We explored the efficacy of an interspace between the popliteal artery and capsule of the posterior knee (IPACK) block when added to an established enhanced recovery after surgery (ERAS) pathway to assist with posterior knee analgesia and functional mobility after total knee arthroplasty (TKA). We recruited participants undergoing TKA in our prospective, randomized, triple-blinded controlled trial. All study patients participated in our ERAS pathway consisting of a primary spinal anesthetic, adductor canal nerve catheter, and periarticular joint infiltration. Patients were randomized to receive an IPACK block or no block. The primary outcome was total postoperative opioid consumption. Secondary outcomes included pain scores, recovery unit length of stay, time to first opioid use, the incidence of posterior knee pain, ambulation distance and activities of daily living on postoperative day 1, and hospital length of stay. A total of 96 patients were randomized to the control and IPACK groups. There were no statistical differences in primary or majority of secondary outcomes. There was a lower incidence of posterior knee pain (39%) in the IPACK group when compared with controls (8.7%), p < 0.01. In terms of opioid consumption and a majority of functional outcomes, our study demonstrates no overall benefits of adding an IPACK block in this ERAS pathway in TKA. Nevertheless, IPACK may have the potential of mitigating posterior knee pain after TKA. Level of evidence: level 1.Clinical trial number and registry URL: NCT03653416. www.clinicaltrials.gov.

No abstract

Thoracic epidural catheters are often used for acute perioperative pain management in complex and extensive thoracic and abdominal surgeries. There are important clinical considerations when managing an indwelling thoracic epidural catheter postoperatively, especially to prevent catastrophic bleeding complications such as thoracic epidural hematomas in unique scenarios where anticoagulation is employed concomitantly. The timing of catheter removal, timing of postoperative anticoagulation to prevent thromboembolic events or to maintain cardiac stent patency, and adequate neurologic monitoring to identify hemorrhagic consequences can be challenging for the physician anesthesiologist and acute pain medicine physician. Perioperative acute coronary syndrome (ACS) is a complication that can occur after major surgery. The contemporary treatment options for acute coronary syndrome involve cardiothoracic surgery or percutaneous coronary intervention (PCI), followed by administration of potent fibrinolytic agents or anticoagulants. The use of anticoagulants complicates the management of thoracic epidural catheters and can increase the risk of a thoracic epidural hematoma. Prompt diagnosis of a thoracic epidural hematoma in this setting through adequate monitoring, detailed neurological exam, or MRI is paramount to facilitate emergent surgical decompression and to prevent catastrophic and irreversible neurological deficits. This chapter presents a case of a surgical patient with an indwelling thoracic epidural catheter postoperatively who had an episode of ACS treated with PCI and subsequent dual antiplatelet therapy. The patient developed an epidural hematoma and underwent surgical decompression. The chapter reviews the literature and discusses diagnosis, management, treatment options, and prognosis.

We present two patients who underwent double mastectomy and breast reconstruction with deep inferior epigastric artery perforator (DIEP) flap. The goal of this case series was to compare surgeon-provided infiltration block against anesthesiologist-provided regional nerve block, focusing on abdominal analgesia. This case report highlights that pain control for a patient could be successful when done collaboratively. To achieve this, it is important for both the surgical and anesthesia team to discuss the best analgesic plan for the patient while taking into consideration the confidence, experience, and technique that both the surgical and anesthesiology team can offer.

No abstract