Total knee replacement under PNB

[anbuitachi]

We are asked to follow joint commission standards for total joint replacements. It says PNB can also be used as primary anesthetic for TKR. I've never done one under just PNB. For you guys who do these under just PNB, what combination of blocks do you do? Anything to watch out for? Thanks!

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[ToKingdomCome]

lol just under PNB? Feel like femoral
Nerve block would be the only thing strong enough if I was just going to do just a PNB but then they won’t move their leg for 20 hours and the surgeon will be pissed. There’s no way a patient is tolerating just an IPAC and adductor for surgery

 

[UscGhost]

Sounds like a nightmare.

If a patient can't tolerate GA or a spinal, I would question the need for elective major orthopedic surgery

 

[Maz777]

You really need to leave your job. Some idiot is telling you that TJC says this is standard of care?

I would reflexively ignore anything that comes out of the mouth of TJC. I'm pretty sure you have to fail multiple IQ tests to get a job there.

No sane person is routinely doing TKAs under nerve blocks only. You'd have to block femoral, proximal sciatic, obturator, and lateral femoral cutaneous for a complete block. That's a malpractice-level volume of local that will last a long time and destroy the ability to work with PT postop.

 

[aneftp]

Keep it simple stupid.

Don’t reinvent the wheel.

General or spinal.

 

[Steege305]

This doesn’t make any sense to me. Typically as a quality measure as part of a total joint pathway you have to document whether or not the patient received neuraxial and/or a PNB, whether it was a non-qualifying case (revision), or if you’ve documented why they didn’t receive neuraxial and/or PNB (patient refusal, etc).

 

[GassYous]

What are you gonna do, a fem-sci? Lumbar plexus?

 

[narcotics999]

We can try PNB only on these JC old fxxt first.

 

[Hoya11]

We are asked to follow joint commission standards for total joint replacements. It says PNB can also be used as primary anesthetic for TKR. I've never done one under just PNB. For you guys who do these under just PNB, what combination of blocks do you do? Anything to watch out for? Thanks!

View attachment 381458

Yeah agree no one is really doing that that I know of..

Before the movement to motor sparing blocks, we did knees under Fem/Sciatic plus GA and that was a very nice technique..

 

[anbuitachi]

This doesn’t make any sense to me. Typically as a quality measure as part of a total joint pathway you have to document whether or not the patient received neuraxial and/or a PNB, whether it was a non-qualifying case (revision), or if you’ve documented why they didn’t receive neuraxial and/or PNB (patient refusal, etc).

so in your case, if you do GA + PNB, it qualifies? It just has to have some form of neuraxial or PNB?

 

[nimbus]

so in your case, if you do GA + PNB, it qualifies? It just has to have some form of neuraxial or PNB?

GA+PNB qualifies.

Yes, it just needs either neuraxial or PNB.

 

[thinkorswim]

The authors should first themselves undergo a TKA with PNB as the primary (or sole) anesthetic and then see if they still recommend it.

 

[Steege305]

so in your case, if you do GA + PNB, it qualifies? It just has to have some form of neuraxial or PNB?

Yep

 

[GassYous]

We routinely do BKA and AKA with just PNB so it’s possible. Problem is they’ll have motor block for hours and for total joints usually surgeons want them to move and work with PT asap

Bka is easy. What do you do for aka? A high sciatic and femoral? I've found it is hard to get perfect analgesia so I usually just put an lma

 

[PpfSuxTube]

We are asked to follow joint commission standards for total joint replacements. It says PNB can also be used as primary anesthetic for TKR. I've never done one under just PNB. For you guys who do these under just PNB, what combination of blocks do you do? Anything to watch out for? Thanks!

View attachment 381458

What is a joint commission standard? What makes it a standard?
Standard implies a certain level of quality... since no one does this it's not a standard, it's an experiment.

 

[fakin' the funk]

We are asked to follow joint commission standards for total joint replacements. It says PNB can also be used as primary anesthetic for TKR. I've never done one under just PNB. For you guys who do these under just PNB, what combination of blocks do you do? Anything to watch out for? Thanks!

View attachment 381458

The TJC standard that says this reads:
"Peripheral nerve blocks (PNBs) can be used as the primary anesthetic for total knee replacement facilitating faster postoperative recovery than general anesthesia."
and cites on this topic a single trial where they did lumbar plexus+ sciatic blocks with propofol sedation.

Suffice to say - citing this is dumb, and the citation and claim are not applicable to current practice.

 

[cchoukal]

Did this once as a resident. Femoral + proximal sciatic. Lady did fine, but on POD2 developed a PE and died.

 

[Maz777]

The TJC standard that says this reads:
"Peripheral nerve blocks (PNBs) can be used as the primary anesthetic for total knee replacement facilitating faster postoperative recovery than general anesthesia."
and cites on this topic a single trial where they did lumbar plexus+ sciatic blocks with propofol sedation.

Suffice to say - citing this is dumb, and the citation and claim are not applicable to current practice.

Is anyone surprised? No one at TJC is able to evaluate research and make sensible, evidence-based decisions.

 

[anbuitachi]

We routinely do BKA and AKA with just PNB so it’s possible. Problem is they’ll have motor block for hours and for total joints usually surgeons want them to move and work with PT asap

Bka is easy. What do you do for aka? A high sciatic and femoral? I've found it is hard to get perfect analgesia so I usually just put an lma

yea what do you do for aka? sciatic femoral obturator?

 

[AKMD_1984]

No thanks.
Will pass.

 

[AKMD_1984]

We are asked to follow joint commission standards for total joint replacements. It says PNB can also be used as primary anesthetic for TKR. I've never done one under just PNB. For you guys who do these under just PNB, what combination of blocks do you do? Anything to watch out for? Thanks!

View attachment 381458

“Facilitating faster post op recovery than GA”.
I mean how fast is fast for these people?
Where do you draw the line?

Ridiculous.

The few hours saved in PACU will make zero difference to the patent 6 months down the road.

And good luck doing the case with just regional.
Actually, Surgeons complain about spinals because their patients “remember” the whole surgery on post op visits.

Amnesia is important.

So is the JC article suggesting straight regional and awake surgery? I hope not.

 

[jwk]

The TJC standard that says this reads:
"Peripheral nerve blocks (PNBs) CAN BE used as the primary anesthetic for total knee replacement facilitating faster postoperative recovery than general anesthesia."
and cites on this topic a single trial where they did lumbar plexus+ sciatic blocks with propofol sedation.

Suffice to say - citing this is dumb, and the citation and claim are not applicable to current practice.

Seems like y'all are misunderstanding this. CAN BE does not mean MUST BE. There is NO requirement for type of anesthesia that must be used.

 

[abolt18]

Seems like y'all are misunderstanding this. CAN BE does not mean MUST BE. There is NO requirement for type of anesthesia that must be used.

It's not even a recommendation or guideline or anything! I just says "it's an option"