- 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 +–Postoperative +++

• Postoperative pain related to flessum

Anesthetic technique ?

• GA ? Why not?– Preoperative epidural or femoral catheter

• Spinal anesthesia– Combined Spinal-epidural– Femoral catheter

• Nerve blocks– Psoas block (catheter) + sciatic block– Intraoperative sedation or TIVA

Prevention of Spinal anesthesia- induced hypotension in the elderly Buggy D, A&A 1997

Cristalloids500 ml

Colloid500 ml

control P =

hypotension 62 39 46 0.1

% vasopressors 45 29 39 0.4

Ephedrine (mg) 6.4 5.9 6.8 0.4

Nausea/vomiting 7 14 7 0.7

Mortality / Morbidity: RA – GA : No difference

Operating time

Mortality

Cardiovascular morbidity

DVT / Pulmonary embolism

Intra-operative blood loss

Bleeding after major orthopedic surgery GA = Reg Anesth

Major bleeding

0

1

2

3

4

5

2.32.1

regional anesthesia other anesthesia% major bleeding

TKR: tourniquet or not ?

• Any effect on bleeding? NO– Hersekli MA, Int Orthop. 2004 – Schuh A, Zentralbl Chir. 2003 – Tetro AM, Can J Surg. 2001– Jorn LP, Acta Orthop Scand. 1999

• Any effect on venous thrombosis?– Wauke K, Arch Orthop Trauma Surg. 2002 Yes– Harvey EJ, J Arthroplasty. 1997 No

The postoperative challenge !

Why Regional Analgesia ?

• Superior to iv PCA (opioids)

• Excellent “dynamic analgesia”… 72h

• Avoids opioid-side effects– nausea-vomiting +++– sedation

Total knee

replacement• Epidural analgesia ?• Psoas, femoral block, iliofascial block ?• Is an obturator nerve block really useful ?• Sciatic block ?• Single shot or catheter?• Infiltration ?

Peripheral nerve catheters > Epidural

• Efficacy: PNB Epid

• Side effects: PNB < Epid

• Major Complications: PNB < Epid

* Epidural abcess* Epidural hematoma

Watson M.W, RAPM 2005Spinal anesthesiaSciatic 15 ml levoB

Psoas Catheter: - bolus 25 ml levoB - perfusion

* placebo* L-Bupi

PCA iv (morphine)

Is a femoral catheter re

ally

indicated ?

Is the catheter really necessary ?

Prolonged analgesia

similar 3 months outcome

Resting and Peak VAS Pain

Systemic analgesic requirement

Functional Outcome

Sciatic nerve block for total-knee replacement: is it really necessary in all patients ?

Levesque S, Delbos A, RAPM 2005

200 TKR patients

N= 25 (12.5%) needed a single sciatic block in PACU

Predictive risk factors of pain

1- Flessum

2- important preoperative pain

• PCA Morphine (mg)

23 mg vs 4 mg *

• Vomiting

43% vs 14% *

Pham Dang C, RAPM 2005

Is the femoral catheter enough

or

is a sciatic block necessary ?

What about 0,3mg spinal morphine ?

Effective

Adverse effects: PONV– Pruritus

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

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

Femoral Nerve Block Improves Analgesia Outcomes after Total Knee Arthroplasty

A Meta-analysis of Randomized Controlled Trials

(JE Paul, Anesthesiology 2010)

• Single shot FNB >> iv PCA till 48h• Compared to a single shot FNB:

–Addition of Sciatic block no benefit–Femoral catheter no

benefit

Functional Outcome after TKR:

Any benefit from Regional

analgesia ?

D0 D3 1w 2-3 months 1year

Colwell 1992Munin 1998

Carli 2010Kadic 2009

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

Infiltration + intraarticular analgesia vs femoral nerve catheter after TKR

Toftdahl K, Acta Orthopaedica 2007

femoral Infilt + artic statistics

Worst pain score during physical therapy D1

5 3 *

Oxycodone (mg) D1 100 83 * *

Able to hold quadriceps D1 50% 80% * * *

• 80 TKR, spinal anesthesia• Femoral catheter• Infiltr at the end of surg + Intraarticular catheter 2 inj

INFILTRATION :EFFECTIVE

INFILTRATION VS OPIODS

Better analgesia

Less consumption of opiods

EVIDENCE

• 150ml Ropi 0,2% • Capsule, muscles, S/cut• Subcutan Catheter

Andersen LO, Acta Anaesth Scand 2010

Infiltration- Bolus effective- Catheter: no efficacy

Total Knee Replacement

The Past ... The Present ... And the Future !

• Anesthesia GA = Spinal = Blocks• Postoperative Regional Analgesia

–Femoral block is the standard today–Femoral catheter … longer analgesia–Obturator block … weak interest–Sciatic block … for the first 24h–LIA … promising but requires larger surveys

EARLIEST FUNCTIONAL OUTCOME IMPORTANCE OF ANALGESIA TECHNIQUE

A B C

Day 5Discharge1 month3 month

608090125

809095125

8590 105130

Knee flexion depends on analgesia technique

EVIDENCE

12

0

20

40

60

80

25 h 71 h

Ilfeld BM Anesthesiology 2008

Discharge Critera : adequate analgesia independence from iv analgesics ambulation of at least 30 meters

Continuous blockade of the lumbar plexus after knee

surgery Dahl JB, Anaesthesia 1988

• TKR under GA & femoral catheter

Urgent urinary drainage : 20% !!!

Bladder management after total joint arthroplasty Knight RM, J Arthroplasty 1996

Foley intermittent p =ECBU (+) 8% 12% NS

Resondage > J3 16% 25% **

174 patients

Economie - 150 minutes de nursing time- 3000 $ par patient

EFFECTIVE

LESS SIDE EFFECTS

FAST FUNCTIONNAL RECUPERATION

FEMORAL NERVE BLOCK IDEAL TECHNIQUE

EVIDENCE