Anesthesia Plan for Manipulation/Closed Reduction Post Left Knee ACL Repair
Regional anesthesia with monitored anesthesia care (MAC) is the recommended approach for this 32-year-old male patient with history of psychosis undergoing manipulation/closed reduction post left knee ACL repair. 1
Patient Information
- 32-year-old male
- Weight: 174 lbs (79 kg)
- Height: 180.3 cm
- BMI: 24.3 kg/m² (normal range)
- Medical history: Psychosis
Pre-procedure Assessment
Airway and Respiratory Assessment
- Assess airway for potential difficult intubation
- Evaluate respiratory status and baseline oxygen saturation
Cardiovascular Assessment
- Assess baseline vital signs
- Review current medications, especially antipsychotics that may affect cardiovascular function
Psychiatric Assessment
- Review current psychiatric medications
- Assess current mental status and stability
- Consider potential drug interactions with anesthetic agents
Anesthetic Plan
Primary Technique: Femoral Nerve Block (FNB)
- Positioning: Supine with slight external rotation of the affected limb
- Equipment: Ultrasound guidance, nerve stimulator
- Local anesthetic: Ropivacaine 0.5%, 20 mL (total dose: 100 mg, well below maximum of 3 mg/kg or 237 mg for this patient) 2
Supplemental Anesthesia: Monitored Anesthesia Care
Premedication:
Induction/Maintenance:
Multimodal Analgesia
- Paracetamol (acetaminophen) 1000 mg IV pre-procedure
- Ketorolac 15 mg IV (if no contraindications)
- Consider ketamine 15 mg IV (0.2 mg/kg) for anti-hyperalgesic effect 2
Intraoperative Management
Positioning
- Supine position with slight elevation of the head
- Ensure proper padding of pressure points
- Minimum of three staff members for safe positioning 2
Monitoring
- Standard ASA monitors (ECG, NIBP, SpO2, EtCO2)
- Depth of anesthesia monitoring if using general anesthesia
- Neuromuscular monitoring if muscle relaxants are used
Fluid Management
- Maintenance: Lactated Ringer's solution at 3-5 mL/kg/hr (240-400 mL/hr)
Post-procedure Management
Recovery
- Continue multimodal analgesia
- Monitor for return of sensation in the blocked limb
- Ensure complete recovery from sedation before discharge
Pain Management
- Continue acetaminophen 1000 mg PO q6h
- NSAIDs if not contraindicated
- Opioids only for breakthrough pain
Rehabilitation Considerations
- Early mobilization as tolerated 2
- Immediate knee mobilization should be used following manipulation 2
- Continuous passive motion may be considered in the immediate postoperative period 2
Special Considerations for Patient with Psychosis
- Avoid benzodiazepines if patient is on clozapine due to risk of respiratory depression
- Consider using lower doses of sedatives to minimize risk of postoperative delirium
- Ensure clear communication and reassurance throughout the procedure
- Have antipsychotic medications available if needed for acute agitation
- Consider psychiatric consultation if patient is unstable
Potential Complications and Management
- Inadequate analgesia: Supplement with additional local anesthetic (staying within maximum safe dose) or convert to general anesthesia
- Hemodynamic instability: Reduce propofol infusion rate, administer fluids
- Respiratory depression: Reduce sedation, provide supplemental oxygen, maintain patent airway
- Psychiatric decompensation: Have psychiatric support available, consider haloperidol 2-5 mg IV if needed for acute agitation
This anesthesia plan prioritizes regional anesthesia as recommended by guidelines, which has been shown to reduce postoperative pain, decrease opioid requirements, and allow for earlier mobilization compared to general anesthesia 1, 6. The femoral nerve block specifically has strong evidence supporting its use for knee procedures 2.