REGIONAL ANESTHESIA From Past to Present and Beyond
Cheryl Turzanski RN BScN
Debora Morandi RN
Biljana Nenadovic RN
September 2013
• To Enhance the Nurses’ Knowledge of Regional
Anesthesia
• The 5 W’s of Our Regional Program:
Who, What, When, Where, Why
• Increase Awareness and Knowledge of
Peripheral Nerve Blocks, Neuraxial Techniques,
and Blood Patches
• Highlight Effects of the Regional Room on the OR,
Post-Operative Floors and Out-Patient Population
Objectives
THE FIVE W’S
• WHO -- We Are
• WHY-- We Are
• WHERE -- We Are
• WHAT -- We Are Doing
• WHEN -- We Are
• 5 Bed Monitored Unit
opened Sept. 2006
• Staffing: 2-3 RNs, 1 Staff Anesthetist, 1 Anesthesia Fellow,1 PGY 3
• Patient Clientele:
• Day Surgery
• First Day Admission
• In-Patients
• Emergency Patients
Who We Are?
• Chief of Anesthesia put forth a proposal
• Outcome:
– Streamline process
– Relaxed, calm environment
– Protected teaching time
– Improved patient satisfaction
– Savings in OR time
Why We Are
Where We Are
Regional Room
What We Are Doing
• One Stop Pre-Operative Care of the Patient
from the Time They Enter the Hospital
• Admission of the Patient
• Sign Patient into OR, All Checks Done
• Transfer of Accountability Pilot Program
between Core Staffing, Regional Nurse
and OR Nurse
• Pre-Operative Regional
Anesthesia and Analgesia
• Peripheral Nerve Blocks
• Neuraxial Blocks (spinals
and epidurals)
• Local Anesthetic Injected to
Surround a Cluster of
Nerves….Providing:
• Analgesia (numbness for
pain control)
• Anesthesia (numbness
for Surgery)
What We Are Doing
• May Avoid General Anesthesia
• Better Pain Control and Patient Satisfaction
• Reduce Incidence of Nausea and Vomiting
• Less Narcotic Side Effects/ Sedation
• Faster Discharge Readiness
Why Peripheral Nerve Blocks?
• Positioning Frame
• Ultrasound
• Nerve Stimulator
• Sterile Prep, Gel and
Drapes
• Block Cart and Trays
• Stimulating Needle or
Catheter
• Medications
(sedation, and local)
Equipment
Ultrasound
Nerve
Stimulator
Equipment
When We Are
• Hours of Operation
• Monday- Friday, 0600-1600hrs
• When Does Patient get Identified as a
Candidate for Regional Anesthesia?
• In the Pre-Admission Facility
• Day Before Surgery by the Anesthetist
Reviewing the OR List
Utilization Comparison
Utilization by Service
Three Forms of Anesthesia!
• Lidocaine - Short Acting (lasts 2-6 hours)
- Quick Onset (minutes)
- Used for Anesthesia
• Ropivacaine - Slower Onset ( 20 minutes)
- Longer Lasting (6-24 hours)
- Used for Pain Control
• May be Used in Combination to Provide both Analgesia and Anesthesia
Local Anesthetics for PNB
• Block Failure
• Temporary or
Permanent Nerve
Damage
• Infection
• Hematoma/Bruising
• Local Anesthetic
Systemic Toxicity
(LAST)
Complications of PNB
• Intrascalene BPB for
Shoulder and Upper
Arm
• Supra/Infra Clavicular
for Elbow to Hand
• Axillary for Forearm to
Fingers
Upper Extremity – Brachial Plexus Blocks
NYSORA.com
NYSORA.com
• Blocks are Tested
with Ice
• Individual Nerves can
be Isolated with U/S
and “Topped Up with
Local”
Nerves of the Forearm
NYSORA.com
Forearm Nerve Blocks
• Radial
• Ulnar
• Median
• Musculo-
Cutaneous NYSORA.com
• Single Injection or
Catheter (continuous
infusion)
• Knee Surgeries
• Above Knee Amp
• Pain Control
FEMORAL
Lower Extremity PNB
NYSORA.com
Femoral Catheter
• Single Shot Injection or
Catheter (continuous
infusion)
• Ankle Surgery
• Foot Surgery
• Below Knee Amputation
• Outpatient Elastomeric
Pump Program
Popliteal Block
NYSORA.com
• Forefoot Surgery
• Toe Surgery
• Surgical and or Pain
Block
Ankle Block
Outpatient Elastomeric Pump Program
• Disposable Automatic Pump
• Ropivacaine 0.2% at 7cc/hr for 2 Days
• Shoulder, Ankle and Forefoot Surgeries
• Day Surgery Patients (ankles may stay 1 night)
• Must be Motivated and Independent
• Careful Attention to Chronic Pain Needs
• Teaching Done Pre-Operative
• Follow up by Telephone Post op Day 2 and 3
Infuser and Carrying Pouch
Intrascalene Brachial
Plexus Catheter
Baxter Volumeric Pump
Insertion site
Securing
Device
Popliteal Infusion Catheter
Insertion
site
Securing
device
Discharge Instructions and Script
Benefits and Outcomes
• Cost Savings for St. Michael’s Hospital
• Pump $150
• In Patient Bed $1500-$2000/day
• May Free up Beds for More Surgeries,
Decrease Wait Times
• Increase Patient Satisfaction
• Reduce Narcotic Side Effects
• Hospital Funding for 500 Bottles/Year
Neuraxial Techniques
• Spinal
• CSE (combined
spinal and epidural)
• Epidural
• Blood Patch NYSORA.com
• Lower Extremity Surgery
• Lumbar Spine Only (single injection)
• Spinal Lasts up to 3 Hours
• Lumbar Epidural may be Placed to Prolong
Surgical Time, “top up” (epidural catheter)
• Epidural may be Left in Place for Pain Control
for Bilateral Knee or Hip Surgeries or
Medical/Pain Needs
Spinal and CSE
• Indwelling Catheter in Thoracic Epidural Space
• For Post-Operative Pain Control after Large
Abdominal Surgery (eg. AAA, bowel resection)
• For Trauma Patients with Multiple Fractured
Ribs
Thoracic Epidural
Epidural Blood Patch
• Indication- Post Dural Puncture Headache
- Idiopathic low CSF Pressure
• 10-20ml of Patients Own Blood Injected into
Epidural Space
• Improvement of Headache by Increasing
CSFP/ ICP and Patching Leak
• Referrals are Followed in Hospital or at Home
• Outpatients Come Directly to Regional
Room and Discharged home from Regional
Regional Room and its Effect on the
Operating Room
• What is Different
• Positive Effects
• Challenges
Without Regional
Room (RR)
•Registration, DSU,
Holding Area, OR
With RR
•Registration, RR,
OR
•Transfer of
Accountability
What is Different In Patient Flow
Without RR
• OR Nurse takes
the patient to OR
With RR
• Patient taken to
OR by Nurse and
Anesthetist
• Patient
transferred safely
to OR table by
larger team
What is Different
•Position for
Awake Patient
•Dignity
•Position for
Patient with GA
•Emotional
Support
• Anxiety
What is Different
What is Different
•Changes
in Set Up
Time
•Planning
Perfect
Timing for
Next
Patient
What is Different
Positive Effects
•Increased
Efficiency
•Team Development
•Improved Nurse
Patient Relationship
•Enhanced
Cooperation
Communication
Planning
Challenges
•Planning
•Time to Set Up
•Unforeseen Difficulties
•Backlogs in PACU
Post-Operative Orthopedic Floor
Benefits of Regional Anesthesia
• Less Risk of Chest Infection
• Less Effect on Heart and Lungs
• Excellent Pain Relief Immediately After Surgery
• Less or No Nausea and Vomiting
• Earlier Return to Drinking and Eating
• Less Confusion Post Operative in the Elderly
…and Beyond
• 2015 New Building
• 8-10 Beds
• Increased Fellowship Program
• Nurses from 3 to 4