Journal of Anaesthesiology Clinical Pharmacology

EDITORIAL
Year
: 2020  |  Volume : 36  |  Issue : 1  |  Page : 1--4

Are we too focused on blocks, to care, for the patient as an individual who needs holistic care?


Vrushali Ponde 
 National President Academy of Regional Anaesthesia, Holy Family Hospital, Surya Children Hospital, Holy Spirit Hospital, Children Anaesthesia Services, Mumbai, India

Correspondence Address:
Dr. Vrushali Ponde
Department of Anaesthesia, Surya Children Hospital, S V Road, Santacruz West, Mumbai - 400 054, Maharashtra
India




How to cite this article:
Ponde V. Are we too focused on blocks, to care, for the patient as an individual who needs holistic care?.J Anaesthesiol Clin Pharmacol 2020;36:1-4


How to cite this URL:
Ponde V. Are we too focused on blocks, to care, for the patient as an individual who needs holistic care?. J Anaesthesiol Clin Pharmacol [serial online] 2020 [cited 2020 Jun 4 ];36:1-4
Available from: http://www.joacp.org/text.asp?2020/36/1/1/278471


Full Text



“Work is love made visible”

Khalil Gibran

We feel very contented, useful and happy when our patients are safe and comfortable in the perioperative period. Learning new techniques and implementing fresh ideas add a lot of meaning and zeal to our daily work. Keeping abreast with the latest and honing skills at any given opportunity makes daily work enjoyable. Regional anesthesia (RA) is one such aspect that constantly demands grooming. The scope and play of RA are ever increasing. Certainly, because this is one of the best tools to treat perioperative pain with least amount of changes in the patient's physiological milieu. RA is evolving more than ever before. With different techniques, modalities, equipment, drugs and yes, attitude. Well thought of workshops, skill courses, fellowships, etc., offer precise and vigorous teaching to hone these skills. Text books, internet, etc., keep adding to the existing knowledge. Introduction of ultrasound-guided regional anesthesia (USGRA), with its promises, has made all of us take a rightful note of it. We all want to travel over the learning curve of USGRA to make the most of this tool and why not! USGRA has made RA objective and the dual modalities are nullifying the failure rates. Yes, we are steadily marching towards an era where regional blocks and GA may almost have equalled the success rates!

Being an ardent RA enthusiast, I understand the focus, practise and dedication required to perfect these skills. Although this is true, it is high time we ponder on issues that we might miss by being too focused on technical aspects! Apart from dexterity few other skills are required for a successful conduct of RA.

To sum up and introspect on the most pertinent aspects that matter while performing RA is the main reason for penning down this editorial.

Is the preprocedural communication with the patients adequate?

The onus of communication and reassurance is much more on us while conducting a case under RA than otherwise. The RA procedure should be explained adequately. The various other options including sedation should be discussed. The benefits of RA should be explained with a clear emphasis of it being a 'business class in post-operative pain management'. It would be thoughtful to communicate in advance about the insensate and numb extremity post-operatively if the block is expected to remain 'dense'. In our experience, adolescents and school-going children seem to be most affected by this. Sedation and occasional conversion to GA if the block fails could be mentioned, especially if such a question is asked. A well-informed patient is more likely to be cooperative.[1]

Is consent specific to RA taken? And have we documented any previous neurological deficits in the area which the block shall render temporarily insensate?

Fundamentally, we require consent for any procedure. Zarnegar et al.[2] in their survey pointed out the inadequacy in this area. Their results showed that the recall of surgical risks was overall significantly better than recall of brachial plexus block risks. We need to improve our understanding of the consent for RA. The Academy of Regional Anesthesia (AORA), India (Annexure 1), suggests a consent form with a specific mention of RA and its related aspects. Readers would find this form [[SUPPORTING:1]] at the end of this editorial.

Is the Anesthesiologist–Patient interaction before wheeling the patient inside the operation theatres (OT) given its due importance?

The quality of anesthesiologist–patient interaction matters a lot. Surveys have shown that it improves the quality of PNB, and moreover, the willingness of patients to undergo repeat PNB.[3] The anesthesiologist in the OT and pre-anesthesia check-up may be two different people. A quick self-introduction is an etiquette we owe our patients irrespective of the set up. A reassuring tone, positioning the fractured extremity in the least painful position, administration of IV analgesics or sedation[4] go a long way. All this shall set a correct attitude of the patient to the RA procedure, which is shown to influence results.[5] The most crucial time points are shifting through the corridors, from the trolleys to the operation table and back.

Is the checklist seriously looked into?

It is mandatory to keep our resuscitation carts, intralipids and routine anesthesia equipment checked. RA is never an excuse for taking safety for granted.

Is an effective and liberal skin infiltration with local anesthesia our normal practise?

The fear and complaint of needle puncture is the greatest negative factor for RA. Are we so engrossed on visualising the needle on the ultrasound screen that the wincing of the patients faces on repeated adjustment and passes don't strike us? Have we given a thought to the pain elicited by the end motor response of a fractured limb? We need to answer this to improve patient satisfaction which shall go a long way in making RA more acceptable.

Do we communicate with the patients while we give blocks?

We understand it will come with time once the dexterity is mastered but that should be the goal. As awake patient is the best monitor to pick up LAST. Of course, there is no such luxury in pediatric population!

Do our surgical colleagues know our anesthesia plan?

This is team work, and functions the best when well-coordinated. Besides, they know what to expect especially in post-operative interpretations.

Have we planned patients position for the surgery?

A cold operation theatre, uncomfortable position on the operating table, surgical drapes, a full urinary bladder, etc., can add up to a lot of discomfort for an awake patient despite an effective RA. Warmers, reassurance and sedation can ease out these difficulties.

To sum up, RA is a fascinating subject. It imparts lot of safety. It is almost evangelising due to the profound pain relief it offers. But a perfectly placed block can be a nightmare to the patients if we don't take a holistic approach towards it.

We shall miss the point totally if we have a perfectly acting block but an uncomfortable and dissatisfied patient. Our patients should be happy enough to be our ambassadors.

Are our patients really satisfied with RA? should be our main concern today because success rate is something, we are more conditioned to think about and pretty much close to the target.

References

1Jlala HA, French JL, Foxall GL, Hardman JG, Bedforth NM. Effect of preoperative multimedia information on perioperative anxiety in patients undergoing procedures under regional anaesthesia. Br J Anaesth 2010;3:369-74.
2Zarnegar R, Brown MR, Henley M, Tidman V, Pathmanathan A. Patient perceptions and recall of consent for regional anaesthesia compared with consent for surgery. J R Soc Med 2015;11:451-6.
3Ironfield CM, Barrington MJ, Kluger R, Sites B. Are patients satisfied after peripheral nerve blockade? Results from an international registry of regional anesthesia. Reg Anesth Pain Med 2014;39:48-55.
4Höhener D, Blumenthal S, Borgeat A. Sedation and regional anaesthesia in the adult patient, Br J Anaesth 2008;100:8-16.
5De Andrés J, Valía JC, Gil A, Bolinches R. Predictors of patient satisfaction with regional anesthesia. Reg Anesth 1995;20:498-505.