AAOS Bulletin - February, 2006

Risk Management Spotlight

Fall prevention following regional nerve blocks for postoperative analgesia

By Murray J. Goodman, MD

Editor’s Note: Injuries from falls are a major source of liability. In 2005, the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) Board of Commissioners required all health care organizations to implement protocols to reduce the risk of patient harm resulting from falls as part of the JCAHO National Patient Safety Goals

An extensive summary of the issues, strategies and tools to define and measure falls, identify risks and target prevention strategies is available from Premier Inc. After considering the following examples, e-mail the protocols you use to reduce the risk of patient falls to feedback-orm@aaos.org.

Case 1

A 72-year-old diabetic male was admitted for elective total knee replacement (TKR) surgery. In the preoperative holding area, he received a femoral nerve block via an indwelling catheter for postoperative pain relief. Just before transport to the operative suite, he expressed a need to void. The nurse helped him to stand but he was unable to support his weight on the anesthetized leg and fell, and was eased to the floor by the nurses in attendance. No trauma was evident, and the surgery and follow-up were uneventful.

Case 2

A 59-year-old woman underwent an uneventful TKR. She had a femoral nerve block via a percutaneously placed indwelling catheter for postoperative pain relief. While walking from the bathroom to her bed on the second day after surgery, her leg buckled and she fell to the ground. The incision was torn open, and the metallic femoral component was visible in the wound. The wound was dressed with a Betadine dressing and the patient was returned to the operating room (OR) for irrigation, debridement and secondary wound closure. The remainder of her postoperative course and rehabilitation were uneventful.

Discussion

Successful postoperative pain management after lower extremity surgery is important to achieve a good clinical outcome. Patient participation in the rehabilitation program is predicated on satisfactory pain control, and patient participation in physical therapy and gait training is critical to a final successful result. Several adjunctive measures are used to make patients more comfortable so that they can participate more fully in their rehab program.

Parenteral narcotics, adjunctive nonsteroidal anti-inflammatory drugs and cryotherapy all play a role in postoperative analgesia. Lumbar epidural blocks and femoral nerve/sciatic nerve/lumbar plexus blocks, administered via an indwelling catheter, are successful in controlling postoperative pain. Patients who receive this type of pain control are more comfortable and confident in performing range of motion exercises and gait training after surgery.

On the other hand, nerve blocks result in the loss of muscle control necessary to stabilize the lower extremity when the patient is standing or walking. Lower doses of anesthetic agents may produce a partial nerve block with good pain control and some preservation of muscle function. Unfortunately, the dose response curve may not be linear, and the exact dose is difficult to predict.

When a regional nerve block is used, the patient’s entire care team must be aware that the block is in place and that the patient may not have control of the leg. Patients with regional nerve blocks should stand or walk only with appropriate support and assistance until the catheter is discontinued and the effect of the nerve block has worn off. Obviously, a fall in the immediate postoperative period can lead to devastating complications.

As a result of the two cases presented above, one hospital has instituted measures to limit the likelihood of falls in patients with regional nerve blocks. A sign—“Fall Precaution — Nerve Block”—is placed on top of the patient’s chart in the OR holding area and remains with the patient during surgery and the stay in the postanesthesia care unit. When the patient is transferred to the medical-surgical care unit, the sign is placed above the patient’s bed, where it serves as a reminder to caregivers and others that the patient has a nerve block and is at high risk for fall and injury.

These patients also have bright yellow stars outside their rooms. Hospital staff and visitors are told what the stars mean and are asked to serve as “extra eyes” to assist staff in preventing patient injury by alerting medical personnel when they observe a patient in a room with a star who is attempting to stand or walk without assistance.

Advances in regional anesthesia have greatly improved perioperative and postoperative pain control and increased patient participation in rehabilitation. However, when patients are moved from the OR to the surgical floor, hospital staff must be mindful of the consequences of these nerve blocks. Awareness of potential complications and involvement of both hospital staff and patients’ families will help limit adverse events and improve surgical outcomes.

With the current emphasis on preemptive analgesia in the perioperative period, more patients are receiving epidural, femoral, sciatic, popliteal and ankle blocks—individually and in combination for both primary anesthetic technique and postoperative pain control. The use of long-acting agents such as bupivicaine, in conjunction with indwelling perineural catheters, guarantees that an orthopaedic surgeon or an anesthesiologist will not be in attendance at all times while the block is in effect.

Thus, all who come in contact with the patient must be aware of the consequences of these long-acting blocks. The entire health care team and family members can play a role in fall prevention. Patients with regional nerve blocks must be identified, and personnel—whether in the preoperative holding area or on the medical-surgical floors—must be aware of the effects that lower extremity regional nerve blocks have on a patient’s ambulatory ability to limit the likelihood of falls.


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