FNB vs epidural post op pain in TKR

[aged2]

---

Members do not see this ad.

What does anyone prefer for post op pain control in TKR, three in one or epidural? I have had good results with the 3 in 1 with adequate analgesia greater then 24 hrs using a single shot 3 in 1 with 20 cc .5% bupivacaine.
I prefer the 3 in 1 I think it easier and faster to place gives more mobility to the patient post-op, avoids the need for foley cath post op and results in less hassle from the floor regarding the epidural. Thoughts? Anyone aware of a study favoring one over the other?

 

[pmichaelmd]

What does anyone prefer for post op pain control in TKR, three in one or epidural? I have had good results with the 3 in 1 with adequate analgesia greater then 24 hrs using a single shot 3 in 1 with 20 cc .5% bupivacaine.
I prefer the 3 in 1 I think it easier and faster to place gives more mobility to the patient post-op, avoids the need for foley cath post op and results in less hassle from the floor regarding the epidural. Thoughts? Anyone aware of a study favoring one over the other?

I prefer femoral and sciatic PNBs. I use 30-ml 0.5% ropivacaine in the femoral and 20-ml of the same in the sciatic. Ideally, catheters inserted in both sites with a continuous infusion of 0.2% ropivacaine at 8-ml/hr with an 8-ml PCA bolus dose every 60 minutes. Sciatic can be boluses in the evening with 6-mL 0.2% rop to tide the patient over until the AM, when it is time to start PT and ambulation.

Xavier Capdevila did most of the studies on PNBs vs epidurals vs PCA. Search that name out and you shall find all of the info you could want.

Cheers,
PMMD

 

[toughlife]

What does anyone prefer for post op pain control in TKR, three in one or epidural? I have had good results with the 3 in 1 with adequate analgesia greater then 24 hrs using a single shot 3 in 1 with 20 cc .5% bupivacaine.
I prefer the 3 in 1 I think it easier and faster to place gives more mobility to the patient post-op, avoids the need for foley cath post op and results in less hassle from the floor regarding the epidural. Thoughts? Anyone aware of a study favoring one over the other?

The last edition of the AANA journal has a good article on it.

 

[bubalus]

Continuous FNB with 20-30 ml .25% bupiv and infusion of 5 ml/hr .25% bupiv. No complicated nerve block PCA. Single shot pop fossa with .125% bupiv 10-15 ml if you want to be nice and the surgeons are cool with it. The .125% will provide good sensory relief, but keep motor intact to keep the surgeons happy. That posterior pain seems to be the worst during the first day. Our knees are up and ambulating in an immobilizer with their block that evening if they were done in the AM. Add some scheduled tylenol and low dose oxycontin (like 10) Q12 with PRN oxycodone, and they're doing well. I can't tell you how many of my patients say, "What pain?" when I rounded on them post op. Without the pop fossa, they have a little posterior pain, but very few complain.

 

[nchhabra]

i agree with continuous fem and scaitics. we use the same regimen as pmichaelmd. 30 cc of 0.5% ropi bolus fem and 20ish cc 0.5% ropi for the sciatic. i prefer both catheters if possible. antectodetally, if i only get the fem in pre-op due to time, most patients come out needing the sciatic post-op. the ones that get both preop, have a very nice anesthetic intraop - prop/lma/little sevo/1-2cc fent if they get a tube, incredibly stable, pain free. infusions of 0.2% ropi post op - fem @ 7-8cc/hr, sciatic @ 4 cc/hr. at the va, dont have an option for an on demand dose, so just continuous. all have been able to ambulate/pt without motor block. also, it avoids a lot of the anticoag problems with epidurals. all our knees get lovenox + coumadin, started dos, and we like to give them 48 hours with the catheters.

 

[Gator05]

Agree with the above. Alternative for sciatic is to have the surgeon injection the posterior joint with LA, seems to work well.

We'll also sometimes supplement with lateral femoral cutaneous block, just to get a little more coverage.

Are you all doing anterior or posterior approaches for your sciatics?

 

[nchhabra]

Agree with the above. Alternative for sciatic is to have the surgeon injection the posterior joint with LA, seems to work well.

We'll also sometimes supplement with lateral femoral cutaneous block, just to get a little more coverage.

Are you all doing anterior or posterior approaches for your sciatics?

posterior for the sciatics. haven't tried anterior, but it would probably save time. any experience threading catheters with the anterior approach?

 

[Planktonmd]

The last edition of the AANA journal has a good article on it.

You are kidding aren't you?

 

[epidural man]

You are kidding aren't you?

I hope he was because I laughed very hard when I read his post.