MAYO CLINIC College of Medicine Mayo Clinic Total Joint Regional Anesthesia Clinical Pathway Preoperative Holding Area 1. Oxycodone (Extended Release) 20 mg PO upon arrival to patient waiting area 2. Rofecoxib 50 mg PO upon arrival to patient waiting area Anesthesia Procedure Room 1. Lumbar plexus continuous peripheral nerve catheter a. Total knee arthroplasty: posterior lumbar plexus (psoas) or femoral continuous nerve catheter b. Total hip arthroplasty: posterior lumbar plexus (psoas) continuous nerve catheter 2.  Sciatic nerve blockade (total hip and total knee arthroplasty patients) Post-Anesthesia Care Unit (PACU) 1. Acetaminophen 1000 mg + oxycodone 10 mg PO in PACU PRN VAS pain score ≥4 2. Lumbar plexus continuous peripheral nerve catheter a. Bolus 10 mL 0.2% bupivacaine upon arrival in PACU b. Begin continuous infusion bupivacaine 0.2% at 10 mL/hr Patient Care Unit 1. Ketorolac 15 mg IV every 6 hrs x 4 doses 2. Acetaminophen 1000 mg PO TID (08:00, 12:00, 16:00 hrs) 3. Oxycodone (Extended Release) 20 mg PO BID if <70 years old (10 mg PO BID if >70 years old) 4. Oxycodone 5 mg PO every 4 hrs PRN VAS pain score ≤4 (10 mg PO every 4 hrs PRN VAS pain score >4) 5. Lumbar plexus continuous peripheral nerve catheter: Change infusion on POD #1 (6:00 a.m.) to bupivacaine 0.1% at 12 mL/hr for 24 hours 6. Heplock IV PRN 7. Do not discontinue Heplock until peripheral nerve catheter removed

The clinical pathway described above was used for the current investigation. However, subsequent modifi cations have been made and incorporated into our current practice. These include (1) Celecoxib 400 mg PO upon arrival to patient waiting area as a replacement for rofecoxib, (2) the addition of gabapentin 600 mg PO upon arrival to the patient waiting area, (3) sciatic nerve blockade for total knee arthroplasty patients only, and (4) the discontinuation of Oxycodone (Extended Release) after 4 doses. PO = per os; VAS = verbal analog pain score; POD = postoperative day; IV = intravenous; mL = milliliters; hr(s) = hour(s); BID = twice a day; TID = three times a day; PRN = pro re nata (as necessary)

Table 1: Mayo Clinic Total Joint Regional Anesthesia Clinical Pathway.