Peripheral Nerve Catheters Research Articles

Effective plexus anaesthesia in a patient with Ehlers–Danlos syndrome type III

Effective plexus anaesthesia in a patient with Ehlers–Danlos syndrome type III

Échec de retrait de cathéters nerveux périphériques : les nœuds, une complication à connaître

We observed three cases of knots after peripheral nerve catheterism. Catheter removal was impossible and required the intervention of an anaesthetist. This complication should be known and included in the training of nurses. The analgesic technique by peripheral nerve catheter is currently used for the treatment of acute postoperative pain and starts to be used for the treatment of chronic pain. The catheter removal should be included in a protocol. One solution might be the use of a network to meet all the complications that happen in continuous peripheral nerve blocks, particularly at home.

Bacterial Colonization After Tunneling in 402 Perineural Catheters: A Prospective Study

Bacterial colonization of peripheral nerve catheters is frequent, although infection is relatively rare. With central venous catheters, the tunneling of the catheter into the subcutaneous tissue significantly decreases catheter colonization and catheter-related sepsis. We evaluated the incidence of bacterial colonization in adult patients with tunnelized perineural nerve catheters. Peripheral nerve catheters placed under sterile conditions for postoperative analgesia were evaluated prospectively. After removal, they were analyzed for colonization. Quantitative culture was used as described by Brun-Buisson for intravascular catheters. The site of insertion was monitored daily for any signs of infection. Four-hundred-two patients were included in the study during a 2-yr period. The mean duration of peripheral nerve catheters was 48 h (47-50.4). Positive culture occurred in 25 catheters, indicating that the incidence of colonization was 6.22% (3.8-8.5). The microbiological analysis of the catheter tip cultures revealed coagulase-negative staphylococci in 72%. Twenty-two catheters of 25 catheters each had one microorganism, and for three catheters, two microorganisms were identified. No infection was found in any patient. The incidence of perineural catheter colonization is low with subcutaneous tunneling. Controlled randomized studies are warranted to determine whether this procedure decreases the risk for infection.

THA with a Minimally Invasive Technique, Multi-modal Anesthesia, and Home Rehabilitation: Factors Associated with Early Discharge?

Multimodal anesthetic and pain regimens with minimally invasive surgical approaches and rapid rehabilitation protocols are thought to decrease length of stay after hip replacement. We asked whether a program including these three elements could achieve 23-hour discharge in a group of 665 patients and whether the length of hospital stay was influenced by patient age, gender, body mass index, change in hemoglobin or estimated blood loss, duration of surgery (< or = 90 or > 90 minutes), or American Society of Anesthesiologists physical status classification. Of the 665 patients, 259 (38.9%) were discharged home with indwelling peripheral nerve catheters. Hospital discharge in less than 24 hours was achieved in 295 (44.4%) of the 665 patients. After discharge, 73.5% of patients required no home or outpatient nursing care or physical therapy. Eighteen (2.7%) dislocations, eight (1.2%) femoral fractures requiring surgery, and thirteen (2.0%) revision procedures occurred within 90 days. Female gender, increasing age, increasing estimated blood loss, and American Association of Anesthesiologists classification 3 or 4 increased length of stay. Additional study is needed to confirm these factors and develop prospective prediction rules to allow for an outpatient approach to joint arthroplasty. Level II, therapeutic study. See Guidelines for Authors for a complete description of levels of evidence.

Infectious Risk of Continuous Peripheral Nerve Blocks

Infectious Risk of Continuous Peripheral Nerve Blocks

The Safety and Efficacy of Extended Thromboprophylaxis With Fondaparinux After Major Orthopedic Surgery of the Lower Limb With or Without a Neuraxial or Deep Peripheral Nerve Catheter

Survey of Anesthesiology: December 2008 - Volume 52 - Issue 6 - p 315-316 doi: 10.1097/SA.0b013e31818bceb1

Atlas of Peripheral Nerve Blocks and Anatomy for Orthopaedic Anesthesia

Atlas of Peripheral Nerve Blocks and Anatomy for Orthopaedic Anesthesia Boezaart AP. Philadelphia: Saunders Elsevier, 2008. ISBN 978-1-4160-3941-9. 242 pages + DVD, $179.00. In the era of perioperative patient care, utilization of peripheral nerve blocks for intraoperative anesthetics as well as postoperative pain management is becoming increasingly common. As such, there is a great need for anesthesiologists to understand the key anatomical principles and techniques necessary to successfully perform peripheral nerve blocks. In this text and DVD, Boezaart presents the most relevant and commonly performed peripheral nerve blocks utilized for orthopedic surgery. The book is comprised of 19 chapters organized logically from cervical to sacral nerves. Prior to discussion of each peripheral nerve block, there is a chapter discussing pertinent anatomical principles, mainly through full-color illustrations, gross anatomy images, and surface anatomy figures. Concise text accompanies these images to further the reader's understanding of nerve location, motor innervation, and sensory innervation (including dermatomes and osteotomes). Subsequently, 16 peripheral nerve blocks are described in a step-by-step manner, including single injection and continuous catheter techniques. Coinciding detailed clinical photographs taken during actual peripheral nerve block placement solidify the text descriptions. Additionally, basic ultrasound images depict anatomical structures during ultrasound-guided approaches. References in the text to correlating DVD segments provide the reader reinforcement of anatomical principles as well as short video clips of single injection and continuous catheter techniques. The DVD narration is succinct and the video images are of high resolution with readily identifiable anatomical landmarks and easy to follow techniques. Beyond describing techniques, the author includes guidance on the appropriate choice of peripheral nerve block for specific types of orthopedic surgery, especially indications for placement of continuous peripheral nerve catheters. The author also provides practical advice for choosing local anesthetics for both single injection and continuous catheter peripheral nerve blocks based on type of surgery, anticipated postoperative pain, and postoperative physical therapy goals. Specific doses as well as recommendations for patient-controlled bolus doses through continuous catheters included in the text and DVD are very helpful especially for novice practitioners. Furthermore, the author has included a section on common “pitfalls” in regional anesthesia and what to do to prevent their occurrence. It focuses on appropriate indications for use of peripheral nerve blocks, utilizing the correct technique and equipment, and rules to follow to avoid complications such as nerve ischemia. Despite the important information contained in this chapter, side effects or complications of peripheral nerve blocks, such as phrenic nerve block, Horner's syndrome, pneumonthorax, and development of block-related neuropathy, are not consistently discussed within the peripheral nerve block chapters. These are important considerations the regional anesthesiologist and patient must be aware of when performing these procedures. While this text provides readers with a concise resource of common peripheral nerve blocks, as the author mentioned in his preface, the text is not a comprehensive collection of all peripheral nerve blocks or all approaches. However, the focused nature of this atlas makes it an easily portable, quick read. Also, although the gross anatomy images contain detailed dissections, they lack sufficient structure identification. Additional labeling of the structures would improve the reader's understanding of the relationship between these structures. Overall, Dr. Boezaart has provided more than just an atlas with his latest publication. This text provides a step-by-step guide to performing peripheral nerve blocks for orthopedic surgery through text, images, and video clips. In addition, this text provides the reader a solid foundation of anatomical knowledge to utilize in selecting peripheral nerve blocks, understanding landmark-based techniques, and avoiding complications. It is an excellent addition to the regional anesthetist's library. Jennifer A. Sposito, MD Resident [email protected] Stuart A. Grant, MD Assistant Professor of Anesthesiology [email protected] Department of Anesthesiology Duke University Durham, North Carolina

A Novel Approach for Assessing Catheter Position After Ultrasound-Guided Placement of Continuous Interscalene Block

The increasing use of ultrasound has allowed anesthesiologists to perform nerve blocks with a high success rate and without nerve stimulation or eliciting a paresthesia. The ability to visualize peripheral nerve catheters using ultrasound is limited. We present a novel method to confirm the position of an interscalene catheter tip using injection of agitated contrast. The described technique is simple and allows timely assessment of catheter tip position.

Outpatient Management of Continuous Peripheral Nerve Catheters Placed Using Ultrasound Guidance: An Experience in 620 Patients

Outpatient Management of Continuous Peripheral Nerve Catheters Placed Using Ultrasound Guidance: An Experience in 620 Patients

Évaluation d’une colle liquide pour la fixation des cathéters périnerveux périphériques

Accidental dislodgement of continuous peripheral nerve catheters remains a frequent problem that causes failure of postoperative analgesia. We have assessed the use of new synthetic glue (Mastisol) to secure and maintain catheters in the correct position among 60 patients. This method allowed securing an effective fixation in 94% of cases,resulting in efficient ambulatory orthopedic surgery postoperative analgesia. No nervous or infectious complications were observed. This technique offers a simple, complementary method to secure peripheral nerve catheters.

The Safety and Efficacy of Extended Thromboprophylaxis With Fondaparinux After Major Orthopedic Surgery of the Lower Limb With or Without a Neuraxial or Deep Peripheral Nerve Catheter: The EXPERT Study

The benefit-risk ratio of extended fondaparinux therapy has not been assessed in patients undergoing major lower limb joint arthroplasty. Few data on the concomitant use of fondaparinux and continuous neuraxial or deep peripheral nerve blockade are available. We performed a prospective intervention study in patients undergoing major orthopedic surgery primarily designed to assess the efficacy of fondaparinux when drug administration was withheld for 48 h to permit removal of a neuraxial or deep peripheral nerve catheter. The safety and efficacy of extended fondaparinux therapy for the prevention of venous thromboembolism were also evaluated. Patients received a daily subcutaneous injection of 2.5 mg fondaparinux for 3 to 5 wk postoperatively. In patients with a neuraxial or deep peripheral nerve catheter, the catheter was removed 36 h after the last fondaparinux dose. The next fondaparinux dose was administered 12 h after catheter removal. The primary end points were symptomatic venous thromboembolism and major bleeding up to 4-6 wk after surgery. We recruited 5704 patients. A neuraxial or deep peripheral nerve catheter was inserted in 1553 (27%) patients and 78 (1.4%) patients, respectively. The rate of venous thromboembolism was 1.0% (54 of 5387). There was no difference between patients without (1.1%) or with (0.8%) a catheter (the upper limit of the 95% confidence interval of the odds ratio, 1.49, being below the predetermined noninferiority margin of 1.75). The incidence of major bleeding was 0.8% (42 of 5382). No neuraxial or perineural hematoma was reported. Once-daily subcutaneous injection of 2.5 mg fondaparinux given for 3 to 5 wk was effective and safe for prevention of venous thromboembolism after major orthopedic surgery. Temporary discontinuation of fondaparinux for 48 h permitted safe removal of a neuraxial or deep peripheral nerve catheter without decreasing thromboprophylatic efficacy.

Continuous Peripheral Nerve Blockade for Inpatient and Outpatient Postoperative Analgesia in Children

This is an audit of the continuous peripheral nerve blockade (CPNB) program that was implemented at our institution to provide postoperative analgesia after orthopedic procedures in children. We reviewed the departmental regional anesthesia registry and the medical records of consecutive children who received CPNB for postoperative analgesia at The Children's Hospital of Philadelphia between February 2003 and July 2006. Patients were prospectively followed until cessation of the effects of CPNB and/or resolution of any related complications. Data collected contemporaneously included presence of sensory and motor blockade, pain scores in inpatients, opioid administration, and complications related to CPNB. A total of 226 peripheral nerve catheters were placed in 217 patients. One hundred eight patients (112 catheters) were discharged home with CPNB. The ages ranged from 4 to 18 yr (13.7 +/- 3.4). Local anesthetic solution (0.125% bupivacaine [n = 164], 0.1% ropivacaine [n = 12], or 0.15% ropivacaine [n = 27]) was infused at an initial rate of 2-12 mL/h based on patients' weights and locations of catheters. The mean duration of local anesthetic infusion was 48.4 +/- 29.3 h (range 0-160 h). The percentage of patients who did not require any opioids in the first 8, 24, and 48 h after surgery was 56%, 26%, and 21%, respectively. The incidence of nausea and vomiting was 14% (13% in outpatients, 15% in inpatients). Complications were noted in 2.8% of patients. Three patients had prolonged numbness (>24 h) that resolved spontaneously; one developed superficial cellulitis that resolved with a course of antibiotics; one had difficulty removing the catheter at home and one developed tinnitus 24 h after starting CPNB that resolved quickly after clamping of the catheter followed by removal. It is feasible to implement a CPNB program to provide an alternative method of inpatient and outpatient postoperative analgesia after orthopedic surgery in children when appropriate expertise is available. Patient and family education along with frequent follow-up are crucial to detect and address adverse events promptly.

Spinal and Epidural Anesthesia.

Virginia Mason Medical Center, Seattle, Washington. michael.mulroy@vmmc.orgSpinal and Epidural Anesthesia. By Cynthia A. Wong, M.D. New York, McGraw-Hill, 2007. Pages: 374. Price: $99.00.Spinal and Epidural Anesthesia , edited by Cynthia Wong, M.D., is a multiauthor, in-depth textbook on neuraxial anesthesia. The authors have targeted a major subspecialty of regional anesthesia and focused on this subject in greater depth than the broader textbooks are capable of doing. Although Drs. Philip Bromage and J. Alfred Lee might disagree with the authors’ assertion that there “are no textbooks devoted solely to the clinical practice of spinal and epidural anesthesia,” it is true that there has not been such a textbook in the past 20 yr, and their offering makes a substantial step in bringing us all up-to-date with the advances in neuraxial technique and applications.The book is well designed, with in-depth chapters on the anatomy, pharmacology, and physiology of neuraxial techniques, complemented by an extensive section on the clinical application of these techniques to various subspecialties. These latter sections include obstetrics and postoperative pain management, as well as the many surgical subspecialties where neuraxial techniques are particularly useful. The chapters all exhibit extensive depth and modern references, although in the process they have omitted some of the classics that have not been surpassed (such as Abraham et al. ’s description of a spinal test dose of lidocaine).1The text is generally clear and well written and supplemented by a generous quantity of black-and-white illustrations and photographs. The lack of colored illustrations is only a minor drawback. The tables and highlights are particularly useful in stressing the key points and guiding the reader through the pertinent sections.The author has assembled an impressive collection of contributors to the various chapters, many of whom are clearly identified as experts in their subspecialty fields. The multiauthor aspect carries the inevitable counterbalance of depth from each author, combined with an unavoidable overlap on several of the important subtopics. And, of course, there is the personal bias of the individual chapter authors as to their favorite techniques. The issue of post–dural puncture headache, for example, is described in one chapter as “increased with youth” but in another as being “rare in pediatric patients.” The corollary discussion of epidural blood patch similarly suffers an unfortunate lack of detail in the discussion of the timing and ideal volume to be injected. Likewise, many of the chapters on subspecialty application of techniques repeat issues of dosage and side effects that are covered in the general chapters.Overall, however, there is excellent depth, despite a few omissions. In the Orthopedic chapter, there is the most fleeting reference to the advantages of peripheral nerve catheters as an alternative to neuraxial techniques when anticoagulation is an issue. The Chronic Pain section claims to address the issue of prevention of chronic pain, but does not address the recent awareness of chronic postsurgical pain that may be reduced by the more aggressive use of neuraxial analgesic techniques. And sometimes the depth is too much. The Acute Pain chapter includes so many options and alternatives, and even multiple recommended dose regimens, that the reader may leave the text with unanswered questions about where to start with a postoperative infusion. But that may be, as the authors point out, because there is no answer!Nevertheless, this text provides an in-depth review of our current understanding of neuraxial anesthesia and its clinical applications. It is a useful resource for both the trainee and the experienced clinician. The dilemma that will face most potential purchasers is the one that the authors identify in the preface: There are several general and regional anesthesia textbooks that already cover similar material in their specialized chapters. And on the other hand, the obstetrics chapters provide an excellent overview, but are they a substitute for a textbook devoted solely to the subject? There is no doubt that this textbook covers the material involved in great depth, and especially the clinical application of the neuraxial blocks. For someone wishing for a greater depth of knowledge and the most recent references in the field, this textbook offers a welcome addition to his or her library.Virginia Mason Medical Center, Seattle, Washington. michael.mulroy@vmmc.org

Outpatient Continuous Peripheral Nerve Catheters

In Response: We appreciate the comments of Drs. Chidiac and Perov (1) regarding our series of outpatients with continuous peripheral nerve blocks (CPNB). It is reassuring to learn that other programs have produced results similar to our own with respect to outpatient CPNB management. As more institutions adopt these protocols, patient care will be improved and the need for in-hospital pain control will be reduced. We agree that the use of lower anesthetic concentrations during catheter infusion is beneficial. In fact, after sending more than 1,000 patients home with CPNB, we also have transitioned to the use of 0.125% bupivicaine for all outpatient catheters. This change was due in large part to reports by patients of being “too numb.” We have observed that 0.125% bupivicaine provides adequate analgesia while sparing motor function in most cases. With respect to nerve stimulation, we could not disagree more strongly with Chidiac and Perov. For many years, nerve stimulation has been the “de facto” gold standard for peripheral nerve blocks because it was the only alternative to paresthesia techniques. This is despite evidence that nerve stimulators vary greatly in their accuracy of current output (2). Much worse, motor response (even at currents of 1 mA) is not a reliable indicator of direct needle contact with the nerve (3). As for the “further refinement” of stimulating catheters mentioned by Chidiac and Perov, we would direct the readers to recent publications comparing nerve stimulating versus nonstimulating catheters (4,5). These studies do not show any benefit of stimulating over nonstimulating catheters. The largest of these studies (419 patients), concluded, “a convincing argument has yet to be made for the routine use of the stimulating catheter …” (6). Ultrasound has been a welcome relief for those of us who are seeking a better alternative to NS techniques. In 2005, Marhofer reported more than 4000 blocks performed using only ultrasound guidance with success rates approaching 100% (7). Since that time, his numbers have almost certainly increased. Regarding ultrasound techniques, Marhofer accurately states, “Nerves are not blocked by the needle but by the local anesthetic.” Likewise, at the University of Utah, we stopped using the nerve stimulator over 2 years ago. We too, have performed over 3500 blocks (2000 catheters) using only ultrasound guidance. It should be no surprise that a technique successful for single injections would also work for catheter placement. The result has been a generation of residents from our program who have learned to “stay away from the nerve with the needle but reach the nerve with local anesthetic.” A prospective study at our institution shows a success rate of 97% for single blocks and catheters placed using only ultrasound guidance (8). This same study shows the cost savings (by eliminating the cost of stimulating needles) to be more than $16,000/yr when performing more than five nerve blocks per day. Ultrasound is ideal for catheter placement as a “stand alone” technique. We believe the nerve stimulation will soon take its place beside the copper kettle as a technique of only historical interest. In other words, yesterday’s “gold standard” has become today’s “old standard.” Jeffrey D. Swenson, MD Byron Bankhead, MD Department of Anesthesiology University of Utah Orthopaedic Center University of Utah Salt Lake City, Utah [email protected]

Outpatient Continuous Peripheral Nerve Catheters

Outpatient Continuous Peripheral Nerve Catheters

Continuous Peripheral Nerve Catheters in Patients Receiving Low Molecular Weight Heparin

Continuous Peripheral Nerve Catheters in Patients Receiving Low Molecular Weight Heparin

Continuous Peripheral Nerve Catheters in Patients Receiving Low Molecular Weight Heparin

Continuous Peripheral Nerve Catheters in Patients Receiving Low Molecular Weight Heparin

Minimally Invasive Retrieval of Knotted Nonstimulating Peripheral Nerve Catheters

Continuous peripheral nerve blockade is rapidly becoming the technique of choice for the management of postoperative orthopedic pain. However, the insertion of perineural catheters may be associated with complications, including catheter kinking and knotting. A knotted catheter may be difficult or impossible to remove at the patient bedside, requiring surgical excision under general anesthesia. We describe a previously unreported minimally invasive technique of retrieving knotted peripheral nerve catheters and avoiding the need for surgical intervention. Although the described technique has been used by interventional radiologists for the removal of knotted intravascular devices, it has not been previously described for the retrieval of knotted perineural catheters. The Mayo Clinic Acute Pain Service database was queried and patients identified with knotted peripheral nerve catheters during the 3-year period from January 2003 to January 2006. The medical records of all identified patients were retrospectively reviewed and details of catheter placement including catheter type and location, size (gauge), ease of placement, distance threaded, and duration of use recorded. During the study period, 5,964 nonstimulating peripheral nerve catheters were placed. Of these, 8 (0.13%) patients experienced catheter knotting resulting in difficult or impossible catheter removal at the bedside. Seven (88%) of the 8 catheters were successfully removed by using a minimally invasive technique of catheter retrieval using guided fluoroscopy. The remaining catheter was removed at the bedside with patient repositioning. The knotting of peripheral nerve catheters is a relatively uncommon phenomenon, occurring in only 0.13% of patients. However, because the use of perineural catheters has increased within anesthesia practice, clinicians may begin to encounter these complications with greater frequency. Practitioners should be aware of surgical alternatives, including guided-fluoroscopic techniques, when simple catheter traction or tension proves unsuccessful at the patient bedside.

Minimally Invasive Retrieval of Knotted Nonstimulating Peripheral Nerve Catheters

Minimally Invasive Retrieval of Knotted Nonstimulating Peripheral Nerve Catheters

Paediatric regional anaesthesia:new developments and improving accuracy

Regional anaesthesia can provide absolute pain relief without the risks of opiate-induced respiratory depression. The purpose of this paper is to (i) provide insight into some new techniques that may improve the success and accuracy of peripheral nerve blocks, with particular reference to the role of nerve mapping, nerve stimulators and portable ultrasound; (ii) introduce methods to reduce the risk of intraneural injection; (iii) suggest methods to prolong the analgesia provided by peripheral nerve blocks, i.e. continuous peripheral nerve catheters appropriate for use in children; and (iv) propose methods to manage local anaesthetic toxicity, with particular reference to the use of intralipid solutions.