Nerve Blocks: An Easy and Cost Efficient Way to Augment Perioperative Pain Control

By Lisa Moses VMD, DACVIM, CVMA 

If you’ve been to a big CE conference in the last few years, you’ve probably heard some buzz about local and regional anesthesia/analgesia. The hype is appropriate; there are few drugs or techniques that can augment pain control as safely, easily, or cheaply as local blocks. Part of the buzz is about new ways of performing nerve blocks using locator techniques. These methods are really improving the efficacy of local anesthesia. At Angell we use nerve locator techniques to do many different kinds of preoperative blocks, including brachial plexus blocks, psoas compartment blocks and some epidural injections. We are also training to start offering ultrasound-guided nerve blocks, which will greatly expand the types of blocks we can perform. We’ve been using wound diffusion catheters for many years now. These are fenestrated catheters implanted in large incisions during surgical closure of amputations, thoracotomies and large skin wounds. These catheters are used to continuously deliver local anesthestic agents and greatly reduce the need for large amounts of post-op systemic opioids with all their attendant side effects.

Even if your practice doesn’t have the case load to justify training and equipment for directed nerve block techniques, you can quickly and cheaply add local anesthesia techniques to your multimodal analgesia protocols. In most cases, local blocks cost less than a dollar in supplies and drugs, and only take seconds to perform. Don’t forget: few clients will decline modest charges added to surgical fees in exchange for better pain control for their much-loved pets.

I would recommend that you stock your practice with 2% lidocaine and 5% bupivicaine, if you don’t already. Most blocks can be accomplished with the regular 22g and 25g needles that you already stock. In some cases it’s useful to have 1 ½ inch needles as well. If you make sure to use good aseptic technique and avoid injecting directly into a vessel or nerve, the risks are minimal. For all blocks other than oral ones, we do a surgical prep and wear sterile gloves.

My recommendations for easily added techniques are oral blocks for dental procedures and testicular blocks for castrations. Both of these are easy to learn, done with no special equipment, and are proven to greatly increase post-op pain control. See below for resources to help learn these techniques.  And, consider using EMLA cream (topical liposomal lidocaine cream) on skin before attempting IV catheterization in sensitive and frail patients. Clip the area, apply the EMLA cream like frosting a cake and cover it with plastic wrap for about 15-20 minutes. It will help desensitize the area.

There are many resources available now to help you learn these techniques. Most regional and national veterinary CE meetings offer wet labs. The International Veterinary Academy of Pain Management (IVAPM) is sponsoring a wet lab at the Oquendo Center (WVC’s classroom and lab facility) in February 2011, among others coming up. There are also readily accessible resources available on the internet.  Even You Tube has videos of folks performing these blocks.

Some resources that can answer a lot of your questions and give you step-by-step instructions include:

 

·        The International Veterinary Academy of Pain Management (IVAPM) and Pfizer Animal Health have partnered to create a DVD on Anesthesia/Pain Management Techniques for Veterinary Professionals. Volume 1 includes step by step procedures on ring blocks, brachial plexus blocks and many others. Contact your Pfizer rep or go to their web site for information on how to get a copy.

·        Membership in the IVAPM (www.IVAPM.org) includes access to the message boards, which have been recently updated to allow searching and archiving. The message boards are a lively and active place for discussion of all sorts of pain management issues in clinical practice.

·        www.vasg.org is Dr. Bob Stein’s web site, the Veterinary Anesthesia Support Group. This site has easily searchable and very practical information for anesthesia and analgesia techniques in general practice. There is a particularly helpful section on testicular blocks.

·        www.IVIS.org is a free informational resource for veterinarians and has 929 entries if you search for “local anesthesia” in their library

·        www.VIN.com has lots of information gleaned from conference proceedings and on-line course material.

I hope this helps get you interested in local blocks. Don’t hesitate to call or email me if I can help answer questions.

Lisa Moses, VMD, DACVIM, CVMA

Pain Medicine Service

painmedicine@angell.org

617-541-5140