Chapter 46. Incorporating Regional Anesthesia into Anesthetic Practice

1. The one overriding benefit of regional anesthesia techniques is that they do not need to end as the patient leaves the operating room at the end of the intraoperative period.

2. The patient education and expectation-setting process is most effective if started in the surgeon's office at the time of the visit at which the decision for operation is completed. Both the surgeon and the nurses need to understand the general concepts and goals of anesthesia and are often strong coadvocates of better perioperative analgesia for their patients.

3. The perioperative period should be designed so that regional anesthesia does not delay or slow down a surgical day. Perceived surgical delay is one of the most important items to avoid if you desire to successfully add regional anesthetic techniques to your practice.

4. Regional anesthesia techniques should be selected and performed on the basis of clear indications to maximize benefit and minimize complications.

5. The preoperative anesthetic note should clearly outline that the patient has been informed of the risks and benefits of the entire anesthetic experience, including the regional anesthetic portion, if that is applicable to the patient. In addition, any preexisting neurologic deficits should be documented on the preanesthetic assessment.

6. Patients should have regional anesthetics performed in settings where full monitoring, resuscitation equipment, and supplies are available.

7. When a practice adds continuous regional anesthetic techniques (either epidural or continuous peripheral nerve block techniques), it is important that round-the-clock coverage and follow-up is available to the patient and hospital if the patient remains as an inpatient or the patient is discharged to an out-of-hospital setting.

8. One of the most important technical items in the intraoperative period with regional anesthesia is to recognize that if a block is not 100%, the anesthesiologist should be the only individual aware of that fact. This means that if the block is not working as well as desired, general anesthesia or deep sedation should be added efficiently.

9. If a patient is to be discharged with a continuous catheter technique, a clear understanding of catheter and pump management, limb protection, catheter removal, breakthrough pain control, and contact numbers must be assured.

10. Anesthesiologists need to continue their own regional anesthesia education by attending continuing education conferences and workshops that help them to have a more complete understanding of the topic and learn new techniques for introduction into their practice. This enables anesthesiologists to continue the education of physicians, nurses, and others regarding regional anesthesia advances.

Incorporating regional anesthesia into an established anesthesia practice demands that the physicians involved understand and make preparations to address the following:

• Management of regional anesthesia through the entire perioperative period
• Clinical indications for the regional anesthetic chosen
• Resources necessary to perform the blocks efficiently, effectively, and safely
• Establishing of an institutional strategy to optimize the introduction of new techniques

Physicians often desire to immediately transfer "techniques" they have learned in workshops into their own practices. That strategy is often destined to fail, as the 4 areas of understanding clearly need to be managed to predictably and reliably introduce regional anesthesia into established practices. This chapter explores each of these necessary steps for successful introduction of regional anesthesia into a practice and expands on them so that you are able to individualize a plan for your own institution and practice.

Physicians who desire to add regional anesthesia techniques to their own practice are most successful if they fundamentally are truly outstanding physicians and, as a result, excellent anesthesiologists. These physicians must be true perioperative physicians. They must be able to understand patient medical problems, surgeons' operative requirements, and regional anesthesia techniques, as well as recovery pattern, nursing requirements, rehabilitation, and potential complications from the surgical procedure performed. Only if all of these are incorporated into decisions about regional anesthesia will the patient, surgeon, anesthesiologist, and nursing staff be coadvocates of the proposed new technique.

In today's surgical and anesthetic environment, our intraoperative general anesthetic care has advanced to a level where it is unusual to validate clear advantages for regional anesthesia when considering the isolated intraoperative period. There are exceptions, of course. Nevertheless, regional anesthesia may be better termed "regional analgesia," as one seeks to incorporate that concept into an anesthetic and surgical practice. The one overriding benefit of regional anesthesia techniques is that they do not need to end as the patient leaves the operating room at the end of the intraoperative period. Rather, when effectively chosen, these regional techniques can be extended either through appropriate drug selection or via catheter insertion and continuous infusion of medication. Either of these choices may help transition the patient from the intraoperative to the postoperative period and to nearly full recovery with manageable pain. The most obvious example is by inserting home going peripheral nerve plexus catheters to provide local anesthetic-induced analgesia into the immediate and more distant postoperative period.1-4

A key step in successfully introducing regional anesthesia to an established practice is ensuring that preoperative evaluation and education of the patient includes an explanation of regional anesthesia and that realistic patient expectations are established. Far too often patients are under the misunderstanding that because they choose a regional anesthesia technique, they will be "awake" during their surgical procedure. Experts in regional anesthesia are nearly always capable of providing outstanding sedation and anxiolysis for the entire perioperative period for patients undergoing a regional technique. This observation fits with these anesthesiologists being excellent physicians and understanding that it is a rare patient who wants to be, or should be allowed to be, completely unsedated for a surgical procedure. The patient education process is most effective if started in the surgeon's office at the time of the visit at which the decision for operation is completed. Both the nurses and the surgeon need to understand the general concepts and goals of anesthesia, including regional anesthesia techniques. Once they understand these concepts, they are often strong coadvocates of better perioperative analgesia for their patients and help to set appropriate patient expectations for the perioperative period.

When considering patient education, the most important concept is that realistic expectations for both patient and the patient's family are outlined. The patient's expectations should be focused around anesthesia, sedation, postoperative analgesia, and what side effects the patient might experience so that, for example, a "numb" arm does not bother the patient on arrival in the recovery room or discharge to the floor or home. In setting these expectations, it is important that the anesthesiologist and institution design an analgesia transition program that addresses resolution of the regional anesthetic and follow-up analgesia. As an example, outstanding brachial plexus anesthesia and analgesia for an upper-extremity operation can frustrate a patient and the patient's family if the block abruptly wears off while the patient is expecting to sleep through the night and no oral medication regimen has been planned to ease that transition. When setting expectations for surgeons, a key element is that the perioperative period is designed so that regional anesthesia does not delay or slow down a surgical day. This demands that anesthesiologists and institutional leaders be creative about incorporating regional blocks and techniques into their practices. Our experience is that surgical delay is one of the most important items to avoid if you desire to successfully add regional anesthesia techniques to your practice. Avoidance of delay will demand that an effective team approach be designed that allows induction of regional anesthetic techniques to be carried out prior to moving patients into the operating room.

After considering the continuum of anesthesia care in the entire perioperative period, the next step for successful introduction of regional techniques into a practice is to develop clear indications for the use of these techniques. It must be remembered that the dominant focus for regional anesthesia is regional analgesia and the ability to minimize opioids and other intravenous agents in the immediate perioperative period. Additional advantages of regional anesthesia techniques include the ability to avoid airway manipulation in patients who evidence difficult airway characteristics or those with full stomach considerations. This does not mean that regional anesthetics should be applied in every full-stomach situation, but a mature clinical risk-to-benefit approach for many emergency patients suggests that the use of effective regional anesthesia does modify risk. As example, in a patient with obstructive cardiomyopathy, the intravascular volume shifts from both general anesthetic vasodilatation and/or neuraxial anesthetic vasodilatation may be avoided, to the patient's advantage, by the use of a brachial plexus nerve block. Another example might be a patient with end-stage pulmonary disease, who requires open reduction with internal fixation of a hip fracture. This clinical setting might be effectively handled with a continuous spinal anesthetic and minimal sedation, rather than a general anesthetic with tracheal intubation. Finally, there is developing evidence that typical general anesthetics may in selected patients have lasting adverse cognitive effects that make regional anesthetics more appropriate.5

In a patient who is undergoing regional anesthesia, there must be clear documentation of both the technical procedure and the indications for the regional technique in the patient's chart. This is another opportunity for the anesthesiologist to educate both surgeons and nurses about the primary reason why the regional anesthesia technique was chosen. In our opinion, anesthesiologists frequently do not take advantage of the educational opportunities present in writing clear and effective progress notes in a patient's record. The preoperative anesthesia note should clearly outline that the patient has been informed of the risks and benefits of the entire anesthesia experience, including the regional anesthesia portion, if applicable to the patient. In addition, any preexisting neurologic deficits should be clearly documented.

The increasing number of drugs being developed that impact coagulation demands that anesthesiologists interested in adding regional techniques to their practice fully understand the implications of these anticoagulants and platelet-active drugs. For example, consensus statements for the use of neuraxial anesthesia techniques in relation to the use of anticoagulant and antiplatelet agents were recently updated and published by the American Society of Regional Anesthesia and Pain Medicine (ASRA) in 2010.6 Recent data outlining a 10-year Swedish experience with anticoagulants and neuraxial anesthesia underscore the need to understand the potential risks and benefits of this drug and technique combination.7 The Swedish results reiterated the danger of using more than 1 agent with anticoagulant or antiplatelet activity in combination. They also identified subgroups of patients at markedly increased risk; for example, elderly females with osteoporosis undergoing total knee arthroplasty under epidural analgesia and receiving once-per-day low-molecular-weight heparin have a 1 in 3600 incidence of epidural hematoma. The data to develop clear consensus statement guidelines regarding the use of anticoagulants and antiplatelet agents in conjunction with peripheral regional anesthetics is extremely limited. It has been suggested that the ASRA consensus guidelines for neuraxial anesthesia be applied to all regional anesthesia techniques. This may be too restrictive. In most cases, techniques performed in areas that are easily compressed in the event of bleeding may be appropriate. Others, such as paravertebral or subclavian blocks, should be avoided unless coagulation parameters are normal.

A common stumbling block for practices desiring to add regional anesthesia expertise to their practice is being limited by having too few anesthesiologists skilled in the techniques. There must be a critical mass of personnel, resources for the techniques, and interest in the techniques for these to be added successfully to an anesthesia practice. Many practices often seek to have a single individual provide the regional anesthesia expertise. This is nearly always doomed to failure as that individual cannot be present 24 hours a day, year-round. Rather, it seems important to have enough physicians with the technical skills and interest in these anesthesia approaches to be able to provide consistent delivery of regional anesthesia throughout the day, week, and year. In general, this means that at least 3 to 4 physicians with significant regional expertise are available within a practice to ensure continuous provision of sophisticated regional anesthetic care is possible. In addition to the physician resources, it is often helpful to have allied health personnel help to prepare patients and supplies for the regional techniques to optimize timing of the technical performance of the regional anesthetic. This may be with a technician who is well trained in assisting the physicians, a nurse anesthetist who is skilled in this area of practice, or a registered nurse who works for the practice or hospital and has an interest in and a desire to grow this part of the practice.

For the physicians, there must be a complete understanding of anatomy and regional anesthesia technical skills to safely and reliably perform the nerve blocks. Patients should have regional anesthesia performed in settings where full monitoring, resuscitation equipment, and supplies are available. These are major anesthesia techniques and need to be treated as such. Monitoring should meet American Society of Anesthesiologists (ASA) standards for performance of an anesthetic.8 Delays in the surgical day can often be minimized if many of the regional anesthesias are performed outside the operating room itself. This serves 2 functions. First, it allows the regional anesthesia to be performed while the surgical team is still preparing the operating room. Second, it gives the injected local anesthetic additional time to effectively anesthetize the desired region. This, of course, demands that regional anesthesia block rooms, or at least regional anesthesia block areas, are established outside the operating room. In many practices, this could be accomplished in areas of the preoperative holding or of postoperative anesthesia recovery. The ideal is to have induction rooms near the operating rooms. Within these areas of the hospitals, regional anesthesia carts with supplies easily at hand and with appropriate monitoring and resuscitation gear are critical for effectively caring for these patients.

As the regional anesthetic practice is established, allied health staff assisting physicians with the technical features of these nerve blocks need to be trained and to have regional block protocols developed so that they are most effective. This demands significant planning and communication to effectively implement this practice.

When a practice has added continuous regional anesthesia techniques (either epidural or continuous peripheral nerve block techniques), it is important that round-the-clock coverage and follow-up are available to the patient and hospital if the patient remains as an inpatient. Even the most successful technical regional anesthetic can be viewed as unsuccessful if this part of the practice is not accounted for in the development phase of adding regional anesthesia to a practice. Other ideas to ease the transition of regional anesthetic techniques into a practice are to use regional anesthesia continuous infusion pumps that differ from general intravenous infusion pumps used throughout the hospital with tubing that has no injection ports. This difference helps to minimize the inappropriate administration of other intravenous drugs through regional block catheters. Drug swaps remain one of the dilemmas of modern medicine, and the use of different pumps and tubing helps to minimize this type of error and potential neurotoxicity. New devices with the capability to read barcodes and recognize appropriate or inappropriate drugs for the device may provide additional safety in the future. Successful introduction and continued use of regional anesthetic techniques require that physicians stay abreast of the latest technologies, such as ultrasound guidance or the use of stimulating catheters for catheter placement.9-11 The increasing use of ultrasound-guided regional anesthetics demands that physicians incorporate a means to stay abreast of developments in ultrasound as well as providing their assistants with a means of gaining ultrasound fundamentals so the ultrasound equipment can be most effectively used.12,13

Once the preceding 3 major elements are understood and a group decides to move ahead with introduction of regional anesthesia or expansion of regional anesthesia into its practice, strategies need to be developed to optimize this introduction. First, a core group of regional anesthesia physicians who agree, in principle, on the plan must be established. It is most effective if, as a system is rolled out, a small number of surgeons and surgical procedures are used as the initial clinical settings so that "success" can be validated more quickly. One of the easiest ways to cause an introduction of regional anesthesia to a practice to fail is to try to be all things to all patients and all surgeons at the outset. It is important to emphasize that successful introduction of regional anesthesia to a practice demands that all involved perceive that regional anesthesia is truly an advantage to the patient, to the surgeon, to the anesthesiologist, and to the institution. Collins et al14 provided clear evidence for this as they examined the impact of a regional anesthesia–analgesia program for outpatient foot surgery. They documented a marked increase in regional anesthesia use, no decrease in operating room efficiency, reduced postanesthesia care unit and discharge time, decreased analgesic use, and decreased nursing interventions for analgesia.

An important technical item in the intraoperative period with regional anesthesia is to recognize that if a block is not 100%, the anesthesiologist should be the only individual aware of that fact. This means that if the block is not working as well as desired, general anesthesia or deep sedation should be added efficiently. This demands that anesthesiologists interested in this practice understand enough about regional anesthesia and sedation to blend the 2 techniques so that patients are effectively sedated and do not have any painful memories of either block insertion or eventual surgical manipulations. The potential for this transition from conscious sedation to deep sedation or general anesthesia should be explained in advance so that patients have realistic expectations regarding the plan of management.

Successful use of regional anesthesia also requires education and training of the nursing staff and development of care protocols. This often begins in the postanesthesia care unit where the limb must be protected. If the patient is to be discharged, the patient and family must be educated about how to protect the limb until recovery from the block has occurred. If the patient is to be discharged with a continuous catheter technique, a clear understanding of catheter and pump management, limb protection, catheter removal, breakthrough pain control, and contact numbers must be assured. In some settings, this may require training home health nurses to facilitate the process. On the inpatient side, education regarding limb protection, neurologic evaluations, breakthrough pain, fall prevention, and issues with anticoagulation and ambulation must be completed.

Once the techniques are well established within an institution and the anesthesiologists are interested, the anesthesiologists need to continue their own regional anesthesia education by attending continuing education conferences and workshops that help them to an even more complete understanding of the topic and to learn new techniques for introduction into their practice. This enables these anesthesiologists to continue the education of nurses and others interested in regional anesthesia advances. This is a critical component of successful introduction of the practice of regional anesthesia.

Once it is effectively introduced, the registered nurses within an institution often are its most vocal advocates, as they see firsthand the difference between patients having effective regional anesthesia and those having either ineffective regional anesthesia, excessive opioid analgesia, or uncontrolled pain in the perioperative period.

The introduction of regional anesthesia to an established anesthesia practice is no different from the introduction of any new technique to a practice. There must be expertise, planning, and a group of physicians and support staff interested in the entire perioperative period that can coordinate the necessary personnel and resources to provide state-of-the-art medical care.

• Collins L, Halwani A, Vaghadia H. Impact of a regional anesthesia program for outpatient foot surgery. Can J Anaesth. 1999;46:840-845.
• Gray AT. Ultrasound-guided regional anesthesia: current state of the art. Anesthesiology. 2006;104:368-373.
• Horlocker TT, Wedel DJ, Rowlingson JC, et al. Regional anesthesia in the patient receiving antithrombotic or thrombolytic therapy: American Society of Regional Anesthesia and Pain Medicine Evidence-Based Guidelines (Third Edition). Reg Anesth Pain Med. 2010;35:64-101.
• Ilfeld BM, Enneking FK. Continuous peripheral nerve blocks at home: a review. Anesth Analg. 2005;100:1822-1833.
• Liu SS, Ngeow JE, Yadeau JT. Ultrasound-guided regional anesthesia and analgesia: a qualitative systematic review. Reg Anesth Pain Med. 2009;34:47-59.
• Moen V, Dahlgren N, Irestedt L. Severe neurological complications after central neuraxial blockades in Sweden 1990–1999. Anesthesiology. 2004;101:950-959.