Knee replacements can be considerably more painful than hip replacements. The recipe is very similar, with the addition of an adductor canal block.
Pre-op
- Paracetamol PO
Intra-op
- 16G cannula, using lidocaine
- Spinal
- 2.5ml heavy 0.5% bupivicaine
- No opioids
- Propofol TCI for sedation, if necessary. ~1 mcg/ml
- Adductor canal block (ACB)
- Prophylactic antibiotics according to local guidelines
- Tranexamic acid
- Prophylactic anti-emetics including dexamethasone
- Local infiltration of anaesthetic (LIA) into joint
- Avoid use of tourniquet
Post-op
- Analgesia
- Regular paracetamol
- Regular NSAID (unless given regular aspirin)
- 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
- Tourniquets – do not reduce total blood loss, but do cause swelling and impair early functional recovery
- Gabapentin – evidence currently lacking for pain reduction
“Tourniquets – do not reduce total blood loss, but do cause swelling and impair early functional recovery”
Do you have reference(s) for this? Would be interesting to discuss with orthopods
And no blockfor posterior capsule coverage (eg. IPACK)? Eg. in no spinal/GA cases
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Have a look here:
1 Wainwright TW, Gill M, McDonald DA, et al. Consensus statement for perioperative care in total hip replacement and total knee replacement surgery: Enhanced Recovery After Surgery (ERAS®) Society recommendations. Acta Orthop. 2019;91:3–19. doi: 10.1080/17453674.2019.1683790
I think you could show papers that favour either view for blood loss, but the summary is there might be less intra-operative blood loss, but then more post-op / concealed haemorrhage after. When the extra potential complications are taken into account, the evidence comes down in favour of avoiding tourniquet use. I’m afraid I don’t have much experience with iPACK blocks.
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