PERINEURAL CATHETERS/ANESTHESIA IN THE CATH AND EP LABS
| PERINEURAL CATHETERS IN PRIVATE PRACTICE — Joseph M. Neal, MD, Clinical Professor of Anesthesiology,
University of Washington School of Medicine, and Staff Anesthesiologist, Virginia Mason Medical Center, Seattle,
WA
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| Concerns: slows down anesthesia care; dissatisfies customers (eg, surgeon, operating room [OR] nurses); may not receive
payment; possibility of lawsuit; increased complications
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| Advantages: improved analgesia; decreased opioid consumption; fewer opioid-related side effects; better sleep at
night; improved patient satisfaction; perhaps improved rehabilitation (in long-term rehabilitation, eg, total knee replacement);
avoid anticoagulation issues
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| Disadvantages: increased time requirement (for placement and postoperative management; similar to time requirement
for postoperative epidural); increased cost ($20-$60); variable reimbursement (single-shot femoral nerve block 5 base
units; continuous femoral catheter 12 base units; includes catheter placement and postoperative management)
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 | Total knee replacement (or major knee surgery): femoral block easiest to accomplish and most beneficial; Capdevila
showed improved analgesia and rehabilitation, compared to patient-controlled analgesia (PCA); fewer side effects
compared to epidural catheter
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| Foot and ankle surgery: Ilfeld showed continuous posterior popliteal fossa block improves quality of recovery, analgesia,
and sleep, and reduces side effects
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| Upper extremity surgery: improvement with perineural catheters “not nearly as convincing” as with lower extremity surgery,
but studies show advantages over “pain pump”; Ilfeld showed improved analgesia and sleep, less opioid use and
opioid-related side effects; patients extremely satisfied; surgeons noticed early rehabilitation exceeded expectations
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| Technical aspects of perineural catheter placement: study showed catheter placement in lumbar plexus occurs
in only 30% to 40% of cases; ≈1 in 4 patients had inadequate analgesia to sacral segments of knee, thereby making total
knee replacement analgesia less effective option; Capdevila showed only 1 in 4 fascia iliaca catheters reach lumbar
plexus (one third went too far laterally and missed obturator nerve; one third went too far medially and missed
lateral femoral cutaneous nerve); 90% to 95% had femoral nerve block, but only ≈50% had lateral femoral cutaneous
nerve block, and 1 in 5 had good obturator nerve block
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| Accurate catheter placement: primary (<10% failure rate) vs secondary block (10%-40% failure rate); success of primary
block does not indicate success of secondary block; stimulating vs nonstimulating catheter (nonstimulating
catheter placed through Tuohy needle and threaded blindly out tip; stimulating catheter uses electrical current at tip;
if catheter remains by nerve, then motor response continues); Salinas study looked at volunteers and found that side
randomized to stimulating catheter had better motor and sensory blocks, but overall total blockade not statistically
different; Morin study looked at total knee arthroscopy and found no advantage to use of stimulating catheter over
nonstimulating catheter; stimulating catheter should be threaded only 1 to 2 cm out of tip of needle; recent Casati
study suggests advantage to stimulating catheter; speaker continues to use stimulating catheter in lower extremity
procedures; nonstimulating catheter used during interscalene block due to ease of insertion
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| Femoral nerve block: provides more advantage to majority of patients than most other blocks; anatomic relationship between
femoral vein, femoral artery, and femoral nerve (always lateral to femoral artery); femoral nerve located in
compartment underneath fascia lata and fascia iliaca; includes anterior and posterior branches; posterior branch contains
articular branch to knee; secure catheter, then infuse local anesthetic; almost all epidural pumps can be used for
continuous perineural catheters (portable pumps may allow patient to continue for 48-72 hr at home)
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| Infusion choices: use long-acting local anesthetic; best options include ropivacaine 0.2% or bupivacaine 0.125%; another
volunteer study found inability to distinguish block characteristics between ropivacaine and bupivacaine; unnecessary
to add adjuvants to blocks (no need to extend; addition of epinephrine or clonidine “just wasting your money”);
avoid unwanted motor block (primary dosing of 1.5% lidocaine ≈10 mL); constant infusion superior to patient-controlled
regional anesthetic; beginning infusion rate 4 to 5 mL/hr of local anesthetic allows patient to be comfortable
but have strong enough legs for rehabilitation
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| Complications: contraindications include inability to metabolize local anesthetic normally (eg, liver failure, congestive
heart failure), coagulopathy (eg, psoas compartment block); does not increase risk for complications compared to
single-shot block (eg, local anesthetic toxicity, infection, nerve injury, motor weakness)
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| Practice: get educated (American Society of Regional Anesthesia workshops; Regional Anesthesia Study Center of
Iowa [RASCI] pig workshops [www.uianesthesia.com/rasci]; New York School of Regional Anesthesia
[www.nysora.com]); attitude most important; select first blocks on “good” patients; prepare induction room; only part
of multimodal approach
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| ANESTHESIA IN THE CARDIAC CATHETERIZATION AND ELECTROPHYSIOLOGY (EP) LABORATORIES
— Suanne M. Daves, MD, Associate Professor, Departments of Anesthesia and Critical Care and Pediatrics, University
of Chicago Pritzker School of Medicine, Chicago, IL
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Cardiac Catheterization
| Revolution: patients surgical candidates 5 yr ago now coming to cardiac catheterization laboratory for catheter intervention;
nonsurgical candidates also coming to catheterization laboratory for transcatheter interventions; patients younger,
older, and sicker; no option for cardiac bypass rescue (as in OR); procedures include closure of patent foramen ovale
(PFO) and palliation for hypoplastic left-heart syndrome; amount of skilled help may range from having cardiac team
present for extracorporeal membrane oxygenation (ECMO) standby to “no skilled help [available] for miles”
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| Environment: “ice-fishing expedition”; patient may be buried under drapes; difficult to reach because of intravenous
(IV) pole and fluoroscopy units; anesthesia machine pushed to side to make room for additional ventilator and often,
nitric oxide cylinder; always have 4 to 8 infusion pumps available; after patient arrives, fluoroscopy unit with C-arm
in anteroposterior (AP) position comes over patient’s head and chest, television screen brought down into position,
lateral camera “usually takes out ventilator as they bring it down”, 2 interventionalists perform procedure, 2 anesthesia
providers available (one provider passes drugs to other provider located somewhere near IV port), and lights
shut off
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| Patient characteristics: foramen ovale formed when septum primum and septum secundum meet; in postnatal life, fibrous
adhesions form, leading to mechanical closure; 20% to 30% do not form fibrous adhesions; if right atrial pressure
exceeds left atrial pressure, shunt occurs into systemic circulation
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| Indications: cryptogenic stroke (defined as stroke occurring in absence of potential known cardiac, pulmonary, vascular,
or neurologic sources; diagnosis usually made using contrast bubble study); platypnea orthodeoxia (extremely
rare; results in O2 desaturation and breathlessness in upright position)
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| Multicenter trial: average age 40 yr; conventional cardiovascular risk factors infrequent; neurologic issues include ischemic
stroke, transient ischemic attack (TIA), and history of peripheral embolism; some patients present with motor
deficits, aphasia, or cerebellar symptoms; antiplatelet or anticoagulation treatment withheld during PFO closure
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| Procedure: intracardiac echocardiography (ICE) likely to replace transesophageal echocardiography (TEE) in catheterization
laboratory; 2 venous sheaths used during PFO closure (one sheath for delivery of occlusion device, and second
[8 or 11F] sheath for insertion of probe); since TEE rarely necessary, endotracheal tube not required to secure
airway; presence of anesthesiologist not required with use of ICE probe; fentanyl and midazolam (Versed) delivered
by catheterization nurses; patient often talking, looking at echocardiography images, and “quite comfortable”
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| Potential complications: generally, <1% incidence of major complications; concerns include cardiac perforation and
tamponade due to device migration and embolization (left-sided embolization requires quick action), atrial arrhythmias
(rarely require treatment), air embolization (uncommon; causes ischemic changes in cerebral and coronary circulation;
patient monitored with transcranial Doppler imaging), hematomas at injury sites (most frequent
complication; risk factors include coughing or bucking on emergence, delirious movement during transport to recovery,
and large venous sheaths)
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| Anticipate: duration ≈1 hr in skilled hands; determine whether ICE probe or TEE being used; anesthesia provider commonly
asked to help with Valsalva maneuver; venous access only; heparin used for anticoagulation; give antimicrobial
prophylaxis for subacute bacterial endocarditis (SBE)
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| Paravalvar leak occlusion
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| Patient characteristics: occurs following aortic or mitral valve replacement (≤5% incidence); risk factors include
“things that make the tissue integrity poor” (result in leaks around suture line on valve); indications may be severe
regurgitation refractory to maximal medical therapy in setting of inoperability
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| Procedure: patient with inferior paravalvar leak and paravalvar leak at 2 o’clock position required 6-hr procedure before
paravalvar leak closed
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| Potential complications: include device embolization, massive blood loss, arrhythmias, and arterial dissection (during
retrograde approach)
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| Anticipate: sick patients; TEE commonly used; patient often intubated on balloon pumps, but resolution on ICE probe
not good for left-sided lesion (more effective for right side of heart; transseptal puncture used for mitral leak; transfusion
necessary in 25% to 50% of cases; availability of extra pumps to titrate inotropes or vasodilators
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Electrophysiology (EP) Laboratory
| Environment: speaker performs cases in old cardiac catheterization suite; includes defibrillator, 2 chairs and 2 television
screens for electrophysiologists, consult for radiofrequency ablation, 2 electrophysiologists, and then “they turn off the
lights”
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| Patient characteristics: history of tachycardia; includes teenagers and young adults with normal cardiac anatomy
and healthy cardiovascular physiology, and those with structurally abnormal heart due to congenital or acquired heart
disease (eg, ischemic cardiomyopathy, postoperative scars); latter group have complex arrhythmias and complex
physiology; also poor left and right ventricular function
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| Procedure: includes diagnostic and therapeutic EP procedure; access groin on femoral side; insert multi-tip electrode
catheter in strategic locations in heart (eg, in right atrium near sinoatrial node, near Bundle of His at tricuspid valve, in
right ventricle, focusing on ventricular conduction, and in coronary sinus, focusing on left side of heart); some electrophysiologists
use brachial vessels to access coronary sinus and do not want IV lines on that side; recording electrodes
produce local electrograms and provide information about conduction; exploratory catheter may also be used to evaluate
conduction; history of supraventricular tachycardia (SVT) must be verified and characterized by recreating SVT; local
electrograms combined with fluoroscopy create mental image of pathway; known as electrophysiologic mapping; electroanatomic
mapping provides real-time 3-dimensional image of activation sequences (does not require fluoroscopy; may
dramatically increase length of procedure)
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| Potential complications: data from early 1990s show that in 725 patients, complication rate 4.8%; body weight <15
kg carried complication rate of 10%; one death occurred during procedure and 3 deaths postprocedure; more recent
data show similar procedural complication rate and more complications in patients with congenital heart disease;
common complications include atrioventricular (AV) block, valvular regurgitation, brachial plexus injury, and hematoma
at catheter site; recent data show that in patient with structurally normal heart, mortality ≈5 in 4000; death
tended to occur in smaller patients; mortality more frequent in those with structurally abnormal heart
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| Brachial plexus injury: rare (0.2%-0.4%); possibly due to positioning arms high above head (stretches brachial plexus
against humeral head and clavicle); keep elbows further down and avoid lateral rotation
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| Burns from forced-air warmer: speaker uses tubular forced-air warmer on adults and children; on 2 occasions, warmer
laid across limb containing arterial and venous sheaths; compromised perfusion; unable to dissipate heat; resulted in
severe burns; never place on maximum heat setting (set at 38°C, not 42° C); do not allow forced-air warmer to touch
patient
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| Generalizations: easy to incite SVT with propofol, sevoflurane, desflurane, fentanyl, or midazolam (AV node reentrant
tachycardia is exception; acts more like focal arrhythmia; often started with conscious sedation to avoid blunting
sympathetics); radiofrequency ablation requires patient to be immobile (give propofol; provide natural airway; some
add neuromuscular blocking agent if airway secure; use short-acting agents); arterial lines unnecessary for stable
rhythms, but in unstable circulation, small catheter placed in femoral artery to monitor blood pressure
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Educational Objectives
| The goal of this program is to educate the listener about perineural catheters in private practice and anesthesia in the cardiac
catheterization and electrophysiology (EP) laboratory. After hearing and assimilating this program, the clinician
will be better able to:
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| 1. Summarize the advantages of continuous perineural catheters.
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| 2. Review the indications for using perineural catheters.
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| 3. Illustrate the technical aspects of placing a perineural catheter.
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| 4. Describe the necessary steps for making perineural catheters useful in clinical practice.
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| 5. Discuss anesthesia care for patent foramen ovale closure, paravalvar leak occlusion, and EP mapping and ablation
in the catheterization and electrophysiology laboratory.
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Discussed on This Program
Bupivacaine HCl (several trade names)
Clonidine HCl [Catapres, Duraclon]
Desflurane [Suprane]
Fentanyl citrate [Sublimaze]
Lidocaine HCl (several trade names)
Midazolam HCl [Versed]
Oxycodone and acetaminophen [Percocet, others]
Propofol [Diprivan]
Ropivacaine HCl [Naropin]
Sevoflurane [Ultane]
Suggested Reading
Birnbaum Y et al: Ventricular septal rupture after acute myocardial infarction. N Engl J Med 347:1426, 2002;
Boezaart AP: Perineural infusion of local anesthetics. Anesthesiology 104:872, 2006; Capdevila X et al: Continuous
three-in-one block for postoperative pain after lower limb orthopedic surgery: where do the catheters go? Anesth Analg
94:1001, 2002; Capdevila X et al: Effects of perioperative analgesic technique on the surgical outcome and duration of
rehabilitation after major knee surgery. Anesthesiology 91:8, 1999; Casati A et al: 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. Anesth Analg 101:1192, 2005; Chessa
M et al: Transcatheter closure of congenital and acquired muscular ventricular septal defects using the Amplatzer device. J
Invasive Cardiol 14:322, 2002; Hansen TG et al: Brachial plexus injury during cardiac catheterisation in children. Acta
Anaesthesiol Scand 43:364, 1999; Hijazi Z et al: Transcatheter closure of atrial septal defects and patent foramen ovale
under intracardiac echocardiographic guidance: feasibility and comparison with transesophageal echocardiography. Catheter
Cardiovasc Interv 52:194, 2001; Holzer R et al: Transcatheter closure of postinfarction ventricular septal defects using
the new Amplatzer muscular VSD occluder: Results of a U.S. Registry. Catheter Cardiovasc Interv 61:196, 2004;
Hong TE et al: Transcatheter closure of patent foramen ovale associated with paradoxical embolism using the Amplatzer
PFO occluder: initial and intermediate-term results of the U.S. multicenter clinical trial. Catheter Cardiovasc Interv 60:524,
2003; Ilfeld BM et al: Continuous peripheral nerve blocks at home: a review. Anesth Analg 100:1822, 2005; Ilfeld BM
et al: Joint range of motion after total shoulder arthroplasty with and without a continuous interscalene nerve block: a retrospective,
case-control study. Reg Anesth Pain Med 30:429, 2005; Khairy P et al: Transcatheter closure versus medical
therapy of patent foramen ovale and presumed paradoxical thromboemboli: a systematic review. Ann Intern Med 139:753,
2003; Klein SM et al: Peripheral nerve block techniques for ambulatory surgery. Anesth Analg 101:1663, 2005; Kugler
JD et al: Radiofrequency catheter ablation for tachyarrhythmias in children and adolescents. The Pediatric Electrophysiology
Society. N Engl J Med 330:1481, 1994; Lai LP et al: Usefulness of intravenous propofol anesthesia for radiofrequency
catheter ablation in patients with tachyarrhythmias: unfeasibility for pediatric patients with ectopic atrial tachycardia.
Pacing Clin Electrophysiol 22:1358, 1999; Lavoie J et al: Effects of propofol or isoflurane anesthesia on cardiac conduction
in children undergoing radiofrequency catheter ablation for tachydysrhythmias. Anesthesiology 82:884, 1995;
Morin AM et al: Does femoral nerve catheter placement with stimulating catheters improve effective placement? A randomized,
controlled, and observer-blinded trial. Anesth Analg 100:1503, 2005; Morin AM et al: Postoperative analgesia
and functional recovery after total-knee replacement: comparison of a continuous posterior lumbar plexus (psoas compartment)
block, a continuous femoral nerve block, and the combination of a continuous femoral and sciatic nerve block. Reg
Anesth Pain Med 30:434, 2005; Neal JM et al: Brachial plexus anesthesia: essentials of our current understanding. Reg
Anesth Pain Med 27:402, 2002; Omeish A et al: Transcatheter closure of atrial septal defects in children & adults using
the Amplatzer Septal Occluder. J Interv Cardiol 14:37, 2001; Salinas FV et al: Prospective comparison of continuous
femoral nerve block with nonstimulating catheter placement versus stimulating catheter-guided perineural placement in volunteers.
Reg Anesth Pain Med 29:212, 2004; Salinas FV et al: The effect of single-injection femoral nerve block versus
continuous femoral nerve block after total knee arthroplasty on hospital length of stay and long-term functional recovery
within an established clinical pathway. Anesth Analg 102:1234, 2006.
Faculty Disclosure
In adherence to ACCME guidelines, the Audio-Digest Foundation requests all lecturers to disclose any significant financial
relationship with the manufacturer or provider of any commercial product or service discussed. For this issue, the
faculty reported nothing to disclose.
Dr. Neal was recorded at the Eleventh Annual Advances in Physiology and Pharmacology in Anesthesia and Critical
Care, held November 6-9, 2005, in Hilton Head Island, SC, and sponsored by Wake Forest University School of Medicine;
Dr. Daves, at the 19th Annual Challenges for Clinicians, held December 2-4, 2005, in Chicago, IL, and sponsored
by the University of Chicago Pritzker School of Medicine, Department of Anesthesia and Critical Care. The Audio-Digest
Foundation thanks the speakers and the sponsors for their cooperation in the production of this program.
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