PROPER NEEDLE PLACEMENT Starting with your needle about the depth of your target in centimeters away from the probe lets you create an angle of entry to the skin ideal for needle visualization.

We're a married couple that lives, eats and breathes nerve blocks. Brandon is an anesthesiologist who specializes in placing blocks at the famed Andrews Institute for Orthopedics & Sports Medicine. Emily is the founder of blocknursing.com, an educational site for the regional anesthesia nursing specialty, and the director of the Blockjocks Research & Education Foundation. Yes, we're passionate about regional anesthesia. That's why it's so difficult for us to accept that so many facilities aren't fully capitalizing on the magic of nerve blocks: shorter recovery times, less post-op pain, and faster recoveries and discharges. Maybe debunking these 20 common myths and misconceptions will help.

1. I need a dedicated block room. So very often we hear, "We don't have space for a block room." No worries. You can turn you pre-op or PACU bay (private or not) into a safe area to perform blocks. All you need are trained nurses, custom block trays, standard vital sign monitors and extra Mayo stands.

2. We'll have to stock so many needles. If you have to choose just one, stock 4-inch needles. This length needle is not only the most versatile in regards to what procedures you can use it for (we think almost all of them!), but it also is the length that, for most blocks, lets you begin your insertion site 3-4 cm away from the ultrasound probe. This lets your needle come under the transducer at a nice perpendicular angle, giving you excellent visualization for a safe and highly effective block.

3. I have to keep my ultrasound probe sterile. Single-shot blocks are not sterile procedures. Save your money on probe covers and wear and tear on your transducer by not applying Tegaderm dressing on the probe. Although the single-shot block is a clean procedure, sterility in regards to the ultrasound probe and gloves is unnecessary. Clean your equipment between uses and clean the surface area for the block beforehand. And as always, just like an IV start, your single-shot needle must remain sterile until insertion time after a chlohexidine prep of the insertion site.

4. Of course my patients will know what a block is. You'll schedule your patients for a block and educate them beforehand — and still they'll show up for surgery having no idea what you are talking about. What can you do? Educate them in the surgeon's office (a take-home brochure helps!), remind them during the anesthesia screening that a block is scheduled (or may be a possibility) and educate them on the day of surgery. A video patients can watch or listen to on the day of surgery is a great idea — it frees nurses to multitask and is a good distraction to the IV placement and organized chaos going on around patients the morning of surgery.

5. At least we don't have to worry about a medical emergency. Although extremely rare, local anesthetic systemic toxicity is a medical emergency. The time from which you notice the early signs of complication till when you can administer the intralipid is crucial. Make sure each day the lipids are accessible — either on the block nurse's ultrasound machine or on top of the block cart. The quicker you're able to intervene, the better the patient outcome.

6. Nobody wants to be a block nurse. Just the opposite is true: Your nurses will have increased job satisfaction with a regional anesthesia program. Nurses, who historically report feeling overworked and underpaid, have increased job satisfaction when working as a part of a regional anesthesia team. They feel like they're actually making a difference in the surgical outcomes of their patients. Anesthesia teams are thankful for organization and support and the surgeons are happy to have a point person for their patients' pain management.

7. Which block is best: supraclavicular, infraclavicular or axillary? It's a common misconception that you must choose one or the other block based on the location of the patient's injury. Studies that measured pain scores, opioid usage and anesthesia time show that you can use these 3 blocks interchangeably for pain control for upper extremity surgery below the shoulder. Consider patient factors such as respiratory status, BMI and whether you'll want a catheter for the patient when choosing which block to perform.

8. We can't afford an ultrasound machine. An ultrasound machine can pay for itself if you document ultrasound use and become familiar with insurance providers and Medicare/Medicaid reimbursements for ultrasound use in your area.

9. Nobody can help me set up my block program. Wrong. Your regional anesthesia companies are often willing to set up in-services and nurse/physician training on or off site. Ask your vendor reps how they can help support your program when purchasing.

10. Surgeons won't want to be bothered with nerve blocks. Although most commonly listed as a perceived "roadblock" to getting a regional anesthesia program started, collaborating with your surgeons isn't as scary as you may think. Take time away from the clinical day (maybe a dinner during non-clinical office hours) to make a plan. Involve your nurses, management, schedulers and other stakeholders, like physical therapy, to make sure everyone is comfortable with the plan. Sharing knowledge and communicating beforehand is key to making these interactions less stressful and yielding better patient results.

BLOCK CHAMPIONS The husband-and-wife team of Brandon Winchester, MD, and Emily Winchester, RN, is passionate about nerve blocks.

11. It's OK to start with your needle up against the probe. If you start with your needle up against the probe, it doesn't matter how echogenic your needle is, you won't see it. Proper needle placement is key to increasing the safety and efficacy of your blocks. Starting with your needle about the depth of your target in centimeters away from the probe lets you create an angle of entry to the skin ideal for needle visualization. Good needle visualization leads to more effective blocks and more precise catheter placement — it also helps you avoid nerve injury.

12. It's best not to isolate specific nerves. Not only is it possible to isolate specific nerves for blocking — in some cases it's ideal. In our practice, we've found that sometimes isolating specific nerves cannot only be easier to perform, but can have increased benefits. For example, isolating the tibial nerve distal to the sciatic nerve split into peroneal and tibial nerves is a shallower block. This allows for ease of nerve visualization and with only blocking the tibial nerve you have the potential to provide pain control to the posterior knee while avoiding foot drop. Isolating nerves at the terminal branches of the brachial plexus is a good way to rescue a patient who may not have a complete upper extremity block in place and is still having pain in recovery.

13. I don't have to worry about patient positioning when placing blocks. Taking the time to properly position your patient before your block will make your life easier. Position your patient in a way that the provider can perform the block ergonomically and best visualize the nerve and place the needle. You also want to consider patient safety factors such as their airway being accessible and cardiac monitors in view.

14. There's nothing you can do about rebound pain when single-shot blocks wear off. First off, yes, rebound pain is a common yet underappreciated phenomenon that happens when a single-shot nerve block wears off. The pain is often so severe that it results in higher pain scores and higher opioid use in patients at the 24-hour mark than in patients who received no block at all. Rebound pain occurs commonly in such surgeries as wrist fractures, shoulder repairs and ankle repairs. However, continuous perineural catheters can significantly decrease this by controlling pain for days following these procedures.

MEDICAL EMERGENCY In cases of local anesthetic systemic toxicity, make sure each day the lipids are accessible — either on the ultrasound machine or on top of the block cart.

15. I'll need a lot of local anesthetic for a successful block. Neither high volume nor high local anesthetic concentration is needed for a successful block. Less can be more. Consider lower volume and/or lower concentration when working with patients who may require an interscalene block but who have a history of mild to moderate COPD, for example. Practice is showing that even as little as 6 to 8 mls of local anesthetic can still have a positive effect on patients' post-op pain while minimizing side effects such as phrenic block. Also, consider that the smaller nerves, such as the saphenous nerve in the adductor canal may not need as much as your popliteal sciatic block. Choosing the volume and concentration of local specific to the patient procedure and risk factors is an important concept to adopt. Drawing up 2 20-ml syringes of 0.5% of ropivacaine just because that is what has always been given is a way of the past.

16. Nobody still uses nerve stimulators. Nerve stimulation is not extinct. Use it to help you make sure you're at your target but use it to avoid being close to what you want to avoid as well. Nerve stimulators are valuable in a dual guidance plan of care where the provider is using ultrasound as well. The stimulator allows you to check to see that you are near the nerve you want but can also help you avoid hitting nerves that may be in your needle's path, or get too close to the epineurium, putting your patient at risk for nerve injury.

17. I've heard continuous catheters won't stay in place. Skin sealant is worth the money. Continuous catheters are an investment on the providers' end to have placed. They take longer and require more from the care team. Once you have effectively placed one, make sure it stays. There are numerous products on the market that you can use to ensure that your catheter does not dislodge before you are ready for it to be removed. As an added bonus, a lot of these sealants also decrease the pesky leaking your patients might otherwise complain about.

18. If we perform a block, we can't give general. RA vs. GA: It doesn't have to be one or the other. Although it's nice to have the option if your surgeon or patient request it, performing a nerve block doesn't mean you must avoid general anesthesia. They often complement each other very nicely in that a "lighter" anesthetic may be offered so that the patient is comfortable post-operatively, as well as hemodynamically stable and "well behaved" for the surgeon intraoperatively.

19. Patients will call me after hours. Don't worry about giving patients your cell phone number. You really do get a lot fewer calls than you'd expect — and even the ones that do call are so very appreciative and non-intrusive you're grateful to have been able to help. On the flip side, if there is a patient with a serious issue, it's in the best interest to us as their primary providers to know what is going on. Giving patients a contact number from the anesthesia team gives them a sense of reassurance that they need and delivers high patient satisfaction scores.

20. Blocks will disable my patients post-operatively. Blocks enable patients' recovery. You hear a lot about what you "cannot do" with a nerve block after surgery, but what needs more light shed on it is what blocks allow for and enable the patient to achieve post-operatively. You can initiate aggressive physical therapy sooner, contributing to better results and achieved strength and range of motion goals earlier when blocks — and especially nerve block catheters — are in place. OSM