July, 2008

WHEN SHEPHERDING PATIENTS through the rehabilitation process after orthopedic surgery, I find that psychology can be almost as important as physiology. Patients who can do their exercises with minimal pain gain confidence and push harder. Patients who experience breakthrough pain are naturally much more tentative, and their rehab takes longer.

That's a key reason why I recommend peripheral nerve blocks to patients for virtually every extremity procedure I do, from arthroscopic procedures all the way up to complex joint replacements. The superior pain control provides rehab patients the kind of courage they need to work hard. I also find blocks very flexible. Because blocks work across the spectrum of sedation, we're never locked in to just one anesthesia approach. We can be sure patients get the level of anesthesia they need — and only what they need.

My personal "regional anesthesia evolution" began more than 15 years ago. In the early 1990s, I started performing arthroscopy with local infiltration and sedation. When I saw that patients were consistently waking up quickly and comfortably with no nausea and vomiting, I was impressed. Targeting the analgesia to the surgical site enabled us to avoid heavy sedation and its side effects.

Some time later, nerve stimulation appeared on the scene, enabling precise, effective peripheral nerve blocks. Along with an enthusiastic, innovative anesthesiology team, we started using single-shot femoral nerve blocks along with general or epidural anesthesia for total knee replacement, and found that this enabled us to lighten the level of general anesthesia. Next, we tried avoiding general anesthesia altogether and combined single-shot femoral and sciatic nerve blocks with sedation. We were able to do several knee replacements on an outpatient basis with home monitoring of the catheters as part of a research protocol. Now, we routinely use continuousinfusion catheters to keep blocks going for up to 72 hours post-op. The rehab process goes more smoothly than ever for both primary and revision procedures.

Surgeons who have not yet integrated peripheral nerve blocks into their practices can start out slowly. You don't have to jump off the diving board into the deep end. Your anesthesia providers can slowly lighten up on the general anesthesia and opioids your patients are receiving, and then move on to sedation. As long as there is an enthusiastic and well-trained anesthesiologist on board, your peripheral and regional nerve blocks will work very effectively and efficiently.

If you haven't already, I encourage you to take the plunge! If your experience is like mine, your outcomes will improve and your patients will be confident and satisfied.

Dr. Vail is Professor and Chairman of the Department of Orthopedic Surgery at the University of California, San Francisco. He first began using PNBs at Duke University.