Any of the attendings out there doing interscalene catheters? We have a couple of new young orthopods who now want more than just a single shot.... I usually do a posterior approach with the help of ultrasound guidance, along with the stimuplex cath. Run Ropiv 0.2% after initial bolus. So what are you guys doing out there? Equipment wise, what are you using?
interscalene catheters
- Thread starter IN2B8R
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Here we do supraclav catheters under ultra sound. We actually leave the catheters in at discharge and have the patients on homegoing AMBIT pumps for approx 5-7 days. We routinely do these for total shoulders and elbows. Scopes usually single shot.
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How os the catheter managed at home?
Do they really need 7 days? it seems like a lot.
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I'm not an attending yet, but we do the same as you -posterior approach, ultrasound, Ropiv 0.2%- using an ON-Q Continuous Nerve Block System to send them home the same day with a disposable pump and leave it in for 2-3 days.
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So we have nurses who call the patients everyday the catheter is in and guide them through the maintenance process. The Ambit pumps are sent back to the manufacturer for reuse. It would be a real pain in PP to have to maintain these catheters at home. I think in PP I would probably be a fan of single shot techniques.
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How do you bill for a catheter when the patient is at home? Or do you?
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I am a resident, so I do not pretend to know what the billing is on the home going pumps and catheters will ask some attendings in the AM.
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With the pumps we use, they get billed $500 and something for the On Q ball full of Ropivicaine that we hook up to the catheter. I don't know how much of that pays for the ball and how much is profit though. It's definately more convenient to do a single shot, but the patients love the infusions.
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When you guys say posterior do you mean like an post IJ or through the trapezius?
Needle entry should be at the level of C6 and just antero-lateral to the trapezius muscle and postero-medial to the levator scapulae muscle in the apex of the "V" formed by these two muscles. Aim needle medially and approximately 30 degrees caudad toward the suprasternal notch and advance until the TP of C6 is encountered. Walk off the TP and you will get a distinct change of resistance to air and a twitch in the arm when the cervical paravertebral space is entered.
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FWIW - When I was at Virginia Mason, we did all of these with a posterior ultrasound guided approach utilizing the Arrow 17g Tuohy epidural needle and flexible wire reinforced catheter as well as the Stryker disposable pain pumps. Patients went home with the catheter and a resident called them every day to check up on them. When the pump ran dry or the patient was tired if having a numb arm, we instructed them to pull the catheter, verify the black tip, and discard the whole thing.
The approach that I take is quite posterior in order to tunnel the catheter somewhat. I insert into the skin overlying the trapezius, but I skirt around the trapezius and insert my needle through the middle scalene muscle so that my catheter can be anchored by the muscle.
The method...
Pull the stylet out of the needle and place the catheter into the needle until the tip of the catheter is flush at the tip of the needle. Attach a syringe of local to the catheter. With one hand, watch with ultrasound while you inject local with a 25 g needle and insert your Touhy. As you approach your target, you can inject a little local through the catheter in real time so that you can appreciate if the spread is appropriate. Occasionally, you will have to occlude the external end of the Tuohy with your thumb in order to get enough pressure to see the anesthetic spread. In this case, have an assistant do the injection while you occlude the needle.
Once you are satisfied with the spread of LA, thread the catheter. I try to bunch up the catheter in the fascial and subcutaneous spaces to help anchor it and give it some slack should it be pulled on. If you have any question about whether the tip of the catheter is in the right place, just inject a little local in real time and watch the spread. You will be able to see exactly where your local is going and if there is a problem with the block it will not be due to misplacement of the catheter. Pull out your needle while bunching up the catheter. Place a dressing and go to the OR.
Here is a video of a block I did at VM using this equipment/ method. It is a low interscalene that I did for something distal to the shoulder. Since I wasn't worried about getting the suprascapular nerve, I went a little lower so this is somewhat of a hybrid low interscalene/ high supraclavicular approach. One of the nice things about the wire reinforced catheter is that it is really visible under ultrasound. You can visualize it in this video as I thread it around the brachial plexus.
[YOUTUBE]xOCAYYEQq2c[/YOUTUBE]
One of the tricks is making sure that if you are going anterior to the nerve, the bevel is facing posterior so that the catheter threads correctly. If you are posterior to the nerve, face the bevel anterior.
I personally have the patient sit bolt upright when I do this as I feel it gives me the best mechanics.
- pod
The approach that I take is quite posterior in order to tunnel the catheter somewhat. I insert into the skin overlying the trapezius, but I skirt around the trapezius and insert my needle through the middle scalene muscle so that my catheter can be anchored by the muscle.
The method...
Pull the stylet out of the needle and place the catheter into the needle until the tip of the catheter is flush at the tip of the needle. Attach a syringe of local to the catheter. With one hand, watch with ultrasound while you inject local with a 25 g needle and insert your Touhy. As you approach your target, you can inject a little local through the catheter in real time so that you can appreciate if the spread is appropriate. Occasionally, you will have to occlude the external end of the Tuohy with your thumb in order to get enough pressure to see the anesthetic spread. In this case, have an assistant do the injection while you occlude the needle.
Once you are satisfied with the spread of LA, thread the catheter. I try to bunch up the catheter in the fascial and subcutaneous spaces to help anchor it and give it some slack should it be pulled on. If you have any question about whether the tip of the catheter is in the right place, just inject a little local in real time and watch the spread. You will be able to see exactly where your local is going and if there is a problem with the block it will not be due to misplacement of the catheter. Pull out your needle while bunching up the catheter. Place a dressing and go to the OR.
Here is a video of a block I did at VM using this equipment/ method. It is a low interscalene that I did for something distal to the shoulder. Since I wasn't worried about getting the suprascapular nerve, I went a little lower so this is somewhat of a hybrid low interscalene/ high supraclavicular approach. One of the nice things about the wire reinforced catheter is that it is really visible under ultrasound. You can visualize it in this video as I thread it around the brachial plexus.
[YOUTUBE]xOCAYYEQq2c[/YOUTUBE]
One of the tricks is making sure that if you are going anterior to the nerve, the bevel is facing posterior so that the catheter threads correctly. If you are posterior to the nerve, face the bevel anterior.
I personally have the patient sit bolt upright when I do this as I feel it gives me the best mechanics.
- pod
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I like to lay them lateral if they can. I find this gives me the entire posterior neck to drape and keep sterile and not have to fight with the head of the be or the pillow. Give it a shot. We do all of our shoulders scope or open and I find after alll different ways this is the best. I do it with ultrasound and i do not tunnel. I use indermil on the puncture site, i feel it seals the site and you don't get leakage. blaz
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I like to put a roll under the side to be blocked. Lateral is great when they lie still but a lot of people seem to want to roll on their backs rather than staying lateral; which changes my view mid-procedure and makes things more difficult. Most of the time, lateral works fine, but the people who won't stay on their sides are such a pain that I'd just as soon do them all supine with a roll to make room for needle work.
I am an ultrasound man when it comes to blocks, so I do all my interscalene catheters with the ultrasound. I generally prefer doing an inplane approach with the needle for interscalenes, which ends up being a posterior approach, but with catheters I have found it to be easier to use an out of plane approach that mimics a landmark based technique.
My reasoning is that when you approach inplane with the ultrasound you are attempting to thread a catheter at a 90 degree angle to stay with the nerve roots/towards the brachial plexus. If you go out of plane, the path of the catheter is more parallel to the needle and I find it is generally easier to thread.
just my 2 cents. So long as you put it in the right spot, doesn't really matter how it got there.
My reasoning is that when you approach inplane with the ultrasound you are attempting to thread a catheter at a 90 degree angle to stay with the nerve roots/towards the brachial plexus. If you go out of plane, the path of the catheter is more parallel to the needle and I find it is generally easier to thread.
just my 2 cents. So long as you put it in the right spot, doesn't really matter how it got there.
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actually NP the ambits are disposible. they aren't sent back, the pts throw them away. they are not meant for prolonged use... they run about $200, but i bet we got a better deal d/t volume. We bill the pts for the pumps. i don't know if we bill for the follow up phone encounters or whether it is just built into the cost of the whole procedure. again, probably not a realistic business plan for a smaller operation w/o a resident work force but it seems to work here.
pts usually don't use them for the whole 7 days. we send them home with 2 x 300cc bags of 0.2% ropi. they almost never run out or want more. eventually the whole bother of the pump etc becomes too much as they are feeling better and getting around more.
we also send the popliteal cathethers home w a pump as they as surgeons tend not to want these pts to ambulate as quickly as knees.
pts usually don't use them for the whole 7 days. we send them home with 2 x 300cc bags of 0.2% ropi. they almost never run out or want more. eventually the whole bother of the pump etc becomes too much as they are feeling better and getting around more.
we also send the popliteal cathethers home w a pump as they as surgeons tend not to want these pts to ambulate as quickly as knees.
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How many of you folks in private practice send outpatients home with catheters? I am in private practice and our group has started placing catheters for orthopedic procedures. This has mainly been for inpatients up until now but we are starting to do so for outpatients also. We don't have residents or a pain service or a nurse to follow-up these blocks for us. The attending placing the catheter makes the daily call to the patient (or parent for a minor) and leaves their cell number for the patient in case of any problems. Do you guys also base your decision on how far away the patient lives or how compliant you think they are? Not a great incentive system to place them (when comparing time and money) but we do it because it is good for the patient and we want to stay competitive with the other groups in town.
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We do IB catheters as well.
Being fully capable of doing US guided blocks(posterior or regular approach), but, not to sound like an old guy, I also place the IB caths with nerve stim, always have.
When rounding on pts the next day or two (and the Acute Pain Service personnel back me on this), there is little clinically significant difference between the pain control of a USG'd block threaded a cm or two and a nerve stim one threaded 3-4 cm. Really can't seem to see much difference, except there are fewer catheters falling out if they are threaded a bit deeper.
So if you are an old guy, not comfy with US, but still want to do catheters, the old ways will work.
Being fully capable of doing US guided blocks(posterior or regular approach), but, not to sound like an old guy, I also place the IB caths with nerve stim, always have.
When rounding on pts the next day or two (and the Acute Pain Service personnel back me on this), there is little clinically significant difference between the pain control of a USG'd block threaded a cm or two and a nerve stim one threaded 3-4 cm. Really can't seem to see much difference, except there are fewer catheters falling out if they are threaded a bit deeper.
So if you are an old guy, not comfy with US, but still want to do catheters, the old ways will work.
