Tips and tricks to site and maintain nerve catheters

@amit_pawa Dr Amit Pawa
Tips & Tricks To Maintain
Perineural Catheters &
Avoid Complications

Editorial
Interscalene catheters - should we give them the cold shoulder?
The benefits of single-shot inter-
scalene brachial plexus blockade
(SSIB) for patients undergoing
shoulder surgery are well estab-
lished [1]. These blocks have a
consistently high success rate, the
techniques are well described [2–4]
and are suitable for the vast major-
ity of patients presenting for
shoulder surgery. Single-shot blocks
can provide excellent analgesia for
11-14 hours, which mitigates the
that, at the moment, ambulatory
catheter techniques for shoulder
surgery are not widely employed,
and this may be related to logistical
and safety concerns. This seems to
be confirmed by the fact that there
are few published research papers
that have included more than
twenty patients [9]. Fredrickson
et al. should therefore be com-
mended for completing the largest
prospective observational study so
dyspnoea during the infusion at
home, which was surprisingly high
at 27% and was in contrast to the
0.7% of patients who experienced
this symptom immediately postoper-
atively.
As anaesthetists, we are inter-
ested in pain and dyspnoea, but
patients often have different con-
cerns, and they may find numbness
just as unpleasant as pain, thus
influencing their choice of analgesic
Anaesthesia 2016, 71, 359–372
a for shoulder surgery
SIB to allow same day
n the majority of cases.
provide reliable analgesia
ours, which can be pro-
h the use of adjuncts
adrenergic receptor ago-
dexamethasone, but the
d use of these drugs
t their uptake [20]. Sig-
a recent article reported
longation of analgesia of
hours with a single dose
ous dexamethasone com-
perineural dexametha-
The development of
elease formulations such
al bupivacaine may offer
before the branching of the supras-
capular nerve [25]. Performing a
nerve block at this level can provide
adequate analgesia for shoulder sur-
gery and may be less likely to result
in phrenic nerve palsy. Although
not commonly performed, the supe-
rior trunk block could provide a
safer target for catheter placement
because the locations of the needle
and catheter tip should be easily
visible when using ultrasound. A
recent letter by Lin et al. described
a single puncture approach to block
both the supraclavicular nerves and
the superior trunk of the brachial
plexus [26], however much more
work is required to determine the
up the level of knowledge and skill
in the wider anaesthesia community
to allow us to offer this service
safely.
Acknowledgements
No external funding and no com-
peting interests declared.
A. Pawa
Consultant
A. P. Devlin
A. Kochhar
Specialty Registrars
Department of Anaesthesia
Guy’s and St. Thomas’ Hospitals
London UK
Email: amit.pawa@gstt.nhs.uk
ociation of Anaesthetists of Great Britain and Ireland 361

We’ll Learn
together!
@amit_pawa

Sono
Thec
ultra
Who Wants to Site a Catheter?

Sono
Thec
ultra
Anesth Analg 2017;124:308–35.
Anesth Analg 2011;113:904–25.
Anesth Analg 2017;124:308–35.

@davejohnston24 @kiJinnChin

We’ll Cover
What Goals?
What Complications?
Catheter Types
Guidance techniques
Twitter Tips & Tricks
@amit_pawa

First..
Patient Selection
Pre-op Information
Exclude High Risk
Institutional Pathway
Follow Up Patients @amit_pawa

Catheter Goals
Close to Nerve & Effective (Not too close)
Avoid vessels
Quick & Easy to site
Comfortable for Patient
Secure & Leak-free
@amit_pawa

What can go wrong
with Catheters
@amit_pawa

Catheter Complications
They Dislocate & Accidentally Extract
They Get Stuck/Kink
They get Infected
They Migrate
They can be Mis-Located
They Leak
L.A.S.T @amit_pawa

Catheters Can Dislocate!
20 Volunteers
Femoral & Interscalene Catheters
Overall dislocation rate of 15%
(5% Interscalene, 25% Femoral)
@amit_pawa
REGIONAL ANAESTHESIA
Dislocation rates of perineural catheters: a volu
D. Marhofer1,2, P. Marhofer3*, L. Triffterer2, M. Leonhardt4, M. Weber1 and M. Zeit
1
Department of Clinical Pharmacology, Medical University of Vienna, Vienna, Austria
2
Department of Anaesthesiology and General Intensive Care Medicine, Medical University of Vienna, Vien
3
Department of Anaesthesiology and General Intensive Care Medicine, Head of Paediatric Anaesthesia, M
Austria
British Journal of Anaesthesia 111 (5): 800–6 (2013)
Advance Access publication 7 June 2013 . doi:10.1093/bja/aet198
@amit_pawa

4.9% Leaked
4.7% Dislodged
Of 501 Catheters
@amit_pawa

Trapped Catheter
Attempted Removal
Caused Neurology
Needed Surgical
Exploration
Catheters Can Get Stuck!

Catheters Can Get Infected!
nt were significant for tachycardia (heart rate,
e). Blood works were significant for a white
1,000, C-reactive protein 184 mg/L, and lactic
puted tomography of the right lower extremity
nd subcutaneous emphysema in the fat tissue
s lateralis muscle as well as the lateral margin
debridement and wound closure and was discharged to an inpatient
rehabilitation facility.
DISCUSSION
Advantages conferred by continuous over single-injection pe-
s progression of soft tissue infection.
Regional Anesthesia and Pain Medicine • Volume 41, Number 6, November-December 2016
methicillin-susceptible Staphylococcus aureus, and the patient was
placed on 6 weeks of intravenous ertapenem and mupirocin for nasal
staphylococcus decolonization. The rest of her hospital course was
uneventful. She returned to the operating room once for additional
Although the reported rates of inflamm
eter bacterial colonization (6%–57%) are see
evant infection is rare (0%–3%).10,11
The
organisms are coagulase-negative staphyl
FIGURE 2. Computed tomography scan of necrotizing fasciitis in the right lower extremity.
2 © 2016 American Society of Regional An
Copyright © 2016 American Society of Regional Anesthesia and Pain Medicine. Unauthorized reproduction of

Migrating to The Wrong Place
l was aimed
) and a 20-G
e needle tip
catheter was
a transparent
re uneventful
t was allowed
trachea was
sness. Respi-
mained stable
stay in the
is and lack of
or or sensory
or proximal
hours after
ransferred to Figure 1 Postmortem CT scan after attempted inter-
catheter Anaesthesia 2012, 67, 1166–1169
deﬁcit was not detected in the left arm side or proximal
to the brachial plexus distribution. Two hours after
completion of the surgery, the patient was transferred to
the orthopaedic ward.
At 23:00 on the day of surgery, the anaesthesia
resident on duty visited the patient, who was fully
oriented and calm, and described his pain as 3–4 on a
scale of 0–10. The resident elected to top up the catheter
with 10 ml bupivacaine 0.25%. At that time there was no
departmental protocol for checking a peripheral nerve
block catheter or for the administration of additional
local anaesthetic boluses through them. Three small,
fractionated, boluses were administered every 2–3 min,
each preceded by attempted aspiration. Once the top-up
had been completed, the resident noted no change in the
patient’s status and, after a short stay at the patient’s
bedside, he left the ward. The patient was next assessed
at 05:30 the following day when he was found dead in
his bed.
A postmortem CT scan with contrast dye injected
though the catheter revealed the catheter to be sited
intrathecally (Figs 1 and 2).
Discussion
Figure 1 Postmortem CT scan after attempted inter-
scalene catheter placement. The arrow points to a part of
the catheter near the intervertebral foramina at C5-6.
Figure 2 Postmortem CT scan after attempted inter-
Intrathecal “Interscalene"
POST-MORTEM CT SCAN
Case Report
Catastrophic complication of an interscalene catheter for continuous
peripheral nerve block analgesia
B. Yanovski,1
L. Gaitini,2
D. Volodarski3
and B. Ben-David4
Anaesthesia 2012, 67, 1166–1169 doi:10.1111/j.1365-2044.2012.07222.x
Anaesthesia 2012, 67, 1166–1169

Why are we siting catheters?
(Serious complications are uncommon) and …

Single shot block advantages PLUS
Flexibility:-
Block Duration
Block Intensity
Minimising Opioids & Side effects
@amit_pawa

We’ll Cover
What Goals?
What Complications?
Catheter Types
Guidance techniques
Twitter Tips & Tricks

Is One Catheter Better than Another?

Catheter-Types
Stimulating vs Non-Stimulating
Catheter-Through-Needle (C-T-N)
Catheter-Over-Needle (C-O-N)
Stiff vs flexible
Single vs Multioriface Catheters

Role for Stimulation?
Anesth Analg 2017;124:308–35.
@amit_pawa

Anesth Analg 2017;124:308–35.
Some stimulating catheters are
more likely to get stuck
@amit_pawa

Anesth Analg 2017;124:308–35.
Some stimulating catheters are
more likely to get stuck
US-guided catheters higher sucess rates?
US-guided catheters quicker than PNS
US-guided catheters more comfortable
US-guided catheters less vascular puncture?
@amit_pawa

Most Established
@amit_pawa

Needle Hole Bigger
than Catheter
Leakage likely
@amit_pawa

Familiar - Like epidural
Can vary target depth
Can vary amount of catheter threaded
Can tunnel them
No guarantee of tip location
Leakage common
More “complex” insertion
@amit_pawa

Newer Concept
@amit_pawa

Only Hole IS the Catheter
Leakage less likely - in theory
@amit_pawa

Familiar - like Single shot block
Does not leak at insertion site
Known tip position
Simpler insertion process
Less Flexibility:
Catheter has fixed lengths
Catheter protrudes a fixed distance past cannula
@amit_pawa

C-O-N
vs
C-T-N
Study
Terminated

110 patients - Knee arthroplasty
Femoral or Adductor Canal
C-O-N
vs
C-T-N
NO difference in Leak rate!
C-O-N - faster and NO dislodgement!
Note…low overall leakage (dermabond)

Single or Multi-oriface?
156 Out-of-Plane Interscalene catheters
1, 3, 6 hole - 3cm past needle tip
No real differences in pain outcome

Despite Multiple Options…
Catheter-Types
@amit_pawa

Despite Multiple Options…
Catheter-Types
No Superiority of one over another!
Personal/Institutional preference
Anatomical location dependant?
Ease of use/Skill of practitioner
@amit_pawa

PNSvs US
@amit_pawa
US has (largely) replaced PNS

PNSvs US
Use PNS if you would for Single shot block:
To exclude intraneural placement
For deep/poorly visible structures
@amit_pawa
US has (largely) replaced PNS
Dual: (PNS plus US) - no evidence of clear benefit
BUT…

Which Ultrasound Approach ?
@amit_pawa

Ilfeld et al Regional Anesthesia and Pain Medicine & Volume 35, Number 2, March-April 2010
S

& Volume 35, Number 2, March-April 2010
Societ
egionalAnesthesia&PainMedicine:firstpublishedas10.1097/A
LAX-IP takes time & is not easy
“The problem is in the execution: keeping 3
structures - the needle, nerve, and catheter -
in the ultrasound plane is not only very
difficult to learn but also difficult to execute
even after mastery” - Ilfeld 2010

& Volume 35, Number 2, March-April 2010
Societ
egionalAnesthesia&PainMedicine:firstpublishedas10.1097/A
LAX-IP takes time & is not easy
“The problem is in the execution: keeping 3
structures - the needle, nerve, and catheter -
in the ultrasound plane is not only very
difficult to learn but also difficult to execute
even after mastery” - Ilfeld 2010In Both Studies the LAX-IP
took longer to perform &
offered no clear advantages.

Ilfeld et al Regional Anesthesia and Pain Medicine & Volume 35,
What about the SAX techniques?
IP OOPVs

SAX-IP
Makes most sense to me! - But
Needle placement is not the endpoint
Where should tip of catheter go?
Catheter often exits past the nerve
@amit_pawa

SAX-IP
Makes most sense to me! - But
Needle placement is not the endpoint
Where should tip of catheter go?
Catheter often exits past the nerve
Where is the Catheter tip?!
@amit_pawa

SAX-OOP
Familiar technique (PNS-blocks & CVCs)
Probably most logical
Catheter close to nerve for longer?
Needle tip visualisation tricky
@amit_pawa

40 patients - foot & ankle surgery
20 SAX-IP
20 SAX-OOP
48 hrs later - contrast via catheter - MRI
Asses catheter displacement

40 patients - foot & ankle surgery
20 SAX-IP
20 SAX-OOP
48 hrs later - contrast via catheter - MRI
Asses catheter displacement
SAX-IP
SAX-OOP

SAX-OOP SAX-IP
Correct catheter
placement 20/20 20/20
48hrs later
Sub-paraneural
contrast
18/20 12/80 p=0.03
Frequency of
DISPLACEMENT 10% 40%
Oral Morphine (mg) 22.1 57.6 (150%)

Short distance of Catheter in
paraneural space
Muscle contraction causes
catheter movement
irrespective of skin fixation
Why May SAX-IP catheters displace?
@amit_pawa

What about SAX-IP vs OOP
for Interscalene?
Is SAX-OOP best for other sites?

for Interscalene?
Reg Anesth Pain Med 2011;36: 125-133

for Interscalene?
N= 110, Single operator
Interscalene SAX-OOP vs IP
Catheter : 2 cm beyond needle-tip
SAX-OOP - Easier/Quicker/More effective..

Why was the SAX-IP worse?
Reg Anesth Pain Med 2011;36: 125-133Traversed plexus?
@amit_pawa

Why was the SAX-IP worse?
Reg Anesth Pain Med 2011;36: 125-133Traversed plexus?
Kinked catheter?
@amit_pawa

Advtangeous for OOP?
@amit_pawa

SAX - Out-Of-Plane seems better…

Ki Jinn Chin Pro-Tip!
Movement of s/c tissue & muscle can
cause catheter migration
Some catheter slack in tissues may help
Withdraw needle tip into tissues, and then
feed catheter 1-2cm in to create a coil

Inject fluid before passing catheter?
No
Yes
I think fluid via needle
makes catheter
insertion EASIER
Probably no harm
@amit_pawa

LA via Needle OR Catheter?
Reg Anesth Pain Med 2007 32(45) 296-302
J Ultrasound Med 2015 34(2) 333-40
Makes NO
difference for
onset/success
I inject LA via Catheter
I want to know the
catheter is working!
@amit_pawa

How far should I thread my catheter?
@amit_pawa

How far should I thread my catheter?
Far enough - close to nerve
Not too far - avoid knots/kinks
More than 1 cm
Less than 5 cm

How can I find catheter tip?
Direct US visualisation - can be tricky…
Catheter movement
Injection of micro bubbles (use doppler)
Injection of air
Injection of fluid
@amit_pawa

Direct US visualisation - can be tricky…
Catheter movement
@amit_pawa

Injection of air/micro bubbles (use doppler)
@amit_pawa

Injection of fluid
Video courtesy KJC

How should I run my infusions?

Aim for Analgesia but Minimal Motor Block
Dilute LA (0.1-0.2% Ropi or 0.125% Bupi)
Rate 4-12 ml/hr - ?Site Specific
Bolus vs Continuous vs Both - ?Evidence
How should I run my infusions?
@amit_pawa

Tunnelling
To Prevent Dislocation

Porcine Model
Force required to DISLODGE catheter by 1cm?
Force Required (SD)
Untunnelled 0.23 N (0.06)
Single tunnelled 1.16 N (0.51)
Double tunnelled 4 N (1.7)
@amit_pawa

Tunnelling might also reduce infection…
22,411 Epidurals

How to Tunnel?
How to Tunnel?
@amit_pawa

Dermabond
Cyanoacrylate tissue adhesive
Waterproof wound closure
$18.50
Dermabond vs Mastisol
Mastisol (“similar” to Tincture Benzoin)
Liquid medical adhesive used to secure dressings
Not for wound closure
$1.50 @amit_pawa

66 Interscalene Catheters
Dermabond (32) vs Mastisol (34)
Catheter tip-to-nerve apposition at 48hrs
Results strongly IN FAVOUR of Dermabond
Minimal migration
Minimal leakage

What do most of twitterati do?
Dermabond to skin exit site
Mastisol around that
Then Steristrips
Then dressing
Video ——->

John M. Edwards III, MS CRNA @jedwardsIII &
Stace D. Dollar, MS, CRNA @stace_dollar

Lots of Dressings!!
Does it matter what we use?

Dressings - Be Sensible
Clean & dry skin thoroughly
Skin glue to prevent leakage at exit site (cost)
Mastisol/tinc benz under dressing site (allow to dry)
?Steristrips +/- coil of catheter
Use small, well applied dressings (edges stuck down)
Consider Tourniquet placement
Beware surgical drapes @amit_pawa

Don’t let catheters get pulled out

Sandwich Catheter &
connector in a dressing
Sacrificial
dressing

Select Patients carefully
Have Pathways for Monitoring & Follow up
Use Ultrasound to Site Your Catheters
Use a Sterile Technique
Start with the US technique you use for Single Shot blocks
(SAX-IP or SAX-OOP)
Summary 1
@amit_pawa

Familiarise yourself with available catheters
Use non-active fluid to distend the pocket for catheter
Thread no-more than 5 cm catheter in space
Consider Tunnelling you catheters
Deliver your LA via your Catheter
Use a dilute LA solution in your infusion
Summary 2
@amit_pawa

If cost allows - use skin glue at exit site
Be Meticulous with your dressing
Protect against surgical extraction
Follow ur patients up
Summary 3
@amit_pawa

Thank You
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@davejohnston24
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Tips and tricks to site and maintain nerve catheters

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Tips and tricks to site and maintain nerve catheters