Regional Anesthesia Service
New Regional Anesthesia Service Improves Pain Management
The idea of numbing a portion of the body with epidural, spinal or peripheral nerve blocks is far from new, but regional anesthesia is assuming increasing prominence at the University of Maryland Medical Center with the advent of better technology and a dedicated team to integrate the approach among surgical, trauma and other cases.
The past decade has seen an "explosion" in the use of regional anesthesia both on its own and in conjunction with general anesthesia, according to Ron E. Samet, M.D., an assistant professor of anesthesiology at the University of Maryland School of Medicine and director of the Department of Anesthesiology's Program in Regional Anesthesia. "Patients need less general anesthesia, if it's used at all, and sometimes an entire procedure can be done with only a regional anesthetic," explains Dr. Samet, who learned ultrasound-guided regional anesthesia in 2006 and developed special expertise in peripheral nerve blocks for trauma patients.
Anesthesiologists are trained to provide maximal pain relief for surgical and injured patients. Modalities that include regional anesthesia provide superb and longer lasting comfort compared to traditional anesthetic gases and opioid-based treatment while avoiding the side effects associated with such medications. However, regional techniques require additional training and specialized equipment.
An example of this would be high-resolution ultrasound imaging, which allows clinicians to view nerves with unprecedented clarity, promoting greater use of peripheral nerve blocks to numb entire extremities. "Over the last 15 years, we have seen a dramatic increase in the use of high definition ultrasound. This has allowed us to easily visualize and target specific nerve structures, opening a world of accessibility and safety in procedures."
Dedicated Team of Anesthesiologists
Since his appointment as director of the department's regional anesthesia program in 2007, Dr. Samet envisioned the establishment of a dedicated team to better integrate advances in the field among UMMC patients. That concept came to life in 2013 as the University of Maryland Department of Anesthesiology Regional Anesthesia Service (UMRAS), which is composed of a faculty member, resident and fellow every weekday. The service evaluates general operating room patients and trauma victims to determine if a regional anesthetic or a peripheral nerve block for analgesia would be appropriate and beneficial and, after consultation with the surgical team, provides nerve blocks to patients when indicated.
"Having a dedicated team available with the required training and experience to provide nerve blocks for a wide variety of patients has really revolutionized the care patients are receiving at University of Maryland," says Dr. Samet, who has published on the use of peripheral nerve blocks in trauma patients and has lectured and led more than 50 ultrasound-guided regional anesthesia talks and workshops both nationally and internationally. "A specialized regional anesthesia service is rare in our region."
A multi-modal pain management regimen for patients may combine the use of various analgesics, neuropathic pain inhibitors, nerve blocks and other techniques to create the most comfort possible for each patient. Regional anesthesia can often be combined with general anesthesia for specific cases, thereby lessening the amount needed of other drugs, speeding up the recovery process, enhancing patient rehabilitation and physical therapy, and preventing some negative side effects from general anesthetics or opioid-based analgesics.
"A combined approach has allowed patients who used to recover for three to four days in the hospital to leave in a day or two," he says. "Joint replacement surgery patients are a great example. Starting with pre-medication and placement of a nerve block catheter shortly after they arrive in the hospital followed by an intraoperative and postoperative multi-modal approach, these patients are reporting excellent pain control and greater satisfaction during their shortened hospital stay."
Advanced Techniques for Shock Trauma Cases
With the largest trauma center in the nation, UMMC's use of regional anesthesia among Shock Trauma patients is "taking the bull by the horns" in extreme cases such as limb salvage and amputation as well as in abdominal and chest trauma, Dr. Samet says. "Being able to provide regional anesthesia to severely injured patients at any time during their hospitalization has made us unique not only in the region, but in the country," he explains. "Pain is the most common complaint of the trauma patient, and we take it very seriously. Prior to the regional anesthesia service, only patients who were cared for by anesthesiologists trained in these advanced techniques were offered regional anesthetics. Now, the nursing and physician staff in the Trauma Resuscitation Unit, Shock Trauma's admitting area, and the trauma intensive care units know to call our service when they feel a patient can be made more comfortable with a regional technique," he says.
Consideration is given to the optimal time to perform the nerve block and which patients will benefit from a single injection of local anesthetic versus a continuous infusion that can provide pain relief for many hours or even days. In consultation with other anesthesia providers and their surgical colleagues, members of the team are available to block patients before, during or after surgery. "Being able to do nerve blocks at all bedside locations has really allowed us to take care of patients from moments after their admission ... to provide pain relief through the next few days and weeks," Dr. Samet says. "If they're going to endure multiple surgeries, placing indwelling catheters so we can provide the regional anesthetic over a period of days results in much more comfortable patients."
"If we're able to get involved, it can make the world of difference and augment patient's overall well-being during this medically fragile time," he explains. "Having a team available at any time that's not tied to one specific operating room has really improved our care."
New Advances in Pain Management
As ultrasound technology continually improves, clinicians will be increasingly able to zero in on nerve structures and better tailor the delivery of local anesthetics, Dr. Samet says. Other advances include new, longer-lasting local anesthetics that promise continuous pain relief for far longer than 4 or 8 or 12 hours. One known as Exparel (liposomal bupivacaine) can, at times, last up to 72 hours.
"There's no question that patients who have less pain have significant benefits across the board," he says. "Not only do they recover quicker and feel better at the site of surgery or injury, but they have a better state of mind too. This allows patients to actively participate in the healing and rehabilitation process. More importantly perhaps, those patients who receive excellent pain control are spared from an entire host of systemic effects such as alterations in their immune system, cardiovascular system, appetite and mood."
Another notable benefit of regional anesthesia is its ability to offer some patients more control over their surgical experience. Dr. Samet recalls one patient who was disappointed that his leg operation was scheduled right when a Baltimore Orioles game was about to start. "We told him, ‘We'll put the game on the computer monitor, put the surgical drapes up and you won't feel a thing … you'll be comfortable,'" Dr. Samet recalls. After two nerve block injections, the patient underwent surgery and enjoyed the game at the same time. "Others have relaxed by listening to music or watching a movie during their surgery. For many patients, regional anesthesia has really improved their surgical experience."
Dr. Samet credits Dr. Peter Rock, chairman of anesthesiology, the regional anesthesia team, and the entire staff of acute pain medicine nurses for the program's growth and success, noting that UMMC surgeons have also been enthusiastic about more advanced pain control.
"It really is a team approach," he says, "one that the hospital, our department and many surgical colleagues share."
- University of Maryland Regional Anesthesia Service (UMRAS), launched in 2013, provides dedicated team to assess and implement regional anesthesia when indicated and appropriate
- Multi-modal pain management approach may combine regional anesthetics along with other pain relievers and techniques
- Regional anesthesia use can offset some negative side effects from other types of pain relief
- High-resolution ultrasound offers increasing clarity of nerves to target for regional anesthesia techniques
- Some patients enjoy more control over their medical experience with use of regional anesthesia
FACULTY MEMBERS OF THE TEAM
- Paul Bigeleisen, M.D.
- Jeremy Kaplowitz, M.D.
- Aaron Lange, M.D.
- Hanni Monroe, M.D.
- Matthew Tulis, M.D.
- Ron Samet, M.D.