Nerve Blocks for Total Knee Arthroplasty: Using Targeted Blocks to Optimize Patient Outcomes
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- Опубликовано: 5 авг 2024
- In this video, we look at nerve blocks for total knee arthroplasty, with a focus on anatomic rationale for what we choose. We cover in detail the adductor canal block, the interspace between the popliteal artery and the capsule of the knee (iPACK) block, and genicular nerve blocks.
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You have an amazing skill in presenting complex topics in an entertaining and educational way. Wonderful!
Block on self is wild 😂 .Good stuff, learning a lot.
This is exactly video that I have been looking for. Thank you so much!
Fantastic and comprehensive video! This combination for total knees has been used at my clinical site and for my teaching of regional nerve blocks for the past several years. You are doing important work!
Love your videos, your style of presentation is 10 / 10 for practical info delivery
Great Material! Bravo Jeff!
Superb presentation! Shared with the group and now including all for arthrofibrosis getting knee manipulations outpatient (vs inpatient with epidural) a few weeks post-procedure. No pain! Patients going home and doing well.
Great video.. we were just reviewing these with one of the anesthesia residents rotating with us!
Excellent content. Thank you so much
Great video!!!👏🏼
Did my first set of genicular blocks (with ACB & IPACK) today for a string of total knees at the ASC. Will report back on how the patients did! Agreed on the out of plane approach for geniculars saving time 👊🏽
How did they do?
Excellent video
Excellent presentation.
Excellent video 👌
I always do aductor canal out of plane. Great coverage and avoid the NVM with this approach
Hi I really like your videos and detailed anatomy. One issue I have is that in arthroplasty surgery, infection is disastrous. If we are blocking into the surgical field, we should do so with complete aseptic technique, just as the surgeon would operate.
6:12 had me dying LOL
we use exparel (adductor along with surgeon injections) for our tka's. total dose is 20 cc 1.3% exparel with 30 cc .25% marcaine. this seems to be the max recommended dose of local. another 20 cc for the genicular blocks would exceed recommended max mounts.
A fantastic presentation. Thanks. How much dexamethasone are you adding to all of the blocks. If giving with all the blocks as well as intraoperatively, s it not reaching a level where wound healing would be an issue? My surgeons are neurotic about this and as a result push back every time I want to do a block saying they’ll do LIA and it’ll be enough.
perfect!
Superb
Great Video !
For Clare my understanding. In TKA patient,Are you block (adductor canal+NVM)+ iPACK+ 3genau block?
I usually perform Ipack block pre and ACB postoperation
Bookmarking this for my next Ortho list for sure! Just a comment: Why do you give a spinal followed by the targeted nerve blocks? And wouldn’t the spinal block motor nerves? Where I practice (resource-limited), we haven’t advanced to the point of ambulatory surgery, so we tend to give a spinal in the lateral position with heavy bupivacaine and fentanyl, and dexamethasone 8mg IV as adjunct.
would love to see your approach on lumbar plexus block!
Great content! When do you do the block? Do you do these blocks in PACU before the spinal wears off and undo/reapply the surgeons dressings? Or hold up the surgeon in the OR and do them right after your spinal? Or maybe your 6 needle pokes (adductor, ipack, genicular) in pre-op (ouch) with sedation ?
Do you have any recommendations on how to avoid nvm puncture when doing adductor when it’s not easily visualized
Marvelous presentation. You did 4 genicular nerves block and a block of nerve to vastus intermedialis in about 80 seconds. It included skin preparation (sterilization of skin and the execution of US-guided blocks). What is your comment regarding the way you did skin sterilization before blocking these nerves? Was it according to the infection control guidelines ( both international and local for your institution)? Did you give the appropriate time for your skin antiseptic to work? Has ever your orthopedic surgeon seen you doing these blocks?
Great presentation, thank you. I'm interested in the questions posed here as well. I'm sure that the results at your institution would show that this is not an issue but I think a lot of orthopods I work with would baulk at this re infection risk from being so close to the operative site. Perhaps preparing the whole area first then doing the blocks in sequence with a no-touch technique might make it more acceptable to them from an infection risk standpoint and just as quick?
Is there any chance of getting muscle weakness from blocking the NVM?
I’m having amazing results but my billing company doesn’t know how to bill for them. Are Saphenous nerve, NVM, and NVI billed as one Femoral nerve block and the IPACK and the 3 Genicular nerve branches billed as a Sciatic nerve block?
Very useful! How about volume and dose of local anesthetics per each genicular nerves?
@@regionalanesthesiology Thank you!
Blocking the nerve to vastus medialis wouldn’t cause a motor block as well?
yeah, but what about the NVL Jeff?
what if we do popliteal block instead of genicular or ipack, that is, popliteal block + femoral block for postop TKA analgesia? what do you think? can those who have an idea share?there are too many injections in genicular
All the ortho docs I've worked with won’t want any muscle weakness from a block.
Lots of content on your channel. Thank you. This video is a lot to take in lemme say😆, but makes sense. What do you say to doing a fascia iliaca blockade with catheter. It covers obturator n., femoral n. and its branches. Couple with a blockade to the posterior knee? Thanks
You avoid any motor blockade in theory with these blocks. Fascia iliaca not so much. If the goal is early ambulation for TKA which it almost certainly is these days, you don’t want any motor block.
@@spjm11 I understand and I appreciate the response
@@regionalanesthesiology thank you got this. I've been going over the video many times since this response. So in summary, for Total Knee Arthroplasty, you can 1. block the geniculars, plus 2. Block popliteal plexus with iPACK, plus 3. Block nVM?
There is almost no surgeon agreeing to injecting in the vicinity of the knee joint before an endoprothetic kneearthroplasty. In our clinic there is either regional anesthesia or LIA. maybe combining the adductor canal block combined with a dose attentive LIA is a way to go
There are certainly different ways to get the same result. We do genicular blocks because it’s an image-guided, consistent, reproducible way to block those nerves at the knee, and we get excellent results. Obviously we take care to use aseptic technique. Surgeons infiltrating blindly is…just ok. It’s notoriously inconsistent, is operator-dependent, and they frequently miss things. I do appreciate that some centers get good results combining approaches as you suggest. I’m quite biased, but my personal take is let the surgeons cut bone, and leave the analgesia and local anesthetic use to the experts. 😊
@@regionalanesthesiologyIm very pleased for your answer. Im from germany and follow you intensively and appreciate your take on the subject. your participation in the pajunk videos were very stimulating and most of the information that i share with residents derive from your knowledge. maybe one time we meet to share our passion for regional anesthesia. BUT unfortunately surgeons are a very sensitive kind and endoprothetic infections renders most operators superstitious to practices on the operating field. i dont have the capacities or backup to provide studies which compares combined focused genicular blocks by surgeons in combination with NVM and Saphenus nerve blocks respecting toxic LA levels. Maybe you re bringing insight inti this in the future. i d be very interested ☺️
Nice video. What is APAP?
Thank you for watching! APAP is short form for acetaminophen or paracetamol. Just saves space on a slide 🤓
I am a 12-year PACU RN and avid skier! (ie I've BEEN a blocked OrthoSurg PATIENT TWICE!) Second timed SUCKED with No coverage of my lateral foot landing me into the ED 16 hrs PostOp! And id love to see this lecture done with more rare incidences of FOOT blocking! For Calcaneus ORIF and LL reconstruction post /absent of infection risk.
You would need a popliteal block of of the sciatic nerve for lateral foot coverage. Adductor canal will reliably cover the medial side down to the ankle, but the medial foot itself might need the saphenous blocked below the knee.
Who’s your audience? It’s certainly not the patient. It’s certainly not the person paying an average of $30,000 per knee arthroscopy just to experience anesthesia awareness and pain during surgery and, or course, a whole lot of pain for months afterwards. I think surgeons and anesthesiologists get lost in the financial incentives to hurrying patients through outpatient total knee replacement surgery. Regional anesthesia allows the patient to leave sooner to make room for the next patient. It’s like herding sheep into the big money making operation. General anesthesia takes more time to recover. Because of that, your judgement is, at the very least, biased.
If your audience is orthopedic surgeons, how many would admit that they learned something about TKR on RUclips? These are the same doctors that would laugh if a patient mentioned something they learned on RUclips. They would shake their heads and completely dismiss what the patient had to say.
I'm an anesthesiologist from Europe. I work in public healthcare. There are no financial incentives. I get the same pay check at the end of the month regardless of how many procedures I do, or how well I do them. I watch dr. Gadsden's (and some others) youtube videos on regional anesthesia religiously because, inspite of working in a broken system for low pay, I am trying to provide my patients with the best possible care in existence, adjusted to what tools are available to me. I have no one here doing this to show me, teach me or guide me. I'm on my own. So without a chance to experience this in practice, these youtube videos are the next best thing. This youtube channel is one of the sources that has enabled me to elevate my skill and thus the standard of care I am able to provide my patients with to a level I had not thought possible just a few short years ago.
In other words, pipe down because you clearly have no idea what you're talking about.
@@uramalakia As you said, you don’t work in the cattle yard clinic where I was a patient, along with thousands of others. The patients come in and out so often that they could use a revolving door, except that would make it more difficult for the patients to limp in and be carried out by wheelchair. At this clinic, you can sit and watch as patient after patient is seen, operated on, and released. No anesthesiologist is on staff there. They are all contracted to perform their service with the orthopedic surgeons and their team. I have a great deal of respect for anesthesiologists. Whenever I go in for surgery, I tell my anesthesiologist that he/she is the most important person in my life for the next two hours. My comment was aimed at the fact that this clinic’s profits are heavily based on volume. One of the doctors there operated on me long before he became a partner at this clinic. When he was my doctor, I felt like a person, not a number. I was given a great deal of individual attention, and I was actually able to talk at length about the upcoming surgery. The orthopedic surgeon that performed my recent surgery spent a grand total of 5 minutes with me with my initial evaluation. It took just those five minutes for him to determine that I needed a new knee. He knew nothing of my history, whether I had had any cortisone shots, PRP, or any other type of treatment. It didn’t matter. I saw him for another 60 seconds just prior to surgery, long enough for home to put his initials on my right knee. He’s in the assembly line business of rounding up patients for surgery and getting them out the door as soon as possible, and he certainly doesn’t want an anesthesiologist to choose a method that will keep the patient at the clinic any longer that absolutely necessary. I imagine, if an anesthesiologist want to use a method that requires a few hours longer to recover, that anesthesiologist might not be invited back to that clinic. Of course, the patient will come back for lots of follow-up appointments with nurses and physician assistants because that provides the clinic with a good revenue stream. My surgery cost was $72,000 U.S. for the five hours I was there. I imagine that’s what each patient is paying, whether it’s a knee, hip, or some other body part. I was required to purchase walker without wheels and bring it to the clinic. I never used it. I was never asked to use it. It never got unfolded. I was rolled out to my car by wheelchair without any physical therapy whatsoever in order to make room for the next patient. I think it’s absurd that you think my comment was directed at you personally. That narcissism I expect from one of our presidential candidates, but not from an anesthesiologist. Grow up and be a professional.