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Conduct of Anaesthesia

Summary

View or edit this diagram in Whimsical.

Joint Replacement–Conduct of Anaesthesia

Pre-operative Assessment & Optimisation

• Comorbidity & Frailty–document ASA status, frailty score, pulmonary hypertension, obstructive sleep apnoea (OSA) and renal function.
• Anaemia & Nutrition–screen ≥ 4 weeks pre-op; treat iron-deficiency (i.v. ferric carboxymaltose 15 mg kg⁻¹), optimise diabetes (HbA1c ≤ 64 mmol mol⁻¹) and albumin.
• Thrombosis Prophylaxis Plan–stratify venous thrombo-embolism (VTE) risk; commence mechanical measures on admission and prescribe chemical prophylaxis for day 0.
• Patient Education & Expectations–counsel on early mobilisation and realistic pain trajectories; provide written ERAS information.
• Lifestyle Optimisation–smoking and alcohol cessation ≥ 4 weeks; personalised exercise (“pre-habilitation”).

Persistent Post-Surgical Pain (PPSP)–Risk Factors

Domain	High-risk Features
Psychosocial	Pain catastrophising, anxiety, depression, poor coping style
Pre-existing pain	Severe chronic joint pain, neuropathic descriptors, multisite pain
Biological	Younger age (< 60 yr), high BMI, dyslipidaemia, sleep disturbance, central sensitisation
Medication	Long-term opioids, gabapentinoids, high pre-op analgesic burden

• Pre-operative identification permits targeted education, pre-emptive multimodal analgesia and early chronic pain follow-up.

Anaesthetic Technique

Neuraxial versus General Anaesthesia

Setting	Best current evidence	Signal for NA benefit
Urgent hip-fracture surgery	REGAIN (pragmatic RCT, 1 600 pts)	No reduction in mortality or major morbidity; functional recovery equal.
Elective THA/TKA	2024 US-national database (>2 million cases) & other registries	Reduced transfusion, pulmonary complications, AKI and 30-day mortality with NA, even after propensity matching.
Meta-analyses 2024–25 (mixed urgency)	Heterogeneous; pooled estimates favour NA for pulmonary complications and transfusion but not for mortality when only high-quality RCTs included

• Elective total joint arthroplasty: Large observational datasets continue to show lower transfusion requirements, pulmonary complications, acute kidney injury and small absolute reductions in 30-day mortality with NA versus contemporary GA, without delaying mobilisation.
• Hip-fracture surgery The REGAIN RCT demonstrated clinical equivalence between spinal anaesthesia (with light sedation) and protocolised GA for 60-day mortality and ambulation, suggesting that previously observed mortality benefits may be smaller or procedure-specific.
• Likely to benefit most from NA: patients with severe pulmonary disease, obstructive sleep apnoea, right-ventricular dysfunction or high persistent-pain risk—but evidence for mortality benefit in very elderly hip-fracture patients is now uncertain.

Regional Blocks & Local Infiltration

Operation	Preferred Block(s)	Remarks
THA	Pericapsular nerve group (PENG) ± fascia iliaca	Preserves motor power; facilitates early mobilisation
TKA	Adductor canal ± iPACK (infiltration between popliteal artery & capsule of the knee)	Provides sensory analgesia while sparing quadriceps; superior to femoral nerve block for mobilisation
Both	Local infiltration analgesia (ropivacaine 2 mg ml⁻¹ 100 ml + ketorolac 30 mg)	Evidence strong for TKA, limited for THA

• Continuous catheter techniques are reserved for revision surgery or opioid-tolerant patients.

Intra-operative Management

• Monitoring–arterial line for ASA ≥ III, goal-directed fluid therapy (stroke-volume variation or oesophageal Doppler).
• Antibiotic Prophylaxis–cefazolin 2 g i.v. within 60 min of incision (add vancomycin 15 mg kg⁻¹ if MRSA risk).
• Antifibrinolytic–TXA 15 mg kg⁻¹ i.v. at induction ± repeat 3 h later; single dose is non-inferior to multiple doses for primary arthroplasty. Oral TXA 2 g pre-incision is an effective alternative.
• Temperature Management–forced-air or under-body conductive warming; target core 36 °C.
• Fluid & Blood Loss
  • Use an individualised, goal-directed fluid strategy that maintains euvolaemia and avoids both fluid overload and cumulative deficit._ In uncomplicated primary arthroplasty this usually equates to a near-zero to modestly positive (< +0.5 L) balance by skin closure, switching to oral fluids in recovery.
  • Consider advanced haemodynamic monitoring (SVV/PPV, oesophageal Doppler) in ASA ≥ III, revision or bilateral cases.
  • Transfuse at Hb < 80 g l⁻¹ (or < 90 g l⁻¹ if symptomatic coronary disease).
• Tourniquet–lowest effective pressure; deflate before closure to allow haemostasis.
• Bone Cement–apply BCIS precautions (see dedicated note).

Fluid Management in Contemporary Hip & Knee Arthroplasty — where Are We Now?

What has changed?	Why?	Practical takeaway for elective TJA
Strict zero-balance (≤ 1 L positive at end of case) no longer recommended for major procedures	▸ RELIEF RCT: restrictive strategy ↑ acute kidney injury 8.6 % vs 5 % liberal Surgery”▸ Subsequent meta-analyses show U-shaped harm curve (both deficit and overload)	Aim euvolaemia rather than absolute zero
Consensus groups now advise a moderately positive balance for moderate–major surgery	2024 POQI XI consensus: target +1–2 L for major cases; ~+0.5–1 L for shorter procedures	For primary THA/TKA (blood loss usually < 500 mL) a near-zero to modest positive balance is still appropriate.
ERAS TJA guideline reframes the question: “Maintain fluid balance, avoid both overand under-hydration.”	ERAS Society hip/knee statement stresses judicious IV fluids & early oral intake, not fixed volumes	Stop IVF as soon as the patient tolerates oral intake; replace measured losses only.
Goal-directed haemodynamic therapy (GDFT) favoured for high-risk or revision surgery	Small orthopaedic studies & larger meta-analyses show fewer hypotensive minutes and shorter stay with SV-guided GDFT	Use oesophageal Doppler/arterial pressure waveform in ASA ≥ III or revision arthroplasty; give bolus only if fluid-responsive and hypoperfused.

Post-operative Care

Multimodal Analgesia

1. Scheduled–paracetamol 1 g 6-hourly; NSAID or COX-2 inhibitor if no contra-indication.
2. Regional–continuation of catheter technique where used; consider single-shot adductor canal block top-up at 12 h for TKA.
3. Systemic Rescue–i.v. morphine PCA (1 mg bolus, 5 min lock-out) titrated for Was < 4; low-dose ketamine infusion (0.1 mg kg⁻¹ h⁻¹) in opioid-tolerant patients.
4. Adjuncts–dexamethasone 4 mg, ondansetron 4 mg for PONV prophylaxis; gabapentinoids not recommended routinely.

Thromboprophylaxis & Early Mobilisation

• Mechanical prophylaxis on day 0; chemical prophylaxis (LMWH 40 mg s.c. daily or DOAC per protocol) from 6 h post-surgery.
• Physiotherapy to standing on day 0 and ≥ 30 m ambulation day 1.

Neuraxial Anaesthesia & Anticoagulation (ASRA 2025)

Agent	Minimum delay before block	Catheter removal	Restart after removal
LMWH prophylaxis (40 mg od)	12 h	≥ 12 h after last dose	≥ 6 h
LMWH treatment (1 mg kg⁻¹ bid)	24 h	Contra-indicated	–
UFH s.c. (< 15 000 units day⁻¹)	4 h	4–6 h	1 h
Apixaban / Rivaroxaban	72 h (check anti-Xa if < 72 h)	Contra-indicated	≥ 6 h
Dabigatran (CrCl ≥ 50 ml min⁻¹)	72 h	Contra-indicated	≥ 6 h
NSAIDs, aspirin ≤ 325 mg day⁻¹	No restriction	–	–
Thrombolytics	Absolute contra-indication	–	–

Always individualise based on bleeding risk, renal function and concurrent antiplatelets.

Enhanced Recovery After Surgery (ERAS) for TJA

Core Elements

Phase	Key Components
Pre-op	Education, carbohydrate drink (unless insulin-dependent diabetes), active pre-warming, pre-emptive oral analgesia
Intra-op	Spinal anaesthesia with low-dose intrathecal local anaesthetic (no opioid), TXA, normothermia, antibiotic & anti-emetic prophylaxis
Post-op	Opioid-sparing multimodal analgesia, early oral intake (≤ 6 h), VTE prophylaxis, day-of-surgery mobilisation, criteria-led discharge

ERAS pathways halve median length of stay (6 → 3 days) without increasing readmission or complication rates, and confer the greatest benefit in patients ≥ 85 years. Regular audit sustains compliance and outcomes.

Evidence Summary

• NA remains the reference standard for elective TJA when feasible.
• Adductor canal ± iPACK block provides superior mobilisation compared with femoral nerve block for TKA.
• Single-dose i.v. (or 2 g oral) TXA is adequate for most primary arthroplasties.
• Multimodal, opioid-sparing regimens and early physiotherapy are central to reducing PPSP incidence.

Links

• Enhanced recovery after surgery (ERAS)
• Cement
• Tourniquets
• Ortho regionals
• Anticoagulation and blocks

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References:

1. Enhanced recovery after surgery in arthroplasty, N Biyase; Southern African Journal of Anaesthesia and Analgesia. 2021;27(6 Suppl 1):S214-217. https://doi.org/10.36303/SAJAA.2021.27.6.S1.2711
2. Soffin, E. M. and YaDeau, J. T. (2016). Enhanced recovery after surgery for primary hip and knee arthroplasty: a review of the evidence. British Journal of Anaesthesia, 117, iii62-iii72. https://doi.org/10.1093/bja/aew362
3. Shiu, Y. and Lawmin, J. (2015). Anaesthesia for joint replacement surgery. Anaesthesia &Amp; Intensive Care Medicine, 16(3), 89-92. https://doi.org/10.1016/j.mpaic.2014.12.009
4. ERAS® Society. Consensus statement for perioperative care in total hip and knee replacement surgery. Acta Orthop 2019. PMC
5. Enhanced recovery after surgery protocols for total joint arthroplasty–current evidence. Perioper Med 2023. PMC
6. Comparative effectiveness of neuraxial versus general anaesthesia in contemporary THA/TKA patients. Anesthesiology 2024. PubMed
7. Is outcome improved with neuraxial anaesthesia in total joint arthroplasty? J Arthroplasty 2024. arthroplastyjournal.org
8. Impact of neuraxial anaesthesia on postoperative acute kidney injury. Curr Opin Anaesthesiol 2025. SpringerLink
9. Adductor canal block versus femoral nerve block: network meta-analysis. Anaesthesia 2024. PubMed
10. Review: adductor canal block in TKA. Int Orthop 2025. ScienceDirect
11. Systematic review–factors associated with PPSP after TKA/THA. Pain 2023. [PMC](https://pmc.ncbi.nlm.nih.gov/articles/PMC9833456/?utm_source=chatgpt.com
12. Risk factors for chronic postoperative pain after TKA: meta-analysis. J Orthop Surg Res 2024. BioMed Central
13. Long-term pain prevalence after TKA/THA: umbrella review. Bone Joint J 2025. PMC
14. AAOS/AHKS endorsed clinical guidelines: TXA in total joint arthroplasty. AAOS 2018 (still current). American Academy of Orthopaedic Surgeons
15. Randomised study–multiple versus single i.v. TXA doses in TKA. J Clin Orthop Trauma 2025. Journal of Orthopaedic Case Reports
16. American Society of Regional Anaesthesia (ASRA) Evidence-Based Guidelines: anticoagulation & regional anaesthesia, 5th Edition 2025. rapm.bmj.comGuideline Central

Summaries:
Regionals for hip fractures
Lower limb blocks
Analgesia for hips and knees

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Copyright
© 2025 Francois Uys. All Rights Reserved.

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