Stanford Ortho Rotation
Anesthesia and Pain Service Protocol For Primary Total Hip and Knee Arthroplasty
Working Group: Jonay Hill, Stuart Goodman, Jim Huddleston, Alex Macario,Sean Mackey, Bill Maloney, Lindsey Vokach-Brodsky,
Pedro Tanaka, Einar Ottestad, Nicholas Giori, Matthew Miller.
Version: 4 (Date: August 10, 2011)
Background: A coordinated multidisciplinary perioperative approach to total joint replacement
surgery leads to more rapid recovery and improved patient satisfaction. Given the increasing
evidence in many areas of health care that standardization may improve outcome and safety,
the Department of Anesthesiology is working with the orthopedic surgeons on a revision of
the original January 2007 standard operating procedure for best practice anesthesia and
postoperative pain management.
Goal: This document outlines recommended protocol for patients who undergo hip or knee
arthroplasty.
Please note:
- Femoral nerve catheters will be inserted in the preoperative holding area by the regional anesthesia team and in communication and coordination with the operating orthopedists and the anesthesiologist in the OR so as to not delay cases. The surgical team can page the regional anesthesia team through OR front desk with any issues.
- For patients with a high opioid tolerance preoperatively, the use of a continuous epidural anesthetic (for either hip replacement or knee replacement) should be considered. For opioid tolerant patients, low-dose IV ketamine for all anesthetic techniques (not just GA) may be given intraoperatively as an adjunct.
- Gabapentin 600 mg PO, celebrex 200 mg PO and acetaminophen 1 g PO/IV to be given in the pre-op holding area. Write orders in SAU.
- Consideration for a single shot sciatic nerve block or a continuous combined femoral/sciatic nerve block technique for knee replacements will be on a case by case basis in consultation with the in-OR anesthesiologist in and the orthopedist.
- For Dr. Maloney’s patients (coumadin administered night before surgery), epidurals are contraindicated. A single shot spinal is appropriate within 24 hours of starting coumadin (provided no coexisting coagulation disorders).
- No Toradol® unless requested by the surgical team
- Rewarm the room in-between cases when the patients are sitting for spinal, and use forced air warming to maintain normothermia.
- Adjust acetaminophen dose in hepatic impaired patients, and for those patients who abuse alcohol. ****
- Dr. Goodman prefers being able to assess motor function immediately postop in PACU.
- Revision hip replacement or revision knee replacement also follow this protocol, except for the fact that revision cases are usually longer, so if case is expected to last more than 2 hrs, consider general anesthesia in addition to spinal, as patient may not be comfortable under sedation for more than 120 mins.
- Dr. Miller prefers spinal anesthetic in his patients with just local anesthetics, NO intrathecal opioids. His patients do not have a Foley catheter.
- Femoral catheter infused with 0.125% bupivacaine through standard infusion pumps or portable pumps (IFlow or Stryker) 6-10ml/hr. Anticoagulation may continue with peripheral nerve catheter. Catheter to be removed on POD#2 at the latest.
- If epidural analgesia is used, use 0.125% bupivacaine 6-8ml/hr + hydromorphone 0.2mg/hr. Prior to removal of catheter a 0.2mg bolus of hydromorphone to be given. Epidural to be removed on morning of POD#2. LMWH may be started 2hr after catheter removal.
- Goals are to have minimal motor blockade while maintaining good sensory analgesia. If needed, PCA morphine 0.5-2mg every 10-15min lockout, no basal. Transition to PO pain medication as per protocol
- Intraarticular catheter is bolused with 20 cc of 0.5% ropivacaine.**
- Femoral catheter inserted. Bolus with 30ml of 0.5% Ropivacaine. (0,25% if LIA)
- ** LIA = Local Infiltration Anesthesia with 150 cc of 0.2% ropivacaine, 30 mg toradol,
- and 0.5 mcg epinpherine. Toradol is left out in patients with renal disease.
Anesthesia and Pain Service Protocol for Total Hip Arthroplasty
|
Total hip arthroplasty |
Responsibility |
Pre-operatively
|
Preemptive analgesia with: Acetaminophen, gabapentin and celebrex 1hr before surgery in preop holding area |
Anesthesiologist |
Infection prophylaxis with cefazolin 30min before surgery (1 gram IV for patients <80kg, 2 grams for patients ≥80kg) |
Anesthesiologist |
|
Intra-operatively / Anesthesia
|
Spinal anesthesia is 1st choice. Alternatively, choose general anesthesia if contraindications for regional techniques are present or if patient does not give consent for regional anesthesia |
Anesthesiologist |
Spinal anesthesia with General anesthesia |
||
Maintain normothermia (forced air), use fluid warmer (Ranger) PONV prophylaxis with a 5HT3- antagonist |
||
Postoperatively |
Acetaminophen 1g every 6hrs Opioids ordered by service according to protocol for POD#1 if possible If intrathecal opiates placed, Pain Service to follow patient overnight and evaluate in morning of POD#1 If needed, PCA morphine 0.5-2mg every 10-15min lockout, no basal. |
Surgeon, Pain Service, Nursing, Physical Therapy |
Anesthesia and Pain Service Protocol for Total Knee Arthroplasty
|
Total knee arthroplasty |
Responsibility |
|
Pre-operatively
|
Preemptive analgesia with: Acetaminophen, gabapentin and celebrex 1hr before surgery in preop holding area. |
Anesthesiologist |
|
Infection prophylaxis - Cefazolin 1 gram IV (2 grams for pt ≥80kg)30 min before surgery |
Anesthesiologist |
||
Intra-operatively / Anesthesia
|
Regional anesthesia techniques are 1st choice. Alternatively, choose general anesthesia if contraindications for regional techniques are present or if patient does not give consent for regional anesthesia. |
Anesthesiologist
Surgeon |
|
Postop coumadin: Epidural contraindicated
Spinal anesthesia + femoral nerve catheter * – OR – GA + femoral nerve catheter +/- spinal anesthesia
|
Postop LMWH: Spinal anesthesia + femoral nerve catheter * – OR – GA + femoral nerve catheter +/- spinal aneshtesia – OR – Epidural anesthesia (option for chronic pain patients, or stiff revision knees) |
||
If LIA by Surgeon intraop** Communicate Epic MDS – No femoral block unless specified by surgeon |
|||
Maintain normothermia (forced air), use fluid warmer (Ranger) PONV prophylaxis with a 5HT3- antagonist. |
|||
Postoperatively |
Acetaminophen 1gm every 6hrs Opioids ordered by service according to protocol for POD#1 if possible If intrathecal opiates placed, Pain Service to follow patient overnight and evaluate in morning of POD#1 Postoperative Regional Anesthesia: |