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.

Airway Assessment: Mallampati Class 2, 2 fingerbreadth mouth opening, hyomental

distance >6 cm, thyromental distance >6.5cm, no neck masses, no neck rigidity, no
limitations to cervical motion

Anicteric sclerae, pinkish conjunctiva, 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, blood loss of 500cc, 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 maintained on foley catheter 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. No signs of morphine toxicity (e.g. increased somnolence,
respiratory depression RR <10 cpm, chest wall rigidity, urinary retention, pruritus, pinpoint
pupils, constipation, hypotension, nausea/vomiting).

At the wards at 24 hours post-op, the patient was still GCS 15 with stable vital signs, still NRS
0/10, without subjective complains, and with unremarkable PE findings. No signs of
morphine toxicity (e.g. increased somnolence, respiratory depression RR <10 cpm, chest wall
rigidity, urinary retention, pruritus, pinpoint pupils, constipation, hypotension,
nausea/vomiting).

At 48 hours post-op, the patient was still GCS 15 with stable vital signs, still NRS 0/10,
without subjective complains, and with unremarkable PE findings, and still without signs of
morphine toxicity.

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 (e.g., peripheral nerve blocks, LA infiltration, continuous epidural
analgesia, neuraxial opioids), in addition to multimodal systemic analgesics.

A. 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.
In this case, spinal anesthesia was the technique chosen because of the post-operative goals
of the patient: analgesia, early mobilization and rehabilitation, and to minimize the use of
opioids; all of which are satisfied by spinal anesthesia. Furthermore, the benefits of spinal
anesthesia outweigh its risks, as listed in the table below.

Anesthesia Pros Cons

Regional Anesthesia - Profound analgesia (with - Risk for morphine
(spinal) use of intrathecal toxicity
morphine) - Limited duration
- Earlier mobilization - Possible conversion
- Appropriate for a unilateral to general
lower extremity surgery anesthesia
- Predictable - Reduced PONV
pharmacodynamics
- No contraindications for the
procedure (patient refusal,
infection, signs of increased
ICP, coagulopathy)
- Cost-effective
General Anesthesia - Patient comfort - Risk for airway
- Stable hemodynamics complications such
- Rapid onset and reliability as laryngospasm
and bronchospasm
- Risk of aspiration
- PONV
- Increased post-
operative narcotics
requirement

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.

B. Anesthetic agent
The agent used in this procedure was 20 mg hyperbaric bupivacaine (0.5%) with 0.2 mg of
epinephrine and 0.2 mg of morphine sulfate

B.1. Bupivacaine
Bupivacaine is a potent local anesthetic with unique characteristics from the amide group of
local anesthetics. Local anesthetics are used in regional anesthesia, epidural anesthesia,
spinal anesthesia, and local infiltration. Local anesthetics generally block the generation of
the action potential in nerve cells by increasing the threshold for electrical excitation.

At therapeutic levels, local anesthetics block voltage-gated Na-channels at the alpha subunit
inside the channel, preventing Na+ influx, preventing depolarization, and action potential
generation. They affect cardiac Na+-channels and neurons in the brain at toxic levels,
blocking K+, Ca2+, and NMDA receptors. Local anesthetics also interfere with cellular
processes, including oxidative phosphorylation, free fatty acid utilization, and cAMP
production. Toxic levels of local anesthetics on the heart lead to conduction irregularities,
impaired cardiac contractility, and the loss of vascular tone secondary to extreme
vasodilation.

Full dose of hyperbaric bupivacaine was used in this procedure due to the unpredictability of
the duration of the procedure. With its hyperbaric property, the local anesthetic is denser
than CSF and will flow with gravity to the dependent areas of the spine. Lateralization was
done for 3-5 minutes to concentrate the anesthetic on the surgical side (right knee).

B.2. Epinephrine
Reported benefits of epinephrine include prolongation of local anesthetic block, increased
intensity of block, and decreased systemic absorption of local anesthetic. Epinephrine’s
vasoconstrictive effects augment local anesthetics by antagonizing inherent vasodilating
effects of local anesthetics, decreasing systemic absorption and intraneural clearance, and
perhaps by redistributing intraneural local anesthetic.

B.3 Intrathecal Morphine

Opioids have multiple central and peripheral mechanisms of analgesic action. Spinal
administration of opioids provides analgesia primarily by attenuating C-fiber nociception and
is independent of supraspinal mechanisms. Coadministration of opioids with central
neuraxial local anesthetics results in synergistic analgesia.

In reference to the WHO analgesic ladder, the post-op pain of this surgery is classified under
severe pain (due to bone pain) and warrants the use of potent opioids such as morphine.
And its use satisfies our post-op goals: to provide excellent analgesia, early mobilization and
rehabilitation, and to minimize the use of opioids.

In a study by Kukreja et al (2023), there is strong evidence that intrathecal morphine

provided effective analgesia after lower extremity arthroplasty. Their study concludes that
intrathecal morphine of 150 mcg for total knee arthroplasty under spinal anesthesia
provided improved postoperative analgesia with reduced opioid consumption.
Intrathecal morphine can provide prolonged (12 to 24 hours) postoperative analgesia but
side effects, including itching and nausea and vomiting, are common and challenging to
treat. Rarely, intrathecal morphine can produce delayed respiratory depression.

Morphine toxicity should be monitored post-op, and precautions should be taken.

Symptoms of morphine toxicity include the following: increased somnolence, respiratory
depression (respiratory rate <10 cpm), chest wall rigidity, urinary retention, pruritus,
pinpoint pupils, constipation, hypotension, nausea/vomiting).

In the event of adverse effects of morphine, the following treatments may be done:
SIDE EFFECT TREATMENT
Pruritus Apply lotion to the affected area; intravenous or oral delivery of
diphenhydramine (25-50 mg); in severe cases, use an opioid
antagonist (i.e. naloxone) or agonist-antagonist (i.e. nalbuphine, 5
mg every 6 hours
Constipation Use of over the counter laxatives for mild to moderate cases; use
of methylnaltrexone for severe constipation: 12 mg SC qDay or
450mg PO qDay in morning
Nausea/vomiting Decrease opioid dose. Consider nalbuphine, clonidine, and
antiemetics, such as ondansetron 4mg intravenously
Urinary retention Urinary Foley catheter or nalbuphine
Sedation/ Stop opioid temporarily and use naloxone (0.4 mg IV) or
respiratory nalbuphine
depression

C. Analgesia
The WHO analgesic ladder specifies treatment on pain intensity, from simple analgesics for
mild pain to opioid analgesics for moderate and severe pain. Its three steps are:
 Step 1 Non-opioid plus optional adjuvant analgesics for mild pain;
 Step 2 Weak opioid plus non-opioid and adjuvant analgesics for mild to moderate pain;
 Step 3 Strong opioid plus non-opioid and adjuvant analgesics for moderate to severe
pain.
It is advised to move up one step when there is persistent pain. In case of toxicity or severe
adverse effects, providers are advised to either reduce medication doses or move down one
step. The ladder provides five simple recommendations for the usage of analgesics: by
mouth, by clock, by ladder, by individual and attention to the detail. Just two years following
its release, it was already validated in 80–90% of cases.

The stepwise approach had tremendous value when it was introduced for its conservative
and simple principles for pain management, which could be applied everywhere in the
world, even in those underdeveloped countries with fewer pain management specialists. It
has been of significant benefit for the control of pain worldwide. Until now, this guideline
has remained applicable, not only in cancer pain management but also for acute pain and
chronic pain requiring analgesics.

With reference to the WHO Analgesic ladder, my multi-modal post-op pain regimen is
structured as follows:
NSAIDs 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,
(patient is with normal creatinine levels)
Non-opioids 3) Paracetamol 1g IV every 8 hours for 3 doses
Mild opioid (PRN) 4) Tramadol 50 mg slow IV every 6 hours as needed for
breakthrough pain
Strong opioid Intrathecal morphine (as discussed above)
Anti-emetic *5) Ondansetron 4 mg slow IV every 8 hours as needed for nausea
or vomiting.
*Anti-emetic for the side effects of morphine (as discussed above)

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 would therefore result to reduced side effects and complications.

C.1. Peripheral Nerve Blocks for TKA

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.

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
3. Kukreja P, Streetzel C, Short RT, Mabry SE, Feinstein J, Brazeel K, Cerice D, Chapman L,
Kalagara H. Intrathecal Morphine Use Improves Postoperative Analgesia and Reduces
Opioid Consumption in Patients Undergoing Total Knee Arthroplasty Under Spinal
Anesthesia: A Retrospective Study. Cureus. 2023 Aug 6;15(8):e43039. doi:
10.7759/cureus.43039. PMID: 37674945; PMCID: PMC10479995.
 4. Anekar AA, Hendrix JM, Cascella M. WHO Analgesic Ladder. [Updated 2023 Apr 23]. In:
StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2023 Jan-. Available
from: https://www.ncbi.nlm.nih.gov/books/NBK554435/

Ricky G. Jaleco
Level 2 Resident

Western Visayas Medical Center

Department of Anesthesiology

CASE BASED DISCUSSION #2

I. General Data
Patient’s Name: C.N.
Age: 46 y.o.
Sex: F
Civil Status: Married
Birthday: 01/12/1977
Nationality: Filipino
Religion: Roman Catholic
Address: Igpuro, Miagao, Iloilo

II. Chief Complaint

Hypogastric pain

III. History of Present Illness

4 years PTA, patient was diagnosed with Adenomyosis with Adenomyoma & Endometriotic
cyst, left ovary. Patient was advised for surgical management but was lost to follow-up due
to financial constraints.

1 month PTA, patient experienced sudden onset, sharp hypogastric pain rated 9/10 with
radiation to the lower back. Pain was associated with vaginal bleeding, consuming 4-5 pads a
day (fully soaked).

1 day PTA, the patient’s symptoms persisted and consult was done at the OPD. Work-up was
done and patient was advised for surgical intervention, thus admission.

IV. Past Medical History

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
130/90, HR 71, RR 20, SpO2 99%. She weighs around 60 kilograms, stands 5’3”, with a BMI of
23.4 kg/m2 and is classified as normal.

Airway Assessment: Mallampati Class 2, 2 fingerbreadth mouth opening, hyomental

distance >6 cm, thyromental distance >6.5cm, no neck masses, no neck rigidity, no
limitations to cervical motion

Anicteric sclerae, pinkish conjunctiva, symmetrical chest expansion, clear breath sounds,
adynamic precordium normal cardiac rate with regular rhythm, no note of murmurs, (+) with
note of a palpable mass upto the level of the umbilicus, full peripheral pulses. No
sensorimotor deficits noted.

VII. Admitting Diagnosis

G0 Myoma Uteri, Adenomyosis, Endometriosis, Left

VIII. Laboratory Results

CBC 11.7/0.39/4.9/209
S.Na 135.2/K 4.08/Crea 72.76
PT 13.8/94%/1.04
CXR Cardiomeg
ECG SR NSSTWC

UTZ
Enlarged retroverted uterine corpus, thin endometrium,
Adenomyosis with adenomyoma (posterior wall mass 5.4 x 4.8 x 5.7cm; intramural myoma
3.1 x 3.2 x 2.9 cm)
Uterine myomata, unremarkable cervix, Normal size right ovary with follicles
Ovarian endometrioma, left (8.1 x 4.6 x 4.7 cm)

IX. Anesthesia Pre-operative Assessment

The patient was classified as ASA 1 with a Mallampati classification of 2. She was stratified by
the Department of Internal Medicine as Low 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 (3 units of whole blood).
X. Proposed Procedure
Total Abdominal Hysterectomy with Bilateral Salpingooophorectomy, Adhesiolysis

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 150/90, HR 66, 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 700cc of warm lactated Ringer’s solution, and the patient
was placed on left lateral decubitus position; asepsis and antisepsis, and draping followed.
Lumbar puncture was done on the L3-L4 interspace using a Gauge 26 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 then placed back into supine
position. The level of anesthesia was assessed and reached a dermatomal level of T4,
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. There was
note of one episode of hypotension due to the subarachnoid block but responded to
Ephedrine 5 mg IV and continuous hydration with lactated Ringer’s solution.

Upon cutting, the patient was stable with vital signs of BP 110/60, HR 70, 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 around 1 hour from cutting time, the Department of Surgery was called for intraoperative
adhesiolysis. Patient was stable with vital signs of BP 110/70, HR 60, RR 20, SpO2 100%, and
about 1 liter of lactated Ringer’s solution was transfused.

At 1 hour and 45 minutes from cutting time, blood loss was noted to be around 300 cc,
which was 30% from the computed allowable blood loss of 1017 cc. Thus, blood transfusion
with 1 unit of whole blood was started. Patient was stable with vital signs of BP 110/60, HR
60, RR 20, SpO2 100%

At around 3 hours from cutting time, 1 dose of Ketorolac 30 mg IV was given with note of a
negative skin test.
 At 4 hours from cutting time, the specimen (myoma) was released. During this time a total of
2 units of blood was transfused, with the third unit ongoing. Calcium gluconate 1g slow IV
was intraoperatively given to counteract possible hypocalcemia secondary to the citrate
preservative in blood products. Citrate chelates (binds) to the patient's endogenous calcium
when blood products are administered, rendering calcium inactive.

At around 15 minutes before the end of the procedure, Paracetamol 1g IV & Ondansetron 4
mg slow IV was given prior to closing. Overall the intraoperative course was unremarkable
with the operation lasting for approximately 5 hours. A total of 2.2 L of crystalloids was
transfused, with ongoing blood transfusion (3 rd unit), blood loss was around 2.5 L, urine
output was noted to be around 1 cc/kg/hr. The patient’s vital signs were BP 100/60, HR 60,
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 600 mg IV every 6 hours for 3 more doses, 4) Tramadol 50 mg
slow IV every 6 hours as needed for breakthrough pain, 5) Ondansetron 4 mg slow IV every 8
hours for 2 more doses then as needed for nausea or vomiting, 6) Omeprazole 40 mg IV OD
while on NPO. 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 100/60, HR 60, RR 20, SpO2 100%
with O2 at 2 lpm via nasal cannula, and maintained on foley catheter with adequate urine
output.

At around 4 hours post-op, the patient was still with stable vital signs with an NRS of 0/10
and was then transferred back to wards. No signs of morphine toxicity (e.g. increased
somnolence, respiratory depression RR <10 cpm, chest wall rigidity, urinary retention,
pruritus, pinpoint pupils, constipation, hypotension, nausea/vomiting).

At the wards at 24 hours post-op, the patient was still GCS 15 with stable vital signs, still NRS
0/10, without subjective complains, and with unremarkable PE findings. No signs of
morphine toxicity (e.g. increased somnolence, respiratory depression RR <10 cpm, chest wall
rigidity, urinary retention, pruritus, pinpoint pupils, constipation, hypotension,
nausea/vomiting).
 At 48 hours post-op, the patient was still GCS 15 with stable vital signs, still NRS 0/10,
without subjective complains, and with unremarkable PE findings, and still without signs of
morphine toxicity.

XIV. Discussion
A hysterectomy is a surgery to remove a person’s uterus. After a hysterectomy is performed,
the patient will no longer have menstrual periods and cannot become pregnant. Given the
invasiveness and permanence of the surgery, it is highly unlikely that a clinician would
perform a hysterectomy for a nonmedical reason. Despite the fact that many conditions
solved by hysterectomy could be handled with other medical treatments, hysterectomies are
very common; one in three women in the United States has had one by age 60. Because of
the widespread nature of hysterectomy, it is the anesthesia provider’s job to be
knowledgeable about the uses and types of hysterectomy, associated complications and
research in anesthesia for hysterectomy.

Hysterectomy can serve as a treatment for many conditions and has several forms. A patient
may undergo a hysterectomy for a variety of reasons, including uterine fibroids that cause
pain, bleeding or other problems; uterine prolapse, which is a sliding of the uterus into the
vaginal canal; cancer of the uterus, cervix or ovaries; endometriosis, in which uterine tissue
grows in other places of the body; abnormal vaginal bleeding; adenomyosis, or a thickening
of the uterus; or chronic pelvic pain.

Depending on the patient’s condition, a clinician may choose to remove all or only part of
the uterus. There are five types of hysterectomy:
 subtotal or partial hysterectomy, in which the uterus is removed but the cervix is left
in place;
 total hysterectomy, in which the uterus and cervix are removed;
 hysterectomy and bilateral salpingo-oophorectomy, in which the uterus, fallopian
tubes and ovaries are removed;
 hysterectomy with prophylactic bilateral salpingectomy, in which the uterus and
fallopian tubes are removed;
 and radical hysterectomy, in which the uterus, fallopian tubes, ovaries, upper part of
the vagina, pelvic ligaments and lymph nodes are removed.

For different types of surgery, the clinician may consider a traditional abdominal
hysterectomy or a minimally invasive procedure, which entails vaginal incision or
laparoscopy (i.e., a small incision in the abdomen).
Figure 1. Hysterectomy Management by NYSORA

A. Choice of anesthetic technique

TAHBSO may be performed with general or neuraxial anesthesia. The choice of anesthetic
technique should be based on patient comorbidities and patient choice

In this case, spinal anesthesia was the technique chosen. Because of the unavailability of
epidural sets during this period. I opted to perform spinal anesthesia with possible
conversion to general anesthesia. The patient was apprised of the anesthetic plan with
possible conversion to general anesthesia due to the unpredictability of the OR duration.

The benefits of spinal anesthesia (post-op analgesia) outweigh its risks, as listed in the table
below.

Anesthesia Pros Cons

Regional Anesthesia - Profound analgesia (with - Risk for morphine
(spinal) use of intrathecal toxicity
morphine) - Limited duration
- Predictable - Possible conversion
pharmacodynamics to general
- No contraindications for the anesthesia
procedure (patient refusal, - Reduced PONV
infection, signs of increased - At risk for high
ICP, coagulopathy) spinal anesthesia
- Cost-effective due to distended
abdomen
 Epidural Anesthesia - Superior analgesia (with - Risk for morphine
(ruled out due to epidural morphine post-op) toxicity
unavailability of - Predictable - Reduced PONV
epidural sets) pharmacodynamics
- No contraindications for the
procedure (patient refusal,
infection, signs of increased
ICP, coagulopathy)

General Anesthesia - Patient comfort - Risk for airway

- Stable hemodynamics complications such
- Rapid onset and reliability as laryngospasm
- Muscle relaxation and and bronchospasm
controlled ventilation - Risk of aspiration
- PONV
- Increased post-
operative narcotics
requirement

A study conducted by Ciobotaru (2016) compared the post operative pain of Total abdominal
hysterectomy and bilateral salpingo-oophorectomy (TAHBSO) patients under spinal
anesthesia without intrathecal opioids vs general anesthesia. Their findings indicated that
the patients who received general anaesthesia with endotracheal intubation developed
severe postoperative pain more frequently than those who underwent spinal anaesthesia
(P = 0.018).

A.1. Anesthetic Considerations – High Spinal Anesthesia

A uterine mass expands the uterus and displaces the stomach cephalad, resulting in
incompetence of the lower gastroesophageal sphincter (GES) and increased intragastric
pressure. It is known that an increase in intra-abdominal pressure (IAP) causes a decrease in
the volume of cerebrospinal fluid in the lumbar and lower thoracic region, which may
contribute to a greater cephalad spread of spinal anesthesia and development of a high
spinal block.

Measures to avoid a high block were taken in this case namely: site of injection, slower rate
of injection, positioning and baricity, local anesthetic dose, and patient variables.
Hypotension and bradycardia was anticipated thus, emergency medications were on standby
such as atropine and vasopressors (ephedrine & phenylephrine).
 Table 1. Vasopressors: Phenylephrine vs Ephedrine

B. Anesthetic agent
The agent used in this procedure was 20 mg hyperbaric bupivacaine (0.5%) with 0.2 mg of
epinephrine and 0.2 mg of morphine sulfate

B.1. Bupivacaine
Bupivacaine is a potent local anesthetic with unique characteristics from the amide group of
local anesthetics. Local anesthetics are used in regional anesthesia, epidural anesthesia,
spinal anesthesia, and local infiltration. Local anesthetics generally block the generation of
the action potential in nerve cells by increasing the threshold for electrical excitation.

At therapeutic levels, local anesthetics block voltage-gated Na-channels at the alpha subunit
inside the channel, preventing Na+ influx, preventing depolarization, and action potential
generation. They affect cardiac Na+-channels and neurons in the brain at toxic levels,
blocking K+, Ca2+, and NMDA receptors. Local anesthetics also interfere with cellular
processes, including oxidative phosphorylation, free fatty acid utilization, and cAMP
production. Toxic levels of local anesthetics on the heart lead to conduction irregularities,
impaired cardiac contractility, and the loss of vascular tone secondary to extreme
vasodilation.

Full dose of hyperbaric bupivacaine was used in this procedure due to the unpredictability of
the duration of the procedure, with a steady rate of injection due to the increased risk of
high spinal anesthesia.

B.2. Epinephrine
Reported benefits of epinephrine include prolongation of local anesthetic block, increased
intensity of block, and decreased systemic absorption of local anesthetic. Epinephrine’s
vasoconstrictive effects augment local anesthetics by antagonizing inherent vasodilating
effects of local anesthetics, decreasing systemic absorption and intraneural clearance, and
perhaps by redistributing intraneural local anesthetic.
B.3 Intrathecal Morphine
Opioids have multiple central and peripheral mechanisms of analgesic action. Spinal
administration of opioids provides analgesia primarily by attenuating C-fiber nociception and
is independent of supraspinal mechanisms. Coadministration of opioids with central
neuraxial local anesthetics results in synergistic analgesia.

In reference to the WHO analgesic ladder, the post-op pain of this surgery is classified under
moderate to severe pain and warrants the use of potent opioids such as morphine.

Intrathecal morphine can provide prolonged (12 to 24 hours) postoperative analgesia but
side effects, including itching and nausea and vomiting, are common and challenging to
treat. Rarely, intrathecal morphine can produce delayed respiratory depression.

Morphine toxicity should be monitored post-op, and precautions should be taken.

Symptoms of morphine toxicity include the following: increased somnolence, respiratory
depression (respiratory rate <10 cpm), chest wall rigidity, urinary retention, pruritus,
pinpoint pupils, constipation, hypotension, nausea/vomiting).

In the event of adverse effects of morphine, the following treatments may be done:
SIDE EFFECT TREATMENT
Pruritus Apply lotion to the affected area; intravenous or oral delivery of
diphenhydramine (25-50 mg); in severe cases, use an opioid
antagonist (i.e. naloxone) or agonist-antagonist (i.e. nalbuphine, 5
mg every 6 hours
Constipation Use of over the counter laxatives for mild to moderate cases; use
of methylnaltrexone for severe constipation: 12 mg SC qDay or
450mg PO qDay in morning
Nausea/vomiting Decrease opioid dose. Consider nalbuphine, clonidine, and
antiemetics, such as ondansetron 4mg intravenously
Urinary retention Urinary Foley catheter or nalbuphine
Sedation/ Stop opioid temporarily and use naloxone (0.4 mg IV) or
respiratory nalbuphine
depression

C. Analgesia
The WHO analgesic ladder specifies treatment on pain intensity, from simple analgesics for
mild pain to opioid analgesics for moderate and severe pain. Its three steps are:
 Step 1 Non-opioid plus optional adjuvant analgesics for mild pain;
 Step 2 Weak opioid plus non-opioid and adjuvant analgesics for mild to moderate pain;
  Step 3 Strong opioid plus non-opioid and adjuvant analgesics for moderate to severe
pain.
It is advised to move up one step when there is persistent pain. In case of toxicity or severe
adverse effects, providers are advised to either reduce medication doses or move down one
step. The ladder provides five simple recommendations for the usage of analgesics: by
mouth, by clock, by ladder, by individual and attention to the detail. Just two years following
its release, it was already validated in 80–90% of cases.

The stepwise approach had tremendous value when it was introduced for its conservative
and simple principles for pain management, which could be applied everywhere in the
world, even in those underdeveloped countries with fewer pain management specialists. It
has been of significant benefit for the control of pain worldwide. Until now, this guideline
has remained applicable, not only in cancer pain management but also for acute pain and
chronic pain requiring analgesics.

Total abdominal hysterectomy and bilateral salpingo-oophorectomy is frequently associated

with severe or postoperative pain, thus intrathecal opioids is warranted. With reference to
the WHO Analgesic ladder, my multi-modal post-op pain regimen is structured as follows:
NSAIDs 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,
(patient is with normal creatinine levels)
Non-opioids 3) Paracetamol 600 mg IV every 6 hours for 3 more doses
Mild opioid (PRN) 4) Tramadol 50 mg slow IV every 6 hours as needed for
breakthrough pain
Strong opioid Intrathecal morphine (as discussed above)
Anti-emetic *5) Ondansetron 4 mg slow IV every 8 hours as needed for nausea
or vomiting.
 PPI Omeprazole 40 mg IV OD while on NPO
*Anti-emetic for the side effects of morphine (as discussed above)
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 would therefore result to reduced side effects and complications.

XV. References
1. Barash, P., et al. (2017) Clinical Anesthesia, 8th edition
2. Nysora, Hysterectomy. Accessed at: https://www.nysora.com/anesthesia/hysterectomy/
3. Ciobotaru et al. (2016). Postoperative pain after total abdominal hysterectomy and
bilateral salpingo-oophorectomy depending on the type of anaesthesia administration.
Biotechnology & Biotechnological Equipment vol 30, 2016, issue 2. Accessed at:
https://www.tandfonline.com/doi/full/10.1080/13102818.2015.1135759
4. Anekar AA, Hendrix JM, Cascella M. WHO Analgesic Ladder. [Updated 2023 Apr 23]. In:
StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2023 Jan-. Available
from: https://www.ncbi.nlm.nih.gov/books/NBK554435/