Enhanced Recovery Guidelines for Total Knee Replacements (If Sublingual Sufentanil contraindicated) (J. Rudiger, G.Kumar, S.Ati, . Howatsen - Feb 2019) irates in k aceme ck of evi idence) esia by anaesthetist; Heavy or plain 0.5% Bupivacaine 2 to 2.5 ml (max. 3ml) (aveid opioids, urinary catheter only in-out for retention unless enlarged prostate) +/- Subsartorial saphenous +/- Adductor canal block with 2x10ml 0.25-0.375% Levobupivacaine Sedation: |\- TCl-Propofol 0.5 to 2 micrograms/ml (GA in selected pationts) Prior to tourniquet inflation (intravenously by anaesthetist): Antibiotic prophylaxis: Flucloxacillin 2g lV + Gentamicin 160mg IV (If Peniciltin allergic/MRSA positive: Teicoplanin 400mg IV and Gentamicin 160mg single doses) (Reduce Gentamicin dose to 120mg in smallffrail patients with weight below 50kg)’ Tranexamic Acid 1g (slowly IV)? Dexamethasone 6,6 mg (3.3mg in Diabetes), Ondansetron 4mg (could be given at the end) During the operation (intravenously by anaesthetist): 1 Litre of Plasmalyte slowly (maximum volume should be 1L to avoid wound oedema) Magnesium 2-4g infused over 30-60 min. (40mg/kg, unless contraindicated) w 70kg, 150m! al Post-op prescriptions — reqular administration on the ward: Antibiotic prophylaxis: Flucloxacillin 1g IV at 6, 12 and 18 hours post induction. (No further antibiotics required if patient received Teicoplanin and Gentamicin intra-operatively) VTE prophylaxis: Rivaroxaban 10mg OD starting 6-10 hours post-op once haemostasis has been established (2 weeks (14 doses) for knees, 5 weeks (35 doses) for hips) * Pain relief: Paracetamol 1g (QDS) § (orally unless NBM/vomniting) NSAID: Ibuprofen 400mg TDS for 5 days (if not contra-indicated) ® Stress ulcer prophylaxis/while prescribed NSAID: Omeprazole 20 mg OD for 14 days. Anti-neuropathic: Pregabalin 75mg BD for at least 10 days if CrcL>30m\/min, 50mg at night only if weight less than 50kg and older than 75 years to reduce risk of sedation’ Oxycodone MR 10mg (up to max. 20mg) BD for 5-7 days (10mg if age > 75 or GFR below 60) (First dose in recovery before the spinal anaesthesia wears off). (Review dose/pain control/adverse effects daily and step down to Dihydrocodeine 30-60mg up to 4x per day as soon as possible.) Laxatives: Macrogol (1 sachet BD), Senna 1-2 (BD) for 5-10 days For nausea/vomiting: Ondansetron 4mg iv TDS for 2 days then PRN Post-op prescriptions - as required on the ward: [Cooling packs]Enhanced Recovery Guidelines for Total Knee Replacements (With Sublingual Sufentanil) (J. Rudiger, G.Kumar, S.Ali, R. Howatson - Feb 2019) Spinal anaesthesia by anaesthetist: Heavy or plain 0.5% Bupivacaine 2 to 2.6 ml (max. 3ml) (avoid opioids, urinary catheter only in-out for retention, unless enlarged prostate) +1 Subsartorial saphenous +/- Adductor canal block with 2x10ml 0.25-0.375% Levobupivacaine Sedation: IV - TCl-Propofol 0.5 to 2 micrograms/ml (GA in selected patients) Prior to tourniquet inflation (intravenously by anaesthetist): Antibiotic prophylaxis: Flucloxacillin 2g IV + Gentamicin 460mg IV (If Penicillin allergic/MRSA positive: Teicoplanin 400mg IV and Gentamicin 160mg single doses) (Reduce Gentamicin dose to 120mg in smallrail patients with weight below 50kg)* Tranexamic Acid 1g (slowly IV) ? Dexamethasone 6.6 mg (3.3mg in Diabetes), Ondansetron 4mg (could be given at the end) During the operation intravenously by anaesthetist): 1 Litre of Plasmalyte slowly (maximum volume should be 1L to avoid wound oedema) Magnesium 2-49 infused over 30-60 min. (40mg/kg, unless contraindicated) v70kg, 150ml ab Post-op prescriptions ~ reqular administration on the ward: Antibiotic prophylaxis: Flucloxacillin 1g IV at 6, 12 and 18 hours post induction, (Wo further antibiotics required if patient received Teicoplanin and Gentamicin intra-operatively) VTE prophylaxis: Rivaroxaban 10mg OD starting 6-10 hours Post-op once haemostasis has been established (2 weeks (14 doses) for knees, 5 weeks (35 doses) for hips) ‘ Pain relief: Paracetamol 1g (QDS) (orally unless NBM/vomiting) NSAID: Ibuprofen 400mg TDS for § days (if not contra-indicated) ® Stress ulcer prophylaxisAvhile prescribed NSAID: Omeprazole 20 mg OD for 14 days. Opioid: Sufentanil-PCA sublingual prescribed by anaesthetist and set up in recovery (15mcg nano tablets, 20 min lockout, 40 tablets per cartridge administered sublingually, for 72 hours post-op or 3. cartridges, onset: 5-10 minutes, duration of action: 60-90 minutes) — no other opioids | Laxatives: Macrogol (1 sachet BD), Senna 1-2 (BD) for 5-10 days Fornausea/vomiting: Ondansetron 4mg iv TDS for 2 days then PRN Post-op prescriptions - as required on the ward: [Cooling packs] Oxycodone IR 2.5- 5 mg (4-hourly), Glycerine-suppositories 1-2 BD if BNO day3 Stop Anti-hypertensives on Post-op day-0 and day-1 to avoid postural hypotension !