femoral catheter disconnect

[deleted126335]

Routine TKA. Preop femoral block 30ml Ropivicaine, thread catheter behind plan to hook up pump in PACU per your routine, bupivicaine spinal. Moving patient from OR table to bed, adapter to catheter disconnects.

What do you do?

1. Pull catheter. Sorry you just get a single shot block.
2. Pull catheter and redo block if needed many hours later after spinal and single shot ropiv have worn off?
3. Pull catheter redo block in PACU in presence of spinal plus existing block in place?
4. Sterile gloves and scissors alcohol/chlorhexidine catheter and cut a few inches off and attach new sterile adapter?
5 Something else?

Any strong opinions on the options that you didn't select? Particularly #4.

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[urge]

4 would be my choice. Used to happen a lot with the old Braun epidural connectors. Never heard of an infection.

 

[periopdoc]

#3. If you do #4 and there is an infection, you re ****ed. I am not worried about femoral nerve damage from a TKA or a U/S guided catheter placement so no worries. The risk of infection is an order of magnitude greater than the risk of nerve damage in my hands so that is why I feel this way.

-pod

 

[pie944]

#3. If you do #4 and there is an infection, you re ****ed. I am not worried about femoral nerve damage from a TKA or a U/S guided catheter placement so no worries. The risk of infection is an order of magnitude greater than the risk of nerve damage in my hands so that is why I feel this way.

-pod

So if the same thing happened with a labor epidural would you pull that?

 

[BobBarker]

I thought this would be about an occult exsanguination from a femoral line getting disconnected intraop.

 

[i want out]

Pull it.

If you use it and there is any infection skip defense and write blank check.

 

[BLADEMDA]

Routine TKA. Preop femoral block 30ml Ropivicaine, thread catheter behind plan to hook up pump in PACU per your routine, bupivicaine spinal. Moving patient from OR table to bed, adapter to catheter disconnects.

What do you do?

1. Pull catheter. Sorry you just get a single shot block.
2. Pull catheter and redo block if needed many hours later after spinal and single shot ropiv have worn off?
3. Pull catheter redo block in PACU in presence of spinal plus existing block in place?
4. Sterile gloves and scissors alcohol/chlorhexidine catheter and cut a few inches off and attach new sterile adapter?
5 Something else?

Any strong opinions on the options that you didn't select? Particularly #4.

My SDN answer is number 3. No problem placing that catheter again under U/S and the whole procedure is pain free for the patient. (I'd insist on U/S under an existing SAB).

My real world answer is to borrow sterile scissors and cut the tip off and attach a new sterile adapter. I've done this before and will do it again. That said, I would pull the catheter out the next morning just to make certain there won't be any "issues." You could bolus the catheter with 0.25% Bup and decadron (15 mls) around noon so the patient gets another night of good analgesia right before discontinuing it.

The risk of infection from this catheter is minimal if it is discontinued the next day.

 

[psychbender]

Option 4 is what is typically done at my shop. Whether the connector got pulled shortly after catheter placement while moving onto the OR table, or several days later on a contact-precautions wounded soldier, the catheter gets cleaned, clipped, and connector reattached. To the best of my knowledge, we have never seen a catheter-related infection after this, and we leave those things in for a LONG time. Then again, we do have a different med-legal environment in milmed.

 

[Oggg]

#4. Leave a comment on the pain service to pay particular attention to the insertion site

 

[Oggg]

#4. If it gets infected you can still make a case that replacing a catheter has a small but real risk for nerve injury, especially on a patient with a spinal and/or a numbed nerve masks parenthesis. They're both small but real risks.

 

[periopdoc]

Risk of infection >> risk of nerve damage. Of course I come from a place where we did all lower extremity blocks under GA so it doesn't bother me in the slightest.

Yes I have the same policy for labor epidurals.

-pod

 

[Oggg]

Risk of serious infection is insanely rare. Usually a little local redness if it happens. Maybe one or two case reports of abscess I think.

 

[deleted126335]

Risk of serious infection is insanely rare. Usually a little local redness if it happens. Maybe one or two case reports of abscess I think.

Worried about taking the hit for an infected prosthesis is the concern.

 

[BLADEMDA]

Worried about taking the hit for an infected prosthesis is the concern.

You are a conservative type guy with this issue. So, either replace the catheter in pacu for peace of mind or cut off the contaminated tip and use the catheter for 24-28 hours. In my practice I do the latter and the risk of infection is almost nil.

 

[pgg]

Routine TKA. Preop femoral block 30ml Ropivicaine, thread catheter behind plan to hook up pump in PACU per your routine, bupivicaine spinal. Moving patient from OR table to bed, adapter to catheter disconnects.

What do you do?

1. Pull catheter. Sorry you just get a single shot block.
2. Pull catheter and redo block if needed many hours later after spinal and single shot ropiv have worn off?
3. Pull catheter redo block in PACU in presence of spinal plus existing block in place?
4. Sterile gloves and scissors alcohol/chlorhexidine catheter and cut a few inches off and attach new sterile adapter?
5 Something else?

Any strong opinions on the options that you didn't select? Particularly #4.

#4 has been the standard practice everywhere I've been, both for peripheral blocks and epidurals. Can't say I've done it personally since residency. Maybe I'll do it again someday.

Objectively, I think the only real risk here is the chance of an infection occurring, totally unrelated to the actual catheter tip disconnect/sterile-snip/replace ... but then getting blamed for that infection because of the catheter tip disconnect. In a more malpractice-unfriendly environment, I'd probably go with #1 unless the patient really really needed a catheter, in which case I'd go for #3. Purely for defensive, shamefully lawyer-averse reasons, and I'd feel dirty doing it because it's medically ******ed.

 

[dhb]

I've done #4 before.
The question that comes to mind is in case an infection occurs: who is going to know that there was a disconnection?

 

[deleted126335]

I did #4. But. I thought about it for awhile before doing it

 

[periopdoc]

PGG and Doze hit the nail on the head regarding my concerns. Unrelated infection of the prosthesis being pegged on the catheter disconnect.

Like ClimbinginAK said in the CPNB thread "I think "ahhh infections are rare" then after I worry for 3 days straight."

I sleep better by replacing it. Ridiculous? Probably.

- pod

 

[urge]

PGG and Doze hit the nail on the head regarding my concerns. Unrelated infection of the prosthesis being pegged on the catheter disconnect.

Like ClimbinginAK said in the CPNB thread "I think "ahhh infections are rare" then after I worry for 3 days straight."

I sleep better by replacing it. Ridiculous? Probably.

- pod

Yet, an iv tubing gets disconnected and nobody thinks twice about.connecting it back.

 

[deleted126335]

Yet, an iv tubing gets disconnected and nobody thinks twice about.connecting it back.

Excellent point.

 

[sevoflurane]

Doze, I think the answer to you question depends on your tolerance for playing defensive medicine.

Did the catheter hit the floor or did it disconnect and hit the bed sheets or skin?
How long was it disconnected for? Overnight or 5 seconds? If 5 seconds on the bed sheets, I don't think you can really say it's the catheter if they get an infection so long as you cut off the proximal catheter and use some alcohol.

Personnally, I'd probably just remove it. I'd then check on them a little later and offer a second single shot block for overnight analgesia if they wanted it. On the floor single shot block should be a 5 minute procedure. In and out and happy patient.

 

[sevoflurane]

Routine TKA. Preop femoral block 30ml Ropivicaine, thread catheter behind plan to hook up pump in PACU per your routine, bupivicaine spinal. Moving patient from OR table to bed, adapter to catheter disconnects.

In this situation, I'd do what you did. If it's a catheter disconnect on the floor, I'd pull it.

 

[pgg]

On the floor single shot block should be a 5 minute procedure. In and out and happy patient.

Do you take anything with you when you do blocks on the floor (intralipid, resusc supplies, etc)? Or do you just rely on the local crash cart if the patient seizes or has some other complication?

Departmental policies at the handful of places I've worked the last couple years require non-ICU patients to be brought to the PACU for blocks. (I also wouldn't trust floor nurses to monitor a newly blocked patient if I left right after the procedure.)

 

[sevoflurane]

Do you take anything with you when you do blocks on the floor (intralipid, resusc supplies, etc)? Or do you just rely on the local crash cart if the patient seizes or has some other complication?

Departmental policies at the handful of places I've worked the last couple years require non-ICU patients to be brought to the PACU for blocks. (I also wouldn't trust floor nurses to monitor a newly blocked patient if I left right after the procedure.)

Nope (maybe bring some purple stuff). We did them like these all the time in residency. Get called to the trauma ICU on a routine basis to place epidurals/paravertebrals, single shots, catheters, etc. If we needed intralipid, it can get there pretty fast.

Same for the floor. Just need to speak to your nurse and give them specific instructions. Monitor BP q 5 minutes for 15 minuets, pulse ox, and to visually and verbally be with them for those first 15 minutes.

 

[BLADEMDA]

Nope (maybe bring some purple stuff). We did them like these all the time in residency. Get called to the trauma ICU on a routine basis to place epidurals/paravertebrals, single shots, catheters, etc. If we needed intralipid, it can get there pretty fast.

Same for the floor. Just need to speak to your nurse and give them specific instructions. Monitor BP q 5 minutes for 15 minuets, pulse ox, and to visually and verbally be with them for those first 15 minutes.

ICU or Step-Down is one thing but the Floor is an entirely different animal. If I did a nerve block on the regular floor I might as well do the block in my garage. On second thought, my garage would be safer.

 

[sevoflurane]

ICU or Step-Down is one thing but the Floor is an entirely different animal. If I did a nerve block on the regular floor I might as well do the block in my garage. On second thought, my garage would be safer.

I understand your concern.

For a USD guided fem nerve block, I have no issues.