Anesthesia Management for High-Risk Patients Undergoing Total Knee Arthroplasty

Pre-operative Considerations

The American Society of Anesthesiologists recommends assuming significant sleep-disordered breathing in patients with poorly controlled OSA, and having a CPAP machine available for immediate postoperative use 1, 3
The American College of Surgeons suggests ensuring two intravenous cannulae are sited while in the pre-op area, with ultrasound guidance as necessary due to obesity, and considering unusual sites for IV access such as the upper arm or anterior chest wall 4

The American Society of Anesthesiologists recommends using spinal anesthesia with an opioid adjunct as the primary anesthetic technique, and using short-acting agents only if general anesthesia becomes necessary, with depth of anesthesia monitoring to limit anesthetic load 1
The American Society of Anesthesiologists suggests choosing desflurane over sevoflurane for faster emergence and return of airway reflexes 1

The American Society of Anesthesiologists recommends positioning the patient in a slight head-up/sitting position to improve respiratory mechanics, and using pressure-controlled ventilation with sufficient PEEP and recruitment maneuvers to reduce atelectasis if mechanical ventilation is required 4
The American Society of Anesthesiologists suggests implementing neuromuscular monitoring to maintain appropriate block level and ensure complete reversal 1

The American Society of Anesthesiologists recommends having a nasopharyngeal airway available before emergence to mitigate partial airway obstruction, and ensuring complete reversal of neuromuscular blockade using quantitative monitoring if general anesthesia was used 1
The American Society of Anesthesiologists suggests extubating only when the patient is fully awake with return of airway reflexes, and performing extubation with the patient in a sitting position 1

The American Society of Anesthesiologists recommends reinstating CPAP therapy immediately in the PACU, and providing supplemental oxygen via CPAP mask if needed 3
The American Society of Anesthesiologists suggests avoiding intramuscular injections due to unpredictable pharmacokinetics in obesity, and implementing multimodal opioid-sparing analgesia 5

The American Society of Anesthesiologists recommends observing the patient for signs of hypoventilation, apnea, or hypopnea, and monitoring oxygen saturation continuously 1, 3
The American Society of Anesthesiologists suggests transferring the patient to the ward only when routine discharge criteria are met, respiratory rate is normal, and oxygen saturation returns to pre-operative values 3

The American Society of Anesthesiologists recommends considering level-2 care if long-acting opioids are required or patient-controlled analgesia is needed, and continuing oxygen therapy until baseline saturations are maintained without supplementation 1, 5
The American Society of Anesthesiologists suggests implementing early mobilization as part of an enhanced recovery protocol 5