update on continuous peripheral nerve block techniques

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Update on Continuous Peripheral Nerve Blocks

Edward R. Mariano, M.D., M.A.S.Professor of Anesthesiology, Perioperative & Pain

MedicineStanford University School of Medicine

Chief, Anesthesiology and Perioperative CareVeterans Affairs Palo Alto Health Care System

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Financial Disclosures Halyard, B Braun – Unrestricted

educational program funding paid to my institution

The contents of the following presentation are solely the responsibility of the speaker without input from any of the above companies.

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“Precision” Acute Pain Medicine

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OverviewWho can do it?What do you need?Where should you

place them?Why bother?How do you make it

work?

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Mariano ER, et al. JUM 2015;34:1883

Lectures,

Scanning

Iterative Practice,Simulatio

n

8 Hour Program

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work?

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Single-Orifice orMulti-Orifice

Stimulating orNon-Stimulating

Flexible Springwound or

Rigid Plastic

Through or Over the Needle

Catheter Designs

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Remember Other Supplies

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work?

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Indications Surgery limited to one extremity

(ideally one nerve distribution) Moderate to severe postoperative

pain anticipated Facilitate same-day discharge and

avoid hospitalization for pain management

Improve vascular supply Early physical therapy and

rehabilitation

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Possible CPNB Insertion Sites

Catheter Site Surgical SiteInterscalene Brachial Plexus

Shoulder, proximal humerus

Supra- or Infraclavicular Brachial Plexus

Elbow, forearm, wrist, hand

Axillary Brachial Plexus Wrist, handPosterior Lumbar Plexus orFemoral Nerve/Fascia Iliaca

Hip, thigh, knee

Femoral Nerve/Adductor Canal

Knee

Sciatic Nerve Leg, ankle, foot

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Interscalene vs. Supraclavicular

RCT: arthroscopic shoulder surgery

SupraclavicularUS-Guided Catheter

Randomized(n=120, observer blinded)

InterscaleneUS-Guided Catheter

Primary outcome: hemidiaphragmatic paresis in PACU and POD1

Secondary outcomes: pain scores, opioid consumption, lung function, complications

Wiesmann, et al. Acta Anaes Sc 2016;60:1142

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Interscalene vs. Supraclavicular

Any phrenic palsy (PACU) 55% in SC group vs. 82% in IS group

No clinical differences in pulmonary function

No differences in pain or opioid consumption

Wiesmann, et al. Acta Anaes Sc 2016;60:1142

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Supra- vs. Infraclavicular CPNB IRB-approved, distal upper extremity surgery

InfraclavicularUS-Guided Catheter


SupraclavicularUS-Guided Catheter

Primary outcome: average pain on POD 1 Secondary outcomes: onset time, least and

worst pain on POD 1, opioid consumption, leakage rates, awakenings, and satisfaction

Mariano ER, et al. RAPM 2011;36:26

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Results

Oxycodone: IC 0.0 (0.0-5.0) vs. SC 5.0 (0.0-15.0; p=0.048)

No other differencesMariano ER, et al. RAPM 2011;36:26

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Femoral vs. Lumbar Plexus CPNB

IRB-approved, total hip arthroplasty

Lumbar PlexusStimulating Catheter


Femoral Nerve Stimulating Catheter

Primary outcome: average of pain scores for 24 h (equivalency trial)

Secondary outcomes: procedural time, ambulation, opioid consumption, and satisfaction Ilfeld BM, Mariano ER, et al. A&A

2011;113:897

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Results Lumbar plexus

catheters took longer to place than femoral catheters– 12.5 (6.2-19.7) min

LP– 7 (4-17.2) min

femoral– P=0.03

No other differences

Ilfeld BM, Mariano ER, et al. A&A 2011;113:897

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work?

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CFNB and Knee ArthroplastyKnee Flexion (Degrees)PCA CFNB P Value

POD #1 33 ± 15 56 ± 22 0.009POD #3 53 ± 17 74 ± 11 <0.0016 weeks 103 ± 12 116 ± 12 0.033 months 116 ± 11 124 ± 12 NS

Singelyn FJ, et al. A&A 1998;87:88

Is this a possible long-term effect??

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Ropiv Saline

Can Patients Go Home Faster?

50 subjects, tricompartment TKA CFNB with 1 night infusion of

ropivacaine: randomized to ropiv vs. saline on POD1

Ilfeld BM, et al. Anesth 2008;108:703

3 Discharge Criteria:1. NRS (pain) < 42. IV opioid-free x 12

hours3. Ambulating > 30

meters

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We Know They Work…



Ilfeld BM, et al. A&A 2003;96:1089

Placebo group received initial bolus of LA = single-injection block

So Why Isn’t Everyone Doing

Them?

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work?

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The “Gold Standard”

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Why Ultrasound for CPNB?

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Needle Guidance Options

Ilfeld & Mariano. RAPM 2010;35:123

?

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Short-Axis In-Plane Technique


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US vs. NS for CPNB 4 IRB-approved randomized clinical trials

Nerve StimulationStimulating Catheter

Randomized(n=160, not blinded)

UltrasoundNonstimulating Catheter

Primary outcome: catheter placement time (min)

Secondary outcomes: pain during placement, venous puncture and leakage rates, pain on POD 1

Mariano ER, et al. JUM 2009;28:1453Mariano ER, et al. JUM 2010;29:329

Mariano ER, et al. RAPM 2009;34:480Mariano ER, et al. JUM 2009;28:1211

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ResultsPopliteal

Mariano ER, et al. RAPM 2009;34:480Mariano ER, et al. JUM 2009;28:1211Mariano ER, et al. JUM 2009;28:1453Mariano ER, et al. JUM 2010;29:329

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Results US: less procedure-related pain

– Femoral, popliteal US: less inadvertent vascular

punctures– Femoral, infraclavicular

US: higher success rate– Infraclavicular

Mariano ER, et al. RAPM 2009;34:480Mariano ER, et al. JUM 2009;28:1211Mariano ER, et al. JUM 2009;28:1453Mariano ER, et al. JUM 2010;29:329

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Long-Axis In-Plane Technique


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Long- vs. Short-Axis In-Plane IRB-approved; 2 substudies (both lower

extremity)

Short-Axis In-PlaneUS-Guided Catheter


Long-Axis In-PlaneUS-Guided Catheter

Primary outcome: onset time following bolus (min)

Secondary outcomes: procedural time, pain during placement, venous puncture and leakage rates, pain and weakness on POD 1

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Results: Femoral (n=50) Onset time: SAX

took 9.0 (6.0-20.4) min vs. 6.0 (3.0-14.4) min for LAX (p=0.044)

Procedural time: SAX 5.0 (4.0-7.8) min vs. 9.0 (7.0-14.8) min for LAX (p<0.001)

No other differences

Similar results for popliteal-sciatic

Mariano ER, et al. JUM 2013;32:149Kim TE, et al. J Anesth 2014;28:854

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Stimulating techniques: catheters do not stay “next” to nerves1,2

– Non-stimulating catheters: advance <3 cm1 for >96% success rate3,4

– For 4-10 cm: stimulating beats non-stimulating5-6

What about ultrasound-guided catheters?– 1 cm vs. 5 cm (in-plane): no difference7

2. Capdevila X, et al. A&A 2002;94:1001

1. Enneking K. RAPM 2007;32:280 4. Capdevila X, et al. Anesth 2005;103:10355. Rodriguez J, et al. A&A

2006;102:2586. Casati A, et al. A&A 2005;101:1192

3. Borgeat A, et al. Anesth 2003;99:436

How Far Should You Insert?

7. Ilfeld BM, et al. RAPM 2011;36:261

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Leng & Mariano, et al. J Anesth 2015;29:308

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Catheter Type and Migration

Steffel & Mariano, et al. K J Anesth 2017;70:72

Cadaver-based studyCON: 4/15 (27%) dislocated vs. CTN 0/15 (p=0.043)

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Fluid injection (1-3 mL)– Good: does not hinder subsequent ultrasound

visualization– Bad: catheter tip location inferred, not visualized

Air injection (0.5-1 mL)– Good: excellent visualization of catheter tip location– Bad: may hinder subsequent ultrasound

visualization Agitated fluid injection (1-2 mL) with Color

Doppler– Combination of pros & cons of above two methods– Bad: requires additional time to agitate fluid

Checking Catheter Tip Position

Sandhu NS, et al. Anesth 2006;104:199Swenson, JD, et al. A&A 2008;106:1015

Kan & Mariano et al. JUM 2013;32:529Johns & Mariano et al. JUM 2014;33:2197

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Dressing the Catheter Consider tunneling to

minimize leakage Use an anchoring

device1

Liquid adhesive Clear occlusive

dressing Consider glue2

No sutures: patients can remove catheter themselves at home after infusion ends

1. Borg and Mariano, et al. K J Anesth 2016;69:5062. Klein SM, et al. Anesth 2003;98:590

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Select a Regimen Infuse local anesthetic

solution (no adjuvants)

Ropivacaine preferred over bupivacaine

Should include basal rate (4-8 ml/hr) with PC bolus (2-5 ml) every 20-60 minStart: Ropivacaine 0.2%, 6 ml/hr + PCA 5 ml q 30 min

initiallyMay need to hold femoral and lumbar plexus infusions

before PTTitrate infusion and adjust settings to individual patient

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Educate Patients Tell patients to expect leakage Warn patients about motor block Give them contact info for provider

24/7 Clear instructions for infusion device Routine follow-up (esp if catheter)

–Home nursing not necessary–Phone contact by provider once

daily–Caretaker for first 24 hours

preferredIlfeld BM, et al. RAPM 2003;28:418

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Summary We discussed:

–Who can do it?–What do you need?–Where should you place them?–Why bother?–How do you make it work?

update on continuous peripheral nerve block techniques

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