NURSING CARE A skilled block nurse who knows the process and preferences for regional anesthesia practitioners can clear the way for efficiency.

I remember one of my first experiences with nerve blocks, working a case in which the patient — a veteran who was a bilateral amputee — was undergoing the latest in a series of surgeries. I was skeptical at first, thinking we'd need to administer a lot of post-op narcotics. But the patient emerged from the OR, awake and aware, and not burdened with pain.

That case was a real eye-opener for me. Until then, I didn't fully appreciate how versatile and effective regional anesthesia can be. What I've found to be true in the years since is that peripheral nerve blocks are an ideal choice of anesthetic for more cases than you might think (see "Who Benefits From Nerve Blocks?").

When you consider how peripheral nerve blocks and continuous local anesthetic infusion can benefit your patients, it's easy to see why. It's well-known that regional anesthesia improves the quality of patient care in a number of ways: fewer side effects, faster recovery time, and — most important to our patients — dramatically reduced post-surgical pain.

Whom can you block?
Regional anesthesia's true believers advocate for every, or almost every, surgery patient to receive a block. If you're working with a forward-thinking anesthesia group, you have a lot of options. It's arguably the best method of pain control for orthopedic cases, and even breast cases such as mastectomies and augmentations.

Keep in mind, though, that it's not always 100% of your anesthesia solution. Although shoulder, arm, wrist and hand surgeries can be performed successfully with just a block and some sedation, surgeries from the knee through the ankle often require the assistance of general anesthesia and post-op options.

Still, the combination of a nerve block, general anesthesia and post-op opioids allows lighter usage of the last 2 options. As a result, patients emerge from their surgical anesthetic sooner and are much more aware in post-op.

It should be noted that head and neck procedures are not suited for regional anesthesia — unfortunately, we don't have a lot of nerves to work with there — and although a transverse abdominus plane (TAP) block can control the incisional pain resulting from open or laparoscopic hernia or gall bladder cases, it doesn't address the visceral pain.

Some patient conditions demand caution when considering the use of nerve blocks. While regional anesthesia presents a low risk of nerve injury, the risk is increased for patients who have previously suffered nerve injuries at the site. Additionally, it may be advisable for cardiovascular and stroke-risk patients to refrain from taking anticoagulant medications in the week before surgery. Because you're working millimeters from major arteries when you place blocks, the risk of bleeding at the stick site could be a concern.

FOR MOST, BUT NOT ALL Some — but not all — procedures are tailor-made for nerve blocks.

PATIENT SELECTION

Who Benefits From Nerve Blocks?

Peripheral nerve blocks aren't always 100% of your anesthesia solution. While you can successfully perform shoulder, arm, wrist and hand surgeries with just a block and some sedation, surgeries from the knee through the ankle often require the assistance of general anesthesia and post-op opioids. Here's a breakdown of procedures ideally suited for blocks as well as those when blocks aren't your best option.

— Emily DeBusk, RN

Ideal Procedures for Blocks

• total shoulder repair
• rotator cuff repair
• proximal humerus fracture (distal isn't ideal due to chance of radial nerve injury)
• wrist fracture
• hernia repairs
• mastectomy
• total knee arthroplasty
• ACL repairs
• ankle fractures
• ankle arthroscopy
• bunionectomy
• amputation

Less-Than-Ideal Procedures for Blocks

• craniotomy
• spinal surgery (fusion and discectomies, for example)
• cardiac procedures (abdominal aortic aneurysm and valve repair, for example)
• esophagogastroduodenoscopy
• colonoscopy
• surgeries of the bladder, pancreas or GI system
• gastric bypass

SHOT, BLOCK Continuous infusion catheters can keep a patient pain-free for days after a peripheral nerve block wears off.

The benefits of blocks
Regional anesthesia plays a dual role as surgical anesthesia and post-op analgesic. A single-shot peripheral nerve block is highly effective through the procedure and up to 8 to 24 hours afterward. When a patient wakes without pain, PACU nurses won't have to play catch-up to control it, and a continuous infusion "pain pump" can extend the relief for days after discharge.

As an additional benefit, nerve blocks' pain management effects sidestep the complications and side effects that opioids often bring to bear, such as PONV, drowsiness, constipation and respiratory depression. High-acuity patients such as the morbidly obese, elderly and ill are particularly well served by regional anesthesia, as narcotics can couple with obstructive sleep apnea, chronic obstructive pulmonary disease or other co-morbidities to increase the risk of respiratory arrest.

The complications of opioids can also prolong a patient's stay in PACU and their treatment can demand a large amount of nursing time. Nerve blocks may require more time pre-operatively to administer, but they earn it back in post-op with patients' shorter recoveries, earlier mobility and quicker discharges. It should go without saying that all of this equals a more tolerable surgical experience, and the happier you can keep your patients, the healthier your satisfaction scores and overall bottom line.

As surgical providers, our No. 1 priority is obviously to advocate for our patients, and nerve blocks let us do that. But if perioperative efficiency and throughput is your goal, you have to have a nerve block program. The economic benefits of blocks are huge. Especially if your surgeons and anesthetists have seen them expertly performed elsewhere, and especially now that savvy elective surgery patients are being sold on the idea of the pain-free recovery that blocks offer. Those can be compelling motivations to put them into practice.

What it takes
Building a block program at your facility takes a team effort, to be sure. In addition to the process's champions — a couple of surgeons and anesthesia providers who are passionate about regional anesthesia's possibilities and who take the lead in cooperating and putting it into regular use — ?it requires nurses trained to skillfully expedite the practice. The backing of administrators who know how blocks are going to help them accomplish their goals, as mentioned above, is also essential.

There is nothing that will end a budding block program quicker than an adverse event, such as a patient who falls while trying to ambulate too early and too unassisted, or who is burned when a numbed extremity is warmed too actively. So ensuring patient safety is clearly a huge concern, and education is necessary for your nursing staff as well as your patients and their caregivers.

Train your block nurses in accordance with an established protocol. With regard to regional anesthesia, consistency in practice is just as important as a skilled staff, a designated block room to save OR time, or an ultrasound machine for provider confidence. For quality, safety and efficiency, the process should be carried out the same way every time, from the contents of the block cart to the brightly colored socks on fall-risk patients' feet in PACU to the discharge instructions you give patients and their escorts, pre- and post-op.

Patient education is critical. You're sending them out the door with a numb extremity. And you can count on it that 30- to 50-year-old male patients in particular will still want to get up and do everything themselves without assistance, putting themselves at risk in PACU or at home. So you can imagine the potential for injury if you don't emphasize the discharge instructions, warn the families and, in most cases, immobilize the extremity.

Reason for regional
It's a shared view among those practicing in the regional anesthesia field that nerve blocks should be a standard of care, and the reason is simple. We shouldn't have different outcomes, different levels of comfort and different expediencies of discharge between patients just because we can't offer a consistent, and consistently better, method of care.