Setting up a Regional Anesthesia Program
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This document provides guidance on setting up a regional anesthesia practice at a hospital. It discusses the importance of hiring anesthesiologists with good regional training, investing in anatomy education, focusing on patient outcomes and satisfaction, using pharmacology evidence-basedly, gaining surgeon buy-in, and establishing proper infrastructure and billing practices to support the regional anesthesia program. The overall message is that regional anesthesia can enhance surgical recovery when implemented through a thoughtful, multidisciplinary approach.
Setting up a Regional Anesthesia Program
- 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
- 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
- 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?”