Nalini Vadivelu
Editors
Essentials of Regional
Anesthesia
Alan David Kaye, MD, PhD
Director of Interventional Pain Management University Hospital and Ochsner Kenner Hospital
Professor and Chairman Department of Anesthesiology Professor
Department of Pharmacology Louisiana State University School of Medicine
New Orleans, LA 70112, USA Nalini Vadivelu, MD
Associate Professor of Anesthesiology Yale University School of Medicine New Haven, CT 06510, USA
Richard D. Urman, MD, MBA Assistant Professor of Anesthesia Harvard Medical School Director
Hospital Procedural Sedation Management and Safety
Co-Director
Center for Perioperative Management and Medical Informatics
Brigham and Women’s Hospital Boston, MA 02115, USA
ISBN 978-1-4614-1012-6 e-ISBN 978-1-4614-1013-3 DOI 10.1007/978-1-4614-1013-3
Springer New York Dordrecht Heidelberg London Library of Congress Control Number: 2011943562
© Springer Science+Business Media, LLC 2012
All rights reserved. This work may not be translated or copied in whole or in part without the written permission of the publisher (Springer Science+Business Media, LLC, 233 Spring Street, New York, NY 10013, USA), except for brief excerpts in connection with reviews or scholarly analysis. Use in connection with any form of information storage and retrieval, electronic adaptation, computer software, or by similar or dissimilar methodology now known or hereafter developed is forbidden.
The use in this publication of trade names, trademarks, service marks, and similar terms, even if they are not identifi ed as such, is not to be taken as an expression of opinion as to whether or not they are subject to proprietary rights.
While the advice and information in this book are believed to be true and accurate at the date of going to press, neither the authors nor the editors nor the publisher can accept any legal responsibility for any errors or omissions that may be made. The publisher makes no warranty, express or implied, with respect to the material contained herein.
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Springer is part of Springer Science+Business Media (www.springer.com)
for her patience, love, and wisdom in raising our two wonderful children, Aaron and Rachel.
Alan David Kaye To my mentors, students, and trainees
for their inspiration, and to my parents, Dennis and Tanya, and my wife,
Zina Matlyuk-Urman, MD.
Richard D. Urman I dedicate this book to my parents,
my husband Muthu, my sons Gopal
and Vijay, and all my colleagues and friends for their constant encouragement.
Nalini Vadivelu
vii
The editors of Essentials of Regional Anesthesia have asked me to write a Foreword for the book. Their request is most likely due to my involvement in regional anes- thesia and its growth in the last 40 years. I have written and published on regional anesthesia extensively during this period, and this opportunity allows me to refl ect on the progress regional anesthesia has made since its inception in 1884.
Regional anesthesia came to the European medical scene with a bang, when Carl Koller experimented with cocaine for its use in eye surgery and presented the data of his experiments to the Ophthalmological Congress in Heidelberg in September, 1884. His fi ndings were accepted readily by the surgeons, since they were having signifi cant morbidity and mortality with Ether and Chloroform. During the ensuing years up to 1930, regional anesthesia was commonly practiced safely, both in Europe and North America. New techniques such as spinal block, epidural block and peripheral nerve block were developed during this period. The limitation of per- forming regional anesthesia was that there was no training program for any physi- cian who wished to learn this practice. It was done on an ad hoc basis by the assistants to the surgeons and the nurses.
As the specialty of anesthesia started in 1933, the anesthesiologists preferred general anesthesia to regional anesthesia because general anesthesia was easier to learn. The scientifi c growth in monitoring and safety in anesthesia practice was the main reason for popularization of anesthesia techniques.
All the same, Mayo Clinic in 1930s and 1940s still did their major surgeries with spinal anesthesia or peripheral nerve blocks with intravenous sedation by a barbitu- rate. Gaston Labat worked at this institution and became very accomplished in regional anesthesia. He wrote the fi rst book on the subject – Regional Anesthesia:
Its Technique and Clinical Application – which even today is a seminal book for practitioners of regional anesthesia. He was uniquely responsible for forming a society called the “American Society of Regional Anesthesia” (ASRA) for inter- ested regional anesthesia physicians. The society’s deliberations and activities are well documented in the Wood Library Museum. ASRA started to wither with future scientifi c growth in general anesthesia, such as the introduction of Halothane, intra- venous induction of anesthesia with a barbiturate, and the discovery of muscle
relaxants like Curare. This allowed the anesthesiologist to easily monitor the level of anesthesia necessary for surgery and not have the patient kept awake. Surgeons loved this change in anesthesia practice.
During the 1970s, anesthesia training was overwhelmingly for general anesthe- sia practice, and the instances in which physicians used regional anesthesia tech- niques were few and far between. In spite of this state of affairs, giant fi gures like John Bonica, Philip Bromage, Alon Winnie, Daniel Moore, and Donald Bridenbaugh fought hard to advocate for the practice of regional anesthesia for surgical, obstetric, or cancer pain patients. They were the teachers of regional anesthesia and started the training programs in their departments. This culminated in the revival of the American Society of Regional Anesthesia. The residents going into the anesthesia specialty loved to learn about regional anesthesia, and with their support, regional anesthesia practice fl ourished. ASRA created practical workshops and educational programs, and with their infl uence the society was able to spread its wings in Europe, Asia, and Latin America.
During the period 1975–2010, remarkable scientifi c advances were made in the techniques, local anesthetics, and devices that assist in the success of regional anes- thesia. In the 1980s, the peripheral nerve stimulator was an advance in locating nerves, and in the last few years, assistance by ultrasound techniques was intro- duced. Both of these techniques have been well received by the practitioners of regional anesthesia. Many books and documentaries are now available for training the physician in regional anesthesia.
Alan David Kaye has provided me with the reason why this book was conceived.
He explains it is for the clinicians, students, residents, fellows, and attendees to learn and train in the new technology of regional anesthesia practice. He has mostly chosen authors who are Directors of the Regional Anesthesia Fellowship programs;
this provides a sound basis on which the trainee can get the most up-to-date infor- mation on the state of practice of regional anesthesia.
The book is divided into six sections, including general considerations, basic science and clinical practice, equipment, and the modern practice of regional anes- thesia. There are 31 chapters most of the chapters are formatted consistently, such as (a) anatomy of the block (b) indications for the block (c) types of techniques available (d) clinical pearls (e) complications. The chapters commonly end with multiple-choice questions.
I fi nd Essentials of Regional Anesthesia very well organized and timely and that it fi lls the void created by rapidly changing regional anesthesia practices. Even though there are many books available on regional anesthesia, the incorporation of ultrasound for each block is a unique feature of this book and will be well received by the trainees. I recommend this book for all libraries of anesthesia departments, including for training of residents and medical students.
Lubbock, TX, USA P. Prithvi Raj
ix
The practice of regional anesthesia has undergone tremendous evolution in the past few decades. Until recently, older blind techniques were taught, and successful regional anesthetics were typically limited to a few extraordinary clinicians in each department of anesthesia worldwide. Ultrasound, electrical stimulation, fl uoros- copy, and continuous catheters have contributed to a revolution in the fi elds of regional anesthesia and pain management. Advances in technology have changed these fi elds signifi cantly, resulting in the development of formal regional anesthesia and pain fellowships.
The present fi eld of regional anesthesia has challenged not only new residents and fellows but also older practicing anesthesiologists to learn these new techniques and technologies in their clinical practices. Excellence and versatility in regional anesthesia can provide the means by which we better manage acute and chronic pain. Modern regional anesthesia provides hope and optimism for the comfort of future generations of patients affl icted with a wide array of medical conditions.
One of the strategies in creating a book on Essentials of Regional Anesthesia was to make it practical for the clinician. To that end, we have recruited regional anes- thesia fellowship directors and their fellows as authors for most of the chapters in this book. We also requested that authors identify clinical pearls and help us create a databank of questions for trainees to facilitate learning of the subject material. The editors of the book agree that this has been a challenging but rewarding project.
Since this is a fi rst edition, we have endeavored to present the material with clarity and conciseness. Our goal has been a book of practical applicability for the anesthe- sia provider. Best of luck to each of you as you develop your clinical practices in regional anesthesia.
New Orleans, LA, USA Alan David Kaye
Boston, MA, USA Richard D. Urman
New Haven, CT, USA Nalini Vadivelu
xi
Part I General Principles of Regional Anesthesia Practice
1 General Considerations for Regional Anesthesia Practice ... 3 Edward R. Mariano and Karley J. Mariano
2 Monitoring for Regional Anesthesia ... 21 Jeff Gadsden
3 Regional Anesthesia in the Community Practice Setting ... 37 Joseph Marino and Brian E. Harrington
Part II Basic Science and Clinical Practice
4 The Anatomy of Pain ... 83 Harry J. Gould III and Alan David Kaye
5 Practical Pharmacology in Regional Anesthesia ... 121 Jose A. Aguirre, Gina Votta-Velis, and Alain Borgeat
6 Anticoagulation and Regional Anesthesia Concerns ... 157 Rinoo Shah, Alan David Kaye, Adam Kaye, and Jeffrey Y. Tsai
Part III Equipment for Regional Anesthesia
7 Equipment and Clinical Practice: Aids to Localization
of Peripheral Nerves ... 177 Beverly Pearce-Smith and Johnny K. Lee
8 Principles of Sonography ... 191 Paul E. Bigeleisen and Steven Orebaugh
9 Ultrasound-Guided Peripheral Nerve Blockade ... 199 David M. Polaner and Alan Bielsky
10 Sonopathology ... 239 Jonathan T. Weed and Brian D. Sites
Part IV Techniques for Regional Anesthesia
11 Neuraxial Blockade: Subarachnoid Anesthesia ... 261 Maria Teresa Gudin, Ramón López, Jesus Estrada,
and Esperanza Ortigosa
12 Neuraxial Blockade: Epidural Anesthesia ... 293 Sreekumar Kunnumpurath, S. Ramessur, A. Fendius, and Nalini Vadivelu 13 Upper Extremity Nerve Blocks ... 339
De Q.H. Tran, Shubada Dugani, and Juan Francisco Asenjo
14 Peripheral Nerve Blocks for the Lower Extremity ... 385 Sylvia Wilson and Anna Uskova
15 Regional Anesthetic Techniques for Foot Surgery ... 407 Rick Chien-An Chen and Peter A. Blume
16 Regional Anesthesia of Thorax and Abdomen ... 423 Rita Merman and Vlad Shick
17 Head and Neck: Scalp, Ophthalmic, and Cervical Blocks ... 463 Desiree Persaud and Sébastian Garneau
18 Local Anesthesia of the Masticatory Region ... 483 Henry A. Gremillion, Christopher J. Spencer, and Alex D. Ehrlich
19 Topical and Regional Anesthesia of the Airway ... 505 Ryan P. Ellender, Paul L. Samm, and Richard H. Whitworth, Jr.
20 Selective Regional Anesthesia Options in Surgical
Subspecialties... 525 Henry Liu, Charles James Fox, Michael J. Yarborough,
and Alan David Kaye
21 Regional Anesthesia for Chronic Disease States ... 541 Siamak Rahman and Parisa Partownavid
22 Intravenous Regional Anesthesia ... 557 Lindsey Vokach-Brodsky
23 Regional Anesthesia and Trauma ... 565 Daniela Elena Francesca Ghisi, Andrea Fanelli, and Carl Rest
24 Postoperative Pain Management ... 579 Ralf E. Gebhard and Andres Missair
25 Sympathetic Blockade ... 605 Rafael Justiz, Audra Day, and Miles Day
Part V Special Populations
26 Regional Anesthesia for Chronic Pain ... 649 Vijay Krishnamoorthy, Ruben Koshy, Gina Votta-Velis,
and Alain Borgeat
27 Regional Anesthetic Techniques for the Pediatric Patient ... 665 Bryan Fritz, Marlene Barnhouse, Usha Ramadhyani,
and Bobby Nossaman
28 Obstetric Anesthesiology ... 689 Ray L. Paschall
29 Regional Anesthesia for Outpatient Surgery ... 731 Joshua E. Smith
Part VI Additional Topics
30 Outcome Studies and Infection Control in Regional Anesthesia ... 741 Joel Barton and Stuart A. Grant
31 Regional Anesthesiology Education ... 779 Jonathan C. Beathe
Index ... 799
xv
Jose A. Aguirre , MD, MSc Division of Anesthesiology , Balgrist University Hospital Zurich , Zurich 8008 , Switzerland
Juan Francisco Asenjo , MD Department of Anesthesia , Montreal General Hospital , McGill University, Montreal , Quebec H3G-1A4 , Canada
Marlene Barnhouse , MD Department of Anesthesiology , Ochsner Clinic, Jefferson , LA 70121 , USA
Joel Barton , MD Duke University School of Medicine , Durham , NC 27710 , USA
Jonathan C. Beathe , MD Hospital for Special Surgery , Weill Cornell Medical College , New York , NY 10021 , USA
Alan Bielsky , MD Department of Anesthesiology and Pediatrics ,
Children’s Hospital Colorado and University of Colorado School of Medicine , Aurora , CO 80045 , USA
Paul E. Bigeleisen , MD Universities of Maryland and Rochester , Baltimore , MD 21201 , USA
Peter A. Blume , DPM, FACFAS Department of Orthopedics and Rehabilitation , Yale School of Medicine , New Haven , CT 06504 , USA
Alain Borgeat , MD Department of Anesthesiology , Balgrist University Hospital Zurich , Zurich 8008 , Switzerland
Rick Chien-An Chen , DPM Yale/VACT Podiatric Medicine & Surgery Residency , Resident PGY-3, West Haven, CT 06516, USA
Audra Day , PhD, RN Department of Biology , South Plains College , Levelland , TX 79336 , USA
Miles Day , MD, DABA, FIPP, DABIPP Department of Anesthesiology and Pain Management , Texas Tech University Health Sciences Center ,
Lubbock , TX 79430 , USA
Shubada Dugani , MBBS, FRCA Department of Anesthesia , Montreal General Hospital, McGill University , Montreal , Quebec H3G-1A4 , Canada
Alex D. Ehrlich , MS, DDS, FAGD, FAOP Department of Comprehensive Dentistry & Biomaterials , LSU School of Dentistry ,
New Orleans , LA 70119-2799 , USA
Ryan P. Ellender , MD Department of Anesthesiology , Louisiana State University Health Sciences Center , New Orleans , LA 70112 , USA
Jesus Estrada , MD Department of Anesthesiology and Critical Care Medicine , Getafe University Hospital , Madrid 28006 , Spain
Andrea Fanelli , MD Department of Anesthesia , Istituti Ospitalieri Di Cremona , Cremona, Lombardia 26100 , Italy
Adam Fendius , MB BS, DiplMC(RCSEd), FRCA Department of Anaesthesia , St. George’s Hospital , London SW170 QT , UK
Charles James Fox , MD Department of Anesthesiology , Tulane School of Medicine , New Orleans , LA 70112 , USA
Bryan Fritz , MD Department of Anesthesiology , Ochsner Clinic , Jefferson , LA 70121 , USA
Jeff Gadsden , MD, FRCPC, FANZCA Department of Anesthesiology , St. Luke’s–Roosevelt Hospital Center , New York , NY 10025 , USA Sébastian Garneau , MD, DMV, FRCPC Département d’anesthésiologie , Centre Hospitalier de l’Université de Montréal , Montréal , QC , Canada
Ralf E. Gebhard , MD Division of Regional Anesthesia and Acute Perioperative Pain Management, Department of Anesthesiology , Perioperative Medicine and Pain Management, University of Miami, Miller School of Medicine , Miami , FL 33136 , USA
Daniela Elena Francesca Ghisi , MD Department of Anesthesia , Istituti Ospitalieri Di Cremona , Cremona, Lombardia 26100 , Italy
Harry J. Gould III , MD, PhD Department of Neurology and Neuroscience, Louisiana State University Health Sciences Center , New Orleans , LA 70112 , USA Stuart A. Grant , MB ChB Duke University School of Medicine ,
Durham , NC 27710 , USA
Henry A. Gremillion , DDS, MAGD Department of Orthodontics , Louisiana State University Health Sciences Center School of Dentistry , LSU School of Dentistry, New Orleans , LA 70119 , USA
Maria Teresa Gudin , MD Department of Anesthesiology and Critical Care Medicine , University Hospital of Getafe , Madrid 28905 , Spain Brian E. Harrington , MD Billings Clinic Hospital , Billings , MT , USA
Rafael Justiz , MD, MS, DABA/PM, FIPP, DABIPP Medical Director , Oklahoma Pain Physicians , Oklahoma City , OK 73012 , USA
Adam Kaye , PharmD, FASCP, FCPhA Department of Pharmacy Practice , Thomas J. Long School of Pharmacy and Health Sciences,
University of the Pacifi c , Stockton , CA 95207 , USA
Alan David Kaye , MD, PhD Department of Anesthesiology , Tulane School of Medicine , New Orleans , LA 70112 , USA
Ruben Koshy , MD Georgia Pain and Spine Care , Newnan , GA 30265 , USA Vijay Krishnamoorthy , MD Department of Anesthesiology ,
University of Illinois Medical Center , Chicago , IL 60612 , USA Sreekumar Kunnumpurath , MD, FRCA, FFPMRCA
Department of Anaesthetics , Epsom and St. Helier University Hospitals NHS Trust , Carshalton SM5 1AA , UK
Johnny K. Lee , MD Department of Anesthesiology , University of Pittsburgh Medical Center , Pittsburgh , PA 15232 , USA
Henry Liu , MD Department of Anesthesiology , Tulane School of Medicine , New Orleans , LA 70112 , USA
Edward R. Mariano , MD, MAS Anesthesiology and Perioperative Care Service, Veterans Affairs Palo Alto Health Care System , Palo Alto , CA 94304 , USA Department of Anesthesiology, Stanford University School of Medicine , Palo Alto , CA 94304 , USA
Karley J. Mariano , RN, BSN Pediatric Perioperative Services, Lucile Packard Children’s Hospital , Palo Alto , CA 94304 , USA
Joseph Marino , MD Department of Anesthesiology, Huntington Hospital, Hofstra University School of Medicine in partnership with North Shore-LIJ Health System , Huntington , NY 11743 , USA
Rita Merman , MD Department of Anesthesiology , University of Pittsburgh Medical Center , Pittsburgh , PA 15232 , USA
Andres Missair , MD, DESRA Department of Anesthesiology ,
Jackson Memorial Hospital, University of Miami, Miller School of Medicine , Miami , FL 33141 , USA
Bobby Nossaman , MD Ochsner Medical Group , New Orleans , LA 70121 , USA
Steven Orebaugh , MD University of Pittsburgh School of Medicine, UPMC Mercy-Southside Ambulatory Surgery Center , Pittsburgh , PA , USA Esperanza Ortigosa , MD Department of Anesthesiology and Critical Care Medicine , University Hospital of Getafe , Madrid 28905 , Spain
Parisa Partownavid , MD Department of Anesthesiology , Ronald Reagan UCLA Medical Center , Los Angeles , CA 90095-7403 , USA
Ray L. Paschall , MD, MS Department of Anesthesiology , Vanderbilt University Medical Center , Nashville , TN 37232 , USA Beverly Pearce-Smith , MD Department of Anesthesiology ,
Presbyterian University Hospital, University of Pittsburgh Medical Center , Pittsburgh , PA 15213 , USA
Desiree Persaud , MD, FRCPC Residency Training Program,
Department of Anesthesia , University of Ottawa , Ottawa , ON K1Y 4E9 , Canada David M. Polaner , MD, FAAP Department of Anesthesiology and Pediatrics , Children’s Hospital Colorado and University of Colorado School of Medicine , Aurora , Colorado, CO 80045 , USA
Siamak Rahman , MD Department of Anesthesiology , Ronald Reagan UCLA Medical Center , Los Angeles , CA 90095-7403 , USA
Usha Ramadhyani , MBBS Department of Anesthesiology , Ochsner Medical Center , New Orleans , LA , USA
Suneil Ramessur , MBBS, FRCA, FFPMRCA
Department of Anaesthetics , St. Georges University Hospital , Tooting, London , UK
Carl Rest , MD Department of Anesthesia and AIPPS , University of Pittsburgh Medical Center , Pittsburgh , PA 15232 , USA
Paul L. Samm , MD Department of Anesthesiology , Louisiana State University Health Sciences Center , New Orleans , LA 70112 , USA Rinoo Shah , MD, MBA Department of Anesthesiology , Guthrie Clinic , Horseheads , NY 14845 , USA
Vlad Shick , MD University of Pittsburgh Medical Center , Pittsburgh , PA , USA Brian D. Sites , MD Department of Anesthesiology , Dartmouth-Hitchcock Medical Center , Lebanon , NH 03756 , USA
Joshua E. Smith , MD Department of Anesthesiology , University of Alabama Hospitals , Birmingham , AL 35249-6810 , USA
Christopher J. Spencer , DDS Department of Comprehensive Dentistry , University of Florida College of Dentistry , Gainesville , FL 32610 , USA
De Q.H. Tran , MD, FRCPC Department of Anesthesia , Montreal General Hospital, McGill University , Montreal , Quebec H3G-1A4 , Canada
Jeffrey Y. Tsai , MS Medical Student, Medical School at Western U of Health Sciences, New Orleans, CA 91766-1854, USA
Anna Uskova , MD Department of Anesthesiology , Shadyside University of Pittsburgh Medical Center , Pittsburgh , PA 15232 , USA
Nalini Vadivelu , MBBS, MB, DNB Yale University School of Medicine , New Haven , CT 06510 , USA
Ramón López , MD Department of Anesthesiology and Critical Care , Hospital Universitario 12 de Octubre , Madrid 28041 , Spain
Lindsey Vokach-Brodsky , MB, ChB Department of Anesthesia , Stanford University Medical Center , Palo Alto , CA 94304 , USA
Gina Votta-Velis , MD, PhD Department of Anesthesia, University of Illinois at Chicago, Chicago, IL 60612, USA
Jonathan T. Weed , MD Department of Anesthesiology , Tulane Medical Center , New Orleans , LA 70112 , USA
Richard H. Whitworth , Jr. PhD Department of Cell Biology and Anatomy , Louisiana State University Health Sciences Center , New Orleans ,
LA 70112-1393 , USA
Sylvia Wilson , MD Department of Anesthesia and Perioperative Medicine , Medical University of South Carolina , Charleston , SC 29425-9120 , USA Michael J. Yarborough , MD Department of Anesthesiology ,
Tulane School of Medicine , New Orleans , LA 70112 , USA
General Principles of Regional Anesthesia Practice
3 A.D. Kaye et al. (eds.), Essentials of Regional Anesthesia,
DOI 10.1007/978-1-4614-1013-3_1, © Springer Science+Business Media, LLC 2012
Introduction
Setting up a regional anesthesia service requires a reliable and consistent product as well as a sound business plan. Technological advances in nerve stimulation, ultrasound guidance, and perineural catheters have led to rapid growth in the num- ber and types of peripheral nerve block procedures available to regional anesthesia
E. R. Mariano, MD, MAS (*)
Anesthesiology and Perioperative Care Service,
Veterans Affairs Palo Alto Health Care System , Palo Alto , CA, USA Department of Anesthesiology , Stanford University School of Medicine , 3801 Miranda Avenue, 1112A , Palo Alto , CA 94304 , USA
e-mail: emariano@stanford.edu K. J. Mariano, RN, BSN
Pediatric Perioperative Services, Lucille Packard Children’s Hospital , 725 Welch Road , Palo Alto , CA 94304 , USA
General Considerations for Regional Anesthesia Practice
Edward R. Mariano • Karley J. Mariano
1
Contents
Introduction ... 3 Reasons for Starting a Regional Anesthesia Program ... 4 Bringing Your “Product” to Market ... 5 Determine if Regional Anesthesia Will Save Money ... 6 Bill Effectively for Professional Fees ... 7 Figure Out How to Make It Work ... 10 Diligent Follow-up Is Key... 12 Conclusion ... 14 Multiple-Choice Questions ... 14 References ... 17
practitioners. Starting a new regional anesthesia program potentially adds monetary value to a facility’s perioperative services by improving the quality of postopera- tive analgesia and recovery from surgery, thereby reducing perioperative costs and offering a competitive advantage over other surgical facilities. From the patient’s perspective, a regional anesthesia program provides nonmonetary value by prevent- ing pain and reducing the risk of nausea and vomiting after surgery. Unfortunately for anesthesiologists interested in starting a new regional anesthesia program, there are no evidence-based guidelines to follow.
While the argument in favor of developing a regional anesthesia program in terms of nonmonetary value is convincing, determining monetary value is vital to initiating any new program. There are start-up costs to consider, and expected revenues are typically delayed. How does the individual anesthesiologist convince his or her own anesthesiology group or hospital administrators that a new service that provides peripheral nerve blocks and acute pain management is worth the investment? In this era of cost-effective health-care delivery, all medical institu- tions, academic and private, are under similar fi nancial pressures. For academic centers, the primary educational mission must be achieved in the setting of fi nan- cial stability.
Reasons for Starting a Regional Anesthesia Program
As the defi nition of “outpatient” surgery continues to broaden, patients previously hospitalized for the same surgeries several years ago are now scheduled for dis- charge on the day of surgery. Lengthy hospitalizations for some major surgeries are gradually progressing to overnight admission. For example, total joint replacement postoperative protocols have been refi ned to the point that it is currently feasible to practice same-day discharge or short-stay admission for appropriate cases [ 1– 3 ] .
The causes of prolonged recovery after scheduled ambulatory surgery have been studied and are multifactorial. In addition to type of surgery, these factors include postoperative nausea and vomiting, as well as pain following general anesthesia [ 4 ] . The proper application of regional anesthesia techniques in the ambulatory setting can minimize or avoid these common side effects and decrease the time required for patients to meet predetermined discharge criteria [ 5– 7 ] .
According to the results of a survey conducted by Dr. Macario and colleagues, nausea, vomiting, and pain are among the main side effects patients prefer to avoid after anesthesia [ 8 ] . It is increasingly important to consider patient preferences in the current health care system. Ensuring high patient satisfaction will likely lead a patient to return to a particular health care system for future surgical services and potentially result in new referrals. Patients should be considered consumers with the right to the highest quality service, and they have choices regarding their health care. Anesthesiology groups or hospitals who offer regional anesthesia services can employ marketing strategies to outcompete other anesthesiology groups and hospitals that do not offer similar services.
Regional anesthesia is not “one size fi ts all” anesthesia. The combination of spe- cifi c peripheral nerve block techniques can produce anesthesia and postoperative analgesia that is nearly as selective as the surgical procedure itself. In a large case series, Klein and colleagues have demonstrated that peripheral nerve blocks in the ambulatory setting lead to reductions in perioperative intravenous opioid use and high patient satisfaction and can be used in conjunction with oral opioid analgesics [ 9 ] . For the nonorthopedic patient, other regional anesthesia techniques may offer similar advantages [ 10– 12 ] .
In order to extend the duration of site-specifi c pain relief beyond the immediate perioperative period, continuous peripheral nerve blocks (CPNB) and perineural local anesthetic infusions are currently used for a wide variety of surgeries in the ambulatory environment [ 13– 20 ] . Randomized, placebo-controlled studies have conclusively demonstrated signifi cant reductions in patient-reported pain after shoulder, foot, and distal upper extremity surgery as a result of CPNB [ 18– 21 ] . By providing superior analgesia at home, CPNB effectively reduces the need to hospi- talize patients for pain control. Broader application of these advanced regional anes- thesia techniques has contributed to the growing interest in ambulatory total joint replacement [ 1, 2, 22, 23 ] .
Bringing Your “Product” to Market
Developing a new regional anesthesia program is like inventing a new product. In addition to ensuring the consistency and reliability of the product, the prospective clientele and demand for the product should be considered. Applying this analogy, it is essential to identify potential customers and their needs. The patient and patient’s family are the most important customers, and improvements in the overall quality of postoperative recovery resulting from regional anesthesia offer meaning- ful benefi ts to them. S urgeons are clearly important customers to any anesthesiol- ogy practice, hospital, or surgical center. Surgeons’ concerns regarding failed blocks, complications, and case delays must be addressed [ 24 ] , and surgeons may rally behind a regional anesthesia program that improves operating room effi ciency [ 25 ] . When a regional anesthesia program gains surgeon support, the dividends multiply. Since surgeons establish rapport with patients several days or weeks before the surgery, their recommendation in favor of regional anesthesia is likely to lead to higher utilization of these services.
Despite the common belief that surgeons represent the major obstacle to devel- oping a regional anesthesia service, it is often the anesthesiology practice itself that requires the most convincing. Since the initial investment in money, training, and personnel is incurred by the practice, there must be tangible benefi ts from imple- menting a new service. The ability to recoup this cost is dependent on the model of regional anesthesia practice implemented and the anticipated volume of nerve block procedures. For a busy orthopedic hospital, a new regional anesthesia service may generate enough new revenue to support the salary of one dedicated regional
anesthesia provider per clinical day. However, this type of “block room” model is not appropriate to all practices, and every regional anesthesia service should be devel- oped with consultation from the individual practice manager and billing service to ensure proper fi nancial planning.
The hidden customer when developing a new regional anesthesia service is hospital administration . Often, hospital administration receives the requests to pur- chase the initial capital equipment (e.g., nerve stimulators, regional block carts, and ultrasound machines). Although these overhead expenses may be large, they tend to be fi xed and nonrecurring [ 26 ] . Administrators must be assured that this investment will result in quality improvement and possibly fi nancial return, either from cost containment (e.g., reductions in hospital stays or nursing labor), increased revenue (e.g., attracting new patients or insurance contracts), or both. It is important to note that cost savings generated by regional anesthesia and perioperative pain manage- ment tend to benefi t the hospital fi nancially and not the individual anesthesiologist or anesthesiology group. In light of this fact, it is reasonable and expected to request the fi nancial support of administration when developing a comprehensive periop- erative pain management service employing regional anesthesia techniques.
Determine if Regional Anesthesia Will Save Money
Strategies to decrease the total cost of providing perioperative services must focus on variable costs despite the fact that the overwhelming majority of costs associated with any surgical procedure are fi xed [ 26 ] .
For ambulatory surgery, the use of peripheral nerve block techniques leads to increases in PACU bypass and shorter time to discharge compared to general anes- thesia [ 5– 7 ] . Cost savings can result from decreased recovery time associated with PACU bypass by reducing nursing time and labor [ 27 ] . In a high-volume orthopedic surgery center specializing in regional anesthesia for anterior cruciate ligament reconstruction (ACLR), the odds of bypassing PACU are nearly four times higher when the patient receives regional anesthesia compared to general anesthesia [ 27 ] . In this setting, PACU bypass has been shown to reduce the average per-patient cost by approximately $420 (USD) [ 27 ] .
The development of step-down (Phase II) recovery units alters traditional PACU nurse staffi ng since these units are not considered critical care units, and patients classifi ed as Phase II may be staffed in a ratio of four or fi ve patients to one nurse.
By increasing PACU bypass from 0 to 40% with regional anesthesia, PACU staffi ng may be reduced by one full-time nurse in a typical surgical center employing full- time staff paid hourly with frequent overtime [ 28 ] . In practical terms, this increase in PACU bypass can reduce overtime and therefore ease the fi nancial burden on short-staffed hospitals and surgery centers.
Shortening hospital stays and minimizing unplanned hospital admissions for outpatients are potential sources of cost savings. Cost containment is essential when dealing with insurers that only reimburse a fi xed amount per surgical procedure regardless of charges. For scheduled outpatients undergoing ACLR, unplanned
admission to hospital adds $385 (USD) per patient [ 27 ] . When employing femoral CPNB for scheduled surgical procedures requiring inpatient care such as total knee arthroplasty (TKA), patients may meet criteria for discharge home sooner com- pared to conventional analgesic techniques [ 1 ] .
A major advantage of CPNB is that it may be provided on an outpatient basis unlike intravenous opioid patient-controlled analgesia or epidural analgesia.
Shortening hospital stays for TKA by transitioning to outpatient femoral CPNB leads to a 34% decrease in overall hospitalization cost (US$ 2,682) due mostly to room and board savings [ 29 ] . According to data gathered from the National Hospital Discharge Survey, the rate of primary TKA in the United States nearly tripled between 1990 and 2002 to over 400,000 per year and is expected to increase [ 30 ] . Given this trend, the potential cost savings afforded by employing a regional anes- thesia service for just TKA is impressive; extrapolating these data to all joint replacements and other major surgeries generates a staggering fi gure that should change surgical practice.
However, the decision to discharge a patient home early after TKA must be agreed upon by the entire health-care team, and proper patient selection is essential.
For patients to be discharged home with a femoral CPNB after joint replacement, he or she must have a caretaker 24 h/day, an established outpatient physical therapy program, and close follow-up by a health care provider [ 1 ] .
Bill Effectively for Professional Fees
The charge is the sum listed on a bill for services rendered. Taking a hands-on approach to billing professional fees will maximize charges and lead to revenue generation for the individual anesthesiologist and anesthesiology group. Billing strategies should be constantly reevaluated as regulations and procedural codes change, and actual billing practices will vary based on the individual institution, geographic location, and payor mix.
Use appropriate current procedural terminology (CPT) codes and modifi ers.
Anesthesia billing services should not be expected to interpret our handwritten pro- cedure notes and deduce the appropriate codes for regional anesthesia because these procedures continue to evolve. For example, simply writing “infraclavicular block”
on an anesthesia record may not be correctly coded as “64415 – brachial plexus block” unless the billing service happens to educate the staff in brachial plexus anatomy. To avoid confusion, consider doing your own coding on a standardized procedure note (Fig. 1.1 ). Common CPT codes for regional anesthesia are listed in Tables 1.1 and 1.2 . Be aware that CPT codes are revised periodically, so make it a habit to review the updated CPT codes every year. When billing for nerve block procedures performed for postoperative pain management, include the distinct procedure modifi er −59 to distinguish the block from the intraoperative anesthetic technique (e.g., 64416–59 for a brachial plexus catheter placed for postoperative pain management) [ 31 ] . This is especially important when the same provider per- forms the nerve block and the intraoperative anesthesia.
Fig. 1.1 Example of a separate regional anesthesia procedure note
Create a separate procedure note. Since postoperative pain procedures are not a part of intraoperative anesthetic care, it is helpful to develop a separate procedure note to document regional anesthesia techniques [ 32, 33 ] . The use of a different form physically separates the regional anesthesia procedure documentation from the documentation associated with the intraoperative anesthetic care and can even include common billing codes (Fig. 1.1 ). When designing new forms, involve your managers to ensure compliance with hospital policies and mandates from regulatory agencies. When using a separate form to document and bill for nerve blocks placed for postoperative pain management, the anesthesia record should not indicate “nerve block” as being part of the intraoperative anesthetic management. However, nerve blocks performed as the intraoperative anesthetic technique should be billed as such and not billed separately for postoperative pain management.
Document physician referral for pain management consultation. When performing regional anesthesia procedures for postoperative pain management, physician refer- ral must be documented as well as the indication for the procedure. This also serves as the request for postoperative pain management consultation.
Billing for acute pain management and ultrasound guidance. Multimodal postop- erative analgesia as part of integrated clinical care pathways has led to the evolution of some regional anesthesia services into acute pain management services [ 34 ] . Prior to January 2009, the CPT code for continuous nerve blocks included the period of routine follow-up (up to 10 days). Since then, the follow-up care has been unbun- dled, and daily evaluation and management (E&M) is currently a billable charge using 99231–99233 for established in-hospital consults. When utilizing real-time ultrasound guidance for nerve block procedures, use the CPT code 76942. In order
Table 1.1 Commonly-used CPT codes (2010) and suggested unit value charges (ASA Relative Value Guide) for single-injection nerve blocks
CPT code Injection site Units charged
64417 Axillary 8
64415 Brachial plexus 8
64447 Femoral 7
64445 Sciatic 7
64483 Lumbar plexus 9
64450 Other 5
64999 Unlisted N/A
Table 1.2 Commonly-used CPT codes (2010) and suggested unit value charges (ASA Relative Value Guide) for continuous peripheral nerve blocks
CPT code Catheter site Units charged
64416 Brachial plexus 13
64448 Femoral 12
64446 Sciatic 12
64449 Lumbar plexus 12
64999 Unlisted N/A
to charge appropriately for the use of ultrasound, the documentation should include an ultrasound image taken during the procedure and procedure-specifi c interpretation of fi ndings. If long-term data storage is not available, consider printing an image and attaching it to the procedure note with a text annotation identifying relative anatomy, needle placement, injection of local anesthetic solution, and avoidance of complications. The modifi er −26, when added to 76942, limits the ultrasound charge to professional fee only and should be used when the ultrasound equipment is owned by the hospital. Without the professional fee modifi er, 76,942 includes a technical component charge for equipment storage and maintenance.
Foster a team approach to billing. Developing a good relationship with the people that send out claims and negotiate with insurance companies is essential. If regional anesthesia is new to an anesthesiology practice, meet with the billing service man- ager in person to clearly explain what regional anesthesia is, why it is performed, and what volume of procedures should be expected. If patient confi dentiality is preserved, it may be feasible to have the billing manager observe regional anesthesia procedures and witness patients’ postsurgical recovery. The more the billing service manager understands the indications and benefi ts of regional anesthesia, the better he or she is equipped to represent the anesthesiology group when appealing rejected claims.
Figure Out How to Make It Work
To make a regional anesthesia service successful, many pieces must fi t together. All of the customers must be satisfi ed, including the patients, surgeons, and administra- tors. While patients may be satisfi ed by the superior pain control and improvement in the quality of postanesthesia recovery afforded by peripheral nerve blocks and CPNB, surgeons and administrators will also demand effi ciency. In the busy outpatient surgery setting, the addition of a new regional anesthesia service does not have to detract from perioperative effi ciency and may, in fact, contribute positively [ 25 ] .
When regional anesthesia procedures are performed in a regional anesthesia induction area or “block room” while the preceding case is still in the operating room, anesthesia-controlled time is reduced compared to both general anesthesia and nerve blocks performed in the operating room [ 25, 35 ] . This parallel-processing model employing a block room may not work for every group practice or institution as it depends on the availability of resources and personnel [ 36 ] . For private anes- thesia groups that function as a care team utilizing anesthesiologists and nurse anesthetists or academic anesthesiology departments with residents, a block room model is both feasible and recommended [ 33 ] .
Regardless of the regional anesthesia service model employed, specially trained personnel in regional anesthesia techniques are necessary. When developing a service that utilizes specifi c procedural skills and advanced technology (e.g., surface ultra- sound and CPNB), hiring and training staff with these skills is the most important fi rst step. The use of ultrasound guidance for regional anesthesia, especially for CPNB, may offer advantages in terms of procedural effi ciency [ 37– 40 ] but requires
dedicated training [ 41, 42 ] . Not all anesthesiology residency training programs are providing adequate training in regional anesthesia techniques [ 43, 44 ] . The develop- ment of subspecialty regional anesthesia services at academic hospitals may lead to increased volume and complexity of procedures performed by residents [ 45, 46 ] . For private practice anesthesiologists, skills can be learned from partners who have received specialized training or continuing education courses that fulfi ll certain edu- cational parameters [ 41 ] .
With the increasing amount of technology employed in regional anesthesia pro- cedures, centralizing supplies in a convenient location will contribute to effective time management. By storing all necessary supplies in one location, either a “block room” or regional anesthesia cart, performing peripheral nerve blocks and CPNB procedures can be as effi cient as possible. Furthermore, getting all practitioners to conform to standardized supplies simplifi es the ordering, storage, and preparation of equipment associated with each procedure.
A “block room” does not have to be a dedicated enclosed space and may be cre- ated out of existing clinical space in a preoperative holding area or postanesthesia care unit. At a minimum, this space should contain standard ASA monitoring, an oxygen source, and resuscitation equipment in addition to regional anesthesia sup- plies (Fig. 1.2 ). In addition, a portable regional anesthesia cart is advantageous because it can be transported from location to location when necessary.
Fig. 1.2 Example of a regional anesthesia induction area or “block room” with standard ASA monitoring, oxygen source, resuscitation equipment, and regional anesthesia supplies
Planning ahead will lead to effective time management on the day of surgery.
Developing a reliable service is optimal because surgeons can discuss postoperative analgesia options including regional anesthesia with the patient in their clinics prior to scheduling surgery. A facility with a preanesthetic evaluation clinic can introduce the concept of regional anesthesia techniques for postoperative pain management.
Written educational materials on regional anesthesia procedures for particular sur- geries as well as answers to frequently asked questions may be printed or made available on Internet websites to help disseminate information prior to the day of surgery. Educating patients in advance saves time and minimizes patient anxiety on the day of surgery. Otherwise, each practitioner can call his or her own patients prior to surgery to discuss specifi c nerve block techniques. During this preoperative phone call, patients scheduled for surgery amenable to regional anesthesia techniques should be asked to check in at least 2 h prior to their scheduled surgery start time.
It is also necessary to identify potential regional anesthesia patients to preoperative nursing and clerical staff so they may be triaged quickly through the admissions process and provide adequate time to perform procedures.
Diligent Follow-up Is Key
Inserting the needle into the right place is the easiest part of regional anesthesia. The diffi cult part is developing an effective system of follow-up which is necessary for any program to succeed. A survey of outpatients with perineural catheters revealed that once-daily telephone calls from a health care provider is the optimal amount of contact, and 98% of patients are comfortable removing their own perineural catheters [ 47 ] . Only 4% would have liked a provider to remove his or her catheter, while 43% would have been satisfi ed with only written instructions and no person- to-person contact [ 47 ] . Patients with an ambulatory CPNB should be discharged with a caretaker (e.g., friend or family member) and should receive specifi c written instructions for their portable infusion device as well as provide a demonstration of the device function for the patient preoperatively. Written instructions should include expected CPNB issues (e.g., leakage and breakthrough pain) and contact information for a health care provider who will be available 24 h a day, 7 days a week. The patient should be followed on a daily basis until CPNB catheter removal, and each contact should be documented on a designated form [ 48 ] .
For inpatients, a designated acute pain service provider or the anesthesiologist who performed the procedure should perform regular follow-up. Managing regional anesthesia patients, especially those with perineural catheters, is a team effort.
A comprehensive clinical care team involving nurses, physical therapists, pharma- cists, surgeons, and anesthesiologists can result in measurable patient benefi ts on a much broader scale [ 34 ] .
A Guide to Team Building: Nursing Considerations in Regional Anesthesia
When it comes to developing positive physician–nurse interactions, an understanding of the basic tenets of modern nursing training is required.
These are collaboration, approachability, autonomy, and education.
Collaboration fosters open communication with the staff [ 49 ] and prevents you, the physician, from feeling frustrated when managing nerve blocks and epidural catheters outside of the operating room. Nurses respond best to nurses; therefore, developing a model that allows for nurse–nurse interaction is best. Collaborate with nursing management and education to appoint at least one nurse for each unit, covering all shifts, to be a regional-specifi c edu- cator who can function as a resource to his or her fellow nurses. You can educate these appointed nurses initially with the information you feel is important (e.g., functional anatomy and physiology of nerve blockade, expected effects, and untoward side effects), and they can continue this educa- tion into their unit. This will build the bridge you need for open communica- tion, avoidance of unnecessary pages, and mutual respect among team members. If a local resource can answer the questions for which you most commonly receive calls (e.g., catheter leakage and pain not covered by the block), it will be easier for everyone involved and lead to faster intervention for the patient when necessary.
Approachability. Make yourself approachable and allow nurses to put a face to your name. When performing inpatient rounds, talk to the nurses and develop a professional relationship. Make sure the nurses know that you want them to call you about your patients and why they should. Remember that nurses are at the patient’s bedside 24 h a day, 7 days a week, and are respon- sible for everything that happens to their patients. The two most common reasons that nurses call a physician are as follows (1) they are familiar with the situation and suspect that something is wrong, or (2) they are faced with a new situation beyond their comfort level and are requesting guidance. Nurses expect that the physician is there to help the patient and act as a guide when they are faced with unfamiliar clinical scenarios. Although there are times when contact may be inconvenient, it is important to respect the assessment of the nurse and discover the solution for the issue together. Later, you can address any underlying issues regarding education so the nurses may become more confi dent in managing regional anesthesia patients in the future.
Autonomy defi nes modern-day nursing. Recent nursing graduates are not part of the generation that simply followed orders. Finding a way to approach new ideas with nursing that allows for empowerment and self-suffi ciency will avoid pushback and encourage more forward progress. Let the nursing staff determine their own educational goals. For example, fi nd out from the nurses how much they want to know about regional anesthesia procedures, patient
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Conclusion
Regional anesthesia techniques provide superior analgesia and can reduce the incidence of common side effects associated with postoperative recovery. However, an effective regional anesthesia product must offer benefi ts to all customers involved.
For anesthesiologists starting a new regional anesthesia service, a hands-on approach is recommended to ensure the highest quality patient care and strengthen relationships with surgeons and administrators. Emerging technology for ultrasound guidance in regional anesthesia and perineural catheter insertion has created a need for specialized training in these techniques. In addition to proper training, a successful regional anesthesia service requires a team effort and necessitates effective communication.
Multiple-Choice Questions
Questions for General Considerations for Regional Anesthesia Practice:
1. Regarding the ways regional anesthesia provides “value” to an institution, all are true except:
(a) Improving patient satisfaction with pain control and postoperative recovery
(b) Creating a competitive edge versus other anesthesia groups and surgery centers
(c) Reducing perioperative costs by decreasing the acuity of patients recovering from surgery and ensuring same-day discharge
(d) Immediately generating new revenue
management, and technology. Remember that simply demanding something never works. This is the best way to generate resistance from nursing.
Lastly, education is what ties the above concepts together. Education is the key to improving nurse–physician relationships, especially when implement- ing regional anesthesia into nursing practice [ 49 ] . Modern-day nursing thrives on autonomy, and in order to prevent resistance from the nursing staff, one must educate a nurse to be effi cient and productive when providing care for the patient with nerve blocks and continuous catheters. Highlight the benefi ts of regional anesthesia in reducing nursing interventions [ 50 ] . Undoubtedly, the educational process will likely start with you, the physician, then trickle down to nursing-specifi c education with dedicated nurse educators. Many hospitals throughout the nation already have pain resource nurses on indi- vidual units, and these nurses may be the ideal liaisons for you when dissemi- nating regional anesthesia education.
