Thanks for your post. As Greg mentioned we will try to post an iPACK video soon. In the meantime here is a nice little tutorial on YouTube:
Good point. We should be able to get one of those up soon after ASRA this week. We are doing more of those lately. I was a big believer in the low volume selective tibial block but have been having good success with the iPACK the last couple of months. That is primarily with ACL surgery also.
I did 3 so far and seem to have great results. We have a big total knee volume and this block replaces the posterior capsular infiltration by the surgeon. He uses a mixture of ropivicaine toreador and morphine. We are trying to stay of narcotics completely.
That is great to hear. We don't do enough outpatient total knees to easily study iPACKs for TKA, but our fellow is currently compiling our ACL patient PACU data to compare analgesia & narcotic consumption for (1) adductor canal cath vs. (2) adductor canal cath + tibial vs. (3) adductor canal cath + iPACK. We will see.....
We have been using the iPack and Adductor canal block for TKA. So far good success. I avoid the tibial as we have our patients walking 50 to 250 feet evening of surgery. In the most recent scenarios we have used Liposomal bupivacaine and 30 ml bupivacaine 0.25% diluted to 100 mls. I use aprox 20mls of the solution for the iPACK and the surgeon places the remainder intraoperatively (without injecting the posterior capsule). Adductor canal is done with Ropi with decadron- total volume12 mls. Based on what I have read this should keep our LA blood levels in acceptable range. Thoughts?
Hi Fred- thanks for posting a comment. This is a very common question: is it OK to do nerve blocks in addition to infiltration with liposomal bupivacaine? The short answer is that we don't know for certain and many anesthesiologists avoid this combination out of fear for toxicity. Your total dose does seem reasonable assuming your Exparel dose is 20ml (i.e. 266mg). This is especially true since your blocks and their infiltration are likely separated in time. There is always going to be some degree of toxicity (and medicolegal) risk combining blocks with local anesthesia infiltration (both standard LA and liposomal LA). If you do opt to do a combined approach, where the surgeon typically uses large volumes of local anesthesia, your best bet is to use a relatively low volume for your iPACK and AC (as you are doing with 20ml and 12ml, respectively) and use a low concentration local anesthetic (I would consider using 0.2% ropivacaine with dexamethasone as opposed to 0.5% for your AC). I hope that helps. Cheers- Brandon
We may be asked in the near future to add IPACK to our adductor blocks for ACL. Interestingly, we work at an ASC with a VERY strong surgeon preference for regional for these cases which is usually an epidural due to concerns for PDPHA in this young population. So I’m concerned about LAST.
My plan would be to use 0.2% Ropivacaine maybe 25 ml for the blocks and around 15 ml of either chloroprocaine or 1.5% lido for the epidural. Does this sound safe?
25 ml of 0.2% Ropi is only 50 mg so I think you would be fine with this dose plus your epidural.
The low concentration of the ropi keeps you safe in most patients I believe.
We actually use the Adductor Canal catheter and iPACK block with a light general anesthetic with an LMA.
Our anesthesia department has not started using ipack blocks for TKA. Our surgeons use bupiv 150 mg for periarticular injection intra-op. We are trying to standardize the volume and concentration of ropiv. that is used for AC blocks in TKA cases. Our surgeons would like their pts to ambulate the night of surgeon.
What is the optimal volume for effective post op pain control after TKA ,10, 15, 20 mls. Should we decrease the concentration to 0.2 % in order to continue with larger volume or decrease the volume and keep 0.5% concentration of Ropiv?
I have reviewed the literature and have not found the answer.
I would appreciate any help as the anesthesia providers all have different experiences.
If your surgeons are doing a good periarticular block that should alleviate the need for an iPACK block. We use Ropi 0.2% 20mls for our initial block but we also put in a catheter. We sometimes bolus with 0.5% in the PACU if they are having pain and it is ususally helpful. Sometimes we do not need to do that. If we are doing a single shot, we use 0.5% ropivacaine 15-20mls to make sure the block is solid. Best wishes.
These are good questions Janice. I think there are a lot of (volume and concentration) ways to skin the cat. Over time we have settled on 20ml adductor canal blocks, although Dr. Hickman nicely demonstrated in an earlier cadaver video that 10ml spreads up and down nearly the entire adductor canal so you are likely fine anywhere in the 10-20ml range. I am not aware of 0.2% vs. 0.5% data for adductor canal blocks but I do know that 0.2% provided inferior pain control to 0.5% in our femoral blocks years back anecdotally so we switched back to 0.5% for femorals (as I joked to the surgeon at the time who was asking for motor sparing femorals, "we are succeeding in getting more motor sparing femorals, but unfortunately they are also sensory sparing!" :) I wouldn't use 20ml of 0.5% for your AC blocks if the surgeons are injecting 150mg. I would consider 200 mg to be a soft cut-off and 225mg to be an absolute cutoff for total ropivacaine dosing. Take care and good luck. Cheers- Brandon