Postoperative pain management is essential, and the perineural catheter plays a key role in this area. This device, a tube placed near the nerves, continuously diffuses a local anesthetic to relieve moderate to severe pain after surgery, without requiring constant patient intervention.

In this guide, we discuss the role of the perineural catheter in postoperative analgesia, the types of catheters, the installation procedure, monitoring, and removal of the device. It is particularly aimed at State-Registered Nurses (IDE), who are essential in the monitoring and management of patients with perineural catheters, especially for home care. Understanding the practical and clinical details of this device is essential for effective analgesia and a quality care experience.

Understand the role of the perineural catheter in analgesia.

What is a perineural catheter?

The perineural catheter is a small polyethylene tube inserted under the skin, the end of which is positioned near the nerve targeted for the innervation of a specific painful area. It is used for the continuous administration of local anesthetics, either by an elastomeric diffuser, often called a "bottle", or via a programmable pump. This method of locoregional analgesia is ideal for pain relief over a long period, ranging from several days to weeks.

Importance of perineural catheters for pain management

The use of perineural catheters plays an important role in the management of postoperative and chronic pain. They have multiple advantages, including providing continuous and effective analgesia, which reduces the need for intravenous morphine medications and reduces the side effects associated with these medications.

This technique improves the quality of analgesia, enhances patient satisfaction, and contributes to faster post-surgery rehabilitation. Perineural catheters are also suitable for home or outpatient care, a significant advantage with the shift towards outpatient surgery. Research indicates that their use outside the hospital promotes better post-operative pain management, higher quality sleep, and greater patient satisfaction, while reducing the need for additional medication and side effects.

The precision and reliability of perineural catheters in pain management make them an indispensable tool for anesthesiologists and care teams. They make it possible to adapt the treatment to the unique needs of each patient.

Different types of perineural catheters

Catheters for peripheral blocks

Perineural catheters, used for peripheral blocks, specifically target the nerves of the upper and lower limbs. They come in two main types:

• Catheter-over-needle (CON): This type of catheter is placed through an indwelling catheter once the needle is removed. Valued for its ease of use, similar to that of intravenous access, it ensures better stability, reduces the risk of catheter kinking, and minimizes leakage, optimizing treatment efficacy.
• Through-the-needle catheter (TTN): In this technique, the catheter is inserted directly through the needle, allowing for deeper placement near the nerve sheath. While it offers prolonged analgesia and a reduced risk of displacement, this method requires greater technical expertise and carries a higher risk of catheter kinking.

These catheters can be used with different types of needles, such as short-bevel needles or Tuohy-bevel needles, and are often coupled with neurostimulation systems for precise nerve localization.

Catheters for central blocks

Perineural catheters are primarily intended for peripheral blocks, but it is essential to emphasize that central block techniques, such as epidural or spinal analgesia, require specific catheters. Unlike catheters for peripheral blocks, those used for central blocks are inserted into the epidural or subarachnoid space, targeting central regions of the nervous system with a distinct method and expertise. Nevertheless, our focus remains on catheters for peripheral blocks, which are essential for providing localized and effective analgesia during surgical procedures on the limbs and other peripheral procedures.

Perineural catheter insertion procedure

Preparation and necessary equipment

Before inserting a perineural catheter, it is essential to verify the availability of the required equipment and to prepare the patient appropriately. This equipment includes the perineural catheter, the guiding needle, local anesthetics, antiseptics, sterile gloves, as well as a surgical mask and cap to maintain sterility. It is also important to ensure that the patient has no contraindications to local anesthetics and that monitoring and resuscitation equipment is readily accessible in case of complications.

Insertion techniques

The insertion of the perineural catheter takes place in several key steps to ensure safe and precise placement. The needle is positioned in the perineural space using ultrasonography, neurostimulation, or hydrolocation, accurately targeting the local anesthetic infusion site. Confirmation of correct placement is achieved by injecting a small amount of local anesthetic, facilitating catheter introduction by creating space around the nerve structures. The catheter is then inserted, ensuring that it advances without resistance along the nerve to the desired position. After catheter placement, the needle is carefully removed, and the catheter is secured to the skin to prevent displacement.

Risk management and complications

It is important to recognize the potential risks and complications associated with the use of perineural catheters. The risk of infection is increased if the catheter remains in place for more than 48 hours or in the absence of antibiotic prophylaxis, hence the importance of rigorous asepsis and monitoring for signs of infection. Technical complications such as leaks, dislodgements, and analgesia failures require regular verification of the catheter and infusion system. Systemic toxicity due to the local anesthetic, affecting the central nervous system and the heart, as well as direct or compression nerve damage, require a precise insertion technique and continuous monitoring to reduce these risks.

Monitoring patients with perineural catheters

Efficacy monitoring and dose adjustment

Careful monitoring of the patient with a perineural catheter is essential to ensure the effectiveness of analgesia and to adjust doses appropriately. It is essential to monitor the patient's pain regularly, often using pain scales such as the VAS (Visual Analog Scale) or dedicated questionnaires, to assess the effectiveness of the analgesia. Nurses and anesthesiologists must ensure that the catheter remains correctly positioned and that the local anesthetic is administered adequately.

This includes monitoring the infusion rate, checking for leaks or blockages, and adjusting doses based on the patient's response. For patients at home, regular contact with a nurse specializing in pain management is recommended to confirm the treatment is progressing well and to make any necessary adjustments.

Prevention and management of complications

Preventing and managing complications is fundamental in the monitoring of patients with a perineural catheter. Complications may include infections, leaks, catheter displacement, and side effects from the local anesthetic. To avoid infections, strict surgical sterility is essential during catheter insertion, and the insertion site should be monitored daily for signs of infection such as redness, warmth, or presence of pus.

Antibiotic prophylaxis may be advisable, especially if the catheter is to remain in place for more than 48 hours. In the event of leakage or displacement of the catheter, immediate actions are necessary to adjust or replace it if necessary. Patients should be informed of the signs of complications and invited to report any abnormalities, such as unusual pain or leakage. It is also important to monitor the systemic side effects of the local anesthetic, such as the risks of cardiac or neurological toxicity. Vigilance to detect the first signs of toxicity and emergency protocols are essential in the event of an adverse reaction.

Removing the perineural catheter

When and how to remove a perineural catheter

The removal of the perineural catheter must be performed with caution to prevent complications. This important moment depends on the duration of analgesia required and the patient's health status. The catheter is usually in place for a period of 48 to 72 hours, according to medical indications and the patient's specific needs.

A specialized nurse carries out the removal on medical prescription. The procedure requires a rigorous method to ensure patient safety in the operating theatre and minimize risks. The patient must adopt a comfortable position, either lateral decubitus or seated with back support. It is imperative to wash hands in a surgical manner and to wear a mask. The dressing is removed and the insertion point cleaned in accordance with disinfection protocols.

The catheter is then gently removed, applying steady traction. If resistance occurs or the catheter appears to stretch abnormally, repositioning the patient may help. If difficulties arise, it is essential to consult the anesthesiologist. After removal, the end of the catheter should be examined to ensure its integrity and that everything has been properly removed. The insertion site should then be protected with an appropriate dressing.

Post-removal instructions

Following catheter removal, it is essential to follow certain instructions for a smooth recovery. The insertion point must be monitored for signs of infection, such as redness, warmth or the presence of pus. Good hygiene and compliance with local care instructions are essential.

It is recommended to avoid strenuous physical activities and driving for a duration specified by the anesthesiologist in order to reduce the risk of complications. Pain management should continue according to medical guidelines, often with oral analgesics and other treatments. In case of severe pain or complications, it is important to contact the healthcare team.

Regular medical follow-up is essential to check on the patient's recovery and address any complications. Patients need to know who to contact in the event of a problem.

Practical tips for RNs

Pain management at home

Effective pain management at home for patients with perineural catheters requires a meticulous approach. Registered Nurses (RNs) must ensure that the patient receives appropriate care and that the equipment is used correctly. Monitoring the catheter is essential to ensure its correct position, adequate passage of the anesthetic, and the absence of infection or complications at the puncture site. RNs must master the use of pumps for the continuous infusion of local anesthetics and teach patients and their families how to activate boluses as needed, particularly via PCA (Patient-Controlled Analgesia) pumps. It is also important to ensure a regular delivery of necessary consumables, such as local anesthetics and care materials.

Communication with care teams

Effective communication with all caregivers is essential for optimal patient care. IDEs must adopt structured communication tools to minimize the risk of misunderstandings and maximize care safety. Oral transmissions should be systematically supplemented by written notes, supported by tools such as Saed (Système d'Aide à l'Échange de Données), for clear and precise transmission of information. Regular post-intervention debriefings and meetings with care teams are essential for sharing experiences, discussing any complications, and improving practices.

Patient and family education

Patient and family education plays a key role in pain management at home. It is important for patients and their families to be well-informed and capable of independently managing the perineural catheter. They should be trained in the use of pumps and infusion devices, bolus management, and alarm recognition. Education on local care, monitoring for signs of infection, and actions to take in case of complications, such as catheter leakage or displacement, is also vital. The goal is to empower the patient in managing their pain, including learning how to move electrodes for neurostimulation devices and managing consumables and care equipment.

Conclusion

Perineural catheters are an innovative and effective solution for pain management after surgery, especially in the field of orthopedic surgery and peripheral interventions. They provide continuous analgesia, specifically targeting the area of pain while reducing the adverse effects associated with conventional analgesic drugs. Their use increases patient satisfaction, reduces the time spent in the hospital, and encourages rapid and efficient rehabilitation.

Nurses play a vital role in monitoring and caring for patients equipped with these catheters, ensuring effective pain management at home, facilitating communication with medical teams, and educating the patient and their relatives. Adhering to clinical recommendations and exercising rigorous monitoring are essential to avoid and treat potential complications.

By adopting the use of perineural catheters in analgesia protocols, healthcare professionals can offer more comprehensive and compassionate care, thereby helping to improve patient well-being. It is therefore essential to further train and inform healthcare personnel about this method in order to optimize its benefits and ensure superior quality of care for patients.

FAQ

What is a perineural catheter?

A perineural catheter is a medical device designed to be placed close to a nerve. Its purpose is to deliver a local anesthetic on a continuous basis, thus prolonging pain relief after surgery. It is usually installed in the operating room, with the assistance of neurostimulators and ultrasound, for optimal pain management, particularly after particularly painful orthopedic procedures.

How to remove a perineural catheter?

To remove a perineural catheter, proceed as follows:

• Place the patient in the lateral position, with knees drawn towards the abdomen, or seated, with the back rounded around a cushion.
  
  
• Wash your hands as if for surgery and wear a mask.
  
  
• Remove the dressing and disinfect the area with biseptin, as per protocol.
  
  
• Hold the catheter close to the skin entrance and pull gently, applying even force.
  
  
• In case of resistance or abnormal stretching of the catheter, stop the procedure, change the patient's position to clear the intervertebral spaces, and try again.
  
  
• If the problem persists, contact an anaesthetist.

Why insert a peripheral venous catheter?

The placement of a peripheral venous catheter serves several important purposes:

• Compensate for or prevent deficiencies in water, electrolytes, or nutrients.
  
  
• Administer solutions, medications, blood products, or perform sampling.
  
  
• Provide intravenous treatments over short durations, generally less than 7 days.

What is a perineural block?

A perineural block is a form of locoregional anesthesia that targets one or more specific nerves. This method involves injecting a local anesthetic around the targeted nerve, often under ultrasound control, to interrupt nerve transmission and ensure effective analgesia. This technique can be performed with or without a catheter to ensure continuous diffusion of the anesthetic.