Regional's Role In Improved Ortho Outcomes

Anesthesia

By: William Landess

Published: 7/25/2013

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Look no further than nerve blocks for faster and safer recoveries.


nerve block POST-OP PEARL Nerve blocks limit post-op complication risks and help send patients home sooner.

What's not to like about regional anesthesia? Patients who receive nerve blocks before joint or extremity procedures recover with less chance of PONV, less blood loss, fewer blood clots, shorter post-op stays and better pain control. Let's take a closer look at the pain control regimen that's ideally suited for orthopedic procedures.

PROVEN RESULTS
Regional Lowers Complication Risks

neuraxial block

Neuraxial blocks dramatically improve the surgical outcomes of patients undergoing hip or knee arthroplasty, according to a study in the May 2013 issue of the journal Anesthesiology (tinyurl.com/mpvmt2t).

Researchers at Cornell University's Weil Medical College in Ithaca, N.Y., reviewed the records of approximately 382,000 patients who underwent total hip or knee procedures between 2006 and 2010 at hospitals nationwide. Of the group, 11% percent received neuraxial blocks, 14% received a combination of neuraxial blocks and general anesthesia and 75% received only general anesthesia.

They discovered neuraxial blocks lowered 30-day mortality rates by 80%, risk of prolonged hospital stays by 30% and major complication risks by 30% to 50%. "While anesthesia is commonly viewed as a tool to allow surgery to safely take place," says study lead author Stavros George Memtsoudis, MD, PhD, "the type of anesthesia used may have a far bigger impact on patients' outcomes than previously assumed."

— Daniel Cook

Widespread benefits
Extremity and joint procedures match up well with regional anesthesia, because blocks can be placed effectively where a nerve plexus innervates a prospective surgical area, which can be found in nearly all areas of the body. Regional involves applying medications near nerve fibers, bathing them in anesthetizing agents and rendering the blocked area insensate to pain. It's best administered in a separate procedure area or pre-op/PACU bay before patients are wheeled into the OR, which keeps the suites clear for surgery and helps maintain the day's schedule.

Peripheral nerve blocks and epidurals are sterile procedures administered as a single injection into the nerve sheath or with a catheter threaded into place near the targeted joint to deliver an anesthetic continually or intermittently. An intravenous regional block (called a Bier block) involves injecting medications directly into a vein of the arm while using a tourniquet on the affected limbs. For all these methods, patients can typically feel touch and pressure, but not pain.

Regional blocks can extend pain control beyond the OR. Patients who receive regional blocks instead of general anesthesia before foot surgery can be sent home and not require pain medication for 48 to 72 hours. Pain is also controlled without narcotics, allowing for faster discharges and more comfortable convalescing at home. Additionally, patients who receive regional blocks require less airway management, such as endotracheal intubation, thus increasing the safety of the procedures and reducing strain on anesthesia providers.

IMPROVED OUTCOMES
Ortho & Regional — Perfect Together

single-injection block JOINT EFFORT Single-injection blocks can provide up to 24 hours of pain relief after outpatient rotator cuff repair.

Perhaps more than any other specialty, orthopedic surgery lends itself to the practice of regional anesthesia," say Mayo Clinic researchers in the June 2010 issue of Anesthesiology Clinics (tinyurl.com/krxz546). Here are their reasons.

  • Upper extremity surgery. Interscalene blocks for shoulder surgery and axillary brachial plexus blocks or infraclavicular brachial plexus blocks for hand surgery lead to less pain, faster ambulation and faster discharges. Single-injection blocks can provide 12 to 24 hours of pain relief after shoulder procedures, but patients may experience significant discomfort when the blocks wear off. Continuous nerve blocks can extend that pain relief for several days, but catheter-based analgesia after shoulder surgery remains a controversial practice.
  • Lower extremity surgery. Post-op pain may be a limiting factor in discharging hip arthroscopy patients from the outpatient setting, but post-op intra-articular injections lower reported pain scores for 24 hours. Total hip arthroplasties are migrating to the outpatient setting, thanks in part to regional anesthesia. Patients receiving multiple regional anesthesia techniques, including lumbar plexus catheter blocks and single-injection sciatic blocks, are ready for discharge within 23 hours after minimally invasive hip procedures.

Femoral nerve blocks, lumbar plexus blocks and intra-articular injections are commonly used to provide analgesia after outpatient knee arthroscopy involving ligament reconstruction, although the preferred technique remains a matter of debate. As the primary anesthetic agent, lumbar plexus blocks with or without sciatic nerve blocks provide better short-term benefits for outpatient knee patients compared with general anesthesia, including lower post-op pain scores, shorter times to discharge and higher satisfaction scores.

Patients who receive single-injection blocks placed at the ankle before foot surgery have significantly longer times to the first perceptions of pain, but the benefits typically last just 1 day after surgery. However, a perineural catheter placed in the popliteal space (back of the knee) can extend the initial single-injection pain control for up to 3 days after foot and ankle surgery.

— Daniel Cook

Cautious approach
Of course, regional anesthesia isn't for everyone, and placing blocks isn't free of potential complications. The failure rate can be as high as 50%, depending on the skill of the administrating provider. Starting a regional program therefore requires careful planning, including extensive education and training of your providers as well as your entire clinical team.

Regional is contraindicated if there is any skin lesion, infection or skin eruption at the site of the block. Be cautious with diabetics because some evidence indicates prolonged local anesthetic exposure may increase nerve injury risk in this population. Patients with histories of allergies to particular anesthetics or classes of anesthetics aren't suitable block candidates. Regional can drop blood pressure, cause seizures and even cardiac arrest, as well as a host of less serious reactions. It's also contraindicated for patients with pronounced aortic stenosis.

When considering regional for pediatric patients, there must be a clear indication for performing blocks, because adolescent anatomy is more difficult to maneuver around safely. Anesthetic doses must be reduced for geriatrics and great care must be taken to maintain cardiopulmonary systems in this patient population. In any application of regional anesthesia, no matter the patient's age, always prepare for airway rescue or transition to another anesthetic technique in the event blocks fail or prove inadequate.

GETTING STARTED
5 Keys to Regional Anesthesia Success

ultrasound guidance ON TARGET Ultrasound guidance is the gold standard of block placement.

When launching a regional anesthesia program, focus on these essential elements

  • 24/7 patient support. Demand dedication to the program from a small group of specially trained physicians and staff members who will provide around-the-clock support to block patients. The block team, which should include surgeons, anesthesiologists, specially trained CRNAs, pharmacists, members of the nursing staff and trained educators, must be willing to address any problems that arise or answer any questions patients and their family members have. The educators can answer basic questions from patients or family members about, for example, how regional anesthesia works, how blocks feel as they begin to wear off and potential complications to be aware of while recuperating at home. Patients must also be able to reach by phone members of your clinical team at any time if serious complications arise after discharge.
  • Research. Observe well-run programs in your area. If they're successful, they've faced and conquered start-up pitfalls and paved the way for you.
  • Clear organizational framework. Get buy-in from your facility's administration or physician-owners for the manpower and capital requirements related to adequate floor space, equipment, ancillary support and clinical resources.
  • Block nurse. This staffer is an invaluable asset, especially for providing an extra pair of hands in a smaller facility. Our block nurse preps patients, ensures equipment and drugs are readily available, and assists providers and monitors patients while blocks are being placed.
  • The right equipment. Outfit your facility with block trays, which include sterile gloves, gauze, skin markers, a ruler, cleansing agents, syringes of several sizes, local anesthetic, block solutions and insulated nerve stimulator needles if your providers use the nerve stimulator technique. You'll also need well-equipped supply carts stocked appropriately with airway equipment and emergency drugs. Finally, invest in the gold standard of block placement: Ultrasound, the imaging modality that guides and confirms correct needle placement. Our ultrasound units are mounted on roller carts, which are configured to the providers' preferences.

— William Landess, CRNA, JD

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