Setting up a Regional

Anesthesia Practice at Your

Hospital: Six quotes & a 1/2 dozen

ideas

JC Gerancher MD

Associate Professor and Section Head

Regional Anesthesia & Acute Pain Management

Medical Director of Surgical Services Informatics

Objectives:

•To review the current state of regional anesthesia training in the U.S.•To learn a few newer anatomical finding. •To learn a few newer pharmacologic findings. •To consider our choices in patients. •To consider our choices in surgeons. •To review Regional Anesthesia as Reimbursable peri-operative medicine.

Personal Overview and DisclosuresWFU Department has roughly60 faculty35 PGY2-4 anesthesia residents

NCBH employs / trains about50 SRNA’s60 CRNA’s

RAAPM Section has3 full time faculty4 part-time faculty 5 PGY2-4 residents/month1-2 RAAPM fellows/year1-2 SRNA’s/month NCBH employs 3 RN’s in a six bed RAAPM Area

“Thanks for the excellent training. I can't imagine practicing anesthesia without regional.”

-Anesthesiologist, first year in practice, San Francisco, 2004.

Idea #1: Learning regional anesthesia requires

an investment.

2002: A ‘New Teaching Model’ at Duke: The Regional

Anesthesia Rotation

0

50

100

150

200

250

300

350

SAB EPI PNB

Pre-RAR

RAR

-Martin, 2002

Qualities of RAR’s by Survey

Percentage of US Programs offering…..

A Regional Rotation in name 58%

Formal Instruction 69%

Syllabus 58%

Designated Block Area 29%

Cadaveric Dissection 13%

-Chelly 2003

To set up a regional anesthesia practice at your hospital…………………hire a newly graduated anesthesiologist from an institution that provides good regional anesthesia training. Invest time for your partners to attend a preceptorship, workshop, or conference at one of these institutions.

“Anatomy is the foundation upon which the entire concept of regional anesthesia is built. Anyone who wishes to be an expert in the art of regional anesthesia must be thoroughly grounded in anatomy, for without such knowledge one cannot be successful.”

- Gaston Labat, Regional Anesthesiologist NYC, 1922

Idea #2: Regional Anesthesia is the practice of

real life applied anatomy.

Obturator Nerve Cutaneous Innervation

• 57%= no skin innervation

• 23%= superior popliteal fossa

• 20%= medial aspect of thigh

-Bouaziz 2002

Sciatic Nerve

Anatomy in the

popliteal fossa

-Schafhalter-Zoppoth, 2004

To set up a regional anesthesia practice at your hospital…………………..

purchase the clinically oriented texts, keep current with the clinical regional anesthesia literature, use an ultrasound, and return to the anatomy lab at least one more time to perform some cadaveric dissections.

“I didn’t much care for the feeling in my leg. It felt like a sandwich…with an itch in the middle…that I couldn’t get to.”

-A dissatisfied but comfortable patient following lumbar plexus-sciatic block, Winston Salem, 2006

Idea # 3:

Regional Anesthesia keeps healthy, happy patients healthy and happy.

The new paradigm: Outcomes

(Patient satisfaction, Functional recovery, Economics)

III

II III

Patient Satisfaction is an outcome

• All 7 of 10 RCT’s that demonstrated improved patient satisfaction also demonstrated improved post-op analgesia from regional

• 22% “uncomfortable” during surgery• 27% very concerned about “paralysis,

seeing surgery”.• 37% find needle insertion

“uncomfortable”• “Adequate peri-operative sedation

may be an important factor for patient satisfaction”

• “The anesthesia community has not been successful in keeping the public informed about regional anesthesia.”

-Matthey 2004, Rung 1998, Wu 2001

Functional Recovery is an outcome

PCA PNB LEA% with severe pain (3 days) 35% 0% 5%

% with nausea (3 days) 50% 20% 55%

blood loss (2 days) 600cc 100cc 150cc

48o mobility milestone 84% 100% 100%

Degree flexion day 7 80o 90o 90o

Length of stay 5 days 4 days 5 days

-Capdevila 1999, Chelly 2001

To set up a regional anesthesia practice at your hospital…………………. preferentially and routinely using these techniques in healthy patients to improve surgical recovery and patient oriented outcomes. Both adequate sedation and true informed consent is a necessity for patient acceptance and satisfaction.

“Vitamin O is designed to be an additional source of stabilized oxygen molecules. Start with 10-15 drops of ‘Vitamin O” and gradually build up to 30 drops or 1 good squirt 2 to 3 times daily or more often as required.”

-R Garden International Dietary Supplement, Kettle Falls, WA, 2001

Idea # 4:

Know what pharmacology can and cannot do for you.

Local Anesthetics for PNB: No Free Lunch

Manufacturer’s Recommended Maximum Dose

(mg)

Mean Latency to Surgical Anesthesia (minutes)

Mean Durationof SurgicalAnesthesia

(hours)

Mean Duration of Postoperative

Analgesia (hours)

2-chloroprocaine(Nesacaine)

980 5-15 1-2 2-3

Lidocaine(Xylocaine)

490 7-15 2-3 3-5

Mepivacaine(Polocaine,Carbocaine)

400 10-15 3-4 4-6

Bupivacaine (Marcaine)

225 15-40 6-10 12-17

Ropivacaine(Naropin)

250 15-40 5-9 8-14

Alkalinization (in theory)LOCAL

ANESTHETICS– Exists at basic pKa– Formulated at acidic

pH– Non-ionized form

diffuses– Protonated form is

active

-Brown 1996

• Packaged epinephrine? PERHAPS– 1 to 15 minutes faster onset

Decreased intensity and duration

• Freshly added epinephrine? NO

• Plain local anesthetics? NO

Alkalinization (in practice)

Clonidine for PNBAuthor Block Solution

Epi ?

Clonidine DoseControl

?Duration Without

Duration With

ReinhartAnkle (peds)

1.73% lidocaine No 140 mcg No 3 7

Singelyn AXB 1% mepivacaine Yes 0.5 mcg/ kg No 4 8

Iskandar Mid-H 1.5%mepivacaine No 50 mcg No 2 4

Casati AXB 0.75% ropivacaine No 1.0 mcg/kg No 13 15

Casati F-S 0.75% ropivacaine No 1.0 mcg/ kg No 14 17

El Saied AXB 0.75% ropivacaine No 150 mcg No 10 13

Hutschala AXB 0.25% bupivacaine Yes 2mcg/ kg Yes 1 7

Couture F-S 0.5% bupivacaine Yes 1.0 mcg/ kg No 12 12

Culebras ISB 0.5% bupivacaine Yes 150 mcg Yes 16 14

COX-2 plus PCEAPlacebo Rofecoxib

PCEA requests (0-40 hours) 41 21Opioid consumption post PCEA 9 mg 6 mgVomiting 26% 6%VAS daily while in hospital 4 2VAS one week after discharge 4 3Degree flexion at discharge 73 84Degree flexion at one month 101 109

-Buvanendran, 2003

One dose of gabapentin

Characteristics of studies

Number of studies found in the literature 22

Dose of gabapentin studied 300-1200mg

Degree of opioid sparing 20-62%

Mean 24 hour morphine sparing 30 mg

Numbers to treat (nausea) 25

Number to treat (vomiting) 6

Number to treat (urinary retention) 7

-Tiipana, 2007

To set up a regional anesthesia practice at your hospital ……………..

routinely add clonidine rather than sodium bicarbonate, routinely use COX-2’s and “gabanoids”, and be evidence based and very, very careful.

“He’s healthy. He’ll do fine. I can’t see putting him through that”

-Millionaire and orthopedic surgeon, Palo Alto, 1996

Idea #5:

Regional Anesthesia will only work if the surgeon is your customer

Surgeons v. Anesthesiologists(1=strongly disagree, 5=strongly

agree)

Surgeons Anesthesiologists

RA decreases post-op pain? RA improves OR efficiency? Are RA’s successful?

3.6 2.2 3.1

4.2 3.4 3.8

Patient to choose? Surgeon to choose? Anesthesiologist to choose?

3.9 3.7 3.0

4.6 1.7 4.1

Choose RA for yourself?

3.8

4.6

-Weller,2000

Just wanted to let you know it is 830 and we still have not started our 7am case.............truly, this would not happen without consequences at any other hospital in our region. When will we start our 7am cases at 7am? How long can we afford to pay staff to be ready at 7 and stand around for an hour? Can we afford to plan to have everyone wait for 30 minutes for the supposed 730 start time for 700 cases that rarely occurs?

Your first patient of November 4, case code 266601, has a BMI of 46.7 and was having blocks for total knee replacement. Our standard approach includes femoral perineural catheter placement/ sciatic block and spinal and typically take more time than single injections, but are usually completed in 35-45 minutes. Her morbid obesity made all of her procedures difficult and although those procedures started at 0630, she was not turned over until 0815.

I understand that this was a difficult case with regards to her size and medical issues. However, our process requires sending patients to preadmission testing with anesthesia evaluation, so these factors should not have been a surprise (or for that matter, a reason for delay) on the day of surgery.

Why do you think that longer surgical times due to difficult surgical patients and procedures are perfectly understandable, but that all anesthesia procedures, inductions, etc. should take the same amount of time?

The customer is always right

To set up a regional anesthesia practice at your hospital ……………………………….. use them only for surgeons who want them, who know how their patients recovery postoperatively, and who are likely to capitalize on the recovery and efficiency benefits regional blocks provide. Avoid even the perception of delay and manage side effects and complications.

“Regional anesthesia has come to stay. Its development and progress, for various reasons have been slow, principally because the anesthetist must have accurate knowledge of anatomy and a high degree of technical skill in order that the anesthesia may be safe and satisfactory, and the operation not delayed.”

-William Mayo, famous surgeon, Rochester NY 1922.

Idea #6:

Regional Anesthesia encourages the practice of peri-operative medicine

Peri-operative Clinical Workload of RAAPM

0

5

10

15

20

25

30

35

M T W Th F Sa Su M T W Th F Sa Su

APS Patient Census

Patients blocked for pop management

Patients blocked for surgery

Operating rooms covered

Infrastructure

Infrastructure: more than just stuff in an area

Lots of Paper Infrastructure

Does regional anesthesia pay the bills?

0

100,000

200,000

300,000

400,000

500,000

600,000

700,000

800,000

APS Faculty FTE RA Faculty FTE

APS Charges

OR Charges

Total Charges

Billing Codes for Regional Anesthesia

A ‘New’ Definition of General Anesthesia

• “If the patient loses consciousness and the ability to respond purposefully, the anesthesia care is a general anesthetic, irrespective of whether airway instrumentation is required.”

ASA Committee on Economics, ASA House of Delegates, Position on Monitored Anesthesia Care, 2003

To set up a regional anesthesia practice at your hospital………………

Supporting infrastructure and sometimes even a change in culture is necessary. Correct billing practices are crucial to support these efforts.

“Hey daddy, what kinda regional did that man have?”