Archive December 2014 XV, No. 12

Are Continuous Nerve Blocks Worth the Trouble?

The benefits of pain catheters outweigh the drawbacks.

Vincent Kasper, Jr., MD

ultrasound-guided block VISUAL CUES An anesthesiologist places an ultrasound-guided continuous interscalene block.

They're difficult to place and even harder to get paid for, so why does my anesthesia group place so many continuous nerve blocks? We've sent close to 5,000 patients home with pain catheters in the last 4 years for 1 simple reason: Our surgeons and patients love them. Pain catheters push painful procedures that once required hospital stays to the outpatient arena and get patients through the critical first 48 hours surgery with little to no pain medicine. They're not without their challenges, however. Here are 5 pieces of advice on overcoming the obstacles.

1. Shorten the steep learning curve. It takes considerable skill and intense training to place pain catheters. Our anesthesia providers prepare by placing single-shot blocks for several months. Think of pain catheters as extensions of single-shot blocks, but much more complex. You're using a much larger needle to facilitate threading the catheter once it's in the correct position: an epidural-sized needle (usually 18-gauge) vs. a 22-gauge needle for most single-shot blocks. To avoid nerve damage, you should always see the tip of the larger needle on the ultrasound as you advance it.

2. Pain catheters require extra time. Continuous blocks take much longer to place than single-shot blocks. It could take a novice as long as 30 to 40 minutes. A more experienced practitioner can place a catheter in 15 minutes or so. I strongly advise that you place catheters in a separate block room or in the pre-operative holding area, never in the OR. For efficiency's sake, your goal should be to make sure that the patient has a catheter in place as soon as the OR is ready so that you're not eating into room turnover time or delaying the start of the case. For preemptive analgesia, it's obviously preferable to have the catheter in place before surgery, but you could always place it afterward to keep the schedule moving.

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