One page, in case order, covering hip, knee, and shoulder arthroplasty. Every item traces to the Arthroplasty Protocol Quick Reference and the Shoulder Arthroplasty Protocol Sheet — see them for rationale and the companion Reference & Evidence document for studies. Joint-specific items are flagged inline.
Pre-Op Holding
- H&P and consent verified; NPO per ASA — carb drink (Ensure Pre-Surgery) allowed up to 2 h before arrival in non-diabetics.
- Acetaminophen 1,000 mg PO + celecoxib 200 mg PO given (pregabalin 75 mg only if selected).
- Cefazolin 2 g IV (3 g if > 120 kg) started within 60 min of incision. Non-anaphylactic PCN allergy: still cefazolin. Anaphylactic: clindamycin 900 mg. No routine IV vancomycin.
- TXA: oral 1–2 g 2 h pre-op OR IV 1 g before incision. Hold if CrCl < 30, TXA allergy, or VTE within 12 months.
- Forced-air prewarming + warmed IV fluids running; target core ≥ 36 °C throughout.
- Diabetics: baseline glucose; target < 200 mg/dL perioperatively.
Anesthetic Plan
- Spinal is the default — low-dose agent for same-day discharge. General only if the patient cannot have a spinal.
- TKA: single-shot adductor canal block. No femoral nerve block. iPACK only if the surgeon is not doing a PAI or difficult pain is expected.
- Shoulder: interscalene block + general is the default pairing.
- Dexamethasone 10 mg IV at induction — pain, PONV, and length-of-stay benefit. Give even in diabetics with HbA1c < 8% (monitor glucose); single dose only if HbA1c ≥ 8%.
Intra-Op
- Low-dose ketamine, especially for opioid-tolerant patients: 0.25–0.5 mg/kg bolus + 0.1–0.25 mg/kg/h infusion; stop near closure.
- PONV prophylaxis: the induction dexamethasone + ondansetron.
- Keep opioids minimal — the pathway is built for same-day mobilization; avoid long-acting agents that delay PT clearance.
- Redose cefazolin every 3–4 h in long cases.
PACU
- Ketorolac 15–30 mg IV if not given intra-op.
- Ondansetron 4 mg IV PRN — rescue with a different class than prophylaxis.
- Rescue opioid PRN only; aspirin 81 mg starts the evening of POD 0.
- Discharge from PACU when: stable vitals · pain ≤ 4 on oral meds · nausea controlled · neuraxial block regressing (motor returning, can protect the limb) · not over-sedated · voided or bladder plan in place.
Hand-Off Reminder
- Post-op steroid: dexamethasone 16 mg PO the morning after surgery (POD 1) — given in hospital, or sent home with same-day discharges. Confirm it is on the discharge med list.