Introduction
Regional anesthesia in the form of peripheral nerve blocks has been demonstrated to reduce post-operative pain and improve patient-centered outcomes following orthopedic surgery. Unfortunately, ambulatory patients receiving regional anesthesia may require increased resource utilization due to various issues. Sunderland et al. examined healthcare resource utilization in patients after wrist surgery, comparing subjects who received a single-shot peripheral nerve block (PNB) vs. general anesthesia (GA). Subjects who received a PNB had higher rates of unplanned ED/office visits caused by poorly controlled pain after discharge compared to subjects who underwent general anesthesia. Our institution has noticed a similar trend of increased healthcare utilization, especially in patients receiving ambulatory perineural catheters.
Case Presentation
A 66 year old female admitted for an elective repair of a rotator cuff tear received an interscalene catheter with an initial bolus of 20 cc of 0.5% Ropivacaine preoperatively. In the PACU she was found to have a dense nerve block with no significant pain or complications. She was discharged home on POD-0 with a home pump dispensing 6 mL/hr of 0.2% Ropivacaine. Overnight, the patient called with concerns that her pump was not working, as she reported increased ability to move her fingers, decreased numbness, as well as an increase in pain intensity. The resident determined that the block was still working and the changes she was experiencing were part of the expected transition between the dense surgical block and the post operative block. She was instructed to continue using the pump and supplement with the prescribed pain medicine regimen.
A 62 year old male was admitted with an open radial shaft fracture after a motor vehicle crash and underwent an open reduction and internal fixation. He received a supraclavicular perineural catheter for post-operative pain. Prior to his discharge on POD#1, he was given instructions on management and removal of his home pump catheter. The patient called the covering physician on POD#3 with significant stress and anxiety related to discomfort at having to remove the catheter. He had sought care at his primary care physician’s office as well as a local urgent care center. The covering resident guided him through catheter removal by phone and the patient had no additional complications.
Discussion
The ambulatory regional anesthesia challenges encountered in these cases was likely a result of inadequate patient knowledge about homepump and oral analgesic management. Studies have looked at the benefits of patient education on reducing healthcare costs and improving outcomes. Elderly patients who received education on basic pain management and pain communication skills prior to their joint replacement surgery reported less pain on POD0 and POD1 from their surgery. We are currently conducting a prospective cohort study to test the hypothesis that provision of a comprehensive education program directed at patients and their family members will reduce healthcare resource utilization and improve satisfaction in patients undergoing ambulatory surgery combined with a peripheral nerve block. A more extensive and standardized education program could prevent issues such as those experienced by the patients in the cases discussed.
