Preoperative block placement is ideal and does not require a designated block room (Figure 65-1); the monitoring capabilities and availability of staff make the postanesthesia care unit (PACU) a reasonable alternative.

Using a regional block as the primary anesthetic need not result in delays in scheduled start times. If the PACU is unavailable, consider block placement during room “set-up” because the time used to drape the operative field is adequate to achieve the level of block progression essential for surgical trespass.

Interventions performed to supplement a general anesthetic (analgesic versus anesthetic blocks such as interscalene block for shoulder surgery or femoral block for anterior cruciate ligament reconstruction) can be easily executed in the PACU after adequate emergence from general anesthesia. Patient satisfaction is enhanced and PACU discharge times are improved because concurrent doses of side effect-prone opioids are avoided.

Regional techniques result in a superior recovery profile by improving home readiness in the ambulatory setting compared with “fast-track” general anesthesia techniques (Figure 65-2).

The following are suggestions on how to make an impact on quality of analgesia:

The superior analgesia provided by perineural infusion techniques allows for an increase in the scope and complexity of surgical cases performed on an outpatient basis. Before the analgesic advances of peripheral nerve blockade, postoperative pain constituted a major limitation to the expansion of ambulatory surgery.⁶

Severe postoperative pain no longer needs to result in unanticipated hospital admissions.

Witnessing these improvements in analgesia, anesthetic efficiency, recovery profile, and home readiness, surgeons are rapidly embracing perineural techniques as a very potent analgesic strategy.

Figure 65-1. A preoperative block placement area with monitoring and regional anesthesia cart.

Training Requirements

Fear of litigation and compensation issues have forced private practitioners to reevaluate their practices. Introduction of newer, more labor-intensive techniques require specific technical skill and a time investment that may not be adequately reimbursed (Table 65-1) and, thus, may be met with resistance or a lack of enthusiam by practitioners in a community practice setting.

Figure 65-2. Regional anesthesia techniques can substantially help “fast-tracking” by allowing the awake and comfortable patients to bypass the postanesthesia care unit (Phase 1).

One of the barriers to the use of regional techniques among anesthesiologists in community practice is the perception that these techniques (beyond neuraxial techniques) require lengthy, specialized training. Indeed, inadequate exposure to these techniques during residency training leads to a low comfort level with these procedures. Rather than risk failure, many practitioners avoid these procedures and abandon any opportunity for achieving block proficiency.

Table 65–1.

Regional Anesthesia—Acute Pain Management Procedure Billing Codes

Procedure	CPT Code

Brachial plexus, single shot	64415

Brachial plexus, continuous	64416

Sciatic, single shot	64445

Sciatic, continuous	64446

Femoral, single shot	64447

Femoral, continuous	64448

Psoas, continuous	64449

Thoracic epidural	62318

Lumbar epidural	62319

Epidural blood patch	62273

Intravenous PCA	01997

PCA, patient-controlled analgesia.

However, an anesthesiologist should be able to perform a regional anesthetic with the same degree of skill as a general anesthetic. Contrary to the common belief, fellowship training in regional anesthesia is not mandatory to develop profficiency in peripheral block technique. This is analogous to the training in other anesthesia subspecialties. The expertise acquired through formal, fellowship training is useful in the practice of pediatric, ambulatory, obstetric, neurologic, cardiac, and regional anesthesia and is instrumental in advancing the subspeciality but not a prerequisite for successful practice. In contrast, confidence and comfort with regional techniques can be achieved through motivated self-study workshops, and regular practice. Although the prospect of “practicing” peripheral blockade in the private setting may be unattractive to some anesthesiologists, it is no different from acquiring experience with a new general anesthetic drug machine or technique.⁷

Practitioners should develop proficiency with easy techniques (single-injection) before moving on to more advanced blocks (continuous catheter techniques). Because of its readily identifiable landmarks, ease of insertion, and low risk-profile,⁸ a femoral block is considered the ideal technique to develop familiarity with perineural procedures.

A variety of educational tools and on-line teaching sites exist to help the regional enthusiast perfect their craft. For instance, the New York School of Regional Anesthesia (htpp://www.NYSORA.com) website has been a state-of-the-art on-line educational source for more than a decade. It is easy to follow, downloadable, and comprehensive. The American Society of Regional Anesthesia (htpp://www.asra.com), Regional Anesthesia Study Center of Iowa (RASCI, http://www.uianesthesia.com/rasci/), and ARL francophone (htpp://www.alrf.asso.fr) are only a few among several other excellent sites that offer on-line information on practice of regional anesthesia. Consistent review followed by practical application leads to the optimizing consistent success in clinical practice. Although texts and CD-ROMs provide valuable information, the practical application of these skills in a hands-on cadaver workshop may prove to be the training technique with the greatest clinical yield.

SETTING UP A REGIONAL ANESTHESIA PRACTICE

Getting the Word Out

The term “marketing” is defined as the prospect of selling goods or services to actualize a sales transaction.⁹ The term may be viewed as offensive to some practitioners because physicians are often reluctant to sell their services. However, because the public’s perception of regional anesthetic techniques is distorted by a lack of understanding, efforts made to increase the acceptance of these techniques must communicate the message proficiently.

A hospital newsletter is a marketing tool circulated throughout the community to provide patients with information on available resources. Hospital newsletters can be used to explain regional anesthesia services and highlight the physicians skilled in this technique. A hospital newsletter is not a tool to sell goods or services but rather a way to inform the community about the availability of an advanced modern service and a vehicle to change the public’s perception. Without concrete information, patients rely on conjecture. If a hospital newsletter does not exist in an institution, hospital administrators should be lobbied to create one by reminding them that an educated consumer makes the best customer.

Role of the Nursing Staff Members and Around-the-clock Acute Pain Coverage

Nursing staff member support is an implicit prerequisite to the viability of a regional analgesia-based service. The focus of educational in-services should not only effectively prepare the nurse for the nuances of peripheral nerve blockade but should also delineate nursing responsibilities in the entire process

The success of a regional anesthesia service is predicated on a coordinated effort among all nursing disciplines (Figure 65-3). As the healthcare provider with the greatest level of in-house patient contact, an orthopedic floor nurse spearheads the effectiveness of the service by proficiently evaluating analgesic efficacy as well as monitoring for block-related side effects. Working documents, such as acute pain flow sheets and specific block-related order forms, provide clear guidelines to assist nursing staff members making the assessments. (Refer to Chapter 79 for information on regional analgesia forms and flow charts.) Daily correspondence with and immediate access to the anesthesia staff for any catheter-related issues are required to allay any nursing-related concerns associated with the implementation of a new service.¹⁰ An acute pain service pager serves as a valuable nursing resource by permitting access to the anesthesia care provider assigned acute pain duties. If in-house anesthesia coverage is available, then the on-call physician manages overnight block-related issues. If in-house overnight coverage is not available, then a mechanism that provides for timely patient evaluation is needed. The implementation of standardized flow sheets and order forms facilitates documentation, actualizes reimbursement, and applies a structured and organized flow to the service. This organizational structure and team approach translate into optimal patient care.

The results of a regional analgesia-based service include decreased nursing interventions and enhanced patient care. Instead of tending to patients with nausea, administering opioid injections and rescue antiemetics, nurses are able to concentrate on pain assessment, diagnosis, and documentation of patient response to therapy. A nurse that is given the responsibility of removing femoral and interscalene catheters is instructed to document catheter tip visualization and call the anesthesiologist if catheter removal is met with any resistance. This structure has been proved to be a safe and effective practice that empowers the nursing staff to coordinate efficient and timely discharges (Table 65-2; Figure 65-4).

Figure 65-3. A perioperative nurse interviews the patient before administration of regional anesthesia.

A physical therapy program is an essential step in the transition from convalescence to anticipated postoperative outcome. Physical therapists need to be in-serviced regarding the potential for motor blockade with lower extremity perineural techniques and its impact on ambulation. Initially, surgeons may be concerned that a partially blocked extremity would lead to an increase in patient falls during ambulation; however, the vigilance of a well-informed physical therapy team combined with the use of ambulatory-assist devices (eg, knee immobilizers) helps substantially reduce the risk of iatrogenic injuries. As a result of coordinated efforts by the members of the departments of nursing and physical therapy, a more aggressive physiotherapy regimen, together with earlier ambulation, results in a decrease in the length of hospital stay.¹¹

Collectively, fulfillment of these roles enhances the department’s ability to provide a state-of-the-art effective pain management service to all patients. However, without a proactive nursing staff, this goal would be reached with great difficulty.

Table 65–2.

Description of Nursing Roles