1. Ambulatory Catheters Allison Haller, MD

2. Ambulatory Catheters Indications Patient choice Patient Education/Communication Dosing Catheter removal Pitfalls Side Effects

3. A 67yo female presents for outpatient rotator cuff repair. PMH HTN, obesity, OSA. Previously she had the contralateral shoulder repaired but was admitted for pain 24 hours after a single shot interscalene block 1 year ago. What can we offer her this time around to avoid an admission?

4. A75yo otherwise healthy and athletic male presents for a total shoulder arthroplasty. His wife, a former RN, asks if they can go home ASAP. After surgery he does well with no complications. Can he be discharged home POD#1 or even POD#0?

5. A 32year old presents with adhesive capsulitis (frozen shoulder) has failed conservative therapy and will have a manipulation under GA followed by aggressive physical therapy. The surgeon asks if there is anything to do that will help this patient tolerate PT better.

6. Indications for Home Catheters No specific guidelines Surgery specific – Total shoulder arthroplasty – Rotator cuff repair – Painful distal upper extremity ORIF radius, suspensionoplasty, wrist fusion – Foot/ankle osteotomy/arthrodesis/ORIF and Achilles tendon repair – ACL repair Bone-to-bone grafts

7. Indications for Home Catheters Patient specific – History of difficult pain management – Opioid allergies, side effects – Opioid abuse/addiction treatment Discussion with surgeon important

8. Choosing a Patient Patient interest, previous compliance Teaching with patient and care-taker Help to remove catheter Geography Dependable phone Language barrier Education level

9. Education Details PACU RN alerts us when pt alert and cooperative Place and turn on pump Review pump/catheter details with pt and caretaker Reminder – caution with extremity Exchange phone numbers Provide extra tape

10. Education Details Take PO pain meds if needed – Mulitmodal management Pain expectations ***** – Anesthetic bolus vs. Dilute basal rate Pump makes noise Make a plan

11. Patient Communication Pain RN or MD by phone Night of discharge, and then daily Pain? Local anesthetic toxicity Insertion site check – Risk of outpatient infection less than 1% – Need clear dressing Make a plan for continuation/removal

16. Dosing Regimens Basal rates 4-10mL/hour – Lower rates for lower side effect profile – Improved pain scores – Improved sleep over bolus alone – (Ilfeld, et al; Anesthesiology; 2004) Bolus – Improved patient satisfaction – Can titrate for PT

17. Our “Recipe” Bolus Continuous infusion with Ropivicaine 0.2% – Dilute solution 5mL/hour Bolus availability – 5-10mL/hour

18. The Ideal Ambulatory Pump Programmable Ease of use for patient Lightweight Quiet Basal and bolus – Basal preferred, bolus optional Accurate Inexpensive

19. ambIT Pump

20. ON-Q-bloc with ONDEMAND

21. Catheter Removal Over the phone or in person Turned off and worn off Pain under control Document full catheter removed

22. Pitfalls Retained catheters Leaking, Dislodged Infection The unexpected Side Effects

26. Retained Catheter Paresthesia – Consult Ortho vs. Neurosurgery Pain under skin – Pull with more tension towards contralateral side – Move neck – Inject sterile saline – SubQ lidocaine **Patient seen by Pain Physician

27. The Leaky Catheter Reinforce Dressing Dislodged? Stop bolus Reduce Basal Remove Decrease Leaking Risk – Tunnel – Dermabond – Mastisol

28. Infection Visualize whenever possible Stop infusion, remove F/u – Anesthesiologist – Surgeon – Primary Care Consider Abx

29. The Unexpected Keep catheters away from wild (and domestic) animals

30. Side Effects Horner’s Syndrome – Bloodshot conjuctiva, ptosis, miosis – Blockade of stellate ganglion – More common at time of bolus – Reduce rate, stop bolus – Reassurance

31. Side Effects Hoarseness – Blockade of recurrent laryngeal nerve – Lower basal rate – Stop bolus – Consider stopping infusion to rule out: Vocal cord trauma

32. Side Effects Shortness of Breath – DDX: Phrenic nerve paralysis Hypoventilation Pneumothorax Other… – If new onset consider ED, stop infusion

33. Tips Choose patient wisely 2 phone numbers Make a plan Remind patient not to disconnect