From the Editor's Desk: We Will Block You

Aug 6, 2019, 16:03 PM by Kristopher Schroeder, MD

We will, we will block you, yeah, yeah, come on
We will, we will block you, all right, louder!
We will, we will block you, one more time
We will, we will block you.

In the era of unbridled enthusiasm for regional anesthesia, we seem to have a nerve block for every postsurgical or painful condition we are presented with. That was certainly not the case 15 years ago, when we had a limited number of procedures considered amenable to the application of regional anesthesia. I can easily recall a time when our routine regional anesthesia procedures were limited to epidural, spinal, femoral, popliteal sciatic, interscalene, and axillary brachial plexus blocks. Now, with ultrasound guidance, we have new approaches to old blocks and regional anesthesia targets that never would have been possible with the historical limitations in practitioner skill and available technology. Further improvements in ultrasound availability have facilitated an increased interest in enhancing skill with this technology.

The uptick in technique variety, number, and widespread applicability has likely resulted from the confluence of a number of factors. The highly publicized national opioid crisis has resulted in an increased interest from patients and providers alike to diminish the need for profound or sustained doses of opioid analgesics. Carryover from bygone eras may lead patients and providers to believe that the goal of perioperative or ambulatory analgesia is zero pain. We have witnessed improvements in ultrasound technology and availability that allow for visualization of targets that previously were obscured. Certainly, the recent proliferation of fascial plane blocks is largely related to and dependent on these improvements in technology.

Might we have overestimated our collective abilities and risk exposing patients to harm from pushing the boundaries of what might be accomplished in the provision of ultrasound-guided regional anesthesia?

Beyond that, we have accumulated fellowship-trained regional anesthesia practitioners who have committed their lives to the provision of analgesia and ultrasound-guided blocks. Anesthesia practitioners have accumulated more than a decade of experience with ultrasound image acquisition and needle driving, which has resulted in a collective increase in our comfort with the procedures and the idea of future improvements or alternative techniques. The abstracts and medically challenging cases presented at the ASRA and American Society of Anesthesiologists annual meetings share a glimpse at the burgeoning application of new fascial plane blocks, such as erector spinae and quadratus lumborum.   

However, does our increased comfort level with ultrasound-guided regional anesthesia procedures actually exceed our abilities and are we now suffering from an excess of hubris? Might we have overestimated our collective abilities and risk exposing patients to harm from pushing the boundaries of what might be accomplished in the provision of ultrasound-guided regional anesthesia? Have we gone too far extrapolating the results of anatomical studies into changes in our clinical practice? What is the real analgesic impact of these new approaches on our patients? Specifically, how efficacious are these newly introduced regional anesthesia procedures? What risks are we exposing our patients to when performing newly introduced procedures with limited data to support their efficacy? How do we ensure that our experienced faculty are adequately trained in the application of new fascial plane blocks? Should we have a training threshold, or are we satisfied with Dr. Google or Dr. YouTube training our physicians in the provision of these new techniques? How do we advocate for reimbursement for procedures that have limited data to support their widespread application? Ultimately, how do we avoid projecting that we are simply experimenting on patients with these analgesic techniques that possess real but unknown risks?

Full disclosure, I don’t know how to adequately answer these questions and presumably this will be something that providers of analgesic procedures will continue to struggle with over time. Obviously, obtaining data from well-conducted, prospective studies is ultimately required to support the widespread application of these techniques, and ASRA has been incredibly supportive of such efforts. However, faculty at many institutions are burning out simply providing high-quality, compassionate clinical care and have no resources or mental bandwidth to conduct quality research studies. Certainly, making concerted efforts to understand these new procedures through a thorough review of the literature, conference and workshop attendance, and colleague interactions can help to improve our collective consciousness related to these procedures. Regardless, we must acknowledge the uncertainties in our discussions with our patients so that we are able to collectively make a decision regarding what might represent the preferred analgesic technique.

I am heartened and encouraged by the work that we as a society and subspecialty are doing and the meaningful differences that we are making for our patients. I believe that these new procedures might offer tremendous value, and I have been amazed by how they have allowed for us to improve care for a variety of patients. Ten years ago, I never would have conceived that my group would be collaborating with interventional cardiology, hematology or the emergency department. Our current reality is that we collaborate with other specialties on a daily basis and have anecdotally contributed to improvements in patient care and analgesia throughout the hospital. 

What we require now is a balance between our enthusiasm, what can be reasonably supported in the literature, and how these procedures can be explained to our patients. If we continue to keep patients in the forefront of our decision-making process, we likely can’t go wrong. Happy blocking.

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