iPack, teach me!

[acidbase1]

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we didn’t do these in training. Any tips?

 

[sevoflurane]

Curvilinear probe. My go to for this block unless skinny.

Other than that... it’s super easy.

 

[acidbase1]

So inject below the popliteal artery? How much volume/what local do you use in addition to the ACB

 

[dhb]

So inject below the popliteal artery? How much volume/what local do you use in addition to the ACB

15-20cc

 

[vector2]

So inject below the popliteal artery? How much volume/what local do you use in addition to the ACB

Curvilinear probe in the fossa. Add enough depth so you can see the artery and the distal femur. Insert needle to past the artery and start injecting as you withdraw so there’s a nice transverse spread of local between artery and the joint. 15-20 cc of 0.25%

 

[acidbase1]

Do you tend to get pretty good results?

 

[CubsDynasty]

USRA - iPACK Block

 

[Noyac]

Do you tend to get pretty good results?

Fair results but with the recent distaste for FNB and Sciatic blocks, I think it helps.

 

[Planktonmd]

You can do the same block by placing the probe posterior to the knee and inserting the needle from lateral to medial like you do for a lateral popliteal block only go anterior to the artery

 

[deleted162650]

It’s more convenient to do it medial to lateral while you already have them frog-legged for the ACB.

 

[J Peterman]

It’s more convenient to do it medial to lateral while you already have them frog-legged for the ACB.

Same, always with the curvilinear. Externally rotate the leg, do ACB with whatever probe allows you to see the anatomy (in the real morbedos using the curvi)...

Then for IPACK place the curvilinear transverse just above medial femoral condyle to visualize the Popliteal artery & posterior compartment. It’s a steep angled medial to lateral (superficial to deep) needle insertion but curvilinear is ideal for that & you don’t move their leg or bother putting the probe in the fossa. I use a 30cc vial of 0.5% Bupi, 15cc for the ACB, dilute the rest in 10cc of sterile saline , so 25cc ~0.25% for the IPACK. Takes minutes and works well

 

[AdmiralChz]

It’s more convenient to do it medial to lateral while you already have them frog-legged for the ACB.

Exactly how I was taught, and how I do it now. A little tricky with the small Stim Quick needles, we have a batch of Pajunks we use for them specifically.

We don't do them for those with huge tree trunk legs where the target is more than 7-8 cm away.

A few of our arthropods do their own posterior infiltration for TKA, and anecdotally it seems like those patients are more comfortable than the IPACK (both in PACU and the next day when we see them in the AM).

 

[acidbase1]

So we don’t have curvilinear probe, just go medial to lateral with a medial insertion point?

Do you guys feel an OnQ for the saphenous is worthwhile?

 

[dhb]

Do you guys feel an OnQ for the saphenous is worthwhile?

No

 

[Velefunt]

What are you guys billing CPT for iPack and adductor canal blocks? Other somatic nerve block?

 

[sevoflurane]

ACB= selective femoral nerve block at the adductor canal.

Working on language for ipack and ESB

 

[deleted162650]

ACB = femoral

IPack for now = “other peripheral nerve”

 

[kmurp]

Same, always with the curvilinear. Externally rotate the leg, do ACB with whatever probe allows you to see the anatomy (in the real morbedos using the curvi)...

Then for IPACK place the curvilinear transverse just above medial femoral condyle to visualize the Popliteal artery & posterior compartment. It’s a steep angled medial to lateral (superficial to deep) needle insertion but curvilinear is ideal for that & you don’t move their leg or bother putting the probe in the fossa. I use a 30cc vial of 0.5% Bupi, 15cc for the ACB, dilute the rest in 10cc of sterile saline , so 25cc ~0.25% for the IPACK. Takes minutes and works well

I’m having trouble when trying this with the original description of the probe on the medial leg. I’m either bouncing off the femur or when I clear the femur my needle angle is directing the tip too far posteriorly towards the vessels/tibial nerve. Using one bottle of 0.5 bupivacaine with epi diluted like you are doing.

 

[Psai]

Why curvilinear?

 

[deleted162650]

I’m having trouble when trying this with the original description of the probe on the medial leg. I’m either bouncing off the femur or when I clear the femur my needle angle is directing the tip too far posteriorly towards the vessels/tibial nerve. Using one bottle of 0.5 bupivacaine with epi diluted like you are doing.

Probe is on the back of the leg similar to a popliteal. Needle goes medial to lateral.

 

[deleted162650]

Why curvilinear?

Allows you to see the whole width of the leg on screen without having to move the probe.

 

[Velefunt]

Is the iPack good for anything else outpatient? Are y'all only using it in combo with ACB for knee replacements?

 

[dhb]

Is the iPack good for anything else outpatient? Are y'all only using it in combo with ACB for knee replacements?

ACL repair
Yes

 

[J Peterman]

I’m having trouble when trying this with the original description of the probe on the medial leg. I’m either bouncing off the femur or when I clear the femur my needle angle is directing the tip too far posteriorly towards the vessels/tibial nerve. Using one bottle of 0.5 bupivacaine with epi diluted like you are doing.

The curvilinear probe footprint is big. Move it more medially so you’re just barely seeing the posterior “shelf” of the femur almost vertically on the side of your US image with the PA off to the side in SAX. Otherwise you’ll run into the same type of fulcrum effect that can make the in plane USG parasagittal paravertebral block tricky.

The needle entry is very steep and should be right next to the edge of the transducer. With good US skills & this probe you can keep the full needle in plane and avoid being anywhere near the Popliteal.

I’m also using it for ACL’s with posterior tendon harvest.

 

[Velefunt]

And just to confirm, we're not knocking out any motor function of consequence, so rehab post-op and/or outpatient discharge isn't an issue.

Still gonna be a hard sell for my locale's orthopods. Even ACB isn't a common practice for their ACL repairs much less TKA'S.

 

[deleted162650]

I’m also using it for ACL’s with posterior tendon harvest.

The iPack is doing nothing for the hamstring graft. The iPack is blocking the tiny geniculate branches that supply the joint. The tendon/muscle/incision is innervated much higher/more proximal. Even a high popliteal isn’t always sufficient. Infragluteal sciatic block is where the money’s at if you really want to cover the graft site pain (which is often the most painful part).

 

[acidbase1]

The iPacknis doing nothing for the hamstring graft. The iPack is blocking the tiny geniculate branches that supply the joint. The tendon/muscle/incision is innervated much higher/more proximal. Even a high popliteal isn’t always sufficient. Infragluteal sciatic block is where the money’s at if you really want to cover the graft site pain (which is often the most painful part).

What I do on all my ACLs. Zero narcotic

 

[dhb]

What I do on all my ACLs. Zero narcotic

How do they walk out?

 

[deleted162650]

How do they walk out?

Knee immobilizer and crutches.

 

[dhb]

Knee immobilizer and crutches.

Foot drop?

 

[acidbase1]

How do they walk out?

No way, but they aren’t weight bearing for days/weeks so who cares?

 

[J Peterman]

The iPack is doing nothing for the hamstring graft. The iPack is blocking the tiny geniculate branches that supply the joint. The tendon/muscle/incision is innervated much higher/more proximal. Even a high popliteal isn’t always sufficient. Infragluteal sciatic block is where the money’s at if you really want to cover the graft site pain (which is often the most painful part).

Noted!