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EDUCATION
Clinical Best Practice Webinars
Pajunk Education with ESRA - January
Together with the European Society of Regional Anaesthesia & Pain Therapy (ESRA), Pajunk has started a series of clinical webinars which focus on peer clinician training.
Pajunk has always been close with the major Regional Anaesthesia societies by providing our support through attendance of the bigger and smaller meetings, workshops and trainings on the European level. ESRA has been and is very scientific and now open up more towards the industry with different marketing possibilities. Luckily, the pandemic, which caused almost everything to go virtual, had a major impact on ESRA’s decision to work closer with the industry as well. Already now, Pajunk started the first webinar as an official industry partner of ESRA.
This year we plan a total of six webinars together with ESRA.
The first webinar took place on Jaunary, 19th and coverd the following topic: Pre-peritoneal wound infiltration catheter in laparoscopic colorectal surgery
The second webinar will take place on February, 18th and will focuse on Ultrasound-guided WALANT & Ultrasound-guided Ophthalmic Blocks. You can register here.
The January webinar Pre-peritoneal wound infiltration catheter in laparoscopic colorectal surgery was led by Dr. F. Jeroen Vogelaar (Surgeon) and Dr. Ansgar Harm (Anesthesiologist), both from the VieCuri Medisch Centrum, Venlo (Netherlands). During the session they discussed important topics of opioid sparing technique in laparoscopic procedures on the example of a colorectal surgery:
- General introduction about important developments in abdominal surgery and analgesia
- Characteristics of the specific colorectal population that benefits from opioid-free surgery
- Opioid sparing and side effect reducing strategies by use of wound infiltration techniques, including considerations of ERAS guidelines
- Tips and tricks for handling, placement and potential complications of wound infiltration catheters in surgical site
You can view the webinar on our youtube channel - link see below.
Q&A of the webinar:
95,000 died from alcohol in US in 2019. So opiates are safer from a recreational point of view
But alcohol has no place in anesthesia and pain therapy.
Any big differences between TAP catheters and wound catheters?
You only need one catheter if the midline is crossed, easier to perform, faster.
Any comparison between rectus sheath catheters placed by the surgeon and preperitoneal catheters?
Preperitoneal is just easier and thus faster to perform, one catheter, 5 minutes, good results.
Any issues with the infection?
We had no catheter related infections.
Did you try different rates of ropivacaine? In some studies lower rates were not effective.
You need a certain volume to achieve results.
Did you use wound infiltration before starting to use this technique or compared to it?
No.
Do patients need the catheter for the whole three days or can the catheter be removed earlier?
We just leave them in.
Do you discharge patients with the catheter and if not do you plan to do so in the future?
Until now, if a patient is fit enough to go home on day 2, we remove the catheter. Sending a patient home with a catheter for 1 day is not our plan at this moment.
Do you normally also close the peritoneum parietale? Or only because of placement of the catheters?
In a pfannestiel-incision it is quite easy to close the peritoneum, because of a lacking posterior fascia (below the linea arcuata). We closed it also before the catheter-era in this incision, also in favour of a better pneumoperitoneum after extracting the specimen.
Do you place multiple catheter in all incisions?
Just one in the main incision, we infiltrate the other ports.
Do you still place catheter if you open?
The few times we converted to an open procedure we placed the catheter on the closed peritoneum. There was some effect of it, but not that optimal as compared to the pfannenstiel. Therefor a tunnelled positioning (even 2) is necessary in laparotomies, but at this time I am lacking experience with that.
Do you think bolus or catheter dose into peritoneal cavity would be effective?
That has been tried but with little success.
Does the catheter wound method help with visceral pain?
No, it's just for the abdominal wall, but visceral pain plays a small roll in laparoscopic surgery.
For how long do you usually leave the catheter? 2 - 3 days?
70h
For this method, have you any experience with children?
We don't do have many children, but if you make sure not to exceed the (adjusted to weight) maximum amount’s of LA there should be no problems.
Have you observed some wound complications? Surgical site infection?
We had no catheter related infections.
How do you explain that it doesn’t work in gynaecological and obstetric procedures?
The slide wasn't clear. It didn't reduce pain scores over all, only in a subgroup of gynaecological patients and only at 48 h. Gupta et al Acta Ans Scand August 2011 Pages 785-796.
How do you get pain to cover deep visceral pain?
Morphine as necessary, earlier we used PCA, but patients rarely needed much morphine.
How does this differ from rectus sheath catheters?
It can be used at any incision and with rectus sheath you would need two catheters.
How long do you leave the catheter in place?
Until the pump is empty, 350ml / 5ml/h = 70 h after start, shorter if we have to use higher volume, with the planned RCT for spondylosis we are planning to use higher volumes and use a second elastomer pump when needed.
How satisfied are the patients after complete recovery e.g. 6 weeks after surgery?
Patients are very satisfied during hospital stay. Because it is 'common care' in our hospital, we do not pay a lot of specific attention to this topic after 6 weeks.
If there is a stoma in place or gets placed is preperotoneal catheter placement still possible and effective? (midline incision)
In midline incision it is not always easy to place a catheter in the way we do in pfannenstiel incision because the peritoneum if more fixed to the posterior fascia. A tunnel-technique with even 2 catheters seems to be the best way for this, but my experience is lacking at this time. A stoma is not a contradiction itself, but does cause an "integrity-disruption" of the peritoneum which may cause pain itself.
Do you use multimodal analgesia in Venlo in CZE like lidocaine, ketanest pumps preoperatively together with opioids?
Some colleagues do, the most just use propofol/remifentanyl.
Is de fixation material coming with the catheter and pump?
Yes.
Is erector spinae block a good/ popular technique for analgesia in abdominal surgeries?
In theory it is, I don't have any experience with it. I only use it for rib fractures, VATS and mamma surgery.
Is it better to administer non-steroidal drugs alongside the use of wound infiltration catheter to improve pain scores 24 hours post-operative?
We don't use NSAID's not because of possible anastomotic leakage.
Is it different from multiple orifice catheter in terms of efficacy?
Openings in the catheter over the whole length that is inserted in the wound.
Is it possible to use 2 catheters in larger incisions?
Sure, there are different lengths of catheters and you could also use two short ones.
Is there a optimal catheter length/hole configuration compared to incision length? How do you determine this?
The length of incision in the pfannenstiel is max 5-7cm. We use the 7cm catheter. For example in C-section I can imagine you use the 15cm.
Is there also something to say about POWI is this technique?
In general local anaesthetics have an anti-microbial effect (because of the Ph.?). We had no catheter related infectois problems.
Is there not pain differences between colonic and rectal surgery and so do we need to purpose epidural analgesia for laparoscopic or robotic rectal surgery?
Except for abdominoperineal resections there was no difference between colon resections and rectal resections (low anterior). Important difference is of course the perineal wound in APR. A few time we placed also a catheter in this wound with good effect (n=3).
Have you performed statistical analyses with pre-catheter group as now it is not clear whether this is a significant reduction in Hospital stay? You mentioned that you also started prehabilitation how do you now if this is also of influence?
Mean LOS in 2018 in both hospitals was 6 days. With this preliminary results we found a significant reduction to 3-4 days. There will definitely be an ERAS-effect, maybe also any prehabilitation effect, although this was not implemented in the whole study period.
Spinal diamorphine is regularly used by me for laparoscopic colorectal surgeries and i have found it to be effective for Enhanced recovery programme. It also helps in the intra operative period...
...with reduced opioid and relaxant requirements. But I am looking forward to try this technique as an alternative.
We don't use spinal opioids.
Do you give other ‘’drugs’’ to increase the effect of the local anesthesia gived with the catheter?
No, only local anesthetics.
How do avoid systemic spread if you are using local Anaesthetics bc one can see visible bleeding at the operation site where the catheter is placed?
Little bleeding, self-terminating, also compressed with closing of wound. You wouldn't insert a catheter if greater bleeding was visible.
Was there any change in post op ileus?
There were less ileus than in our historical cohort (epidural).
Was there any wound complications related with the continuous infusion? dehiscence par example?
We had no catheter related infections.
What about NSAIDS or N2O as alternatives to opioids?
N2O has no place in our hospital for environmental reasons, NSAID's not because of possible anastomotic leakage.
What is the mechanism of action in preperitoneal LA infusion??
Local anaesthetic at the place of injury.
What is your analgesic technique for redo surgery or in patients with previous surgeries?
If it is laparoscopic surgery morphine (PCA or as asked for) With laparotomy we use epidurals.
What is your surgical time for an Anterior Resection?
120 minutes
What opiate are you using intra and post op?
Intra operative remifentanil, post-operative and as loading dose morphine.
What post op opioids do you use on day 0 and day 1? Is it a set protocol?
Morphine as necessary, earlier we used PCA, but patients rarely needed much morphine.
Which orthopaedic procedures do you use wound infiltration (or is it continuous nerve block?)
Most of the time single shot nerve block, RCT with wound catheters for spondylosis to start soon.
With caesareans we don't normally close the peritoneum, is it still possible to use this catheter?
Since we don't use it for caesarean section yet we would look that up in the literature before starting.
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