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

[undalay]

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 infiltration up to 400 mg by the surgeon.

Do any of you perform the I pack block

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[BLADEMDA]

Plasma Ropivacaine Concentrations Following Local Infiltration Analgesia in Total Knee Arthroplasty: A Pharmacokinetic Study to Determine Safety Following Fixed-Dose Administration - PubMed

The peak total ropivacaine concentration was below quoted toxic concentrations (2.2 μg/mL) in all patients. This peak occurred later than has previously been described in those undergoing neuraxial or peripheral nerve block, occurring between 6 and 24 hours. The influence of age, weight, and...

pubmed.ncbi.nlm.nih.gov

Pharmacokinetics of 400 mg Locally Infiltrated Ropivacaine After Total Knee Arthroplasty Without Perioperative Tourniquet Use - PubMed

This study was registered at Netherlands Trial Registry (http://www.trialregister.nl), trial ID NTR6306.

pubmed.ncbi.nlm.nih.gov

 

[BLADEMDA]

Conclusions: Total serum concentration of ropivacaine after LIA using 270 mg ropivacaine with and without an additional 100 mg perineural ropivacaine remained well below the toxicity threshold of 3.0 µg/mL at all time points. Additional studies are needed to ascertain the safety of combining LIA with peripheral nerve blockade.

Serum ropivacaine levels after local infiltration analgesia during total knee arthroplasty with and without adductor canal block - PubMed

Total serum concentration of ropivacaine after LIA using 270 mg ropivacaine with and without an additional 100 mg perineural ropivacaine remained well below the toxicity threshold of 3.0 µg/mL at all time points. Additional studies are needed to ascertain the safety of combining LIA with...

pubmed.ncbi.nlm.nih.gov

 

[BLADEMDA]

Pain After Unilateral Total Knee Arthroplasty: A Prospective Randomized Controlled Trial Examining the Analgesic Effectiveness of a Combined Adductor Canal Peripheral Nerve Block with Periarticular Infiltration Versus Adductor Canal Nerve Block Alone

Participants who received AC + PI reported significantly less pain on walking on PODs 1 and 2 compared with those who received AC only or PI only.

pubmed.ncbi.nlm.nih.gov

Based on the literature 20 mls of Ropivacaine is sufficient to perform a good Adductor Canal block. The concentration of Ropivacaine you choose for this block is based on the weight of the patient when combined with LIA Ropivacaine (200mg) administered by the surgeon. Typically, some use 0.5% Rop while others will reduce the concentration to 0.25% Rop for smaller patients (elderly, less than 55 kg for example).

 

[Hoya11]

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 infiltration up to 400 mg by the surgeon.

Do any of you perform the I pack block

thats 40cc of 0.5% ropivicaine that they are using.. thats a lot... it should be way less, like 20 cc of 0.25% (so a quarter of that)

If they are stuck on that number, I would probably only do 20cc of 0.25% of ropi for the ACB and no room for the BS ipack..

ideally they would reduce the local they use so you could give more..

 

[GassYous]

I do 10 of 0.5 ropi for adductor and 20 for the ipack + pump for home

I think ipack + surgeon infiltration helps a lot

I don't care much about the "max" dose as I don't think that there's that much absorption around the joint. But I wouldn't give that much bupi

If you talk to some of the old guard orthopods, they used to give massive amounts of local in the joint before we decided that there was a "max" dose. You will be fine.

 

[Blockit]

You don’t need concentrated local for the adductor canal block.

 

[Mehd School]

Anyone else's experience with adductor canal blocks that they ... kind of suck? We have an extremely busy regional service and probably do anywhere from 4-8 adductor canal blocks each day, not counting other bread and butter blocks, and this definitely is one that we are fiddling around with post op blocks or talking to unhappy patients the next day on the phone. We use catheters and verify placement of the tip on ultrasound on probably 80% of them. They just seem very unreliable.

 

[BLADEMDA]

Anyone else's experience with adductor canal blocks that they ... kind of suck? We have an extremely busy regional service and probably do anywhere from 4-8 adductor canal blocks each day, not counting other bread and butter blocks, and this definitely is one that we are fiddling around with post op blocks or talking to unhappy patients the next day on the phone. We use catheters and verify placement of the tip on ultrasound on probably 80% of them. They just seem very unreliable.

Adductor canal blocks help some but not the way a Femoral block does for postop pain. That's the price you pay for not having any motor block: Limited analgesia vs the traditional, time tested Femoral block.

 

[GassYous]

Anyone else's experience with adductor canal blocks that they ... kind of suck? We have an extremely busy regional service and probably do anywhere from 4-8 adductor canal blocks each day, not counting other bread and butter blocks, and this definitely is one that we are fiddling around with post op blocks or talking to unhappy patients the next day on the phone. We use catheters and verify placement of the tip on ultrasound on probably 80% of them. They just seem very unreliable.

They don't cover that much especially if you don't get nerve to vastus medialis. It helps and it's better than nothing. Same thing for peng blocks for hips. Helps a little but if you want to avoid motor block, you're not going to get great sensory.

 

[Blockit]

The adductor canal block is at best an analgesic block and an incomplete one at that. I have found that they tend to work best where the surgeon is also doing LIA. I tell every patient ahead of time that the block will not get rid of all the pain, but it’s just designed to reduce it a bit to make it more manageable.
Although I would love to do so, I don’t have enough time to explain to every single patient the Yin/Yang balance between analgesia and quad weakness.

 

[Airway]

Adductor canal blocks help some but not the way a Femoral block does for postop pain. That's the price you pay for not having any motor block: Limited analgesia vs the traditional, time tested Femoral block.

This! I did 150+ femoral and catheters as a resident. I'm sure a few people fell on pod 0 but the pain control was much better

Adductors are meh.

 

[dhb]

I was very happy with a highish adductor canal block + ipack (no joint infiltration).
Patients would use 10mg of morphine or less on average for the 4 days of hospitalisation.

 

[Blockit]

4 days of hospitalization???? What is this, Europe??? 🤷🏻‍♂️😂

 

[Southpaw]

I was very happy with a highish adductor canal block + ipack (no joint infiltration).
Patients would use 10mg of morphine or less on average for the 4 days of hospitalisation.

People are going home same day or POD1 here. Insurance cos aren’t paying 4 days here - ever. They have C suite bonuses to pay out and parachute retirements that need tens or hundred of millions.