VISUAL CUES An anesthesiologist places an ultrasound-guided continuous interscalene block.

They're difficult to place and even harder to get paid for, so why does my anesthesia group place so many continuous nerve blocks? We've sent close to 5,000 patients home with pain catheters in the last 4 years for 1 simple reason: Our surgeons and patients love them. Pain catheters push painful procedures that once required hospital stays to the outpatient arena and get patients through the critical first 48 hours surgery with little to no pain medicine. They're not without their challenges, however. Here are 5 pieces of advice on overcoming the obstacles.

1. Shorten the steep learning curve. It takes considerable skill and intense training to place pain catheters. Our anesthesia providers prepare by placing single-shot blocks for several months. Think of pain catheters as extensions of single-shot blocks, but much more complex. You're using a much larger needle to facilitate threading the catheter once it's in the correct position: an epidural-sized needle (usually 18-gauge) vs. a 22-gauge needle for most single-shot blocks. To avoid nerve damage, you should always see the tip of the larger needle on the ultrasound as you advance it.

2. Pain catheters require extra time. Continuous blocks take much longer to place than single-shot blocks. It could take a novice as long as 30 to 40 minutes. A more experienced practitioner can place a catheter in 15 minutes or so. I strongly advise that you place catheters in a separate block room or in the pre-operative holding area, never in the OR. For efficiency's sake, your goal should be to make sure that the patient has a catheter in place as soon as the OR is ready so that you're not eating into room turnover time or delaying the start of the case. For preemptive analgesia, it's obviously preferable to have the catheter in place before surgery, but you could always place it afterward to keep the schedule moving.

NO MEDS NEEDED An ultrasound image of a supraclavicular catheter placed for a wrist fracture in a patient who had a history of difficulty managing pain. She didn't need post-op opioids.

3. Getting reimbursed. It's tough to defend doing so many pain catheters to the board of our anesthesia group, because it's a financial loss. We stress that it's a value-added service and focus on the excellent patient outcomes, but the minimal reimbursement is frustrating. In the Philadelphia area, we receive about $50 for a continuous block, which is almost insulting. (We get around $100 for a single-shot block.) It costs us around $350 for the materials needed to place a catheter and for the pain pump that the patient goes home with. Hospitals are reimbursed for the costs of materials, but surgery centers incur the costs. Plus, sometimes we require extra staff on those days when we're placing lots of catheters. We spend considerable time on patient education, e-mailing patients educational materials and making pre-op phone calls to explain how the continuous block will work. We give patients our cell phone numbers so they can call 24/7 with questions or concerns. We're being told we need to focus on patient outcomes and quality, yet we're not incentivized to do so yet. Actually, it's the exact opposite: We're having to invest in good patient outcomes.

4. Managing patient expectations. The silver lining is that our patient satisfaction and pain scores are excellent. With outcomes-based payment coming soon to health care, we expect our efforts will pay off in the long run. If you asked me to name the major benefit of pain catheters, I'd probably say that they prevent hospital readmission for pain control, which for some procedures (shoulder and foot and ankle cases, for example) is as high as 5%. We follow patients for 48 hours when they're at home, and we hardly ever hear of an ER visit for pain. They have less nausea and constipation, they sleep better and they're better able to do their physical therapy. To manage expectations, tell your patients that the pain catheter will bring their pain to a manageable 4 or 5 out of 10. Add that taking oral pain medicines will further reduce their pain scores to 2 or 3. Tell patients that the pain catheter is not to treat all their pain, but is merely an adjunct. Remind them that the problem with the catheter is not in taking it out — it slides right out when you remove the plastic bandages that lie over top of it — but in keeping it in. Tell them to take care not to let the catheter get caught on something. Also warn patients about the unwanted side effects of pain catheters: droopy eye, fullness in the throat or difficulty sensing that you're breathing when used for shoulder surgery, for example.

5. Tools to shorten the learning curve. Pain catheters have become more common because ultrasound technology has improved and become more affordable. Before ultrasound, it wasn't easy to place catheters. You need to visualize the nerves and blood vessels in order to place effective and safe blocks. The key is to see the needle at all times with the ultrasound. If you can see the needle and the structures, you can be confident that you're avoiding the structures you want to avoid.

When you hook the catheters up in the recovery room to the pain pump that the patient will go home with, fill the pain pump or ball with a much lower concentration than the local anesthetic. The patient might receive 0.5% ropivicaine for the procedure and 0.2% ropivicaine from the pain pump. This allows for some feeling and sensation to return to the blocked limb. The goal is not to have the limb so numb that the patient can't feel anything.