![]() ![]() Midazolam and fentanyl (IV) will be titrated for patient comfort, while ensuring that patients remain responsive to verbal cues. The only difference for subjects participating in the study (vs those not participating) will be that they will be randomized to receive an additional nerve block for posterior knee pain.Īdductor canal single shot block + Sham group: In the preoperative holding area, all subjects in this cohort will have a peripheral intravenous (IV) catheter inserted, standard noninvasive monitors applied, supplemental oxygen administered via a nasal cannula or face mask, and positioned supine. ![]() Spinal vs general anesthesia is decided at the discretion of the intraoperative anesthesiologist along with patient preferences and relevant contraindications. They all receive intraoperative intraarticular injections by the surgical team. A regional anesthesia fellow, not participating in the study, will open the sealed envelope and prepare the iPACK solution to be used accordingly.Ĭurrent Standard Care: Currently, all patients undergoing TKA receive preoperative adductor canal block as well as multimodal pain regimen managed by APS. After consenting and prior to surgery, patients will be randomized (utilizing sealed envelopes with 1:1 ratio) to either single-shot adductor canal block with sham iPACK block or single-shot adductor canal block with local anesthetic + dexamethasone iPACK block. Following written, informed consent, we will record baseline anthropomorphic information (age, sex, height, and weight) that is already provided by all patients having surgery. ![]() If a patient desires study participation, written, informed consent will be obtained using a current UCSD IRB-approved ICF. Study inclusion will be proposed to eligible patients prior to surgery. Consenting adults undergoing TKA will be offered enrollment. Ultrasound guided 4-in-1 block technique: a new single injection technique described by Roy R, Agarwal G, et al, 2018 for the combined 4 nerves (saphenous nerve, obturator nerve, nerve to vastus medialis and sciatic nerve) with a single injection point is located at the adductor hiatus where descending genicular artery branches from superficial femoral artery.īupivacaine is a long-acting amide local anesthetic (max.This will be a single-center (UCSD), randomized blinded investigation.Įnrollment. The block is most commonly performed using ultrasound guidance (Thiayagarajan MK, Kumar SV,et al 2019). It can be noted that this block affect sensory branches and avoid blocking the majority of motor branches. In some individuals, the obturator sensory branch (also a femoral nerve branch) can be affected by local anesthetic infiltration into this area. It contains the femoral vein and artery, the saphenous nerve and the nerve to the vastus medialis, both are sensory branches of the femoral nerve. The adductor canal bounded anteriorly by the sartorius muscle, posteriorly and medially by the adductor longus and magnus muscles, and laterally by the vastus medialis muscle. The adductor canal block (ACB) is an interfascial plane block performed in the middle third of the medial side of the thigh. The widespread use of ultrasound to advance peripheral nerve block techniques over the past decade has led to enormous growth in the utilization and efficiency of regional anesthesia (Cozowicz, Crispiana & Poeran, et al, 2015). The skin around the knee is supplied by the cutaneous branches from the femoral nerve and the saphenous nerve (Ritesh Roy, Gaurav Agarwal, et al, 2018). Regarding the functional anatomy of the nerve supply to knee joint: The knee is innervated by genicular branches from the nerve to vastus medialis, saphenous nerve, sciatic nerve and the posterior division of obturator nerve. Multi-modal analgesia is considered the best option for pain management in knee surgeries.Īs non-opioid analgesics alone are not effective enough while opioids alone are associated with many risk factors: nausea, vomiting, decrease intestinal motility and respiratory depression with possibility of addiction (Goode VM, Morgan B, et al, 2019). Many Pain management options following these surgeries are available: non-opioid analgesics, opioids and regional anesthesia techniques (epidural and peripheral nerve block). Improper pain management affects patients' psychological status with prolongation of hospital stay time and rehabilitation period, with the possibility of progression of the acute pain to chronic pain (McCartney CJ, Nelligan K., 2014). Knee surgeries are associated with severe postoperative pain. ![]()
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