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Table of Contents
Year : 2019  |  Volume : 35  |  Issue : 2  |  Page : 279-281

Anesthesia for total knee replacement surgery in a patient with positive stress test

Department of Anaesthesiology and Pain Management, Max Superspeciality Hospital, Patparganj, New Delhi, India

Date of Web Publication25-Jun-2019

Correspondence Address:
Vikky Jaiswal
Department of Anaesthesiology and Pain Management, Max Superspeciality Hospital, I.P. Extension, Patparganj, New Delhi - 110 092
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/joacp.JOACP_23_18

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How to cite this article:
Jain K, Jaiswal V, Puri A. Anesthesia for total knee replacement surgery in a patient with positive stress test. J Anaesthesiol Clin Pharmacol 2019;35:279-81

How to cite this URL:
Jain K, Jaiswal V, Puri A. Anesthesia for total knee replacement surgery in a patient with positive stress test. J Anaesthesiol Clin Pharmacol [serial online] 2019 [cited 2020 Sep 30];35:279-81. Available from:


Joint replacement surgeries are in increasing trend to improve the life quality of aging population. A 65-year-old female with a body mass index of 37.7 kg/m2 was advised total knee replacement (TKR) in view of constant rest pain, swelling, and deformity hampering daily activity. The patient was virtually bedridden. She had hypertension since 8 years. She underwent percutaneous transluminal coronary angioplasty of the left anterior descending artery and was on medical treatment. General physical and systemic examination revealed no abnormality with anticipated difficult airway. Preoperative cardiac evaluation revealed poor cardiac performance with T-wave inversion in the inferior and lateral leads. Her baseline echo revealed that mid anterior septum, apex, and basal inferior wall were severely hypokinetic with left ventricle ejection fraction (LVEF) of 45%, mild left ventricular hypertrophy, and mild mitral regurgitation. While undergoing dobutamine stress echo (DSE) with dobutamine infusion at 20 mcg/kg/min, her mid anterior septum, distal interventricular septum, and distal anterior wall became akinetic with LVEF 40%. The patient complained of uneasiness with electrocardiography showing frequent premature ventricular complexes and bigeminy. Her DSE was positive for myocardial infarction. Blood investigations ruled out end-organ damage. Renal, liver, and coagulation parameters were in normal limit. Her preoperative hemoglobin, serum sodium, and serum potassium were 10.8 g/dL, 135 mmol/L, and 3.9 mmol/L, respectively.

After a board meeting, the patient was accepted for two-staged TKR under American Society of Anesthesiologists (ASA) grade IV in view of her present cardiac status.

Given the risk of perioperative complications, we opted to perform ultrasound-guided right continuous femoral nerve block (FNB) with single-shot sciatic nerve block (SNB) after ASA standard monitoring and arterial cannulation. Epidural catheterization was done for rescue anesthesia perioperatively.

Under all aseptic conditions, right SNB was administered in left lateral position with partial flexion at hip and knee. Under ultrasound guidance, sciatic nerve was identified in transverse plane using curvilinear probe in subgluteal region [Figure 1]a and was confirmed by tracing it till popliteal fossa. A 5-cm 17-G stimucath needle was inserted out of plane to approach sciatic nerve and was confirmed by plantar flexion of the right foot in response to the stimulating current of 1 mA. Local anesthesia spread pattern on ultrasound was observed while injecting 20 mL of 0.5% ropivacaine. Then, the patient was given right FNB under ultrasound guidance using 20 mL of 0.5% ropivacaine in supine position [Figure 1]b. Femoral catheter was inserted and fixed with LOCKIT Plus® to prevent dislodgement of the catheter. Infusion of 0.5% ropivacaine was started at 5 mL/h. Meanwhile, tourniquet was applied and the limb was prepared for surgery. After 20 min, motor and sensory blockade was checked and surgery started. Peripheral nerve block was supplemented by intravenous 1 mg midazolam and 50 mcg fentanyl. Vitals were within normal limits. The surgery lasted for 1.5 h with tourniquet time of 61 min and was uneventful. The total fluid given was 700 mL with output 100 mL. Postoperatively, infusion 0.2% ropivacaine was started at 5 mL/h for postoperative analgesia. The patient was comfortable perioperatively without rescue epidural analgesia. She was hemodynamically stable and was shifted to the surgical intensive care unit.
Figure 1: (a) Sciatic nerve block and (b) femoral nerve block. AT- adipose tissue, GMM – Gluteus maximus muscle, GT – greater trochanter, IT – ischial tuberosity, SN – sciatic nerve, QF – Quadratus femoris muscle, F.I. – Fascia iliaca, F.A. – Femoral artery, F.V. – Femoral vein, F.N.- Femoral nerve , L.A.- Local anesthesia

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TKR is one of the popular surgeries involving cost, complications, and outcome. With increased risk associated with one-stage bilateral TKR, the final decision whether to attempt simultaneous or staged bilateral TKR should be made on individual basis.[1]

Urban et al.[2] published guidelines for unilateral indication of TKR including age more than 75 years, ASA class III, positive stress test, and poor ventricular function. Therefore, in this case two-staged bilateral TKR was opted.

Combined spinal epidural anesthesia (CSEA) provides excellent surgical conditions, thus becoming the anesthesia of choice in TKR.[3]

CSEA was not used as it would have affected both the limbs which was not required and predispose the patient to cardiac and other complications. Dusanka et al. demonstrated that the FNB and SNB were safer when compared with epidural group on the first postoperative day. Moreover, they also found that motor blockade was more intense in the operated limb on the day of surgery and the first postoperative day in the peripheral nerve block group, whereas the nonoperated limb was more blocked in the epidural group on the day of surgery.[4]

The knee joint is supplied by femoral, obturator, and sciatic nerves. The obturator nerve (L2, 3, 4) supplies the adductor muscles on the medial side of the thigh [Table 1] and [Table 2]. Anterior innervation groups include femoral, common peroneal, and saphenous nerves. Posterior innervation group includes posterior articular nerve of tibial nerve.[5]
Table 1: Femoral nerve block

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Table 2: Sciatic nerve block

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Peripheral nerve blocks including FNB and SNB are one of the current trends used for postoperative analgesia in patients undergoing TKR.[6]

In this case, TKR was performed under ultrasound-guided continuous FNB and single-shot SNB. SNB was given along FNB so as to cover the posterior compartment of the knee. Among several approaches, we preferred subgluteal approach as the patient was obese and nerve is superficial when compared with other positions and imaging is not interfered by the bones. Systemic reviews demonstrated that addition of SNB provides additional postoperative analgesia with FNB in patients undergoing TKR.[7]

Ultrasound helps in confirmation of femoral nerve and catheter placement with local anesthetic spread. While administering SNB, we used both ultrasound and nerve stimulation technique to confirm sciatic nerve. Ultrasound helps in nerve localization and monitoring spread of local anesthetic along the needle placement with confirmatory evidence by motor response obtained during nerve stimulation. The motor response of hamstrings, foot, or toes obtained during nerve stimulation often provides contributory information. Ultrasound may facilitate more rapid onset of block and prolong duration of block. Use of ultrasound also decreases the doses of drug and the incidence of local anesthetic toxicity.[8]

Continuous FNB with single-shot SNB efficiently provided anesthesia and postoperative analgesia for TKR. Perioperatively, the patient was comfortable with no hemodynamic disturbances as demonstrated by Fanelli et al.[9] for leg surgery. The patient did not require any epidural top up or rescue anesthesia perioperatively.

These blocks are reported to cause quadriceps paresis, intravascular injection, hemotoma, and nerve injury/foot drop.[6] No such complication was observed in our case.

To conclude, ultrasound-guided continuous FNB with single-shot SNB can be used as an anesthetic technique for TKR. They are perhaps ideal for high-risk candidates who cannot tolerate altered hemodynamics.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

  References Top

Bagsby D, Pierson J. Functional outcomes of simultaneous bilateral versus unilateral total knee arthroplasty. Orthopedics 2015;38:43-7.  Back to cited text no. 1
Urban MK, Chisolm M, Wukovitx B. Are postoperative complications more common with single-stage bilateral (SBTKR) than with unilateral knee arthroscopy: Guidelines for patients scheduled for SBTKA. HSS J 2006;2:78-82.  Back to cited text no. 2
Kakar PN, Roy PM, Pant V, Das J. Anesthesia for joint replacement surgery: Issues with coexisting diseases. J Anaesthesiol Clin Pharmacol 2011;27:315-22.  Back to cited text no. 3
[PUBMED]  [Full text]  
Dusanka Z, Klavs B, Christian C, Jadwiga C, Snorre S, Bodil C. A comparison of epidural analgesia with combined continuous femoral-sciatic nerve blocks after total knee replacement. Anesth Analg 2006;102:1240-6.  Back to cited text no. 4
Wheeless C. Wheeless' Textbook of Orthopaedics [Internet]. Wheeless Online. 2017 [cited 20 January 2018]. Available from: [Last accessed on 2018 May 29].  Back to cited text no. 5
Turnbull Z, Sastow D, Giambrone G, Tedore T. Anesthesia for the patient undergoing total knee replacement: Current status and future prospects. Local Reg Anesth 2017;10:1-7.  Back to cited text no. 6
Grape S, Kirkham K, Baeriswyl M, Albrecht E. The analgesic efficacy of sciatic nerve block in addition to femoral nerve block in patients undergoing total knee arthroplasty: A systematic review and meta-analysis. Anaesthesia 2016;71:1198-209.  Back to cited text no. 7
Munirama S, McLeod G. Ultrasound-guided femoral and sciatic nerve blocks. Continuing Educ Anaesth Critical Care Pain 2013;13:136-40.  Back to cited text no. 8
Fanelli G, Casati A, Aldegheri G, Beccaria P, Berti M, Leoni A. Cardiovascular effects of two different regional anaesthetic techniques for unilateral leg surgery. Acta Anaesthesiol Scand 1998;42:80-4.  Back to cited text no. 9


  [Figure 1]

  [Table 1], [Table 2]


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