Transformation of anesthesia for ambulatory orthopedic surgery: A mixed-methods study of a diffusion of innovation in healthcare.

INTRODUCTION: To provide insight into how an innovation in healthcare is implemented and diffused, we studied the transition from routine use of general anesthesia to peripheral nerve blocks (PNBs) for ambulatory orthopedic extremity surgery. Rogers' diffusion of innovations (DOI) theory was used as our theoretical framework. We identified themes that would be helpful for others attempting to diffuse innovations into healthcare settings. MATERIAL AND METHODS: A mixed quantitative and qualitative methodology was used. We retrospectively reviewed operative and anesthesia records of patients who underwent ambulatory repair of distal radius fractures or arthroscopic knee meniscus procedures from 1998 to 2012 to identify whether general anesthetics or PNBs were used and the time course of the innovation. We interviewed orthopedic surgeons, anesthesiologists, and a nursing administrator working in the ambulatory surgery unit during the innovation to identify key themes associated with the adoption of PNBs. RESULTS: From 2003 to 2012, use of PNBs increased from less than 10% to 70% of cases studied. The adoption timeframe followed an S-shaped curve. Key themes included improved safety, quality, efficiency, physician leadership and trust, organizational structure, and technological change. The innovation involved an optional decision-making process and took root in a satellite facility and generally fit with Rogers DOI theory. CONCLUSIONS: The adoption and diffusion of PNBs provides a useful model for understanding innovations with optional decision-making in healthcare. Critical elements in our case were the characteristics of the innovation, which facilitated the decision-making process, and the positioning of the innovation in a peripheral structure away from core clinical facilities.

Preoperative L1 and L2 paravertebral block is an effective postoperative analgesia for hip arthroscopy in a multimodal analgesic regimen.

We describe the case of a 30-year-old woman with chronic hip pain secondary to avascular necrosis. She received preoperative L1-L2 paravertebral block for postoperative pain control after arthroscopic hip surgery. Preoperative paravertebral block at the level of L1-L2 provided an effective postoperative analgesia for hip arthroscopy when used in a multimodal approach.

Ultrasound-guided parasacral approach to the sciatic nerve block in children.

BACKGROUND: The parasacral (PS) approach to sciatic nerve blockade has the potential for safe and effective use in children, but has never been studied in this population. Its potential advantages include increased posterior cutaneous nerve block reliability, potential for hip joint analgesia, and decreased nerve depth, making ultrasound guidance easier. OBJECTIVE: To assess the efficacy of an ultrasound-guided PS sciatic nerve block in children. METHODS: Nineteen patients, 1-16 years old, scheduled for lower limb surgery with peripheral nerve blockade (PNB) were prospectively enrolled. A PS sciatic block was performed using both ultrasound guidance and nerve stimulation, and 0.5 ml·kg(-1) ropivacaine 0.2% (maximum 20 ml) was administered. Patient demographics, the time to perform the block, the lowest intensity of nerve stimulation, evoked response, identification of gluteal arteries, and amount of narcotic given were recorded. Postoperatively, pain scores, block success or failure, block duration, and complications were recorded. RESULTS: The block was performed using the PS approach in 95% of the cases. The success rate was 100% in the PS sciatic blocks performed. The pain scores for all patients in the first postsurgical hour were zero, except one patient that had a pain score of 3 of 10 at 30 min; his pain improved to 0 of 10 after administration of one dose of fentanyl and distraction techniques. The blocks lasted 17.3 ± 5.4 h. No complications were identified. CONCLUSION: The PS approach is an effective option for sciatic nerve blockade to provide postoperative pain relief in children having lower extremity surgery.

Ultrasound-guided sciatic nerve block in the popliteal fossa using a lateral approach: onset time comparing separate tibial and common peroneal nerve injections versus injecting proximal to the bifurcation.

BACKGROUND: We hypothesized that blocking the tibial and common peroneal nerves individually using ultrasound distal to sciatic bifurcation would decrease time to complete block compared with a block proximal to the bifurcation. METHODS: Seventy-six patients undergoing foot or ankle surgery received a sciatic nerve block either proximal or distal to the point of bifurcation. A mixture of 28 mL 1.5% mepivacaine with 100 microg clonidine and 1 mL 8.4% sodium bicarbonate for a total of 30 mL was used. Ultrasound was used to guide needle adjustments to achieve circumferential spread. Block success was defined as a loss of sensation to pinprick in both nerve distributions within 46 minutes. RESULTS: Patients in the tibial-peroneal group had significantly faster time to complete block than the sciatic group (19.2 vs 26.1 minutes; P = 0.006). CONCLUSIONS: Blocking the tibial and common peroneal nerves in the popliteal fossa separately provides for a faster onset than a prebifurcation sciatic block.