Bilateral TKA

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Doughy315

Doughy315

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Patient is a 58 year old male with PMH of Asthma well controlled with Advair, Ventolin, and Singulair presents to preop for Bilaterial Total Knee Arthroplasty. Surgeon would like Bilaterial Salphenous nerve blocks and a spinal. He is planning injecting Exparel in the joint capsule and for skin local. Regarding his asthma, He is not SOB, no recent hospitalizations, his Oxygen saturation is 98% on room air. He is not wheezing on physical exam. The question for you guys is would you place a spinal, Combine Spinal Epidural, or tell the surgeon that your doing a General with a LMA?
 
Doughy315 said:
Patient is a 58 year old male with PMH of Asthma well controlled with Advair, Ventolin, and Singulair presents to preop for Bilaterial Total Knee Arthroplasty. Surgeon would like Bilaterial Salphenous nerve blocks and a spinal. He is planning injecting Exparel in the joint capsule and for skin local. Regarding his asthma, He is not SOB, no recent hospitalizations, his Oxygen saturation is 98% on room air. He is not wheezing on physical exam. The question for you guys is would you place a spinal, Combine Spinal Epidural, or tell the surgeon that your doing a General with a LMA?
Click to expand...


Spinal. Tetracaine with Epi plus fentanyl. This is a 7 hour cocktail.

Adductor canal block with 0.25 percent Bup plus dexamethasone (20 ml volume) for each side.

25 gauge non cutting spinal needle single shot technique for the SAB


https://forums.studentdoctor.net/threads/joint-replacement-spinal-cocktail.1069302/
 
Last edited:
I've seen 12 hour spinals when tetracaine and bupivacaine plus Epi are mixed together then injected into the csf. Because the duration is so long I do not recommend that technique.

I can see choosing a CSE technique with this scenario. I've done those and they work great. Typically, if I know the duration of surgery I can tailor my SAB to about one hour longer than the surgical operating room time.
 
CSE + prop MAC. If your surgeon is really slow then very deep LMA placement and deep LMA removal.
 
Fast surgeons can do a bilateral knee in the same time it takes a slow surgeon to do one total knee. So, I tailor my anesthetic to the surgeon.

I prefer single shot SAB to catheters in the back. Single shot SAbs are fast and reliable with a success rate of over 99 percent. CSEs work fine but why do an epidural technique when it isn't needed? That's the reason I typically do single shot SABs in OB as well for c sections.

KISS
 
Surgeon doesn't want narcotics in the spinal.
 
Doughy315 said:
Surgeon doesn't want narcotics in the spinal.
Click to expand...

Why does the surgeon care if fentanyl goers in the spinal...? Does he want to do the surgery or provide the anesthesia? And I know some surgeons are particular on what they want and have reasonable requests, but I'm not getting the spinal narcotic issue.
 
Because they think the Duramorph will cause urinary retention and prevent the patient from going home pod 1 or 0 or whatever their place does
 
partydoc said:
Because they think the Duramorph will cause urinary retention and prevent the patient from going home pod 1 or 0 or whatever their place does
Click to expand...

Well nobody suggested putting Duramorph in the spinal now did they.

BLADEMDA said:
Spinal. Tetracaine with Epi plus fentanyl.
Click to expand...

What's the benefit to adding Fentanyl to the Tetracaine/Epi spinal for knees? I routinely add Fentanyl to my iso Bupi SAB's for joints as I think the 4ish hour duration helps with the transition in PACU/the floor as the spinal is resolving - but when the spinal is gonna last 3 hours longer than the Fentanyl what's the point?? It's not like you need the "visceral" coverage that narcotics help with for joints.
 
IT fentanyl can prolong analgesia up to 6 hours:


Afr J Med Med Sci. 2011 Sep;40(3):213-9.
Effects of intrathecally administered fentanyl on duration of analgesia in patients undergoing spinal anaesthesia for elective caesarean section.
Idowu OA1, Sanusi AA, Eyelade OR.
Author information

Abstract
BACKGROUND:
Intrathecal opioids have gained popularity in obstetrics; they augment the analgesia produced by local anaesthetic agents. The aim of this study is to determine the duration of analgesia following addition of fentanyl to bupivacaine during elective Caesarean section.

METHOD:
This is a prospective randomized study comparing the effect of addition of 25 microg of fentanyl to 2.5 mls of 0.5% hyperbaric bupivacaine intrathecally on sixty healthy women of American Society ofAnaesthesiologist (ASA) physical status I scheduled for elective Caesarean section at the UCH, Ibadan. Patients were randomized to group B, n=30 and group FB, n=30. Maternal heart rate, blood pressure, respiratory rate, sensory level, motor block, pain score (NRS) and side effects were observed every 2 minutes for first 15 minutes, then at 5 minutes interval for the remainder of the operation. Thereafter at 30 minutes interval until the first complaint of pain.

RESULTS:
Complete analgesia (time from injection of intrathecal drug to first report of pain) lasted longer in group FB (240 +/- 29 minutes) than group B (99 +/- 12 minutes) with a p-value of 0.002. The duration of effective analgesia (time from injection of intrathecal drug to first request for analgesic) in group FB (276 +/- 26 minutes) while group B was (121 +/- 10 minutes) with a p-value of 0.001. Both were statistically significant.

CONCLUSION:
We conclude that the addition of 25 microg of fentanyl to bupivacaine intrathecally for elective Caesarean section increases the duration of complete and effective analgesia thereby reducing the need for early postoperative use of analgesics.
 
BLADEMDA said:
IT fentanyl can prolong analgesia up to 6 hours:


Afr J Med Med Sci. 2011 Sep;40(3):213-9.
Effects of intrathecally administered fentanyl on duration of analgesia in patients undergoing spinal anaesthesia for elective caesarean section.
Idowu OA1, Sanusi AA, Eyelade OR.
Author information

Abstract
BACKGROUND:
Intrathecal opioids have gained popularity in obstetrics; they augment the analgesia produced by local anaesthetic agents. The aim of this study is to determine the duration of analgesia following addition of fentanyl to bupivacaine during elective Caesarean section.

METHOD:
This is a prospective randomized study comparing the effect of addition of 25 microg of fentanyl to 2.5 mls of 0.5% hyperbaric bupivacaine intrathecally on sixty healthy women of American Society ofAnaesthesiologist (ASA) physical status I scheduled for elective Caesarean section at the UCH, Ibadan. Patients were randomized to group B, n=30 and group FB, n=30. Maternal heart rate, blood pressure, respiratory rate, sensory level, motor block, pain score (NRS) and side effects were observed every 2 minutes for first 15 minutes, then at 5 minutes interval for the remainder of the operation. Thereafter at 30 minutes interval until the first complaint of pain.

RESULTS:
Complete analgesia (time from injection of intrathecal drug to first report of pain) lasted longer in group FB (240 +/- 29 minutes) than group B (99 +/- 12 minutes) with a p-value of 0.002. The duration of effective analgesia (time from injection of intrathecal drug to first request for analgesic) in group FB (276 +/- 26 minutes) while group B was (121 +/- 10 minutes) with a p-value of 0.001. Both were statistically significant.

CONCLUSION:
We conclude that the addition of 25 microg of fentanyl to bupivacaine intrathecally for elective Caesarean section increases the duration of complete and effective analgesia thereby reducing the need for early postoperative use of analgesics.
Click to expand...

I'm not talking about a C/S. That's a whole 'nother ballgame. Try to stay with me here old man 😉:poke:
 
partydoc said:
Because they think the Duramorph will cause urinary retention and prevent the patient from going home pod 1 or 0 or whatever their place does
Click to expand...
We routinely put in 0.1 mg duramorph in our total joints and have had no issues with retention or the ability to go home the next day which the vast majority of our patients do. We tried to get rid of it but pain became a bigger issue and we started again. It works great in our experience. We do not use fent as I'm not sure what it adds. We adjust duration based on 0.5 bupi volume and will go as low as 1.2 ml for our fast surgeons and as high as 3ml for the slowest guys. In our experience 3ml gets you a solid 4+hrs of anesthesia which is usually more than enough.
 
OP this is not a problem even with a slow surgeon in academics. SAB with 0.5% bupi or tetracaine if your facility has it. I don't use fentanyl either for the joints but duramorph yes :0
 
I would do a CSE if the surgeon is fast or an epidural + GA if he's slow.
facted are you really doing bilateral joints that go home the next day? Even sending a majority of single joints home the next day is interesting. What kind of population do you have? I have a hard time picturing obese 70+ y/o being sufficiently functional to go home the next day.
 
dhb said:
I would do a CSE if the surgeon is fast or an epidural + GA if he's slow.
facted are you really doing bilateral joints that go home the next day? Even sending a majority of single joints home the next day is interesting. What kind of population do you have? I have a hard time picturing obese 70+ y/o being sufficiently functional to go home the next day.
Click to expand...
Sorry to be unclear. None of our surgeons are doing bilateral joints these days. I meant for one-sided.
 
facted said:
We routinely put in 0.1 mg duramorph in our total joints and have had no issues with retention or the ability to go home the next day which the vast majority of our patients do. We tried to get rid of it but pain became a bigger issue and we started again. It works great in our experience. We do not use fent as I'm not sure what it adds. We adjust duration based on 0.5 bupi volume and will go as low as 1.2 ml for our fast surgeons and as high as 3ml for the slowest guys. In our experience 3ml gets you a solid 4+hrs of anesthesia which is usually more than enough.
Click to expand...

I'm not arguing with you about your outcomes, I'm just saying why these surgeons don't like it (at least at our place). They have one bad experience and that screws it up for everyone else. We all know there's several reasons to have urinary retention, but it has to be because of the narcotic in the spinal.

And come on, these guys don't know the difference between fentanyl or Duramorph, it's just narcotic to them.
 
As above, I don't see any reason to not do a neuraxial technique. I might do a CSE just to have a safety net in case my surgeon takes a bit longer.

Also AC blocks at the end to add a couple extra hours of post-op coverage.
 
As far as the narcotic issue goes, this is private practice and our group covers this orthopedic group both in hospital and at a surgery center. We don't put narcotic in the spinal because the want the patient ambulating after surgery if possible. Most of the TKA, get send home the following day. The surgery only lasted 3 hours total. Arguing with the surgeon about the narcotic issue in the spinal is no win situation, especially in Private Practice. Anesthesia Resident don't understand this because everything is slower in an academic center. I ended up using a LMA with bilateral saphenous nerve block with decadron. Patient did fine postop, once again the surgery last only 3 hours.
 
Doughy315 said:
As far as the narcotic issue goes, this is private practice and our group covers this orthopedic group both in hospital and at a surgery center. We don't put narcotic in the spinal because the want the patient ambulating after surgery if possible. Most of the TKA, get send home the following day. The surgery only lasted 3 hours total. Arguing with the surgeon about the narcotic issue in the spinal is no win situation, especially in Private Practice.
Click to expand...
Agree about arguing not worth it. But showing them data it works helps. I'm also in PP and my patients ambulate same day and go home next day. Duramorph is totally fine for all of that. Then again, we're using small dose of 0.1mg
 
I readily admit that IT fentanyl is unnecessary for joints and it won't make or break the anesthetic (although I do think it adds a nice touch of analgesia as the numbness fades), but not using IT fentanyl because your surgeons don't like Duramorph is one of the more ******ed things I've read on this board in quite a while.
 
dhb said:
How are these patient getting adequate help at home was the question
Click to expand...

I would guess only the real strong candidates go home that early and the higher risk/older/fatter get to stay in hospital for the usual 2-3 days and some even do a stint in inpatient rehab before home.
 
SaltyDog said:
I would guess only the real strong candidates go home that early and the higher risk/older/fatter get to stay in hospital for the usual 2-3 days and some even do a stint in inpatient rehab before home.
Click to expand...
Well they said a majority was going home the next day, which i would find difficult to achieve in the population i see for TKA.
 
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