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Archive November 2016 XVII, No. 11

5 Keys to Success With Continuous Nerve Blocks

A master of ultrasound-guided regional anesthesia takes the mystery out of setting up an efficient program.

Brandon Winchester

Brandon Winchester, MD


block placement BLOCK JOCKS Having a senior expert on each block team who works as part clinician, part educator will improve your block placement success.

The Andrews Institute for Orthopaedics & Sports Medicine is known for treating many famous athletes, but many of our patients choose us for surgery because we offer continuous nerve blocks that help reduce their post-op pain as they recover at home. You might be hesitant to start a CNB program due to the time, effort and complications associated with placing blocks, but you can develop an efficient program if you follow the 5 keys to our success.

1. Have a dedicated block team
If you're starting a regional anesthesia program, begin by hiring and training the very best staff. There's nothing wrong with the "everyone does everything" mentality of ambulatory surgery centers, but when it comes to a perineural catheter team, everyone should be specialized.

I recommend a dedicated block team and block nurse to help with placing catheters. A one-to-one ratio of a block nurse to an anesthesia provider tends to work best. Our block nurse helps with setting up catheter trays, leading time-outs, educating patients, preparing local anesthetics, completing documentation and assisting with block placement.

While everyone on the team should be trained in placing CNBs, not everyone needs to be an expert. Aim to have at least one senior member on every block team. In our 8-OR facility, there's at least one expert per block team who acts as part-clinician, part-educator when the patient is receiving the block.

Your anesthesia staff can stay up-to-date about placing blocks by attending lectures, visiting other facilities to watch experts, using online resources like, and, and seizing every opportunity they can to practice catheter placement.

2. Take advantage of ultrasound
I'm a firm believer that anesthesia providers should use ultrasound for every catheter placement. Not only does it make the procedure more efficient, but we're also starting to see data that show that there are safety benefits as well, such as decreased incidence of vascular puncture and decreased risk of systemic toxicity. It's also a big draw for your facility. Many anesthesia providers, especially younger ones, expect ultrasound to be available for block placement. This doesn't mean that you need to run out and purchase a $100,000 machine. The latest portable ultrasound machines are more streamlined, have a smaller footprint and offer much higher quality images — all at a lower price tag.

Technique is important when performing ultrasound-guided blocks. Inserting the needle right next to the probe makes the needle much harder to visualize with ultrasound, due to the steep insertion angle. To see the needle better, insert the needle much farther from the ultrasound probe.

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