October, 2004
Anesthesiologists now have the tools to perform peripheral nerve blocks (PNBs) effectively, precisely and consistently. Still, it's never easy to change surgical practice. Here are three things you need to know before adding a regional anesthesia program.
1. Training and skills vary. Although it may seem that a practitioner who can perform one block can just as easily perform another, this is not so. Not only do blocks vary in their levels of technical difficulty, but practitioners vary in their levels of expertise. It is essential to have well-trained, capable anesthesiologists on staff. Ideally, they should complete a regional anesthesia fellowship to be able to institute teaching programs, although this is not necessary for successful implementation of nerve blocks in community practice. Innate spatial-conceptual abilities, good dexterity and understanding of anatomical and nerve stimulation principles are necessary to perform advanced locks. The outcome of any PNB is highly operator-dependent.
2. Blocks take time to set. Since some blocks take up to 20 minutes to set, regional anesthesia requires a change in protocol. Many recommend using a separate “block room” when possible. Here at St. Luke's-Roosevelt, however, we often bring patients into the OR as soon as the room is clean and administer anesthesia while nurses set up for the case. Although we've had to overcome obstacles—like nurse opposition and rigid same-site surgery protocols that require the surgeon to mark the limb before analgesia—this now works well for us. An advantage to this approach is that the necessary equipment is in place— including monitoring equipment, the nerve stimulator, insulated needles, local and general anesthetics, intubation supplies, continuous infusion pumps, and a block cart for emergencies. Also, anesthesia professionals are already in the OR to monitor patients after the block. In addition, we allow the surgical team to begin prepping the patient immediately after block placement, avoiding the traditional “soak” time and block testing before the procedure. In all settings however, you will need a well-trained staff that works together to administer the block and monitor the patient at all times.
While regional anesthesia can require more preparation time than general anesthesia, it can be much more efficient overall. Significantly more “blocked” patients bypass PACU, fewer patients experience postop pain and PONV, patients ambulate earlier, and they go home sooner.1
3. Fear of complications hinders progress.Fear of neurologic complications has unjustly hampered widespread adoption of regional anesthesia. Neurologic injury after nerve blocks is rare. The uneasiness about the medico-legal aspect of regional anesthesia is partly due to the lack of universal patient monitoring parameters. However, recent advances in our understanding of mechanisms of nerve injury and standard documentation procedure being drafted by a subgroup of the American Society of Regional Anesthesia hold promise to reduce the risk of these procedures even further.
Overall, our experience and that of others shows that PNBs—when performed with expertise and with the support of a well-trained team—are as safe or safer than general anesthesia, improve overall efficiency, and enhance patient satisfaction.
Dr. Hadzic, pictured above, is Director of Regional Anesthesia at St. Luke's-Roosevelt Hospital Center and an Associate Professor of Clinical Anesthesiology at Columbia University's College of Physicians and Surgeons.
1. Hadzic A, Arliss J, Kerimoglu B, et al. A comparison of infraclavicular nerve block versus general anesthesia for hand and wrist day-case surgeries. Anesthesiology. 2004 Jul;101(1):127-32.
