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When a patient wakes up after two to three hours of surgery on his shoulder, you expect to hear some complaint of pain or discomfort in the recovery room. But at our two-OR multi-specialty surgery center in Southern California, you're just as likely to hear that patient remark, "I don't even feel like I've had surgery!"
That declaration, and the reassuring smile that usually accompanies it, is why we're deeply satisfied with the results we get from using regional nerve blocks to manage post-op pain in patients undergoing orthopedic procedures. But it hasn't always been easy. Here are eight lessons we've learned along the way to regional success.
1. An informed patient is a happy patient.
We've been doing blocks at our center since it opened in 2004. When we started, about half of our patients were familiar with regional anesthesia and half weren't. Since then, we've built such an aggressive pre-op education structure into our practice that by the time the anesthesiologist approaches a patient on the day of surgery for a final interview before performing the block, chances are the patient's heard the rationale for it two or three times and has already wrapped her head around the idea. As a result, we encounter very little resistance from patients.
Before the day of surgery, all patients complete a pre-anesthesia questionnaire, which an anesthesiologist reviews the day before the scheduled procedure to determine if there are any contraindications to doing the block. Many of the typical contraindications — patients with severe COPD or patients taking anti-coagulants — are rarely seen in the ASC setting because we don't do emergency surgeries and most of our patients are relatively healthy. However, we don't perform blocks on children under the age of 18 or in cases where there's a language or communication barrier with the patient. For forearm procedures, if the surgeon believes there's a risk of compartment syndrome (the compression of nerves and blood vessels within an enclosed space), we will forego the block because the patient will need to feel pain to indicate the onset of this potential complication.
Once the patient is deemed eligible for the block, the nurse doing the pre-op phone call will explain the block procedure along with routine pre-operative instructions. On the day of surgery, patients arrive 45 minutes to one hour before their scheduled operations. In the pre-op holding area, before they sign the surgical and anesthesia consent forms, a nurse, followed by an anesthesiologist, will once again briefly explain what the regional block entails and why it's being performed.
Before patients go under general anesthesia, we also explain their post-op regimen for managing the pain after the block wears off. Since patients are sometimes groggy in recovery and might not remember all their instructions, we also provide printed directives.
2. Some surgeons need a nudge.
Although our patient satisfaction rate is quite high, we have encountered some surgeons who were resistant to the idea of doing regional nerve blocks, primarily because they believed they'd be too time consuming and would significantly lengthen turnover time. If you have a good system in place, like we do, that perception is not true. In fact, our use of regional blocks actually improves productivity and turnover time by speeding patients' recoveries, which frees up the pre-op, operating and recovery rooms for a higher volume of procedures per day.
Still, some surgeons won't believe it until they see it. Try this trick I learned a long time ago: Administer the first block of the day before the skeptical surgeon even arrives at your facility. The surgery will start on time and the patient will wake up quickly, comfortably and virtually pain-free. In my experience, it only takes one such case to convince the surgeon that blocks are worthwhile. It's the patient who "sells" the block to the surgeon.
3. Build a reliable support staff.
Some facilities designate a specific room and anesthesia team dedicated solely to performing blocks. As we only have two ORs and rarely need to perform more than one block at a time, each anesthesiologist is responsible for performing her own blocks in between cases, right in the pre-op holding area. All our staff nurses are cross-trained to help with blocks. Their primary duties are to reassure and position the patient and to dial the nerve stimulator, which helps the anesthesia provider (who's positioning a needle) determine that she's as close to the nerve bundle as she can get before injecting the drugs. Typically blocks take about 10 minutes from start to finish, but the time may vary depending on the patient's anatomy.
4. Monitor patients for potential complications.
We monitor patients' pulse oximetry and blood pressure while the block is being performed. The patients are mildly sedated intravenously, but they remain aware enough to tell us if they're experiencing pain so we can stop and reposition the needle. Some risks and complications to look for when performing blocks include:
- intravascular injection;
- incomplete block;
- nerve injury if drugs are injected intraneurally; and
- pneumothorax (in cases using interscalene blocks).
For our most common procedure — shoulders — we give patients an interscalene block, which can paralyze the diaphragm on the side where we administer the block. Sometimes very shortly after we perform the block, patients will complain that they can't take a deep breath, usually because their chest wall is numb and their diaphragm is not functioning normally. This feeling is not common, but we keep patients monitored with the pulse oximeter to ensure they're oxygenating well and haven't suffered the more serious complication of pneumothorax. Meanwhile, we treat their anxiety about perceived breathing difficulties with reassurance. Most patients are going into the OR rather quickly after the block is administered, because we don't wait for the block to be set before administering a general anesthetic. By the time they're recovered from general anesthesia, they rarely complain about breathing difficulties.
5. A detailed record makes coding easy.
I developed a standardized perioperative block record that goes into the patient's chart and is attached to the billing file to ensure we're properly reimbursed for all our blocks. The anesthesiologist fills out the record after the block is performed, specifying the type of block (CPT codes are listed on the sheet), where it was performed, who performed it, the instruments, devices and medications used, and any complications that arose. We also list on the block record the patient's pain level, measured on a scale of 1 to 10, in pre-op and PACU. This helps us keep track of how well the blocks are working to manage post-op pain. You can download a PDF of our block record at www.outpatientsurgery.net/forms.
6. Faster recovery saves time and money.
Although we use regional blocks primarily to treat post-op pain, they also help reduce the amount of anesthetic agents and narcotics needed during surgery, which saves us in drug costs and lets patients wake up faster from general anesthesia. Our patients are typically awake and on their way to the recovery room, about five to 10 minutes after the procedure has ended, which is about five to 10 minutes faster than they'd be if we didn't use blocks. Our facility is designed for fast-track recovery: Patients on average spend an hour to an hour-and-a-half in the recovery room before they're ready to go home.
Patients who've had blocks are generally comfortable when they wake up. For shoulder procedures, the block alone is often enough to control the pain. For more involved procedures, like ACL reconstructions, patients may require a little pain medication in the recovery room, but they usually describe feeling a manageable level of pain that we can treat with oral medications, not IV analgesia. By controlling post-op pain and reducing our use of anesthetics during surgery, regional blocks have also helped keep our PONV rate quite low, which not only makes our patients happier, but also helps save our facility money on narcotics and anti-emetics.
7. Patients need a post-op plan.
The regional nerve blocks last anywhere from six hours to 12 hours after the procedure is done. It's very important to educate patients before and after their procedures about how to manage their blocks after they leave the facility. Advise them to take it easy — to read a book or watch TV, but not to cook dinner or engage in other activities that require use of the numb extremity.
One problem we encountered early on was a rash of complaints from patients who felt so comfortable once they got home, they were startled by a sudden onset of pain when their blocks began to wear off, sometimes in the middle of the night. Now we instruct all patients to rest, have something light to eat and begin taking their pain medications on schedule, even if they aren't feeling pain yet, so they don't suddenly go from feeling nothing to feeling everything. Since then, we haven't been getting those frantic phone calls from patients in pain. In a few cases involving more complicated orthopedic procedures, we've sent patients home with continuous blocks, which require more aggressive management, including daily check-up phone calls with patients to make sure their catheters are working properly and that they're satisfied with the pain relief they're getting.
8. Always room for improvement.
We've been performing regional blocks for four years and our patient satisfaction rate is quite high, but we're still looking to improve our patients' experiences. We're currently conducting a performance improvement project aimed at eliminating the undesirable side effects of interscalene blocks, specifically the shortness of breath and heavy-chest sensation some patients feel due to diaphragmatic paralysis. We're trying different concentrations of local anesthetics on different patients and documenting the side effects some patients experience, their pain level in PACU and the duration of their blocks, which we ascertain through standard post-op phone calls. After several months, we hope to have enough data to determine the concentration of local anesthetics that gives patients the longest relief from pain with the least amount of motor block.
This type of follow-up and constant evaluation has helped us continue to leverage aggressive use of regional nerve blocks to manage post-op pain, achieve greater surgical and anesthesia efficiency and maintain a high level of patient satisfaction.
6 Pearls for Advanced Regional Catheter Success
As more and more complex surgical procedures continue to migrate from inpatient settings to outpatient settings, the need for better pain management has become paramount. Indwelling regional catheters provide continuous post-op pain management via regional anesthesia. Here's a report from the Advanced Regional Catheter Techniques workshop I attended at the May 2008 SAMBA meeting in Miami. Drs. Brian Williams, Jeffrey Swenson, David McLeod and Roy Greengrass shared these pearls:
1. A twitch monitor is superfluous and unnecessary when ultrasound is being used to guide block or catheter placement.
2. Shaking a syringe of local anesthetic (or saline solution) to create air bubbles can create hyperlucent areas on the ultrasound when injecting small amounts of solution to better visualize placement of the needle tip.
3. If practicing on an animal model, pork is a good choice of meat. The multiple fascial planes serve as substitute nerve sheaths and are good landmarks to visualize under ultrasound guidance.
4. A standard epidural catheter kit is more than adequate to use for indwelling catheter regional blocks.
5. Practitioners lacking the experience or skills in block placement rarely find improved success by prolonged use of a twitch monitor or multiple attempts to get muscle stimulation with a twitch monitor.
6. With or without ultrasound guidance, the best regional block clinicians are usually those with a solid understanding of the underlying anatomy and, in essence, give a quick, successful block via anatomic landmarks.
Although indwelling catheters have risks — infection, device malfunction, risk of falls and, theoretically, overdose — these take-home regional catheters address the risk of unmanageable pain, opiate overdose and need for hospital re-admission.
— Adam F. Dorin, MD, MBA
Dr. Dorin ([email protected]) is an anesthesiologist and author.