Total Knees

[RxBoy]

Been doing a ton of knees at my new gig as attending. Spinal is the anesthetic of choice. I prefer 15 mg bupivacaine and 40 mcg fentanyl.

We recently started doing single shot adductor canal blocks for the total knees in PACU. Occasional do a femoral nerve block for pt with low pain tolerance however I see little difference in analgesia. Typically use 30 cc 0.25% bupivacaine w/ epi + 4 mg PF decadron. Orthopods also supplement with intrarticular joint injections as well. Excellent results and surgeons very happy.

Some questions for my fellow anesthesiologists:

1) Any other good adjuncts for multimodal analgesia? Like anyone routinely give PO Tylenol loading doses preop or toradol (if orthopedic OK?). I avoid narcotics completely unless absolutely necessary for knees.

2) Anyone doing adductor canal catheters? Im not sure what kind of results they are experiencing with these. What solution/rate do you run?

3) Anyone doing anything special with elective hip replacements? Im not a fan of lumbar plexus blocks. Anyone use duramorph with spinals? Not sure how well that works for hips.

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[OB1🤙]

I agree with your approach and do it similarly. I think it's a great way of doing these cases.

For TKA: I do single shot spinal with 12.5mg isobaric bupivicaine and 100-150 mcg duramorph. Honestly, no fentanyl is needed- it's not like a C/S where you need that narcotic to cover visceral discomfort. Propofol to nap through case. At end of case, LIA by surgeons. I then do an adductor canal block with 20cc 0.5% PF bupi (same stuff as I used for the spinal) with 5mg PF decadron.

I instruct the PACU to give a gram of IV tylenol once the spinal starts wearing off.

With this approach patients feel fantastic immediately postop, can ambulate within hours of surgery and have excellent pain control for 32-40 hours. We are working on getting Exparel, which should be even better when divided between the LIA and ACB as Blade has previously suggested.

For THA (our surgeons do posterolateral approach usually) I've just been doing a single shot spinal with duramorph, and LIA by the surgeon. They have seemed very comfortable with this.

 

[Mman]

1) Any other good adjuncts for multimodal analgesia? Like anyone routinely give PO Tylenol loading doses preop or toradol (if orthopedic OK?). I avoid narcotics completely unless absolutely necessary for knees.

Celecoxib 200 mg po preop (or ketorolac 15 mg IV intraop)
Acetaminophen 650-1000 mg po preop
Gabapentin 600-900 mg po preop
Ketamine 50-100 mg IV after induction


The more the merrier for a TKA.

 

[somedumbDO]

Celecoxib 200 mg po preop (or ketorolac 15 mg IV intraop)
Acetaminophen 650-1000 mg po preop
Gabapentin 600-900 mg po preop
Ketamine 50-100 mg IV after induction


The more the merrier for a TKA.

Knees
Spinal 15mg marcaine
Iv Tylenol
Adductor canal single shots .5 marcaine clonidine plus decadron

Hips
Spinal w duramorph
Contraindications for spinal fascia iliaca block ya w lma

 

[BLADEMDA]

I think you guys should try the Isobaric Bup or Isobaric tetracaine and stop with the big doses of Hyperbaric Bup. The BP is more stable and the chances of Bradycardia are nil.

12 mg of Isobaric Tetracaine or Bupivacaine will exceed 15 mg of Hyperbaric Bup in terms of duration.

 

[BLADEMDA]

I like the Exparel.

I like Lumbar Plexus Blocks for Classic Total Hip replacements but you need to really be good at Regional to do these blocks.

I like the Adductor Canal block combined with LIA- the best combo IMHO.

I like the FICB as described in Regional Anesthesia and Pain Medicine this month. This technique with U/S is Dabomb (great results).


Regional Anesthesia & Pain Medicine:
September/October 2013 - Volume 38 - Issue 5 - p 459–460
doi: 10.1097/AAP.0b013e31829d27fa
Letters to the Editor
The Efficacy of Ultrasound-Guided Fascia Iliaca Block in Hip Surgery: A Question of Technique?
Murgatroyd, Harry FRCA; Forero, Mauricio MD; Chin, Ki Jinn FRCPC



We have had good clinical success with ultrasound-guided FIB for intraoperative and postoperative analgesia in both THR and fixation of femoral neck fractures. We ensure and look for suprainguinal spread of local anesthetic by injecting as close to the inguinal ligament as possible and inserting the needle in a caudadcephalad direction. We initially place our probe in a transverse orientation and make our initial needle approach out-of-plane to the ultrasound beam, aiming to pierce the fascia iliaca just lateral to the femoral nerve (Fig. 1A). Once we have confirmed needle-tip placement under the fascia iliaca by hydrolocation, we rotate the probe 90 degrees into a longitudinal parasagittal orientation to visualize the needle tip inplane and to track cephalad spread of the injectate under fascia iliaca (Fig. 1B). This is influenced by the description by Hebbard et al3 of an ultrasound-guided suprainguinal FIB, in which they also placed the probe in a parasagittal orientation, and, using hydrodissection, advanced the needle-tip cephalad to the inguinal ligament to maximize proximal spread of the local anesthetic. This resulted in dye spread to the femoral and lateral femoral cutaneous nerve in all cadavers in their study.

 

[bcat85]

We dose Celebrex, OxyContin, and lyrica preop for TKAs. We use an isobaric bupivacaine spinal--normally 15mg plus a single shot femoral. All of our surgeons use exparel. It seems to work about 50-60% of the time, but this is purely anecdotal on my part.

For hips we use the same formula, but we do fascia iliaca plus a spinal. Also seems to work reasonably.

The place we've had difficulty is with ankles. We normally put in a popliteal catheter and do a single shot saphenous, but the saphenous can be patchy sometimes. Anyone doing anything different for ankles?

 

[Oggg]

Continuous adductor canal catheter and single shot pop sciatic (0.2%ropiv) in preop. LMA. LIA. Surgeon has to be okay with a midthigh catheter in terms of surgical field draping. If they use navigation, this may not be acceptable as there is a pin to place in the mid lateral thigh.