Despite the growing recognition of regional anesthesia's benefits, your surgeons might be hesitant to take the plunge into peripheral nerve blocks if they're worried about surgical delays, block failures, neurologic complications and other factors. We asked surgeons who do nearly all their procedures using regional how they'd respond to the six objections your docs are likely to express.

"I don't want surgical delays."
This is the top worry of reluctant surgeons, because peripheral nerve blocks require a lot more patient prep time than general anesthesia. The key to preventing delays is across-the-board institutional support - including anesthesia, nursing and administrative backing, says William N. Levine, MD, associate professor of orthopedic surgery and director of sports medicine with Columbia University in New York.

In part, this means having a full interdisciplinary staff available, including at least two trained anesthesiologists and two block nurses who can cover for each other. "We have grappled with this issue. If the block nurse is on vacation and there is no one to replace her, we have had to revert to doing blocks in the OR," says Dr. Levine.

To him, and to all the surgeons we talked to, institutional support also means having a dedicated area for performing the blocks outside the OR, so the anesthesiologist can prep patients while the surgeon uses the OR for surgery. "Doing blocks in the OR adds 30 minutes to the operation, and you lose the efficiency benefits of regional. This is totally unacceptable in this day and age," says Dr. Levine. He says his director of regional anesthesia set up a block room, which dramatically improved the flow of the OR.

Regional anesthesia-related delays are typically strictly procedural; they tend to occur when the facility isn't well-structured to accommodate the flow of PNB patients. Many blocks take a half-hour or longer to set up, and both staff and patients must be scheduled accordingly.

Bob Teasdall, MD, associate professor with the Wake Forest University School of Medicine Department of Orthopedic Surgery in Winston-Salem, N.C., offers a useful tip for avoiding delays: Schedule a general anesthesia case as your first case of the day. This will give your anesthesiologist time to set up the block for the second case.

"I don't want to deal with block failures."
Surgeons who view general anesthesia as an easier, more fail-safe approach must develop the skills to supplement incomplete blocks with local anesthesia at the surgical site rather than convert to general unnecessarily. They must become "skilled regional anesthesia surgeons," says Jack T. Fulmer, MD, general surgeon and consultant with the Mayo Clinic in Jacksonville, Fla., who commonly supplements paravertebral blocks with a local infiltration of lidocaine around the hernia sac during inguinal hernia repair "because this block does not block the peritoneal nerves."

His colleague, Mary I. O'Connor, MD, chair of the Mayo Clinic's department of orthopedic surgery, advises a reality check. "There is no perfect anesthetic," she says, "but when patients are on the floor puking their guts out [after general anesthesia and opioids], patients are unhappy, nurses are unhappy, and there is a lot of misery. Surgeons must keep this in mind."

If surgeons are really resistant, combine nerve blocks with "light" general anesthesia initially, and base your success rate on post-op analgesia and PONV incidence, say Brian A. Williams, MD, MBA, and Michael L. Kentor, MD, both assistant professors of anesthesiology with the University of Pittsburgh Medical Center.1 When surgeons see success rates climb, they'll likely gain more confidence in the idea of foregoing the general anesthesia altogether, they say.

"My patients want to be asleep, and I prefer them to be asleep."
The key to addressing this concern is to find out exactly why patients say they want to be asleep, and why surgeons prefer this. Typically, patients just want to be unaware, and good sedation will achieve this. "I explain to patients that they're likely to feel motion and pressure during surgery, and I find they're very accepting of this as long as they understand that they won't feel pain," says Dr. Fulmer. Surgeons, on the other hand, may like general anesthesia because they don't want patients to talk in the OR or they may want to achieve muscle relaxation.

"Patients who are aware literally ask questions over and over again, and this is something you just deal with because it is in the patient's best interest,"
says Dr. Levine. Drs. Williams and Kentor also note that a well-functioning nerve block or neuraxial anesthetic will achieve muscle relaxation.[1]

The regional anesthesia surgeon must also accept the reality that the patient is unlikely to lie absolutely still throughout surgery. "I take extra care to use gentle operative technique because rough tissue handling can cause PNB patients to become apprehensive," says Dr. Fulmer. "And while a more deliberate approach may take a little extra time, I believe it is in the patient's best interest."

"I can't perform the post-op evaluation effectively."
Initially, Dr. Teasdall, who spends nearly three-quarters of his surgical time performing foot and ankle procedures, was concerned that regional anesthesia would inhibit the post-op neurovascular evaluation. "I can't ask patients to wiggle their toes or ask them if they can feel my touch," he explains, "and I was worried about this. But I learned that I could still evaluate for perfusion by simply looking to be sure the patient's toes are pink. I haven't had any problems."

"Blocks increase the risk of neurologic complications."
Major complications after regional anesthesia are rare but they do occur. While most experts say more definitive research is needed, at least one survey shows that neurologic complications occur less often after PNBs (1.6 per 10,000) than after spinal anesthesia (6 per 10,000).[2] Nevertheless, experts agree that the key to maximizing regional anesthesia safety is to ensure that the anesthesia team is highly skilled and very well-trained in PNB techniques. Many also recommend building a new regional anesthesia program progressively, beginning with the least complicated blocks first, and moving on to more complicated blocks and then to continuous catheter infusions.

"Blocked patients are more prone to post-op falls."
This is a common concern among orthopedic surgeons, since PNBs can render an operative leg numb for some time after surgery. But this is no excuse for surgeons to throw up their hands and abandon regional anesthesia. Rather, find ways to address the problem. After a couple of Dr. O'Connor's patients fell because their quads were weak, the anesthesiologists changed the mixture of medication in the patients' catheters to reduce the motor block while maintaining sensory block. "It worked," she says.

Don't settle for the status quo
Whatever concerns your surgeons may raise, you can work through them if you enter into a regional anesthesia program with a spirit of cooperation, teamwork and commitment, says Dr. O'Connor. "Don't throw the baby out with the bathwater every time a concern arises. Identify issues, take them to the team and say, 'OK, how will we work through this together?'" she says. "And keep in mind it's not about one anesthetic technique versus another. It's about the entire operative approach. It's about the patient."

The benefits of modern blocking techniques and long-acting agents like ropivacaine and bupivacaine are universal: Modern PNBs provide good intraoperative analgesia, fast emergence, better recovery and, most importantly, superior 18-hour to 24-hour post-op pain control. "Simply put," says Dr. Fulmer, "I request them whenever I can."

References
1. Williams BA, Kentor ML. Making an ambulatory surgery centre suitable for regional anaesthesia. Best Practice & Research Clinical Anaesthesiology. 2002;16(2):175-194.
2. Auroy Y, Narchi P, Messiah A, et al. Serious complications related to regional anesthesia: Results of a prospective survey in France. Anesthesiology. 1977;87(3):479-486.