American Society of Regional Anesthesia and Pain Medicine November 2017 - 23
patient daily as long as the continuous nerve catheter is in place.
After the continuous infusion is complete, we typically have the
patient's caregiver pull the catheter at home. If, however, the
patient is uncomfortable performing catheter removal at home, we
offer to talk the patient through the procedure on the phone or have
the catheter removed in the surgeon's office during the follow-up
visit.
change assists in helping the catheter slide out. If the catheter
continues to have resistance, we offer to have the patient present
to us for catheter removal or to have the catheter removed during
their follow-up appointment in the surgery clinic. If the catheter
was indeed stuck, I would ensure a member of the peripheral nerve
catheter team was present at the surgical appointment to assist in
the catheter removal.
Dr Maniker: Patients are instructed prior to hospital discharge
and over the phone about catheter removal as well as monitoring
after removal. The patient is instructed to contact the service if any
evidence of bleeding, swelling, significant erythema, or paresthesia
develops or if the denseness of numbness increases over time.
Dr Maniker: Gentle continuous traction is first applied. Next,
arm movements such as abduction as well as neck flection and
extension can be attempted while providing gentle catheter
traction. Next, a small amount (3-5 mL) of preservative-free sterile
normal saline can be injected through the catheter, which has
been reported to aid in removal of peripheral nerve catheters. This
can also be performed under ultrasound to visualize the catheter
trajectory. Unfortunately, catheters can become knotted and in rare
cases may require surgical removal.
Dr Harrington: Normally, patients can remove the catheter
themselves after the home infusion is complete. It would not be
uncommon to have a patient who lives this close return to the
hospital for catheter removal. In this particular case, the patient's
daughter would ideally remove the catheter, if she's comfortable.
Dr Pawa: I do not send patients home with ambulatory catheters in
my current practice, and so my answers to this would not be based
on my experience. I would be more comfortable with coached
removal over the phone that was assisted by a family member
(assuming adequate preoperative training).
Does the presence of LMWH therapy alter your planning?
Dr Auyong: I would recommend pulling the continuous catheter
during the trough, prior to the next dose of LMWH. I would instruct
the patient to apply pressure if bleeding starts or persists at the
catheter insertion site. If the patient is uncomfortable with pulling
the catheter at home, I would suggest having the catheter pulled in
the surgeon's office at the follow-up visit.
Dr Maniker: In this case, given that the daughter is a physician,
I would feel comfortable with the daughter assisting in catheter
removal and monitoring the site afterward.
Dr Harrington: Removal of the catheter should be timed to be no
sooner than 10-12 hours after the last dose of LMWH.
Dr Harrington: Although catheters can usually be removed by
patients at home, if any resistance is encountered, the catheter
should be removed only by anesthesia personnel. Steady tension on
the catheter is advised.
Dr Pawa: In this instance, I would advise the patient to return to the
hospital and aim to use ultrasound or x-ray to determine whether
the catheter had kinked or knotted. If no knotting or kinking were
found, I would apply continuous steady traction.
How would this be altered if the patient complained of
paresthesias with attempted catheter removal?
Dr Auyong: If paresthesias were encountered during catheter
removal, I would not allow further traction or pulling on the
continuous catheter. I would have the patient present in person for
evaluation by myself and the peripheral nerve catheter team. My
evaluation would entail a physical exam and ultrasound exam of
the brachial plexus (with and without traction on the catheter). If
paresthesias persisted without the ability to remove the catheter, I
would consult my neurosurgical colleagues for further evaluation
and possible surgical removal.
What steps do you take when resistance is encountered with
attempted catheter removal, and how do you plan to remove it?
Dr Maniker: I would stop traction on the catheter. The catheter
could be knotted and either wrapped around a nerve or positioned
in a way that contacts or compresses a nerve. Patient positioning
could be changed with very gentle traction, which is again
stopped with any patient report of paresthesia. As previously
mentioned, ultrasound could be used to define the course of the
catheter, but surgical consultation may be needed to remove the
catheter.
Dr Auyong: If resistance is encountered, we have patients change
position and try pulling the catheter again. Often a simple position
Dr Harrington: In that case, I would be concerned about
knotting. I would try to visualize the catheter by injecting a
Dr Pawa: Yes, assuming a once-daily dosing, I would want the
catheter removal to be at least 12 hours after last dose.
Resistance is encountered with attempted catheter removal.
American Society of Regional Anesthesia and Pain Medicine
2017
23
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