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Why Isn’t Every Hospital Using Ultrasound-Guided Regional Nerve Blocks?

Posted on Tue, Jan 06, 2015
Why Isn’t Every Hospital Using Ultrasound-Guided Regional Nerve Blocks?


Better recovery. Faster recovery. Fewer side Effects. Shorter length of stay. Possible reduction in cancer recurrence. But despite all of these benefits (and more) associated with ultrasound-guided regional nerve blocks, not every hospital uses these blocks.

Ultrasound-guided regional anesthesia is relatively new, but as we learn more about these benefits, the interest in using it is growing rapidly. While use of nerve blocks dates back to the late 1970s, it was the advancement of ultrasound technology in the 1990s that fostered greater interest in the technique.

Published findings related to ultrasound-guided regional nerve blocks have primarily concentrated on brachial plexus blockade in the interscalene, supraclavicular, infraclavicular and axillary regions.

Recent Studies by the Ultrasound for Regional Anesthesia (USRA) to determine efficacy for femoral, sciatic, psoas compartment, celiac plexus and stellate ganglion blocks show potential, while ultrasound visualization of epidural space can promote neuraxial blockade in children, adults and parturients.

Despite the anecdotal and empirical data, some physicians resist implementation of these blocks. The main reason seems to be a lack of familiarity and training.

RELATED ARTICLE: Meet EmCare's 2014 Physician of the Year: ACE Award for Anesthesia, Dr. Harry Jung III

"Most of the physicians and anesthesiologists from my era did not have this training in their residency and therefore have had little exposure to the technique," says Dr. Harry Jung, III, a Regional Medical Director for EmCare Anesthesiology Services and staunch advocate for ultrasound-guided regional nerve blocks. "EmCare embraced the fact that this is an evolving science that’s proving advantageous for our patients. In addition, the company is willing to further train anesthesiologist on nerve blocks.

New graduates are getting the training in their residency. And I want to help spread the message to the other anesthesiologists in the EmCare Anesthesia line."

Dr. Jung travels extensively to hospitals to lobby for ultrasound-guided regional nerve blocks. One reason for his conviction was his own experience. Dr. Jung’s father received a reverse shoulder replacement. Dr. Jung was impressed with his father’s own rapid recovery and early discharge.

"With the advent of peripheral nerve blocks, especially when they’re ultrasound-guided, it’s really gotten to where we can do very complex surgeries on an outpatient basis," says Dr. Jung. "As a matter of fact, very soon, total joint replacement will be done with these blocks. We’re already doing that, to a certain extent, and part of the way that we’re able to do that is the fact that we do have such good post-operative pain management techniques. We can send these patients home after major surgery and not have to worry about their pain control. Plus, the evolution of this particular field is changing daily, basically, with new medications, finer definition on the ultrasound screen where we can see anatomic constructions that we couldn’t even see five years ago. This lets us more expertly and efficiently put in the blocks and know that they’re going in the right place with very little if any discomfort for the patient."

Outside of the obvious pain reduction, there are many advantages to a peripheral nerve block, now even perivertibral blocks, placed pre-operatively for the management of post-operative discomfort and pain in patients. One exciting concept that’s come out in the last few years is that post-operative pain blocks may be effective in lowering the cancer reoccurrence rate.

"This is still very new literature and findings," says Dr. Jung. "However, it’s very exciting because narratively and traditionally we’ve been unable to assess the effectiveness of post-operative pain management and peripheral nerve blocks in our patients. They tell us that they feel better after having these blocks, rather than traditional narcotic post-operative medications. However, now there are studies that show - perhaps because of the increased blood flow to the area, the augmentation of the immune response, for whatever reason, these could be lowering cancer reoccurrence rates and promoting healing. That’s a very exciting part of the peripheral nerve blocks that we do."

Pain reduction, though, is the primary benefit which leads to the secondary benefits of quicker recovery, earlier discharge from the hospital and more effective physical therapy. Patients are more satisfied with the regional anesthesia because there are fewer side effects such as nausea, hallucinations, psychoses, paranoia, constipation and addiction – all of which are associated with more traditional narcotics.

Outside of surgery, these blocks can be used for pain management, sometimes in lieu of surgery. They’ve been shown to reduce hot flashes for menopausal and pre-menopausal women. They have also been used to treat migraine patients. Use of the blocks in emergency departments (E.D.s) is also gaining popularity. A recent study in "The Journal of Emergency, Trauma and Shock" concluded that the feasibility of the technique in Indian E.D.s, where there are ultrasound machines at nearly every bedside, was strong.

"Residents with minimal training and experience in ultrasonography were able to successfully perform this procedure to achieve adequate regional anesthesia," the study asserts in its conclusion. The study recommends that Emergency ultrasonography training include core areas (e.g., the FAST exam - Focused Assessment with Sonography for Trauma) and an expanded set of bedside applications (e.g., vascular access, nerve blocks, etc.). The study goes on to encourage all academic emergency medicine departments to begin these processes, which can then be disseminated to smaller hospitals. This progression will likely be enhanced as ultrasound technology advances and becomes more cost-effective.

The afore-mentioned "cost effectiveness" can also be a major impediment to widespread use of the nerve blocks. In the era of healthcare reform, hospital administrators have been reluctant to invest in the equipment, materials and training necessary to fully embrace the technique. But experienced anesthesiologists such as Dr. Jung see nerve blocks as a wise investment.

"In this era of HCAPS scores and patient satisfaction scores affecting the way hospitals flourish or not, pain management is a very important part of our job," says Dr. Jung. "As a matter of fact, in our new scoring system for patient satisfaction and HCAHPS, pain management is one of the eight criteria of those patient scores. I joke around a lot but I really mean it - I think it’s the most important HCAHPS score. I mean, if someone’s television is not working, and their food is cold but they’re not in pain, they’re probably not going to complain very much. Conversely, if they get 150 channels on their television and their food is gourmet but they are really hurting, they probably are going to complain. I interview patients who are about to have surgery every day. Many times it’s very serious heart surgery or neurosurgery. Many times, those patients are more afraid of the post-operative pain than of the operations themselves."

As EmCare offers emergency department services as well as anesthesia, the company is seeing first-hand the overarching benefits of adopting the practice in the OR and the ER.

"My whole career I’ve been interested in regional anesthesia and pain blocks," Dr. Jung continues. "With the advent of ultrasound, which is what we’ve been using for about the last ten years, this has really become a science that can be instituted in all particular anesthesiology departments - rural or urban - and I think that the pain level and pain management is probably one of the most important things in a patient’s hospitalization. It’s better for the patient, which in turn helps the hospital in a value-based purchasing environment. And I can’t think of a downside of any hospital adopting ultrasound-guided regional nerve blocks."


Drug Interaction Identified for Ondansetron, Tramadol

Posted on Sat, Jan 03, 2015
Drug Interaction Identified for Ondansetron, Tramadol

Ondansetron linked to increased requirement for tramadol; decrease in the effect over time

THURSDAY, Dec. 18, 2014 (HealthDay News) -- In the early postoperative period, ondansetron is associated with increased requirements for tramadol consumption, according to a review and meta-analysis published online Dec. 10 in Anaesthesia.

A.J. Stevens, from Flinders University in Bedford Park, Australia, and colleagues conducted a systematic review and meta-analysis to examine the presence of a drug interaction between tramadol and ondansetron that reduces the efficacy of tramadol. The authors reviewed data from six studies involving 340 participants. The studies compared the cumulative dose of tramadol administered by patient-controlled analgesia within the first 24 hours after surgery between subjects receiving tramadol alone and those receiving tramadol with ondansetron.

The researchers found that patients receiving ondansetron had an increased requirement for tramadol. At four, eight, 12, and 24 hours postoperatively, the standardized mean difference in tramadol, expressed in terms of standard deviations, was 1.03 (P < 0.001), 0.66 (P = 0.03), 0.86 (P < 0.001), and 0.45 (P = 0.046), respectively. Over the 24 hours there was a significant linear time effect, indicating that the impact of ondansetron on tramadol consumption decreased over time.

"The results support the presence of a drug interaction between tramadol and ondansetron in the early postoperative period that potentially decreases the effectiveness of tramadol," the authors write.

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Editorial (subscription or payment may be required)


In Case You Missed It: Week of Oct. 10, 2014

Posted on Fri, Oct 10, 2014
In Case You Missed It: Week of Oct. 10, 2014

“In Case You Missed It” is a weekly roundup of popular healthcare headlines. 

[OPINION] The Ebola Outbreak: Don’t Blame the Nurse.
There is a lot of talk about why the man diagnosed with Ebola at Texas Health Presbyterian Hospital … >>

Is the Quantified Employee a Healthier Employee? Wearable fitness trackers are seen as a way for companies to ensure employees are keeping active, but are they fit for everyone? Read more at

[VIDEO] Medications Containing Hydrocodone Subject to New, Stricter Prescribing Rules. The Food and Drug Administration has recommended new restrictions on prescription medicines containing hydrocodone, the highly addictive painkiller that has grown into the most widely prescribed drug in the U.S. Click here to learn more.

[Leader’s Choice] This post is recommended by Dr. Michael Lozano, EmCare’s South Division EVP. Questions and Answers on Ebola | Ebola Hemorrhagic Fever via CDC.

[FOR CLINICAL JOB SEEKERS] How to Answer “Tell Me about Yourself” in a Job Interview. Whether you're a clinician or a healthcare professional, here's how to ace one of the most important interview questions.

NEW! Listen to the October podcast from Annals of Emergency Medicine. This podcast covers patient satisfaction, pediatric appendicitis and more. Listen now!

Click here for a handy guide to ACEP 2014.

A Roadmap to Patient Engagement. With patient engagement becoming a central theme in the shifting consumer-driven world of healthcare delivery, providers, payers and patients alike are still in the midst of figuring what, exactly, that means. Read more at

Visit us at these upcoming conferences!

10/11: Anesthesiology 2014 Booth 2136

10/12: ACOEP-The Edge Booth 34

10/16: OTA Annual Meeting

10/27: ACEP 2014 Booth 1611 

11/6: EmCare's Inaugural Cook County Crash Course (C4)

View all upcoming events!


Hydrocodone Combo Products Reclassified As Schedule II

Posted on Sun, Oct 05, 2014
Hydrocodone Combo Products Reclassified As Schedule II

New rule from DEA, taking effect Oct. 6, will impact prescribing practices for these products

THURSDAY, Oct. 2, 2014 (HealthDay News) -- A new rule taking effect Oct. 6 reclassifies hydrocodone combination products as Schedule II controlled substances, which will impact prescribing practices for these products, according to a report from the federal Drug Enforcement Administration (DEA).

The new rule does not allow refills for prescriptions written after Oct. 6, 2014, although prescriptions issued earlier can be refilled through April 8, 2015. Pharmacies will no longer be able to fill prescriptions delivered over the phone or via fax; electronic prescriptions can be used if state law permits, if the prescriber is certified to prescribe these substances, and if the pharmacy is certified to accept electronic prescriptions.

In addition, depending on the state restrictions, non-physician health care team members will not necessarily be able to issue prescriptions for these products. Patients should be made aware of these issues and the new procedures that they will need to follow.

"The American Medical Association and other groups have warned the DEA about the potential unintended consequences of reclassifying hydrocodone combination products since the agency made the proposal early last year," according to an AMA news release. "Eliminating phoned-in prescriptions and refills could make it difficult for some patients to get the pain relief they need, especially patients in nursing homes and those with persistent pain and disabilities."

DEA Rule
AMA News Release


Smoking Rates Still Low for Most Health Care Professionals

Posted on Wed, Jan 15, 2014
Smoking Rates Still Low for Most Health Care Professionals

Pattern persists with rates lowest in physicians (2 percent), highest in LPNs (25 percent)

WEDNESDAY, Jan. 8, 2014 (HealthDay News) -- Compared with 2006 to 2007, smoking rates among health care professionals for 2010 to 2011 continue to be lowest in physicians and highest in licensed practical nurses (LPNs), according to a research letter published in the Jan. 8 issue of the Journal of the American Medical Association, a theme issue on tobacco control.

Linda Sarna, Ph.D., R.N., of the University of California in Los Angeles, and colleagues analyzed public data to compare changes in the prevalence of smoking among health care professionals for 2003, 2006 to 2007, and 2010 to 2011.

According to the results of a 2010 to 2011 survey of 2,975 health care professionals, 8.34 percent reported being current smokers. The researchers note that current smoking rates were lowest in physicians (1.95 percent) and highest in LPNs (24.99 percent). Registered nurses were the only group with a significant decline in smoking rates for 2010 to 2011 (7.09 percent) compared with 2006 to 2007 (10.73 percent) or 2003 (11.14 percent).

"The majority of health care professionals continued as never smokers," the authors write. "In 2010 to 2011, current smoking among these health care professionals, excepting licensed practical nurses, was lower than the general population (16.08 percent)."

One author disclosed financial ties to Pfizer.

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