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Regional anesthesia offers multiple clinical advantages that contribute to both an improved patient outcome and lower overall health care costs.1–4 Peripheral nerve blocks provide excellent anesthesia, postoperative pain relief, reduced complications of wound healing compared with infiltration anesthesia, fewer side effects than general anesthesia, and facilitate early physical activity.5–8 Peripheral nerve blocks are frequently used in elderly patients to limit excessive sedation while providing excellent pain control.9 Nerve blocks are associated with reduced use of opioids for postoperative pain, fewer postoperative complications, and earlier discharges.6,10–12 Single-injection regional blocks and continuous peripheral catheters play a valuable role in a multimodal approach to pain management in the critically ill patient, providing excellent patient comfort while reducing the physiologic stress response.13

However, compared with neuraxial and general anesthesia, success with peripheral nerve blocks is undoubtedly more anesthesiologist-dependent.14–16 Technical skills and determination are required for the successful implementation of peripheral nerve blocks. Factors such as accurate identification of surface landmarks and an adequate number of supervised, successful attempts at each block are necessary for safe, effective peripheral nerve block implementation.14,16–18 A dedicated team of well-trained anesthesiologists is a prerequisite to ensure consistent peripheral nerve block service in any institution.19,20 Intraoperative management, once the block has been placed, requires diligent observation and judicious use of supplemental drugs for anxiolysis and sedation. Postoperative management, including patient and nursing education, discussion of the block duration, expected sensory and motor deficits, and a plan for pain management as the block diminishes, is the final element required for success with nerve blocks (Figure 61–1).

Fig. 61-1

Five elements for success with nerve blocks.

Even before the anesthesiologist meets the patient, planning for anesthetic management begins with a review of the operative schedule. Attention to the procedure, what portion of the patient's body is involved, the patient's name and age, and the surgeon's preference direct the anesthesiologist toward the choice of general, regional, or combined techniques. Knowing the surgeon's abilities plays a role in selecting both the block technique and the local anesthetic to be used if regional techniques are to be implemented. Advance planning includes placing equipment and supplies necessary for the chosen technique in the block area or the operating room (OR) prior to the patient's arrival, increasing the efficiency of the anesthetic experience.

Medical Record Review

The patient's chart should be reviewed for relevant history, physical examination findings, and laboratory studies that may influence the anesthetic plan. The chart review should be conducted with as much care as is taken with surgery involving general anesthesia. Laboratory tests, the electrocardiogram (ECG), tests of cardiovascular risk, radiographic reports, and any additional consultations should be reviewed.

Routine laboratory studies are not indicated for the low-risk patient undergoing low-risk procedures. Selective laboratory ...

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