Block Evaluation 4
“Doctor, you’re block isn’t working…..”
I get calls to the PACU and get told while rounding on my patients that a patient is hurting. If you are proficient at doing blocks and focused on optimizing pain control, you probably have to briefly fight the urge to say, “They can’t be hurting…I put that block in!” Right after this, there is a brief moment of worry and disbelief. “What if…what if my block…failed?” This disconcerting feeling may diminish, but it won’t completely abate until you lay eyes on the patient yourself. At this point, I begin to review in my head what objective ultrasound cues that I had during block placement and what I recall from the intraoperative management.
I’m not saying this happens to you, of course, but you may cover the PACU when your partners place blocks. Of course. The question of what to do and how to evaluate the patient still remains. There are numerous clues that you have at your disposal to evaluate the patient’s report of pain. I will discuss some of this in this edition of ‘Tips and Tricks’.
The complaint of pain by a patient may, in fact, be pain. And it is possible that the complaint of pain is due to acute pain from the surgical site that should be covered by the nerve block. In reality, it is a rare circumstance (especially in the PACU) that this is actually the problem. I am fortunate to work with a thoughtful and well-trained group of CRNA’s, PACU RN’s and floor/ICU RN’s (that have heard me go on and on about pain evaluation more times than they probably care to have heard) who know: 1) what questions to ask the patient beyond an initial complaint 2) how to objectively evaluate the patient and 3) what to do in the meantime. It does continue to frustrate me on occasion when I arrive to see a patient that has received a dose of IV opioids (after requiring zero opioids intra-operatively and had ‘railroad track’ vitals throughout the case) who is now quite sedated, and I determine with further investigation that their complaint of pain actually consists of a ‘pressure’ sensation that is creating a sense of anxiety…and when I can get them awake enough to respond, they tell me that this sensation is still fully present.
The most common circumstance that I encounter when evaluating complaints of pain in the PACU is …
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