Claire Blandford, Consultant Anaesthetist
David Isaac, Consultant Orthopaedic Surgeon,Torbay & South Devon NHS Foundation Trust, Devon.

Patient Selection

• Symptomatic knee pathology requiring TKR

• Engaged with day case pathway

• No unstable medical co-morbidity requiring in-patient management

• No high dose opioid based analgesia /chronic pain regimen pre-operatively

• Suitable social support

Pre-online Preparation

From booking:

• Pt counselled to expect DC procedure
• Nurse led pre-assessment process completed
• Participation in ‘joint-school’ patient education programme

On the day:

• Listed first on theatre list (ideally)
• Withhold ACE inhibitor/ A2RB drug on day of and day before surgery
• Carbohydrate drink 2hrs pre-op
• Pre-medication:
• Paracetamol 1g
• Ibuprofen 1600mg SR (if not contraindicated)
• Oxycodone MR 10mg (5mg dose if age >70)

Anaesthetic Technique

Spinal:

• 3 – 3.4ml hyperbaric 2% Prilocaine

• NO intrathecal opioid

Sedation:

• Aim to minimise/ avoid. If required then low dose Propofol TCI with capnomask.

Local Anaesthesia:

• Ultrasound guided saphenous nerve block (0.25% levobupivacaine up to 20mls) + Surgical infiltration (ensure maximal LA dose not exceeded with combined technique)

Antiemetics: (dual agents as standard)

• Dexamethasone 6.6mg IV

• Ondansetron 4mg IV

• Intra Operative Care

Goal directed:

• Normothermia: proactively warm patient with forced air blanket (commence pre-op) & fluid warmer

• Normovolaemia: IV fluids 1000-2000mls (warmed)

Blood Conservation:

• Tranexamic Acid 1g IV start of case + further 1g at end of case (dose reduced for eGFR<50 and or weight <50kg)

• Cell salvage collection routinely

Antibiotic Regimen:

• Teicoplanin (slowly in 100mls n/saline) & Gentamicin [weight adjusted doses]

• Thromboprophylaxis: mechanical- foot pump used intra-operatively & until mobilisation. Dalteparin 5000units (weight adjusted) sc pre-discharge.

Key recovery priorities:

• Manage any PONV aggressively

• Commence oral fluids

• Fortisip 200ml drink

Surgical Technique

• Parapatellar approach

• Tourniquet only inflated for cementation

• Local Infiltration of Anaesthetic to divided tissue, periosteum and subdermal fat layers. 80 ml 0.125% levobupivacaine or 40mls 0.25% levobupivacaine according to individual surgeon’s preference.

• Careful wound closure in layers to include continuous absorbable suture to skin, plus tissue glue

Take Home Medication

• Paracetamol 1g qds

• Ibuprofen 400mg-600mg po qds 5/7 (if no contraindication) + PPI cover (Lansoprazole 15mg)

• Oxycodone MR 10mg po bd for 5 post op doses (*5mg if age >70) with reinforced non continuation of this via discharge summary (automated process)

  THEN step down on Day 3 to: Codeine 30-60mg po qds OR Tramadol 50-100mg qds if codeine intolerant for 3/7.

  Ondansetron 4mg po tds  2/7

  Macrogols 1 sachet po bd 5/7
  Dalteparin 5000units sc od for 2/7 (+ sharps bin) then step down onto:
  Aspirin 150mg po od 14/7
  unless other anticoagulation plan in place eg warfarin/clopidogrel/ DOAC  then usually restart this day 1 post op 

Post Operative Care

• Patient fulfils all standard daycase discharge criteria and demonstrate satisfactory mobilisation/ transfer abilities commensurate with safe discharge

• X-ray taken pre-discharge and reviewed by surgeon

• Day 1 nurse led telephone call from DSU

• In-house ‘orthopaedic outreach’ nursing team visit patient in community; days 1,5,10 & 14 to support. Tasks include wound reviews, medication assistance, performing post op blood tests/ vital signs monitoring.

• Direct telephone access to this service for patients

Organisational Issues

• Theatre listing – patient needs first (or possibly 2^nd) slot on a list

• Consider your facilities estate resources to build your pathway; location of clean air theatres & day case discharge facilities.

• Working hours of MDT support staff eg: physios may not align with time of patients discharge

• Post-operative support for patients; diverse ways this may be able to be provided. Bespoke solution to your unit may be needed.

Common Pitfalls

• Short acting spinal technique required to ensure full offset of sensory/motor block to allow adequate time for mobilisation. If unanticipated complications/ delays occur duration of block may become an issue.

• All staff need to be ‘on message’ so that the patient has confidence in the daycase pathway

• First mobilisation hypotension – we have found the ‘fortisip’ drink invaluable in reducing this, alongside good hydration and dual antiemetic regimen

Anticipated Day case Rates

• Not all patients will be suitable for daycase management.
• Estimates indicate approx. 20% of a waiting list cohort may be DC suitable