Regional Gurus- Need Help Dev Outpatient Total Joint Program

[masterPain]

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We are having extended stays for our total joints, lasting two and three days. I know the new literature shows appropriate regional anesthesia can get them out within 23 hours, which seems standard for most orthopedic hospitals.

I haven’t done full-time general Anesthesia for three or four years now. Typically for TKA, I would perform adductor canal with iPack. I know some people started performing ultrasound guided genicular blocks. For THA, I would do fascia iliaca, however, you would get femoral nerve involvement. I then started doing PENG blocks for motor sparing purposes. For reverse total shoulder arthroplasty, I would float interscalene perineural catheter with OnQ balls.

I know a lot of the above has been improved with use of liposomal bupivacaine.

Your help is much appreciated!

 

[CopaceticOne]

TKA = spinal + iPACK SS + ACB catheter
THA = spinal
Shoulder = GA + interscalene (catheter vs exparel depending on the patient)

OnQ for the catheters. At least 50% leg joints are same day discharge.

 

[2019medstudent]

See if your surgeons will do R.E.C.K joint injections. Their joint patients leave the same day and we haven’t needed to do any rescue blocks or catheters for a few years. For shoulders, we do exparel and no catheters

 

[pgg]

TKA = spinal + iPACK SS + ACB catheter
THA = spinal
Shoulder = GA + interscalene (catheter vs exparel depending on the patient)

OnQ for the catheters. At least 50% leg joints are same day discharge.

I'm surprised anyone is still doing catheters for these cases. Kudos if you've got the bandwidth to do them and the buy-in from everyone else. I haven't even seen a take-home nerve block pump in at least 10 years.

Here - single shot blocks + opioids + GA + same day discharge.

IMO there's no point to doing a spinal for a TKA for outpatients, since you can't use intrathecal morphine. Put them to sleep and be done with it.

 

[masterPain]

See if your surgeons will do R.E.C.K joint injections. Their joint patients leave the same day and we haven’t needed to do any rescue blocks or catheters for a few years. For shoulders, we do exparel and no catheters

Do you still do regional nerve blocks with the R.E.C.K. injections?

 

[Lab Lover]

Mepivacaine Isobaric Spinals for THA and TKA. +/- single shot ACB with 10ml exparel and 10ml 0.5% Bupivacaine.

 

[JoelJoel84]

Mepivacaine Isobaric Spinals for THA and TKA. +/- single shot ACB with 10ml exparel and 10ml 0.5% Bupivacaine.

Absolutely what I do as well , except for 20ml Exparel and 10 ml 0.5% Bupi. IV decadron as well.

Not one complaint from a single patient or surgeon over 5 years, and I’ll often call the patient to follow up out of curiosity and they maybe took one Oxy on POD 3, with Motrin and Tylenol.

They wake up super clear and fresh in PACU from low dose propofol gtt, working with Pt right away and home within 2 hours post op.

We’ll do 5-6 TKAs and be done by 3pm, with all patients home by 5pm.

 

[Howard888]

Yeah you are a real outlier. 80% of our joints go home same day. Average pacu time 140 minutes.

Is it your surgeons?

 

[Howard888]

And catheters are dead. Exparel or zynrelef. The only people I know doing catheters still are just trying to milk the extra units

 

[Ashers]

I work in a hospital with a lot of catheters. I asked why they won't use exparel, and they said "it doesn't work. We tried it." I have absolutely seen exparel work, but i couldn't convince them. I don't have that many more days with them (job change!) Before working here, I hadn't done a catheter since residency, and i did none in my regional fellowship.

 

[CopaceticOne]

And catheters are dead. Exparel or zynrelef. The only people I know doing catheters still are just trying to milk the extra units

For joints, I don’t disagree with you. I’m stuck doing what everyone I work with does for the sake of consistency.

For amps, I think catheters are the best choice.

 

[Hoya11]

We are having extended stays for our total joints, lasting two and three days. I know the new literature shows appropriate regional anesthesia can get them out within 23 hours, which seems standard for most orthopedic hospitals.

I haven’t done full-time general Anesthesia for three or four years now. Typically for TKA, I would perform adductor canal with iPack. I know some people started performing ultrasound guided genicular blocks. For THA, I would do fascia iliaca, however, you would get femoral nerve involvement. I then started doing PENG blocks for motor sparing purposes. For reverse total shoulder arthroplasty, I would float interscalene perineural catheter with OnQ balls.

I know a lot of the above has been improved with use of liposomal bupivacaine.

Your help is much appreciated!

single shot blocks with bupi 0.5 and decadron mixed in, 30ml

you dont need catheters or exparel

 

[UscGhost]

single shot blocks with bupi 0.5 and decadron mixed in, 30ml

you dont need catheters or exparel

Generally this.

Data still seems pretty ambivalent towards exparel vs bupiv plus dex.

Anecdotal, its all over the place

 

[DocVapor]

I just want to say that it is very surgeon-dependent too.

@JoelJoel84 likely has amazingly efficient and good surgeons which leads to their success.

My place? Lucky to get a 2 and a half arthroplasty's done by 3 pm (and the surgeon has a flip room / PA closes).

Doesn't matter what we do. Some patients go home same day. Most don't.

 

[Simba1711]

single shot blocks with bupi 0.5 and decadron mixed in, 30ml

you dont need catheters or exparel

Since it is for post op pain and patient is getting spinal or ga 0.25% bupi with iv 8-10 mg decadron is more appropriate. You don’t need a surgical block. The block duration will be very similar between 0.5 and 0.25.

10cc for acb and 20cc for ipack

20cc for Peng

 

[caligas]

We just do spinals and about 75% go home same day 🤷‍♂️

 

[Maz777]

Exparel is a waste of money. Equivalent or maybe even worse than a plain bupi block (it's like doing a watered-down block). Definitely not better than a well-placed catheter (only if you compare them to ****ty catheters).

You have to be pretty damn good and facile to do catheters. Most are not and don't want to deal with the headache of managing catheters. Plus, the prolonged quad weakness is not desirable for postop ambulation/recovery at home. If you are doing good adductors, you will be getting a decent degree of quad weakness postop whether you appreciate it or not.

Blocks for THAs are pointless. Spinal.

For TKAs, mepi spinal, single-shot ACs, and good patient selection is all you need here.

TSAs benefit from IS catheters but again you have to be really good to get a proper result (even more so than an AC catheter). Anyone can thread a ****ty catheter into the belly of MS that will just cause you more headache than doing a single-shot IS.

 

[BLADEMDA]

I have worked in several outpatients centers doing total joints including a high volume center (30+ totals per week). The concepts posted here are all correct in that they work for the individual center and that group of surgeons. For example, Mepivacaine Spinals (work great) vs GA under 1.5 hours (also works great). Discharge times are typically under 1.5 hours either way with GA actually being a little shorter. As for blocks KISS as many have posted on here. I want to add that since I began making sure I am blocking the nerve to vastus medialis along with the saphenous nerve the post op pain control is significantly better. I recommend you all add that to your "adductor canal" block.

 

[BLADEMDA]

We just do spinals and about 75% go home same day 🤷‍♂️

Spinal or GA and 99.9% go home from the ASC the same day and 95% within 2 hours. YMMV but that is where you try things at your ASC to both shorten stay while maintaining quality (post op pain relief). I want to add that 90% are 70+ years old and ASA 3.