Anaesthetists

Anaesthetic Recipe for TKRs

We have spent some time looking at various enhanced recovery anaesthetic recipe’s from all over the UK and from overseas. One thing that all the successful enhanced recovery programmes tell you is that ‘you need to find out what works in your department’. There is no magic recipe that will work everywhere, but in putting our recipe together we used bits of recipes from many other centres as well as using our own ideas. The majority of our patients having elective primary knee replacements have the following.

Preop

  • Paracetamol
  • Ibuprofen
  • Omeprazole
  • Pregabalin

Intraop

  • Spinal. 1.8 to 2.2mls 0.5% heavy Marcaine. No opiate
  • Subsartorial saphenous nerve block with 10mls 0.25% bupivacaine
  • Propofol TCI with an LMA
  • Antibiotics
  • Ondansetron
  • Dexamethasone
  • Paracetamol
  • Parecoxib
  • Tranexamic Acid
  • 150mls of LA with adrenaline and clonidine injected by surgeon (50mls in posterior capsule/ PCL and around collaterals, 50mls in the deep approach and 50mls in superficial soft tissues)

Post Op

  • Oxycontin in recovery pre the spinal fully wearing off
  • Paracetamol
  • Etoricoxib for 5/7 (or Ibuprofen if concerns)
  • Pregabalin for 5/7
  • Omeprazole
  • Pregabalin
  • Tranexamic Acid at 6 hours
  • Apixaban
  • Oxycontin for 48 hours

We assess each patient to satisfy ourselves and them that this is the best anaesthetic for them and adjust the medications as we feel the risk : benefit ratio changes. Most of our patients will have about 1.5 litres of crystalloid in the perioperative period and we avoid catheterisation where possible, unless the patient requests it or we consider them to be very high risk for going into urinary retention.

Enhanced Recovery

Mr Qureshi firmly believes in the benefits that Enhanced Recovery and early mobilisation gives his patients. By ensuring that everything is done before, during and after surgery to enable as rapid a recovery as possible this allows Mr Qureshi’s patient’s to return to their normal life quickly after surgery. Having developed Enhanced Recovery programmes in hospitals in the UK and Australia, and having visited other programmes throughout the UK, Europe, and the USA, Mr Qureshi feels the key components to successful Enhanced Recovery include:

  • Pre operative education of patients to ensure they know what to expect
  • Surgical and anaesthetic techniques that aim for, pain free mobilization shortly after surgery. We hope you will be moving your new knee in the recovery room and will walk on it a few hours later
  • Returning to a normal diet as soon as possible following surgery
  • Sitting out of bed in your normal home clothes

The results of these Enhanced Recovery techniques have meant that the hospitals have reduced the expected length of stay for Mr Qureshi’s patients following joint replacement surgery down to just 3 nights. Many of his patients go home before even that.

Mr Qureshi said that 'What we have done is take the best points from a great many other Enhanced Recovery programmes to work out what works best in our hands and in those of our multidisciplinary team in Southampton. It is a joy to see to see so may of our patients walking again so quickly and freely following their surgery.’