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![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
severe postoperative pain that can
follow shoulder surgery. In the
UK, these patients are commonly
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
far that has investigated the safety
of such an analgesic regimen.
In approximately 1500 patients
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
technique. It would have been inter-
esting to learn how patients per-
ceived their recovery with
Anaesthesia 2016, 71, 359–372
houlder surgery
llow same day
ajority of cases.
eliable analgesia
ich can be pro-
se of adjuncts
ic receptor ago-
hasone, but the
of these drugs
ptake [20]. Sig-
article reported
of analgesia of
th a single dose
methasone com-
ral dexametha-
evelopment of
mulations such
caine 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
naesthetists of Great Britain and Ireland 361
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Peripheral Nerve Catheters - an introduction
Dr. Amit Pawa discusses the use of peripheral nerve catheters for analgesia in shoulder surgery, highlighting the effectiveness of single-shot interscalene blocks and the potential benefits of catheter techniques despite current logistical challenges. The document emphasizes the importance of patient selection, safety during catheter placement, and multimodal analgesia to improve postoperative outcomes. It also reviews complications and suggests improvements for catheter use based on a retrospective study conducted at Guy's Hospital.
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Peripheral Nerve Catheters - an introduction
- 1. Dr Amit Pawa@amit_pawa Peripheral Nerve Catheters So Th ul
- 2. Disclosures RA-UK President Honoraria fromGE Healthcare Consult for B Braun Medical Ltd @amit_pawa
- 3.
- 4. I have aconfession…
- 5. 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 severe postoperative pain that can follow shoulder surgery. In the UK, these patients are commonly 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 far that has investigated the safety of such an analgesic regimen. In approximately 1500 patients 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 technique. It would have been inter- esting to learn how patients per- ceived their recovery with Anaesthesia 2016, 71, 359–372 houlder surgery llow same day ajority of cases. eliable analgesia ich can be pro- se of adjuncts ic receptor ago- hasone, but the of these drugs ptake [20]. Sig- article reported of analgesia of th a single dose methasone com- ral dexametha- evelopment of mulations such caine 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 naesthetists of Great Britain and Ireland 361 @amit_pawa
- 6.
- 7. I will ShareOur Experience @amit_pawa
- 8. In the next30mins… Why Catheters? Indications Our Practice at GSTT Tips @amit_pawa
- 9.
- 10. @amit_pawa Essential analgesic “ingredient” OpioidReduction Alternative to GA Superior Recovery Patient Satisfaction Ambulatory/Fast-Track Surgery Why Regional Anaesthesia?
- 11. @amit_pawa Essential analgesic “ingredient” OpioidReduction Alternative to GA Superior Recovery Patient Satisfaction Ambulatory/Fast-Track Surgery Why Catheters?
- 12. @amit_pawa Essential analgesic “ingredient” OpioidReduction Alternative to GA Superior Recovery Patient Satisfaction Ambulatory/Fast-Track Surgery Why Catheters? Maintain These Benefits for Longer
- 13.
- 14. Catheter Goals Close toNerve & Effective (Not too close) Avoid vessels Quick & Easy to site Comfortable for Patient Secure & Leak-free
- 15. Why might webe siting more? Catheter design Fascial Plane Blocks Ultrasound
- 16.
- 17.
- 18. Sono Theco ultraso Catheter-Through-Needle (C-T-N) Needle HoleBigger than Catheter Leakage likely
- 19. Familiar - Likeepidural Can vary target depth Can vary amount of catheter threaded Can tunnel them No guarantee of tip location Leakage common More “complex” insertion Catheter-Through-Needle (C-T-N)
- 20.
- 21. Only Hole ISthe Catheter Leakage less likely - in theory Catheter-Over-Needle (C-O-N)
- 22. Familiar - likeSingle shot block Does not leak at insertion site Known tip position Simpler insertion process Less Flexibility: Catheter has fixed lengths Catheter-Over-Needle (C-O-N)
- 23.
- 24. Fascial Plane Blocks TAP PECS SerratusPlane ESP Easier/Safer/Alternative end-points?
- 26.
- 27.
- 28. Contraindications… Patient Refusal Allergy toLocal Anaesthetic Infection at Insertion Site (& Systemic) Chronic Pain unrelated to admission?
- 29. What can gowrong with Catheters
- 30. 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
- 31. 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 Despite these (rare) risks, there is still a role for catheters!
- 32.
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- 36.
- 37.
- 38. Orthopaedics TKR - AdductorCanal catheters Ankle - Popliteal catheters Shoulder - Interscalene catheters Hand/wrist - Infra/supraclavicular catheters
- 39.
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- 48.
- 49. Regional Anesthesia andPain Medicine • Volume 42, Number 2, March-Ap COMBINATION?
- 50. General/Gynae Rectus Sheath catheters TAPcatheters QLB catheters ESP catheters
- 51.
- 52. Thoracics Paravertebral catheters Serratus Planecatheters ESP catheters
- 53.
- 54. Vascular Femoral catheters Sciatic catheters BrachialPlexus catheters
- 55.
- 56. Plastic/Breast Surgery Breast -PECS/PVB/ESP catheters Limbs - BPB/Sciatic catheters Abdomen - TAP/QLB catheters
- 57.
- 58. Trauma #NOF- Femoral/FICB catheters #Ribs- PVB/ESP/Serratus catheters
- 59. GSTT Experience KT11 1EW DataCollection thanks to Dr Ann “The Red” Barron Dr Simon “Big G’ FitzGerald Dr Joel “Deep Mind” Lockwood
- 60. 01-Jan-2018 to 31-Dec-2018 Retrospective PatientsIdentified via MedChart Data collection - scanned anaesthetic chart - electronic patient records (EPR) - E-noting - MedChart
- 61. Yield & Demographics 50nerve catheters identified (data on 45) Average patient age = 63.89 years Average prescription duration (days) = 2.83 (0.16 – 8)
- 62. Surgery Type Count AboveKNEE Amputation 14 Below KNEE Amputation 10 Lower limb Free flap sugery 2 ANKLE ORIF 1 HIP metastases 1 ischaemic FOOT 1 Revision Total KNEE Replacement 1 WRIST fusion 5 MCPJ replacement 2 Above ELBOW amputation 1 Abdominal surgery 3 RIB fractures 2 Open oesophagectomy 1 VATs + pleurectomy 1 WLE BREAST 1 Lower Limb Upper Limb Trunk
- 63.
- 64. Nerve catheter typeCount Sciatic nerve 18 Tibial 4 Femoral 2 Fascia iliaca 1 Infraclavicular 7 Erector spinae plane (ESP) 4 Paravertebral (PVB) 3 Quadratus Lumborum (QLB) 1 Rectus sheath 1 Serratus plane 1 Lower Limb Upper Trunk
- 65.
- 66. Documented complications Fell outwithin 24hrs Fell out, PRN morphine increased Pulled out by patient Slightly dislodged, leaking Pulled out by patient overnight on day 0, fent. PCA Catheter separated from filter Catheter occlusion overnight - switched to PCA Pain in recovery. Catheter taken out Poorly tolerated, inhibited mobilisation, asked to remove Fixation issues Failure Poor Patient Selection/Preparation
- 68. First year data- small numbers Lessons/Room for Improvement Surgical Engagement = Key Guidelines/Pathway essential Training essential Need infrastructure…
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- 70.
- 71.
- 72. Nurses Anaes Surgeons ODP/ODA STAFF 24 Hr cover Patient Selection Block Room Engaged Data Capture Tool Adverse Event Detection Catheters Consumables & Infrastructure MONEY Governance Training @amit_pawa STAFF MONEY Governance Infrastructure ODP/ODA Nurses Data Capture Tool 24Hr cover Training Anaes Adverse Event Detection Block Room Engaged Surgeons Catheters Consumables Patient Selection
- 73.
- 74.
- 75. First.. Patient Selection/Identification Pre-procedure Info ExcludeHigh Risk Institutional Pathway/guidelines Follow Up Patients - Pain team
- 76. How should Irun my infusions?
- 77.
- 78.
- 79. Infusion Options Depends onavailable equipment!
- 80. Aim - Analgesia& 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 +/- PCRA ?Evidence How should I run my infusions?
- 81. ConsiderTunnelling To Prevent Dislocation ToPrevent Dislocation To Prevent Dislocation To Prevent Dislocation
- 82. How to Tunnel? Howto Tunnel…
- 83. How to Tunnel? Howto Tunnel…
- 84.
- 85. Dermabond Cyanoacrylate tissue adhesive Waterproofwound closure $18.50 Dermabond vs Mastisol Mastisol (“similar” to Tincture Benzoin) Liquid medical adhesive used to secure dressings Not for wound closure $1.50
- 86. What do mostpeople do? Dermabond to skin exit site Mastisol around that Then Steristrips Then dressing Video ——->
- 87. John M. EdwardsIII, MS CRNA @jedwardsIII & Stace D. Dollar, MS, CRNA @stace_dollar
- 88.
- 89.
- 90. Lots of Dressings Doesit matter what we use?
- 91. Dressings - BeSensible 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
- 92. Don’t let cathetersget pulled out
- 93. Sandwich Catheter & connectorin dressing Sacrificial dressing
- 94. Sandwich Catheter & connectorin dressing Sacrificial dressing
- 95.
- 96.
- 97. Select Patients carefully Guidelinesfor Monitoring & Follow up Use Ultrasound to Site Your Catheters Use a Sterile Technique Summary 1
- 98. Familiarise yourself withavailable catheters Consider Tunnelling your catheters Deliver your LA via your Catheter Use a dilute LA solution in your infusion Summary 2
- 99. If cost allows- use skin glue at exit site Meticulous dressing Protect against surgical extraction Co-Prescribe Multimodal analgesia Document Back-up/Cessation Plan Follow ur patients up Summary 3
- 100.