Information
- Peripheral nerve blockade can be an excellent addition or alternative to general anesthesia (GA) for many surgical procedures. Regional anesthesia (RA) may provide sensory and motor blockade without significantly disrupting systemic autonomic function. Single-shot blocks can provide postoperative analgesia that may last for hours.
- Continuous peripheral nerve catheters prolong the analgesia of RA techniques beyond the maximum duration of a single injection block. This can be especially useful for patients with chronic pain or opioid tolerance. A nerve block catheter is inserted percutaneously adjacent to the peripheral nerves or fascia plane, often with ultrasound guidance. Local anesthetic (LA) is then infused through the catheter(s) providing analgesia for days or in certain circumstances even for weeks.
- The preoperative evaluation includes patient history, particularly history of coagulopathy, and physical examination, with special attention to any preexisting neurological deficits. ASA guidelines for perioperative care are similar to those for patients receiving GA.
- Surgical considerations must be incorporated into the regional anesthetic plan. These include intraoperative factors, such as projected surgical incision and extension, total surgical time, and tourniquet placement, and postoperative factors like anticipated level of pain and duration of recovery.
- Consent for RA should include a thorough description of the risks, benefits, options, and common side effects. Need for supplemental LA, sedation, or potential for GA should always be discussed. Laterality of the procedure and thus block placement must be confirmed with the patient, case booking, available preprocedure imaging or notes, and markings made by the surgical team on the day of surgery.
- Preoperative anxiolysis may be appropriate as long as the patient remains alert and cooperative. Conscious sedation is usually achieved by using short-acting agents such as midazolam and/or fentanyl.
- Standard ASA monitoring of electrocardiogram, blood pressure measurement, and pulse oximetry with audible pitch tone must be used during placement of all blocks. Resuscitation medications and equipment should be readily available (see Section IV.G).
- A time-out must be conducted prior to starting regional block placement to confirm patient identity, correct procedure site, and regional anesthetic to be performed.
- Aseptic technique must be employed during performance of all blocks. This includes removal of jewelry; hand hygiene; use of caps, masks, and sterile gloves; use of individual packets of chlorhexidine solution (preferably alcohol based) for skin preparation and adequate drying time; sterile equipment; placement of sterile occlusive dressings over catheter insertion sites; and limiting disconnection and reconnection of LA delivery systems.
- Postoperative follow-up should include assessment of block efficacy and duration, presence of residual sensory or motor blockade, paresthesia or other side effects, and patient satisfaction.