The focus here is on early mobilisation and discharge, using enhanced recovery protocols. Patients tend to have been well briefed to expect a spinal +/- sedation
Pre-op
- Paracetamol PO
Intra-op
- 16G cannula, using lidocaine
- Spinal
- 2.5-2.8ml 0.5% bupivicaine
- No opioids
- Propofol TCI for sedation, if necessary. ~0.5-1 mcg/ml
- Prophylactic antibiotics according to local guidelines
- Tranexamic acid
- Dexamethasone 6.6 mg
- Local infiltration of wound with LA
Post-op
- Analgesia
- Regular paracetamol
- Regular NSAID (unless contraindicated)
- Oral opioid for breakthrough pain
- VTE prophylaxis
- Early return to oral intake
- Avoid post-op IV fluids
Out of fashion
- Pre-op carbohydrate drinks – don’t accelerate discharge or reduce complications
- Opiates in spinal – although they reduce pain scores and analgesic use, benefit might be outweighed by risk of urinary retention, pruritis and respiratory depression. (Could consider 100mcg morphine)
- Nerve blocks – negatively affect early mobilisation (Could consider fascia iliaca block)
- Gabapentin – evidence currently lacking for pain reduction
Anaesthetic Recipes 
Any thoughts on lower concentration intrathecal bupivacaine?
Seen 0.25% on a few local trust elective joint protocols
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I know colleagues who use 0.25% combined with a GA, but I do not have any experience using it as a sole anaesthetic technique, I’m afraid.
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