Anesthesia and Pain Service Guidelines For Primary Total Hip and Knee Arthroplasty
Working Group: Jonay Hill, Stuart Goodman, Hutch Huddleston, Alex Macario,
Sean Mackey, Bill Maloney, Lindsey Vokach-Brodsky,
Pedro Tanaka, Einar Ottestad, Nicholas Giori, Matthew Miller.
Version: 5 (Date: November 30, 2012)
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 guidelines for patients who undergo hip or knee
arthroplasty.
Please note:
- A Continuous Adductor canal block will be performed 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. NP/PA will fill out orders in ortho clinic.
- Consideration for a single shot sciatic nerve block or a continuous combined adductor canal/sciatic nerve block technique for knee replacements will be on a case by case basis in consultation with the in-OR anesthesiologist 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.
- For infected total hip consider single shot spinal +/- GA. For infected total knee consider single shot ACB and GA.
- Revision hip replacement, bilateral TKA’s or revision knee replacement also follow this guidelines, 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.
- Continuous ACB infused with 0.25% 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 0.1mg/hr. 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.
- Continuous ACB. Bolus with 30ml of 0.5% Ropivacaine. ( Bolus with 20 ml 0,5% if LIA)
- ** LIA = Local Infiltration Anesthesia with 100 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 Primary Total Hip Arthroplasty
|
Primary Total Hip Arthroplasty |
Responsibility |
Pre-operatively
|
Preemptive analgesia with: Acetaminophen, gabapentin and celebrex 1hr before surgery in preop holding area |
NP/PA ortho |
Infection prophylaxis with cefazolin 30min before surgery (1 gram IV for patients <80kg, 2 grams for patients ≥80kg); If true PCN allergy use vancomycin 1gm IV, with infusion completed prior to skin incision |
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 Roxicodone 5 to 20 mg PO q2h PRN; Morphine 0.5-2.0 mg IV q3h PRN
|
Surgeon, Pain Service, Nursing, Physical Therapy |
Anesthesia and Pain Service Protocol for Primary Total Knee Arthroplasty
|
Primary Total Knee Arthroplasty |
Responsibility |
|
Pre-operatively
|
Preemptive analgesia with: Acetaminophen, gabapentin and celebrex 1hr before surgery in preop holding area. |
NP/PA ortho |
|
| Infection prophylaxis with cefazolin 30min before surgery (1 gram IV for patients <80kg, 2 grams for patients =80kg); If true PCN allergy use vancomycin 1gm IV, with infusion completed prior to skin incision | Anesthesiologist |
||
Intra-operatively / Anesthesia
|
General anesthesia + Continous ACB are 1st choice. Alternatively, choose spinal anesthesia if there is a clear clinical indication over GA or patient preference.
|
Anesthesiologist
|
|
If LIA by Surgeon intraop** Continuous ACB with 20 cc ropivacaine 0,5% |
|||
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: |
Surgeon, Pain Service, Nursing, Physical Therapy |
|
