Peripheral Nerve Catheter Cheat Sheet
Sarah Ladunzenski MD
Updated June 2012
Placement Troubleshooting
1. Consider shaving/clipping where the dressing will be placed, especially in
MEN!
2. When threading the stimulating catheter in the yellow connector (same
connector as an epidural), consider dipping the catheter in the lidocaine to
facilitate threading of the catheter. The catheter can easily kink which
prevents it from fully sliding into the connector. If this happens, cut off the
bent end with sterile scissors and try again.
3. If there is air in the elastomeric pump’s tubing it will create an airlock. If
you have to remove this air, connect a 3-way stopcock and syringe to the
connector at the end of the pump’s tubing and aspirate the air out.
Post-op Troubleshooting
1. Leakage: Reinforce to patient that a small amount is normal
A tegaderm will be given to them to reinforce the dressing PRN
If their pain is controlled, then it is working
2. Redness: A small amount (the size of an eraser head) is normal
Ask about fevers/chills/purulent drainage – if yes, removal is
indicated.
3. Not working (I have a lot of pain): Reinforce taking pain medication
If the patient is close by, bring in to check
if
pump is working properly
4. Disconnected: Do not reconnect because of infection risk. Have patient
remove
catheter. Tell them to take pain meds.
5. Difficulty removing catheter: Encourage slow but firm traction on the
catheter. There may be some fibrinous adhesions already formed at this
time. If the patient experiences any pain, especially shooting electrical
paresthesias, STOP and have them come in. Evaluate the catheter and
insertion site. Make sure dressing is fully removed and there are no clots,
etc at skin insertion. Make sure the block is fully resolved before
attempting removal.
Inject 10-20mL of sterile saline via the catheter and then attempt removal.
Repeat injection of saline as necessary.
If after 3 attempts, you are still unable to remove the catheter, the patient
will need a radiological evaluation of catheter tip position.
Upon official read, decision made for surgical removal.
6. Signs of toxicity: Have patient clamp tubing from pump. Wait for block to
resolve, then have patient remove catheter.
Update June 25, 2012
Hi guys,
So I have vetted some issues with the powers that be (TM,DA,ON
etc) and we will now be expanding our catheter service.
We are loosening of our inclusion/exclusion criteria to the following:
1. Increasing BMI to 40
2. Increasing ASA to 3
3. Still single shot only for patients with chronic opiate use (greater than 2
weeks)
4. Still single shot for distance (with a caveat of a patient being willing to
come back from the North Woods).
5. Obviously no catheters for active infection, patient disinterest, etc.
6. Of course, clincal judgement prevails in all circumstances
In addition, there is now the potential for the on-call anesthesiologist to
make the
Catheter-removal Phone Calls
during weekdays if a Monday or Wednesday catheter is placed late in the
day and also for the Sat backup person to call any patients for catheter
removal if catheters are placed on a Thursday as Danielle is not available
to make these phone calls.
For example, a catheter is being placed right now at 2pm for a Pomeroy
case. The pump will be connected in PACU (around 4pm) On Wednesday,
that patient will need to be contacted sometime after 4 pm (assuming that
the pump infuses for 48 hours 4pm plus 2-3 hours to allow for the block to
wear off this will bring us to 6-7pm) and the caretaker will be talked through
the removal process. To document this phone call, you may write on a
Mercy Progress Note something to the effect that:
"Contacted patient for peripheral nerve catheter removal. Standard
removal protocol followed. No issues and patient toolerated removal. Blue
tip intact."
If you need any help in figuring out what to say/ask, I have attached a
monologue to that end.
"Hello. I'm Dr. Feelgood from Mercy Hospital. I'm calling you to assist in
removing your catheter. I will talk you or your caretaker through the
removal process.
First, has the block worn off? Can you feel your foot and ankle? [If yes,
continue. If not, plan for a call back to remove in a few hours]
Next you will need to peel back the tape and clear plastic dressing that is
over the catheter.
Now that the catheter is fully exposed, while holding counter pressure at
the entry site, you will need to firmly but slowly pull the catheter out. If you
feel any electrical sensation down your leg while the catheter is being
pulled out - stop pulling. It is normal to feel a "giving" sensation as some
clots next to the catheter are released. [There may be some fibrous
connections formed attached to the catheter]
Once the catheter is out, is there a blue tip at the end that was inside of
you? [If yes, you are done. If not, the catheter has sheared off and the
patient will need a radiological/surgical evaluation. Have the patient bring
all of the equipment/dressings/etc with him. This is not an emergency and
can be done the next day if there are no signs of infection - but use your
clinical judgement].
The patient can then throw the tubing/pump apparatus away.
Danielle will call on POD 7 for another follow up."
Thanks,
Sarah