Clinical case

[Direct Laryngoscopy]

For the residents and med students. Elder statesman (and women) can chime in.

81 yo retired Internist for R TKA.

PMHx: Afib, Gilbert syndrome, cervical stenosis, HTN, GERD, overweight (BMI 30), BPH

PShx: L TKA, cataracts, litho, tonsils



What are your concerns? What else would you like to know before proceeding? What's Gilbert syndrome? Will it affect your peri operative plan? Spinal or GA? Will you do a PNB? Which one?

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[Planktonmd]

Femoral + Pop block pre-op using Bupivacaine.
Propofol ---> LMA

 

[sanityonleave]

I'll chime in as a soon-to-be CA-1:

Based on his history, there are a few more things I'd like to know --
How bad is his cervical stenosis? Does he have any restriction of flexion/extension of his neck and, if so, how much? (a lot of people have the dx without much to show for it, but if his ROM is compromised that's something concerning)
Is he anticoagulated for his a fib? Rate controlled?

Gilbert's syndrome is a benign hyperbilirubinemia related to a defect in transport of bilirubin across hepatocyte cell membranes (I think). It can cause transient hyperbilirubinemia under conditions of stress (infection, surgery) but is usually an indolent condition. I do not think it affects actual hepatocyte metabolism. I had an acetaminophen overdose a few months ago with Gilbert's and we were looking this up, so iirc hepatic metabolism is preserved - it's just transport into the hepatocyte of bilirubin that is slow. It should not effect your periop plan, except maybe to warn him that a little transient jaundice could be expected.

Now I'm getting way out of my element: I think I'd do lumbar plexus + sciatic block for the TKA. Definitely neuraxial over GA, but not sure exactly what route would be best. I'll leave this to the more experienced folks.

 

[amyl]

Our surgeons prefer an adductor canal block for knees to spare the quad.

 

[bcat85]

For the residents and med students. Elder statesman (and women) can chime in.

81 yo retired Internist for R TKA.

PMHx: Afib, Gilbert syndrome, cervical stenosis, HTN, GERD, overweight (BMI 30), BPH

PShx: L TKA, cataracts, litho, tonsils



What are your concerns? What else would you like to know before proceeding? What's Gilbert syndrome? Will it affect your peri operative plan? Spinal or GA? Will you do a PNB? Which one?

Gilbert syndrome doesn't really change management other than the above mentioned transient jaundice. I would be mildly concerned about the severity of his cervical stenosis/range of motion/potential for a difficulty airway (though this really isn't typically that big of a deal). The bigger issue is whether he has been appropriately bridged from his Afib anticoagulation so that he can receive neuraxial anesthesia. I'd plan for a spinal with adductor canal and popliteal catheters for postop pain. As amyl said, its helpful to spare the quad with the adductor canal block as opposed to a femoral.

 

[ranvier]

How did his L TKA go for him? Any records to review?

 

[deleted162650]

Are that many of you guys really doing sciatic blocks (pop or otherwise) for TKA's? I've yet to meet an orthopod either in training or PP who wants that much motor block post-op. Our patients are ambulating DOS. We do adductor canal's and exparel by surgeon in the field. Results have been really good, and I would say superior to when we were doing fem caths with traditional local by surgeon. Plan for this case really wouldn't differ from any other TKA: isobaric Bupi SAB (assuming off any anticoag for Afib) w/ ACB and a little prop sedation intra-op.

 

[Hoya11]

Are that many of you guys really doing sciatic blocks (pop or otherwise) for TKA's? I've yet to meet an orthopod either in training or PP who wants that much motor block post-op. Our patients are ambulating DOS. We do adductor canal's and exparel by surgeon in the field. Results have been really good, and I would say superior to when we were doing fem caths with traditional local by surgeon. Plan for this case really wouldn't differ from any other TKA: isobaric Bupi SAB (assuming off any anticoag for Afib) w/ ACB and a little prop sedation intra-op.

my issue with ACB is how do you assess a successful block? the anatomy of the saphenous nerve is variable, i like asking the patient to lift their leg after the fem block and ensure motor block prior to fileting the knee open. The pessimist in me thinks the ACB has become popular for two reasons, one is early ambulation (which is stupid, does 24h really make a difference?, if it was me id take the femoral with the ensured success of analgesia as confirmed by motor block, xaralto, and chill the rest of the day rather than walking for what an hour or less?) and secondly because there actually is no way to assess a successful block and people who suck at blocks can get away with high frequency of failed blocks because no way to tell. they all get narcotic anyway in addition to blocks and how much is variable.

And yes I do also do pop-scis for posterior pain with the same mindset, let them rest for the day, give them anticoagulation for DVT, , no big deal. I have done hundreds of knees this way. General with these blocks with LMA or ETT after. is there any actual data that shows ambulating DOS for a few mins is superior to POD1 in terms of long term outcomes? not that im aware of.

I feel the same way about epidurals. Will they be able to ambulate early? No. Give them AC and let them chill for a DOS and POD1. That big belly case patient is not going to be running around the halls anyhow. I pull it on POD 2 AM or sooner if issues. Again is there data about early ambulation after abd surg on DOS vs POD1 effecting long term outcomes?

Id do the guy above in the knee case the same way he had the left TKA done, or if any issues, with a fem and popsci block and ett.

 

[deleted162650]

my issue with ACB is how do you assess a successful block?

Put an ice cube on the guy's antero-medial ankle (saphenous distribution) and say "sir is that cold?" It's not really that hard.

By your line of thinking there's no way to assess the adequacy of a thoracic epidural either

And a patient should be able to ambulate with an appropriately placed/dosed thoracic epidural.

I'm not aware of any data supporting or refuting the importance of early ambulation but it makes the orthopods happy, and like I said the patients are doing very well/happy on the current regimen.

I will agree with you however that those with weak regional skills can skate under the radar with ACB's.

 

[Gas you down]

my issue with ACB is how do you assess a successful block? the anatomy of the saphenous nerve is variable, i like asking the patient to lift their leg after the fem block and ensure motor block prior to fileting the knee open. The pessimist in me thinks the ACB has become popular for two reasons, one is early ambulation (which is stupid, does 24h really make a difference?, if it was me id take the femoral with the ensured success of analgesia as confirmed by motor block, xaralto, and chill the rest of the day rather than walking for what an hour or less?) and secondly because there actually is no way to assess a successful block and people who suck at blocks can get away with high frequency of failed blocks because no way to tell. they all get narcotic anyway in addition to blocks and how much is variable.

And yes I do also do pop-scis for posterior pain with the same mindset, let them rest for the day, give them anticoagulation for DVT, , no big deal. I have done hundreds of knees this way. General with these blocks with LMA or ETT after. is there any actual data that shows ambulating DOS for a few mins is superior to POD1 in terms of long term outcomes? not that im aware of.

I feel the same way about epidurals. Will they be able to ambulate early? No. Give them AC and let them chill for a DOS and POD1. That big belly case patient is not going to be running around the halls anyhow. I pull it on POD 2 AM or sooner if issues. Again is there data about early ambulation after abd surg on DOS vs POD1 effecting long term outcomes?

Id do the guy above in the knee case the same way he had the left TKA done, or if any issues, with a fem and popsci block and ett.

i always thought sure, why not get them up early. At the very least, that means faster move to rehab, right? well not really, because many folks need three days inpatient before the insurance will pay for them to go to rehab!

 

[Urzuz]

my issue with ACB is how do you assess a successful block?

What nerve are you blocking? And what does that nerve supply? A good bet is to test that anatomical area...

edit: just saw SaltyDog pretty much posted the same thing.

 

[Direct Laryngoscopy]

I'll chime in as a soon-to-be CA-1:

Based on his history, there are a few more things I'd like to know --
How bad is his cervical stenosis? Does he have any restriction of flexion/extension of his neck and, if so, how much? (a lot of people have the dx without much to show for it, but if his ROM is compromised that's something concerning)
Is he anticoagulated for his a fib? Rate controlled?

Gilbert's syndrome is a benign hyperbilirubinemia related to a defect in transport of bilirubin across hepatocyte cell membranes (I think). It can cause transient hyperbilirubinemia under conditions of stress (infection, surgery) but is usually an indolent condition. I do not think it affects actual hepatocyte metabolism. I had an acetaminophen overdose a few months ago with Gilbert's and we were looking this up, so iirc hepatic metabolism is preserved - it's just transport into the hepatocyte of bilirubin that is slow. It should not effect your periop plan, except maybe to warn him that a little transient jaundice could be expected.

Now I'm getting way out of my element: I think I'd do lumbar plexus + sciatic block for the TKA. Definitely neuraxial over GA, but not sure exactly what route would be best. I'll leave this to the more experienced folks.

Pt states he has constant symptoms related to his cervical stenosis (right shoulder pain and numbness and tingling of his extremities), but no limitation in ROM. He is presently rate controlled with Atenolol and his EKG showed sinus rhythm. As expected the only thing noteworthy with his Gilbert syndrome is a slightly elevated total bilirubin. Labs otherwise WNL.

 

[Direct Laryngoscopy]

Femoral + Pop block pre-op using Bupivacaine.
Propofol ---> LMA

Do you routinely do your joints with GA? and why not a saphenous nerve block?

 

[Direct Laryngoscopy]

How did his L TKA go for him? Any records to review?

I proceeded with a spinal along with a saphenous nerve block for post op pain relief. I routinely do adductor canal blocks as the pt does not have the weakness in the quad muscles and facilitates early PT. There were a few instances of pt falls which were attributed to femoral nerve blocks in the past. Some of my partners still do fem blocks, but they are slowly changing to the adductor canal nerve block. Takes literally 90 seconds and pt has no weakness.

 

[Hoya11]

Put an ice cube on the guy's antero-medial ankle (saphenous distribution) and say "sir is that cold?" It's not really that hard.

By your line of thinking there's no way to assess the adequacy of a thoracic epidural either

And a patient should be able to ambulate with an appropriately placed/dosed thoracic epidural.

I'm not aware of any data supporting or refuting the importance of early ambulation but it makes the orthopods happy, and like I said the patients are doing very well/happy on the current regimen.

I will agree with you however that those with weak regional skills can skate under the radar with ACB's.

appreciate the very reasonable responses.

i personally would not rely on an ice cube test or alcohol swab test. very subjective especially after sedation is given. when i test a level for a spinal that may be iffy its a needle on/in the skin vs my finger.

and you assess an epidural by sympathectomy observed after bolus.

 

[Urzuz]

appreciate the very reasonable responses.

i personally would not rely on an ice cube test or alcohol swab test. very subjective especially after sedation is given. when i test a level for a spinal that may be iffy its a needle on/in the skin vs my finger.

and you assess an epidural by sympathectomy observed after bolus.

I may be the minority here, but I never test blocks that I perform strictly for postoperative pain. For me, I don't want to wait for the block to set up before I get them off to sleep, and more importantly, it doesn't matter to me how adequate the block is pre-incision. The ultimate test will be how the patient feels postoperatively and if they are having any pain. If they are, then you can go about assessing how good your block was by performing various tests, and supplement the block if needed (repeat block, IV pain meds, etc)

 

[Planktonmd]

Do you routinely do your joints with GA? and why not a saphenous nerve block?

In my current practice the surgeons do not allow the patients to walk until next day so there is no advantages to doing a saphenous block and the femoral block gives you more surgical anesthesia and relaxation of the quad.
We do a femoral and a high lateral sciatic blocks and we place an LMA just in case they have tourniquet pain but we rarely give any opiates intra-op.
They do great post op

 

[epidural man]

Do ya' all think you can apply this data to TKA? The thing that really is interesting in this study was that infection rates are way less with neuraxial anesthesia - just another quill in the quiver lending data to the fact that general anesthesia and opioids are huge immune modulators.

http://jbjs.org/content/97/3/186.abstract

 

[pgg]

appreciate the very reasonable responses.

i personally would not rely on an ice cube test or alcohol swab test. very subjective especially after sedation is given. when i test a level for a spinal that may be iffy its a needle on/in the skin vs my finger.

and you assess an epidural by sympathectomy observed after bolus.

It's not a surgical block. It's an analgesic block. Beyond satisfying your curiosity, why test it at all? Will your plan change at that moment? The only assessment that's really needed is postoperative - ask the patient if their pain is adequately controlled, and go from there.

ACBs are easy and reliable. You shouldn't see many outright failures.