Ortho/Trauma/Regional

Question 1

COMPLICATIONS of severe post operative pain post TKA (total knee join arthroscopy)

BJA Ed 01.18 Anaesthesia and analgesia for knee going arthroplasty

Answer 1

• AB - Decreased pulmonary function
• C - Myocardial ischaemia
• Development of chronic pain
• D - Delaying early mobilization
• Delirium or an anxiety disorder (if elderly)
• Prolonging Hospital stay
• Increased risk of infection

Question 2

How can you reduce LOS in hospital for patients undergoing TKA (total knee join arthroscopy)

Answer 2

• Enhanced recovery programmes (ERPs)
• Good Pain Control
• Early mobilization

Question 3

Describe the neural innervation of the knee joint

Answer 3

articular nerves are derived from the

• femoral
• obturator
• tibial
• common peroneal
• recurrent peroneal nerves

Question 4

Independent predictors of severe postoperative pain after TKA (total knee join arthroscopy)

Answer 4

• higher preoperative pain scores
• depression
• younger age

Question 5

Potential PRE OP factors that may improve postoperative outcomes in patients undergoing TKA

Answer 5

Preop assessment and optimisation

•Consider preemptive analgesia on the day of surgery (NSAIDS 2h before)
• An -inflammatory or Cox-2 inhibitors
• Modified release opioids e.g. oxycodone
• An -neuropathic agents e.g. gabapen n and pregabalin
(• Preoperative education ‘Joint School’)

Question 6

Potential POST OP factors that may improve postoperative outcomes in patients undergoing TKA

Answer 6

• po analgesics: paracetamol; NSAIDs or Cox-2 inhibitors (monitor U&E)
• po morphine (SA/LA e.g. oxycodone and oxycodone)
• PCA
• Transdermal opiate—fentanyl patch
• Continuous infusions LA (wound infiltration /adductor canal catheter < 3d postop)
• Cryocuff

Question 7

What are the benefits of using Regional over general anaesthesia in a TKA?

Answer 7

Avoidance of:
• B - pneumonia
• B - respiratory depression
• B - pulmonary embolism
• C - blood transfusion requirements
• D - DVT

Lower
• 30- day mortality (small but statistically significant)
• length of stay

Question 8

Potential INTRA OP factors that may improve postoperative outcomes in patients undergoing TKA

Answer 8

Regional Central neuraxial anaesthesia
+/- intrathecal opiates (depending on patient)
+/-Regional nerve block
+/-local infiltra on (intraopera ve by surgeon or ultrasound-guided)
Decision 3: Regional anaesthesia op ons available:
Tranexamic acid (i.v. +/- topical) I.V. an eme cs (e.g. ondansetron) I.V. steroids (dexamethasone)

Question 9

In ANTERIOMEDIAL KNEE surgery, what regional anaesthesia options are available? (Apart from central neuroaxial block)

Answer 9

Antero medial knee: Femoral nerve or adductor canal

Question 10

In LATERAL KNEE surgery, what regional anaesthesia options are available? (Apart from central neuroaxial block)

Answer 10

Lateral knee:

Placement of LA around the distal Nerve to vastus lateralis

Question 11

In POSTERIOR KNEE surgery, what regional anaesthesia options are available? (Apart from central neuroaxial block)

Answer 11

Posterior knee: Sciatic nerve or IPACK

Question 12

Where is the LA infiltrated in the IPACK block?

Answer 12

I nterspace between the 
P opliteal 
A rtery and the 
C apsule of the 
K nee, posteriorly (IPACK)