Perineural catheters and continuous peripheral nerve blocks (CPNB) are synonymous. Those two terms will be used indifferently in this chapter.
- More commonly used for inpatients after surgical procedures expected to cause significant pain for >12–24 hours
- Can be used in ambulatory setting. Appropriate patient selection is paramount
- Help minimize opioid consumption and adverse effects
- Fewer side effects (hemodynamic) than neuraxial analgesia, less interference with thromboprophylaxis
- Sympathectomy and vasodilation to increase perfusion after vascular accident, digit transfer/replantation, or limb salvage
- Possible benefits include increased tolerance of passive range of motion for joint replacements and shorter times to meet discharge criteria
- Full sterile precautions (chlorhexidine skin prep, sterile gloves, hat, mask, and large drape)
- Kits on the market contain an insulated needle for nerve stimulation and either a stimulating or a nonstimulating catheter
- If not available, an epidural kit may be used with ultrasound guidance
- Unclear whether using a stimulating catheter results in lower rates of secondary block failure. Some data suggest that US-guided catheter insertion results in more effective postoperative analgesia
- Technique used ultimately dependent on operator preference and time available for procedure. Consider combined use of US and nerve stimulator for deeper nerve blocks (e.g., sciatic, psoas compartment), where US view may be suboptimal
Placement of Stimulating versus Nonstimulating Catheters Using Neurostimulation
|Nonstimulating catheter||Stimulating catheter|
Clip off hair surrounding block site if needed
Sterile prep and drape
Set nerve stimulator to 2 Hz, 0.01–0.03 ms, 1.2 mA
Tuohy needle to elicit appropriate motor response
Optimize needle position to maintain response at 0.2–0.5 mA
Aspirate to rule out intravascular/intrathecal position
Hold needle steady in that position and inject desired dose of local anesthetic
Catheter is advanced about 2–3 cm past needle tip
See the section “Securing Catheter”
- 7. Holding needle steady, inject 5–10 mL D5W (nonconductive) to distend perineural space
- 8. Attach stimulator to catheter and advance through needle
- 9. The motor response should be similar to that elicited by needle stimulation
- 10. Catheter is advanced 2–3 cm beyond the needle tip while maintaining an appropriate motor response
- 11. There is no clear guideline as to what is an acceptable stimulating current to confirm proper catheter placement
- 12. Remove needle and catheter stylet
- 13. See the section “Securing Catheter”
- Ultrasound can be used in conjunction with nerve stimulator depending on operator preference, but does not necessarily guarantee higher catheter success
- Cover ultrasound transducer with sterile sheath, ensuring there is a generous amount of sterile acoustic gel between the transducer and the inside of sterile sheath
- Once target nerves are visualized on ultrasound, insert Tuohy needle in-plane or out-of-plane depending on operator preference (Figure 128-1). In-plane catheter insertion has similar quality of analgesia as out-of-plane approach and shorter time of insertion
- When Tuohy tip is appropriately positioned, aspirate and inject desired dose of local anesthetic. ...
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