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Designing the "Best" Pain Management Plan for Knee Replacement

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Descripción

Here are the slides from my #CSAHSWinter20 lecture "Designing the "Best" Pain Management Plan for Knee Replacement.

Upon completion of this presentation, participants will be able to:
1. Define elements of multimodal analgesia;
2. Present innervation of the knee joint; and
3. Discuss peripheral nerve block options that can be included in a multimodal analgesic plan for TKA patients.

Transcripción

  1. 1. 2020 CSA Winter Anesthesia Conference @EMARIANOMD Designing the “Best” Pain Management Plan for Knee Replacement Edward R. Mariano, M.D., M.A.S. Professor of Anesthesiology, Perioperative & Pain Medicine Stanford University School of Medicine Chief, Anesthesiology and Perioperative Care Veterans Affairs Palo Alto Health Care System
  2. 2. No financial disclosures. 2020 CSA Winter Anesthesia Conference
  3. 3. @EMARIANOMD #CSAHSWinter20 Kurtz S, et al. JBJS 2007 Apr;89(4):780 Arthroplasties Are Increasing
  4. 4. @EMARIANOMD #CSAHSWinter20 Mr. X is Going to Have a TKA
  5. 5. @EMARIANOMD #CSAHSWinter20 The best pain management plan is the one that can be most consistently applied to every patient.
  6. 6. @EMARIANOMD #CSAHSWinter20 What Patients Want
  7. 7. @EMARIANOMD #CSAHSWinter20 What Surgeons Don’t Want
  8. 8. @EMARIANOMD #CSAHSWinter20 Start with a Protocol (Checklist, Not a Recipe) Hebl JR, et al. JBJS 2005;87 Suppl 2:63
  9. 9. @EMARIANOMD #CSAHSWinter20 Start with Multimodal Analgesia Class Mechanism of Action Options Frequency Considerations Nonpharmacologic Variable Patient Education Compression Cryotherapy Acupuncture Electrical Stimulation Routine No clear guidelines NSAIDs Nonselective COX-1,2 inhibition Selective COX-2 inhibition Ketorolac Ibuprofen Celecoxib Routine Renal insufficiency, gastric ulcers, platelet dysfunction, cardiovascular disease Acetaminophen Central prostaglandin synthesis inhibition Acetaminophen (Paracetamol) Routine Hepatic dysfunction Gabapentinoids Binding to alpha-2-delta subunits of voltage- dependent calcium channels Gabapentin Pregabalin If indicated Renal impairment NMDA Antagonists N-methyl-D-aspartate blockade Ketamine Magnesium If indicated Severe psychiatric disorders, raised intracranial or intraocular pressure (ketamine only) Local and Regional Analgesia Sodium channel blockade Spinal/Epidural Lumbar Plexus ± Sacral Plexus Femoral Nerve ± Sciatic Nerve Femoral Nerve ± LIA Adductor Canal ± LIA Adductor Canal ± IPACK LIA Only Routine Allergy to local anesthetic, site infection, available resources and training level of staff NSAIDs = nonsteroidal anti-inflammatory drugs; NMDA = N-methyl-D-aspartate; LIA = local infiltration analgesia; IPACK = infiltration between the popliteal artery and capsule of the knee Kandarian, Elkassabany, Tamboli, Mariano. Best Pract 2019;33:111
  10. 10. @EMARIANOMD #CSAHSWinter20
  11. 11. @EMARIANOMD #CSAHSWinter20 What is Online about Regional Anesthesia?
  12. 12. @EMARIANOMD #CSAHSWinter20 What Regional Anesthesia Does  Mitigates maximal pain intensity after surgery1 and can be titratable  Decreases opioid consumption2 (maybe less opioid- induced hyperalgesia)  Facilitates early mobility3  Avoids immobility which can produce hyperalgesia and persistent pain4,5 1. Ilfeld BM. A&A 2011;113(4):904 2. Richman JM, et al. A&A 2006;102:248 3. Ilfeld & Mariano, et al. Pain 2010;150:477 4. Ohmichi Y, et al. Eur J Pain 2012;16:338 5. Guo TZ, et al. J Pain 2014;15:1033
  13. 13. @EMARIANOMD #CSAHSWinter20 Why Peripheral Nerve Blocks  >1 million patients  Peripheral nerve blocks associated with: – Lower rates of complications – Decrease length of stay – Lower rates of transfusion – Lower rate of ICU admission (THA only) Memtsoudis SG, et al. Pain 2016;157:2341
  14. 14. @EMARIANOMD #CSAHSWinter20 I ♥ Regional Anesthesia
  15. 15. @EMARIANOMD #CSAHSWinter20 2017;42:368 http://www.edmariano.com/archives/1196 27%! J Arthroplasty 2016
  16. 16. @EMARIANOMD #CSAHSWinter20
  17. 17. @EMARIANOMD #CSAHSWinter20 So Many Options Kandarian, Elkassabany, Tamboli, Mariano. Best Pract 2019;33:111
  18. 18. @EMARIANOMD #CSAHSWinter20 So Many Options Kandarian, Elkassabany, Tamboli, Mariano. Best Pract 2019;33:111
  19. 19. @EMARIANOMD #CSAHSWinter20 2017;42:368 http://www.edmariano.com/archives/1196 27%! J Arthroplasty 2016 100% at VA Palo Alto
  20. 20. @EMARIANOMD #CSAHSWinter20 Clinical Pathway (VA Palo Alto) Preop Adductor canal catheter insertion +/- IPACK Intraop If no IPACK, periarticular local anesthetic infiltration: ropivacaine 0.2% (150 ml) with ketorolac 30 mg and epinephrine Postop 1. Perineural infusion of ropivacaine 2. Scheduled meds: acetaminophen, celecoxib, and oxycodone (when indicated) 3. PRN meds: oxycodone (PO) and hydromorphone (IV) for breakthrough pain No IV PCA
  21. 21. @EMARIANOMD #CSAHSWinter20 “Adductor Canal” Nomenclature  Technically, our “adductor canal” blocks and catheters are in the distal femoral triangle Wong WY, et al. RAPM 2017;42:241
  22. 22. @EMARIANOMD #CSAHSWinter20
  23. 23. @EMARIANOMD #CSAHSWinter20  Patients in the adductor canal group walked 37 (0-90) meters vs. 6 (0-51) meters in the femoral catheter group (p=0.003).  Pain scores, opioid consumption, and hospital length of stay were similar. Mudumbai & Mariano, et al. CORR 2014;472:1377 Changing from Femoral to Adductor Canal
  24. 24. @EMARIANOMD #CSAHSWinter20 Evidence from RCTs  TKA: continuous ACB vs. FNB1 – Greater preservation of quad MVIC in ACB group (median 52% vs. 18%) – No differences in pain, opioids, flexion, TUG  TKA: repeated bolus ACB vs. FNB2 – ACB had better TUG, 10 meter walk time, and 30 sec chair test – No differences in pain, opioids 1. Jaeger P, et al. RAPM 2013;38:526 2. Shah NA and Jain NP. J Arthro 2014;29:2224
  25. 25. @EMARIANOMD #CSAHSWinter20 Proximal vs. Distal Adductor Canal Mariano ER, et al. JUM 2014;33:1653
  26. 26. @EMARIANOMD #CSAHSWinter20 Proximal vs. Distal Adductor Canal Burckett-St.Laurant, et al. RAPM 2016;41: 321
  27. 27. @EMARIANOMD #CSAHSWinter20 Time to Redefine What is Basic Turbitt, Mariano, El-Boghdadly. Anaesthesia 2019 epub
  28. 28. @EMARIANOMD #CSAHSWinter20 Time to Redefine What is Basic Turbitt, Mariano, El-Boghdadly. Anaesthesia 2019 epub Teach Transferable Skills
  29. 29. @EMARIANOMD #CSAHSWinter20
  30. 30. @EMARIANOMD #CSAHSWinter20 Implementing IPACK  IPACK blocks were added to a standard multimodal regimen including adductor canal catheters Kandarian & Mariano, et al. KJA 2019;72:238
  31. 31. @EMARIANOMD #CSAHSWinter20 Implementing IPACK  Post-implementation, 48/50 (96%) of TKA patients received an IPACK block, and they were compared with 32 patients in the PRE group Kandarian & Mariano, et al. KJA 2019;72:238
  32. 32. @EMARIANOMD #CSAHSWinter20 Tran, et al. RAPM 2019;44:234
  33. 33. @EMARIANOMD #CSAHSWinter20 Tran, et al. RAPM 2019
  34. 34. @EMARIANOMD #CSAHSWinter20 Summary  We discussed: – Elements of multimodal analgesia; – Innervation of the knee joint; – Peripheral nerve block options that can be included in a multimodal analgesic plan for TKA patients; and – The growing body of evidence favoring selective nerve block techniques.

Descripción

Here are the slides from my #CSAHSWinter20 lecture "Designing the "Best" Pain Management Plan for Knee Replacement.

Upon completion of this presentation, participants will be able to:
1. Define elements of multimodal analgesia;
2. Present innervation of the knee joint; and
3. Discuss peripheral nerve block options that can be included in a multimodal analgesic plan for TKA patients.

Transcripción

  1. 1. 2020 CSA Winter Anesthesia Conference @EMARIANOMD Designing the “Best” Pain Management Plan for Knee Replacement Edward R. Mariano, M.D., M.A.S. Professor of Anesthesiology, Perioperative & Pain Medicine Stanford University School of Medicine Chief, Anesthesiology and Perioperative Care Veterans Affairs Palo Alto Health Care System
  2. 2. No financial disclosures. 2020 CSA Winter Anesthesia Conference
  3. 3. @EMARIANOMD #CSAHSWinter20 Kurtz S, et al. JBJS 2007 Apr;89(4):780 Arthroplasties Are Increasing
  4. 4. @EMARIANOMD #CSAHSWinter20 Mr. X is Going to Have a TKA
  5. 5. @EMARIANOMD #CSAHSWinter20 The best pain management plan is the one that can be most consistently applied to every patient.
  6. 6. @EMARIANOMD #CSAHSWinter20 What Patients Want
  7. 7. @EMARIANOMD #CSAHSWinter20 What Surgeons Don’t Want
  8. 8. @EMARIANOMD #CSAHSWinter20 Start with a Protocol (Checklist, Not a Recipe) Hebl JR, et al. JBJS 2005;87 Suppl 2:63
  9. 9. @EMARIANOMD #CSAHSWinter20 Start with Multimodal Analgesia Class Mechanism of Action Options Frequency Considerations Nonpharmacologic Variable Patient Education Compression Cryotherapy Acupuncture Electrical Stimulation Routine No clear guidelines NSAIDs Nonselective COX-1,2 inhibition Selective COX-2 inhibition Ketorolac Ibuprofen Celecoxib Routine Renal insufficiency, gastric ulcers, platelet dysfunction, cardiovascular disease Acetaminophen Central prostaglandin synthesis inhibition Acetaminophen (Paracetamol) Routine Hepatic dysfunction Gabapentinoids Binding to alpha-2-delta subunits of voltage- dependent calcium channels Gabapentin Pregabalin If indicated Renal impairment NMDA Antagonists N-methyl-D-aspartate blockade Ketamine Magnesium If indicated Severe psychiatric disorders, raised intracranial or intraocular pressure (ketamine only) Local and Regional Analgesia Sodium channel blockade Spinal/Epidural Lumbar Plexus ± Sacral Plexus Femoral Nerve ± Sciatic Nerve Femoral Nerve ± LIA Adductor Canal ± LIA Adductor Canal ± IPACK LIA Only Routine Allergy to local anesthetic, site infection, available resources and training level of staff NSAIDs = nonsteroidal anti-inflammatory drugs; NMDA = N-methyl-D-aspartate; LIA = local infiltration analgesia; IPACK = infiltration between the popliteal artery and capsule of the knee Kandarian, Elkassabany, Tamboli, Mariano. Best Pract 2019;33:111
  10. 10. @EMARIANOMD #CSAHSWinter20
  11. 11. @EMARIANOMD #CSAHSWinter20 What is Online about Regional Anesthesia?
  12. 12. @EMARIANOMD #CSAHSWinter20 What Regional Anesthesia Does  Mitigates maximal pain intensity after surgery1 and can be titratable  Decreases opioid consumption2 (maybe less opioid- induced hyperalgesia)  Facilitates early mobility3  Avoids immobility which can produce hyperalgesia and persistent pain4,5 1. Ilfeld BM. A&A 2011;113(4):904 2. Richman JM, et al. A&A 2006;102:248 3. Ilfeld & Mariano, et al. Pain 2010;150:477 4. Ohmichi Y, et al. Eur J Pain 2012;16:338 5. Guo TZ, et al. J Pain 2014;15:1033
  13. 13. @EMARIANOMD #CSAHSWinter20 Why Peripheral Nerve Blocks  >1 million patients  Peripheral nerve blocks associated with: – Lower rates of complications – Decrease length of stay – Lower rates of transfusion – Lower rate of ICU admission (THA only) Memtsoudis SG, et al. Pain 2016;157:2341
  14. 14. @EMARIANOMD #CSAHSWinter20 I ♥ Regional Anesthesia
  15. 15. @EMARIANOMD #CSAHSWinter20 2017;42:368 http://www.edmariano.com/archives/1196 27%! J Arthroplasty 2016
  16. 16. @EMARIANOMD #CSAHSWinter20
  17. 17. @EMARIANOMD #CSAHSWinter20 So Many Options Kandarian, Elkassabany, Tamboli, Mariano. Best Pract 2019;33:111
  18. 18. @EMARIANOMD #CSAHSWinter20 So Many Options Kandarian, Elkassabany, Tamboli, Mariano. Best Pract 2019;33:111
  19. 19. @EMARIANOMD #CSAHSWinter20 2017;42:368 http://www.edmariano.com/archives/1196 27%! J Arthroplasty 2016 100% at VA Palo Alto
  20. 20. @EMARIANOMD #CSAHSWinter20 Clinical Pathway (VA Palo Alto) Preop Adductor canal catheter insertion +/- IPACK Intraop If no IPACK, periarticular local anesthetic infiltration: ropivacaine 0.2% (150 ml) with ketorolac 30 mg and epinephrine Postop 1. Perineural infusion of ropivacaine 2. Scheduled meds: acetaminophen, celecoxib, and oxycodone (when indicated) 3. PRN meds: oxycodone (PO) and hydromorphone (IV) for breakthrough pain No IV PCA
  21. 21. @EMARIANOMD #CSAHSWinter20 “Adductor Canal” Nomenclature  Technically, our “adductor canal” blocks and catheters are in the distal femoral triangle Wong WY, et al. RAPM 2017;42:241
  22. 22. @EMARIANOMD #CSAHSWinter20
  23. 23. @EMARIANOMD #CSAHSWinter20  Patients in the adductor canal group walked 37 (0-90) meters vs. 6 (0-51) meters in the femoral catheter group (p=0.003).  Pain scores, opioid consumption, and hospital length of stay were similar. Mudumbai & Mariano, et al. CORR 2014;472:1377 Changing from Femoral to Adductor Canal
  24. 24. @EMARIANOMD #CSAHSWinter20 Evidence from RCTs  TKA: continuous ACB vs. FNB1 – Greater preservation of quad MVIC in ACB group (median 52% vs. 18%) – No differences in pain, opioids, flexion, TUG  TKA: repeated bolus ACB vs. FNB2 – ACB had better TUG, 10 meter walk time, and 30 sec chair test – No differences in pain, opioids 1. Jaeger P, et al. RAPM 2013;38:526 2. Shah NA and Jain NP. J Arthro 2014;29:2224
  25. 25. @EMARIANOMD #CSAHSWinter20 Proximal vs. Distal Adductor Canal Mariano ER, et al. JUM 2014;33:1653
  26. 26. @EMARIANOMD #CSAHSWinter20 Proximal vs. Distal Adductor Canal Burckett-St.Laurant, et al. RAPM 2016;41: 321
  27. 27. @EMARIANOMD #CSAHSWinter20 Time to Redefine What is Basic Turbitt, Mariano, El-Boghdadly. Anaesthesia 2019 epub
  28. 28. @EMARIANOMD #CSAHSWinter20 Time to Redefine What is Basic Turbitt, Mariano, El-Boghdadly. Anaesthesia 2019 epub Teach Transferable Skills
  29. 29. @EMARIANOMD #CSAHSWinter20
  30. 30. @EMARIANOMD #CSAHSWinter20 Implementing IPACK  IPACK blocks were added to a standard multimodal regimen including adductor canal catheters Kandarian & Mariano, et al. KJA 2019;72:238
  31. 31. @EMARIANOMD #CSAHSWinter20 Implementing IPACK  Post-implementation, 48/50 (96%) of TKA patients received an IPACK block, and they were compared with 32 patients in the PRE group Kandarian & Mariano, et al. KJA 2019;72:238
  32. 32. @EMARIANOMD #CSAHSWinter20 Tran, et al. RAPM 2019;44:234
  33. 33. @EMARIANOMD #CSAHSWinter20 Tran, et al. RAPM 2019
  34. 34. @EMARIANOMD #CSAHSWinter20 Summary  We discussed: – Elements of multimodal analgesia; – Innervation of the knee joint; – Peripheral nerve block options that can be included in a multimodal analgesic plan for TKA patients; and – The growing body of evidence favoring selective nerve block techniques.

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