By Amy Colori

Anaesthetic case report

This report describes the anaesthetic journey of a 77 year old male who underwent a
right total knee replacement. I shall detail the patient’s history and his pre-operative
assessment, his peri-operative management and his post-operative pain
management.

Pre-operative management
(I have underlined aspects of the medical history which present potential problems for
anaesthetic management which are discussed below.)

Medical History
BS is a 77 year old retired man with painful osteoarthritis of the right knee. His x-ray
revealed that there was significant loss of the articular cartilage and space and so he
was scheduled for a total knee replacement.

PMH
• 2007 - Ca prostate for which he has undergone radiotherapy
• 2007 – bilateral cataract removal
• 2006 – OA – Total hip replacement and total left knee replacement
• 2005 – Chest Infection (nil problems since then)
• 2000 – GI bleed following use of aspirin – Subsequent OGD revealed NAD
• 2000 – Hypertension (controlled with drugs – see DH)
• 1943 – Rheumatic fever

DH – Sensitivity to NSAIDs – bleed following asprin

• Amlodipine 10mg OD

• Salbutamol inhaler PRN

• Beclomethasone 100 BD
• Zolaex depot 10.8mg Every 12 weeks
SH
• Active with good exercise tolerance

Pre-operative assessment
Respiratory system:
• BS had a chest infection but this does not present a problem as there have
been no problems since
• He is on beclomethasone inhaler which could suggest asthma but he is on a
low dose (possibly not for asthma) and does not have regular asthma attacks
and so this does not present a problem.
• He has good exercise tolerance and can climb two flights of stairs before
getting short of breath.
• His airway was assessed to be Malampati II.
• There was no need for further respiratory investigations.

Cardiovascular system
• BS had no history of CCF, IHD or CVA
• He did have hypertension but this was controlled with drugs and at 129/75 on
admission the day prior to the operation. His anti-hypertensive medication was
continued.
• Because BS is over 55, and therefore at risk of silent MI he had and ECG.
There was slight bradycardia of 57 (which is normal for him) but otherwise his
ECG showed a normal sinus rhythm.

Other anaesthetic risks

• His BMI is 31.5 which is higher than ideal but it was deemed safe to operate.
He was well nourished.
• His U+Es were normal: Na = 143, K=4.2, Creatinine = 87
• On FBC his Hb was slightly low at 12.8. It was deemed safe to operate without
transfusion with post-operative monitoring. Platelet count was normal at 178.
• Previous surgery under GA and epidural had no complications.
• He was assessed as having ASA status 2.
• He wore a TED stocking on his left leg (and a calf compressor was used peri-
operatively).
Preoperative preparation
• He was fasted of food from 2200 the previous evening and of clear fluids 0200
the morning of surgery although he had take a few sips of water to enable him
to swallow his medication.
• A 16 bore cannula was inserted into his left hand and he was given pre-
operative 50% oxygen.

Anaesthetic management
• It was jointly decided that BS would have a spinal and nerve block with light
sedation. (This means that he was able to protect his own airway.)
• He was given 2mg of midazolam preoperatively for sedation and 0.5mg of
alfentanil for analgesia. He was also give 2g of ceftriaxone for antibiotic
prophylaxis as it was an orthopaedic procedure.
• Anaethesia was established with a single shot spinal (intrathecal injection) of
2.2ml 0.5% bupivacaine with 0.5mg of diamorphine.
• This was supplemented with a local nerve block to sciatic, femoral and
obturator nerves (3 in 1) of 10ml 0.75% ropivocaine and 10ml 2% lignocaine
was give with stimulation to 0.4mA.
• Sedation and analgesia was maintained throughout the procedure with propofol
(20mg IV) and the same dose of alfentanil every 15 minutes.
• He was given 50% oxygen peri-operatively through a face mask 2000ml of
warmed saline and 500ml of warmed gelefusin IV.
• Throughout the operation his CVS, sats and FIO2 were monitored. While his
BP dropped to 90/50 during the operation there were no untoward events.

Post-operative events
• In recovery his BP went back up to 142/82 and the sedation wore off well.
• He was transferred back to ward on 4-5 litres of oxygen per minute via a nasal
tube for 24 hours.
• His haemoglobin in recovery was 10.2 so this will require further monitoring and
possibly investigation and treatment
• There were no residual problems with the spinal or block and as the patient had
not been under GA there were no problems of nausea and vomiting.
• The patient did describe his post-operative pain as moderate to severe but did
not want any opiate analgesia as he had felt confused and “out of it” when he
had taken it before. He was content to take paracetemol and allow the pain to
subside.
• By the second day post operatively he was mobile and feeling better in himself.