Nerve block catheter survey

[fakin' the funk]

At my shop we do a steady volume of podiatry and ortho foot/ankle cases like fresh trauma, ORIFs, ankle reconstructions, redos, etc, that are worthy of nerve blocks for postop analgesia. Most pts get popliteal catheters but there is significant variation within our group with what to do if there is medial work (SS or continuous adductor, or nothing). This leads to a fair number of inpatients with 2 continuous catheters, some of which go on for 4-6 days. I'm curious how usual or unusual this is, so I wanna get a sense of the following:

1. What's your absolute max for # of days to leave a continuous nerve block catheter in?
2. If you "refill" the continuous LA infusion pump, why and for what type of patients/cases?
3. Would you routinely do popliteal AND adductor catheters in patients with postop pain in both distributions?
4. If so, what is the max combined rate you'd run the two catheters at?
5. If a patient had bilateral foot/ankle work, would you consider 3 catheters? 4 catheters?

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[dhb]

I rarely do catheters anymore.
I don't see many scenarios that would warrant a double cath...

 

[Hoya11]

At my shop we do a steady volume of podiatry and ortho foot/ankle cases like fresh trauma, ORIFs, ankle reconstructions, redos, etc, that are worthy of nerve blocks for postop analgesia. Most pts get popliteal catheters but there is significant variation within our group with what to do if there is medial work (SS or continuous adductor, or nothing). This leads to a fair number of inpatients with 2 continuous catheters, some of which go on for 4-6 days. I'm curious how usual or unusual this is, so I wanna get a sense of the following:

1. What's your absolute max for # of days to leave a continuous nerve block catheter in?
2. If you "refill" the continuous LA infusion pump, why and for what type of patients/cases?
3. Would you routinely do popliteal AND adductor catheters in patients with postop pain in both distributions?
4. If so, what is the max combined rate you'd run the two catheters at?
5. If a patient had bilateral foot/ankle work, would you consider 3 catheters? 4 catheters?

I would keep it simple and do single shot blocks for both and no catheters... lots of places do this kind of work but id doubt many do indwelling catheters for foot stuff .. we dont

 

[facted]

We rarely do catheters. All catheters come out inside of 48 hours. There is good data that infection rate rises precipitously after that time point.

Infectious Risk of Continuous Peripheral Nerve Blocks | Anesthesiology | ASA Publications

 

[Psai]

We don't really do catheters. We have one at most and pull it pod1. Usually only bolus it if the patient is having significant pain or if they're going back to the OR.

 

[Planktonmd]

Catheters are exciting when you are just starting in this business but eventually you start realizing the futility and unnecessary work involved in placing and maintaining these catheters, and that the difference in results (including patient satisfaction) between single shot simple blocks and labor intensive catheters is basically negligible.

 

[pgg]

I have a hard enough time convincing surgeons to leave thoracic epidurals in more than 24 hours.

I don't do a lot of other regional these days, but it's been 4 or 5 years since I've put in a peripheral catheter.

 

[fakin' the funk]

For those who don't do catheters, can you elaborate why? Here are some reasons that come to mind:
- don't "believe" in catheters -- i.e., no evidence of efficacy/need, belief in excessive infectious risk
- lack of support (or $$$) for inpatient/outpatient followup
- surgeon aversion
- institutional culture ("we have never done them")

 

[fakin' the funk]

We rarely do catheters. All catheters come out inside of 48 hours. There is good data that infection rate rises precipitously after that time point.

Infectious Risk of Continuous Peripheral Nerve Blocks | Anesthesiology | ASA Publications

Unfortunately the data in that paper aren't good, they don't address infection rate (they address inflammation), and they don't support the idea that there is some sort of spike after 48h.

This paper better addresses that question, and is shiny and new!
Prolonged Catheter Use and Infection in Regional Anesthesia:A Retrospective Registry Analysis | Anesthesiology | ASA Publications

 

[facted]

Unfortunately the data in that paper aren't good, they don't address infection rate (they address inflammation), and they don't support the idea that there is some sort of spike after 48h.

This paper better addresses that question, and is shiny and new!
Prolonged Catheter Use and Infection in Regional Anesthesia:A Retrospective Registry Analysis | Anesthesiology | ASA Publications

Interesting. Reading the German study though, do you wear a gown, use sterile sheets, and shave the block site when you do your catheters? Yea, me neither.

Gonna stick to 2 days. Not sure I want local around a peripheral nerve longer than that anyway.

Also, there are studies that show infection rate greater than 48 hrs. Here's one:

Capdevila X, Pirat P, Bringuier S, Gaertner E, Singelyn F, Bernard N, Choquet O, Bouaziz H, Bonnet F: French Study Group on Continuous Peripheral Nerve Blocks. Continuous peripheral nerve blocks in hospital wards after orthopedic surgery: a multicenter prospective analysis of the quality of postoperative analgesia and complications in 1,416 patients. Anesthesiology 2005; 103:1035–45Capdevila, X Pirat, P Bringuier, S Gaertner, E Singelyn, F Bernard, N Choquet, O Bouaziz, H Bonnet, F

 

[deleted126335]

We have one busy foot surgeon who does a lot of ankle reconstructions. He likes two catheters. All as outpstients. He said that when we were doing single shots there were lots of calls for pain meds and several ER Visits for pain control.

 

[Psai]

We have one busy foot surgeon who does a lot of ankle reconstructions. He likes two catheters. All as outpstients. He said that when we were doing single shots there were lots of calls for pain meds and several ER Visits for pain control.

Thats because you didnt have blade wielding his exparel

 

[pgg]

We have one busy foot surgeon who does a lot of ankle reconstructions. He likes two catheters. All as outpstients. He said that when we were doing single shots there were lots of calls for pain meds and several ER Visits for pain control.

Someone should do a study. Randomize patients with messed up ankles to BKA vs ankle reconstruction. I bet p<.001 in favor of the BKAs.

 

[Modanq]

For the proper reimbursement anesthesiologists would love to manage in hospital post operative pain. Until CMS figures out that - 1) its complicated and requires more than a protocol ordering norcos 2) Anesthesiologists do pain management for a living 3) there is an opioid epidemic 4) set appropriate reimbursement for post op pain control and pain procedures and we will gladly take the time to manage recalcitrant pain.
Im sure some of us will say - you can't pay me enough to deal with that...

 

[Planktonmd]

For those who don't do catheters, can you elaborate why? Here are some reasons that come to mind:
- don't "believe" in catheters -- i.e., no evidence of efficacy/need, belief in excessive infectious risk
- lack of support (or $$$) for inpatient/outpatient followup
- surgeon aversion
- institutional culture ("we have never done them")

The benefit is not worth the headache.

 

[Orin]

The military guys will leave catheters in for weeks I thought? I trained at a place that would rotate PNC insertion sites q5d.

End of life pain cases there are good data for tunneled neuraxial catheters being safe for over 30 days without significant risk of deep infections.

I agree though, that unless you're a bleeding heart, the benefit is not worth the stress for most physicians or hospital systems.

 

[dhb]

For those who don't do catheters, can you elaborate why?

Because a good block with dexa will easily last 24h and pain after that is manageable for most surgeries.
Most people don't like to have a limb numb for more than 24h.
I also feel that the dexa smooth out the wake up phase of the block.

 

[Psai]

The military guys will leave catheters in for weeks I thought? I trained at a place that would rotate PNC insertion sites q5d.

End of life pain cases there are good data for tunneled neuraxial catheters being safe for over 30 days without significant risk of deep infections.

I agree though, that unless you're a bleeding heart, the benefit is not worth the stress for most physicians or hospital systems.

The **** you need a catheter for weeks for? Closing by secondary intention?

 

[nimbus]

Does anybody repeat blocks POD1 instead of placing a catheter? I’ve never done it but it seems like a simpler solution to get an extra day for inpatients.

 

[pgg]

The **** you need a catheter for weeks for? Closing by secondary intention?

Yes actually. Actually, I don't know about weeks ... but a lot of combat casualties have very dirty traumatic amputations that need daily repeated washouts for a while. We'd put in catheters a couple hours after injury, and they'd run through the flights back to the US and for a while afterward. I know some of those guys kept catheters in for a week+.

 

[psychbender]

Yes actually. Actually, I don't know about weeks ... but a lot of combat casualties have very dirty traumatic amputations that need daily repeated washouts for a while. We'd put in catheters a couple hours after injury, and they'd run through the flights back to the US and for a while afterward. I know some of those guys kept catheters in for a week+.

Over a week was rather normal at the Flagship. After 10 days, we usually got a little antsy, but I had a few out to (past?) two weeks while I was a resident. Polytrauma multi-amputees with two or three catheters, all getting infusions and bolused for their thrice-weekly washouts for weeks. No LAST. Good times.

We also did other crazy stuff, like place and pull catheters while therapeutically anticoagulated, because everyone got diagnosed with subsegmental PEs within days of injury and started on lovenox.

 

[DrZzZz]

Does anybody repeat blocks POD1 instead of placing a catheter? I’ve never done it but it seems like a simpler solution to get an extra day for inpatients.

We do it for total shoulders in the patients "too sick" to be done in the surg center. They often stay overnight, get blocked in the morning, and head home right after. The patients at the surg center all have the option to come back the next day for a reblock, though few do.

 

[BLADEMDA]

I've repeated blocks a second and even a third time on several patients in my career. Typically, a Popliteal block will last about 30 hours with 0.5% Bup, decadron and precedex. Sure, it is easy to place a catheter but not everyone is good at blocks and some institutions have limited personnel at night.

Although I know this comment will spur controversy I'd likely use 2 bottles of FULL DOSE Exparel (266 mg per block) for the Popliteal and Adductor/Saphenous in this patient with the expectation of 48 hours or more of analgesia. If needed, re-block again in 2-3 days using Bup with Decadron.

Fascia Iliaca block with liposomal bupivicaine for hip fractures prior to surgery | 41st Annual Regional Anesthesiology and Acute Pain Medicine Meeting, 2016

 

[fakin' the funk]

Does anybody repeat blocks POD1 instead of placing a catheter? I’ve never done it but it seems like a simpler solution to get an extra day for inpatients.

That's not simpler.

 

[nimbus]

That's not simpler.

It would be simpler for me since we don’t have a catheter program up and running. Maybe not for you.

 

[BLADEMDA]

It would be simpler for me since we don’t have a catheter program up and running. Maybe not for you.

I agree that both methods are "simple" and re-doing a block in PACU isn't a big deal. That said, using an epidural needle and catheter along with running your local solution (typically dilute local like in OB) isn't that hard either and most departments can "survive" 1 catheter running on the floor or ICU.

 

[fakin' the funk]

It would be simpler for me since we don’t have a catheter program up and running. Maybe not for you.

What constitutes a program, and why is one necessary?

 

[nimbus]

What constitutes a program, and why is one necessary?

A program constitutes nurses who are accustomed to catheters. It’s necessary so I don’t get endless phone calls.