Ready to Standardize Your Regional Anesthesia Program?

Here’s how to keep your block program running smoothly.

Regional anesthesia has emerged as a valuable technique in the outpatient surgery world, offering effective pain management, reduced opioid consumption and enhanced recovery for patients. With the growing emphasis on multimodal pain management and opioid-sparing approaches, regional blocks have gained traction as an integral component of outpatient anesthesia protocols.

However, the utilization of regional blocks in outpatient facilities can vary, leading to inconsistent practices and outcomes. According to Girish P. Joshi, MD, professor in the department of anesthesiology and pain management at UT Southwestern Medical Center in Dallas, studies suggest that only around 25% of ambulatory patients receive regional anesthesia. A primary reason is the lack of a standardized program for performing these techniques.

“Regional anesthesia is one of the critical components of a multimodal pain management approach,” says Dr. Joshi. “It has become clear that every patient — no matter the surgical procedure — should have some type of local or regional anesthesia.”

There are several potential reasons that regional isn’t being used as often as it should be, says Dr. Joshi. Facilities may lack the right technology or staffing, or they may be faced with time constraints and surgeons fear that adding a block will slow things down. Luckily, many of these challenges can be addressed with proper standardization, he says.

“If we plan appropriately, standardization comes into play, and many of these concerns will be taken care of,” he says.

Find your champions

If you’re looking to start standardizing your regional block procedures, Rajnish Gupta, MD, professor of anesthesiology and director of the Vanderbilt Health Belle Meade Surgery Center in Nashville, Tenn., notes that the best place to start is to bring together a group of champions from nursing, surgery and anesthesia to work collaboratively to define your protocol.

“Establishing this champion team allows for the identification of best practices and streamlining the standardized processes,” says Dr. Gupta. “That is the single best piece of advice I can give to those looking to improve their program.”

This group should work together to define what the standard protocol is, how to best implement it at your facility and what scope of nerve blocks are permitted. A well-structured standardization process involves understanding which nerve block is most appropriate for each patient and the expected outcomes during and after the procedure, says Dr. Gupta.

Your program should also take into account factors like surgeon requirements, such as timing when blood thinners need to be stopped, says Dr. Gupta. That means, for most, that the anesthesia providers would assume responsibility for patient safety, emergency medication preparedness and the necessary knowledge to perform these procedures effectively, while your nursing team may be involved in documentation and potentially even helping during the procedure itself, he says.

Dr. Joshi suggests first designating a champion of your regional block program, typically from your anesthesia team. This champion can help not only to set up the program’s requirements and protocol by collaborating with other departments but can also take on tasks such as setting up the regional cart. This cart should contain all the necessary equipment, needles, and drugs required for regional anesthesia procedures.

This cart is key to the program, Dr. Joshi says. Regional blocks should be performed before surgery, ideally in the preoperative area, as doing them in the operating room could be time-consuming and costly. Most blocks take no more than five minutes to perform, he notes, as long as there is efficient coordination among the surgical team, nurses and anesthesiologist.

CONSIDER THE RISKS

Ensure Your Block Program Has a Plan in Place for These Four Dangers of Regional Anesthesia

While standardizing your regional anesthesia program is essential, you’ll also want to ensure your program manages the risks associated with regional blocks. Regional anesthesia, while generally safe and effective, does come with certain potential risks that require careful management and prevention. According to Dr. Gupta, the four main categories of risks are nerve block failure, significant bleeding, rebound pain and local anesthetic systemic toxicity (LAST):

• Nerve block failure is a concern when the intended nerve block misses its target or is incomplete. Detecting this occurrence is vital, especially when patients are in recovery but still experience pain in areas that should be numb. Collaboration between nurses, surgeons and anesthesia providers is crucial to ensure the patient’s comfort and safety before they leave the medical facility. Prevention of nerve block failure involves careful selection of the appropriate block and ensuring that all relevant areas are covered by the block being administered. “It is essential to have a solid plan before discharging patients home,” says Dr. Gupta. “This may involve considering a secondary nerve block or opting for non-opioid or opioid medications to manage the pain.”

• Significant bleeding is another risk associated with regional anesthesia, especially when the procedure involves areas deep within the body, hidden from view. Bleeding can be further complicated when patients are on blood-thinning medications. Collaboration with surgeons and patients is essential to determine the appropriate timing of stopping blood thinners before the surgery. If significant bleeding occurs during the procedure, a higher level of care may be required, potentially leading to admission. To address this risk, Dr. Gupta and the American Society of Regional Anesthesia and Pain Medicine (ASRA) developed the ASRA Coags app that provides valuable information on managing bleeding risks associated with various medications. “It’s a searchable tool to find the medication you’re concerned about, and it gives you guidance,” says Dr. Gupta.

• Rebound pain is a situation where the nerve block effectively manages pain during the procedure, but once it wears off, severe pain returns. This can be a consequence of nerve block failure or the block being too short-acting for the patient’s pain management needs. To prevent rebound pain, anesthesia providers must collaborate and develop a pain management plan for after the block wears off, says Dr. Gupta. This may involve using alternative medications or techniques that can provide pain relief for a longer duration. “In our institution, we do this by using nerve catheters with pumps, so we can get three to five days of additional pain relief to bridge over that time where the patient would be experiencing the most severe pain,” says Dr. Gupta.

• Local anesthetic systemic toxicity (LAST) is a rare but severe complication that arises when too much local anesthetic enters the bloodstream too quickly. This can lead to seizures if it reaches the brain and cardiac arrest if it affects the heart, says Dr. Gupta. Prevention is crucial in managing LAST, including being aware of the maximum dosage of local anesthetic, tracking the total dosages provided by different providers and using antidote medications like lipid emulsion promptly if a reaction occurs. Having the antidote readily available is vital when performing nerve blocks. If LAST or any other severe event occurs, the patient should be transferred to a higher level of care once stabilized. “LAST is a risk that needs to be mitigated by following systemic prevention methods,” says Dr. Gupta. “The entire team needs to be paying attention to who else is providing local anesthetic, and informing the anesthesia team so that they can pay attention to total dosages.”

—Kendal Kloiber

“To be effective, it has to work like clockwork,” says Dr. Joshi. “But that only can happen if everyone is on the same page. It might take some time to set up initially, but eventually, it will become simple.”

Your block champion should also lead the process of outlining standardized techniques for nerve localization, block administration, monitoring and postoperative care. Dr. Joshi notes that the regional programs that tend to struggle the most “do not take into account the big picture of pain management.” The patient should be taking scheduled acetaminophen and NSAIDs or COX-2 inhibitors post-op — and in some situations there should be surgical infiltration of the site with local anesthesia — alongside the use of regional anesthesia so that once the block wears off, they aren’t flooded with rebound pain, which will often trigger a call to the surgeon or an unexpected ER visit.

“If this is not done, they will have rebound pain,” he says. “The facilities that stop doing regional blocks on patients often do so because they don’t consider proper use of non-opioid analgesics.”

Other considerations

TRIED AND TRUE Patients who receive nerve blocks are less prone to opioid-associated side effects like respiratory distress or PONV, and are discharged more quickly following surgery.

Physicians performing regional blocks may have different levels of experience and training, so standardization efforts must include robust educational programs and ongoing training to ensure competency among anesthesia providers.

Outpatient facilities also sometimes face resource constraints, including limited access to ultrasound equipment and specialized block needles. Standardization efforts should consider the availability and allocation of resources, ensuring that facilities have the necessary equipment and supplies to implement standardized regional block anesthesia programs, says Dr. Joshi.

It’s not enough to have any old technology available. For example, ultrasound has played a pivotal role in advancing regional anesthesia, says Dr. Gupta, but the tech has evolved drastically over the years. “It’s crucial for leadership to recognize the significance of up-to-date equipment,” he says. “While much attention is given to improving surgical tools, it is equally essential to invest in anesthesia technology.”

Dr. Gupta also notes that a systematic approach to post-procedure follow-up is essential, particularly when patients are discharged home. Facilities should establish a robust phone access or follow-up process to detect and address any potential problems early on. Dr. Joshi adds that discharge instructions should be direct and easy to understand and should include both a handout and verbalization, so the patient can ask questions before they leave the facility, as well as a call the following day that specifically asks the patient how their block is working.

If for some reason a patient is having a concern post-op, Dr. Gupta’s facility has set up a formal process that allows patients to skip waiting in the ER and instead return to the surgery center if they have questions or concerns.

“It’s certainly not an easy process, but it enhances our ability to provide good care,” says Dr. Gupta. “In general, it’s critical that however you manage this follow-up care, it’s a well thought-out process.” Finally, Dr. Joshi adds that while there are plenty of “fancy blocks” out there, they can feel intimidating and often aren’t necessary. He notes that several common blocks — like interfascial plane blocks and peripheral nerve blocks — will cover “about 95%” of the cases in most outpatient facilities.

“Focus on a small, limited number of blocks to start and expand it as the program grows,” he says. OSM