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Overcoming Hidden Barriers to Peripheral Nerve Blocks
One of the biggest obstacles is a lack of practitioner training.
Barry Cranfill
Publish Date: November 17, 2007   |  Tags:   Anesthesia

We've all seen the articles espousing the benefits of neural blockade and the multimodal, proactive approach to post-op pain management. Facilities and anesthesia practices that have embraced this system have reported decreased costs and significant increases in patient and surgeon satisfaction. However, many are still hesitant to initiate a comprehensive neural blockade program. The reasons range from operational and timing problems of completing the blocks without interrupting the surgical schedule to the subject of this article: a lack of training.

Why we shy away
The American Society of Anesthesiologists and the American Association of Nurse Anesthetists have long recognized that training in the use of peripheral nerve blocks is less than optimal in many anesthesia residency and nurse anesthesia programs. With the notable exception of a few programs that place a great emphasis on neural blockade, many training centers struggle to graduate practitioners with even a minimal level of experience in these valuable techniques. Given this lack of exposure, it's no wonder that many otherwise fine clinicians find peripheral nerve blocks intimidating, time consuming and professionally unsatisfying.

Then there are the more common problems encountered early in the learning curve for placing peripheral nerve blocks. Imagine the frustration of taking the time to place a technically difficult block only to find that the patient lacks adequate surgical anesthesia during the operation due to an incomplete or "spotty" block.

Most practitioners are comfortable with the concepts, anatomy, pharmacology and physiology of neural blockade. However, some view the psychomotor aspect of placing the blocks and the perceived unreliability of the blocks as a disincentive to adding this skill set to their anesthetic armamentarium. Unfortunately, maintaining fewer tools in your anesthesia toolbox may be limiting the quality of your anesthesia product.

Training Your Staff for Regional Success

  • Discuss the goals and inherent advantages of neural blockade with your surgeons and staff before you implement the program to ensure cooperation and support.
  • Integrate a discussion of neural blockade into the standard pre-operative patient assessment and interview to include risks, benefits, side effects and expectations.
  • Don't skimp on equipment or supplies. Select and stock an appropriate variety of localization tools (nerve stimulators and ultrasound devices), needles, catheters and anesthetic agents that will meet the needs of your program.
  • Dedicate and equip a specific area for the placement and monitoring of peripheral nerve blocks. One of the key issues for successful implementation of nerve block is that supplies, drugs, and other equipment for the block procedure must be readily available in the room and prepared at the bedside. The physical size of the block area should allow for enough room for the proper monitoring, emergency access and resuscitation of the patients.
  • Be prepared for complications and emergencies. Have emergency equipment available and run periodic drills for the treatment of emergencies such as cardiac and respiratory arrest, local anesthetic toxicity and allergic reactions. At the very minimum, proper lighting, oxygen administration and emergency airway management with positive-pressure ventilation and suction must be available at all times.
  • Allow time and resources for initial and periodic training and updates for peripheral nerve block techniques.
  • Staff sites with an appropriate talent mix of providers. Match experts with novices for mentoring and training.
  • Continuously evaluate peripheral nerve block results objectively (block adequacy, block duration, time required to place the block and complications) and develop systemic approaches for quality improvement.

— Barry Cranfill, CRNA, MHS, MBA, FAAPM

Steepening the learning curve
Obtaining training and experience in peripheral nerve blocks isn't difficult. Many institutions and educational organizations offer formal training programs that will introduce you to the basics of peripheral nerve blockade. Most offer hands-on skill stations and many even afford the student the opportunity to participate in cadaver lab reviews of the pertinent anatomy. These training courses vary from full fellowship programs to short continuing education courses. However, as with most educational endeavors, the best and most relevant learning occurs after the course of study, in the real world. Once you return to the relative comfort of your own practice environment, you must apply and successfully execute what you learned or you'll abandon the newly acquired techniques forever.

Phase in your new neural blockade program slowly and deliberately, one technique at a time. Strengthen your program with continued study and frequent self-directed learning activities.

Where to start? Select a procedure that's common to your facility and a peripheral nerve block that's appropriate for the case. For example, hand surgery may lend itself to the axillary approach to brachial plexus blockade. Knee surgery may be best approached with a femoral nerve block. And foot and ankle surgery might require sciatic and saphenous nerve blocks. Whatever you choose, select an appropriate surgical procedure and the corresponding block. Then spend some time perfecting that technique. In this phased-in approach, once you've mastered a technique, select another and soon you'll have a block for almost every occasion.

Once the didactic area is refreshed in your mind, you may want to use a couple of new and innovative tools to help guide you in the actual localization of the nerves and placement of the specific blocks. B. Braun's new Stimuplex Pen uses cutaneous electrical nerve stimulation in the localization and surface mapping of many peripheral nerves. This device has proven to be an invaluable teaching tool in our facilities as novices study the surface landmarks of non-patient volunteers (instructors or other staff members) and search for the specific nerve response with the Stimuplex Pen — without ever breaking the surface of the skin. The inexpensive device also helps beginners who are hesitant to submit their patients to the trauma of a needle without first verifying the underlying nerve pathway.

Another valuable but decidedly more expensive tool to aid in the teaching and placement of specific nerve blocks is ultrasound. Armed with training from the various manufacturers of these devices, you can actually visualize the underlying structures, map the desired needle approach to the specific target nerve and in many cases visualize the injection of the anesthetic agent. Practice is the key. In our facilities, practitioners are continuously experimenting with these tools on one another in an effort to perfect their craft, improve their technique, increase their efficiency and better serve their patients.

What causes blocks to 'fail'?
Many practitioners abandon regional anesthetics because the block alone doesn't always provide timely and adequate surgical anesthesia throughout the entire case. The causes of these perceived "failed" blocks are multifactorial:

  • inadequate time allowed for the block to take effect ("soak time");
  • unexpected extension of the surgical site into non-anesthetized areas;
  • patient apprehension during the procedure;
  • patient discomfort in non-surgical areas of the body (such as back pain, aching joints and soreness);
  • patient psychological factors; and
  • incomplete blockade of the target area.

Too many practitioners have the unrealistic expectation that neural blockade has failed if they don't achieve absolute surgical anesthetic conditions every time without the need for parenteral pharmacologic supplementation with other agents. This would be comparable to planning and executing a general anesthetic with inhalational desflurane — from induction through emergence and recovery — alone. Sure it can be done, but most practitioners would recommend a balanced technique using various other agents (hypnotics, opioids and benzodiazepines, for example) for a much smoother anesthetic and a more satisfied patient and surgeon.

Why should clinicians expect regional anesthesia to stand alone without other agents to help balance the technique? A block has not "failed" simply because the patient required sedation or analgesics during the procedure. As Phillip Bridenbaugh and Michael Cousins have espoused in the text Neural Blockade, "It is totally inappropriate, and unnecessary to have a 90 percent successful regional anesthetic converted to a 100 percent general anesthetic because the patient responded in some fashion at some time during the procedure." Instead, a balanced approach, providing just enough supplementation accompanied by the utilization of appropriate neural blockade will produce much more effective results. Finally, clinicians should understand that many blocks that may be insufficient for surgical anesthesia will still provide excellent post-operative pain control for their patients.

A final word
Change is sometimes difficult and obstacles to change are not always clearly defined or apparent to the casual observer. In many cases, the true barriers to new and innovative techniques are disguised and camouflaged in an effort to veil the personal biases and limitations of the personnel involved. Peripheral nerve blocks are proven and valuable tools that have been shown to increase patient and surgeon satisfaction with the added benefit of increasing economic efficiency within most centers. Facilities and practitioners should strive to remove hidden impediments to these techniques in an effort to bring the best possible product to their patients and surgeons.