The Building Blocks of Regional Anesthesia

Anesthesia

By: Edward Mariano

Published: 2/11/2020

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A back-to-basics approach is needed to expand the use of one of the most effective ways to manage post-op pain.


TRIED AND TRUE Edward Mariano, MD, MAS, says new procedures aren't necessarily better because they're more complicated than the ones they're designed to replace or improve upon.

We're nearly 20 years into our experience using ultrasound guidance for regional anesthesia, so the growing movement among experts in the field to focus on creating new, more complicated nerve blocks makes sense. These efforts have the best of intentions — to deliver the best possible care to patients with more precise pain-relieving techniques.

The problem is, regional anesthesia is not yet performed by the majority of anesthesia practitioners on a regular basis. In outpatient settings, nerve blocks are used in a mere 3% of surgeries that are eligible for them. Even during shoulder arthroscopies — obvious candidates for regional anesthesia — blocks are used only 41% of the time, giving patients a less-than-a-coin-flip chance of getting one.

If only a small number of anesthesia practitioners are using basic blocks, even fewer understand and perform the newer novel blocks that have emerged. The advent of these often more complicated blocks can easily intimidate some practitioners and convince them to avoid using regional anesthesia at all.

This "complexity bias" has widened the gap between pioneers in the field and anesthesia generalists, and patient care may suffer in the long run. While the pursuit of new techniques is always a worthy one, I also think there needs to be a movement toward getting the most out of the current blocks we have (see "5 Blocks Every Provider Should Know" below).

ESSENTIAL SKILLS
5 Blocks Every Anesthesia Provider Should Know
LET'S TALK Barriers to more widespread use of regional anesthesia will be cleared through the constant sharing of best practices.

If every anesthesia practitioner knew how to perform these five basic block techniques with ultrasound guidance, there would be a massive increase in patient access to regional anesthesia. Each of these blocks represents a transferable skill, and practitioners may choose to substitute a block on the list with an alternative block used for a similar indication.

1. Interscalene brachial plexus. Everyone should be able to offer a block for shoulder surgery, and the interscalene block is still the gold standard. Other ultrasound-aided blocks have been developed in the last few years, but a basic interscalene block is something any anesthesiologist should be comfortable placing. It has a long track record and it covers the entire site of pain for every shoulder procedure, including total shoulder replacements.

2. Infraclavicular brachial plexus. This block is good for patients undergoing distal upper-limb surgery at the elbow, wrist or hand. Some practitioners prefer to use an axillary brachial plexus block, which may work just as well. For these surgeries, you need a block of the brachial plexus below the clavicle close to the shoulder. If you know how to do one of these two types of blocks, that's sufficient.

3. Adductor canal. Providers used to place a femoral nerve block for knee surgeries. Today, we perform the adductor canal block, which is a more selective block in the femoral triangle to minimize motor weakness. Again, members of your anesthesia team should know how to place a femoral or an adductor canal block. Either provides pain relief for major knee surgeries, and knowing how to do one of these is a springboard to expand your practice should you decide to perform more advanced blocks.

4. Popliteal sciatic. Anesthesia practitioners should be able to identity the sciatic nerve behind the knee in the popliteal fossa. A popliteal sciatic block provides great pain relief for foot and ankle surgeries, which are common procedures in outpatient settings.

5. Transversus abdominis plane (TAP). A TAP block is the most common interfascial plane block for abdominal and pelvic surgeries. It can be performed quickly in the operating room and provide somatic abdominal wall analgesia for outpatients having minor surgeries such as inguinal hernia repair or laparoscopy.

When more anesthesia practitioners know how to use these techniques, attitudes will change about the effectiveness of regional anesthesia and barriers to implementing the pain-relieving practice into clinical pathways will be addressed, including differing opinions on how much patients benefit from their use and how practical the techniques are to implement. Concerns about liability and cost persist as well. It's my hope that improving research, sharing best practices and increasing awareness of the benefits of these blocks will remove those obstacles.

— Edward R. Mariano, MD, MAS

A back-to-basics approach — offering a basic blocks package and standardizing how they are taught and implemented — would bridge the gap between academic experts in the field and practitioners who are in the trenches every day. It would also go a long way toward providing patients with more consistent and reliable opioid-sparing pain-relief.

Gradual change

Making competency in even a basic set of blocks the norm won't happen overnight. Training must evolve. Currently, an anesthesiology resident must have provided care to 40 peripheral nerve block patients in order to graduate. There's no breakdown, however, on which nerve blocks must be performed or how many times they're used. So, a resident can theoretically meet the requirement by administering 40 different nerve blocks one time each. For experienced anesthesia practitioners, access to improved simulation tools are needed in order for them to maintain their current skills and learn new ones. In day-to-day clinical practice, narrowing the range of block procedures that general anesthesia practitioners perform regularly will help them hone their techniques and competency.

I also suggest training to the highest level of care. If regional anesthesia is going to be offered at all, every anesthesia practitioner should be able to perform effective continuous nerve blocks (CNBs) with catheter insertion because the worst block is the one that wears off in the middle of the night, leaving the patient in pain. The second worst block is the one that lasts too long from the patient's perspective. When they don't have control over the operative limb, they describe the feeling in the arm or leg as "paralyzed" or "dead."

Long-acting suspended release blocks or a cocktail of adjuvants don't provide titratability, which gives patients the feeling of control that they want. CNBs are currently the only titratable, long-duration nerve blocks. In terms of personalized pain medicine for surgical patients, there's nothing else like it. From the patient's perspective, it's never good to have a therapy that you can't adjust and can't control.

Increased access

GUIDED BY SOUN\D
GUIDED BY SOUND Ultrasound guidance helps providers place more effective blocks, which decrease opioid consumption and can help patients ambulate sooner after surgery.

The most important discussion for administrators and managers in outpatient surgery settings surrounds increasing access to regional anesthesia for every patient who would benefit from it. One way to deliver consistent care is to standardize the procedures offered. Having ultrasound guidance available and the latest technologies in anesthetic delivery systems should make it easier to establish consistent techniques for regional anesthesia and help your practitioners learn and perform effective continuous nerve blocks. You should work with your anesthesia team to standardize a blocks package and work with them to ensure they're administered the same way to each patient.

For regional anesthesia to no longer be considered a novelty, it has to be cemented as a core competency for all anesthesia practitioners. We have decades of research proving regional's effectiveness, so there's no reason every practitioner can't be as well-trained in placing nerve blocks as they are in airway management.

We need to start pushing for the widespread use of regional anesthesia, so more patients have access to it. Creating a deliberate strategy of standardizing a small number of versatile, high-value nerve blocks is what will transform regional anesthesia from a niche subspecialty delivered by and for a few into a mainstream practice performed and received by many. OSM

Gradual change

Making competency in even a basic set of blocks the norm won't happen overnight. Training must evolve. Currently, an anesthesiology resident must have provided care to 40 peripheral nerve block patients in order to graduate. There's no breakdown, however, on which nerve blocks must be performed or how many times they're used. So, a resident can theoretically meet the requirement by administering 40 different nerve blocks one time each. For experienced anesthesia practitioners, access to improved simulation tools are needed in order for them to maintain their current skills and learn new ones. In day-to-day clinical practice, narrowing the range of block procedures that general anesthesia practitioners perform regularly will help them hone their techniques and competency.

I also suggest training to the highest level of care. If regional anesthesia is going to be offered at all, every anesthesia practitioner should be able to perform effective continuous nerve blocks (CNBs) with catheter insertion because the worst block is the one that wears off in the middle of the night, leaving the patient in pain. The second worst block is the one that lasts too long from the patient's perspective. When they don't have control over the operative limb, they describe the feeling in the arm or leg as "paralyzed" or "dead."

Long-acting suspended release blocks or a cocktail of adjuvants don't provide titratability, which gives patients the feeling of control that they want. CNBs are currently the only titratable, long-duration nerve blocks. In terms of personalized pain medicine for surgical patients, there's nothing else like it. From the patient's perspective, it's never good to have a therapy that you can't adjust and can't control.

Increased access
GUIDED BY SOUND Ultrasound guidance helps providers place more effective blocks, which decrease opioid consumption and can help patients ambulate sooner after surgery.

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