Femoral Catheter

[turnupthevapor]

Did my first fem catheter for a knee the other day. Wasn't thrilled. Patient had lot of pain in the back of the knee.

i dialated the space and didnt stimulate the catheter. This makes sense to me but was wondering how many of you stimulate catheters

Are you guys throwing in a 1 shot sciatic block? I also don't see the point of using a 400 dollar on cue ball when i could just hook up an epidural pump.

please advise

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[Planktonmd]

Did my first fem catheter for a knee the other day. Wasn't thrilled. Patient had lot of pain in the back of the knee.

i dialated the space and didnt stimulate the catheter. This makes sense to me but was wondering how many of you stimulate catheters

Are you guys throwing in a 1 shot sciatic block? I also don't see the point of using a 400 dollar on cue ball when i could just hook up an epidural pump.

please advise

The role of the continous femoral nerve block is to decrease the need for narcotics and for best results it has to be used as a part of a multimodal approach ( Narcotics, Cox2 inhibitors...).
Some patients will have almost no pain at all with the block alone but most patients will have some degree of pain and in a small percentage you will need a sciatic block to get any meaningful pain relief.
I found that when you do the procedure under spinal anesthesia and use a femoral block for post op pain you rarely need a sciatic block.
I don't use stimulating catheters and I don't think they are necessary.

 

[thegasman]

The role of the continous femoral nerve block is to decrease the need for narcotics and for best results it has to be used as a part of a multimodal approach ( Narcotics, Cox2 inhibitors...).
Some patients will have almost no pain at all with the block alone but most patients will have some degree of pain and in a small percentage you will need a sciatic block to get any meaningful pain relief.
I found that when you do the procedure under spinal anesthesia and use a femoral block for post op pain you rarely need a sciatic block.
I don't use stimulating catheters and I don't think they are necessary.

agree - stimulating catheters are more trouble than they are worth. If you use pns get the twitch you want, inject the local then thread the cath while maintaining needle position. Alternatively (my preference) is US guided placement. Single shot sciatic block (or continuous technique) will improve the back of knee pain that some patients have. It seems unpredictable to me - some patients are very comfortable with only femoral block - others seem to really need sciatic distribution to be comfortable.

 

[Gator05]

First, completely agree with the multimodal approach. Neurontin/lyrica, tylenol, cox inhibition, low-dose ketamine, avoiding high-dose/potent narcotics (like remi) intraop, all will help post-operatively.

Was the catheter placed blindly or with US?

We use exclusively stimulating catheters. Amazing how the catheters have a mind of their own once you thread them; quite easy for them to exit the perineural compartment. We've had almost no failures with the stimulating catheters. Also find them a little easier to place compared with US-guided catheters if you don't have a third hand (or nimble fingers) available.

How much did you dilate the space? We've found that dilating the space with excessive amounts of non-local (D5 if stimulating, for example) can dilute the local's effect appreciably.

As for the posterior pain, it's (nearly) all in the sciatic distribution. FNB gets ~80% of the innervation, but the remaining 20% still causes considerable pain. Some of our orthopods will inject the capsule, which helps with posterior pain for about 12-18h. They'll use a slurry of local, steroids and narcotics. For others, a single-shot sciatic does the trick. We prefer a posterior approach, but for positioning purposes an anterior approach will work as well. It's just a lot of tissue to put a very long needle through in the wrong kind of patient.

We do frequently save some local for a lateral femoral cutaneous block; jury's out on how much it helps. Easy enough block to perform.

As for the epidural...our PT's like to start PT very, very early. Indeed, this is one of the benefits of the block! Bilateral weakness hampers this. We'll even hold out on the sciatic block in some circumstances simply due to concerns for difficulty with early PT, or adjust the sciatic's local anesthetic. Aggressive DVT prophylaxis is another reason we avoid epidurals.

With the above combination, we have excellent results with post-op pain. Our orthopods are our biggest fans and keep our block room plenty busy. Patients coming in for revisions specifically request blocks.

 

[mille125]

If you add an intraarticular injection to your femoral catheter, it still wont be perfect but the patient will be happier. I have found that you need to block the sciatic if you want "perfect" conditions. Use something like mepivicaine so that their leg is not blocked for 18 hours after the procedure.

 

[Noyac]

Place the FN cath. I inject my local once I've got the twitch to 0.4 or less then I thread the cath. Next move to the anterior sciatic approach and give 0.5% ropiv 30cc. This will last till the next morning or at least that evening. The only time I use mepivicaine is when I want the block to work right away and I am using it as the sole anesthetic.

Now comes the tricky part. Are you doing the case with just these blocks, I don't. Are you putting the pt to sleep, not me. I take them to the OR and place a spinal with 13mg bupiv and 200-300mg duramorph.

Now actually I don't even place a FN cath any longer. I just do the FNB and Sciatic with spinal duramorph. But the FN cath is a nice touch.

BTW spinal duramorph works better than intra-articular.

 

[turnupthevapor]

5 oxycodone, 100 celebrex preop?

what does do you give them and what time (on call to OR?)

appreciate all your input so far


I agree with the astramorph, even read one study where only 50 mcg was given with pretty good results.

 

[pmichaelmd]

I don't use the stim caths unless I'm doing something very specific and am counting on getting a specific distribution (ie interscalene, axillary, or infraclav cath). Otherwise, I use non-stim caths and they work well.

For the knee, I use the Contiplex kit, inject 30-ml 0.5% rop, then drop the fem cath and thread it several mm past the tip of the Tuohy (about 10cm at skin). I then do a sciatic cath the same way, but inject 20-ml 0.5% rop prior to threading. I thread this past the tip 5-10 cm (about 15cm at skin). I attach both caths to a 3-way stopcock and infuse 0.2% rop at 8-ml/hr with an 8-ml bolus q1h into the femoral cath. I leave the sciatic cath for bolusing prn posterior knee pain >6/10. When I was a resident, and we had a resident in-house, we'd bolus that sci cath with 6-ml 0.2% rop at 2200 hrs or so, just to get the pt. through the night. I have found that it is easier to get the pt. up and mobilized the next day if I limit the amount of rop I shoot through the sciatic cath. Either way, the caths come out on POD #3, just before the pt. heads to the rehab facility.

This works well with the multimodal approaches noted above. Celebrex and Lyrica are great adjuncts and help.

Regards,
PMMD

 

[ncdoc1974]

I always place my catheters under stimulation, then dose...I can't remember the last time one failed...If you are going to go through the trouble of placing a fem cath, go ahead and do a single shot sciatic...about 50% of patients will have sciatic nerve pain after a TKA & if you don't cover the sciatic the surgeon will think you suck 50% of the time when the see the patient in pain postop...Also I usually, do the case under a spinal with sedation...10mg oxycontin & a celebrex preop in the holding room when the patient arrives...Lately, I have not been using IT morphine in addition to all this other stuff...It might help a little, but I don't like hearing the patients complain about the side effects.

 

[Oggg]

Anyone do fem blk then SAB w/Duramorph then LMA? I figure the duramorph should help cover the sciatic distribution. And this would be an easy way to teach my partners U/S fem blks

 

[Mman]

Anyone do fem blk then SAB w/Duramorph then LMA? I figure the duramorph should help cover the sciatic distribution. And this would be an easy way to teach my partners U/S fem blks

That strikes me as a little time consuming to do 3 separate procedures. If you are placing subarchnoid duramorph, why not just throw some local in with it and have a spinal with no need for GA on top of it? You are already puncturing the dura.

 

[BLADEMDA]

Did my first fem catheter for a knee the other day. Wasn't thrilled. Patient had lot of pain in the back of the knee.

i dialated the space and didnt stimulate the catheter. This makes sense to me but was wondering how many of you stimulate catheters

Are you guys throwing in a 1 shot sciatic block? I also don't see the point of using a 400 dollar on cue ball when i could just hook up an epidural pump.

please advise

The 'pain" was the due to the sciatic nerve. 10-15% of TKR need a good Sciatic block plus Femoral or Femoral with Catheter. A Femoral block alone will not suffice in this subgroup.

 

[Idiopathic]

The 'pain" was the due to the sciatic nerve. 10-15% of TKR need a good Sciatic block plus Femoral or Femoral with Catheter. A Femoral block alone will not suffice in this subgroup.

yeah this is classic. the technique and block were fine, likely, since knees hurt A LOT if they dont get a block, IMO. posterior knee pain is sciatic. we have actually adjusted our protocol so that we place our fem catheter and then do an anterior sciatic with dilute ropivacaine...i think i scoffed when someone mentioned that a year or so ago, but the machines of progress are always moving forward...

 

[sevoflurane]

yeah this is classic. the technique and block were fine, likely, since knees hurt A LOT if they dont get a block, IMO. posterior knee pain is sciatic. we have actually adjusted our protocol so that we place our fem catheter and then do an anterior sciatic with dilute ropivacaine...i think i scoffed when someone mentioned that a year or so ago, but the machines of progress are always moving forward...

Anterior Sciatics... one of my favorite. Very useful in PP. Simultaneous prep for fem and ant. sciatic. No need for sims position any more. 2 blocks done SUPA quick.

 

[Tuohy]

My formula for TKR patients (n of 400 patients by now):
Spinal with isobaric (plain) 12.5 mg of bupivicaine; then lay them supine; femoral catheter and single shot anterior sciatic-

Awesome combo!

 

[Idiopathic]

i hope you do the block before the spinal.

i usually get away with 10mg isobaric lidocaine for TKA. I add 25mcg clonidine/25mcg fentanyl and +/- 100 mcg morphine. they get femoral catheter and ant sciatic blocks preop.

 

[sevoflurane]

My formula for TKR patients (n of 400 patients by now):
Spinal with isobaric (plain) 12.5 mg of bupivicaine; then lay them supine; femoral catheter and single shot anterior sciatic-

Awesome combo!

I've been needing to say this to you.....

I LOVE your avatar.


BIG IRON MAIDEN fan... even the first 2 albums with Di'Anno.

Favorite albums: Number of the beast, Powerslave, Seveth son of the Seventh son, Live after Death and Somewhere in Time.

So funny how these guys were protraid early on....

Some of them have history degerees and a lot of their music deals with history... not the devil....

One of my favorite:

Alexander the Great. "ask thyself for another kingdom for this kingdom is too small for thee....." (alexanders father, Phillip II)



Congrats on your regional fellowship. I'm sure you da man!

End of hijack...

 

[sevoflurane]

Before you correct me... here is the actual quote:

“My son, ask for thyself another kingdom, for that which I leave is too small for thee.” (King Philip of Macedonia, 339 BC)

End of hijack... for real this time.

 

[imfrankie]

That strikes me as a little time consuming to do 3 separate procedures. If you are placing subarchnoid duramorph, why not just throw some local in with it and have a spinal with no need for GA on top of it? You are already puncturing the dura.

I bet you know the answer begins with a $

 

[imfrankie]

My formula for TKR patients (n of 400 patients by now):
Spinal with isobaric (plain) 12.5 mg of bupivicaine; then lay them supine; femoral catheter and single shot anterior sciatic-

Awesome combo!

Ultrasound or Electricity?

 

[epidural man]

I take them to the OR and place a spinal with 13mg bupiv and 200-300mg duramorph.

Love this idea. Can't get our floor nurses to buy off on the idea of the extra checking the first few hours, etc. We are still working on it. I think it would work great for hip resurfacing, scopes, etc. We have had some crazy shtuff happen with our lumbar plexus blocks.

I will often do epidural and FI cath. Epidural removed post op day 1, fem cath turned on.

Stimulating fem caths can be your friend if using it for a hip. Thread the catheter cephalad maintaining a twitch. It helps you get north a bit for better hip coverage.

By the way, just did a few 2-cholorprocaine spinals today. I love that ****.

 

[Multifidus]

I bet you know the answer begins with a $

I have some partners that do pure Duramorph spinals for post-op pain and GA for the primary anesthetic in their hips and knees. Actually, a few surgeons are requesting this combination. I still can't convince myself it is doing right by the patient, so I have not adopted it yet.

 

[AFibber]

Non-medical person here with a basic question about analgesia when a catheter is inserted into the femoral vein.

I understand the common protocol is to inject lidocaine in the groin area just prior to the insertion of the catheter.

But if a patient is under GA - and presumably already has fentanyl flowing through their body from an IV - then I'm curious why the lidocaine shot is necessary.

To a lay person like myself, it seems like a case of wearing both a belt and a pair of suspenders. Thanks in advance for any clarification.

 

[B-Bone]

Not sure where to start with this one...


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[lane]

Non-medical person here with a basic question about analgesia when a catheter is inserted into the femoral vein.

I understand the common protocol is to inject lidocaine in the groin area just prior to the insertion of the catheter.

But if a patient is under GA - and presumably already has fentanyl flowing through their body from an IV - then I'm curious why the lidocaine shot is necessary.

To a lay person like myself, it seems like a case of wearing both a belt and a pair of suspenders. Thanks in advance for any clarification.

This is a forum for physicians - if you have any questions you may consult your physician or curbside Dr. Google.

Femoral nerve blocks do not involve catheters being inserted into the vein... at least not intentionally.

 

[AFibber]

I have tried to pose this question to a local anethesiologist, but most are too busy to respond to generic questions. Rather than be a pest, I thought I would try here.

 

[Noyac]

A fibber, your line of reasoning is on track but the details are off.
This site unfortunately for you is not a site for medical advice so you won't be getting any here.
Any reasonable anesthesiologist or crna shou,d be able to explain this to you in a couple minutes face to face. I would try that.

 

[AFibber]

Not seeking medical advice. Just reading a lot about catheter ablations and the use of both lidocaine and fentanyl struck me as odd. The question is purely one of curiosity.

As I mentioned, I have tried connecting with a local anesthesiologist - twice. I don't wish to try a 3rd time. Message received: there is no interest in responding. Perhaps when I am visiting a larger city, I will try to find a "reasonable anesthesiologist" there.

 

[WholeLottaGame7]

Not seeking medical advice. Just reading a lot about catheter ablations and the use of both lidocaine and fentanyl struck me as odd. The question is purely one of curiosity.

As I mentioned, I have tried connecting with a local anesthesiologist - twice. I don't wish to try a 3rd time. Message received: there is no interest in responding. Perhaps when I am visiting a larger city, I will try to find a "reasonable anesthesiologist" there.

Edited because I should have read the poster's previous thread before commenting; didn't realize it was a specific situation.

Suffice it to say, local anesthetic is a reasonable choice there.

This is the 2nd thread you've started regarding this; you are either a very curious person or are upset by something. If it's the former: unfortunately, this is not a Q&A forum for laypeople to satisfy their curiosity. If it's the latter and there are some other motivations, then this is definitely not the forum for you.

I can tell you that you have had very reasonable if not textbook experiences so far.

 

[AFibber]

Hi, WholeLottaGame7. You are correct. I have made 2 inquiries over the course of 7 months.

Late last year, I inquired about the drug midazolam during induction. The inquiry from yesterday related to lidocaine and fentanyl.

My experience with cardiac ablation last year piqued an interest in anesthesia and in my spare time I have done some introductory reading on the subject. To my surprise, never having been a science student, I found the subject to be quite interesting. So yes, I am curious.

However, you've indicated that lay person inquiries are not appropriate for this forum. Given that, and not wishing to be an uninvited guest, I will refrain from making any further inquiries. Message received.

 

[vector2]

Hi, WholeLottaGame7. You are correct. I have made 2 inquiries over the course of 7 months.

Late last year, I inquired about the drug midazolam during induction. The inquiry from yesterday related to lidocaine and fentanyl.

My experience with cardiac ablation last year piqued an interest in anesthesia and in my spare time I have done some introductory reading on the subject. To my surprise, never having been a science student, I found the subject to be quite interesting. So yes, I am curious.

However, you've indicated that lay person inquiries are not appropriate for this forum. Given that, and not wishing to be an uninvited guest, I will refrain from making any further inquiries. Message received.

You can read some literature directed to patients about midazolam here: https://www.drugs.com/cons/midazolam.html

and some information about nerve blocks here: http://umrehabortho.org/programs/surgery/anesthesia/patient-information

 

[Planktonmd]

Non-medical person here with a basic question about analgesia when a catheter is inserted into the femoral vein.

I understand the common protocol is to inject lidocaine in the groin area just prior to the insertion of the catheter.

But if a patient is under GA - and presumably already has fentanyl flowing through their body from an IV - then I'm curious why the lidocaine shot is necessary.

To a lay person like myself, it seems like a case of wearing both a belt and a pair of suspenders. Thanks in advance for any clarification.

When the patient is under GA the injection of a local anesthetic at the surgical site is not uncommon, it decreases the need for additional opiates or deeper anesthesia, which is always a good thing.

 

[Noyac]

When the patient is under GA the injection of a local anesthetic at the surgical site is not uncommon, it decreases the need for additional opiates or deeper anesthesia, which is always a good thing.

And it hurts less when they wake up.