Rescue Blocks
NERVE BLOCK TO THE ‘RESCUE’
You’ve prepared for a new block, you have an agreeable surgeon, and you have a great application for it with the very reasonably-sized patient in front of you in the holding area….but you’re not sure that the first (or one of your first) attempt will be ‘quick and slick’. What if you hold-up the case? A great way to initiate a new nerve block into your practice [nonmember]…
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once you are ready to make the jump is to do it as a ‘rescue block’. That is, you do the nerve block after the surgery if (and when) it becomes necessary due to intolerable pain in the PACU.
You may want to prime the patient and family with the idea that ‘if’ this procedure is more difficult than expected (which you already suspect will be such), you have something that should (you can be more affirmative as you see for yourself that you really can do this block reliably) help them that you can perform in the recovery room. This also allows you to obtain consent at a much more convenient time. If you are not sure you are ready to ‘offer’ this solution ahead of time, and only would be pressed to do it if it really were a significant issue, you can hold back on ‘advertising it’, but you will need to obtain consent at a less convenient time later.
Beyond avoiding the possible 15 yard ‘delay of surgical case’ penalty, there are other benefits to this strategy. First, even a partial success will be appreciated by the patient and the PACU RN and considered a success. Secondly, when you DO knock it out of the park….people really notice. Everyone saw (and heard) that obviously tormented patient, and they all knew it would be all day getting them under control, waking them back up and treating the opioid side-effects from the monstrous amount of morphine it will end up taking. You walk in, and shortly (it will be short compared with what they were expecting) afterward, the patient is calm and relieved and very appreciative. Suddenly, you have a desired commodity…not only desired by patients but by PACU RN’s. Now, you have the attention and the support of the staff. Suddenly, people realize that ‘Procedure X’ really is pretty painful, and it deserves this kind of attention and treatment. Lastly, you are likely to be in a better position to await a moment when you can hand off your pager or arrange for coverage of other responsibilities to tend to the block.
There are some things to keep in mind with rescue blocks. They can be more challenging because of bandages or casts. Also, the patient now is in significant pain and may not be as cooperative (especially with positioning that may be involved) or as easy to monitor for paresthesias or toxicity due to the anesthetic and additional opioid that they’ve been given to this point.
Another important point to consider is the opioid that you will need to use until the block can be placed. Remember that if your rescue block is successful as desired, you will now have a ‘relatively over-dosed’ patient that could now become apneic who will now need to be in the PACU all day waiting for them to wake up (comfortably, mind you). To avoid this problem, instruct those caring for the patient to use short-acting opioids like fentanyl in the meantime. It is intense but short-lived. As your block sets up, it should be wearing away. Also, instruct those caring for the patient to expect and prepare for apnea, especially when long-acting opioids have been given. Depending on how confident you are of the use of a rescue block, it may be advisable to consider this as it relates to the intraoperative use of opioids.
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