Audiovisual Distraction for Patients Undergoing Total Knee or Hip Replacement Surgery

The perioperative period is often anxiety-provoking experience for many of our patients. Pain
and awareness are the two primary concerns voiced most frequently. For total knee and hip
replacement surgery, we offer our patients a spinal anesthetic which produces complete
sensory blockade below the level of the waist. Despite a completely insensate knee or hip,
patients still desire sedation during the surgery in order to remain unaware of their
surgical surroundings. Propofol is commonly used in these monitored anesthesia care
procedures because of its favorable drug profile. However, we have observed that anesthesia
providers often use high infusion rates of propofol in order to achieve 'adequate patient
comfort'. In this scenario, providers are often left with the dilemma of providing deeper
levels of sedation for a pleasant patient experience and dealing with the potential
cardiorespiratory complications that follow from oversedation. Unwanted side-effects include
respiratory depression, airway obstruction and hypotension. Clinicians have began looking for
other non-pharmacological ways to provide safe anxiolysis in the operating room while
avoiding these undesirable side-effects.

Previous studies have shown that audiovisual distraction (AVD) can reduce stress and anxiety
during the perioperative period. In 1997, Ganapathy et al. examined the use of sedative
medications in elderly patients undergoing orthopedic procedures under spinal anesthesia.
They compared patient-controlled propofol administration and anesthesiologist-controlled
midazolam and fentanyl administration.This study found that there were no differences in
patient satisfaction between the two groups. The secondary outcomes did show that propofol
consumption was associated with significantly more episodes of brief respiratory rate
depression but did not increase the need for emergency airway interventions.1

Ayoub et al studied propofol consumption in patients undergoing orthopedic procedures under
spinal anesthesia using auditory distraction. This study demonstrated that auditory
distraction decreased the amount of propofol consumed in patients using auditory distraction
compared to those who had propofol sedation alone.2

Lee et al. began to shift the paradigm of medication induced anxiolysis and pain control
during painful procedures through a series of studies examining different forms of
distraction. An initial study conducted by this group confirmed that audio distraction during
stimulating procedures (colonscopies) reduced the amount of propofol required. In 2003, they
combined audio and visual distraction in patients undergoing and compared the dosages of
propofol required to patients having only visual distraction or no distraction. This study
found that patients with both audio and visual distraction required significantly less
propofol than patients receiving visual distraction or patient-controlled sedation alone.
Other key findings in the AVD group included reduced procedure time, a greater willingness by
the patient to repeat the procedure under the same circumstances, and a statistically
significant higher satisfaction score with the process.3

None of these studies has attempted to evaluate a possible reduction in propofol consumption
for patients having a spinal anesthetic with both audio and visual distraction. We believe
the next step to improving the perioperative experience for our patients is to incorporate
AVD for patients having total knee and hip replacement surgery under a spinal anesthetic. Our
hypothesis is that AVD will significantly reduce standard of care administered propofol
consumption while still providing a pleasant experience for our patients and reducing
unwanted side-effects associated with higher levels of propofol sedation.

Inclusion Criteria:

- Adults >18 years of age having a

- Primary total hip or knee arthroplasty

- Surgery under a spinal anesthetic

Exclusion Criteria:

- ASA status >3

- parturients

- documented hearing or vision loss

- chronic opioid use (>30mg PO MEQ daily for >1 month)

- diagnosis of OSA, contraindications to spinal (coagulopathy, infection, spinal
hardware)

- non-English speaking

- current history of substance abuse

- schizophrenia

- generalized anxiety disorder

- Alzheimer's disease

- other dementia