Regional Fellowship

[deleted162650]

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If you can do a single shot, you can put a catheter there. Takes more time, but isn’t any more difficult.

 

[Mman]

Really? Is the difference enough to justify the trouble? Are the knees ambulatory? A total knee with a single shot technique will have a comfortable first 24h needing on average 10mg of morphine, the next 24h are not as great but on average they're at 30-40mg of morphine over the first 3-4 days so i'm not placing a catheter to save them from taking 3-4 10mg oxy.

takes about an additional 3 minutes for me to place a catheter instead of a single shot and it provides them with superior analgesia on days 2-4 and has essentially cut our readmission rate to zero. And TKA patients (at least around here) were needing way, way, way more than 3-4 pills over a few days.

 

[dhb]

way, way, way more

How much is way way? 🙂
It may be useful if you go from 200mg to 20, but my range is 10 to 60mg and often the ones that use more than 30 do so because of pain from another source (back). We don't have a lot of patients on narcs preop which probably helps.
Also a fem cath with PT are going to shift in a significant amount of cases.

 

[Simba1711]

Why are you putting a femoral catheter for patients getting physical therapy they’re going to have a motor block.

 

[Mman]

How much is way way? 🙂
It may be useful if you go from 200mg to 20, but my range is 10 to 60mg and often the ones that use more than 30 do so because of pain from another source (back). We don't have a lot of patients on narcs preop which probably helps.
Also a fem cath with PT are going to shift in a significant amount of cases.

I'd ballpark previous average around 10-20 5 mg percocets over the first week and we had readmission rate >5%. AC caths are where it's at.

But seriously what is the point of a regional fellowship that doesn't do catheters? That's like a cardiac fellowship that doesn't do echo.

 

[dhb]

But seriously what is the point of a regional fellowship that doesn't do catheters? That's like a cardiac fellowship that doesn't do echo

I don't disagree, i just don't think there is much use for nerve catheters in 2020

 

[BLADEMDA]

Why are you putting a femoral catheter for patients getting physical therapy they’re going to have a motor block.

FYI, If a patient receives a Femoral Block utilizing Exparel (10 ml) 133mg with 10 ml of 0.25% Bup the motor block is minimal after 12-16 hours and the analgesia lasts 48 hours. I have been very impressed with this combo for pain relief while still allowing ambulation.

I have no issues with an Adductor Canal Catheter for the first 48 hours either but the analgesia from the low dose Femoral block with Ipack is superior.
Yes, I'm aware of a half dozen studies or more showing equivalence of analgesia with Adductor Canal Blocks but that depends on the skill of LIA by the Orthopedic surgeon. An adductor canal block or catheter without LIA simply isn't enough for most patients IMHO.

YMMV and I respect the data you all see in your own practices. But, once you have seen/performed 500+ of these cases I doubt the literature has the final say in how you practice.

 

[Simba1711]

That’s good to know. I don’t use exparel for my upper extremity or lower extremity blocks as I don’t feel there is enough data on the long term effects to make me feel comfortable using them even though it’s fda approved. I only use exparel for Truncal blocks.

 

[Mman]

I don't disagree, i just don't think there is much use for nerve catheters in 2020

helps our hospital turn a profit on even CMS joint patients so they are quite appreciative

 

[Southpaw]

helps our hospital turn a profit on even CMS joint patients so they are quite appreciative

If our joints get readmitted for paint control it’s always a knee and always when the prescription for oxycodone runs out. It’s never in PODs 2-4.

I have no opinion on a regional fellowship. It’s like an OB fellowship honestly. Little to no real utility (provided your residency program held up its end of the deal), but there are some unicorn private practice jobs who recruit the fellowships Bc the group/hospital like to brag about it. And academic shops recruit it to lead the division. So I don’t fault anyone for doing it.

 

[nimbus]

If our joints get readmitted for paint control it’s always a knee and always when the prescription for oxycodone runs out. It’s never in PODs 2-4.

I have no opinion on a regional fellowship. It’s like an OB fellowship honestly. Little to no real utility (provided your residency program held up its end of the deal), but there are some unicorn private practice jobs who recruit the fellowships Bc the group/hospital like to brag about it. And academic shops recruit it to lead the division. So I don’t fault anyone for doing it.

I imagine it is now mandatory if you want to be regional faculty in academics. That said, many current regional faculty did not do a fellowship since the fellowships are relatively new. They had an interest and are self taught.

 

[dhb]

I'd ballpark previous average around 10-20 5 mg percocets over the first week

That's 50-100mg over a week which isn't that bad.

 

[Mman]

That's 50-100mg over a week which isn't that bad.

for a median age of about 70, it's definitely not good

 

[dhb]

for a median age of about 70, it's definitely not good

10mg of morphine/day? Not too bad for getting your leg cut off.
Why not a repeat ACB for the 5% that need readmission?

 

[Mman]

10mg of morphine/day? Not too bad for getting your leg cut off.
Why not a repeat ACB for the 5% that need readmission?

It's a big deal in terms of side effects for geriatric patients.

Also who the hell has time to go down to the ER to place a block at some random off hour that you probably won't even get paid for? Bigger waste of time than slipping a catheter into 100% of patients (which also pays better).