Best Regional Analgesic Protocol for Total Knee Arthroplasty

@EMARIANOMD@EMARIANOMD

Best Regional Analgesic Best Regional Analgesic Protocol for Total Knee Protocol for Total Knee

ArthroplastyArthroplasty

Best Regional Analgesic Best Regional Analgesic Protocol for Total Knee Protocol for Total Knee

ArthroplastyArthroplasty

Edward R. Mariano, M.D., Edward R. Mariano, M.D., M.A.S.M.A.S.

Associate Professor of AnesthesiologyAssociate Professor of AnesthesiologyStanford University School of MedicineStanford University School of Medicine

Chief, Anesthesiology and Perioperative Chief, Anesthesiology and Perioperative CareCare

Veterans Affairs Palo Alto Health Care Veterans Affairs Palo Alto Health Care SystemSystem

Edward R. Mariano, M.D., Edward R. Mariano, M.D., M.A.S.M.A.S.

Associate Professor of AnesthesiologyAssociate Professor of AnesthesiologyStanford University School of MedicineStanford University School of Medicine

Chief, Anesthesiology and Perioperative Chief, Anesthesiology and Perioperative CareCare

Veterans Affairs Palo Alto Health Care Veterans Affairs Palo Alto Health Care SystemSystem

Perioperative Analgesia for TKA Perioperative Analgesia for TKA PatientsPatients

Financial DisclosuresFinancial DisclosuresFinancial DisclosuresFinancial Disclosures Halyard (formerly I-Flow), B Braun – Halyard (formerly I-Flow), B Braun –

Unrestricted educational program Unrestricted educational program funding paid to the institutionfunding paid to the institution

The contents of the following The contents of the following presentation are solely the presentation are solely the responsibility of the speaker without responsibility of the speaker without input from any of the above input from any of the above companies.companies.

Halyard (formerly I-Flow), B Braun – Halyard (formerly I-Flow), B Braun – Unrestricted educational program Unrestricted educational program funding paid to the institutionfunding paid to the institution

The contents of the following The contents of the following presentation are solely the presentation are solely the responsibility of the speaker without responsibility of the speaker without input from any of the above input from any of the above companies.companies.


ObjectivesObjectivesObjectivesObjectives At the end of this session, participants At the end of this session, participants

will be able to:will be able to:– Propose an analgesic plan for the Propose an analgesic plan for the

perioperativeperioperative management of the patient management of the patient undergoing total knee arthroplasty;undergoing total knee arthroplasty;

– Discuss the merits and demerits of the Discuss the merits and demerits of the continuous and single-injection femoral continuous and single-injection femoral block; andblock; and

– Assess the evidence for adductor canal Assess the evidence for adductor canal blocks.blocks.

At the end of this session, participants At the end of this session, participants will be able to:will be able to:– Propose an analgesic plan for the Propose an analgesic plan for the

perioperativeperioperative management of the patient management of the patient undergoing total knee arthroplasty;undergoing total knee arthroplasty;

– Discuss the merits and demerits of the Discuss the merits and demerits of the continuous and single-injection femoral continuous and single-injection femoral block; andblock; and

– Assess the evidence for adductor canal Assess the evidence for adductor canal blocks.blocks.


#1: One Size Does Not Fit #1: One Size Does Not Fit AllAll

#1: One Size Does Not Fit #1: One Size Does Not Fit AllAll

REGIONAL ANESTHESIOLOGIST


#2: Use Multi-Modal #2: Use Multi-Modal AnalgesiaAnalgesia

#2: Use Multi-Modal #2: Use Multi-Modal AnalgesiaAnalgesia

Hebl JR, et al. JBJS 2005;87 Suppl Hebl JR, et al. JBJS 2005;87 Suppl 2:632:63


#3: Deliver a Consistent #3: Deliver a Consistent ProductProduct

#3: Deliver a Consistent #3: Deliver a Consistent ProductProduct


OverviewOverviewOverviewOverview

Targeting analgesiaTargeting analgesia Improving functional outcomesImproving functional outcomes Avoiding complicationsAvoiding complications Putting it all togetherPutting it all together







Sensory Innervation of the Sensory Innervation of the KneeKnee

Sensory Innervation of the Sensory Innervation of the KneeKnee

Obturator


Epidural AnalgesiaEpidural AnalgesiaEpidural AnalgesiaEpidural Analgesia Bupiv Bupiv 0.25% at 6-15 ml/h0.25% at 6-15 ml/h vs. opioids vs. opioids11

– Epid group had lower pain scores but high Epid group had lower pain scores but high proportion had proportion had complete motor blockcomplete motor block

Epid bupiv+MS vs. epid MS vs. IV Epid bupiv+MS vs. epid MS vs. IV opioidsopioids22

– Bupiv+MS: shorter time to achieve Bupiv+MS: shorter time to achieve ambulation distance and range of motion ambulation distance and range of motion goalsgoals

– Shorter hospital length of stayShorter hospital length of stay

Bupiv Bupiv 0.25% at 6-15 ml/h0.25% at 6-15 ml/h vs. opioids vs. opioids11

– Epid group had lower pain scores but high Epid group had lower pain scores but high proportion had proportion had complete motor blockcomplete motor block

Epid bupiv+MS vs. epid MS vs. IV Epid bupiv+MS vs. epid MS vs. IV opioidsopioids22

– Bupiv+MS: shorter time to achieve Bupiv+MS: shorter time to achieve ambulation distance and range of motion ambulation distance and range of motion goalsgoals

– Shorter hospital length of stayShorter hospital length of stay

1. Raj PP, et al. A&A 1987;66:4011. Raj PP, et al. A&A 1987;66:4012. Mahoney OM, et al. CORR 2. Mahoney OM, et al. CORR 1990;Nov:301990;Nov:30


““Evolution” of Regional Evolution” of Regional AnalgesiaAnalgesia

““Evolution” of Regional Evolution” of Regional AnalgesiaAnalgesia

Spinal & Epidural -> Nerve Block -> Continuous Nerve Spinal & Epidural -> Nerve Block -> Continuous Nerve BlockBlock


CFNB vs. Epidural for TKACFNB vs. Epidural for TKACFNB vs. Epidural for TKACFNB vs. Epidural for TKA Comparable analgesia Comparable analgesia Better side effect profile with CFNBBetter side effect profile with CFNB

– Less nausea and vomitingLess nausea and vomiting– Less urinary retention (no need for Less urinary retention (no need for

foley)foley)– Sparing of non-operative limbSparing of non-operative limb– No epidural hematoma (anticoagulation)No epidural hematoma (anticoagulation)

Epidurals require hospitalizationEpidurals require hospitalization

Comparable analgesia Comparable analgesia Better side effect profile with CFNBBetter side effect profile with CFNB

– Less nausea and vomitingLess nausea and vomiting– Less urinary retention (no need for Less urinary retention (no need for

foley)foley)– Sparing of non-operative limbSparing of non-operative limb– No epidural hematoma (anticoagulation)No epidural hematoma (anticoagulation)

Epidurals require hospitalizationEpidurals require hospitalization

Barrington MJ, et al. A&A Barrington MJ, et al. A&A 2005;101:18242005;101:1824Zaric D, et al. A&A 2006;102:1240Zaric D, et al. A&A 2006;102:1240


Meta-analysis: CPNB vs. Meta-analysis: CPNB vs. OpioidsOpioids

Meta-analysis: CPNB vs. Meta-analysis: CPNB vs. OpioidsOpioids

Richman JM, et al. A&A 2006;102:248Richman JM, et al. A&A 2006;102:248Richman JM, et al. A&A 2006;102:248Richman JM, et al. A&A 2006;102:248

Mean VASMean VAS24h24h 48h48h

InfraclaInfraclavv

1.0 vs. 1.0 vs. 4.34.3

p<0.00p<0.0011

0.6 vs. 0.6 vs. 4.04.0

p<0.00p<0.0011

InterscaInterscall

1.4 vs. 1.4 vs. 3.63.6

p<0.00p<0.0011

0.5 vs. 0.5 vs. 2.32.3

p<0.00p<0.0011

Fem/LPFem/LP 2.1 vs. 2.1 vs. 4.04.0

p<0.00p<0.0011

1.6 vs. 1.6 vs. 3.23.2

p<0.00p<0.0011

SciaticSciatic 0.9 vs. 0.9 vs. 4.64.6

p<0.00p<0.0011

0.9 vs. 0.9 vs. 3.53.5

p<0.00p<0.0011


Why CPNB? Patient Why CPNB? Patient SatisfactionSatisfaction

Why CPNB? Patient Why CPNB? Patient SatisfactionSatisfaction Meta-analysis CPNB vs. single-injection Meta-analysis CPNB vs. single-injection

block: 21 studies (702 subjects) included block: 21 studies (702 subjects) included Meta-analysis CPNB vs. single-injection Meta-analysis CPNB vs. single-injection

block: 21 studies (702 subjects) included block: 21 studies (702 subjects) included

Bingham AE and Horn JL. RAPM Bingham AE and Horn JL. RAPM 2012;37:5832012;37:583


Single-Injection vs. CFNB for Single-Injection vs. CFNB for TKATKA

Single-Injection vs. CFNB for Single-Injection vs. CFNB for TKATKA

Non-blindedNon-blinded RCT of single vs. continuous RCT of single vs. continuous femoral nerve blocks for TKA within an femoral nerve blocks for TKA within an established clinical pathway (n=36)established clinical pathway (n=36)

Spinal anesthesia, IV morphine PCA Spinal anesthesia, IV morphine PCA overnight; then oxycodone po + overnight; then oxycodone po + scheduled ibuprofen scheduled ibuprofen + usual postop care+ usual postop care

Pain scores and opioid consumption Pain scores and opioid consumption lower in CFNB grouplower in CFNB group

No difference in length of stay (3.9 v. No difference in length of stay (3.9 v. 3.8) d3.8) d

Non-blindedNon-blinded RCT of single vs. continuous RCT of single vs. continuous femoral nerve blocks for TKA within an femoral nerve blocks for TKA within an established clinical pathway (n=36)established clinical pathway (n=36)

Spinal anesthesia, IV morphine PCA Spinal anesthesia, IV morphine PCA overnight; then oxycodone po + overnight; then oxycodone po + scheduled ibuprofen scheduled ibuprofen + usual postop care+ usual postop care

Pain scores and opioid consumption Pain scores and opioid consumption lower in CFNB grouplower in CFNB group

No difference in length of stay (3.9 v. No difference in length of stay (3.9 v. 3.8) d3.8) d

Salinas FV, et al. A&A Salinas FV, et al. A&A 2006;102:12342006;102:1234


Ropiv Saline

““Single-Injection” vs. CFNB for Single-Injection” vs. CFNB for TKATKA

““Single-Injection” vs. CFNB for Single-Injection” vs. CFNB for TKATKA

50 subjects50 subjects, tricompartment TKA, tricompartment TKA CFNB with 1 night infusion of ropivacaine: CFNB with 1 night infusion of ropivacaine:

randomized to ropiv vs. saline on POD1randomized to ropiv vs. saline on POD1

50 subjects50 subjects, tricompartment TKA, tricompartment TKA CFNB with 1 night infusion of ropivacaine: CFNB with 1 night infusion of ropivacaine:

randomized to ropiv vs. saline on POD1randomized to ropiv vs. saline on POD1

Ilfeld BM, et al. Anesth Ilfeld BM, et al. Anesth 2008;108:703 2008;108:703

3 Discharge Criteria:

1. NRS (pain) < 4

2. IV opioid-free x 12 hours

3. Ambulating > 30 meters


Sciatic Nerve Block: Yes or No?Sciatic Nerve Block: Yes or No?Sciatic Nerve Block: Yes or No?Sciatic Nerve Block: Yes or No? TKA patients (n=16) received CFNB TKA patients (n=16) received CFNB

onlyonly TKA patients (n=16) received CFNB TKA patients (n=16) received CFNB

onlyonly

0

2

4

6

8

10

12

14

16

18

0 1 2 3 4

Postoperative Day

IV M

orp

hin

e (

mg

)

Placebo Ropivacaine

randomizedrandomized

Ilfeld BM, et al. Anesth 2005;103:A1013Ilfeld BM, et al. Anesth 2005;103:A1013


Sciatic Nerve Block: Yes or Sciatic Nerve Block: Yes or No?No?

Sciatic Nerve Block: Yes or Sciatic Nerve Block: Yes or No?No?

Wegener JT, et al. RAPM Wegener JT, et al. RAPM 2011;36:4812011;36:481Ilfeld and Madison. RAPM Ilfeld and Madison. RAPM 2011;36:4212011;36:421

Pham-Dang C, et al. RAPM Pham-Dang C, et al. RAPM 2005;30:1282005;30:128Abdallah and Brull. RAPM Abdallah and Brull. RAPM 2011;36:4932011;36:493

Yes

No

Maybe


Local Infiltration AnalgesiaLocal Infiltration AnalgesiaLocal Infiltration AnalgesiaLocal Infiltration Analgesia Ropivacaine ≥300 mg + ketorolac + Ropivacaine ≥300 mg + ketorolac +

epinephrine ± opioidepinephrine ± opioid– vs. control (blinding issues): lower pain vs. control (blinding issues): lower pain

scores, less opioid consumption scores, less opioid consumption – vs. CFNB (blinding issues, mixed results): vs. CFNB (blinding issues, mixed results):

LIA: better early function but more complications?LIA: better early function but more complications? CFNB: possibly better late functional benefits?CFNB: possibly better late functional benefits?

Benefits may be limited to 6-12 hoursBenefits may be limited to 6-12 hours

Ropivacaine ≥300 mg + ketorolac + Ropivacaine ≥300 mg + ketorolac + epinephrine ± opioidepinephrine ± opioid– vs. control (blinding issues): lower pain vs. control (blinding issues): lower pain

scores, less opioid consumption scores, less opioid consumption – vs. CFNB (blinding issues, mixed results): vs. CFNB (blinding issues, mixed results):

LIA: better early function but more complications?LIA: better early function but more complications? CFNB: possibly better late functional benefits?CFNB: possibly better late functional benefits?

Benefits may be limited to 6-12 hoursBenefits may be limited to 6-12 hours

Toftdahl K, et al. Acta Ortho 2007;78:172Toftdahl K, et al. Acta Ortho 2007;78:172Carli F, et al. BJA 2010;105:185Carli F, et al. BJA 2010;105:185Kehlet and Andersen. Acta Anaes Kehlet and Andersen. Acta Anaes 2011;55:7782011;55:778

Ventittoli PA, et al. JBJS 2006;88:282Ventittoli PA, et al. JBJS 2006;88:282Busch CA, et al. JBJS 2006;88:959Busch CA, et al. JBJS 2006;88:959McCartney and McLeod. BJA McCartney and McLeod. BJA 2011;107:4872011;107:487






Effect of CFNB on Knee ROMEffect of CFNB on Knee ROMEffect of CFNB on Knee ROMEffect of CFNB on Knee ROMKnee Flexion (Degrees)Knee Flexion (Degrees)

PCAPCA CFNBCFNB P ValueP Value

POD #1POD #1 33 33 ± 15± 15 56 56 ± 22± 22 0.0090.009

POD #3POD #3 53 53 ± 17± 17 74 74 ± 11± 11 <0.001<0.001

6 weeks6 weeks 103 103 ± 12± 12 116 116 ± 12± 12 0.030.03

3 months3 months 116 116 ± 11± 11 124 124 ± 12± 12 NSNS

Singelyn FJ, et al. A&A 1998;87:88Singelyn FJ, et al. A&A 1998;87:88

Is this a possible Is this a possible long-termlong-term effect??effect??

If so, what is the mechanism?If so, what is the mechanism?


Functional Outcomes at 6 Functional Outcomes at 6 WeeksWeeks

Functional Outcomes at 6 Functional Outcomes at 6 WeeksWeeks

RCT (n=40) of CFNB vs. LIARCT (n=40) of CFNB vs. LIA– At 6 weeks, the CFNB group showed greater At 6 weeks, the CFNB group showed greater

within-group improvement in 6-MWT, physical within-group improvement in 6-MWT, physical activity (CHAMPS), KSS, and WOMACactivity (CHAMPS), KSS, and WOMAC

– Preop 6-MWT, walking on POD1, time spent Preop 6-MWT, walking on POD1, time spent walking during POD1-3 were predictors of 6-walking during POD1-3 were predictors of 6-MWT at 6 weeksMWT at 6 weeks

RCT (n=40) of CFNB vs. LIARCT (n=40) of CFNB vs. LIA– At 6 weeks, the CFNB group showed greater At 6 weeks, the CFNB group showed greater

within-group improvement in 6-MWT, physical within-group improvement in 6-MWT, physical activity (CHAMPS), KSS, and WOMACactivity (CHAMPS), KSS, and WOMAC

– Preop 6-MWT, walking on POD1, time spent Preop 6-MWT, walking on POD1, time spent walking during POD1-3 were predictors of 6-walking during POD1-3 were predictors of 6-MWT at 6 weeksMWT at 6 weeks

Carli F, et al. BJA Carli F, et al. BJA 2010;105:1852010;105:185


Functional Outcomes at 1 Functional Outcomes at 1 YearYear


1 yr Western Ontario and McMaster Univ 1 yr Western Ontario and McMaster Univ Osteoarthritis Index (WOMAC) scoresOsteoarthritis Index (WOMAC) scores


Ilfeld & Mariano, et al. A&A Ilfeld & Mariano, et al. A&A 2009;108:13202009;108:1320Ilfeld & Mariano, et al. A&A Ilfeld & Mariano, et al. A&A 2009;109:5862009;109:586






Ilfeld & Mariano, et al. A&A Ilfeld & Mariano, et al. A&A 2009;108:13202009;108:1320Ilfeld & Mariano, et al. A&A Ilfeld & Mariano, et al. A&A 2009;109:5862009;109:586


Selection of OutcomesSelection of OutcomesSelection of OutcomesSelection of Outcomes Range of motion Range of motion

(degrees)(degrees) Timed ambulation Timed ambulation

distance (meters)distance (meters)– 6-MWT6-MWT– 2-MWT2-MWT

Muscle strength Muscle strength (force)(force)

Timed performance Timed performance (min)(min)– TUGTUG

Range of motion Range of motion (degrees)(degrees)

Timed ambulation Timed ambulation distance (meters)distance (meters)– 6-MWT6-MWT– 2-MWT2-MWT



Western Ontario Western Ontario and McMaster Univ and McMaster Univ Osteoarthritis Osteoarthritis Index (WOMAC)Index (WOMAC)

Knee Society ScoreKnee Society Score Lower Extremity Lower Extremity

Functional ScaleFunctional Scale Health-Related Health-Related

Quality of LifeQuality of Life





Choi S, et al. RAPM 2013;38:340Choi S, et al. RAPM 2013;38:340Bernucci & Carli. Curr Op Anaes Bernucci & Carli. Curr Op Anaes 2012;25:6212012;25:621


Selection of OutcomesSelection of OutcomesSelection of OutcomesSelection of Outcomes Range of motion Range of motion

(degrees)(degrees) Timed ambulation Timed ambulation

distance (meters)distance (meters)– 6-MWT6-MWT– 2-MWT2-MWT



Range of motion Range of motion (degrees)(degrees)

Timed ambulation Timed ambulation distance (meters)distance (meters)– 6-MWT6-MWT– 2-MWT2-MWT











Choi S, et al. RAPM 2013;38:340Choi S, et al. RAPM 2013;38:340Bernucci & Carli. Curr Op Anaes Bernucci & Carli. Curr Op Anaes 2012;25:6212012;25:621

Performance-BasedPerformance-Based Self-ReportedSelf-Reported&&






Avoid “Never” EventsAvoid “Never” EventsAvoid “Never” EventsAvoid “Never” Events

Federal Register May 3, Federal Register May 3, 20072007


State the Obvious!State the Obvious!State the Obvious!State the Obvious!


Lower Extremity CPNB and Lower Extremity CPNB and FallsFalls


Pooled analysis of 3 published RCTs Pooled analysis of 3 published RCTs (knee and hip arthroplasty) with (knee and hip arthroplasty) with CPNB x 4 daysCPNB x 4 days– 85 subjects received ropivacaine 0.2%85 subjects received ropivacaine 0.2%– 86 subjects received saline86 subjects received saline

NoNo falls in the saline group vs. falls in the saline group vs. 77 falls falls in the ropiv group (P=0.013)in the ropiv group (P=0.013)

Pooled analysis of 3 published RCTs Pooled analysis of 3 published RCTs (knee and hip arthroplasty) with (knee and hip arthroplasty) with CPNB x 4 daysCPNB x 4 days– 85 subjects received ropivacaine 0.2%85 subjects received ropivacaine 0.2%– 86 subjects received saline86 subjects received saline

NoNo falls in the saline group vs. falls in the saline group vs. 77 falls falls in the ropiv group (P=0.013)in the ropiv group (P=0.013)

Ilfeld BM, et al. A&A Ilfeld BM, et al. A&A 2010;111:15522010;111:1552




Workload impact is often Workload impact is often unmeasuredunmeasured

10/25 (10/25 (43%43%) ropivacaine subjects ) ropivacaine subjects required required reduction in dosereduction in dose on POD1 on POD111



Workload impact is often Workload impact is often unmeasuredunmeasured




1. Ilfeld & Mariano, et al. Anesth 1. Ilfeld & Mariano, et al. Anesth 2008;108:7032008;108:7032. Ilfeld & Mariano, et al. Anesth 2. Ilfeld & Mariano, et al. Anesth 2008;109:4912008;109:4913. Ilfeld & Mariano, et al. Pain 3. Ilfeld & Mariano, et al. Pain 2010;150:4772010;150:477


Location and Dose Matter Location and Dose Matter MostMost

Location and Dose Matter Location and Dose Matter MostMost

Lumbar plexus: ropiv 0.1% (12 ml/h, bolus Lumbar plexus: ropiv 0.1% (12 ml/h, bolus 4 ml) vs. 0.4% (3 ml/h, bolus 1 ml)4 ml) vs. 0.4% (3 ml/h, bolus 1 ml)– Quadriceps maximum voluntary isometric Quadriceps maximum voluntary isometric

contraction (MVIC) decreased by mean of contraction (MVIC) decreased by mean of 64.1% 64.1% for 1% vs. for 1% vs. 68.0%68.0% for 0.4% (p=0.70) for 0.4% (p=0.70)

Femoral nerve: ropivacaine 0.1% either 5 Femoral nerve: ropivacaine 0.1% either 5 ml/h infusion vs. 5 ml bolus q 1 h x 6 hrsml/h infusion vs. 5 ml bolus q 1 h x 6 hrs– MVIC decreased by mean of MVIC decreased by mean of 84%84% (infusion) vs. (infusion) vs.

83%83% (bolus; p=0.91) (bolus; p=0.91)

Lumbar plexus: ropiv 0.1% (12 ml/h, bolus Lumbar plexus: ropiv 0.1% (12 ml/h, bolus 4 ml) vs. 0.4% (3 ml/h, bolus 1 ml)4 ml) vs. 0.4% (3 ml/h, bolus 1 ml)– Quadriceps maximum voluntary isometric Quadriceps maximum voluntary isometric

contraction (MVIC) decreased by mean of contraction (MVIC) decreased by mean of 64.1% 64.1% for 1% vs. for 1% vs. 68.0%68.0% for 0.4% (p=0.70) for 0.4% (p=0.70)

Femoral nerve: ropivacaine 0.1% either 5 Femoral nerve: ropivacaine 0.1% either 5 ml/h infusion vs. 5 ml bolus q 1 h x 6 hrsml/h infusion vs. 5 ml bolus q 1 h x 6 hrs– MVIC decreased by mean of MVIC decreased by mean of 84%84% (infusion) vs. (infusion) vs.

83%83% (bolus; p=0.91) (bolus; p=0.91)

Ilfeld & Mariano, et al. Anesth Ilfeld & Mariano, et al. Anesth 2010;112:3472010;112:347Charous MT, et al. Anesth Charous MT, et al. Anesth 2011;115:7742011;115:774


Increasing SelectivityIncreasing SelectivityIncreasing SelectivityIncreasing Selectivity Injectate administered Injectate administered

distal to the femoral distal to the femoral triangle in triangle in adductor adductor canalcanal

Many variations on Many variations on technique technique

Effective vs. placebo Effective vs. placebo injectioninjection

Decreases quad strength Decreases quad strength but less than FNBbut less than FNB

Injectate administered Injectate administered distal to the femoral distal to the femoral triangle in triangle in adductor adductor canalcanal

Many variations on Many variations on technique technique

Effective vs. placebo Effective vs. placebo injectioninjection

Decreases quad strength Decreases quad strength but less than FNBbut less than FNB

Tsui & Ozelsel. RAPM 2009;34:178Tsui & Ozelsel. RAPM 2009;34:178Ishiguro S, et al. A&A Ishiguro S, et al. A&A 2012;115:14672012;115:1467Jaeger P, et al. Acta Anaes Jaeger P, et al. Acta Anaes 2012;56:10132012;56:1013Jaeger P, et al. Anesth Jaeger P, et al. Anesth 2013;118:4092013;118:409

Lund J, et al. Acta Anaes 2011;55:14Lund J, et al. Acta Anaes 2011;55:14Manickam B, et al. RAPM Manickam B, et al. RAPM 2009;34:5782009;34:578Krombach & Gray. RAPM Krombach & Gray. RAPM 2007;32:3692007;32:369

LATE

RA

L

SFA

N

SARTORIUS


Increasing SelectivityIncreasing SelectivityIncreasing SelectivityIncreasing Selectivity Case-control study of Case-control study of

unilateral primary TKA unilateral primary TKA Nov 2011-June 2012Nov 2011-June 2012

All patients received All patients received SAB with IT morphine SAB with IT morphine plus:plus:– CFNB ± sciatic NBCFNB ± sciatic NB or or– LIALIA or or– LIA + single-injection LIA + single-injection

ACBACB

Case-control study of Case-control study of unilateral primary TKA unilateral primary TKA Nov 2011-June 2012Nov 2011-June 2012

All patients received All patients received SAB with IT morphine SAB with IT morphine plus:plus:– CFNB ± sciatic NBCFNB ± sciatic NB or or– LIALIA or or– LIA + single-injection LIA + single-injection

ACBACB

Perlas A, et al. RAPM Perlas A, et al. RAPM 2013;38:3342013;38:334


Increasing SelectivityIncreasing SelectivityIncreasing SelectivityIncreasing Selectivity

Perlas A, et al. RAPM Perlas A, et al. RAPM 2013;38:3342013;38:334






Clinical Pathway (VA Palo Clinical Pathway (VA Palo Alto)Alto)

Clinical Pathway (VA Palo Clinical Pathway (VA Palo Alto)Alto)

PreopPreop Perineural catheter insertionPerineural catheter insertion

IntraopIntraop Periarticular local anesthetic Periarticular local anesthetic infiltration: ropivacaine 0.2% (150 infiltration: ropivacaine 0.2% (150 ml) with ketorolac 30 mg and ml) with ketorolac 30 mg and epinephrineepinephrine

PostopPostop 1.1. Perineural infusion of ropivacaine Perineural infusion of ropivacaine

2.2. Scheduled meds: oral oxycodone, Scheduled meds: oral oxycodone, acetaminophen, and diclofenac acetaminophen, and diclofenac

3.3. PRN meds: oxycodone (PO) and PRN meds: oxycodone (PO) and morphine (IV) for breakthrough morphine (IV) for breakthrough pain pain No IV PCA


Clinical Pathway ChangeClinical Pathway ChangeClinical Pathway ChangeClinical Pathway Change In April 2012, clinical pathway changed In April 2012, clinical pathway changed

from CFNB to continuous adductor canal from CFNB to continuous adductor canal blocks due to concern over quad blocks due to concern over quad weaknessweakness

Hypothesis for retrospective cohort study: Hypothesis for retrospective cohort study: patients with continuous adductor canal patients with continuous adductor canal blocks blocks ambulate further ambulate further than those with than those with continuous femoral nerve blocks on continuous femoral nerve blocks on postoperative day (POD) 1 without postoperative day (POD) 1 without reduction in analgesiareduction in analgesia

In April 2012, clinical pathway changed In April 2012, clinical pathway changed from CFNB to continuous adductor canal from CFNB to continuous adductor canal blocks due to concern over quad blocks due to concern over quad weaknessweakness

Hypothesis for retrospective cohort study: Hypothesis for retrospective cohort study: patients with continuous adductor canal patients with continuous adductor canal blocks blocks ambulate further ambulate further than those with than those with continuous femoral nerve blocks on continuous femoral nerve blocks on postoperative day (POD) 1 without postoperative day (POD) 1 without reduction in analgesiareduction in analgesia

Mudumbai & Mariano, et al. CORR Mudumbai & Mariano, et al. CORR 2013;Jul30[Epub]2013;Jul30[Epub]


MethodsMethodsMethodsMethods



ResultsResultsResultsResults Primary outcome: Patients in the Primary outcome: Patients in the

adductor canal group walked a adductor canal group walked a median (10th-90th percentiles) of median (10th-90th percentiles) of 3737 (0-90) meters vs. (0-90) meters vs. 66 (0-51) meters in (0-51) meters in the femoral catheter group the femoral catheter group (p=0.003). (p=0.003).

Primary outcome: Patients in the Primary outcome: Patients in the adductor canal group walked a adductor canal group walked a median (10th-90th percentiles) of median (10th-90th percentiles) of 3737 (0-90) meters vs. (0-90) meters vs. 66 (0-51) meters in (0-51) meters in the femoral catheter group the femoral catheter group (p=0.003). (p=0.003).



Adductor canal Adductor canal patients ambulated patients ambulated further than femoral further than femoral catheter patients at catheter patients at 3 of 4 physical 3 of 4 physical therapy time points.therapy time points.

Pain scores, opioid Pain scores, opioid consumption, and consumption, and hospital length of hospital length of stay were similar. stay were similar.

Adductor canal Adductor canal patients ambulated patients ambulated further than femoral further than femoral catheter patients at catheter patients at 3 of 4 physical 3 of 4 physical therapy time points.therapy time points.

Pain scores, opioid Pain scores, opioid consumption, and consumption, and hospital length of hospital length of stay were similar. stay were similar.

ResultsResultsResultsResults



SummarySummarySummarySummary We discussed:We discussed:

– Possible options that you can use to Possible options that you can use to develop an analgesic plan for the develop an analgesic plan for the perioperativeperioperative management of a patient management of a patient undergoing total knee arthroplasty; undergoing total knee arthroplasty;

– Merits and demerits of the continuous Merits and demerits of the continuous and single-injection femoral block; andand single-injection femoral block; and

– The growing body of evidence favoring The growing body of evidence favoring adductor canal blocks in certain adductor canal blocks in certain situations.situations.

We discussed:We discussed:– Possible options that you can use to Possible options that you can use to

develop an analgesic plan for the develop an analgesic plan for the perioperativeperioperative management of a patient management of a patient undergoing total knee arthroplasty; undergoing total knee arthroplasty;

– Merits and demerits of the continuous Merits and demerits of the continuous and single-injection femoral block; andand single-injection femoral block; and

– The growing body of evidence favoring The growing body of evidence favoring adductor canal blocks in certain adductor canal blocks in certain situations.situations.


Lessons LearnedLessons LearnedLessons LearnedLessons Learned

1.1. One size does not fit allOne size does not fit all

2.2. Use multimodal analgesiaUse multimodal analgesia

3.3. Deliver a consistent Deliver a consistent productproduct

1.1. One size does not fit allOne size does not fit all

2.2. Use multimodal analgesiaUse multimodal analgesia

3.3. Deliver a consistent Deliver a consistent productproduct

Date post:	08-Aug-2015
Category:	Healthcare
Upload:	edward-r-mariano
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Best Regional Analgesic Protocol for Total Knee Arthroplasty

Healthcare