which patients historically rely on opioids for pain relief.
"Right now, placing a continuous nerve block with a catheter is the only
way to blockade nerves, and control the duration and the level of the
block," says Edward R. Mariano, MD, MAS, chief of anesthesiology and
perioperative care service and associate chief of staff for inpatient surgical
services at VA Palo Alto (Calif.) Health Care System. "It's the only titrat-
able, long-duration form of a nerve block."
A titratable drug is key because in addition to pain relief, patients want
functionality and appreciate being able to control boluses of local anes-
thetic if they can't cope with breakthrough pain.
To extend the effects of an interscalene block, for example, providers use
ultrasound guidance to identify where the interscalene nerve exits the ver-
tebrae body and inject 20cc to 30cc of bupivacaine or ropivacaine around
the nerve, says Dr. Gan. They then thread the catheter using ultrasound
guidance, leaving about 5 cm in the nerve space, and attach the other end
to a pain pump, which infuses 10 ml to 12 ml of local anesthetic per hour,
depending on the concentration, for a day or two.
At the 48-hour mark, the worst of the pain has subsided, meaning the
patient has gotten through that critical post-op pain window without the
aid of opioids.
"One of the questions I'm always asked is, 'Does every patient need a
nerve block catheter?' And the answer is no," says Dr. Mariano. "The
problem is we don't know who the patients are that will need one before
they have the operation." Because of that, it's always better to administer
a therapy you can add to rather than a therapy you can't extend, adds Dr.
Mariano.
Dr. Gan agrees, and points to another key benefit of using catheters and
pain pumps. "If patients suffer from chronic pain or have been on long-term
opioids, post-op pain controls can be problematic," he says. "In these cases,
catheters can prolong the pain relief, provide comfort over a longer period
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