Anyone here familiar with R.E.C.K. Injection for TKA?

[GassmanMD]

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Do you guys do an adductor canal block after a patient has received over 2.5-3mg/kg of ropivacaine from the RECK solution ? The only studies I’ve found on it use a solution like RECK as a replacement for PNB’s, not as an adjunct.

A state-of-the-art pain protocol for total knee replacement - PMC

Total knee replacement is acknowledged as a successful and durable operation, but recovery from this surgery is often lengthy and painful. A great deal of attention has recently been directed at enhancing this recovery, most of which has focused on ...

www.ncbi.nlm.nih.gov

 

[PAC2DO]

My practice does. Joint surgeons will inject RECK and we supplement it with our own adductor canal block. They often miss the medial aspect and posterior aspect. Some use ropi 0.2% via catheter after bolusing 20 cc of ropi 0.2%. I personally just use Exparel with little bit of 0.25% bupi since we have decent amount of catheter migration issue.

 

[Simba1711]

I usually don’t do a block if the surgeon does their own injection with local. I don’t know how much they inject and where they are injecting. Don’t want to give additional local.

 

[Beeftenderloin]

Most of our joint THA/TKA guys don’t request a block and just inject this stuff.

 

[centdoc]

Most of our joint THA/TKA guys don’t request a block and just inject this stuff.

Joint Juice by the surgeon is best. Always works. We don’t have to waste time with the block, and don’t have
To worry about not getting paid for a block. As stated before, blocks are a waste of time since very often they don’t get paid these days. At a busy place, this is what gets the day done.

 

[Lecithin5]

Joint Juice by the surgeon is best. Always works. We don’t have to waste time with the block, and don’t have
To worry about not getting paid for a block. As stated before, blocks are a waste of time since very often they don’t get paid these days. At a busy place, this is what gets the day done.

Do preop blocks (that are not being used as the sole anesthetic) not normally get reimbursed? I’m sure it’s insurance dependent, but I thought they generally do…

 

[jwk]

Do preop blocks (that are not being used as the sole anesthetic) not normally get reimbursed? I’m sure it’s insurance dependent, but I thought they generally do…

Ours do. Pretty much every post-op pain block we do is billed and gets paid. My peronal n=2 is 100%.

 

[Hoya11]

R.E.C.K. Non-Opioid Periarticular Injection (50mL) | Quva Pharma

Order Quva's patented R.E.C.K. (Ropivacaine, Epinephrine, Clonidine, Ketorolac) ready-to-administer syringe for non-opioid periarticular injection. Ships to your hospital.

www.quvapharma.com

Do you guys do an adductor canal block after a patient has received over 2.5-3mg/kg of ropivacaine from the RECK solution ? The only studies I’ve found on it use a solution like RECK as a replacement for PNB’s, not as an adjunct.

A state-of-the-art pain protocol for total knee replacement - PMC

Total knee replacement is acknowledged as a successful and durable operation, but recovery from this surgery is often lengthy and painful. A great deal of attention has recently been directed at enhancing this recovery, most of which has focused on ...

www.ncbi.nlm.nih.gov

I had not heard of this, thanks.

I doubt the toradol and clonidine in the cocktail add anything (already getting oral nsaids), and the main component is the ropivicaine which is essentially 100ml of 0.25%.

I would not do a block on top of 100 of 0.25% ropivicaine. I would ask the surgeon to do maybe 60cc of that solution if they want me to block also.

The article is from an ortho journal which is in line with the logic used to argue against a PNB.

IMO the ACB is going to give you longer lasting analgesia compared to this technique and also spares motor.

I think they are getting away with this in the context of a spinal and then keeping them in the hospital with frequent narcotics..

 

[Urzuz]

I usually don’t do a block if the surgeon does their own injection with local. I don’t know how much they inject and where they are injecting. Don’t want to give additional local.

I know this is a crazy idea but you could pretend to be a colleague of theirs for ten seconds and ask them.

Everywhere I have worked we tell the surgeons how much they can inject after taking into account how much ever we used for the peripheral nerve block.

We block every TKA with an adductor block and surgeons will supplement the nerve block with an injection on the field.

 

[GassmanMD]

I know this is a crazy idea but you could pretend to be a colleague of theirs for ten seconds and ask them.

Everywhere I have worked we tell the surgeons how much they can inject after taking into account how much ever we used for the peripheral nerve block.

We block every TKA with an adductor block and surgeons will supplement the nerve block with an injection on the field.

What if the surgeon expects a post-op adductor canal block after they’ve injected 2.5-3mg/kg of ropi ?

 

[GassYous]

What if the surgeon expects a post-op adductor canal block after they’ve injected 2.5-3mg/kg of ropi ?

How well do you think the surgeon's local will absorb from around the knee? I think it's perfectly fine and have no issues putting 10-20 cc of local in the adductor

You should hear about how much local surgeons used to put in totals before blocks were a thing

 

[GassmanMD]

How well do you think the surgeon's local will absorb from around the knee? I think it's perfectly fine and have no issues putting 10-20 cc of local in the adductor

You should hear about how much local surgeons used to put in totals before blocks were a th

How well do you know the local will be absorbed? That’s exactly my argument for following the standard of care which ive never seen reported exceeding a max dose of 3mg/kg of ideal body weight.

 

[GassmanMD]

My practice does. Joint surgeons will inject RECK and we supplement it with our own adductor canal block. They often miss the medial aspect and posterior aspect. Some use ropi 0.2% via catheter after bolusing 20 cc of ropi 0.2%. I personally just use Exparel with little bit of 0.25% bupi since we have decent amount of catheter migration issue.

How much reck do they inject?

 

[UscGhost]

How well do you know the local will be absorbed? That’s exactly my argument for following the standard of care which ive never seen reported exceeding a max dose of 3mg/kg of ideal body weight.

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

Serum concentrations don't exceed safe levels when combining PNB with periarticular injection.

We have been combining them for 10+ years with no issues

 

[GassmanMD]

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

Serum concentrations don't exceed safe levels when combining PNB with periarticular injection.

We have been combining them for 10+ years with no issues

Wow this is super helpful, thank you.

 

[sevoflurane]

Minus the clonidine (not sure if it actually does much)… isn’t this the standard cocktail for like the last 10 years?

 

[sevoflurane]

We also supplement w ACB.

 

[circleK]

When our joint guys injected we needed to be informed ahead of time and would use a decreased dose for our ACNBs

 

[PAC2DO]

How much reck do they inject?

They have a chart based on weight. This does not account for the fact that some pts have CHF or ESRD. We still supplement with ACB and we haven’t seen any LA complications.

 

[cchoukal]

I know this is a crazy idea but you could pretend to be a colleague of theirs for ten seconds and ask them.

Everywhere I have worked we tell the surgeons how much they can inject after taking into account how much ever we used for the peripheral nerve block.

We block every TKA with an adductor block and surgeons will supplement the nerve block with an injection on the field.

This has been my practice across 10 years and two institutions.

 

[FiO2@21]

Joint Juice by the surgeon is best. Always works. We don’t have to waste time with the block, and don’t have
To worry about not getting paid for a block. As stated before, blocks are a waste of time since very often they don’t get paid these days. At a busy place, this is what gets the day done.

This seems like a biller + efficiency issue. Our group does not have issues billing post-op pain blocks. Excluding very obese patients, adductor does not appear to add more than 2-3 min. I also go after AFCN in that time frame. I don't do iPACK if surgeons infiltrate. If your culture precludes you from talking to surgeon for whatever reason I'd still do it but dilute the local.