American Society of Regional Anesthesia and Pain Medicine August 2016 - 10
Figure 1: Step-by-step, laminated instructions of how to do the block were laminated and attached to the ultrasound unit used for ER blocks.
as well as off-service providers who have to travel off-site and do
not realize what equipment is missing until they arrive in the ER.
Additionally, step-by-step instructions (Figure 1) of how to do the
block were laminated and attached to the ultrasound unit used for
ER blocks. It is critical that the step-by-step instructions include
specific instructions about site marking a block time-out. These
will not be common practice for the off-service (ie, non-acute pain
service) anesthesiologists so must be emphasized and explained
within the instructions.
After a block time-out, a femoral nerve catheter is placed.
Lidocaine infiltration in the skin is followed by catheter placement.
Local anesthetic is placed through the needle or catheter. The
catheter is for analgesia. We use 0.2% ropivacaine 20 mL
(0.25% bupivacaine 20 mL is also appropriate) with 1 in 400,000
epinephrine added as a marker for intravascular injection. A low
concentration of local anesthetic has been selected because our
goal is an analgesic block; a low concentration in a nutritionally
depleted patient is likely a safer choice as well.
10
2
Following placement of the initial bolus, an infusion of 6-8 mL/hr
of 0.2% ropivacaine is commenced and continued until arrival in
preoperative holding. Patient follow-up and management by an acute
pain service is critical to ensuring appropriate management of the
nerve catheter. The acute pain service manages the pain medications
in coordination with the floor staff, including a step-down analgesia
plan for when the peripheral nerve catheter is removed.
The peripheral nerve catheter is not used in isolation but as
part of a comprehensive multimodal analgesia plan including
scheduled-not as-needed-prescriptions of nonopioid analgesics.
The patient's medication record should be reviewed as part of the
initial assessment, and coanalgesics should be optimized as patient
health permits. Acetaminophen, celecoxib, and a gabapentanoid
are our first-choice agents. Celecoxib should be used with caution
in dehydrated patients, especially in the presence of elevated
creatinine.
We use our visit with the patient and family in the ER as an
opportunity to perform a preoperative evaluation for the block and
American Society of Regional Anesthesia and Pain Medicine
2016
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