interscalene catheters tips

[CD125]

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Been having issues with catheters becoming dislodged after surgery despite good u/s confirmation of catheter location and good catheter tape job ( ie catheters at same cm mark at skin as documented). Any other tips for successful placement that lasts? Are you guys leaving your catheters posterior or anterior to the plexus? Do you guys try to coil the catheter in the muscle or subq tissues? I do them solo - my technique is epidural kit -> touhy with 20 cc syringe of LA -> find spot, inject LA (usually go anterior to plexus between C5/6 if I can safely pass Touhy, if not I drop it posterior) -> drop probe -> thread catheter 1-2 cm past touhy - i try to not overthread and try to coil when touhy is in muscle/subq tissue -> refind view with probe and confirm good location with some LA through the catheter -> secure with dermabond over insertion site, steristrips and tegaderm

 

[Ronin786]

Place them with the patient in the lateral position. Easier to tape and place.

 

[ethilo]

In residency we put a drop of dermabond at the cath insertion site, there were little tinctures of dermabond in all kits, plus we made a mini steristrip tower over that dermabond. We tegedermed it around the back of the neck and made a "landing pad" on the contralateral chest for the hookup port. I can't recall ever having a catheter dislodge unless pulled out by surgeons drapes. We also had ample time for it to dry and to dress it well so not sure how practical that would be for you.

 

[AdmiralChz]

What’s your catheter confirmation that you do, ultrasound or stim? My direct point - are you sure the catheter stayed in the right place on placement/tunneling?

I agree with others that once we properly tunneled it away from the site and used mastisol on the insertion site I can’t remember one being dislodged easily. I don’t see myself ever really doing a catheter again with my current practice setup (we only do a handful total each year so the regional folks place them) though so thankfully I don’t have to deal with this.

 

[sevoflurane]

I like the catheter over needle Braun kits. Just fast, easy and reliable. Dermabond is my preferred glue of choice.

 

[Ferrismonk]

You didn't say, but one thing I've found that also helps is making sure you go in-plane to the ultrasound transducer and tunnel a few cm under the skin. Angle of approach is flatter, it tapes down easier than out-of-plane, and the angle of pull is less likely to move the catheter (and more forgiving).

 

[dhb]

If you don't put them in they won't dislodge.

 

[facted]

We used to put catheters in a lot. I now do bupi/dex blocks and for some surgeons bupi/exparel. Tons of outpatient total shoulders. Not really sure why anyone needs a catheter anymore. Bupi/dex lasts 20-26 hrs, and bupi/exparel pain control approaches 48 hrs per our surgeon data.

 

[dhb]

We used to put catheters in a lot. I now do bupi/dex blocks and for some surgeons bupi/exparel. Tons of outpatient total shoulders. Not really sure why anyone needs a catheter anymore. Bupi/dex lasts 20-26 hrs, and bupi/exparel pain control approaches 48 hrs per our surgeon data.

I thought exparel was the devil?

 

[facted]

I thought exparel was the devil?

We work at an Ortho ASC where they want us to use it for their TSR and some RCRs. It's now approved for interscalene and so we use it to make them happy.

 

[dhb]

We work at an Ortho ASC where they want us to use it for their TSR and some RCRs. It's now approved for interscalene and so we use it to make them happy.

Ok but i remember you stating that exparel was not superior to bupi/dex but now you are getting 2x durations...

 

[facted]

Ok but i remember you stating that exparel was not superior to bupi/dex but now you are getting 2x durations...

There's still no published data that I'm aware of that shows a difference between bupi/dex and exparel. One of the surgeons we work with consults with Pacira and collects pain data for all his patients. He's showed me his data suggesting improved pain scores at 48 hrs vs our regular blocks (which include plain bupi for some and bupi/dex for others).

He says his exparel pts routinely get 40+ hrs of comfort. I don't call the pts myself so not sure, but he seems to think it works well, but he also takes some money from Pacira so.. Not sure.

 

[dhb]

I'll get 40h+ blocks if i can get some of that Pacira money

 

[BLADEMDA]

I'll get 40h+ blocks if i can get some of that Pacira money

The blocks do last 40 hours and I don't get a dime. I agree these Exparel blocks are NOT as good as catheters but they are simple and effective. Simply mix 10-12 mls of 0.5% Bup with 10 mls of Exparel then do the block. For Infraclavicular blocks or Suprclavicular blocks where you may want 25 mls of volume I typically go with 0.375% (15 mls) Bup added to the 10 mls of Exparel.

I haven't had one block with 10 mls of Exparel last beyond 50 hours so far. This means that you either need a full 20 ml bottle of Exparel or place a catheter with a pain pump utilizing dilute local.

 

[BLADEMDA]

I am using Braun Catheters but recently got some Pajunk catheter over needle kits. Do any of you prefer the Pajunk system over the typical Braun non stimulating catheter?

 

[woopedazz]

I am using Braun Catheters but recently got some Pajunk catheter over needle kits. Do any of you prefer the Pajunk system over the typical Braun non stimulating catheter?


View attachment 283955

We use that Pajunk catheter over needle kit for pretty much everything. Our regional guys showed us (trainees) and the other attendings how to use them and in the past 12 months we've almost universally adopted the Pajunk catheter over needle system - with only a few older docs using whatever we had previous.

I haven't had any issues with dislodgement or migration on pain rounds and putting them in is pretty straightforward and forgiving without requiring a 3rd hand. I haven't used many other catheter options; but the attendings seem to think they're better than whatever we had previous.

Very rarely get any leak (largest bore is the catheter which goes in with the needle and remains in situ with the inner catheter being exchanged for the needle). Also never had dislodgment with just a single Tegaderm, even if left in for a week (ESP). We never suture ours in, but the profile looks pretty easy for suturing.

Like a Christmas tree on USS too.

 

[dhb]

I agree these Exparel blocks are NOT as good as catheters

I call BS on anybody that will say that their upper extremity catheters stay in for 2+ days reliably without dislodging in >95% of patients.

 

[Arch Guillotti]

I call BS on anybody that will say that their upper extremity catheters stay in for 2+ days reliably without dislodging in >95% of patients.

Why? Just tunnel the catheter and it stays very secure.

 

[dhb]

Why? Just tunnel the catheter and it stays very secure.

I've had the tip of a catheter migrate away from it's initial position without it moving at the site of puncture just from shear forces between the infraclav artery and pectoral muscle.