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Total Knees

Discussion in 'Anesthesiology' started by Noyac, Nov 14, 2005.

  1. Noyac

    Noyac ASA Member
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    If any of you guys have a good system with regards to treating the post-op pain in TKA's I would like to know it. Currently, I do a Continuous FNB pre-op bring them to the room for a spinal with 0.4 mg duramorph and 10mg bupiv. and then depending on the surgeon (length of case) put them to sleep or sedate them. I think that going to sleep is over kill but it is needed for some of my surgeons. THe CFNB runs for 2 days at 8cc/hr of 0.2% ropiv. This is the best thing that I have come up with but it is alot of different procedures which I don't mind cause they only take a few minutes anyway. Just curious as to how others may be doing these cases.
     
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  3. jetproppilot

    jetproppilot Turboprop Driver
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    Nice technique, Noy. At least my old partners think so.
    We (old gig) did CSE for the case then Duramorph/Stadol epidural PCA afterwards, for years. Sometimes it worked fantastic, sometimes so so. After I left they switched to exactly how you describe it above and they really like it.

    At my new gig the hospital is still in the Flintstone era of not allowing epidural/nerve infusions on the floor...will work on that at some point.
     
  4. UTSouthwestern

    UTSouthwestern 1K Member
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    Haven't done a knee in a while, but CFNB was desirable, but I also put in a CSNB, no spinal, LMA or sedation depending on the patient. Blocks in for 2-3 days then out. Alternatively, one sided spinal with durmorph 400 mcg, 8-12 mg bupi, and sedation.
     
  5. Noyac

    Noyac ASA Member
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    Yeah, the CSNB would make them more comfortable but the orthopods don't like it b/c they can't assess nerve function and potential nerve injury post-op.
     
  6. jetproppilot

    jetproppilot Turboprop Driver
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    :laugh: :laugh:

    Gimme a f uc...ng break, bro. Tell them this is 2005.
     
  7. Noyac

    Noyac ASA Member
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    Yeah I know what you mean.
     
  8. jetproppilot

    jetproppilot Turboprop Driver
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    BTW, if my previous snowboard avatar had as much spray as yours, I'd be in traction!
    Seriously, what did you do to get that much spray??? Were you leaning back, stopping?
     
  9. pmichaelmd

    pmichaelmd Senior Member
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    Our pts. tend to like the CFNB/CSNB technique but we also have several orthopods who poo-poo on the CSNB because they claim the resultant muscle weakness impairs early ambulation and, thus, early discharge. We have taken to doing CFNB/sciatic cath with a single bolus up front and orders for prn sciatic boluses of 8-ml 0.2% ropiv for posterior pain. The CFNB runs at 8-mL/hr. In the OR they get a spinal with 8-12 mg bupiv, prop infusion.


     
  10. Tenesma

    Tenesma Senior Member
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    the only potential problem that i have heard of are a few surgeons who got burned by delayed diagnosis of compartment syndrome....

    i had a friend go through one, and she was an anesthesiologist... guess what she chose? dilaudid PCA.... boy did she regret not having a regional technique (fnb or epidural) for post op...
     
  11. militarymd

    militarymd SDN Angel
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    We do GA for almost all cases with single shot femoral nerve block (0.5% ropivicaine) + ivpca for post op pain.

    I'm pretty sure there was a study comparing single shot to nerve catheter 3 to 5 years ago....patient satisfaction the same.

    I'm thinking about adding intrathecal morphine to the mix.....something I'm working on.
     
  12. jetproppilot

    jetproppilot Turboprop Driver
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    As you know, my friend, I will disagree with you on this subject.

    I, anecdotally, of course, will not contend that a PCA gives commensurate analgesia to regional techniques, assuming proper placement/management.
     
  13. Noyac

    Noyac ASA Member
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    Actually, that is coming down a slope and hitting a catwalk and jumping off the edge of the catwalk on a POW POW day. When the snow is coming down I usually take off work and head for the slopes or the backcountry. Just some of the perks of the job.
     
  14. Noyac

    Noyac ASA Member
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    Study or no study, I can tell you that in the very few cases that the FNB wears off because of poor catheter placement, there is a huge difference. These pts are even hard to get comfortable with PCA, possibly b/c they had a block earlier and now its not working and they want to be as comfortable as they were before it wore off. We also have locums and they will do these cases differently many times. Sometimes they don't do the CFNB and sometimes they don't do the spinal narcs. The surgeons are really starting to like this technique and request the staff anesthesiologists for these cases now because the difference in their opinion is big. They have even begun to call me when the pt is on the floor and asking me to place a CFNB post-op after the pt has been on a PCA.
    I was curious when I posted this mesage as to whether there was something else that was working for others.
     
  15. militarymd

    militarymd SDN Angel
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    I have one surgeon who requests no blocks because he feels they interfere with physical therapy.
     
  16. Noyac

    Noyac ASA Member
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    Thats the first time I have ever heard that. Usually they help with PT. These blocks don't have to be so dense that they can't use the muscles. With 0.2% ropiv they can usually move the leg and they participate well in PT unlike with the bupiv. If still to dense go to 0.1% ropiv. But thats my opinion and I would suspect that the surgeon you are talking about will start to lose pts as the word gets out. Not alot of pts but he will lose some and the longer he practices this way the more pts he will lose. Just my opinion.
     
  17. militarymd

    militarymd SDN Angel
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    I'm referring to single shot blocks.
     
  18. s204367

    s204367 Member
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    I trained with epidurals for bilateral TKR, but this sometimes interfered with anticoagulation on these patients and would require pulling the catheter early. Then I went to spinal, duramorph, single shot FNB. I am now in private practice and want to convert to the spinal, duramorph, CFNB. However, all but one of the orthopods complain about the ambulation on POD 1 with PT.

    I am going to push one of the younger surgeons tommorrow to letting me place one of these catheters in the PACU after the case, last case of the day...However, what do you think about placing the catheter when the spinal is still in effect...no parasthesia would be felt?? DO you guys place these prior to the spinal??

    One of the old school guys who does most of the knees does not even want duramorh...foolish. pt suffer like hell on a morphine PCA....

    My biggest question though si with PT and the femoral catheters.
    Thanks
     
  19. kmurp

    kmurp Junior Member
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    I'm in private practice. We still mostly do epidurals for postop pain unless the patient refuses. Recently, due to anticoagulation issue, some surgeons have requested femoral catheters so we are doing more of them with or without PCA. but the posterior pain is really annoying for some. Interesting to see the use of duramorph.I guess I have never really liked the drug due to minor side effects and potential for late resp depression in these old folks. Was there a study citing the 400 mcg. number?i use less for c-sections. We also employ an RN who not only rounds on our patients but is very helpful with nursing education on the floors. I highly recommend it. She has cut the number of phone calls way down. She has trained a hospital RN to be available for each shift as a pain resource nurse. This onsite RN then can handle many things without calling us.
     
  20. Noyac

    Noyac ASA Member
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    My routine is to place the catheter in pre-op b/4 the case and dose it with 30cc 0.5% Ropiv. Then go to the room and do a spinal. Then depending on the surgeon (one of our surgeons take >3 hrs to do a TKA) the pt. gets either nothing, or propofol drip, or GA. I don't believe that the catheter interferes with PT. Our surgeons really like them and the pts can tolerate PT much better. I just checked on the 2 caths that I have running from yesterday and the pts love them. Well one pt said that his knee was hurting somewhat and I said on a scale of 1-10 what is it. He said a 2. WOW that much huh?
     
  21. Noyac

    Noyac ASA Member
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    In training I had an attending that would have us put 1 mg of duramorph in the spine (not epidural) for radical prostates. I though he was crazy. The pts never touched the PCA for 3 days. They did have a little puritis though. I don't recall the study that quoted the 400mcg dose but it was a couple of years back and it showed that this was the optimal dose for pain relief while keeping the SE's at a minimum. Above 400 mcg you didn't get any more pain relief and just add more SE's, and below this dose you lost some pain relief. I don't give everyone 400mcg but I do give it to most people. Obese, OSA, >70yrs are a few of the exceptions. Just a note, the best treatment for the puritis if you are worried about that is nubain. The delayed resp. dep. is real but I have not had 1 case of it with this dose and they are on a continuous pulse ox for 24 hrs. Now I know that there are cases of this but I like to think that I choose my pts well also. And you can say that I just haven't done enough but I have given this dose to all of my hips, knees, c/s and hyst's this date that fit the need and wasn't one of the above exceptions. You can however use 200-250 mcg and they will use the PCA more but this may be safer and if your floor nursing is of question then this may be a better approach.
     
  22. hokie

    hokie Junior Member
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    We use a femoral catheter, single shot sciatic, and spinal. It's a bit labor intensive but works nicely. PRN oxycodone for when the sciatic wears off. When we started using fem caths we had some PT issues but now they are up POD 1 with PT helping to hold the knee and keep it stable.
     
  23. Noyac

    Noyac ASA Member
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    This is what I was looking for. If any of you guys were doing anything more or different then my current practice. What is the conc. of your fnb when it is running on the floor?
     
  24. jetproppilot

    jetproppilot Turboprop Driver
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    I like naloxone .4mg per liter of their maintenance fluids better, Noy.

    At maintenance IV fluid rate, the pt gets just enough to suppress the side effects without affecting analgesia. Try it out.
     
  25. Noyac

    Noyac ASA Member
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    Is that the Narcan stuff that I have heard about? I hear that it really works well.





    HA HA just kiddin. I go to that after nubain and I use it just as you described. I don't really see all that much puritis though. :thumbup:
     
  26. jetproppilot

    jetproppilot Turboprop Driver
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    Yeah Dudeski, youre a jokster.

    But I still cant get over all the spray commin' off your board. :eek:
     
  27. hokie

    hokie Junior Member
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    We also usually use 0.2% ropivicaine - generally 6-10 cc/hr with a PCA dose of 3-5 cc (60 min lockout). Catheters out on POD 2 for total knees, POD 1 for unicompartmental knees.
     
  28. jetproppilot

    jetproppilot Turboprop Driver
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    All kidding aside, Snowboard-Total-Porn-Star-Stud,

    I'm surprised to hear you say that since, in my humble opinion,

    DURAMORPH SUCKS.

    AND EVERY PATIENT YOU USE DURAMORPH ON WILL HAVE SIDE EFFECTS, PRIMARILY ITCHING, LIKE THEY HAVE NEVER ITCHED.

    I still use it when I cant think of any other modality, but when I can avoid it, I avoid it.
     
  29. jetproppilot

    jetproppilot Turboprop Driver
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    BTW,

    VERY NICE THREAD, everyone.
     
  30. Noyac

    Noyac ASA Member
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    Ditto everyone.

    Wolf (Jet to most of you), I am surprised that you are getting so much itching. None of us here are really having much itching and the surgeons (mostly OB) are really liking the duramorph.
     
  31. Disse

    Disse Member
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    What about Depodur? At the ASA some guy was spouting how fantastic it was for their hips and knees. Touhy--depodur--GA (I think). No catheter post-op. Ambulate etc. etc. etc. POD1. Raves and raves from the speaker.

    Of course, the patients needed respiratory monitoring for the next 48 hours.

    Sounded kind of fun though and I think some of the guys in his group were doing CSE's with it for their joints as well.
     
  32. hokie

    hokie Junior Member
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    We use depodur for our hips (CSE - bupi spinal , depodur through Tuohy, no catheter). It has worked well to extremely well. A few cases of side effects (similar profile to duramorph but less frequent IMHO).
     
  33. Noyac

    Noyac ASA Member
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    Nice technique. Its not approved for spinal as you know but I am interested in it for sure. We don't have it currently but we were talking about trying to get it. In my previous practice the hips frequently were discharged on POD#2 so depodur may get in the way of this for some practices. But nice addition to the thread anyhow and I would like to hear from others that may be using it.
     
  34. jetproppilot

    jetproppilot Turboprop Driver
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    HAHAHAHAHAHAHA

    (WOLF IS THE MAN AND MUCH COOLER THAN ME).

    Dude, all kidding aside,

    Duramorph haunts me with itching.

    I think Duramorph-induced-pruritus approaches 90%.

    And if you tell me its less than 50%, I'll know youre a fake, an anesthesia tech in Hoboko, Iowa, living vicariously through our thread.

    :laugh: :laugh:
     
  35. Noyac

    Noyac ASA Member
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    OK here's the trick!




    Are you ready?






    If you don't ask, they don't itch! :laugh:
     
  36. hokie

    hokie Junior Member
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    Hope I didn't make it sound like we use it intrathecally - we don't. We either use it with CSE or single shot epidural dose + general (mainly for gyn-onc stuff so far). I also believe (will have to check) that most of our hips still go home in the evening of POD 2 - the likelihood of developing resp. depression if no problems in the first 36 hours should be low... also POD 2 will be 48 hrs after dose anyway. We also use less than the recommended dose if the patients are frail or much older than 70 or so. We have had a few resp. depression cases but no long term morbidity that I am aware of.
     
  37. Noyac

    Noyac ASA Member
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    I didn't think that you were using it intrathecally. I was just stating that its not approved for the few that may not be familiar with it. So, what is your dose just for curiousity?
     
  38. militarymd

    militarymd SDN Angel
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    That's what I do....I get called about itching from the nurses about once a month.
     
  39. Disse

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    How are you doing your "respiratory monitoring (this always seemed odd b/c it was explicitly stated as resp monitoring not continous pulse ox)?

    I would love to try a technique like this because it avoids the catheter (we've got nursing issues w/ epidurals on the floor) but would be worried about the post-op monitoring for the same reasons (nursing issues on the floor). The difference with the epidurals is that patients oftentimes aren't being evaluated by the nurses (so you don't know they're in pain) but I'd prefer that to a patient who isn't being evaluated by the nurses and is found cold and blue the next day.

    (not to make it seem like all our nurses suck but those that do suck do so with gusto)
     
  40. Noyac

    Noyac ASA Member
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    I was just thinking. Resp. monitoring is different depending on your hosp. policies. Ours is 24hr pulse ox and a bed as close as possible to the nursing station. We are building a new hosp. which will have central monitoring (may be good or bad, since now the nurses won't need to get up to check on pts.). But As I said I was just thinking. What if we developed a monitor that woke the pt up if the sats fell below 90% (or some preset value). Something like a NERVE STIMULATOR. It could zap them causing them to wake up and take a breath. Or better yet, it could zap the nurse causing the nurse to go into the room and reset the monitor. :rolleyes: All kidding aside, our nurses are pretty good and we have not had any issues to date.
     
  41. CanGas

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    Spinal intra-op. CFNB post-op. ~10-20% will have significant posterior knee pain and those get a single shot sciatic. Doing it this way means you avoid doing an extra procedure in 80-90% of your patients instead of giving a sciatic to everyone.

    Epidurals just as good as CPNB but more side-effects and not great if you surgeons love the higher doses of LMWH.

    With regards to DepoDur, take a look at the orginal articals for respiratory side-effects. Reasonably high rates of respiratory depression, hypoxia and opoid antagonist needs. I don't want a hypoxic or hypercapnic arrest because of something I did.

    With regards to rehab, it is clear that pt's with continous nerve blocks have a better range of motion post rehab than PCA groups. The issue of how much "active movement" vs "passive movement" is required in the immediate post-op period for good long term results is yet to be determined. It is clear though that a patient in pain will do worse than a patient not in pain.

    I personally think a femoral CPNB is standard of care for a TKA.

    The artical that you may want to share with your surgeons is from way back in 1998:
    http://www.anesthesia-analgesia.org/cgi/reprint/87/1/88
    Anesth Analg. 1998 Jul;87(1):88-92.

    Effects of intravenous patient-controlled analgesia with morphine, continuous epidural analgesia, and continuous three-in-one block on postoperative pain and knee rehabilitation after unilateral total knee arthroplasty.

    Singelyn FJ, Deyaert M, Joris D, Pendeville E, Gouverneur JM.

    Department of Anesthesiology, UCL School of Medicine, St. Luc Hospital, Brussels, Belgium.

    In this study, we assessed the influence of three analgesic techniques on postoperative knee rehabilitation after total knee arthroplasty (TKA). Forty-five patients scheduled for elective TKA under general anesthesia were randomly divided into three groups. Postoperative analgesia was provided with i.v. patient-controlled analgesia (PCA) with morphine in Group A, continuous 3-in-1 block in Group B, and epidural analgesia in Group C. Immediately after surgery, the three groups started identical physical therapy regimens. Pain scores, supplemental analgesia, side effects, degree of maximal knee flexion, day of first walk, and duration of hospital stay were recorded. Patients in Groups B and C reported significantly lower pain scores than those in Group A. Supplemental analgesia was comparable in the three groups. Compared with Groups A and C, a significantly lower incidence of side effects was noted in Group B. Significantly better knee flexion (until 6 wk after surgery), faster ambulation, and shorter hospital stay were noted in Groups B and C. However, these benefits did not affect outcome at 3 mo. We conclude that, after TKA, continuous 3-in-1 block and epidural analgesia provide better pain relief and faster knee rehabilitation than i.v. PCA with morphine. Because it induces fewer side effects, continuous 3-in-1 block should be considered the technique of choice. Implications: In this study, we determined that, after total knee arthroplasty, loco-regional analgesic techniques (epidural analgesia or continuous 3-in-1 block) provide better pain relief and faster postoperative knee rehabilitation than i.v. patient-controlled analgesia with morphine. Because it causes fewer side effects than epidural analgesia, continuous 3-in-1 block is the technique of choice.
     
  42. jetproppilot

    jetproppilot Turboprop Driver
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