best regional analgesic protocol for total knee arthroplasty
TRANSCRIPT
@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.
Perioperative Analgesia for TKA Perioperative Analgesia for TKA PatientsPatients
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.
Perioperative Analgesia for TKA Perioperative Analgesia for TKA PatientsPatients
#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
Perioperative Analgesia for TKA Perioperative Analgesia for TKA PatientsPatients
#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
Perioperative Analgesia for TKA Perioperative Analgesia for TKA PatientsPatients
#3: Deliver a Consistent #3: Deliver a Consistent ProductProduct
#3: Deliver a Consistent #3: Deliver a Consistent ProductProduct
Perioperative Analgesia for TKA Perioperative Analgesia for TKA PatientsPatients
OverviewOverviewOverviewOverview
Targeting analgesiaTargeting analgesia Improving functional outcomesImproving functional outcomes Avoiding complicationsAvoiding complications Putting it all togetherPutting it all together
Targeting analgesiaTargeting analgesia Improving functional outcomesImproving functional outcomes Avoiding complicationsAvoiding complications Putting it all togetherPutting it all together
Perioperative Analgesia for TKA Perioperative Analgesia for TKA PatientsPatients
OverviewOverviewOverviewOverview
Targeting analgesiaTargeting analgesia Improving functional outcomesImproving functional outcomes Avoiding complicationsAvoiding complications Putting it all togetherPutting it all together
Targeting analgesiaTargeting analgesia Improving functional outcomesImproving functional outcomes Avoiding complicationsAvoiding complications Putting it all togetherPutting it all together
Perioperative Analgesia for TKA Perioperative Analgesia for TKA PatientsPatients
Sensory Innervation of the Sensory Innervation of the KneeKnee
Sensory Innervation of the Sensory Innervation of the KneeKnee
Obturator
Perioperative Analgesia for TKA Perioperative Analgesia for TKA PatientsPatients
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
Perioperative Analgesia for TKA Perioperative Analgesia for TKA PatientsPatients
““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
Perioperative Analgesia for TKA Perioperative Analgesia for TKA PatientsPatients
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
Perioperative Analgesia for TKA Perioperative Analgesia for TKA PatientsPatients
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
Perioperative Analgesia for TKA Perioperative Analgesia for TKA PatientsPatients
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
Perioperative Analgesia for TKA Perioperative Analgesia for TKA PatientsPatients
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
Perioperative Analgesia for TKA Perioperative Analgesia for TKA PatientsPatients
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
Perioperative Analgesia for TKA Perioperative Analgesia for TKA PatientsPatients
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
Perioperative Analgesia for TKA Perioperative Analgesia for TKA PatientsPatients
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
Perioperative Analgesia for TKA Perioperative Analgesia for TKA PatientsPatients
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
Perioperative Analgesia for TKA Perioperative Analgesia for TKA PatientsPatients
OverviewOverviewOverviewOverview
Targeting analgesiaTargeting analgesia Improving functional outcomesImproving functional outcomes Avoiding complicationsAvoiding complications Putting it all togetherPutting it all together
Targeting analgesiaTargeting analgesia Improving functional outcomesImproving functional outcomes Avoiding complicationsAvoiding complications Putting it all togetherPutting it all together
Perioperative Analgesia for TKA Perioperative Analgesia for TKA PatientsPatients
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?
Perioperative Analgesia for TKA Perioperative Analgesia for TKA PatientsPatients
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
Perioperative Analgesia for TKA Perioperative Analgesia for TKA PatientsPatients
Functional Outcomes at 1 Functional Outcomes at 1 YearYear
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
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
Perioperative Analgesia for TKA Perioperative Analgesia for TKA PatientsPatients
Functional Outcomes at 1 Functional Outcomes at 1 YearYear
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
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
Perioperative Analgesia for TKA Perioperative Analgesia for TKA PatientsPatients
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
Muscle strength Muscle strength (force)(force)
Timed performance Timed performance (min)(min)– TUGTUG
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
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
Perioperative Analgesia for TKA Perioperative Analgesia for TKA PatientsPatients
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
Muscle strength Muscle strength (force)(force)
Timed performance Timed performance (min)(min)– TUGTUG
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
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
Performance-BasedPerformance-Based Self-ReportedSelf-Reported&&
Perioperative Analgesia for TKA Perioperative Analgesia for TKA PatientsPatients
OverviewOverviewOverviewOverview
Targeting analgesiaTargeting analgesia Improving functional outcomesImproving functional outcomes Avoiding complicationsAvoiding complications Putting it all togetherPutting it all together
Targeting analgesiaTargeting analgesia Improving functional outcomesImproving functional outcomes Avoiding complicationsAvoiding complications Putting it all togetherPutting it all together
Perioperative Analgesia for TKA Perioperative Analgesia for TKA PatientsPatients
Avoid “Never” EventsAvoid “Never” EventsAvoid “Never” EventsAvoid “Never” Events
Federal Register May 3, Federal Register May 3, 20072007
Perioperative Analgesia for TKA Perioperative Analgesia for TKA PatientsPatients
State the Obvious!State the Obvious!State the Obvious!State the Obvious!
Perioperative Analgesia for TKA Perioperative Analgesia for TKA PatientsPatients
Lower Extremity CPNB and Lower Extremity CPNB and FallsFalls
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
Perioperative Analgesia for TKA Perioperative Analgesia for TKA PatientsPatients
Lower Extremity CPNB and Lower Extremity CPNB and FallsFalls
Lower Extremity CPNB and Lower Extremity CPNB and FallsFalls
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
10/24 (10/24 (42%42%) ropivacaine subjects ) ropivacaine subjects required required reduction in dosereduction in dose on POD1 on POD122
10/39 (10/39 (26%26%) ropivacaine subjects ) ropivacaine subjects required required reduction in dosereduction in dose on POD1 on POD133
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
10/24 (10/24 (42%42%) ropivacaine subjects ) ropivacaine subjects required required reduction in dosereduction in dose on POD1 on POD122
10/39 (10/39 (26%26%) ropivacaine subjects ) ropivacaine subjects required required reduction in dosereduction in dose on POD1 on POD133
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
Perioperative Analgesia for TKA Perioperative Analgesia for TKA PatientsPatients
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
Perioperative Analgesia for TKA Perioperative Analgesia for TKA PatientsPatients
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
Perioperative Analgesia for TKA Perioperative Analgesia for TKA PatientsPatients
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
Perioperative Analgesia for TKA Perioperative Analgesia for TKA PatientsPatients
Increasing SelectivityIncreasing SelectivityIncreasing SelectivityIncreasing Selectivity
Perlas A, et al. RAPM Perlas A, et al. RAPM 2013;38:3342013;38:334
Perioperative Analgesia for TKA Perioperative Analgesia for TKA PatientsPatients
OverviewOverviewOverviewOverview
Targeting analgesiaTargeting analgesia Improving functional outcomesImproving functional outcomes Avoiding complicationsAvoiding complications Putting it all togetherPutting it all together
Targeting analgesiaTargeting analgesia Improving functional outcomesImproving functional outcomes Avoiding complicationsAvoiding complications Putting it all togetherPutting it all together
Perioperative Analgesia for TKA Perioperative Analgesia for TKA PatientsPatients
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
Perioperative Analgesia for TKA Perioperative Analgesia for TKA PatientsPatients
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]
Perioperative Analgesia for TKA Perioperative Analgesia for TKA PatientsPatients
MethodsMethodsMethodsMethods
Mudumbai & Mariano, et al. CORR Mudumbai & Mariano, et al. CORR 2013;Jul30[Epub]2013;Jul30[Epub]
Perioperative Analgesia for TKA Perioperative Analgesia for TKA PatientsPatients
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).
Mudumbai & Mariano, et al. CORR Mudumbai & Mariano, et al. CORR 2013;Jul30[Epub]2013;Jul30[Epub]
Perioperative Analgesia for TKA Perioperative Analgesia for TKA PatientsPatients
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
Mudumbai & Mariano, et al. CORR Mudumbai & Mariano, et al. CORR 2013;Jul30[Epub]2013;Jul30[Epub]
Perioperative Analgesia for TKA Perioperative Analgesia for TKA PatientsPatients
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.
Perioperative Analgesia for TKA Perioperative Analgesia for TKA PatientsPatients
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