Nerve Catheter Research Articles

Removal of Hydrus® microstent due to uveitis-glaucoma-hyphema syndrome.

Regional anesthesia has become a mainstay of analgesia following shoulder arthroscopic and reconstructive procedures. Local anesthetic can be injected in the perineural space of the brachial plexus by a single shot or continuously by an indwelling catheter. Although previous studies have compared efficacy and direct cost of single shot to catheters, few have evaluated unanticipated costs of on-going care or complications. Pulmonary complications can lead to unexpected admissions and emergency room visits. The purpose of the study was to identify unplanned hospital admissions or emergency room visits related to regional anesthesia after shoulder surgery and determine the additional associated costs.A series of 1888 shoulder surgeries were identified in 1856 unique patients at a single large academic center. As part of an interscalene nerve catheter program, a continuous interscalene block (CIB) was given to 1728 patients; whereas, 160 patients had a single shot interscalene block (SSIB). A hospital-employed quality control nurse contacted all patients receiving a CIB at one, two, seven, and fourteen days following surgery. All emergency room visits and readmissions were recorded, and the associated billing charges were reviewed for the inpatient and any outpatient visits immediately preceding or immediately following the readmission. The regional average Medicare fee schedule was used to determine a cost for these episodes of care.Of the 1728 patients who had CIB, ten patients were readmitted following open or arthroscopic surgery or presented to the emergency department in the immediate postoperative period for pulmonary compromise. No patient in the SSIB group had an emergency room visit or readmission. The average age of the ten patients with readmission was 60 years (7 females, 3 males). The majority were diagnosed with hypoxemia on admission (R09.02). Length of stay during readmission ranged from 0 to 4 days with one patient requiring admission to the ICU. The average cost of admission to the hospital or visit to the emergency room was $6,849 (range, $1,988 to $19,483). These costs were primarily related to chest X-Rays and EKG (9/10), chest CT with contrast (3/10), and head CT (2/10).Although uncommon, unanticipated pulmonary complications after CIB can result in significant cost compared to SSIB. The indirect costs of pulmonary workup after readmission or emergency room work-up may be overlooked if only considering direct costs, such as medication charges, medical supplies, and physician fees.

Effects of catheter orifice configuration (triple-hole versus end-hole) in continuous infraclavicular brachial plexus block on analgesia after upper limb surgery.

The configuration of a nerve block catheter may affect the local anesthetic spread in epidural analgesia and continuous peripheral nerve blocks. This prospective and randomized study aims to compare the multi-orifice nerve block catheter with an end-hole catheter in ultrasound-guided continuous infraclavicular brachial plexus block (BPB) in terms of providing postoperative analgesia for the orthopedic upper limb surgery below the shoulder. The primary outcome measure was mean pain scores. Secondary outcome measures were the consumption of rescue analgesic and the amount of local anesthetics delivered by a Patient-Controlled Analgesia (PCA) device. A total of 58 adult patients who underwent orthopedic upper limb surgery below the shoulder were randomly assigned into two groups: group end-hole catheter (EHC) (n=31) and group multi-orifice catheter (MOC) (n=27). All patients received a single-shot infraclavicular BPB using 100 mg lidocaine 2% and 75 mg bupivacaine 0.5% administrated through a Tuohy needle. Then, a multi-orifice (triple-hole) nerve catheter was placed in the group MOC and an end-hole (one-hole) catheter in the group EHC at the same location. Bupivacaine 0.125% was infused through the catheters via PCA (infusion rate: 2 mlh-1, automated regular bolus: 5 mlh-1, patient-controlled bolus: 3 ml, lock-out time: 1 hour, 4 hours limit: 40 ml). Pain intensity was evaluated using a visual analogue scale (VAS). Mean VAS scores were higher in group EHC than group MOC in the first postoperative day (p=0.001). Mean rescue analgesic consumption, the number of bolus demand on PCA, PCA bolus demand dose, and total PCA dose were higher in group EHC than group MOC during the first postoperative day (p<0.05). It is concluded that the use of MHC is more effective than EHC for continuous infraclavicular brachial plexus blocks in providing postoperative pain relief during the first 24 hours.

Comparison of Femoral Nerve Catheter, Adductor Canal Catheter, and Periarticular Liposomal Bupivacaine Infiltration for Postoperative Analgesia After Primary Total Knee Arthroplasty

BackgroundPeripheral nerve catheters are used to provide analgesia after total knee arthroplasty (TKA) and have been shown to decrease pain and opioid use, to facilitate participation with physical therapy (PT), and to hasten discharge. More recently, pericapsular infiltration using liposomal bupivacaine (LB) has been employed as an alternative analgesic approach. MethodsThis retrospective study compared outcomes for three analgesic approaches: femoral nerve catheter (FNC), adductor canal catheter (ACC), and intraoperative LB infiltration. The primary outcome was numeric rating scale (NRS) pain scores at 24 hours. Secondary outcomes included pain scores at 12, 36, and 48 hours, time-to-first opioid, cumulative opioid use, distance walked, and time-to-discharge. ResultsPain scores at 24 hours were significantly lower in both the ACC and FNC cohorts when compared to the LB cohort (3.1 versus 4.6 [P = .017] and 2.4 versus 4.6 [P < .0001]). The ACC and FNC groups did not differ significantly at that timepoint (P = .27). Similar comparisons were found at 12 and 36 hours, while at 48 hours the FNC group was superior. Time to first opioid and opioid consumption favored the ACC and FNC groups. Walking distance favored the ACC group. Both the ACC and LB groups had a faster time-to-discharge than the FNC group. ConclusionBoth ACCs and FNCs provided superior analgesia at 24 hours compared to LB, while being equivalent to each other. Pain scores at 12 hours and 36 hours as well as opioid consumption through 48 hours mirrored this finding. Although various differences were found between groups in terms of time-to-first analgesic, walking distance and time-to-discharge, the ACC approach appeared to optimally balance analgesia, ambulation, and time-to-discharge.

Quality of Recovery After Rotator Cuff Repair With Interscalene Liposomal Bupivacaine Versus Interscalene Nerve Catheter

Interscalene nerve catheters have been proven to be effective in managing pain after rotator cuff repair (RCR) surgery. Liposomal bupivacaine is a newer approved therapy for use around the interscalene brachial plexus, but its analgesic efficacy has limited supporting data in various patient populations. The purpose of this study was to investigate the quality of recovery after arthroscopic RCR in patients who received either single-injection interscalene liposomal bupivacaine or an interscalene peripheral nerve catheter. It was hypothesized that interscalene peripheral nerve catheters would provide more reliable analgesia and improved patient satisfaction 48 hours after surgery. Cohort study; Level of evidence, 2. Enrolled were 93 consecutive patients who underwent arthroscopic rotator cuff surgery at a single ambulatory surgery center between October 2020 and June 2021. Of these patients, 13 were lost to follow-up; thus, 80 patients were included in statistical analysis. One group of patients (n = 48) received a preoperative interscalene nerve block placed with 10 mL 0.5% bupivacaine and 10 mL 1.3% liposomal bupivacaine. The second group (n = 32) received a preoperative interscalene catheter with an initial bolus of 20 mL 0.25% bupivacaine and a 0.2% ropivacaine infusion by an elastomeric pump set at 10 mL/hr for 48 hours. The primary outcome was the difference between preoperative and 48-hour postoperative quality of recovery-15 (QoR-15) scores. Secondary outcomes included visual analog pain scores, opioid use, and patient satisfaction. Complications and adverse effects were also noted. The Kruskal-Wallis test was used to analyze means and standard deviations for continuous endpoints; Fisher exact test was used to analyze counts and proportions for categorical endpoints. The liposomal bupivacaine group had a mean reduction of 3.9 in their postoperative QoR-15 scores, and the catheter group had a mean reduction of 25.1 in their postoperative QoR-15 scores, indicating a significantly worse functional recovery period compared with liposomal bupivacaine within the first 48 hours (P < .001). Patients who received liposomal bupivacaine also had significantly lower pain scores on the second postoperative day, improved quality of sleep, and improved satisfaction with analgesia (P < .05 for all). The use of interscalene liposomal bupivacaine demonstrated significantly improved quality of recovery when compared with interscalene nerve catheter after RCR.

Double-tunneled catheter method for continuous peripheral nerve block.

Dear Editor, Continuous peripheral nerve block provided by an infusion through a peripheral nerve catheter is an attractive option for both the patient and the anesthesiologist. One of the main problems is dislodgement of the catheter, which can occur in up to 10% of cases.[1] Methods used to prevent peripheral catheter displacement are dressings, tissue glue, suturing and tunneling. The benefit of a dressing probably decreases with time, as the dressing becomes less sticky with time, and is interfered with by sweat or by ooze from the catheter site. Additionally, the site of catheter, presence of hairy skin and type of dressing have a large impact on occurrence of catheter displacement. Tunneling has been described as a method of reducing catheter displacement and infection rates, and seems to have a high rate of success.[2,3] Byrne et al.[4] compared the force requirement for extraction for peripheral nerve catheters under three different situations, tunneled, tunneled and double-tunneled catheters in a porcine model. They concluded that double tunneled catheters were associated with nearly a fourfold increase in force required for displacement compared with single-tunneled catheters, and a 17-fold increase in force of displacement compared with tunneled catheters in porcine model. Double tunneling is not much tested in human subjects. It could be because of chances of kinking of catheter at the site of second tunnel, lack of enough space, requirement of special care at the time of removal, and increase in infection rate due to two skin punctures. Infection is unlikely to be a major problem due to its very low incidence in short-term peripheral nerve catheters.[5] Double-tunneling allows catheter to circle the bridge of skin created between two loops of catheter Figure 1. In our case, we double tunneled the continuous catheter in the infraclavicular region after its placement under ultrasound guidance. We did not face any technical difficulty while inserting it. Insertion required the help of an assistant to stabilize the catheter during the procedure. The catheter was maintained for 48 hours and was removed without any problems. The patient did not complain of any scar formation on successive follow up. Catheter dislodgement is prevented due to the tightening of the bridge of skin in case any untoward force pulls it. This benefit of tunneling is less affected by the site of the catheter or the nature of the surrounding skin, unlike dressings. We have successfully extended the use of this technique to supraclavicular continuous catheter placements. Double-tunneling is a new technique of peripheral nerve catheter fixation which provides more protection from catheter dislodgement. The incidence of infection and scar formation needs to be studied further.Figure 1: Steps of double tunneling peripheral nerve catheterDeclaration of patient consent The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.

Ultrasound-Guided Peripheral Nerve Blocks: A Practical Review for Acute Cancer-Related Pain.

Ultrasound-guided regional techniques, including catheter-based approaches, are a subset of interventional therapies that have gained interest as an option for managing acute cancer-related pain. The authors sought to review the available published evidence and to discuss practical recommendations for expanding access to such therapies. In a MEDLINE/Pubmed search of ultrasound-guided peripheral nerve blocks and peripheral nerve catheters for specific anatomic targets, a total of 28 case reports and case series were identified. Included studies described improved analgesia and reduced opioid requirements with highly variable duration of effect. Current level of evidence remains limited. Pain is a symptom that markedly impacts the quality of life of cancer patients and ultrasound-guided regional techniques are a promising therapeutic option albeit with a limited evidence base. Practical recommendations offered for coordinating access to such therapies in the inpatient, emergency department, and outpatient settings may expand interest and facilitate higher quality research.

Holter electrocardiogram research trends and hotspots: bibliometrics and visual analysis.

With the help of metrology, we can identify research hotspots and development trends in dynamic electrocardiography, and thereby provide corresponding reference material to aid further theoretical research. All research data derived from the core collection of Web of Science, and all searches were completed on the same day (February 6, 2022). The obtained data were stored in plain text format and imported into CiteSpace for subsequent analysis. Citation analysis and visualization technology were used to draw a visual map of the research elements, using factors such as annual literature volume, country, journal, author, abstract, keywords, and citation. After screening, 2,937 papers were obtained. Research on ambulatory electrocardiography is increasing worldwide every year. Using research hotspots, keyword-clustering time-zone maps, and high-frequency emerging words, the research in this field was roughly divided into two stages, with 2017 as the divider. The first stage primarily focuses on areas such as atrial fibrillation, stroke, autonomic nerve function, catheter ablation, and T-wave alternation. The second stage saw the focus shift to wearable devices, sudden cardiac death, obstructive sleep apnea, feature extraction, cryptogenic stroke, and similar topics. With the development of various wearable technologies, the daily monitoring of healthy people engaged in sporting activities and the development of innovative analysis algorithms providing more accurate data may represent the hotspots and direction of future research.

Efficacy of sub para-neural sciatic nerve catheters for wound care-related procedural pain in hospital ward settings.

Efficacy of sub para-neural sciatic nerve catheters for wound care-related procedural pain in hospital ward settings.

Improving Postoperative Pain Score Among Charcot Marie Tooth Reconstructive Surgery Receiving Ambulatory Nerve Infusion Therapy

<h3>Background Information</h3> As the practice in outpatient foot and ankle surgeries increases, more painful and invasive procedures are being performed. One such procedure, Charcot Marie Tooth (CMT) reconstructive surgery, has proven to cause severe pain well beyond the 24-hour period postoperatively. Use of continuous local anesthetic-based peripheral regional analgesic techniques for patient undergoing surgical procedures is preferred where postoperative pain is likely to be more prolonged. Furthermore, there has been a rapid rise in use of ambulatory nerve infusion therapy (AMBIT) for orthopedic surgeries and may prove to be effective for more invasive CMT surgery. <h3>Objectives of Project</h3> To improve postoperative pain scores for CMT reconstructive surgery patients receiving the ambulatory nerve infusion therapy. <h3>Process of Implementation</h3> The Pavilion Post Anesthesia Care Unit (PACU) was chosen to initiate the use of AMBIT from November 2020 to August 2021. Regional Anesthesia team coordinated the initial process for appropriate implementation of this device. Upon approval, Regional Anesthesia, Pharmacy, Informatics, and PACU nursing team collaborated and prepared a protocol for this device to be implemented. Educational in-services were provided to all PACU, emergency room, and inpatient nurses to ensure proper nursing and patient education and safety. Test of change was implemented with appropriate patient selection guidelines. Patients who received the AMBIT pump therapy were evaluated after 72 hours of surgery. <h3>Statement of Successful Practice</h3> The implementation of the ambulatory nerve infusion therapy for CMT patients showed significant improvement in postoperative pain for 72 hours postoperatively. Pre-implementation pain scores average in the severe range. Post implementation pain scores average in the mild to moderate range. <h3>Implications for Advancing the Practice of Perianesthesia Nursing</h3> A multi-disciplinary test of change created an effective workflow for implementing peripheral nerve catheters for a novel and invasive procedure. Furthermore, preliminary results proved this ambulatory nerve infusion therapy improves postoperative pain for CMT reconstructive surgery well beyond the 24-hr period after discharge. Future studies should examine the effectiveness of postoperative pain management using AMBIT pump therapy for other procedures, as well as compared to other conventional treatments.

A Case Illustrating the Practical Application of the AAOS Clinical Practice Guideline: Pharmacologic, Physical, and Cognitive Pain Alleviation for Musculoskeletal Extremity/Pelvis Surgery.

The American Academy of Orthopaedic Surgeons Clinical Practice Guideline "Pharmacologic, Physical, and Cognitive Pain Alleviation for Musculoskeletal Extremity/Pelvis Surgery" is a summary of the available literature designed to help guide surgeons provide a safe and effective means of pain alleviation for orthopaedic surgery patients. The following case study demonstrates these guidelines at work in a patient undergoing total shoulder arthroplasty. The recommendations listed in the following sentences are from the Clinical Practice Guideline. Preoperative patient education regarding the effects of opioids and benefits of early termination may help patients discontinue opioids earlier in their postoperative course. Perioperative use of intravenous ketamine and regional anesthesia continuous peripheral nerve catheters help reduce pain scores and decrease opioid use. Postoperative cryotherapy may provide a modest benefit in reducing pain scores. Postoperative cyclooxygenase-2 selective nonsteroidal anti-inflammatory medications (NSAIDs) and oral acetaminophen improve pain and decrease opioid use. Combination opioid/NSAIDs may provide a modest improvement in pain scores at the expense of NSAID dose optimization in the postoperative period. Gabapentin has not been shown to improve patient outcomes; however, pregabalin may decrease pain and opioid use after total joint arthroplasty.

Implementation and Postoperative Management of Continuous Adductor Canal Catheters for Total Knee Arthroplasty to Reduce Surgical Backlog Related to the COVID-19 Pandemic: An Acute Pain Service Nursing Perspective and Educational Resource

PurposeIn response to the surgical backlog created by the COVID-19 pandemic and to spare valuable hospital resources, we developed and implemented a continuous adductor canal catheter (CACC) program for total knee arthroplasty (TKA) patients. CACC's offer superior analgesia, decrease opioid use, and increase patient satisfaction while simultaneously promoting a decreased length of hospital stay and even same day discharges. The implementation of analgesia protocols using continuous peripheral nerve catheters and isometric pumps has been described for other surgical procedures and populations; however, the role of the Acute Pain Service Nurse (APS RN) in the implementation of such a program has not been described. DesignAn best practice initiative for TKA patients receiving CACC was developed and implemented for patients recovering both in the hospital and at home. MethodsWe describe the development and implementation of a CACC program for TKA patients in response to the surgical backlog created by the COVID-19 pandemic from the perspective of the APS RN. We provide a detailed narrative description of our postoperative assessment and experience, and offer practical insights for the postoperative care of these patients. We share the educational resources and assessment tools we developed to ensure consistent, safe, and effective clinical management of CACC patients in the hospital and at home. FindingsCACCs via elastomeric pumps have been shown to offer significant advances to pain control following TKA, decrease opioid use, enable earlier discharge, and improve patient satisfaction, all of which we observed unequivocally in our patients. In our experience, implementation of a daily telephone follow up by an APS RN for discharged TKA patients with a CACC was crucial for patient safety, patient satisfaction, and reducing emergency phone calls and emergency room visits. ConclusionsWe anticipate this description will provide an invaluable educational resource for other Acute Pain Service programs as similar outpatient peripheral nerve catheter programs are developed in response to the pandemic.

Abstract P131: Cerebral Venous Sinus Thrombosis Risk Factors, Treatments, And Sequelae: 2011-2019

Introduction: Cerebral venous sinus thrombosis (CVST) is a rare but potentially debilitating thrombosis affecting 3-4 cases per million adults in the United States. Risk factors are thought similar to venous thrombosis, but there is little epidemiologic data corroborating this assertion. Concern about a possible association between the Janssen (Johnson and Johnson) and Oxford-AztraZenaca COVID-19 vaccines and cases of CVST resulted in increased global attention to this condition. Thus, large epidemiological assessment of the risk factors, treatment and outcomes of CVST are needed. Objective: Estimate the distributions of risk factors antecedent to CVST diagnosis, report CVST treatments in clinical practice, and potential sequelae of CVST in a large retrospective cohort of adults with CVST in the United States. Methods: MarketScan Commercial and Medicare Supplemental administrative databases were employed to assess CVST diagnosed between 2011 and 2019 in the U.S. Validated International Classification of Disease (ICD) codes and receipt of an outpatient anticoagulant (either oral or subcutaneous anticoagulant) prescription within 30 days of the ICD code identified incident CVST. Antecedent clinical characteristics, treatments, and sequelae of CVST were identified using inpatient, outpatient, and prescription data. For outcomes, proportions and incidence with 95% confidence intervals (CIs) were calculated, stratified by sex. Results: We identified 1,869 CVST patients. Of these 1,314 (70%) were female, with 200 (10%) events identified as a pregnancy-related CVST. The average age was 41 years for females and 48 years for men. Among women, 24.7% were on hormonal therapy (oral contraceptive, estrogen, and progestin) prior to diagnosis. Men had a higher prevalence of comorbidities, such as diabetes (15% men vs. 9% women) and cancer (19% men vs. 10% women). Oral anticoagulant (OAC) use was the most common treatment for CVST in both men (88%) and women (85%) and did not vary by sex. Use of procedures to treat CVST, optic nerve fenestration and catheter directed thrombolysis, were 0.5% and 4.1%, respectively. The most common sequela after CVST was incidence of intracranial hypertension (Incidence: 4.2 per 100 person-years; 95% CI: 3.3, 5.1) and palliedema was rare. Conclusions: Overall, a majority of CVST patients were women of reproductive age. Our findings suggest a potential association with both endogenous (pregnancy) and exogenous (oral contraceptives, HRT) hormones which needs further study. In our sample, CVST was managed with oral anticoagulants, regardless of sex, and intracranial hypertension was elevated following CVST. This large claims-based analysis is a descriptive insight into the risk factors and management of CVST, a rare and debilitating condition.

A not so sweet scenario: impact of perioperative glucose control on regional anesthetic techniques for orthopedic surgery.

Diabetes and hyperglycemia are well established risk factors for complications associated with common orthopedic surgeries. In some practice settings, these conditions are also viewed as contraindications to regional nerve catheters. In this article, we aim to present our approach to offering the benefits of this modality in a safe manner for patients with diabetes and even some with preexisting, localized infections. Evidence suggests that reduction in opioids and avoidance of general anesthesia can be particularly beneficial for patients with diabetes and high blood sugar, who often suffer from comorbid conditions such as obesity and obstructive sleep apnea. On our high volume, high acuity acute pain service, we take a selective approach to nerve catheter placement in this population and even some who already have localized infections. In our experience, with careful monitoring and risk mitigation strategies these patients have improved pain control and an exceedingly low rate of complications associated with nerve catheter use. Based on our experience and reading of the literature, we advocate for a liberalized approach to use of continuous regional anesthesia for diabetic patients having for orthopedic surgery. A set of consensus guidelines tailored to institutions' resources and monitoring capabilities can be a useful tool for standardizing care. It may also increase access to the clinical benefits of this modality in a population particularly vulnerable to opioid related adverse effects.

Acute Pain Management for a Tibial Plateau Fracture Shortly After a Buprenorphine XR Depot Injection: A Case Report

Acute pain management of patients on buprenorphine for opioid use disorder remains a challenge. The buprenorphine extended-release depot injection which lasts for 1 month and has a higher plasma concentration of buprenorphine compared to the sublingual formulation is increasingly being used in patients. Acute pain management of patients on buprenorphine depot remains a challenge because waiting for the washout of the medication is not feasible and discontinuation is challenging because it requires surgical excision. We describe here the pharmacokinetics of the buprenorphine depot formulation and the clinical implications of its long duration of action. A 39-year-old woman with a history of alcohol and opioid use disorder, on buprenorphine depot, was admitted to the hospital with a left tibial plateau fracture. Acute pain service managed her pain by utilizing a multimodal analgesia plan including femoral and popliteal nerve catheters, intravenous patient-controlled analgesia and oral opioid and nonopioid medications. The patient had a prolonged length of stay of 11 days but was successfully weaned off nerve catheters and intravenous medications and converted to an oral medication regiment such that she could be discharged from the acute care hospital.

Preoperative Factors Associated with Press Ganey Patient Satisfaction Scores after Anterior Cruciate Ligament Reconstruction.

Patient satisfaction is increasingly used as a metric to evaluate the quality of healthcare services and to determine hospital and physician compensation. The aim of this study was to identify preoperative factors associated with Press Ganey Ambulatory Surgery (PGAS) satisfaction scores, and to evaluate the effect of each PGAS domain score on the total PGAS score variability in patients undergoing anterior cruciate ligament reconstruction (ACLR). A review of a Press Ganey (PG) database at a single center was performed for patients undergoing ACLR between 2015 and 2019. Ninety-nine patients completed the PGAS survey and 54 also completed preoperative demographic and patient-reported outcome measures (PROMs) for an orthopaedic registry. PGAS scores were calculated and bivariate analysis was performed. Multivariable linear regression determined the effect of each of the six PGAS domains on the total PGAS score variability. In the total cohort of 99 patients, no factors were significantly associated with the total PGAS score or any domain scores. For the 54 patients who also participated in the orthopaedic registry, none of the preoperative PROMs were significantly correlated with total PGAS score. However, having a college degree (89 vs. 95 or 97 points; p = 0.02) and continuous femoral nerve catheter (92 vs. 100 points; p = 0.04) was associated with lower personal issue domain scores, while patients with a greater number of prior surgeries had worse registration domain scores (ρ = -0.27; p = 0.049). For the entire cohort, the registration and facility domains contributed the most variability to the total PGAS score, while the physician domain contributed the least. Few preoperative factors are associated with PGAS scores, and total PGAS scores do not significantly correlate with baseline PROMs. Surgeons may have limited ability to improve their PGAS scores given most of the variability in total scores stems from systemic aspects of the patient experience.

Popliteal Nerve Catheters for Perioperative Pain Control in Charcot-Marie-Tooth Patients

Category:Hindfoot; OtherIntroduction/Purpose:The underlying neuropathy of Charcot-Marie-Tooth (CMT) disease often makes postoperative pain control difficult. Previous institutional regimens for outpatient foot and ankle surgery in this population included preoperative single-shot regional nerve blocks and oral narcotic analgesics, but still resulted in unplanned visits for uncontrolled pain, especially after block effects abated. Longer duration of regional anesthesia effects were desired to manage pain and reduce opioid intake. We aimed to investigate the safety and efficacy of ultrasound-guided placement of popliteal nerve catheters in CMT patients undergoing foot deformity correction surgery.Methods:Twelve CMT patients, average 28 (range 13-53) years old, undergoing reconstructive surgery by a single foot and ankle attending surgeon were consented for preoperative ultrasound-guided popliteal catheters and single-shot adductor canal blocks. Patients were separately consented for enrollment in this study and follow-up questionnaires as per Institutional Review Board protocol. Seven patients underwent joint sparing reconstruction and 5 patients had subtalar fusion. Patients were discharged on postoperative day (POD) 0. Popliteal catheters were maintained, providing continuous infusion and patient-controlled bolus doses until POD3, and then self-discontinued. Oral oxycodone 5 mg (#60-80 pills) was prescribed as needed for breakthrough pain.Daily visual analog scale (VAS) pain scores were collected by phone. Patient satisfaction (0-10) was surveyed on POD5. A pill count for opioid consumption occurred at the surgeon's office on POD14. Five-point sensory testing using a 10g Semmes- Weinstein monofilament was performed preoperatively and on POD14.Results:All patients tolerated the catheters well. There were no complications related to infection or catheter malfunction requiring replacement. Four of the twelve patients had pre-existing sensory deficits involving at least two areas on the five-point monofilament test (Table 1). Postoperative testing showed these deficits were unchanged and there were no instances of new sensory deficits. Postoperative VAS pain scores were typically low with the median value (interquartile range IQR) 3.7 (1.5 - 5.75) on POD1, 3.2 (1.75 - 4.25) on POD2, and 2.5 (1 - 3.5) on POD3 (Figure 1). At POD14, VAS pain was 1 (0.75-1). Patients consumed an average total of 25 oxycodone pills (IQR 9-42) over 2 weeks, less than half the prescribed number. Patient satisfaction was high with the mean (standard deviation) score of 9.1 (1.6). All patients reported they would choose to have a nerve catheter again for a similar surgery.Conclusion:Regional anesthesia using ultrasound-guided popliteal catheters was effective for pain control in this series of CMT patients undergoing deformity correction. Opioid consumption was reduced from historical levels and no patients required emergency treatment for uncontrolled pain. These catheters provided three days of local anesthetic infusion. No new sensory deficits were detected and patients with underlying preoperative sensory deficits remained unchanged. Patients were highly satisfied. This small study group provides preliminary evidence supporting nerve catheter usage in CMT patients. Utilizing ultrasound guidance to minimize nerve injury, nerve catheters may allow safe and successful outpatient correction of CMT foot deformity.

COVID-19 pandemic as impetus for sustained utilization of home peripheral nerve catheter program.

COVID-19 pandemic as impetus for sustained utilization of home peripheral nerve catheter program.

Safety and Efficacy of Postoperative Indwelling Popliteal Nerve Catheters for Outpatient Charcot-Marie-Tooth Surgery.

Outpatient surgical deformity correction for Charcot-Marie-Tooth (CMT) disease is limited by effective postoperative pain control. Our previous institutional protocol for foot and ankle surgery in this population included preoperative single-injection nerve blocks, but patients often experienced uncontrolled pain when the block wore off postoperative day 0 or 1, resulting in high opioid requirements and unplanned emergency department visits. The use of ultrasonography-guided continuous nerve catheters in CMT patients has not previously been studied. We aimed to prospectively investigate the safety and efficacy of ultrasonography-guided indwelling popliteal catheters in CMT patients undergoing outpatient foot deformity correction surgery. Twenty CMT patients, average 28 (range 13-53) years old, undergoing reconstructive surgery by a single foot and ankle attending surgeon were consented for preoperative ultrasonography-guided popliteal catheters. This series included 24 total outpatient procedures; 4 were staged bilateral. Indwelling popliteal catheters were maintained on discharge, providing continuous infusion until postoperative day (POD) 3, and then self-discontinued. Patients were prescribed oxycodone 5 mg (60-80 pills) as needed for breakthrough pain. Outcomes collected included daily pain scores (0-10), an opioid pill count on POD 14, and patient satisfaction ratings. Neurologic evaluation by 5-point 10g Semmes-Weinstein monofilament testing was performed preoperatively and on POD 14. There were no observed catheter-site infections or hematomas. Nine of the patients had pre-existing sensory deficits involving at least 2 areas on the 5-point monofilament test. Postoperative testing showed these deficits were unchanged and there were no instances of new sensory deficits. Postoperative pain scores were typically low, with median values (interquartile ranges [IQRs]) of 3.5 (2.0-5.0) on POD 1, 2.5 (2.0-5.0) on POD 2, and 2.5 (1.0-3.75) on POD 3. At POD 14, pain was 1.0 (0-1.0). Patients consumed a median of 25 oxycodone pills (IQR 8-43) over 2 weeks, less than half the prescribed number. Patient satisfaction was high. All patients reported they would choose to have a nerve catheter again for a similar surgery. This cases series demonstrated that regional anesthesia using ultrasonography-guided indwelling popliteal catheters was safe and effective for pain control in CMT patients undergoing outpatient foot and ankle surgery. Opioid consumption was comparable to published rates following major bony procedures, and no patients required emergent treatment or hospital admission for uncontrolled pain. No new sensory deficits were detected and patients with underlying sensory deficits remained unchanged. Patients were highly satisfied. Level IV, case series.

Color Doppler ultrasonography of an agitated solution is predictive of accurate catheter placement for a continuous popliteal sciatic nerve block

BackgroundContinuous peripheral nerve catheters (PNCs) have been shown to provide superior postoperative analgesia, decrease opioid consumption, and improve patient satisfaction compared with single injection techniques. In order to achieve success and reliability, accurate catheter positioning is an essential element of PNC placement. An agitated solution of normal saline, D5W, or a local anesthetic solution can be produced by the introduction of air to the injectate, creating air bubbles that can enhance ultrasonographic visualization and possibly improve block success.MethodsEighty-three patients were enrolled. Ultrasound-guided continuous popliteal sciatic nerve blocks were performed by positioning the tip of a Tuohy needle between the tibial and common peroneal branches of the sciatic nerve and threading a catheter. An agitated local anesthetic solution was injected through the catheter, viewed with color Doppler ultrasound and video recorded. A peripheral block score (lower score = greater blockade, range 0-14) was calculated based upon the motor and sensory testing at 10, 20, and 30 min after block completion. The color Doppler agitation coverage pattern for the branches of the sciatic nerve was graded as follows: complete (> 50%), partial (> 0%, ≤ 50%), or none (0%).ResultsThe degree of nerve blockade at 30 min as judged by median (10th, 90th percentile) peripheral block score was significant for partial or complete color Doppler coverage of the sciatic nerve injectate compared to no coverage [3 (0, 7) vs 8 (4, 14); p < 0.01] and block onset was faster (p = 0.03). The block success was higher in groups with partial or complete coverage of the branches of the sciatic nerve vs no coverage (96% vs 70%; p = 0.02).ConclusionsInjection of an agitated solution through a popliteal sciatic perineural catheter is predictive of accurate catheter placement when partial or complete coverage of the sciatic nerve branches is visualized with color Doppler ultrasound.Trial registrationNCT01591603

How Do We Best Educate Our Patients' Caregivers? Comparing the Efficacy of Print Versus Media-based Education Materials in Peripheral Nerve Catheter and Pain Pump Education.

Media-based educational materials (EMs) are becoming prominent. The purpose of this study was to compare print versus media-based EMs given to caregivers of pediatric and young adult patients undergoing surgery. We aimed to see whether print or media-based EMs lead to greater caregiver satisfaction, comfort, and preparedness for outpatient peripheral nerve catheter and pain pump management. We also assessed caregiver preference for EM modality. We hypothesized that media-based EMs would demonstrate greater overall efficacy and thus generate higher caregiver preference. Randomized control trial. After IRB approval, clinicaltrials.gov registration (17-0638), and informed consent, caregivers were randomized to either media or print-based EM groups. Caregivers reviewed their assigned EM and completed a standardized assessment of their comprehension. We assessed caregiver satisfaction, preparedness, and comfort level with the content on a 5-point Likert scale. On postoperative days 1 to 2, caregivers reported satisfaction, comfort, and preference for EM modality. An intent-to-treat analysis was used to compare the 2 groups. From our final cohort of 135 caregivers, we found no difference [P>0.05] in satisfaction, comfort level, level of preparedness, or discharge readiness scores between groups. After the caregivers were given both EMs, they were evenly split in their preference for print (49.6%) versus video (50.4%) based methods. We did not detect a significant difference in caregiver preference or feelings of preparedness between groups. Interestingly, a significant proportion of caregivers (25%) did not feel comfortable managing the peripheral nerve catheter and its pain pump at home. Future studies should work to improve caregiver comfort with educational content before patient discharge. Providers and institutions should feel comfortable providing both print and media-based patient and caregiver education. Caregiver education may be best suited based on caregiver preference of one EM modality versus the other. Level I.