A surgeon friend of mine had been a grunt Marine right out of high school. I asked him, "What is it like to be a Marine?" He said, "Ready!" Not that being ready is a new concept for nurses, but for peripheral nerve blocks, which require so much focus and accuracy, the term is particularly apt. There are inherent dangers in regional anesthesia: seizures, vascular collapse, pneumothorax, sudden loss of consciousness and nerve injury. We need to be ready (Ready!) for all of these possibilities. But what we really need is focus for accurate and safe placement. We need a nurse whose whole attention is on assisting and knowing what to have in hand, what the sequence is, how to adjust the nerve stimulator and the ultrasound, how to properly aspirate the syringe and give the local anesthetic. She also needs to help observe nerve stimulator twitches, improve the image on the ultrasound, and observe hydro-dissection and flow around the target nerve or plexus. We may need to administer more sedation. Read on as we outline 3 challenges that OR nurses must meet when a block patient presents.

1. Maintain an organized block cart. Nurses must be familiar with each of the blocks in terms of prep solutions, drapes and ultrasound probe covers, needle sizes and doses of drugs. Backup supplies should be close at hand. All patients need to have basic monitoring: EKG, pulse oximetry, blood pressure cuff and supplemental oxygen. We must be prepared for immediate induction of general anesthesia or airway management needs (resuscitative measures may be required). One of the devastating complications of inadvertent intravascular administration of local anesthetics is vascular collapse/cardiac arrest. This complication is particularly severe with the use of bupivacaine, as its molecule attaches to the conduction fibers of the heart, making restarting the heart rhythm particularly difficult. Fortunately, an intuitive physician tried intravenous lipid emulsion in this situation and found an "antidote" to this potentially fatal complication. This drug, Intralipid, is stocked routinely where nerve blocks are administered.

2. Know the complexities of the block. The block itself requires experience and knowledge. Aspiration of the syringe is a careful technique that must be applied very gently. Since the most likely structure to be inadvertently punctured is a blood vessel, negative pressure that is too strongly applied will likely attach the end of the needle to the wall of the vessel and blood will not be aspirated, yet the needle will still be intraluminal. Similarly, the assistant must develop a "feel" for the pressure needed to inject the drug and to potentially detect intraneural placement. A patient may not always appreciate pain or experience paresthesias. An experienced nurse will see appropriate as well as inappropriate twitches elicited by the nerve stimulator.

3. Help perform rescue and continuous blocks. Occasionally, we perform "rescue blocks," blocks done in the PACU when a patient might have unanticipated pain following a procedure. A nurse who can help gather the resources to perform such blocks with the same degree of safety and efficiency is also invaluable. Additionally, many surgical facilities are developing continuous peripheral nerve block (CPNB) programs. CPNBs provide 2 or 3 days of excellent pain management by infusing a continuous flow of low concentration local anesthetic, usually 0.2% ropivacaine. This modality is appropriate for foot and ankle (popliteal, saphenous), knee (femoral, sciatic), arm, hand and elbow (infra- or supraclavicular), and shoulder (interscalene) surgeries. Highly accurate and dependable elastomeric pumps make this modality possible. Nurse and physician involvement in follow-up is, of course, a requirement.