What is the recommended anesthesia plan for an 82-year-old lady with a history of Atrial Fibrillation (AF) with Rapid Ventricular Response (RVR), anticoagulation, Type 2 Diabetes Mellitus (T2DM), Gastroesophageal Reflux Disease (GERD), Hypertension (HTN), Obstructive Sleep Apnea (OSA), spinal stenosis, Osteoarthritis (OA), and hypothyroidism undergoing revision Total Knee Arthroplasty (TKA)?

Anesthesia Plan for 82-Year-Old Patient Undergoing TKA Revision

Recommendation Summary

Neuraxial anesthesia (spinal) with arterial line monitoring is the preferred approach for this high-risk elderly patient with complex cardiac comorbidities undergoing TKA revision surgery.

Patient Risk Assessment

This 82-year-old female presents with:

• Complex cardiac history: AF with RVR requiring high-dose bisoprolol and verapamil
• Previous ICU admissions after initial TKA for AF with RVR and fluid management issues
• Cardiac abnormalities: mitral annular calcification, mild MR, moderate TR, mild pHTN, reduced EF
• Multiple comorbidities: T2DM, GERD, HTN, OSA (non-compliant with CPAP), spinal stenosis, OA, hypothyroidism
• Anticoagulation for AF (currently held preoperatively)

Anesthesia Plan

1. Anesthetic Technique

• Primary technique: Spinal anesthesia (SAB) with adductor canal block (ACB)
  • Rationale: Neuraxial anesthesia is associated with better outcomes for TKA including fewer thromboembolic events, lower transfusion requirements, fewer respiratory complications, and reduced hospital length of stay 1
  • Previous successful SAB with ACB for initial TKA surgery

2. Monitoring

• Standard ASA monitors
• Arterial line for continuous blood pressure monitoring and blood sampling
• Consider central venous access if significant fluid shifts anticipated
• Continuous pulse oximetry during recovery period

3. Perioperative Anticoagulation Management

• Continue to hold anticoagulation preoperatively
• Follow institutional protocol for timing of postoperative anticoagulation resumption
• Consider bridging therapy based on CHA₂DS₂-VASc score (likely high in this patient) 1
• Apixaban would be preferred when restarting anticoagulation due to lower renal clearance (27%) compared to rivaroxaban (33%) 2

4. Cardiac Management

• Continue bisoprolol and verapamil on the day of surgery to maintain rate control
• Have antiarrhythmic medications readily available (diltiazem, metoprolol IV)
• Metoprolol is preferred if breakthrough AF with RVR occurs during surgery 3
• Avoid fluid overload given history of heart failure and previous overdiuresis

5. OSA Management

• Consider CPAP in the immediate postoperative period despite previous non-compliance
• Position patient in lateral, semi-upright, or non-supine position during recovery 1
• Continuous pulse oximetry monitoring postoperatively
• Minimize opioid use to prevent respiratory depression

6. Postoperative Pain Management

• Multimodal analgesia to minimize opioid requirements:
  • Continue ACB with catheter for 48-72 hours
  • Scheduled acetaminophen and NSAIDs if not contraindicated
  • Low-dose opioids as rescue only
  • Consider gabapentinoids if appropriate

7. Contingency Plan

• If spinal anesthesia fails or is contraindicated:
  • General anesthesia with secure airway (ETT preferred over LMA)
  • Full reversal of neuromuscular blockade before extubation
  • Extubate when fully awake in semi-upright position

Rationale for Neuraxial Technique

1. Evidence-based benefit: The 2019 International Consensus on Anaesthesia-Related Outcomes after Surgery (ICAROS) guidelines recommend neuraxial anesthesia for TKA based on systematic review and meta-analysis 1

2. Cardiac stability: Avoids hemodynamic fluctuations associated with general anesthesia induction/emergence in a patient with cardiac disease

3. Previous success: Patient had uneventful intraoperative course with SAB during initial TKA

4. Reduced complications: Lower risk of thromboembolic events, which is particularly important given the patient's AF and need for anticoagulation 1

5. OSA management: Avoids airway manipulation and reduces postoperative opioid requirements in a patient with untreated OSA 1

Potential Challenges and Mitigations

1. Duration of surgery: For a 2.5-hour case, consider:

   • Higher dose/concentration of local anesthetic in spinal
   • Have low-dose sedation available if needed for patient comfort
   • Be prepared to convert to GA if spinal duration insufficient

2. Hemodynamic instability:

   • Arterial line for beat-to-beat monitoring
   • Careful fluid management given cardiac history
   • Vasopressors readily available for hypotension
   • Avoid rapid position changes

3. Anticoagulation resumption:

   • Coordinate with surgical team for optimal timing
   • Balance risk of bleeding vs. thromboembolism
   • Consider bridging with LMWH if high stroke risk 1

4. Breakthrough AF with RVR:

   • Have IV beta-blockers and calcium channel blockers immediately available
   • Consider preemptive administration of oral medications

This anesthesia plan prioritizes the patient's cardiac stability while providing optimal surgical conditions and postoperative pain control, with careful consideration of her multiple comorbidities.