Regional Gurus- Need Help Dev Outpatient Total Joint Program

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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!
 
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
 
CopaceticOne said:
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.
Click to expand...
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.
 
2019medstudent said:
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
Click to expand...
Do you still do regional nerve blocks with the R.E.C.K. injections?
 
Mepivacaine Isobaric Spinals for THA and TKA. +/- single shot ACB with 10ml exparel and 10ml 0.5% Bupivacaine.
 
Lab Lover said:
Mepivacaine Isobaric Spinals for THA and TKA. +/- single shot ACB with 10ml exparel and 10ml 0.5% Bupivacaine.
Click to expand...

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

Is it your surgeons?
 
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.
 
masterPain said:
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!
Click to expand...

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

you dont need catheters or exparel
 
Hoya11 said:
single shot blocks with bupi 0.5 and decadron mixed in, 30ml

you dont need catheters or exparel
Click to expand...
Generally this.

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

Anecdotal, its all over the place
 
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.
 
Hoya11 said:
single shot blocks with bupi 0.5 and decadron mixed in, 30ml

you dont need catheters or exparel
Click to expand...
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
 
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.
 
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.


 
caligas said:
We just do spinals and about 75% go home same day 🤷‍♂️
Click to expand...
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.
 
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Simba1711 said:
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
Click to expand...
Disagree.

You’ll get more length with 0.5

What is the downside of 0.5?

10cc of 0.25 for acb is not appropriate imo

You guys must be doing full dose spinals and or keeping patients overnight

Peng doesn’t work.

And not all spinals are full surgical spinals in some protocols. For shoulders 0.25 is foolish.
 
BLADEMDA said:
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.


Click to expand...

There are downsides to blocking NVM for TKA patients.
 
BLADEMDA said:
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.


Click to expand...

very useful video
 
Hoya11 said:
Disagree.

You’ll get more length with 0.5

What is the downside of 0.5?

10cc of 0.25 for acb is not appropriate imo

You guys must be doing full dose spinals and or keeping patients overnight

Peng doesn’t work.

And not all spinals are full surgical spinals in some protocols. For shoulders 0.25 is foolish.
Click to expand...
You do what works for you. I get 24-36 hour block duration with quarter percent and dex. For adductor canal block I can see injecting 20cc if you are using twitch monitor to block vm and saphenous. 10cc for each nerve. Jeff gadsen the guy that made the video above recommends 0.25 percent for ipack because you risk foot drop with concentrated local.

My hip and knee patients leave the same day after their spinal wears off and pass physical therapy.

A good percentage of my knee patients dont get any narcotics intra or post op

Hip patients usually need a single dose of Percocet before going home. I would probably get better pain control if I added lateral femoral cutaneous nerve block

Shoulders I give 30cc of 0.25 percent and they also don’t get any narcotics intra or post op and go home.
 
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one of the chairs at a nearby academic hospital also told us she doesn’t think blocks are useful for hips. She just does spinal.
 
If it's one thing my storied career in anesthesia and medical training has taught me...

Whenever anyone says there's only one way to do something and reasonable options are "wrong" they're usually full of #%*$. Even when they're some of the smartest and established practitioners.
 
cchoukal said:
I watched the video but couldn’t get the sound. Did they address VM weakness and fall rate with this approach?
Click to expand...
I have performed about 100 so far and zero falls post op. I follow up on every patient. The pain control with the VM/Saphenous plus ipack or surgeon injection into the posterior capsule is very good. I will continue with this technique for all total knees/Uni knees until something better comes along. My Ortho surgeons are very satisfied with this technique and they would tell me very quickly if there were any complications. If you have a recipe which works well for you then by all means continue doing it.
 
BLADEMDA said:
I have performed about 100 so far and zero falls post op. I follow up on every patient. The pain control with the VM/Saphenous plus ipack or surgeon injection into the posterior capsule is very good. I will continue with this technique for in total knees/Uni knees until something better comes along. My Ortho surgeons are very satisfied with this technique and they would tell me very quickly if there were any complications. If you have a recipe which works well for you then by all means continue doing it.
Click to expand...
No, it’s d like something better than my ACBs, which I would say still leave some post-op pain after the spinal wears off. Dobyou stimulate, as the video suggests, or do you flood the gap and move the needle past the visible nerve?
 
cchoukal said:
No, it’s d like something better than my ACBs, which I would say still leave some post-op pain after the spinal wears off. Dobyou stimulate, as the video suggests, or do you flood the gap and move the needle past the visible nerve?
Click to expand...
I do a proximal adductor canal block. This means i Find the artery several inches proximal to the midline which makes blocking the VM nerve and Saphenous nerve easier. Second, I dissect the fascial plane just below the sartorius muscle as I work the needle towards the Saphenous nerve. This means I start about 3-4 inches distal to the saphenous nerve and work the needle towards the artery. I don't worry about stimulation as much as not hitting the nerve to the VM as I dissect the plane. With this technique of a proximal adductor canal block the 2 nerves are typically within 2 inches of each other.
 
Last edited:
It seems as the evidence for Peng blocks isn’t that convincing and I know a lot of people that stopped doing blocks for hip replacement so I get hoya11’s sentiment.

On a different note. I get several spinals a year that last an insanely long time. Like close to 6-8 hours for 3cc of 0.5% bupiviciane. Not sure what I should be doing differently or what is contributing. I have read that iv precedex can prolong spinals in the literature. Our surgeons are not fast.
 
Last edited:
Simba1711 said:
It seems as the evidence for Peng blocks isn’t that convincing and I know a lot of people that stopped doing blocks for hip replacement so I get hoya11’s sentiment.

On a different note. I get several spinals a year that last an insanely long time. Like close to 6-8 hours for 3cc of 0.5% bupiviciane. Not sure what I should be doing differently or what is contributing. I have read that iv precedex can prolong spinals in the literature. Our surgeons are not fast.
Click to expand...
3ccs is quite a big dose. How long are the cases?
 
Simba1711 said:
On a different note. I get several spinals a year that last an insanely long time. Like close to 6-8 hours for 3cc of 0.5% bupiviciane.
Click to expand...
This happened to me the other day with 1.6 mL of heavy bupivacaine. Technically, it was just residual saddle numbness as his motor Block had worn off in the usual amount of time. Fortunately, I was at a hospital, but would be a real bummer at a surgery center expecting same-day joints.
 
Simba1711 said:
It seems as the evidence for Peng blocks isn’t that convincing and I know a lot of people that stopped doing blocks for hip replacement so I get hoya11’s sentiment.

On a different note. I get several spinals a year that last an insanely long time. Like close to 6-8 hours for 3cc of 0.5% bupiviciane. Not sure what I should be doing differently or what is contributing. I have read that iv precedex can prolong spinals in the literature. Our surgeons are not fast.
Click to expand...
3cc is good for 5-6 hr revisions.

I use 1.5cc isobaric bupiv plus 20mcg fent. Pt moving feet upon pacu arrival. Home same day.
 
One great tip I’ve learned after working in high volume ortho places: place the spinal in preop, use heavy bupi, have them lie on the operative side on the way back to the OR. Learned this from an experienced anesthesiologist at one place I worked. Walk slowly, have them go all the way on the side. 1cc will get you a dense block for two hours but goes away fast, way less sympathectomy/hypotension bc the operative side gets most of the local. It takes doing the block in preop, coordinating the OR etc but if you can’t I would just do mepi for fast surgeons in the OR. Some people get ancy doing preop spinal but if the system is set up it can work nicely
 
Last edited:
Maverikk said:
One great tip I’ve learned after working in high volume ortho places: place the spinal in preop, use heavy bupi, have them lie on the operative side on the way back to the OR. Learned this from an experienced anesthesiologist at one place I worked. Walk slowly, have them go all the way on the side. 1cc will get you a dense block for two hours but goes away fast, way less sympathectomy/hypotension bc the operative side gets most of the local. It takes doing the block in preop, coordinating the OR etc but if you can’t I would just do mepi for fast surgeons in the OR. Some people get ancy doing preop spinal but if the system is set up it can work nicely
Click to expand...
i had a patient who was put on the side for spinal to set up on that side and it greatly prolonged the motor block on that side and delayed discharge, i also do 1cc but i have them stay sitting for 2 minutes and then lay down.
 
2019medstudent said:
3ccs is quite a big dose. How long are the cases?
Click to expand...
UscGhost said:
3cc is good for 5-6 hr revisions.

I use 1.5cc isobaric bupiv plus 20mcg fent. Pt moving feet upon pacu arrival. Home same day.
Click to expand...
For primary knees they usually take 2 hours of procedure time but not uncommon to go to 3 hours if they struggle.

For primary hips usually 2.5 hours but sometimes over 3 hours.

Hmm. 3cc usually lasts plus or minus 3 hours for me. I usually give 3.5 cc for knee and 4cc for hips. Everybody else in the group just does GA which is probably safer.
 
pubmed.ncbi.nlm.nih.gov

The anesthetic and recovery profile of two doses (60 and 80 mg) of plain mepivacaine for ambulatory spinal anesthesia - PubMed

We evaluated the anesthetic and recovery profiles of 60- and 80-mg doses of plain mepivacaine for ambulatory spinal anesthesia. Both doses produced comparable sensory and motor block. Sensory and motor regression and ambulatory milestones were 20-30 min longer with the 80-mg dose. Side effects...
pubmed.ncbi.nlm.nih.gov pubmed.ncbi.nlm.nih.gov

I typically use Mepivacaine for outpatient total joints. Even the slower surgeons can finish the case with 80 mg of Mepivacaine. Unfortunately, there is no fixed formula for SAB in an ASC as the drug and dosages are surgeon dependent. Some are now adding 5-10 ug of Precedex to their spinals as well.
 
BLADEMDA said:
pubmed.ncbi.nlm.nih.gov

The anesthetic and recovery profile of two doses (60 and 80 mg) of plain mepivacaine for ambulatory spinal anesthesia - PubMed

We evaluated the anesthetic and recovery profiles of 60- and 80-mg doses of plain mepivacaine for ambulatory spinal anesthesia. Both doses produced comparable sensory and motor block. Sensory and motor regression and ambulatory milestones were 20-30 min longer with the 80-mg dose. Side effects...
pubmed.ncbi.nlm.nih.gov pubmed.ncbi.nlm.nih.gov

I typically use Mepivacaine for outpatient total joints. Even the slower surgeons can finish the case with 80 mg of Mepivacaine. Unfortunately, there is no fixed formula for SAB in an ASC as the drug and dosages are surgeon dependent. Some are now adding 5-10 ug of Precedex to their spinals as well.
Click to expand...

understand that any spinal complications will be attributed to Precedex. It is not FDA approved as an adjunct to GA, it DEFINITELY is not approved for spinal use.

I understand you probably have studies behind what you do.
 
Simba1711 said:
For primary knees they usually take 2 hours of procedure time but not uncommon to go to 3 hours if they struggle.

For primary hips usually 2.5 hours but sometimes over 3 hours.
Click to expand...

Im ortho and do mostly joints. Unless I’m misunderstanding “procedure time” that seems like a loooong time to do a primary.
 
VA Hopeful Dr said:
I'm sure I'm preaching to the choir here, but plenty of not all that great surgeons doing joints.
Click to expand...

Don’t get me wrong I’ve heard plenty of stories. It’s not like I’m gods gift to surgery or anything but never fails whenever I hear them I think “what can you possibly be doing for that long??” Anyway I should stop being surprised.

Sorry don’t mean to derail as I’m always interested in making things more streamlined and less miserable for the patient.
 
I work in 3 hospitals and 7 surgery centers so the practices vary somewhat depending on the center. All discharge patients same day, usually within a couple of hours after arrival to the PACU. Only 2 centers routinely employs Exparel, with one using Exparel in the joint itself. For shoulder replacement surgery, typically 30ml 0.5% bupivacaine plus dexamethasone in an interscalene block works well- use a two location block (proximal and distal) with 75% of the injection split superficial to and just deep to C5 nerve. We do the same for most shoulder scopes but frequently add an intermittent cervical plexus block for distal clavicle resection and for two surgeons that use up to 12 liters irrigation, a pec I plus serratus anterior block because of massive painful edema of the chest wall after surgery. For hip surgery, only one surgeon allows a PENG whereas all the others are vehemently opposed. One surgeon does not use any local anesthesia at all nor allow any hip blocks, resulting in patients being in severe pain when the spinal wears off. Our spinal blocks vary in content from one anesthesiologist to another, with some using mepivacaine but because of the contraindication printed on the label, most have switched to spinal marcaine or lidocaine or ropivacaine. For knee replacements, most use AC or low femoral triangle blocks plus NVM plus superior lateral geniculate nerve blocks with 0.25-0.5% bupivacaine plus dex.
 
Aether2000 said:
I work in 3 hospitals and 7 surgery centers so the practices vary somewhat depending on the center. All discharge patients same day, usually within a couple of hours after arrival to the PACU. Only 2 centers routinely employs Exparel, with one using Exparel in the joint itself. For shoulder replacement surgery, typically 30ml 0.5% bupivacaine plus dexamethasone in an interscalene block works well- use a two location block (proximal and distal) with 75% of the injection split superficial to and just deep to C5 nerve. We do the same for most shoulder scopes but frequently add an intermittent cervical plexus block for distal clavicle resection and for two surgeons that use up to 12 liters irrigation, a pec I plus serratus anterior block because of massive painful edema of the chest wall after surgery. For hip surgery, only one surgeon allows a PENG whereas all the others are vehemently opposed. One surgeon does not use any local anesthesia at all nor allow any hip blocks, resulting in patients being in severe pain when the spinal wears off. Our spinal blocks vary in content from one anesthesiologist to another, with some using mepivacaine but because of the contraindication printed on the label, most have switched to spinal marcaine or lidocaine or ropivacaine. For knee replacements, most use AC or low femoral triangle blocks plus NVM plus superior lateral geniculate nerve blocks with 0.25-0.5% bupivacaine plus dex.
Click to expand...
Are you all using 15mg or 12.5 mg of Ropivacaine for your spinals? Does the lack of motor block bother your surgeons?

 

Warmed ropivacaine shortens the time for the recovery of lower limb muscle strength after spinal anesthesia, which is beneficial for the rapid recovery of patients undergoing lower limb joint replacement surgery and reduces the length of hospital stay.

bmcanesthesiol.biomedcentral.com

Effect of warmed ropivacaine versus room temperature ropivacaine administered spinal anesthesia on recovery of lower limb muscle strength following total knee or hip replacement: a prospective, double-blind, randomized controlled study - BMC Anesthes

With the aging of the population, the number of hip and knee replacements worldwide continues to increase. Postoperative enhanced recovery has become a clinical focus, and an increasing number of hip and knee replacement surgeries are completed on an outpatient basis. Spinal anesthesia is the...
bmcanesthesiol.biomedcentral.com bmcanesthesiol.biomedcentral.com

The authors speculate that warm Ropivacaine becomes more Isobaric at 37 degrees C vs room temperature.
 
Last edited:
We have faster surgeons in ASCs- there we use ropivacaine 12.5mg and in hospitals 15mg. We add a propofol infusion IV to both. That ropivacaine become isobaric at 37 degrees is fascinating!
 
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