ACL Postop Pain control

[kmurp]

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I have a question regarding pain control for ACL patients. We currently do a femoral block on all these folks and for most, with some celebrex and postop fentanyl we do OK. Some of these patients, however, express a great deal of discomfort from the hamstring graft site. I realize that a sciatic would help this but most don't seem to need it. What are you all doing for postop pain control in this patient population?
Thanks.

 

[USAnesthesiaDoc]

I definitely do a high popliteal block and femoral for ACL with hamstring grafts. They're in agony without blocking the sciatic component, unless you use a lot of narcotics, which then slows up the discharge. I give toradol for acl patients as long as the surgeon is okay with it. I also used to do just a femoral block, even for patellar tendon grafts and cadaver grafts. But I have added a high popliteal for those as well because they have a surprising amount of posterior knee pain without a popliteal, and then you play the narcotic versus discharge game in pacu.

 

[kmurp]

I definitely do a high popliteal block and femoral for ACL with hamstring grafts. They're in agony without blocking the sciatic component, unless you use a lot of narcotics, which then slows up the discharge. I give toradol for acl patients as long as the surgeon is okay with it. I also used to do just a femoral block, even for patellar tendon grafts and cadaver grafts. But I have added a high popliteal for those as well because they have a surprising amount of posterior knee pain without a popliteal, and then you play the narcotic versus discharge game in pacu.

How high in the leg are you talking about?

 

[lobelsteve]

What were they taking pre-op. Pain patients also blow out their ACL and then the post-op course is typically more difficult to manage.

 

[Noyac]

I do a FNB and then drop down 4-5 cm and add an anterior Sciatic block. The Sciatic takes about twice as long as the FNB.

 

[DrDre']

Are you using stim only? Do you have US for blocks or lines? Are your orthopods supportive of regional or just tolerate it.

We do a lot of PNB, including home catheters. We do stim and/or US.

I do a FNB and then drop down 4-5 cm and add an anterior Sciatic block. The Sciatic takes about twice as long as the FNB.

 

[USAnesthesiaDoc]

When I do a sciatic/popliteal for ACL, I do the femoral first (ultrasound only because the femoral nerve is usually unmistakable), then have the patient turn onto their side. I use a curved ultrasound probe and trace the sciatic nerve as cephalad as I can (posterior approach), frequently this can mean subgluteal, but it is at least 2/3 up the posterior thigh. I always stim with the ultrasound for sciatic because I have been fooled; stim confirms 100%. I use low concentration without epi for the sciatic because foot drops scares the orthopods; the sciatic nerve is very sensitive to local and the block tends to last a long time anyway, so this works out fine. In general, the orthopods are supportive of regional and do request it. Not currently doing femoral catheters for home, but working towards that. Do lots of inpatient femoral catheters for TKRs with ultrasound combined with stimulating catheter.

 

[Planktonmd]

I do a FNB and then drop down 4-5 cm and add an anterior Sciatic block. The Sciatic takes about twice as long as the FNB.

You can block the sciatic 4-5 cm deeper to the femoral! 😱
Your patients must be really really skinny!
I guess this is the advantage of living in a place where people are healthy and athletic.

 

[Noyac]

You can block the sciatic 4-5 cm deeper to the femoral! 😱
Your patients must be really really skinny!
I guess this is the advantage of living in a place where people are healthy and athletic.

NO, no, you are misreading my poor description. I meant that I move 4-5 cm distal to my FNB insertion site. The depth is quite variable.

 

[Noyac]

Are you using stim only? Do you have US for blocks or lines? Are your orthopods supportive of regional or just tolerate it.

We do a lot of PNB, including home catheters. We do stim and/or US.

Stim only right now. US is on its way next week. Surgeons are supportive mostly because we are efficient and our blocks work well.

 

[periopdoc]

NO, no, you are misreading my poor description. I meant that I move 4-5 cm distal to my FNB insertion site. The depth is quite variable.

Man I would love to come visit and learn this technique. I tried to talk so many of my attendings into letting me try this in residency, but no one would bite. Not sure if I can learn it on my own once I am in PP due to efficiency issues, but who knows. I am reasonably facile with a needle so...

btw what are you planning on doing with the U/S? I thought you were in the "u/s is pretty much unnecessary camp." <-- That was not meant as a comment of criticism

- pod

 

[drccw]

Just femoral block for us...
i think for the autograft a sciatic would be helpful too but i don't want to push them because working crutches on the way home sucks after a sciatic block. So I tell patients I can cover about 70% of the pain with a FNB if they have an autograft... Also ketorolac...

Did one yesterday, did well... no analgesic needs in PACU, which actually surprised me... I actually gave the young dude 4 mg of midazalom and 200 mcg of fentanyl for block placement and he was still sedated but interactive.. actually.. conversing normally....

As for learning blocks in private practice- it's doable. i'm fairly facile with a needle but for some reason when I was in residency i never performed a sciatic nerve block from the "classical" approach (only subgluteal or in the popliteal fossa) or a lumbar plexus block... when I got out I helped a couple dudes who were good at blocks, read a lot, (NYSORA) and just tried them.. I can honestly say with learning those two blocks I never held a room up

 

[USAnesthesiaDoc]

I agree that adding an anterior sciatic to a femoral under u/s is definitely a plus (as opposed to turning the patient to do a popliteal or subgluteal block). Have tried that approach but only on my TKR patients (admittedly not many times). It is not easy to find the sciatic in an obese thigh anteriorly because the depth is significant. However, in the ambulatory athletic ACL tear population, it should be much easier. You guys have motivated me to try this some more in these patients.

 

[Noyac]

Man I would love to come visit and learn this technique. I tried to talk so many of my attendings into letting me try this in residency, but no one would bite. Not sure if I can learn it on my own once I am in PP due to efficiency issues, but who knows. I am reasonably facile with a needle so...

btw what are you planning on doing with the U/S? I thought you were in the "u/s is pretty much unnecessary camp." <-- That was not meant as a comment of criticism

- pod

I learned it on my own in PP, you can too. Just review the technique and the next case you get give it a try.

I do think the US is not necessary. There was monies left over at our hospital and we are hiring new grads on occasion so we said that an US would possibly be a good purchase since some residents are not learning to use nerve stim for regional these days. I will give it a go though. I'll report back once I have formed an opinion.

 

[periopdoc]

I am ALWAYS looking for an excuse to fly out to the mountains.

Looking forward to a life where I can try out something new without having to have someone supervise me. Still in the resident mindset for now.

- pod