This is one of many ways to do this successfully. What I would add is that you should secure the hell out of the catheter, including dermabonding the catheter exit site unless you want to receive a million phone calls about leakage.
I'd love to hear how you secure them. If we don't tunnel them I use surgical glue at the insertion site, let it dry completely. Then steri strip x2 in alternating directions with surgical glue over them, let it dry. Tegaderm over that. Tension loops x3 over the length of the catheter. They still get pulled out. If it isn't the staff, the patient accidently do it themselves. All catheters independent of location get pulled. What is your follow up like with these patients?
Private practice acute pain service? What alternate universe are you in?
Who pays for the NP? How many catheters need rounding on each day?
Thats the most important part
that’s bizarre that they want a catheter. 1) unless the patient is a chronic pain patient or there is some other special circumstance, my upper extremity ortho guys tell me that total shoulders really aren’t that painful (like, shoulder scopes hurt more), 2) single shot bupivacaine with adjuvants like decadron will buy you 24h+ of pain relief, more than enough time to get them out of the hospital, get them home, and start their oral pain regimen, 3) the time it takes to educate patients on it, place it, secure it, follow up with them etc just isn’t worth the incremental benefit they may get, 4) multimodal analgesia is the way to go.
And not to rehash an old debate, but I’m surprised people are still using Exparel for nerve blocks given what the non-industry funded studies show about its efficacy
that’s bizarre that they want a catheter. 1) unless the patient is a chronic pain patient or there is some other special circumstance, my upper extremity ortho guys tell me that total shoulders really aren’t that painful (like, shoulder scopes hurt more), 2) single shot bupivacaine with adjuvants like decadron will buy you 24h+ of pain relief, more than enough time to get them out of the hospital, get them home, and start their oral pain regimen, 3) the time it takes to educate patients on it, place it, secure it, follow up with them etc just isn’t worth the incremental benefit they may get, 4) multimodal analgesia is the way to go.
And not to rehash an old debate, but I’m surprised people are still using Exparel for nerve blocks given what the non-industry funded studies show about its efficacy
Reliably 48 hours for interscalene blocks (20 0.5% bupi + 20 exparel). Up to 72 hours in some cases.
I'm pretty tired, but I don't understand this. Surely you aren't putting 40cc's into the interscalene space. Milligrams doesn't make sense either.
All day everyday haha
I love seeing the widely different way we all do things. I probably wouldn't put that much volume into somewhat of a tight space since it's just going to spread up and down, but I'm glad to hear you get great results with it.
I agree it’s probably a bit overkill and it definitely spreads up and down but we use the block as the primary anesthetic (native airway) for antsy surgeons who are testing your block 5 minutes after you put the needle down so the carpet bomb approach tends to work out well.
Not sure if srs. Are you blocking the patient in the room after they are prepped and draped?
Only half serious. Block in preop but they really do come and check for dense motor block and an easy way to make them happy is to have a fast setting block. Irrational creatures, they often judge your competence on that one metric. Work with some surgeons who are doing 90 minute total shoulders and often we are not ready to block until they are scrubbing out of the prior case.
Thems Blade-like numbers!
Doing it during room turnover saves a few min in OR.
Because when you run around like a chicken all day it helps to do a block ahead of time so that you don't get pulled away right before you do the block.
What kind of local
In fellowship we'd place the block in the preop area and start the OnQ pump during the case after positioning. Our surgeons preferred beach chair, so it was it just easier to hook it up after all the acrobatics. We'd use Mepivacaine to place the catheter for 1) quick verification that the block was working and 2) have surgical block for the procedure. Our OnQ infusions would be 0.2% Ropivacaine at 6 cc/hr. Catheter would be preinserted into tuohey needle, inserted into skin to desired location (usually deep to C6 nerve roots), once local spread sufficient, catheter could be threaded. Takes some practice, but you can do it all with one hand while visualizing the catheter placement on US. In terms of securing. Dermabond the insertion site to minimize leakage, wrap the catheter below the neck around to the contralateral shoulder and secure it down on the chest just below the clavicle. Lots of tegaderm. In fellowship, had maybe 4-5 catheters fail, only a few got pulled prematurely. For our RCR/TSA, it wasn't uncommon for our patients to have zero pain for 3 days...
