Download orthopedic surgery pain management techniques

ORTHOPEDIC SURGERY PAIN
MANAGEMENT TECHNIQUES
& CLINICAL EVIDENCE
PAIN MANAGEMENT
YOU CAN DEPEND ON.
Orthopedic Surgery
3
Techniques
Total Knee Arthroplasty - Dr. Mokris
5
Adductor Canal Blocks for:
ACL Reconstruction - Dr. Hickman
6
ACL Reconstruction and Total Knee Arthroplasty - Dr. Zimmerman
8
ACL Reconstruction and Total Knee Arthroplasty - Dr. Bommarito
10
Interscalene Block for Total shoulder Replacement & Rotator Cuff Repair - Dr. Szlyk
12
Clinical Summaries
16
Additional Resources for Adductor Canal Blocks
20
DISCLAIMERS
The disclaimers contained herein pertain to all information included in this booklet. The information provided herein is provided for educational purposes and represents
the surgical techniques used by specific doctors. Catheter placements are intended for guidance only and are subject to the individual expertise, experience and schoolof-thought of the surgeon placing the catheter. Always refer to the drug manufacturer’s prescribing information when administering any drug with the ON-Q* Pain Relief
System. This protocol is not to be construed as a specific recommendation of Halyard, LLC.
Cautions & Warnings
• Make sure the catheter is not in a vein or artery. Inadvertent intravascular delivery may result in systemic toxic effects. Refer to the drug manufacturer’s package insert.
• Avoid placing the catheter in joint spaces. Although there is no definitive established causal relationship, some literature has shown a possible association between
continuous intra-articular infusions (particularly with bupivacaine) and the subsequent development of chondrolysis.
• Patient may experience loss of motor control or feeling at and around the surgical area. Physician should instruct patient on appropriate measures to follow to avoid
patient injury.
• Medications used with this system should be administered in accordance with instructions provided by the drug manufacturer. Physician is responsible for prescribing
drug based on each patient’s clinical status (e.g., age, body weight, disease state of patient, concomitant medication(s)).
• Vasoconstrictors such as epinephrine or adrenaline are not recommended for continuous infusions.
• Refer to ON-Q* Instructions for Use for full instructions on using the ON-Q* Continuous Nerve Block System.
Indications For Use
• The ON-Q* pump is intended to provide continuous and/or intermittent delivery of medication (such as local anesthetics or narcotics) to or around surgical wound
sites and/or close proximity to nerves for preoperative, perioperative and postoperative regional anesthesia and/or pain management. Routes of administration include:
intraoperative site, perineural, percutaneous, and epidural.
• ON-Q* is intended to significantly decrease pain and narcotic use when used to deliver local anesthetics to or around surgical wound sites, or close proximity to nerves,
when compared to narcotic only pain management.
Contraindications
• ON-Q* is not intended for blood, blood products, lipids, fat emulsions, or Total Parenteral Nutrition (TPN).
• ON-Q* is not intended for intravascular delivery.
There are inherent risks in all medical devices. Please refer to the product labeling for Indications, Cautions, Warnings, and Contraindications. Failure to follow the product
labeling could directly impact patient safety. Physician is responsible for prescribing and administering medications per instructions provided by the drug manufacturer.
Refer to www.halyardhealth.com for product safety Technical Bulletins.
2
Orthopedic
Surgery
A continuous infusion, which provides pain management over multiple days, rather than a single injection
provides better pain relief and additional benefits during
a patient’s postoperative recovery. As demonstrated in
a systematic review of over 700 patients, compared to
single shot nerve blocks, continuous peripheral nerve
Management of postoperative pain is a complex challenge
facing healthcare professionals in daily clinical practice.
Inadequate pain control may alter the patient’s metabolic
blocks (CPNB) resulted in5:
Decrease in pain scores through POD2 (P<0.001)
response to surgical trauma and is associated with increased
Higher patient satisfaction (P<0.001)
morbidity that may delay recovery, prolong hospital stays
Decreased opioid use (P<0.001)
and lead to the development of persistent sensitization
Reduced nausea (P<0.003)
manifesting as chronic pain. Effective surgical pain treatment
involves a multimodal approach to diminish the intensity of
acute pain. This approach offers improved postoperative pain
where patients may achieve earlier mobilization and return
control while minimizing the side effects associated with any
to daily activities, in addition to shorter hospital stays with
one therapeutic option.1,2
fewer complications.4-7
Included in today’s multimodal approach are continuous local
Continuous infusions through surgical wound site catheters
anesthetic infusion techniques either with surgically placed
are also associated with a significant improvement in
wound catheters or peripheral nerve or compartment block
patient outcomes. Liu analyzed 44 randomized controlled
catheter techniques. These modalities have enabled patients
studies with over 2,000 patients and also found a significant
to benefit from non-narcotic postoperative pain control,
improvement in patient outcomes, including a reduced
reducing the need for opioids and their related complications.
length of stay for patients undergoing a variety of orthopedic
The impact is particularly evident in orthopedic surgery,
procedures.3
3
Advancement in regional anesthesia has resulted in
In a retrospective study of over 190,000 cases, the incidence of
techniques such as adductor canal blocks for ACL and TKA
inpatient falls for patients after TKA was 1.6%, and perioperative
procedures. Femoral nerve blocks, which may be used
use of nerve blocks was not associated with increased risk. The
for these procedures have been associated with femoral
use of general anesthesia compared to neuraxial anesthesia
quadriceps muscle weakness and, in turn, a potential increase
was associated with an increased risk of falls.11
risk of falls. Unlike a femoral nerve block, the adductor canal
block is predominately a sensory block, which preserves
In today’s healthcare environment there is also an increasing
quadriceps muscle strength and improves ambulation
emphasis on patient satisfaction scores, which influence
ability without compromising pain control.8 Fall prevention
Medicare reimbursement (HCAHPS). This includes patient
strategies after these procedures should continue to be
perception of pain.12
reinforced to promote patient safety.9,10
Postoperative pain management protocols that minimize
adverse events and standardize treatment modalities that
may have added benefits of reducing costs and promoting
“
Titratable local analgesics are our choice
when appropriate for post-surgical patients.
better patient outcomes.13,14
control
over their medication, avoid issues
associated with opioids, and make
The ON-Q* Pain Relief System is a non-narcotic constituent
the most economic sense for patients
analgesic benefits for up to 120 hours, compared to the 8-24
and payers.
hours of relief provided by single shot nerve blocks or injections
Craig D. Tifford, M.D.
and liposomal bupivacaine.18-21
They offer the patient more
“
of a multimodal therapeutic approach and is clinically proven
to deliver more effective pain management than traditional
methods alone with fewer side effects.15-17 ON-Q* maximizes
4
JEFFREY G. MOKRIS, MD
TOTAL KNEE ARTHROPLASTY
Products Used: ON-Q* Pump: PM026-A: 400 ml x 5 ml/hr
5 inch ON-Q* Soaker* catheter
Drugs in Pump: Local anesthetic of the physician’s choice.
Right Leg (Medial View)
Pre-Incisional Infiltration: Local anesthetic
Catheter Placement: Insert the introducer needle from inside the suprapatellar
pouch approximately 3 cm distal to the distal aspect of the incision. Exit out the
lateral skin superiorly along the tensor fascia lata. Insert the catheter through the
sheath into the joint and tuck into the medial gutter. Peel away the sheath and
discard.
Postoperative Bolus Technique: Secured the catheter with Steri-Strip™ and
Tegaderm™. A bolus dose of local anesthetic may be administered with
consideration given to total daily dose delivered and patient’s clinical status.
Femoral
component
Prosthesis
Articular
surface
Stemmed
tibial plate
Catheter Securement Technique: Secure the catheter with Steri-Strips™. Coil
approximately 4 cm of catheter and secure with wound dressing.
Additional Post-Op Pain Medications: OxyContin®, morphine, or oxycodone per
physician’s prescription.
Results with ON-Q*:
Before ON-Q*
After ON-Q*
Pain Management Method
Dilaudid® or morphine
PCA
Eliminated PCA
Average Narcotic Usage
6-8 weeks
4-6 weeks
Average Pain Score
3 days
1-2 days
Patella
ON-Q SilverSoaker
catheter
LOWER EXTREMITY
Carolinas Medical Center, Charlotte, NCL
Fem
Fe
mu
ur
Vastus medialis
muscle
Medial
joint capsule
Medial collateral
ligament
Pes anserinus tendon group
5
Products Used: ON-Q* Pump: CB004, ON-Q* with Select-A-Flow*,
400 ml x 2-14 ml/hr
Occasionally use CB6004, ON-Q* with the
Select-A-Flow*, 600 ml x 2-14 ml/hr
Needle: 18 gauge Tuohy needle
GREG HICKMAN, MD
Medical and Anesthesia Director
The Andrews Institute, Gulf Breeze, FL
Figure A – Patient A Pre-Injection
Drugs in Pump: Local anesthetic of the physician’s choice.
Pre-operative Technique: Because 50-60 percent of our patients have posterior
pain after their ACL reconstruction, I selectively give a single shot tibial block to
help patients get through the first night comfortably. Single shot femorals are
a good option too, but at Andrews, we are going away from the femoral single
shot, per surgeon request. If the patient is not required to have motor strength
the first night, I still believe a single shot femoral is a good idea and a viable option
to help get patients through the first night comfortably. The single shot femoral
is not a great option for practices that want motor function the day of surgery.
Note: I now do a single shot adductor canal block and place the catheter in
the PACU or do a pre-op adductor canal catheter placement. If I do place the
catheters preoperatively, I come a little more proximal and turn the probe so it is
proximal to distal and thread the catheter distally into the canal.
Adductor Canal Catheter Placement: Chlorhexidine prep and sterile drape over
block area. Introduction of needle will be anterior thigh. Position ultrasound
probe on with a cross section (short axis) view. Turn the probe to a 45 degree
angle to help “aim” the needle and catheter up the canal. When you utilize the
mid-thigh approach, the nerve to the vastus medialis is typically outside of the
canal and usually visible (See Figure A). The needle will be brought in from distal
to proximal in a medial approach to help with advancing the catheter up the
canal (See Figures B and C). On smaller legs you go through the vastus medialis
with the needle. On obese legs, the needle will often go through the Sartorius
muscle, and the angle of the needle will be a little steeper.
LOWER EXTREMITY
ADDUCTOR CANAL BLOCK FOR
ACL RECONSTRUCTION
This approach from the anterior side allows for better needle visualization. Pop
through vastus medialis into the adductor canal. The nerve will be anterior to the
artery. Inject 1 ml of local anesthetic to make sure you are in the correct area.
The fascia of the sartorius muscle is lifted up and the adductor canal will open
up (See Figure D). Continue to inject 1-2 ml to open adductor canal up for a
total of approximately 10 ml, with consideration given to total dose delivered and
patient’s clinical status. Thread catheter about 3-4 cm up the adductor canal.
Catheter Securement: Secure catheter with Tegaderm™. Skin glue can also be
used to seal the needle insertion site.
6
Postoperative Bolus Technique: Patients go home with the catheter and the
ON-Q* Pump set on zero since they already have the single shot block to get
them through the night. We instruct patients to turn their pumps on at bedtime
to 4-6 ml/hr so they don’t wake up in pain when the initial block wears off. When
the single shot wears off and the pump infusion is started, about 10-20% of
patients get a bolus of local anesthetic (approximately 10 ml) to help them get
thru the transition on the morning of POD1. If we don’t have access to the patient
to give them a bolus, we instruct them to turn the pump up to 14 ml/hr for one
hour to give them a good local anesthetic spread throughout the canal.
GREG HICKMAN, MD
Medical and Anesthesia Director
The Andrews Institute, Gulf Breeze, FL
LOWER EXTREMITY
ADDUCTOR CANAL BLOCK FOR
ACL RECONSTRUCTION (CONTINUED)
Figure C
Why I like to do adductor canal blocks:
• Ability to do outpatient ACL repairs
• Avoid motor weakness and quad weakness with femoral nerve blocks
• Aggressive PT and quad strengthening on POD1
• Speed up rehabilitation
- Having their quad control,
patients can fully extend their
legs immediately on POD1.
- Patients also get to weight
bearing faster.
Figure B
Figure D – Patient A Post-Injection
Adductor canal
opened with local
injection
7
ADDUCTOR CANAL BLOCK FOR
ACL RECONSTRUCTION AND
TOTAL KNEE ARTHROPLASTY
Midwest Orthopedic Specialty
Hospital, Franklin, WI
Advance the catheter into the adductor canal through the needle. Catheter
is advanced slightly past the needle tip, and needle is pulled out keeping the
catheter in place.
Drugs in Pump: Local anesthetic of the physician’s choice.
Small amount of air and/or fluid is injected through the catheter under ultrasound
visualization to verify catheter position.
Preoperative Technique: The patient is given Celebrex™ 400 mg and Gabapentin
300-600 mg p.o. preoperatively as part of multi-modal approach.
Catheter Securement: Catheter is secured with your preference of skin adhesive,
SteriStrips and Tegaderm™.
Catheter is placed preoperatively, but the pump is hooked up and started in the
recovery room.
Postoperative Technique: Patients go home with the catheter in place. For my
total knee patient, I prescribe Celebrex™ 200 mg BID and Gabapentin 300 mg
BID are also prescribed as part of our multi-modal approach to pain management.
A single shot tibial nerve block is placed utilizing 6-8 ml of local anesthetic to help
manage posterior knee pain with consideration given to the total dose delivered
and patient’s clinical status.
Adductor Canal Catheter Placement: The adductor canal block is performed in
the upper thigh slightly caudal to the end of the femoral triangle in the proximal
portion of the adductor canal.
In the proximal adductor canal the femoral artery is under the medial portion of
the sartorius muscle (See Figure A).
Penetrate the sartorius muscle fascial layers just lateral to the femoral artery using
a Tuohy needle (See Figures B and C).
Total dose is 20 ml of local anesthetic given in 5 ml increments with consideration
given to the total dose delivered and patient’s clinical status. Negative aspiration
and a 1 ml test dose should be given prior to each increment.
LOWER EXTREMITY
Products Used: ON-Q* Pump: CB004, ON-Q* with Select-A-Flow*,
400 ml X 2-14 ml/hr
Pump is started in PACU at 6 ml/hr
Needle: 10 or 11 cm Tuohy needle
MARK ZIMMERMAN, MD
Figure A
Sartorius Muscle
Femoral Artery
Femoral Vein
Watch spread of drug in the canal and be certain the drug spreads below the
fascia and not into the muscle.
Occasionally additional fascial layers appear during injection. Penetrate the fascial
layers so that the catheter is placed in the adductor canal. You may want to utilize
color doppler if necessary to distinguish drug from venous structures.
8
Figure B
Figure C
MARK ZIMMERMAN, MD
Midwest Orthopedic Specialty
Hospital, Franklin, WI
LOWER EXTREMITY
ADDUCTOR CANAL BLOCK FOR
ACL RECONSTRUCTION AND
TOTAL KNEE ARTHROPLASTY (CONTINUED)
9
Products Used: ON-Q* Pump: CB004, ON-Q* with Select-A-Flow*,
400 ml X 2-14 ml/hr
Needle: 18 gauge Tuohy Needle
Drugs in Pump: Local anesthetic of the physician’s choice.
Preoperative Technique: For the last two years we have been performing
adductor canal blocks exclusively for total knee arthroplasties and ACL repairs,
per surgeons’ request. In our practice, all continuous adductor canal blocks are
performed pre-operatively. Since we switched from continuous femoral nerve
blocks to continuous adductor canal blocks, we have had zero falls attributed to
blocks, while maintaining a greater than 90% reduction in average pain scores.
We have also been able to achieve early ambulation with all patients actively
participating in physical therapy. These blocks have allowed us to reduce the
length of stay and dramatically reduce overall narcotic consumption. This block
has significantly improved the quality of care for our orthopedic patients.
Figure A
SALVATORE BOMMARITO, DO
Senior Staff Anesthesiologist
Henry Ford Macomb Hospital
Charter Township of Clinton, MI
LOWER EXTREMITY
ADDUCTOR CANAL BLOCK FOR
ACL RECONSTRUCTION AND
TOTAL KNEE ARTHROPLASTY
Adductor Canal Catheter Placement:
- All blocks are performed under strict sterile conditions.
- The block is performed approximately at the midpoint of the thigh (See Figure
A). One must be careful not to perform the block too proximal as a “true”
femoral nerve block may develop with loss of the advantages of the adductor
canal block.
- We are looking to ultrasound an image where the femoral artery sits below the
sartorius muscle and slightly on top of the vastus medialis. I perform all blocks
in plane from a “lateral to medial” direction. I follow the needle tip under/
between the fascial plane of the sartorius muscle and position my needle in the
adductor canal (See Figure B). It may not be possible to see the nerve but this
is not important.
10
SALVATORE BOMMARITO, DO
Senior Staff Anesthesiologist
Henry Ford Macomb Hospital
Charter Township of Clinton, MI
- In my opinion, the most important step is confirming placement of the catheter.
You do not have to see the catheter but you must see re-expansion of the
adductor canal when a small bolus is given in the catheter. I ultrasound the
area where the block was performed and another 2-4 ml of local is given via
the catheter to confirm its placement. Remember that the catheter tip may
be in correct placement but if the majority of the infusion travels outside the
adductor canal, this will lead to a high number of failed blocks.
Figure B
Sartorius Muscle
Femoral Artery
Femoral Vein
LOWER EXTREMITY
ADDUCTOR CANAL BLOCK FOR
ACL RECONSTRUCTION AND
TOTAL KNEE ARTHROPLASTY (CONTINUED)
Catheter Securement: I routinely use skin adhesive on all of my catheter insertion
sites as this helps prevent any leakage. This step is not mandatory but if eliminated,
you must reassure your patients and staff that the catheter may leak from the
insertion site and as long as the block is proving effective, it is not a problem.
Postoperative Technique:
ACL’s: Patients are discharged with catheter/ON-Q* Postoperative Pain
Management System. Catheter is set at 10 ml/hr. Patients are given detailed
instructions.
Total Knee Arthroplasty: Patients go to the floor with catheter/ON-Q*
Postoperative Pain Management System. Pump is set at 10 ml/hr and it may be
adjusted on a PRN basis. Currently, we have been giving the TKA patients a bolus
prior to discharge and re-attaching a second pump for continued relief while
they are at home with consideration given to total daily dose and clinical status
of the patient.
- After negative aspiration, 20 ml of local is injected in 5 ml increments with
negative aspiration after each 5 ml. It is paramount that you are able to see
the bolus expanding/dilating the adductor canal and not outside the intended
target.
- I then feed the catheter in approximately 3 cm past the needle tip and the
needle is then removed.
Our experience: Advantages of Continuous Adductor Canal Blocks
• Zero to negligible motor weakness (Quad sparing)
• Early ambulation/improved effort during physician therapy
• Reduction in overall narcotic consumption
• Decrease in length of stay
• Improved patient satisfaction/HCAHPS scores
• Improved surgeon/administrator satisfaction
• Quicker time to discharge
• Decrease in expected admissions for pain control
11
Pump Used: CB004, ON-Q* with Select-A-Flow*, 400 ml x 2-14 ml/hr.
Needle Used: 18 gauge Tuohy needle. SONIA SZLYK, MD
Director, Regional Anesthesia
North American Partners in Anesthesia
Mid-Atlantic
between the anterior and middle scalene muscles (IMAGE 2). Scan as high up the
neck as possible while maintaining visualization of C5, C6, and C7. This ensures
the needle and catheter will be away from the surgical site and drapes.
Drugs in Pump: Local anesthetic of physician’s choice.
Applications: Total shoulder replacement, reverse total shoulder replacement,
and rotator cuff surgery warrant a well-planned pain management
technique. Interscalene catheters provide excellent intraoperative and
postoperative pain control. Interscalene catheters are also a great option
for patients that have shoulder adhesions and will undergo a shoulder
manipulation to regain range of motion in the shoulder joint. Optimal pain
control facilitates compliance with an aggressive postoperative physical therapy
protocol.
IMAGE 1: Interscalene nerve block catheter overview
UPPER EXTREMITY
INTERSCALENE BLOCK FOR
TOTAL SHOULDER REPLACEMENT
& ROTATOR CUFF REPAIR
Figure A
Patient Positioning
Interscalene catheters should be placed preoperatively for maximum intraoperative
benefit. Postoperative placement may be difficult due to arthroscopic fluid
distortion of tissue and limited access to the neck due to surgical bandages and/
or sling.
As for all nerve blocks, full monitoring (NIBP, EKG, pulse ox) should be utilized
during and after block placement. A Time Out should also be performed
immediately prior to block placement.
Interscalene Catheter Placement (IMAGE 1): Position the patient in the sitting
position, head of bed elevated >65 degrees. Rotate the patient’s head away from
the operative shoulder, and move the pillow to the vertical position under the
patient’s head to create an empty space behind the operative shoulder. Apply
Chlorhexidine skin prep then sterile drape or towels over block area. Place sterile
ultrasound gel and a sterile probe cover onto a high frequency linear probe.
Position probe in the short-axis orientation behind the clavicle on operative
side. Visualize the subclavian artery. The trunks of the brachial plexus will be
superficial and lateral to the artery. Scan up the neck to trace the brachial plexus
from supraclavicular to interscalene position until visualization of the C5, C6,
C7 nerve roots. The brachial plexus is located within the interscalene groove
Figure B
Brachial Plexus
12
Use an in-plane approach. Place a 1% lidocaine skin wheal approximately 2 cm
from the edge of the probe and infiltrate the projected needle path. Introduce
Tuohy needle through wheal and advance in a lateral to medial direction through
the middle scalene muscle. This approach enables in-plane needle visualization
and will anchor the catheter within the middle scalene muscle.
Advance needle tip through the middle scalene muscle and into the interscalene
groove (IMAGE 3). After negative aspiration, inject 2 mL of local anesthetic to
confirm desired spread around nerve roots within the interscalene groove.
Inject a total of 25 mL through the Tuohy (with consideration given to total dose
delivered and patient’s clinical status). The needle may need to be advanced or
repositioned within the interscalene groove to visualize spread of local anesthetic
on both the sides of the nerve roots.
Figure C – Needle Placement
SONIA SZLYK, MD
Director, Regional Anesthesia
North American Partners in Anesthesia
Mid-Atlantic
UPPER EXTREMITY
INTERSCALENE BLOCK FOR
TOTAL SHOULDER REPLACEMENT
& ROTATOR CUFF REPAIR (CONTINUED)
Under US visualization, thread the catheter, and then inject 5 mL through catheter
to verify proper catheter position yielding spread of local anesthetic within the
interscalene groove. (IMAGE 4)
Catheter Securement Technique: Apply skin glue to seal the catheter insertion
site. Secure catheter with a small Tegaderm®. (IMAGE 5) Cover the Tegaderm®
with gauze dressing to protect from surgical drapes.
Postoperative Bolus Technique: The pump is connected in PACU and set at 8
mL/hr. On POD 1 most patients have pain scores <3 at an infusion rate of 8 mL/hr.
Some patients require additional pain control on POD 1 as they transition from
the initial local anesthetic bolus to the more dilute local anesthetic infusion.
Rather than increase PO narcotic intake, the patient can easily adjust the pump
incrementally to 14 mL/hr, then decrease the rate on POD 2 or earlier. This will
shorten the overall duration of the infusion, but allows customization of pain
control to the patient’s needs.
13
INTERSCALENE BLOCK FOR
TOTAL SHOULDER REPLACEMENT
& ROTATOR CUFF REPAIR (CONTINUED)
Director, Regional Anesthesia
North American Partners in Anesthesia
Mid-Atlantic
Benefits of Interscalene blocks:
•Enables surgeons to perform more complex shoulder surgeries on an outpatient
basis.
•Excellent pain control yields high patient and surgeon satisfaction, and facilitates
participation in physical therapy.
UPPER EXTREMITY
Figure D – Transverse Section
(viewed from above)
SONIA SZLYK, MD
•More stable hemodynamics and less intraarticular bleeding in the operating
room allows for a clear visual field for the surgeon during arthroscopy.
•Minimal narcotics reduces postoperative nausea and vomiting, allows faster
PACU discharge times, and improves OR efficiency.
IMAGE 2: Short-axis US image of brachial plexus (N) in interscalene groove.
SCM
ASM
N
N
MSM
LATERAL
Figure E – Ultrasound
Probe
Position
N
1.7
ASM: Anterior Scalene Muscle
MSM: Middle Scalene Muscle
SCM: Sternocleidomastoid Muscle
14
yyyy y
IMAGE 5: Catheter securement
Director, Regional Anesthesia
North American Partners in Anesthesia
Mid-Atlantic
LATERAL
IMAGE 3: Needle (triangles) position
SONIA SZLYK, MD
UPPER EXTREMITY
INTERSCALENE BLOCK FOR
TOTAL SHOULDER REPLACEMENT
& ROTATOR CUFF REPAIR (CONTINUED)
1.7
C
y
y
y y
LATERAL
IMAGE 4: Catheter (c) placement
1.7
15
CLINICAL SUMMARIES
Auyong D, Allen C, Pahang J, Clabeaux J, MacDonald K and Hanson N. Reduced
length of hospitalization in primary total knee arthroplasty patients using an
updated enhanced recovery after orthopedic surgery (ERAS). J of Arthroplasty
2015.
Jaeger P, Zaric D, Fomsgaard J, Hilsted K, Bjerregaard J, Gyrn J, Mathiesen,
O, Larssen T, Dahl J. Adductor canal block versus femoral nerve block for
analgesia after total knee arthroplasty. A randomized, double-blind study. Reg
Anesth Pain Med 2013;38: 526–532.
STUDY DESIGN: Retrospective
STUDY DESIGN: Double-blind, randomized controlled
NUMBER OF PATIENTS: 126 patients who had undergone TKA surgery with a
NUMBER OF PATIENTS: Adductor Canal Block (ACB): 23 patients
standardized care pathway
126 Patients who had undergone TKA surgery with the
updated ERAS pathway
SUMMARY: This study evaluated if updates to an existing orthopedic enhanced
recovery after surgery (ERAS) pathway would improve length of hospitalization.
Postoperatively, the pre-updated pathway included intermittent femoral nerve
block and the updated pathway included continuous adductor canal block for
48 hours.
Primary outcome of this investigation was hospital LOS. Median LOS was 76.6
hours in the pre-pathway cohort compared to 56.1 hours in the post-pathway
cohort (p < 0.001). The following secondary functional outcomes were significantly
improved in the ERAS pathway group: Decreased need for transfusion (p=0.007);
decreased nausea (p=0.029); increased ambulation distance POD 1-2 p< 0.006);
discharged to home (27% vs 52%) (p=0.002).
Femoral Nerve Block (FNB): 27 patients
SUMMARY: Patients undergoing total knee arthroplasty (TKA) with spinal
anesthesia received a 30 ml bolus of ropivacaine 0.2% followed by a continuous
infusion of ropivacaine 0.2%, 8 ml/hr via an electronic PCA pump for 24 hours.
Primary measurement was difference in quadriceps muscle strength between
the groups, assessed using muscle volumetric isometric contraction (MVIC) as
a percentage from baseline. Quadriceps strength was significantly higher in the
ACB group (52%) compared with the FNB group (18%), P=0004 at 24 hours. No
difference between the groups regarding morphine consumption, pain during
flexion, adductor muscle strength, mobilization ability.
ADVERSE EVENTS AND COMPLICATIONS: One overdose of morphine, which
resolved quickly. No other adverse events or falls.
CONCLUSION: “ACB preserved quadriceps muscle strength better than FNB,
without demonstrating statistically or clinically significant inferiority in pain relief.”
COMPLICATIONS AND ADVERSE EVENTS: Two hospital falls in the pre-pathway
group and none in the updated ERAS group. 30 day readmission rate 3 patients in
the updated ERAS pathway group vs 7 patients in the standard group.
CONCLUSION: “Significant reduction in LOS after updating an existing orthopedic
enhanced recovery pathway by focusing on evidence-based changes. The
reduction in LOS was accompanied by a multi-faceted improvement in postsurgical recovery and not associated with an increase in readmissions. Execution
of the updated standard pathway was made possible through clinician-led,
integrated partnerships”.
Dr. Auyong has a consulting/speaking financial relationship with Halyard Health, Inc.
but was not compensated by Halyard Heath, Inc. for his participation in this study.
16
CLINICAL SUMMARIES
Jenstrup MT, Jaeger P, Lund J, Fomsgaard JS, Bache S, Mathiesen O, Larsen T,
Dhal B. Effects of adductor-canal-blockade on pain and ambulation after total
knee arthroplasty: a randomized study. Acta Anaesthesiol Scand 2012;56:35764.
Liu J, Richman J, Thirlby R, Wu, C. Efficacy of continuous wound catheters
delivering local anesthetic for postoperative analgesia: a quantitative and
qualitative systematic review of randomized controlled trials. J Am Coll Sur
2006; 23 (6): 914-932.
STUDY DESIGN: Parallel double-blind, placebo-controlled randomized trial
STUDY DESIGN: Meta-analysis. 44 randomized controlled studies analyzed.
NUMBER OF PATIENTS: Ropivacaine Group: 34 patients
Placebo Group: 37 patients
SUMMARY: Total knee arthroplasty (TKA) patients had a catheter placed in the
adductor canal using US-guided technique immediately postoperatively. Patients
received intermittent 30 ml injections of ropivacaine, 0.75% or saline (Placebo) via
the catheter at 6, 12, and 18 hour intervals for postoperative pain relief. Patients
in the ropivacaine group had significantly reduced morphine consumption from
0 to 24 h (40 ± 21 vs. 56 ± 26 mg, P = 0.006) Additionally, pain was significantly
reduced during flexion of the knee (P = 0.01), but not at rest compared to the
placebo group. Patients in the ropivacaine group also ambulated significantly
faster at 24 h (36 ± 17vs. 50 ± 29 s, P = 0.03) per the Timed-up-and-go (TUG) test.
CONCLUSION: “This almost pure sensory block may be a useful analgesic
adjuvant for acute postoperative pain management after TKA.” Compared
to placebo, continuous adductor canal block (CACB) reduced morphine
consumption and pain during 45 degrees flexion of the knee and significantly
improved ambulation.
2,141 patients.
SUMMARY: Patients had a variety of surgical procedures including cardiothoracic,
general, orthopedic, and gynecologic-urologic. Continuous infusion wound
site catheters were placed in a variety of locations and delivered a continuous
infusion of local anesthetic to the surgical area. Continuous wound site catheters
consistently demonstrated reduced pain scores and less morphine use across all
groups. Additionally, better patient satisfaction achieved in all groups combined,
(p< 0.007) and length of stay was reduced by one hospital day overall. Infection
rates were 0.7% in the treatment group and 1.2% in the control group. There was
less PONV in all groups combined (P< 0.001).
ADVERSE EVENTS AND COMPLICATIONS: Incidences of technical failure were
low (1%). No reports of local anesthetic toxicity.
CONCLUSION: “Both qualitative and quantitative systematic review identified
the efficacy of continuous wound catheters with improved analgesia, reduced
opioid use and side effects, increased patient satisfaction and perhaps reduced
hospital stay.”
17
CLINICAL SUMMARIES
Goyal N, McKenzie J, Sharkey P, Parvizi J, Hozack W, Austin M. The 2012
Chitranjan Ranawaat Award: Intraarticular analgesia after TKA reduces pain:
a randomized double-blinded, placebo-controlled, prospective study. Clin
Orthop Relat Res 2013; 471:64-75.
STUDY DESIGN: Double-blind, placebo-controlled, randomized
NUMBER OF PATIENTS: Bupivacaine infusion: 75 patients
Normal saline infusion (control): 75 patients
Patients undergoing unilateral total knee arthroscopy were
randomized to receive either a local anesthetic (bupivacaine) infusion or a saline
solution infusion (placebo). Infusions were delivered via the ON-Q* elastomeric
pump filled with either the saline or bupivacaine solution at 5 ml/hr. The catheter
was placed in a periarticular position. Primary measurement was VAS scores
assessed every 12 hours through POD 3 and at 4 week postoperative follow-up
and narcotic consumption/side effects. Patients in the treatment group had a
33% reduction in narcotic use on POD 2 (p = 0.021) and 54% reduction on POD
3 (p = 0.038). There was a trend toward lower pain scores throughout POD 2.
Significant difference in all pain scores on POD 1 (p = 0.03). Significant difference
in highest pain scores on POD 2 (p = 0.04). No difference in LOS or narcotic side
effects. At 4 week follow-up visit patients when asked about their postoperative
pain, patients reported lower VAS score during hospitalization.
SUMMARY:
ADVERSE EVENTS AND COMPLICATIONS: Six complications in the treatment
group (4 reoperations, pulmonary embolus, and allergic dermatitis) and nine
complications in the placebo group (7 reoperations, postoperative cellulitis,
supratheratpeutic normalized ration and hemarthrosis.
Gomez-Cardero P and Rodriguez-Merchan C. Postoperative analgesia in
TKA: ropivacaine continuous intra-articular infusion. Clin Orthop Relat Res
2010;468:1242-1247.
STUDY DESIGN: Randomized, double-blind, placebo-controlled
NUMBER OF PATIENTS: Ropivacaine infusion: 25 patients
Normal saline infusion: 25 patients
SUMMARY: Patients undergoing total knee arthroplasty (TKA) were randomized
to receive 300 ml ropivacaine at 5 ml/hr delivered with the ON-Q* elastomeric
pump or 300 ml normal saline at 5 ml/hr with an elastomeric pump. Catheter was
placed in the upper knee area. Primary measures included VAS scores during the
first 3 days and 1 month after surgery, opioid use/side effects, joint function and
mean hospital stay. Compared to the saline group, patients receiving ropivacaine
infusion had Lower pain scores X 3 days (p<0.001), less opioid consumption
(p<0.004) and a 1.5 day reduction in LOS (p<0.001. No difference in joint ROM
throughout study period and up to 1 month.
ADVERSE EVENTS AND COMPLICATIOMS: No wound complications or infections
associated with the ON-Q* pump or ropivacaine-related adverse events.
CONCLUSION: “Use of an infusion pump is effective in treating pain after
TKA, reducing postoperative pain and opioid use. It also improves immediate
functionality and patient comfort, reducing mean hospital stay without increasing
the risk of complications.”
CONCLUSION: “In patients undergoing TKA, continuous intrarticular analgesia
provided effective adjunct for pain relief in the immediate postoperative period
without the disadvantages encountered with other analgesic methods.”
18
CLINICAL SUMMARIES
Salviz EA, Xu D, Frulla A, Kwofie K, Sjhastri U, Chen J, Shariat AN, LItwin S, Lin E,
Choi J, Hobeika P, Hadzic A. Continuous interscalene block in patients having
outpatient rotator cuff repair surgery: a prospective randomized trial. Anesth
Analg 2013;117:1485-1492.
STUDY DESIGN: Prospective, randomized, blinded, controlled with 1 week
follow-up.
NUMBER OF PATIENTS: Continuous Interscalene Block (CISB): 24 patients
Single Shot Interscalene Block (SISB): 24 patients
General Anesthesia (GA): 22 patients
SUMMARY: Patients scheduled for outpatient arthoscopic rotator cuff repair
received either a CISB infusion with 0.2% ropivacaine at 5 ml/hr delivered through
an elastomeric pump with patient-controlled bolus of 5 ml every 60 minutes, a
SISB or GA. Measures included NRS pain scores through the first postoperative
week, time to first analgesic consumption, PACU bypass and LOS, time to
discharge home, total hours of sleep and adverse events. By the end of the study,
patients in the CISB group (74%) reported NRS ≤4, compared to patients in the
SISB (83%) and GA (58%) groups who with reported NRS ≥ 4. Length of PACU
stay was shorter in the CISB and SISB group compared to the GA group (P <
0.0001). Most patients in the SISB (87%) and CISB (95%) groups were fast tracked
to PACU discharge. No patient in the GA group was fast-tracked. (p=0.003) Time
to discharge home was significantly shorter in CISB (94 min)and SISB (115 min)
than GA(302 min) group. On POD 1 and 2, use of narcotics was lower in the
CISB group compared to SISB or GA, but did not differ among groups by POD 3.
Patients in CISB reported significantly longer sleep compared to the other groups
(P <0.01)
COMPLICATIONS AND ADVERSE EVENTS: One patient in the CISB group had
difficulty breathing on arrival to PACU, which resolved and home recovery was
uneventful. No complications or complaints related to the equipment.
CONCLUSION: “In conclusion, CISB confers important recovery and analgesic
benefits in outpatients having arthroscopic rotator cuff surgery. While both CISB
and SISB conferred better analgesia, faster recovery, and discharge home than
GA only, these benefits were sustained through the first postoperative week only
in patients who received CISB.”
19
ADDITIONAL RESOURCES FOR ADDUCTOR CANAL BLOCKS
ADDUCTOR CANAL BLOCKS ON BLOCKJOCK.COM
Adductor Canal Catheters for Major Knee Surgery (basic membership required to view)
http://www.blockjocks.com/FKFGY/adductor-canal-catheters-for-major-knee-surgery-live-webcast-archive-from-42214/
Adductor anatomy and landmarks: 4:10 – 5:07
Distribution of lower leg innervation: 5:09 – 5:40
The clinical data: 6:22 – 8:40
Technique: 8:42 – 10:00
Live technique: 10:01 – 13:45
ACL ADDUCTOR TECHNIQUE TIME POINTS (DR. GREG HICKMAN)
Technique/Protocol: 16:44 – 19:50
ADDUCTOR CANAL TECHNIQUE TIME POINTS (DR. MARK ZIMMERMAN)
Technique/Protocol: 36:37 – 43:49
Narcotic Sparing with Adductor Canal Blocks: 43:50 – 48:30
Postoperative Adjuncts to Adductor Canal Blocks: 48:36 – 51:50
BLOCKJOCKS WEBINAR (DR. GREG HICKMAN TECHNIQUE)
US-Guided Adductor Canal Catheter — Oblique Technique Distal to Proximal (requires VIP Subscription to view)
http://www.blockjocks.com/LEqU/us-guided-adductor-canal-catheter-oblique-technique-distal-to-proximal/
Technique overview: 0:17 – 1:39
Prepping and draping: 1:40 – 2:06
Local injection technique: 2:08 – 3:53
Needle approach: 3:53 – 6:19
Threading the catheter: 6:20 – 7:29
Testing the catheter placement: 7:30 – 8:12
Viewing the saphenous nerve and Sartorius muscle to confirm correct placement: 8:39 – 9:05
20
For more information, please send
an email to [email protected]
or visit www.halyardhealth.co.uk.
*Registered Trademark or Trademark of Halyard Health, Inc. or its affiliates. © 2016 HYH. All rights reserved.
MK-00717_Rev3_EMEA 02/2016