Adductor/ipack local dose

[residency2010]

Hi all, my orthopod uses a cocktail of local which includes 30ml of 0.5% Bupi for total knees.Then I do adductor with 10-12 ml of 0.2 ropi and ipack with 12-15ml of 0.2 ropi in the PACU. I am concerned about toxicity in very thin patients. I understand the absorption is poor and gradual. Can some regional guys shed some light on this? How much higher can I go after the surgeon uses 30ml of 0.5% Bupi? Thanks.

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[woopedazz]

150mg bupi for them, huh? Bit greedy if they want you to do more blocks. Or they trying to tell you not to do more blocks 😜

 

[Mehd School]

I don't think there's much point to an ipack if the surgeon is localizing the compartment.

 

[ethilo]

I don't think there's much point to an ipack if the surgeon is localizing the compartment.

I agree. I'm rather unimpressed with iPACK. I'll do them in ACLs but I don't think they really do much. I'd just stick with the ACB.

 

[UscGhost]

They inject 400mg ropiv periarticular

We inject 15ml 0.25% bupiv for ipack, 20ml 0.5% bupiv for the Adductor.

0.2 ropi is barely better than saline.

Most of the total joint literature shows that even with doses in this range, patients remain far below the serum concentration needed for toxicity.

 

[GassYous]

They used to do crazy amounts periarticular like 50 cc+ of 0.5%. I think you can use what you want

 

[Mehd School]

The academic practice I'm joining about 50% of the staff do Ipacks. I'll do them occasionally so that the residents can do them but I don't plan on doing them much. As I posted above I don't think the utility is there and they can also be technically challenging blocks on the 5'6" 340 woman that is getting her knee replaced for obvious reasons.

 

[GassYous]

The academic practice I'm joining about 50% of the staff do Ipacks. I'll do them occasionally so that the residents can do them but I don't plan on doing them much. As I posted above I don't think the utility is there and they can also be technically challenging blocks on the 5'6" 340 woman that is getting her knee replaced for obvious reasons.

No, not obvious. why are you doing that?

 

[2Fast2Des]

No, not obvious. why are you doing that?

Really??

 

[GassYous]

Really??

yea if your bmi 55 you need weight loss not a new knee

 

[UscGhost]

The academic practice I'm joining about 50% of the staff do Ipacks. I'll do them occasionally so that the residents can do them but I don't plan on doing them much. As I posted above I don't think the utility is there and they can also be technically challenging blocks on the 5'6" 340 woman that is getting her knee replaced for obvious reasons.

Some of it depends on surgical technique too. I have done rescue ipacks in the pacu and they worked (I was surprised because we didn't do them prior to that). They can help with posterior knee pain

 

[DocVapor]

yea if your bmi 55 you need weight loss not a new knee

But they can't start exercising until they get that new knee! They promise!!1!

 

[Hoya11]

Hi all, my orthopod uses a cocktail of local which includes 30ml of 0.5% Bupi for total knees.Then I do adductor with 10-12 ml of 0.2 ropi and ipack with 12-15ml of 0.2 ropi in the PACU. I am concerned about toxicity in very thin patients. I understand the absorption is poor and gradual. Can some regional guys shed some light on this? How much higher can I go after the surgeon uses 30ml of 0.5% Bupi? Thanks.

agree with the notion to skip the IPACK if they are going to give that much bupi on their end

 

[residency2010]

Thank you all for the replies.

 

[UscGhost]

agree with the notion to skip the IPACK if they are going to give that much bupi on their end

30 ml won't do much if they inject it in the wrong spot. If the patients routinely have posterior knee pain in the pacu then they should get ipacks. If the surgeon is good and injects in the right location, then they should be fine in pacu.

 

[Mehd School]

Some of it depends on surgical technique too. I have done rescue ipacks in the pacu and they worked (I was surprised because we didn't do them prior to that). They can help with posterior knee pain

You took down the dressing to do the ipack? This is something I've been interested in doing before but the surgeons said don't mess with it.

 

[Hoya11]

30 ml won't do much if they inject it in the wrong spot. If the patients routinely have posterior knee pain in the pacu then they should get ipacks. If the surgeon is good and injects in the right location, then they should be fine in pacu.

yes but with a limited number of bullets to shoot, i would shoot more at the ACB to make it last longer than waste ammunition trying to acheive posterior coverage with a small amount of dilute local with an already sketchy block to begin with

 

[UscGhost]

You took down the dressing to do the ipack? This is something I've been interested in doing before but the surgeons said don't mess with it.

It's a pain..so we do them pre-incision now. Anatomy less distorted too

Spinal then acb and ipack. Both blocks take a few mins to do so it's negligible delay if everything is setup and ready.

 

[Modoc]

I personally stopped doing IPACK blocks (0.5% Bupi +/- 50 mcg precedex), I see little utility and difference in post op pain control. Especially when the surgeon is injecting local around surgical site intra op.

 

[anbuitachi]

Hi all, my orthopod uses a cocktail of local which includes 30ml of 0.5% Bupi for total knees.Then I do adductor with 10-12 ml of 0.2 ropi and ipack with 12-15ml of 0.2 ropi in the PACU. I am concerned about toxicity in very thin patients. I understand the absorption is poor and gradual. Can some regional guys shed some light on this? How much higher can I go after the surgeon uses 30ml of 0.5% Bupi? Thanks.

wait you are saying you are only doing adductor and ipack after surgeon injects a crapload of bupi??

why arent you also doing obturator blocks??? max it out

 

[nimbus]

yea if your bmi 55 you need weight loss not a new knee

Upside is that you can give a lot of local and do many blocks on the 340 pounders.

 

[teacher2md]

I’ve found that ACB+iPACK works really well for ACLs. My two cents.

 

[GassYous]

I’ve found that ACB+iPACK works really well for ACLs. My two cents.

I agree with this. When I chart check they have a 0-2 in pain after surgery.

 

[narcusprince]

Stop it…. My current gig is mainly ortho. I do adductor canal blacks mepi spinals and my patients are ambulating and going home from their total knees. ACLs are weight bearing so no Ipac even though they say its only sensory. I have found not a lot of utility in IPAC block especially when the surgeon injects local periarticularly. 0.5% Ropi no Bupi this works….. I only use 0.5% Bupi in lower extremity blocks that are not weight baring. Upper extremities I use 0.5% bupi. In the .mil we did 2 totals a day in my current gig we do 9 in one day. We used 0.2% in the .mil ropi for adductors in TKRs and it was no better than saline flush.

 

[GassYous]

Stop it…. My current gig is mainly ortho. I do adductor canal blacks mepi spinals and my patients are ambulating and going home from their total knees. ACLs are weight bearing so no Ipac even though they say its only sensory. I have found not a lot of utility in IPAC block especially when the surgeon injects local periarticularly. 0.5% Ropi no Bupi this works….. I only use 0.5% Bupi in lower extremity blocks that are not weight baring. Upper extremities I use 0.5% bupi. In the .mil we did 2 totals a day in my current gig we do 9 in one day. We used 0.2% ropi for adductors in TKRs and it was no better than saline flush.

Damn dude 9 total knees in one room?

 

[narcusprince]

Damn dude 9 total knees in one room?

2 rooms……

 

[Status Sciaticus]

yea if your bmi 55 you need weight loss not a new knee

why exercise when you can get a knee that wont ever get arthritis again ?

 

[BLADEMDA]

How much ropivacaine per kg body weight in adductor canal blocks for TKA

Our Ortho use 200 mg ropivacaine in the cocktail for local infiltration, the question is how much of ropivacaine can be used safely in the adductor canal block in this situation. Our orthopedic like the patient to have GA for the surgery. Blade MDa had posted an article re ropivacaine...

forums.studentdoctor.net

Local anesthetic toxic doses

How are LA toxic doses calculated if multiple locals are given - ie doing a block with bupi and lido. Are they independent of each other or cumulative - ie I can give 50% of the toxic dose of lidocaine and 50% of the toxic dose of bupi?

forums.studentdoctor.net

 

[kmurp]

I’m going to disagree that IPACK blocks have little utility as some stated above. We do IPACK Adductor on all our TKRs at the ASC. Don’t know how we would get them all home without it. Surgeons do no injections.