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