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


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
Clinical Area: 


This information is meant to serve as an educational resource. Clinicians should use their own professional judgment in the care of any individual patient as the guidance contained in this document may not be appropriate for all patients or all situations.