The popularity of regional anesthesia is growing by leaps and bounds, but an Outpatient Surgery Magazine survey found quite a variation in technique and success rates among practitioners. While 90% of respondents say they're using peripheral nerve blocks more than they did 5 years ago, more than one-fourth (27.7%) report that blocks fail "sometimes" and sizable minorities say they "rarely" (11.5%) or "never" (20.5%) receive separate reimbursement for peripheral nerve blocks.

Surgeons like it
As we all know, surgeons can resist change, especially if they fear it's something that might slow them down or lead to them receiving phone calls from patients in pain. In the beginning, regional anesthesia requires a bit of selling. "Prove to them that's it's beneficial," says Jim Laughner, CRNA, DO, director of surgical services and anesthesia at the Punxsutawney (Pa.) Area Hospital.

Yet the tide seems to have turned toward acceptance. More than 91% of anesthesia providers and administrators said that their orthopedic surgeons viewed nerve blocks positively. "Orthopedic surgeons drive a lot of this. Their literature has touted the benefits of regional anesthesia," says Peter Bravos, MD, medical director at Sutter North Surgery Center in Yuba City, Calif.

Indeed, some surgery centers and hospitals use their regional anesthesia program to attract surgeons to their ORs. "It's allowed us to move in-patient cases to outpatient," says Carolyn Moles, RN, the administrator at the Orthopedic Associates Ambulatory Surgery Center in Oklahoma City, Okla. The telltale signs of peripheral nerve block success — short recovery times of 45 minutes, less PONV and less post-op pain — have brought anterior cruciate ligament, hemi shoulder and shoulder resurfacing procedures that were formerly performed in the hospital to the surgery center.

Conversely, Kernan Hospital, a teaching hospital in the University of Maryland Medical System in Baltimore, is using the success of its regional anesthesia program to draw community orthopedic surgeons to its ORs, says Eric Shepard, MD, FCCM, an assistant professor of anesthesiology at the university's school of medicine. The quick turnaround is a selling point for private practice surgeons who demand efficiency. "You can't slow them down," says Dr. Shepard, who sets most blocks in 5 minutes using ultrasound guidance.

Getting paid for blocks
Only about 15% of respondents said that their facilities get reimbursed for blocks every time, and about 32% said they're often reimbursed. Although many facilities are not reimbursed (11.5% rarely and 20.5% never), administrators still see value in peripheral nerve blocks. With a materials cost of less than $40, a peripheral nerve block is worth the expense for some, with or without separate reimbursement. "Patient satisfaction goes up exponentially when they have a block," says Linda Petersen, RN, BSN, nurse director at Emerald Surgical Center in Boise, Idaho. "They go and tell their friends."

Whether a nerve block will be reimbursed depends on the payor and how you code and bill the block (see "The Economics of Peripheral Nerve Blocks" in Outpatient Surgery Magazine, March 2008). "We get paid about 50% of the time," says Michelle Kerr, RN, MHA, administrator at Special Surgery of Houston in Texas.

Multimodal therapy
Our survey found that regional anesthesia doesn't preclude using other therapies at the same time. Nearly 35% of respondents use multimodal therapy with every nerve block and another 37% usually administer multimodal therapy in conjunction with blocks. The success of a combination of the block, opioids and NSAIDs for post-op pain control depends on patient education. In many facilities, patients are encouraged to begin taking post-op pain medicine while the block is still working. This helps the patient avoid a big jolt of pain (an "analgesic gap") once the block wears off. "Don't let yourself get into the vicious cycle of playing catch-up," says Deena Lee, RN, director of surgery at Physicians' Day Surgery Center in Fort Smith, Ark.

For pediatric orthopedic cases, Steven Butz, MD, medical director at the Surgicenter of Greater Milwaukee in Wisconsin, administers general anesthesia and then a nerve block for analgesia.

Although continuous infusion can prolong the analgesia of a peripheral nerve block, many anesthesia providers and facilities choose not to use them. About 45% of the respondents never use continuous catheters. Only about 9% of respondents usually use continuous catheters, or do so with every applicable case. For some providers, the time it takes to insert the catheter is not worth the benefit of prolonged analgesia. "We don't feel that they're necessary," says John Curtis, MD, a partner with Valley Anesthesia in Phoenix, Ariz. "Adding a catheter takes more time and it adds the potential of complications." The disposable pump can add several hundred dollars to the cost of care as well.

Even fewer providers and facilities send patients home with an ambulatory catheter hooked up to an infusion pump. About 66% of respondents don't use pumps outside the facility, according to the survey. When patients do have the pumps, Dr. Bravos calls every day to make sure that the pump is still in place and working correctly.

Who makes post-op calls varies from facility to facility. Among respondents who use ambulatory catheters and pumps, 44% of the time the anesthesia provider follows up with the patient. About 37% of the time, the recovery nurse does.

When a patient leaves the facility with an ambulatory catheter and pump, providers are concerned about infection (59%), local anesthetic toxicity (29%) and bleeding (12%). A patient falling down at home is another concern for some anesthesia providers. For that reason, after lower extremity surgery Dr. Butz prefers to send patients home with pumps only when they are prescribed orthopedic braces as well.

Needle guidance
While ultrasound is generating a lot of attention, it's still not the most common method for guidance during peripheral nerve blocks. More than 87% of respondents said they use nerve stimulation. About 52% use ultrasound. Some providers use both methods at the same time.

The cost of portable ultrasound machines, $24,000 to $50,000, is why some providers don't use ultrasound. Another barrier is the time and effort it takes to master the technology. "There's a significant learning curve," says Dan Hagengruber, MD, a partner at Northwest Anesthesia Physicians in Eugene, Ore. "You can't just buy the machine and fumble into this."

But once you are proficient, ultrasound can save time and help avoid mishaps, says Dr. Shepard. Ultrasound helps you avoid blood vessels and lets you make focused injections because you can see the nerve roots. You can also get the needle into the sheath of the nerve. "The onset of our blocks is much faster," says Dr. Shepard.

One area of concern identified in the survey is that 16% of respondents still use paresthesias for guidance. Although no method of identifying nerves is risk-free, an emerging opinion is that newer techniques (nerve stimulation and ultrasound) are safer and more effective. Now that more direct methods of identifying nerves have evolved, the idea of squaring nerves has become less appealing to most.

Proficient providers
The steep learning curve and relative newness of nerve blocks make it difficult for some facilities to find enough anesthesia providers proficient in peripheral blocks. About 32% of respondents said they sometimes have trouble finding a provider with regional anesthesia experience. About 7% said that they often have a hard time. This is especially the case for rural hospitals and surgery centers. "Out of my local pool, only about 50% are proficient," says Bryan Hunter, CRNA, director of anesthesia and surgical services at Mercy Hospital in Moose Lake, Minn. As a result, surgical facilities have to juggle their schedules in order to accommodate surgeons who prescribe blocks. Eventually that will change, says Mr. Hunter. Regional anesthesia skills will be part of the job of an anesthesia provider. "Everybody's going to have to be able to do this."