Analgesia for Total Knee Arthroplasty

J. Pisini, D.O.
Date: February 21, 2007

The currently recommended plan for anesthesia and analgesia in TKA patients is as follows:

1) Femoral Nerve Block (pre-operatively is preferable if time permits, post-op as alternative).
2) General Anesthetic with LMA
3) Post-op : PCA hydromorphone usually ordered by the block team.


Note: Surgeons from the Maine Orthopedic Center (Hanley, Barr, Oliviero, Gramse, Kuhn, Parisien) generally prefer SAB followed by a fascia iliaca block post-operatively.

If a SAB is used, do not add Duramorph unless it is requested by the surgeon or patient.


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OLD PROTOCOL  (for reference purposes still included here):

Oct  06: Rintel/Dixon

Overview:  
The recommended approach for patients having TKA is 
     a. pre-operative insertion of a lumbar epidural catheter, followed by 
     b. general anesthesia. 
Local anesthetic will be infused via the epidural during the surgery and the epidural will be utilized for post-operative analgesia until POD #1.

Pre-Operative Medications (ordered by the surgeon)
- Tylenol 1000mg po
- Celecoxib 200mg po

Epidural Insertion:
-Lumbar Epidural catheter should be placed in the ASU unit prior to the case (no test dose given in ASU). 
-Sterile Prep and Insertion per usual protocol
-Catheter site – low lumbar (L4-5); thread catheter 3- 4 cm
-Secure with mastisol, small tegaderm and 2 inch paper tape around edges of tegaderm. Tape the catheter up the back using 2 inch paper tape.
-Tape hub connector to epidural catheter with cloth tape, attach filter to hub. 
-Label catheter.

Operating Room:

-Patients are then moved to the operating room. Administer the epidural test dose. 
-General anesthesia is induced and the airway established via an LMA unless contraindicated.
-CSE as alternative (no Duramorph) / i.e. "spinal-epidural”
-Initiate an epidural infusion of 0.25% bupivacaine at 10 cc/hour soon after induction. 

PACU Management:

-Epidural infusion is continued on arrival to PACU. (If SAB was administered, start infusion when patient can move feet).
-When assessing block, check popliteal fossa to determine if S2 is blocked.

Infusion Solutions: 

- Bupivacaine 0.25% Epidural continuous infusion 6 ml/hr.

- IV PCA (Recommend Hydromorphone 0.2mg/8 min lockout/ 4mg four hour limit)

All patients who do not have specific contraindications should receive oral acetaminophen and celecoxib on schedule. (Suggested dose: acetaminophen 1000 mg tid, celecoxib 200mg q12hr). This is ordered by surgeon. 

Nursing Unit Management:

•Epidural catheter will be turned off at 0600 hrs on the morning of POD #1, and removed on rounds later that same morning. The INR does not need to be checked. If LMWH is ordered, it is held until the epidural is removed. The first dose of LMWH may be given two hours after the epidural is removed.

•Remove foley catheter 2 hours after the epidural is removed. 

•Continue PCA

•APMS signs off when epidural is removed. All further analgesic management per the surgeon.

Total Hip Arthroplasty NEW

Alison Drury August 2009


I. Anterolateral Total Hip Arthroplasty (Minimally Invasive, Babikian)

Outpatient PreMed: 

All patients receive celebrex BID, lyrica BID, and Tylenol QID on the day prior to surgery per Dr. Babikian's orders. 
Exceptions: 
-patients with diabetes do not receive celebrex
-elderly patients only receive lyrica HS prior to surgery

Some Patients receive Oxycontin 10mg on the AM of surgery.

Induction/Maintenance/Emergence

1) All patients will require general anesthesia/ETT with full muscle relaxation until closure begins. Surgical time prior to closure for Dr. Babikian is usually about 40 minutes.
2) Patients are placed in the lateral decubitus position.
3) Narcotic administration per the anesthetist's preference. Fentanyl alone is usually sufficient intraop for patients who are pre medicated with oxycontin. For patients not receiving oxycontin, Dilaudid can be added.
4) Relaxant reversal can occur as soon as closure begins and extubation in lateral position is acceptable.

II. Posterior Total Hip Arthroplasty

Outpatient PreMed:

No premeds given by surgeons for posterior hips

Induction/Maintenance/Emergence

1) General anesthesia with LMA/ETT acceptable or SAB with 0.5% Marcaine.
2) Muscle relaxation not required for procedure, most surgeons okay with intubating dose of vecuronium but do not want the patient redosed during the case for nerve monitoring purposes.
3) Patients are placed in lateral decubitus position.
4) Narcotic administration per anesthestist's preference (Fentanyl & Dilaudid/Morphine commonly used).