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- Anesthesia and Analgesia after Total knee replacement- « State of the Art »

- Anesthesia and Analgesia after Total knee replacement- « State of the Art ». Patrick NARCHI, MD Centre Clinical 16800- Soyaux France. TKR: surgical characteristics. Surgical risk moderate Surgical duration 60 – 240 minutes !!! Bleeding intraoperative +

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- Anesthesia and Analgesia after Total knee replacement- « State of the Art »

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  1. - Anesthesiaand Analgesiaafter Total kneereplacement- « State of the Art » Patrick NARCHI, MD Centre Clinical 16800- Soyaux France

  2. TKR: surgicalcharacteristics • Surgicalriskmoderate • Surgical duration 60 – 240 minutes !!! • Bleeding • intraoperative + • Postoperative +++ • Postoperative painrelated to flessum

  3. Anesthetic technique ? • GA ? Why not? • Preoperativeepidural or femoralcatheter • Spinal anesthesia • Combined Spinal-epidural • Femoralcatheter • Nerve blocks • Psoas block (catheter) + sciatic block • Intraoperativesedation or TIVA

  4. Prevention of Spinal anesthesia- induced hypotension in the elderlyBuggy D, A&A 1997

  5. Mortality / Morbidity: RA – GA : No difference • Operating time • Mortality • Cardiovascularmorbidity • DVT / Pulmonaryembolism • Intra-operativebloodloss

  6. Bleedingafter major orthopedicsurgeryGA = Reg Anesth % major bleeding

  7. TKR: tourniquet or not ? • Anyeffect on bleeding?NO • Hersekli MA, IntOrthop. 2004 • Schuh A, ZentralblChir. 2003 • Tetro AM, Can J Surg. 2001 • Jorn LP, ActaOrthop Scand. 1999 • Anyeffect on venousthrombosis? • Wauke K, Arch Orthop Trauma Surg. 2002 Yes • Harvey EJ, J Arthroplasty. 1997No

  8. The postoperativechallenge !

  9. Why Regional Analgesia ? • Superior to iv PCA (opioids) • Excellent “dynamic analgesia”… 72h • Avoids opioid-side effects • nausea-vomiting +++ • sedation

  10. Total knee replacement • Epidural analgesia ? • Psoas, femoral block, iliofascial block ? • Is an obturator nerve block reallyuseful ? • Sciatic block ? • Single shot or catheter? • Infiltration ?

  11. Peripheral nerve catheters > Epidural • Efficacy: PNB Epid • Side effects: PNB <Epid • Major Complications: PNB < Epid * Epidural abcess* Epidural hematoma

  12. Watson M.W, RAPM 2005 Spinal anesthesia Sciatic 15 ml levoB Psoas Catheter: - bolus 25 ml levoB - perfusion * placebo * L-Bupi PCA iv (morphine) Is a femoral catheter really indicated ?

  13. Is the catheterreallynecessary ? • Prolongedanalgesia • similar 3 monthsoutcome FunctionalOutcome Resting and Peak VAS Pain Systemicanalgesicrequirement

  14. Sciatic nerve block for total-knee replacement: isitreallynecessary in all patients ? Levesque S, DelbosA, RAPM 2005 • Predictive risk factors of pain 1- Flessum 2- important preoperative pain 200 TKR patients N= 25 (12.5%) needed a single sciatic block in PACU

  15. Pham Dang C, RAPM 2005 • PCA Morphine (mg) 23 mg vs 4 mg* • Vomiting 43% vs 14%* Is the femoralcatheterenough or is a sciatic block necessary ?

  16. What about 0,3mg spinal morphine ? • Effective • Adverse effects: PONV– Pruritus

  17. Total knee replacementis the femoral catheter enough ? • (D0- D1): pain anterior & posterior ! • The catheter is not enough • - Sciatic block (Allen, Weber, Mansour) • - morphine: iv PCA, spinal, s/cut … • (D2- D4): physiotherapy …. • the femoral catheter is sufficient

  18. Total knee replacment …Regional analgesia >> PCA morphine • Quality of analgesia • Quality of early physiotherapy: KINETEC • Discharge criteria: Knee Flexion at 90 • Duration of physiotherapy +++ • PCA 50 days • Epidural 37 days • PNB 40 days

  19. Femoral Nerve Block ImprovesAnalgesiaOutcomesafter Total KneeArthroplastyA Meta-analysis of RandomizedControlledTrials(JE Paul, Anesthesiology 2010) • Single shot FNB >> iv PCA till 48h • Compared to a single shot FNB: • Addition of Sciatic block no benefit • Femoralcatheterno benefit

  20. Functional Outcome after TKR: Any benefit from Regional analgesia ? D0 D3 1w 2-3 months 1year Colwell 1992 Munin 1998 Carli 2010 Kadic 2009

  21. Total knee replacement Regional Analgesia > PCA morphine But … The final functional result of the operated knee is not related to any analgesia technique or drug … Colwell 1992, Munin JAMA 1998

  22. 80 TKR, spinal anesthesia Femoralcatheter Infiltrat the end of surg + Intraarticularcatheter 2 inj Infiltration + intraarticularanalgesia vs femoral nerve catheterafter TKRToftdahl K, Acta Orthopaedica 2007

  23. INFILTRATION : EFFECTIVE EVIDENCE INFILTRATION VS OPIODS Better analgesia Less consumption of opiods

  24. 150ml Ropi 0,2% • Capsule, muscles, S/cut • SubcutanCatheter Andersen LO, Acta AnaesthScand 2010 Infiltration - Bolus effective - Catheter: no efficacy

  25. Total Knee Replacement The Past ... The Present ... And the Future ! • Anesthesia GA = Spinal = Blocks • PostoperativeRegionalAnalgesia • Femoral block is the standard today • Femoralcatheter … longer analgesia • Obturator block … weakinterest • Sciatic block … for the first 24h • LIA … promising but requireslargersurveys

  26. EARLIEST FUNCTIONAL OUTCOME IMPORTANCE OF ANALGESIA TECHNIQUE Ilfeld BM Anesthesiology 2008 EVIDENCE Discharge Critera : adequate analgesia independence from iv analgesics ambulation of at least 30 meters 25 h 71 h Knee flexion depends on analgesia technique

  27. Continuous blockade of the lumbar plexus after knee surgeryDahl JB, Anaesthesia 1988 • TKR under GA & femoral catheter Urgent urinary drainage : 20% !!!

  28. Bladder management after total joint arthroplasty Knight RM, J Arthroplasty 1996 174 patients Economie - 150 minutes de nursing time - 3000 $ par patient

  29. FEMORAL NERVE BLOCK IDEAL TECHNIQUE EVIDENCE Effective Lesssideeffects Fastfunctionnalrecuperation

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