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.
Spinal. 1.8 to 2.2mls 0.5% heavy Marcaine. No opiate
Subsartorial saphenous nerve block with 10-15 mls 0.25% bupivacaine
Posterior obturator block with 10 mls 0.25% bupivacaine
Propofol TCI with an LMA/ igel in the majority of patient
Tranexamic Acid- 1g pre KTS
150mls of Local Anaesthetic- 100mls with 1mg adrenaline and 150 micrograms of clonidine is split between the posterior capsule/ PCL and around the collaterals (50mls) and the other 50 mls is injected into the deep approach. The is then an extra 50 mls of plain local anaesthetic with no additives injected into the superficial soft tissues.
Oxycontin in recovery pre the spinal fully wearing off. This is continued into the morning of Day 2 post op
Etoricoxib for 5/7 (or Ibuprofen if concerns)
Pregabalin for 5/7
Tranexamic Acid 1g orally at 3 and 8 hours post op
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 2 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.
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. Most of his patients are back at home in their own bed by the 3rd post operative night.
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.’