MMC Orthopedic Guidelines & Protocols

Updated March 14, 2015   Author: C. Cary MD

Description: Anesthesia Guidelines for Joint Replacement surgery, and other orthopedic procedures at MMC


Anterolateral Total Hip Arthroplasty    (1-1.5 hrs)

  1. GA/ETT
    1. SAB only if
      1. patient request
      2. high risk for exacerbation of dementia
  2. Relaxant: Relaxation most needed when ‘trialing’ the femoral component- putting the ball back into the acetabulum.  This occurs at the end of the operation.
    1. Vecuronium 0.1 mg/Kg or
    2. Rocuronium 0.6 mg/Kg
  3. Tranexamic Acid (TXA) started after antibiotic infusion is complete.

Posterior Total Hip Arthroplasty         (1.5-2.0 hrs)

  1. GA/ETT
    1. SAB only if
      1. patient request
      2. high risk for exacerbation of dementia
  2. Relaxant: No relaxation needed so surgeon can interrogate sciatic nerve if necessary
    1. Succinylcholine 1.5 mg/Kg or
    2. ½ dose of non depolarizing NMB
  3. Tranexamic Acid (TXA) started after antibiotic infusion is complete.

Total Knee Arthroplasty         (1-1.5 hrs)

  1. TKR Clincal Pathway
  2. Adductor Canal Block pre-op
  3. LMA
  4. TXA after cementing 
  5. Dexamethasone 10 mg IV
  6. Ketamine 0.5 mg/Kg IV

Total Shoulder Arthroplasty   (1.5 h)

  1. GA/ETT
  2. Relaxant: Relaxation needed for glenoid. This occurs mid-procedure
  3. Postioning by surgeon
  4. Tranexamic Acid (TXA)

Antibiotics, Doses:

  1. Ancef 2 g; Ancef 3 g if > 120 Kg
    1. If Penicillin allergic (anaphylaxis/resp distress not simple rash)
      1. Clindamycin 900 mg IV over 20 min
      2. Gentamicin: Pharmacy will determine dose and prepare drug

Tranexamic Acid (TXA)

  1. 10 mg/Kg IV by infusion over 20'
  2. Inclusion criteria (Indications)
    1. Pre-op anemia  hgb<12
    2. Refusal of blood products
    3. Complex revision
    4. Total Knee Arthroplasty
    5. Total Hip Arthroplasty
  3. Exclusion Criteria (ContraIndications)
    1. Creatinine clearance <30cc/min (Link to Calculator)
    2. Hx venous thrombo-embolism
    3. Hx coagulation disorder
    4. Hx CVA/MI
    5. Hx coronary stent
  4. For References and more info, see theapms.com drug section