September, 2006

When we recently studied the efficacy of peripheral nerve blocks in orthopedic surgery patients, we weren't surprised to find that our regimen, which included nerve blocks, patient-controlled anesthesia (PCA) and NSAIDs, was much more effective at controlling post-op pain than PCA/NSAIDs alone. Prior studies already showed that nerve blocks provide superior pain relief and patient satisfaction. We were surprised, however, by another finding. Even though patients who didn't receive nerve blocks were dissatisfied with their pain relief, more than half said they would not opt for peripheral nerve blocks for future procedures.

After some investigation, we understood why. We were suggesting nerve blocks for the first time just minutes before surgery, and this created lots of anxiety. We heard responses like “No, no … I just want to go to sleep,” “I don't want to make any last-minute changes,” “Dr. B. never told me about this!” or “Is this going to hurt?”

To help patients become better educated and choose the most effective anesthesia method, we enlisted our surgeons. We asked them to review nerve blocks in their offices to give patients the time they need to absorb the information, better understand their options, and accept peripheral nerve blocks as a superior mode of analgesia/anesthesia.

Now, our surgeons describe how blocks work, briefly review the benefits of blocks, and inform patients that the anesthesiologist will discuss a nerve block for pain relief in our pre-anesthesia clinic. For example, a surgeon may tell a total knee replacement patient: “Our anesthesiologist can offer you a block, which will provide you with the best pain relief you can get and help make your range of motion therapy a lot more comfortable.” They often compare continuous PNBs to the Novacaine dentists give, explaining that the difference is the small plastic catheter we leave near the nerve so patients can get pain relief for a few days after the operation. Surgeons also tell patients that blocks often reduce the need for morphine.

In our pre-anesthesia clinic, we reinforce these advantages and further describe the benefits—including avoidance of general anesthesia and airway management and reduced PONV. We also ensure that patients' expectations are realistic. We tell them there is a chance the blocks may not work fully but that they will still help with pain relief, and if the block does not work at all, patients still have back-up analgesia that they control as well as an on-call anesthesiologist. Finally, we always take the time to review the specific risks of each procedure and ensure that all patients sign a PNB consent form.

It took a while to gain surgeon buy-in, but their participation has definitely improved patient acceptance. Now, we even educate future surgeons by letting residents rotate through our regional anesthesia service so they can see firsthand the great success and patient satisfaction that comes from using PNBs.

Dr. Lam is Assistant Professor and Director of Regional and Orthopedic Anesthesia with the Department of Anesthesiology at The University of Texas Medical School in Houston.