Regional & Acute Pain

The Division of Regional Anesthesia includes two sites with designated block rooms for initiating regional blocks. These sites have a dedicated teaching staff and infrastructure that are involved in regional anesthesia education. St. Joseph's Health Care, is the home of the Hand and Upper Limb Centre, which performs over 2500 blocks per year, while the London Health Sciences Centre currently performs over 1000 neuraxial and lowerlimb blocks. The program supports both resident and fellow education and strives to provide lateral education to consultants from University of Western Ontario and other hospitals. The program continues to grow.

The division introduced ultrasonography for regional anesthesia in 2003. Ninety percent of the regional blocks are completed through the use of ultrasonography. The division has a well-run ambulatory regional analgesia program.

On an annual basis the division conducts a very popular workshop. During the workshop, live demonstrations of actual regional blocks are completed through the use of ultrasonography. The hands-on technique of ultrasonography is taught on human volunteers and animals in the lab. There is full support from the Department of Anatomy for educational activities.

The division has ongoing research projects in regional techniques, ultrasonography, pain management and collaborative research with other divisions. The volume is growing tremendously. Research in the basic sciences lab is also being initiated. 

For more information on Research in Acute Pain Management and Regional Anesthesia, please visit the Department's Current Research section.

In 2013 we welcomed two nurse practitioners (NP) to the department and the APS. Heather Whittle (VH) and Charlotte McCallum (UH) graduated from the Nurse Practicioners’ Programs in January. After an opportunity to develop a deeper understanding of the assessment and management of chronic pain with our chronic pain colleagues (Pat Morley Forster, Geoff Bellingham, Collin Clarke and Kate Ower) they joined the APS. With these expanded skills and together with our nurse clinicians Cindy Carnegie (UH), and Heather Fisher (VH), we now have greater resources to address patients who come to the hospital with pre-existing pain issues or those who develop challenges in the perioperative period. The intention is to expand our reach to the patients pre-operatively as well as post operatively. Eventually these Nurse Practitioners will provide a bridge to both Chronic Pain and Palliative Care patients in the Comprehensive Pain Management Program.

2013 saw us initiate the UH block room. There are a number of goals here, the first is to increase the ability to offer patients who would benefit most, or those who wish to have regional anesthesia as part of their anesthesia and/or pain management.

Regional anesthesia takes time to both perform and learn. Although resources are required to maintain a block room, there will be gains for patient care, education and clinical research . The OR is a highly resourced environment and is subject to significant time restraints. The block room will improve overall efficiencies through reduced OR utilization when possible. It will allow a better environment for learning by our trainees. Similarly clinical research in RA often requires additional time for assessment pre-operatively, this is more readily achieved without impacting negatively on the time of the anesthesiology, surgery and OR nursing teams. Intended care and research includes lower and upper limb peripheral nerve block, central nerve blockade and spinal imaging. Development of an outpatient regional analgesia program for patients having a high tibial osteotomy is moving ahead.

The St. Joseph’s block room continues to be the location where patient care, and the education of our residents, and subsequent research related to upper limb regional anesthesia takes place simultaneously. Over the years it has become an efficient, and integral process of the operating room. From the surgical day care unit, the OR, the PACU and the day surgery or inpatient units, there are approximately 2000 procedures done here yearly. This requires a significant commitment by all stakeholders (anesthesia, nursing, surgeons and patients) to team work and communication. The outpatient regional program continues to allow patients from Middlesex and Elgin counties to be discharged home with regional analgesia. 

As in the past, our residents gain their greatest structured APS learning through exposure at the Victoria Hospital site. Under the direction of Kate Ower, the VH site has also served as a test site for the electronically generated electronic orders. This project will ease the transition to computer provider order entry in early 2014. For the past few years electronic charting at both LHSC sites, has been the norm for APS charting. As with electronic generated orders, when the electronic patient record becomes a reality there is hope the transition is smooth.

Over the past year there has been considerable effort and education toward improving perioperative pain management through the expanded use of multimodal analgesia.

More recently there has been pharmacy and therapeutics (P&T) approval for the use of lidocaine infusions as well as the addition of ketamine to intravenous opioid, patient controlled analgesia (PCA). Kate Ower, Heather Fisher, Ian McConachie, Michael Pariser and others, have been influencial in leading the way for developing new protocols, providing education and implementing the use of the agents for our patients who would most benefit.

With the leadership of Chris Harle and Chris Schlachta (surgery), LHSC has entered into the ERAS program. This initiative is designed to assess the adherence and outcomes of evidence informed practices which improve recovery after colorectal surgery. In addition to some measures which affect traditional anesthesia management of these patients, there is an emphasis on pain management. These include intra-operative lidocaine infusions, epidural analgesia and multimodal analgesia. The APS and RA programs will contribute significantly in this project.

The Acute Pain Service website is managed by Cindy Carnegie. This provides visitors the opportunity to gain insight into topics related to acute and chronic pain management. Be it the assessment of pain, anatomy, mechanisms of pain, regional anesthesia, oral and parenteral agents or non-pharmacological methods. This site serves as an educational portal for our consultants, trainees and nurses.

Jo Morrell, Kate Ower, Heather Fisher and Ian Herrick through HUGO (Health UnderGoing Optimization) have provided great input to the anesthesia orders which will become part of the electronic ordering system. One aspect of the orders will be those orders used by the APS and RA groups. Over the coming year (early 2014), the implementation will be enhanced due to their contributions.