Hand bolusing peripheral nerve catheters

[Oggg]

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Is anyone placing peripheral nerve catheters for postop pain and hand bolusing the catheters? There is so much bureaucratic and nursing and paperwork crap at my hospital to let me run continuous infusions, both for inpatient and outpatient. The other day I did a pop sci catheter and bolused with bupiv 0.5%. The patient was 23h obs The next morning I rebolused with 0.25% bupiv and the pt went home. I was considering doing CFNB for TKAs this way. Maybe hand bolus 20cc 0.2%ropiv at 6pm everyday, so pts can sleep easier and still do PT.

In the end we'll get continuous infusions but if I can get hand bolusing to work, the success stories will help push the infusions through.

 

[Oggg]

I was also considering placing catheters in ambulatory surgery patients and having them come back to the hospital for a rebolus, but that would probably a hassle for the pt and it would be expensive I suppose.

 

[periopdoc]

I have seriously thought about it. My concern is the hassle of getting the patient into an area where I feel safe for the rebolus. I do feel that it should be done in an area where the patient can be continually monitored and the necessary equipment for resuscitation is immediately at hand. Perhaps I am to cautious though. Can't say that I have ever heard of a problem from a migrating catheter which is, of course, my concern.

-pod

 

[pgg]

I have seriously thought about it. My concern is the hassle of getting the patient into an area where I feel safe for the rebolus. I do feel that it should be done in an area where the patient can be continually monitored and the necessary equipment for resuscitation is immediately at hand. Perhaps I am to cautious though. Can't say that I have ever heard of a problem from a migrating catheter which is, of course, my concern.

-pod

I think it'd be OK, at least for lower extremity catheters ... even without monitors. The 20 cc of 0.2% ropiv mentioned in the OP is only 40 mg of ropivacaine, far less than the max safe dose in an adult (which are set based on the worst-case assumption of inadvertent IV administration). Even if it all goes directly intravascular the patient is going to be OK. I don't see any appreciable risk there.

However I have seen an interscalene catheter migrate and 24+ hours later produce clinically significant effects on the RLN (patient had pre-existing contralateral RLN palsy), so I might be less cowboyish about bolusing those in an unmonitored setting. Even without migration, a large volume bolus might get the phrenic or RLN while a slow infusion hadn't.

 

[proman]

I think it'd be OK, at least for lower extremity catheters ... even without monitors. The 20 cc of 0.2% ropiv mentioned in the OP is only 40 mg of ropivacaine, far less than the max safe dose in an adult (which are set based on the worst-case assumption of inadvertent IV administration). Even if it all goes directly intravascular the patient is going to be OK. I don't see any appreciable risk there.

Do you know what it is for bupi? I've searched all over without finding how many cc I can accidentally inject IV without harm.

 

[Oggg]

I don't know if there is a safe dose to inject IV. Toxic dose is 2.5-3mg/kg but I can't imagine you could inject all that IV before going code blue

 

[pgg]

Do you know what it is for bupi? I've searched all over without finding how many cc I can accidentally inject IV without harm.

Why do I get the feeling you're asking a deliberately loaded question? 🙂

2.5 - 3 mg/kg for both ropiv and bupiv are the classic max safe doses. 20 mL of 0.2% ropiv is 40 mg, or roughly .5 mg/kg in your average 80kg adult. The OP's example of 20 mL of 0.25% bupiv is 50 mg, or about .6 mg/kg. I know you know these numbers ...

Can you get lung cancer from the radiation of a CXR? Sure, there's no guaranteed safe dose of radiation. Is there a guaranteed safe dose of IV bupivacaine? I don't know.

But I would inject 50 mg of bupivacaine into a normal-sized-adult's catheter without fear of a LA toxicity event. Do you disagree?

 

[epidural man]

Is anyone placing peripheral nerve catheters for postop pain and hand bolusing the catheters? There is so much bureaucratic and nursing and paperwork crap at my hospital to let me run continuous infusions, both for inpatient and outpatient. The other day I did a pop sci catheter and bolused with bupiv 0.5%. The patient was 23h obs The next morning I rebolused with 0.25% bupiv and the pt went home. I was considering doing CFNB for TKAs this way. Maybe hand bolus 20cc 0.2%ropiv at 6pm everyday, so pts can sleep easier and still do PT.

In the end we'll get continuous infusions but if I can get hand bolusing to work, the success stories will help push the infusions through.

For some very strange reason, bolusing a catheter never lasts as long as a single shot bolus. It is the strangest thing...and it makes no sense.

but it's true.

 

[dhb]

For some very strange reason, bolusing a catheter never lasts as long as a single shot bolus. It is the strangest thing...and it makes no sense.

but it's true.

I would think that it depends on the proximity of your catheter to the nerve which is generally not as well placed as the needle under US

 

[epidural man]

I would think that it depends on the proximity of your catheter to the nerve which is generally not as well placed as the needle under US

Yeah, you would think this,

but I can often find the catheter tip with ultrasound....

 

[dhb]

Yeah, you would think this,

but I can often find the catheter tip with ultrasound....

Me too but don't forget that with the needle you are often intraneural while with the cathether you aren't.

 

[proman]

Why do I get the feeling you're asking a deliberately loaded question? 🙂

2.5 - 3 mg/kg for both ropiv and bupiv are the classic max safe doses. 20 mL of 0.2% ropiv is 40 mg, or roughly .5 mg/kg in your average 80kg adult. The OP's example of 20 mL of 0.25% bupiv is 50 mg, or about .6 mg/kg. I know you know these numbers ...

Can you get lung cancer from the radiation of a CXR? Sure, there's no guaranteed safe dose of radiation. Is there a guaranteed safe dose of IV bupivacaine? I don't know.

But I would inject 50 mg of bupivacaine into a normal-sized-adult's catheter without fear of a LA toxicity event. Do you disagree?

No not a loaded question. I always wondered how many cc of bupi I could mistakenly give IV. I can find what plasma levels are toxic but not how much it takes to get there.

 

[imfrankie]

Me too but don't forget that with the needle you are often intraneural while with the cathether you aren't.

I go with that theory.

 

[periopdoc]

For some very strange reason, bolusing a catheter never lasts as long as a single shot bolus. It is the strangest thing...and it makes no sense.

but it's true.

Multi-orifice catheter?

Me too but don't forget that with the needle you are often intraneural while with the cathether you aren't.

👍

- pod

 

[dhb]

No not a loaded question. I always wondered how many cc of bupi I could mistakenly give IV. I can find what plasma levels are toxic but not how much it takes to get there.

3.5 - 4L of plasma so the math is easy if you consider direct iv injection