possible, to facilitate early mobilisation and discharge.

• Use of joint replacements as per NJR Best Practice Tariff and GIRFT recommendations:

o 80% of patients aged 70 and over should receive hybrid or cemented primary hip replacement prosthesis.

o Furthermore, surgeons are strongly encouraged to perform fully cemented replacement on both femoral and acetabular sides on 80% of patients aged 70 or over.

o The type of hip replacement (uncemented, hybrid, cemented) should be documented clearly on the operation note.

• Aim to standardise surgical procedures and theatre workflow as much as possible so that the whole process is predictably reproducible and familiar to the whole staff. This process will result in shortening the operative time and hence the surgical stress and blood loss.

• It is recommended that the core clinical theatre team (surgeon, anaesthetist, ODP and nursing) for every list is consistent on a week to week basis.

• Optimum productivity is 4 cemented primary joint replacements per 8 hour list (cutting time). The lists should be uninterrupted with scheduled breaks for staff.

• Consider cell salvage for cases where the need for blood may be triggered (e.g. revision joint replacement surgery).

• A high-quality submission into the National Joint Registry database must be completed.

http://www.bucksformulary.nhs.uk/docs/Guideline_733FM.pdf


8.1 Intraoperative local anaesthetic infiltration If no nerve block is performed, surgeons are encouraged to perform LA Infiltration as per BHT Guideline (weight-based dose):

• 100 ml cocktail of: o 30 ml of 0.5% levo-bupivacaine o 1 ml of adrenaline 1:1000 o 69 ml of N/S

Areas of Infiltration: • THR: 50 ml around capsule and 50 ml around incision site. • TKR/UKR: 50 ml posterior capsule and periosteum and 50 ml around incision site.

9. POST-OPERATIVE MANAGEMENT – THE 3 PHASES OF RAPID RECOVERY 7-day review should occur for all patients with 7-day physiotherapy service. 9.1 PHASE 1 of Rapid Recovery: In Recovery

• Monitor temperature, HR, BP, assess for respiratory problems. • Ibuprofen 400 mg tablet po (if no contraindication). • Ensure Plus nutrition drink 1 bottle. • No IV fluids - encourage oral intake. • Encourage breathing, circulatory, range of movement exercises as taught in Joint

School. 9.2 PHASE 2 of Rapid Recovery: In Ward 12B (Day 0 until discharge) The important aspect of rapid recovery is to enable patients to independently perform routine activities like eating, dressing and walking as early as possible.

• An initial assessment takes place as soon as the patient returns from recovery. • Encourage patients to get dressed in their own clothes prior to mobilising to reinforce

that they are in the rehabilitation phase of their recovery. • Offer food and drink. Aim for patients to have meals in the chair. • Monitor degree of motor block and pain.

9.2.1 Post-operative pain management • Pre-emptive multimodal oral analgesia is the cornerstone of the Rapid Recovery

Pathway. It aims to improve patients’ comfort and to decrease side effects and opioid consumption. A strong controlled-release opioid (oxycodone MR) is recommended in combination with non-opioid analgesia for managing high intensity pain following hip and knee replacement.

• Oxycodone MR, although very effective, is also very addictive and therefore should only be prescribed until day 2. On day 3 the patient is stepped down to codeine or tramadol.

• The 1st dose of oxycodone MR is given pre-operatively and is tailored to the time of operation to ensure adequate analgesia. However, this means that timing between subsequent doses may not be 12 hours. Although effort should be made to space the doses as much apart as possible (i.e. the night-time dose on day 0 delayed as much as possible) it is acceptable to administer the 2nd dose in less than 12 hours. Equally, the 3rd dose on day 1 should be administered at 08.00 as prescribed although this may again be less than 12 hours from the previous dose.

• Some patients are reluctant to take analgesia if they are not in pain. It is important to educate patients regarding the use of regular analgesia. Therefore, patients should never refuse regular oral analgesia unless there is a good reason to, for instance intolerable side effects.


9.2.2 Standard post-operative pain management regime • Regular Medication

o Paracetamol 1 g tablet QDS o Oxycodone MR 10 mg tablet BD (5 mg if patient <50 kg or >75 years old)

FOR 3 DAYS ONLY (1st dose in SAU, 5 more doses post-operatively), then step down to:

o Codeine phosphate 30 – 60 mg tablet QDS (or tramadol 50 – 100 mg tb TDS) o Ibuprofen 400 mg tablet TDS (if no contraindication) o Lansoprazole 15 mg capsule OD (whilst on ibuprofen) o Movicol 1 sachet BD (max 4 daily PRN)

• As required (PRN) medication o Oxycodone IR liquid (1 mg/1 ml solution) 5 mg 4 hourly PRN (50 ml bottle) (for

breakthrough pain) o Ondansetron 4 mg tablet TDS PRN (if nausea)

9.2.3 Patients on long standing opiate therapy for chronic pain

• Patients that take opiates for long standing pain (e.g. fentanyl patches, oxycodone MR, Zomorph®) should continue these during the intra-operative and post-operative periods.

• These patients will likely require increased opiate dose or even patient-controlled analgesia (PCA) peri-operatively. This should be highlighted at pre-operative assessment and a plan should be documented.

• An effort should be made to reduce opiate intake or change to other pain regimes prior to surgery to avoid issues peri-operatively.

• Day-case arthroplasty should be avoided with these patients as they usually present with challenges in their post-operative pain management. However, there is no contraindication to the use of WARP®.

• Patients wishing to reduce their opiates post-operatively should be encouraged to do so with the support of their GP. However, this should not be considered in the immediate post-operative period.

9.2.4 Therapy

• The Therapy Team should be informed in advance about potential day-cases. • Aim for rapid mobilisation with Therapy Team on day 0 as soon as block fully worn

off, pain score 0-1, BP stable. Nurses should also have competency in day 0 mobilisation.

• Consider offering breakthrough analgesia (oxycodone IR liquid) prior to mobilisation. • Encourage the patient to achieve independent mobility for toileting needs as soon as

possible. Urinary catheter should not be inserted unless symptomatic retention is confirmed with bladder scan.

• If the patient is not discharged on day of surgery (day-case), then: o Encourage patient to continue own exercises regularly and adjust exercise

sheets according to progress. o Aim to remain out of bed as much as possible, dressed in own day clothes. o Twice daily therapy sessions as required to progress walking, strength,

movement and independence. o Post-discharge care needs are assessed by Therapy and Nursing Team and

provisioned accordingly – referral to social services if needed.

9.2.5 Delayed knee flexion for unicompartmental +/- total knee replacements • Delayed knee flexion can be considered as an option to reduce post-operative pain

and swelling, to mobilise early and to go home on the day of surgery. • Consider keeping the compression bandage intact and delay knee flexion for 4 - 5

days. For this period patients should be instructed to flex their knee only as required for walking and climbing/descending stairs until they return to a (virtual) follow up clinic 4 to 5 days later.


• Cryo-cuff should still be used over the bandage as normal. • Patients should be reviewed in a (virtual) follow up clinic on day 4 – 5. At this point

the compression bandage should be removed, the wound/dressing should be checked, and the patient should be advised to commence formal knee flexion exercises.

9.2.6 Physiotherapy discharge criteria

• Able to get in/out of bed independently • Able to stand and walk with aids • Able to climb/descend stairs (if necessary) • Able to wash and dress with no or little help • Pain controlled with analgesia • Adequate support at home for first 5 - 7 days or Section 2 if needed. • Check equipment in place for discharge if needed.

9.2.7 Other

• Check post-operative blood tests (FBC, U&E, INR if on anticoagulants). • Check post-operative radiographs to confirm prosthesis placement. The Radiology

Team should be informed in advance about potential day-cases to ensure prioritisation.

o AP pelvis (+/- LAT hip) for hip replacements o AP and LAT knee for total knee replacements o Fluoroscopically aligned radiographs for unicompartmental knee replacements

(in Theatre) o Imaging on COVID-19 protected pathway at Wycombe Hospital should be

obtained using the dedicated ‘Green Zone’ DR portable X-ray machine.

9.3 PHASE 3 of Rapid Recovery: Discharge criteria • A Criteria-Led Discharge Checklist is available on Ward 12B to facilitate doctor or

nurse-led patient discharge. The document should be completed and signed by the responsible doctor or nurse and added to the clinical notes. All following criteria need to be met prior to discharge:

o Vital signs stable o Oriented to time/place/person o Able to drink/eat o Passed urine – no catheter o Minimal nausea o Minimal pain o Wound checked – minimal bleed o Cannula removed o Discharged by Therapy Team (walk/dress/stairs) o Post op X-ray checked o Discharged by T&O Team o Take home medication given o Medication diary and information given o Written and verbal post-operative instruction given o 24 – 48 hours post-operative care organised o Contact number for emergency o Virtual and face to face follow up appointments booked o Dressings (x2) supplied o Patient copy of GP letter o Sickness note (if required) o Responsible escort present


10. FOLLOW UP PROCEDURES Patient information provided on the ward prior to discharge:

• Patient Medication Diary and Information Leaflet including Contact Details for Emergencies.

• Falls prevention leaflet. • Manufacturer’s instructions for any equipment or mobility aids provided. • Discharge booklet. • DVT leaflet (mandatory). • Wound care instructions. • Exercise advice (exercise sheet), mobility progression and referral plan. • Discharge letter. • For primary total hip replacement patients are advised to wash and dress their lower

half whilst sitting and to apply caution when getting in and out of the car. • If the consultant specifies full hip precautions due to increased risk of dislocation the

advice given will be no hip flexion more than 90 degrees, no internal rotation, no adduction for 6 weeks.

10.1 Wound care

• Oozing should have ceased by 72 hours. • Patients are advised that the surgical dressing should not be changed or disturbed

unless it moves out of place or becomes fully saturated. Extra dressings are supplied together with instructions for aseptic dressing change if required.

• Patients are advised to phone the number provided and contact the Consultant’s Team or Rapid Recovery Nurse if there are any concerns, rather than the GP.

• Initial urgent wound review can be done via video consultation using MS Teams. • If patients present with problems to the peripheral site hospitals, they should not be

empirically treated with antibiotics as it may diminish ability to later isolate an organism to treat.

• Suture removal at GP surgery (staples or non-absorbable 10 - 14 days post-op). 10.2 Pain management and other prescriptions on discharge

• Patient is provided with adequate multimodal analgesia and medications to prevent potential side-effects to cover 2 weeks post-operatively. Adequate VTE prophylaxis is also provided as per BHT Guidelines. Medications include:

o Paracetamol 1 g tablet QDS o Oxycodone MR 10 mg tb BD (5 mg if patient <50 kg or >75 years old) FOR 3

DAYS ONLY (1st dose in SAU, 5 more doses in TTO), then step down to: o Codeine phosphate 30 – 60 mg tablet QDS (use tramadol 50 – 100 mg

capsule TDS if codeine intolerance) o Ibuprofen 400 mg tablet TDS (if no contraindication) o Lansoprazole 15 mg capsule OD (whilst on ibuprofen) o Movicol 1 sachet BD (max 4 daily PRN) o Oxycodone IR liquid (1 mg/1 ml solution) 5 mg 4hourly PRN (50 ml bottle) o Ondansetron 4 mg tablet TDS PRN o Weight-based dalteparin injection SC or rivaroxaban 10 mg tablet OD

(28 days for hips, 14 days for knees) • Patient is asked to complete daily Pain Diary and Top-Up requirements to assess

their post-operative pain at rest, when mobilising, and overnight. • Discuss individual patient pain management goals in terms of ADLs, physical therapy,

long term activity goals and a level of comfort that optimises healing. • Consider delirium and possibility of over or under treatment in older adults. • Discuss side effects with patients. • Non-medical pain management techniques (cold therapy, relaxation, medication, self-

massage).


10.3 Therapy on discharge • All patients will attend a physiotherapy appointment within 2 weeks following surgery

to receive tailored exercise programme: o Discuss individual patient activity goals o Continue daily exercise as prescribed o Expectations setting o Dependent on outcome of first physiotherapy review further appointments will

be arranged and tailored advice given • Physio-at-Home Team (Outreach) may also visit patients in the early post-operative

period for assessment and instructions. • Efforts are made to arrange further physiotherapy appointment sessions at a hospital

closest to where the patients live. • If concerns, the patients are instructed to contact the Physiotherapy Team at

Wycombe Hospital. 10.4 Follow-up appointments

• On day 1 (for day-cases): o Telephone consultation by surgical, nursing, or therapy team. o Assess general feeling, pain (0 - 10), nausea/vomiting, dizziness, drowsiness,

signs of DVT/PE, bowel function, wound, patient satisfaction using Virtual Follow Up Proforma. Document outcome of consultation in clinical notes (Evolve).

• On day 4 (for day-cases and knee replacements): o Video consultation using MS Teams by surgical, nursing, or therapy team. o For knee replacements: Compression bandage to be removed and

wound/dressing to be checked. If satisfactory, encourage patient to commence formal flexion exercises.

o Assess general feeling, pain (0 -1 0), nausea/vomiting, dizziness, drowsiness, signs of DVT/PE, bowel function, wound, patient satisfaction using Virtual Follow Up Proforma. Document outcome of consultation in clinical notes (Evolve).

• At 2 weeks: o District nurse appointment to review wound and remove sutures or clips.

• At 6 weeks: o Surgical outpatient appointment to review clinical progress post-surgery. o If no clinical concerns, patient officially discharged from pathway and moves to

‘surveillance’ phase. Patient may require further imaging and follow up if any clinical concern.

o Patient is asked to complete validated Patient Satisfaction Questionnaires: Surgical Satisfaction Questionnaire (SSQ-8) Outcomes and Experiences Questionnaire (OEQ)

• At 6 months: Patient completes Oxford Hip or Knee Score (either via portal or paper).

11. RELATED BHT GUIDELINES 1. Guideline 733FM Thromboprophylaxis in the Hospital Setting: Reducing the Risk of

Hospital Acquired Deep Vein Thrombosis or Pulmonary Embolism 2. Guideline 178 Orthopaedic Surgery Antibiotic Prophylaxis 3. Guideline 330 Administration of Ketamine for Acute Pain 4. Guideline 332FM Management of Patient Controlled Analgesia (PCA) in Adults 5. Guideline 49FM Post-Operative Analgesic Ladder for Adults 6. Guideline 299FM Prescribing Non-Steroidal Anti-Inflammatory Drugs (NSAIDs) in Adults 7. Guideline 216 Prevention and Management of Post-Operative Nausea and Vomiting in

Adults 8. SOP: BHT Post-Operative Hip and Knee Imaging



http://swanlive/sites/default/files/guideline_178.pdf








12. REFERENCES 1. GIRFT Elective Hip or Knee Replacement Pathway 2020 2. National Day Surgery Delivery Pack, The Journal of One Day Surgery 2020 3. The British Association of Day Surgery. Commissioning Day Surgery A Guide for Clinical

Commissioning Groups 2012 4. www.northumbria.nhs.uk Orthopaedic Helpline to reduce unnecessary hospital

readmissions 2014 5. Guidelines and recommendations, British Association of Day Surgery 1 Day Course

2019 6. Jenkins C, Jackson W, Bottomley N, Price A, Murray D, Barker K. Introduction of an

innovative day surgery pathway for unicompartmental knee replacement: no need for early knee flexion. Physiotherapy. 2019 Mar;105(1):46-52. doi: 10.1016/j.physio.2018.11.305. Epub 2018 Nov 26. PMID: 30704751.

7. Teunkers A, Vanhaecht K, Vermeulen K. Measuring satisfaction and anaesthesia related outcomes in surgical day case centre: A three year single- centre observational study. J Clin Anaesth 2017; 43: 15-23

8. Ben-David B, Solomon E, Levin H Intrathecal fentanyl with small dose dilute bupivacaine: better analgesia without prolonging recovery. Anesth Analg 1997; 85: 560-565

9. Horlocker TT, Burton AW, Connis BR American Society of Anesthesiologists Task Force on Neuraxial Opioids. Practice guidelines for prevention, detection and management of respiratory depression associated with neuraxial opioid administration. Anesthesiology 2009; 110: 218-230

10. Varrassi G, Celleno G, Capogna G. Ventilatory effects of subarachnoid fentanyl in elderly. Anaesthesia 1992; 47:558-562

11. Henry A, Tetzlaff JE, Stecker K. Ondansetron is effective in treatment of pruritus after intrathecal fentanyl. Reg Anesth Pain Med, 2002; 27: 538-539

12. Watson B, Allen JG. Spinal Anaesthesia in Day Surgery- an audit of the first 400 cases. Journal of One Day Surgery, 2003; 12: 59-62

13. Watson B, Allen J. Spinal anaesthesia for day surgery patients a practical guide. 3rd Edition 2013; British Association of Day Surgery Publications, UK

14. Reed M, Khan M, Lawton R. Enhanced recovery and day surgery management for hip and knee replacement. 2018 British Association of Day Surgery, UK

15. Mann A, Harper I, Brock S. Levobupivacaine for low dose spinal anaesthesia. BJ Anaesth, 2014; 112: 380

16. Jackson I. Sedation in day surgery. www.esahq.org. 2009 17. Baldini G, Bagry H, Aprikian A, Carli F. Postoperative Urinary Retention: Anestetic and

perioperative Considerations. Anaesthesiology 2009; 110;1139-1157 18. Bailey CR, Ahuja M, Bartholomew K. Guidelines for day- case surgery 2019. Guidelines

from the AAGBI and the British Association of Day Surgery Anaesthesia 2019 19. Mulroy MF, Salanis FV, Larkin KL, Polissar NL. Ambulatory surgery patients may be

discharged before voiding after short acting spinal and epidural anaesthesia. Anaesthesiology, 2002; 97: 315-319

20. Fettes PD, Jansson JR, Wildsmith JA. Failed spinal anaesthesia: mechanisms, management and prevention. Br J Anaesth, 2009; 102: 739-748

21. Fornot CD, Fleisher LA, Keogh J. Providing value in ambulatory anaesthesia. Curr Opin Anaesthesiol. 2015; 28: 617-22

22. Gaiser RP. Postdural puncture headache: a headache for patient and a headache for the anaesthesiologist. Curr opin Anaesthesiol, 2013; 26: 296-303

23. Verma R, Alladi R, Jackson I. Day case and short stay surgery:2 Anaesthesia 2011; 66: 417-434

http://www.northumbria.nhs.uk/

http://www.esahq.org/


13. ACKNOWLEDGMENTS 1. Northumbria Healthcare NHS Foundation Trust, Hip and Knee Replacement Surgery

Enhanced Recovery Pathway 2. Kings College Hospital NHS Foundation Trust, Elective Hip or Knee Replacement

Pathway 3. Torbay and South Devon NHS Foundation Trust, Day Case Surgery Guidelines 4. Derby Hospitals NHS Foundation Trust, Day Case Information Pack and Guidelines 5. Nuffield Orthopaedic Centre, Oxford University Hospitals NHS Foundation Trust, Knee

Replacement Enhanced Recovery Pathway 6. Chelsea & Westminster Hospital NHS Foundation Trust, Knee Replacement Enhanced

Recovery Pathway 7. Ottawa University Hospital, Department of Surgery, Division of Orthopaedic Surgery, Hip

and Knee Surgery Pathway

Title of Guideline Wycombe Arthroplasty Rapid-Recovery Pathway (WARP®) for Primary Hip and Knee Arthroplasty Patients

Guideline Number 576FM Version 1.1 Effective Date June 2021 Review Date June 2024 Amended September 2021 Original Version Published June 2021 Approvals: Stakeholders review:

• Trauma & Orthopaedics (Arthroplasty) • Anaesthetics • Senior Acute Pain Nurse • Senior Physiotherapist & OT • Pre-operative Assessment Matron • Orthopaedic Ward Matron • Senior Pharmacist • SDU Leads/Departments responsible for

updating the guideline • Operations directorate BHT • Clinical Guidelines Group BHT

Medicines Check (Pharmacy) 15th April 2021 Clinical Guidelines Group 20th April 2021 Author/s Mr Sakis Pollalis & Dr Aniko Frigyik SDU(s)/Department(s) responsible for updating the guideline

• Trauma & Orthopaedics • Anaesthetics • Pain Team

Uploaded to Intranet 14th June and 8th September 2021 Buckinghamshire Healthcare NHS Trust


Wycombe Arthroplasty Rapid Recovery Pathway

SP & AF v 1.2 (Apr 2021)

Appendix 1: Complete Pathway Flowchart

Pre-Op

• WARP is applicable to ALL patients for primary arthroplasty • A selected cohort would be suitable for day-case surgery • Opportunities for patient selection: Outpatient Clinic, Preassessment Clinic, Consenting clinic • Patient Education on WARP +/- day-case at EVERY PATIENT CONTACT • Patient’s attendance at Joint School is mandatory • Communicate with anaesthetist of list – Inform of potential day-case

Day-Case Patient

Selection Criteria

• Straightforward surgery expected • Age <75 • BMI <30 • ASA 1 or 2 • No complex pain issues – not on increased opioids already • No severe/unstable cardiovascular or pulmonary disease • No prostate symptoms (?) • Motivated patient – support at home for at least 7/7

Intra-op

SAU: • 1st (or 2nd) on the list if day-case – inform nursing team to prioritise patient • Keep warm • Premedication: Oxycodone MR, paracetamol, lansoprazole • If day-case, complete TTOs in SAU – Use Outpatient Prescription (as per TTO template)

Anaesthesia – Liaise with scrub team prior to start of anesthetic: • First preference: Short-acting spinal (0.25% plain bupivacaine – no long-acting opioids) and

sedation • No urinary catheter • One dose of antibiotics, tranexamic acid, dexamethasone, ondansetron, balanced fluids

Surgery: • Assistant scrubbing whilst surgeon positioning, prep and drape whilst surgeon scrubbing • MIS surgical technique - implant choice as per NJR BPT and GIRFT recommendations • Local infiltration by surgeon (50% deep, 50% incision site) unless nerve block performed • Complete operation note, NJR data entry, discharge ;letter

Recovery Inform Recovery to follow WARP:

• Ibuprofen 400 mg (if no contraindication) • Ensure Plus nutrition drink 1 bottle • No IV fluids, encourage oral intake • Encourage breathing, circulatory, early range of movement exercises

Ward

• Offer food and drink • Change to patient’s own clothes as soon as comfortable • Monitor degree of motor block and pain • Mobilise with Physiotherapy as soon as block fully worn off, pain score 0 - 1, BP stable

o In/out bed, stand, walk, climb/descent stairs, able to dress (1 - 2 visits) • Post Op X-ray once convenient – inform radiographer about day-case • Ensure able to pass urine – motivate to walk to toilet • REGULAR analgesia to be given as prescribed regardless of pain score

Discharge Ward doctor or specialist nurse–led discharge

• Ensure review by surgeon, anaesthetist, physiotherapist prior to discharge • Complete and sign Criteria-Led Discharge Checklist

Follow up Virtual follow up (use Post-op Virtual Consultation Proforma)

• Day 1 telephone, day 4 video (MS Teams) Face to Face

• 2 weeks, 6 weeks


Wycombe Arthroplasty Rapid Recovery Pathway Appendix 2: Anaesthetic Pathway Flowchart

SP & AF v 1.2 (Apr 2021)

On

Adm

issi

on

Ensure patients are ready to go to theatre – day-case patients will be 1st (or 2nd) on theatre list Ensure patients are not cold – prewarm Pre-meds

• Oxycodone MR 10 mg tablet po (5 mg if patient <50 kg or >75 years old) • Paracetamol 1 g tablet po • Lansoprazole 15 mg capsule po

If day-case, complete TTOs at SAU (use Outpatient Prescription Form) • Paracetamol 1 g tablet QDS • Oxycodone MR 10 mg tablet BD (5 mg if patient <50 kg or >75 years old) FOR 3 DAYS ONLY, then step down to: • Codeine phosphate 30 – 60 mg tablet QDS or tramadol 50 – 100 mg capsules TDS (FROM DAY 3 POST-OP) • Ibuprofen 400 mg tablet TDS (if no contraindication) • Lansoprazole 15 mg capsule OD (whilst on ibuprofen) • Movicol 1 sachet BD (max 4 daily PRN) • Oxycodone IR liquid (1 mg/1 ml solution) 5 mg 4 hourly PRN (50 ml bottle) – max 20 mg/24 hours • Ondansetron 4 mg tablet TDS PRN • Weight-based dalteparin injection SC or rivaroxaban 10 mg tablet OD (28 days for hips/14 days for knees)

Intr

a-O

p

Anaesthesia: FIRST PREFERENCE IS SHORT-ACTING SPINAL AND SEDATION Spinal and sedation (insertion of spinal is timed with scrub team opening sets)

• Spinal anaesthesia with 0.25% plain bupivacaine 3 – 4 ml No long-acting opioids (if necessary, add 10 – 15 mcg of fentanyl)

• Sedation with short-acting sedative (e.g. propofol), avoid midazolam If spinal not an option, consider general anaesthesia +/- nerve block

• General anaesthesia (avoid long-acting opioids) • Nerve block with 0.25% bupivacaine using US guided technique

o THR: Lumbar plexus block (20 - 25 mL) o UKR/TKR: Adductor canal block (20 - 25 mL) o Avoid femoral nerve motor block as it prevents post-operative mobilisation

Antiemetics: • Dexamethasone IV 3.3 - 6.6mg • Ondansetron IV 4mg

Antibiotics: • Teicoplanin IV 800 mg • Gentamicin IV 3 mg/kg • No postoperative antibiotics required

Other: • Tranexamic acid: 1 g IV on induction +/- 1g IV/intra-articular post-op • Hartmann’s solution: 1000 - 1500 mL IV • No urinary catheter inserted

Local anaesthesia (not required if nerve block performed): • 100 ml cocktail of:

o 30 ml of 0.5% levo-bupivacaine o 1 ml of adrenaline 1:1000 o 69 ml of N/S

• Infiltration by surgeon: o THR: 50 ml around capsule & 50ml subcuticular o TKR/UKR: 50 ml posterior capsule and periosteum and 50 ml subcuticular

Post

-Op

Recovery: • Ibuprofen 400 mg tablet po (unless contraindicated) • Ensure Plus nutrition drink 1 bottle • No IV fluids, encourage oral intake • Encourage breathing, circulatory, range of movement and strengthening exercises

Post op medication whilst in hospital: • Paracetamol 1 g tablet QDS • Oxycodone MR 10 mg tablet BD (5 mg if patient <50 kg or >75 years old) FOR 3 DAYS ONLY, then step down to: • Codeine phosphate 30 – 60 mg tablet QDS or tramadol 50 – 100 mg capsule TDS (FROM DAY 3 POST-OP) • Ibuprofen 400 mg tablet TDS (if no contraindication) • Lansoprazole 15 mg capsule OD (whilst on ibuprofen) • Movicol 1 sachet BD (max 4 daily PRN) • Oxycodone IR liquid (1 mg/1 ml solution) 5 mg 4 hourly PRN (50 ml bottle) – max 20 mg/24 hours • Ondansetron 4 mg tablet TDS PRN • Weight-based dalteparin injection SC or rivaroxaban 10 mg tablet OD (28 days for hips/14 days for knees)


Patient Label

CRITERIA Yes No N/A Details Vital signs stable

Oriented to time/place/person

Able to drink/eat

Passed urine – no catheter

Minimal nausea

Minimal pain

Wound checked – minimal bleed

Cannula removed

Discharged by Therapy Team (walk/dress/stairs)

Post op X-Ray checked

Discharged by T&O Team

Take Home Medication given

Medication Diary and Information given

Written and verbal post-operative instruction given

24 -4 8hrs post-op care organised

Contact number for emergency

Virtual and F2F follow up appointments booked

Dressings (x2) supplied

Patient copy of GP letter

Sickness note (if required)

Responsible escort present

Discharged by: (Print Name)

(Signature)

Date:

Appendix 3: Criteria-Led Discharge Checklist


Guideline 576FM.1 20 of 24 Uncontrolled if printed


Appendix 4: Medication To Take Home

Drug Formulation Dose Frequency Route Quantity Stop/Continue Additional Comments PARACETAMOL Tablets 1 g QDS PO 2OP Continue For 1 week regular,

then PRN OXYCODONE HYDROCHLORIDE

Modified-Release Tablets

10 mg BD PO 5 x 10 mg (CD Rx)

Up to 5 doses only STOP ON DAY 3

Up to FIVE TABLETS TOTAL STOP ON DAY 3, then step down to Codeine or Tramadol

CODEINE PHOSPHATE OR TRAMADOL

Tablets

30 – 60 mg 50 – 100 mg

QDS TDS

PO 2OP START ON DAY 3 Continue

START ON DAY 3 POST OP DO NOT TAKE WHILST ON OXYCODONE For 1 week regular, then PRN

IBUPROFEN Tablets 400 mg TDS PO 42 x 400 mg Continue If no contraindications or drug interactions. For 1 week regular, then PRN

LANSOPRAZOLE Capsules 15 mg OD PO OP Continue While on ibuprofen MOVICOL Sachets 1 sachet BD PO OP Continue While on opioids (max 4 daily PRN) OXYCODONE IR (LIQUID) 1MG/1ML

Solution 5 mg 4 – 6 hourly PRN

PO 50 ml (CD Rx)

Continue PRN if breakthrough pain. MAX 20 mg in 24hrs Strength: 1 mg/1 ml

ONDANSETRON Tablets 4 mg TDS PRN PO 15 Continue PRN if nauseated RIVAROXABAN OR DALTEPATIN

Tablets Injection

10 mg 5000 IU (weight-based)

OD OD (weight-based)

PO SC

28 for hips 14 for knees Continue

28 days for hips 14 days for knees If normally on NOAC or warfarin restart as per Trust guidelines. No further prophylaxis is required. Bridging is required if on warfarin.




Appendix 5: Patient Medication Diary (Codeine)

SP & AF v 1.2 (Apr 2021)

Medication Day 0 Day 1 Day 2 Day 3 Day 4 Day 5 Day 6 Day 7 Notes

08.00

Paracetamol

Given in hospital

as required

Oxycodone MR STOP medicine

Codeine DO NOT TAKE Ibuprofen If no contraindication

Lansoprazole Only if on ibuprofen Movicol

14.00 Paracetamol


18.00

Paracetamol Oxycodone MR STOP medicine

Codeine DO NOT TAKE Dalteparin

or Rivaroxaban Hip replacement: Continue for 28 days Knee replacement: Continue for 14 days

Movicol

22.00 Paracetamol


Day 0 Day 1 Day 2 Day 3 Day 4 Day 5 Day 6 Day 7

Pain Score At rest Please rate your overall pain in a scale of 10

(0: no pain, 10: unbearable pain) When mobilising Overnight

Severe Pain Oxycodone liquid Please document your top op medication

requirements in this diary. Constipation Movicol Nausea/Sickness Ondansetron

Patient Label

The regular pain relief medicines should be taken for 7 days irrespective of the pain score.

Your Oxycodone MR is prescribed for the first 3 days only – this medication can be very addictive and must not be continued longer than this period. Please do not approach your GP

to ask for it to be continued – they have been asked by us not to reissue it.

At day 3 you should take the codeine (or tramadol) that you have been sent home with instead. Do not take the codeine (or tramadol) whilst you are still taking the oxycodone MR.

Working Hours Out of Hours Rapid Recovery Nurse

(Dona Round) Tel: 07815701638

Email: [email protected] Ward 12B: 01494 426398

For urgent medical attention please attend

A&E at Stoke Mandeville Hospital for review by the on-call

Orthopaedic Team

FOR ANY CONCERNS PLEASE CONTACT:

mailto:[email protected]

Guideline 576FM.1 22 of 24 Uncontrolled if printed


SP & AF v 1.2 (Apr 2021)

Appendix 6: Patient Medication Diary (Tramadol)

Medication Day 0 Day 1 Day 2 Day 3 Day 4 Day 5 Day 6 Day 7 Notes

08.00

Paracetamol

Given in hospital

as required

Oxycodone MR STOP medicine

Tramadol DO NOT TAKE Ibuprofen If no contraindication

Lansoprazole Only if on Ibuprofen Movicol

14.00 Paracetamol


18.00

Paracetamol Oxycodone MR STOP medicine

Dalteparin or Rivaroxaban Hip replacement: Continue for 28 days

Knee replacement: Continue for 14 days Movicol

22.00 Paracetamol


Day 0 Day 1 Day 2 Day 3 Day 4 Day 5 Day 6 Day 7

Pain Score At rest Please rate your overall pain in a scale of 10

(0: no pain, 10: unbearable pain) When mobilising Overnight

Severe Pain Oxycodone liquid Please document your top op medication

requirements in this diary. Constipation Movicol Nausea/Sickness Ondansetron

Patient Label

The regular pain relief medicines should be taken for 7 days irrespective of the pain score.

Your Oxycodone MR is prescribed for the first 3 days only – this medication can be very addictive and must not be continued longer than this period. Please do not approach your GP

to ask for it to be continued – they have been asked by us not to reissue it.

At day 3 you should take the codeine (or tramadol) that you have been sent home with instead. Do not take the codeine (or tramadol) whilst you are still taking the oxycodone MR.

Working Hours Out of Hours Rapid Recovery Nurse

(Dona Round) Tel: 07815701638

Email: [email protected] Ward 12B: 01494 426398

For urgent medical attention please attend A&E at Stoke

Mandeville Hospital for review by the on-call Orthopaedic Team

FOR ANY CONCERNS PLEASE CONTACT:

mailto:[email protected]



Appendix 7: Post-Operative Medication Information

SP & AF v 1.2 (Apr 2021)

Drug Name How many

times a day do I take this?

How many days do I take this for? What is it for? Additional Information

Paracetamol 4 7 days Pain Relief This is an excellent ‘foundation’ pain reliever which will improve the effect of your other pain medicines.

Oxycodone MR Tablet 2 Day 0 – day 2 only VERY STRONG pain relief

This medication is prescribed for the first 3 days only – it can be very addictive and must not be continued longer than this period. Please do not approach your

GP to ask for it to be continued – they have been asked by us not to reissue it. After the first 3 days this will be ‘stepped down’ to a different pain medicine,

either codeine or tramadol. IMPORTANT: DO NOT TAKE CODEINE OR TRAMADOL WHILST ON

OXYCODONE MR.

Codeine Phosphate OR

Tramadol

4

3 Day 3 – day 7 only STRONG pain relief

ONE of these two will have been prescribed as your ‘step-down’ pain medicine when your very strong oxycodone MR medicine ends. Your anaesthetist will have

decided which one is the most appropriate for you. IMPORTANT: DO NOT TAKE CODEINE OR TRAMADOL WITH OXYCODONE

MR.

Ibuprofen 3 7 days Pain relief Some people can’t take Ibuprofen. Your anaesthetist will have decided if this is an appropriate medicine for you and if so, you will have been discharged with it.

Lansoprazole 1 7 days Stomach protection This medicine will help protect your stomach lining if you have been prescribed ibuprofen.

Movicol 2 7 days To reduce/prevent constipation Strong pain medicines like oxycodone or codeine can cause constipation. We

don’t want this to happen for you, so we have prescribed these sachets to prevent this.

Dalteparin/Rivaroxaban 1 14 days for knees 28 days for hips

To reduce risk of a blood clot (DVT/PE)

We need you to take dalteparin/rivaroxaban to reduce the chance of you getting a blood clot in the veins of the leg (DVT) or lung (PE). You may not require this if

you are already on other ‘blood thinning’ drugs e.g. warfarin.

Oxycodone IR Liquid Every 4 - 6

hours (If required)

5 days VERY STRONG pain relief

This is a very strong, fast-acting pain medicine to be used for breakthrough pain. Please take 5 mg/5 ml initially. After that, you should wait for at least 4 – 6 hrs before taking more. You should not require this medicine for more than 5 days.

IMPORTANT: DO NOT TAKE MORE THAN 20 mg/20 ml IN 24 HRS.

Ondansetron 3 (If required) 7 days To reduce/prevent nausea Strong pain medicines like oxycodone or codeine can cause nausea or vomiting.

This medication will reduce these symptoms should they occur.

From week 2, post-operative pain medication if still required: Paracetamol 1 g: 4 times a day for 7 days

Ibuprofen 400 mg: 3 times a day for 7 days (+ Lansoprazole: once a day whilst on ibuprofen)

If more than the above post-operative painkillers are required, please discuss on post op follow up appointment

IF R

EQU

IRED

RE

GU

LAR

Patient Label

SP & AF v 1.2 (Apr 2021)


Appendix 8: Virtual Follow-up Proforma

Day 1 Day 2 Day 4

General Feeling Very Good Good Reasonable Bad

Pain (0 - 10)

At rest When mobilising/WB At night Oxycodone liquid required

Nausea/Vomiting

None Mild Moderate Severe Anti-sickness tb required

Dizziness None Mild Moderate Severe

Drowsiness None Mild Moderate Severe

Calf No concerns Pain/swelling/erythema

Breathing No concerns Short of breath/chest pain

Bowels Opened Not opened Laxatives required

Wound

No ooze Some strike-out Dressing saturated/leaking Surrounding skin red Blisters

Satisfaction Very Satisfied Satisfied Not Satisfied

Did you like

being a day case Yes No

Did you like our Unit Yes No

Patient Label Consultant: Operation: Date of Operation: Date of Discharge:


Documents

WARP for Primary Hip and Knee Arthroplasty Patients