Decreased Opioid Consumption and Length of Stay Using an IPACK and Adductor Canal Nerve Block following Total Knee Arthroplasty

Eccles, Christian; Swiergosz, Andrew M.; Smith, Austin; Bhimani, Samrath; Smith, Langan S.; Malkani, Arthur L.

doi:10.1055/s-0039-1700840

Cited by 29 publications

(34 citation statements)

References 28 publications

(28 reference statements)

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“…Furthermore, opioid requirements, length of stay, and distance walked on postoperative day 0 were all analyzed in a review of 100 TKA patients who received IPACK + ACB compared to femoral nerve block and SNB. It was concluded that the IPACK + ACB combination resulted in earlier ambulation, decreased opioid use, and decreased length of stay [ 6 ].…”

Section: Discussionmentioning

confidence: 99%

Adductor Canal Block Duration of Analgesia Successfully Prolonged With Perineural Dexmedetomidine and Dexamethasone in Addition to IPACK Block for Total Knee Arthroplasty

Herman¹,

Urits²,

Eskander³

et al. 2020

Cureus

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Total knee arthroplasty (TKA) is among the most commonly performed orthopedic procedures. Controlling the pain of this patient population is essential in improving outcomes such as opioid consumption, hospital length of stay, overall function, and rehabilitation participation following their procedure. Local anesthetic infiltration of the interspace between the popliteal artery and capsule of the posterior knee, known as the IPACK block, combined with an adductor canal block (ACB) can be used to reduce pain in the challenging area of the posterior knee after knee surgery without compromising motor function of the quadriceps muscles. One limiting factor to this combination of techniques is the duration of analgesia provided. This case series demonstrates the combination of dexmedetomidine and dexamethasone (Dex-Dex) as local anesthetic adjuvants to significantly prolong the analgesic duration of ACB (in addition to IPACK block) in three patients undergoing TKA. Preoperative ACB and IPACK blocks were performed for postoperative analgesia in three TKA patients. The anesthetic mixture was 10 cc 0.2% ropivacaine combined with 25 mcg of dexmedetomidine and 5-mg preservative-free dexamethasone for the ACB, and 0.2% ropivacaine combined with 5-mg preservative-free dexamethasone was utilized for the IPACK block. Two of the patients reported experiencing four days of analgesia and one patient reported five days of analgesia following the ACB + IPACK block. Two of the patients required no opioid analgesics postoperatively. An ACB utilizing 0.75% ropivacaine has been demonstrated to provide approximately 10.8 hours of analgesia. Our series demonstrates a significantly prolonged duration of analgesia from this injectate combination. Few studies have utilized the Dex-Dex combination. The combination, however, was previously proven to safely increase the analgesic duration of a caudal block prior to hypospadias surgeries in pediatrics. More studies are needed to understand a potential synergistic effect of Dex-Dex, which could have a substantial impact on postoperative analgesia for TKA patients.

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Section: Discussionmentioning

confidence: 99%

Adductor Canal Block Duration of Analgesia Successfully Prolonged With Perineural Dexmedetomidine and Dexamethasone in Addition to IPACK Block for Total Knee Arthroplasty

Herman¹,

Urits²,

Eskander³

et al. 2020

Cureus

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“…The authors acknowledge that confounders within the studies included in this review must be taken into account, such as flaws in study design or execution of other treatments that may provide for posterior knee coverage such as sciatic blocks or PAI in some of the experimental arms. 13 , 40 When assessing only RCTs with treatment arms comparing iPACK+ACB vs PAI+ACB, two RCTs 29 , 31 reported no clinically significant difference in opioid consumption or pain scores with movement. While this may indicate that PAI targets similar nerves that overlap with the iPACK coverage, additional objective studies, such as cadaver studies comparing injectate spread, are warranted.…”

Section: Discussionmentioning

confidence: 99%

Ultrasound-Guided Local Anesthetic Infiltration Between the Popliteal Artery and the Capsule of the Posterior Knee (IPACK) Block for Primary Total Knee Arthroplasty: A Systematic Review of Randomized Controlled Trials

D’Souza¹,

Langford²,

Olsen³

et al. 2021

LRA

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Posterior knee pain after total knee arthroplasty (TKA) is common despite multimodal analgesia and regional anesthesia use. This review included randomized controlled trials (RCTs) comparing analgesic outcomes after inclusion of local anesthetic infiltration between the popliteal artery and capsule of the knee (iPACK) block versus pathways without iPACK. Electronic databases (MEDLINE, Cochrane Library, Web of Science, Scopus) were searched from inception to 10/11/2020. Eligible studies evaluated iPACK use on primary outcomes: opioid consumption and pain scores with movement. Secondary outcomes included rest pain, patient satisfaction, length of stay (LOS), gait distance, knee range of motion (ROM), and complications. Bias and quality were appraised using the Cochrane Risk of Bias tool and Grading of Recommendations, Assessment, Development, and Evaluations (GRADE) guidelines. Eight RCTs (777 patients) were included. iPACK block use demonstrated similar opioid consumption in the PACU (4/7 RCTs) and 24 hours after TKA (5/7 RCTs) compared to without iPACK (moderate-quality GRADE evidence). Additionally, iPACK block use demonstrated lower movement pain scores in PACU (3/5 RCTs) but similar or higher pain scores after 24 hours (5/7 RCTs; lowquality GRADE evidence). Studies consistently reported no difference in gait distance (4/4 RCTs) or complications (7/7 RCTs) between treatment arms (high-quality GRADE evidence), although differing effect estimates were observed with resting pain, satisfaction, LOS, and knee ROM. This review provides a foundation of knowledge on iPACK efficacy. While evidence does not currently support widespread inclusion of iPACK within enhanced recovery pathways for TKA, limitations suggest further study is warranted.

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“…Eccles CJ et al . [ 11 ] demonstrated that patients receiving IPACK block in combination with ACB could be ambulated early, had decreased opioid consumption and duration of hospitalisation when compared to femoral and sciatic nerve blockade. However, both these studies were retrospective in nature.…”

Section: Discussionmentioning

confidence: 99%

Comparison of sensory posterior articular nerves of the knee (SPANK) block versus infiltration between the popliteal artery and the capsule of the knee (IPACK) block when added to adductor canal block for pain control and knee rehabilitation after total knee arthroplasty---A prospective randomised trial

Kar¹,

Padhy²,

Patki³

et al. 2021

Indian Journal of Anaesthesia

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Background and Aims: Adductor canal block (ACB), though an effective procedure for postoperative analgesia in total knee arthroplasty (TKA), does not provide analgesia to the posterior articular aspect of the knee joint. Infiltration between the popliteal artery and the capsule of the knee (IPACK block) and sensory posterior articular nerves of the knee (SPANK block) are two single injection techniques that have been shown to provide effective analgesia in posterior knee pain. This study aims to compare the effect of IPACK block and SPANK block when combined with ACB for analgesia and postoperative rehabilitation in TKA. Methods: A total of 82 patients were randomised into two groups: (1) ACB combined with IPACK, (2) ACB combined with SPANK block. The primary outcome was the pain scores from 6 h to 48 h after surgery and the duration of postoperative analgesia. The secondary outcome measures were 24 h opioid consumption, ambulation parameters like mobilisation ability, quadriceps muscle strength and patient satisfaction score at discharge. Results: Numerical rating scale (NRS) scores at rest and on movement, duration of analgesia, total opioid consumption, and patient satisfaction were significantly better ( P < 0.05%) in the IPACK group than in the SPANK block. There were no significant differences in the knee rehabilitation parameters between the blocks. Conclusion: ACB with IPACK block offers better analgesia, less opioid consumption and better patient satisfaction with comparable knee rehabilitation parameters in the immediate postoperative period after TKA compared to ACB with SPANK block.

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Decreased Opioid Consumption and Length of Stay Using an IPACK and Adductor Canal Nerve Block following Total Knee Arthroplasty

Cited by 29 publications

References 28 publications

Adductor Canal Block Duration of Analgesia Successfully Prolonged With Perineural Dexmedetomidine and Dexamethasone in Addition to IPACK Block for Total Knee Arthroplasty

Adductor Canal Block Duration of Analgesia Successfully Prolonged With Perineural Dexmedetomidine and Dexamethasone in Addition to IPACK Block for Total Knee Arthroplasty

Ultrasound-Guided Local Anesthetic Infiltration Between the Popliteal Artery and the Capsule of the Posterior Knee (IPACK) Block for Primary Total Knee Arthroplasty: A Systematic Review of Randomized Controlled Trials

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