CHAPTER 48: Peripheral Nerve Blocks

The introduction of long-acting local thesias, perivascular/transarterial in-

CHAPTER 48 anesthetics and adjuvants, the refine-
ment of imaging modalities to facilitate
jection, electrical stimulation, and field
infiltration. More recently, direct imag-
neural localization, as well as innova- ing using ultrasonography, fluorosco-
tions in equipment technology, includ- py, computer tomography (CT), and
Peripheral Nerve ing stimulating needles and catheters magnetic resonance imaging (MRI)
Blocks* and portable infusion devices, have in-
creased the success rate and popularity
have been used. Although there is no
definitive study that identifies the
of peripheral blockade. Undoubtedly, “best” method for needle placement,
Denise J. Wedel, MD, and peripheral nerve blocks represent a generalities are possible. For example,
Terese T. Horlocker, MD new era in regional anesthesia and anal- elicitation of a paresthesia appears to
gesia. Competence in these techniques be equivalent to electrical stimulation.
is crucial to future practice models. Success rate and onset time with both
The techniques of peripheral neural Peripheral blockade is a well-accept- paresthesia and nerve stimulation tech-
blockade were developed early in the ed component of comprehensive anes- niques are further improved if multiple
history of anesthesia. American sur- thetic care, with a role not only within injections are performed.7 A recent Co-
geons Halsted and Hall1,2 described the the operating suite, but also within the chrane review evaluating single-, dou-
injection of cocaine into peripheral sites, arena of postoperative and chronic ble-, and multiple-injection tech-
including the ulnar, musculocutaneous, pain management. With appropriate niques for axillary block reported that
supratrochlear, and infraorbital nerves, selection and sedation, these tech- multiple-injection techniques were as-
for minor surgical procedures in the niques can be used in all age groups. sociated with fewer block failures and
1880s. James Leonard Corning3 recom- Skillful application of peripheral neu- improved motor blockade compared
mended the use of an Esmarch bandage ral blockade broadens the anesthesiol- to both single and double injections.8
in 1885 to arrest local circulation, thus ogist’s range of options in providing Conversely, the time to perform sin-
prolonging the cocaine-induced block optimal anesthetic care. gle injection is less, but the time re-
1025
and decreasing the uptake of that local quired to perform supplementary
anesthetic from the tissues. This con- blocks increased the time to readiness
cept was furthered by Heinrich F.W. TECHNIQUES FOR LOCALIZING for surgery. Unfortunately, there are
Braun,4 who substituted epinephrine, a NEURAL STRUCTURES insufficient data to compare other out-
“chemical tourniquet,” in 1903. Braun5 comes, such as safety.8 Although used
also introduced the term conduction an- Several methods of needle localization chiefly for axillary blockade, transar-
esthesia in his 1905 textbook on local have been described, including fascial terial injection is variably successful;
anesthesia, which described techniques “pops,” elicitation of one or more pares- a two-injection transarterial technique
for every region of the body. In 1920, the
French surgeon, Gaston Labat, was in-
vited by Charles Mayo to teach innova- KEY POINTS
tive methods of regional anesthesia at
the Mayo Clinic. During his appoint- 1. In performing peripheral nerve blocks, superior analgesia compared to con-
ment there, Labat authored Regional An- elicitation of a paresthesia is equiva- ventional systemic opioid therapy.
esthesia: Its Technic and Application.6 lent to electrical stimulation. Success In addition, continuous femoral
Published in 1922, Labat’s text popu- rate and onset time are improved if nerve block improves outcome and
larized regional anesthesia in the multiple stimulations are performed, rehabilitation following total knee
United States by describing tech- particularly with axillary blockade. replacement and is superior to epi-
niques already familiar to European dural analgesia.
surgeons and anesthesiologists. Im- 2. The use of ultrasonography for pe-
portantly, Labat described the use of ripheral blockade improves the 6. Because the sciatic nerve divides
infiltration, peripheral, plexus, and quality of blockade and decreases into its tibial and peroneal compo-
splanchnic blockade (using cocaine and onset time. However, overall suc- nents 7–10 cm above the knee,
procaine) for surgery to the head and cess rate is not substantially altered. popliteal fossa block should be per-
neck, intrathoracic, intraabdominal, and 3. The role of stimulating versus nonstim- formed at this level.
extremities, as general and neuraxial ulating catheters for continuous pe- 7. Total local anesthetic dosage should
anesthesia were not widely accepted ripheral nerve blocks to improve suc- be determined and kept within ac-
and/or considered more dangerous. cess rate is an active area of research. ceptable limits. Accumulation with
Thus, while the techniques of peripher- 4. Diaphragmatic paresis in 100% of pa- time may occur with continuous
al neural blockade were developed early tients undergoing interscalene block, techniques.
in the history of anesthesia, the im- even with dilute local anesthetic so- 8. The frequency of neurologic compli-
proved safety of neuraxial and general lutions. Phrenic nerve paresis has cations following peripheral block-
anesthesia supplanted their use and also been reported following both su- ade is less than that associated
their application diminished. praclavicular and infraclavicular ap- with neuraxial techniques. Neuro-
proaches, but with less frequency. toxicity and direct-needle trauma
*Modified with permission from Wedel DJ,
Horlocker TT: Nerve blocks. In: Miller RD, ed. 5. Continuous lower-extremity periph- are the major etiologies of neuro-
Anesthesia. 6th ed. Philadelphia: Churchill eral blockade consistently provides logic complications.
Livingston, 2005:1685–1717.

Copyright © 2008 by The McGraw-Hill Companies, Inc. Click here for terms of use.
 PART 4: Managing Anesthesia Care

is comparable to either single-injection levobupivacaine, or ropivacaine. Al-

TABLE 48–1.
paresthesia or nerve stimulator ap- though this feature may result in excel-
proaches. Finally, success rate with a lent postoperative pain relief for the Recommended Maximum Doses
fascial pop or click is variable and may inpatient, it may be undesirable or cause of Local Anesthetics
be more reliable in pediatric (compared for concern in the ambulatory patient
to adult) patients.7 because of the potential for falls with a Maximum
Ultrasound guidance (with and with- partially insensate/weak lower extremi- Local Anesthetic Dose (mg)
out neural stimulation) is increasing ty. Likewise, prolonged upper-extremity
2-chloroprocaine 800
used for peripheral blockade. Initial blockade may impede the ability to per-
With epinephrine 1000
applications involved upper-extremity form daily tasks, such as dressing and
Lidocaine 300
techniques, because of capability of the grooming. Consequently, a medium-act-
ultrasound to penetrate relatively su- ing agent may be more appropriate in With epinephrine 500
perficial soft-tissue structures.9,10 How- the outpatient setting for orthopedic pro- Mepivacaine 400
ever, visualization of lower-extremi- cedures with minimal to moderate post- With epinephrine 550
ty anatomy was recently described.11 operative pain. In general, equipotent Bupivacaine 175
Major advantages of ultrasonography in- concentrations of the long-acting amides 400 mg/24 h
clude the ability to identify the neural have a similar onset and quality of block. With epinephrine 225
structure, eliminating the need for However, bupivacaine may have a Levobupivacaine 150
“blind” needle placement, and obser- slightly longer duration than levobupiv- 400 mg/24 h
vance of the spread of local anesthetic acaine or ropivacaine. Likewise, higher With epinephrine NA
during injection. For example, investiga- concentrations are more likely to be Ropivacaine 225
tors have noted that equal distribution associated with profound sensory and 800 mg/24 h
of local anesthetic within the neural motor block, whereas infusions of 0.1– With epinephrine 225
sheath is associated with successful 0.2% bupivacaine or ropivacaine may
Reprinted from Rosenberg PH, Veering BT,
block.12 Real-time visualization of local not result in motor blockade (and allow Urmey WF. Maximum recommended doses
1026
anesthetic spread during injection al- complete weight bearing with lower-ex- of local anesthetics: a multifactorial con-
lows the proceduralist to redirect the tremity techniques). Recent investiga- cept. Reg Anesth Pain Med 2004;29:564,
needle, as necessary to assure adequate tions suggest that increasing the local with permission from American Society of
distribution. The overall usefulness of anesthetic concentration alters the char- Regional Anesthesia and Pain Medicine.
ultrasonography remains to be deter- acter (i.e., degree of sensory and/or
mined. Existing knowledge suggests that motor block), but not the duration. Epinephrine also allows for the early
ultrasound-guided blockade may be as- The lowest effective dose and con- detection of intravascular injection. Im-
sociated with a decreased performance centration should be used to minimize portantly, concentrations of epineph-
time and local anesthetic requirement, local anesthetic systemic and neural rine ranging from 1.7–5 +g/mL (1:
more rapid onset, and superior quality toxicity. It is important to note that the 600,000 to 1:200,000 dilution) reduce
blockade compared to nerve stimulation recommendations for maximum doses the uptake and prolong the blockade of
alone. However, overall success rate has of local anesthetics were established by medium duration local anesthetics to a
not been reportedly increased. Impor- the manufacturers (Table 48–1).15 Max- similar extent. However, concentra-
tantly, neural structures are not always imum doses based on patient weight tions of 1.7–2.5 +g/mL have little effect
visualized by ultrasonography and in (with the exception of the pediatric pop- on nerve blood flow, which theoretical-
obese patients or “deep” techniques, ulation) also are not evidence based. ly may reduce the risk of nerve injury
such as psoas compartment or proximal Recommendations for 24-hour doses of for patients with a preexisting angiopa-
sciatic blockade. Thus, ultrasound guid- local anesthetics also were established thy or neuropathy. In addition, larger
ance is not possible in patients in whom without controlled studies. In essence, doses of epinephrine injected systemi-
the technique would be theoretically the safe dose of a local anesthetic cally may cause undesirable side effects
most useful.13,14 should be individualized based on site in patients with known cardiac disease.
of injection, patient age, and the pres- Concerns regarding neural or cardiac
ence of medical conditions that affect ischemia must be balanced with the
CHOICE OF LOCAL ANESTHETIC local anesthetic pharmacology and tox- need to detect intravascular injection.
icity. These considerations are believed In general, because of the high doses of
The choice of local anesthetic for a pe- to be most critical when large doses of local anesthetics administered during
ripheral nerve block obviously depends local anesthetics are injected, or in asso- peripheral block, the benefits of adding
to some degree on the duration of the ciation with repeated blocks/continu- epinephrine outweigh the risks.16
surgical procedure; however, other fac- ous infusions because of the potential Commercially prepared solutions with
tors are also important. Local anesthetic for local anesthetic accumulation. epinephrine have a lower pH than
and the addition of adjuvants for periph- those in which it is freshly added, re-
eral nerve block are dependent on the Adjuvants sulting in a higher percentage of ion-
anticipated duration of surgery, the Epinephrine ized drug molecules. These ionized
need for prolonged analgesia, and the Epinephrine decreases local anesthetic molecules do not readily cross the neu-
timing of ambulation/weight-bearing uptake and plasma levels, improves the ral membrane, delaying the onset of
postoperatively. Prolonged blockade for quality of block, and increases the dura- local anesthetic action after injection.
24 hours (or greater) may occur with tion of postoperative analgesia during Epinephrine should not be added for
long-acting agents such as bupivacaine, lower-extremity peripheral blockade. ankle block. The addition of epineph-
 CHAPTER 48: Peripheral Nerve Blocks

rine to local anesthetics with intrinsic UPPER-EXTREMITY BLOCKS The cervical plexus is derived from
vasoconstrictive properties, such as the C1, C2, C3, and C4 spinal nerves
ropivacaine, may not increase block Successful regional anesthesia of the and supplies branches to the preverte-
duration, but would still facilitate detec- upper extremity requires knowledge of bral muscles, strap muscles of the
tion of intravascular injection. brachial plexus anatomy from its ori- neck, and phrenic nerve. The deep
gin as the nerves emerge from the cervical plexus supplies the muscula-
Clonidine intervertebral foramina to its termina- ture of the neck segmentally, as well
Clonidine consistently prolongs the tion in the peripheral nerves. Detailed as the cutaneous sensation of the skin
time to first analgesia when added to anatomic knowledge enables the anes- between the trigeminally innervated
intermediate-acting agents during bra- thesiologist to choose the appropriate face and the T2 dermatome of the
chial plexus blockade. The effect is technique for the intended surgical trunk. Blockade of the superficial cer-
most likely peripherally mediated and procedure and to salvage “inadequate” vical plexus results in anesthesia of
dose dependent. Side effects such as blocks with local anesthetic supple- only the cutaneous nerves.
hypotension, bradycardia, and sedation mentation. Without mastery of the
do not occur with a dose less than 1.5 anatomy, luck rather than skill will be Clinical Applications
+g/kg or with a maximum dose of 150 the primary determinant of successful Blocks of the cervical plexus are easy
+g. Conversely, the efficacy of cloni- neural blockade. Also important is an to perform and provide anesthesia for
dine as an adjuvant for lower-extremity understanding of the side effects and surgical procedures in the distribution
single injection and continuous tech- complications of upper-extremity re- of C2 to C4, including lymph node
niques is less defined. Most studies gional techniques, as well as the clini- dissections, plastic repairs, and carotid
report a modest (20%) prolongation cal application of available local anes- endarterectomy. The ability to moni-
with the addition of clonidine to long- thetics for these blocks. Finally, one tor the awake patient’s neurologic sta-
acting local anesthetic solutions.7,14,17 must not underestimate the role of tus continuously is an advantage of
appropriate sedation during placement this anesthetic technique for the latter
Opioids procedure and has resulted in an up-
Although opioids, including morphine, of the block as well as during the
surge in the popularity of this tech- 1027
sufentanil, and fentanyl, are often surgical procedure. Many a “perfect”
regional anesthetic technique has been nique.18,19 Bilateral blocks can be used
added to lumbar plexus infusions, there for tracheostomy and thyroidectomy.
are no convincing data to suggest that undone by inadequate management of
block onset, quality, or duration is im- sedation. Techniques
proved when opioids are added to the Superficial Cervical Plexus The
local anesthetic solution.7,14 Cervical Plexus Blockade superficial cervical plexus is blocked
Blockade of the cervical plexus is brief- at the midpoint of the posterior border
Systemic Local ly discussed because of the overlap- of the sternocleidomastoid muscle. A
Anesthetic Toxicity ping innervation of the cervical and skin wheal is made at this point, and a
The potential for systemic local anes- brachial plexus. Supplementation of a 22-gauge, 4-cm needle is advanced,
thetic toxicity would seem to be very proximal brachial plexus technique injecting 5 mL of solution along the
high for peripheral nerve blocks be- with a deep or superficial cervical plex- posterior border and medial surface of
cause of the relatively large doses of us block is often required to assure the sternocleidomastoid muscle (Fig.
local anesthetic commonly injected and complete blockade of the surgical site. 48–1). It is possible to block the acces-
the proximity of needle/catheter inser-
tion to vascular structures and highly
vascularized muscle beds. The few cases
of systemic toxicity requiring resuscita-
tion occurred shortly after injection,
suggesting that it is accidental intravas-
cular injection, rather than systemic ab-
sorption, that is the mechanism. Preven-
tion and treatment of local anesthetic
toxicity is dependent on the injection of
an appropriate volume and concentra-
tion of local anesthetic, the use of a
vasoconstrictor adjuvant slow injection
with frequent aspiration, and increased
vigilance for the early detection and
treatment of toxic reactions. It is notable
that local anesthetic levels peak at ap-
proximately 60 minutes following depo-
sition following peripheral block. Thus,
patients should be appropriately moni-
tored for signs and symptoms of rising
blood levels for this duration. Resuscita- FIGURE 48–1. Anatomic landmarks and method of needle placement for superficial cervical
tion equipment and medications should plexus block. (Reprinted from Wedel DJ, Horlocker TT. Nerve blocks. In: Miller RD, ed. Anesthesia.
also be readily available. 6th ed. Philadelphia: Churchill Livingston, 2005:1686–1717, with permission from Elsevier.)
 PART 4: Managing Anesthesia Care

to a variety of neural and vascular

structures. Reported complications
and side effects include intravascular
injection, blockade of the phrenic and
superior laryngeal nerve, and spread
of local anesthetic solution into the
epidural and subarachnoid spaces.

Brachial Plexus Anatomy

The brachial plexus is derived from the
anterior primary rami of the fifth,
sixth, seventh, and eighth cervical
nerves and the first thoracic nerve,
with variable contributions from the
fourth cervical and second thoracic
nerves. After leaving their interverte-
bral foramina, these nerves course an-
terolaterally and inferiorly to lie be-
tween the anterior and middle scalene
muscles, which arise from the anterior
and posterior tubercles of the cervical
vertebra, respectively. The anterior
scalene muscle passes caudad and lat-
erally to insert into the scalene tuber-
cle of the first rib; the middle scalene
1028 muscle inserts on the first rib posterior
to the subclavian artery, which passes
between these two scalene muscles
FIGURE 48–2. Anatomic landmarks and method of needle placement for deep cervical plexus along the subclavian groove. The pre-
blocks at C2, C3, and C4. (Reprinted from Wedel DJ, Horlocker TT. Nerve blocks. In: Miller RD, vertebral fascia invests both the anteri-
ed. Anesthesia. 6th ed. Philadelphia: Churchill Livingston, 2005:1686–1717, with permission or and middle scalene muscles, fusing
from Elsevier.)
laterally to enclose the brachial plexus
in a fascial sheath.
Between the scalene muscles, these
nerve roots unite to form three trunks,
sory nerve with this injection, result- angulation. The transverse process is which emerge from the interscalene
ing in temporary ipsilateral trapezius contacted at a depth of 1.5–3 cm. If a space to lie cephaloposterior to the
muscle paralysis. paresthesia is obtained, 3–4 mL of subclavian artery as it courses along
solution is injected after careful aspira- the upper surface of the first rib.
Deep Cervical Plexus The deep tion for blood and cerebrospinal fluid. Therefore, the “superior” (C5 and C6),
cervical plexus block is a paravertebral If no paresthesia is elicited initially, “middle” (C7), and “inferior” (C8 and
block of the C2 to C4 spinal nerves as the needle is walked along the trans- T1) trunks are arranged accordingly
they emerge from their foramina in verse process in the anteroposterior and are not in a strict horizontal for-
the cervical vertebrae (Fig. 48–2). The plane until a paresthesia is obtained. mation, as often depicted. At the later-
traditional approach uses three sepa- This block can also be performed al edge of the first rib, each trunk
rate injections at C2, C3, and C4. The with a single injection of 10–12 mL at forms anterior and posterior divisions
patient lies supine with the neck the C4 transverse process.20 Cephalad that pass posterior to the midportion
slightly extended and the head turned spread of the local anesthetic usually of the clavicle to enter the axilla. With-
away from the side to be blocked. A anesthetizes the C2 and C3 nerves. in the axilla, these divisions form the
line is drawn connecting the tip of the Cervical plexus anesthesia can also be lateral, posterior, and medial cords,
mastoid process and the Chassaignac observed after injection at the inter- named for their relationship with the
tubercle (transverse process of C6); a scalene level for brachial plexus block- second part of the axillary artery. The
second line is drawn 1 cm posterior to ade. Maintenance of distal pressure superior divisions from the superior
this first line. The C2 transverse pro- and a horizontal or slightly head-down and middle trunks form the lateral
cess lies 1–2 cm caudad to the mastoid position may facilitate the onset of cord, the inferior divisions from all
process, where it can usually be pal- cervical plexus blockade using the in- three trunks form the posterior cord,
pated. The C3 and C4 transverse pro- terscalene technique. and the anterior division of the inferi-
cesses lie at 1.5-cm intervals along the or trunk continues as the medial cord.
second line. After skin wheals are Side Effects/Complications At the lateral border of the pectoralis
raised over the transverse processes of Although these blocks are technically minor, the three cords divide into the
C2, C3, and C4, three 22-gauge, 5-cm straightforward, needle placement for peripheral nerves of the upper extrem-
needles are advanced perpendicular to the deep cervical block allows local ity. The lateral cord gives rise to the
the skin entry site with a slight caudad anesthetic injection in close proximity lateral head of the median nerve and
 CHAPTER 48: Peripheral Nerve Blocks

from the roots of the brachial plexus

providing motor innervation to the
rhomboid muscles (C5), the subclavian
muscles (C5 and C6), and the serratus
anterior muscle (C5, C6, and C7). The
suprascapular nerve arises from C5 and
C6 and supplies the muscles of the
dorsal aspect of the scapula, as well as
making a significant contribution to the
sensory supply of the shoulder joint.
Branches arising from the cervical
roots are usually blocked only with the
interscalene approach to the brachial
plexus. Figure 48–4 shows the sensory
distributions of the cervical roots and
the peripheral nerves.

Interscalene Block
Clinical Applications
The principal indication for inter-
scalene block is surgery on the shoul-
der. Blockade occurs at the level of
FIGURE 48–3. Roots, trunks, divisions, cords, and branches of the brachial plexus. (Reprinted the upper and middle trunks. Al-
from Wedel DJ, Horlocker TT. Nerve blocks. In: Miller RD, ed. Anesthesia. 6th ed. Philadelphia: though this approach can be used for
Churchill Livingston, 2005:1686–1717, with permission from Elsevier.) forearm and hand surgery, blockade
1029
of the inferior trunk (C8 through T1)
the musculocutaneous nerve; the medi- posterior cord divides into the axillary is often incomplete and requires sup-
al cord gives rise to the medial head of and radial nerves (Fig. 48–3). plementation at the ulnar nerve for
the median nerve, as well as the ulnar, Aside from the branches from the adequate surgical anesthesia in that
the medial antebrachial, and the medi- cords that form the peripheral nerves distribution.21 In addition, supple-
al brachial cutaneous nerves; and the as described, several branches arise mentation with a suprascapular nerve

FIGURE 48–4. A. Cutaneous distribution of the cervical roots. B. Cutaneous distribution of the peripheral nerves. (Reprinted from Wedel DJ, Horlocker
TT. Nerve blocks. In: Miller RD, ed. Anesthesia. 6th ed. Philadelphia: Churchill Livingston, 2005:1686–1717, with permission from Elsevier.)
 PART 4: Managing Anesthesia Care

block may further prolong the analge-

sic effect.7

Technique
The brachial plexus shares a close
physical relationship with several
structures that serve as important land-
marks for the performance of inter-
scalene block. In its course between the
anterior and middle scalene muscles,
the plexus is superior and posterior to
the second and third parts of the sub-
clavian artery. The dome of the pleura
lies anteromedial to the inferior trunk.
This technique can be performed
with the patient’s arm in any position
and is technically simple because of
easy identification of necessary land-
marks.22 The patient should be in the
supine position with the head turned
away from the side to be blocked. The FIGURE 48–5. Interscalene block. The fingers palpate the interscalene groove, and the needle is
posterior border of the sternocleido- inserted with a caudad and slightly posterior angle. (Reprinted from Wedel DJ, Horlocker TT. Nerve
mastoid muscle is readily palpated by blocks. In: Miller RD, ed. Anesthesia. 6th ed. Philadelphia: Churchill Livingston, 2005:1686–1717,
having the patient briefly lift the head. with permission from Elsevier.)
The interscalene groove may be pal-
1030
pated by rolling the fingers posterolat-
erally from this border over the belly Once the appropriate paresthesia or respiratory disease. A case of lower-
of the anterior scalene muscle into the motor response is obtained, the needle lobe collapse (at home) during contin-
groove. A line is extended laterally is stabilized. The use of flexible exten- uous interscalene infusion has been
from the cricoid cartilage to intersect sion tubing facilitates the maintenance reported, documenting the need for
the interscalene groove indicating the of the needle position while aspiration careful patient selection and ongoing
level of the transverse process of C6. and injection occur. After negative as- monitoring.27
Although the external jugular vein piration, 10–40 mL of solution is in- Involvement of the vagus, recurrent
often overlies this point of intersection, jected incrementally, depending on laryngeal, and cervical sympathetic
it is not a constant or reliable landmark. the desired extent of blockade. Ra- nerves is rarely significant, but the pa-
The use of a nerve stimulator or diographic studies suggest a volume- tient experiencing symptoms related to
elicitation of a paresthesia is recom- to- anesthesia relationship with 40 mL these side effects may require reassur-
mended with this technique so as to of solution associated with complete ance. The risk of pneumothorax is low
place the local anesthetic solution ac- cervical and brachial plexus block.22 when the needle is correctly placed at
curately. After ordinary sterile precau- Clinical studies, however, indicate the C5 or C6 level because of the dis-
tions and injection of a skin wheal, a variable blockade of the lower trunk, tance from the dome of the pleura.
22- to 25-gauge, 4-cm needle is inserted which includes the ulnar nerve, even Severe hypotension and/or brady-
medially with a 45° caudad and slight- with large volumes of solution.21 Digi- cardia (Bezold-Jarisch reflex) have
ly posterior angle (Fig. 48–5). The nee- tal pressure above the injection site been reported in awake, sitting pa-
dle is then advanced until a paresthe- and downward massage along with a tients undergoing shoulder surgery
sia (usually C5 and C6 dermatomes) or 45° head-up position may facilitate under interscalene block. The etiology
nerve stimulator response is elicited. caudad spread and blockade of the is presumed to be stimulation of intra-
This usually occurs at a very superfi- lower trunk. cardiac mechanoreceptors (by de-
cial level. Paresthesia/motor response creased venous return), producing an
to the arm or shoulder are equally Side Effects/Complications abrupt withdrawal of sympathetic
efficacious.23 If a blunt needle bevel is Ipsilateral phrenic nerve block result- tone, as well as enhanced parasympa-
used, a “click” may be detected as the ing in diaphragmatic paresis occurs in thetic output. This results in bradycar-
needle passes through the preverte- 100% of patients undergoing inter- dia, hypotension, and syncope. The
bral fascia. Should bone be encoun- scalene blockade,24 even with dilute frequency is decreased when prophy-
tered within 2 cm of the skin, it is solutions of local anesthetics, and is lactic -blockers are administered.28
likely to be a transverse process, and associated with a 25% reduction in Nerve damage or neuritis can occur
the needle may be “walked” across this pulmonary function.25,26 This effect is in any peripheral nerve block, but it is
structure to locate the nerve. Like- probably a consequence of anterior uncommon and usually is self-limited.
wise, contraction of the diaphragm in- spread of the solution over the anteri- Some surgical approaches to the shoul-
dicates phrenic nerve stimulation and or scalene muscle and may cause der are associated with neurologic risk
anterior needle placement; the needle subjective symptoms of dyspnea. Al- to the brachial plexus, for example,
should be redirected posteriorly to lo- though rare, respiratory compromise total shoulder arthroplasty.29 In such
cate the brachial plexus. can occur in patients with severe cases, interscalene block should be
 CHAPTER 48: Peripheral Nerve Blocks

placed postoperatively for pain relief

after the surgical service has ascer-
tained and documented that no neuro-
logic damage has occurred. Epidural
and intrathecal injections have been
reported with this block, a finding em-
phasizing the importance of inserting
the needle in a caudad direction. The
proximity of significant neurovascular
structures may increase the risk of seri-
ous neurologic complications when in-
terscalene block is performed in heavi-
ly sedated or anesthetized patients.30
Several vascular structures are in
close proximity to a correctly placed
needle. Local anesthetic toxicity as a
result of intravascular injection should
be guarded against by careful aspira-
tion and incremental injection. Seizure
activity secondary to this complication
is particularly undesirable following
rotator cuff surgery, because the repair
can be compromised by the associated
muscular activity.

Supraclavicular Block 1031

FIGURE 48–6. A. Supraclavicular block. The needle is systematically walked anteriorly and
Clinical Applications posteriorly along the rib until the plexus is located. B. The three trunks are compactly arranged
Indications for supraclavicular block at the level of the first rib. (Reprinted from Wedel DJ, Horlocker TT. Nerve blocks. In: Miller RD, ed.
are surgery to the elbow, forearm, and Anesthesia. 6th ed. Philadelphia: Churchill Livingston, 2005:1686–1717, with permission from
hand. Blockade occurs at the distal Elsevier.)
trunk–proximal division level. At this
point, the brachial plexus is compact
and a small volume of solution produc- anteroposterior orientation at the site this orientation causes the needle shaft
es rapid onset of reliable blockade of of the plexus. and syringe to lie almost parallel to a
the brachial plexus. An additional ad- The patient is placed in a supine line joining the skin entry and the pa-
vantage is that the block can also be position, with the head turned away tient’s ear. If the first rib is encountered
performed with the patient’s arm in from the side to be blocked. The arm without elicitation of a paresthesia, the
any position. to be anesthetized should be adducted needle can be systematically walked
Reliable supraclavicular blockade re- and the hand should be extended anteriorly and posteriorly along the rib
quires elicitation of a paresthesia or along the side toward the ipsilateral until the plexus or the subclavian artery
motor response. The classic block may knee as far as possible. In the classic is located (Fig. 48–6). Location of the
be somewhat difficult to describe and technique, the midpoint of the clavicle artery provides a useful landmark; the
to teach. Observation of an experienced should be identified and marked. The needle can be withdrawn and reinsert-
anesthesiologist is perhaps the best posterior border of the sternocleido- ed in a more posterolateral direction
way to learn the technique. A proposed mastoid can be easily palpated when that will usually result in a paresthesia
modification of the technique, the so- the patient raises the head slightly. or motor response. Upon localization of
called plumb-bob approach, may de- The palpating fingers can then roll the brachial plexus, aspiration for blood
crease complications and may simplify over the belly of the anterior scalene should be performed prior to incremen-
the vertical concept of this block.31 muscle into the interscalene groove, tal injections of a total volume of 20–30
where a mark should be made approx- mL of solution.
Technique imately 1.5–2.0 cm posterior to the Usually, the rib is contacted at a
Several anatomic points are important midpoint of the clavicle. Palpation of needle depth of 3–4 cm; however, in
in the performance of the supraclavic- the subclavian artery at this site con- an obese patient or in the presence of
ular approach. The three trunks are firms the landmark. tissue distortion resulting from hema-
clustered vertically over the first rib After appropriate preparation and in- toma or injection of solution, the
cephaloposterior to the subclavian ar- jection of a skin wheal, the anesthesiol- depth may exceed the needle length.
tery, which can often be palpated in a ogist stands at the side of the patient Nonetheless, gentle probing in the an-
slender, relaxed patient. The neu- facing the patient’s head. A 22-gauge, 4- terior and posterior directions should
rovascular bundle lies inferior to the cm needle is directed in a caudad, be done at the 2–3-cm depth if pares-
clavicle at about its midpoint. The first slightly lateral and posterior direction thesias are not obtained before the
rib acts as a medial barrier to the until either a paresthesia or motor re- needle is advanced farther. Multiple
needle’s reaching the pleural dome sponse is elicited or the first rib is injections may improve the quality or
and is short, broad, and flat, with an encountered. If a syringe is attached, may shorten the onset of blockade.
 PART 4: Managing Anesthesia Care

The modified vertical (plumb-bob) ry compromise because of underlying this could result in respiratory failure.
approach uses similar patient position- disease. Other complications include These effects should be considered
ing, although the needle entry site is at frequent phrenic nerve block (40– when evaluating a patient for this
the point at which the lateral border of 60%), Horner syndrome, and neuropa- technique.37,38 Other rare complica-
the sternocleidomastoid muscle in- thy. The presence of phrenic or cervi- tions, such as infection and hemato-
serts into the clavicle. After prepara- cal sympathetic nerve block usually ma, are theoretically possible.
tion and injection of a skin wheal, a 22- requires only reassurance. Although
gauge, 4-cm needle is inserted while nerve damage can occur, it is uncom- Axillary Block
mimicking a plumb-bob suspended mon and usually is self-limited. Clinical Applications
over the needle entry site. Often, a The axillary approach to the brachial
paresthesia or motor response is elicit- Infraclavicular Block plexus is the most popular because of
ed prior to contacting the first rib or Clinical Applications ease of block, reliability, and safety.39
artery. If no paresthesia or motor re- Infraclavicular block provides anes- Blockade occurs at the level of the
sponse is elicited, the needle is rein- thesia to the arm and hand. Blockade terminal nerves. Although blockade of
serted while angling the tip of the occurs at the level of the cords and the musculocutaneous nerve is not al-
needle cephalad, and finally caudad in offers the theoretic advantages of ways produced with this approach, it
small steps until the first rib is contact- avoiding pneumothorax while afford- can be supplemented at the level of the
ed (Fig. 48–7). ing block of the musculocutaneous axilla or at the elbow. Indications for
and axillary nerves. No special arm axillary block include surgery to the
Side Effects/Complications positioning is required. A nerve stimu- forearm and hand. Elbow procedures
The prevalence of pneumothorax fol- lator is required because there are no are also successfully performed using
lowing supraclavicular block ranges palpable vascular landmarks to aid in the axillary approach.40 This block is
from 0.5–6% and diminishes with expe- directing the needle. Historically, this ideally suited for outpatients and is
rience. The onset of symptoms is usual- approach was considered to be more easily adapted to the pediatric popula-
ly delayed and may take up to 24 hours. painful than blockade at the axillary tion.41,42 However, axillary block is un-
1032 Consequently, routine chest radiogra- level. However, this has been refuted suitable for surgical procedures on the
phy after the block is not justified. The by recent investigations.32 In addition, upper arm or shoulder and the patient
supraclavicular approach is best avoid-
this approach is optimal for indwelling must be able to abduct the arm to
ed when the patient is uncooperative or
brachial plexus catheters because of perform the block.
cannot tolerate any degree of respirato-
the ease of site maintenance.
Technique
Technique Anatomic concepts that should be con-
The needle is inserted 2 cm below the sidered prior to performing an axillary
midpoint of the inferior clavicular bor- block include the following:
der and is advanced laterally, using a
nerve stimulator to identify the plex- 1. The neurovascular bundle is multi-
us.33 Marking a line between the C6 compartmental (Fig. 48–8).43
tubercle and the axillary artery with 2. The axillary artery is the most im-
the arm abducted is helpful in visualiz- portant landmark; the nerves main-
ing the course of the plexus. An incre- tain a predictable orientation to the
mental injection of 20–30 mL of solu- artery.
tion is sufficient once the needle is 3. The median nerve is found superior
correctly placed. Stimulation of the to the artery, the ulnar nerve is
posterior cord or a multiple injection inferior, and the radial nerve is pos-
technique improves success rate.34,35 terior and somewhat lateral (Fig.
A coracoid technique, with the nee- 48–9).
dle insertion site 2 cm medial and 2
cm caudal to the coracoid process, has 4. At this level, the musculocutaneous
also been described.36 However, the nerve has already left the sheath
more lateral insertion site may result and lies in the substance of the
in the absence of blockade of the mus- coracobrachialis muscle.
culocutaneous nerve, removing the 5. The intercostobrachial nerve, a
major advantage of this approach over branch of the T2 intercostal nerve,
the simpler axillary block. is usually blocked by the skin wheal
overlying the artery; however, ade-
Side Effects/Complications quate anesthesia for the tourniquet
Because of the necessarily blind ap- can be ensured by extending the
proach to the plexus, the risk of intra- wheal 1–2 cm caudad and cephalad.
vascular injection may be increased.
FIGURE 48–7. Supraclavicular block. Plumb- Exaggerated medial needle direction The patient should be in the supine
bob approach. (Reprinted from Wedel DJ, Hor- may result in pneumothorax. A 30% position with the arm to be blocked
locker TT. Nerve blocks. In: Miller RD, ed. Anes- reduction in pulmonary function as a placed at a right angle to the body,
thesia. 6th ed. Philadelphia: Churchill Livingston, consequence of diaphragmatic paresis with the elbow flexed to 90°. The
2005:1686–1717, with permission from Elsevier.) is noted in the majority of patients; dorsum of the hand rests on the bed or
 CHAPTER 48: Peripheral Nerve Blocks

pillow; hyperabduction of the arm

with placement of the hand beneath
the patient’s head is not recommended
because this position frequently oblit-
erates the pulse.
The axillary artery is palpated, and a
line is drawn tracing its course from
the lower axilla as far proximally as
possible. The artery is then fixed
against the patient’s humerus by the
index and middle fingers of the left
hand, and a skin wheal is raised direct-
ly over the artery at a point in the
axilla approximating the skin crease.
Proximal needle placement and main-
tenance of distal pressure facilitate
proximal spread of the solution.
Method of Needle Localization
Several methods of identifying the ax-
illary sheath have been described, all
FIGURE 48–8. Axillary block. Computed tomogram after axillary block with bupivacaine 0.5% and with reportedly good results. Overall,
iodothalamate. Separate injections of 10-mL solution were made after obtaining median and paresthesia is unnecessary. However,
radial nerve paresthesia and transarterially. Contrast medium appears to remain in three separate multiple injections may shorten the
compartments. (Reprinted from Wedel DJ, Horlocker TT. Nerve blocks. In: Miller RD, ed. Anesthe- onset and may improve the reliability
sia. 6th ed. Philadelphia: Churchill Livingston, 2005:1686–1717, with permission from Elsevier.) of blockade. 1033

FIGURE 48–9. Axillary block. The arm is abducted at right angles to the body. Distal digital pressure is maintained during needle placement and
injection of local anesthetic. (Reprinted from Wedel DJ, Horlocker TT. Nerve blocks. In: Miller RD, ed. Anesthesia. 6th ed. Philadelphia: Churchill
Livingston, 2005:1686–1717, with permission from Elsevier.)
 PART 4: Managing Anesthesia Care

1. Paresthesias can be sought with a superficially at the lateral aspect of the Peripheral Blocks at the
25-gauge, 2-cm needle, beginning ei- antecubital fossa just above the in- Midhumeral Level, Elbow,
ther deep (radial nerve) or with the terepicondylar line. and Wrist
nerves supplying the surgical site.
Needles longer than 2 cm are rarely Success Rate with Axillary Clinical Applications
needed to reach the neurovascular Block Techniques As techniques for brachial plexus
bundle; smaller needles and a short- Success rate for axillary block depends blockade have gained popularity, indi-
bevel needle may be associated with on how a successful block is defined cations for peripheral nerve blockade
a lower risk of nerve damage.41,44 (surgical anesthesia vs. blockade of all at the wrist and elbow have dimin-
Ten milliliters of local anesthetic is four terminal nerves of the upper ex- ished. However, these techniques can
injected at each paresthesia. tremity), the technique used to localize be useful when limited anesthesia is
the brachial plexus, and the number of required, when contraindications to
2. A nerve stimulator can also be em- injections. Success rates with single- brachial plexus block (infection, bilat-
ployed with an insulated needle to injection techniques are variable.49,50 eral surgery, coagulation abnormalities,
locate the nerves. This technique ob- Thompson and Rorie43 concluded that bleeding diathesis, difficult anatomy)
viates the need for paresthesia. How-
the presence of multiple compart- exist, and when brachial plexus block-
ever, this has not been proven to ments limits diffusion of the solution ade is incomplete. Only the midhumer-
lower the risk of nerve damage.45,46
(and the success of single-shot tech- al approach provides anesthesia for
3. A short-bevel needle can be ad- niques). Although Partridge et al.51 the use of a tourniquet. Most patients
vanced until the “axillary sheath” confirmed the presence of these com- tolerate an inflated tourniquet for only
is entered, as evidenced by a “fas- partments, they concluded that the a brief period.
cial click,” whereupon 40–50 mL of “septa” dividing them were incomplete
solution is injected after negative on the basis of injections of methylene Midhumeral Block
aspiration.39,47 blue and latex solutions into cadavers. A midhumeral approach to the brachi-
4. A transarterial technique can be em- Eliciting a paresthesia is as effica- al plexus has been described. This
1034 ployed, whereby the needle pierces cious as peripheral nerve stimulation novel approach involves blocking each
the artery and 40–50 mL of solution (with a motor response of 0.5–0.8 of the four nerves of the brachial plex-
is injected posterior to the artery; or, mA). In addition, most studies suggest us separately in the humeral canal at
alternatively, half the solution is in- that two-injection transarterial tech- the level of the proximal one-third and
jected posterior and half anterior to niques are equivalent to single pares- distal two-thirds of the humerus. At
the artery. Great care must be taken thesia or single nerve stimulation ap- this level, the median and ulnar nerves
to avoid intravascular injection with proaches. In general, the efficacy of are located on the lateral and medial
this technique, particularly because paresthesia and peripheral nerve stimu- aspects of the brachial artery, respec-
the pressure of injection within the lator techniques increases when multi- tively. The musculocutaneous nerve is
compartments of the axillary sheath ple injections are employed. Converse- identified within the body of the biceps
may move anatomic structures in ly, success rates with perivascular or muscle, while the radial nerve lies
relation to the immobile needle. fascial click approaches are variously adjacent to the humerus. Eight to 10
Some practitioners avoid intentional reliable.7 Familiarity with a variety of mL of local anesthetic is injected after
arterial puncture in the belief that it techniques for axillary block of the localization of each nerve with a nerve
is unnecessarily traumatic. brachial plexus allows the anesthesi- stimulator. Midhumeral block is re-
ologist maximal flexibility in tailoring ported to have a higher success rate
5. Field block of the brachial plexus
the anesthetic approach to the clinical than traditional (defined as stimulation
with a fanwise injection of 10–15
situation. of two nerves) axillary brachial plexus
mL of local anesthetic solution on
block.53 In this study, time to complete
each side of the artery is a varia- Side Effects/Complications the block did not differ between the
tion of the sheath technique. Pares-
Nerve injury and systemic toxicity are two techniques; however, onset of
thesias, although not sought, are
the most significant complications as- complete sensory block was shorter in
often encountered in this tech-
sociated with the axillary approach. the axillary approach, whereas the suc-
nique and provide evidence of cor-
The assertion that neuropathies are cess rate of blockade of all four major
rect placement.
more common with the paresthesia nerves was higher in the midhumeral
When the injection is completed, technique may be valid, but it is not group. This technique may have appli-
the arm should be adducted and re- supported by the available data. In cations when anatomic difficulties pre-
turned to the patient’s side. This pre- addition, even when paresthesias are clude a traditional approach or when
vents the humeral head from obstruct- not sought, they often occur uninten- the surgical procedure requires a dense
ing proximal flow of the solution; tionally.52 Injection of large volumes block of all four major nerves.
distal pressure and massage may also of local anesthetic, particularly with
help. Vester-Andersen et al.48 were the transarterial approach, increases Median Nerve Block
unable to consistently block the mus- the risk of intravascular injection and Block of the median nerve provides
culocutaneous nerve with volumes up systemic local anesthetic toxicity. He- anesthesia of the palmar aspects of the
to 80 mL. Thus, if the musculocutane- matoma and infection are rare compli- thumb and index finger, middle finger,
ous nerve is not blocked by the axil- cations. Central neural blockade and and radial half of the ring finger, and
lary approach, it can be blocked by pneumothorax are not complications, the nail beds of the same digits. Motor
injection within the body of the cora- as in other approaches to the brachial block includes the muscles of the the-
cobrachialis muscle or at the elbow plexus. nar eminence, lumbrical muscles of
 CHAPTER 48: Peripheral Nerve Blocks

scending along the dorsum and radial

side of the wrist. The extensor pollicis
longus tendon can be identified when
the patient extends the thumb. The
needle insertion is over this tendon at
the base of the first metacarpal; the
injection is superficial to the tendon.
Two milliliters of local anesthetic is
injected proximally along the tendon,
and an additional 1 mL is injected as
the needle passes at a right angle across
the “anatomic snuffbox” (Fig. 48–12).

Ulnar Nerve Block

Blockade of the ulnar nerve provides
anesthesia of the ulnar side of the
hand, the little finger, and the ring
finger and all the small muscles of the
hand, except those of the thenar emi-
nence and the first and second lumbri-
cal muscles.
Technique at the Elbow Although
the ulnar nerve is easily accessible at
its subcutaneous position posterior to
the medial epicondyle, blockade at 1035
this site is associated with a high inci-
FIGURE 48–10. Anatomic landmarks for median and radial nerve block at the elbow. (Reprinted
dence of neuritis. The nerve is sur-
from Wedel DJ, Horlocker TT. Nerve blocks. In: Miller RD, ed. Anesthesia. 6th ed. Philadelphia: rounded by fibrous tissue at this point,
Churchill Livingston, 2005:1686–1717, with permission from Elsevier.) requiring an intraneural injection for
successful blockade. Use of a very fine
needle along with a small volume of
solution (1 mL) diminishes the risk;
the first and second digits, and, in the tion should be injected. A superficial
however, the nerve can be satisfactori-
case of the block at the elbow, median- palmar branch supplying the skin of
ly blocked with 5–10 mL of solution at
innervated wrist flexor muscles of the the thenar eminence can be blocked by
a site 3–5 cm proximal to the elbow.
forearm. injecting 0.5–1 mL of solution subcuta-
The local anesthetic should be injected
neously above the retinaculum. Pares-
Technique at the Elbow With the in a fanwise fashion without elicitation
thesia should not be sought because of
patient’s arm placed in the anatomic of a paresthesia.
the confinement of this nerve within
position (palm up), a line is drawn
the carpal tunnel. Technique at the Wrist At the wrist,
connecting the medial and lateral epi-
the ulnar nerve lies beneath the flexor
condyles of the humerus. The major
Radial Nerve Block carpi ulnaris tendon between the ulnar
landmark for this technique is the
Block of the radial nerve provides an- artery and the pisiform bone. At this
brachial artery, which is found medial
esthesia to the lateral aspect of the point, it has already given off its palmar
to the biceps tendon at the intercondy-
dorsum of the hand (thumb side) and cutaneous and dorsal branches. The
lar line. The median nerve lies medial
the proximal portion of the thumb, nerve can be approached by directing
to the artery (Fig. 48–10) and can be
index, middle, and lateral half of the the needle medially from the radial
blocked with 3–5 mL of solution after
ring fingers. side of the tendon or, alternatively, by
eliciting a paresthesia. If no paresthe-
directing the needle radially from the
sia is obtained, the solution can be Technique at the Elbow The radi-
ulnar side of the tendon (Fig. 48–11).
injected fanwise medial to the palpat- al nerve can be blocked at the elbow as
After eliciting a paresthesia, 3–5 mL of
ed artery. it passes over the anterior aspect of
solution is injected or spread in a fan-
the lateral epicondyle. The inter-
Technique at the Wrist The me- wise fashion.
condylar line and lateral edge of the
dian nerve is located between the flex-
biceps tendon are marked. A 22-gauge,
or carpi radialis and palmaris longus Musculocutaneous Nerve Block
3–4-cm needle is inserted at a point 2
tendons and can be blocked at a point The musculocutaneous nerve termi-
cm lateral to the biceps tendon and is
2–3 cm proximal to the wrist crease nates as the lateral cutaneous nerve of
advanced until bone is encountered
(Fig. 48–11). (The palmaris longus the forearm. This nerve provides sen-
(Fig. 48–12). A fanwise injection is
tendon is congenitally or postsurgical- sory innervation to the skin on the
made using 3–5 mL of solution.
ly absent from some patients.) A loss radial side of the forearm up to the
of resistance is felt as the needle Technique at the Wrist The radial radiocarpal joint. This block is usually
passes through the flexor retinacu- nerve block at the wrist is a field block performed to supplement the axillary
lum, at which point 2–4 mL of solu- of the multiple peripheral branches de- approach to brachial plexus anesthesia.
 PART 4: Managing Anesthesia Care

ing elbow with wrist techniques; both

provide sensory anesthesia of the hand.
Side Effects/Complications
In general, distal peripheral blocks are
associated with a lower risk of compli-
cations. However, intravascular injec-
tion can occur, and the usual precau-
tions of incremental injection after
aspiration are recommended. The risk
of nerve injury is theorized to be
higher when more distal peripheral
blocks are performed. This may be a
result of superficial nerve placement
between bony and ligamentous struc-
tures, thereby offering ready access to
the probing needle point.

Intravenous Regional Blocks

Intravenous regional blocks were first
described by August Bier, a German
surgeon, in 1908.54 Early methods in-
volved two tourniquets and the first
synthetic local anesthetic, procaine.
The technique lost popularity as more
1036 reliable methods of blocking the bra-
chial plexus evolved.
Clinical Applications
The Bier block has multiple advantag-
es, including ease of administration,
rapidity of recovery, rapid onset, mus-
FIGURE 48–11. Anatomic landmarks for median and ulnar nerve block at the wrist. An alternative
method for ulnar nerve block, from the ulnar side of the wrist, is shown. (Reprinted from Wedel DJ, cular relaxation, and controllable ex-
Horlocker TT. Nerve blocks. In: Miller RD, ed. Anesthesia. 6th ed. Philadelphia: Churchill Living- tent of anesthesia. It is an excellent
ston, 2005:1686–1717, with permission from Elsevier.) technique for short () 90 minutes)
open surgical procedures and for
closed reductions of bony fractures.

Technique at the Elbow The lat- Peripheral Blockade at Technique

eral cutaneous nerve of the forearm the Elbow versus the Wrist An intravenous cannula is placed in
can be blocked 1 cm proximal to the The forearm cutaneous nerves arise in the upper extremity to be blocked as
intercondylar line immediately lateral the upper arm and are not anesthe- distally as possible (the patient should
to the biceps tendon. Fanwise infiltra- tized by block of the peripheral nerves also have an intravenous cannula in
tion of 3–5 mL of solution subcutane- at the elbow. Hence, there is no advan- the nonoperative upper extremity for
ously at this site provides excellent tage of block of the peripheral nerves administration of fluids and other
anesthesia of this nerve. of the upper extremity when compar- drugs). Traditionally, a double tourni-
quet is placed on the operative side;
both cuffs should have secure closures
and reliable pressure gauges. After ex-
sanguination of the arm, the proximal
cuff is inflated to approximately 150
mm Hg more than the systolic pres-
sure (absence of a radial pulse con-
firms adequate tourniquet pressure).
Total dose of local anesthetic is based
on the patient’s weight and is injected
slowly (4–6 mg/kg of 0.5% prilocaine
or lidocaine—without epinephrine).
The onset of anesthesia is usually
within 5 minutes. When the patient
complains of tourniquet pain, the dis-
FIGURE 48–12. Anatomic landmarks and method of needle insertion for radial nerve block at the tal tourniquet, which overlies anesthe-
wrist. (Reprinted from Wedel DJ, Horlocker TT. Nerve blocks. In: Miller RD, ed. Anesthesia. 6th ed. tized skin, is inflated, and the proxi-
Philadelphia: Churchill Livingston, 2005:1686–1717, with permission from Elsevier.) mal tourniquet is released. There are
 CHAPTER 48: Peripheral Nerve Blocks

data suggesting that the use of a single

wide cuff allows use of lower inflation
pressures during intravenous regional
anesthesia. The postulated advantage
is that the lower pressures will de-
crease the incidence of neurologic
complications related to high inflation
pressures with the narrow double
cuffs.55 The tourniquet may be safely
released after 25 minutes, but the pa-
tient should be closely observed for
local anesthetic toxicity for several
minutes after the tourniquet release.
Slow injection of local anesthetic solu-
tions at a distal site has been shown to
lower the risk of toxicity.56

Side Effects/Complications
Technical problems with this block in-
clude tourniquet discomfort, rapidity
of recovery leading to postoperative
pain, difficulty in providing a bloodless FIGURE 48–13. Portable infusion pumps. A. Accufuser, McKinley Medical, Wheat Ridge, CO;
field, and the necessity of exsan- (B) Sgarlato, Sgarlato Labs, Los Gatos, CA; (C) Pain Pump, Stryker Instruments, Kalamazoo,
guination in the case of a painful inju- MI; (D) MedFlo II, MPS Acacia, Brea, CA; (E) C-Bloc, I-Flow Corp, Lake Forest, CA; and (F) Microject
ry. Accidental or early deflation of the PCA, Sorenson Medical, West Jordan, UT. (Reproduced with permission from Ilfeld BM, Morey
TE, and Enneking FK.59) 1037
tourniquet or use of excessive doses of
local anesthetics can result in toxic
reactions. Injection of the drug as dis-
tally as possible at a slow rate decreas- and maintenance still exists, the use of tient satisfaction.7,67 However, sub-
es blood levels of anesthetic and theo- stimulating catheters and radiographic stantial improvements in surgical
retically increases safety.56 The use of confirmation may further improve the outcomes and economics have not
bupivacaine for intravenous regional functionality.61,62 Risks of infection, in- been noted. This may be because of
anesthesia is associated with local an- adequate anesthesia/analgesia, and ac- the relatively minor nature of upper-
esthetic toxicity and death57 and is not cumulation of local anesthetic (system- extremity procedures (and the associ-
recommended. Cyclic deflation of the ic toxicity) are the major disadvantages. ated decreased analgesic require-
tourniquet at 10-second intervals in- Catheter migration, catheter kinking ments) compared to neuraxial or
creases the time to peak arterial lido- or coiling, and nerve damage also rare- lower-extremity operations.
caine levels that may decrease poten- ly may occur.63
tial toxicity.58 Other rare complications Methods of providing continuous
associated with this technique include brachial plexus anesthesia have been LOWER-EXTREMITY BLOCKS
phlebitis (2-chloroprocaine), develop- described since at least the 1940s,64
ment of compartment syndrome, and and frequently offer ingenious solu- Knowledge of the anatomy of the lum-
loss of limb. tions for the placement and securing bosacral plexus and peripheral nerves
of the needle or catheter. Longer cath- of the lower extremity enables anes-
Upper Extremity Continuous eters may be easier to secure and thesiologists to provide more compre-
Catheter Techniques provide superior blockade if the tip hensive anesthetic care. These blocks
The advantages cited for continuous lies more proximal in the plexus.65 are safe and have certain advantages,
nerve blockade include prolongation This technique is especially applicable such as postoperative pain relief and
of surgical anesthesia, decreased risk to patients with upper extremity or lack of complete sympathectomy,
of toxicity because of lower incremen- digit replantation, total elbow arthro- which make them ideal for selected
tal doses, and postoperative pain relief plasty, or reflex sympathetic dystro- patients.
and sympathectomy. Catheter place- phies, for which prolonged pain relief Lower-extremity blocks are less pop-
ment using both over- and through- and sympathectomy are advanta- ular than those routinely employed for
needle methods have been described. geous.66 Despite increased use, few surgical procedures of the upper ex-
Advances in equipment technology, studies have critically analyzed the tremity. In part, this is a result of the
including the development of stimu- benefits and outcomes of brachial widespread acceptance and safety of
lating needles and catheters and porta- plexus catheters to single injection or spinal and epidural anesthesia. Fur-
ble pumps allowing local anesthetic conventional methods of postopera- thermore, unlike the brachial plexus,
infusion after hospital dismissal, have tive analgesia. Overall, superior anal- the nerves supplying the lower extrem-
increased the success rate and popu- gesia is consistently reported, with ity are not anatomically clustered
larity of continuous peripheral block- lower opioid use and decreased pain where they can be easily blocked with
ade (Fig. 48–13).59,60 Although concern scores. Other benefits include fewer a relatively superficial injection of local
regarding accurate catheter placement sleep disturbances and increased pa- anesthetic. Because of the anatomic
 PART 4: Managing Anesthesia Care

1038

FIGURE 48–14. The lumbar plexus lies in the psoas compartment between the psoas major and quadratus lumborum muscles. (Reprinted from Wedel
DJ, Horlocker TT. Nerve blocks. In: Miller RD, ed. Anesthesia. 6th ed. Philadelphia: Churchill Livingston, 2005:1686–1717, with permission from Elsevier.)

considerations, lower-extremity blocks the anterior and medial thigh. The Lumbar Plexus Block
are technically more difficult and re- anterior divisions of L2, L3, and L4
quire more training and practice be- form the obturator nerve; the posteri- Clinical Applications
fore expertise is acquired. Many of or divisions of the same components The lumbar plexus can be blocked by
these blocks were classically performed form the femoral nerve; and the later- three distinct approaches. Block of the
using paresthesia, loss of resistance, or al femoral cutaneous nerve is formed full lumbar plexus (femoral, lateral
field block technique; success was vari- from posterior divisions of L2 and L3. femoral cutaneous, obturator) is ac-
able. Advances in needles, catheters The posterior cutaneous nerve of the complished with the psoas block.14,68,69
and nerve stimulator technology have thigh and the sciatic nerve are derived In comparison, the fascia iliaca and
facilitated localization of neural struc- from the first, second, and third sacral femoral approaches will reliably block
tures and improved success rate. Re- nerves plus branches from the anterior the femoral but not the lateral femoral,
cent applications have focused on pro- rami of L4 and L5, respectively. These cutaneous, and obturator nerves.68–70
longed postoperative analgesia to assist nerves pass together through the pelvis Lumbar plexus block is often used to
rehabilitation and hospital dismissal. and the greater sciatic foramen and provide postoperative analgesia for pa-
are blocked by the same technique. tients undergoing major knee and hip
Anatomy The sciatic nerve is actually a combi- surgery. Selection of regional analgesic
The nerve supply to the lower extrem- nation of two major nerve trunks, the technique is dependent on the surgical
ity is derived from the lumbar and tibial (ventral branches of the anterior site. For example, the psoas compart-
sacral plexuses. The lumbar plexus is rami of L4, L5, S1, S2, and S3) and the ment approach to the lumbar plexus is
formed by the anterior rami of the first common peroneal (dorsal branches of preferable for surgery to the hip be-
four lumbar nerves, frequently includ- the anterior rami of L4, L5, S1, S2, and cause it is the most proximal lumbar
ing a branch from T12 and occasional- S3), which form the sciatic nerve. At or plexus technique. Conversely, for sur-
ly from L5 (Fig. 48–14). The plexus lies above the popliteal fossa they separate, gery to the knee, the more distal femo-
between the psoas major and quadra- the tibial nerve passing medially and ral and fascia iliaca approaches are
tus lumborum muscles, in the psoas the common peroneal laterally. Figure sufficient. Importantly, although differ-
compartment. 48–15 shows the cutaneous distribu- ences in frequency of complete lumbar
The lower components of the plex- tions of the lumbosacral and peripher- plexus blockade exists between tech-
us, L2, L3, and L4, primarily innervate al nerves. niques, no clinical differences in pain
 CHAPTER 48: Peripheral Nerve Blocks

1039

FIGURE 48–15. A. Cutaneous distribution of the lumbosacral nerves. B. Cutaneous distribution of the peripheral nerves of the lower extremity.
(Reprinted from Wedel DJ, Horlocker TT. Nerve blocks. In: Miller RD, ed. Anesthesia. 6th ed. Philadelphia: Churchill Livingston, 2005:1686–1717, with
permission from Elsevier.)

scores or supplemental opioid require- line) identifying the fourth lumbar cephalad to the upper edge of the iliac
ments has been noted. For example, spine. After skin preparation, a skin crests.) The needle is advanced per-
femoral and psoas compartment block wheal is raised 3 cm caudad and 5 cm pendicularly to the plane of the back
appear to provide equivalent analgesia lateral to the midline on the side to be until contact with the transverse pro-
following total knee replacement.14,68 blocked. A 21-gauge, 10-cm stimulat- cess of L4 is obtained and advanced
Supplemental sciatic71–73 or obturator74 ing needle is then advanced perpen- under the transverse process until
block is required to obtain adequate dicular to the skin entry site until it quadriceps femoris muscle twitches
analgesia following total knee (but not contacts the fifth lumbar transverse are elicited. Despite a difference be-
hip) arthroplasty. process. The needle is redirected tween men and women in the depth of
cephalad until it slides off the trans- the lumbar plexus (median values: 8.5
Technique verse process. The lumbar plexus is and 7.0 cm, respectively), the distance
Psoas Compartment Approach The identified by elicitation of a quadri- from the L4 transverse process to the
psoas compartment block offers a sin- ceps motor response. When the needle lumbar plexus was comparable (medi-
gle injection rather than three sepa- is in place, 30 mL of solution is inject- an value: 2 cm) in both sexes. Thus the
rate needle insertions for anesthesia of ed (Fig. 48–16). authors stressed the importance of
the lumbar plexus and involves needle Based on anatomic imaging studies, achieving contact with the L4 trans-
placement into the space between the Capdevila et al.76 modified the classic verse process to establish appropriate
psoas major and quadratus lumborum psoas technique. Needle insertion site needle depth and position.
muscles. A large volume of injected is the junction of the lateral third and
solution anesthetizes the hip and an- medial two thirds of a line between Perivascular Approach (“3-in-1
terolateral thigh.75 the spinous process of L4 and a line Block”) The perivascular approach
The patient is placed in the lateral parallel to the spinal column passing to the psoas compartment is based on
position, hips flexed, and operative through the posterior superior iliac the premise that injection of a large
extremity uppermost. A line is drawn spine. (The spinous process of L4 was volume of local anesthetic within the
to connect the iliac crests (intercristal estimated to be approximately 1 cm femoral canal while maintaining distal
 PART 4: Managing Anesthesia Care

1040

FIGURE 48–16. A. Lumbar plexus block, psoas compartment approach: patient position and surface landmarks. B. The needle is advanced
perpendicularly until it contacts the transverse process. It is redirected to walk off the caudad surface of the transverse process and advanced 1–2 cm.
(Reprinted from Wedel DJ, Horlocker TT. Nerve blocks. In: Miller RD, ed. Anesthesia. 6th ed. Philadelphia: Churchill Livingston, 2005:1686–1717, with
permission from Elsevier.)

pressure will result in proximal spread until a paresthesia or nerve stimulator identified, elicitation of a paresthesia
of the solution into the psoas compart- response is obtained. The needle is or motor response is not required.
ment and consequent lumbar plexus held immobile while distal pressure is Rather, successful needle position is
block.77 The key anatomic assumption applied digitally to the femoral sheath. determined by a double “pop.”
is that the fascial sheath surrounding A total of 20–40 mL of solution is The patient is positioned supine and
the lumbar roots extends into the fem- injected incrementally after negative the inguinal ligament is identified and
oral canal and acts as an enclosed aspiration. Reliable anesthesia of the divided into thirds. The junction of the
conduit for the spread of local anes- femoral and lateral femoral cutaneous lateral one-third and medial two-thirds
thetic solutions. However, despite nerves can be predicted with 20 mL. is determined. A 17-gauge Tuohy nee-
many efforts to consistently produce a However, obturator nerve block may dle is inserted 1 cm below this point.
3-in-1 block, the femoral nerve is the not occur even with volumes greater An initial loss of resistance is noted as
only nerve consistently blocked with than 30 mL (Fig. 48–17A). the needle penetrates the fascia lata.
this approach.78 In addition, blockade The second loss of resistance is felt as
of the lateral femoral cutaneous and Fascia Iliaca Approach The more the needle penetrates the fascia iliaca
obturator nerves occurs through later- lateral needle insertion site with this and 30 mL of local anesthetic in incre-
al and medial diffusion of local anes- approach to the lumbar plexus in- mentally injected (Fig. 48–18).
thetic, respectively (and not through creases the likelihood of successful
proximal spread to the lumbar plexus). lateral femoral cutaneous block and Side Effects/Complications
The patient lies in the supine posi- decreases the frequency of obturator The deep needle placement with the
tion. The inguinal ligament is marked blockade.14,70 However, proximal cath- posterior (psoas compartment) ap-
as a line connecting the pubic tubercle eter advancement is often associated proach increases the risk of possible
and the anterior superior iliac spine. with sciatic spread and improved anal- epidural, subarachnoid, or intravascu-
The femoral artery is marked. A 22- gesia.79 An additional advantage of this lar injection. Peripheral nerve dam-
gauge, 5- cm needle is advanced later- approach is the simplicity; because age is also a potential risk with this
al to the artery in a cephalad direction neural structures are not specifically technique. Cardiac arrest caused by
 CHAPTER 48: Peripheral Nerve Blocks

Femoral Nerve Block

The femoral nerve is formed within
the psoas major muscle by posterior
divisions of the second, third, and
fourth lumbar nerves. It emerges
from the lateral border of the psoas
muscle to descend in the groove be-
tween the psoas and iliacus muscles
and enters the thigh by passing be-
neath the inguinal ligament lateral to
the femoral artery. At this point, the
nerve divides into multiple terminal
branches, which have been classified
as anterior and posterior. The anteri-
or branches are primarily cutaneous,
the deep branches chiefly motor.
The femoral nerve supplies the an-
terior compartment muscles of the
thigh (quadriceps, sartorius) and the
skin of the anterior thigh from the
inguinal ligament to the knee. Its
terminal branch is the saphenous
nerve, which supplies an area of skin
along the medial side of the leg from
the knee to the big toe. 1041

Clinical Applications
The femoral block is primarily used in
concert with other peripheral blocks.
However, it can be used alone for
muscle biopsies of the quadriceps
muscle or other surgical procedures
limited to the anterior thigh, and it
is reported effective for anesthetic
management of knee arthroscopy and
FIGURE 48–17. A. Anatomic landmarks for lateral femoral cutaneous, femoral, and obturator surgical repair of midfemoral shaft
nerve blocks. B. Obturator nerve block. The needle is walked off the inferior pubic ramus in a fractures.81,82
medial and cephalad direction until it passes into the obturator canal. (Reprinted from Wedel DJ,
Horlocker TT. Nerve blocks. In: Miller RD, ed. Anesthesia. 6th ed. Philadelphia: Churchill Living-
ston, 2005:1686–1717, with permission from Elsevier.) Technique
The patient is placed in the supine
position. A line is drawn between the
anterior superior iliac spine and the
pubic tubercle, identifying the in-
guinal ligament. The femoral artery
total spinal anesthesia has been re- for choosing a lower-extremity block is marked. A 22-gauge, 4-cm needle
ported.80 Thus, the depth of the neu- over spinal or epidural blockade is is advanced lateral to this line (Fig.
ral structures and potential for seri- prevention of sympathectomy, the 48–17A). When the needle reaches the
ous side effects associated with the advantage of a psoas compartment depth of the artery, a pulsation of the
psoas compartment approach to the block is diminished should this effect hub is visible. Elicitation of a paresthe-
lumbar plexus (compared to more occur. sia or motor response verifies correct
superficial fascia iliaca and femoral Intravascular injection and hemato- needle position. Commonly, the ante-
techniques) warrant consideration. ma are possible with femoral perivas- rior branch of the femoral nerve will
Several authors have advocated use of cular and fascia iliaca techniques be- be identified first. Stimulation of this
the psoas compartment block only cause of the close proximity of the branch leads to contraction of the sar-
when more distal approaches are not femoral artery. The presence of femo- torius muscle on the medial aspect of
indicated/efficacious.68 An additional ral vascular grafts is a relative contra- the thigh and should not be accepted.
side effect of the psoas compartment indication. Nerve damage is rare with The needle should be redirected
block is the development of a sympa- these techniques. The lateral needle slightly laterally and with a deeper
thetic block secondary to extravasa- insertion site with the fascia iliaca direction to encounter the posterior
tion of local anesthetic. This unilater- approach overlies the hip joint; a third branch of the femoral nerve. Stimula-
al sympathectomy is usually of little “pop” may signify advancement into tion of this branch is identified by
consequence. Although one reason the articular space. patellar ascension as the quadriceps
 PART 4: Managing Anesthesia Care

passage through the fascia lata. As the

needle is moved fanwise laterally and
medially, 10–15 mL of solution is inject-
ed, depositing local anesthetic above
and below the fascia (Fig. 48–17A).
The nerve can also be blocked just
medial and posterior to the anterior su-
perior iliac crest with 10 mL of solution.
Combining the two techniques increas-
es the success rate, but the total volume
of solution used may be limiting.
Side Effects/Complications
The extent of anesthesia is quite limit-
ed with this block, but there is a low
risk of associated complications. Neu-
ritis of this nerve secondary to needle
trauma or drug toxicity is a potential
but unlikely complication. Because
there are no large blood vessels in the
vicinity of this nerve, the likelihood of
rapid uptake or intravascular injection
is very small.

Obturator Nerve Block

1042 The obturator nerve is derived primar-
ily from the third and fourth lumbar
nerves with an occasional minor con-
tribution from L2. The nerve lies deep
in the obturator canal, having de-
scended from the medial border of the
psoas muscle. As the nerve leaves the
obturator canal, it divides into anterior
and posterior branches. The anterior
FIGURE 48–18. Lumbar plexus block: fascia iliaca approach. A discernable “pop” is noted as the
branch supplies an articular branch to
needle traverses the fascia lata and then the fascia iliaca. (Reproduced with permission from
the hip and the anterior adductor mus-
Lennon RL, Horlocker TT. Mayo Clinic Analgesic Pathway: Peripheral Nerve Blockade for Major
Orthopedic Surgery. Rochester, MN: Mayo Clinic Scientific Press, 2005:45.) cles and a variable cutaneous branch
to the lower medial thigh. The posteri-
contract. Local anesthetic, 20 mL, is ly caudad to the ilioinguinal nerve. It or branch innervates the deep adduc-
injected fanwise, lateral to the artery. descends under the iliac fascia to enter tor muscles and may send an articular
If a paresthesia/nerve stimulator re- the thigh deep to the inguinal ligament branch to the knee.
sponse is obtained, 7–10 mL of solu- 1–2 cm medial to the anterior superior
tion should be injected at that site. iliac spine. The nerve emerges from
Clinical Applications
the fascia lata 7–10 cm below the spine Usually, the obturator nerve is blocked
Side Effects/Complications and divides into anterior and posterior as part of regional anesthesia for knee
Intravascular injection and hematoma branches. The skin of the lateral por- surgery. Because it is primarily a
are possible because of the close proxim- tion of the thigh from the hip to motor nerve, it is rarely blocked on its
ity of the femoral artery. However, ana- midthigh is supplied by the posterior own; however, obturator nerve block
tomically, the nerve and artery are lo- branch; the anterior branch supplies can be useful in treating or diagnosing
cated in separate sheaths approximately the anterolateral thigh to the knee. the extent of adductor spasm in pa-
1 cm apart. In most patients with nor- tients with cerebral palsy and other
mal anatomy, the femoral artery can be Clinical Applications muscle or neurologic diseases affect-
easily palpated, allowing correct, safe This block is useful for skin graft ing the lower extremities prior to sur-
needle positioning lateral to the pulsa- harvesting and can be used in con- gical intervention, such as adductor
tion. The presence of femoral vascular cert with other peripheral nerve tenotomy.
grafts is a relative contraindication to blocks for complete anesthesia of the
this block. Nerve damage is rare. lower extremity.
Technique
The patient is placed in the supine
Technique position, and a mark is made 1–2 cm
Lateral Femoral Cutaneous A point is marked 2 cm medial and 2 lateral and 1–2 cm caudad to the pubic
Nerve Block cm caudad to the anterior superior iliac tubercle. A skin wheal is raised, and a
The lateral femoral cutaneous nerve spine. A 22-gauge, 4-cm needle is ad- 22-gauge, 8–10-cm needle is advanced
(L2 and L3) emerges at the lateral vanced perpendicular to the skin entry perpendicular to the skin entry site
border of the psoas muscle immediate- site until a sudden release indicates with a slight medial direction. The
 CHAPTER 48: Peripheral Nerve Blocks

inferior pubic ramus is encountered at

a depth of 2–4 cm, and the needle is
walked in a lateral and caudad direc-
tion, until it passes into the obturator
canal. The obturator nerve is located
2–3 cm past the initial point of contact
with the pubic ramus (Fig. 48–17B).
After negative aspiration, 10–15 mL of
local anesthetic is injected. A nerve FIGURE 48–19. Posterior approach to the sciatic nerve: patient positioning. (Rerprinted from
stimulator is helpful in locating the Wedel DJ, Horlocker TT. Nerve blocks. In: Miller RD, ed. Anesthesia. 6th ed. Philadelphia: Churchill
obturator nerve; correct needle posi- Livingston, 2005:1686–1717, with permission from Elsevier.)
tion is evidenced by contraction of the
adductor muscles of the medial thigh. fossa. It supplies cutaneous innerva- or nerve stimulator response is elicit-
The classic approach to obturator tion to the posterior thigh and all of ed or bone is contacted (Fig. 48–20). If
nerve block involves painful periosteal the leg and foot below the knee, ex- bone is encountered, the needle is
contact and multiple needle redirec- cept for a thin medial strip supplied by redirected systematically in a lateral
tions. An alternate interadductor ap- the saphenous nerve. or medial direction. Once the needle
proach was described by Wasseff.83 In is properly placed, a total of 20–30 mL
this technique, the needle is inserted Clinical Applications of solution is injected.
behind the adductor tendon, near its Because of its wide sensory distribu-
pubic insertion, and is directed lateral- tion, the sciatic nerve block can be Anterior Approach This tech-
ly toward a mark on the skin 1–2 cm used, together with a saphenous or nique is useful when the patient can-
medial to the femoral artery and im- femoral nerve block, for any surgical not be positioned for the classic
mediately below the inguinal ligament procedure below the knee that does posterior approach because of pain or
representing the obturator canal. The not require a thigh tourniquet. It can lack of cooperation.84 Blockade of the
also be combined with other peripher- femoral nerve can be accomplished 1043
nerve is identified by a motor re-
sponse to peripheral nerve stimulation al nerve blocks to provide anesthesia with the same needle insertion site.
in the adductor muscle. for surgical procedures involving the With the patient in the supine posi-
thigh and knee. The sciatic nerve may tion, a line drawn along the inguinal
Side Effects/Complications also be blocked at several sites in the ligament from the anterior superior
Although complications are rare, this hip and thigh. However, the more iliac crest to the pubic tubercle is
block is technically more difficult than proximal approaches are necessary to trisected. A second line parallel to the
other lower-extremity blocks. Because achieve blockade of the posterior fem- inguinal ligament is drawn, beginning
the obturator canal contains vascular oral cutaneous nerve, which is impor- at the tuberosity of the greater tro-
and neural structures, there is a theo- tant in decreasing the posterior knee chanter. A 22-gauge, 10.5–12-cm nee-
retical risk of intravascular injection, pain that knee replacement patients dle is inserted perpendicularly with a
hematoma, and nerve damage. Ab- often experience in the early postoper- slightly lateral angulation at the point
sence of anesthesia in the obturator ative period.14 where the line representing the junc-
nerve distribution can render an oth- Because this form of anesthesia ture of the middle and medial thirds
erwise perfect lower-extremity block avoids the sympathectomy associated crosses the second line. This needle
inadequate for surgical procedures on with neuraxial blocks, it may be advan- is advanced until it contacts bone,
the knee. tageous when any shift in hemodynam- the lesser trochanter of the femur
ics could be deleterious, such as in (Fig. 48–21). The needle is redirected
Sciatic Nerve Block patients with significant aortic stenosis. medially past the femur, and a pares-
The sciatic nerve (L4 and L5, S1 thesia/nerve stimulator response is
through S3) is the largest of the four Technique sought at a depth of about 5 cm past
peripheral nerves of the lower extrem- Classic Approach of Labat (Pos- bone. A total of 20–25 mL of solution
ity, with a width of 2 cm as it leaves terior) The patient is positioned is injected incrementally after careful
the pelvis with the posterior cutane- laterally, with the leg to be blocked aspiration.
ous nerve of the thigh. The sciatic rolled forward onto the flexed knee as
nerve is actually two nerves bound by the heel rests on the knee of the Other Approaches The sciatic nerve
a common sheath of connective tissue; dependent (nonoperative) leg (Fig. can also be blocked with the patient in
the tibial component is medial and 48–19). A line is drawn to connect the the lateral85 and lithotomy positions,86
anterior, whereas the common pero- posterior superior iliac spine to the although these are rarely employed
neal component is lateral and slightly greater trochanter of the femur. A clinically. A subgluteal approach, with
posterior. After passing through the perpendicular line is drawn bisecting needle insertion occurring at the mid-
sacrosciatic foramen beneath the piri- this line and extending 5 cm caudad. point of a line drawn between the
formis muscle, it lies between the A second line is drawn from the great- greater trochanter of the femur and
greater trochanter of the femur and er trochanter to the sacral hiatus. The the ischial tuberosity has been de-
the ischial tuberosity. The nerve be- intersection of this line with the per- scribed.87 However identifying these
comes superficial at the lower border pendicular line indicates the point of bony landmarks in very obese patients
of the gluteus maximus muscle, where needle entry and is located 3–5 cm is sometimes difficult and the patient
it begins its descent down the posteri- along the line. A 22-gauge, 10–12-cm position requires additional personnel
or aspect of the thigh to the popliteal needle is advanced until a paresthesia to maintain. Furthermore, when using
 PART 4: Managing Anesthesia Care

FIGURE 48–20. Anatomic landmarks for the posterior approach to sciatic nerve block. (Reprinted from Wedel DJ, Horlocker TT. Nerve blocks. In: Miller
1044 RD, ed. Anesthesia. 6th ed. Philadelphia: Churchill Livingston, 2005:1686–1717, with permission from Elsevier.)

more distal approaches to the sciatic Techniques to Improve Success cess rates.88 Another method is the
nerve, the posterior femoral cutane- Rate Many methods have been tried concept of multiple injections where
ous nerve of the thigh will remain to improve success with sciatic nerve the two major components of the sciat-
unblocked in a significant number of blockade. Attempts to place the needle ic nerve are separately identified and
patients and result in pain as a conse- in the middle of the sciatic nerve by blocked.46 Some experts recommend
quence of surgery and/or tourniquet identifying a specific motor end point that sciatic nerve blocks be initiated
ischemia. (foot inversion) might increase suc- well before the scheduled time of sur-
gery to allow for long latencies.
Side Effects/Complications
The block is technically difficult to
perform and can be quite painful.46
Hematoma formation is possible; the
risk of nerve damage is also reported,
although persistent paresthesias are
usually self-limited. A minimal degree
of vasodilatation may occur with sciat-
ic nerve block.

Popliteal Fossa Block

The posterior muscles of the thigh are
the biceps femoris, the semimembra-
nosus, semitendinosus, and the poster-
ior portion of the adductor magnus. As
these muscles are traced distally from
their origin on the ischial tuberosity,
they separate into medial (semimem-
branosus, semitendinosus) and lateral
(biceps) musculature, and form the
upper border of the popliteal fossa.
The lower border of the popliteal fossa
is defined by the two heads of the
gastrocnemius. In the upper part of
the popliteal fossa, the sciatic nerve
FIGURE 48–21. Anatomic landmarks for the anterior approach to the sciatic nerve block. lies posterolateral to the popliteal ves-
(Reprinted from Wedel DJ, Horlocker TT. Nerve blocks. In: Miller RD, ed. Anesthesia. 6th ed. sels. Specifically, the popliteal vein is
Philadelphia: Churchill Livingston, 2005:1686–1717, with permission from Elsevier.) medial to the nerve, while the
 CHAPTER 48: Peripheral Nerve Blocks

popliteal artery is most anterior, lying

on the popliteal surface of the femur.
Near the upper border of the popliteal
fossa, the two components of the sciat-
ic nerve separate. The peroneal nerve
diverges laterally and the larger tibial
branch descends almost straight down
through the fossa. The tibial nerve and
popliteal vessels then disappear deep
to the converging heads of the gastroc-
nemius muscle.

Clinical Applications
This block is chiefly used for foot and
ankle surgery. The block has also been
successfully used in the pediatric pop-
ulation. Popliteal fossa block is prefer-
able to ankle block for surgical proce-
dures requiring the use of a calf
tourniquet. The components of the
sciatic nerve may be blocked at the
level of the popliteal fossa through
posterior or lateral approaches. Sup-
plemental block of the saphenous
nerve is required for surgical proce-
1045
dures to the medial aspect of the leg,
or when a calf tourniquet/Esmarch
bandage is used.

Technique
Posterior Approach The classic ap-
proach to the popliteal fossa is posteri-
orly, with the patient positioned
prone. However, access may also
occur with the patient in the lateral
(operative side nondependent) or su-
pine (with leg flexed at the hip and
knee) positions.
The borders of the popliteal fossa
are identified by flexing the knee joint.
A triangle is constructed, with the base
consisting of the skin crease behind
FIGURE 48–22. A. Anatomic landmarks for posterior approach to the sciatic nerve in the popliteal
the knee, and the two sides composed fossa. B. Anatomic landmarks for lateral approach to the sciatic nerve in the popliteal fossa.
of the semimembranosus (medially) (Reprinted from Wedel DJ, Horlocker TT. Nerve blocks. In: Miller RD, ed. Anesthesia. 6th ed.
and the biceps (laterally). A bisecting Philadelphia: Churchill Livingston, 2005:1686–1717, with permission from Elsevier.)
line is drawn from the apex to the base
of the triangle, and a 5-cm needle is
inserted at a site 5–10 cm above the
skin fold and 0.5–1 cm lateral to the
bisecting line (Fig. 48–22A). Classical- Success rate is typically 90–95%.89,91 Lateral Approach A lateral approach
ly, the 5-cm distance was described.89 No formal comparison between pares- to blockade of the sciatic nerve in the
However, in an attempt to block the thesia and nerve stimulator techniques popliteal fossa has been described.93
sciatic nerve prior to its division, a 7– has been performed to assess efficacy Although block time is somewhat
10-cm distance has been recommend- and complications. It is believed that longer, onset and quality of block are
ed.90 The needle is advanced at a 45° incomplete block is the result of poor similar to the posterior approach.94
angle until either a paresthesia or diffusion (because of the size of the The lateral approach allows the pa-
nerve stimulator response is elicited. sciatic nerve), the separate fascial cov- tient to be positioned supine and elim-
With a nerve stimulator technique, erings of the tibial and peroneal inates the need for repositioning. The
inversion is the motor response that nerves, or to blockade of only a single patient’s leg is extended, with the long
best predicts complete neural block of component of the sciatic nerve. Identi- axis of the foot at a 90˚ angle to the
the foot.91 Injection of approximately fication of both tibial and peroneal table. The site of insertion is the inter-
30-mL of local anesthetic solution is components decreases onset time and section of the vertical line drawn from
sufficient. improves success rate.92 the upper edge of the patella and the
 PART 4: Managing Anesthesia Care

groove between the lateral border of atic nerve (with supplemental saphe- The needle is now directed laterally
the biceps femoris and vastus latera- nous nerve block) or spinal anesthet- through the same skin wheal while
lis. A 10-cm needle is advanced at a ic is performed.87 injecting 3–5 mL of solution subcuta-
30° angle posterior to the horizontal neously, thus blocking the superficial
plane (Fig. 48–22B). Because the com- Technique peroneal nerve and resulting in anes-
mon peroneal nerve is located lateral Posterior Tibial Nerve The poste- thesia of the dorsum of the foot, ex-
to the tibial nerve, the stimulating rior tibial nerve can be blocked with the cluding the first interdigital cleft. The
needle encounters the common pero- patient in either the prone or the su- same maneuver can now be per-
neal nerve first with the lateral ap- pine position. The posterior tibial ar- formed in the medial direction, there-
proach. As with the classic posterior tery is palpated, and a 25-gauge, 3-cm by anesthetizing the saphenous nerve,
approach, an elicited inversion re- needle is inserted posterolateral to the a terminal branch of the femoral nerve
sponse is sought.91 If a response asso- artery at the level of the medial malle- that supplies a strip along the medial
ciated with common peroneal nerve olus (Fig. 48–23A and B). A paresthesia aspect of the foot.
stimulation (such as eversion) is elic- is often elicited; however, it is not nec-
ited, the needle is redirected more essary for a successful block. If a pares- Side Effects/Complications
posteriorly. thesia is obtained, 3–5 mL of local anes- Multiple injections are required for
thetic should be injected. Otherwise, 7– some techniques, resulting in dis-
Side Effects/Complications 10 mL of solution should be injected as comfort for the patient. Persisting
As with other peripheral nerve blocks, the needle is slowly withdrawn back paresthesia may occur, but it is self-
neuropathy is the most common com- from the posterior aspect of the tibia. limited. The presence of edema or
plication. Intravascular injection may Blockade of the posterior tibial nerve induration in the area of the ankle
occur as a result of the presence of provides anesthesia of the heel, plantar block can make palpation of land-
vascular structures within the popliteal portion of the toes, and the sole of the marks difficult. Intravascular injec-
fossa. Performance of popliteal fossa foot, as well as some motor branches in tion is possible but unlikely if aspira-
block in patients with previous total the same area. tion for blood is negative. The volume
1046
knee arthroplasty or vascular bypass of local anesthetic used is small,
(femoral–popliteal) should be done Sural Nerve The sural nerve is lo- thereby decreasing the risk of local
with care. To date, however, there are cated superficially between the lateral anesthetic toxicity.
no cases of graft disruption or joint malleolus and the Achilles tendon. A
infections relating to needle placement 25-gauge, 3-cm needle is inserted lat- Continuous Catheter
in these patients. eral to the tendon and is directed Techniques
toward the malleolus as 5–10 mL of Continuous lower-extremity tech-
Nerve Blocks at the Ankle solution is injected subcutaneously niques were described decades ago,
Four of the five individual nerves (Fig. 48–23A and C). This block pro- but remained underused compared
that can be blocked at the ankle to vides anesthesia of the lateral foot and to continuous upper-extremity and
provide anesthesia of the foot are the lateral aspects of the proximal sole neuraxial approaches. For example,
terminal branches of the sciatic of the foot. Brands and Callanan95 placed psoas
nerve: the posterior tibial, sural, su-
compartment catheters to provide an-
perficial peroneal, and deep peroneal Deep Peroneal, Superficial Pero- algesia for femoral neck fractures in
branches. The sciatic nerve divides at neal, and Saphenous Nerves The 1978. Reliable (and improved) success
or above the apex of the popliteal deep peroneal, superficial peroneal, rates and the risk of spinal hematoma
fossa to form the common peroneal and saphenous nerves can be blocked following neuraxial techniques lead
and tibial nerves. The common pero- through a single needle entry site clinicians to again consider continu-
neal nerve descends laterally around (Fig. 48–24). A line is drawn across ous lower-extremity blocks. Contem-
the head of the fibula, where it di- the dorsum of the foot connecting the porary applications for continuous
vides into the superficial and deep malleoli. The extensor hallucis longus psoas compartment, sciatic, femoral,
peroneal nerves. tendon is identified by having the and popliteal fossa blockade have
The tibial nerve divides into the pos- patient dorsiflex the big toe. The ante- been reported.60,76,96 Compared to
terior tibial and sural nerves in the rior tibial artery lies between this conventional systemic and neuraxial
lower leg. The posterior tibial nerve structure and the tendon of the exten- analgesic methods, continuous lower-
becomes superficial at the medial bor- sor digitorum longus muscle and is extremity blocks provide superior an-
der of the Achilles tendon near the palpable at this level. A skin wheal is algesia with fewer side effects, im-
artery of the same name, and the sural raised just lateral to the pulsation prove perioperative outcomes, and ac-
nerve emerges lateral to the Achilles between the two tendons on the inter- celerate hospital dismissal following
tendon. malleolar line. A 25-gauge, 3-cm nee- major joint replacement.76,96,97
dle is advanced perpendicular to skin
Clinical Applications entry site, and 3–5 mL of local anes-
Ankle blocks are simple to perform thetic injected deep to the extensor Perioperative Outcomes with
and offer adequate anesthesia for sur- retinaculum to block the deep pero- Lower-Extremity Peripheral
gical procedures of the foot not re- neal nerve. This technique anesthetiz- Regional Techniques
quiring a tourniquet above the ankle. es the skin between the first and The unilateral nature of lower-extrem-
When a thigh tourniquet is required, second toes and the short extensors of ity peripheral techniques makes them
a more proximal approach to the sci- the toes. ideal for the patient undergoing total
 CHAPTER 48: Peripheral Nerve Blocks

1047

FIGURE 48–23. A. Anatomic landmarks for block of the posteri-

or tibial and sural nerves at the ankle. B. Posterior tibial nerve.
Method of needle placement for block at the ankle. C. Sural
nerve. Method of needle placement for block at the ankle.
(Reprinted from Wedel DJ, Horlocker TT. Nerve blocks. In: Miller
RD, ed. Anesthesia. 6th ed. Philadelphia: Churchill Livingston,
2005:1686–1717, with permission from Elsevier.)

hip or knee arthroplasty, as the contra- after total joint replacement. For exam- temic approaches. Similar results were
lateral limb is immediately available to ple, after total knee arthroplasty, pa- reported for patients undergoing total
assist with early ambulation. Although tients receiving epidural analgesia or hip arthroplasty who received a contin-
single-injection techniques have been continuous femoral block reported uous psoas block rather than epidural
used, the duration of effect after a lower pain scores, better knee flexion, analgesia or intravenous morphine.76
single injection is insufficient to result faster ambulation, and shorter hospital Recent innovations emphasize con-
in major improvements in analgesia or stays than did patients who received tinuous peripheral nerve blocks com-
outcome.68,98,99 intravenous morphine.96,97,100 Howev- bined with multiple scheduled analge-
Studies demonstrate that peripheral er, continuous femoral block was the sics (OxyContin, acetaminophen) and
techniques are equally effective as epi- preferred analgesic technique in each oral analgesics (e.g., oxycodone); no
dural analgesia (and both are superior study because there were fewer techni- intravenous opioids are administered.
to intravenous morphine) in providing cal problems and fewer side effects Using strict criteria, 90% of patients
analgesia and facilitating rehabilitation noted compared to epidural and sys- undergoing minimally invasive prima-
 PART 4: Managing Anesthesia Care

dition of epinephrine increases the

neurotoxicity of local anesthetic solu-
tions and decreases nerve blood flow.
However, the clinical relevance of
these findings in humans remains un-
clear. Finally, nerve damage caused by
traumatic needle placement, local an-
esthetic neurotoxicity and neural is-
chemia during the performance of a
regional anesthetic may worsen neu-
rologic outcome in the presence of an
additional patient factor or surgical
injury.7
Prevention of neurologic complica-
tions begins during the preoperative
visit with a careful evaluation of the
patient’s medical history and appropri-
ate preoperative discussion of the risks
and benefits of the available anesthetic
techniques. It is imperative that all
preoperative neurologic deficits are
documented to allow early diagnosis
of new or worsening neurologic dys-
function postoperatively. Postopera-
tive sensory or motor deficits must
1048
also be distinguished from residual (pro-
FIGURE 48–24. A. Anatomic landmarks for block of the deep peroneal, superficial peroneal, and longed) local anesthetic effect. Imaging
saphenous nerves at the ankle. B. Method of needle placement for block of the deep peroneal, techniques, such as CT and MRI are
superficial peroneal, and saphenous nerves through a single needle entry site. (Reprinted from useful in identifying infectious process-
Wedel DJ, Horlocker TT. Nerve blocks. In: Miller RD, ed. Anesthesia. 6th ed. Philadelphia: Churchill es as well as expanding hematomas.
Livingston, 2005:1686–1717, with permission from Elsevier.)
Although most neurologic complica-
tions resolve completely within several
days or weeks, significant neural inju-
ry hip or knee replacement achieved However, postoperative neurologic in- ries necessitate neurologic consultation
readiness for hospital discharge within jury as a result of pressure from im- to document the degree of involvement
48 hours.101 These studies support the proper patient positioning, tightly ap- and coordinate further workup. Neuro-
movement toward continuous periph- plied casts/surgical dressings, and physiologic testing, such as nerve con-
eral technique as the optimal analgesic surgical trauma are often attributed to duction studies, evoked potentials, and
method following total knee and hip the regional anesthetic. Patient fac- electromyography are often useful in
arthroplasty. Additional information is tors, such as body habitus or a preex- establishing a diagnosis and prognosis.
needed to determine the effectiveness isting neurologic dysfunction, can also
of these techniques in conventional pri- contribute to postoperative neurologic
mary and revision joint arthroplasty. injury. HEMORRHAGIC
Although needle gauge, type (short COMPLICATIONS
vs. long bevel), and bevel configura-
NEUROLOGIC tion can influence the degree of nerve Although spinal hematoma is the most
COMPLICATIONS injury following peripheral nerve significant hemorrhagic complication of
block, the findings are conflicting and regional anesthesia because of the cata-
Nerve injury is a recognized complica- there are no confirmatory human strophic nature of bleeding into a fixed
tion of peripheral regional techniques. studies. Theoretically, localization of and noncompressible space, the associ-
In a series involving more than 100,000 neural structures with a nerve stimu- ated risk following plexus and peripher-
regional anesthetics, the frequency of lator would allow a high success rate al techniques remains undefined. No
neurologic complications following pe- without increasing the risk of neuro- investigation has examined the frequen-
ripheral blockade was less than that logic complications, but this has not cy and severity of hemorrhagic compli-
associated with neuraxial techniques, been established. Indeed, serious neu- cations following plexus or peripheral
and was associated with pain on needle rologic injury has been reported fol- blockade in anticoagulated patients.
placement or injection of local anes- lowing uneventful brachial plexus Several cases of vascular injury
thetic.102 Risk factors contributing to block using a nerve stimulator tech- with (or without resultant nerve dys-
neurologic deficit after regional anes- nique.30 Likewise, prolonged expo- function) have been described follow-
thesia include neural ischemia, trau- sure, high dose and/or high concentra- ing plexus or peripheral techniques in
matic injury to the nerves during nee- tions of local anesthetic solutions also patients with normal and abnormal
dle or catheter placement, infection, can result in permanent neurologic hemostasis. In all patients with neuro-
and choice of local anesthetic solution. deficits. In laboratory models, the ad- logic deficits, neurologic recovery was
 CHAPTER 48: Peripheral Nerve Blocks

complete within 6–12 months. Thus, ied 1416 patients in 10 centers under- is under general anesthesia, the addi-
while bleeding into a neurovascular going continuous peripheral nerve tion of peripheral nerve block tech-
sheath may result in significant de- blocks for orthopedic procedures. A niques to the anesthesiologist’s arma-
creases in hematocrit, the expandable total of 969 (68%) catheters were cul- mentarium adds flexibility and skills
nature of peripheral site may de- tured when removed, and patients that benefit the patient both intraoper-
crease the chance of irreversible neu- were actively monitored for signs of atively and postoperatively. Success-
ral ischemia.103 localized infection or sepsis. A positive fully mastering these techniques and
Importantly, all cases of major bleed- bacterial colonization was found in applying them to the appropriate clin-
ing associated with nonneuraxial tech- 278 (29%) catheters, most commonly ical situations add valuable options to
niques occurred after psoas compart- Staphylococcus epidermidis. Local in- the anesthetic care. Finally, for the
ment or lumbar sympathetic blockade. flammation was present in 3% of pa- anesthesiologist, knowledge of region-
Anticoagulants implicated included war- tients. In these patients, 44% of the al anesthesia is essential for the diag-
farin, low-molecular-weight and stan- catheters were colonized, whereas nosis and treatment of acute and
dard heparin, and thienopyridine deriv- only 19% of catheters were colonized chronic pain syndromes.
atives (clopidogrel and ticlopidine). in patients without inflammatory
These cases suggest that significant signs. There was no correlation be-
blood loss, rather than neural deficits tween colonization and the presence
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in continuous peripheral nerve blocks. Although it is possible to perform all Analg 1998;87:88.
Capdevila et al.104 prospectively stud- surgical procedures while the patient
 PART 4: Managing Anesthesia Care

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26:589. 95. Brands E, Callanan VI. Continuous lum-
lumbar plexus anesthesia: The “3-in-1
62. Capdevila X, Biboulet P, Morau D, et al. block.” Anesth Analg 1973;52:989. bar plexus block--analgesia for femoral
Continuous three-in-one block for postop- 78. Marhofer P, Nasel C, Sitzwohl C, Kapral neck fractures. Anaesth Intensive Care
erative pain after lower limb orthopedic S. Magnetic resonance imaging of the distri- 1978;6:256.
surgery: where do the catheters go? Anesth bution of local anesthetic during the three- 96. Singelyn FJ, Deyaert M, Joris D, et al.
Analg 2002;94:1001. in-one block. Anesth Analg 2000;90:119. Effects of intravenous patient-controlled
63. Bergman BD, Hebl JR, Kent J, Horlock- 79. Ganapathy S, Wasserman RA, Watson analgesia with morphine, continuous epi-
er TT. Neurologic complications of 405 JT, et al. Modified continuous 3-in-1 block dural analgesia, and continuous three-in-
consecutive continuous axillary catheters. for post-operative pain after TKA. Anesth one block on postoperative pain and knee
Anesth Analg 2003;96:247. Analg 1999;99:1197. rehabilitation after unilateral total knee ar-
64. Ansbro PF. A method of continuous throplasty. Anesth Analg 1998;87:88.
80. Auroy Y, Benhamou D, Bargues L, et al.
brachial plexus block. Am J Surg 1946;71: Major complications of regional anesthesia 97. Capdevila X, Barthelet Y, Biboulet P, et
716. in France: the SOS Regional Anesthesia al. Effects of perioperative analgesic tech-
65. Gaumann DM, Lennon RL, Wedel DJ. Hotline Service. Anesthesiology 2002;97: nique on the surgical outcome and dura-
Continuous axillary block for postoperative 1274. tion of rehabilitation after major knee sur-
pain management. Reg Anesth 1988;13:77. gery. Anesthesiology 1999;91:8.
81. Berry FR. Analgesia in patients with
66. O’Driscoll SW, Giori NJ. Continuous fractured shaft of femur. Anaesthesia 1977; 98. Allen HW, Liu SS, Ware PD, et al.
passive motion (CPM): theory and princi- 32:576. Peripheral nerve blocks improve analgesia
 PART 4: Managing Anesthesia Care

after total knee replacement surgery. 101. Hebl JR, Kopp SL, Ali MH, et al. A ASRA Consensus Conference on Neuraxial
Anesth Analg 1998;87:93. comprehensive anesthesia protocol that em- Anesthesia and Anticoagulation). Reg
99. Stevens RD, Van Gessel E, Flory N, et phasizes peripheral nerve block markedly Anesth Pain Med 2003;28:172.
al. Lumbar plexus block reduces pain improves patient care and facilitates early 104. Capdevila X, Pirat P, Bringuier S, et al.
and blood loss associated with total hip discharge after total hip and knee arthro- Continuous peripheral nerve blocks in hos-
arthroplasty. Anesthesiology 2000;93: plasty. J Bone Joint Surg Am 2005;87:63. pital wards after orthopedic surgery. Anes-
115. 102. Auroy Y, Narchi P, Messiah A, et al. thesiology 2005;103:1035.
100. Chelly JE, Greger J, Gebhard R, et al. Serious complications related to regional 105. Cuvillon P, Ripart J, Lalourcey L, et al.
Continuous femoral blocks improve recov- anesthesia. Anesthesiology 1997;87:479. The continuous femoral nerve block cathe-
ery and outcome of patients undergoing 103. Horlocker TT, Wedel DJ, Benzon H, et ter for postoperative analgesia: bacterial
total knee arthroplasty. J Arthroplasty al. Regional anesthesia in the anticoagulat- colonization, infectious rate and adverse
2001;16:436. ed patient: defining the risks (the second effects. Anesth Analg 2001;93:1045.

1052
 CHAPTER 49: Managing Adverse Outcomes during Regional Anesthesia

The first task at hand is to perform a tice is closely associated with the severi-
CHAPTER 49 thorough preoperative assessment of
the patient. Good results are obtained
ty of patient injury rather than the
occurrence of negligence; this is particu-
when a skilled anesthesiologist uses larly true of regional anesthesia injuries.
appropriate equipment and technique. The Closed Claims study in the United
Managing Adverse Careful intraoperative sedation and States reported a high incidence of suc-
Outcomes during monitoring are vital to the practice of
safe regional anesthesia. Resuscitation
cessful suits against anesthesiologists in-
volved in regional anesthesia cases,
Regional drugs and equipment must always be even though the standard of care was
immediately available in the event of met. The importance of effective com-
Anesthesia a problem or if general anesthesia is munication and truthful disclosure with
required. Last but not least, patients the patient and the patient’s family can-
Ban C.H. Tsui, MSc, MD, FRCPC, must be carefully observed during the not be overemphasized. Litigation gen-
postoperative period when most of the erally results from the combination of
and Brendan T. Finucane, serious complications become evident. an adverse event and a poor physician–
MBBCh, FRCPC Early intervention is of the utmost patient relationship. A patient who feels
importance in preventing permanent that the physician has the patient’s best
neurologic injury. The anesthesiolo- interests at heart is less likely to pursue
No matter how skillful an anesthesi- gist should also be familiar with and litigation than is a patient who does not
ologist may be, adverse periopera- aware of the legal implications of ad- respect or trust the physician; thus, the
tive events are inevitable during re- verse events should they occur. anesthesiologist should pay particular
gional anesthesia practice. Adverse Poor outcomes and serious complica- attention toward developing a good rap-
events have been associated with tions are not prima facie evidence of port with the patient in the limited time
regional anesthesia since local anes- negligence. However, the risk of litiga- allotted. Table 49–1 summarizes basic
thetics were first introduced by Kol- tion in contemporary anesthesia prac- recommendations for maintaining a
1053
ler in 1884,1 and will continue no
matter how skillful we become. Be-
cause it is difficult to thoroughly KEY POINTS
address all regional anesthesia com-
plications in this chapter, we focus 1. Safe regional anesthesia begins 5. Knowing when to stop performing re-
our attention on those areas that with a thorough knowledge of gional anesthesia techniques is cru-
have the most relevance to today’s anatomy. In Labat’s words, “anato- cial. Dogged persistence in the face of
practice. This chapter addresses the my is the foundation upon which failure is inadvisable. Do not hesitate
principles involved in managing com- the entire concept of regional an- to seek assistance when faced with
plications that are common to all esthesia is built.” Studying the difficulties and be prepared to change
regional anesthesia techniques. Sub- anatomy of the major plexuses and to an alternative route of anesthesia if
sequently, we address specific man- peripheral nerves is critical for persistent failure (more than 3 at-
agement of complications associated learning regional anesthesia and tempts or 20 minutes) occurs.
with the most commonly used re- avoiding its complications. 6. Do not perform regional anesthesia
gional anesthesia techniques. 2. Prior to performing regional anes- procedures in anesthetized adult
thesia, it is imperative to thoroughly patients unless the benefits far out-
discuss the techniques, and their weigh the risks. If this principle is
GENERAL PRINCIPLES limitations, with the patient. Assess- violated, the reasoning must be doc-
ing which patients are most appro- umented in the patient’s file.
Importance of Prevention priate for performing these tech-
7. Always be accompanied by a skilled
The time-honored statement that “an niques on is important, as some are
assistant when performing regional
ounce of prevention is worth a pound not suitable candidates (e.g., those
anesthesia.
of cure” is essential to remember2 with major anatomic distortion or
when considering the management of serious mental illness). 8. Always ensure adequate patient
adverse outcomes in regional anesthe- monitoring during regional anesthe-
3. One of the most important princi-
sia practice. The most effective way to sia performance and continuing until
ples for safe regional anesthesia is
manage regional anesthesia complica- the block has completely worn off.
provision of a comfortable patient
tions is to prevent or minimize the risk environment. If a patient suffers as a 9. If neurologic injury is suspected fol-
of these complications occurring in result of one’s intervention, a basic lowing regional anesthesia, the
the first place. Neurologic injury is principle of the practice of anesthe- cause should be determined quickly
one of the most dreaded complications sia has been violated. so as to prevent permanent injury.
associated with all anesthesia tech-
4. Resuscitation equipment must be 10. One must not assume that all pa-
niques, including regional anesthesia,
immediately available when per- tient injury is from regional anesthe-
and it is important to realize that once
forming regional anesthesia and one sia, as other possibilities exist. Do
a serious neurologic injury occurs the
must be prepared, at all times, to not hesitate to involve other disci-
chances of full recovery are unlikely.
anesthetize and resuscitate the pa- plines in the quest to determine the
Safe regional anesthesia begins with
tient when necessary. cause of injury.
the first encounter with the patient.

Copyright © 2008 by The McGraw-Hill Companies, Inc. Click here for terms of use.
 PART 4: Managing Anesthesia Care

as not all patients are suitable candi- to the discretion of the patient. It is
TABLE 49–1.
dates for regional anesthesia. Some pa- very important to discuss the options of
Maintaining a Standard of Care during tients are not psychologically suitable anesthesia with patients even if they
Regional Anesthetic Practice for regional anesthesia. A number of are undergoing minor operative proce-
patients suffer from needle phobias and dures. It is imperative to follow nation-
• Preoperative patient selection faint at the least provocation. Patients al and international guidelines pertain-
• Appropriate consent with schizophrenia are not suitable ing to regional anesthesia practice (i.e.,
• Using appropriate equipment and candidates for regional anesthesia un- American Society of Anesthesiologists
technique less it is combined with general anes- [ASA] monitoring, American Society of
• Monitoring regional anesthesia thesia. Gross anatomic distortion may Regional Anesthesia and Pain Medicine
practice preclude the performance of regional [ASRA] guidelines for anticoagulated
• Accurate and meticulous anesthe- anesthesia in some patients. Neuraxial patients), and if there is any deviation
sia documentation techniques are frequently associated it is important to specify the reasons
• Physician–patient communication with hemodynamic disturbances such and to document them. Table 49–2
• Postoperative followup visit as bradycardia and hypotension; there- summarizes the important factors in-
fore they are contraindicated in hemo- volved in selecting suitable patients for
dynamically unstable patients and in regional anesthesia.
standard of care in regional anesthesia those with fixed cardiac outputs. Re-
practice. Maintaining a standard of care gional anesthesia should be used cau- Consent
at all times does not guarantee against tiously in patients with preexisting neu- Potentially serious complications asso-
legal action, but it certainly will mini- rologic disease and if these techniques ciated with regional anesthesia should
mize the risk and is to be encouraged at are employed in these patients, neuro- be disclosed to patients, including con-
all times.3 Legal issues involving anes- logic deficits must be clearly document- vulsions and the risk of cardiac toxicity
thesiology practice are discussed in de- ed prior to the performance of regional from systemic injections of local anes-
tail in Chap. 95. anesthesia. Some patients are rigidly thetics, spinal cord/nerve injury lead-
1054 The following is a simple guide de- opposed to regional anesthesia and it is ing to paralysis or neurologic deficit,
tailing how to minimize the risk of an important not to badger them into ac- pneumothorax, hematoma, infection,
adverse legal event by maintaining cepting these techniques if they are cardiac arrest, and death. Any com-
accepted standards of care during the reluctant to participate in the first mon unpleasant side effects specific to
practice of regional anesthesia. place. If it is clearly evident that a certain procedures such as the failure
patient will benefit from regional anes- to achieve surgical anesthesia, patient
Patient Selection thesia, it is reasonable to explain in awareness during conscious sedation,
Proper patient selection is a critical detail the rationale behind the proce- nausea, pruritus, headache, shivering,
consideration for the safe and success- dure; however, the decision to undergo backache, dizziness, and urinary reten-
ful performance of regional anesthesia, regional anesthesia must be finally left tion should also be discussed. Howev-

TABLE 49–2.
Patient Selection Factors

Factors Involved in Patient Selection Relative Contraindications Absolute Contraindications

Patient cooperation Anxiety states; needle phobias; poorly con- Patient refusal
trolled psychiatric disease; language bar-
riers; pediatric patients
Anatomic and physiologic Anatomical anomalies; technical challeng-
considerations es: obesity, severe arthritis, degenerative
joint disease
Anesthetic considerations Lack of experience and skills; lack of
appropriate equipment for performing
the block (e.g., nerve stimulator, ultra-
sonogram); lack of appropriate equip-
ment for resuscitation and monitoring
(e.g., oxygen, mask, drugs)
Coexisting diseases Preexisting progressive neurologic disease; Infection at the site of injection; allergy
comatose states; sepsis; coagulopathy to local anesthetics; coagulopathy (al-
though an International Normalized
Ratio [INR] of <2 is acceptable for oph-
thalmic procedures)
Surgical procedures Lengthy procedures that outlast the duration
of action of the local anesthetic (single-
injection techniques; uncomfortable posi-
tioning for an extended period of time)
 CHAPTER 49: Managing Adverse Outcomes during Regional Anesthesia

er, anesthesiologists should bear in injectates on nerve stimulation has in vitro experiment showed that injec-
mind that even with informed consent, never been fully explained. The classi- tions of solutions, such as 0.9% NaCl,
proper disclosure, effective communi- cal unanswered question concerning cause a change in the electrical field at
cation, and an appropriate ethical ap- electrical stimulation is why is it that the needle–tissue interface. It was
proach, there is no guarantee that they one may not be able to consistently concluded that the injection of electri-
will be legally protected.4 stimulate a nerve with a current of less cally conducting solutions (saline or
Informed consent and an explana- than 0.5 mA, even after eliciting a local anesthetic) increases the conduc-
tion of the risks and alternatives to paresthesia in that nerve? Another tive area surrounding the stimulating
regional anesthesia must be provided phenomenon that is poorly under- needle tip, leading to a decrease in the
to the patient (the anesthesiologist stood is the “Raj test.” The following is current density surrounding the target
should never coerce a patient to ac- a brief description of the Raj test: nerve. The current density surround-
cept or reject any anesthetic plan). when nerve stimulation is being used ing the needle tip is then no longer
to locate a nerve, a twitch is observed sufficient to stimulate the desired
Use of Appropriate Equipment when the needle tip is close to the nerve.7 This observation suggests that
and Technique neural target. Ideally, the twitch is effective nerve stimulation is sensitive
As advances in regional anesthesia required to persist at a current of 0.5 to changes that occur at the needle–
continue, techniques used must be mA. The clinician then injects a small tissue interface, such as the angle of
continuously revised in light of any volume of local anesthetic or normal the needle or the injection of the local
new, clinically relevant information saline through the needle. If the nee- anesthetic. The net effect of these
and developments. For years, we have dle tip is in the correct location, the changes is to alter the current density
been percutaneously inserting needles muscle twitch immediately disap- at the tip of the needle or the path of
toward neural targets and have relied pears.5 Until very recently the disap- the electric current, ultimately result-
solely on our knowledge of anatomy pearance of the twitch was thought to ing in a change in the quality of the
and our somewhat primitive tech- be caused by physical displacement of motor response.8 This phenomenon
niques (i.e., paresthesia and the loss- the nerve by the injectate.6 We recent- has also recently been reported in a
of-resistance [LOR] technique). The in- 1055
ly learned that this mechanism is best clinical setting (Fig. 49–1).9,10 In a clin-
troduction of nerve stimulation was an explained in electrical terms and is not ical study, the mean current required
important advance in regional anes- entirely a result of the physical dis- to stimulate the supraclavicular, axil-
thesia because it provided some objec- placement of the nerve.7 In a porcine lary, femoral, and sciatic nerves when
tive evidence that the needle tip was model, the injection of 0.9% sodium using an insulated needle was 0.6, 0.5,
close to the neural target. Although it chloride solution (NaCl) abolished the 0.7, and 0.5 mA, respectively.11 In
did take a long time to convince the motor response, and a subsequent in- contrast, the mean current required to
artisans of regional anesthesia that the jection of 5% dextrose reestablished a stimulate these same nerves when
application of nerve stimulation in re- motor response during peripheral using a stimulating catheter following
gional anesthesia was useful, most an- nerve stimulation.7 An accompanying the injection of normal saline, was
esthesiologists currently use nerve
stimulation techniques in regional an-
esthesia. Although nerve stimulation
techniques have been used in regional
anesthesia for more than 30 years, the
science of this technique has not been
studied in any great detail.
Nerve stimulation was the first step
in the conversion of regional anesthe-
sia from an art to a science. One of the
most exciting new advances in regional
anesthesia in recent years has been the
introduction of ultrasonography as a
method to accurately place needles in
close proximity to neural targets. Ultra-
sonography allows real-time visualiza-
tion of anatomical structures and offers
the potential to guide needle and cath-
eter placement in regional anesthesia.
This section highlights recent advances
in nerve stimulation and ultrasonogra-
phy that may play an important role in FIGURE 49–1. Gel electrophoresis: changes in the electrical field with uninsulated and insulated
preventing complications during re- needles after 5% dextrose in water (D5W) and saline injection. Arrows show the margin of the clear
gional anesthesia practice. zone/electric field. Far left: Diffuse electric field with an uninsulated needle; center left: narrow electric
field with an uninsulated needle; (center right): electric field with an insulated needle after D5W
Nerve Stimulation in Regional injection remains narrow; far right: diffuse electric field with an insulated needle after normal saline
Anesthesia: Peripheral Nerve injection. (Reprinted and adapted from Tsui BC, Wagner A, Finucane B. Electrophysiologic effect of
Blockade Despite years of clinical injectates on peripheral nerve stimulation. Reg Anesth Pain Med 2004;29(3):189–193. Copyright May
use, the electrophysiologic effect of 2004, with permission from American Society of Regional Anesthesia and Pain Medicine.7)
 PART 4: Managing Anesthesia Care

much higher (1.5, 1.5, 2, and 3 mA, TABLE 49–3.

respectively).11 Those findings had im-
portant clinical implications as: Comparison of the Standard Test Dose with the Epidural Stimulation (Tsui) Test for
Confirming Epidural Catheter Location
• One may potentially use a noncon-
ducting solution, such as 5% dex- Catheter Location Test Dose Epidural Stimulation Test
trose in water (D5W), rather than
saline to dilate the perineural space.7 Subarachnoid Hypotension/total Positive unilateral/bilateral motor
spinal response (< 1 mA)
• Initial reports of the use of noncon-
ducting injectates (e.g., D5W) in pe- Subdural ? Diffuse motor response in many
ripheral nerve block are promising segments (< 1 mA)
and appear to provide stability Epidural space ? Unilateral motor response (<1 mA)
when using electrical stimulation close to the
techniques.9,10 nerve root
? Positive motor response (1–10 mA);
• Another possible use of D5W is to
threshold current increased after
inject a small amount to highlight the
local anesthetic injection
needle tip and observe the spread of
Not intravascular ↑ Heart rate Remain or return to baseline positive
injectate without inhibiting the abili-
motor response (1–10 mA) even
ty to use nerve stimulation12 when
after local anesthetic injection
using ultrasonography. However, fu-
Intravascular ↑ Blood pressure Electrocardiogram changes
ture studies are warranted to deter-
Subcutaneous ? Negative response
mine the merit of this technique.
Reprinted and modified from Tsui BC, Finucane B. Epidural stimulator catheter. Tech Reg
Nerve Stimulation in Regional Anesth Pain Manage 2002;6(4):150–154. Copyright 2002, with permission from Elsevier. 27
Anesthesia: Neuraxial Blockade
1056 Epidural stimulation has recently
been used to confirm and guide cathe-
ter placement in the epidural space.
traoperative monitoring for spinal of time before this technology will
The epidural stimulation test confirms
surgery (2–40 mA).21–24 Although no become a mainstream technique in
catheter placement through stimula-
known complication or patient discom- regional anesthesia practice.
tion of the spinal nerve roots (not the
fort has resulted from the epidural
spinal cord) with a low-amplitude elec- Ultrasound Usage in Regional
stimulation test, it has been recom-
trical current conducted through nor- Anesthesia: Peripheral Nerve
mended to keep the current below 15
mal saline via an electrically conduct- Blocking Brachial plexus anesthesia
mA and the stimulation time as brief
ing catheter.13 Correct placement of is one of the most challenging tech-
(less than a few minutes) as possi-
the epidural catheter tip (1–2 cm from niques in regional anesthesia; therefore,
ble.13,14,25,26 In particular, the current
the nerve roots) is indicated by a ultrasound has a great potential to im-
output must be carefully increased
motor response elicited with a current prove success rates with this technique.
from zero and stopped once motor ac-
between 1–10 mA.13,14 Any motor re- The reason that the classic approach to
tivity is visible to ensure that all motor
sponse observed with a significantly the brachial plexus (the supraclavicular
responses, even those elicited with a
lower threshold current (<1 mA) sug- approach) has not withstood the test of
low current (<1 mA), are detected.
gests that the catheter is in the sub- time is because of the risk of pneumo-
The nerve stimulator must be sensitive
arachnoid or subdural space, or is in thorax. The application of ultrasound
enough to allow a gradual increase in
close proximity to a nerve root15,16; in in regional anesthesia may renew in-
current output to at least 10 mA.
these rare cases, a motor response is terest in the classic approach to the
Table 49–3 compares features of the
elicited with a significantly lower brachial plexus (Fig. 49–2). With ad-
epidural “test dose” (lidocaine with
threshold current because the stimu- vances in this technology, we will be
1:200,000 epinephrine) and the epidu-
lating catheter may be very close (<1 better able to see nerve trunks, blood
ral stimulation test. Epidural stimula-
cm) to the nerve roots or because it vessels, pleura, and the approaching
tion is a new tool for clinician use that
may be in direct contact with highly needle.29,30
may have a significant impact on three
conductive cerebrospinal fluid (CSF) To maximize the safety of regional
of the most significant complications
(Table 49–3). anesthesia, one may potentially com-
associated with epidural anesthesia:
Electrical stimulation has been ap- bine ultrasonography and nerve stim-
systemic toxicity, accidental subarach-
plied to neural structures for neuro- ulation techniques when performing
noid or subdural injections of local
physiologic evaluation and pain con- regional anesthesia.
anesthetics, and neural damage.
trol for many years,17–20 and has
proven to be safe. The safety of the Ultrasound Usage in Regional • Ultrasonography allows the clini-
epidural stimulation test is not com- Anesthesia The application of ultra- cian to see the advancing needle
pletely known, but it is anticipated that sound in regional anesthesia was first approaching what appears to be the
the risk of a brief intermittent electrical published in 1989 by Ting et al.28 Since target nerve or trunk.
stimulation used in this setting would then there has been an increasing • Nerve stimulation allows one to
be lower than the risk of chronic epidu- number of reports in the world litera- identify which nerve is being ap-
ral stimulation (4–30 mA) used in long- ture on this exciting application in proached and if indeed what is being
term pain management and during in- regional anesthesia. It is only a matter approached is a neural structure.
 CHAPTER 49: Managing Adverse Outcomes during Regional Anesthesia

particularly in older children and

adults, when visualization of the spi-
nal cord and relevant structures is
sought.38,39 Calcification of the pos-
terior vertebral bodies in children
older than 6 months of age prevents
reliable imaging of the spinal cord.38
At the present time, ultrasonogra-
phy guidance is helpful for viewing
the lumbar region of most patients,
although its use for thoracic epidural
placement is of value only in infants
and small children, as their vertebrae
are not fully ossified.

Monitoring Regional Anesthesia

It is very important to have an assis-
tant observe and aid the patient at all
times during the performance of re-
gional anesthesia. As many as 15% of
FIGURE 49–2. Ultrasonogram of supraclavicular region. The trunks of the brachial plexus can be patients have a great fear of needles
identified as a cluster of circles (i.e., a honeycomb shape) positioned lateral and superior to the and vasovagal episodes occur when
subclavian artery. If the identity of the hollow structure was in doubt, the color-flow Doppler performing regional anesthesia.40
provided further verification (left bottom).
• Standard electrocardiogram and pulse
oximetry are essential monitors while 1057
Ultrasonograph technology is undeni- percentage of cases (96%). This new performing regional anesthesia.
ably a great advance in regional anesthe- observation allows one to increase • Before performing the neural block,
sia; however, it does not completely the accuracy of placement of contin- a baseline blood pressure reading
eliminate difficulty in accurately identi- uous catheters.10 should be obtained. Once the re-
fying structures and observing the ad- • By using ultrasonography, one can gional anesthesia procedure is com-
vancing needle in detail in all cases. A observe the pattern of spread of plete, the monitors should remain
number of regional anesthesia experts D5W before committing to the injec- attached. In conscious patients, end
practicing ultrasonography, have already tion of local anesthetic tidal carbon dioxide monitoring is
abandoned neurostimulation, upon dis- not used; however, there are special
covering the value of ultrasound, yet it is Ultrasound Usage in Regional nasal prongs available for monitor-
essential to take a deliberate approach Anesthesia: Neuraxial Blockade ing awake patients.
when considering the absolute use of Ultrasonography is useful for guiding
• Evidence of regressing sensory and
ultrasound technology. peripheral nerve block placement in
motor blockade and stable vital
adult patients;31,32 however its applica-
• Individually, ultrasonography (ana- signs must be present so as to fulfill
tion for guiding neuraxial blockade in
tomic locating tool) and nerve stimu- the criteria for discharge from the
adults and children remains limited,
lation techniques (physiologic re- recovery area.
and its use is not as yet widespread.
sponse aid) have their limitations, • Local anesthetic infusions are now
but when used in combination, these • Real-time ultrasound imaging of the routinely used in many medical
techniques may serve to compensate lumbar spine is a simple procedure. centers around the world. Patients
for each other’s weaknesses and may Ultrasound aids the placement of receiving local anesthetic infusions
facilitate optimal needle placement lumbar epidural catheters and en- should be visited regularly by a qual-
for peripheral nerve blocks. hances the performance of combined ified physician postoperatively (i.e.,
spinal–epidural anesthesia.33,34 Acute Pain Service).
• With the use of ultrasonography,
one can observe neural targets, vas- • Ultrasonography use improves the
learning curve of obstetric lumbar Record Keeping/Documentation
cular structures, the advancing nee-
epidural catheter placement for an- Accurate and meticulous recording of
dle, and the actual spread of the
esthesia trainees.35 anesthesia information is essential for
local anesthetic solution, following
maintaining the quality of care in re-
the injection of the local anesthetic, • In patients with anticipated difficult
gional anesthesia, and this will also ben-
in real time. epidural localization, this technolo-
efit the clinician if involved in litigation.
• When one uses D5W as a preinjec- gy is helpful for estimating lumbar
tate, in conjunction with nerve stim- epidural depth; it also facilitates • Detailed documentation of patient
ulation, accurate needle/catheter- ease of placement.36,37 consent and the clinical procedure
tip visibility is enhanced. The motor • Although ultrasound imaging has is very important.
response resulting from electrical been used to guide lumbar epidural • Open and honest communication
stimulation is augmented following needle placement, it may be of lim- with the patient is essential for pro-
an injection of D5W in a very high ited value in the thoracic region, viding good quality patient care.
 PART 4: Managing Anesthesia Care

Physician–Patient result of unintentional intravascular in- if the lungs are bypassed (e.g., an acci-
Communication jection and rarely follow the injection of dental intraarterial injection in the head,
Effective communication with each pa- an excessive quantity of local anesthetic face, or neck region).46 Plasma concen-
tient is essential for the prevention and into an appropriate site. The incidence trations of local anesthetics are also in-
early diagnosis of any potential compli- of systemic toxicity has substantially de- fluenced by the tension of carbon diox-
cations. Discussing the procedures, in- creased within the past 30 years. In ide (CO2 ) and the pH. An elevated
cluding their benefits and any signifi- 1969, Massey Dawkins42 reported the arterial CO2 tension increases cerebral
cant risks involved, is the medicolegal incidence of seizures following local an- blood flow, and an acidotic state increas-
and professional responsibility of all esthetic injections to be 0.2% following es intracellular ion trapping and the
anesthesiologists. Equally important, epidural anesthesia. A recent study amount of free drug available. This com-
maintaining good patient rapport re- from France reported an incidence of bination of factors has a synergistic ef-
spective of how to recognize and mini- seizures of 0.01%, which represents a fect on the seizure threshold.47
mize potential risks during the postop- 20-fold decline in a 30-year period.42,43 Systemic toxic reactions occur much
erative period will help ensure that the A higher occurrence of systemic reac- less frequently when local anesthetics
maximum outcome is achieved follow- tions occurs following peripheral nerve are administered in peripheral sites. A
ing regional anesthesia. blocks, especially brachial plexus and number of factors influence the degree
caudal blocks in adults.44 The maximum of absorption taking place from the pe-
• A telephone call to the patient on the plasma concentration of local anesthetic riphery to the central circulation. The
first postoperative day is a reasonable (Cmax) resulting from an unintentional most important factor influencing ab-
and practical alternative to a visit. intravascular injection depends on a sorption is the site of injection—absorp-
• Specific common risks for certain number of factors,45 including the total tion is more rapid in highly vascular
blocks should be discussed with the dose of local anesthetic injected, the tissues and less so in poorly perfused
patient prior to discharge. For in- speed and site of injection, and whether tissue. Rapid absorption also occurs
stance, patients undergoing supra- the injection is administered intrave- from intrapleural injections and very
clavicular blocks should be warned nously or intraarterially. The lungs are slow absorption occurs from the bladder
1058 about the risk of pneumothorax and an important repository for local anes- and skin. Consequently, local anesthet-
be informed about potential symp- thetic drugs; plasma concentrations of ic absorption increases from the highest
toms and what to do if they develop. these drugs will be substantially higher to the lowest rates in the following
• Caution patients about the risk of
burns (i.e., from radiators), or the
consequences of applying pressure Intercostal
to desensitized areas when sensory
Caudal
anesthesia continues after discharge.
Mepivacaine
• Warn patients about lying on para- Epidural
500 mg
lyzed extremities for any length of Brachial plexus
time.
Sciatic femoral
• Patients should receive written in-
structions and information about
when to seek medical attention prior Intercostal
to discharge from the hospital. Lidocaine Epidural
(lignocaine)
400 mg Brachial plexus
COMPLICATIONS INVOLVED Subcut
WITH LOCAL ANESTHETIC
ADMINISTRATION IN
Intercostal
REGIONAL ANESTHESIA
Prilocaine
Caudal
400 mg
Local Anesthetic Epidural
Allergic Reactions
Although allergies to local anesthetics
Intercostal
are rare, a full array of allergic symptoms
and signs ranging from mild skin irrita- Etidocaine
Caudal
tion to full-blown anaphylaxis have been 300 mg Epidural
described. These signs and symptoms
Brachial
are almost always associated with amino plexus
ester preparations or preservatives (e.g.,
methylparaben). Allergic reactions are 0 2 4 6 8
more common following exposure to Blood concentration (µg/mL)
ester compounds than amides.41 FIGURE 49–3. Comparative peak blood concentrations of several local anesthetic agents follow-
ing administration into various anatomical sites. Subcut, subcutaneous. (Reprinted from Covino
Systemic Toxic Reactions BG, Vassalo HG. Pharmacokinetic Aspects of Local Anesthetic Agents. Local Anesthetics. Mecha-
Systemic toxic reactions to local anes- nisms of Action and Clinical Use. New York: Grune and Stratton, 1976:95–123. Copyright 1976
thetic drugs occur more commonly as a Grune and Stratton, with permission from Elesevier.45)
 CHAPTER 49: Managing Adverse Outcomes during Regional Anesthesia

42
Death TABLE 49–4.
39 Cardiovascular
collapse Signs of Early Accidental
36 Intravascular Injection
33
Plasma concentration (µg/mL)

Early Signs Late Signs

30
27 Light-headedness Muscle twitching
Tinnitus Drowsiness
24
Blurred vision Generalized
21 tonic-clonic
18 Respiratory arrest convulsions
Perioral numbness
15 Coma
12 Convulsions
Twitching injection of a test dose containing epi-
9
Auditory and visual signs nephrine. A single injection of 15 µg of
6 epinephrine produces a heart rate in-
Perioral numbness
3 crease of greater than 10 beats/min, a
Drowsiness blood pressure increase greater than 15
mm Hg, and a decrease in T-wave ampli-
FIGURE 49–4. Concentration–toxicity profile of lidocaine. (Reprinted with permission from Covi- tude of 25%.52 In the sedated patient,
no BG. Clinical pharmacology of local anesthetic agents. In: Cousins MJ, Bridenbaugh PO, eds. changes in heart rate may not be as
Neural Blockade in Clinical Anesthesia and Management of Pain. 3rd ed. Baltimore: Lippincott reliable as T-wave and blood pressure
Williams & Wilkins, 1998:107.) changes.53 Elderly patients (> 60 years
old) and those on β-blockers and anes- 1059
anatomic sites: intercostal, epidural, current treatment with CNS depressant thetized patients are also less sensitive to
brachial plexus, lower extremity, and medications may modify the typical β-adrenergic stimulation.
subcutaneous tissue (Fig. 49–3). clinical signs of a toxic reaction, and can In summary, sensible precautions
The rate of absorption is reduced by mask some of the early warning signs should be undertaken to minimize the
the addition of epinephrine to local an- (Table 49–4). impact of accidental intravascular in-
esthetic drugs, but this also depends on The cardiovascular system is more jection. These precautions include the
the local anesthetic used. Furthermore, resistant to the toxic effects of local following:
the addition of epinephrine itself may anesthetics than the CNS, especially
lead to other complications (see Com- following toxic doses of lidocaine. Local • Incremental administration of the
plications of Peripheral Nerve Blocks anesthetics affect both electrical and local anesthetic
below). As the plasma concentration of mechanical cardiac activity. Tachycar- • Frequent aspiration
lidocaine increases, there is a typical dia and hypertension are early signs of • Close observation of heart rate, systol-
progression of effects on the CNS and cardiac toxicity and with increasing ic blood pressure, and T-wave changes
the cardiovascular system. This pattern doses patients develop bradycardia and
of symptomatology is not typically seen hypotension; however, this pattern of • Close observation of the patient
with the more potent local anesthetics symptomatology may not be seen
(Fig. 49–4).48 Central nervous system when the patient receives a rapid intra- Management of Local
excitation and cardiovascular manifes- vascular injection and this pattern of Anesthetic Toxicity
tations of systemic toxic responses fol- symptoms and signs is not evident with The initial treatment recommended
lowing epidural anesthesia almost al- potent local anesthetics. for the management of patients with
ways arise as a result of unintentional systemic toxicity is very similar to that
intravascular injections. Local anesthet- Prevention used for any resuscitation. The follow-
ics are amphiphilic molecules, having Early recognition of an intravascular in- ing mnemonic can be used when deal-
both lipophilic and hydrophilic proper- jection is the key to prevention. Meth- ing with allergic reactions and system-
ties; these drugs enter a variety of cellu- ods investigated for detecting intravas- ic toxicity to local anesthetics 54:
lar compartments, and have the poten- cular injection include the following: Stop injection
tial to interact with a wide variety of
molecules including inotropic signaling • Careful aspiration Airway
pathways (sodium, potassium and calci- • The injection of dye (detected by Ventilation
um ion channels), and also influence pulse oximetry)50 Evaluation of the circulation
adrenergic and lysophosphatide signal- • The administration of epinephrine Drugs
ing systems, cardiac bioenergetics, and and isoproterenol51
mitochondrial dynamics.49 Symptoms Because hypoxia, hypercapnia, and
• Injections of lidocaine
and signs of an unintentional intravas- acidosis exacerbate all local anesthetic
cular injection must be closely moni- Increased heart rate and systolic blood toxic reactions,55,56 control of the air-
tored. As plasma concentrations of local pressure in addition to T-wave changes way and ventilation is of paramount
anesthetic increase, signs of local anes- are considered sensitive and specific end importance in the treatment of local
thetic toxicity increase in severity. Con- points in response to an intravascular anesthetic toxicity. Recent studies dem-
 PART 4: Managing Anesthesia Care

onstrate improved hemodynamics and • Therapeutic agents that are less ar- routine technique used during micron-
survival in animal models of bupiv- rhythmogenic have been investigat- eurography and surgical repair proce-
acaine toxicity with the administration ed, including the use of vaso- dures, which results in insignificant
of intravenous lipid emulsion.57,58 Al- pressin,61,62 and phosphodiesterase nerve damage.66 Considerable nerve
though the mechanism by which this inhibitors such as milrinone and damage is more likely to be caused or
occurs is unclear, it is suggested that amrinone.63 worsened by both mechanical and
lipid emulsion may remove local anes- • Effective resuscitation in this setting chemical injury during intraneural in-
thetic molecules from binding sites that is difficult, and atrioventricular pacing jections of neurotoxic substances (i.e.,
are responsible for the profound cardio- and cardiopulmonary bypass are addi- local anesthetics). High-pressure injec-
vascular depression that is part of tional options in refractory cases.64 tions cause mechanical destruction of
bupivacaine toxicity. Propofol, which the neural fascicular architecture,
is formulated in lipid, may reduce pathophysiologic damage, and neural
susceptibility to local anesthetic toxic- scarring.67 Chemically induced damage
ity, however its negative inotropic ef- COMPLICATIONS OF is also possible from high concentra-
fects may mitigate against its use as an PERIPHERAL NERVE BLOCKS tions of local anesthetics, vasoconstric-
antidote in the face of cardiovascular tors, preservatives, and other additives.
collapse.59 Before either lipid or propo- Direct Needle Trauma There is an ongoing debate among
fol become recommended elements of to the Nerve anesthesiologists about the safety of de-
the resuscitation paradigm, further Most of the complications resulting liberately seeking paresthesia in region-
evaluation needs to be done. Anticon- from peripheral nerve blocks (PNBs) al anesthesia.68 There is also concern
vulsant medications such as thiopen- are similar to those of neuraxial blocks about performing regional anesthesia in
tal and the benzodiazepines should be with the exception of those resulting comatose/anesthetized patients because
used with caution and in greatly re- from ophthalmic, brachial, and inter- of the inability to detect paresthesia.69,70
duced dosage as they themselves may costal/paravertebral blocks, each of However, there is no substantial evi-
precipitate cardiovascular collapse. which has its own unique complica- dence that performing nerve blocks in
1060 tions. The incidence of minor neural
The following are the most current (as awake patients is any safer than per-
of this writing) recommendations for injury following PNBs is in the range of forming them in anesthetized patients.
the management of significant local 1–2%; most of these injuries are tran- With advances in the technology
anesthetic systemic toxicity: sient neurapraxias, which represent ax- used for regional anesthesia such as
onal disruption. Typically neurapraxia nerve stimulation and ultrasonogra-
• Bronchospasm and generalized ede- injuries are observed postoperatively phy, the need to use paraesthesia as a
ma, sometimes associated with aller- when patients complain of persistent method to identify the location of a
gic reactions may require use of numbness in the distribution of a pe- given nerve should diminish. Despite
bronchodilators, antihistamines, and ripheral nerve. One cannot simply as- the recent advances in technology in
corticosteroids. sume that all neurapraxia injuries are regional anesthesia, there is no proof
• Endotracheal intubation and venti- anesthesia related, as patient position- that any one method is safer or better
lation are required to correct acido- ing, surgical trauma, and tourniquet in terms of success achieved. Intuitive-
sis and hypoxia and hypercarbia. application can all give rise to these ly, one might expect more success and
• Chest compressions, cardioversion symptoms. Numbness gradually re- fewer complications if one could ob-
may be defibrillation are required to gresses over a period of weeks and is serve a needle advancing toward a neu-
restore organ perfusion and should rarely observed beyond 3 months, ral structure as opposed to the “conven-
be instituted as necessary. which is the amount of time required tional” blind insertion of needles.
for axonal regeneration to occur. Re- Common sense dictates that small-
• Profound hypotension can occur in
gional anesthesia related injuries are gauge needles are less likely to damage
both allergic reactions and systemic
usually the result of needle trauma, nerves than larger-gauge ones. More
toxicity, and usually responds well
injection pressure or the toxic effects of than 30 years ago Selander71 recom-
to vasopressors (e.g., epinephrine
local anesthetics or additives. Auroy et mended using blunt needles when per-
and vasopressin); hypotension oc-
al.43 reported an incidence of serious forming regional anesthesia, as it was
curring in allergic reactions and sys-
nerve injury (permanent sensory and/ thought that blunt needles were less
temic toxicity respond well to plas-
or motor loss) following PNBs as 1.9 per likely to penetrate neural structures,
ma “expansion.”
10,000 nerve block cases; in this study, and resultant intraneural injections
• As reduced cardiac contractility is a all patients with serious injury experi- would be less likely to occur; this rec-
core element in this condition, it is enced either pain on injection, or par- ommendation was based on informa-
thought that the maintenance of cor- esthesia, or both during the perfor- tion derived from animal experiments.
onary perfusion with the adminis- mance of the block. Selander’s influence on this topic per-
tration of epinephrine and norepi- sists to this very day. Even though
nephrine improves outcome.60 Prevention subsequent studies show that blunt
• However, malignant dysrhythmias, Most neural injuries are associated with needles, although far less likely to pen-
which particularly occur with bupiv- either paresthesia or pain on injection. etrate neural structures, are far more
acaine systemic toxicity, should be Needle damage or pressure generated disruptive to neural tissue than sharp
controlled in a timely fashion as during injection of local anesthetics ac- needles.66 Nevertheless, there are no
epinephrine can exacerbate these count for most of these injuries.43,65 clinical trials supporting any recom-
dysrhythmias. Needle insertion without injection is a mendations as to what type of needle is
 CHAPTER 49: Managing Adverse Outcomes during Regional Anesthesia

best for regional anesthesia procedures. used judiciously to support the team of
TABLE 49–5.
Most clinicians prefer small-gauge, short, clinicians in arriving at a correct diag-
blunt needles. nosis; this is when we must rely on our Suggested Methods/Equipment for
Injection pressures may influence neurology and radiology colleagues to Preventing Peripheral Nerve Injuries
the amount of damage inflicted on a guide us. Electrodiagnostic and imag- When Performing Regional Anesthesia
nerve. One study suggested that per- ing techniques can often take the
• Needle type: small gauge, short
sistent motor deficits were observed in guesswork out of many diagnostic di-
beveled
animals injected with pressures ≥ 20 lemmas and allow for quick and pre-
• Patient: awake with appropriate
psi.72 Clinicians should avoid rapid cise diagnoses. Table 49–6 summarizes
level of sedation
and high-pressure injections. the key steps involved in determining
• Nerve stimulation: use accurate nerve
Sterilizing agents, skin cleansing sub- neurologic injury.
stimulators and insulated nerve nee-
stances, detergents, and certain preser-
Diagnostic Tools for the Deter- dles (current at least >0.2 mA)
vatives (e.g., metabisulfite) all cause
mination of Nerve Injury Direct • Ultrasonography: direct visualiza-
neurotoxicity and should be carefully
injury to the spinal cord, nerve roots, tion of nerves ad surrounding struc-
avoided when introduced into perineu-
or peripheral nerves is best evaluated tures by using high-resolution ul-
ronal spaces.
using imaging techniques, especially trasound equipment if available
The neurotoxicity of a local anes-
in the early stages of an injury. Elec- • Paresthesia: injection should be
thetic is related to its potency and its
trophysiologic techniques are more stopped and needle repositioned if
concentration.73 High concentration
useful in the later phases of an injury. persistent
local anesthetics such as 2% lidocaine
The most common imaging modalities • High injection pressure: avoid rapid
and 0.75% bupivacaine should be
used are computerized tomography and high-pressure injections (pres-
avoided in peripheral nerve blocks.
(CT) and magnetic resonance imaging sure <20 psi)
The addition of vasoconstrictors (e.g.,
(MRI). Electrodiagnostic techniques • Local anesthetic: avoid high con-
epinephrine) to local anesthetics may
include evoked potentials, nerve con- centrations (i.e., lidocaine 2% or
enhance the damage caused by an
duction studies, and needle electrode bupivacaine 0.75%) 1061
intraneural injection.74–76
examination of muscles (electromy-
Generally, neural damage resulting
ography [EMG]). The use of these tools
from peripheral nerve blocks is rare; axonal injury and is also useful for
should complement the clinical exam-
consequently, it may be difficult to quantitating the severity of the neu-
ination, rather than replace an exami-
clearly demonstrate the safest equip- rologic injury and for identifying the
nation. Choosing the best tools/tech-
ment and techniques to be used. How- actual site of injury.
nologies for diagnosis should be a joint
ever, Table 49–5 lists several measures
decision made with the neurologist, The only effective way to manage
that have been suggested to prevent
surgeon, and radiologist. neurologic complications is to prevent
nerve injuries.
any mishaps from occurring in the first
• CT is best suited for evaluating bony
Management place, as there is limited chance of
abnormalities.
Because most regional anesthesia pro- recovery once the damage has oc-
cedures involve the percutaneous in- • MRI is ideally suited for the exami- curred. Currently, there are no reliable
sertion of needles toward neural, the nation of soft-tissue abnormalities, standards or guidelines for the manage-
burden often lies with the anesthesiol- especially the spinal cord. ment of neurologic injury. Neurologic
ogist to prove that damage was not • For peripheral nerve, nerve plexus, consultation and testing should be con-
caused as a result of improper tech- and peripheral nerve complications, sidered if there are any persistent
nique and unsafe practice. Clinicians imaging is less likely to be useful for symptoms or signs following a proce-
are obliged to maintain a very open the demonstration of nerve injury. dure. If symptoms are mild and are not
mind when dealing with such challeng- interfering with the patient’s daily ac-
• MRI may demonstrate the accumula- tivities, reassurance can be offered
ing cases. When a neurologic injury is
tion of blood and edema fluid, which after evaluating the extent and severity
suspected postoperatively, a thorough
can lead to compartment syndrome; of the patient’s symptoms. It is of prime
history must be taken, and a complete
MRI may also indicate neural com- importance to continue to follow pa-
physical examination must be per-
pression caused by injury from the tients suffering from nerve injury fol-
formed. The anesthesiologist should
needle and local anesthetic injection. lowing discharge from the hospital; it is
play a major role in determining the
Thus, electrodiagnostic techniques also necessary to instruct patients to
cause of the injury, as anesthesiologists
can complement imaging, especially seek medical attention if their symp-
have far more information concerning
for peripheral nerve complications. toms worsen or do not improve. Most
preoperative and intraoperative events
Nerve conduction studies test the residual dysthesias or hypesthesias re-
than do most neurologists. Symptoms
function of large sensory and motor solve in 4–6 weeks, and the majority
and signs of compression of the spinal
nerve fibers. Evaluating nerve con- are resolved (>99%) within 1 year.77,78
cord must be dealt with urgently (with-
duction can reveal axonal loss or de-
in 6–8 hours); otherwise permanent
myelination of the nerve; however,
paraplegia or quadriplegia may result.
nerve conduction is less useful in tim-
The anesthesiologist, neurologist, neu-
ing lesions when the injury occurs.
NEEDLE TRAUMA TO THE
rosurgeon, and radiologist must work SURROUNDING ANATOMY
as a team and strive to arrive at a • EMG is preferentially used for eval-
diagnosis before serious permanent in- uating smaller motor units. EMG Surrounding tissues may be uninten-
jury occurs. Diagnostic tools should be can be useful for the diagnosis of tionally injured during peripheral nerve
 PART 4: Managing Anesthesia Care

volve deviations from the recommend-

TABLE 49–6.
ed anesthetic practice standards. Cur-
Key Steps in Determining Neurologic Injury rently, it is recommended to perform
• Recognize and identify the neural dysfunction. these blocks in awake patients so as to
• The history of any new or intensifying neural dysfunction in the absence of further detect paresthesia or pain on injection,
anesthetic injection must be considered as a warning sign of possible neural injury. which is a clear indicator of the risk of
permanent damage. Ultrasonography
• When neural damage is suspected, a careful history assessment and a physical
may help to reduce the risk of spinal
examination must be promptly carried out.
injury as needle advancement can be
• The sequence and onset of the symptoms must be determined.
observed in real-time.
• The nature of pain, motor weakness, sensory deficit, and sphincter control should
The best option for avoiding the risk
be compared to information obtained preoperatively about the patient’s baseline
of nerve injury is to select a blocking
neurologic status; such information may provide clues to the cause of injury and
insertion site remote from the spinal
appropriate management.
cord. Axillary blocks appear to be safer
• Symptoms/signs of spinal cord compression must be dealt with urgently (within
than supraclavicular blocks; however,
6–12 hours), otherwise permanent paraplegia or quadriplegia may occur.
supraclavicular approaches to the bra-
• A thorough postoperative followup should be completed, even if a neurologic chial plexus are required in shoulder
injury is not suspected. surgery. In most published cases of
• Consider surgical causes nerve injury involving the brachial
• Surgical trauma to neural structures from retractors, a scalpel blade, or tension plexus, the recommended standard of
within the surgical site may not have been mentioned to the anesthesiologist. care was not followed.
• Long-acting local anesthetics may have been injected by the surgeon. Small-gauge needles and short nee-
• Compartment syndrome resulting from edema, or bleeding around the wound dles are strongly recommended when
caused by dressings or casts, can compromise neural function. performing brachial blocks in the su-
• Vascular injury during the surgery could result in nerve injury (e.g., spinal cord praclavicular region. Longer-than-usual
1062 injury after thoracic aneurysm repair). Because of this, it is probably desirable needles were associated with many of
to let the local anesthetic blockade abate after aortic surgery. the spinal cord injuries associated with
• Patient positioning must be reviewed to rule out direct pressure (e.g., peroneal brachial plexus blocks.
nerve at the fibular head) or tension on nerves (e.g., traction on the brachial
plexus from hyperextension of the shoulder during thoracotomy); improper pa- Management
tient positioning may produce nerve injury that might otherwise be attributed There is no specific treatment for pri-
to a regional anesthetic mishap. mary needle damage to the spinal cord.
• Consider anesthetic causes Nevertheless, the initial step in the
• The details of anesthesia management should be thoroughly reviewed, especially management of spinal cord injury is
if portions of the anesthetic care were delivered by other anesthesiologists. the recognition and identification of
• Drug choice, dose, and last time of administration should be recorded. neural dysfunction. Acute, potentially
• Duration of nerve blockade should be noted; a long duration of blockade can re- reversible causes of spinal cord injury,
sult in neural injury. such as nerve compression from hema-
• High concentrations of agents probably increase the risk of neural complications. tomas, must be identified and dealt
• Multiple nerve-blocking attempts can increase the risk of injury. with early (within 6–8 hours) otherwise
• The presence of parasthesia during needle insertion and the subsequent injec- permanent paraplegia or quadriplegia
tion of local anesthetic can be a warning sign indicating neural injury. may result. The anesthesiologist, neu-
• The level of sedation must be appropriated without compromising the ability to rologist, and radiologist must work as a
observe a parasthesia. team to arrive at a correct diagnosis.
Appropriate electrodiagnostic and im-
aging techniques must be used to make
blocks. Vascular injury can also occur T1 level.79 In another instance, an anes- a quick and precise diagnosis.
during PNB as many peripheral thetized patient suffered permanent spi-
nerves travel in parallel with vascular nal cord injury following an interscalene Pneumothorax
structures. Other injuries may be block.80 A patient has suffered from Any regional technique requiring nee-
caused by direct needle trauma, in- Brown-Séquard syndrome following an dle insertion toward the lung involves
cluding pneumothorax and direct spi- attempted interscalene block using a the risk of pneumothorax. Pneumotho-
nal cord injury. spinal needle.81 Other peripheral blocks rax has been an unwelcome complica-
may also increase the risk of spinal cord tion of supraclavicular techniques
Spinal Cord Injury injury. Permanent spinal cord injuries since Kulenkampff first described the
Permanent spinal cord injury follow- may occur following paravertebral classic supraclavicular approach in
ing brachial plexus block is the most blocks because the needles used for 1911.82 The incidence of pneumotho-
severe complication resulting from paravertebral blocks are inserted in rax is difficult to determine and varies
PNB. There are a number of reported close proximity to the spinal cord. depending on the approach. Brand et
spinal injuries associated with peripher- al. reported an incidence of 6.1% in a
al nerve blocks: an interscalene block Prevention large teaching hospital using the clas-
performed with an 8-cm needle resulted It is important to note that most of the sic Kulenkampff technique.83 DeJong
in a permanent neural deficit at the C8- serious nerve injury cases reported in- found radiologic evidence of pneumo-
 CHAPTER 49: Managing Adverse Outcomes during Regional Anesthesia

thorax in 25% of patients.84 Phrenic are discharged within a few hours of Local anesthetics are proposed to
nerve paresis is very common follow- surgery, it is imperative that patients be cause a pathologic efflux of Ca2+ from
ing supraclavicular blocks, yet patients warned about the risk of pneumothorax the sarcoplasmic reticulum, resulting
do not usually become symptomatic.85 before leaving the hospital. Patients in contracture, cell destruction, and
The risk of pneumothorax has deterred who develop chest pain, dyspnea, or necrosis. Following this occurrence,
many anesthesiologists from using the cyanosis following discharge should be the regeneration of fibrils occurs with-
supraclavicular approach and is the instructed to go to the nearest emer- in a few weeks. Among the local anes-
most likely reason that axillary ap- gency center. Symptoms and signs may thetics tested, bupivacaine caused the
proaches are so popular. The risk of not develop for hours, and patients most damage, and procaine caused the
pneumothorax is much lower follow- may not become symptomatic until a least.95 Injury was noted to be worse
ing the interscalene approach to the 20% pneumothorax is present. A chest with repeated injections and when epi-
brachial plexus compared to the classic tube is usually required when the de- nephrine was used.96–98 All of these
supraclavicular approach.86 Ward et al. gree of lung collapse is 25% or greater. mentioned features are highlighted in
reported a 3% incidence of sympto- Positive pressure ventilation with N2O/ a case in which a patient who received
matic pneumothorax following the in- O2 in the presence of a small pneumo- an interscalene block later developed
terscalene technique.87 The risk of thorax may lead to tension pneumotho- intense neck pain and tenderness over
pneumothorax is reduced following rax with the rapid deterioration of vital the sternocleidomastoid muscle, which
the vertical technique mainly because signs. Consequently, a high index of persisted for 2 months.99 In clinical
the needle is not directed toward the suspicion should always be present practice, myotoxicity is largely unno-
lung.88 when general anesthesia is required ticed except in ophthalmic regional
following a failed supraclavicular block, anesthesia. Diplopia has been reported
Prevention and nitrous oxide should be avoided in following retrobulbar blocks; however,
Anesthetic techniques requiring the in- this situation. this symptom is short-lived in most
sertion of a needle directed toward the cases and permanent damage is rare.
lung in the supraclavicular region all Ropivacaine was found to be less myo-
1063
carry the risk of pneumothorax. Extra toxic than bupivacaine in an animal
TOXIC EFFECTS OF LOCAL
care should be exercised in tall, thin model.100 The full implications of the
ANESTHETICS ON THE
patients as they appear to be at greater effects of local anesthetics on muscle
NERVES AND
risk of pneumothorax. For all patients, have not yet been evaluated.
SURROUNDING ANATOMY
a right-sided pneumothorax occurs
more frequently because the cupola of
Incidence of Toxic Phrenic Nerve Paralysis
the lung is higher on the right side. The incidence of hemidiaphragmatic
Patients should be warned in advance
Effects of Local Anesthetics paresis and decreased respiratory func-
of this risk, and ambulatory patients on the Nerves and tion following supraclavicular blocks in
should be given careful instructions on Surrounding Anatomy 8 healthy volunteers was noted; the
how to proceed should symptoms devel- Neural Toxicity overall incidence of paresis was 50%
op. Supraclavicular techniques should Local anesthetics are considered harm- following the administration of 30 mL
be used only when indicated. less substances when injected perineu- of lidocaine 1.5% with epinephrine;
Supraclavicular approaches should rally in appropriate concentrations and none of the volunteers reported respi-
be avoided in patients with moderate quantities. High concentrations of local ratory symptoms.101 However, anecdot-
or severe impairment of pulmonary anesthetics can permanently damage al reports exist concerning patients
function. Blocks should never be per- neural tissue in some instances.89 Pre- who are devoid of respiratory disease,
formed bilaterally. Intuitively, compli- servatives in local anesthetic drugs may and who later became symptomatic
cations can be avoided or reduced if also damage nerves and other sur- following an interscalene block.87,102–104
clinicians are able to visualize the ad- rounding tissues. In the United States Temporary phrenic nerve paralysis
vancing needle approaching the target during the 1970s, it was noted that a following interscalene brachial plexus
nerve or trunk. Ultrasonograph tech- change in the constitution of a sodium block is expected in up to 100% of cases.
nology facilitates this goal in real time. metabisulfite, a preservative found in Permanent phrenic nerve palsy has
However, this technique requires sig- chloroprocaine, resulted in several been observed following interscalene
nificant training and much practical cases of cauda equina syndrome.90 The block,105 but is extremely rare.106
experience. Despite adequate training, addition of ethylenediaminetetraacetic The incidence of ipsilateral phrenic
it can be difficult to accurately identify acid (EDTA) to chloroprocaine is associ- nerve paresis associated with all types
structures using ultrasonography, and ated with severe back pain in some of supraclavicular techniques is re-
the advancing needle is not easily patients following epidural anesthe- ported to vary between 36% and 40%,
viewed in all cases. The clinician sia.91,92 Studies show that 5% hyperbaric regardless of the technique chosen.107
should pay attention to needle depth lidocaine for spinal anesthesia is linked In another study, the effects of ipsilat-
in relationship to the classical anatom- to the syndrome transient neurologic eral hemidiaphragmatic paralysis on
ical landmarks at all times, even when symptoms (TNS).93 respiratory function following contin-
using ultrasonography. uous interscalene blocking showed
Myotoxicity that all patients had a 27% reduction
Management Myotoxicity is a recognized complica- in forced vital capacity (FVC), a re-
Because upper-extremity operations are tion of intramuscular injections of duced forced expiratory volume (FEV)
carried out on ambulatory patients who local anesthetics.94 of 26%, and a decreased peak expirato-
 PART 4: Managing Anesthesia Care

ry flow (PEF) rate.108 In another small chial plexus blocks, including bron- and coverings: cauda equina syn-
study, the effects of hemidiaphragmat- chospasm, hematoma formation, audi- drome, adhesive arachnoiditis, and an-
ic paralysis lead to a significant de- tory impairment, total spinal/epidural terior spinal artery syndrome. These
crease in PaO2, despite normal pulmo- block, and carotid compression. syndromes are addressed in other
nary function studies. chapters under specific complications.
Thus, the use of supraclavicular tech- Prevention/Management
niques in certain groups of patients The key to preventing complications Prevention
must be reevaluated. Supraclavicular associated with brachial plexus block To avoid nerve trauma, a studied tech-
techniques may need to be avoided in is to increase the accuracy of needle nique and accurate anatomic knowl-
patients with advanced pulmonary dis- placement and to use the minimum edge is advised.111 Although epidural
ease. Bilateral supraclavicular tech- volume and concentration of local an- placement in the anesthetized child is
niques are absolutely contraindicated. esthetic required to successfully com- considered safe, similar placement in
plete the block. With a better under- the adult population remains contro-
Prevention Until we have more standing of neural anatomy and versial. Recent case reports highlight
data on this topic, it would be prudent distances between structures gained the potential for neurologic trauma
to avoid all brachial plexus techniques by using nerve stimulation, the accu- when performing epidural anesthesia
above the clavicle (especially inter- rate needle placement is a reality. The in the anesthetized patient.69,112,113 The
scalene blocking) in patients with se- introduction of ultrasonography has use of the epidural stimulation cathe-
vere impairment of lung function. The revolutionized regional anesthesia, as ters allow pediatric anesthesiologists to
majority of healthy patients do not ultrasonogram visualization makes it place lumbar or thoracic epidurals from
experience any symptoms. The dura- possible to directly visualize, in real the caudal space, minimizing the risk
tion of action of this impairment de- time, the needle tip and the local of needle-mediated nerve injury.26
pends on the dose and the individual anesthetic spread. With this technolo- When performing an epidural in an
properties of the local anesthetic gy, we believe regional anesthesiolo- awake, cooperative adult, needle ad-
used.109 It has also been suggested that gists will have much greater success vancement should be halted if the pa-
1064 reducing the volume and quantity of with regional anesthesia and fewer tient complains of pain. In most adults,
local anesthetic chosen for supracla- complications. As with other adverse the spinal cord terminates at the lower
vicular blocks may influence the inci- effects, careful diagnosis of brachial portion of the body of L1; however,
dence of hemidiaphragmatic paresis. plexus complications and the provi- there are considerable variations among
Management Ipsilateral phrenic sion of supportive measures are essen- individuals. The ability of the clinician
nerve paresis is quite common follow- tial for proper clinical management. to correctly identify lumbar spinous
ing all supraclavicular approaches to interspaces has been questioned by
the brachial plexus. Such approaches to Broadbent et al. using magnetic reso-
the brachial plexus should be avoided nance imaging.114 In this study, only
in patients with significant lung dis-
COMPLICATIONS OF 29% of the interspaces were correctly
ease. Proper consent and information
NEURAXIAL BLOCKS identified, whereas 51% of the time
should be provided to the patients. For
(EPIDURAL/SPINAL) clinicians were at a higher vertebral
mild symptoms, reassurance given by level than anticipated; furthermore, the
the anesthesiologist to the patient and
Direct Needle Trauma spinal cord terminated below L1 in 19%
family is generally sufficient for man- As a needle or catheter is advanced of subjects. Oblique lateral entry into
agement. For more severe symptoms into the epidural space, direct trauma the ligamentum flavum may direct the
and patient distress, appropriate moni- to the spinal cord, conus medullaris, needle into the dural cuff region, re-
toring and ventilatory support should and spinal nerve roots can occur. Sen- sulting in potential nerve trauma with
be considered and employed until the sory loss and, less commonly, motor resultant unisegmental paresthesia;
phrenic nerve paralysis recovers. deficits occur as a result of spinal cord this is a warning sign in a conscious
trauma. Some patients recover com- patient indicating that the needle or
Horner Syndrome pletely from this unfortunate circum- catheter is encroaching on a neural
Horner syndrome (ipsilateral, miosis, stance; however the injury persists in structure.115
ptosis, enophthalmos, loss of sweating) is the majority of patients. The inci- Paresthesia associated with spinal
frequently observed following supracla- dence of this complication is very low, cord injury can occur at the time of
vicular approaches to the brachial plex- and much of the data available comes needle placement, yet it may also
us,110 and patients and other caregivers from retrospective sources. In a pro- occur during the injection of the solu-
should be informed of this temporary spective multicenter study Auroy43 tion or as a secondary consequence of
distortion to avoid diagnostic confusion. found 5 cases of radiculopathy follow- irritation, edema, or hematoma.116,117
ing 30,413 epidurals. In each of these Pain is more commonly associated
Hoarseness patients, pain or paresthesia was noted with extraaxial lesions affecting the
Hoarseness may occur if the local an- during needle insertion and drug ad- nerve roots or blood vessels that are
esthetic spreads to the recurrent laryn- ministration, and the radiculopathy innervated by pain-mediating sensory
geal nerve. was observed in the distribution of the neurons.118 In contrast, because there
associated paresthesia. One of the most are no pain receptors within the spinal
Other Complications of disturbing complications of neuraxial cord (or the brain), intraaxial trauma
Brachial Plexus Blocks blockade is neurologic injury. Three may be painless118; this allows percu-
There are a number of other, less well-known syndromes are associated taneous cervical cordotomy to be per-
common complications following bra- with damage to the spinal cord, roots, formed in awake patients.119,120 During
 CHAPTER 49: Managing Adverse Outcomes during Regional Anesthesia

this procedure, the cervical cord is eral popliteal nerve. If an adverse out- lowing regional anesthesia is a vital
typically punctured multiple times come occurs, the lesion should be local- part of adverse outcome management.
with a 22-gauge needle electrode, yet ized by taking the patient’s history and Back pain with lower-limb weakness
the patient generally describes neither by performing a thorough neurologic and sensory deficit should alert the
pain nor paresthesia.121 In addition, examination. clinician to the presence of a central
pain following dural puncture is rare compressing lesion.
• Bilateral symptoms associated with
in clinical practice. Thus, anesthesiol-
pain should alert one to the possibil- • Bowel and bladder incontinence can
ogists should be reminded that they
ity of neuraxial pathology. be an associated finding.
should not simply assume that pares-
thesia will always be reported as the • Injury at the nerve roots affects both • Painless evolution of this complica-
needle encroaches on the spinal posterior and anterior rami. tion has been reported, and early
cord.122,123 However, one might expect • Preservation of sensation over the warning signs may be masked by
a motor response if a needle encroach- paraspinous muscles suggests a more the administration of local anesthet-
es on a motor tract during attempts at distal injury. ic via an epidural catheter and the
epidural anesthesia. Electrical stimula- presence of a urinary catheter.
• Investigations should include blood
tion during epidural needle advance- cultures and coagulation studies. • If MRI confirms the diagnosis, then
ment may provides an additional rapid surgical intervention within 6–
• Immediate MRI is the standard for
warning sign.124,125 Despite all of the 8 hours is recommended.
evaluating neuraxial lesions.
controversy on this topic, during tho- • Epidural catheters containing metal
racic epidural placement risk, minimi- • EMG can be used to determine the
elements should be avoided while
zation should be considered, while site of injury and the degree of
undergoing MRI as it will not only
placing epidural needles and catheters axonal loss, although it may take up
generate artificial interference and
at a site remote from the spinal cord to 3 weeks for changes to appear on
inaccurate diagnoses, but other po-
(i.e., lower lumbar or caudal region) if the electromyogram. It may be use-
tential risks are possible albeit pres-
at all possible. ful to perform this immediately
ently unknown.130 Such catheters 1065
Ischemic injuries are among the rar- upon recognition of neural dysfunc-
should be removed if it is safe to do
est complications reported following tion to establish the possibility of a
so; if catheter removal is unsafe, a
regional anesthesia procedures; howev- preexisting lesion.
CT scan should be considered in-
er, when such injuries occur, several stead of an MRI.
factors play a role, including hypoten- Hematoma
sion, abnormal positioning, vascular
disease, diabetes mellitus, and the
Epidural hematoma after neuraxial an- Infection
esthesia is a rare event. Bleeding from Epidural abscess formation, although
clamping of major vessels.65,126 The ad- an epidural vein may occur on needle
dition of epinephrine to local anesthet- rare, is a serious, potentially devastat-
or catheter insertion, but is usually self- ing complication. Kane’s retrospective
ic solutions is controversial, as seen in limiting. Neurologic symptoms and
an animal study where epinephrine review of 50,000 epidurals found no
signs caused by an epidural hematoma case of abscess formation,131 whereas
and phenylephrine were administered are atypical in the presence of normal
with the result of a significant reduc- Moen et al. reported 12 cases of ab-
coagulation; the true incidence is un- scess formation from an estimated
tion in dural blood flow and no reduc- known, but is estimated to occur in less
tion in spinal cord blood flow.127 It 250,000 patients following epidural in-
than 1 in 150,000 cases of neuraxial sertion.132 Of these patients, only 3
seems prudent, however, to avoid the anesthesia.128 Vandermeulen reviewed
use of large amounts of epinephrine in were healthy, while the others had
61 case reports between 1906 and 1994 infection risk factors. Six of the pa-
patients at greater risk of ischemia. and found that two-thirds of the cases tients received their epidural for anal-
Management had a hemostatic abnormality.129 Early gesia following trauma, and of these, 5
The management of postoperative neu- diagnosis and intervention are essential were thoracic epidurals for chest trau-
rologic sequelae requires the coopera- to preventing any long-term adverse ma. The authors speculated that the
tion of the anesthesiologist, surgeon, outcomes. overrepresentation of thoracic trauma
and neurologist. Advice may also be Prevention patients might in part be a result of a
needed from the radiologist and neuro- In recent years, new anticoagulant and lesser hygienic standard being ob-
surgeon. Although it is easy to blame antiplatelet drugs have been introduced served, where placement likely oc-
an adverse neurologic outcome on the and have given rise to new challenges curred outside the “cleaner” environ-
presence of an epidural, it should be in the management of the anticoagulat- ment of the operating suite.
borne in mind that other factors can ed patient undergoing neuraxial block- Although the immunocompromised
lead to demonstrable nerve injury, in- ade. The American Society of Regional patient may carry a greater risk of
cluding undiagnosed preexisting neuro- Anesthesia has released guidelines in developing infective complications
logic disorders, ligation of nutrient spi- response to this evolving shift in medi- with epidural use, extensive experi-
nal cord vessels during abdominal or cal practice128; it is important to follow ence using epidural analgesia and an-
thoracic surgery, injury to the femoral these guidelines to minimize the risk of esthesia with patients who have HIV
nerve during pelvic surgery, injury to hematoma. has countered early fears surrounding
the lateral cutaneous nerve of the thigh regional anesthesia in this population.
during retraction close to the inguinal Management Regional anesthesia is particularly
ligament, and pressure on the fibular Similar to the peripheral nerve injury, beneficial for the HIV carrier popula-
head leading to neurapraxia of the lat- the evaluation of neurologic injury fol- tion, as it eliminates delayed metabo-
 PART 4: Managing Anesthesia Care

lism of systemic opioids caused by been safely performed in potentially the engorged epidural venous plexus
protease inhibitors.133 Patients with bacteremic patients.138 Following is a reduces spinal CSF volume and predis-
AIDS often have neurologic manifesta- list of guidelines for the prevention of poses this population to cephalad local
tions of their disease, and the preva- epidural abscess formation: anesthetic spread. Total spinal anes-
lence of peripheral neuropathy in- thesia is rarely seen in nonobstetric
• Factors that contribute to a lower
creases as the disease progresses.134 cases, as observed by Dawkins, who
incidence of epidural space infec-
Attention should be given to assessing reported an incidence of 0.2% of total
tions involve, meticulous aseptic
preoperative neurologic status, as this spinal anesthesia in 48,000 patients
technique, monitoring of the infec-
allows the clinician to correctly at- undergoing epidural anesthesia.140
tion site, antibiotic prophylaxis, and
tribute postblock neurologic sequelae
bacterial filter use.
to the true underlying cause. Prevention
Epidural abscess presentation can • While both lidocaine and bupiv- To prevent total spinal anesthesias
be variable, but the cardinal symptoms acaine are bactericidal in high con- from occurring, it is essential to use
and signs involve back pain with local- centration, this property is much predictable technique when aspirating,
ized tenderness and fever. With the reduced at the concentrations com- and the epidural test dose should be
presence of an epidurally induced ab- monly used in clinical practice.139 used. The subsequent use of small
scess, a leucocytosis can be expected • The performance of neuraxial block incremental doses of local anesthetics
and may occur several days or months should be avoided where local infec- may reduce the risk of this complica-
following needle and catheter inser- tion exists at the needle entry site. tion. The use of electrical stimulation
tion. Following the formation of an • Debate continues as to whether sys- is a useful and reliable real-time tech-
epidural abscess, the patient can de- temic or localized infection distal to nique for confirming epidural catheter
velop progressive weakness and may the entry site carries significant risk. placement.13,25,26,141,142 The advantage
develop paraplegia if untreated. Men- Another concern is whether the of the real-time electrical stimulation
ingitis may develop if the patient has catheter may act as a secondary test is that intrathecal placement can
endured a lumbar puncture in this focus for infection. The clinician be eliminated prior to the administra-
1066
setting. The most common pathogen must weigh the risks and benefits of tion of a potentially large test dose. A
involved in abscess formation is Sta- neuraxial block. test dose of lidocaine and epinephrine
phylococcus aureus; it should act as a should still be administered to detect
standard for guiding antibiotic treat- Management unintentional intravascular placement.
ment until definitive culture results Following is a list of guidelines for However, when combined with the
are available. As with an epidural he- the management of epidural abscess epidural stimulation test as described
matoma, prompt surgical consultation formation: in the previous section, the test dose
is warranted for abscess development. can be given with confidence as there
In pediatric patients, there is some • Daily catheter site inspection is es- is a reduced risk of developing total
concern regarding catheter infection sential for the early prevention of spinal anesthesia.12
with prolonged use of caudally placed epidural abscess formation.
catheters because of the proximity of • Prompt removal of the catheter is Management
the sacral hiatus to the anal region. essential when erythema and local Total spinal anesthesia is a true medi-
Although studies have not found clini- discharge are present. cal emergency, as patients become
cal evidence of greater infection rates • Carefully assess any symptoms or profoundly hypotensive, apneic, and
with the caudal approach to catheter signs of back pain. unconscious with pupillary dilation.
placement, increased bacterial coloni- Resuscitation with endotracheal intuba-
zation has been reported with this tech- • If any neural dysfunction occurs, a tion, mechanical ventilation and vaso-
nique. Staphylococcus epidermidis was diagnosis must be immediately made pressor therapy is frequently required,
the predominant microorganism colo- in order to evaluate infective causes. and recovery may take between 30
nized on the skin and catheters of lum- • Once a diagnosis of epidural abscess minutes and 6 hours, depending on the
bar and caudal epidurals, and gram- is made, a combination of medical agent used and the type of dose admin-
negative bacteria were also found on (antibiotic) and surgical (incision istered. Cerebrospinal fluid lavage via
tips of caudal catheters.135 While the and drainage) treatment may be an epidural catheter has been used to
overall infection rate associated with needed. successfully treat a total spinal in a 14-
caudal epidural catheters appears to be year-old child; in this case, the patient
quite low, tunneling caudal catheters or Total Spinal Anesthesia recovered within 30 minutes.143
simply fixing the catheter with occlu- Total spinal anesthesia occurs when With a high spinal, the patient may
sive dressing in an immediate cephalad an excessive dose of local anesthetic is complain of numbness in the hands or
direction has been recommended to injected into the subarachnoid space; may have difficulty breathing; if this
reduce the risk of contamination by this is usually the result of an uninten- occurs, the situation can usually be
stool and urine.26,136 tional injection of a dose of local anes- managed with reassurance, careful use
thetic intended for the epidural space. of sedation and treatment of hypoten-
Prevention A high spinal may be seen when a sion. Respiratory function should be
Epidural abscesses can occur sponta- small epidural dose or a large spinal closely monitored with pulse oximetry,
neously (a reported incidence of 0.2–2 dose of local anesthetic enters the and measurements of adequate airflow
per 10,000 hospital admissions per subarachnoid space. Obstetric patients should be made (i.e., determine the
year),137 and lumbar puncture has are particularly vulnerable because patient’s ability to vocalize or to blow
 CHAPTER 49: Managing Adverse Outcomes during Regional Anesthesia

out a match [the match test]).144 The sciousness can result within 2 minutes, local anesthetics in regional anesthesia.
potency of sedative agents is increased and cardiorespiratory arrest has been Bupivacaine was implicated in 50% of
in the presence of a high spinal,145–147 reported in the obstetric setting.152 toxic reactions reported by Auroy and
and one should be prepared to inter- Based on cases reported, the epidural in a large percentage of cases in
vene in the event of significant respira- stimulation test appears to be a poten- Brown’s study.43,153
tory compromise. tial diagnostic test providing informa-
tion about the location of the needle or Prevention/Management
Subdural Injections of catheter in the subdural space.16,151 To avoid potential local toxicity, the
Local Anesthetic Drugs use of local anesthetic free of preser-
The subdural space is a potential space
Management vatives in an appropriate concentra-
between the dura and the arachnoid The treatment of subdural injections tion should be considered for use in
that extends from the level of the sec- of local anesthetics is predominantly the neuraxial space.
ond sacral vertebra up to the floor of supportive. Patients sometimes re- For epidural catheter anesthesia,
the third ventricle; the subdural space quire intubation, ventilation, and seda- using soft-tipped catheters (e.g., metal-
differs from the epidural space in that tion and usually recover within 6 reinforced catheter) may reduce the
it is both extra- and intracranial. This hours of the injection introduction of the catheter into the
space envelops the cranial and spinal vessel.156 The most important aspects
nerves for a short distance, and is Systemic and Local Toxicity of prevention were discussed in Local
widest in the cervical area. The inci- Unintentional intravascular catheter Anesthetic above but are summarized
dence of subdural injections of local placement can go unrecognized and as follows:
anesthetic drugs is reported to range may lead to local anesthetic toxicity. • Aspiration
from 0.1% to 0.8%,148 and this occurs There has been a dramatic decline in
more frequently following epidural in- the incidence of systemic toxic reac- • Test dose
jections.149 However, subdural injec- tions to local anesthetics following epi- • Incremental dosing
tion may be an explanation for the dural anesthesia within the past 30 1067
occasional failed spinal anesthesia years. Dawkins reported a 0.2% inci- The epidural stimulation test has the
when pencil-point needles with side dence of toxicity in a retrospective potential to detect intravascular cathe-
apertures are used. The design of a analysis of 48,292 cases of epidural ter placement, and should not be over-
pencil-point needle with side apertures anesthesia in 1969140; this series includ- looked.15 In normal circumstances, re-
makes it possible for the opening to ed thoracic, lumbar, and sacral epidur- peated injections of local anesthetic
exist partially in both the subarachnoid als. More recently, Brown reported a into an appropriately placed epidural
and the subdural spaces.150 The diagno- 0.01% incidence of toxicity following catheter results in the impairment of
sis of a subdural catheter placement is lumbar epidural anesthesia in a retro- nerve conduction and requires a grad-
best achieved using an injection of spective study of 16,870 cases,153 and a ual increase in the amplitude of electri-
radiopaque dye. A typical radiologic 0.69% incidence of toxicity following cal current to produce a positive motor
pattern is pathognomic of subdural caudal epidural anesthesia in a series of response to the stimulation test.141 The
catheter placement. 1295 cases. This 20-fold reduction in absence of this trend after repeated
toxic reactions following epidural anes- doses of local anesthetic suggests that
Prevention thesia during the past 30 years is in part the injected local anesthetic may be
Extra care should be exercised in pa- explained by significant changes in re- rapidly disappearing from the epidural
tients who have had previous back sur- gional anesthesia practice and by the space, as is the case with intravascular
gery or a dural puncture at the same or influence of regional anesthesia societ- placement. However, there have only
adjoining interspace, as subdural injec- ies in North America, Europe, Asia, been a few reported cases of intravascu-
tions are more likely to occur in these Australia, and New Zealand. In the lar catheter detection when using this
patients. The practice of rotating the early 1980s, several deaths were re- technique. The general principles and
Tuohy needle upon entering the epidu- ported in the United States following treatment involved in managing unin-
ral space has been implicated as a accidental intravascular injections of tentional intravascular toxicity from
cause of subdural placement, yet there bupivacaine whilst performing epidur- local anesthetic have been addressed
is no firm data to support this allega- al anesthesia. These deaths occurred as earlier (see Management of Local An-
tion. Clinically, the subdural injection a result of cardiac toxicity which had esthesia Toxicity above).
of local anesthetic drugs should be sus- not been previously reported with bupi-
pected when motor or sensory changes vacaine.154 Several deaths were also re- Postdural Puncture Headache
do not follow the expected pattern. ported in the United Kingdom when Postdural puncture headache (PDPH)
Subdural injections result in a very bupivacaine was used for intravenous is a widely discussed and published
slow onset of motor and sensory anes- regional anesthesia.155 These tragedies topic in regional anesthesia; it is also
thesia and extensive and/or patchy led to a practice change in regional one of the most common complica-
sensory blocking.151 Patients may also anesthesia. Single injection epidural tions of epidural and spinal anesthe-
complain of respiratory difficulties and techniques commonly practiced 30 sia. Advances in needle design and
may appear obtunded. The degree of years ago have been replaced by con- gauge, as well as a better understand-
cardiovascular depression may vary tinuous techniques involving injections ing of the physiologic mechanism of
but hypotension is usually not severe; of small incremental doses of local an- PDPH have dramatically reduced the
however, rapid onset of cardiovascular esthetics; subsequently, “test dosing” incidence of PDPH associated with
depression with concurrent loss of con- has become a standard when using spinal anesthesia, even in the obstetric
 PART 4: Managing Anesthesia Care

population.157 However, the incidence duced incidence of PDPH as opposed pensive than intravenous caffeine,
of PDPH following epidural anesthesia to sharp cutting-point needles (e.g., and offers temporary relief. Caffeine is
in obstetric patients remains un- Quincke). Blunt needles rather than a potent CNS stimulant and should be
changed, with headaches ranging from sharp needles are the tool of choice, avoided in women who have pregnan-
0 to 2.6% of cases.157 particularly in patients with a high risk cy-induced hypertension, as it may
of developing PDPH (e.g., adolescent lower the seizure threshold.167 When
Prevention and young adult patients). The most considering the usage of caffeine as
Prevention of PDPH relies on the edu- effective way to treat PDPH is to pre- treatment for mild headache, it is
cation of clinicians regarding the fac- vent this problem in the first place. worth noting that the cerebral vaso-
tors influencing the incidence of The principal factor responsible for the constrictive properties of caffeine are
PDPH; such information is based on development of PDPH is the size of the transient, and the headache may re-
previous clinical case reports and stud- dural perforation. Thus, smaller, blunt turn after 48 hours.
ies. There is a strong link between needles should be used for spinal anes- Sumatriptan is a serotonin type 1-d
onset of headache and needle gauge, thesia. On the other hand, the most receptor agonist, and has been used
age, gender, pregnancy, bevel design, commonly used epidural needle used for cluster headaches and migraine
and bevel orientation. is the 16- or 17-gauge Tuohy needle for and also as a treatment of PDPH.168
The dura consists of a mixture of continuous epidural anesthesia. Cosyntropin, the synthetic form of
elastic collagen and elastin fibers con- Because sleep deprivation or contin- adrenocorticotropic hormone (ACTH),
tained in a viscous intercellular ground uous night work can be a confounding has been used to treat PDPH; this
substance158; it is primarily a longitudi- factor influencing the higher inci- pharmaceutical is thought to work by
nally oriented structure, and its great- dence of unintentional dural punc- stimulating CSF production and β-
est tensile strength and stiffness exists ture, clinicians should be well rested endorphin output.169
in the longitudinal orientation. When a when performing these techniques.
needle penetrates the dura, the size of Epidural Blood Patch The epidu-
the defect will be dependent on the Treatment ral blood patch (EBP), was introduced
1068 number of elastin fibers cut, as well as Following unintentional dural punc- by Gormley in 1960, and is known to
by the tendency of those cut fibers to ture with a Tuohy needle during epidu- be the most effective treatment for
recoil in opposing directions, creating a ral catheter placement, some authors PDPH. Gormley observed that patients
crescent-shaped defect. As the gauge of suggest that the epidural catheter who bled during myelography had a
the needle increases, more elastic fi- should be advanced through the punc- lower incidence of PDPH,170 and when
bers are cut. Fink examined the dura of ture hole in an effort to reduce the he himself subsequently developed
elderly cadavers and found less vis- incidence of PDPH. Intrathecal place- PDPH, Gormley requested an injec-
coelastic material and more fibrous ment of the epidural catheters follow- tion of autologous blood into his epidu-
connective tissue.159 Young patients are ing accidental dural puncture in the ral space with the positive result of the
at greatest risk of PDPH as their greater obstetric setting is common practice in alleviation of his headache. In 1970,
dural elasticity maintains a patent de- some centers.163 It is thought that the DiGiovanni and Dunbar’s report of the
fect compared to the less elastic dura of presence of the epidural catheter gen- successful use of epidural blood patch-
the elderly. erates an inflammatory response, lead- ing in 41 of 45 patients lead to its
Norris160 demonstrated the impor- ing to early closure of the dural de- popularization.171 This form of treat-
tance of bevel orientation in relation fect.164 Because the epidural catheter is ment is indicated when conservative
to the incidence of PDPH following in the intrathecal space in this circum- measures have failed and the head-
penetration of the dura with an epidu- stance, extreme caution should be ex- ache is severe or is likely to extend the
ral needle. Lybecker161 suggested that ercised to treat this catheter as a spinal hospital stay. The success rate for a
bevel orientation may be even more catheter so as to avoid possible neuro- first epidural blood patch is 85%, ris-
important than needle gauge and was logic complications and infection.157 ing to 98% after a second patch.
unable to show any difference in PDPH Conservative measures, including bed- DiGiovanni suggested that an epidu-
when using 22- and 25-gauge needles, rest and oral hydration remain popular ral blood patch acts as a gelatinous
provided that the bevel was vertically therapies for PDPH, despite no evi- tamponade and when injected, the
oriented. Ready162 suggested that the dence to support them. Bedrest may blood generates sufficient pressure to
incidence of PDPH is reduced when the postpone the occurrence of the head- lift the brain;172 this author has sug-
needle is placed in an oblique direction. ache, yet it does not prevent the on- gested that blood acts as a sealant,
The arachnoid is closely adherent to the set.165 Obstetric patients should be en- plugging the hole created by the nee-
dura, and when a needle is advanced couraged to mobilize soon after dle, thus preventing further CSF leak-
perpendicularly, the holes made by the delivery, so that PDPH, if present, can age. Magnetic resonance images dis-
bevel in the dura and arachnoid regions be diagnosed and treated while yet in playing the lumbar region after blood
are directly in line with one another. the hospital. patching shows a mass effect that com-
When a needle is directed obliquely, the Mild headaches can be treated with presses the thecal sac and conus. The
dural puncture does not line up with intravenous fluids, caffeine, and theo- blood spreads 3–5 spinal segments
that in the arachnoid layer, thus ob- phylline; methylxanthines may block from the injection site, and spreads
structing CSF leakage. cerebral adenosine receptors, leading mostly in the cephalad direction. The
Needle design has been implicated to cerebral vasoconstriction. Camann mass effect persists beyond 3 hours,
as a factor in the development of demonstrated the efficacy of caffeine and clot resolution occurs in 7
PDPH. Blunt-pointed needles (e.g., in 40 postpartum patients.166 A single hours.173 Symptoms are frequently re-
Sprotte, Whitacre) are linked to a re- oral dose of caffeine is safe, less ex- lieved within minutes of the proce-
 CHAPTER 49: Managing Adverse Outcomes during Regional Anesthesia

dure, and this response supports the crosses the blood–brain barrier and patients where anatomy may be ill-
counterpressure theory. infects the CNS early in the clinical defined. Sharrock suggested that false
Szeinfeld studied the dynamics of an course. EBP is unlikely to introduce loss of resistance may also occur in the
epidural injection of blood using tagged HIV into the CNS.165 elderly who have a high incidence of
red cells.174 Blood was injected into the cyst formation within the interspinous
Prophylactic Epidural Blood
lumbar region until patients complained ligaments.191
Patching Prophylactic blood patch-
of discomfort in the back, buttocks, or
es are controversial and have support-
legs. The mean volume of blood re- Prevention
ers and detractors.183,184 The effective-
quired to produce these symptoms was An important distinction that should be
ness of using EBP as a prophylactic
14.8 mL. This study demonstrated that made during epidural anesthesia is that
depends on the proximity of the cath-
the blood injectate extended over 9 seg- of complete failure versus a partial
eter tip to the dural tear. Although
ments, in which 6 were in the cephalad blockade/failure. The inability to pass a
blood patching is a relatively safe pro-
direction, and 3 in the caudad direction. catheter into the epidural space fre-
cedure, there are some risks associat-
When performing an EBP care quently indicates that the needle is not
ed with its use, and patients do not
should be taken to maintain a sterile in the epidural space. Catheters may
always get a headache following dural
field, and the epidural space should be become occluded with blood, or the
puncture, even with a large-gauge nee-
identified in the usual manner. catheter may kink, take a unilateral
dle. Aldrete describes a case of intra-
To undergo EBP, an assistant draws course, break, or become knotted, all of
thecal hematoma and arachnoiditis after
15–20 mL of autologous blood asepti- which can contribute to the complete
prophylactic blood patching through a
cally, which we believe should be fur- failure of epidural anesthesia.
catheter.185
ther analyzed for cultures. The admin- The presence of a midline epidural
istration of blood should be done at a Variations on the Epidural Blood band has been suggested192 and may
rate of 1 mL/3 sec. The end point of Patch Epidural saline treatment has explain why difficulty may be encoun-
injection occurs when the patient been used for PDPH, but is less effec- tered when threading the catheter
complains of back, neck, or buttock tive than EBP. Successful use of pro- through the Tuohy needle.
1069
pain. Much less blood is required for longed saline infusion has been report- When epidural local anesthetic dos-
blood patches in the in the midthorac- ed in patients with failed EBP.186,187 ing for anesthesia approaches the
ic region than in the lumbar region, Fibrin glue, a pooled plasma prod- maximum safe limit without notice-
usually in the order of 5–10 mL. uct, has been used to treat CSF leak in able analgesia, a failed epidural must
To ensure adequate healing, the pa- cancer patients,188 and in PDPH cases be considered and should prompt the
tient should remain recumbent for 1– following spinal anesthesia where two clinician to pursue an alternative
2 hours following a blood patch and EBPs had failed.189 course of anesthesia.
may resume ambulation thereafter; Dextran-40 has also been used to Careful matching of the dermatomal
the patient should refrain from any treat PDPH as it undergoes delayed level of the catheter tip to that of the
strenuous activity for several days. absorption from the epidural space surgical site will yield greater success
Complications from EBP are rare, but because of its high viscosity and mo- of epidural blockade. The epidural
can be serious. Transient bradycardia, lecular weight.190 stimulation test has been used to veri-
lumbovertebral syndrome, and facial fy accurate epidural tip placement,26
palsy have all been reported.175–178 One Failure of Spinal/Epidural ensuring that the dermatomes in-
case of cauda equina syndrome has Anesthesia volved in the surgical procedure are
been reported in a patient who was Failure of neuraxial blockade is more selectively blocked.
subjected to six blood patches; the common with epidural rather than spi-
patient made a full recovery following nal anesthesia. Thus, this section will Management
evacuation.179 focus on discussing failed epidural an- Effectively managing partially work-
EBP has also been successfully per- esthesia. Anesthesiologists recognize ing and/or failed epidurals is very
formed in children. A caudal blood entry into the subarachnoid space by important in patient satisfaction and
patch has been performed in a 4-year- the tactile sensation produced and the safety, particular in obstetric patients.
old child180 and a lumbar EBP has been visual element of CSF. The partially working epidural is com-
performed in a 7-year-old child.181 The On the other hand, anesthesiologists monly encountered when undergoing
case reported by Kowbel involved a 4- recognize entry into the epidural space anesthesia for cesarean sections; re-
year-old child who developed a sub- by the tactile sensation produced ported failure rates are in the order
arachnoid cutaneous fistula following when using the LOR technique and of 2–13.1%.193 A poorly functioning
repeated lumbar punctures for chemo- the ease of epidural catheter insertion. epidural or partially working spinal
therapy.180 In this situation, the epidu- Thus, entry into the epidural space should be identified early before the
ral blood patch was performed by pass- is purely tactile, and the end point of decision to proceed to cesarean sec-
ing an epidural catheter via the caudal entry is subject to more misinterpreta- tion is made. In an emergency situa-
canal, and by injecting 8 mL of blood. tion than spinal anesthesia. In epidur- tion, the anesthesiologist has a num-
Furthermore, there has been one case al anesthesia, false loss of resistance ber of options available to rescue the
reported of cervical dural puncture may occur and quite often the only situation; such options include con-
treated successfully with a lumbar epi- proof that the needle is correctly posi- verting to general anesthesia, supple-
dural blood patch.182 tioned is that a successful block oc- mental epidural or caudal injections
Blood patches have been safely per- curs. False losses of resistance are and local infiltration anesthesia. Intra-
formed in HIV-positive patients. HIV more frequently encountered in obese operative discomfort and visceral pain
 PART 4: Managing Anesthesia Care

may occur in up to 50% of cesarean the number of spinal segments blocked. tered is retained by hypotensive than
patients.194 A block to the T4 level is Cardiac output is altered by changes in normotensive patients,203 resulting in
considered optimal in most cesarean heart rate and stroke volume. The re- hemodilution. Holte’s recent study204
patients, however debate exists con- duction in stroke volume is a result of a showed that it was not the epidural
cerning the best modality with which fall in preload and contractility, which that leads to changes in blood volume,
to test the upper level of the block. is load dependant. If the block involves but rather the infusion of fluid that
Loss of pinprick and cold sensation are the cardiac sympathetic nerve supply, effects blood volume. Hydroxyethyl
popular testing options, but may have bradycardia and reduced contractility starch and ephedrine have similar he-
poor predictive value.195,196 The loss of can be expected. modynamic effects; ephedrine may be
touch is considered by some to best Borghi et al. evaluated the frequency the preferred option for patients when
equate with surgical anesthesia.197 of hypotension and bradycardia during excess fluid administration is undesir-
Surgical factors increasing the likeli- general anesthesia, combined epidural- able. Fluid administration prior to in-
hood of intraoperative discomfort in- general anesthesia, and in epidural an- duction of spinal and epidural analge-
clude exteriorization of the uterus and esthesia alone, in a population of 210 sia usually can reduce the risk of
round ligament stretching, both of patients undergoing hip arthroplas- hypotension. Patient position is crucial
which exceed the analgesia provided ty.199 In this study, hypotension was in preventing low cardiac output states
during an apparently adequately dense observed in 18% of patients during the in patients undergoing epidural anes-
nerve block. Subdiaphragmatic blood induction of the epidural block. The thesia. If severe hypotension occurs
or amniotic fluid may cause back, induction of general anesthesia in the during the course of epidural anesthe-
chest or shoulder discomfort. presence of an epidural block was asso- sia, the most likely cause is inadequate
Intervention by the clinician should ciated with a 4-fold increase in the venous return as a result of blood loss,
involve direct communication with odds of developing hypotension com- an unfavorable patient position, or sur-
the patient. Pharmacologic manage- pared to general anesthesia without an gical obstruction.
ment may be necessary depending on epidural, and a 2-fold increase in these
the level of distress. Intravenous ket- odds when compared to epidural anes- Management
1070
amine in 10–20-mg increments and thesia alone. One criticism of this The first step in the management of
small doses of fentanyl or benzodiaze- study is that the local anesthetic dose hypotension is making sure that there
pines are considered safe, although administered was the same whether is no interference with venous return.
some advise waiting to administer the patient received a general anes- Place the patient in 5° of Trendelen-
these medications until the umbilical thetic or not. Many practitioners would burg and in a slightly head-down posi-
cord is clamped.193 Nitrous oxide has discriminate between epidural analge- tion. The presence of hypotension
been used in the treatment of patients sia with general anesthesia and epidur- prompts the clinician to intervene
with breakthrough pain, but this treat- al anesthesia, and would adjust the with fluid or pressor administration to
ment is controversial in obstetrics an- dosing regimen accordingly. restore the systemic blood pressure to
esthetics.198 If rescue efforts fail, gen- High thoracic epidural anesthesia acceptable levels.
eral anesthesia should be considered has the potential to block cardiac affer- Significant changes in blood pres-
paying special attention to preoxygen- ent and efferent fibers originating at sure are uncommon in pediatric pa-
ation and potential airway difficulties. the first to fifth thoracic levels. Interest tients after the proper administration
For postoperative epidural analgesia, has evolved concerning the potential of epidural analgesia. A high sympa-
it is also important to confirm the work- positive effects of cardiac sympathetic thetic single-shot caudal block to T6
ing condition of epidural analgesia blockade in patients with coronary ar- caused no significant changes in heart
(sensory test, epidural stimulation test, tery disease: dilation of coronary ves- rate, cardiac index, or blood pressure
low pain scores). If the epidural analge- sels, reduced heart rate, and decreased in children.205,206 Even when thoracic
sia is not sufficient, an alternative myocardial oxygen demand.200 epidural blockade is combined with
mode of analgesia must be considered general anesthesia, cardiovascular sta-
prior to discharge from the recovery Prevention bility is usually maintained in other-
room or as soon as possible. The effect of prophylactic administra- wise healthy pediatric patients.
tion of intravenous fluid, ephedrine, Hypotension should prompt anes-
Hypotension and methoxamine on cardiovascular thesiologists to immediately eliminate
Hypotension is a common physiologic responses to both epidural and com- a total spinal and/or intravascular in-
change associated with neuraxial block- bined epidural and general isoflurane jection leading to local anesthetic tox-
ade. Its presence predicts block suc- anesthesia in 45 adult patients under- icity and cardiovascular collapse.
cess, but as a side effect, if left untreat- going knee arthroplasty has been ex-
ed or poorly managed, hypotension can amined.201 In Wright’s study, systolic Respiratory Complications
lead to serious morbidity or death. Hy- blood pressure was significantly great- Several studies have examined high
potension results from preganglionic er after ephedrine administration than thoracic epidurals in both healthy peo-
sympathetic blockade that leads to a after fluid preloading or methoxamine ple and in those with chronic obstruc-
reduction in systemic vascular resis- administration. An increase in plasma tive airway disease. Peak expiratory
tance (SVR) and cardiac output if the volume triggered by epidural-induced flows, forced vital capacity, forced expi-
venous return is not maintained. Sys- hypotension has been observed as a ratory volume in 1 second (FEV1), and
temic vascular resistance decreases as result of fluid movement from the in- maximum expiratory pressures are
a result of a reduction in sympathetic terstitial to the intravascular space.202 reduced207,208 in those suffering from
tone, the extent of which is related to A larger percentage of fluid adminis- this disorder. Kochi investigated the
 CHAPTER 49: Managing Adverse Outcomes during Regional Anesthesia

effect of high thoracic epidural anesthe- • Use hydrophilic drugs (e.g., mor- • Epidural fentanyl and meperidine
sia on the hypercapnic ventilatory re- phine) with caution. do not appear to influence PONV in
sponse and ventilation pattern;209 dura- the same way that morphine does;
tion of inspiration, rib cage excursion, Management as reported, fewer PONV cases have
and its contribution to tidal volume To manage respiratory complications been documented with the use of
decreased significantly, whereas mean do the following: fentanyl and meperidine after or-
inspiratory flow rate and minute venti- • Treat mild respiratory depression thopedic surgery when compared
lation increased. Furthermore, end- with oxygen. with morphine.227
tidal PCO2 and the tidal excursion of
• If an infusion is used, then reduce Prevention/Management
the abdomen remained unchanged,
the rate. To prevent and/or manage PONV do
whereas hypercapnic ventilatory re-
sponse decreased significantly. Lumbar • Depending on the severity of respi- the following:
and high-thoracic-region-induced epi- ratory complications, consider ven-
• Reduce the dose administration and
durals do not interfere with the ventila- tilatory support, the administration
avoid neuraxial opioid administra-
tory response to hypoxemia.210 Gruber of narcotic antagonists, and the dis-
tion. Doing so is effective in reducing
demonstrated the safety of thoracic continuation of the opioid infusion.
the incidence of nausea and pruritus.
epidural anesthesia with bupivacaine • Carefully monitor during the central
• Use antihistamines, opioid antago-
0.25% in patients with severe chronic nerve blocking period—this cannot
nists (naloxone and nalbuphine),
obstructive pulmonary disease.211 The be overemphasized.
propofol, nonsteroidal antiinflam-
potential for phrenic (C3-C5) palsy is
Nausea and Pruritus matory drugs (NSAIDs), and 5-HT3
low with an epidural block, except
receptor antagonists as both preven-
during unintentional blockade follow- Nausea and pruritus are common side
tative and therapeutic measures.
ing an interscalene brachial plexus effects seen with the administration
Dexamethasone has been shown to
block.212 Cervical epidural anesthesia of neuraxial opioids. The reported
be a superior antiemetic for PONV-
has been used for upper limb, parathy- incidence of postoperative nausea
associated epidural morphine when 1071
roid and carotid operations.213–215 and vomiting (PONV) with opioid ad-
compared to metoclopramide228 and
Bonnet reported respiratory difficul- ministration is 30–65%,218–220 and 80%
5-HT3 receptor antagonists.229
ties in 3 of 394 patient undergoing carot- for pruritus.221 Pruritus is thought to
id endarterectomy using 15 mL 0.5% be multifactorial in nature, and is Postoperative Urinary
bupivacaine or 0.37–0.40% bupivacaine speculated to operate via an “itch Retention
plus fentanyl (50–100 µg).213 Many case center” in the CNS via medullary dor-
Postoperative urinary retention (POUR)
series, although smaller in number than sal horn activation, and antagonism
is common following major surgery and
this study published by Bonnet, have of inhibitory transmitters.222 Pruritus
occurs in:
not reported respiratory difficulties to be is a dose-dependant phenomenon,
a significant problem.214,215 where its onset involves possible me- • 20–68% of patients after abdomino-
Capdevila reported that both 0.25% diators including C fibers in the skin, perineal resection.
and 0.375% cervical epidural bupiv- serotonin (5-HT3) receptors, and pros- • 16–80% of patients after radical hys-
acaine impaired diaphragmatic excur- taglandins. The obstetric population terectomy.
sion, tidal volume, forced vital capaci- seems to be at greater risk for devel-
oping pruritus. • 20–25% of patients after anterior
ty, and hand grip strength in patients
PONV is a complex, multifactorial resection.
having postoperative hand rehabilita-
tion, and did not recommend the tech- problem: • 10–20% of patients after procto-
nique for this purpose.216 colectomy.230
• Epidural administration of local an-
The incidence of respiratory depres- POUR is a multifactorial problem
esthetics alone carries a low risk of
sion is closely associated with the use and involves factors such as age, pain,
causing the occurrence of PONV.223
of neuraxial opioids. The rate of inci- bladder outlet obstruction, detrusor-
dence of respiratory depression requir- • Factors such as surgery, age, and
inhibiting medication, pelvic autonom-
ing intervention after conventional opi- gender influence the reported inci-
ic nerve damage, and the inhibition of
oid dosing is approximately 1%.217 dence of PONV associated with epi-
sympathetic reflexes. A single episode
dural anesthesia.224
Prevention of bladder overdistension can result in
• Within 5–15 minutes of epidural ad- significant POUR morbidity. Overfill-
To prevent respiratory complications ministration, peak plasma opioid ing of the bladder can stretch and
do the following: concentrations can reach levels sim- damage the detrusor muscle, leading
ilar to those seen following an intra- to atony of the bladder wall, so that
• Avoid the use of high doses of opioids.
muscular injection.225 recovery of micturition may not occur
• Limit opioid dosages, especially in
• In patients receiving epidural mor- when the bladder is emptied. On the
the intrathecal space.
phine, there have been no differenc- other hand, the excessive use of an
• Avoid the concomitant use of paren- es in PONV onset or duration when indwelling catheter can lead to urinary
teral opioids or sedatives. different doses up to 5mg were ad- tract infection, urethral stricture, pro-
• Avoid or limit doses in the patient ministered,226 whereas higher doses longed hospital stay, or death.231,232
with advanced age (> 60 years old), have been shown to lead to both an Epidural use for postoperative pain
sleep apnea and other coexisting increase and a decrease in reported management is usually reserved for
diseases PONV.224 patients undergoing major surgery,
 PART 4: Managing Anesthesia Care

where urinary catheter placement may risk: 1.8); 903 of 4766 women (18.9%) anesthesia practice today; Bier first de-
be performed for reasons other than who had had epidural anesthesia report- scribed IVRA in 1908.246 The technique
anticipated postoperative urinary re- ed this symptom, compared with 731 of was not widely practiced for the first
tention. Stenseth et al. found an inci- the 6935 women (10.5%) who had not 50 years of its inception because it was
dence of 42% for POUR in 1085 un- undergone epidural anesthesia. Howev- not practical to perform a venous cut
catheterized patients having epidural er, prospective data refutes the findings down on patients undergoing relatively
morphine for a variety of major opera- of Macarthur, as noted by Breen who minor extremity procedures. Holmes
tions.233 Epidural morphine relaxes interviewed 1185 women and found that made a very simple adjustment to the
the detrusor muscle with a corre- of the 1042 (88%) for which followup technique in 1963, and demonstrated
sponding increase in the maximal data was available, the incidence of post- that Bier’s technique could be per-
bladder capacity; epidurally injecting partum back pain in those who received formed using a percutaneous intrave-
morphine gives a localized effect, epidural anesthesia was equivalent to nous approach.247 IVRA is now widely
whereas intramuscular and intrave- those who did not (44% vs. 45%).242 used for minor upper- and lower-
nous morphine have no effect on de- Multiple logistic regressions revealed extremity procedures all over the
trusor contraction. This is further sup- postpartum back pain was associated world247 because of its ease to perform
ported by the fact that detrusor with a history of back pain, younger age, and association with a very high suc-
changes occur 15–30 minutes follow- and greater weight. Russell and cowork- cess rate. There are a number of rec-
ing epidural morphine administration, ers demonstrated that new-onset post- ognizable risks associated with this
and are reversed by intravenous nalox- partum back pain was not associated procedure, the most serious being com-
one, suggesting that spinal opioid re- with regional anesthesia.196 Among the partment syndrome and local anesthet-
ceptors have an important role.234 women in Russell’s study who received ic toxicity. A primary limitation of the
either 0.125% bupivacaine or 0.0625% technique is the duration of tolerability
Prevention/Management bupivacaine, the incidence of new long- of the tourniquet, which, without opi-
Other epidural opioids such as fentanyl, term back pain was 7.6% when com- oid supplementation, is about 45 min-
meperidine, and methadone may also pared to controls, and there was no utes. The addition of ketamine in very
1072
contribute to POUR, but contribute to a difference found between the groups. low doses (0.1 mg/kg) greatly extends
lesser degree than that observed with Women who are seeking analgesia for the time that patients can tolerate the
morphine.227,235 In addition to bladder labor should be reassured that back pain tourniquet. Clonidine and Ketoralac
catheterization, treatment options for following epidural analgesia is minimal have also been recommended for this
opioid-mediated POUR may include in- and is usually limited to the early post- purpose. Fortunately systemic toxicity
travenous naloxone administration.236 partum period. and compartment syndrome are rare
Nalbuphine is an opioid-mixed agonist– In 1987, 2-chloroprocaine was market- complications when IVRA is properly
antagonist and has been used to restore ed by Astra Zeneca in a new formula- administered.
detrusor function without reversing tion (Nesacaine-MPF) involving disodi-
the analgesic effects of epidural mor- um EDTA as a chelating agent, for Complications of IVRA
phine.237 Short-term (24 hours) urinary epidural and caudal use. Reports linking
catheterization for major surgery involv- this new formulation with backache
Compartment Syndrome
ing morphine epidural analgesia may emerged,92,244 and gave way to a possible Compartment syndrome has been re-
help prevent the morbidities associated ported following IVRA of the upper and
explanation that the EDTA could cause
with both POUR and longer-term epidu- lower extremities.248,249 In one reported
hypocalcemic tetany of the paraspinous
ral catheterization.238 muscles. The drug now comes preserva- case, hypertonic saline was mistakenly
tive-free, and is prepared in dark-glass used as a diluent for the local anesthetic.
bottles to prevent light-induced disinte- Long bone fractures of the forearm or
Backache leg increase the risk of compartment
gration. Despite the elimination of
Backache is a common complaint fol- syndrome and IVRA should not be used
EDTA from this medication, backache
lowing epidural anesthesia and its inci- in this circumstance. Severe ischemia of
continues to be reported with its use.245
dence ranges between 2% and 30% of the upper extremity has been reported
patients.140,239 The causal relationship Prevention/Management in at least one case following IVRA in an
between epidural anesthesia and back- otherwise healthy young female, where
Backache following epidural place-
ache has been suggested by some stud- the etiology was unclear.250 Table 49–7
ment should not be ignored, as it can
ies,240,241 and refuted by others.242,243 lists some of the possible causes of com-
be a cardinal symptom of a space-
The etiology of backache is multifac- partment syndrome.
occupying lesion within the spinal ca-
torial in nature. Drug use, abnormal Venous thrombosis is a recognized
nal. Complications such as an epidural
posture, muscle relaxation, and in ob- complication of tourniquet applica-
hematoma and abscess, although rare,
stetric cases, exaggerated lumbar lordo- tion. There are some anecdotal reports
can have catastrophic outcomes if un-
sis and the process of undergoing labor of subclavian steal syndrome follow-
recognized and untreated.
have been implicated as causes.165 ing sudden loss of resistance in the
In a retrospective study Macarthur et upper extremity, leading to transient
al. looked at 11,701 patients.240 Of the COMPLICATIONS cortical blindness.251
1634 women who reported backache, OF INTRAVENOUS
1132 (69%) had experienced it for more REGIONAL ANESTHESIA Local Anesthetic Toxicity
than 1 year. In this study, a significant The risk of local anesthetic toxicity is
association was found between back- Intravenous regional anesthesia (IVRA) quite low following IVRA. Auroy et al.
ache and epidural anesthesia (relative is one of the oldest techniques used in reported an incidence of 2.7 seizures
 CHAPTER 49: Managing Adverse Outcomes during Regional Anesthesia

mended dose is 3 mg/kg. Other

TABLE 49–7. TABLE 49–8.
drugs, such as prilocaine, have been
Causes of Compartment Syndrome used because of their favorable phar- Factors for Proper
macokinetic profile; however, some Patient/Surgical Selection
• Excessive tourniquet pressures of these drugs, such as prilocaine, are
• Allergic reactions no longer available in many coun- • The upper-limb surgical procedure
• Undiagnosed Raynaud disease tries. A preservative-free form of should not last longer than 1 hour.
• Sickle cell disease chloroprocaine was recently intro- Surgical procedures lasting longer
• Intraarterial injection duced in Europe and has many po- than 1 hour are not recommended
• Drug administration error tential benefits, especially with re- because patients become very in-
gard to toxicity.252 tolerant of the tourniquet.
• Failed IVRA occurs more frequently
per 10,000 cases following IVRA in • Ropivacaine has also been studied
in lower-extremity procedures.
their study.43 Deaths have been report- as a potential local anesthetic for
• The risk of toxicity is much greater
ed when increased amounts of toxic IVRA.
in lower-limb surgery where larger
cardiac drugs (e.g., bupivacaine) have • Bupivacaine is contraindicated in quantities of drug are required.
been used for IVRA.155 The main cause IVRA. • In addition to the usual contraindica-
of this complication is faulty tourni- tions of regional anesthesia, physi-
quet technique as noted. Management cians should avoid admitting pa-
Inadequate exsanguination before The management of local anesthetic tients for IVRA who have the
the inflation of the tourniquet allows toxicity is the same as that discussed following: sickle cell disease,
the operator to exceed the tourniquet in the previous section. The clinician Raynaud disease, sickle cell anemia,
inflation pressure during the injection, must have dedicated intravenous ac- or allergies to local anesthetics.
thereby allowing local anesthetic solu- cess to inject other medications if
• Patients with gaping venous
tion to escape into the circulation. required. Proper equipment and per-
wounds, those with infected le-
Interosseous escape of the local anes- sonnel must be available for emergen- 1073
sions, and those patients with long
thetic can occur during injection. Acci- cy cardiopulmonary support (airway,
bone fractures of the extremities
dental or premature deflation of the breathing, circulation).
should not be recognized as pa-
tourniquet (within 20 minutes) allows
tients suitable for IVRA.
the local anesthetic to enter the circu-
• IVRA is generally not recommended
lation in toxic concentrations. When COMPLICATIONS OF in lengthy procedure.
an excessive dose of local anesthetic is OPTHALMIC REGIONAL
IVRA, intravenous regional anesthesia.
injected, toxicity may occur on release ANESTHESIA
of the tourniquet, even when follow-
ing appropriate recommendations. Like other types of nerve blocks, there
site of injection is also important to
are some serious risks associated with
Prevention consider in avoiding hemorrhage.
the use of ophthalmic regional anes-
Intravenous regional anesthesia is easy thesia. Common complications in- Prevention of Complications
to perform yet one must pay particular clude hemorrhage, brainstem anes- Resultant of Ophthalmic
attention to the details surrounding thesia, and myotoxicity. However, the
the procedure. Preventing complica-
Regional Anesthesia
clinician should be aware of other
tions begins with appropriate patient less-frequently occurring complica- To prevent complication as a result of
selection and a positive surgical indi- tions of ophthalmic regional anesthe- ophthalmic regional anesthesia, do the
cation. Good intravenous access is im- sia that include globe ischemia, perfo- following:
portant as is proper exsanguination of ration of the globe, optic nerve and • Consider only selected patients who
the limb. Table 49–8 lists points to facial nerve damage, and elicitation of are taking anticoagulant medication
consider for proper patient and surgi- the oculocardiac reflex. with the current INR (<2) levels not
cal selection. exceeding twice the normal value as
Proper techniques for effective and Hemorrhage candidates for ophthalmic regional
safe IVRA essential to prevent compli- The reported risk of retrobulbar hem- blocking.255
cations are as follows: orrhage varies substantially in anes-
• Carefully weigh the benefits and
thetic literature.253 In one of the larg-
• Place the tourniquet above the risks of performing ophthalmic re-
est reported series, Hamilton reported
elbow (tourniquet application is less gional anesthesia in patients who
an incidence of 0.44% hemorrhages in
reliable in the distal portion of the have discontinued their anticoagu-
12,500 ophthalmic regional anesthesia
extremity). lant medication.
cases.254 The severity of retrobulbar
• Thorough exsanguinations should hemorrhage varies depending upon • Consider alternative methods of
take place prior to injection of the the origin of the bleeding. Arterial applying ophthalmic anesthesia if
local anesthetic. Appropriate doses bleeding is the most dangerous com- there is risk of thrombotic complica-
of preservative-free local anesthetic plication of retrobulbar injections be- tions following discontinuation of
should be administered. cause tamponade can occur, which anticoagulant medication.256,257
• Lidocaine free of preservatives is one leads to ischemia of the globe. In this • Let patients on antiplatelet therapy
of the most frequently used local situation, lateral canthotomy may be continue their medications if medi-
anesthetics for IVRA; the recom- required to relieve the pressure. The cally indicated.258
 PART 4: Managing Anesthesia Care

• Postpone surgery in severely hyper- TABLE 49–9.

tensive patients.
Signs and Symptoms of Brainstem Anesthesia, Prevention, and Management
The use of small-gauge disposable
needles (25 gauge), less than 31 mm in Brainstem • Confusion
length is recommended for use in oph- anesthesia • Shivering
thalmic regional anesthetic proce- • Convulsions
dures.259,260 The site of anesthetic in- • Paralysis
jection should be carefully considered. • Loss of consciousness
Vascular structures are larger in the • Apnea
apex of the orbit, and also the upper • Hypotension
nasal area is particularly vascular.
• Bradycardia
Areas with increased vascular archi-
• Nausea/vomiting
tecture should be avoided to prevent
Prevention • Use short needles <31 mm) and small doses of local anesthetics.
complications during the induction of
Management • Surgery should be postponed and the patient should be
ophthalmic regional anesthesia.
observed and treated appropriately if symptoms of brainstem
anesthesia develop. The treatment varies depending upon the
Management symptoms and is mostly supportive in nature.
As with other nerve blocks, once dam-
age has occurred as a result of ophthal-
mic regional anesthesia it is difficult to
reverse. If complications do occur, The clinician should attempt to visu- sensitive eye muscles can permanent-
supportive measures are recommend- alize in the “mind’s eye” the equator of ly damage them. The inferior rectus
ed for patient care. the globe and to avoid repositioning muscle appears to be particularly vul-
the needle until it is located past the nerable to injury.104,264
1074 Brainstem Anesthesia equator. All needles should be direct-
When local anesthetic spreads directly ed tangentially with the bevel facing Miscellaneous Complications
into the brain from the orbit, brain- the globe. Pain or resistance to needle Resulting from Ophthalmic
stem anesthesia occurs. The incidence advancement is a warning sign of per- Regional Anesthesia
of brainstem anesthesia is 1 case for foration of the sclera. Some experts
Globe ischemia, optic nerve and facial
every 350–1500 ophthalmic cases259 suggest aiming the needle midway be-
nerve damage and oculocardiac reflex
and symptoms may appear within 2 tween the inferior and lateral rectus
are less-frequent complications of oph-
minutes of the injection. Maximum ef- muscles to allow a clear point of entry
thalmic regional anesthesia.
fects usually occur within 20 minutes to the intraconal space. The inferior
and recovery occurs in 2–3 hours. rectus muscle should be carefully
Symptoms and signs can vary greatly avoided to prevent diplopia. SUMMARY
and include the following (Table 49–9).
Management This chapter provides a comprehensive
Globe Perforation The key to successful management of review of the management of complica-
Blindly inserting a needle into the globe perforation is early diagnosis tions following regional anesthesia.
orbit is associated with the risk of and treatment. The patient may report
paresthesia at the time of needle inser- • Although the overall incidence of
globe perforation. The site of injection
tion. Funduscopic examination by an complications following brachial plex-
and the axial length of the globe must
ophthalmologist may confirm the diag- us anesthesia is low, the proportion of
be carefully considered before needle
nosis of globe perforation. Depending complications following supraclavic-
insertion so as to prevent damaging
on the severity of damage, globe perfo- ular methods is higher than that re-
the globe. In one reported series, there
ration can be managed by laser photo- ported following axillary blocks (i.e.,
were no globe perforations in 2000
coagulation therapy, cryotherapy, and the incidence of seizure activity fol-
cases of ophthalmic regional anesthe-
other prompt surgical procedures. Be- lowing interscalene or subclavian
sia,261 whereas another study reported
cause the appropriate management of perivascular methods is at least 6
an incidence of 1 case of globe perfora-
globe perforation is complex, careful times that of the axillary approach).
tion per 12,000 ophthalmic cases.262
consultation should take place with • Many of the complications of supra-
Prevention the ophthalmologist. clavicular methods have an impact
Globe perforation can be prevented by on pulmonary function; consequent-
presurgically assessing the axial length Myotoxicity ly, supraclavicular methods should
of the patient’s eye. Patients susceptible Myotoxic effects of local anesthetic be avoided in patients with signifi-
to perforation of the globe include those drugs were discussed in Toxic Effects cant pulmonary dysfunction. In a
with elongated globes (>26 mm), which of Local Anesthetics on the Nerves and sense, there should always be a clear-
occur in myopic patients, in those with Surrounding Anatomy above. Typical- cut indication for selecting supracla-
retinal detachment, and in those who ly, diplopia and ptosis can occur for up vicular methods because of the risk
require refractive surgery. Myopic pa- to 48 hours when using long-acting of pulmonary complications.
tients with staphyloma are particularly local anesthetics. However, direct in- • Local anesthetic drugs must be in-
vulnerable to globe perforation.263 jection of these drugs into the highly jected slowly and incrementally,
 CHAPTER 49: Managing Adverse Outcomes during Regional Anesthesia

and patients must be observed care- ral analgesia should be carefully con- 8. Hadzic A. Peripheral nerve stimulators:
fully for signs of local anesthetic sidered, and prevention of patient inju- cracking the code-one at a time. Reg Anesth
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