Drs. Weber and Jain are to be commended for gathering retrospective data on
experience with regional scalene anesthesia in 218 patients treated over
a three year period in two communnity hospitals. They conclude that pre-op consent discussions should include
information on the complications that can occur.
Their article seems to
imply that the rate of complications when using this procedure in a community setting is so high that
it is not a satisfactory adjunct for perioperative pain
control. The authors also present a cost analysis which implies that it is more expensive than alternative pain control modalities.
We also work in a
community hospital based surgery center
about an hour away from Sacramento. Our anesthesiologists, some of whom had been performing blocks for the past two to three years, have done 230
blocks since last July. In that period,the failure rate of the initial block was between 5 and 7%,but those patients who failed to achieve pain relief with the first block were
routinely re-blocked and we know of no patient who failed to achieve analgesia by the
time he or she went home. Our anesthesiologists are not aware of any nerve
or cardiovascular injuries. There was one seizure with no sequelae. I have encountered a few patients with some persistent sensory
changes in the forearm. These residual signs have uniformly resolved and have
been considered negligible by the patients in comparison to the primary
shoulder problem.
We agree with the authors that some blocks "wear
off in the middle of the night". A handful of patients have required an
emergency room visit (but not a hospital admission).
Thus patients should be advised that a block will wear off eventually, and that more
pain can be expected. But that event is well managed with pre-emptive
analgesia with Oxycontin and rofecoxib in post op doses.
I also agree
with the authors that the block does have risks. For that reason, we have
never used them for post op pain in arthroscopic acromioplasties. This
group of patients seems to do well with conventional analgesia and local
wound infiltration. Our surgeons typically reserve scalene block for open
cuff repairs, open capsulorrhaphies, arthroplasties and fracture work and
refractory adhesive capsulitis.
The authors cost analysis also differs
from our experience. The material cost is basically the cost of the local
anesthetic, syringe, and needle. Blocks are done in 15 minutes
in the preop area while the operating room is turned over, or in some cases, post-operatively
on the awake patient to prolong post op pain relief. The anesthesia fee
of $440 described as "usual and customary charge"in the article is a fee
that no one collects. Our average fee is $150, with lower reimbursement from
Medicare and Workers Compensation. Not included in the cost analysis are
the cost savings of doing the block. Without blocks, many of the
patients who are discharged several hours after their procedure would need
over night hospitalization. Given that more than half the patients in this
article were in a community hospital, the added PACU and overnight costs
would be very significant.
I have personally undergone a major repair of the rotator cuff, long head of the biceps, and subscapularis.
My only anesthesia
was the block with supplementary oral rofecoxib, and I had little discomfort for 12 to 18 hours.
Therefore, based on our experience, I would make the
following recommendations:
1.Reserve blocks for procedures
traditionally requiring hospitalization,or where pain relief is essential
for early passive motion.
2.Just as with introducing a new surgical procedure, blocks should be performed
initially by two to four interested anesthesiologists, who will
commit to extra training and devise protocols to provide the
opportunity for re-block when necessary,and pre-emptive analgesia
regimens.
3. Consider blocks not so much for intraoperative
anesthesia as for post op pain management.
I would like to credit
Steve Jacobs,MD,Department of Anesthesia Sequoia Surgical Pavilion and
John Muir Medical Center for most of the analysis presented.
Jerome H. Davis, MD
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