Nerve blocks do more than just stop pain. They decrease the time your patients spend in your facility and reduce the number of opioids they need to take post-op. Yes, there are risks that come with nerve blocks as with any procedure, but there are a number of things you can do to make sure your facility runs a successful nerve block program.

1. Surgeon buy-in

You need surgeon buy-in to your block program. Surgeons want what is best for their patients so communication is the key. It's my job, as a trained anesthetist, to show them the value nerve blocks can bring and the benefits for patient recovery. I have found that the best way to get buy-in is to approach surgeons about specific cases where nerve blocks would be appropriate, armed with the physiology of the block and evidence of the benefits to the patient. Benefits like faster discharge, lower post-op opioid use and increased patient satisfaction.

2. Patient education

Before I perform a peripheral nerve block, I like to meet with the patient personally and go over everything. I also go over all of the risks and benefits associated with the block and get informed consent. My spiel goes something like this:

Hello, my name is Adam, I am a nurse anesthetist. I will be administering your anesthetic today and will be with you every second making sure you are safe. I will be performing a nerve block for post-op pain. I will insert a needle near your nerve and inject some numbing medicine that will block the pain you would feel from the procedure. I use ultrasound so I can see where my needle tip is at all times. After the injection, I will leave a catheter in place that will give you continuous numbing medicine 24 hours a day for up to 3 days. This should take care of 60% to 90% of your pain. The rest of your pain will be controlled by other non-opioid methods. After the 3 days, you'll return to our office and the catheter painlessly slides right out.

Many facilities, like my own, have a Joint Camp program for orthopedic patients receiving joint replacement surgeries. The patients spend an afternoon going through what to expect on the day of surgery and meet the entire patient care team: surgeon, anesthetist, nursing, respiratory therapy and physical therapy staff. That's a great time to provide your patient with nerve block education.

After the surgery, the anesthetists and discharge nurses reinforce the education to patients. We send patients home with an informational booklet and handout that lists numbers they can call 24 hours a day to walk them through any problems they encounter with the device. If that doesn't work, we instruct the patient to call us and we will either ask them to come in or send them to the ER. Educating patients both before and after surgery may seem repetitive but making time for it is beneficial for a couple reasons: 1) It gives the patient time to absorb the information which means when you go over it again, they'll probably have questions they didn't think of the first go round and 2) hearing things more than once often helps people retain the information.

3. Ultrasound + nerve stimulation

Now that you have surgeon buy-in and educated patients, you can focus on your block techniques. Ultrasound guidance is the gold standard for peripheral nerve block insertion. I also recommend combining nerve stimulation with ultrasound if you can.

Ultrasound helps you see all the structures and blood vessels surrounding the nerves you're targeting. You can watch the needle the entire time and see the anesthetic pooling around the nerves. This provides visual confirmation that the anesthetic is not in the nerve where it can cause damage or in a blood vessel where it can cause local anesthetic toxicity (LAST). Visualizing the nerve is extremely beneficial but not 100% reliable. Stimulating the nerves before you administer the anesthetic allows you to verify that you are blocking the correct nerve. A nerve stimulator uses specialized peripheral nerve needles that are insulated except at the tip to find and stimulate the nerve that we are trying to block. The device sends a small electrical current through the tip to the nerve, which causes a muscle to twitch, providing another useful visual confirmation that you've found the right nerve. There are safety measures in place that limit the amount of milliamps sent through the tip.

My procedure is as follows: I first use the ultrasound to find my nerve on the ultrasound machine. For safety, I use the "in plane and short axis view" so the nerve shows up as a circle and I can identify all of the appropriate surrounding anatomy and make note of all of the vessels. Then I insert my needle "in plane," which looks like a needle in this view. I use the nerve stimulator to make the nerve twitch to verify I'm looking at the correct one. Then I administer the anesthetic and watch it pool around the nerve. Once the single shot block is complete, I thread the catheter all while looking on the ultrasound screen. It may seem like a lot of steps but once you get into a routine it makes the blocks go much smoother and quicker.

Quick note: Not all nerve blocks actually have a nerve that can be stimulated as with transversus abdominis plane (TAP) blocks. Nerves can come in 2 flavors: those that are sensory only and those that are mixed motor and sensory. Nerve stimulators can only make mixed nerves twitch.

4. Manometer

Another device you can add to your arsenal is a manometer or a pressure regulator. Place a manometer between the syringe and the injection tubing of the needle so you can quantify and monitor the injection pressure exiting the needle. We're constantly using smaller and smaller needles to try to make our patients comfortable, but if you decrease the diameter of the needle and try to force the same amount of fluid through it, you'll increase the force that the liquid exits the needle.

It's like comparing the different sized holes on your showerhead. The water stream that comes out of the smaller holes tends to sting you more than a wider water stream. This can cause serious nerve damage if you have your anesthetic exiting the needle faster than it should. It can cause damage to the external structures of the nerve. The manometer also prevents intraneural injection by limiting overall injection pressure. Most manufacturers limit the exiting pressure to less than 15-20 psi.

5. Monitoring

Then there is the thing you don't want to think about happening but you have to be prepared for — local anesthetic systemic toxicity (LAST). This is why you must continually monitor the patient while performing your procedures. If an inadvertent intravascular injection occurs, the signs and symptoms of LAST will be obvious on a monitored patient. The anesthetist and block nurse monitor the patient's EKG, blood pressure, pulse oximetry, and respiration before the block begins and every 5 minutes for 30 minutes afterwards. You should also have 20% lipid emulsion in your block cart so you can quickly grab them if your patient starts showing signs of LAST and then follow ACLS. The initial dose of 20% lipid emulsion is 1.5mL/kg.

6. Reduce post-op infection

Here is where you can have some fun and add your own personal touches to your nerve block regiment if you're sending patients home with catheters. Since the catheter is going to remain in the patient for 2 to 3 days, there are risks for post-op infections at the insertion site. Here is what I do to make sure that the site stays infection-free and the catheter stays in place.

• Use sterile technique for the procedure, including prepping the site with chlorhexidine before inserting nerve blocks
• Apply a topical skin adhesive at the site to prevent leaking and for catheter securement
• Place a biopatch over top of the dried skin adhesive to prevent infection
• Wrap the catheter with two loops and put steri-strips over top to hold it in place
• Place a clear occlusive dressing over that to prevent infection

You may find a different catheter wrapping that works for you. I like this method because if something pulls on the catheter, the loops unravel instead of the catheter getting pulled out.

Backbone of a good program

A successful nerve block program shows your patients that your facility is committed to effectively managing their pain and getting them home quicker — with little or no opioids — but only if your anesthetists are well trained in the latest ultrasound guidance and other techniques that increase their block success rates and patient safety. That's the backbone of a good continuous nerve block program. OSM