Ether– Resources for Anesthesia Research and Education

Perioperative Pain Management Guidlines for Total Knee and Hip Arthroplasty (May 2015)

 

Working Group:     Derek Amanatullah, Ryan Derby, Jean-Louis Horn, James Huddleston, Meredith Kan, Matthew Miller, Jordan Newmark, Einar Ottestad.

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 outcomes and safety, the Department of Anesthesiology, Pain and Perioperative Medicine and the Department of Orthopedic Surgery are working together on a revision of the prior 2007 and 2012 versions of standard operating procedure for best practice anesthesia and perioperative pain management.

These guidelines are suggestions based on clinical committee consensus and recent literature.  Final patient care decisions may vary for individual patients and are ultimately up to the anesthesiology team, pain service and surgical team taking care of the individual patient.

PLEASE SEE GUIDELINES IN TABLE FORMAT ON FOLLOWING PAGE.

TKA/THA PERIOPERATIVE PAIN MANAGEMENT PROTOCOL

PREOP
MEDS

To be given in preop holding, day of surgery:
-Tylenol 1g IV. Reduce dose/use caution in liver disease.
-Celebrex 200mg PO. Caution in renal insufficiency.
-Gabapentin 600mg PO (300 mg if age >70 or GFR < 50; 100mg for dialysis patients).

 

Primary TKA
(non-chronic
pain pts)

Primary TKA
w/ Chronic Pain

Revision TKA

Primary THA

Revision THA

REGIONAL

ACC1 for Goodman, Huddleston cases

ACC for all except Miller cases

ACC for all except Miller cases

LPB2 SS for Bellino anterior THA

LPB SS for Bellino anterior THA

RECOMMENDED ANESTHETIC TYPE

Spinal/MAC
(no intrathecal morphine)

Spinal/MAC (consider intrathecal morphine)

NO spinal opioids for Miller cases

GA as cases tend to be > 2 hrs. 

Spinal/MAC for Miller cases (no IT opioids)

Spinal/MAC
(consider intrathecal morphine for chronic pain patients only)

Spinal + GA

INTRAOP MULTIMODAL
PAIN
THERAPY
  • Ketamine

0.25-0.5 mg/kg IV at incision




  • Decadron

4-8mg IV

  • LIA3 by surgeon
  • Ketamine

0.25-0.5mg/kg IV at incision, consider adding infusion


  • Decadron

4-8mg IV

  • LIA by surgeon
  • Ketamine

0.25-0.5 mg/kg at incision




  • Decadron

4-8mg IV

  • LIA by surgeon
  • Ketamine

0.25-0.5 mg/kg at incision, consider adding infusion for chronic pain

  • Decadron

 4-8mg IV

  • LIA by surgeon
  • Ketamine

0.25-0.5mg/kg at incision, consider adding infusion for chronic pain

  • Decadron

4-8mg IV

  • LIA by surgeon

POSTOP
MULTIMODAL
PAIN
REGIMEN

Oxycodone
Gabapentin
Celebrex
Acetaminophen

ACC infusion
Oxycodone
Gabapentin
Celebrex
Acetaminophen

ACC infusion
Oxycodone
Gabapentin
Celebrex
Acetaminophen

Oxycodone
Gabapentin
Celebrex
Acetaminophen

Oxycodone
Gabapentin
Celebrex
Acetaminophen

Guidelines for postop pain medication dosing:
-Continue outpatient pain medications when appropriate
-Tylenol 1g PO q8h (max total daily dose 3 gm, reduce dose for liver disease)
-Celebrex 100mg PO BID (caution in renal insufficiency)
-Gabapentin 600mg PO TID (300 mg TID if age >70 or GFR < 50; 100mg TID for dialysis
patients).  Consider decreasing dose if drowsiness occurs.
-Oxycodone:  5-10mg PO q3h PRN (increase dose as necessary for chronic pain patients).

1 ACC: Adductor Canal Catheter

2 LPB: Lumbar Plexus Block

3 LIA: Local Infiltration of Analgesia.  Plain bupivacaine +/- Exparel injection at surgical site.

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