S3 E16: "Can't stop, won't stop (infusing local): The Catheter Chronicles"

Interactive Transcript

spk_0 Ah, Ms. Money Penny, please get me my continuous catheter,

spk_0 I need to make this block last for days.

spk_0 I'm Jeff Getson.

spk_0 Whilst it may not be Christmas yet, we hope you'll love the wrapping of your presents

spk_0 and the week and prolong your joy, just like on Earth blocks.

spk_0 I'm Amit Power.

spk_0 And this is...

spk_0 Block it like it's hot.

spk_0 So Amit, it's coming.

spk_0 What's coming?

spk_0 Christmas?

spk_0 Oh, well actually, Christmas is coming pretty soon and you know how excited I get about

spk_0 that.

spk_0 But actually, I meant our next landmark download number.

spk_0 Oh, yes, you were talking about the magic number of a hundred thousand downloads of our

spk_0 podcast.

spk_0 Can you believe that our content has been listened to that many times around the world?

spk_0 There's nuts, right?

spk_0 I actually can't.

spk_0 I wonder if it could just be my mom listening to it over and over again.

spk_0 Is that how...

spk_0 Does that work?

spk_0 Would that work?

spk_0 Like get the nut?

spk_0 I don't know if that actually happened.

spk_0 I'm not as sure whether that's possible.

spk_0 I'm pretty sure I've got my kids to listen to it even though they don't want to.

spk_0 But you know what?

spk_0 Speaking of folks that like to listen to us, we have got to give a shout out to the

spk_0 two founding members of our international block it like it's hot fan club.

spk_0 Who we met as real this year.

spk_0 Oh my God.

spk_0 Yes.

spk_0 A big shout out to Dr. Sandra Valet and Andre Antonov from Germany who came and said hi to us

spk_0 and showed us their t-shirts that they made.

spk_0 We even got them on the pod too.

spk_0 Yes.

spk_0 That was so much fun actually.

spk_0 I really look forward to releasing that episode.

spk_0 It was lovely to see and to meet them in person.

spk_0 Yeah.

spk_0 They were awesome to meet and to chat with and they both shared a joke which everyone will

spk_0 hear at some other point.

spk_0 We don't want to give it away.

spk_0 Yeah.

spk_0 But these guys had obviously put some thought process into that.

spk_0 I've got to say this is the first time I've seen my face on a t-shirt since I was eight

spk_0 years old.

spk_0 Wait, what?

spk_0 Oh, okay.

spk_0 I've just given that away.

spk_0 Listen, don't ask bro.

spk_0 When I was a kid, I'm sure there was a time when it was like trendy to walk around with

spk_0 a picture of self on a t-shirt.

spk_0 At least that's what my mum told me.

spk_0 I definitely had a t-shirt with me kind of a pixelated picture of me with like a rainbow

spk_0 over my head.

spk_0 Oh my God.

spk_0 Please tell me you still have that.

spk_0 I need to dig that out.

spk_0 Call up Mama Power and find that shirt.

spk_0 I think she probably has got it.

spk_0 I think I might have seen it.

spk_0 And the worst thing is I think I had the teeth that was missing at the same time so you

spk_0 can, I've got like me a toothless child on it power.

spk_0 Yeah.

spk_0 This just keeps getting better and better.

spk_0 Anyway, Sandro and Andrei, thank you so much, guys.

spk_0 Again, for coming to find us and for making those t-shirts.

spk_0 That was incredible.

spk_0 What a moment.

spk_0 We're sure.

spk_0 All right.

spk_0 So back to our impending 100,000 downloads.

spk_0 You know what means we're going to have to get creative again with a wrap, right?

spk_0 Seriously.

spk_0 Okay, now I'm nervous because you know, do you remember we got some constructive criticism

spk_0 for one of our Dutch colleagues, Zandra from X, who said that we need to be faster when

spk_0 spitting our lyrics?

spk_0 Yeah, I remember that.

spk_0 And when we saw her in Oslo, she definitely reminded us.

spk_0 Yeah, she did.

spk_0 I think I think we should ask our listeners, which style or artist they want us to be inspired

spk_0 by like, you know, West Coast.

spk_0 I don't know if that's such a great idea because they may come up with something like sugar

spk_0 hill gang, you know, I said a hip up the hippie, the hippie to the hipstick and needle and

spk_0 dumpstap are black and brown.

spk_0 It's almost like we rehearsed that like six, seven times.

spk_0 Hate harness.

spk_0 Did you say six, seven on purpose?

spk_0 I did.

spk_0 And I wanted to see if you'd heard of the whole six, seven fad craze meme.

spk_0 It seems like you have you got way too much wrist bro.

spk_0 You are the alpha.

spk_0 Oh no.

spk_0 This I can hear the eyes rolling in the back.

spk_0 Yeah.

spk_0 And cars across the across the country.

spk_0 And well, how, how can we explain six, seven to those who don't know?

spk_0 I'm not entirely sure we should probably it's best left unsaid because I thought I knew

spk_0 this and then I started explaining it and somebody was like, I don't think they were talking

spk_0 about his height.

spk_0

spk_0 And yeah, so you know, maybe we should just leave that.

spk_0 Oh, no.

spk_0 Yeah.

spk_0 Okay.

spk_0 Anyway.

spk_0 All right.

spk_0 So in that case, what are we going to talk about today?

spk_0 Well, you know, a few friends and followers have asked us to cover nerve catheters and continuous

spk_0 regional anesthesia.

spk_0 So I figured, let's give them what they want.

spk_0 Oh my God.

spk_0 This is going to be good.

spk_0 Can't wait.

spk_0 Okay.

spk_0 Let's dig in.

spk_0 Okay.

spk_0 Right.

spk_0 So listen, the problem, I, you know, I remember the time we got fascinated or one over

spk_0 the convinced that regional anesthesia is the way forward, right?

spk_0 And the problem is you get great effects, but then it wears off.

spk_0 So we're single shot regional anesthesia is always limited by the duration of the drug

spk_0 administered plus or minus any and additives or adjuvants.

spk_0 And that's, that's the problem, right?

spk_0 True that.

spk_0 So, you know, how do we determine what the optimal length for a nerve log or analgesia

spk_0 is and what are the things that we can do to prolong it?

spk_0 Well, ultimately it's about the patient, right?

spk_0 And we have good data to show sort of what the average pain trajectory would look like

spk_0 with different procedures.

spk_0 Uh-huh.

spk_0 However, there's obviously a big range there.

spk_0 And so some patients might need a little bit more.

spk_0 Some people might need not so much.

spk_0 A lot of minor surgeries might just need a good block for overnight.

spk_0 There's lots of things we do, man, that need pain relief and good quality pain relief

spk_0 for days and days and days.

spk_0 And the other problem is, you know, I kind of, I think when, you know, I'm just trying

spk_0 to think back to the days when I first was taught how to do interscaling and break your

spk_0 plexus blocks, we were putting in significant volumes of local anaesthetic in that area.

spk_0 So let's say I don't know, 20, maybe 30.

spk_0 And I know you published some papers with 30 cc's of local anaesthetic and interscaling

spk_0 area, but we're not going to talk about that.

spk_0 The problem is they got great.

spk_0 Oh, you, I know that I've said this before on this podcast, but we, we use number

spk_0 of the five.

spk_0 Oh, my God, in that area.

spk_0 Yeah.

spk_0 Okay.

spk_0 Yeah, yeah.

spk_0 So apart from, if you put 50 cc's of local anaesthetic or 50 mils of local anaesthetic

spk_0 in the interscaling area, you might as well get a brain block with that, but the point

spk_0 I was trying to make is not only would you get great analgesia, you're going to get a

spk_0 motor block of the limb affected right when you saturate all of those five is going

spk_0 to get a motor block now.

spk_0 Sometimes a motor block of the other limb too.

spk_0 Exactly.

spk_0 Now, I think it's patients want analgesia, but I remember some folks saying to me, I

spk_0 go into consent them for surgery.

spk_0 It's a little last time.

spk_0 I had a nerve block and I couldn't move my arm for 28, 29, 30 hours.

spk_0 I don't like that.

spk_0 So kind of that dream is to be able to prolong analgesia, but not necessarily prolong the

spk_0 motor block.

spk_0 Right.

spk_0 So if you're faced with a situation and you've already beautifully highlighted the fact

spk_0 that different surgeries will have different paint trajectories, but not only that within

spk_0 each surgery, each paint trajectory, patients respond differently.

spk_0 Some people are more stoic and they can take it.

spk_0 Others actually need a bit more.

spk_0 So what can we do?

spk_0 We've got a patient in front of us.

spk_0 We're going to do a nerve block.

spk_0 What are the different things that we can do to prolong analgesia?

spk_0 And of course, we're going to focus on catheter, but if we were to give an overview, what

spk_0 are the things that we can do?

spk_0 So I start with adjuvants.

spk_0 So dexamethasone, dexamethametamidine are common ones, clonoredine, buprenorphine.

spk_0 There's a whole bunch of potions that you can put into the cauldron and mix up.

spk_0 And that's actually a cool episode we should do at some point.

spk_0 Talking about all the different weird and wacky things people put in there.

spk_0 We've talked a bit about liposomal and where that fits in.

spk_0 There's also lots of new tech and pharmacologic options coming down the pipe that are being

spk_0 innovated.

spk_0 But I think for the vast majority of people, if you want to extend a block, I think

spk_0 a catheter seems to be a great fit.

spk_0 Okay.

spk_0 I think that's fair.

spk_0 The only thing that confuses me whenever we talk about adjuvants or additives is, what

spk_0 is the correct term?

spk_0 Are we doing local acidic plus an additive or is it local acid plus an adjuvant?

spk_0 Are they synonymous?

spk_0 I don't know.

spk_0 I always get confused.

spk_0 Look at people.

spk_0 They use them interchangeably.

spk_0 But I don't know if they think what the correct term is.

spk_0 I think they're the same.

spk_0 I mean, I don't know.

spk_0 Maybe I'm saying it wrong the whole time.

spk_0 No, no, no, you haven't been saying it wrong.

spk_0 I think that's highly unlikely.

spk_0 Adetive?

spk_0 What's that?

spk_0 Adetive adjuvant.

spk_0 I'll come on shut up.

spk_0 Sorry.

spk_0 Okay, they said, so let's start.

spk_0 That's a, that's a way of saying it.

spk_0 Adetive adjuvant.

spk_0 That's a horrible batch.

spk_0 That is German.

spk_0 That's a German.

spk_0 Everything goes, everything goes to German or Indian.

spk_0 Yeah.

spk_0 Okay, I'm going to stop.

spk_0 Stop now, I'm it.

spk_0 Right, so listen.

spk_0 So you talked about catheters and this episode is all about catheters.

spk_0 But what I want to know is in an elective ornamental setting, what are the type of procedures

spk_0 where nerve catheters have a role?

spk_0 So if I think about my elective orthopedic practice, I don't know a lot of people are doing

spk_0 stuff for knee surgery.

spk_0 So knee arthroplasty, this seems to be a role for some catheters and we can talk about

spk_0 which later definitely have done interscaling nerve catheters before.

spk_0 Yeah, upper limb low limb indications.

spk_0 Where do you think they have a role?

spk_0 Well, I think it's, it's really, really broad, right?

spk_0 So the question I asked myself, is this patient going to have pain that extends beyond,

spk_0 let's say, 24, 36 hours?

spk_0 And if the answer is yes, then catheter becomes part of my decision making tree.

spk_0 And we'll talk a bit later about who maybe shouldn't get a catheter and what you do

spk_0 with that.

spk_0 But all those things are on the table.

spk_0 So for upper limb, we like it for major arthroplasty of the elbow complex reconstructions

spk_0 of the forearm wrist hand, that sort of thing.

spk_0 Trauma.

spk_0 Catheters are huge in our trauma population because one of the great things about catheters

spk_0 is you can turn them on, turn them off.

spk_0 You can titrate them.

spk_0 So if you have someone who's got polytrauma, multiple injuries, they've got an ankle fracture

spk_0 and they've got a femur fracture and they've got a humerus fracture or rib fractures,

spk_0 you can be catheters in all those places.

spk_0 And obviously be thoughtful about dosing and toxicity and that sort of thing.

spk_0 But you can customize an analgesic routine that is very, very thoughtful about where you're

spk_0 and where you're putting the local.

spk_0 So, you know, I remember the very first time I met Sandy Coppe was a meeting in the

spk_0 UK, actually she won't remember me.

spk_0 I was a trainee, a resident, but she was talking to us back when you're missing a tooth.

spk_0 Yeah, this had a teeth fit with your face on it.

spk_0 Maybe slightly after that, but she was talking about how she introduced protocolized pathways

spk_0 at the Mayo Clinic for certain procedures.

spk_0 And I remember her talking about hip arthroplasty, how every patient she got, everyone's

spk_0 seeing from the same hem sheet, everybody got a Lumberplex's catheter back then.

spk_0 And they ran an effusion overnight and at a certain time in the morning, they stopped

spk_0 the infusion so that by the time people would round, they'd start to get their motor function

spk_0 back.

spk_0 So I see what you mean about that tithetral ability, right?

spk_0 Because, of course, while the catheter's running, it's going to have an effect, but you

spk_0 want to be able to then say, hey, let me just stop for a second and reassess things and

spk_0 then reload or restart the catheter if needed.

spk_0 Exactly.

spk_0 I get that.

spk_0 And another good example of that tithetral ability is inner scaling catheters.

spk_0 Sometimes patients go home with these and they're too numb.

spk_0 They can't move their fingers and their cervical plexis is numb and you can talk them through

spk_0 over the phone about how they turn their right down to this on the pump and then they

spk_0 get settled into a lower infusion regimen that is appropriate or the reverse.

spk_0 You know, my pain is more than expected.

spk_0 No problem.

spk_0 We can turn that catheter up or turn the bolus up or, you know, that's everything.

spk_0 Yeah.

spk_0 And I'm just trying to think there's a couple of areas at my hospital.

spk_0 And to bear in mind, in the UK generally, but certainly in my hospital, catheters wasn't

spk_0 a massive thing.

spk_0 You know, for a while, there was one pink, pink, is that on Teo Grozenich, who's been around

spk_0 for a long time is very well known of internationally.

spk_0 He used to put in federal nerve catheters a guy's many, many years ago and he used to do

spk_0 them sort of landmark or well, nerve simulator guided, but they kind of fell out of favor.

spk_0 And we certainly don't do ambulatory catheters, but I tell you where we've got a massive

spk_0 growth in nerve catheter use for chronic limit scheme.

spk_0 Vascular patients has a massive expansion.

spk_0 These patients come in in intractable pain.

spk_0 Right.

spk_0 And we institute therapy with peripheral nerve block catheters early.

spk_0 And of course, in the patients preemptively with amputation, but certainly chronic limit

spk_0 scheme, that's that whole area has expanded for us.

spk_0 And again, now we tightened up our rib fracture pathway.

spk_0 Patients will come in and if they score a certain level on the stumble score, or

spk_0 however rating system we're using part of the therapy, part of the process is they get

spk_0 a serratus plane or an ESP or a paravertoal catheter.

spk_0 So those are a couple of areas that have expanded massively.

spk_0 Hit fractures, we tend to do a lot more of the single shot blocks and EDs and then they

spk_0 then have the surgery, but that's again, another area where potentially we should be targeted

spk_0 in a lot.

spk_0 And then rectusheath catheters, our surgeons are putting in a lot of the rectusheath

spk_0 catheters.

spk_0 So we're not necessarily getting a chance to do them unless there's an issue where we're

spk_0 doing them as rescue.

spk_0 Do you have a big use for rectusheath catheters?

spk_0 Growing.

spk_0 Yeah.

spk_0 We were a huge epidural center for a long time.

spk_0 So if you were getting a labyrinomy, you get an epidural.

spk_0 Yeah.

spk_0 And listen, epidural gold standard, right?

spk_0 For abdominal pain.

spk_0 But the downsides are a little bit of mobility and hypertension.

spk_0 So we moved a lot of those cases to facial plane blocks and some of the advantages of a

spk_0 catheter-based therapy are again, you can keep it for weeks, literally, if you need to.

spk_0 It's titratable.

spk_0 Right.

spk_0 And so we use fair amount of liposomal, bepivocane as well, for some of these facial plane

spk_0 blocks.

spk_0 But one of the problems with that is that you may not use other local anesthetics for

spk_0 96 hours after that.

spk_0 So there's a lot of decision making sometimes in our my day to day where it's like, ugh,

spk_0 will this patient need another labyrinomy down the line or another operation or an

spk_0 ostomy or something like that?

spk_0 Right.

spk_0 If the answer is anywhere close to yes, we think hard about placing catheter-based therapy

spk_0 instead of tying our hands or the patient's hands metaphorically with the liposomal,

spk_0 which is sort of like one and done.

spk_0 So that's a, and I read to you, the catheter is just like a treat to place, right?

spk_0 Yeah.

spk_0

spk_0 Oh, when that plane opens up and you just sort of slide that catheter in.

spk_0 Yeah, no, no, no, for sure.

spk_0 I totally get that.

spk_0 No, just just give me a moment here for a second.

spk_0 If you can see this face right now, you know how much is it showing this visual treat?

spk_0 And the other thing that, you know, you mentioned something there about somebody needing

spk_0 a repeat surgery.

spk_0 I'll tell you where we have had interesting use of that.

spk_0 So we've had patients that come in with hand trauma.

spk_0 So you know, either amputated their fingers or had multiple vascular or tendon injuries.

spk_0 And they have operation number one done.

spk_0 And then they need to come back to the operating theatre, you know, 24, 36 hours later for a

spk_0 reluck or a rewashed.

spk_0 So we've had situations there when we put a nerve catheter in.

spk_0 And then when they've represented for the second operation, we just simply bolus that

spk_0 nerve catheter and converted it, you know, to operative energies.

spk_0 It much is the same way you would do for an epidural, right?

spk_0 Oh, yeah.

spk_0 I don't use the epidural labelling to convert it.

spk_0 This is their infection.

spk_0 Exactly.

spk_0 Maybe think of another indication that we use it for, unfortunately, not uncommonly, which

spk_0 is finger amputations, like when they're doing a replant, someone's cut their fingers

spk_0 off of the skill saw or something.

spk_0 And yeah, that's a, that's a 12 to 24 hour operation sometimes to get all those fingers

spk_0 back on and all the micro surgery and stuff.

spk_0 But part of what that patient needs, irrespective of the pain control is a break up like this

spk_0 catheter so that you can effect a sympathetic to me for days and days and days, which increases

spk_0 the likelihood those fingers are going to survive.

spk_0 Yes.

spk_0 That's an important one.

spk_0 Another one, sorry, you could be talking on this topic.

spk_0 I won't shut up.

spk_0 But speaking of your threatened limb population, in amputations, and also reboil using at the

spk_0 time of surgery, we do about it one a day.

spk_0 So it's a decently common operation.

spk_0 And so we had had some sort of workflow issues when these patients, unfortunately, some

spk_0 of them come down to the end of the day as an add-on case.

spk_0 And sometimes the regional expertise at that time at like 5.36 pm has dwindled.

spk_0 People go home from their day shifts and you're left with like one person who knows how

spk_0 to do blocks effectively and it was, it was not a great, abacrate mix.

spk_0 So we should find no problem.

spk_0 We want these patients to get great quality control, pain control.

spk_0 So let's bring them down the day before if you know about these patients and you know

spk_0 they're going to post them for an amputation between like 1 to 3 pm in our block area.

spk_0 It's kind of a lull.

spk_0 Most of the elective cases have been blocked by that point.

spk_0 And so you've got patient in the block area.

spk_0 We can take our time.

spk_0 We can just be teaching, put two catheters in.

spk_0 Usually a subgluteal sciatic and a femoral.

spk_0 Make sure they're perfect.

spk_0 Really secure the well, which we'll get to in a few minutes.

spk_0 And you may have not bolus them at that time.

spk_0 Yeah.

spk_0 But really what they're for is for the next day.

spk_0 So my colleague who isn't a regionalist, who right here, it's that patient on their

spk_0 vascular list can just go boom, boom, bolus and go that smart, but that requires some

spk_0 planning and some organization right.

spk_0 But that's a great, that's a great, a great tip.

spk_0 If you're going to be providing a regional service for somebody who may not be, have the

spk_0 skills to put the castor in themselves, find the patients in advance and block them.

spk_0 That's brilliant.

spk_0 I love that idea.

spk_0 It's been working, working well.

spk_0 And the other area that I wanted to talk about some, I wondered whether patients having

spk_0 messed up to me might need catheters, but I haven't, I haven't needed to put paravertable

spk_0 catheters in.

spk_0 But there is a big population of the chest where paravertable catheters have a big role.

spk_0 And that's our thoracic surgical population.

spk_0 At the moment, they're doing a study.

spk_0 In fact, they might have just finished recruiting it guys called the parasol study, I believe,

spk_0 with a looking at the difference between a preemptive, single-shot paravertable block,

spk_0 and then a surgically cited paravertable catheter versus not doing something preemptively.

spk_0 But that's certainly that thoracic population really seemed to benefit from having a paravertable

spk_0 catheter put in, either before or immediately after surgery.

spk_0 So that's one area where I think there's going to be, there is a lot of evidence already

spk_0 and we're going to get a lot more evidence hopefully coming soon.

spk_0 Yeah, yeah.

spk_0 Oh, that's great.

spk_0 Look, if I were to see the results of that.

spk_0 Okay, so we talked about the techniques and the indications, potentially.

spk_0 What about drugs?

spk_0 Let's talk about drugs.

spk_0 Sounds like my fifth grade health class.

spk_0 Okay.

spk_0 Do you want to start because I know you guys use a lot of repivocane, right?

spk_0 It's not something we're necessarily using buckets at my place, but tell us about, let's

spk_0 start with repivocane.

spk_0 So if you're going to use repivocane in a nerve caster, what concentration are you using?

spk_0 Yeah, repivocane has become our infusate of choice because of the, you know, long

spk_0 gesturation and the toxicity profile is just, you know, a little bit better than

spk_0 repivocane.

spk_0 So if you're going to expose a patient to a bucket load of low clannicetic over the

spk_0 course of four, five, six, ten days, then repivocane seems to be a good choice from that

spk_0 point of view.

spk_0 And it's a nice trade off between sensory block and motor block.

spk_0 So back to your, one of your original points, which was, gosh, wouldn't it be nice if you

spk_0 could just get sensory block and the patient could move your arm?

spk_0 Now, that's not always achievable with repivocane and you need to do some fiddling with

spk_0 the concentration sometimes, but it gives you a good chance compared to some other low

spk_0 clannic.

spk_0 Like the reason we don't use latacaninides pumps typically is the motor block is so profound.

spk_0 And so patients don't enjoy that.

spk_0 Yes.

spk_0 So repivocane point two percent is typically what we use.

spk_0 Now for pediatric catheters, we'll often use point one percent just so that we can get

spk_0 the volume required without concern for toxicity.

spk_0 I've got a couple of issues here and that is, so do you do your pumps, whatever pumps

spk_0 you're using, do they come pre-filled with a drunk or do you have to mix and dilute

spk_0 yourself?

spk_0 No, they, we have used different pumps over the years.

spk_0 And so typically either they use a bag with a specialized tubing that the bag gets spiked

spk_0 and the tubing gets sort of locked into the pump.

spk_0 Yes.

spk_0 So pharmacy would make that bag up or purchase that bag from a compounding pharmacy or something

spk_0 or there's a cartridge that gets sort of like clicked into the pump.

spk_0 And that cartridge has a reservoir that's filled with locals.

spk_0 So I'm not at the cauldron sort of putting in repivocane powder and water and...

spk_0 So you're provided with pre-doluted, pre-stereilly created medication.

spk_0 Correct.

spk_0 And often you have point two percent repivocane or point one percent repivocane.

spk_0 Yeah.

spk_0 Because as a continuous infusion medication by law in our country, it has to be prepared

spk_0 in a certain sterile condition with a hood and all that kind of stuff.

spk_0 Yes.

spk_0 So we don't, we can't sort of mix that bedside.

spk_0 Okay.

spk_0 I'm just interested to find out because we've got probably the communist medication we have

spk_0 available in our hospital and this stems back to the old days when you put an

spk_0 epidural in but then you wanted to give them a PCA as well.

spk_0 So you'd have the low dose, what used to be the low dose makes a point one, two,

spk_0 five percent repivocane with two mics from a little fentanyl in it.

spk_0 Yeah.

spk_0 But if you wanted to give them a PCA for something else that wasn't covered by the

spk_0 epidural, you just have a plain bag of repivocane and then give them a PCA.

spk_0 So we have easy access to repivocane but now thankfully we've managed to get the

spk_0 Levo bubivocane.

spk_0 And so the other thing I haven't been able to work out is one of them comes as

spk_0 0.1 percent or one of them comes as 0.125 percent.

spk_0 But these are pre-made solutions that we have.

spk_0 Yeah.

spk_0 But there is interest in getting rupevocane as well because you know, of course it's

spk_0 better to be using that.

spk_0 We know that the cardiac toxicity profile is better with Levo bubivocane.

spk_0 And actually, did you know that rupevocane was actually Levo rupevocane?

spk_0 I know.

spk_0 Yeah, no, no, did I.

spk_0 So, you know, we've got the mix, the 5050 mix of bubivocane or Marcan as some people

spk_0 call it.

spk_0 Yeah, we've got, you know, Levo indexed through versions.

spk_0 But when rupevocane was made, it's only the Levo version.

spk_0 Ah, interesting.

spk_0 So, level, why don't you use rupevocane?

spk_0 What's the limiting factor for using rupevocane in your hospital?

spk_0 Tradition.

spk_0

spk_0 Tradition.

spk_0

spk_0 We have had bubivocane as the sole anaesthetic for a long time and everyone was just

spk_0 happy using it.

spk_0 And then when the first manufacturer's got Levo bubivocane, we got access to that.

spk_0 It used to come in the little sterile packs and everyone was like, this is safer to use

spk_0 than bubivocane.

spk_0 So, that happened.

spk_0 Yeah.

spk_0 And then that one particular manufacturer came with patents.

spk_0 So, we had plenty of access to Levo bubivocane, the generic version in unsterile ampules.

spk_0 But that practice never translated across to epidurals.

spk_0 And because we didn't have a nerve catheter practice at that stage, the same process didn't

spk_0 happen.

spk_0 So, it kind of takes somebody to initiate it.

spk_0 And when you're working a big teaching hospital that's kind of conglomerate of a few different

spk_0 hospitals and we have pharmacy that covers three or four different sites, trying to change

spk_0 anything is a problem.

spk_0 Sure.

spk_0 Yeah.

spk_0 So, we are working on that.

spk_0 And I believe now we have, we've made the one sterile from bubivocane to Levo.

spk_0 Rupe, I'd love to have.

spk_0 But I can't just get it for myself.

spk_0 It has to be something that everybody across all hospitals agree with.

spk_0 Have you used the do you know who I am argument with pharmacy?

spk_0 Unfortunately, I have, I have, I don't think they give a damn who I am.

spk_0 And I have the last time I use that do you know who I am line?

spk_0 Yeah, it was a way to embarrassing.

spk_0 Maybe I'll say that's different.

spk_0 Oh, what?

spk_0 Yeah, I'm not going to use it.

spk_0 Really intrigued.

spk_0 Have he never used that line?

spk_0 I'd be, I'd be loved to hear your story.

spk_0 Yeah, I used it once because I was frustrated, but yeah, I won't do it again.

spk_0 Oh, God.

spk_0 Okay.

spk_0 Yeah.

spk_0 So, hey, for the benefit of our U.S. listeners at least and probably, probably some more in the

spk_0 world, do you reckon that Levo bubivocane is more or less the same as ropey in terms of

spk_0 the pharmacodynamics and or the toxicity?

spk_0 Do you?

spk_0 I think from a toxicity point of view, I think it's pretty much the same.

spk_0 Okay.

spk_0 I think with Rupe, and again, Paul, his lecture preparation has taken me back to the old

spk_0 school.

spk_0 And if you look at the liposolubility of bubivocane, Levo bubivocane, a ropey vacane,

spk_0 actually bubivocane is ever so slightly less liposolubal.

spk_0 Rupevocane is ever so slightly less liposolubal, which means it doesn't penetrate.

spk_0 Minalinated motor fibers quite so well, which is why you get a little bit of motor sparing

spk_0 with rupevacane.

spk_0 So effectively, I think you could probably treat them all most interchangeably, although from

spk_0 what I understand and don't even get me talking about doses of local and so they can

spk_0 max with doses because that's a whole nother minefield.

spk_0 But I feel that with Rupevocane, you've got a little bit more space with the dose compared

spk_0 with Levo.

spk_0 So effectively interchangeable.

spk_0 I think it says in the closest thing to ropey and Levo are pretty similar.

spk_0 Yeah.

spk_0 So maybe that's why ropey hasn't taken off as quite as much.

spk_0 But speaking of doses, how about infusion strategies?

spk_0 So you've placed a catheter and we'll get back to that and tips and tricks us to how

spk_0 to make the catheter going nicely and stay in and all that kind of stuff.

spk_0 But assuming that's been done, what are our choices?

spk_0 How do you deliver that local anesthetic through the catheter?

spk_0 So bro, this is I think, and then we talk about some specialty and niches.

spk_0 We could almost have a whole episode just on this.

spk_0 So simple terms.

spk_0 You've got a mills per hour.

spk_0 You can just start off, you know, your simple prompt doesn't take very much.

spk_0 You can go electronic and elastomeric pumps.

spk_0 You can dial up a mills per hour thing.

spk_0 And at the very least, what that does is make sure the catheter stays patent and it doesn't

spk_0 get blocked off by things.

spk_0 But that's not very dynamic and actually a lot of blocks.

spk_0 It depends on the block right?

spk_0 If you've got the catheter placed beautifully by a nerve, it may be that after initial

spk_0 bonus, just gently tickling that nerve with local anesthetic is all you need to keep

spk_0 it kind of going.

spk_0 You get the sensory block without the motor block tickling.

spk_0 You're talking about a fascial plane block.

spk_0 Often we know these work by fluid expansion.

spk_0 You need that big bulk flow to open up the space and so mills per hour might not cut it.

spk_0 So at one extreme, you've got mills per hour.

spk_0 Then you've got the intermittent bolus therapy.

spk_0 Now this can be a manual intermittent bolus.

spk_0 I.e. a person comes along and boluses the catheter themselves that cost man or woman

spk_0 power to do that.

spk_0 Or you've got programmed intermittent boluses, which is at every two, three, four hours,

spk_0 whatever you decide, the pump will deliver a catheter.

spk_0 That can be with or without a background infusion running.

spk_0 Or you've got patient controlled regional anesthesia where the patient can give themselves

spk_0 a bolus much like they would with a PCA on top of a background.

spk_0 So this is where I think it gets a bit confusing because there are so many options.

spk_0 But I remember you talking way back when we were talking about shoulder surgery, you

spk_0 actually found out that you ended up using less local anesthetic cumulatively with some

spk_0 of your blocks where you switched to an intermittent bolus as opposed to a continuous

spk_0 infusion system.

spk_0 Yes.

spk_0 To tell me what your experience is, because at the moment the easiest access we have at

spk_0 our hospital is to a simple mills per hour and we're in the process of procuring some

spk_0 new pumps that can do all of the new stuff.

spk_0 So tell me about your experience.

spk_0 Well, yeah.

spk_0 So we had been used to doing, starting usually about eight mills an hour as a straight-up

spk_0 continuous infusion for our inter-scaling catheters.

spk_0 And that was, that's a compromise, right?

spk_0 Like, we want to make sure that the vast majority of patients, well, every patient is comfortable

spk_0 with that.

spk_0 And that's going to be a bit too much for some, but that's okay.

spk_0 And as I said, sometimes we had phone calls or we were like, well, clamp the tubing and

spk_0 we'll see how you feel in a few hours and that sort of thing.

spk_0 When we switched from, there was a time when we switched from a last-emarric design to

spk_0 a programmable electronic pump for ambulatory catheters and what we realized was, okay, let's

spk_0 go down and, because we can always give a patient control bolus with that or a Pib, a

spk_0 programmed intermittent bolus.

spk_0 And we got down to like two, three, four mills an hour range and that seemed to be fine

spk_0 as long as you had the option to give a little bit of a bolus.

spk_0 And patients found that they-

spk_0 So you just run somewhere between two to four mills in the background and then give

spk_0 the patient the option to stop out only if they needed to?

spk_0 Exactly.

spk_0 So bottom line is we found that we needed, we probably needed a whole lot less than we

spk_0 thought in terms of a background infusion provided you could give someone a little bit

spk_0 of a bolus.

spk_0 And so our total, that allowed for a, you know, less mills used per day, which ultimately

spk_0 meant that we could extend the life of that bag of local anesthetic out to more and more

spk_0 days.

spk_0 So do you think actually now, again, depending upon the location, that we could just get

spk_0 away without the background infusion and just do patient controlled region anesthesia

spk_0 only, is that ultimately where we're headed?

spk_0 Well, that's exactly where we headed.

spk_0 And that's how we program ours now.

spk_0 So we typically don't even give a background infusion.

spk_0 Sometimes when I explain this to trainees, especially when thinking about fascia

spk_0 plane blocks and fascia plane catheters is, imagine the end of the catheter and you've

spk_0 programmed it at like, say, eight or 10 mills an hour.

spk_0 What does that look like at the end of the catheter?

spk_0 It is drip.

spk_0 Yeah.

spk_0 Dr.

spk_0 Oh my God, I thought you forgot.

spk_0 I thought you froze.

spk_0 No, that's, that was a deliberate, uncomfortable pause.

spk_0 So, so this, you're like, I've maintained eye contact with a whole thing.

spk_0 So but you can imagine if you didn't ESP catheter and your initial bolus of 20, 25, 30

spk_0 mills, whatever to bulk flow, expand that space, then if you just run a continuous infusion,

spk_0 that is going to recede down to maybe one dermatome.

spk_0 Yeah, I think an intermittent bolus is amazing.

spk_0 So for many of our blocks, interscaling may be a bit of an exception or need less because

spk_0 if you're very precise with where your catheter tip is and there, that's not a big area.

spk_0 You need to give.

spk_0 Just thinking about that 50 mills.

spk_0 But yeah, a lot of patients ended up with a background infusion of two and then a

spk_0 PIP of four.

spk_0 Oh, I see.

spk_0 It's a really tailoring it.

spk_0 So not giving them a big bit.

spk_0 Yeah.

spk_0 This kind of feels like we're mirroring.

spk_0 I remember back in the day, it's not the first time I mentioned a name, but Geraldine

spk_0 is Sullivan, one of our big doyens of obstetric anesthesia.

spk_0 She was really moving to the mobile lab at a pejoral and we almost done away with the

spk_0 background infusion of our low dose mix and they just used to get very small patient control

spk_0 boluses.

spk_0 I kind of see that's where we're going with this and that sort of makes sense to me because

spk_0 I've got a colleague at Cleveland Clinic London call and Barry Phillips.

spk_0 He puts a lot of adept to canal catheter's in and he has a system where he can bolus

spk_0 them manually himself.

spk_0 And actually, he much prefers that he doesn't want to tie the patients up to something

spk_0 even though a lot of our pumps now as we know are ambulatory, you can put them with body

spk_0 straps on them.

spk_0 But he's opted to just do, you know, boluses X times a day and he finds that that works

spk_0 better.

spk_0 They get the effects.

spk_0 It lasts a period of time and then when they're ready for the next effect, you talk them

spk_0 up.

spk_0 So I kind of feel that this may be the duration of travel for all of our nerve blocks maybe.

spk_0 Yeah, I think so.

spk_0 It's worked for us and it translates across block site for the most part.

spk_0 So pervertubro catheters.

spk_0 So I think certainly every fascia plane catheter needs needs to have an intermittent bolus

spk_0 to make it function properly.

spk_0 And there's in that doctor's a good example to that as you mentioned.

spk_0 So that is a tricky catheter to place sometimes, especially since we've realized that

spk_0 there are two different compartments and two different nerves.

spk_0 But with catheter design where you have multiple side holes at the end, you can lay it down

spk_0 sort of over that vast of a doctor membrane.

spk_0 And I remember I recorded a video once that was perfect and it just got the spread going

spk_0 both ways towards the NVM and the saffon as like a record record record that.

spk_0 Yeah.

spk_0 So that's the ideal.

spk_0 We'll be right back after this word from our sponsor.

spk_0 All right, Jeff, real question.

spk_0 How many times have your patient said that nerve block was great, but why did the pain

spk_0 come back the next day?

spk_0 Oh, man, too many.

spk_0 That's why I'm a huge fan of placing catheters and sending them home with a pump.

spk_0 Amen.

spk_0 The nerve stain numb, the patient stays happy and you don't get that 3am where's my

spk_0 oxycodone call?

spk_0 Exactly.

spk_0 And when I say pump, I mean avanus.

spk_0 Their on cue and embedded systems have been total game changers.

spk_0 Both are amazing.

spk_0 The on cue is the elastomeric one, a squishy pain grenade with elastic recoil, no buttons,

spk_0 no batteries, just steady delivery for up to five days.

spk_0 Right.

spk_0 I call it the set it and forget it option.

spk_0 But if you want more control like adjustable boluses or programming different delivery rates,

spk_0 I'm a huge fan of ambit.

spk_0 The ambit is the Tesla of pain pumps, digital, portable and way easier to explain than my

spk_0 EMR.

spk_0 Yeah.

spk_0 Plus, both pumps are backed by real clinical evidence.

spk_0 Over 100 peer reviewed studies showing better pain control, less nausea and decreased

spk_0 opioid use.

spk_0 If you need prolonged pain relief, pump-based therapy delivers literally.

spk_0 And here's the kicker.

spk_0 Both pumps are covered under the no pain act, so hospitals and ASCs can get separate

spk_0 Medicare reimbursement for the device and supplies.

spk_0 Wait, so CMS actually pays extra to reduce opioid use?

spk_0 I know.

spk_0 It's like they finally read the literature.

spk_0 Between on cue simplicity and ambit's programmability, it's easy to pick based upon the needs

spk_0 of the case.

spk_0 I love that.

spk_0 New replacement with fluctuating pain needs?

spk_0 Ambit.

spk_0 Rest fracture in a pickleball addicted dad?

spk_0 On cue.

spk_0 He doesn't want to read a manual.

spk_0 He just wants to get back to dinking.

spk_0 And let's not forget the avanoss perks.

spk_0 24-7 nurse support, local reps and even hell with coding and billing.

spk_0 So yeah, pumps, pain relief and painment.

spk_0 What's not to love?

spk_0 Pump it up, my friend.

spk_0 And you got it.

spk_0 And now back to our show.

spk_0 So let's talk about catheter design because it's not as simple as saying give me the nerve

spk_0 catheter, right?

spk_0 Because it's like, there's quite a lot of different nerve castes.

spk_0 Yeah, yeah.

spk_0 Hey, do you know what the first nerve catheter design was?

spk_0 Is this a joke?

spk_0 No, no, no, no.

spk_0

spk_0 Okay, no, I don't.

spk_0 A piece of holospigetti.

spk_0 Well, maybe there was some like, you know, prehistoric innovations or something.

spk_0 But there was no, the first one that I can think of and I'll put the reference in the

spk_0 show notes was was a needle, just a, you know, standard sharp needle pushed through a cork.

spk_0 And then the cork was taped to the patient's subruchal vacuator fossa.

spk_0 And the needle tip was held in place by this cork and tape so that it was at the right

spk_0 spot near the brachial plexus.

spk_0 Are you for real?

spk_0 Oh, yeah, yeah.

spk_0 And the publication has a picture of this.

spk_0 It's wild.

spk_0 I forget.

spk_0 I want to say it's like the 1940s.

spk_0 Oh my gosh.

spk_0 Okay, that's crazy.

spk_0 Anyway, so we've come a long way.

spk_0 Yeah, I remember the first time we did this in a unit where we didn't have dedicated

spk_0 nerve catheters, we just used an epidural catheter because that's all we had access to.

spk_0 Or the other thing that one of my mentors, a chap called Sanjay Galati, did was what do

spk_0 you call those?

spk_0 You guys Americans call them Sunday Canadians call them something where it's like an IV

spk_0 cannula, but it's a specific type of IV cannula, like a gelco or anjuicath.

spk_0 Anjuicath.

spk_0 Yeah, yeah, yeah, we call them abacats, but same thing.

spk_0 So he did the nerve block with an abacath or anjuicath and the supercalibular fossa

spk_0 go into the right place and then remove the needle and just left essentially the cannula

spk_0 there.

spk_0 So it's like leaving an IV cannula in the location.

spk_0 So those are some of the early nerve blocks I did.

spk_0 Yeah, clearly that's not dedicated for that reason, but it kind of did the job.

spk_0 Oh, you can definitely go low tack with this.

spk_0 And you know, we're not advocating that though, right?

spk_0 We're not advocating that.

spk_0 No, no, I think, I think, but in a pinch, I don't want to give the idea to some of

spk_0 the listeners that you need to have a fancy catheter kit for this.

spk_0 You can get good continuous regal anesthesia with a standard epidural setup.

spk_0 My issue with the anjuicath is that it's sharp, so I don't use that.

spk_0 Right.

spk_0 Typically our products come in one of two categories and it's the way they're designed.

spk_0 So there's either catheter through needle or catheter over needle.

spk_0 So the catheter through needle is like your epidural.

spk_0 So you have a sort of a two-way set.

spk_0 You get the needle where you like it.

spk_0 You give it a little bolus.

spk_0 Uh-huh, everything looks great.

spk_0 And then you pause and then get the catheter into the needle, push it through, and then

spk_0 do what I call a push pole.

spk_0 So you're advancing the catheter well, attracting the needle.

spk_0 Which is the maneuver that always makes me a bit nervous, but we'll talk about that later.

spk_0 But yeah.

spk_0 Yeah.

spk_0 And then the needle is out and the catheter has remained hopefully in the same spot.

spk_0 Yeah.

spk_0 And that's catheter through needle.

spk_0 Very common.

spk_0 That is still a lot of what we do every day in catheters at our spot.

spk_0 And then there's catheter over needle, which is a clever innovation that is like an

spk_0 angelic catheter.

spk_0 Yeah.

spk_0 And they're usually longer these sets.

spk_0 There's often some echogenicity built into the needle.

spk_0 And so you can advance a needle to where you like it.

spk_0 Again, bolus, excellent.

spk_0 And then just pull the inner needle, style out of the catheter and you're left with the

spk_0 catheter in place.

spk_0 And although there are variations of that.

spk_0 And there are variations.

spk_0 Yeah.

spk_0 So there's one where exactly you do it like an angelic catheter.

spk_0 You know, you get the tip of the needle where you would want the tip of the catheter to

spk_0 rest.

spk_0 Do your bolus, remove the needle.

spk_0 But then you thread a catheter through the cannula.

spk_0 So that kind of goes through the middle hole.

spk_0 So it replaces where the needle was and you screw it into place.

spk_0 Yeah.

spk_0 And kind of got an outer cannula and inside that central loom in, you thread it in a

spk_0 catheter, which just emerges a fixed proportion outside the cannula.

spk_0 So that's really clever.

spk_0 And the reason it's clever is those catheters have an end hole, but they also have a hole

spk_0 that's protected inside the cannula.

spk_0 Yeah.

spk_0 You can check these things out there.

spk_0 They're very commonly available and you can search on the internet.

spk_0 But the beauty about the catheter over needle technique is that you essentially know where

spk_0 the tip of the catheter is going to be.

spk_0 There should be no doubt about that.

spk_0 But also one thing we didn't talk about is when you do catheter through needle, the hole

spk_0 that you're left with in the skin is larger than the catheter because of course the needle

spk_0 has to accommodate the catheter.

spk_0 So when you remove the needle, the hole you got left in the skin is larger than the

spk_0 catheter itself was with the castor over needle.

spk_0 The biggest hole is the thing that you punctured the skin with the first time.

spk_0 So maybe we need some diagrams or some pictures or a video.

spk_0 I'm enjoying your hand motions and stuff.

spk_0

spk_0 I'm at my face.

spk_0 And we'll talk a bit about how to prevent leakage as a public service announcement.

spk_0 Okay.

spk_0 But what about the catheter itself?

spk_0 You can have a stiff catheter, a flexible catheter.

spk_0 The catheter has got a guide or inside it or you can stimulate the catheter.

spk_0 What do you think the commonest catheter uses are?

spk_0 Do you use them all?

spk_0 We use both.

spk_0 Yeah.

spk_0 And I think there's a time and a place.

spk_0 And by place, I mean, an atomic place for each of these.

spk_0 So if it's a straight shot to my target, femoral block would be a good example.

spk_0 I'm not planning on doing any advanced maneuvers with my needle to get to the space where the

spk_0 femoral nerve lives.

spk_0 Catheter over needle is fantastic.

spk_0 So drive it in.

spk_0 It's like a single shot block, right?

spk_0 Yeah.

spk_0 Single shot block.

spk_0 Yeah, that's my Sean Connery impression.

spk_0 I'm going to our minestrar, a single shot block, gold finger.

spk_0 So drive it in.

spk_0 Bullets awesome.

spk_0 Pull out the needle.

spk_0 Pluck catheters there.

spk_0

spk_0 One potential drawback to some of those sets is that they're a bit more flexible.

spk_0 So if I need to joystick my needle to get to the place I want the catheter to go or

spk_0 I'm going to throw a lot of muscle like a subgluteal catheter sometimes.

spk_0 Right.

spk_0 Then I might like a more stiff two-e needle catheter through a needle to get.

spk_0 Do you have used stimulating catheters?

spk_0 I used to.

spk_0 Those are the first ones we ever used.

spk_0 The first catheter I ever did.

spk_0 I just like I heard about catheters and thought this sounds really cool.

spk_0 And I was doing a femoral catheter and I was trying to advance it the wrong way.

spk_0 It's like, what do you mean?

spk_0 Try to advance it distally?

spk_0 Like down the nerve?

spk_0 Oh, I see.

spk_0 Like how I can't believe what a what a non intuitive moment that was for me.

spk_0 Like why would and the attending was who's not a regional guy?

spk_0 He was just like had to stand there because I had to have an attending with me.

spk_0 And he's like, do you think it should be the other way?

spk_0 Like should we put in the catheter up into the pelvis of it as opposed to like down the thigh?

spk_0 Anyway, one of the pain points with doing the catheter through needle for us is you've

spk_0 got your needle in the right spot.

spk_0 But then putting the catheter in, it can be either too much catheter and then your catheter's

spk_0 shot way off into the distance.

spk_0 Yeah.

spk_0 And then you don't know where it is or worse as the trainees pulling the needle back and

spk_0 doing the push pull, they don't do enough push.

spk_0 And then you go and you bolus through it under image guidance to see where your catheter

spk_0 tip is and low and behold, it's subcutaneous.

spk_0 So you have to sort of do it again.

spk_0 So it takes some experience to get the right push pull to make sure that your catheter tip

spk_0 stays sort of right where you want it.

spk_0 I usually try to get my catheter about three to four centimeters beyond the tip.

spk_0 Right.

spk_0 Expecting there to be a little bit of retraction when the catheter's taped to the skin, the

spk_0 patient's moving around and stuff.

spk_0 So catheter's usually pull back a bit over the first few days.

spk_0 They don't, they never go in further.

spk_0 So well, with that in mind, when we talk about insertion tips, I want to talk about a

spk_0 little tip I heard from Key Jam, which I thought was quite clever.

spk_0 But what about coiling catheter?

spk_0 Because I've seen some catheters where you place a catheter where you want and then when

spk_0 you're ready, you pull the central wire out and a little coil forms at the end.

spk_0 Have you ever used those?

spk_0 And I found, I did a cat a very excited with those.

spk_0 I found them a bit weird.

spk_0 Yeah, like a little pig tail.

spk_0 Yeah, exactly.

spk_0 Yeah.

spk_0 I saw, I saw a poster once at a meeting with those, but I never ever seen one in practice.

spk_0 Some people swear by them.

spk_0 If anyone out there is using them, let us know in the comments how they're working.

spk_0 Because the idea is cool, right?

spk_0 Like maybe that helps prevent dislocation.

spk_0 Yeah, yeah, yeah.

spk_0 There was another catheter which I think has kind of disappeared.

spk_0 It basically came in a big needle, like a curved needle.

spk_0 And you'd have to go through and under the nerve and pull the needle out the other end.

spk_0 And basically you could kind of position the catheter through the skin so that the holes

spk_0 were just underneath the nerve.

spk_0 Did you ever, did you ever see that?

spk_0 Yeah.

spk_0 We had that.

spk_0 When that first came around, we tried it in, I don't think we did it in a patient.

spk_0 I think we did it in some like gel models.

spk_0 But it was a cool idea.

spk_0 The challenges with catheters are number one, getting the thing to be in the right place

spk_0 in the first place.

spk_0 And that requires a ton of expertise and finesse and training and that sort of thing to

spk_0 get the tip to.

spk_0 And then once it's there, it's keeping it there.

spk_0 So so many times it's heartbreaking.

spk_0 You've done all this work and then the orthopedic surgeon takes a drape off at the end and

spk_0 rips the catheter out.

spk_0 And you're like, oh God.

spk_0 So that was that I forget the name of that device, but it was it was a really clever innovation

spk_0 to make sure that the holes could be adjusted.

spk_0 Yeah, yeah, that's right.

spk_0 Afterwards and you could like sort of fiddle with it and I'm not sure it ever it ever

spk_0 really took off, but it was a cool innovation.

spk_0 I think the concept was cool.

spk_0 Yeah.

spk_0 And but I can also imagine sort of taking with one through this needle, taking the

spk_0 crotted archery with me or the IJV or something.

spk_0 But anyway, and that's the thing that made me nervous.

spk_0 All right.

spk_0 Cool.

spk_0 So listen, before we hit the, the dad joke break, I just

spk_0 wanted to talk about pump design because back in the old days, we just used to have electronic

spk_0 pumps that used to do mills per hour.

spk_0 And then I heard about the whole elastomeric pumps that just used to be mills per hour.

spk_0 But now we've got a whole host of different designs available, right?

spk_0 Yeah, yeah, that's great.

spk_0 And the nice thing about that is there are different needs, right?

spk_0 So not everyone needs the Cadillac of electronic pumps to manage that particular catheter.

spk_0 Sometimes the catheter is best served by something that's much more simple and sort of set

spk_0 and forget it.

spk_0 So, yeah, two big categories, I guess, is elastomeric.

spk_0 And that's the idea that you have this rubber ball that you fill up.

spk_0 So it's really taught with low clannicetic.

spk_0 And then the elastic recoil of that ball sort of pushes out the low clannicetic at a calibrated

spk_0 rate.

spk_0 And some of them have a rate change device on it.

spk_0 So you can say, oh, I want four, six, eight, whatever, mills per hour.

spk_0 So some of them are fixed, some of them are fixed and some you can adjust.

spk_0 Right.

spk_0 Exactly.

spk_0 So giving you some flexibility there.

spk_0 And so that's a technology that's super easy, doesn't need electricity, et cetera.

spk_0 And then I think more and more commonly for our boutique regional practice, we're finding

spk_0 places like ours are using a electronic programmable pump.

spk_0 And you can get all the parameters that you talked about.

spk_0 Plus or minus continuous infusion, plus or minus a patient bolus, plus or minus an intermittent

spk_0 automated bolus.

spk_0 And so you can mix and match those parameters to get what I'd be like.

spk_0 That's the kind we use for our home pumps and even in hospitals.

spk_0 So there was a time when our practice had like a pump for in hospital, which has a

spk_0 spectace much like the pump you guys use.

spk_0 The same pump we use for epidurals.

spk_0 And then if they're going to go home, we would switch them over to an ambulatory pump.

spk_0 Yeah.

spk_0 But that seemed complicated and it was a pain for the pain service.

spk_0 And so we just said, all right, fine, we're just going to start you with this pump.

spk_0 Right.

spk_0 And that you're going to live with that.

spk_0 That's going to be a pump for in house.

spk_0 And when you just go home and this goes with you.

spk_0 Okay, I love that because an ambulatory pump is got to be something that you, you can't

spk_0 rely on having to plug it into the mains power because that's a pain.

spk_0 I remember that that was my worst call when I was a registrar on calling you to say,

spk_0 oh, the pumps are alarming and you know that and they didn't have a power cable at around

spk_0 at batteries.

spk_0 So, oh, yeah, they're going to be something that either doesn't require power or is battery

spk_0 run and the batteries will last the duration of the pump requirements.

spk_0 So yeah, the ambulatory pumps that are out there now give you so much flexibility.

spk_0 So I think that's cool.

spk_0 Is there anything else you want to talk about pump design before I drop some of my best

spk_0 jokes?

spk_0 I mean, there's little things that make a difference in terms of, I've seen pumps that

spk_0 are quite heavy and are a challenge for, you know, a 75 year old lady who's at a

spk_0 near place to sort of haul around for five days.

spk_0 I think something that's decently light is an advantage and something that's small,

spk_0 right?

spk_0 So you can put in your Fanny pack and your Fanny pack.

spk_0 Yeah, I don't that's not a big lot of term you guys use a lot over there first for different

spk_0 reasons.

spk_0 Bumbag.

spk_0 Yeah.

spk_0 You know, I just as an aside, I do not like the move that industrial manufacturers are making

spk_0 towards touch screens for everything.

spk_0 Like I don't know what your inside of your car looks like.

spk_0 Touch screen.

spk_0 Exactly.

spk_0 Well, I have, I have an older car and thankfully the, all the controls for like the

spk_0 climate and that sort of and my radio or whatever are still knobs and clickers and that

spk_0 sort of thing.

spk_0 So I can keep my eyes in the road, reach my hand down and adjust things without having

spk_0 to go through like 16 sub menus to get to do you want rear climate?

spk_0 Oh, we're shopping for an oven later day and they don't make them which is knobs anymore.

spk_0 It's all like, oh, it's a flat glass screen to look at the LED thing.

spk_0 Like I don't actually want that.

spk_0 I just want a knob that I can turn on off.

spk_0 That's going to be a bumper sticker.

spk_0 Jeff says I just want a knob.

spk_0 Anyways, but I was going to be back to the pump design.

spk_0 I think that's something to think about is like if you have a 80 year old person at home,

spk_0 it has to be fairly simple to operate in terms of giving yourself a bolus or stopping

spk_0 the pump or whatever.

spk_0 That was, that was a long way to get to that point.

spk_0 Well, just to go back to your point about touchscreen in the car, the one thing I can say

spk_0 is I don't use a function enough.

spk_0 There are a lot of touch screens and a lot of menus, but actually mine is voice activated.

spk_0 Oh, so I can say, hey, manufacturer of car, can you blah, blah, blah and it will do it

spk_0 for me.

spk_0 But anyway, that's kind of a nice, I don't realize Ross Royce made a touchscreen.

spk_0 Oh, that was, oh, very good.

spk_0 Listen, it's time for a joke.

spk_0 Yeah, why are pirates?

spk_0 Why are pirates bad at singing the alphabet?

spk_0 To pirates, I, no, I don't know.

spk_0 Because they get stuck at sea.

spk_0 That's good.

spk_0 Okay.

spk_0 Okay, another one.

spk_0 Why do bees have sticky hair?

spk_0 Okay.

spk_0 Honey, yeah, I don't know.

spk_0 Yeah, yeah, yeah, because they use honeycombs.

spk_0 Honeycombs, yeah, right.

spk_0 Okay.

spk_0 I've got to tell you something though, actually.

spk_0 We love music in our house, but I've decided.

spk_0 I can't ever let my kids watch the orchestra.

spk_0 Oh, you know how to class music fan?

spk_0 Well, it's just there's two mucks, uh, sax and violins.

spk_0 Sax and violins.

spk_0 Nice.

spk_0

spk_0 So listen, that's the last time I tried to do a joke that's not on brand with the episode

spk_0 thing because that's bad for it.

spk_0 Anyway, have you got something for me?

spk_0 Your foot joke was, you had one, two, three, bang, bang, bang, feet jokes.

spk_0 Okay.

spk_0 All right, I can tell more about traditional joke this time.

spk_0 And it's making use of some stereotypes here.

spk_0 Okay.

spk_0 So trigger warning.

spk_0 A Texan walks into a pub in Ireland and you know, these Texans are big, loud, big, big

spk_0 personalities.

spk_0 And he says, all right, people, I hear you ours can drink.

spk_0 I'll give $500 to anybody in here can drink 10 pints of Guinness back to back.

spk_0 Room goes quiet.

spk_0 No, nobody, nobody puts their hand up.

spk_0 One guy even leaves.

spk_0 Okay.

spk_0 So, all right.

spk_0 So he sits down at the bar and he figures, you know, no one's going to take him up.

spk_0 It's 30 minutes later, the guy who left comes back taps a Texan on the shoulder and says,

spk_0 each of our bets still good.

spk_0 And the Texan says, yeah, okay.

spk_0 And ask the bartender to line up 10 pints of Guinness and the Irishman tears into it.

spk_0 Just one after another, boom, boom, boom, back to back.

spk_0 Get our, get our breathe.

spk_0 So the pub is cheering and Texans like flabbergasted jaws in the floor.

spk_0 He goes, well, my hat's off to you, man.

spk_0 Here's your, here's a $500.

spk_0 And if you don't mind me asking, where'd you go for 30 minutes while you were gone?

spk_0 Irishman goes, oh, I had to go down to the pub down the street to see if I could do it first.

spk_0 Oh, I'm very good.

spk_0 Oh my God.

spk_0 Well, two things.

spk_0 Number one, I didn't see that was going.

spk_0 And number two, you're actually got better.

spk_0 Your Irish accent improved from the opening to the end.

spk_0 Your Texan accent is pretty good.

spk_0 I love that joke.

spk_0 That's very, very good.

spk_0 Okay.

spk_0 Good, good, good.

spk_0 All right, that's my joke.

spk_0 Let's get back into it.

spk_0 So I want to talk about insertion tips and tricks because most of us now are happy that

spk_0 we can do a single short nerve block.

spk_0 But putting a catheter in requires some extra thought processing, some planning, just

spk_0 to optimize success.

spk_0 Yeah.

spk_0 First question, how much acepsis is required when citing a nerve caster?

spk_0 In the UK, if we're putting individual caster, traditionally we use a full gown, you know,

spk_0 mask hat drapes, all the rest of it.

spk_0 How much acepsis you need for a nerve caster?

spk_0 Well, at minimum, hat mask, sterile gloves, and then sterile, obviously sterile skin

spk_0 prep drape, et cetera.

spk_0 I think that's our minimum.

spk_0 I don't personally use a gown.

spk_0 I think the funny thing is now in this sustainable world that we're living on with a thought about

spk_0 sustainability, you wonder how essential the gown is to the setup, but it's something

spk_0 that some places will insist on.

spk_0 Yeah, I tend not to belly up to my block area.

spk_0 Like, you know, it would take a lot for that catheter to whip around and hit me in the

spk_0 torso.

spk_0 But a drape is quite essential though, right?

spk_0 Because if the catheter, if it's flipping around somewhere, you don't want it to touch

spk_0 something that's not clean as it's going in, right?

spk_0 Certainly the opposite.

spk_0 You need a good drape, yeah, absolutely.

spk_0 Obviously, probe cover goes without saying.

spk_0 So, you know, we've talked about shorties, you know, a little 30 centimeter probe cover.

spk_0 No, this is where you want the entire cord, because you're going to be dragging that cord

spk_0 over your sterile setup.

spk_0 So, you want the long probe cover for this.

spk_0 Oh, you know, I've got to tell you something.

spk_0 I've been trying to work out for the right time to bring this up because...

spk_0 Confession.

spk_0 We have some friends that I've known for a long time from blackjack.com.

spk_0 Oh, yeah.

spk_0 And I'm talking about Brandon Winchester and Gregory Hickman.

spk_0 If you watch the way that they do their blocks of the drape, it's very clever.

spk_0 I have never seen them use a probe cover.

spk_0 Do you know why?

spk_0 Because they put the drape on.

spk_0 And the whole of the drape is where the needle insertion is going to be.

spk_0 And they put the probe underneath the drape.

spk_0 And so they grasp the probe via the drape.

spk_0 Really?

spk_0 The drape is in contact with the skin.

spk_0 It's so clever, but you do need to have done it before and you totally need to have understood

spk_0 how this works.

spk_0 It's so clever.

spk_0 So, literally, they never make contact with the probe itself.

spk_0 The probe is held via the drape, which is a see-through drape.

spk_0 The probe has got full contact with the skin.

spk_0 So you've got a beautiful image.

spk_0 But they never have to put a probe cover on because they're never in direct contact.

spk_0 You've got to check out blackjack.com.

spk_0 Oh, that American accent.

spk_0 Okay.

spk_0 Cool.

spk_0 But yeah, so that's just an extra consideration.

spk_0 Okay.

spk_0 So, Asepsis is important.

spk_0 We possibly are not necessarily in agreement with using again.

spk_0 I kind of get that.

spk_0 But I think masks, because we know talking is a bad thing.

spk_0 You know, that's the thing that's associated with spreading the most bacteria.

spk_0 Yeah.

spk_0 What about do you open up the space, the location with the active drug, or do you open up

spk_0 the space with saline or dextrose?

spk_0 What's the best thing to do?

spk_0 And because there's two ways to do this, right?

spk_0 Yeah, I like to, I'm a big fan of saline as you know.

spk_0 So I will saline our way down to the target facial plane or target site.

spk_0 And then once I see some good saline going in the area that I like, I'll say, okay,

spk_0 stop.

spk_0 I'll switch to local.

spk_0 It depends if I'm using this.

spk_0 The initial ball is a surgical block or not, but you know, that's a concentration question.

spk_0 And then give 10 to 15 mils of local to really create a little pocket there in that facial

spk_0 plane.

spk_0 And then throw the catheter through it.

spk_0 Now, save five mils because after the catheter is in place, I want to make sure it is truly,

spk_0 and I think this is a critical step.

spk_0 So it's easy enough to sort of fire a catheter through the needle and then take the needle

spk_0 out and say, that's it.

spk_0 How do you make sure it's in the right spot?

spk_0 I'll do a couple of things.

spk_0 First, I'll attach a saline syringe to the hub.

spk_0 And so now the trainee has the probe over top of the catheter site.

spk_0 And we're looking on the screen to see the catheter.

spk_0 And these catheters are not always that echo genic.

spk_0 So what I'll do is I'll pump aspirate.

spk_0 So I'll go on the plunger repeatedly.

spk_0 And nothing's going back.

spk_0 It's just sort of creating this motion artifact in the catheter.

spk_0 And sometimes that's enough as he or she sort of slides or fans the probe back and forth.

spk_0 Oh, there it is.

spk_0 You'll see a little motion artifact.

spk_0 Great.

spk_0 Yeah.

spk_0 Once we think we're in the correct plane, give it a ball as a saline.

spk_0 Hopefully you see it close to where you are.

spk_0 And then you can sort of fine tune it.

spk_0 Oh, we're just, we've overshot a little bit.

spk_0 Let's pull it back and touch another ball, another ball.

spk_0 And then finally, you're in the right spot.

spk_0 And then I'll give the last five nails.

spk_0 So it's interesting.

spk_0 I don't know where I got this idea from.

spk_0 It might have been because I was certainly late to catheter.

spk_0 In fact, I used to have a hashtag on Twitter, hashtag no catheter.

spk_0 So that, and we wrote an editorial about how we didn't think they were essential.

spk_0 But when I started putting catheters in, the biggest failure for me was I created a beautiful space

spk_0 with my local anaesthetic seeker solution.

spk_0 I probably didn't use a saline initially.

spk_0 I basically got to where I wanted, started using the local anesthetic to find the right space.

spk_0 Threaded the catheter, stuck it down, hooked it up.

spk_0 And then after 18 hours, the patient was suddenly in pain.

spk_0 And that's because the catheter was never in the right place.

spk_0 I'll never made an effort to check it.

spk_0 So I'm a little bit more on the opposite of you.

spk_0 I will use saline right the way down till even creating the pocket.

spk_0 So I don't use a massive volume, but you know, saline around the target.

spk_0 So I'm happy.

spk_0 Then I throw the caster and I only put local anaesthetic via my caster.

spk_0 So therefore, if the patient is comfortable after my intervention,

spk_0 it is only because the caster is in the right place as demonstrated by the local anaesthetic

spk_0 being admitted by the caster.

spk_0 As opposed to me having done a single shot block with a plastic tube lying anywhere.

spk_0 And I know that seems a bit unfair and a bit meticulous.

spk_0 And some people say, why don't you do half and half?

spk_0 Well, I just really want to know the cast is in the right place.

spk_0 So that's what I do.

spk_0 I don't know whether that's wrong or too aggressive, but it just sort of works for me.

spk_0 Yeah.

spk_0 I can see the thinking there.

spk_0 We do a lot of sequential scanning too.

spk_0 Afterwards, just to make sure the catheter is staying in the right place.

spk_0 And so we've come to rely on option guidance to say, oh, we pulled it back.

spk_0 And we actually did a poster at the ASA one year showing that the placement rates of

spk_0 other canal catheters were wildly high.

spk_0 So we put them in pre-op, had their operation for knees, total knees.

spk_0 And the pack you over 10% of them had already been pulled back out of the spot.

spk_0 And then by the next day, it was another sort of 10% or so.

spk_0 Yeah.

spk_0 Probably because the knee is being manipulated during the course of the total knee operation.

spk_0 It sort of gets pulled out.

spk_0 But we've become very used to saying, oh, the patient is not quite as comfortable as I

spk_0 thought it should be.

spk_0 Let's image that and see where it is.

spk_0 Right.

spk_0

spk_0 But I like that a true test.

spk_0 That's a purest test of is my catheter in the right spot.

spk_0 I mean, because then if it doesn't work, then you know, your cast is not in the right

spk_0 place.

spk_0 But yeah, yeah, yeah, for sure.

spk_0 I understand, maybe I'm a, maybe a bit too fanatical about this.

spk_0 Okay, well, listen, you kind of alluded to this.

spk_0 And I think you've given away your answer beforehand about how much cast are to thread.

spk_0 This has always been my worry.

spk_0 If you over thread, then you'll overshoot the cast that will leave the space, maybe even

spk_0 pop out of the paranural sheath or so, come, you're gonna be somewhere else.

spk_0 Go to the other side, go to the brain.

spk_0 What is the optimal length of cast to thread?

spk_0 A bit of a different answer for facial plane blocks where I think you have a lot more wiggle

spk_0 room to place to, you know, for right, right to sheath, for example, often try to push

spk_0 it quite far away from the needle tip.

spk_0 But for paranural, you usually three to four centimeters, knowing that that still will

spk_0 allow that infuse it to get where it needs to go and gives me a couple of centimeters of

spk_0 wiggle room if that catheter gets retracted a bit, which it often does.

spk_0 So that seems to be the sweetest.

spk_0 But any, any more in it, it starts to coil and go off into weird planes.

spk_0 But also people do some clever stuff, you know, and remember Coisee Coffey and you've

spk_0 talked about before about, you know, you place the needle in the certain position and you

spk_0 keep threading the cast until it goes back and it pops back on itself and there's the

spk_0 Hickman flip.

spk_0 There's a few different variations for how you can advance the cast to get to do crazy

spk_0 things.

spk_0 So I guess that's also a determinant.

spk_0 I've never been that flashy with managed to get these special coiling flipping maneuvers.

spk_0 Yeah, there's some, there's some people have innovated some really cool ways to get that

spk_0 tip to just what it needs to be for sure.

spk_0 So the thing, you mentioned the push and pull thing and that was a bit, I remember as a

spk_0 resident doing epigurals a lot.

spk_0 As you're withdrawing the needle, if you're doing a cast that's through needle, in an

spk_0 ideal world, if you've got the cast to tip where you want it to be, what should be happening

spk_0 is that plastic tube should stay where it is and you just pull the needle back.

spk_0 But the reality is you know there's going to be a bit of pulling out the cast a bit.

spk_0 So you end up trying to advance the cast to whilst you're pulling the needle, but you

spk_0 don't want to overcompensate whenever I did that.

spk_0 Inveribly, I didn't certain more of the cast than I wanted to.

spk_0 And that's okay, right?

spk_0 Because that's the worst thing is to not.

spk_0 And then you got, oh, you turn to the training and say, well, I guess we're doing that again.

spk_0 Yeah, but I do find it difficult.

spk_0 So I've heard of two different things to do.

spk_0 So I remember watching an Australian and he's just talking at one of the European meetings

spk_0 before.

spk_0 And he said, you know, why do you guys, you know, you get a great, you get a great single

spk_0 shot block type picture and then you thread your cast, you know, a certain distance

spk_0 past the tip of the needle and then you pull the needle out and you got no idea what

spk_0 you're doing.

spk_0 He said, why don't you place the tip of your needle way you want the tip of the cast to

spk_0 be.

spk_0 And then essentially, all you need to do when you're throwing the cast through the needle

spk_0 is just get the cast to emerge just with a tip of needle is and then pull the needle out.

spk_0 That's one variation.

spk_0 The other variation is, okay, do your block open up your space, get your needle just short

spk_0 or maybe a centimeter short of where you want the cast to lie and then thread the cast

spk_0 in real time, pass the tip of the needle so you can see the cast of tip, exit the needle

spk_0 and go to where you want it.

spk_0 Well, it, that sounds great.

spk_0 But if you're pulling your needle out and your catheter has, is just the tip of the needle,

spk_0 you're pulling the catheter back to.

spk_0 Yeah.

spk_0 There's just no way that's, that's not going to happen.

spk_0 So I mean, it's one, it's nice to do it in real time.

spk_0 But what that requires is a little bit of dexterity with your hands and this is like one of

spk_0 the final things we'll teach the fellow is when they're, when they've run out of things

spk_0 to teach them, hold the needle with your fourth and fifth fingers, all right.

spk_0 And then third fingers extraneous, second and first, the thumb and index are grasping

spk_0 the catheter and you can push and pull that way, one handed and you're giving me the middle

spk_0 finger.

spk_0

spk_0 Yeah.

spk_0 And then you can hold the ultrasound probe with the other and that way you can, you can

spk_0 advance your needle, then advance your catheter and then withdraw the needle while doing

spk_0 a push pull.

spk_0 Push pulls essential.

spk_0 If you don't do that, you're pulling back your catheter.

spk_0 But your, your technique requires catheter to preloading.

spk_0 Uh, not necessarily.

spk_0 No, no, no, we'll, we'll usually get the needle in the right spot and then lay the probe

spk_0 down.

spk_0 Switch hands very carefully and it would drive me crazy as people let go of the needle

spk_0 and then the hub goes, boom.

spk_0 Yeah.

spk_0 And it's like, well, how do you know where your hub is now?

spk_0 Yeah.

spk_0 So care, meticulous attention to where that needle tip is, then load the catheter into when

spk_0 it's just about to emerge and then get your probe back on the skin and then do this

spk_0 little advance, advance, advance, advance, advance with it.

spk_0 I've got, I've got one up on that.

spk_0 But that is, it is, it's manufacturer dependent.

spk_0 So we have one manufacturer where you've got the needle and the injectate is a side port.

spk_0 So it doesn't come out the end of the hub or the needle comes out the side and then

spk_0 where you throw the catheter is at the top, the little rubber bung.

spk_0 So essentially, I can preload the catheter into the needle.

spk_0 Yes.

spk_0 While still having access to injectate tubing, the only key to that particular piece of kit

spk_0 is a little green gizmo that allows you to thread the catheter through the bung.

spk_0 You have to remove that green gizmo once a catheter is inserted because otherwise low

spk_0 class it will just pop out through the green gizmo.

spk_0 So pop the green gizmo through the end of the needle, thread the catheter, remove the

spk_0 green gizmo and then advance the catheter so it's just before the end of the needle.

spk_0 I then do my nerve block with the catheter poking out the back end of the needle.

spk_0 I want to min the right place.

spk_0 I can then thread it without having to do any letting go of anything.

spk_0 So that is, I think that is the dream.

spk_0 Can you say gizmo one more time?

spk_0 Green gizmo.

spk_0 That sounds great.

spk_0 Now here's, here's something that drives me crazy.

spk_0 You want to, this is number two drives me crazy.

spk_0 Letting go of the needle.

spk_0 The other thing is using air to find the tip of your catheter.

spk_0 So people, I've seen people do this.

spk_0 They put air through the catheter.

spk_0 Now you don't have to be an ultrasound physicist to understand that when you get air in your

spk_0 tissues it ruins your view.

spk_0 So let's say your needle, your catheter tip is not where you hope it is.

spk_0 Now what?

spk_0 Now you've messed up your view and, okay?

spk_0 All right, how's it going?

spk_0 Where's your catheter?

spk_0 Now what do you do?

spk_0 If it's in the right place and you can see a little flash of air like right beside the,

spk_0 that's cool.

spk_0 Maybe.

spk_0 But if it's not, yes.

spk_0 That drives me nuts when I see people do that.

spk_0 How about tunneling, do you tunnel catheters?

spk_0 Yeah, so depending upon the location I might do sometimes.

spk_0 If you know, if a needle insertion point is a little bit too close to where they're going

spk_0 to be operating or a little bit too close to tunicay, I do sometimes double tunnel.

spk_0 If I need to get, you know, two lengths of needle out of the way, any problem I find

spk_0 on it and you did a beautiful video and I can't remember what your tip is.

spk_0 I sometimes will just leave that little bridge.

spk_0 Yes, little bridge, yeah.

spk_0 But you've got a little technique because I'm always nervous about driving the needle towards

spk_0 the catheter exit site.

spk_0 So if I'm using the same needle that I've used to insert the catheter, then of course

spk_0 you want to get the needle to exit near the catheter without impaling it.

spk_0 But I think you do something where you use a separate device to tunnel and leave the

spk_0 catheter needle in place originally, right?

spk_0 There are, yeah, there are different ways to do this.

spk_0 People will use an angiocath separately while you're too in needle for the catheter

spk_0 is still in the tissue.

spk_0 So that way, if you're coming, for those of you who haven't tunneled, the purpose for

spk_0 tunneling, there's twofold.

spk_0 One is to create some additional friction so that the catheter doesn't get displaced.

spk_0 Kelly burned the nice study.

spk_0 I'll put the link in showing that the amount of traction required to pull a catheter out

spk_0 increased substantially if you can tunnel the catheter a little bit.

spk_0 That's one reason.

spk_0 The other reason is to keep the plastic catheter out of the way of the insertion sites so

spk_0 that the affection risk is lower and there'll be less bacterial colonization of the catheter.

spk_0 But to Thomas Point, you can leave a little bridge of catheter that goes out of the skin

spk_0 and then jumps like a little dolphin and then goes back into the skin again and then you

spk_0 tunnel it, which achieves goal number one, additional friction, but doesn't do much for

spk_0 the sterility.

spk_0 But the other way to do it is to, it's tricky getting that catheter to come through back

spk_0 in the skin and get, I'll put a link to that video that we did the catheter tips and tricks.

spk_0 But it's, it's, we don't do a lot of it, to be honest.

spk_0 Once in a while, if I need the catheter to stay in for a long time.

spk_0 But it's not something to do routinely.

spk_0 We're going to, we're going to talk about securing catheters in a second, but two last things

spk_0 I wanted to finish up this part of the podcast are number one.

spk_0 You talked about rapid aspirating and pumping on the catheter essentially to see if you create

spk_0 a motion artifact to identify what the tip is.

spk_0 What about using color Doppler when you're rejecting it or agitated sailors?

spk_0 So you're not introducing air, but you just shake this rinse you get micro bubbles.

spk_0 Is that something you ever done?

spk_0 Yeah, Doppler for sure.

spk_0 I don't find that the addition of the micro bubbles helps me personally a lot compared

spk_0 to just putting some fluid in there with a Doppler can be sensitive and have to see that,

spk_0 that signal.

spk_0 But yeah, that has, especially when the resident has overfired the catheter into Noman's land,

spk_0 you know, like where on earth is this thing?

spk_0 Are you starting to hunting with a Doppler around?

spk_0 Oh, there it is.

spk_0 We had to pull a bag like 10 centimeters, kind of.

spk_0 Right.

spk_0 So that's how full.

spk_0 And the other thing is we kind of assume people were on the same pages.

spk_0 There are different ways you could image the target structure and then needle into that

spk_0 image.

spk_0 So a lot of the time, if it's a target nerve, we're talking about a short axis cross sectional

spk_0 view of that nerve and a lot of what we've been talking about could be needling in

spk_0 plain.

spk_0 But of course, there's a role for out of plain needling depending upon how you want the

spk_0 catheter to run the path of the nerve.

spk_0 So for example, interscaling and nerve catheters, there's a role for outer plane to kind of

spk_0 line it up, although many people do do in plain needling.

spk_0 And likewise, when you're doing a femoral nerve block, kind of makes sense for short axis

spk_0 scan in plain needling, but I know that people do their catheters out of plain.

spk_0 So do you have one technique which you use exclusively or do you switch depending upon

spk_0 what sort of nerve block you're doing?

spk_0 Yeah, I'll often do in plain.

spk_0 I think there's a lot to be said about outer plane for catheters because it makes sense

spk_0 to drive the catheter along the same orientation as the nerve for interscaling.

spk_0 For example, is a nice one that way you can sort of thread it down the plexus.

spk_0 Papa teo sciatic, there's some good evidence.

spk_0 They're showing that dislocation rates are four times less if you thread it longitudinally

spk_0 with the outer plane compared to...

spk_0 I think there was a paper.

spk_0 I think Mahlhoffer might have done that.

spk_0 No, it was a dainst.

spk_0 I think it might be Benston and Boglum.

spk_0 The, the Dr. Canal catheters, we found that it was often helpful to come at an angle,

spk_0 at a 45 degree angle, as opposed to coming straight across.

spk_0 One of the things with in plain transverse is, okay, well, the catheter is coming at

spk_0 the nerve coming coming.

spk_0 Oh, now it's past the nerve and you're way over there.

spk_0 Some tangential or sometimes directly in the plane of the nerve can be helpful.

spk_0 Absolutely.

spk_0 I think that one of the issues with popliteal sciatic nerve blocks is, you can get a cross

spk_0 section of you, a short axis view of the nerve, and you're coming in in plain from

spk_0 naturally, that catheter is passing through the muscle.

spk_0 I want to get contraction and relaxation of that muscle.

spk_0 It has the potential to retract the caster out of the way and come out of the sheath, and

spk_0 that's kind of what they showed with some of their dice studies, but we're a little bit

spk_0 of movement of the limb or amulacian that caster retracts out of the way.

spk_0 So one of the ways that keyed gin tries to minimize against that is, he plays to the

spk_0 caster where he wants it to be, you know, the, the appropriate location.

spk_0 He pulls the needle back, but before he pulls the needle out the skin, he threads some extra

spk_0 caster into the tissue below the skin, sort of like a redundant length of caster.

spk_0 So caster tip is not moving, and you know, the needle has come out, but as it's in that

spk_0 subcutaneous tissue, or maybe a bit deeper than subcutaneous, he threads a little bit of extra

spk_0 caster.

spk_0 So you've got a bit of redundancy in that.

spk_0 So it's almost like if the caster moves, that coil is going to unwrap before the actual

spk_0 distal part, which is something I've never considered before.

spk_0 He's a clever chap.

spk_0 That's a keyed gin.

spk_0 And there was one variation, Jeff.

spk_0 There's one variation.

spk_0 You needle out of plain, get into the location, and then when you're happy, you've got the

spk_0 needle where you want it to, you rotate the pro-390 degrees.

spk_0 So you do a long axis scan over the target and watch the, and a long axis scan over the

spk_0 needle and watch the, the caster exit from the needle.

spk_0 That's something else I've seen do.

spk_0 People do.

spk_0 So we've done all the work to get the catheter in.

spk_0 How do we keep it in?

spk_0 Yeah.

spk_0 So we kind of touched on the size of the hole.

spk_0 And if you're doing a caster through needle, when you remove the needle, the caster's

spk_0 sticking out of the skin, but there's a big gap.

spk_0 And that's where you can get backward flow of fluid local and so that it can lift the

spk_0 dressing off.

spk_0 So I think the key strategy is skin glue.

spk_0 Dermabont to the first thing you've got to do, once you've got the caster in the right

spk_0 place, is seal that hole.

spk_0 What do you think, you agree?

spk_0 Absolutely.

spk_0 Yeah, skin glue has changed everything for us.

spk_0 So you used to get some leakage through that and that made the dressing come apart and

spk_0 then the catheter gets displaced and the people were complaining about wet bed sheets and

spk_0 that sort of thing.

spk_0 So a drop of skin glue on the insertion site really, really helps.

spk_0 I think after that, it really is much less important about how you secure it to the

spk_0 skin.

spk_0 I think we use some sticky stuff on the skin.

spk_0 So either Benzwin or Massasal to make the skin around the site a bit sticky, stereo

spk_0 strips.

spk_0 So I do a stereo strip that goes longitudinally.

spk_0 So if the catheter's coming out and heading towards 9 o'clock, I will lay that stereo

spk_0 strip down over the hole, like along the axis of the catheter itself.

spk_0 And Amanda Kumar, my colleague did a study in volunteers to show that the force required

spk_0 to pull the catheter out was best with that sort of arrangement.

spk_0 And then after that, it's just artistry.

spk_0 So however you want to put your tegaterms in.

spk_0 And people have put coils in sometimes that put a redundant coil around the disease,

spk_0 doing that Anthony Valley.

spk_0 I think so.

spk_0 I mean, it feels good, right?

spk_0 I mean, it's sort of like what you're saying about Keygins, a redundant catheter in

spk_0 there.

spk_0 If it's going to be pulled, at least for that length of that coil, it wouldn't come out

spk_0 of the tissue.

spk_0 The other thing with a, where catheters fail in terms of like mechanically fail is at

spk_0 the hub.

spk_0 And so there's been different ways to mitigate that.

spk_0 What we'll typically do is when the hub has been snapped onto the catheter, I will fold

spk_0 it over.

spk_0 Uh-huh.

spk_0 So there's a U. And then I'll stereo strip that together.

spk_0 So that's an SNS in the video as well that I'll post.

spk_0 But it's some.

spk_0 Yeah.

spk_0 So that way there's no tension on the slippery PVC catheter and the hub itself.

spk_0 Uh-uh.

spk_0 And what about putting glue at that cast exit point from the clip where it clips into?

spk_0 Is there only a value in doing that?

spk_0 There we, we did that.

spk_0 James Kim, I think, was the one that came up with that when he was a fellow with us.

spk_0 It worked.

spk_0 I think there was a couple of times when we glued the catheter closed somehow.

spk_0 So it wouldn't, it wouldn't go through.

spk_0 But I think it's, that's another cool idea because you get the glue there anyway.

spk_0 It's a zero cast way of doing it.

spk_0 Okay.

spk_0 And then we also got to think about when you've put the cast on you again, references

spk_0 already, they put the drapes on and then they take the drapes off and then they pull

spk_0 the catheter out at the end of the case.

spk_0 So have you heard about the whole concept of sacrificial dressings?

spk_0 You stick it down beautifully and then you put a whole host of gals on top of it and

spk_0 then a fake dressing on top of it.

spk_0 So if anything gets pulled down, is that the ghost?

spk_0 Yeah.

spk_0 That's great.

spk_0 I, I, I saw you're, you did a talk on that once, I think.

spk_0 That's right.

spk_0 I got that, I heard about that from James French from Nottingham.

spk_0 He told me that.

spk_0 Yeah.

spk_0 That's cool.

spk_0 The other thing I've seen to mitigate that too is you're using ultrasound gel.

spk_0 Take a little bit of that gel and smear it over the, over the dressing.

spk_0 So when the, oh yeah, surgical drapes are on it, they're not going to stick to it.

spk_0 So they'll, uh, two clever ways to keep the surgeons from destroying your efforts.

spk_0 What else do we have to talk about with catheters?

spk_0 Well, I mean, we've, we've talked about when we'd use it, the different ways to image.

spk_0 We talked about the drugs, the infusion strategies, the pumps, how to identify the tip and

spk_0 how to secure it.

spk_0 What about what happens with that patient?

spk_0 What information do we give that patient?

spk_0 What infrastructure do we need to make the castor service work?

spk_0 Where should they inside it?

spk_0 So I kind of, I'm talking about infrastructure requirements.

spk_0 So do all of your patients get clear information beforehand about the castors part of that,

spk_0 like consent process?

spk_0 Yeah.

spk_0 There's a whole, there's a whole sort of pre discussion we have and what to expect.

spk_0 But then on discharge, there's a whole separate set of materials they get either in form of

spk_0 a pamphlet or a video to say, here, here's what to expect.

spk_0 And the information has to be tailored to the block site.

spk_0 So obviously interscaling side effects from a catheter, horners syndrome, et cetera, et

spk_0 cetera, might be different than a canal catheter, right?

spk_0 But some of them are the same.

spk_0 Like toxicity, toxicity is the main thing.

spk_0 That's the thing that is the most serious problem with this.

spk_0 So we want to make sure every patient understands the really premonatory signs of toxicity

spk_0 knows to stop the pump and call us right away.

spk_0 So they have to have our number.

spk_0 I love that word, premonitory.

spk_0 Premonitory.

spk_0

spk_0 Yeah.

spk_0 I like to throw one big word into these podges just to big people think that I'm, yeah,

spk_0 I'm the clever.

spk_0 But every time, every time.

spk_0 Toxicity is really, really important.

spk_0 So they have to have our number or way to get a hold of a healthcare provider, whether

spk_0 that's a nurse.

spk_0 So like an emergency contact number that is staff 24, seven, correct.

spk_0 And then we will call them every day they have a catheter just to ask them the usual questions.

spk_0 Any problems?

spk_0 Has it working?

spk_0 Do you need to go up?

spk_0 Do you go down?

spk_0 That's sort of thing.

spk_0 And then you could advise them over the telephone, but you will make sure you follow them

spk_0 up every day 24, seven or seven days a week.

spk_0 Essentially, there's someone that will call that individual up.

spk_0 Correct.

spk_0 And then you got to have a way to to fix things if, so we had patients, yeah, let's come

spk_0 up and make a move and meet you in the ER.

spk_0 And I will meet you there and we will fix that catheter.

spk_0 Well, it's gotten displaced or put it back in.

spk_0 And this is covered by your block service.

spk_0 There's always somebody covering the blocks who, or who has a capacity to cover that.

spk_0 Or is this one nominated individual for the week?

spk_0 How does that work?

spk_0 Different places to have different ways of doing it.

spk_0 If it's daylight hours during the week, it's our regional block team.

spk_0 Yeah.

spk_0 After hours, we have a 24, seven inpatient pain service team that responds to inpatients,

spk_0 but can also take care of this sort of thing if they need expertise.

spk_0 And they, everyone on that team can manage catheters.

spk_0 So I know what you're thinking or some people are thinking, like that's a lot of effort

spk_0 and infrastructure to have available, which, and I agree, yeah, it takes a lot of work

spk_0 to set this up and to stand it up and to keep it going.

spk_0 So, but, you know, worth it for having this, this ability to prolong that pain relief.

spk_0 Yeah, yeah.

spk_0 I mean, I think our place, we would struggle at the moment to have an ambulatory service

spk_0 because of all of those things.

spk_0 You know, we're, we want to be able to resource the basic things.

spk_0 But if you have the ability to do that, I can see in order to make it succeed, you need

spk_0 to have all of those steps in place.

spk_0 Now, when you're citing these catheters, presumably you've, you've got a fellow with you,

spk_0 but then you've also got a skilled nurse who knows what to expect and how, and yet to

spk_0 assist and to prepare things with you.

spk_0 Is that, is that right?

spk_0 So what's the minimum number of people you need to cite catheter safely?

spk_0 Uh, minimum, probably two.

spk_0 Um, and that, that's, that's ignoring sort of a timeout procedure, which might involve

spk_0 a third uninterested party to, yeah.

spk_0 But, but I think two is the right number, a minimum number.

spk_0 And you're generally, again, it depends where you, where you're doing them.

spk_0 But a lot of these are being done in a block room or a block area beforehand,

spk_0 because the biggest anxiety for us, if we were doing this in the middle of an operating

spk_0 list is the time it takes to do them.

spk_0 And I know James Kim in the past has said it takes him like 30 seconds to put two catheters

spk_0 in if he's all prep, but it does take a bit of time.

spk_0 He said if you're learning for the first time, so what's the ideal place to put them in?

spk_0 Well, you want to make sure I've done the catheters in a lot of not ideal places,

spk_0 cramped bed spaces in the, yeah, emergency room and, uh, you know,

spk_0 ward beds that are tucked into the back of beyond.

spk_0 But, um, OR is nice in terms of serility, but, you know, you get the foot tapping

spk_0 everybody else in the room watching you do this as you, as you, as sweat is rolling down your

spk_0 temple. Yeah.

spk_0 So pre-op or pack you, I think is a great place.

spk_0 You've got resources, you've got skilled nursing, you've got monitoring and all that stuff.

spk_0 Absolutely. Okay.

spk_0 Cool. I like that.

spk_0 And the other thing you kind of touched on is it's really important that everybody who's

spk_0 going to have responsibility for caring for that patient understands what you've done.

spk_0 You hand over the medication you've given, you told them tell them what monitoring is required,

spk_0 and there's clear instructions for how to look after those patients.

spk_0 So whether it be the pack you on the floor, on the ward, um, people need to know how to manage

spk_0 these, um, these catheters afterwards.

spk_0 And more importantly, what to do if things go wrong.

spk_0 Yeah.

spk_0 If you'd line those things up, you should be good to go, right?

spk_0 Yeah.

spk_0 And just to finish off this whole arc, when a time comes to the catheter to be

spk_0 removed, most patients are okay with that, doing it themselves.

spk_0 You just, I have to talk some of them through on the phone or a face time people before and

spk_0 had, you know, say like, you got this, okay?

spk_0 Just it's not that bad.

spk_0 It's a weirder idea than they get it out and they're like, oh, that wasn't that bad.

spk_0 Right.

spk_0 I have had to have people come into the hospital to remove a catheter once in a while.

spk_0 Like there's no way to know how am I taking this out myself.

spk_0 Right.

spk_0 Kind of thing.

spk_0 But, um, yeah, usually, usually that's the, the easiest part of the whole thing.

spk_0 So, well, man, that was a, that was a fun discussion on catheters.

spk_0 For sure.

spk_0 Really enjoyed that.

spk_0 Yeah.

spk_0 No, thank you very much, guys.

spk_0 We hope you enjoyed that.

spk_0 So you know what to do.

spk_0 Please like and subscribe to our podcast, or a usual podcast provider.

spk_0 Uh, please give us a rating.

spk_0 Let us know what you think.

spk_0 Leave a comment and let us know what you want to hear about next.

spk_0 Hit us up on the, on the socials and, and let us know what your catheter practice looks like

spk_0 and what tips and tricks you have.

spk_0 You can also get a hold of us at blockatlichetat.com, where we have videos and transcripts of the

spk_0 pod and all that kind of stuff there.

spk_0 We want to hear from you to keep this podcast going.

spk_0 So thank you so much, guys.

spk_0 Until the next time, we hope you all block it like it's hot.

S3 E16: "Can't stop, won't stop (infusing local): The Catheter Chronicles"

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