1.
@EMARIANOMD
Update on Continuous
Peripheral Nerve Blocks
Edward R. Mariano, M.D., M.A.S.
Professor of Anesthesiology, Perioperative & Pain Medicine
Stanford University School of Medicine
Chief, Anesthesiology and Perioperative Care
Veterans Affairs Palo Alto Health Care System

2.
@EMARIANOMD
Financial Disclosures
 Halyard, B Braun – Unrestricted
educational program funding paid to my
institution
The contents of the following presentation
are solely the responsibility of the speaker
without input from any of the above
companies.

3.
@EMARIANOMD
“Precision” Acute Pain Medicine

4.
@EMARIANOMD
Overview
 Who can do it?
 What do you need?
 Where should you
place them?
 Why bother?
 How do you make it
work?

5.
@EMARIANOMD
Overview
 Who can do it?
 What do you need?
 Where should you
place them?
 Why bother?
 How do you make it
work?

6.
@EMARIANOMD

7.
@EMARIANOMD
Mariano ER, et al. JUM 2015;34:1883
Lectures,
Scanning
Iterative
Practice,
Simulation
8 Hour Program

8.
@EMARIANOMD
Overview
 Who can do it?
 What do you need?
 Where should you
place them?
 Why bother?
 How do you make it
work?

9.
@EMARIANOMD
Single-Orifice or
Multi-Orifice
Stimulating or
Non-Stimulating
Flexible Springwound
or Rigid Plastic
Through or Over the
Needle
Catheter Designs

10.
@EMARIANOMD
Remember Other Supplies

11.
@EMARIANOMD
Overview
 Who can do it?
 What do you need?
 Where should you
place them?
 Why bother?
 How do you make it
work?

12.
@EMARIANOMD
Indications
 Surgery limited to one extremity (ideally
one nerve distribution)
 Moderate to severe postoperative pain
anticipated
 Facilitate same-day discharge and avoid
hospitalization for pain management
 Improve vascular supply
 Early physical therapy and rehabilitation

13.
@EMARIANOMD
Possible CPNB Insertion Sites
Catheter Site Surgical Site
Interscalene Brachial Plexus Shoulder, proximal
humerus
Supra- or Infraclavicular
Brachial Plexus
Elbow, forearm,
wrist, hand
Axillary Brachial Plexus Wrist, hand
Posterior Lumbar Plexus or
Femoral Nerve/Fascia Iliaca
Hip, thigh, knee
Femoral Nerve/Adductor Canal Knee
Sciatic Nerve Leg, ankle, foot

14.
@EMARIANOMD
Interscalene vs. Supraclavicular
 RCT: arthroscopic shoulder surgery
Supraclavicular
US-Guided Catheter
Randomized
(n=120, observer blinded)
Interscalene
US-Guided Catheter
 Primary outcome: hemidiaphragmatic paresis in
PACU and POD1
 Secondary outcomes: pain scores, opioid
consumption, lung function, complications
Wiesmann, et al. Acta Anaes Sc 2016;60:1142

15.
@EMARIANOMD
Interscalene vs. Supraclavicular
 Any phrenic palsy (PACU) 55% in SC group
vs. 82% in IS group
 No clinical differences in pulmonary function
 No differences in pain or opioid consumption
Wiesmann, et al. Acta Anaes Sc 2016;60:1142

16.
@EMARIANOMD
Supra- vs. Infraclavicular CPNB
 IRB-approved, distal upper extremity surgery
Infraclavicular
US-Guided Catheter
Randomized
(n=60, observer blinded)
Supraclavicular
US-Guided Catheter
 Primary outcome: average pain on POD 1
 Secondary outcomes: onset time, least and worst
pain on POD 1, opioid consumption, leakage rates,
awakenings, and satisfaction
Mariano ER, et al. RAPM 2011;36:26

17.
@EMARIANOMD
Results
 Oxycodone: IC 0.0 (0.0-5.0) vs. SC 5.0 (0.0-
15.0; p=0.048)
 No other differences
Mariano ER, et al. RAPM 2011;36:26

18.
@EMARIANOMD
Femoral vs. Lumbar Plexus CPNB
 IRB-approved, total hip arthroplasty
Lumbar Plexus
Stimulating Catheter
Randomized
(n=50, observer blinded)
Femoral Nerve
Stimulating Catheter
 Primary outcome: average of pain scores for 24 h
(equivalency trial)
 Secondary outcomes: procedural time, ambulation,
opioid consumption, and satisfaction
Ilfeld BM, Mariano ER, et al. A&A 2011;113:897

19.
@EMARIANOMD
Results
 Lumbar plexus
catheters took longer
to place than femoral
catheters
– 12.5 (6.2-19.7) min LP
– 7 (4-17.2) min femoral
– P=0.03
 No other differences
Ilfeld BM, Mariano ER, et al. A&A 2011;113:897

20.
@EMARIANOMD
Overview
 Who can do it?
 What do you need?
 Where should you
place them?
 Why bother?
 How do you make it
work?

21.
@EMARIANOMD
CFNB and Knee Arthroplasty
Knee Flexion (Degrees)
PCA CFNB P Value
POD #1 33 ± 15 56 ± 22 0.009
POD #3 53 ± 17 74 ± 11 <0.001
6 weeks 103 ± 12 116 ± 12 0.03
3 months 116 ± 11 124 ± 12 NS
Singelyn FJ, et al. A&A 1998;87:88
Is this a possible long-term effect??

22.
@EMARIANOMD
Ropiv
Saline
Can Patients Go Home Faster?
 50 subjects, tricompartment TKA
 CFNB with 1 night infusion of ropivacaine:
randomized to ropiv vs. saline on POD1
Ilfeld BM, et al. Anesth 2008;108:703
3 Discharge Criteria:
1. NRS (pain) < 4
2. IV opioid-free x 12 hours
3. Ambulating > 30 meters

23.
@EMARIANOMD
We Know They Work…
Ilfeld BM, et al. Anesth 2002;97:959
Ilfeld BM, et al. Anesth 2002;96:1297
Ilfeld BM, et al. A&A 2003;96:1089
Placebo group received initial bolus of
LA = single-injection block
So Why Isn’t Everyone
Doing Them?

24.
@EMARIANOMD
Overview
 Who can do it?
 What do you need?
 Where should you
place them?
 Why bother?
 How do you make it
work?

25.
@EMARIANOMD
The “Gold Standard”

26.
@EMARIANOMD
Why Ultrasound for CPNB?

27.
@EMARIANOMD
Needle Guidance Options
Ilfeld & Mariano. RAPM 2010;35:123
?

28.
@EMARIANOMD
Short-Axis In-Plane Technique
Ilfeld & Mariano. RAPM 2010;35:123

29.
@EMARIANOMD
US vs. NS for CPNB
 4 IRB-approved randomized clinical trials
Nerve Stimulation
Stimulating Catheter
Randomized
(n=160, not blinded)
Ultrasound
Nonstimulating Catheter
 Primary outcome: catheter placement time (min)
 Secondary outcomes: pain during placement,
venous puncture and leakage rates, pain on POD 1
Mariano ER, et al. JUM 2009;28:1453
Mariano ER, et al. JUM 2010;29:329
Mariano ER, et al. RAPM 2009;34:480
Mariano ER, et al. JUM 2009;28:1211

30.
@EMARIANOMD
Results
Popliteal
Mariano ER, et al. RAPM 2009;34:480
Mariano ER, et al. JUM 2009;28:1211
Mariano ER, et al. JUM 2009;28:1453
Mariano ER, et al. JUM 2010;29:329

31.
@EMARIANOMD
Results
 US: less procedure-related pain
– Femoral, popliteal
 US: less inadvertent vascular punctures
– Femoral, infraclavicular
 US: higher success rate
– Infraclavicular
Mariano ER, et al. RAPM 2009;34:480
Mariano ER, et al. JUM 2009;28:1211
Mariano ER, et al. JUM 2009;28:1453
Mariano ER, et al. JUM 2010;29:329

32.
@EMARIANOMD
Long-Axis In-Plane Technique
Ilfeld & Mariano. RAPM 2010;35:123

33.
@EMARIANOMD
Long- vs. Short-Axis In-Plane
 IRB-approved; 2 substudies (both lower extremity)
Short-Axis In-Plane
US-Guided Catheter
Randomized
(n=100, observer blinded)
Long-Axis In-Plane
US-Guided Catheter
 Primary outcome: onset time following bolus (min)
 Secondary outcomes: procedural time, pain during
placement, venous puncture and leakage rates, pain
and weakness on POD 1

34.
@EMARIANOMD
Results: Femoral (n=50)
 Onset time: SAX took
9.0 (6.0-20.4) min vs.
6.0 (3.0-14.4) min for
LAX (p=0.044)
 Procedural time: SAX
5.0 (4.0-7.8) min vs.
9.0 (7.0-14.8) min for
LAX (p<0.001)
 No other differences
 Similar results for
popliteal-sciatic Mariano ER, et al. JUM 2013;32:149
Kim TE, et al. J Anesth 2014;28:854

35.
@EMARIANOMD
 Stimulating techniques: catheters do not stay
“next” to nerves1,2
– Non-stimulating catheters: advance <3 cm1 for
>96% success rate3,4
– For 4-10 cm: stimulating beats non-stimulating5-6
 What about ultrasound-guided catheters?
– 1 cm vs. 5 cm (in-plane): no difference7
2. Capdevila X, et al. A&A 2002;94:1001
1. Enneking K. RAPM 2007;32:280 4. Capdevila X, et al. Anesth 2005;103:1035
5. Rodriguez J, et al. A&A 2006;102:258
6. Casati A, et al. A&A 2005;101:11923. Borgeat A, et al. Anesth 2003;99:436
How Far Should You Insert?
7. Ilfeld BM, et al. RAPM 2011;36:261

36.
@EMARIANOMD
Leng & Mariano, et al. J Anesth 2015;29:308

37.
@EMARIANOMD
Catheter Type and Migration
Steffel & Mariano, et al. K J Anesth 2017;70:72
Cadaver-based study
CON: 4/15 (27%) dislocated vs. CTN 0/15 (p=0.043)

38.
@EMARIANOMD
 Fluid injection (1-3 mL)
– Good: does not hinder subsequent ultrasound visualization
– Bad: catheter tip location inferred, not visualized
 Air injection (0.5-1 mL)
– Good: excellent visualization of catheter tip location
– Bad: may hinder subsequent ultrasound visualization
 Agitated fluid injection (1-2 mL) with Color Doppler
– Combination of pros & cons of above two methods
– Bad: requires additional time to agitate fluid
Checking Catheter Tip Position
Sandhu NS, et al. Anesth 2006;104:199
Swenson, JD, et al. A&A 2008;106:1015
Kan & Mariano et al. JUM 2013;32:529
Johns & Mariano et al. JUM 2014;33:2197

39.
@EMARIANOMD
Dressing the Catheter
 Consider tunneling to
minimize leakage
 Use an anchoring device1
 Liquid adhesive
 Clear occlusive dressing
 Consider glue2
No sutures: patients can remove catheter themselves
at home after infusion ends
1. Borg and Mariano, et al. K J Anesth 2016;69:506
2. Klein SM, et al. Anesth 2003;98:590

40.
@EMARIANOMD
Select a Regimen
 Infuse local anesthetic
solution (no adjuvants)
 Ropivacaine preferred
over bupivacaine
 Should include basal rate
(4-8 ml/hr) with PC bolus
(2-5 ml) every 20-60 min
Start: Ropivacaine 0.2%, 6 ml/hr + PCA 5 ml q 30 min initially
May need to hold femoral and lumbar plexus infusions before PT
Titrate infusion and adjust settings to individual patient

41.
@EMARIANOMD
Educate Patients
 Tell patients to expect leakage
 Warn patients about motor block
 Give them contact info for provider 24/7
 Clear instructions for infusion device
 Routine follow-up (esp if catheter)
– Home nursing not necessary
– Phone contact by provider once daily
– Caretaker for first 24 hours preferred
Ilfeld BM, et al. RAPM 2003;28:418

42.
@EMARIANOMD
Summary
 We discussed:
– Who can do it?
– What do you need?
– Where should you place them?
– Why bother?
– How do you make it work?