All other TKA patients continued to receive surgeon-administered LIA.įor all patients undergoing knee arthroplasty surgery, the RAAPM team placed an ultrasound-guided adductor canal catheter (ACC) pre-operatively using a technique described previously. The IPACK technique was researched and disseminated to RAAPM team members, and the project was initiated in May 2018 for all knee arthroplasty patients of this single surgeon. A collective decision was made for the RAAPM team to provide pre-operative IPACK blocks as part of the TKA clinical pathway with strong support from the new surgeon who favored this approach due to the timing (prior to insertion of implants) and image guidance (ultrasound). A need for an infiltrative technique was identified and options included LIA administered by the new surgeon or IPACK blocks performed by the RAAPM team. The steps were planned in advance with various stakeholder groups including RAAPM anesthesiologists, orthopedic surgeons, and nurses in the post-anesthesia care unit (PACU) and surgical ward. This implementation of a clinical practice change was designed as a quality improvement project using 1 cycle of a plan-do-study-act. We also describe the process of implementing this clinical practice change. We retrospectively compared postoperative outcomes before and after implementation of IPACK blocks, hypothesizing that post-IPACK patients will report lower pain scores on postoperative day (POD) 0 than pre-IPACK patients. With the hiring of a new surgeon who does not perform LIA and who is a strong supporter of regional anesthesia, the RAAPM team introduced a new ultrasound-guided procedure: the Infiltration between the Popliteal Artery and Capsule of the Knee (IPACK) block, for controlling posterior knee pain in the new surgeon’s TKA patients as a quality improvement project to ensure consistency in care among TKA patients at our facility. Maintaining long-term clinical pathway adherence can be challenging for many reasons and pathways should be adaptable. This pathway is managed by a dedicated regional anesthesiology and acute pain medicine (RAAPM) team, which routinely inserts adductor canal catheters pre-operatively for all TKA patients and prescribes inpatient postoperative analgesics. Therefore, this combination has been integrated into a multimodal analgesic clinical pathway for TKA patients at our institution with extremely high adherence rates. When combined, LIA and peripheral nerve blockade provide superior pain control when compared to either approach alone. Local infiltration analgesia (LIA) involves local anesthetic administration by the surgeon in close proximity to the operative site and has proven efficacious. Regional analgesia for patients undergoing total knee arthroplasty (TKA) has evolved over the past 3 decades to become more selective to the operative site and balance the goals of effective pain management with early rehabilitation.
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