Outpatient Surgery Magazine, providing current information on Surgical Services, Surgical Facility Administration, Outpatient Surgery News and Trends, OR Excellence and more.
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5 6 • O U T P A T I E N T S U R G E R Y M A G A Z I N E • N O V E M B E R 2 0 2 0 cant post-op pain can last for many days. In fact, single-shot blocks for these cases are actu- ally counter-productive because the patient will feel great for 24 hours, then experience "rebound analgesia," dur- ing which they go into a pain crisis. Catheter placements are appropri- ate for outpatient total joints, as is the use of bupivacaine. A nerve block is an effective alternative to general anesthesia for hand surgeries. Instead of injecting a dilute for- mulation of bupivacaine or ropivacaine in pre-op, the anesthesia provider doubles the concentration to eliminate feeling and movement in the arm. Light sedation can be administered to improve patient comfort. Rapid evolution There are several factors that are allowing anesthe- sia providers to deliver more effective and longer- lasting blocks that keep patients comfortable for days after discharge. • New options. The number of blocks available to perform have grown dramatically in recent years. Only 15 or 20 years ago, an anesthesia provider's choices were limited to femoral, interscalene, tap, supraclavicular and infraclavicular blocks. Since then, ultrasound-guided regional anesthesia has opened the door to a variety of possibilities. A distal femoral triangle block, for example, is very similar to a femoral block, but targets branches of the femoral nerve to provide better pain relief after knee surgery. There are now numerous blocks that are more targeted to single nerves throughout the body. Truncal blocks have particularly exploded in popu- larity. Epidurals and tap blocks are approximately 15 additional blocks that control abdominal pain. A patient who had a thoracic epidural placed 15 years ago could not have been sent home the day of surgery because they had to be monitored for hypotension or hematomas. Anesthesia providers can now place a fascial plane block and safely discharge patients after surgery. The anes- thetic used with the fas- cial plane block isn't as strong as an epidural, but it provides more than adequate analgesia for many procedures. • Advanced pain pumps. Catheter-placed pain pumps are our best option for prolonged analgesia for patients who have undergone outpatient sur- gery. Elastomeric pumps deliver consistent, moder- ate amounts of analgesia, while electronic pumps can provide more targeted and controlled pain con- trol. Some electronic pumps allow the provider to administer pre-programmed intermittent boluses, while others allow for patient-controlled boluses. These allow the medicine to fill into the incision space as needed instead of continuously running the anesthetic at a higher volume. Many electronic pumps feature integrated sensors to detect interrup- tions in medication delivery and alarms to alert the patient of malfunctions. Limitations with continuous nerve blocks include the volume in the pain pump's reservoir. If you give a patient 400ccs of local and send them home with a pump that dispenses at 10ccs per hour, patients receive 40 hours of pain relief before the catheter must be removed. Newer pumps allow you to refill the reservoir, but the literature surrounding how long it's safe to leave peripheral nerve or fascial plane catheters in place is scant. How long continu- ON POINT Ultrasound guidance has increased the number of available nerve blocks, which can serve as the primary anesthetic for procedures — not just a tool to reduce post- op pain — and could be less expensive to administer than general anesthesia.