Impact of Integrated Care Pathways for Prevention of Post-operative Urinary Retention (POUR)
Impact of Integrated Care Pathways for Prevention of Post-operative Urinary Retention (POUR)
A prospective randomized control trial will be conducted at Good Samaritan Hospital and
 TriHealth Evendale Hospital. Subjects will receive total hip or knee surgery and follow-up
 via standard care at the discretion of the treating physician or the experimental study arm
 in which all patients will undergo the integrated care pathway.
Patients will be randomized to the control group or the experimental group. Patients in the
 control group will receive the treating physician's standard of care, and undergo bladder
 scans in the post anesthesia care unit (PACU), upon admission to the unit, and prior to
 discharge from the hospital. Patients in the experimental group will undergo a multimodal
 pain control care pathway that minimizes opioid consumption.

 The primary endpoint will be the presence of or absence of post-operative urinary retention
 (POUR) between discharge from the PACU and prior to discharge from the hospital. POUR will be
 defined as bladder volume of greater than 500cc and the inability to void for at least 2
 hours within the first 24 hours. POUR, once identified will be treated with intermittent
 straight catheterization (ISC). Secondary endpoints will include opioid consumption (in
 morphine milligram equivalents; MME), genito-urinary consultation, type (knee or hip) and
 duration of surgery, type of anesthesia, duration of anesthesia, total amount of IV fluids,
 blood loss, length of hospital stay (LOS), discharge status (home with early outpatient
 physical therapy, etc.), time of first spontaneous voiding, and the number of ISCs and any
 necessary indwelling catheterization and adverse events of interest including POUR,
 post-operative nausea and vomiting (PONV), severe pain of 7 or greater on the numeric rating
 scale(NRS), blood loss requiring transfusion, and lower urinary tract symptoms (LUTS).
Inclusion Criteria:

 -  ASA grade I- III

 -  BMI under 36 kg/m^2

 -  Scheduled surgery for primary total hip or knee replacement

 -  Age 18+ years

 Exclusion Criteria:

 -  Contraindications or failure of neuraxial anesthesia

 -  Patients must not be outpatient total hip or knee procedure

 -  Known intercurrent UTI, incontinence, or urinary retention not addressed by
 pre-operative urologic consultation and correction

 -  Pregnancy

 -  Current nicotine, alcohol or drug abusers

 -  Pre-operative narcotic use (any narcotic consumption within 3 days prior to surgery)

 -  Post- operative parenteral narcotic administration

 -  Allergy or intolerance to liposomal bupivacaine, bupivacaine, celecoxib, dexamethasone
 and/or pregabalin