Implementing a Spinal Induced Hypotension Guideline in Total Knee Arthroplasty Patients

Abstract

Problem: At a community hospital, approximately 20 total knee arthroplasties are performed each week. In 90% of these patients, spinal anesthesia is used to alleviate surgical pain. Nearly one-third of these patients develop spinal induced hypotension. Administration of 4mg of ondansetron, 5 minutes prior to spinal anesthesia reduces incidence of spinal induced hypotension by antagonizing the Bezold-Jarisch Reflex. Despite this, there was no guideline in place for preventing spinal induced hypotension at this facility. Purpose: The purpose of this quality improvement project was to implement and assess compliance with a spinal induced hypotension guideline supporting administration of 4mg of ondansetron, 5 minutes prior to spinal anesthesia in total knee arthroplasty patients. Methods: A guideline recommending administration of ondansetron prior to spinal anesthesia in total knee arthroplasty patients was created by the Project Lead and approved by anesthesia leadership. Education on the guideline was held both virtually and in-person for all 41 anesthesia providers. Attendance was measured by the Project Lead via quick response code. Following this, anesthesia providers administered 4mg of ondansetron, 5 minutes prior to spinal anesthesia in total knee arthroplasty patients. Over a 15-week period, guideline compliance was measured by the Project Lead via retrospective chart review and disseminated to staff weekly. Total knee arthroplasty patients who did not receive spinal anesthesia and those with documented contraindication to ondansetron were excluded from data collection. Total knee arthroplasty patients who received spinal anesthesia were included. A run chart and descriptive statistics were used to analyze the data. Results: Guideline education was attended by 41% of the anesthesia staff. A total of 262 total knee arthroplasty patients were included in the project data and 23 patients were excluded. Anesthesia providers were compliant with the guideline in 225 total knee arthroplasties, and non-compliant in 37. On weeks 7, 13, and 14, compliance rose to 100%. Median guideline compliance was 87.5%. Conclusion: Findings suggest implementing a spinal induced hypotension guideline is a feasible intervention. When paired with site specific strategies, guideline implementation can initiate and sustain evidence-based practice change.