Arthroplasty - Anesthesia Clinical Pearls

Reviewed 3/1/21

Arthroplasty - Anesthesia Clinical Pearls

Spinal Procedure

• For new residents, Attending anesthesiologist should glove up for 1st 3 spinal procedures performed by a new resident
• Goal <25min for spinal procedure
  • 15 min resident attempt (attending glove at 10min to help w/ landmarks)
  • 10 min attending attempt
• At 25min mark, BEGIN conversation about converting to GA (based on patient comorbidities, etc)

Spinal Meds

• Bupivacaine 10-15 mg
• It is reasonable to add 10-15mcg of fentanyl and it is preferred over the addition of epinephrine (100mcg) or epinephrine wash given greater variability of effect w/ epi (prolonged spinal)
• In patients w/ chronic opiate use/ pain syndrome, consider adding duramorph (discuss w/ APS and surgical team first)

Intraop Meds

• TXA- 2 doses- 10mg/kg bolus prior to incision, and second during closure

            Exception- prior history of VTE, embolic CVA, MI, vascular stent

• Kefzol - weight based, given prior to incision, ideally during prep/drape

Exception- 

a. clindamycin 900mg IV x1 if documented anaphylaxis to PCN/ cephalosporin
b. Vancomycin IV administered in preop area if documented MRSA/E carrier  

• Decadron- 8mg IV x1
• Zofran- 4mg IV x1

Intraop Fluids

• Goal 15-20mL/kg (IBW) crystalloid during cases (e.g. 1-2L)
• If hypotensive in PACU, 500mL bolus x1, then reassess

Revision TJA

• Discuss in advance plan for GA vs neuraxial based on:
  • Estimated length/complexity of case/EBL
  • Position of patient [lateral decubitus (rev THA) harder to convert to GETA, than supine (rev TKA)]
• Vancomycin 1-1.5g IV (weight based) x1 administered in preop area (ordered by Ortho team) PLUS
• Kefzol- weight based, given prior to incision, ideally during prep/drape
• APS places regional catheters in pre-op area
• Additional lines (2nd large bore IV, a-line) as indicated on EBL and patient comorbidities