How much LA are your orthopods using for total joints?

[sevoflurane]

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For let's say TKA and THA's?

They are really heavy around here... I'm wondering what other practices are seeing.

They want to use about 170mls/350 mg of ropivicaine with epi and toradol for skin and joint. That is a lot considering the max dose is about 250mg w/o epi. I usually persuade them to cut their cocktail in half... especially if I'm adding a regional block to the mix. At the very least, I bet 170mls into a knee has a negative effect on ROM.

I believe there are some studies out there that say this practice is OK. Our orthopods say this is not uncommon in their circles of colleagues.

My thought is that it is unnecessary if you are doing regional... but they insist on adding their own mixture.

Any thoughts?

 

[SleepIsGood]

For let's say TKA and THA's?

They are really heavy around here... I'm wondering what other practices are seeing.

They want to use about 170mls/350 mg of ropivicaine with epi and toradol for skin and joint. That is a lot considering the max dose is about 250mg w/o epi. I usually persuade them to cut their cocktail in half... especially if I'm adding a regional block to the mix. At the very least, I bet 170mls into a knee has a negative effect on ROM.

I believe there are some studies out there that say this practice is OK. Our orthopods say this is not uncommon in their circles of colleagues.

My thought is that it is unnecessary if you are doing regional... but they insist on adding their own mixture.

Any thoughts?

170 mls!! wtf? I thought it causes wound issues and degradation of joint issues when that much local is applied DIRECTY into the joint. Regional Ansthesia (what we do) I thought avoids these issues. Plus given its a joint, i'm surprised orthopods are using "toradol' a well.

 

[sevoflurane]

Yes, yes, and yes....I know.. it sounds like a lot.. and I believe it is too much. However, this practice is out there. No doubt. It existed at my practice before I arrived although I am attempting to change it. I would like to know more about what others are doing before I have our Anesthesia/Orthopedics meeting next month.

Doing a quick literature search, it seems that the cocktail being used consists of:

170 ml of .2% rop. + 30mg of toradol + .1mg of epi.= what I've seen most when they use "high infiltration local anesthesia".

Here is a comparison BTW/ local anesthesia and epidural anesthesia done in Sweden:

http://www.orthosupersite.com/view.asp?rID=60132

How much do your surgeons use?? Or do they? (skin, posterior compartment, lat. compartment etc..)

 

[SleepIsGood]

Yes, yes, and yes....I know.. it sounds like a lot.. and I believe it is too much. However, this practice is out there. No doubt. It existed at my practice before I arrived although I am attempting to change it. I would like to know more about what others are doing before I have our Anesthesia/Orthopedics meeting next month.

Doing a quick literature search, it seems that the cocktail being used consists of:

170 ml of .2% rop. + 30mg of toradol + .1mg of epi.= what I've seen most when they use "high infiltration local anesthesia".

Here is a comparison BTW/ local anesthesia and epidural anesthesia done in Sweden:

http://www.orthosupersite.com/view.asp?rID=60132

How much do your surgeons use?? Or do they? (skin, posterior compartment, lat. compartment etc..)

at our institution, surgeons put NO local at all. They rely on our blocks, which they've been very happy with. My institution used to NOT allow blocks for several reasons. now they welcome blocks like crazy after seeing the results (the surgeons are requesting them).

I would site the literature that shows increased wound infections/healing problems. I'm sure they are trying to do this to some how bill for 'pain mgt'. ...

 

[sevoflurane]

Here is another one... This one is 400mg of ropivicaine... and it's comparing intrathecal morphine.

http://clinicaltrialsfeeds.org/clinical-trials/show/NCT00992082

Look under interventions... 😱

Anyways.. here are some things to consider:

1) Too much local being used. Ropivicaine is still cardiotoxic.
2) Some cocktails I read on the net stated there was as much as .5 mg of epi into 170mls.... way too much for the 70 y/o going for TKA.
3) Passive ROM can't be any better with that much volume
4) Wound healing as stated above can't be better with all that edema, not to mention nerve compression in the joint by stated volume.
5) Chondrolysis?
6) Toradol into the joint?

Could probably add a couple more to the list.... Still wondering what goes on out there in other practices.

I agree. No local needed. PNB's always do the trick. It is hard to convince some old timer orthopods that their interventions are not necessary. Unless... they can prove me otherwise.

 

[Noyac]

Our surgeons don't use any if we place a block. If we didn't place one they put in about 30cc of 0.25% Marcaine.