Looking for the Perfect Anesthetic for TKA

Kathmandu - photo by JoAnn Sturman

Scott Sturman, M.D.

To improve anesthesia for TKA in the private practice setting, the combination of SAB with very low dose intrathecal narcotics and adductor canal block holds promise.  SAB with Duramorph 200 mcg and propofol infusion combined with multimodal therapy are the mainstays of the current TKA protocol, and although simple to perform, they yield highly reproducible results.

The nagging problems with this technique continue to be PONV and pruritis on the day of surgery.  It is worthwhile noting that these side effects dissipate by POD #1, and most patients at this time, unless narcotic dependent, have pain scores of 0-2.  Improvement is needed for treating pain on the day of surgery and avoiding the side effects of intrathecal narcotics.

Proposed Protocol:

SAB with either Duramorph 0.1mg or Dilaudid 0.1mg.  The comparative side effects at these doses remains to be seen, but if any conclusions can be drawn from our experience with epidurals, Dilaudid has fewer of them.

Single shot Adductor Canal Block with Bupivacaine 0.5% and 4 mg P.F. dexamethasone usually lasts 24 hours, and patient ambulation is unaffected on the day of surgery.

Surgeon protocols using multimodal RX: Pre op Celebrex and Oxycontin followed by p.o. narcotics with or without IV acetaminophen on the floor.

Continued investigation of buprenorphine 150 ug IV for RX of intractable pruritis following intrathecal narcotics.

Haute Route - photo by JoAnn Sturman