Peripheral Nerve Catheters - Rajnish Gupta

PERIPHERAL NERVE CATHETERS
LESSONS FROM A DECADE OF PRACTICE
Rajnish Gupta, MD 
Associate Professor, Anesthesiology 
Vanderbilt University Medical Center
August 31, 2018
@dr_rajgupta

DISCLOSURES
▸ I’m the lead developer for the ASRA Coags, ASRA LAST, & ASRA Timeout apps
▸ My institution receives revenue from sales of the apps. I do not.

Youalreadyknow
thisstuff…
Peripheral nerve blocks improve patient outcomes

Youalreadyknow
thisstuff…
Opioid reduction in any amount is good for the patient

Youalreadyknow
thisstuff…
A lot can be achieved with multimodal analgesia and ERAS protocols

Youalreadyknow
thisstuff…
A lot can be achieved with multimodal analgesia and ERAS protocols
Peripheral nerve blocks can facilitate OR and PACU efﬁciency

OBJECTIVES
01Value of Continuous Peripheral Nerve Blocks over Single Shot Blocks

OBJECTIVES
02Complications related to CPNB and Pitfalls to avoid

OBJECTIVES
03Tips for an Ambulatory Catheter Management Program

OBJECTIVES
03Tips for an Ambulatory Catheter Management Program
04Alternatives and Future Directions

EDDIE 
 
68 yo M with
osteoarthritis,
scheduled for
primary Right TSA
VANESSA 
 
57 yo F with
reduced ROM after
TKA presenting Left
Knee Manipulation
and aggressive PT
KIKI 
 
24 yo F with history
Left ankle ORIF after
MVC. Presents for
ankle fusion due to
chronic ankle pain

BENEFITS OF CPNB
Improved analgesia vs Single-shot
Can reduce length of stay, particularly in ambulatory
Potential in reducing chronic pain and long-term
opioid escalation
Longer duration reduces risk of rebound pain
Enhanced physical therapy and rehabilitation
Improved Patient Satisfaction
Ilfeld BM. Anesth Analg. 2017

PAIN
HYPERSENSITIVITY
Kissin I. Anesthesiology. 2000
Prevention of long term pain or rebound pain is
dependent on both the timing and duration of nerve block

PAIN
HYPERSENSITIVITY
Short Duration Block — allows for rebound pain and
potential for long-term hypersensitivity

PAIN
HYPERSENSITIVITY
Longer Duration, Early Block - prevents re-initiation of
hypersensitivity, particularly for moderate levels of pain

PAIN
HYPERSENSITIVITY
Longer Duration, Early Block - prevents re-initiation of
hypersensitivity, particularly for moderate levels of pain
Longest Duration Block - will need significantly longer
analgesia if re-initiation has begun or surgical pain is profound

LENGTH OF STAY 
SINGLE SHOT VS CPNB
Lenart MJ. Pain Med. 2012

LENGTH OF STAY 
SINGLE SHOT VS CPNB
Patients with catheters were nearly twice as likely to be
discharged from the hospital than patients with no blocks for
Orthopedic surgeries

LENGTH OF STAY 
SINGLE SHOT VS CPNB
Didn’t hold true for our Total Knee Arthroplasty patients

LENGTH OF STAY 
SINGLE SHOT VS CPNB
Biggest benefit in Shoulder surgeries, LE amputations, and
Foot/ankle surgeries

NURSING
ADMINISTRATION
PHARMACY
SUPPLIES
PHYSICIANS
HOUSEKEEPING
COMPLICATIONS
ROOM
Hospital Day
$1000-$2000

SINGLE VS DUAL CATHETER FOOT/ANKLE SURGERY
Jarrell K. Foot Ankle Int. 2018

PATIENT SATISFACTION
0
1
2
3
4
5
6
7
8
9
10
DOS POD1 POD2 POD3

PATIENT SATISFACTION
0
1
2
3
4
5
6
7
8
9
10
DOS POD1 POD2 POD3
More pain in the single catheter (popliteal) group
Less satisfaction with the pain control in single catheter group
Increased opioid use on POD1 in the single catheter group

REBOUND PAIN
Rotator cuff repair:
single shot (G1) vs
catheter (G2) vs
no block (G3)
Kim J-H. Journal of Shoulder and Elbow Surgery. 2018.

REBOUND PAIN
Editorial Commentary:
“Pain and Stress
Response After
Shoulder Arthroscopic
Rotator Cuff Repair:
Does Interscalene Block
Make a Clinically
Important Difference?”
Rossi MJ. Arthroscopy. 2017.
*SISB - single dose interscalene block

REBOUND PAIN
Editorial Commentary:
“Pain and Stress
Response After
Shoulder Arthroscopic
Rotator Cuff Repair:
Does Interscalene Block
Make a Clinically
Important Difference?”
Rossi MJ. Arthroscopy. 2017.
*SISB - single dose interscalene block
“This calls into question the true
clinically important magnitude of the
effect of SISB* … further confounded
by the “rebound effect” seen by the
SISB/GA group at 18 hours
postoperation… We have all witnessed
this “getting behind the 8 ball” among
our patients when the block abandons
them to their less than saturated m-
opioid receptor… In the end, could the
rebound in pain mitigate against the
potential benefit of a block?”

REBOUND PAIN
Ankle Fracture Surgery - Patients’ experiences
Pre-emptive oral medications can help, but not 100%
People do value the mental alertness and pain relief when 
the blocks are working
Morphine was effective at controlling pain and 
temporarily decreasing the feeling of despair
Severe pain predominately occurred at night
Henningsen MJ. Anaesthesia. 2018.

REBOUND PAIN
“It was like they poured boiling
water over my foot – and then
imagine that for two hours without
any decrease in pain”

REBOUND PAIN
“I woke up at midnight, and
then, it was like ... it burned and at
the same time I couldn’t feel my
toes.”

REBOUND PAIN
“I woke up at midnight, and
then, it was like ... it burned and at
the same time I couldn’t feel my
toes.”
“When you’re in it, you must do
what’s necessary and then deal with
that [side effects] later.”

13,897 CONSECUTIVE REGIONAL ANESTHETICS AT AN AMBULATORY SURGERY CENTER
Malchow RJ. Pain Medicine. 2017

About 93% patients rate as
Good, Very Good, or Excellent

About 93% patients rate as
Good, Very Good, or Excellent
Leaking - 17% 
Dislodgment - 3.7% 
Pump/catheter issue - 0.9% 
Skin reaction - 0.8%

SAFETY FIRST
AMBULATORY SURGERY CATHETERS

SAFETY
Many prefer to keep catheter patients in
the hospital:
falls
leaking
dislodgment
block failure

SAFETY
Many prefer to keep catheter patients in
the hospital:
falls
leaking
dislodgment
block failure
“in the literature, an increase in catheter related
complications in the outpatient setting has never been shown”

COMPLICATIONS

COMPLICATIONS
Minimal complications during insertion
Catheter failures - 0.5 - 26%
Dislodgements (up to 25%)
Leaking (much less with skin glue)
Catheter damage/retention

COMPLICATIONS
Minimal complications during insertion
Catheter failures - 0.5 - 26%
Dislodgements (up to 25%)
Leaking (much less with skin glue)
Catheter damage/retention
LAST 
 
Major Hematoma
Infection
Nerve injury

INFECTION
Catheter colonization vs  
Inﬂammation of insertion site vs  
Actual local or systemic infection
Nicolotti D. J Clin Anesth. 2016. 
Bomberg H. Anesthesiology. 2018.

INFECTION
6-57%

INFECTION
6-57%
3-9%

INFECTION
6-57%
3-9%
0-3%

INFECTION
6-57%
3-9%
0-3%
Pathogen penetration is primary concern
breach in aseptic technique
contamination of lines (hub, filter, medication)

INFECTION
6-57%
3-9%
0-3%
Risk Factors:
trauma drug abuse malignancy diabetes
chemotherapy DMARDs ICU immunosuppression
location (axillary, femoral, interscalene) duration (↑ after 48 hr)

INFECTION
6-57%
3-9%
0-3%
Risk Factors:
trauma drug abuse malignancy diabetes
chemotherapy DMARDs ICU immunosuppression
location (axillary, femoral, interscalene) duration (↑ after 48 hr)
Only 31 out of 44,555
patients had severe infections
prompting surgical
intervention 
 
Only 5 of these had minimal
external signs of infection

INFECTION PREVENTION
Nicolotti D. J Clin Anesth. 2016
RECOMMENDED REASONABLE DISCUSSED
Remove watches and jewelry
Bacterial ﬁlters for long-term
catheters
Medicated dressings (chlorhexidine
impregnated)
Hand wash (surgical scrub or
antiseptic alcohol solution)
Prevent catheter, hub, site, dressing
violations
Antibiotic prophylaxis
Cap/mask/sterile gloves Catheter tunneling
Skin prep - Chlorhexidine gluconate
with isopropyl alcohol
Proper drug preparation and
storage
Sterile draping
Avoid frequent catheter
disconnections
Sterile Field
Appropriate dressings

NERVE INJURY (PONS)
Ilfeld BM. Anesth Analg. 2017 
Malchow RJ. Pain Medicine. 2017 
ASRA Image Gallery. www.asra.com/education/image-gallery
Incidence about 5% at 6 months
0.3 - 0.7% at 11 months

NERVE INJURY (PONS)
0.3 - 0.7% at 11 months
Etiology is often multifactorial
surgical 
positioning 
nerve block 
tourniquet 
Unclear how many would have PONS without blocks

NERVE INJURY (PONS)
0.3 - 0.7% at 11 months
Our incidence was 2.3% out of 13,897 patients 
Most were transient 
7% (12) of these, lasted beyond 6 months and probably due to anesthesia 
50% (6) of these were popliteal blocks
surgical 
positioning 
nerve block 
tourniquet 

NERVE INJURY (PONS)
0.3 - 0.7% at 11 months
surgical 
positioning 
nerve block 
tourniquet 
ULTRASOUND DOESN’T MAKE A DIFFERENCE

NERVE INJURY (PONS)
0.3 - 0.7% at 11 months
surgical 
positioning 
nerve block 
tourniquet 
ULTRASOUND DOESN’T MAKE A DIFFERENCE
CATHETERS AREN’T BETTER OR WORSE

CATHETER TYPES
Standard multipore

CATHETER TYPES
Tapered tip multipore

CATHETER TYPES
Flexible, monopore 
echogenic

CATHETER TYPES
Stimulating, monopore 
?echogenic 
?risk of retention
?

CATHETER TYPES
Catheter over needle

STIMULATION?
U/S favored over stimulation
Higher success rate
Takes less time
Less procedure-related discomfort
Lower risk of vascular puncture
Less costly
stimulation may be beneﬁt as adjunct
to U/S or for difﬁcult to visualize targets

SECURING THE
CATHETER
Transparent Dressings

SECURING THE
CATHETER
Mastisol

SECURING THE
CATHETER
Tunneling
Mastisol

SECURING THE
CATHETER
3-octyl cyanoacrylate
Tunneling
Mastisol

ADVICE FOR AMBULATORY SURGERY CATHETER SERVICE
Goldberg SF. Adv Anesth. 2017

Patient Selection
•Must be able to understand instructions
•Have Support systems
•Opioid tolerant patients often benefit the most from catheters
•Careful of high risk patients (e.g. respiratory dz and brachial
plexus catheters)

Patient Selection
plexus catheters)
Detailed instructions
•Common problems - leaking, dislodgement, block failure
•Major problems - LAST, falls, limb protection
•When to go to ED
•Instructions on how to protect catheter
•How to remove catheter

Patient Selection
plexus catheters)
•When to go to ED
Patient Followup and Contact
•24 hour contact number - for questions and problems
•Followup phone calls - until catheter removed

Patient Selection
plexus catheters)
•When to go to ED
Patient Followup and Contact
•24 hour contact number - for questions and problems
•Followup phone calls - until catheter removed
In our experience, patient phone calls are
minimal…about a 4% incidence of calls.

IMPROVED PAIN CARE
• PATIENTS GO HOME EARLIER
• PAIN IS BETTER CONTROLLED
• SIDE EFFECTS ARE MINIMIZED
• PATIENTS ARE MORE SATISFIED
A T - H O M E P A I N C O N T R O L
RECOVER WITH MANAGED PAIN IN YOUR OWN HOME
You are receiving a relatively new method of pain control, called
Continuous Regional Analgesia. A soft catheter lies near the nerves which
provide sensation to all or part of the surgical site, allowing local anesthetics
to numb the area and reduce pain. This provides very good pain control,
minimizes side effects such as constipation and drowsiness that are often
caused by traditional narcotic pain medications, and improves function, re-
covery, and overall patient satisfaction.
HOW IT WORKS
The type of pump you receive and how it operates will be explained to you
when you are discharged. There may be some patient controls on the pump
with which you will need to be familiar. All pumps, whether balloon-type or
battery-operated, are designed to rest in a pouch where it is connected to
the pain catheter. This allows you to perform normal daily activities such as
walking. The pump administers a small amount of local anesthetic medicine
through the catheter on a regular basis
— about a teaspoon or two an hour.
This medicine helps to decrease the
pain by partially numbing the area
where you had surgery. The idea is not
to completely numb the area, but to
decrease the pain you feel. Most likely,
both muscle strength and pain sensa-
tion will be decreased in the area to
some degree. If the area is completely
numb, and you have no strength in the
affected area, we may be able to re-
store some of your function without
pain by decreasing the rate of infusion.
Likewise, if the pain is too great, we
can usually increase the rate of
infusion.
For your safety, do not operate a vehicle or machinery with a pain
catheter in place. In addition, protect the numb extremity from injury by
using a sling, crutches, padding, knee immobilizer or other device while the
pain catheter is in place.
MANAGING YOUR PAIN CONTROL
A nurse or physician will contact you daily after your
discharge to follow up on your pain, nausea, itching,
and medication management. You will be asked to
rate your pain on a scale from 0-10, with “0” being
no pain and “10” being the worst pain imaginable. If
you experience mild to moderate pain, you may
increase the rate by 2ml per hour every 1-2 hours,
or you may take conventional pain medication by
mouth (such as Motrin, Percocet). If you experience
severe pain, it is safe for you to maximize your rate
at 14ml/hr for 1-3 hours until you are more comfort-
able, and then gradually decrease your rate to
6-10ml/hr as needed. Set the pump at only even
rates (for example, 6 ml per hour) since the pump
will not run with the dial set between even numbers
(for example, between 4 and 6 ml per hour).
During your follow-up call, you will also be asked if
you have the following symptoms: numb lips, ringing
in the ears, metal taste in the mouth, sudden in-
crease in anxiety, dizziness, sudden tiredness and
shortness of breath. If you have any of these symp-
toms or any other concerns at any time before, or
after the hospital contacts you, simply close the
clamp on the pump tubing (or turn the pump off) and
notify your anesthesiologist immediately. Please do
not disconnect the pump, leaving the catheter open
and exposed.
You will be asked if your catheter is secure, if the
clamp is open, if there is any pain, swelling, redness
at the catheter site, if the pump is delivering medica-
tion, and approximately how much medication is left
in the pump.
REMOVING THE CATHETER
You will be instructed at discharge and again by
phone on how to remove the catheter. It should
slide out easily with gentle pulling. There should not
be any electric, shooting pain in the same extremity
as you pull out the catheter. If there is electric, radi-
ating pain, stop pulling the catheter and contact the
anesthesiologist. Examine the blue tip of the cathe-
ter to make sure it is intact.

PUMPS - DISPOSABLE VS ELECTRONIC

PUMPS - PUMP SETTINGS

REPEATED BOLUSES

REPEATED BOLUSES
BASAL INFUSION ONLY

REPEATED BOLUSES
BASAL INFUSION ONLY
BASAL + BOLUS DOSE

REPEATED BOLUSES
BASAL INFUSION ONLY
BASAL + BOLUS DOSE
PROGRAMMED MANDATORY INTERMITTENT BOLUS

PUMPS - MEDICATIONS

PUMPS - MEDICATIONS
LOCAL ANESTHETICS:
Ropivacaine 
Bupivacaine 
Levobupivacaine 
(Lidocaine)
ADDITIVES:
None

PUMPS - MEDICATIONS
LOCAL ANESTHETICS:
Ropivacaine 
Bupivacaine 
Levobupivacaine 
(Lidocaine)
ADDITIVES:
None
“evidence accumulates that prolonged ropivacaine infusions—even at
relatively high doses >40 mg/h—have an extraordinarily low incidence of
inducing toxicity signs, symptoms, or plasma levels”

CPNB ALTERNATIVES TO
PROLONG NERVE BLOCKADE

ADJUVANTS
opioids
clonidine
dexmedetomidine
dexamethasone
epinephrine
magnesium
midazolam
tramadol
buprenorphine
Turner JD. The Journal of arthroplasty. 2018.

ADJUVANTS
opioids
clonidine
dexmedetomidine
dexamethasone
epinephrine
magnesium
midazolam
tramadol
buprenorphine
Most add less than 12 hours
None consistently exceed 24 hours 
May be able to reach 48 hours with combo
May increase side effects
Risk of neurotoxicity
May get same benefit given systemically

ADJUVANTS
opioids
clonidine
dexmedetomidine
dexamethasone
epinephrine
magnesium
midazolam
tramadol
buprenorphine
Most add less than 12 hours
None consistently exceed 24 hours 
May be able to reach 48 hours with combo
May increase side effects
Risk of neurotoxicity
May get same benefit given systemically
Since CPNB is used for at least 2 days,
these two techniques don’t really
“compete” with each other, but rather are
complementary

LIPOSOMAL BUPIVACAINE
Abildgard JT, J Shoulder Elbow Surg. 2017

Improved analgesia against saline - wound inﬁltration

Equivocal against plain bupivacaine  
(10/12 RCTs - no advantage for primary analgesic outcome)

No blinded RCTs comparing CPNB to LB

One study - FNB with LB - 72 hrs analgesia

Recent approval for ISB block 
based on a phase 3 study comparing it to placebo

Recent approval for ISB block 
based on a phase 3 study comparing it to placebo
One study showed better results with CPNB vs LB for ISB 
VAS scores in the PACU (1.91 vs 7.25) 
VAS scores on POD0 (3.20 vs 4.99) 
Total opioid consumption (91.70 vs 189.50)

PERCUTANEOUS NERVE
STIMULATION
Gabriel RA. Anesthesiology Clinics. 2018

PERCUTANEOUS NERVE
STIMULATION
Unclear mechanism

PERCUTANEOUS NERVE
STIMULATION
Unclear mechanism
Possible Gate-control theory

PERCUTANEOUS NERVE
STIMULATION
Unclear mechanism
Ideally - no sensory, proprioception, or motor
deﬁcits

PERCUTANEOUS NERVE
STIMULATION
Unclear mechanism
deﬁcits
No risk of LAST or leakage

PERCUTANEOUS NERVE
STIMULATION
Unclear mechanism
deﬁcits
Can be left in for long periods of time (6 weeks+)

PERCUTANEOUS NERVE
STIMULATION
Unclear mechanism
deﬁcits
Can be left in for long periods of time (6 weeks+)
???Does it work

CRYO-ABLATION

CRYO-ABLATION
Cold temperatures generated at the tip of probe

CRYO-ABLATION
Wallerian degeneration of nerve (reversible?)

CRYO-ABLATION
Inhibits future transmission of efferent signals

CRYO-ABLATION
Ideally for non-motor nerves only

CRYO-ABLATION
Unpredictable duration of actions (weeks…. months)

CRYO-ABLATION
Unpredictable duration of actions (weeks…. months)
Examples: 
iliac crest harvesting 
cutaneous and patellar nerves for TKR 
superﬁcial nerves for thumb surgery 
suprascapular nerve for rotator cuff repair 
digit/limb amputations

INSPIRATIONWhat was the most inspiring thing I’ve ever said to you?…”Don’t be an idiot.” Changed my life. 
Whenever I’m about to do something, I think “would an idiot do that?”… and if they would, I do not do that thing.

THANK YOU! raj.gupta@vumc.org
@dr_rajgupta

Peripheral Nerve Catheters - Rajnish Gupta

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