Tunnelled epidural catheters...

[Ligament]

Hi All,

I am in a pain fellowship and have the option to do a fair number of tunnelled epidural catheters. I have already done/assisted in a few. I don't think I will be doing much inpatient pain medicine when I graduate, so I'm wondering if I should be dedicating much time to learning this procedure, as opposed to focusing on things I know I will be using a lot of such as SCS. I'm am certainly glad I have the opportunity in the first place, of course.

What are your opinions? thanks!

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[JackPB]

I don't think you should have much concern at all. First, it's an easy procedure that is not much more difficult than placing a regular epidural.

Second, the tunneled epidural cather has an important place in the treatment of CRPS, cancer pain, and such as outpatients. Many prospective SCS patients would be benefit from a long-term TEC. Most are worth a trial.

 

[C Fiber]

I would not sweat over the tunneled catheters. Unless you are planning to trial your baclofen pumps as inpatient...even then, most people don't tunnel it. Let the general anesthesiologists do the thoracic catheters for rib fx, post-op pain stuff, etc, they have to be on call anyways. Take time to learn your other bread and butter stuff...do them fast...learn your high end procedures...discograms, IDET, diskectomy, SCS, some pumps, vertebroplasties/kypho if you are interested....this will already take up your short 12 month of training.

 

[drusso]

Although, if you do plan on practicing more of a "full scope" pain practice including malignant pain, it's nice to have the tunnelling skill nailed down tight.

 

[lobelsteve]

I think it would be good to know. Not useful, just good to know.

I see all procedures as a continuum of our knowledge in anatomy, radiology, and 3D spacial relationships.

If a needle is going in the body and you know where you want it to go, you can put it anywhere with the above skill set. The minor surgical skills we acquire all help to keep things in place, keep out infection, and let things heal up faster.

Do everything you can in training.

 

[bbbmd]

Although, if you do plan on practicing more of a "full scope" pain practice including malignant pain, it's nice to have the tunnelling skill nailed down tight.

I agree with David. Fellowship is only a year long so learning as much as you can will only benefit you in the future. You do not necessarily have to do it out in practice, but at least you know how and this will make you much more marketable during your job search. Tunneled catheters are not that hard and many of our gas counterparts have done them during residency. I think that non-gas pain docs should be competent in this in order to be considered "comprehensive pain physicians".

 

[drrinoo]

a number of regional anesthesiologists place outpt epidural catheters (non-cuffed) and use a 'through the needle' tunneling approach...it works nicely...I used to use this for my 3 day lysis (I don't do 3 day lysis anymore)

we did a fair number of tunneled cuffs back in fellowship...but at the time, I was only concerned about the technical/medical aspects;

I didn't pay attention to the costs....

I am still unclear as to who pays for what with long term tunneled epidural catheters...my understanding is that medicare will pay for the equipment, but not for the drugs (similar to oupt. IV antibiotics). Additionally, if the patient is at a hospice, the costs of drugs, etc... can be expensive and break the hospice's bank...I confess my memory is rusty on this...

does anyone know who pays for what with respect to tunnelled epidural catheters....the regional anesthesiologists don't have problems since they just have to fill the reservoir once in the hospital or ASC...and that should be enough for 24 hours (our pharmacy used to make epidural infusion bags at 500cc)

 

[Aether2000]

We use the tunneled through the needle technique (modified) for all our intrathecal continuous infusion outpatient trials. Slides 52-68 of the Comprehensive IT Pump module at the bottm right of the home page of
www.algosresearch.org
shows our technique. It appears to be similar to that of Dr Shaw's description. I must make a trip to Texas to learn how the southerners do things