Title: Continuous Peripheral Nerve Blocks: Are We Improving Ambulatory Patient Care
1Continuous 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
3Perineural Catheters
- Site-specific analgesia
- Catheter adjacent to peripheral nerve(s)
- For moderate-to-severe painful procedures
4Selection 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
5Ambulatory 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?
7Tuohy Needles
Single-shot needles
818g Tuohy needle
20g non-stimulating catheter
to nerve stimulator
Injection tubing
B-Braun Contiplex Kit (non-stimulating catheter)
9Stimulating Catheter Kit
Gold tip
Tuohy needle
Stimulating catheter
to nerve stimulator
connector
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11Are 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
16How To Secure Catheter?
17Ambulatory Perineural Infusion Pumps
- Large infusion reservoir
- Uncomplicated infusion settings
- Reliable infusion rates
- Light weight
- Transportable
- Inexpensive
- Support PCA bolus function
- Safety alarms
18Elastomeric Infusion Devices
Baxter LV Infusor 5ml/hr
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20Baxter LV Infusor with Bolus Ability
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22 Electronic Infusion Devices
Stryker Pain Pump with Programmable Infusion/Bolus
23Ideal 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
24Types of Ambulatory Infusions?
- No ideal medication to provide profound analgesia
with minimal motor block - Consider risk of LA toxicity
- Ideal infusion strategy?
25Infusion 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
26Continuous 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
27Popliteal Catheter Program
- Discharged with popliteal catheters
- Elastomeric pumps
- Continuous infusion
- Ropivacaine 0.2 - 0.3
- Adjunctive medication
28 29Popliteal 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
31Effect of Patient-Controlled Perineural Analgesia
on Rehabilitation and Pain after Ambulatory
Orthopedic Surgery(Capdevila X, et al.
Anesthesiology 2006 105 566-73)
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33Are 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?
34The 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
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36Control group
Bupivacaine
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38Continuous 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
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40At rest
P lt 0.001 compared to saline
P lt 0.05 compared to saline grp
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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
43Does Continuous Peripheral Nerve Block Provide
Superior Pain Control to Opioids? A
Meta-Analysis(Richman J, et al. Anesth Analg
2006 102 248-57)
44Ambulatory Perineural Infusion The Patients
Perspective(Ilfeld BM, et al. Reg Anesth Pain
Med 2003 28 418-23)
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46Postoperative 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
47Are We Doing Harm?
- Any concerns regarding use of CPNBs?
- Are Popliteal Catheters doing harm?
- 3 recent articles review outcomes of CPNBs
48The 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)
50Continuous 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
53Nerve 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
55Outpatient 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
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57What 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
59Im 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
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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)
62Patients are very capable of managing and
removing catheters when they receive appropriate
preoperative instruction and education
63Where Do We Go From Here?
- Appropriate patient selection
- Education
- Adjunct Medications
- Proper pumps and infusions
- Approach for post-op concerns
64Education
- 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
65How to Educate?
- Healthcare team teaching sessions
- reading material
- interaction with patient
- Patients verbal and written instructions
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67In Conclusion
- Regional Anesthesia has proven benefit
- Patient Satisfaction
- Low risk of serious harm
- Ongoing effort to improve technical skill
- Ongoing education
68Questions?
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70Benzoin Tincture
Mastisol
7120g non-stimulating catheter (blue tip)
20g stimulating catheter (gold tip)
72 Tuohy Needles
Single-shot needles
73Patient 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