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Korean J Anesthesiol > Epub ahead of print
DOI: https://doi.org/10.4097/kja.d.18.00346    [Epub ahead of print]
Published online February 19, 2019.
Implementation of the IPACK (Infiltration between the Popliteal Artery and Capsule of the Knee) block into a multimodal analgesic pathway for total knee replacement
Brandon Kandarian1, Pier F. Indelli4,5, Sanjay Sinha3, Oluwatobi O. Hunter2, Rachel R. Wang1,2, T. Edward Kim1,2, Alex Kou1,2, Edward R. Mariano1,2
1Department of Anesthesiology, Perioperative and Pain Medicine; Stanford University School of Medicine; Stanford, CA
2Anesthesiology and Perioperative Care Service; Veterans Affairs Palo Alto Health Care System; Palo Alto, CA
3Department of Anesthesiology; St. Francis Hospital and Medical Center; Hartford, CT
4Department of Orthopaedic Surgery; Stanford University School of Medicine; Stanford, CA
5Orthopaedic Surgery Section, Surgical Service; Veterans Affairs Palo Alto Health Care System; Palo Alto, CA
Corresponding author:  Edward R. Mariano, Tel: (650) 849-0254, Fax: (650) 852-3423, 
Email: emariano@stanford.edu
Received: 5 December 2018   • Revised: 17 January 2019   • Accepted: 14 February 2019
The IPACK (Infiltration between the Popliteal Artery and Capsule of the Knee) block is a new anesthesiologist-administered analgesic technique for controlling posterior knee pain in total knee arthroplasty (TKA) patients that has not yet been well studied. We compared pain outcomes in TKA patients before and after implementation of IPACK with the hypothesis that patients receiving IPACK blocks will report lower pain scores on postoperative day (POD) 0 compared to non-IPACK patients.
With IRB approval, we retrospectively reviewed data for consecutive TKA patients by a single surgeon four months before (PRE) and after (POST) IPACK implementation. All TKA patients received adductor canal catheters and perioperative multimodal analgesia. The primary outcome was pain on POD 0. Other outcomes were daily pain scores, opioid consumption, ambulation distance, length of stay, and 30-day adverse events.
Post-implementation, 48/50 (96%) of TKA patients received an IPACK block, and these cases were compared with 32 patients in the PRE group. On POD 0, 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), respectively; p=0.003]. Highest patient-reported pain scores on any POD were not different between groups, and there were no differences in other outcomes.
Within a multimodal analgesic protocol, addition of IPACK blocks decreases 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.
Key Words: Adductor canal catheter; Implementation; IPACK; Local infiltration analgesia; Multimodal analgesia; Total knee arthroplasty


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