Peripheral Nerve Catheters


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Presented by Dr.Nabil El-Kassabany

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Peripheral Nerve Catheters

  1. 1. Peripheral Nerve Catheters; Stimulating Versus Non stimulating An Evidence Based Approach Nabil M Elkassabany MD MSCE Assistant Professor Director; Orthopedic Anesthesia Section Department of Anesthesiology and Critical Care University of Pennsylvania Health System
  2. 2. Objectives <ul><li>1- Why do we need continuous nerve blocks? </li></ul><ul><li>2- The rationale behind using a stimulating catheter </li></ul><ul><li>3- Tutorial and practical tips for insertion of peripheral nerve catheter </li></ul><ul><li>4- To stimulate or not to stimulate; that is the question? </li></ul>
  3. 3. Continuous perineural analgesia <ul><li>Potential advantages: </li></ul><ul><li>better analgesia with fewer side effects than systemic opioids . </li></ul><ul><li>Peripheral techniques offer more targeted sensory and motor block </li></ul><ul><li>Minimal sympathetic block and hemodynamic disturbances </li></ul><ul><li>Less risk of catastrophic complications </li></ul><ul><li>Richman JM, et al. Anesth Analg 2006;102:248–57 </li></ul><ul><li>Fanelli G at al, Acta Anaesthesiol Scand 1998;42:80–4. </li></ul>
  4. 4. Continuous perineural analgesia versus systemic opioids A meta-analysis published in 2006 (19 RCTs with 603 patients) compared continuous perineural analgesia versus mixed systemic opioids (13 of 19 RCTs used IV PCA) Richman JM, et al. Anesth Analg 2006;102:248–57 Perineural analgesia, which can be used on an ambulatory basis, provided statistically superior analgesia at rest and with activity for 48–72 h with a reduction in risk of nausea, sedation, pruritus but increased risk of motor block. Clinically superior analgesia was apparent at rest for the first24 h and with activity for the first 48 h. Ilfeld BM, Enneking FK. Et al: Anesth Analg 2005;100:1822–33 Summary statement: Meta-analysis indicates that continuous perineural analgesia provides clinically superior analgesia for up to 48 h after surgery with reduced side effects when compared with systemic opioids.
  5. 5. Continuous perineural analgesia versus single shot blocks <ul><li>No consistent findings were reported. Three RCTs reported equivalent analgesia and side effects for total knee replacement, whereas the other two RCTs reported statistically superior efficacy with continuous analgesia for POD 1–3 or 4 in total knee replacement and anterior cruciate ligament repair. Analgesic differences were likely to be clinically appreciable for POD 1 and 2. No differences were noted in side effects. </li></ul>Hirst GC, et al. Reg Anesth 1996;21:292–7 Salinas FV, et al. Anesth Analg 2006;102:1234–9 Williams BA, et al. Anesthesiology 2006;104:315–27 Delaunay L, et al. Reg Anesth Pain Med 2005;30:117–22 Watson MW, et al. Reg Anesth Pain Med 2005;30:541–7
  6. 6. CONCLUSIONS: SSFNB or continuous FNB (plus PCA) was found to be superior to PCA alone for postoperative analgesia for patients having total knee arthroplasty. The impact of adding a sciatic block or continuous FNB to a SSFNB needs to be studied further.
  7. 7. Non Stimulating Catheres
  8. 8. The Rationale behind Stimulating Catheters <ul><li>Catheters need to be closely placed in the proximity of the target nerve(s) in order to decrease secondary block failure </li></ul><ul><li>Stimulating the nerve via the needle AND through the catheter while advancing the catheter achieve that goal </li></ul><ul><li>Assurance in “real time” that the catheter is correctly placed </li></ul>
  9. 9. The Rationale behind Stimulating Catheters <ul><li>Failure rate with conventional catheter is very variable. In some studies reported as high as 40% </li></ul><ul><li>Salinas FV. Reg Anesth Pain Med. 2003;28:79Y82. </li></ul><ul><li>CasatiA, et al,AnesthAnalg2005;101:1192-7 . </li></ul><ul><li>First introduced to practice in 1998 and then followed in 1999 by two reports using commercial systems </li></ul><ul><li>Sutherland. Reg Anesth Pain Med. 1998;23:496Y501. </li></ul><ul><li>KickO,et al. Anesth Analg. 1999;89:533Y534.5. </li></ul><ul><li>BoezaartAP, et al Can J Anaesth. 1999;46:275Y281 . </li></ul>
  10. 10. Stimulating Catheter Placement
  11. 11. The Catheter
  12. 12. The Needle
  13. 13. The Snap Lock
  14. 14. Catheter placement
  15. 15. Catheter placement ( cont)
  16. 16. Catheter placement ( cont)
  17. 17. <ul><li>Reg Anesth Pain Med. 2010 May-Jun;35(3):245-8 . </li></ul><ul><li>Does &quot;opening the perineural space&quot; before stimulating catheter placement for continuous nerve block add value in clinical practice? </li></ul><ul><li>Ficarrotta MR, Morey TE, Boezaart AP.Department of Anesthesiology, University of Florida College of Medicine, Gainesville, FL 32610-0254, USA. </li></ul>
  18. 18. Fixation of the catheter <ul><li>1- Surgical Glue (dermabond) </li></ul><ul><li>2- Paper sutures ( steristrips) </li></ul><ul><li>3- Benzion ( Mastisol) </li></ul><ul><li>4- Tegarderm </li></ul><ul><li>5- Tunneling ( Technique- Benefits) </li></ul><ul><li>6- Lock stat </li></ul>
  19. 19. Tunneling ( technique)
  20. 20. Tunneling ( technique)
  21. 21. Evidence for stimulating versus non stimulating catheters <ul><li>What is the evidence? </li></ul><ul><li>So far we have 12 RCTs </li></ul><ul><li>One observational study </li></ul><ul><li>Pham-DangC, et al. Reg Anesth Pain Med. 2003;28:83-88. </li></ul><ul><li>One cohort study </li></ul><ul><li>JackNT, et al. Br J Anaesth. 2005;95:250-254. </li></ul>
  22. 22. More about the evidence <ul><li>5 trials continous femoral nerve block </li></ul><ul><li>SalinasFV,et Reg Anesth Pain Med. 2004;29:212-220. </li></ul><ul><li>MorinAM,et al, Anesth Analg.2005;100:1503-1510. </li></ul><ul><li>HayekSM,et al. Anesth Analg. 2006;103:1565-1570. </li></ul><ul><li>DauriM, et al. Reg Anesth Pain Med. 2007; 32:282-287. </li></ul><ul><li>BarringtonMJ, et al. Anesth Analg. 2008;106:1316-1321. </li></ul><ul><li>4 trials sciatic at the popliteal fossa </li></ul><ul><li>PaqueronX, et al. Reg Anesth Pain Med. 2009;34:290-295. </li></ul><ul><li>CasatiA, et al. Acta Anaesthesiol Scand. 2006; 50:1284-1289. </li></ul><ul><li>RodriguezJ, et al. Anesth Analg. 2006;102:258-262. </li></ul><ul><li>Salinas FV. Reg Anesth Pain Med. 2003;28:79Y82 </li></ul>
  23. 23. More about the evidence <ul><li>2 trials interscalene blocks </li></ul><ul><li>StevensM, et al. Anesth Analg. 2007;104:442-447. </li></ul><ul><li>Birnbaum J, et al. J Clin Anesth. 2007;19:434-439 </li></ul><ul><li>1 trials infraclavicular block </li></ul><ul><li>DhirS,, et al. Acta Anaesthesiol Scand. 2008;52:1158-1166. </li></ul>
  24. 24. GREAT !!!! SO, Why we do not have a definitive answer? <ul><li>Different Outcome endpoints </li></ul><ul><li>Inconsistent study design across the RCTs, sometimes including more than one comparison group </li></ul><ul><li>Within the technique, different local anesthetic, different concentration, different adjuncts </li></ul>
  25. 25. <ul><li>Based on existing RCT data that examined diverse clinical scenarios and dissimilar outcomes, this semiquantitative review suggests improvement with stimulating catheters compared with nonstimulating catheters for continuous regional anesthesia. An effect on functional outcome remains to be proven. </li></ul>
  26. 26. Evidence for ultrasound placed catheter versus stimulating catheters
  27. 27. US guided catheter insertion
  28. 28. <ul><li>J Ultrasound Med. 2009 Sep;28(9):1211-8. </li></ul><ul><li>Ultrasound guidance versus electrical stimulation for infraclavicular brachial plexus perineural catheter insertion . </li></ul><ul><li>Mariano ER, Loland VJ, Bellars RH, Sandhu NS, Bishop ML, Abrams RA, Meunier MJ, Maldonado RC, Ferguson EJ, Ilfeld </li></ul>CONCLUSIONS : Placement of infraclavicular perineural catheters takes less time, is more often successful, and results in fewer inadvertent vascular punctures when using ultrasound guidance compared with ES.
  29. 29. <ul><li>J Ultrasound Med. 2010 Mar;29(3):329-36 . </li></ul><ul><li>A trainee-based randomized comparison of stimulating interscalene perineural catheters with a new technique using ultrasound guidance alone. </li></ul><ul><li>Mariano ER, Loland VJ, Sandhu NS, Bishop ML, Meunier MJ, Afra R, Ferguson EJ, Ilfeld </li></ul>CONCLUSIONS: Trainees using a new ultrasound-guided technique can place inter-scalene perineural catheters in less time compared to a well-documented technique using ES with a stimulating catheter and can produce equivalent results.
  30. 30. CONCLUSION: For popliteal-sciatic perineural catheters, ultrasound guidance takes less time and results in fewer placement failures compared with stimulating catheters. However, analgesia may be mildly improved with successfully placed stimulating catheters.
  31. 32. In Summary <ul><li>The rationale behind stimulating catheter </li></ul><ul><li>Technique </li></ul><ul><li>Evidence to support or to refute superiority of one versus the other </li></ul><ul><li>Ultrasound placement versus placement of stimulating catheter </li></ul>