saphenous and selective tibial NB for TKA..anyone doing it?

[panetrain]

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Looking at performing these 2 blocks (adductor canal and selective tibial) instead of ITN for TKA. Can anyone offer some insight such as optimal LA volumes, LA concentrations, residual motor block or delayed ambulation?, overall efficacy? any other advice? Thanks

 

[Consigliere]

No

 

[AdmiralChz]

Just do an adductor and call it a day! Surgical infiltration of posterior capsule.

 

[DM27]

You may enjoy this if you like different regional techniques.

Novel Regional Techniques for Total Knee Arthroplasty Promote Reduced Hospital Length of Stay: An Analysis of 106 Patients

 

[panetrain]

cool article...N= 106 only, but still looks like ACB with iPACK wins

 

[GaseousClay]

cool article...N= 106 only, but still looks like ACB with iPACK wins

iPACK is a waste of time and resources. ACB and give surgeon plenty of local to inject

 

[AdmiralChz]

I’ll find the Anesthesiology article from this month, much higher N, which showed great results with ACB and infiltration.

 

[GaseousClay]

I’ll find the Anesthesiology article from this month, much higher N, which showed great results with ACB and infiltration.

the iPACK people are pointing to this study now
Comparison of adductor canal block and IPACK block (interspace between the popliteal artery and the capsule of the posterior knee) with adductor ca... - PubMed - NCBI

or

http://www.orthopaper.com/archives/2017/vol3issue2/PartC/3-1-69-918.pdf

 

[sevoflurane]

I have been very impressed with pre-op ACB with IPACK on a handful of chronic pain patients. I don’t do them routinely, but they definitely work.

 

[2Fast2Des]

We do adductor catheter and single shot tibial with around 7 or 8cc 0.5 % bupi. There are still cohort of pts with some discomfort even with surgeon injection, but its better than having to do rescue sciatic block in pacu and cause further leg weakness and delay rehab

 

[GaseousClay]

We do adductor catheter and single shot tibial with around 7 or 8cc 0.5 % bupi. There are still cohort of pts with some discomfort even with surgeon injection, but its better than having to do rescue sciatic block in pacu and cause further leg weakness and delay rehab

not like we're doing anything spectular at my gig but we do tons and tons of knees. Never once had to do a rescue sciatic block nor has any of my colleagues.

 

[2Fast2Des]

not like we're doing anything spectular at my gig but we do tons and tons of knees. Never once had to do a rescue sciatic block nor has any of my colleagues.

In residency it was in infrequent but not unusual to have to do the sciatic rescue..

 

[Psai]

Wtf is a sciatic rescue

 

[Aether2000]

I have used superior lateral geniculate nerve blocks and mid thigh adductor canal blocks for the past year with better results than I had with the adductor canal block alone. Using 5cc volume for the geniculate and 25 for the adductor canal.

 

[ChiDO]

I have my anesthesiologists doing ipack and adductor

 

[BLADEMDA]

If the surgeon injects into the posterior capsule an iPACK isn't necessary. But, if he/she doesn't inject the posterior capsule then I do an iPACK. A selective tibial nerve block simply isn't needed if you know how to do a proper IPACK or posterior capsule injection.

 

[kmurp]

If the surgeon injects into the posterior capsule an iPACK isn't necessary. But, if he/she doesn't inject the posterior capsule then I do an iPACK. A selective tibial nerve block simply isn't needed if you know how to do a proper IPACK or posterior capsule injection.

Do you do the IPACK as originally described or more like one would do a popliteal with the probe posterior to the knee? I’ve had a bit of trouble trying it per the original description getting the angle to stay posterior to the vessels while not hitting the femur. Perhaps my needle insertion point is too far from the probe?

 

[Hoya11]

I have used superior lateral geniculate nerve blocks and mid thigh adductor canal blocks for the past year with better results than I had with the adductor canal block alone. Using 5cc volume for the geniculate and 25 for the adductor canal.

Similarly, I have found the adductor to be inadequate in 1/5-10 patients.

I still wish we could do FNBs and send the patients home with PT the following day... why must there be full ambulation on POD 0? We send people home after ACL and lots of other stuff with a FNB all the time. We have compromised for the surgeons at the detriment to the patients. ACB is an inferior block to FNB

 

[ChiDO]

If the surgeon injects into the posterior capsule an iPACK isn't necessary. But, if he/she doesn't inject the posterior capsule then I do an iPACK. A selective tibial nerve block simply isn't needed if you know how to do a proper IPACK or posterior capsule injection.

I inject about 20cc of a joint Cocktail into the posterior capsule even with my ipacks. Probably overkill

 

[dhb]

iPACK is a waste of time and resources.

1 min and 5$ of local???
I do ACB and IPACK with great results (as in no opioids given)

 

[deleted162650]

1 min and 5$ of local???
I do ACB and IPACK with great results (as in no opioids given)

You doin’ a spinal for the case?

They gettin’ preop PO opioids?

 

[ChiDO]

You doin’ a spinal for the case?

They gettin’ preop PO opioids?

I give pregabalin, celebrex and Tylenol preop. Anesthesia gives a anti-emetic cocktail + spinal. Abx of ancef + vanco. Then ipack + acb.

Intraop Joint Cocktail consists of some tordal, morphine, ketamine, NS, and bupivacaine. Although one of the anesthesiologists told me I'm overdosing patients with 12mg of morphine in my injection and causing them to be in pacu longer🙄

Only opiods would be the morphine joint injection which I'd guess absorption is very slow. I don't think my anesthesiologists give any intraop narcotics.

 

[deleted162650]

I give pregabalin, celebrex and Tylenol preop. Anesthesia gives a anti-emetic cocktail + spinal. Abx of ancef + vanco. Then ipack + acb.

Intraop Joint Cocktail consists of some tordal, morphine, ketamine, NS, and bupivacaine. Although one of the anesthesiologists told me I'm overdosing patients with 12mg of morphine in my injection and causing them to be in pacu longer🙄

Only opiods would be the morphine joint injection which I'd guess absorption is very slow. I don't think my anesthesiologists give any intraop narcotics.

That’s pretty much exactly what we do. I was asking @dhb because if he’s doing a spinal, then I don’t see why he be giving any opioids anyway.

 

[kmurp]

I give pregabalin, celebrex and Tylenol preop. Anesthesia gives a anti-emetic cocktail + spinal. Abx of ancef + vanco. Then ipack + acb.

Intraop Joint Cocktail consists of some tordal, morphine, ketamine, NS, and bupivacaine. Although one of the anesthesiologists told me I'm overdosing patients with 12mg of morphine in my injection and causing them to be in pacu longer🙄

Only opiods would be the morphine joint injection which I'd guess absorption is very slow. I don't think my anesthesiologists give any intraop narcotics.

That sounds like a lot of local anesthesia. Though I read a study that the peak plasma levels of Ropivacaine in a joint cocktail do not approach toxic levels and peak many hours after injection. I’m not sure when peak levels occur in an Adductor block or IPACK but I’m guessing that the adductor peaks well before the joint injection. That study was, I think, from Europe on the joint cocktail and they used epi in their cocktail.

 

[BLADEMDA]

You doin’ a spinal for the case?

They gettin’ preop PO opioids?

Spinal: Isobaric Bup or Hyperbaric Bup plus Fentanyl 20 ug
Blocks: ACB +/- Ipack
Surgeon: Injects local cocktail

Intraop Opioids IV: none

Rescue blocks in PACU: less than 2% of the time

There is no need for a selective tibial nerve block any longer for TKA.

 

[BLADEMDA]

Send to



Br J Anaesth. 2001 Oct;87(4):570-6.
Efficacy and uptake of ropivacaine and bupivacaine after single intra-articular injection in the knee joint.
Convery PN1, Milligan KR, Quinn P, Sjövall J, Gustafsson U.
Author information

Abstract
The efficacy of ropivacaine 100 mg (5 mg ml(-1)), 150 mg (7.5 mg ml(-1)) and 200 mg (10 mg ml(-1)) and bupivacaine 100 mg (5 mg ml(-1)) given by intra-articular injection into the knee after the end of surgery was studied in 72 ASA I-II patients scheduled for elective knee arthroscopy under general anaesthesia in a randomized, double-blind study. Kapake (paracetamol 1 g and codeine 60 mg) was given as a supplementary analgesic. Pain scores were assessed 1-4 h after surgery and a verbal rating scale of overall pain severity was assessed on second postoperative day. Ropivacaine or bupivacaine concentrations were determined in peripheral venous plasma up to 3 h after injection in eight patients in each group. Verbal rating pain scores were lower with ropivacaine 150 mg compared with bupivacaine 100 mg (P<0.05). There was a tendency for lower analgesic consumption and pain scores with all doses of ropivacaine (not significant). The mean (SD) maximum total plasma concentrations of ropivacaine were 0.64 (0.25), 0.78 (0.43), and 1.29 (0.46) mg litre(-1) after 100, 150 and 200 mg. The corresponding unbound concentrations were 0.018 (0.009), 0.024 (0.020) and 0.047 (0.022) mg litre(-1). Both were proportional to the dose. The maximum total concentration after bupivacaine 100 mg was 0.57 (0.36) mg litre(-1). The time to reach maximum plasma concentration was similar for all doses and varied between 20 and 180 min. All concentrations were well below the threshold for systemic toxicity.

 

[BLADEMDA]

Patients received infiltration of ropivacaine 400 mg followed by infusion at 20 mg.h−1

This study has shown that free plasma levels of ropivacaine previously associated with toxicity are not reached during local infiltration analgesia followed by continuous catheter infusion during total knee arthroplasty in an elderly population, although raised total plasma levels were observed.

https://onlinelibrary.wiley.com/doi/full/10.1111/anae.13017

 

[BLADEMDA]

Send to



Acta Anaesthesiol Scand. 2017 Mar;61(3):338-345. doi: 10.1111/aas.12849. Epub 2017 Jan 9.
Pharmacokinetics of 400 mg ropivacaine after periarticular local infiltration analgesia for total knee arthroplasty.
Fenten MG1,2, Bakker SM1, Touw DJ3, van den Bemt BJ4,5,6, Scheffer GJ2, Heesterbeek PJ7, Stienstra R1.
Author information

Abstract
BACKGROUND:
Although considered safe, no pharmacokinetic data of high dose, high volume local infiltration analgesia (LIA) with ropivacaine without the use of a surgical drain or intra-articular catheter have been described. The purpose of this study is to describe the maximum total and unbound ropivacaine concentrations (Cmax , Cu max ) and corresponding maximum times (Tmax , Tu max ) of a single-shot ropivacaine (200 ml 0.2%) and 0.75 mg epinephrine (1000 μg/ml) when used for LIA in patients for total knee arthroplasty.

METHODS:
In this prospective cohort study, 20 patients were treated with LIA of the knee for primary total knee arthroplasty. Plasma samples were taken at 20, 40, 60, 90, 120, 240, 360 min and at 24 h after tourniquet release, in which total and unbound ropivacaine concentrations were determined.

RESULTS:
Results are given as median [IQR]. Highest ropivacaine concentration (Cmax ) was 1.06 μg/ml [0.34]; highest unbound ropivacaine concentration (Cu max ) was 0.09 μg/ml [0.05]. The corresponding time to reach the maximum concentration for total ropivacaine was 312 min [120] after tourniquet release, and for the unbound fraction 265 [110] min after tourniquet release.

CONCLUSION:
Although great inter-individual variability was found between the maximum ropivacaine concentrations, both maximum total and unbound serum concentrations of ropivacaine remained well below the assumed systemic toxic thresholds of 4.3 and 0.56 μg/ml.

 

[BLADEMDA]

I give pregabalin, celebrex and Tylenol preop. Anesthesia gives a anti-emetic cocktail + spinal. Abx of ancef + vanco. Then ipack + acb.

Intraop Joint Cocktail consists of some tordal, morphine, ketamine, NS, and bupivacaine. Although one of the anesthesiologists told me I'm overdosing patients with 12mg of morphine in my injection and causing them to be in pacu longer🙄

Only opiods would be the morphine joint injection which I'd guess absorption is very slow. I don't think my anesthesiologists give any intraop narcotics.

I'd be careful with the Toradol dosing and limit it to 30 mg because it is similar to an IM injection. Some of your patients are very elderly and have pre-existing renal disease.



Acta Anaesthesiol Scand. 2014 Oct;58(9):1140-5. doi: 10.1111/aas.12371. Epub 2014 Jul 31.
Plasma concentration of ketorolac after local infiltration analgesia in hip arthroplasty.
Affas F1, Eksborg S, Wretenberg P, Olofsson C, Stephanson N, Stiller CO.
Author information

Abstract
BACKGROUND:
Local infiltration analgesia (LIA) with local anaesthetic (ropivacaine), a nonsteroidal anti-inflammatory drug (ketorolac) and epinephrine after lower extremity arthroplasty has gained increasing popularity during the last decade. This method has certain advantages, which include minimal systemic side effects, faster post-operative mobilization, earlier post-operative discharge from hospital and less opioid consumption. However, information regarding plasma concentrations of ketorolac after LIA mixture is insufficient to predict the risk of renal impairment in patients subjected to arthroplasty.

AIM:
To determine the maximal plasma concentration and the exposure of ketorolac during the first 30 h following LIA in hip arthroplasty.

METHODS:
Thirteen patients scheduled for primary total hip arthroplasty with LIA (ropivacaine 200 mg, ketorolac 30 mg and epinephrine 0.5 mg in a volume of 106 ml) were included. Plasma concentration of ketorolac was quantified by liquid chromatography-mass spectrometry. In addition, we assessed the effect of increasing age and decreasing glomerular filtration rate on the maximal plasma concentration and the total exposure to ketorolac during 30 h.

RESULTS:
The range of the maximal plasma concentration, 0.3-2.2 mg/l, was detected 30 min-4 h after completing the infiltration. Similar plasma levels have been reported after intramuscular injection of the same dose of ketorolac to healthy elderly volunteers.

CONCLUSION:
Exposure to ketorolac after LIA may be comparable to an intramuscular injection of the same dose. Decision of dose reduction should be based on clinical assessment of risk factors.

 

[Arch Guillotti]

Spinal: Isobaric Bup or Hyperbaric Bup plus Fentanyl 20 ug
Blocks: ACB +/- Ipack
Surgeon: Injects local cocktail

Intraop Opioids IV: none

Rescue blocks in PACU: less than 2% of the time

There is no need for a selective tibial nerve block any longer for TKA.

Why would any patient need a “rescue block” with a spinal?!😕

 

[dhb]

That’s pretty much exactly what we do. I was asking @dhb because if he’s doing a spinal, then I don’t see why he be giving any opioids anyway.

No nothing pre-op, no infiltration in the field no BS. Surgeon doesn't like spinals so i don't do many. Some patients need 2-4mg of morphine in pacu. Paracetamol, tramadol and sometimes NSAIDS post op, will probably need some p.o morphine on pod2 but overall the change is dramatic over what was done 10 years ago when you could still hear patient screaming on the wards post op.

 

[2Fast2Des]

No nothing pre-op, no infiltration in the field no BS. Surgeon doesn't like spinals so i don't do many. Some patients need 2-4mg of morphine in pacu. Paracetamol, tramadol and sometimes NSAIDS post op, will probably need some p.o morphine on pod2 but overall the change is dramatic over what was done 10 years ago when you could still hear patient screaming on the wards post op.

Sounds like the surgeon needs to get with the times... I don't get why surgeon cares what the anesthetic technique is, pt is not going to move either way, especially when spinal is the usual method

 

[nimbus]

Spinal: Isobaric Bup or Hyperbaric Bup plus Fentanyl 20 ug
Blocks: ACB +/- Ipack
Surgeon: Injects local cocktail

Intraop Opioids IV: none

Rescue blocks in PACU: less than 2% of the time

There is no need for a selective tibial nerve block any longer for TKA.

Foley or no foley?

 

[BLADEMDA]

Foley or no foley?

No foley.

 

[Planktonmd]

I give pregabalin, celebrex and Tylenol preop. Anesthesia gives a anti-emetic cocktail + spinal. Abx of ancef + vanco. Then ipack + acb.

Intraop Joint Cocktail consists of some tordal, morphine, ketamine, NS, and bupivacaine. Although one of the anesthesiologists told me I'm overdosing patients with 12mg of morphine in my injection and causing them to be in pacu longer🙄

Only opiods would be the morphine joint injection which I'd guess absorption is very slow. I don't think my anesthesiologists give any intraop narcotics.

They don't need to give intra-op opioids if they are doing a spinal, and Your Morphine in the cocktail is unnecessary.
Actually if they are doing an ACB + Ipack the spinal is not necessary, a simple GA with LMA would work great and they can walk immediately post op without concerns for urinary retention.

 

[dhb]

Sounds like the surgeon needs to get with the times... I don't get why surgeon cares what the anesthetic technique is, pt is not going to move either way, especially when spinal is the usual method

Does it really matter? If you're going to run propofol with the spinal then just do a GA.
He's had a number of failed spinal so that's why he prefers GA.

 

[facted]

I'm naive, but can someone explain to me how intra-articular morphine works? Are there are actual mu receptors in the joint or is just systemic absorption?

 

[deleted162650]

I'm naive, but can someone explain to me how intra-articular morphine works? Are there are actual mu receptors in the joint or is just systemic absorption?

I’ve had this discussion with the orthopods. Apparently yes, they have literature which shows there are mu receptors within the joint.

 

[2Fast2Des]

They also inject toradol as part of the mixture sometimes, does that mean we should avoid giving IV at the end of case? Since pt usually gets po celebrex, so is all that Cox inhibitor needed?

 

[deleted162650]

If you're going to run propofol with the spinal then just do a GA.

Disagree that low dose prop gtt = GA.

I messed around with iPacks for little while. I don't think it adds much over surgeon infiltration.

We do spinal + ACB with good results. It's what I would want for myself after having done a lot of GA + ACB/Fem at my last gig.

No opioids from us - just the Oxy that's part of the pre-op PO cocktail.

Foley or no foley?

Big push this year to eliminate the Foley. Maybe 20% end up needing a Foley in PACU. No change in infection rates which were 0 before the change. If it was me I'd say just place a Foley in the OR and pull it while I'm still a bit numb before I leave PACU.

 

[dhb]

I messed around with iPacks for little while. I don't think it adds much over surgeon infiltration.

I don't know, it's really easy and you can skip surgeon infiltration.
Why do a full court press with pre-op cocktails and multiple infiltrations when you can keep it simple?

 

[deleted162650]

I don't know, it's really easy and you can skip surgeon infiltration.
Why do a full court press with pre-op cocktails and multiple infiltrations when you can keep it simple?

The preop stuff is all surgeon driven. Patients are doing well so everyone is happy.

 

[Dakota02]

Why would you bother? Just do a femoral block and tell the patient they may have some pain in the back of the knee? LESS is MORE

 

[dhb]

LESS is MORE

Right until the point less is less.

 

[GaseousClay]

Right until the point less is less.

1 extra vial of bupi/ropi, 1 extra block needle +/- tubing, training people who can be pretty inept to somehow do this correctly, minimal to no benefit over a good posterior capsule injection by surgeon, plus extra time and with around 30-40 knees done per week that definitely is a cost that adds up. you also end up giving less in the adductor than normal and less to the surgeon to infiltrate which again i stress is much more valuable than the iWhack imho

 

[dhb]

1 extra vial of bupi/ropi, 1 extra block needle +/- tubing

What extra? I'm doing all the injections and the surgeon is doing all the operation. There is no extra time, needle, or products.
If you want to differ to the surgeon for analgesia fine, i'd rather not.