SEEING IS BELIEVING Ultrasound guidance lets providers view the location of the needle in relation to targeted nerves, so they have a better idea of where the local anesthesia will spread.

Post-op pain doesn't disappear at discharge, so why should your efforts to lessen it stop then? Combining continuous nerve blocks with ambulatory pumps to infuse surgical sites with pain-relieving agents extends the analgesic efforts of your anesthesia providers and lets you perform more complex procedures in the outpatient setting. We asked a couple regional anesthesia experts for insights on implementing and managing a continuous nerve block program that sends patients home with long-lasting relief from post-op discomfort. Here's their best advice.

1. Inform patients
Make sure patients know what to expect after blocks are placed. If you fail to do that, you're unlikely to succeed with your program. Telling patients that their pain may still be at a 2 or 3 — and not a zero — is crucial. "Oftentimes the initial block has a higher concentration of medication that lasts 18 to 24 hours," says Mitchell Fingerman, MD, an associate professor of anesthesiology at Washington University School of Medicine in St. Louis, Mo. "The block will wear off and the pain pump will take over. Patients will experience pain relief, but not at the same level as the initial block. If you don't explain that, they'll think the pain pump isn't working."

Patients might also experience pain outside of the areas covered by the block. For example, says Dr. Fingerman, patients who receive interscalene nerve blocks for labral repairs could experience some pain in the posterior area of the joint. After arthroscopic procedures, fluid can seep into tissue, causing joint pain where the block doesn't reach. Make sure patients are aware of this possibility.

It's best if patients are introduced to the concept of a continuous nerve block before the day of surgery. Provide your surgeons with information and talking points they can share with patients in the clinic or review how blocks work with patients who come to your facility for pre-op assessments.

"If the day of surgery is the first time they're hearing about the block, and they aren't aware of its benefits or how to take care of it post-op, they may be uncomfortable with the process," says Nabil Elkassabany, MD, MSCE, director of orthopedic anesthesiology at the University of Pennsylvania in Philadelphia. "I've seen patients decline a block simply because they weren't sure about what it would entail."

Dr. Elkassabany says a patient who has a low pain tolerance or one who is in chronic pain and takes opioids is a good candidate for a continuous nerve block.

2. Offer round-the-clock support
Before launching a continuous nerve block program, make sure you have the infrastructure in place for dealing with patients who may have a problem at home with a pain pump. While many pain pump companies now offer 24/7 hotlines that patients can call after hours when they have questions, Dr. Fingerman suggests having a member of your anesthesia team or clinical staff contact patients each day they have pain pumps at home. "It's not very labor intensive, and it's worth it to us because we get a lot of repeat patients who say they appreciated that constant support," says Dr. Fingerman.

Also, give patients a number they can call to always reach someone at your facility who can respond to questions or help them manage issues that might arise. Dr. Fingerman's facility has a cell phone that members of the anesthesia team share, so they can take turns answering calls made by concerned patients.

3. Tap into new technology
Newer ultrasound units are more affordable and a worthwhile investment, even for smaller facilities. Zeroing in on the type of probes needed to place the blocks your anesthesia providers use most often will help you save money on a new purchase, according to Dr. Fingerman. "For most peripheral nerve blocks, you need only one high-frequency probe," he says. "Low-frequency probes, meanwhile, are useful for obese patients or for placing blocks deeper than 5 cm."

Another innovation to consider is catheter-over-needle technology, which can make placing continuous blocks easier. Dr. Fingerman notes that skilled providers can use the technique to place a block in just over 3 minutes.

Dr. Elkassabany says the catheter-over-needle technology seems to reduce the risk of leakage and its echogenic qualities make it easy to see the catheter on the ultrasound screen. And while previous editions of the technology weren't easy to work with, newer versions aren't as "technically challenging," says Dr. Fingerman.

Pain pumps have also come a long way, from simple, single-flow-rate devices to high-tech models that feature patient controlled boluses, adjustable infusion rates, 24-hour start delays, Wi-Fi connectivity and much more.

Though Dr. Elkassabany believes some of the new "smart" pumps can be helpful, he suggests you find models that offer features patients find helpful, but not overwhelming. "My concern is that newer pumps can become a burden," he says. "If they're constantly sounding alarms or are hard to use, that becomes annoying or confusing to the patient and will generate phone calls to the provider."

HELPFUL HINT Nabil Elkassabany, MD, MSCE (left), suggests using ultrasound to confirm that catheters are placed correctly, which will limit calls from concerned patients.

4. Learn to troubleshoot
Dr. Elkassabany says providers may place a block and send the patient home, only to receive a call hours later from the patient complaining of severe pain. Part of the issue surrounds the catheters, which connect to the pain pumps and often "have a mind of their own" by shifting after they've been placed, says Dr. Elkassabany. To avoid this problem, train a nurse to hold the ultrasound probe while the anesthesia provider uses the imaging to help guide placement of the catheter.

Providers should also get into the habit of double-checking their work, suggests Dr. Elkassabany. "Before you tape the catheter in place, inject solution through it and use the ultrasound probe to watch where the solution is distributed and confirm that it's reaching the correct area," he says.

5. Ease into it
Dr. Fingerman says the best way to launch a continuous nerve block program is to start small. Though they have a robust regional program in place at his facility, where providers place 15 to 20 continuous nerve blocks per week, it began much smaller. "Start with one surgeon, one day a week, and send patients home with one type of pain pump," he says. "Over time, surgeons will rubberneck and see how well the blocks are working and say, 'Hey I want that for my patients.' That's how you develop buy-in and grow the program." OSM