June, 2005
When it comes to regional anesthesia programs, success or failure can hinge on the perception of the surgical team. The good news is that we can do a lot to ensure that the benefits of regional anesthesia shine through. Often, the first step is to challenge our conventions.
Several studies have shown that orthopedic surgeons perceive OR inefficiency as the greatest liability of regional anesthesia. They're right, sort of. Regional anesthesia is inefficient in a facility that is set up for general anesthesia. Patients who receive blocks require more preparation time and preoperative nursing support than those who do not, and this can cause surgical delays when the schedule and nursing personnel are weighted toward post-op recovery. Yet it doesn't have to be this way. In our facility, patients arrive two hours before surgery. We immediately ‘fast-track' them through admission so we have enough time to obtain an informed consent, answer questions, sedate patients, perform the blocks, and allow time for the blocks to set up in our holding room bays. These bays are part of a dedicated ‘regional anesthesia area' that we specifically designed and equipped to facilitate regional anesthesia. We also train enough nurses and ensure that they are dedicated specifically to supporting the pre-op administration of peripheral and neuraxial blocks. We cross-train our other nurses and teach them the unique skills they need to efficiently ready patients for regional anesthesia.
Some surgeons also think regional anesthesia is less effective than general anesthesia because “general anesthesia always works.” But is it our sole goal to have a smooth intraoperative experience with an unconscious patient, regardless of what happens in the PACU and at home? Or, is it our goal to ensure the best and most efficient perioperative care? When we broaden our focus to include the entire course of care—including pre- and postop nursing requirements, prep and recovery times, immediate postop and post-discharge interventions for pain and PONV, and patient satisfaction —the perception that general anesthesia ‘always works' may change. In cases where it's indicated, regional anesthesia typically comes out on top.
Some surgeons also believe that regional anesthesia causes more complications than general anesthesia. I know of no evidence to support this perception, but it may stem from the fact that we sometimes follow-up with regional anesthesia patients more rigorously, and as a result uncover more information. For example, we might routinely ask patients who receive peripheral nerve blocks about transient neuropraxia, but we do not routinely solicit these reports from general anesthesia patients. In fact, neuropraxia is a common finding in controlled studies, regardless of type of anesthesia. Here is another example. For a while at our own institution, we became concerned that regional anesthesia patients were more prone to falling postoperatively. Further investigation showed that we weren't asking general anesthesia patients about falls. When we did, we learned that these patients were also at risk of falling. One possible reason had nothing to do with anesthesia. We were not routinely issuing crutches to lower extremity surgery patients, and they were literally “hopping” home!
In many ways, regional anesthesia success depends on the ability of facility managers and the surgical team to challenge some long-held paradigms. No matter the ultimate decision, this is always a worthwhile exercise. Whenever we can take a step back, evaluate the entire course of care, and think deliberately about why we do what we do, we take strides toward improving patients' experiences—and our own.
Dr. Gerancher is Associate Professor with the Department of Anesthesiology at Wake Forest University School of Medicine and Section Head of Regional Anesthesia and Acute Pain Management in Winston-Salem, N.C.
