Tips for fast continuous nerve catheters?

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Oggg

Oggg

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I am using a Braun epidural kit with 18g non stim Tuohy, 20g closed tip non stim catheter. I add an ultrasound probe drape, benzoin steristrip +/- dermabond then tegaderm, plastic tape. I bolus most of the local thru the Tuohy, the. Pass the catheter under US. Then I remove the Tuohy and feed some excess catheter into the muscular and subcut tissues. Then I try an air test injection, then inject the remainder of the local. If i can't Confirm, then I pull out and redo it. I always go in plane.

Shortest time from in room to PPF has been 18min, but the longest time has been much higher. My sports ortho guy will do a shoulder scope in 15-30 min. I can't have my catheter placements take longer than the surgery.
 
for femorals i put the needle in the right spot and inject full local block through the 18g thy all in plane, then i drop the us probe, hold on tightly to the needle, and blindly feed the catheter to around 15-20cm mark (deep), remove the needle, pull catheter back to ~5-7cm past where you injected, then i use the ultrasound to confirm that a bolus of air or a little extra local is in reasonable position, then i teggy and tape the catheter neatly and start the infusion
 
NotAMD said:
for femorals i put the needle in the right spot and inject full local block through the 18g thy all in plane, then i drop the us probe, hold on tightly to the needle, and blindly feed the catheter to around 15-20cm mark (deep), remove the needle, pull catheter back to ~5-7cm past where you injected, then i use the ultrasound to confirm that a bolus of air or a little extra local is in reasonable position, then i teggy and tape the catheter neatly and start the infusion
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Femoral catheters are easy. Your technique is sound because all it takes for a successful catheter is the fact that the catheter is underneath the nerve in close proximity. The local will track back along the path of the catheter.

The only difference between a perfectly placed femoral catheter and a poorly placed one (still located under the fascia iliaca) a cm from the nerve is the amount of local needed via infusion. A perfectly placed catheter should require a lower infusion rate than Quickly placed catheter.

Try it sometime. Place the catheter quickly underneath the nerve. Your catheter will still work just fine. The key is to surround the nerve well with local prior to catheter placement so you can see the tip of the touhy needle under the most medial portion of the femoral nerve. This technique allows a block and catheter to be placed in less than 10 min (usually 8 min if everything is setup to go)
 
Oggg said:
I am using a Braun epidural kit with 18g non stim Tuohy, 20g closed tip non stim catheter. I add an ultrasound probe drape, benzoin steristrip +/- dermabond then tegaderm, plastic tape. I bolus most of the local thru the Tuohy, the. Pass the catheter under US. Then I remove the Tuohy and feed some excess catheter into the muscular and subcut tissues. Then I try an air test injection, then inject the remainder of the local. If i can't Confirm, then I pull out and redo it. I always go in plane.

Shortest time from in room to PPF has been 18min, but the longest time has been much higher. My sports ortho guy will do a shoulder scope in 15-30 min. I can't have my catheter placements take longer than the surgery.
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Scopes don't need catheters. Only open rotator cuffs (large incision) and total shoulders.
This is what I would want for myself or a family member.

Remember, we used to placed these catheters quickly under NS only. Almost all of them worked well. I think most of your catheters are fine and don't need to be redone. I don't bother with your air test for any of mine and my success is high. The key is to place the Cather near the nerve plexus (I like C6) after it has been surrounded with local. Stop worrying so much and try it.
 
Any given shoulder arthroscopy may be booked by my orthopod as a subacromial decompression, but once the scope is in, they may discover a rotator cuff tear, which often hurts 10/10 after a single shot wears off. I plan to put catheters in whenever the surgeon thinks there is at least some potential for rotator cuff repair. His rotator cuff repairs take about 45-90min depending on how bad it is. But if he books a "possible RCR", and it turns out the patient needs a 15-30min non painful cuff debridement, I will look really bad if I do a 30min catheter.
 
My tip for fast peripheral nerve cath's is to not use US.

And no way I'd be putting a catheter in a shoulder scope. Completely unnecessary. Only open shoulders and major repairs thru the scope.
 
Wondering which portion you feel is taking you the longest? 15 minutes isnt bad, but you can get down to 10. Is it placing the needle in the proper place that is taking longer, or the securing it etc after?

I use same BBraun as you. Open kit, add probe cover, dermabond and tegaderm. Squirt local in to sterile tray. Draw up lido, open cath baggie. Draw up local in 10cc of local into 20 cc syringe. The probe cover i use is a sheathes 6 in X 48 in. I stick my hand through it inside out, grab the probe and pull the cover down. Put probe in supraclav position follow up to IS. local, then place needle wherever anatomy lets me (usually above c6). Inject 5cc local under US make sure good spread and then put probe down. Thread cath in needle out. Connect. Put probe back on and inject other 5cc through cath under US to assure proximity to C5 (important due to suprascap coming off). Wipe gel off then dermabond insertion site and a little on the skin to make it sticky. Coil it out of surgeons way and tegaderm. I place patient in lateral position so my insertion site is posterior. This gives room for my needle syringe combo and also takes the long thoracic more out of play.

I'd just try to see which portion is taking you the longest. If its needle placement, then thats just repetition. You need to go slow until you are ultra comfortable. If its securing it, or preparing, then try to eliminate or speed up steps. Fast in the straight aways, slow in the curves. Good nursing help can speed you up by placing US for you, gel etc. Thats institution dependent.
 
I think I lose a lot of time with confirming catheter position. I confirm it when I first advance the catheter thru the Tuohy. Then I look for it after Tuohy removal. Then air. Then local again. It seems like the first check might be superfluous -- I could just advance blindly 1cm past the needle tip, then pull the Tuohy out.
 
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Oggg said:
I think I lose a lot of time with confirming catheter position. I confirm it when I first advance the catheter thru the Tuohy. Then I look for it after Tuohy removal. Then air. Then local again. It seems like the first check might be superfluous -- I could just advance blindly 1cm past the needle tip, then pull the Tuohy out.
Click to expand...

While the evidence for a Stimulating Catheter over a non stimulating catheter is scant you seem extremey concerned about the catheter position. Hence, have you tried stimulating catheters?

Watch the video:
http://vimeo.com/1856634
 
Oggg said:
I think I lose a lot of time with confirming catheter position. I confirm it when I first advance the catheter thru the Tuohy. Then I look for it after Tuohy removal. Then air. Then local again. It seems like the first check might be superfluous -- I could just advance blindly 1cm past the needle tip, then pull the Tuohy out.
Click to expand...


http://www.youtube.com/watch?v=LgHlYrUbC7w

7 minutes in the sitting position from start to finish (if you delete the extra skin injections).
 
Oggg said:
Any given shoulder arthroscopy may be booked by my orthopod as a subacromial decompression, but once the scope is in, they may discover a rotator cuff tear, which often hurts 10/10 after a single shot wears off. I plan to put catheters in whenever the surgeon thinks there is at least some potential for rotator cuff repair. His rotator cuff repairs take about 45-90min depending on how bad it is. But if he books a "possible RCR", and it turns out the patient needs a 15-30min non painful cuff debridement, I will look really bad if I do a 30min catheter.
Click to expand...

Why not just do the catheter in PACU then and only if they have a full tear and will need it. You end up not wasting the time on the majority of cases when you won't have needed to do it.
 
Not a fan of pacu blocks (pain can be an inhibitor to a cooperative patient). I believe in the concept of preemptive analgesia and I don't like seeing any of my patients in pain in recovery. Kind of a pride thing I guess.

That being said, I rarely do fem catheters. My goal is to keep them comfortable overnight = adding 4mg of PF decadron to my single shots = no catheter rounding and a good 20-24 hrs of good analgesia.
 
sevoflurane said:
Not a fan of pacu blocks (pain can be an inhibitor to a cooperative patient). I believe in the concept of preemptive analgesia and I don't like seeing any of my patients in pain in recovery. Kind of a pride thing I guess.

That being said, I rarely do fem catheters. My goal is to keep them comfortable overnight = adding 4mg of PF decadron to my single shots = no catheter rounding and a good 20-24 hrs of good analgesia.
Click to expand...

If the choice is between doing a procedure that is unnecessary most of the time or doing it in PACU when it is necessary, I'll lean towards PACU. Besides, the patient never remembers the pain in PACU if you do the block quickly after arrival.
 
1. Turnover time is less than 10min between shoulder scopes, so I can't waste time in the pacu doing a CISB on a pt in pain. Doing a CISB after a single shot preop ISB seems a bit wasteful.
2. My surgeon wants preop blocks cuz it keeps BP low and seems to give him less bleeding/ better visualization.
3. I pretty much have to do the CISB in lateral decub, which is tough in a pacu pt with an abduction pillow and neck strap.
 
Question about non stim catheter placement-- I have seen two methods:
1) place catheter 1cm past needle tip (x cm). Leave catheter at skin at (x+1) cm.
2) (block jocks) lay the catheter between the nerves and the middle scalene, tryin to get the catheter to bend or flop in place. Pull Tuohy into muscle, then feed lots of catheter into the subcut and muscular tissue. The catheter will end up about 20cm at skin.

It seems that method 2 might be less prone to catheters falling out, but when I tried it, the catheter managed to overshoot the nerves, and it was difficult as hell pulling the slack out and then pulling the tip back 2cm, doing air boluses every cm.

Method 1 seems like it would be easy to know if you're in the right position by the catheter markings at skin. The downside is that it is prone to pulling out.

I need to do more by each method. I'm doing these on inpatients right now so I can see them and check catheter position. But I want to get outpatient infusions going so I need to get a good secondary block rate
 
Mman said:
Besides, the patient never remembers the pain in PACU if you do the block quickly after arrival.
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That does not sound like a good idea to me... maybe for a lower extremity block. I wouldn't be placing an upper extremity block or catheter in someone who is not cooperative. Either GA if necessary (only for lower extremity blocks with USD) or sedated and cooperative. Anything in the middle is a no go for me. Patients are too unpredictable and that first stick can cause an unwanted reaction and cause you to either abort, or try to place a block in a less safe environment. Even worse, you can get through skin and then get stimulation and right then your patient reacts potentially causing a BP injury. You work with CRNA's so it gives you time to let the patient recover from anesthesia a little. That is when I would do a pacu block in a ACT model. Not once they hit the pacu.

As for need or no need for a preop block... that is an old story that is debatable:

This month I am the sole provider at an ortho only ASC that we recently took over. 8-12 blocks a day. ISB, axillary, fem, pops, adductor canal, foot, hand, individual terminal branches, etc.... you name it (except for high sciatics and lumbar plexus) and we are probably doing them routinely. This is a new takeover and it used to be done with no regional. Apparently, it is night and day now that we have implemented a regional service.

Surgeons are happier, pacu nurses are happier and patients are happier. I've heard this a dozen + times over the last couple of weeks. Pain control, nausea/vomiting, patient satisfaction, early discharge, etc, is vastly improved. 23hr stays are now getting D/C'd much earlier.

Everyone sees it and appreciates it. Now our surgeons are calling and asking to place pre-op blocks left and right. It's nice to have that conversation and although no block is absolutely necessary, a lot of the times it is a better choice as a sole anesthetic or a component to sevo/des sparing GA.
 
Oggg said:
Question about non stim catheter placement-- I have seen two methods:
1) place catheter 1cm past needle tip (x cm). Leave catheter at skin at (x+1) cm.
2) (block jocks) lay the catheter between the nerves and the middle scalene, tryin to get the catheter to bend or flop in place. Pull Tuohy into muscle, then feed lots of catheter into the subcut and muscular tissue. The catheter will end up about 20cm at skin.

It seems that method 2 might be less prone to catheters falling out, but when I tried it, the catheter managed to overshoot the nerves, and it was difficult as hell pulling the slack out and then pulling the tip back 2cm, doing air boluses every cm.

Method 1 seems like it would be easy to know if you're in the right position by the catheter markings at skin. The downside is that it is prone to pulling out.

I need to do more by each method. I'm doing these on inpatients right now so I can see them and check catheter position. But I want to get outpatient infusions going so I need to get a good secondary block rate
Click to expand...

You are doing the right thing here... you are testing what works best for you.

The way I do my catheters involves stim>catheter placement>LA bolus under direct USD visualization to confirm placement (if you have a stim catheter you'll see a + Raj>tunnel or heavy benzoin and small/medium tegaderm with a window to the catheter site and a good tape seal around the edges.
 
Normally I would do a single shot for a case like this but I know guys at practices where the orthopods specifically request interscalene catheters for simple shoulder scopes.

Oggg said:
Any given shoulder arthroscopy may be booked by my orthopod as a subacromial decompression, but once the scope is in, they may discover a rotator cuff tear, which often hurts 10/10 after a single shot wears off. I plan to put catheters in whenever the surgeon thinks there is at least some potential for rotator cuff repair. His rotator cuff repairs take about 45-90min depending on how bad it is. But if he books a "possible RCR", and it turns out the patient needs a 15-30min non painful cuff debridement, I will look really bad if I do a 30min catheter.
Click to expand...
 
sevoflurane said:
That does not sound like a good idea to me... maybe for a lower extremity block. I wouldn't be placing an upper extremity block or catheter in someone who is not cooperative. Either GA if necessary (only for lower extremity blocks with USD) or sedated and cooperative. Anything in the middle is a no go for me. Patients are too unpredictable and that first stick can cause an unwanted reaction and cause you to either abort, or try to place a block in a less safe environment. Even worse, you can get through skin and then get stimulation and right then your patient reacts potentially causing a BP injury. You work with CRNA's so it gives you time to let the patient recover from anesthesia a little. That is when I would do a pacu block in a ACT model. Not once they hit the pacu.

As for need or no need for a preop block... that is an old story that is debatable:

This month I am the sole provider at an ortho only ASC that we recently took over. 8-12 blocks a day. ISB, axillary, fem, pops, adductor canal, foot, hand, individual terminal branches, etc.... you name it (except for high sciatics and lumbar plexus) and we are probably doing them routinely. This is a new takeover and it used to be done with no regional. Apparently, it is night and day now that we have implemented a regional service.

Surgeons are happier, pacu nurses are happier and patients are happier. I've heard this a dozen + times over the last couple of weeks. Pain control, nausea/vomiting, patient satisfaction, early discharge, etc, is vastly improved. 23hr stays are now getting D/C'd much earlier.

Everyone sees it and appreciates it. Now our surgeons are calling and asking to place pre-op blocks left and right. It's nice to have that conversation and although no block is absolutely necessary, a lot of the times it is a better choice as a sole anesthetic or a component to sevo/des sparing GA.
Click to expand...


Continue doing whatever works best for you. I merely brought up the suggestion of doing it postop when a poster commented that he felt rushed for time preop and was doing them on cases that often didn't even need it in the end. In that particular situation, doing it postop makes far more sense than preop. As to turnover times, BFD. Either the surgeon is waiting for you to do it preop or they are waiting on the turnover to the next one. Either way the overall wait time is the same.

I've done boat loads of upper extremity single shot and catheters postop. I've also done as many preop. I talk to the patients about the pros and cons of both and let them decide. Doing them postop isn't hard. The patients aren't combative in PACU, at least not in our PACU. They sit there peacefully half snoring and responsive to questions. Takes <30 seconds to do a single shot and takes maybe 5-6 minutes to do a catheter (total time of <2 minutes with a needle in the neck).

Pros and cons to both. Anybody that does it one way or the other 100% of the time isn't providing optimal patient care. Gotta balance it for the patient.
 
So far I'm doing everything myself, except for having a nurse or tech save some images. Sometimes I have the nurse put on the monitors and give additional sedation.

Are most people here using dermabond at the insertion site? My feeling is that it's expensive but it'll hold the catheter in place and prevent leakage, and I want to use it on my ambulatory catheters when I start doing them.
 
I read another technique where you preload the catheter into the Tuohy, advance the Tuohy to the nerve, inject thru the catheter to dilate the space, then advance the catheter. I suppose you might get some leaking back out the Tuohy which might be a nifty way to limit your injection pressure. I think I'm going to try this out.
 
Anyone have experience with the Arrow flextip epidural catheter? I've heard it curls up in the hydrodissected space, instead of shooting past the nerve like the Braun epidural catheter or a nerve stim catheter.
 
I think you can limit the cath shooting past the nerves by using the nerves as a backstop. Once I break through the anterior fascia of the middle scalene, I inject 5ccs to make sure I am getting spread around the nerves and not back into the muscle, then I thread the cath. If you place your needle between the roots and push past to get spread on the anterior side of the nerves, these are the times I see my catheter shooting by after threading it.

I use the spring wound braun. Its pretty soft. It is a single orifice at the end. With multiorifice, you are almost forced to go between the nerves, or at least make sure all the orifices are past the anterior fascia on the middle scalene.I like the single end orifice, but I know a lot of guys who like the multi a lot better.

I do all outpatient caths. I do use dermabond on all of them. It helps stop the leaks. I am the only anesthesiologist at my asc so I take all the calls on them. Since I started using dermabond, only had 1 call in the last year and a half for leaking.
 
Last edited:
sevoflurane said:
This month I am the sole provider at an ortho only ASC that we recently took over. 8-12 blocks a day. ISB, axillary, fem, pops, adductor canal, foot, hand, individual terminal branches, etc.... you name it (except for high sciatics and lumbar plexus) and we are probably doing them routinely. This is a new takeover and it used to be done with no regional. Apparently, it is night and day now that we have implemented a regional service.

Surgeons are happier, pacu nurses are happier and patients are happier. I've heard this a dozen + times over the last couple of weeks. Pain control, nausea/vomiting, patient satisfaction, early discharge, etc, is vastly improved. 23hr stays are now getting D/C'd much earlier.
Click to expand...
Does this result in lower overall cost with early discharges and probably shorter PACU stays? Not that those other reasons aren't good enough to do it, I'm just curious.
 
Yes to faster discharge, but it's hard to be so consistent across the board in decreasing pacu times to make an argument, for example, for hiring one less pacu nurse.
 
Oggg said:
The benefits of CPNB are so obvious, but it's been so difficult for me to start up a program
Click to expand...

The benefits of a continuous catheter are not much different than the benefits of a single shot block. Single shot saves time and provides same PACU benefits.
 
Oggg said:
I read another technique where you preload the catheter into the Tuohy, advance the Tuohy to the nerve, inject thru the catheter to dilate the space, then advance the catheter. I suppose you might get some leaking back out the Tuohy which might be a nifty way to limit your injection pressure. I think I'm going to try this out.
Click to expand...

Have to put the lure lock adapter on to inject then take it off to pull Touhy then put it back on, otherwise I'd love that technique
 
Ok I've been inserting the Tuohy with the 20cc ropiv syringe attached. Inject around nerve, then place tip of Tuohy right under nerve. Insert catheter without ultrasound. Air injection test. Repeat air test until Paraneural spread confirmed. Dressing.

Fewer catheter checks seems to help speed. Dermabond seems to slow you down, but I'm hearing more ppl are using it.
 
Although I scan and needle ambidextrously, I've noticed I need my mayo stand and sterile tray to be on my right side (I'm right handed).

Anyone cutting their catheters? Might make it easier to tape down, and less resistance for bolusing. I was thinking of cutting our 20g non springwound catheter about a foot from the end, prior to insertion, using the 18g hypo needle. Might be hard to cut.
 
So far, for CFNB, I like to dig my Tuohy into some iliacus muscle before reaching the undersurface of the nerve. I dilate the space deep to the nerve and place the catheter. I've seen videos where the operator dilates above the nerve and then below the nerve, then places the catheter. Possible benefits are better visualization of the nerve after superficial local is injected, and possible faster block from circumferential spread. Downsides are that it takes longer and it may not be possible to dig into iliacus and come back above the nerve.

I'm using Dermabond prn only, when I have no excess catheter burrowed inside. I'll probably use it for ambulatory CPNB though.
 
Flexible/springwound vs stiff/non springwound?
Some people argue that with a flexible catheter, if you advance to much, the catheter will coil and stay Paraneural. With a stiff catheter, you could end up shooting past the nerve. Careful catheter tip evaluation and adjustment using air and local test doses will ensure Paraneural location, but if a flexible catheter gives you more leeway, will it also save you time?
 
I prefer flexible springwound. You can see it great on ultrasound, less parasthesias, and doesn't burrow its way past the nerve. Plus if someone had trouble pulling them out, the spring wound should be a safety feature not to snap the cath and leave part of it in.

I don't like to shoot past the nerve. If you do, you can pull it back under US guidance, but now you have no play in your catheter because you had to pull all the slack out to move the tip. I find this is a formula for failure especially on ISB for shoulders. When the surgeon pulls the 10-10 drape off of the skin, it pulls the skin a little. If the cath has no slack, that pulls the tip further away from the nerves in my mind at least.
 
Can you actually see a springwound catheter coil up and stay near the nerve? How far past the Tuohy tip do you advance a springwound catheter? I usually advance my stiff non springwound catheter 0.5-1cm only.
 
I still use the stiff bbraun multioriface catheter. I thread the catheter 2 cm past the needle. I find that even if the catheter is past the nerves that the local infusion with track back along the catheter to bath the nerves especially with the multioriface. My concern of threading only .5 cm past the needle for interscalenes is that the catheter really likes to pop out a bit when you take out the needle.

For the folks using the spring wire catheters, is there any concern of too much coiling or potential knotting if you thread more?
 
You can see the catheter very well. I use the open tip single port so I know where the tip is by where the local accumulates when I am injecting. I thread it just past the tip, back the needle out, and thread in some extra play as I am pulling the needle out so that the majority of the excess catheter is in the muscle and sub q. I have never had one knot up although this has been described.
 
We use exclusively the arrow spring wound catheter. We thread in 2-4 cm after injecting local and confirm position with air. As we back out with the tuohy we thread in an additional 1-2cm as we cross each tissue plane so that there is slack to be taken up if the catheter or skin moves a significant amount after its secured. Knots can occur if you advance the tuohy after threading in extra catheter. As long as you only withdraw the needle once catheter is threaded a know should not be able to form.
 
I think an invisible air test is usually due to 1 of 2 reasons:

a) the catheter threaded in farther than expected/intended so the tip of the catheter/air is off the screen

or

b) the U/S beam got slightly out of plane with the catheter, to fix this I'll bring the probe right up to where the the catheter enters the skin and trace along the length of it back to my intended target
 
Blockjocks advises threading extra catheter in the subcutaneous space and the using Dermabond to seal and fix the site. I've had good results doing this with femoral catheters and not dermabonding. But two of my continuous interscalene catheters haven't done well, both inpatients. Air test at time of placement was perfect both times. Both times the secondary block via the catheter didn't work or barely worked, and when I went up to ultrasound the catheters, they both had migrated 2cm past the nerves. I pulled them both back and got then working again. I use the stiffer standard 20g closed tip BBraun Perifix epidural catheter, not a 19g springwound flextip. I wonder if the extra catheter that I coil in the subq space, I wonder if it tries to straighten itself out and pushes the catheter tip forward. Since I plan to dermAbond all my CISBs, maybe I should stop adding extra catheter.
 
Oggg said:
Can you actually see a springwound catheter coil up and stay near the nerve?
Click to expand...

Yes, for interscalenes I've been entertained to see them coil around the nerve root on U/S.

For interscalenes I really like a single-end-hole catheter. The stiff plastic catheters just bounce off the opposite fascia and I'm always anxious that the proximal hole isn't going to be within the sheath. It hasn't actually ended up being a problem in reality, though.

What I really want is a blunt block needle that I can put a springwound catheter through. Tuohys have a pretty sharp leading edge and I'm worried about nerve injuries (particularly with trainees who haven't yet developed subtlety and finesse).
 
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