Designing the "Best" Pain Management Plan for Knee Replacement

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

No financial disclosures.
2020 CSA Winter Anesthesia Conference

@EMARIANOMD #CSAHSWinter20
Kurtz S, et al. JBJS 2007 Apr;89(4):780
Arthroplasties Are Increasing

Mr. X is Going to Have a TKA

The best pain management
plan is the one that can be
most consistently applied to
every patient.

What Patients Want

What Surgeons Don’t Want

Start with a Protocol (Checklist, Not a Recipe)
Hebl JR, et al. JBJS 2005;87 Suppl 2:63

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

What is Online about Regional Anesthesia?

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

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

I
♥
Regional
Anesthesia

2017;42:368
http://www.edmariano.com/archives/1196
27%!
J Arthroplasty 2016

So Many Options
Kandarian, Elkassabany, Tamboli, Mariano. Best Pract 2019;33:111

2017;42:368
http://www.edmariano.com/archives/1196
27%!
J Arthroplasty 2016
100% at VA Palo Alto

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

“Adductor Canal” Nomenclature
 Technically, our “adductor
canal” blocks and catheters are
in the distal femoral triangle
Wong WY, et al. RAPM 2017;42:241

 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

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

Proximal vs. Distal Adductor Canal
Mariano ER, et al. JUM 2014;33:1653

Proximal vs. Distal Adductor Canal
Burckett-St.Laurant, et al. RAPM 2016;41: 321

Time to Redefine What is Basic
Turbitt, Mariano, El-Boghdadly. Anaesthesia 2019 epub

Time to Redefine What is Basic
Turbitt, Mariano, El-Boghdadly. Anaesthesia 2019 epub
Teach Transferable Skills

Implementing IPACK
 IPACK blocks were added to a standard
multimodal regimen including adductor canal
catheters
Kandarian & Mariano, et al. KJA 2019;72:238

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

Tran, et al. RAPM 2019;44:234

Tran, et al. RAPM 2019

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.

Designing the "Best" Pain Management Plan for Knee Replacement

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