Ricky G.

Jaleco
Level 2 Resident

Western Visayas Medical Center

Department of Anesthesiology

CASE BASED DISCUSSION #1

I. General Data
Patient’s Name: G.P.
Age: 46 y.o.
Sex: F
Civil Status: Married
Birthday: 07/07/1977
Nationality: Filipino
Religion: Roman Catholic
Address: B25, L52, Country Homes Subdivision, Balabago, Jaro, Iloilo City, Iloilo

II. Chief Complaint

Knee pain right

III. History of Present Illness

7 months PTA, patient experienced aching pain at her right knee, opted consult at a private
physician; and was given pain medications with relief.

However, a month PTA, patient’s knee pain persisted and is no longer relieved by medications,
and with note of associated stiffness of the affected knee joint. The patient sought consult to
the Department of Orthopedics and was apprised & scheduled for elective surgery, thus
admission.

IV. Past Medical History

(+) Known Type 2 Diabetic – maintained on Metformin + Sitagliptin
(+) Known Hypertensive – maintained on Losartan & Amlodipine
No other known comorbids

No known allergies to drugs, foods, and other environmental agents

V. Personal, Social and Environmental History

Patient is a non-smoker and a non-alcoholic beverage drinker
VI. Physical Examination
Patient is GCS 15, not in cardiopulmonary distress, with baseline vital signs of Vital Signs: BP
120/80, HR 88, RR 20, SpO2 99%. She weighs around 86 kilograms, stands 5’6”, with a BMI of
30.8 kg/m2 and is classified as obese class 1.

Anicteric sclerae, symmetrical chest expansion, clear breath sounds, adynamic precordium
normal cardiac rate with regular rhythm, no note of murmurs, soft abdomen, (+) limited ROM
on right knee, (+) pain on right knee, full peripheral pulses. No sensorimotor deficits noted.

VII. Admitting Diagnosis

Osteoarthritis Knee Right

VIII. Laboratory Results

CBC 10.8/0.35/340
S.Na 133/S.K 4.04/Crea 86.06
PT 14.8/84%/1.11
CXR Normal
ECG NSSTTWC

IX. Anesthesia Pre-operative Assessment

The patient was classified as ASA 2 for controlled hypertension & type 2 diabetes mellitus,
elderly, and obese 1, and with a Mallampati classification of 2. She was stratified by the
Department of Internal Medicine as Moderate Risk to develop perioperative complications

The patient was placed on NPO status 8 hours prior the procedure, and was premedicated
with 1) Omeprazole 40 mg IV 1 hour PTOR, and 2) Metoclopramide 10 mg slow IV 1 hour PTOR.
The patient was go on OR with available blood (1 unit of whole blood).

X. Proposed Procedure
Total Knee Arthroplasty Right

XI. Anesthetic Technique

Subarachnoid Block/Spinal Anesthesia

XII. Intra-operative Course

The patient was received at the Operating Room, conscious, coherent, oriented and not in
cardiopulmonary distress. She was then transferred to the operating table and basic monitors
were attached to the patient. Oxygen supplementation was given at 3 liters per minute via
nasal cannula. Baseline vital signs were BP 120/80, HR 90, RR 20, SpO2 100%. The patency of
IV lines were also checked and maintained.
 Anxiolysis was done by giving the patient a dose of 1.5 mg Midazolam IV. The patient was then
pre-hydrated with around 900cc of warm lactated Ringer’s solution, and the patient was
placed on right lateral decubitus position; asepsis and antisepsis, and draping followed.
Lumbar puncture was done on the L4-L5 interspace using a Gauge 25 Quincke spinal needle.
The tap was atraumatic and after getting a free flow of cerebrospinal fluid, 20 mg of hyperbaric
bupivacaine (0.5%) with 0.2 mg of epinephrine and 0.2 mg of morphine sulfate was injected
in the subarachnoid space. The patient was maintained on right lateral decubitus position for
3-5 minutes to allow the block to settle, before positioning her back into the supine position.
The level of anesthesia was assessed and reached a dermatomal level of T6, another dose of
Midazolam 1.5 mg IV was given, and the surgeons proceeded to prepare the surgical site. A
dose of 1 gram Tranexamic Acid IV was slowly given prior cutting.

Upon cutting, the patient was stable with vital signs of BP 100/60, HR 90, RR 20, SpO2 100%.
Around twenty minutes from cutting time, a dose of Midazolam 1mg IV, and Nalbuphine 2mg
slow IV was given for sedation. At 1 hour and 15 minutes from cutting time, there was note of
blood loss of around 300cc, which was around 30% of the computed allowable blood loss of
860cc, and blood transfusion of 1 unit of whole blood was initiated.

At around 15 minutes before the end of the procedure, Ketorolac 30mg IV was given with note
of a negative skin test. Overall the intraoperative course was unremarkable with the operation
lasting for approximately 3 hours. There was no note of intraoperative hypotension nor
tachycardia. A total of 1.2 L of crystalloids was transfused, with ongoing blood transfusion,
urine output was noted to be 0.9cc/kg/hr. The patient’s vital signs were BP 120/80, HR 85, RR
20, SpO2 100% prior transfer to the Post Anesthesia Care Unit for post-operative monitoring.

Post-operative medications given are as follows: 1) Ketorolac 30 mg IV ANST every 8 hours for
2 more doses, and is then shifted to, 2) Celecoxib 200 mg/cap, 1 cap PO every 12 hours for 7
days, 3) Paracetamol 1g IV every 8 hours for 3 doses, 4) Tramadol 50 mg slow IV every 6 hours
as needed for breakthrough pain, 5) Ondansetron 4 mg slow IV every 8 hours as needed for
nausea or vomiting. CBC and APC were then repeated 6 hours post blood transfusion.

XIII. Post-operative Course

At immediate post-op, patient was GCS 15, awake with NRS of 0/10, not in cardiopulmonary
distress, with pinkish conjunctiva, symmetrical chest expansion and clear breath sounds, other
PE findings were unremarkable. Vital signs were BP 120/80, HR 79, RR 20, SpO2 100% with O2
at 2 lpm via nasal cannula, and with adequate urine output. At 4 hours, post-op patient was
still with stable vital signs with an NRS of 0/10 and was then transferred back to wards.

At the wards at 24 hours post-op, the patient was still GCS 15 with stable vital signs, still NRS
0/10, and with unremarkable PE findings.
XIV. Discussion
Total knee arthroplasty (TKA) is a very common operation that is increases in frequency as the
population ages. Because TKA involves the cutting and cementing of two long bones, the
femur and tibia, these procedures have a painful recovery with a high incidence of chronic
pain following both primary and revision procedures. It is important to create an appropriate
postoperative analgesia plan to minimize pain while maximizing early mobilization.

TKA causes moderate to severe postoperative pain for most patients. The goals for pain
control after TKA are to provide excellent analgesia, early mobilization and rehabilitation, and
to minimize the use of opioids. A multimodal approach to pain management allows
administration of lower doses of various medications and less dense regional anesthesia
techniques than would be required otherwise, and therefore reduced side effects and
complications.

Multimodal, opioid-sparing strategies for postoperative pain control may include regional
analgesia techniques (eg, peripheral nerve blocks, LA infiltration, continuous epidural
analgesia, neuraxial opioids), in addition to multimodal systemic analgesics.

Choice of anesthetic technique

TKA may be performed with general or neuraxial anesthesia. The choice of anesthetic
technique should be based on patient comorbidities and patient choice; for patients who
undergo unilateral TKA in whom either general anesthesia or neuraxial anesthesia would be
appropriate, neuraxial anesthesia (spinal anesthesia) is highly preferred.

Spinal anesthesia provides consistent, dense, bilateral anesthesia. A single injection spinal can
reliably provide a duration of block adequate for primary unilateral TKA. The duration of spinal
anesthesia is determined by the local anesthetic (LA) used and the dose.

Epidural anesthesia may be used for prolonged procedures (eg, bilateral or revision TKA) in
which the duration of surgery is expected to outlast spinal anesthesia or when postoperative
epidural analgesia is desired.

Analgesia
The optimal analgesia for TKA is a complex and evolving topic. Regional anesthesia improves
patient pain outcomes compared to traditional opioid regimens. Ultrasound-guided regional
anesthesia has led to a significant increase in the use of nerve blocks and catheters as
components of postoperative analgesic regimens. A balanced multimodal analgesic approach
has the potential to maximize analgesic efficacy while minimizing side effects.
The femoral, sciatic, and obturator nerves provide sensation to the knee joint. The most
commonly utilized peripheral nerve blocks are the LBP, fascia iliaca (3-in-1 block), FNB, and
adductor canal (or saphenous) nerve blocks. These blocks can be performed in combination
with a sciatic nerve block and/or an obturator nerve block. Literature and clinical practice
continue to evolve regarding which blocks or combination of blocks best facilitate
rehabilitation and postoperative mobilization, thereby reducing time to hospital discharge,
enhancing cost effectiveness, and reducing the risk for complications such as ambulation-
related falls.

Healthy, opioid naïve patients who undergo unicompartmental, primary, or simple revision
TKA are often candidates for rapid recovery with the potential for "fast-track" status with a
reduced length of stay. Pain control strategies should include a muscle sparing regional
anesthetic technique (adductor canal, interspace between popliteal artery and posterior
capsule of the knee [IPACK], periarticular injection [PAI]) to facilitate early physical therapy.

Relevant nerve and muscle anatomy

Comprehensive analgesia for TKA involves blocking some or all of the sensory nerves that
innervate the knee joint, depending on patient factors and the planned surgery.

The majority of the innervation to the knee joint arises from the femoral nerve (nerves to the
vastus medialis, intermedius, and lateralis, medial and intermediate femoral cutaneous, and
saphenous nerves), a smaller but still significant contribution from the sciatic nerve (peroneal
and tibial nerves), and yet even smaller contribution from the lateral femoral cutaneous and
posterior obturator nerves. The saphenous nerve is the sensory component of the femoral
nerve.
Adductor canal block
The ACB involves block of the saphenous nerve (sensory only), likely the nerve to the vastus
medialis, and possibly the posterior branch of the obturator nerve. It is classically performed
at the level of the mid-thigh, midway between the anterior superior iliac spine and the base
of the patella. However, the extent and location of the adductor canal is debated by
anatomists, and this point on the thigh may actually overlay the inferior aspect of the femoral
triangle. ACB results in less quadriceps weakness than femoral nerve block because the ACB
generally spares the nerves to the rectus femoris and vastus intermedius muscles.

Femoral nerve block

The femoral nerve block anesthetizes all of the sensory innervation to the knee except for
branches of the sciatic and obturator nerves, including sensorimotor nerves to the vastus
medialis, vastus intermedius and vastus lateralis, and the sensory saphenous nerve.
The FNB is currently considered the peripheral nerve block of choice for TKA analgesia because
it has a low complication profile and is easy to perform with either nerve stimulation or
ultrasound guidance owing to well-defined anatomic landmarks. FNBs can be performed in a
single shot or via catheter; both techniques are associated with reduced morphine
consumption after TKA. A major drawback to FNB is quadriceps weakness (up to 80%) and
associated fall risk; however, the correlation between FNB and postoperative falls is disputed.

Neither the femoral nerve block nor the ACB provide complete analgesia of the knee, because
they do not include the contributions from the sciatic nerve. For patients who undergo
complex revision, who are poor candidates for fast-track protocol, or who require complete
analgesia of the knee because of opioid tolerance or chronic pain, a femoral plus sciatic nerve
block may be performed.

Interspace between popliteal artery and posterior capsule of the knee (IPACK) block – The
IPACK block is designed to block the small sensory branches of the sciatic nerve that travel in
this space without affecting motor components. The IPACK block provides analgesia for the
posterior portion of the knee only, and would likely be ineffective alone for postoperative
analgesia; thus it is often performed along with an ACB in a multimodal analgesic pathway.
The IPACK block may be an alternative to PAI or provide additional coverage for posterior knee
pain.
XV. References
1. Barash, P., et al. (2017) Clinical Anesthesia, 8th edition
2. Amundson, A., et al. “Anesthesia for total knee arthroplasty”. UptoDate. Feb 09, 2023