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
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).
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.
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 ...