December, 2004

Starting a regional anesthesia program is a bit like starting a personal fitness program. These programs are most successful when phased in slowly, making progress step by step.

Here at St. Luke's-Roosevelt Hospital Center, we recommend beginning with “basic” blocks. They provide excellent analgesia and immediate post-op pain control and are the easiest blocks to administer. The entry points are unfettered by patient positioning restrictions or the need to place a catheter, the nerves are relatively easy to find and the safety risk is low. Here is a sampling of some common basic blocks:

• Axillary brachial plexus blocks for forearm and hand surgery.
• IV regional block. Indicated for minor surgery on the wrist, hand and fingers, this is a simple venous injection into an exsanguinated arm. Onset is 5 minutes.
• Genitofemoral blocks complement ilioinguinal and iliohypogastric nerve blocks for inguinal herniorrhaphy, orchiopexy or hydrocelectomy, as well as femoral nerve blocks for long saphenous vein stripping. These selective blocks limit anesthesia to the surgical field, hastening recovery and preventing hemodynamic effects associated with spinal or epidural anesthesia.
• Ankle block is indicated for orthopedic and podiatry procedures on the foot. It is very easy to perform and results in high success rate and very low risk of complications

Once your anesthesia professionals and surgeons are comfortable with basic blocks, consider moving to intermediate-level blocks. These typically involve nerves that are more challenging to anesthetize due to deeper, more complex anatomy and more training required for their successful use in clinical practice. Such training can be acquired in many anesthesiology residency program where regional anesthesia is taught in a well structured regional rotation or through self-studying and attending CME workshops on regional anesthesia. The training with blocks is also important to decrease the greater risk of complications with these blocks. Some common intermediate-level blocks include the interscalene brachial plexus block (very common for shoulder, arm and elbow surgery); cervical plexus and deep cervical plexus blocks (carotid endarterectomy and neck surgery); infraclavicular brachial plexus blocks (elbow, forearm and hand surgery); sciatic blocks (for the knee, tibia, Achilles tendon, ankle and foot); and popliteal blocks (foot and ankle surgery).

Advanced blocks are even more technically demanding; however they unleash the full power of regional anesthesia and offer incredible flexibility. Advanced procedures include continuous infusion blocks, which can provide days of post-op pain control. They require advanced skills because it can be difficult to stabilize the needle for catheter insertion, needles must be angled to facilitate catheter threading, and the practitioner must use larger needle gauges, increasing the risk of intra-arterial placement.

In these days of instant messengers, instant access and overnight delivery, it behooves us to remember that good things sometimes still come to those who wait. As Aesop said, slow and steady wins the day.

Dr. Hadzic 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.