Knee Procedures Often for knee surgery TKA ACL repair etc we can provide good analgesia for the anterior portion of the surgery however not for the posterior portion Options for anterior ID: 1038461
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1. Pooja Dave IPACK Block: Posterior Knee Pain
2. Knee ProceduresOften for knee surgery (TKA, ACL repair, etc) we can provide good analgesia for the anterior portion of the surgery, however, not for the posterior portionOptions for anterior:Femoral (significant motor block with sensory as well) Adductor canal (less motor block, gets sensory) However, if you use enough local at adductor you will get some femoral nerve and almost always you will still affect some motor (vastus medialis)
3. Knee Procedures Posterior knee painPopliteal block (will block lower extremity motor and sensory) Sciatica (more significant motor block down lower leg along with sensory) Problems with current posterior knee coverage include:Inability to stand up steadily Decreased ability to participate in physical therapy Increased time in bed increases risks of complications including: DVT, PE, muscle atrophy, pneumonia, increased hospital stay But…….there’s a new technique
4. IPACK Block IPACK stands for infiltration between the popliteal artery and the posterior capsule of the knee Provides posterior knee pain by blockade of the terminal branches innervating the posterior knee capsule BUT spares the tibial and peroneal nerves Biggest advantage: NO MOTOR BLOCK!
5. IPACK BlockUltrasound guided infiltration technique 15-20 mL of local anesthetic between artery and posterior capsule/femur Used for any knee procedure EXCEPT if patellar graft being harvested
6. IPACK BlockCan be done with patient supine, lateral, or bending of the knee Look for the popliteal artery and the white dark line of the posterior knee capsule Direct needle under the popliteal artery and towards the posterior capsule Inject 15-20 ml of local anesthetic above the posterior capsule underneath the popliteal artery
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11. Video of IPACK block https://vimeo.com/221434876
12. IPACK BlockStudies are starting to show improved posterior knee pain post knee surgery Ability to get out of bed earlier than without IPACK block Decrease in hospital stay! Hopefully this will translate into fewer postoperative complications as well!
13. Other Analgesia Pre-operativeGabapentin or other neuropathic pain medications Long acting opioids Acetaminophen PO or IV NSAIDS: ibuprofen, ketorolace, celecoxib( does not inhibit platelet function) Regional peripheral nerve blocks
14. Other Analgesia Intraoperative Acetaminophen IV Ketorolac IV Fentanyl, morphine, hydromorphone
15. Postoperative Continuous nerve block catheter (adductor vs femoral) Continue acetaminophen Continue NSAIDS, if appropriate PO Opioids, if necessary Other Analgesia
16. References https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5625980/http://bjaed.org/article/S2058-5349(17)30183-X/fulltexthttps://vimeo.com/221434876http://www.orthopaper.com/archives/2017/vol3issue2/PartC/3-1-69-918.pdf