| Preoperative |
Acetaminophen: - 1000 mg orally in preoperative holding area followed by scheduled dosing every 6 hours
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Celecoxib: - 400 mg orally (patients ≤65 years of age and GFR >50 mL/minute)
- 200 mg orally (patients >65 years of age and GFR >50 mL/minute)
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Scopolamine transdermal patch (applied to skin behind ear): - 1 mg as needed for high risk PONV
- Use cautiously for patients >65 years of age and patients at risk of urinary retention
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Caffeine: - Consider 200 mg orally if the patient consumes caffeine >100 mg (1 to 2 cups of coffee or ≥3 caffeinated soft drinks) daily and has not consumed caffeine prior to surgery
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Optional peripheral nerve block: - Adductor canal block/saphenous nerve block (single injection preferred, catheter per patient/provider preference)
- Ropivacaine 0.2% to 0.5% or bupivacaine 0.25% 10 mL ± epinephrine 1:200,000
- Suggested sedation for block – midazolam 1 to 2 mg IV and fentanyl 50 to 100 mcg IV. Ketamine 10 to 20 mg IV may replace fentanyl.
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| IV fluid bolus – 500 to 1000 mL lactated ringers started in preoperative holding area |
| Intraoperative |
Anesthetic: - Spinal anesthesia plus sedation (preferred)
- Local anesthetic options*
- Chloroprocaine 50 mg (<1 hour surgery, <1.5 hour surgery plus prep time)
- Mepivacaine 50 to 80 mg (<2 hour surgery, <2.5 hour surgery plus prep time)
- Ropivacaine 12.5 to 15 mg (<2 hour surgery, <2.5 hour surgery plus prep time)
- Bupivacaine 8 to 10 mg (<2.5 hour surgery, <3 hour surgery plus prep time)
- Sedation
- Propofol infusion titrated to effect (preferred rate <100 mcg/kg/minute)
and/or - Dexmedetomidine – optional loading dose 1 mcg/kg IV over 10 minutes, followed by infusion 0.2 to 1 mcg/kg/hour IV until skin closure
- General anesthesia (spinal contraindicated)
- SGA plus TIVA with propofol infusion
- Dexamethasone 0.1 mg/kg up to 8 mg IV¶
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Periarticular injection (PAI): - Local anesthetic solution may contain ketorolac, epinephrine, opioid, glucocorticoid
- NOTE: Review total local anesthetic dose (PAI and nerve block) to avoid LAST
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| Tranexamic acid |
PONV prophylaxis: - Ondansetron 4 mg IV
- Dexamethasone 0.1 mg/kg up to 8 mg IV¶
- Haloperidol 1 mg IV or droperidol 0.625 mg IV for patients at high risk for PONV (eg, history of severe PONV, female and nonsmoker), or at discretion of anesthesiologist
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| Ketamine 10 to 40 mg IV in divided doses, reduce dose or eliminate for patients >75 years of age |
| Acetaminophen 1000 mg IV at end of surgery if no acetaminophen preoperatively (if weight <50 kg then 15 mg/kg IV up to 750 mg) |
| Opioid – At discretion of anesthesiologist, fentanyl preferred if block is placed |
| Post anesthesia recovery |
Acetaminophen: - 1000 mg orally or IV at least 6 hours after last dose (if weight <50 kg IV dose: 15 mg/kg up to 750 mg)
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Oral opioids – Use only one oral option at a time. Consider early use in patients with short acting spinal anesthetic. Options: - Oxycodone
- Patients ≤75 years of age – 5 to 10 mg orally every 4 hours as needed; 5 mg for pain rated 4 to 6/10; 10 mg for pain rated 7 to 10/10
- Patients >75 years of age and/or sensitive to opioids or sedatives – 2.5 to 5 mg orally every 4 hours as needed; 2.5 mg orally for pain rated 4 to 6/10; 5 mg for pain rated 7 to 10/10
- Hydromorphone (for patients with allergy or intolerance to oxycodone)
- Patients ≤75 years of age – 2 to 4 mg orally every 4 hours as needed; 2 mg for pain rated 4 to 6/10; 4 mg for pain rated 7 to 10/10
- Patients >75 years of age and/or sensitive to opioids or sedatives – 1 to 2 mg orally every 4 hours as needed; 1 mg orally for pain rated 4 to 6/10; 2 mg for pain rated 7 to 10/10
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Breakthrough IV analgesics options: - Ketamine
- 10 mg IV every 10 minutes for pain rated >4/10, maximum total dose 40 mg during perioperative period
- For patients >75 years of age, consider reducing dose to 5 mg IV every 10 minutes, maximum total dose 20 mg in the perioperative period
- Ketorolac 15 mg IV at the discretion of the anesthesiologist and surgeon (NOTE: PAI solution may contain ketorolac)
- Fentanyl 25 mcg IV every 2 minutes as needed for pain rated >4/10, up to maximum total dose 200 mcg
- Hydromorphone (for patients with allergy or intolerance to fentanyl) 0.2 mg IV every 5 minutes as needed for pain rated >4/10, up to maximum total dose 2 mg
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