As regional blocks grow increasingly popular for perioperative pain control, anesthesia providers who've had little or no training in their use during residency or practice remain stuck on the sidelines, afraid to fail. But with most regional blocks being safe and easy to learn, how much longer will inexperience hold up as an excuse?

Continuous nerve blocks, with the added use of perineural catheters and infusion devices, allow excellent pain control for days after surgery. These, too, require minimal training and practice for proficiency. Careful sterile technique is important, since these catheters may be in place for a few to several days. Here's a look at some commonly used, easy-to-learn nerve blocks.

• Fascia Iliacus block. Let's start with an extremely useful (as well as easy) block that you can master for total hip arthroplasty as well as femur and hip fractures. You can quickly rescue an elderly and'confused patient who's suffering post-op pain with this technique, particularly if you don't wish to use more narcotics.

The Fascia Iliacus block can be either a single shot or a catheter inserted for continuous pain control. With the patient supine and the anesthesiologist standing on the side to be blocked, palpate the anterior superior iliac spine and the pubic tubercle and mark the overlying skin. Draw a line connecting these two points and divide it into thirds. Draw a perpendicular line at the junction between the outer one-third and the inner two-thirds. The perpendicular line will extend only 1cm to 2cm below the line. That is your needle insertion point. After an appropriate prep and wheal, make an introducing hole with a 19- or 18-gauge needle. Next, using a 22-gauge short bevel spinal or bullet-tipped needle, insert the needle perpendicular to the skin. You'll feel the initial "pop" as the needle penetrates the fascia lata. You'll feel the second fascial "pop" after penetration of the fascia iliacus. Trust your senses and stop right there ' you're at the injection site. This is a volume block. On removal of the stylet, inject 30ml to 40ml with intermittent aspiration. If you were planning a continuous block, use a Tuohy needle and thread the catheter 10cm to 15cm beyond the needle tip. Secure with transparent dressings. Set the infusion at 6ml to 10ml per hour, depending on the size of the patient. This approach is aimed at blocking the lateral femoral continuous nerve that supplies several fibers to the hip joint; it can also block the femoral nerve per se, which could produce quadriceps weakness. Observe "out-of-bed precautions."

• Femoral nerve block. Easy and safe, this block consistently blocks the anterior thigh, both sensory and, to some extent, motor. It extends several centimeters below the knee in the femoral nerve distribution. But because the obturator and the lateral femoral cutaneous nerves are inconsistently blocked, it's a misnomer to call it a "3-in-1" block. Nonetheless, it's an extremely effective block for total knee arthroplasty and anterior cruciate ligament repair, significantly decreasing the amount of morphine needed post-op.

With the patient supine, prepped and draped, mark the location of the femoral artery and make a line along the inguinal crease. The needle entry point will be 1cm to 2cm lateral to the artery just below the inguinal crease. Through a local wheal, advance a 2-inch insulated needle cephalad at a 40- to 60-degree angle. Since this is a motor block, a nerve stimulator is routinely used ' initially set at 1.5 to 2 milliamps. Usually two "pops" will be felt (fascia lata and fascia iliacus) and quadriceps contractions are sought, shown by rhythmic patellar ascension. As a nerve stimulator at this setting may be uncomfortable for the patient, reduce the setting to about 0.5 milliamps or less, while still seeing brisk twitches.

If you're using a catheter, you have two choices. available. The "Stim-Cath" (Arrow International) permits continued stimulation of the nerve as you advance the catheter along the nerve cephalad 3 to 5cm. Place the local anesthetic after the catheter is in place. If you're using a regular catheter, such as that produced by Braun, deliver the drug immediately through the needle and then thread the catheter 10 to 15cm. After a 2 or 3ml ablation dose (Raj test to see the twitch disappear), incrementally inject up to 40ml of local anesthetic with careful intermittent aspiration and patient contact with regards to pain, paresthesias and any change in sensorium. Tunnel the catheter to decrease possible displacement. Carefully apply transparent dressings.

• Interscalene block, antero-lateral approach. You may prefer this approach, which is distinct from the classic "Winnie" technique, because it uses a more proximal needle entry point and is aimed antero-lateral to the brachial plexus, thus is more aligned with the plexus for easier catheter insertion. Since the injection is usually made more caudad, particularly when a catheter is introduced, you'll dramatically reduce the incidence of phrenic nerve block. This block is particularly useful for total shoulder arthroplasty and essentially any repairs of the shoulder, depending on surgeon preference. With a little practice, it's as easy as the "Winnie" approach.
• Infra-clavicular block. This highly useful block, ideal for hand surgery as well as for prolonged post-operative analgesia, can significantly reduce time to discharge.
• Tibial block, popliteal approach. You can use either a single or continuous technique for this easy block to handle post-op pain following major foot and ankle surgery.
• Ultrasonography. I have no experience with the use of this modality to aid in the accurate identification of nerves and nerve plexuses, and the more precise placement of local anesthetics (see "Keys to Success With Ultrasound-guided Nerve Blocks," July, page 24). Limiting factors appear to be the expense of efficient devices and the rather steep learning curve. We've observed clinical demonstrations at our institution and are planning some hands-on experience in the near future. Attending a workshop might be the best way to see if ultrasonography is right for your facility.

Informed consent
In addition to describing the reasons for the nerve block, the approach and the need for their cooperation, tell patients that the block may fail or be incomplete, and that there's a slight risk of temporary nerve injury.