title: Ultrasound-guided (needle-in-plane) perineural catheter insertion: the effect of catheter-insertion distance on postoperative analgesia.
abstract: BACKGROUND
  When using ultrasound guidance to place a perineural catheter for a continuous peripheral nerve block, keeping the needle in plane and nerve in short axis results in a perpendicular needle-to-nerve orientation. Many have opined that when placing a perineural catheter via the needle, the acute angle may result in the catheter bypassing the target nerve when advanced beyond the needle tip. Theoretically, greater catheter tip-to-nerve distances result in less local anesthetic-to-nerve contact during the subsequent perineural infusion, leading to inferior analgesia. Although a potential solution may appear obvious-advancing the catheter tip only to the tip of the needle, leaving the catheter tip at the target nerve-this technique has not been prospectively evaluated. We therefore hypothesized that during needle in-plane ultrasound-guided perineural catheter placement, inserting the catheter a minimum distance (0-1 cm) past the needle tip is associated with improved postoperative analgesia compared with inserting the catheter a more traditional 5 to 6 cm past the needle tip.
  
  
  METHODS
  Preoperatively, subjects received a popliteal-sciatic perineural catheter for foot or ankle surgery using ultrasound guidance exclusively. Subjects were randomly assigned to have a single-orifice, flexible catheter inserted either 0 to 1 cm (n = 50) or 5 to 6 cm (n = 50) past the needle tip. All subjects received a single-injection mepivacaine (40 mL of 1.5% with epinephrine) nerve block via the needle, followed by catheter insertion and a ropivacaine 0.2% infusion (basal 6 mL/hr, bolus 4 mL, 30-min lockout), through at least the day after surgery. The primary end point was the average surgical pain as measured with a 0- to 10-point numeric rating scale the day after surgery. Secondary end points included time for catheter insertion, incidence of catheter dislodgement, maximum ("worst") pain scores, opioid requirements, fluid leakage at the catheter site, and the subjective degree of an insensate extremity.
  
  
  RESULTS
  Average pain scores the day after surgery for subjects of the 0- to 1-cm group were a median of 2.5 (interquartile range, 0.0-5.0), compared with 2.0 (interquartile range, 0.0-4.0) for subjects of the 5- to 6-cm group (P = 0.42). Similarly, among the secondary end points, no statistically significant differences were found between the 2 treatment groups. There was a trend of more catheter dislodgements in the minimum-insertion group (5 vs 1; P = 0.20).
  
  
  CONCLUSIONS
  This study did not find evidence to support the hypothesis that, for popliteal-sciatic perineural catheters placed using ultrasound guidance and a needle-in-plane technique, inserting the catheter a minimum distance (0-1 cm) past the needle tip improves (or worsens) postoperative analgesia compared with inserting the catheter a more traditional distance (5-6 cm). Caution is warranted if extrapolating these results to other catheter designs, ultrasound approaches, or anatomic insertion sites.
authors.affiliation: Department of Anesthesiology, University of California, San Diego, CA, USA. bilfeld@ucsd.edu
authors.forename: Brian M
authors.initials: BM
authors.lastname: Ilfeld
authors.forename: Navparkash S
authors.initials: NS
authors.lastname: Sandhu
authors.forename: Vanessa J
authors.initials: VJ
authors.lastname: Loland
authors.forename: Sarah J
authors.initials: SJ
authors.lastname: Madison
authors.forename: Preetham J
authors.initials: PJ
authors.lastname: Suresh
authors.forename: Edward R
authors.initials: ER
authors.lastname: Mariano
authors.forename: Michael L
authors.initials: ML
authors.lastname: Bishop
authors.forename: Alexandra K
authors.initials: AK
authors.lastname: Schwartz
authors.forename: Daniel K
authors.initials: DK
authors.lastname: Lee
mesh_terms: D000328:Adult; D000779:Anesthetics, Local / Q000008:administration & dosage; D001340:Autonomic Nerve Block / Q000295:instrumentation* / Q000379:methods; D002404:Catheterization / Q000295:instrumentation* / Q000379:methods; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D009339:Needles; D010149:Postoperative Pain / Q000209:etiology / Q000517:prevention & control*; D010543:Peroneal Nerve / Q000000981:diagnostic imaging; D011446:Prospective Studies; D012584:Sciatic Nerve / Q000000981:diagnostic imaging; D018084:Ultrasonography, Interventional / Q000295:instrumentation / Q000379:methods*
chemical_list: D000779:Anesthetics, Local