CISB idea/ question

[periopdoc]

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I have a guy coming in for RCR in the morning who has requested a ISB. We don't have any of the disposable pumps for ambulatory surgery, so I had an idea and wanted to see if anyone thinks it is worth it and if you think I will get paid for it.

I was thinking of placing a catheter in preop and bolusing it with lido for the surgery, then bolusing it with Bupi in PACU about an hour before discharge.

Anyone think the extra couple of hours is not worth it? Anyone think I could successfully bill for catheter placement?

I am thinking that I should probably bill it as a single shot since I am using it that way for the post-op pain component, but is there any reason you couldn't bill for CISB if you gave repeated post-op boluses? For example, have the patient come back in the morning for a second bolus and then pull it?

Probably not worth the trouble, but just wondering if anyone has tried this or has thoughts on it.

- pod

 

[Oggg]

Have you considered leacing the catheter in and Having the pt come back on POD1 for a repeat bolus ?

 

[BLADEMDA]

Pod,

Place 30 mls of 0.5 percent of Bup with decadron (4 mg). You can expect 22-27 hours of post op pain relief. In addition, you can place a catheter (epidural catheter) at around C6 for a possible bolus injection tomorrow morning.

Another option is to borrow an OB infusion pump for the night. As long as the patient is reliable and honest he will bring your pump back tomorrow so you can d/c the catheter.

IMHO, patients usually do fine with a good 24 hour block. But, if low pain tolerance or chronic opioid use then they need 48 hours of pain control.

 

[periopdoc]

Yep, OP, 4th paragraph, second sentence. 😀

- pod

 

[BLADEMDA]

Yep, OP, 4th paragraph, second sentence. 😀

- pod

Yes, you can bill for the catheter as a continuous block or just bill for a second block tomorrow when you redose the catheter again before pulling it out.

 

[periopdoc]

For one of our nurses who had her RCR, I did just that. I purloined a epidural pump and ran her for 96 hours or so with 0.125% bupi plus Sufenta 0.1mcg/ml at 5 ml per hour with 2.5 ml q 30 min demand boluses based on this paper.

http://www.ncbi.nlm.nih.gov/pubmed/10553837

Previously, I had only done plain bupi for outpatient infusions.

Worked like a dream except that I didn't get enough initial motor block since I didn't bolus with a more concentrated bupi. The patient was moving her shoulder in post-op which was quite distressing. Thankfully, the repair held, but next time I would plan to give the patient a motor block for the first few hours after surgery.

No opiate requirement after pulling the catheter.

She had a previous RCR on the other side with a single shot block and she was so much happier with the CISB.

Some mid-level admin types weren't so happy with me sending one of our pumps out and called me at frequent intervals to be certain that it would be returned.

I can only imagine the holy hell they would raise if I tried to send out a normal patient with one of our pumps.

Interestingly, no one had an issue with me sending a patient out of the hospital with a bag full of sufent.

- pod

 

[BLADEMDA]

For one of our nurses who had her RCR, I did just that. I purloined a epidural pump and ran her for 96 hours or so with 0.125% bupi plus Sufenta 0.1mcg/ml at 5 ml per hour with 2.5 ml q 30 min demand boluses based on this paper.

http://www.ncbi.nlm.nih.gov/pubmed/10553837

Previously, I had only done plain bupi for outpatient infusions.

Worked like a dream except that I didn't get enough initial motor block since I didn't bolus with a more concentrated bupi. The patient was moving her shoulder in post-op which was quite distressing. Thankfully, the repair held, but next time I would plan to give the patient a motor block for the first few hours after surgery.

No opiate requirement after pulling the catheter.

She had a previous RCR on the other side with a single shot block and she was so much happier with the CISB.

Some mid-level admin types weren't so happy with me sending one of our pumps out and called me at frequent intervals to be certain that it would be returned.

I can only imagine the holy hell they would raise if I tried to send out a normal patient with one of our pumps.

Interestingly, no one had an issue with me sending a patient out of the hospital with a bag full of sufent.

- pod

Even if I place a catheter I bolus with 15-20 mls of 0.5 percent Rop or Bup for a good surgical block.

If I was in your shoes I'd bolus with 0.5 percent Bup wth decadron (20 mls). Prior to discharge I'd bolus with another 10 mls of 0.5 percent Bup with decadron (2mg). I'd have the patient come back early AM for reassessment of the block and possibly an additional bolus. You may be shocked to see that your patient still has a block the next day.

 

[periopdoc]

Given that it is a Monday, that is exactly what I am thinking except that I will probably add some sufent for the initial block and maybe the second as well.

- pod

 

[BLADEMDA]

Anesth Analg. 2001 Jan;92(1):218-23.
Patient-controlled interscalene analgesia with ropivacaine 0.2% versus bupivacaine 0.15% after major open shoulder surgery: the effects on hand motor function.
Borgeat A, Kalberer F, Jacob H, Ruetsch YA, Gerber C.
Source
Department of Anesthesiology, University Hospital of Zurich/Balgrist, Zurich, Switzerland. [email protected]
Abstract
We compared the effects of patient-controlled interscalene analgesia with ropivacaine 0.2% and patient-controlled interscalene analgesia (PCIA) with bupivacaine 0.15% on hand grip strength after major open shoulder surgery. Sixty patients scheduled for elective major shoulder surgery were prospectively randomized to receive in a double-blinded fashion either ropivacaine or bupivacaine through an interscalene catheter. Before surgery, all patients received an interscalene block (ISB) with either 40 mL of 0.6% ropivacaine or 40 mL of 0.5% bupivacaine. Six h after ISB, the patients received a continuous infusion of either 0.2% ropivacaine or 0.15% bupivacaine for 48 h. In both groups, the PCIA infusion rate was 5 mL/h plus a bolus of 4 mL with a lockout time of 20 min. Strength in the hand was assessed preoperatively, 24 h, and 48 h after ISB and 6 h after stopping the infusion of local anesthetic. The presence of paresthesia in the fingers was checked. Pain relief was assessed using a visual analog scale; side effects were noted, and the patients rated their satisfaction 54 h after the block. A significant decrease of strength in the hand was observed in the Bupivacaine group 24, 48, and 54 h after ISB (P < 0.05). Paresthesia was more frequently reported in the Bupivacaine group for the second and third fingers 48 h after ISB (P < 0.05) and in the first three fingers 6 h after discontinuation of the local anesthetic infusion (P: < 0.05). The pain score was similar in the two groups at all times, and patient satisfaction was comparable between the two groups. We conclude that the use of the PCIA technique with ropivacaine 0.2% or bupivacaine 0.15% provides a similar pain relief after major shoulder surgery. However, ropivacaine 0.2% is associated with better preservation of strength in the hand and less paresthesia in the fingers. Implications: We compared the patient-controlled interscalene analgesia technique with ropivacaine 0.2% and bupivacaine 0.15% after major open shoulder surgery. For similar pain control ropivacaine is associated with better preservation of strength in the hand and less paresthesia in the fingers.

 

[BLADEMDA]

Anaesthesia. 2012 Oct;67(10):1166-9. doi: 10.1111/j.1365-2044.2012.07222.x.
Catastrophic complication of an interscalene catheter for continuous peripheral nerve block analgesia.
Yanovski B, Gaitini L, Volodarski D, Ben-David B.
Source
Department of Anaesthesiology, Bnai Zion Medical Center, Haifa, Israel. [email protected]
Abstract
We report a catastrophic postoperative complication of a prolonged interscalene block performed under general anaesthesia. The course of the anaesthetic was uneventful and the patient remained stable during his stay in the recovery area with the operative extremity paralysed and insensate. No further local anaesthetic was administered until later that day when the patient received 10 ml bupivacaine 0.25% through the catheter. Upon completion of the top-up dose, no change in the patient's status was noticed. The patient was next assessed 6.5 h later when he was found dead in his bed. A postmortem CT scan revealed the catheter to be sited intrathecally, presumably the result of dural sleeve penetration.
Anaesthesia © 2012 The Association of Anaesthetists of Great Britain and Ireland.
Comment in

 

[BLADEMDA]

BMC Anesthesiol. 2012 Mar 23;12:6. doi: 10.1186/1471-2253-12-6.
The effect of initial local anesthetic dose with continuous interscalene analgesia on postoperative pain and diaphragmatic function in patients undergoing arthroscopic shoulder surgery: a double-blind, randomized controlled trial.
Hartrick CT, Tang YS, Siwek D, Murray R, Hunstad D, Smith G.
Source
Department of Anesthesiology, Oakland University William Beaumont School of Medicine, Beaumont Hospitals - Royal Oak and Troy, Rochester, MI, USA. [email protected].
Abstract
BACKGROUND:
Interscalene block (ISB) is commonly performed using 20-40 mL of local anesthetic. Spread to adjacent structures and consequent adverse effects including paralysis of the ipsilateral hemidiaphragm are frequent. Pain ratings, analgesic requirements, adverse events, satisfaction, function and diaphragmatic excursion were compared following interscalene block (ISB) with reduced initial bolus volumes.
METHODS:
Subjects undergoing arthroscopic rotator cuff repair were randomized to receive 5, 10, or 20 mL ropivacaine 0.75% for ISB in a double-blind fashion (N = 36). Continuous infusion with ropivacaine 0.2% was maintained for 48 h. Pain and diaphragmatic excursion were assessed before block and in the recovery unit.
RESULTS:
Pain ratings in the recovery room were generally less than 4 (0-10 NRS) for all treatment groups, but a statistically significant difference was noted between the 5 and 20 mL groups (NRS: 2.67 vs. 0.62 respectively; p = 0.04). Pain ratings and supplemental analgesic use were similar among the groups at 24 h, 48 h and 12 weeks. There were no differences in the quality of block for surgical anesthesia. Dyspnea was significantly greater in the 20 mL group (p = 0.041). Subjects with dyspnea had significant diaphragmatic impairment more frequently (Relative risk: 2.5; 95%CI: 1.3-4.8; p = 0.042). Increased contralateral diaphragmatic motion was measured in 29 of the 36 subjects. Physical shoulder function at 12 weeks improved over baseline in all groups (baseline mean SST: 6.3, SEM: 0.6; 95%CI: 5.1-7.5; 12 week mean SST: 8.2, SEM: 0.46; 95%CI: 7.3-9.2; p = 0.0035).
CONCLUSIONS:
ISB provided reliable surgical analgesia with 5 mL, 10 mL or 20 mL ropivacaine (0.75%). The 20 mL volume was associated with increased complaints of dyspnea. The 5 mL volume was associated with statistically higher pain scores in the immediate postoperative period. Lower volumes resulted in a reduced incidence of dyspnea compared to 20 mL, however diaphragmatic impairment was not eliminated. Compensatory increases in contralateral diaphragmatic movement may explain tolerance for ipsilateral paresis.
TRIAL REGISTRATION:
clinicaltrials.gov. identifier: NCT00672100.

 

[Idiopathic]

Anaesthesia. 2012 Oct;67(10):1166-9. doi: 10.1111/j.1365-2044.2012.07222.x.
Catastrophic complication of an interscalene catheter for continuous peripheral nerve block analgesia.
Yanovski B, Gaitini L, Volodarski D, Ben-David B.
Source
Department of Anaesthesiology, Bnai Zion Medical Center, Haifa, Israel. [email protected]
Abstract
We report a catastrophic postoperative complication of a prolonged interscalene block performed under general anaesthesia. The course of the anaesthetic was uneventful and the patient remained stable during his stay in the recovery area with the operative extremity paralysed and insensate. No further local anaesthetic was administered until later that day when the patient received 10 ml bupivacaine 0.25% through the catheter. Upon completion of the top-up dose, no change in the patient's status was noticed. The patient was next assessed 6.5 h later when he was found dead in his bed. A postmortem CT scan revealed the catheter to be sited intrathecally, presumably the result of dural sleeve penetration.
Anaesthesia © 2012 The Association of Anaesthetists of Great Britain and Ireland.
Comment in

a good reason not to do blocks asleep, although i guess the theory has to be that it migrated after the case. and a postmortem CT? why not a postmortem autopsy?

 

[dhb]

Given that it is a Monday, that is exactly what I am thinking except that I will probably add some sufent for the initial block and maybe the second as well.

- pod

I don't believe the sufenta would be of any benefit when added to a long lasting LA

 

[periopdoc]

Performance of this block under GA is unlikely a significant contributor to the result given the following sequence of events.

• Lateral approach with needle (needle was pointed right at the spinal cord during the procedure)
• bolus needle with 40 mL local before threading catheter
• threaded catheter to 7 cm beyond needle tip
• use of a non-wire-reinforced catheter
• the first bolus through the catheter was given on the orthopedic ward by a resident who left "after a brief time"
• patient was not continuously monitored for a reasonable length of time after the bolus.

We all know that the thecal sack can be pierced without the patient feeling it (sure they sometimes get a twinge, but not always) and when they do get the twinge, it is almost always very brief.

Same patient with reasonable sedation would have had the same result. Given the 40 mL bolus prior to threading the catheter, even a non-sedated patient likely would have had the same result.

The critical mistake here is that the patient was not monitored long enough after the bolus. My preference is one hour. Had the bolus been performed in the OR area with good observation and monitoring you would have had significant patient morbidity without the mortality.

I am not saying that upper extremity blocks are safe under GA, just that the GA almost certainly did not contribute to the complication with this particular procedure.

- pod

 

[periopdoc]

Anaesthesia. 1997 Sep;52(9):858-62.

The addition of opioids to local anaesthetics in brachial plexus block: the comparative effects of morphine, buprenorphine and sufentanil.
Bazin JE, Massoni C, Bruelle P, Fenies V, Groslier D, Schoeffler P.
Département d'Anaesthésie et de Réanimation, Hôpital Universitaire G. Montpied, Clermont-Ferrand, France.

Abstract
We compared the duration of analgesia produced by a mixture of lignocaine and bupivacaine, either alone or combined with morphine (75 micrograms.kg-1), buprenorphine (3 micrograms.kg-1) or sufentanil (0.2 microgram.kg-1) in 80 patients after brachial plexus block for orthopaedic surgery of the upper limb. The characteristics of analgesia were evaluated hourly using a visual analogue scale. The analgesia was considered satisfactory for scores of 30 or less. The median duration (range) of satisfactory analgesia was: 11.5 (8-15) h without an opioid, 21 (9-27) h with morphine, 20 (14-34) h with buprenorphine and 24.5 (11-38) h with sufentanil. We conclude that the addition of an opioid to a local anaesthetic mixture lengthens the duration of analgesia.

- pod

 

[BLADEMDA]

I don't believe the sufenta would be of any benefit when added to a long lasting LA

DHB,

I agree with your statement; my experience has shown adding opioids doesn't prolong my blocks. Only decadron has consistently been shown to prolong nerve blocks when used an adjunct.

There is no harm in adding Sufenta and if if makes POD feel better about his cocktail and block then he can add it.

The guys at Pittsburgh use a cocktail,as well and they are claiming over 30 hours of post op analgesia from a single shot block.

 

[Oggg]

It sounds like that catheter wasn't tested with local after insertion. That would have helped solve the problem. Hydro dilation of the perineural space (thru the Tuohy) could have been done with 30cc, then 10cc thru the catheter along with an air test. Then if you get a spinal, you'll find out immediately. I think migration into the intrathecal space is unlikely; it's confirmation of catheter tip placement that is key.

 

[dhb]

http://www.ncbi.nlm.nih.gov/pubmed/9349066

- pod

30+h with bupivacaine and buprenorphine or sufentanil??? 😱 never seen those numbers before!