Please find below information for my routine peri-operative management preferences. There is option to vary on a case-by-case basis. This information is intended only for clinicians working with me, caring for our patients (anaesthetists, medical staff, nursing staff).
I want you to deliver the anaesthetic type you feel is appropriate for the individual patient in front of you. I have some preferences regarding blocks and peri-operative medications below that unless you feel strongly against them I would appreciate you working with to help standardise care.
These are hopefully fairly standard, with possibility to vary on case-by-case basis Spinal for joints: Opioid free spinal 0.5% bupivicaine (low volume if possible eg 2-2.5mL - can discuss) No IDC routinely, exceptions: Significant frailty Significant LUTS/prev post op retention episode PVR >500mL at 6h and no void Local anaesthetic for joints: 150mL of 0.2% ropivicaine with 500 mcg adrenaline for knees and hips 100mL if <60kg Hip: THR: Spinal +/- GA/sedation + no block + local Knee: No tourniquet will be used/applied for TKR/UKR TKR/UKR: Spinal +/- GA/sedation + SS ACB pre-op + local ACL, MPFL, Osteotomies: GA + SS ACB pre op + local Meniscus, other knee scope: GA, no block, local Foot and Ankle: Local + surgeon-performed ankle block as a general rule Shoulder: TSR, cuff, labrum, latarjet, biceps tenodesis: GA + ISB Day cases: GA + LA Elbow: GA + Local generally Wrist: GA + Local generally Hand/fingers: WALANT (wide awake, Local anaesthetic, no TQ) as mainstay GA + local if complex/patient preference/anxiety etc
Antiplatelets: Aspirin: continue Clopidogrel, ticagrelor: withhold with cardiologist approval for 7 days pre-op If combined medication encourage aspirin to continue as solo treatment Anticoagulants: Withhold with cardiologist approval Aapixaban, rivaroxaban, edoxaban: Fairly normal kidneys: no dose for 2 days prior to surgery (last dose is 3rd day pre-op) E.g. Monday operation; last dose is Friday CrCl <30: no dose for 4 days prior to surgery (last dose is 5th day pre-op) E.g. Monday operation; last dose is Wednesday Dabigatran: Very normal kidneys: no dose for 2 days prior to surgery (last dose is 3rd day pre-op) E.g. Monday operation; last dose is Friday CrCl <50: no dose for 4 days prior to surgery (last dose is 5th day pre-op) E.g. Monday operation; last dose is Wednesday Note this is more sensitive to renal impairment than the other NOACs Warfarin: Withhold for 5 days prior to surgery, last dose 6th day pre-op Aim INR <1.5 on day of surgery Bridging therapy Rarely required For warfarin patients only Consider in below situations: Patients with mechanical heart valves, particularly mitral valve prostheses or older aortic valve prostheses. Patients with atrial fibrillation who have a CHA₂DS₂-VASc score of 5+ Patients with a recent (<3m) history of venous thromboembolism Patients with severe thrombophilia, such as antiphospholipid syndrome, homozygous Factor V Leiden, or multiple thrombophilic conditions. Bridging regime: 1.5mg/kg once daily clexane when INR falls below that patients therapeutic target (1mg/kg BD an alternative but less convenient) Stopped 24h pre-op - none the day prior to surgery Resumed 48-72h post op if no bleeding Bridging is for warfarin only and is not recommended for NOACs due to shorter half-lives - American College of Chest Physicians
Manage in accordance with the latest ACR/AAHKS guidelines 2022 guidelines, published every 5y Continue DMARDs Methotrexate Sulfasalazine Hydroxychloroquine Leflunomide (Arava) Doxycycline Apremilast (Otezla) Withhold: Biologics: Infliximab (Remicade) Adalimumab (Humira) Etanercept (Enbrel) Golimumab (Simponi) Abatacept (Orencia) Certolizumab (Cimzia) Rituximab (Rituxan) Tocilizumab (Actemra) Anakinra (Kineret) IL-17 secukinumab (Cosentyx) Ustekinumab (Stelara) Ixekizumab (Taltz) IL-23 guselkumab (Tremfya) JAK inhibitors: Tofacitinib (Xeljanz) Baricitinib (Olumiant)§ Upadacitinib (Rinvoq)§ SLE medications: Withheld in non-severe SLE, continued in severe SLE or in discussion with patient if flares are difficult to manage Mycophenolate mofetil Azathioprine Cyclosporine Tacrolimus Rituximab (Rituxan) Belimumab SC (Benlysta) Belimumab IV (Benlysta) Anifrolumab (Saphnelo) Voclosporin (Lupkynis) Definition of severe SLE: currently treated (induction or maintenance) for severe organ manifestations: lupus nephritis, CNS lupus, severe hemolytic anemia (hemoglobin <9.9 gm/dl), platelets <50,000, vasculitis (other than mild cutaneous vasculitis), including pulmonary hemorrhage, myocarditis, lupus pneumonitis, severe myositis (with muscle weakness, not just high enzymes), lupus enteritis (vasculitis), lupus pancreatitis, cholecystitis, lupus hepatitis, protein-losing enteropathy, malabsorption, orbital inflammation/myositis, severe keratitis, posterior severe uveitis/retinal vasculitis, severe scleritis, optic neuritis, anterior ischemic optic neuropathy (derived from the SELENA-SLEDAI flare index and the BILAG 2004 index) Recommencement: For patients with rheumatoid arthritis, ankylosing spondylitis, psoriatic arthritis, or all SLE for whom antirheumatic therapy was withheld prior to undergoing total joint arthroplasty, antirheumatic therapy should be restarted once the wound shows evidence of healing, any sutures/staples are out, there is no significant swelling, erythema, or drainage, and there is no ongoing nonsurgical site infection, which is typically ~ 14 days.
Wean/discontinue as able in discussion with patient and rheumatologist Stress steroid dosing if steroid continued through to surgery if: Dose is Pred >5mg, Hydrocort >20mg, Dex > 0.75mg, AND 3 weeks+ duration, AND Taken in the last 3 months Stress-dose regimen can be individualised, but is typically: 100mg IV hydrocortisone on induction 50mg IV hydrocortisone q8h for 24h Resume usual oral maintenance following day
Cease 4 weeks prior to surgery Requires consultation with patient and if symptoms and personal situation allows Includes: Tamoxifen OCP HRT
Natural Remedies: Cease all 1 week prior to surgery, recommence post op
Continue, consider switching to COX-selective (celecoxib) if non-selective
All to be withheld for 4 days pre-operatively Eg. Op day Monday; Last dose Wednesday Examples: Invokana (Canagliflozin) Forxiga (Dapagliflozin) Jardiance (Empagliflozin) Steglatro (Ertugliflozin) Xigduo XR (Dapagliflozin + Metformin) Jardiamet (Empagliflozin + Metformin) Glyxambi (Empagliflozin + Linagliptin) Steglujan (Ertugliflozin + Sitagliptin)
Management: Clear fluid diet for 24 hours pre-op 6 hours normal fasting 2 hours nil by mouth pre-op Medication not discontinued pre-op Clear fluid diet may include: Water Apple juice Black tea or black coffee Clear soft drinks (eg lemonade) Peri-op carbohydrate rich drinks Jelly Icy poles Clear cordial (eg lemon) Electrolyte "sports" drinks Clear broths or clear miso soup (without any solids such as seaweed or tofu) Not ok: Drinks containing milk Yoghurt drinks Ice cream Cloudy fruit juices (eg prune juice) Fruit juices containing pulp (eg orange juice) Alcohol Soluble fibre (eg Benefiber, Metamucil) Examples: Wegovy (semaglutide) Saxenda (liraglutide) Mounjaro (tirzepatide) Ozempic (semaglutide) Victoza (liraglutide) Trulicity (Dulaglutide) Victoza (Liraglutide) Byetta (Exenatide) Bydureon (Exenatide MR) Elective preprocedural cessation of GLP-1RAs and GLP-1/GIPRAs is not recommended, and risks hyperglycaemia in people with diabetes or may compromise weight control Patients should be asked about the use of other medications and medical conditions which may exacerbate gastrointestinal symptoms and delay gastric emptying, such as bowel dysmotility, gastroparesis, and Parkinson’s disease. Preprocedural diet modification with 24-hour clear fluid diet, followed by standard 6-hour fasting, should be recommended for all patients receiving GLP-1 RAs and GLP-1/GIPRAs.
Paracetamol 1330mg PO Celecoxib 400mg PO
For all arthroplasty cases I wish to use an intermediate dosing regime Standard patient: 0.3mg/kg IV (based on actual weight) after spinal Typically 16-24mg IV High pain responders: 1mg/kg IV after spinal Catastrophisers Pre-op opiate use Chronic/complex pain issues Exclusions to above: Insulin-dependent diabetic Anti-psychotic treatment or history of bipolar/schizophrenia Pregnant/breast-feeding (hopefully not having elective surgery..) If you’d like more information on this regime let me know and I can send some research papers specifically looking at dosing regimes
150mL of 0.2% ropivicaine with 500 mcg adrenaline for lower limb arthroplasty 100mL if <60kg
Indications: all procedures that bleed! Joints, ACL, shoulders Absolute contra-indications: Active intravascular thrombosis: acute DVT/PE, stroke, AMI TXA hypersensitivity or allergy Relative contraindications (individualise risk-benefit): Recent VTE (<6m) Recurrent VTE in past Thrombophilia (APLS, homozygous FV Leiden) Mechanical valve (esp mitral) Recent ischaemic stroke or AMI <6m ago Seizure disorder, previous peri-op seizures eGFR<30 Acquired colour blindness NOT a contraindication: Prev VTE >12m ago Age Obesity Cancer history with no active thrombosis Bilateral TKR Dosing and route: All patients - 1g IV as soon as possible after entering theatre None post-operatively
All procedures involving implantation of any implant, hardware or anchor, without allergies: cefazolin Not required in meniscectomy (yes for meniscus repair), carpal tunnel, removal of metal, trigger finger, morton’s neuroma etc. Timing: As soon as possible, with TXA, after IV access obtained Well before knife to skin Can be given up to 60min pre-op Dose: <120kg: 2g >120kg: 3g Re-dose intra-op: Surgery >3h Blood loss >1.5L Sensitivities: Mild rash, Gl upset, vague childhood history: GIVE Anaphylaxis, angioedema, bronchospasm, Stevens-Johnson: AVOID cefazolin and all beta-lactams Vancomycin is VICNISS recommended antibiotic Vancomycin: Indications: Severe penicillin allergy (instead of cef) Known MRSA patient (added to cef) Revision arthroplasty (added to cef) 15mg/kg IV Max 2g Infuse over 60-120min depending on dose - start early This requires early identification and planning No repeat intra-op dosing required Check local hospital guideline for infusion duration Infusion needs to be finished 15min prior to incision Can be given up to 2h before surgery Identify patients early, do not place first on list Clindamycin is a less-preferred option for cef replacement due to allergy in arthroplasty 600mg IV or 900mg if >120kg Rising rates of skin staph with clindamycin resistance Higher rates of C. Diff Use Vancomycin in preference
Risk stratify (see options below) Low Risk: Aspirin PO 100mg daily 8pm day of surgery for 28 days for all joints, AND Mechanical device: calf pumps, stockings, unless contraindicated High Risk: NOAC and mechanical device Duration: as per PBS THR: 35 days TKR: 14 days Dosing: Rivaroxaban (preferred): 10mg daily PO Apixaban: 2.5mg BD PO Dabigatran (not preferred): 110mg PO day 0, 220mg daily thereafter PBS Authority codes (rivaroxaban): 4132: History of VTE (prevention with prior Hx), 10mg, 30 tabs, up to 5 rpts 4402: THR Prevention of VTE, 10mg, 15 tabs, 1 rpt 4382: TKR prevention of VTE, 10mg, 15 tabs, no rpts Timing: Day 0 at 8pm if the case is complete before 4pm Otherwise next morning Pre-existing anti-coagulants: 5 days of prophylactic dosing regime of the same NOAC post-op (starting nocte day 0 except for last case of the day - mane day 1), then back to usual therapeutic dose on morning of day 5 post-op Individualise according to thrombosis risk (valves) or CHADSVASC for AF - earlier therapeutic recommencement may be required in some cases Examples below: Apixaban: 2.5mg BD (prophylactic) -> 5mg daily (therapeutic) Rivaroxaban: 10mg daily (prophylactic) -> 15 or 20mg daily (therapeutic) Dabigatran: 110mg first night, then 220mg daily (prophylactic) -> 150mg BD (therapeutic) Edoxaban: 30mg daily (prophylactic) -> 60mg daily (therapeutic) Pre-existing anti-platelets: Aspirin only, low risk: no change to medications Aspirin only, high risk: continue aspirin, add NOAC prophylaxis as per high risk above Ticagrelor/clopidogrel: withhold 7d pre-operatively, recommence on morning of day 5 post-op Risk stratification between high risk (NOAC) and low risk (aspirin + stockings/SCD): Can use the CEC NSW guidelines, local hospital guidelines (adapted from CEC) or the Arthroplasty Society of Australia guidelines (most prescriptive) Arthroplasty society criteria for high risk (non aspirin) VTE prophylaxis: Major Criteria (one or more) Hypercoagulability conditions * Metastatic cancer Stroke (occlusion or stenosis with infarction) Chronic Obstructive Pulmonary Disease (COPD) Sepsis Minor Criteria (three or more) Immobility ** History of VTE (PE and proximal DVT) Tamoxifen and oestrogen therapy *** Medical comorbidities; Charlston index≥ 3, cardiac failure, advanced renal impairment Lymphoma, myeloproliferative disorder Obesity, BMI > 30 Severe weight loss Acute MI Knee replacement (greater risk than THR) * Hypercoagulability conditions (protein C and protein S deficiency, antiphospholipid antibodies, antithrombin deficiency, factor V Leiden, acquired or congenital thrombophilias, prothrombin mutation 20210A, SLE inhibitor) **Immobility: institutionalized patients, prolonged bed rest, severe pain, ileus, fracture. Age >80 is controversial: HR of 1.7 in USA and 0.89 in Denmark. Consider frail elderly as a risk. ***Tamoxifen and ostrogen therapy, recommend cease ostrogen OCP and HRT 4 weeks pre op CEC NSW guidelines/Safer Care Vic list of risk factors list to consider: Age > 60 years Obesity (BMI > 30kg/m3) Prior history of VTE Known thrombophilia (including inherited disorders) Active malignancy or cancer treatment Myeloproliferative neoplasms Acute myocardial infarction Congestive heart failure Active or chronic lung disease Active infection Active rheumatic disease Acute inflammatory bowel disease Hormonal replacement therapy (discontinue if able) Oestrogen-based contraceptives (discontinue if able) Nephrotic syndrome Varicose veins/chronic venous stasis Significantly reduced mobility relative to normal state Pregnant or < 6 weeks post-partum Sickle cell disease
None post-operatively for any cases unless the procedure is performed for an infection (including aseptic revision arthroplasty)
1st line: charted and annotated as first line Ondansetron 4-8mg q8h PRN IV or PO/SL up to 32mg/d 2nd line agents: at least 1-2 of the following to be charted, and annotated as second line Cyclizine IV 25-50mg q8h Droperidol IV 0.5-1.25mg IV q8h Metoclopramide 10mg IV/PO q8h up to 30mg/d Contra-indications & precautions: Ondansetron: Hypersensitivity: Contraindicated in patients with known hypersensitivity to ondansetron or any of its components. Concomitant use with Apomorphine: Due to the risk of profound hypotension and loss of consciousness.Congenital Long QT Syndrome: Avoid in patients with congenital long QT syndrome due to the risk of QT prolongation and Torsade de Pointes. Cyclizine: Hypersensitivity: Contraindicated in patients with known hypersensitivity to cyclizine or any of its components. Glaucoma: Use with caution in patients with underlying glaucoma due to its anticholinergic effects. Urinary Retention: Caution in patients predisposed to urinary retention. Droperidol: QT Prolongation: Contraindicated in patients with known or suspected QT prolongation, including congenital long QT syndrome. Severe Hypotension: Use with caution in patients with severe hypotension or those at risk for developing prolonged QT syndrome (e.g., congestive heart failure, bradycardia, electrolyte imbalances). Parkinson's Disease: Avoid in patients with Parkinson's disease due to the risk of exacerbating symptoms. Metoclopramide: Gastrointestinal Conditions: Contraindicated in patients with gastrointestinal hemorrhage, mechanical obstruction, or perforation. Pheochromocytoma: Contraindicated due to the risk of hypertensive crisis. Epilepsy: Avoid in patients with epilepsy or those receiving other drugs likely to cause extrapyramidal reactions. Parkinson's Disease: Avoid in patients with Parkinson's disease due to the risk of exacerbating symptoms.
Paracetamol:
1330mg (2 tabs panadol osteo) 8 hourly
Continue on discharge
Celecoxib 200mg BD PO 5 days
If <50kg or moderate hepatic failure decrease to 100mg dose
Otherwise ALL patients receive 200mg BD
Continue on discharge up to 5d total
Tapentadol IR OR oxycodone IR:
Tapentadol:
<65: 50-100mg Q3H PRN, Max 600mg/24hrs
65-75: 50-75mg Q3H PRN, Max 600mg/24hrs
75+:: 50mg Q3H PRN, Max 400mg/24hrs
Oxycodone:
<65: 10-20mg Q3H PRN
65-76: 5-10mg Q3H PRN
75+: 2.5-5mg Q3H PRN
Continue on discharge
Slow release opiate:
No routine use of slow release
Chronic pain/chronic opiate use patients:
New course SR opiate considered
Limited to short course of 3d, end date documented clearly
Avoid ceasing pre-op regimes in early post op period
Consider adjuncts such as clonidine (if not contraindicated) and tramadol (if not contraindicated) in consultation with an Acute Pain Service (APS) or anaesthetist
Aperients:
BD coloxyl & senna (start PM Day 0)
PRN lactulose + movicol
Movicol may cause nausea day 0/1
Nutrition:
Early post op oral fluid and nutrition
Icy pole in recovery
Normal diet and fluids immediately on return to ward
Bloods - ordered by surgeon, results reviewed and findings managed by anaesthetist: FBE and UEC for all cases G&H: revision arthroplasty only HbA1c: diabetics if not done in past 3m Other tests can be ordered and reviewed by anaesthetist as required ECG: Arranged by anaesthetist if desired pre-operatively Otherwise taken on day of admission by hospital staff Advanced tests (echo, PFT) Arranged and followed up by anaesthetist for the list as required after patient screened
Bloods only ordered if: Pre-operative abnormality requiring monitoring/management 500mL+ blood loss (e.g. revision surgery, bilateral TKR)
High flexion pillow Knee flexed to 90 degrees for 6h on high flexion pillow This is proven to decrease swelling Remove and position as tolerated thereafter Knee does not need to rest completely straight in bed - pillow under knees is permitted Mobility: Mobilise patients day 0 Start with or progress to forearm crutches as soon as possible Any issue that prevents mobility should be addressed in a timely manner Anti-emetics for nausea, with early re-assessment and 2nd line therapy added as required Analgaesia for pain Sit on edge of bed first, slow to rise for vasovagal or hypotension Multi-modal analgesia as per post-operative medications above Nutrition: Early oral intake initiated (recovery/arrival to ward) Cryotherapy: Ensure skin protected with thin cloth if no dressing Theatre bandage adequate for protection otherwise Apply for 20 min every 2 hours for first 48 hours post surgery After 48h, patient to use 3-4 times daily as required for pain and swelling Encourage patient ownership of management, self-initiation Ensure ice-man machines have adequate ice/cold temperature Do not use if patient has poor circulation, cold sensitivity or if it is not tolerated
Elective cases: 3 weeks wound check Thursday in rooms face to face for local patients Telehealth or with local GP for long distance patients Public patients closer to wangaratta have option of OSCA clinic 8 weeks follow-up appointment in bright Telehealth for long distance patients or if issues accessing rooms Public trauma patients: OSCA clinic for simple wound check (no physio/casting/boot required) Fracture clinic for all other patients Anton’s Friday if complex patient or patient of concern, otherwise a friday or midweek clinic as specified on op note
