Regional Anesthesia at Outpatient Surgery
Regional Anesthesia at the Outpatient Surgery Center
At UVA, we have separate regional anesthesia rotations for outpatient and inpatient surgery. There is a separate, dedicated Regional Anesthesia resident at the Outpatient Surgery Center (OPSC) and one in the main operating rooms. The regional resident is responsible for performing peripheral nerve blocks and managing nerve catheters for those patients on the floor who have them for postoperative pain control. Significantly, the regional resident is not assigned to administer the primary anesthetic for any room, which frees up time to provide the maximum number of blocks possible.
The minimum number of regional blocks required during residency is 40. After 3 weeks on the service, I have completed 105 blocks. And I will do more regional next year as a CA3. An average day in the Main OR will provide between 5 to 7 blocks. At OPSC, an average day is 7 to 10 blocks. Thursdays and Fridays are busy days for the hand surgeons, and there can be as many as 15 blocks in one day. While this may seem like a lot, typically you are finished by 3:30 to 4:00 PM—and when you are finished, you go home.
A day placing blocks at OPSC
6:25 I arrive at OPSC and take a look at the schedule. The regional fellow will send out an email the day before with potential nerve blocks listed on the schedule. At this point, I start drawing up syringes of lidocaine for skin infiltration and ropivacaine for the nerve blocks.
6:40 Today there is only one first start block, for a shoulder arthroscopy. I talk to the patient, and he agrees that a brachial plexus block would be a good idea for postop pain control. The surgeon has also suggested that he gets a block, so it doesn’t take any convincing. After the consent is signed and the nurse has placed the IV, we bring him back to the dedicated block room to place his block.
7:00 The patient is in the block room, we perform our time-out, and take a look with the ultrasound. He has good anatomy, and I easily place the needle beside the trunks and watch the local anesthetic surround them while we inject. Soon after, I ask him to try to lift his arm to the ceiling before heading back to surgery. He can’t do it—success!
At both the Main ORs and OPSC there is a nurse dedicated to assisting with nerve blocks, and they are a tremendous help. Their help ranges from moving the patients to the block rooms, to placing EKG leads, to the paperwork of charting vitals and postop notes. Also, at OPSC there are 6 ORs, and 3 attendings. Generally, there is a regional attending for the day who is assigned to only one room. That way they are always available for blocks.
8:00 The next round of cases is ready to get going, so I start consenting, and getting ready. By 9:30, I’ve done 4 blocks already (3 brachial plexus blocks and a femoral nerve block for an ACL repair).
9:30 There is a little lull between cases, and I start to call patients from the previous day to see how their pain is and make sure their block has worn off. Ninety-nine percent of patients are extremely grateful for their regional anesthetic, and most were pain free for a significant amount of time postoperatively. Everyone’s block has appropriately worn off 24 hours postop, and it seems the patients are tolerating their pain with oral meds.
10:30 Now the fun begins. There are about 6 cases starting within the next 2 hours, and they all need blocks. One of the other anesthesiology attendings gives me a hand with consents, and we start bringing patients in. Block room A, supraclavicular block: done. Move to block room B, where the patient has been set up for monitoring and positioned while I was performing the last block (another supraclavicular block): done. Back to A, supraclavicular: done. Back and forth, 6 blocks within 2 hours. Phew, that was exhausting, but so satisfying.
12:45 Another lull before the last round of blocks, an ACL and a shoulder. I pop my head into the rooms of the patients that I just blocked, and none of them are under a general anesthetic—successful blocks. I also talk with my attending for the day regarding some ultrasound anatomy. We also go over some basic pharmacology of local anesthetics.
13:45 Last round of consenting and blocks.
15:30 By the end of the day, I have done 12 blocks, and they have all worked very well. Used ultrasound for all of them, and by this time, I feel extremely comfortable with my skills at regional anesthesia.