"I'd be worried, too, if you told me that the anesthetic you were about to give me has a 35 percent chance of not working," says Brian Sites, MD, assistant professor of anesthesiology and director of regional and orthopedic anesthesia at Dartmouth-Hitchcock Medical Center in Lebanon, N.H. He's widely regarded as the leader in the use of hand-carried ultrasound to perform nerve blocks.

His point is this: For all of regional anesthesia's benefits, it's not without its challenges. Chief among them: placing a needle to administer anesthesia in a targeted area within the body isn't easy. There are also the issues of the time it takes to administer a nerve block compared to general anesthesia and the fact that nerve blocks should be performed in a dedicated block room.

They've got to work
Peripheral nerve blocks have well-known benefits - faster recovery, smoother discharge, diminished post-operative pain and faster throughput. But for facilities to capitalize on these benefits, the nerve blocks have to work. Enter an imaging modality, which Dr. Sites calls long overdue.

"Historically, the success rates of the procedures have not been wonderful, from as low as 60 percent to as high as 90 percent," says Dr. Sites. "There's little doubt that regional anesthesia is far superior. But its success rate - or lack thereof - is troublesome."

Many regional anesthesia providers rely on seeing and feeling anatomical landmarks to guide needle placement. They may also use a nerve stimulator to prompt an observable muscle twitch when the needle locates the targeted nerve. Dr. Sites dismisses these techniques as a "surrogates for what you cannot see" and as "blind, random approaches based on anatomical assumptions." Ultrasound, on the other hand, lets you see the needle, the anesthetic, the nerves and other structures that you don't want to injure. "You can strategically and accurately position the needle in a very delicate area," he says.

With their promise of faster, more accurate needle placement, ultrasound-guided nerve blocks will become the standard of care in the next five to 10 years, Dr. Sites believes. He qualifies that statement by adding that changes in behavior are needed.

• Time. Nerve blocks take longer, but Dr. Sites says that after performing about 60 ultrasound-guided blocks, you can perform nerve block placements in about 10 minutes. "You're not going to spend 25 minutes searching for a nerve," he says.
• Learning curve. Ultrasound guidance can be tricky. You must be able to identify various nerves, learn the techniques of needle insertion so that the needle is visualized as it's inserted (if the needle's not in line with the ultrasound beam, you can't see it) and deal with ergonomic issues (it can be very tiring, says Dr. Sites, to hold a probe at odd angles while applying a certain amount of pressure).
• Space. You need a dedicated place to perform blocks (not the OR), which includes committing such resources as monitoring equipment and nursing support. Have patients arrive in your block room a little earlier than normal so that you can perform several blocks at a time. Dartmouth-Hitchcock's block room is right outside its five outpatient ORs. A dedicated group of nurses is assigned to the block room to prep and monitor patients.

Buying considerations

• Cost. You can spend as much as $70,000 on a larger, cart-based ultrasound machine that offers slightly better image quality than a $35,000 laptop machine, says Catherine Jensen, director of finance and operations at Dartmouth-Hitchcock's department of anesthesiology.

• Payment. Ultrasound-guided procedures are fully billable. The facility fee for CPT code 76942 (ultrasound guidance of nerve blocks) is $73.04. The national average for a physician's professional fee is $32.21.

Kevin Neff, MD, medical director of Lakes Surgery Center in West Bloomfield, Mich., is considering buying an ultrasound at the surgery center he owns and at Huron Valley-Sinai Hospital in Commerce, Mich., where he's a staff anesthesiologist.

"As an owner of a surgery center, is it cost-effective for me to get this machine here? The price is proving to be a very big hurdle," says Dr. Neff. "And unfortunately, I don't know of any data that proves my clinical impressions to be true: that ultrasound is clearly safer and leads to superior success rates."

To get approval for a capital expenditure from the hospital, Dr. Neff has to document a medical need or a financial need.

"If there's clear documentation that it's safer for patients," says Dr. Neff, "it would be a no-brainer."