The Benefits of Regional Blocks

Patient Experience Pain Management Anesthesia

By: Heather Towers, CRNA, MS, DNAP

Published: 8/23/2021

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Advances in technology and technique allow you to send patients home sooner, in less pain and more satisfied with their care.


COMBINED FORCES When you combine an iPACK block with an adductor canal block, analgesia is achieved at the anterior and posterior regions of the knee.   |  Heather Towers

Regional anesthesia requires a blending of science and art. Bathing nerves that innervate specific body parts with local anesthetics is a proven way to eliminate sensation and movement at surgical sites. Knowing exactly where to administer the anesthetic in order to optimize a nerve block’s effectiveness requires anesthesia providers to rely on their experience and skill.  

When I began my anesthesia training in 1998, regional anesthesia was performed by recognition of anatomical landmarks, a positive response of fluid (cerebral spinal fluid or blood) or stimulation of the targeted nerve. These types of methods were difficult, time-consuming and often resulted in a failed block. Because of the many issues involved, regional blocks were used sparingly. But the widespread accessibility of ultrasound guidance has become a game-changer for regional anesthesia — providers are now able to place blocks with more precision and confidence. It’s also become an invaluable weapon to combat the opioid crisis. Combining ultrasound-guided regional blocks with a multimodal approach to perioperative pain management drastically reduces the need for postoperative narcotic use.

Of course, decreasing opioid use is only one of the many benefits of regional anesthesia. It can also decrease lengths of stay and reduce risks of postoperative complications such as nausea, vomiting and respiratory depression. In addition, CMS’s value-based purchasing program provides incentives for hospitals based on patient satisfaction.  Even though the verbiage of pain management was removed from the program in 2016, patients’ overall safety and satisfaction are still measured. Mortality and complications, healthcare-associated efficiency and cost reduction are, too. Regional anesthesia addresses all of these factors by allowing surgical teams to deliver cost-effective, efficient and patient-satisfying care.

Next Gen Nerve Blocks
FUTURE CARE
FULL FUNCTION Blocks done in a way where patients don’t experience any loss of motor function to the leg make it easier for them to ambulate immediately after surgery.  |  Heather Towers

Ultrasound capability has expanded and enhanced the use of regional anesthesia, and has paved the way for newer, more precise regional techniques that surgical leaders everywhere are eager to employ at their facilities. The following nerve blocks are all fairly new additions to the regional anesthesia toolkit providers are using with great success. These blocks do not have definitive tangible landmarks and must be performed with the aid of ultrasound guidance, which allows providers to place the blocks with more precision and identify the location of critical structures that must be avoided such as arteries, veins, intestines and lungs.

• PENG. A pericapsular nerve group (PENG) block is most commonly used during procedures to treat fractures of the neck of the femur, but can also be used to manage postoperative pain after a total hip arthroplasty. Even though the anterior hip capsule is innervated by the femoral nerve, obturator nerve and the accessory obturator nerve, this block provides pain relief without muscle weakness. It is performed by identifying the anterior superior iliac spine, superior pubic ramus, iliopubic eminence, iliacus muscle, iliopsoas tendon, femoral artery and the pubic ramus. Again, these structures are easily identifiable with the use of ultrasound. In my experience, this block, when done preoperatively, can provide some postoperative pain control and allow the patient to be positioned for a spinal with minimal discomfort.

• iPACK. This block is an injection between the popliteal artery and the posterior compartment of the knee. Analgesia is provided to the posterior aspect of the knee. The block is a sensory block, unlike the sciatic or popliteal block, so there is no loss of motor function to the patient’s leg, which makes it easier to ambulate more quickly post-op. When this block is combined with the adductor canal block (quadriceps-sparing femoral block), analgesia is also achieved at the anterior aspect of the knee. During knee procedures, such as total joint cases, the combination of these blocks provides pain control while affording weight-bearing capabilities for the patient.

• PEC, TAP & QL. The pectoralis (PEC) and serratus plane nerve block provides analgesia to the upper chest, and the transversus abdominis plane (TAP) and quadratus lumborum (QL) nerve blocks are both used for somatic and visceral analgesia to the abdomen. With both techniques, the fascial planes are identified.

The target for the TAP block is the fascial plane between the transversus abdominis muscle and the sheath of the muscle that is to be innervated (posterior rectus, internal and external oblique, QL and psoas major muscles). The TAP block is commonly used for surgeries involving the abdominal wall. PEC blocks are used to provide analgesia to the medial and lateral pectoralis muscles (PECS 1) and pectoralis minor and serratus anterior muscle (PEC 2). These blocks are most commonly used for breast surgery, but have also provided some relief to patients who suffer rib fractures or for those who experience post-thoracotomy pain syndrome.

— Heather Towers, CRNA, MS, DNAP

Block selection

GAME-CHANGER Widespread access to ultrasound-guidance technology removed of the top barriers that limited outpatient facilities usage of regional anesthesia for many years.

Regional anesthesia can do wonders for post-op pain control, patient satisfaction and opioid-sparing efforts as long as providers select the right block for the right procedure. Selecting the type of block to perform depends on surgical need, postoperative expectation, weight-bearing needs and family support. Nerve blocks can be divided into two main categories:

• Upper extremity. These blocks are accomplished by identifying the brachial plexus nerves and surrounding the plexus with the local anesthetic. Depending on the surgical site, the plexus can be blocked by performing an interscalene, supraclavicular, infraclavicular or axillary block.  Determining surgical need and optimal patient outcome is where the art of performing regional anesthesia comes into play. A combination of blocks can be performed to prevent surgical pain and tourniquet discomfort. The tourniquet discomfort can be treated by administering a block with a short-acting local anesthetic such as lidocaine. Postoperative pain control can be accomplished by identifying the direct nerve or nerves that innervate the surgical site and blocking them with a longer-acting local anesthetic such as ropivacaine or bupivacaine. Communication between the patient, anesthesia provider and surgeon is extremely important in achieving the best outcome.

• Lower extremity. This group of blocks consists of spinal, epidural, lateral femoral cutaneous, femoral, popliteal and ankle blocks. It also includes blocks that are advancing regional anesthesia’s potential to manage post-op pain, including adductor canal (quad-sparing femoral), sciatic, PENG and iPACK blocks (see “Next Gen Nerve Blocks”). Just like with the upper extremity blocks, properly communicating the needs of the surgeon and patient are determining factors in the type of block or combination of blocks performed.

To perform a nerve block, the innervating nerves must become inactive by a local anesthetic that binds to their sodium channels, causing the lack of an action potential (electrical, chemical, thermal or mechanical response). How long the lack of response lasts is related to the lipid (fat) solubility and protein-binding of the medication used.

In addition to the local anesthetic, additives such as dexamethasone increase the duration of action, thus prolonging the block. I conducted a study to determine if the addition of dexamethasone to ultrasound-guided supraclavicular brachial plexus blocks prolonged the duration. Although the sample size was very small, there was a significant prolongation of the block. The mean difference between the two groups was around 12 hours. In other words, dexamethasone may prolong the effectiveness of the block significantly.

Positive developments

As an increasing number of complex surgeries are being done on an outpatient basis and as newer, more precise nerve blocks are being perfected, the use of ultrasound-guided regional anesthesia is becoming more widespread. What’s more, it’s a proven way to reduce the need for perioperative opioids, something all surgical leaders are looking to do. When this precise, effective technique is combined with non-opioid pain medication such as NSAIDs and acetaminophen, the length of stay in recovery is shortened. Patients are discharged sooner and are often pain-free for the first 12 to 24 hours post-op, a critical period when their discomfort is generally at its worst. When you combine a faster recovery with improved patient safety and satisfaction, it’s easy to see why an increasing number of anesthesia professionals are turning to regional anesthesia whenever it’s appropriate. OSM

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