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Continuous Peripheral Nerve Blocks: Are We Improving Ambulatory Patient Care

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Title: Continuous Peripheral Nerve Blocks: Are We Improving Ambulatory Patient Care


1
Continuous Peripheral Nerve Blocks Are We
Improving Ambulatory Patient Care?
  • Dr. Jacelyn Kolman
  • Regional Fellow
  • Ottawa Hospital

2
  • Up to 40 of orthopedic ambulatory surgical
    patients can experience pain at home
  • Peripheral nerve blocks improve pain control
  • Perineural catheters first described in 1947

3
Perineural Catheters
  • Site-specific analgesia
  • Catheter adjacent to peripheral nerve(s)
  • For moderate-to-severe painful procedures

4
Selection of Surgery
  • Shoulder
  • Rotator Cuff Repair
  • Acromioplasty
  • Arthroplasty
  • Bankart
  • Elbow/Wrist
  • Arthroplasty
  • Arthrolysis
  • Trauma
  • Knee
  • Arthroplasty
  • ACL repair
  • Ankle
  • Arthroplasty
  • ORIF Fractures
  • Achilles Tendon repair
  • Foot
  • Hallux valgus
  • Metatarsal osteotomy
  • Other
  • Breast/thoracic surgery
  • Lower limb amputation
  • Ischemic limb pain

5
Ambulatory Patient Selection
  • Inclusion
  • Good cognitive understanding
  • Caretaker at home
  • Within 1 hour from health care facility
  • Adequate functional capacity pre-block
  • Exclusion
  • Cognitive/linguistic difficulty
  • Unreliable
  • Severe hepatic/renal disease
  • Severe cardiac/respiratory
  • Cardiac conduction blocks
  • Poor functional capability
  • Chronic analgesic therapy
  • Coagulopathy
  • Sepsis
  • Allergy to medication

6
  • How Do We Perform Continuous Peripheral Nerve
    Blocks?

7
Tuohy Needles
Single-shot needles
8
18g Tuohy needle
20g non-stimulating catheter
to nerve stimulator
Injection tubing
B-Braun Contiplex Kit (non-stimulating catheter)
9
Stimulating Catheter Kit
Gold tip
Tuohy needle
Stimulating catheter
to nerve stimulator
connector
10
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11
Are Stimulating Catheters Better?
  • Reduce risk of failed secondary block
  • Visual confirmation during advancement
  • No reported risk to patient

12
  • 124 out of 130 stimulating catheters demonstrated
    successful anesthesia plus good position with
    opacified radiography.
  • (Pham-Dang C, Kick O, Thurial C, et al.
    Continuous Peripheral Nerve Blocks With
    Stimulating Catheters. Reg Anesth Pain Med 2003
    28 83-88)
  • More attempts were required to place femoral
    nerve stimulating catheters compared to
    non-stimulating catheters
  • (Hayek SM, Ritchey RM, Sessler D, et al.
    Continuous Femoral Nerve Analgesia After
    Unilateral Total Knee Arthroplasty Stimulating
    Versus Nonstimulating Catheters. Anesth Analg
    2006 103 1565-1570)
  • Stimulating catheters require more minutes to
    place but demonstrate shorter onset time
  • (Casati A, et al. Using Stimulating Catheters
    for Continuous Sciatic Nerve Block Shortens Onset
    Time of Surgical Block and Minimizes
    Postoperative Consumption of Pain Medication
    After Halux Valgus Repair as Compared with
    Conventional Nonstimulating Catheters. Anesth
    Analg 2005 1011192-7)

13
(Casati A, et al. Using Stimulating Catheters for
Continuous Sciatic Nerve Block Shortens Onset
Time of Surgical Block and Minimizes
Postoperative Consumption of Pain Medication
After Halux Valgus Repair as Compared with
Conventional Nonstimulating Catheters. Anesth
Analg 2005 1011192-7)
14
  • (Casati A, et al. Using Stimulating Catheters for
    Continuous Sciatic Nerve Block Shortens Onset
    Time of Surgical Block and Minimizes
    Postoperative Consumption of Pain Medication
    After Halux Valgus Repair as Compared with
    Conventional Nonstimulating Catheters. Anesth
    Analg 2005 1011192-7)

15
  • Stimulating catheters
  • placed closer to the nerve
  • require less LA medication
  • less need for rescue analgesia
  • faster onset of motor and sensory block

16
How To Secure Catheter?
17
Ambulatory Perineural Infusion Pumps
  • Large infusion reservoir
  • Uncomplicated infusion settings
  • Reliable infusion rates
  • Light weight
  • Transportable
  • Inexpensive
  • Support PCA bolus function
  • Safety alarms

18
Elastomeric Infusion Devices
Baxter LV Infusor 5ml/hr
19
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20
Baxter LV Infusor with Bolus Ability
21
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22
Electronic Infusion Devices
Stryker Pain Pump with Programmable Infusion/Bolus
23
Ideal Pump?
  • ELASTOMERIC
  • Temperature and height dependent
  • No alarms/warnings
  • Infusion rate can vary
  • Fixed infusion rate during manufacturing
  • ELECTRONIC
  • Highly accurate and consistent
  • Programmable
  • Bolus ability
  • Expensive but reusable/refillable

24
Types of Ambulatory Infusions?
  • No ideal medication to provide profound analgesia
    with minimal motor block
  • Consider risk of LA toxicity
  • Ideal infusion strategy?

25
Infusion Strategies
  • Continuous Infusion
  • Simple, reliable, convenient
  • Does not allow dosage adjustment
  • Intermittent bolus
  • Great control
  • Potential for breakthrough pain
  • Continuous infusion with intermittent bolus
  • Preferred method
  • Greatest flexibility

26
Continuous Peripheral Nerve Blocks State of the
Art(Grossi P, Allegri M. Current Opinion in
Anaesthesiology 2005, 18522-26)
  • Reviewed 27 articles
  • Basal with bolus infusion most ideal
  • Reduces risk of breakthrough pain
  • Bolus ability allows patient reinforcement
  • Require less total dose of LA

27
Popliteal Catheter Program
  • Discharged with popliteal catheters
  • Elastomeric pumps
  • Continuous infusion
  • Ropivacaine 0.2 - 0.3
  • Adjunctive medication

28
  • Can We Do Better?

29
Popliteal Sciatic Perineural Local Anesthetic
Infusion(Ilfeld BR, Thannikary LJ, Morey TE, et
al. Anesthesiology 2004 101 970-77)
30
  • Overall
  • continuous infusion, with bolus ability, allows
    lower basal rate and decreased LA consumption
  • Increases duration of infusion benefits with
    ambulatory setting

31
Effect of Patient-Controlled Perineural Analgesia
on Rehabilitation and Pain after Ambulatory
Orthopedic Surgery(Capdevila X, et al.
Anesthesiology 2006 105 566-73)
32
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33
Are We Making a Difference?
  • Improvement of patient care most important
  • Are we making post-operative experience better
    for patients?
  • Are we utilizing the perineural catheters
    appropriately?

34

The Use of a Continuous Popliteal Sciatic Nerve
Block After Surgery Involving the Foot and Ankle
Does it Improve the Quality of Recovery?(White
PF, Issioul T, Skrivanek G,et al. Anesth Analg
2003 95 1303-09)
  • 24 healthy patients
  • Foot (bunionectomy / clawtoe / hammertoe
    correction)
  • Ankle (bone fusions / internal fixation)
  • Popliteal perineural catheter inserted
  • Double-blinded placebo-controlled study
  • Bupivacaine (0.25 5ml/hr) vs Saline for 48 hours
    via elastomeric pump

35
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36
Control group
Bupivacaine
37
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38
Continuous Popliteal Sciatic Nerve Block for
Postoperative Pain Control at Home(Ilfeld BM, et
al. Anesthesiology 2002 97 959-65)
  • Randomized double-blinded placebo-controlled
  • 30 ambulatory patients
  • Popliteal catheter
  • Battery-powered pump with bolus ability using
    ropivacaine 0.2 vs saline
  • Moderately painful lower extremity surgery

39
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40
At rest
P lt 0.001 compared to saline
P lt 0.05 compared to saline grp
41
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42
  • Ropivacaine Group Satisfaction 9.7/10
  • Desire to repeat the technique if another surgery
  • Better sleep
  • Less narcotics
  • Less SFX

43
Does Continuous Peripheral Nerve Block Provide
Superior Pain Control to Opioids? A
Meta-Analysis(Richman J, et al. Anesth Analg
2006 102 248-57)
44
Ambulatory Perineural Infusion The Patients
Perspective(Ilfeld BM, et al. Reg Anesth Pain
Med 2003 28 418-23)
45
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46
Postoperative Nausea and Vomiting In Regional
Anesthesia A Review(Borgeat A, et al.
Anesthesiology 2003 98 530-47)
  • Incidence of PONV
  • GA 70 vs CNB 6.3 vs PNB 3
  • Opioid sparing effects of PNBs significantly
    reduces amount of N/V that occurs

47
Are We Doing Harm?
  • Any concerns regarding use of CPNBs?
  • Are Popliteal Catheters doing harm?
  • 3 recent articles review outcomes of CPNBs

48
The Feasibility and Complications of the
Continuous Popliteal Nerve Block A 1001-Case
Survey(Borgeat A, et al. Anesth Analg 2006
103229-33)
49
  • ACUTE Complications
  • 5 pts transient paresthesias
  • 8 pts pain with injection of LA medication
  • 4 pts blood aspiration via needle
  • LATE Complications
  • No paresthesias, sensorimotor, unusual pain 3
    days or 3 months
  • 2 pts with inflammation at site no infection or
    neuropathy
  • Only 2 catheters dislodged (tunneling used)

50
Continuous Peripheral Nerve Blocks in Hospital
Wards after Orthopedic Surgery(Capdevila X, et
al. Anesthesiology 2005 103 1035-45)
  • 1416 pts
  • Various orthopedic procedures with CPNB
  • Non-stimulating catheters with ropiv/bupiv/mepiv
  • Various infusion strategies
  • Catheters 2 7 days

51
  • Minor adverse events
  • 253 (19.9) technical problems
  • Most frequent (10.5) catheter dislodgement
  • 80.5 events resolved by staff the day they
    occurred
  • OTHER
  • 41 pt (2.9) bloody cath during placement
  • 42 pt (3) persistent sensory block
  • 31 pt (2.2) persistent motor block
  • 21 pt (1.5) paresthesia during CPNB
  • 47 pt (3.3) failed pain relief
  • Serious adverse events
  • 12 events (0.84)
  • All resolved without sequelae
  • 2 pt diaphragm paralysis ICU for acute resp
    failure
  • 2 pt laryngeal/recurrent nerve trouble
    swallowing
  • 3 pt hypotension d/t epidural spread from psoas
    catheter
  • 1 pt catheter migration into IV noted at 24 hr
    point
  • 1 pt epileptic sz
  • 3 pts FN Lesions all resolved

52
  • 969 catheters (68) submitted to culture study
  • 28.7 (278 catheters) positive bacterial
    colonization
  • Single organism 242 catheters
  • Organisms found
  • Gm positive cocci
  • Gm negative bacilli

53
Nerve Damage?
  • Overall occurrence post-op neurologic deficit
    0.21
  • Comparable to other studies

One must remember that risk of surgery involves
nerve damage
54
  • 8 different centers various staff
  • Truthful with reporting?
  • Pts had faster short-term functional recovery
    during rehab (compared to IV PCA)
  • Low rate of neurologic infectious complications
  • No significant difference in results at
  • 6 - 12 weeks

55
Outpatient Management of Continuous Peripheral
Nerve Catheters Placed Using Ultrasound Guidance
An Experience in 620 Patients(Swenson JD, et al.
Anesth Analg 2006 103 1436-43)
  • Placed all catheters using direct ultrasound
    visualization
  • Extensive written and oral preoperative
    instruction
  • Close follow-up postoperatively

56
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57
What Happened?
  • 1st pt weakness/sensory loss 1 wk post-op
  • Common peroneal nerve area with tarsometatarsal
    osteotomies
  • Compression injury
  • Return to normal 6 weeks
  • 2nd pt severe burning/allodynia in foot
  • Suspicious of CRPS
  • 3 SNS blocks
  • Full resolution within 2 weeks

58
  • Advantages of CPNBs
  • Home faster
  • Less pain
  • Less opioids
  • Less SFX
  • Patient satisfaction
  • Faster functional recovery
  • Reduced breakthrough pain
  • Improved sleep
  • Improved perceived quality of recovery (as
    reported by pts)
  • Disadvantages of CPNBs
  • Technically challenging
  • Equipment malfunction
  • Catheter trouble
  • Toxicity
  • Home patient follow-up
  • Infection
  • Cost
  • Possible failed 2ary block
  • Unpredictable catheter direction

59
Im gonna get called every hour?!
  • The previous study also looked at interventions
    required for the 620 pts
  • INTERVENTION?
  • Any problem that required the involvement of the
    anesthesiologist after the patient was discharged
    from hospital

60
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61
  • Of the 26 interventions
  • 7 occurred in evening/weekend
  • 19 during normal work hours
  • Only 1 patient admitted for IV PCA
  • (chronic pain patient using chronic opioids)

62
Patients are very capable of managing and
removing catheters when they receive appropriate
preoperative instruction and education
63
Where Do We Go From Here?
  • Appropriate patient selection
  • Education
  • Adjunct Medications
  • Proper pumps and infusions
  • Approach for post-op concerns

64
Education
  • Involves the entire healthcare team
  • Surgeon pt selection, adjunct medication,
  • consult to anesthesia
  • Nursing pt selection, pt education, how to care
    for
  • nerve blocks/catheters
  • Anesthesia pt selection, pre-op ordering of
  • medications, pt
    education, review of
  • techniques

65
How to Educate?
  • Healthcare team teaching sessions
  • reading material
  • interaction with patient
  • Patients verbal and written instructions

66
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67
In Conclusion
  • Regional Anesthesia has proven benefit
  • Patient Satisfaction
  • Low risk of serious harm
  • Ongoing effort to improve technical skill
  • Ongoing education

68
Questions?
69
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70
Benzoin Tincture
Mastisol
71
20g non-stimulating catheter (blue tip)
20g stimulating catheter (gold tip)
72
Tuohy Needles
Single-shot needles
73
Patient Selection
  • Inclusion
  • Good cognitive understanding
  • Caretaker at home
  • Within 1 hour from health care facility
  • Adequate functional capacity pre-block
  • Exclusion
  • Cognitive/linguistic difficulty
  • Unreliability
  • Severe hepatic/renal disease
  • Severe cardiac/respiratory
  • Cardiac conduction blocks
  • Neurological dysfunction
  • Poor functional capability
  • Chronic analgesic therapy
  • Coagulopathy
  • Severe sepsis
  • Allergy to medication
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