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Close Counts
Close Counts
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lose only counts in horseshoes and hand grenades. Perhaps we should add perineural catheters to this list as well because I believe that close counts. Now don’t get me wrong; there is no prettier sight than an arm twitching seemingly independently via stimulation of a perfectly placed stimulating catheter. Yet, in this issue of Regional Anesthesia and Pain Medicine, we have another comparison of stimulating versus nonstimulating catheters for treatment of pain after anterior cruciate ligament (ACL) reconstruction with inconclusive evidence of superiority of one technique over the other.1 Let’s review the evidence that has accumulated to date on this subject. This is what we know about stimulating catheters: (1) there is a low rate of secondary block failure in patients who receive perineural analgesia via this type of catheter;2,3 (2) there is a faster rate of block onset when local anesthetic is placed through a stimulating catheter than through a nonstimulating catheter;1,4 and (3) in most hands and with some approaches these catheters take more time to place. This is what we know about nonstimulating catheters: (1) There is a very low rate of secondary failure if the catheter is not threaded a great distance from the initial stimulating needle;5,6 (2) patients have improved analgesia with nonstimulating perineural catheters compared with no catheters;7,8 (3) evidence of clinical superiority by pain scores has not been demonstrated between stimulating and nonstimulating catheters;1,5,9,10 and (4) in most hands nonstimulating catheters take little additional time to place compared with single injection peripheral nerve blocks. I believe that close counts when placing a perineural catheter. Two studies have demonstrated successful perineural catheter analgesia at rates of 98% and 97.5% in over 1,100 patients when the catheter is purposely threaded only two centimeters past the tip of the stimulating needle. This places the catheter tip close to the nerve yielding successful analgesia. The length that a nonstimulating catheter is threaded from the tip of the stimulating needle is a critical bit of information that is frequently overlooked in the literature. In fact, overthreading catheters whether stimlating or nonstimulating is likely to result in coiling of the catheter at best and may lead to less than ideal placement or dangerous placement at worst.11-13 Placing and effectively managing a perineural catheter is not a skill shared by many of our anesthesiologist brethren. I hate to discourage the use of nonstimulating catheters from one’s practice because of the purported superiority of stimulating catheters. The evidence of superiority is clear: perineural catheters work better than no catheters. Close is probably good enough. Kayser Enneking, M.D. Department of Anesthesiology University of Florida College of Medicine Gainesville, FL, USA
References 1. Dauri M, Sidiripoulou T, Fabbi E, Gianelli M, Faria S, Mariani P, Sabato AF. Efficacy of continuous femoral nerve block with stimulating versus nonstimulating catheters for anterior cruciate ligament reconstruction. Reg Anesth Pain Med 2007;32:282-287. Accepted for publication June 25, 2007. doi:10.1016/j.rapm.2007.06.386
280
See Dauri et al. page 282
Regional Anesthesia and Pain Medicine, Vol 32, No 4 (July–August), 2007: pp 280 –281
Close Counts
•
Enneking
2. Ilfeld BM, Morey TE, Wright TW, Chidgey LK, Enneking FK. Interscalene perineural ropivacaine infusion: A comparison of two dosing regimens for postoperative analgesia. Reg Anesth Pain Med 2004;29:9-16. 3. Taboada M, Rodriguez J, Valino C, Vazquez M, Laya A, Garea M, Carceller J, Alvarez J, Atanassoff V, Atanassoff PG. A prospective randomized comparison between the popliteal and subgluteal approaches for continuous sciatic nerve block with stimulating catheters. Anesth Analg 2006;103:244-247. 4. Casati A, Fanelli G, Koscielniak-Nielsen Z, Cappelleri G, Aldegheri G, Danelli G, Frazier R, Singelyn F. Using stimulating catheters for continuous sciatic nerve block shortens onset time of surgical block and minimizes postoperative consumption of pain medication after hallux valgus repair as compared with conventional nonstimulating catheters. Anest Analg 2005;101:1192-1197. 5. Gaertner E, Lascurain P, Venet C, Maschino X, Zamfir A, Lupescu R, Hadzic A. Continuous parasacral sciatic block: a radiographic study. Anesth Analg 2004;98:831834. 6. Borgeat A, Blumenthal S, Lambert P, Theodorou P, Vienne P. The feasibility and complications of the continuous popliteal nerve block: A 1001-case survey. Anesth Analg 2006;103:229-233. 7. Richman JM, Liu SS, Courpas G, Wong R, Rowlingson AJ, McGready J, Coen SR, Wu CL. Does continuous peripheral nerve block provide superior pain control to opioids? A meta-analysis. Anesth Analg 2006;102:248-257. 8. De Ruyter M, Brueilly K, Harrison B, Greengrass R, Putzke J, Brodersen MA. A pilot study on continuous femoral perineural catheters for analgesia after total knee arthroplasty: The effect on physical rehabilitation and outcomes. J Arthroplasty 2006;21:11111117. 9. Hayek SM, Ritchey RM, Sessler D, Helfand R, Samuel S, Xu M, Beven M, Bourdakos D, Barsoum W, Brooks P. Continuous femoral nerve analgesia after unilateral total knee arthroplasty: Stimulating versus nonstimulating catheters. Anesth Analg 2006; 103:1565-1570. 10. Morin AM, Eberhart LHJ, Behnke HKE, Wagner S, Koch T, Wolf U, Nau W, Kill C, Geldner G, Wulf H. Does femoral nerve catheter placement with stimulating catheters improve effective placement? A randomized controlled and observer blinded trial. Anesth Analg 2005;100:1503-1510. 11. De Tran QH, De La Cuadra-Fontaine JC, Chan SY, Kovarik G, Asenjo JF, Finlayson R. Coiling of stimulating catheters. Anesthesiology 2007;106:189-190. 12. Ganapathy S, Wasserman R, Watson J, Bennett J, Armstrong KP, Stockall CA, Chess DG, MacDonald C. Modified continuous femoral three-in-one block for postoperative pain after total knee arthroplasty. Anesth Analg 1999:89:1197-1202. 13. Capdevila X, Biboulet P, Morceau D, Bernard N, Deschodt J, Lopez S, d’Athis F. Continuous three-in-one block for postoperative pain control after lower limb orthopedic surgery: Where do the catheters go? Anesth Analg 2002;94:1001-1006.
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C
lose only counts in horseshoes and hand grenades. Perhaps we should add perineural catheters to this list as well because I believe that close counts. Now don’t get me wrong; there is no prettier sight than an arm twitching seemingly independently via stimulation of a perfectly placed stimulating catheter. Yet, in this issue of Regional Anesthesia and Pain Medicine, we have another comparison of stimulating versus nonstimulating catheters for treatment of pain after anterior cruciate ligament (ACL) reconstruction with inconclusive evidence of superiority of one technique over the other.1 Let’s review the evidence that has accumulated to date on this subject. This is what we know about stimulating catheters: (1) there is a low rate of secondary block failure in patients who receive perineural analgesia via this type of catheter;2,3 (2) there is a faster rate of block onset when local anesthetic is placed through a stimulating catheter than through a nonstimulating catheter;1,4 and (3) in most hands and with some approaches these catheters take more time to place. This is what we know about nonstimulating catheters: (1) There is a very low rate of secondary failure if the catheter is not threaded a great distance from the initial stimulating needle;5,6 (2) patients have improved analgesia with nonstimulating perineural catheters compared with no catheters;7,8 (3) evidence of clinical superiority by pain scores has not been demonstrated between stimulating and nonstimulating catheters;1,5,9,10 and (4) in most hands nonstimulating catheters take little additional time to place compared with single injection peripheral nerve blocks. I believe that close counts when placing a perineural catheter. Two studies have demonstrated successful perineural catheter analgesia at rates of 98% and 97.5% in over 1,100 patients when the catheter is purposely threaded only two centimeters past the tip of the stimulating needle. This places the catheter tip close to the nerve yielding successful analgesia. The length that a nonstimulating catheter is threaded from the tip of the stimulating needle is a critical bit of information that is frequently overlooked in the literature. In fact, overthreading catheters whether stimlating or nonstimulating is likely to result in coiling of the catheter at best and may lead to less than ideal placement or dangerous placement at worst.11-13 Placing and effectively managing a perineural catheter is not a skill shared by many of our anesthesiologist brethren. I hate to discourage the use of nonstimulating catheters from one’s practice because of the purported superiority of stimulating catheters. The evidence of superiority is clear: perineural catheters work better than no catheters. Close is probably good enough. Kayser Enneking, M.D. Department of Anesthesiology University of Florida College of Medicine Gainesville, FL, USA
References 1. Dauri M, Sidiripoulou T, Fabbi E, Gianelli M, Faria S, Mariani P, Sabato AF. Efficacy of continuous femoral nerve block with stimulating versus nonstimulating catheters for anterior cruciate ligament reconstruction. Reg Anesth Pain Med 2007;32:282-287. Accepted for publication June 25, 2007. doi:10.1016/j.rapm.2007.06.386
280
See Dauri et al. page 282
Regional Anesthesia and Pain Medicine, Vol 32, No 4 (July–August), 2007: pp 280 –281
Close Counts
•
Enneking
2. Ilfeld BM, Morey TE, Wright TW, Chidgey LK, Enneking FK. Interscalene perineural ropivacaine infusion: A comparison of two dosing regimens for postoperative analgesia. Reg Anesth Pain Med 2004;29:9-16. 3. Taboada M, Rodriguez J, Valino C, Vazquez M, Laya A, Garea M, Carceller J, Alvarez J, Atanassoff V, Atanassoff PG. A prospective randomized comparison between the popliteal and subgluteal approaches for continuous sciatic nerve block with stimulating catheters. Anesth Analg 2006;103:244-247. 4. Casati A, Fanelli G, Koscielniak-Nielsen Z, Cappelleri G, Aldegheri G, Danelli G, Frazier R, Singelyn F. Using stimulating catheters for continuous sciatic nerve block shortens onset time of surgical block and minimizes postoperative consumption of pain medication after hallux valgus repair as compared with conventional nonstimulating catheters. Anest Analg 2005;101:1192-1197. 5. Gaertner E, Lascurain P, Venet C, Maschino X, Zamfir A, Lupescu R, Hadzic A. Continuous parasacral sciatic block: a radiographic study. Anesth Analg 2004;98:831834. 6. Borgeat A, Blumenthal S, Lambert P, Theodorou P, Vienne P. The feasibility and complications of the continuous popliteal nerve block: A 1001-case survey. Anesth Analg 2006;103:229-233. 7. Richman JM, Liu SS, Courpas G, Wong R, Rowlingson AJ, McGready J, Coen SR, Wu CL. Does continuous peripheral nerve block provide superior pain control to opioids? A meta-analysis. Anesth Analg 2006;102:248-257. 8. De Ruyter M, Brueilly K, Harrison B, Greengrass R, Putzke J, Brodersen MA. A pilot study on continuous femoral perineural catheters for analgesia after total knee arthroplasty: The effect on physical rehabilitation and outcomes. J Arthroplasty 2006;21:11111117. 9. Hayek SM, Ritchey RM, Sessler D, Helfand R, Samuel S, Xu M, Beven M, Bourdakos D, Barsoum W, Brooks P. Continuous femoral nerve analgesia after unilateral total knee arthroplasty: Stimulating versus nonstimulating catheters. Anesth Analg 2006; 103:1565-1570. 10. Morin AM, Eberhart LHJ, Behnke HKE, Wagner S, Koch T, Wolf U, Nau W, Kill C, Geldner G, Wulf H. Does femoral nerve catheter placement with stimulating catheters improve effective placement? A randomized controlled and observer blinded trial. Anesth Analg 2005;100:1503-1510. 11. De Tran QH, De La Cuadra-Fontaine JC, Chan SY, Kovarik G, Asenjo JF, Finlayson R. Coiling of stimulating catheters. Anesthesiology 2007;106:189-190. 12. Ganapathy S, Wasserman R, Watson J, Bennett J, Armstrong KP, Stockall CA, Chess DG, MacDonald C. Modified continuous femoral three-in-one block for postoperative pain after total knee arthroplasty. Anesth Analg 1999:89:1197-1202. 13. Capdevila X, Biboulet P, Morceau D, Bernard N, Deschodt J, Lopez S, d’Athis F. Continuous three-in-one block for postoperative pain control after lower limb orthopedic surgery: Where do the catheters go? Anesth Analg 2002;94:1001-1006.
281