The Need for Patient Teaching, Follow Up, and Physician Availability for the Prevention of Outpatient Perineural Catheter Complications

摘要

Perineural catheters have influenced the way we manage postoperative pain and sometimes require us to care for patients beyond the postoperative period on an outpatient basis. We have found that while appropriate instruction, follow up and physician availability are essential in the management of outpatient perineural catheters, patient misunderstanding or noncompliance contributes to complications. Here we report such a misunderstanding with a complication. Introduction Perineural catheters have begun to influence the way we manage postoperative pain.1-2 With this approach to pain management, we often find ourselves caring for patients beyond the immediate postoperative period. More recently, the use of perineural catheters in the outpatient setting has extended our role in pain management even further.3-4 As we implement new techniques in regional anesthesia and expand our role in caring for patients in the days following surgery, we are likely to encounter new complications that result from these advances in regional anesthesia.5-11 Swenson et al. described their experience with 620 outpatient perineural catheters. Their outpatient management included appropriate discharge instructions, patient follow up, and physician availability for patient contact. Last year, our institution placed 338 outpatient perineural catheters. Through this experience, we have found that while appropriate instruction, follow up and physician availability are essential in the management of outpatient perineural catheters, patient misunderstanding or noncompliance contributes to complications. In this report we highlight the need for the continued effective engagement of the care team through the immediate postoperative period of an outpatient who had been discharged with a perineural catheter. Case Report A 46-year-old ASA I male presented for outpatient left anterior cruciate ligament repair. Following the surgery, he received a femoral perineural catheter in the post-anesthesia care unit (PACU). It was uneventfully placed with a 17 G Tuohy needle in a strict sterile fashion under ultrasound guidance. Twenty ml of 0.2% ropivicaine was injected directly through the Tuohy needle to dilate the perineural space. An in-plane approach was used with the probe just below the femoral crease, providing a cross-sectional view of the femoral vessels and nerve. A 19 G Arrow Stimucath Continuous Nerve Block Catheter (Arrow International, Reading, PA, USA) was inserted approximately 3 cm past the tip of the needle, allowing it to slightly curve posterior to the femoral nerve without forming a loop. An additional 10 ml of .2% ropivicaine was injected through the catheter to verify correct placement with ultrasound guidance. The catheter was secured at the insertion site using a skin adhesive and a sterile dressing was applied. An On-Q elastomeric pump (I-flow, Lake Forest, CA, USA) containing 550 ml of 0.1% ropivicaine was set to deliver 10 ml/hr with a demand button allowing 5 ml of local anesthetic every 30 minutes. Prior to discharge from the PACU, the patient was given written and verbal instructions on catheter care and discharged home. The discharge instructions included the manner in which to contact an anesthesiologist if any problems arose. The patient was also instructed to remove the catheter after the pump was depleted of local anesthetic, which should occur no later than postoperative day (POD) #3. On POD #1, the patient began to feel pain in his knee and noticed that his demand button wasn’t working correctly. Upon examination of the bag containing the pump, he discovered a severed section of tubing that had resulted in spillage of the local anesthetic into the bag. He disconnected the pump tubing from the catheter and discarded it. Unfortunately, the patient misunderstood the discharge instructions and thought the catheter needed to remain inserted for three full days. A registered nurse followed up with the patient on POD #1 via a message on his