Practical Considerations for Adding Regional Anesthesia to Your Practice
I am lucky to work at an institution that has been doing regional anesthesia for many years and I have benefited from the wisdom of those years. Many things that have been learned in the name of regional anesthesia are obviously also relevant to pediatric anesthesia. Avoiding some common mistakes can go a long way in growing your pediatric regional anesthesia practice.
Pre-operative considerations
In this day and age we are all familiar with the surgical timeout. I will make the case for also doing an anesthesia timeout. This timeout has become second nature at our institution, but it does require buy-in from the nursing staff and surgeons, especially depending on where you will be performing blocks, i.e. in the holding area or a block room or in the operating room. All patients must have the surgical site marked and have surgical consent signed and be entirely ready for surgery before performing sedation for any blocks, even in the pediatric population where the parents are signing consent and not the patient. Being consistent about these things is the only way to eliminate avoidable mistakes like blocking a patient and then having the surgeon and family decide to change the procedure or order of cases. We have the nurses maintain custody of the block needles in order to ensure the time out is performed prior to the block placement. Much like a surgical timeout, all activity stops and everyone in the room focuses on the patient and the timeout. The nurse uses the surgical consent and surgeon’s markings on the patient to confirm the site of the block. Then the needle is handed to the anesthesiologist and the nurse stays with the patient until the needle enters the skin. This is similar to the recent “Prep, Stop, Block” initiative in the UK. This is particularly important for surgeries where the patient will be heavily sedated or put under general anesthesia, especially in the case of pediatric patients who are unable to confirm the surgical site. During such surgeries, the timeout process becomes even more critical because mistakes can occur more easily.
Clebone, Burian, and Polaner published a paper in Regional Anesthesia & Pain Medicine with a suggested time out procedure specific to pediatric regional anesthesia. Components they recommend adding include:
preoperative check of anticoagulation and bleeding tendency
patient’s weight, dose and timing of other local anesthetics and maximal allowable dose of local for the block
Intra-operative considerations
Surgeons often champion for blocks to be done in the holding area or a “block room” to save time in the operating room. This may or may not be possible at your institution. Even if this is logistically possible it may not work for the pediatric population. Blocks may have to be performed under deep sedation or general anesthesia for many pediatric patients which is often not something safely done in these other locations. Additionally, the patient may need a mask induction for IV placement before any kind of procedure is done, which necessitates an anesthesia machine. Being efficient about block placement can go a long way, i.e., having your ultrasound at the ready for when the patient is asleep, (this way you also have it available to place IVs or arterial lines as needed!).
It is not necessary to have particularly fancy equipment or needles available to perform most blocks. A spinal needle with some IV tubing (to allow for easier ergonomics) will usually be sufficient. Needle visualization on ultrasound is really a matter of pattern recognition and practice!
Dosing of local anesthesia is an obvious concern, especially in the pediatric population where weights can vary widely. I always recommend only having the maximum dose you would give in your syringe when performing a block to prevent careless errors, particularly when working with an associate provider or trainee. Additionally, communication with the surgical team can prevent them from infiltrating the wound with local anesthetic and thereby administering a toxic dose to the patient.
Post-operative considerations
Another great way to set yourself up for success is to set expectations ahead of time. Preparing the family and the surgeon for the benefits of an adductor canal block is very different then preparing them for a popliteal nerve block. Be cautious not to overpromise and guarantee no pain unless you are certain that you can deliver on that promise! Additionally, discuss with all parties involved (including nursing!) if the plan is to send a patient home with a dense motor block. This may inform the surgeon’s choice of dressing (i.e. splint vs soft dressing, sling for upper extremity), the nursing discharge instructions, and possibly even the criteria needed to be met with physical therapy before discharge.
It's important to properly prepare the family for the patient's transition from a dense motor block to full sensation at home. This includes educating them on what sensations the patient can expect and what options are available for pain control. During this transition phase as the peripheral nerve block wears off, the patient may experience a "pins and needles" sensation. To manage this, it's important to instruct families to administer analgesia as soon as possible. Even a simple dose of acetaminophen or an NSAID can significantly improve preemptive pain management for the patient. Providing families with a reasonable time frame for the block's duration can help facilitate this process.
When performing regional anesthesia the anesthesiologist should also be prepared to provide post-operative follow-up as needed. We often advise families to first reach out to the surgeon’s office to avoid any miscommunications and to simplify instructions, but the surgeon’s teams should have a low threshold to reach out to the anesthesia department with any questions. Many times issues can be clarified and reassurance provided with a simple phone call from the performing anesthesiologist. On the rare occasion that further work-up or procedures are needed, we coordinate with the surgical team, our pain and/or neurology colleagues, and nursing (especially if the patient needs to come something like a blood patch).
Haslam, N., Bedforth, N. and Pandit, J.J., 2022. ‘Prep, stop, block’: refreshing ‘stop before you block’with new national guidance. Anaesthesia, 77(4), pp.372-375.
Clebone, A., Burian, B.K. and Polaner, D.M., 2017. A time-out checklist for pediatric regional anesthetics. Regional Anesthesia & Pain Medicine, 42(1), pp.105-108.
