American Society of Regional Anesthesia and Pain Medicine February 2015 - (Page 10)

How We Do It: Managing an Acute and Perioperative Pain Medicine (APPM) Service at the University of Florida Linda Le-Wendling, MD Clinical Associate Professor Fellowship Director Allison Haller, MD Clinical Assistant Professor Barys Ihnatsenka, MD Clinical Assistant Professor Division of Acute and Perioperative Pain Medicine Department of Anesthesiology University of Florida Gainesville, Florida greater value than single-injection techniques for the majority of surgeries that generate severe pain. 4. Ongoing education for patients in the preoperative clinic, for our surgical colleagues about available options for their patients, as well as ward nurses, physical therapists, and residents to provide consistency in care of patients with peripheral and neuraxial blocks in any unit in the hospital. 5. An emphasis on systemic multimodal analgesia (acetaminophen, NSAIDs, antineuropathic pain medications) in addition to regional analgesia. NUTS AND BOLTS To successfully perform CPNB at UF, the system must be organized such that procedures are routinely performed preoperatively, with Section Editors: Steven Orebaugh, MD, and Melanie Donnelly, MD, MPH trained and dedicated staff, whereby patients are admitted 2 hours prior to their scheduled he Acute and Perioperative Pain Medicine (APPM) service surgery time. A dedicated environment-space, equipment, and has evolved extensively since its inception in 1998 at the nursing staff-is key, as procedures placed in the operating room University of Florida (UF). The volume of patients has surged or recovery unit in a rushed manner or with unfamiliar medical from an average of 50-100 inpatient procedures per month to staff will result in a higher incidence of failed blocks and less now 500-600 per month, with safe conditions. Staff must be this increase most pronounced in knowledgeable in the basics of 2007. So, what has changed during sedation, airway management, this interval to increase patient regional anesthesia equipment, and surgeon demand for regional positioning, and the timeout process analgesia? (to confirm site of surgery and block, coagulation status, consents). THE BIG PICTURE A successful venture always begins with a vision-a framework Preparation and planning for adequate staffing the day before upon which to build. At UF Health, the foundation of the APPM surgery (both nurse and physician) allow smoother execution, service is built on the following principles: especially helpful on busy days to avoid delays. For routine cases, established protocols describe which blocks, local anesthetic bolus 1. A dedicated team that includes fellowship-trained faculty, fellows, concentrations/volumes, and pump infusion rates are expected. For residents, and nursing staff, all motivated to take ownership of the nonroutine surgery (oncology, trauma), patient images are reviewed patient. The team that performs interventional procedures also and surgeons are contacted in advance to confirm details of the rounds on the patients to ensure the best outcomes. A dedicated surgery: positioning, tourniquet location, extent and location of resident stays in-house while a faculty member is also on call for surgery, planned anticoagulation, and discharge planning. the APPM service, both available 24/7. 2. An unobstructed line of communication between the surgeon, All catheters are secured away from the surgical field. To the anesthesiologist, acute pain physician, and the patient. reduce dislodgement, modalities such as tunneling, wound and Protocols and frameworks provide consistency in management skin adhesives, and specialized tape are utilized. To maintain of routine cases, while discussions on an individual basis occur simplicity, CPNB catheters are bolused with ropivacaine 0.5% for unique cases. at predetermined volumes depending on the type of block (eg, 3. Focus on high-yield continuous peripheral nerve block (CPNB) femoral 20 mL, sciatic 30 mL). Paravertebral and neuraxial techniques using dual guidance (ultrasound and nerve stimulation) catheters are dosed in a more tailored fashion based on as needed. The use of CPNB catheter-based techniques provides the individual case, and all sympathectomies that result in T "A successful venture always begins with a vision-a framework upon which to build." 10 2 American Society of Regional Anesthesia and Pain Medicine 2015

Table of Contents for the Digital Edition of American Society of Regional Anesthesia and Pain Medicine February 2015

In Memoriam : Alon Palm Winnie, M.D., ASRA Founding Father
President’s Message
40th Annual Regional Anesthesiology and Acute Pain Medicine Meeting
Resident and Fellow Events at the 2015 Spring Meeting
How We Do It: Managing an Acute and Perioperative Pain Medicine (APPM) Service at the University of Florida
Ketamine—an Old Drug with New Tricks
Optimal Postcesarean Delivery Pain Management
Palliative Care and Pain Medicine—Beyond Intrathecal Pumps and Opioids
Scientist Spotlight—Dr. Guy Weinberg, Trailblazer in Patient Safety

American Society of Regional Anesthesia and Pain Medicine February 2015