How to set up a standard regional anesthesia service?

The practice of regional anesthesia is getting more popular after the introduction of ultrasound technology in anesthesia practice. The biggest obstacle in conducting regional anesthesia is the delay in operation room time. This brief report focuses on the set up of the so called "block room".

INTRODUCTION

The practice of regional anesthesia is getting more popular after introduction of ultrasound technology in anesthesia practice. Regional anesthesia has many advantages such as reduction of the incidence of deep vein thrombosis, early patient ambulation, better postoperative pain, and decreased incidence of PONV which commonly occurs following general anesthesia.[1-3]

The biggest obstacles in conducting regional anesthesia are: delay in the operating room time and unpredictable success of nerve blockade. Therefore and in order to improve the success rate of nerve blockade and avoidance of any delay in operating room time establishing the standard of regional anesthesia service (RAS) is required.

Settings of RAS

Trained personnel

Trained physician in accredited institute for at least 1 year is considered sufficient to be competent in regional anesthesia. It was reported that approximately 20-25 procedures each year are sufficient for residents to attain adequate skills during the residency period. Not only that but if a 90% success rate is desired, 45 and 60 attempts of spinal and epidural anesthesia, respectively, may be necessary.[4] Unfortunately, there are no available data, to date, showing the numbers of regional blocks that an anesthesiologist has to do to achieve the adequate skills required in that field. We believe that the trained anesthesiologist has to perform 20 successful blocks in each approach, and 20 unsupervised blocks prior to competency. The availability of a trained regional anesthesiologist is not enough to conduct and maintain a good RAS. There should be other departmental members willing to learn and help in performing the technical aspects of regional anesthesia for a safe practice. Once they work as a team the work load will be reduced and the productivity will increase. No successful RAS without a follow up for all the patients who received any kind of regional anesthesia. The follow up can be very helpful for early detection of delayed complications, and to have continuity of care especially pain control if single injection was used or even with a catheter in situ. This major role can be done by an acute pain service team, whether a physician or trained nurse in pain management.

Equipments

Regional anesthesia cart [Figure 1] and ultrasound machine are required. Regional anesthesia cart includes different size of needles and catheters sets for peripheral nerve block, nerve stimulator, preparation and sterilization kits, local anesthetics and emergency medications in the case of mishaps. Ultrasound machine which provides real-time nerve blockade is an important prerequisite for a complete RAS. Moreover, US machine minimize the need of nerve stimulation in case of amputated limb where the nerve stimulation cannot be helpful or in the case of traumatic limb injury or fracture where stimulation will aggravate the existing pain.

Figure 1

The block room is fully equipped

Block room

A survey of the Canadian orthopedics on 768 questionnaire revealed that only 40% directed their patients to regional anesthesia.[5] Those who are in favor of regional anesthesia thought regional anesthesia resulted in less postoperative nausea and vomiting and good pain control postoperative. Those who are not in favor of regional anesthesia thought it results in delay of the operating room time and unpredictable success with possible conversion to general anesthesia. In this case, the availability of a designated area to perform the regional anesthesia namely “the block room” will expedite the flow of the operating room and reduces the delay which may happen while performing regional anesthesia blocks and enhance residents teaching.[6] Armstrong and his colleagues reported that brachial plexus block when performed in the block room can significantly reduce the total anesthesia time when compared to brachial plexus performed in the operating room.[7] The block room [Figure 1] should be fully equipped with monitors, resuscitation, and regional anesthesia carts and should be staffed adequately. Depending on the work load there may be more than one block room available in the operation suite.

Quality control

The practice of regional anesthesia should be closely monitored. Each institute should develop a pathway where the safety of the patient with the safe practice of regional anesthesia is maintained. Each department should assign a coordinator, ideally the most qualified among the group, who can facilitate and maintain the quality of safe practice by direct supervision with keeping up the records of each block in a log book.

The availability of a digital library is preferable where the images and videos can be reviewed at later time where the operator can discover abnormal finding such as incorrect placement of the needle or unequal distribution of the Local anesthetics. Russon et al. reported a case of intraneural injection of the musculocutaneous nerve while reviewing the static images at the end of the day.[8]

In conclusion, we believe that every institute practicing regional anesthesia should have well-organized RAS which include well-trained physicians, cooperative teams, US equipment, well-equipped block room, and finally a coordinator who can maintain the high standard of practice.