Epidural for knee procedures

[B-Bone]

One of my partners had a unique situation yesterday that has me considering using an epidural as a primary anesthetic for knee procedures (ACL, TKA, etc). However, I have never used an epidural as a primary anesthetic for anything other than a c-section or a perc neph tube. How does one dose it? Lido or bupi? What concentration? How much? I imagine it takes less than a c-section, but just wondering where folks start. Anyway, any input would be much appreciated.

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[Urzuz]

One of my partners had a unique situation yesterday that has me considering using an epidural as a primary anesthetic for knee procedures (ACL, TKA, etc). However, I have never used an epidural as a primary anesthetic for anything other than a c-section or a perc neph tube. How does one dose it? Lido or bupi? What concentration? How much? I imagine it takes less than a c-section, but just wondering where folks start. Anyway, any input would be much appreciated.

We used to do CSEs for our bilateral knees in training. I can't say I've ever done an epidural for an ACL or unilateral TKA (though perhaps for a revision knee that the surgeon knew was going to take forever?). Care to share what the situation was your partner was in?

Most of the time if you want neuraxial anesthesia for a knee, a single shot spinal should be the way to go (just like a C-section). And, if you think the knee will take a long time, CSE would be superior to a straight epidural.

That being said, if I had to dose an epidural for a surgical block, I would do it the same way we do for C-sections, as you need surgical anesthesia and I don't think it would be any less than a C-section. I would start with giving 10 ml of 2% lidocaine and go from there.

 

[B-Bone]

The case was an ACL at an outpt surgery center in a surgeon who takes about 3 hrs. Pt really preferred spinal (and happened to be one of my other partner's sons). He was first case of the day. got SAB with 1.6 cc 0.75% bupivacaine. case done at 10:30; pt unable to walk until about 3:00 pm. Usually only do chloroprocaine spinals at the surgery center, and would have done a GA in this case for anybody else.

 

[nimbus]

The case was an ACL at an outpt surgery center in a surgeon who takes about 3 hrs. Pt really preferred spinal (and happened to be one of my other partner's sons). He was first case of the day. got SAB with 1.6 cc 0.75% bupivacaine. case done at 10:30; pt unable to walk until about 3:00 pm. Usually only do chloroprocaine spinals at the surgery center, and would have done a GA in this case for anybody else.

Great example of "VIP treatment" leading to worse outcome.

 

[Noyac]

that happens from time to time. It's the reason most people don't do spinals very often in out-pt cases.

You could do a FNB/SNB combo and sedation but I wouldn't recommend that routinely. I did a TKA this way.

 

[BLADEMDA]

that happens from time to time. It's the reason most people don't do spinals very often in out-pt cases.

You could do a FNB/SNB combo and sedation but I wouldn't recommend that routinely. I did a TKA this way.

LMA with Des or Sevo and no Nitrous. Adductor Canal block preop and popliteal/tibial post op if needed. I've had anesthesia multiple times and although Propofol IV is superior to an LMA with Vapor it isn't THAT much better to those of us (vast majority) who don't get N/V from Inhalational agents. Unless high risk I avoid Epidural/SAB for outpatients; that said, I do a lot of high risk patients who do get Neuraxial anesthesia.

 

[BLADEMDA]

Anesth Analg. 2000 Oct;91(4):860-4.
A comparison of spinal, epidural, and general anesthesia for outpatient knee arthroscopy.
Mulroy MF1, Larkin KL, Hodgson PS, Helman JD, Pollock JE, Liu SS.
Author information

Abstract
We compared general, epidural, and spinal anesthesia for outpatient knee arthroscopy (excluding anterior cruciate ligament repairs). Forty-eight patients (ASA physical status I-III) were randomized to receive either propofol-nitrous oxide general anesthesia with a laryngeal mask airway with anesthetic depth titrated to a bispectral index level of 40-60, 15-20 mL of 3% 2-chloroprocaine epidural, or 75 mg of subarachnoid procaine with 20 microg fentanyl. All patients were premedicated with <0.035 mg/kg midazolam and <1 microg/kg fentanyl and received intraarticular bupivacaine and 15-30 mg of IV ketorolac during the procedure. Recovery times, operating room turnover times, and patient satisfaction were recorded by an observer using an objective scale for recovery assessment and a verbal rating scale for satisfaction. Statistical analysis was performed with analysis of variance and chi(2). Postanesthesia care unit discharge times for the general and epidural groups were similar (general = 104+/-31 min, epidural = 92+/-18 min), whereas the spinal group had a longer recovery time (146+/-52 min) (P = 0.0003). Patient satisfaction was equally good in all three groups (P = 0.34). Room turnover times did not differ among groups (P = 0.16). There were no anesthetic failures or serious adverse events in any group. Pruritus was more frequent in the spinal group (7 of 16 required treatment) than in the general or epidural groups (no pruritus) (P<0.001). We conclude that epidural anesthesia with 2-chloroprocaine provides comparable recovery and discharge times to general anesthesia provided with propofol and nitrous oxide. Spinal anesthesia with procaine and fentanyl is an effective alternative and is associated with a longer discharge time and increased side effects.

IMPLICATIONS:
For outpatient knee arthroscopy, anesthesia can be provided adequately with regional or general anesthesia. Epidural and general anesthesia provide equal recovery times and patient satisfaction, whereas spinal anesthesia may prolong recovery and have increased side effects. The choice of anesthesia may depend primarily on the patient's interest in being alert or asleep during the procedure.

 

[Planktonmd]

To answer the original question: You can very well do a knee arthroplasty or arthroscopy with an epidural and the medication choice could be Lidocaine 2% or Bupivacaine 0.5% titrated to the desired level.
This could be a good technique if you want to do a neuraxial anesthetic but you don't think a spinal is appropriate or well tolerated due to patient's morbidities.
For your example "ACL in ambulatory surgery center" I would have done a femoral block + LMA regardless of the VIP status of the patient.

 

[urge]

One of my partners had a unique situation yesterday that has me considering using an epidural as a primary anesthetic for knee procedures (ACL, TKA, etc). However, I have never used an epidural as a primary anesthetic for anything other than a c-section or a perc neph tube. How does one dose it? Lido or bupi? What concentration? How much? I imagine it takes less than a c-section, but just wondering where folks start. Anyway, any input would be much appreciated.

Really? Your program never did a straight epidural for below the belly cases? Weird.

Every once in a blue moon my attendings would do an epidural for laparoscopy on professional singers.

 

[Ignatius J]

CSE on a total knee with a long surgeon is a trap. A one-sided epidural can make that a pain in the ass very quickly.

I do knees with a surgeon who wants an epidural catheter. I just do straight up epidural and test well beforehand. I don't have the patience to be trouble shooting my epidural while the orthopod is hammering in the new prosthesis. Been here, done that. Got the t-shirt. Cursed myself and said I wouldn't do it again.

 

[kmurp]

Group near us that runs two high volume ortho surgery centers does almost all outpatient knee scopes with epidurals. Not sure what drug they use. I would guess either 1.5 lido with epic or 1.5 mepivacaine? One of their guys told me he uses chloroprocaine for one very fast surgeon. 1.5% mepivacaine spinal would work as well but I would imagine if you’re high volume you would eventually see too many PDPHA in a population that trends younger.
The risk of a headache is low with the spinal TKR patients and toxicity with epidural local and the large volume of injection by the surgeon would likely lead to problems.

 

[Hoya11]

Group near us that runs two high volume ortho surgery centers does almost all outpatient knee scopes with epidurals. Not sure what drug they use. I would guess either 1.5 lido with epic or 1.5 mepivacaine? One of their guys told me he uses chloroprocaine for one very fast surgeon. 1.5% mepivacaine spinal would work as well but I would imagine if you’re high volume you would eventually see too many PDPHA in a population that trends younger.
The risk of a headache is low with the spinal TKR patients and toxicity with epidural local and the large volume of injection by the surgeon would likely lead to problems.

seems crazy to me to do an epidural for a knee scope.. lma and less than 100 of fentanyl and its over in 20 minutes.. your going to stab someone in the back with a tuohy to avoid that plan?

 

[Ezekiel2517]

Epidurals for knee scopes? Lol. This is what you get when you allow completely clueless people to choose their anesthetic. This isn't Mcdonalds.

 

[facted]

Like much of medicine... You COULD do that, but why on Earth would you?

 

[deleted171991]

Like much of medicine... You COULD do that, but why on Earth would you?

 

[kmurp]

I think they do it so there’s never a holdup waiting for them to be present for induction when they are busy putting in an ISB on another patient. They believe that it maximizes their thruput. I realize they are a couple standard deviations from the mean, but they have set the standard in our area. Perhaps they do it this way at the hospital for special surgery as well?
I’d be interested in hearing others experiences from ortho only surgicenters.

 

[kmurp]

Epidurals for knee scopes? Lol. This is what you get when you allow completely clueless people to choose their anesthetic. This isn't Mcdonalds.

I think they do spinals or epidurals for most of their knee scopes at HSS. I’d be interested to hear from anyone who has worked there how they avoid post dural puncture headaches.

 

[facted]

I think they do spinals or epidurals for most of their knee scopes at HSS. I’d be interested to hear from anyone who has worked there how they avoid post dural puncture headaches.

They also put Central lines and A lines in most of their total joints (no joke). Again... You can do it, but why on Earth would you?!?

 

[IMGASMD]

They also put Central lines and A lines in most of their total joints (no joke). Again... You can do it, but why on Earth would you?!?

Practice ultrasound skills? Or promote culture of “safety”? I can just see someone telling the patient we put all the available monitors on you so we can monitor you the best there is to offer.....
And obviously charge everyone of the patients for TLC and A-line placement... 4 units extra?

 

[nimbus]

They also put Central lines and A lines in most of their total joints (no joke). Again... You can do it, but why on Earth would you?!?

https://www.hss.edu/Anesthesiology-anesthesia-hip-arthroplasty.pdf

Surely things have evolved since this very old reference, but if you’re putting every total hip patient on an epi infusion, you’d need a cvp+Aline too😉

 

[kmurp]

They also put Central lines and A lines in most of their total joints (no joke). Again... You can do it, but why on Earth would you?!?

I’m thinking it’s an efficiency issue. No induction or emergence time might allow one extra case to be scheduled per day. There would also never be a holdup waiting for the Anesthesiologist to be present for a medically directed induction.

 

[Urzuz]

I’m thinking it’s an efficiency issue. No induction or emergence time might allow one extra case to be scheduled per day. There would also never be a holdup waiting for the Anesthesiologist to be present for a medically directed induction.

How long are your inductions/wake ups that you would save enough time to do another case by doing an epidural before every knee scope?!?

 

[facted]

Practice ultrasound skills? Or promote culture of “safety”? I can just see someone telling the patient we put all the available monitors on you so we can monitor you the best there is to offer.....
And obviously charge everyone of the patients for TLC and A-line placement... 4 units extra?

I heard it was for billing reasons but of course they talk about how great the epi infusion is at reducing blood loss.

They talk less about the complications. Know an attending that did a grand rds there and that day, they had a pt transferred to Cornell after a total joint for bowel ischemia...

 

[Psai]

They also put Central lines and A lines in most of their total joints (no joke). Again... You can do it, but why on Earth would you?!?

I like doing procedures and I also like billing

 

[IMGASMD]

I heard it was for billing reasons but of course they talk about how great the epi infusion is at reducing blood loss.

They talk less about the complications. Know an attending that did a grand rds there and that day, they had a pt transferred to Cornell after a total joint for bowel ischemia...

Ding ding ding! I certainly don’t have first hand knowledge, didn’t train at big name places.

I also can see someone along the way justify everything with less OR time, as you pointed out, and “better safety” with more lines. If they do it enough, have a preop team, placing lines and epi under ultrasound. Sounds like close to 10 (?) units before you even get into OR? Since I have a feeling maybe I would still like to do the case under MAC with a little prop. This case just sounds better and better......

Disclaimer: purely speculation.

 

[T-burglar]

I remember hearing about HSS’s practice a while ago and it is 100% about extra money with no benefit to the patient. I would only agree to solid peripheral access for my own total hip unless I had some kind of mortal end stage cardiac condition

 

[facted]

I like doing procedures and I also like billing

Who doesn't?

I also like doing right by my patients and sticking their neck, putting an Aline in, and running them on epi for a total joint is far from doing right. It's egregious and immoral (and not without risk).

 

[nimbus]

Who doesn't?

I also like doing right by my patients and sticking their neck, putting an Aline in, and running them on epi for a total joint is far from doing right. It's egregious and immoral (and not without risk).

How about a PA catheter? From the Sharrock paper.

“Pulmonary artery catheters may also be used to identify intraoperative pulmonary emboli (Fig. 3). When pulmonary emboli enter the pulmonary vasculature, pulmonary artery pressure increases[181. The timing and perhaps the degree of the embolization can be characterized with pulmonary artery catheters. In our experience, about 20-30% of patients who have a cemented femoral prosthesis inserted have significant increases in pulmonary artery pressure shortly following insertion of the femoral prosthesis. Patients who have insertion of long-stem prostheses have the highest risk of acute circulatory collapse from acute pulmonary emboli. This may result in cardiac arrest. For these reasons we recommend monitoring those patients undergoing cemented long-stem total hip arthroplasties with arterial and pulmonary artery catheters(Fig. 4) [1.9'].“

Anybody try this in PP?

 

[kmurp]

How long are your inductions/wake ups that you would save enough time to do another case by doing an epidural before every knee scope?!?

Well, I guess it’s maybe 3-4 minutes on the induction side and five minutes or less on emergence. If one could save five minutes per case with seven turnovers, you could do one extra knee scope before 3:30.

 

[facted]

How about a PA catheter? From the Sharrock paper.

“Pulmonary artery catheters may also be used to identify intraoperative pulmonary emboli (Fig. 3). When pulmonary emboli enter the pulmonary vasculature, pulmonary artery pressure increases[181. The timing and perhaps the degree of the embolization can be characterized with pulmonary artery catheters. In our experience, about 20-30% of patients who have a cemented femoral prosthesis inserted have significant increases in pulmonary artery pressure shortly following insertion of the femoral prosthesis. Patients who have insertion of long-stem prostheses have the highest risk of acute circulatory collapse from acute pulmonary emboli. This may result in cardiac arrest. For these reasons we recommend monitoring those patients undergoing cemented long-stem total hip arthroplasties with arterial and pulmonary artery catheters(Fig. 4) [1.9'].“

Anybody try this in PP?

This isn't for total joints, it's for a long stem fx case. This does not apply to what HSS is doing for elective total joints.

But are you REALLY advocating putting a PA catheter in every long stem fx? These pts should definitely get an Aline, but how does a PA catheter help you if they have a PE? If they collapse, you already know the mechanism, no???

 

[nimbus]

This isn't for total joints, it's for a long stem fx case. This does not apply to what HSS is doing for elective total joints.

But are you REALLY advocating putting a PA catheter in every long stem fx? These pts should definitely get an Aline, but how does a PA catheter help you if they have a PE? If they collapse, you already know the mechanism, no???

No I think it’s insane.

 

[Psai]

The swan is probably causing the pes theyre catching lol

 

[fakin' the funk]

Uhhhh what in the holy hell are they doing at HSS?

THAs on healthy people coming from home are isobaric spinal, 1 PIV maybe 2 if the first is sketchy, home as early as the next day, or POD2-3.

 

[Psai]

Uhhhh what in the holy hell are they doing at HSS?

THAs on healthy people coming from home are isobaric spinal, 1 PIV maybe 2 if the first is sketchy, home as early as the next day, or POD2-3.

They're not the top orthopaedic hospital for no reason