affect motor function as much as femoral nerve blocks. That used to be
a problem. The risk that patients would fall was a serious concern.
• Pick the right pump. The kind of pain pump you use to extend the
analgesic effects of a block is also a major consideration. Electronic
pumps that nurses can program are fine for inpatients. But for outpa-
tients, be careful. You don't want a patient who has just had surgery
and may still be under the influence of medication to have to figure
out how a pump works.
Simpler is sometimes better, such as the elastomeric pumps that are
very easy to use and that continually infuse local anesthetic at a spe-
cific rate that you set. The closer to auto-pilot for the patient, the bet-
ter. After all, this is likely to be something completely new and a very
specific situation for the patient.
Forward thinking
Single-shot nerve blocks provide great relief for about a day, but the chal-
lenge has always been figuring out how to make the relief last longer
without resorting to opioids.
Providers have tried additives like dexamethasone or clonidine to
try to make blocks last longer, but those medications wear off, too.
There was some hope that liposomal bupivacaine would be the silver
bullet we needed, but the marketing got ahead of the science. With
knee replacements, for example, there's no evidence that liposomal
bupivacaine is any better than regular bupivacaine.
Recent developments are certain to increase the trend toward
CNBs, the most notable being the increasing popularity of same-day
total joint replacements. To remain competitive in that enormous mar-
ket, you're going to have to get on board with new and sophisticated
protocols. The problems that keep joint replacement patients in the
4 4 • O U T PA T I E N T S U R G E R Y M A G A Z I N E • J U L Y 2 0 1 8
