Nerve Blocks Needed

Injecting a nerve cluster with a local anesthetic can provide patients with days of pain relief following orthopedic, abdominal or spine surgery. Regional anesthesia means patients require fewer narcotics, so they feel better after their procedures and are discharged as quickly and as safely as possible, a key to success for any outpatient surgical facility.

That’s why it’s imperative for facilities to have high-performing regional anesthesia programs in place to get patients to the point where their postoperative pain is well-controlled while they’re recovering in their own home. Your anesthesia providers should have the mindset that they’re involved in managing and controlling the patient’s pain not just on the day of surgery, but for those critical three or four days post-op to get them over that initial surgical pain hump. 

For your regional anesthesia program to run efficiently, providers must first be trained in the standard and emerging nerve blocks that are generally service-line-specific (see “Regional Blocks Every Provider Should Know”). Of course, there are several other key components of top nerve block programs.

If your anesthesia providers are placing more than five or six blocks a day, you need a block nurse.

• A well-trained team. Widespread ultrasound usage, which is done to place more precise blocks, has increased the prevalence of regional anesthesia. While most new anesthesia providers are coming out of medical school with a solid working knowledge of ultrasound guidance and placing nerve blocks, proper and consistent training is still paramount. There is no shortage of training and education resources available. I run a site (blockjocks.com) that includes numerous instructional videos, and our center has a preceptorship in which anesthesiologists can visit for two days to observe our nerve block practices and get 20 continuing education credits. After that, they can take cadaver courses to practice block placement techniques.

If your anesthesia providers are placing more than five or six blocks a day, you need a block nurse. These individuals get the necessary equipment ready for block placements while anesthesia providers finish current cases, which is a critical efficiency gain. A dedicated block room isn’t required unless your pre-op bays are too small to accommodate block placements. A standard-sized pre-op bay works fine, and it’s always preferable to avoid moving patients to a different location to have their blocks placed. Facilities with extremely limited space might need to place blocks in the OR.

• Continuous nerve blocks. Our center frequently uses catheter-placed pain pumps because the increasingly complex procedures taking place on an outpatient basis mean patients will experience significant post-op pain at home for several days. We feel strongly that total knee replacements require the placement of pain pumps for four days and use catheters on most of our shoulder surgeries, as well.

Our anesthesia providers use ultrasound guidance to place an indwelling catheter near the nerve bundle where the block is placed. The other end of the catheter connects to an electronic pump filled with several days of anesthetic that is delivered to the patient at a rate set by the anesthesia provider. Most pain pump models also allow patients to give themselves a dosage increase when they’re experiencing breakthrough pain. We use a diluted concentration of the local anesthetic to make it last for several days, and a much higher concentration for a single-shot block to make it strong and dense for 24 hours.

The latest pain pumps have all but eliminated concerns that include kinking, leaking, clogging or pump failure that existed a decade ago. In fact, the current delivery systems work so well that the key to success for continuous nerve blocks isn’t a hardware issue — it’s patient education on how to use the pumps. Patients need precise, written instructions to take home and should be repeatedly told about how the device works before they leave your facility.

Our pre-op nurses talk about the pumps when they’re starting patients’ IVs and getting them ready for surgery. Patients also watch a 10-minute instructional video our nurses created on proper pump use. Following the video presentation, our block nurses show them their pump and catheter. Finally, the anesthesia provider reviews the written instructions with patients before they’re discharged.

Reiteration is key, as we throw a lot of information at patients undergoing regional anesthesia. We need to constantly remind them about potential complications, when to call for follow-up care — and when not to call. Our patients also go home with anesthesiologists’ cell phone numbers. I know many anesthesiologists cringe at that practice, but we feel so strongly about safe patient care that we want to solve any problems they have right away. Often, surgeons never even know there was a problem. Short of providing your anesthesia providers’ personal cellphone numbers, you must have a staff member on call around the clock to answer questions from patients with pain pumps.

The use of nerve blocks is on the rise for many reasons. There’s the desire to minimize narcotic exposure, not only to prevent PONV and other opioid-related complications, but to reduce the possibility of patients becoming dependent on painkillers after they’ve recovered from surgery. Frequent use of regional anesthesia means you’ll have patients receiving minimal intraoperative opioid anesthetics in the OR, which means they’ll wake up faster and your nurses won’t scramble to get them antiemetics for PONV that opioids often cause. The PONV rate at our center is less than 3% because we control pain and nausea with nerve blocks, which make the patients’ first few days at home much more comfortable as well.

There are also a host of intraoperative and secondary benefits to preoperatively placed nerve blocks — even though the block’s main purpose is to control post-op pain. For instance, a block can reduce the need for general anesthesia, which can lead to brain fog and cognitive issues months after surgery. Then there’s the theory of preemptive analgesia, to which I subscribe. Essentially, this theory says that once you get a block placed — or deliver any type of analgesia ahead of the scheduled surgical insult — the nerves never start to fire and don’t rush signals up the spinal cord, so the patient’s brain never gets the message that they’re supposed to be in pain. Regional anesthesia may also result in a lower rate of blood loss, blood clotting and infections than general anesthesia.

Positive surgical outcomes will continue to increase as the use of regional anesthesia grows. In athletic circles, some patients no longer only choose their surgeons and follow them to the surgical facilities in which they practice. Some surgeries have a reputation for nerve block placements, and many athletes want to be operated on in facilities with a block program in place. 

Other patients must be convinced and are often pleased by the results of regional anesthesia. A recent 80-year-old patient with spinal injuries at our center insisted he be put to sleep. The surgeon and anesthesiologist had concerns about his medical profile and explained they would rather use a local anesthetic and a pain catheter, along with propofol for light sedation. The patient agreed and did fantastic. 

Skeptical patients who wind up pleasantly surprised by the powerful pain-relief of regional anesthesia are a tremendous source of word-of-mouth marketing for facilities everywhere. OSM