obstacles and opportunities abound for regional anesthesia at most hospitals and healthcare systmes

1. 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

2. 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.

3. Personal Overview and Disclosures
WFU Department has roughly
60 faculty
35 PGY2-4 anesthesia residents
NCBH employs / trains about
50 SRNA’s
60 CRNA’s
RAAPM Section has
3 full time faculty
4 part-time faculty
5 PGY2-4 residents/month
1-2 RAAPM fellows/year
1-2 SRNA’s/month
NCBH employs
3 RN’s in a six bed RAAPM Area

4. “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.

5. 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

6. 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

7. 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.

8. “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.

9. Obturator Nerve
Cutaneous Innervation
• 57%= no skin
innervation
• 23%= superior
popliteal fossa
• 20%= medial aspect
of thigh
-Bouaziz 2002

10. Sciatic
Nerve
Anatomy
in the
popliteal
fossa
-Schafhalter-Zoppoth, 2004

11. 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.

12. “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.

13. The new paradigm: Outcomes
(Patient satisfaction, Functional recovery, Economics)

14. III
I
I
I
II

15. 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

16. 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

17. 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.

18. “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.

19. Local Anesthetics for PNB: No Free Lunch
Manufacturer’s
Recommended
Maximum Dose
(mg)
Mean Latency
to Surgical
Anesthesia
(minutes)
Mean Duration
of Surgical
Anesthesia
(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

20. Alkalinization (in theory)
LOCAL
ANESTHETICS
– Exists at basic pKa
– Formulated at acidic
pH
– Non-ionized form
diffuses
– Protonated form is
active
-Brown 1996

21. • Packaged epinephrine? PERHAPS
–1 to 15 minutes faster onset
Decreased intensity and duration
• Freshly added epinephrine? NO
• Plain local anesthetics? NO
Alkalinization (in practice)

22. Clonidine for PNB
Author Block Solution
Epi
?
Clonidine Dose
Control
?
Duration
Without
Duration
With
Reinhart
Ankle
(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

23. COX-2 plus PCEA
Placebo Rofecoxib
PCEA requests (0-40 hours) 41 21
Opioid consumption post PCEA 9 mg 6 mg
Vomiting 26% 6%
VAS daily while in hospital 4 2
VAS one week after discharge 4 3
Degree flexion at discharge 73 84
Degree flexion at one month 101 109
-Buvanendran, 2003

24. 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

25. 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.

26. “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

27. 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

28. 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

29. 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.

30. “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

31. 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

32. Infrastructure

34. Infrastructure:
more than just
stuff in an area

35. Lots of Paper
Infrastructure

38. 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

39. Billing Codes for Regional
Anesthesia

40. 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

41. 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.

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