Multiple scientific studies and articles in this publication have touted the advantages of regional anesthesia for ambulatory surgery patients.1 The superior pain relief allows for a dramatically rapid recovery, with patients often leaving within 15 minutes of the end of a procedure. With excellent analgesia, there is no need to titrate intravenous or oral opioids with the associated risks of nausea and vomiting.2 The greatest advantages are seen when peripheral nerve blocks are used, since they do not limit ambulation. Even spinal anesthesia, with the right choice of drugs and dosages, can provide competitive discharges in the outpatient setting, and the short duration spinal anesthetics do not carry the risk of urinary retention previously associated with the longer-acting blocks.3

You'll reap the greatest advantages when you use regional techniques with continuous catheters for prolonged anesthesia after discharge.4 Many centers are using continuous brachial plexus, femoral and sciatic nerve catheters to send patients home for 48 to 72 hours of analgesia following procedures such as rotator cuff repair, ACL repair and major foot surgery.5 With these techniques, sleep disturbance is minimized, analgesia is superior and without side effects, and patient satisfaction is very high.

These excellent results, however, come with a price. Regional anesthesia takes extra time, both to perform the blocks and for the onset of local anesthetics. This can be an expensive proposition in a rapid turnover surgery center. Here are six ways to expand the use of regional in your center.

1. Find a place other than the OR to perform a regional block. Although some centers can perform blocks rapidly and successfully in the OR,6 it's generally more efficient and productive to perform these blocks in the admitting area, or in a corner of the PACU if that's the only space available.7 Blocks can be done while a room's being cleaned, or even while the previous procedure is in process if there are enough personnel. The additional location must have adequate space to perform the block, as well as the standard monitoring and resuscitation equipment that might be necessary if there's any adverse reaction. A PACU bed is a practical choice, as long as the anesthesia provider also brings resuscitation drugs to the scene. Ideally, a mobile cart with all of the necessary equipment to perform the block will speed the process. This lockable cart should include the trays, needles, drugs and gloves that an anesthesia team might use, so that no time is wasted gathering supplies.

2. Get help. The second asset is extra personnel. A high-volume regional anesthesia practice is easier to implement in an anesthesia care team practice where nurse anesthetists are available to monitor patients during surgery while an anesthesiologist performs blocks in the admitting area. Otherwise, the scheduling of one additional anesthesia provider each day can provide the early placement of blocks that allow sufficient time for adequate surgical anesthesia. In a busy practice, the anesthesia staff also frequently rely on the admitting or PACU nurses to provide a significant amount of help in preparing, positioning and prepping the patient, as well as doing the monitoring while the block is performed. In such a practice with a well-established protocol, the admitting nurse can have patients prepared for a block when the anesthesiologist arrives. Preparation can include having the block tray opened, site marked and prepped, and localization equipment (nerve stimulator or ultrasound) turned on and ready. With this pre-staging, the block can be rapidly performed before the OR is ready.

3. Educate patients. A critical aspect of this preparation is early patient education. Success starts with the surgeons. If a surgical group is aware of the advantages of regional techniques, it has the first opportunity to introduce the concept to the patient and prepare him for the process. Many groups, especially orthopedic surgeons and podiatrists, recognize the benefits of regional, both for patient comfort and their own peace of mind (fewer "pain control" phone calls), and are willing to work with their anesthesia group to prepare the patients for the prospect of a pre-operative injection technique. Patients who arrive with the expectation of a block dramatically shorten the anesthesia discussion. From the anesthesiologist's perspective, it's helpful if the patients can be seen before the day of surgery to evaluate their medical conditions and to educate them about the details of the block procedures so that little time is required for the day of surgery assessment. Even a phone call is useful in answering patients' questions and concerns, since the reality is that most patients aren't aware of the advantages of regional techniques and are anticipating general anesthesia. Good pre-operative education can also reduce the need for sedation during the block, which may later delay discharge (although small amounts of midazolam and fentanyl also enhance patient acceptance).

4. Choose the right techniques and drugs. The choice of techniques and drugs can also facilitate success. Blocks that are quick and easy to perform (in experienced hands) include the interscalene, the axillary, the femoral and spinal anesthesia (see "Is There a Role for Spinal Anesthesia in Ambulatory Surgery?"). Intravenous regional is also an option if a tourniquet is to be used for the surgery. With all of these, the use of rapid onset drugs such as 2-chloroprocaine and lidocaine can produce a quicker onset, although they may not provide prolonged duration. In these situations, the use of continuous catheter techniques for infusions of longer-acting drugs can bridge the patient into recovery and allow a virtually pain-free surgical experience.

5. Combine anesthetics. Another technique in busy practices is the use of combined anesthetics. The long-acting local anesthetics are frequently associated with a slower onset, so that when blocks are performed with these drugs (or when a complex catheter technique is used), there's often inadequate set-up time for the anesthetic. In this situation, the block is placed pre-operatively and the surgery can be performed with a short general anesthetic or short-duration spinal anesthetic so when the patient recovers in the PACU, there is no analgesia requirement and discharge can be quite rapid. A combination technique of course involves exposing the patients to the risks of general or spinal anesthetic, but is very effective in getting the procedure started and moving rapidly along. What's more, the avoidance of narcotics can eliminate the major risk of PONV that potentially delays discharge after routine general anesthesia.

6. Master block technique. An experienced anesthesia team with good regional anesthesia skills is helpful. Fortunately, most residency programs are graduating physicians with higher skill levels due to enhanced residency requirements. But experienced practitioners still have many opportunities to advance their skills with numerous workshops that are available, especially for the newer ultrasound techniques (www.asra.com/education). The recent addition of ultrasound guidance to perform peripheral nerve blockade appears to have improved success and speed in experienced hands, and patient discomfort from paresthesias and nerve stimulation are eliminated. Although improved speed and success have not been confirmed completely by scientific evidence, the rapid expansion of ultrasound suggests that many practitioners are already convinced of its advantages. Most ambulatory centers already employ ultrasound for some of their surgical localizations, and the purchase of a machine with a potential for both functions appears to be a cost-effective investment for most centers.

Willing to adapt?
Regional techniques offer major advantages to outpatients in terms of recovery and pain relief, but require adaptations to allow sufficient time for blocks to be performed and take effect. Judicious use of space and personnel can greatly facilitate regional anesthesia. If the effort is made, it can provide significant improvements in patient recovery and satisfaction, and prove to be a worthwhile investment for your facility.

For references, go to www.outpatientsurgery.net/forms.