Implementation of the IPACK (Infiltration between the Popliteal Artery and Capsule of the Knee) block into a multimodal analgesic pathway for total knee replacement / 대한마취과학회지

BACKGROUND: The Infiltration between the Popliteal Artery and Capsule of the Knee (IPACK) block is a new anesthesiologist- administered analgesic technique for controlling posterior knee pain that has not yet been well studied in total knee arthroplasty (TKA) patients. We compared pain outcomes in TKA patients before and after implementation of the IPACK with the hypothesis that patients receiving IPACK blocks will report lower pain scores on postoperative day (POD) 0 than non-IPACK patients. METHODS: With Institutional Review Board approval, we retrospectively reviewed data for consecutive TKA patients by a single surgeon 4 months before (PRE) and after (POST) IPACK implementation. All TKA patients received adductor canal catheters and peri-operative multimodal analgesia. The primary outcome was pain on POD 0. Other outcomes were daily pain scores, opioid consumption, ambulation distance, length of stay, and adverse events within 30 days. RESULTS: Post-implementation, 48/50 (96%) of TKA patients received an IPACK block, and they were compared with 32 patients in the PRE group. On POD 0, the lowest pain score (median [10th–90th percentiles]) was significantly lower for the POST group compared to the PRE group (0 [0–4.3] vs. 2.5 [0–7]; P = 0.003). The highest patient-reported pain scores on any POD were similar between groups with no differences in other outcomes. CONCLUSIONS: Within a multimodal analgesic protocol, addition of IPACK blocks decreased the lowest pain scores on POD 0. Although other outcomes were unchanged, there may be a role for new opioid-sparing analgesic techniques, and changing clinical practice change can occur rapidly.

Implementation of the IPACK (Infiltration between the Popliteal Artery and Capsule of the Knee) block into a multimodal analgesic pathway for total knee replacement / 대한마취과학회지

BACKGROUND@#The Infiltration between the Popliteal Artery and Capsule of the Knee (IPACK) block is a new anesthesiologist- administered analgesic technique for controlling posterior knee pain that has not yet been well studied in total knee arthroplasty (TKA) patients. We compared pain outcomes in TKA patients before and after implementation of the IPACK with the hypothesis that patients receiving IPACK blocks will report lower pain scores on postoperative day (POD) 0 than non-IPACK patients.@*METHODS@#With Institutional Review Board approval, we retrospectively reviewed data for consecutive TKA patients by a single surgeon 4 months before (PRE) and after (POST) IPACK implementation. All TKA patients received adductor canal catheters and peri-operative multimodal analgesia. The primary outcome was pain on POD 0. Other outcomes were daily pain scores, opioid consumption, ambulation distance, length of stay, and adverse events within 30 days.@*RESULTS@#Post-implementation, 48/50 (96%) of TKA patients received an IPACK block, and they were compared with 32 patients in the PRE group. On POD 0, the lowest pain score (median [10th–90th percentiles]) was significantly lower for the POST group compared to the PRE group (0 [0–4.3] vs. 2.5 [0–7]; P = 0.003). The highest patient-reported pain scores on any POD were similar between groups with no differences in other outcomes.@*CONCLUSIONS@#Within a multimodal analgesic protocol, addition of IPACK blocks decreased the lowest pain scores on POD 0. Although other outcomes were unchanged, there may be a role for new opioid-sparing analgesic techniques, and changing clinical practice change can occur rapidly.

Simultaneous computed tomography and seminal vesiculography in a patient with ejaculatory duct obstruction

A 32-year-old man presented with primary infertility. He had azoospermia with low volume ejaculate. Physical examination was normal. Transrectal ultrasonography [TRUS] revealed grossly dilated seminal vesicles. No other genitourinary tract abnormality was noted. He underwent TRUS-guided aspiration of the seminal vesicles with simultaneous instillation of contrast media and methylene blue dye into the seminal vesicles. The aspirate showed scanty sperms. Conventional radiograph [Figure 1] and simultaneous computed tomography [CT] and seminal vesiculogram images [Figure 2] were taken, which revealed the spectacular appearance of huge seminal vesicles and retrograde flow of contrast media into the proximally dilated system upto the epididymis. The dilated ejaculatory duct anatomy could be seen with exceptional clarity. The patient underwent transurethral resection of the ejaculatory ducts on the same day until free flow of methylene blue was noted from a wide open orifice [Figure 3]. Postoperatively, he developed seminal vesiculitis which was treated with oral ciprofloxacin. He showed a delayed return of sperms into the ejaculate at 9 months. Transrectal ultrasonography alone is insufficient for the diagnosis of ejaculatory duct obstruction.[1] Only about half of the patients with TRUS findings show confirmed obstruction on additional diagnostic evaluation such as examination of TRUS-guided aspirate, instillation of colored dye, and seminal vesiculography. [2] Computed tomography and seminal vesiculography may be combined easily at the time of contrast instillation and gives excellent anatomical detail. Further studies are needed to better elucidate the role of imaging with CT in patients with obstructive azoospermia