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Overcoming the Roadblocks to Regional Anesthesia
If it's as great as everyone says it is, why isn't everyone doing it? For starters, you have to promote the benefits and downplay the barriers.
Julia Pollock
Publish Date: October 10, 2007   |  Tags:   Anesthesia

Regional anesthesia can decrease the intensity of post-op care, incidence of PONV and recovery times, and increase mobility and post-op alertness.[1-3] So why isn't everyone doing it? A lot of it has to do with anesthesia provider experience. But as these techniques gain acceptance and more providers learn how to perform them, the practice will grow. Here's a look at the benefits of - and the roadblocks to - performing regional anesthesia in your facility, and eight tips for making it work for you.

Why regional?
Interest is growing in regional anesthesia as more anesthesia providers become more involved in the treatment of pain syndromes, financial pressure mounts to decrease hospitalization times, and patient and provider satisfaction gain in importance. There's more information available than ever on techniques, drugs and adjuvants.

Recent studies indicate that patients who undergo regional anesthesia or regional anesthesia combined with general anesthesia might actually have decreased morbidity and mortality when compared with patients undergoing general anesthesia alone.[4] It can also save money: Using developed models of the cost of general, regional and monitored anesthesia care, Columbia University Medical Center researchers found that using regional anesthesia could save facilities from about $30 to almost $65 per case, and that both regional anesthesia and monitored anesthesia care were significantly less expensive than general anesthesia.[4-5]

Despite these benefits, regional techniques were used in only 30 percent of anesthetics performed in the United States in 1990.7 There are many potential barriers to practice:

  • reluctance to invest valuable pre-induction time on regional techniques;
  • fear that a block might not work intraoperatively; or
  • most commonly, the anesthesiologist's lack of experience performing regional blocks.

Contemporary anesthesiologists can provide regional anesthesia effectively and efficiently.

A Rundown of Techniques

Here's a glance at the most common regional block techniques and a brief description of each.

  • Thoracic epidural. The most versatile and extensively utilized of currently available regional anesthetic techniques, it offers the post-op benefits of enhanced pain relief and decreased use of systemic analgesics, improved pulmonary function and early extubation, early ambulation, as well as early return of GI function and fulfillment of discharge criteria.[8]
  • Spinal anesthesia. You need to pick the right drugs to make this work. Ideally, that means local anesthetics with an appropriate duration of action and acceptable side effect profile, and adjuvants that enhance anesthetic efficacy without prolonging recovery.
  • Arm blocks. Brachial plexus blocks are the most extensively used peripheral nerve block technique. Advantages include less PONV and airway intervention, faster discharge, smooth transition to oral pain medications and increased blood flow to the extremity.
  • Axillary. This technique is associated with a very low incidence of complications; it is useful for surgery of the hand, forearm and upper arm.
  • Supraclavicular. Has the fastest onset time of any of the arm blocks and is ideal for surgery of the forearm, elbow and even shoulder.
  • Intrascalene. Will provide excellent analgesia for shoulder surgery; however, you should consider that the ulnar nerve is frequently not blocked with this approach, that the posterior shoulder will not be anesthetized (important for shoulder arthroscopy), and that general anesthesia with pectoral muscle relaxation may be needed for a Bankhart repair.
  • Leg blocks. The second lumbar through third sacral spinal segments are responsible for motor and sensory innervation. The upper branches (L2-4) supply the upper leg, with a branch of the femoral extending medially below the knee. The lower roots (L4-S3) provide the bulk of the innervation below the knee.
  • Femoral. This block is easy to learn and perform, has a very low complication rate and provides terrific post-op analgesia not only for outpatients undergoing anterior cruciate ligament repair but also for patients undergoing total knee replacement surgery.[16]
  • Psoas compartment block. The psoas compartment block anesthetizes all the branches of the lumbar plexus and, combined with a sciatic nerve block, can provide complete surgical anesthesia for the lower extremity - but this combination is not appropriate for outpatient anesthesia.

- Julia E. Pollock, MD

For a complete list of this article's references, go to www.outpatientsurgery.net/forms.

Obviously, you shouldn't implement regional anesthesia at your facility if your anesthesia provider isn't familiar with the salient anatomy and block technique. But if he is, here are a few tips.

  • Start early. While you're in the beginning stages of adding regional anesthetics, perform these techniques on the first case of the day. That way, the anesthesia provider will have extra time to perform the block without the pressure of knowing the surgeons and OR nurses are waiting for him. If the case your anesthesia provider wants to do a regional technique for begins later in the day, assign someone to prepare all the necessary equipment during the previous case.
  • Centralize your equipment. Keep everything in one place. An induction room, rolling cart or set of plastic bins are all acceptable places to store drugs, adjuvants, needles and other equipment to ensure it is easily accessible to the anesthesia provider. Organize all supplies by type; for example, keep bicarbonate, syringes and tape for securing catheters each in their own designated place.
  • Pick the right block. Knowing the extent and limitations of each block is essential for picking the appropriate block (see "A Rundown of Techniques"). You wouldn't want to use an interscalene block for hand surgery because of the high incidence of ulnar nerve sparing, and you wouldn't pick a sciatic nerve block for outpatients, because it wouldn't let them ambulate safely until their blocks have resolved.
  • Know the anatomy. Familiarity with the relevant anatomy is the single most important factor for determining the success of regional anesthesia. Review the relevant anatomy for any unfamiliar technique before performing a block.
  • Know the potential complications. This can help you prevent complications before they present themselves. For example, if you know there's 100 percent incidence of phrenic nerve paralysis with the intrascalene block, you'd know not to use that block for a patient with pulmonary compromise.
  • Pick the right patient. Not everyone is a candidate for regional blocks. Appropriate patient selection is critical to safely and successfully performing regional anesthesia. Most patients accept the idea of regional techniques when you reassure them that they have the option of pre-operative and intraoperative sedation. You might not want to perform regional anesthesia on patients with great anxiety, needle phobia, poorly controlled psychiatric disease or language barriers. Regional anesthesia techniques might be more technically difficult for your anesthesia provider to perform on obese patients or patients with severe arthritis or degenerative joint disease.
  • Choose the right surgeon. Pick the surgeon who's patient and amenable to learning about the potential outcome benefits for his patients with regional anesthesia.
  • Be confident. Remember, you have back-up: Even if your blocks don't always work perfectly, you still have the option of inducing general anesthetic or providing supplement sedation. Don't be afraid to try.