Regional nerve blocks are an opioid-sparing alternative that minimizes narcotic side effects, reduce pain and nausea post-surgery, lessen the cognitive impact on the patient, eliminate risks of respiratory depression and allow patients to ambulate sooner. These benefits mean providers are able to wring costs out of their bundles by reducing length of stay and after-hospital costs, including those associated with opioid-related adverse events, readmissions and skilled nursing facilities.
“If you care about outcomes, if you care about bundled payments and value-based care, if you care about satisfaction for all your staff members and your patients, if you’re aware of the spiraling opioid epidemic we have in this country and if you are interested in doing outpatient joints, then there is a nerve block — there is a type of regional anesthesia that can help us accomplish all of these goals,” Sonia Szlyk, MD, director of regional anesthesia for the mid-Atlantic division of North American Partners in Anesthesia, said during a presentation at the 15th Annual Spine, Orthopedic and Pain Management-Driven ASC Conference + The Future of Spine in Chicago.
In a survey conducted by the University of Toronto in Canada, most orthopedic surgeons (84 percent) indicated they support using regional anesthesia on their patients. These surgeons cited less postoperative pain, improved safety and decreased nausea and vomiting as their principal reasons for favoring nerve blocks. However, it is equally important to look at the concerns surgeons had about using regional anesthesia, according to Dr. Szlyk.
Surgeons were most concerned about delays in inductions of the anesthesia and unpredictable success rates. “Avoiding delay in the operating room and having nerve blocks that work are key paramount factors that you need to be able to deliver to your patients, to your administrators and to your surgeons,” Dr. Szlyk said.
However, these anxieties can easily be addressed using new technologies and strategies in the OR, she said.
First, physicians can use ultrasound guidance to visualize the structures under the skin and find what needs to be surrounded by local anesthetic in a matter of moments. “Gone are the days where regional anesthesia took 20 minutes to do a single shot nerve block,” Dr. Szlyk said. “Nerve blocks are much more efficient and effective because of the advent of ultrasound guidance.”
Second, delays in the OR can be eliminated with strategic preparation. “Just like you don’t all the sudden decide your patient is going to have their knee replaced, you shouldn’t all the sudden decide your patient is going to have a nerve block,” Dr. Szlyk said. During the preoperative visit, surgeons should introduce the idea of the nerve block and have patients sign consent forms. Then patients who are receiving nerve blocks should be told to arrive at the facility early to allow more time for triage. While the blocks themselves do not take a lot of time to administer, patients must be positioned and aware. Dr. Szlyk advises administering the nerve blocks preoperatively in a designated block bay. “We really feel that the operating room is for surgery,” she said. This work can be led by block nurses specially trained to work with patients before, during and after the procedure, which helps improve efficiency, she added.
Regarding concerns about the effectiveness of regional anesthesia, one of the top concerns surgeons have is how well nerve blocks are able to balance the need for pain control with quadriceps weakness post-surgery. To address these concerns, Dr. Szlyk suggests using adductor canal catheters for partial and total knee replacements and ACL repair. These catheters enable patients to maintain strength in their quadriceps, allowing for faster ambulation and discharge. They are portable and can be removed at home by patients themselves.
“This has been a way for some of our surgeons in the past that always said no to nerve blocks because they didn’t want any type of quadriceps weakness, they are now so excited about adductor canal catheter because you can have that pain control without the weakness,” Dr. Szlyk said.
These strategies and technologies make regional anesthesia an asset to bundled payments by decreasing pain scores, PONV, length of stay, PACU time, use of opioids, readmissions and the need for SNF or inpatient rehab. Alongside these reductions, providers can expect to see increased patient and surgeon satisfaction, ambulation, physical therapy participation and discharge to the home, according to Dr. Szlyk.
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