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."

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