Using CPNB, the benefits of regional anesthesia can be extended for days
into a patient's recovery from surgery. This advantage can have a profoundly
positive influence on the care of patients who require evacuation over long
distances or have injuries that necessitate frequent surgical interventions
or dressing changes. Although this technique has important advantages in
AEA, it also presents the medical team with unique management challenges
that are best addressed by the regional anesthesia/acute pain
anesthesiologist working outside of the operating room. The decision to use
CPNB on AEA patients must be individualized to each patient's clinical
situation. During the clinical evaluation of the patient for anesthesia, the
anesthesiologist will be able to ascertain if the patient is a suitable
candidate for CPNB. Not all patients are willing or able to tolerate CPNB
infusions despite the relative simplicity of the technology. If a patient
remains resistant to CPNB therapy after thoughtful discussion with a
physician, then the technique should be abandoned in favor of more
traditional anesthetic and pain management techniques. Additionally,
personnel resources must be available to monitor and appropriately manage
any development of local anesthetic toxicity following a block. The
anesthesiologist must also weigh the benefits of applying CPNB for each
surgical situation against the risks of the technique. In the author's
practice, all patients are warned, “The use of a block needle can result in
injury or infection and because we are working near nerves the possibility
of nerve damage does exist, though these complications are rare.” The least
invasive intervention that can adequately control a patient's pain should
always be sought for each clinical situation. Finally, the anesthesiologist
must have an established plan for a follow-up of CPNB patients. Follow-up
can be as simple as a telephone call, but CPNB patients and their catheters
should be evaluated daily. Patients treated with CPNB catheters should also
be educated on signs and symptoms of local anesthetic toxicity. The patient
must have 24-h access to an anesthesia provider should problems occur during
the infusion. Fortunately, the answer for any CPNB infusion problem is the
same, stop the infusion, resort to back-up pain medications, seek medical
help. The U.S. Air Force has developed a series of infusion pump labels to
provide CPNB patients and their caregivers basic instructions during air
evacuation to manage infusion problems when an anesthesiologist may not be
immediately available (Figure 66–3). Internet e-mail is also a
valuable communication tool when physicians and nurses are required to treat
CPNB patients that are being transferred to medical facilities separated by
great distance. E-mail can often be accessed in the most remote areas where
other forms of long-distance communication are unavailable. Although these
CPNB management principles may seem burdensome to apply in the AEA
environment, the advantages in pain relief for patients are clear and
consistent with compassionate anesthetic care. With proper planning, CPNB
works well in austere environments.