Standardized Analgesia Protocol (pdf)
Screening for Obstructive Sleep Apnea (pdf)
Preoperative Oral Adjuvant Protocol (pdf)
Analgesia for Gynecologic Surgery Algorithm (pdf)
Hip Arthroplasty Protocol (pdf)
Knee Arthroplasty Protocol (pdf)
Acute Pain Service Algorithms (pdf)
Surgeon Preference List (pdf)
Ten Rules to Secure a Catheter (pdf)
Making Regional Anesthesia Work at Your HospitalSix Quotes and Half a Dozen Ideas
JC Gerancher MD
Associate Professor and Section Head,
Regional Anesthesia and Acute Pain Management,
Wake Forest University School of Medicine
|
Self Study Questions:
| A: 2:7 | B: 0:70 | C: 1:1 | D: 15:1 |
See Self-Study answers.
Quote: "Thanks for the excellent training! I can't imagine practicing anesthesia without regional."
—Anesthesiologist, first year in practice, San Francisco, 2004.
Idea: Learning regional anesthesia requires an investment
In a recent Time magazine article, a one-half page color photo depicted an attending anesthesiologist performing a regional anesthetic in a healthy outpatient presenting for mastectomy. "(The anesthesiologist) inserts a needle at six different points along (the patient's) bony back and injects 4 ml of local long-acting anesthetic each time. She is only sedated for the surgery; a paravertebral block will numb the region around her breast. Under it, patients experience less pain following surgery, and that reduces hospital stay from a few days to a few hours. Six hours after the initial injection, (she) leaves the hospital. 'I'm feeling fine,' she says."(1)
Just as recently, Smith et al. reported the results of a retrospective survey of regional anesthesia training(2). These authors surveyed anesthesia residents who attended 42 accredited U.S. training programs. They found that during three years of training, residents performed (on average) five thoracic epidurals, three interscalene brachial plexus blocks, zero sciatic nerve, zero femoral nerve, and six ankle blocks. As might be expected after exposure to so few regional anesthetics during residency, the surveyed residents reported a corresponding lack of confidence in applying these techniques to their future practice.
These two references illustrate regional anesthesia practices as they exist today. At the moment, individuals with special interests and skills at a few institutions are making advances toward fully exploiting the benefits of regional anesthesia, sharing their knowledge, and teaching their trainees. In most programs however, trainees may not be learning what they need to know in order to apply these advances to their own practices in the future. Clinicians who have already finished their dedicated training and want to make regional anesthesia work at their hospital may have an even harder time bridging the gap between the state of training in regional anesthesia and the state of the art.
Recently, academic anesthesiology training programs have made in-roads towards training their residents by developing organized rotations in regional anesthesia. At Wake Forest University, we initiated such a rotation in 2000. Compared with the complete lack of exposure found by Smith in 1994, our residents perform at least 70 femoral and sciatic blocks and greater than 200 PNB's overall during residency. Duke University started their regional anesthesia rotation in 1998 and Martin et al(3) have reported that their residents complete 350 PNB's during residency. Chelly et al(4). have recently surveyed institutions to determine the specific characteristics of these dedicated regional anesthesia rotations. Nationwide, they found that 58% of programs offered a rotation in name, but that only 69% of these included formal instruction, only 58% of these used a syllabus, only 29% of these had a designated area to perform blocks, and only 13% offered cadaver dissection.
Fortunately for clinicians beyond residency, many programs offer visiting preceptorships. WFU, Duke, Jefferson, Iowa, NYSORA are some of the ones that do. Web-based education is a second, complimentary resource for practitioners.
Quote: "Anatomy is the foundation upon which the entire concept of regional anesthesia is built. Anyone who wishes to be an expert in the art of regional anesthesia must be thoroughly grounded in anatomy, for without such knowledge one cannot be successful."
—Gaston Labat, Regional Anesthesiologist NYC, 1922
Idea: regional anesthesia is the practice of applied anatomy
Anatomy is as important today for making regional anesthesia work as it was in 1922. What is different today is that the practice of regional anesthesia is advancing our understanding of anatomy beyond what is found in the newest edition of modern anatomy textbooks. Developments in regional anesthesia are outpacing the texts by utilizing imaging and clever study design to re-write them.
One example of such a development is the recent observation of movement of the components or the sciatic nerve to identify the location of the sciatic nerve using the 'see-saw sign' Schafhalter-Zoppoth et al(5) used movement of the foot and ultrasound examination of the lateral popliteal fossa to identify a pathognomonic pattern of movement of the peroneal and tibial components of the sciatic nerve. This approach not only helps find the nerves but also explains the variability in position of these nerves found during clinical blockade.
Another example is a study of the sensory distribution of the obturator nerve by Bouaziz et al(6). These authors combined clinical blockade of femoral, sciatic, and obturator nerve blocks with cadaveric study to demonstrate that the sensory innervation of the obturator nerve was a spot on the anteromedial thigh in 20% of subjects, a vague area behind the knee in 23%, and no sensory innervation at all in the remaining 57%. These findings directly contradict every clinical anatomy book in print. Texts generally depict the sensory distribution of the obturator nerve on the medial thigh. The findings also explain why femoral-sciatic blockade may be inadequate for knee surgery and analgesia (likely 100% of subjects do have bony innervation of the posterior-medial knee by the obturator nerve). Furthermore they explain why an entire generation of clinicians has been mislead into accepting femoral nerve blockade as a so-called 'three-in-one' block (likely femoral block with absent sensory innervation to the skin by obturator nerve in 57% of patients.)
Authors of web-based education often illustrate that the stagnant anatomy we learned in medical school is constantly being put to the test with the use of a nerve stimulator and ultrasound probe for regional anesthesia, allowing us to relearn and expand our understanding of the same anatomy in a fun, dynamic, and clinically relevant application. New developments are described in journals (especially Anesthesia and Analgesia and Regional Anesthesia and Pain Medicine, Techniques in regional Anesthesia and Pain Management) and a few specialty texts (Hadzic and Vloka's regional anesthesia: Principles and Practice, and Brown's Atlas of Regional Anesthesia).
Quote: "Vitamin O is designed to be an additional source of stabilized oxygen molecules. Start with 10-15 drops of 'Vitamin O" and gradually build up to 30 drops or 1 good squirt 2 to 3 times daily or more often as required."
—R Garden International Dietary Supplement, Kettle Falls, WA, 2001
Idea: Know what pharmacology can and cannot do for you.
The current pharmacologic menu for regional anesthesia involves multiple choices of local anesthetics in column A and multiple adjuvants in column B. The ideal local anesthetic cocktail would quickly and safely provide long lasting pain relief without long lasting motor blockade. The ideal cocktail does not exist, but several practices are arguably important to make regional anesthesia work.
In most practices, the use of long lasting regional anesthesia is probably one of the most important ways to make blocks 'work' because the primary clinical utility of regional anesthesia that patients and attentive surgeons notice is analgesia(7). It is important to realize that long durations of analgesia (8-18 hours) are routinely obtainable with local anesthetics when they are injected near peripheral nerves. The development of safer, long lasting local anesthetics for regional anesthesia such as ropivacaine has helped to make long acting regional anesthesia work in two ways.
First, ropivacaine is probably safer than bupivacaine in the setting of a large intravenous injection. After injection of large doses of ropivacaine have induced cardiovascular collapse, survival of patients has been described when resuscitation has been prompt(8) and animal study support at least some wider therapeutic index for ropivacaine(9). (It is more important to realize that the use of epinephrine as a marker of intravascular injection, aspiration preceding incremental injection, and a healthy respect for the narrow therapeutic index of all local anesthetics—especially all the long acting ones—is more important for patient safety than drug choice(10).)
Second, ropivacaine is indeed a different drug than bupivacaine: It likely provides a little shorter latency along with its duration which is very useful for success. As with many choices in regional anesthesia, there is no 'free lunch:' a quicker onset buys less potency and probably less duration. There is little evidence for limitation of motor blockade by choosing ropivacaine for regional anesthesia. The practice of using a long lasting/long latency local anesthetic along with a short lasting/short latency local anesthetic has its advocates and is a reasonable way of making regional anesthesia work. However, like the situation with ropivacaine, there is no 'free lunch' here as well--latency is improved but duration is diminished(11).
Of the adjuvants, epinephrine has been shown to be an effective I.V. test dose, to diminish plasma levels, and to provide more prolonged regional anesthesia (for the local anesthetics except ropivacaine)(11). It is indispensable(10).
Clonidine has proven to be the single most important modern adjuvant to regional anesthesia. It is especially useful in extending the duration of analgesia from short and intermediate acting agents close to that of the long acting agents. It has both a systemic and local action so that it works most effectively with fewest side effects when used as an adjunct to peripheral nerve block. A dose of 30 mcg is probably minimally effective, while doses greater than 150 mcg are more likely to be associated with side effects (sedation and diminished blood pressure)(11).
On the other hand, the use of sodium bicarbonate as an adjuvant--while theoretically attractive--has not been shown to have much clinical utility for regional anesthesia(11). Even low doses have been show to decrease the concentration of local anesthetics in solution, cause microprecipitation, and speed the onset of blockade by about two minutes at best. The literature supporting sodium bicarbonate as an adjuvant to regional anesthesia has been muddled by data from studies using sodium bicarbonate to correct the low pH of local anesthetics prepackaged with epinephrine. Here sodium bicarbonate has a dramatic effect but corrects the latency to that of local anesthetic with freshly added epinephrine and no bicarbonate.
Another approach to making regional anesthesia work better is to use the local anesthetics in the regional anesthesia as part of a multi-modal regimen using non-steroidal anti-inflammatory agents. These agents have been shown to decrease opioid use as much as 50% following surgery(12). The development of cyclooxygenase-2 specific inhibitors devoid of platelets effects have made the use of NSAID's perioperatively easier. Recently, Buvnendren et al(13) have demonstrated that even when postoperative pain management is very sophisticated, COX-2s improve outcome. These authors performed a randomized, controlled trail in which the addition of a COX-2 inhibitor for 2-8 days decreased nausea, sleep disturbance, and epidural opioid consumption as a complement to patient controlled epidural analgesia following total knee replacement under CSE and propofol sedation. Even at one month (long after the epidural and COX-2 analgesia was stopped) improved range of motion of the joint and better patient satisfaction with analgesia was found in the group who previously receiving the COX-2. We routinely administer COX-2 oral medications prior to regional anesthesia at WFU.
Quote: "I didn't much care for the feeling in my leg. It felt like a sandwich...with an itch in the middle...that I couldn't get to."
—A dissatisfied but comfortable patient following lumbar plexus-sciatic block, Winston Salem, 2004
Idea: Regional Anesthesia keeps healthy, happy patients healthy and happy.
Beside the common sense approach of avoiding regional anesthesia in patients with unpredictable eccentricities (such as the patient quoted above), which patient characteristics make patients bad or good candidates for regional anesthesia? Much of the debate surrounding the choice of regional anesthesia versus general anesthesia for neuraxial anesthetics (spinals and epidurals) has been conducted in an era where the paradigm for choosing neuraxial blockade was patient safety. Therefore, older studies have shown that epidural analgesia has provided for lower rates of pulmonary complications, less blood loss, less DVT, lower vascular graft occlusion rates, less arrhythmia, less inhibition of GI function, and better pain control than general anesthesia with intravenous opioids(14). Neuraxial blockade has retrospectively been found to improve survival(15). While neuraxial blockade has been used to provide better outcomes such as less ileus and better bowel recovery in healthy patients,(16) medically compromised patients have been the primary focus of clinical research for this modality. In some recent well controlled studies the safety benefits of neuraxial blockade over general anesthesia have not been supported(17), (18). The methodology or the utility for looking for these safety benefits in the future has also been questioned(19).
The paradigm for regional anesthesia has shifted since many of these studies and peripheral nerve blockade are helping anesthesiologists to make the shift. Under the new paradigm (as seen the first paragraph above), regional anesthesia is being used primarily in healthy patients—not in medically compromised ones. The role of the regional anesthesiologist in the new paradigm is to provide for better recovery from surgery, not just anesthesia. The new outcomes of interest are not survival or avoidance of major morbidity, but patient oriented benefits, improved surgical recovery, provision of more efficient anesthesia care and less cost. Patient oriented outcomes are increasingly incorporating measures of 'patient satisfaction' which has grown to be validated in clinical studies of regional anesthesia(7). At the same time, more concrete improvements in surgical outcome and in the cost and efficiency of anesthesia care have been demonstrated for regional anesthesia--arguably more so than anywhere else in the anesthesia literature. For example, studies by Singelyn(20), Capdevila(21), and Chelly(22) et al. have all demonstrated advantages to regional anesthesia over systemic opioids via PCA and epidural analgesia in the challenging context of TKA analgesia. Also for example, studies such as those by Williams(23), Klein(24), and Ilfeld et al(25) have indicated benefits in OR efficiency and cost while providing high measures of patient satisfaction.
Still, relatively little information is available through the perspective of patients about outcomes: their desires for recovery and their concerns regarding regional anesthesia. A recent review of patient satisfaction associated with regional anesthesia and analgesia by Wu et al(7) describes that studies have failed to find a difference in patient satisfaction between intra-operative regional anesthesia and general techniques. On the other hand, most comparisons have found greater patient satisfaction from post-operative regional analgesia compared to analgesia provided by systemic opioids. Regional analgesia patients usually had lower pain scores and lower incidences of side effects, earlier interactions with family, and control of analgesia that are inseparable benefits in most of these studies.
Macario et al(26) asked patients using a 'willingness to pay' questionnaire which outcomes these patients believed were important to avoid. Vomiting and gagging on an endotracheal tube where the most important outcomes to avoid. Pain, nausea, and recall shared secondary importance. Shevde et al(27) found that patients who have never had surgery before feared regional anesthesia mostly due to concerns about being too alert during surgery. Matthey et al(28) found that non-patient Canadians most feared paralysis, seeing the surgery, or pain during surgery under regional anesthesia. These authors concluded that 'the anesthesia community has not been successful in keeping the public informed about regional anesthesia." On the other hand, Wu et al(7). describe that multiple authors have demonstrated that patients who actually have had regional anesthesia in the past prefer it again. Painful needle placements, intraoperative discomfort , and anxiety are all factors which have been demonstrated to diminish patient satisfaction while appropriate sedation has been shown to improve patient satisfaction during regional anesthesia(7).
Quote: "He's healthy. He'll do fine. I can't see putting him through that."
—Millionaire and orthopedic surgeon, Palo Alto, 1996.
Idea: regional anesthesia will only work if the surgeon is your customer
Although anesthesiologists often pride themselves on formulating an individualized plan for patient care, twenty five percent of patients report that they decided on a regional anesthesia technique because they discussed it with their surgeon(7) and almost half of the orthopedic surgeons surveyed by Oldman et al (29). report that they direct their patients in the choice of anesthesia. Very little data is available outlining the preferences of surgeon regarding anesthetic technique. Oldman et al. found that, of the orthopedic surgeons they surveyed, 84% directed their patients toward regional anesthesia and noted decreased pain as the greatest benefit. The greatest liability of regional anesthesia was perceived as OR inefficiency followed by block unreliability. We surveyed our WFU surgeons and anesthesiologists in 1999 just prior to instituting a dedicated regional anesthesia rotation. Not only did our surgeons perceive a much greater negative effect of regional anesthesia on OR efficiency than did our anesthesiologists but they also perceived a greater risk of nerve injury and less benefit in terms of pain relief. Our anesthesiologists believed they or the patient should choose the anesthetic technique, while our surgeons believed they or the patient should(30). Now that our regional practices are better established we intend to repeat the survey. We are not so naive to expect the results to change dramatically because perceptions are often formulated anecdotally in the face of data. When anecdotes guide patient care, each delay erases 9 unnoticed on-time starts and each complication experienced with a patient undoes 9 successes (an un-referenced and personal observation).
Quote: "Regional anesthesia has come to stay. Its development and progress, for various reasons have been slow, principally because the anesthetist must have accurate knowledge of anatomy and a high degree of technical skill in order that the anesthesia may be safe and satisfactory, and the operation not delayed."
—William Mayo, famous surgeon, Rochester NY 1922.
Idea: Regional Anesthesia encourages the practice of perioperative medicine
By incorporating into practice the five ideas above (investing in regional anesthesia education, practicing applied anatomy, knowing what pharmacology can do for regional anesthesia, focusing on patient oriented outcomes, and picking surgeons carefully) the practice of anesthesia as perioperative medicine is reinforced. As illustration, compare the anesthetic considerations guiding care for the same patient undergoing ORIF of the ankle using two different anesthetics: GA (sevoflurane+ LMA) versus regional anesthesia (with an ambulatory continuous regional anesthesia catheter). While knowledge of the patient's medical condition, past anesthetic experiences, and preferences is probably important for both anesthetics, the list of things to know for ambulatory regional anesthesia management is more encompassing of the entire perioperative period and includes: nerve distribution of the incision, likelihood of tourniquet use, likelihood of bone grafting from the iliac crest, discharge status, criteria for ambulatory discharge, days planned in the hospital, physical therapy goals, weight bearing limitations, surgeon's preference for analgesics, and perhaps even what floor in the hospital the patient is going to or how far from the hospital the patient lives.
Creating the infrastructure of policies and procedures for regional anesthesia is important in order to support the extra effort required to make regional anesthesia work at your hospital. This may be a daunting task as managing regional anesthesia often requires more discussion with patients, earlier preparation of patients, a specific 'block area,' development of protocols, and the creation of regional anesthesia specific paperwork to streamline care. Often nothing short of a change in culture for anesthesiologists, CRNA's, surgeons, nurses, physical therapists, and pharmacists is required. Stearns et al(31) and others(3), (23) have demonstrated that instituting such an infrastructure can result in more efficient perioperative medicine.
Although little information has been documented(32), most academic centers that use regional anesthesia as a matter of routine bill for multiple blocks on individual patients, use continuous PNB codes that include 10 days of management, bill for blocks dosed in addition to general anesthesia, and consider heavy propofol sedation as general anesthesia. The same infrastructure that streamlines the process of regional anesthesia can be used to ensure that regional anesthesia procedures are billed (and hopefully reimbursed) correctly in order to support the endeavor of making regional anesthesia work at your hospital.
| To make regional anesthesia work at your hospital a supporting infrastructure and sometimes even a change in culture is necessary. Correct billing practices are crucial to support these efforts. |
Self-study Answers:
| 1: B | 2: D | 3: A, C | 4: B, D |
References:
Return to:
Objectives
Self-Study Questions
Idea: Learning regional anesthesia requires an investment
Idea: regional anesthesia is the practice of applied anatomy
Idea: Regional Anesthesia keeps healthy, happy patients healthy and happy.
Idea: regional anesthesia will only work if the surgeon is your customer
Idea: Regional Anesthesia encourages the practice of perioperative medicine
Return to:
Objectives
Self-Study Questions
Idea: Learning regional anesthesia requires an investment
Idea: regional anesthesia is the practice of applied anatomy
Idea: Regional Anesthesia keeps healthy, happy patients healthy and happy.
Idea: regional anesthesia will only work if the surgeon is your customer
Idea: Regional Anesthesia encourages the practice of perioperative medicine
