Same-day total hip and knee replacements are rapidly transforming ambulatory orthopedic care. The success of these procedures hinges on effective analgesia—one that facilitates early ambulation while minimizing motor block, opioid use, and nausea. Regional anesthesia, including single-shot and continuous peripheral nerve blocks, offers this balance when implemented with consistency and precision. Certified Registered Nurse Anesthetists (CRNAs), operating as dedicated block teams, provide the expertise and efficiency required to support early discharge protocols in joint arthroplasty. This article outlines best practices for block selection, workflow integration, and outcome measurement in same-day joint programs.
For total knee arthroplasty, the adductor canal block is a motor-sparing technique that preserves quadriceps strength and provides 14 to 16 hours of pain relief with bupivacaine. Supplementing with an IPACK block addresses posterior knee discomfort. For posterior total hip replacements, the pericapsular nerve group (PENG) block provides motor-sparing analgesia for up to 18 hours. In anterior hip approaches, the supra-inguinal fascia iliaca block offers broad coverage, while PENG may be added for residual groin pain.
Shoulder arthroplasty typically involves a low-volume interscalene block, which may produce temporary deltoid weakness. To maintain coverage while reducing motor impairment, continuous catheter infusions with 0.2 percent ropivacaine can be employed. CRNAs using a standardized block protocol and structured patient education support consistent outcomes.
In two-room surgical settings, a parallel workflow allows continuous turnover without delays. While one CRNA performs an ultrasound-guided peripheral nerve block in the preoperative area, a second CRNA administers spinal anesthesia in the operating room. As the surgeon closes the first case, the next patient is prepared and ready for transfer. This configuration typically saves 12 minutes per case, allowing six joint replacements to be completed within a standard eight-hour shift, without requiring overtime staffing.
A balanced regional anesthesia plan includes bupivacaine 0.25 percent, administered in volumes of 20 to 25 milliliters for sensory-selective effects. Adjuncts such as clonidine (50 micrograms) and dexamethasone (4 milligrams) can extend block duration by several hours and help reduce rebound pain. Ketorolac, administered intravenously post-induction at a dose of 15 milligrams, provides opioid-sparing anti-inflammatory effects. Epinephrine should be avoided in adductor canal blocks to preserve the motor-sparing advantage.
Effective regional anesthesia supports early ambulation with a goal of at least 75 feet using a walker. Pain on movement should be managed to maintain a score of 4 out of 10 or less. Total morphine milligram equivalents in the post-anesthesia care unit (PACU) should remain below five milligrams, and postoperative nausea should be minimal or absent. Regional blocks significantly reduce opioid requirements and associated side effects, helping to meet discharge criteria reliably.
Performance should be tracked through consistent quality assurance processes. Key indicators include a block success rate of 95 percent or higher, motor strength scores in PACU demonstrating quadriceps strength at 4 out of 5 or above, a fall rate of zero per 1,000 discharges, and a total day-zero opioid burden under 50 milligrams morphine equivalent. Monthly dashboards help align anesthesia providers, surgeons, and administrative teams around shared clinical goals.
Regional anesthesia, delivered by a dedicated CRNA team, plays a pivotal role in enabling successful same-day joint replacement. By reducing opioid use, shortening PACU stays, and maintaining patient mobility, CRNA-led block programs contribute to higher patient satisfaction and greater operating room efficiency. Facilities seeking to launch or refine a same-day joint program can benefit from experienced CRNA partners who bring both technical expertise and operational structure.
For institutions preparing to implement adductor canal and IPACK block protocols, Advanced Anesthesia Services provides specialized CRNA coverage, equipment, and quality tracking support—ensuring scalable, high-performing same-day joint programs from day one.
