the knee before patients have the joint replaced. Some facilities are
also using continuous peripheral nerve blocks, which involve infusing
a local anesthetic at the surgical site over several days using a
catheter system and pain pump.
Dr. Joshi, though, urges caution regarding the use of continues
nerve blocks. He says they're a good option for pain control in other
surgeries, but are a risky option for total knee replacement patients,
who must ambulate shortly after the procedure. Instead, Dr. Joshi rec-
ommends using peripheral nerve blocks — typically adductor canal
blocks, iPACK blocks or surgical site infiltration. He says peripheral
nerve blocks should be placed using ultrasound guidance to provide
targeted and theoretically more effective pain relief.
Dr. Soffin also acknowledges the risk of using continuous nerve
blocks for this patient population, and notes where the catheter is
placed can make a difference in the analgesic effects and safe use of
the blocks.
"Data supports continuous femoral plus sciatic nerve catheters as
profoundly analgesic and opioid-sparing after knee replacements," she
says. "However, the analgesia that can be achieved may come at the
cost of safe ambulation and meeting physical therapy discharge goals,
since these anatomic sites of blockade can cause motor weakness.
For these reasons, adductor canal catheters have become the pre-
ferred method."
Combined effort
Non-opioid analgesics are another key component of an opioid-spar-
ing approach to pain management. An effective multimodal regimen
could include:
• Preoperatively. Acetaminophen 1 gm PO + celecoxib 400 mg PO
(If available. If not, use an NSAID intraoperatively). Use in combina-
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