Anesthesia and Nerve Block Complications

Regional Anesthesia Benefits

• Improved analgesia
• Less need for narcotics and/or pain medications
• Improved physical therapy, mobility, and functional recovery after surgery
• Decreased recovery room and/or hospital stay
• Improved blood flow to extremity due to sympathectomy
• Improved patient satisfaction

Regional Anesthesia Disadvantages

• Potential for harm: local anesthetic toxicity, cardiac collapse, seizure, allergic reaction, respiratory compromise, paresthesia, nerve injury, infection, hematoma, and failed block

Regional Anesthesia Considerations

• Patient refusal
• Surgeon refusal
• Clinician lack of knowledge or skill
• Infection at sight of block
• Existing neurologic injury
• Patient cooperation (pediatrics, combative, dementia)
• Anticoagulation issues
• Bloodstream infection
• Allergy to local anesthetics
• Preexisting peripheral neuropathy

Regional Anesthesia for a Coagulated Patient

• Spinal hematoma is the most significant hemorrhagic complication of regional anesthesia
• Due to bleeding into a fixed and noncompressible space
• Management (performance, catheter maintenance, and catheter removal) based on site compressibility, vascularity, and consequences of bleeding, should it occur

Neurologic Injury

• Classified by degree of functional disruption
• 1. motor response disappears after injection of local anesthetic or saline
• PNS does not prevent intravascular, intraneural, or pleural puncture

Ultrasound-Guided Regional Anesthesia

• Decrease the incidence of block failure
• Improve upon the false negative rate of nerve stimulation techniques
• Allows for alternative approaches for nerve blockade
• May accelerate the learning curve for regional anesthesia
• Additional layer of safety

Advantages of UGRA

• Allows for visualization of nerve location and surrounding anatomic structures
• Provides real-time imaging of needle advancement and local anesthetic injection
• Reduces the number of needle insertions
• Studies have shown that the addition of ultrasound improves the block quality, onset time, and success rate

Limitations of UGRA

• Adds an additional layer of complexity
• Needles may be slightly longer for ultrasound-guided blocks

Single-Injection vs. Continuous Infusion

• Catheter benefits: prolonged analgesia, improved ability to participate in rehabilitation, and improved patient satisfaction

Continuous Infusion Needle Systems

• Prolonged analgesia
• Improved ability to participate in rehabilitation
• Improved patient satisfaction

Block Room

• Needed equipment: Doppler

U/S Image Modes

• A-Mode: a simple one-dimensional ultrasound image generated as a series of vertical peaks corresponding to the depth of the structures
• B-Mode: a two-dimensional image of the area, with horizontal and vertical directions representing real distances in tissue, and intensity of the grayscale indicating echo strength
• Doppler-Mode: a color-coded map of Doppler shifts superimposed onto a B-mode ultrasound image
• M-Mode: a single beam used to produce a picture with a motion signal, where movement of a structure can be depicted in a wave-like manner

Optimizing Image Quality

• Appropriate probe
• Adjust depth
• Compensate for attenuation with gain
• Optional modes: A, B, and M

Needle Guidance Fundamentals

• "X" marks the spot: needle guidance fundamentals

Long vs. Meds Before the Block Wears Off

• Remember that a nerve injury following a peripheral nerve block may not be from the peripheral nerve block
• Always follow patients who receive regional anesthesia until sensory and motor function return

Assess Your Work

• Follow patients who receive regional anesthesia until sensory and motor function return

Time to Make the Donuts

• Keys to success: the anesthesia team, technique, preoperative management, patient selection, patient education, surgeon, intraoperative management, postoperative management

Keys to Success

• Acronym for success: SCANNING
• S: Supplies
• C: Comfortable positioning
• A: Ambiance
• N: Name and procedure
• N: Nominate a transducer
• I: Infection control
• N: Note lateral/medial side on screen
• G: Gain and depth adjustments

Local Anesthetics

• Sensory vs. motor block