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Peripheral Nerve Blocks

Chang A, Dua A, Singh K, et al.

Continuing Education Activity

Recent advances in surgical techniques and the development of a greater number of minimally invasive procedures have led to an increase in
outpatient procedures. Analgesic techniques must keep pace with these surgical advancements. Studies have shown that peripheral nerve blocks
are usually well-tolerated and provide regional analgesia that is superior to other modalities, such as oral pain medications or general anesthesia.
This activity reviews the indications, contraindications, and mechanisms of action of medications used in nerve blocks. Additionally, this activity
highlights the critical role of the interprofessional team members in monitoring patients to minimize complications and improve outcomes.

Objectives:

Identify the indications for peripheral nerve blocks.

Describe the preparation needed before performing a peripheral nerve block.
Describe the potential complications of medications used for peripheral nerve blocks.
Describe interprofessional team strategies for optimizing care coordination and communication to ensure patient safety during
peripheral nerve blocks.

Access free multiple choice questions on this topic.

Introduction
Recent advances in various surgical techniques and the development of more minimally invasive procedures have spurred an increase in
outpatient procedures. With these developments, it requires that analgesic techniques keep pace with these surgical advancements. Studies have
shown that peripheral nerve blocks are usually well-tolerated and provide regional analgesia superior to other modalities such as oral pain
medications or general anesthesia.[1][2][3]

Anatomy and Physiology

Anatomy and landmarks depend on the type of block being performed. Please refer below to techniques for specifics to the more common
peripheral nerve blocks performed.

Indications
There is no strict set of guidelines for the use of peripheral nerve blocks. However, the general rationale is to implement regional blocks in cases
where conservative measures have failed or to avoid the side effects and complications of general anesthesia and oral medications. The following
include examples of where peripheral nerve blocks may be preferable:

Patients who are at high risk of respiratory depression related to general anesthesia
Patients who want to avoid systematic medications
Patients intolerant or not responsive to oral medications

Contraindications
Absolute contraindications to the use of peripheral nerve blocks include allergy to local anesthetics, inability to cooperate, or patient refusal. It is
advised to postpone or reconsider a nerve injection when there is an active infection at the injection site, pre-existing neural deficits along with
the distribution of the block, and in patients with coagulopathies or on antithrombotic drugs.

Equipment
Equipment that is used is dependent upon the type of technique utilized. The following is a list of equipment used based on technique.

Nerve stimulator guidance: peripheral nerve stimulator that delivers an adjustable electrical current to the tip of a hollow insulated
disposable needle. The needle has specific tubing attached to a syringe that allows for aspiration and injection of a local anesthetic. A
wire runs between the needle and an electrode and allows the electrical pulse to be transmitted to stimulate the nerve.
Ultrasound guidance: portable ultrasound machines with both high and low-frequency probes that can identify superficial and deeper
nerves
Continuous catheter: numerous kits available, which usually contain a needle and catheter. A standard epidural kit can often be utilized.

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Personnel
A well-versed medical professional that is highly familiar and experienced with the type of block being performed should be performing the
specific injection.

Preparation
Taking a detailed medical history is necessary to determine conditions like coagulopathy or respiratory compromise that may impact the decision
to perform a block. A thorough physical exam is prudent as well to determine preexisting sensory or motor deficits in the distribution of the
block. Studies show that patients with preexisting sensory or motor deficits may be more likely to develop new deficits following a block than
patients without preexisting deficits. Following the history and physical, the patient should be made familiar with the risks, benefits, and care
needed during the recovery phase of the block.

For patients that are receiving a nerve block for a surgical procedure, they should follow the same fasting guidelines for the surgery as it may be
necessary for deep sedation to be used in cases of an inadequate block. Also, intravenous access should be obtained due to the risk of potential
complications like vasovagal events, local anesthetic toxicity, and the possible use of general anesthetics.

Technique
The technique for peripheral nerve blocks is based on the type of block. A quick summary of some of the more common blocks is listed below.

Interscalene block: anesthetizes nerve roots from the cervical plexus (C3, C4, supraclavicular nerve) and upper and middle trunks of the
brachial plexus (C5-C7). For positioning, the patient is placed in a supine position with the head turned away from the side of the block.
Sternal notch, the sternal and clavicular heads of the sternocleidomastoid muscle, and clavicle are identified and marked. A probe is
placed in a transverse position with its long axis across the neck just above the clavicle if using ultrasound. The carotid artery and
internal jugular vein are visualized. The subclavian artery is identified by directing the beam towards the first rib. Nerves are then
traced to cephalad. At the C6 nerves of the brachial plexus are visualized in a vertical orientation within the interscalene groove. A
needle is then placed in-plane or out-of-plane and directed toward the nerves. A needle tip is placed next to the nerve roots. A total of
12 cc to 30 cc of local anesthetic is injected.
Supraclavicular block: the patient is placed in the supine position with arms by the sides and the head turned away from the side of the
block. The probe is placed in a transverse position just above the clavicle using ultrasound. The carotid artery and internal jugular vein
are visualized. The needle is inserted in-plane (parallel to the probe), and a local anesthetic is injected to hydro dissect between the
nerves until the tip reaches an area bordered by the first rib, subclavian artery, and brachial plexus. 20 cc to 30 cc of local anesthetic is
injected. Before injection, however, aspiration should be performed to ensure there is no blood.
Infraclavicular block: the patient is placed in the supine position with the head turned away from the side of the block. The arm is
abducted with the elbow flexed to identify the coracoid process. The axillary artery is identified, and the cords of the brachial plexus are
visualized adjacent to the artery using ultrasound. The needle is placed adjacent to the axillary artery in the cranio-posterior quadrant,
and 30 to 40 cc of local anesthetic is administered. Before injection, however, aspiration should be performed to ensure there is no
blood
Axillary block: block anesthetizes nerves of the brachial plexus at the level of the individual nerves and often requires multiple
injections. The patient is positioned supine with the arm abducted 90 degrees, and the elbow is flexed. The transducer is placed
transversely in the axilla using ultrasound. The needle is introduced perpendicular to the skin and advanced until the tip is next to each
nerve.
Intercostobrachial block: the patient is positioned supine with the arm abducted to expose the axillary fossa. The intercostobrachial
nerve runs in the subcutaneous tissue of the medial upper arm. The needle is advanced subcutaneously across the medial aspect of the
arm while injecting 5 cc to 10 cc of local anesthetic.
Radial nerve block: radial nerve emerges between the brachioradialis tendon and the radius, just proximal to the styloid process. The
needle is inserted subcutaneously, just proximal to the styloid process of the radius, aiming medially, and 3 cc to 5cc of local anesthetic
is injected.
The median nerve block is located between the tendons of the flexor palmaris longus and the flexor carpi radialis. The need is inserted
between the two tendons until it penetrates the fascia and advanced until contact is made with bone. The needle should be redirected
and local anesthetic injected in lateral and medial directions.
Ulnar nerve block: ulnar nerve runs between the ulnar artery and flexor carpi ulnaris tendon. The tendon is just superficial to the ulnar
nerve. A needle is placed under the tendon close to its attachment just above the styloid process of the ulna and advanced 5 mm to 10
mm, and 3 cc to 5 cc of local anesthetic is injected at this location.
Lumbar plexus block: The patient is placed in the lateral decubitus position operative side up with the leg flexed at the hip and knee. It
is placed longitudinally adjacent to the spine at the second to third lumbar level using the ultrasound probe. The needle is inserted at the

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cephalad edge using the in-plane technique. The length of the needle should be seen as it approaches the target structure, which is the
posterior third of the psoas major muscle.
Femoral nerve block: The patient is placed in a supine position. Using ultrasound, the nerve is visualized, which is lateral to the artery.
An in-plane or out-of-plane approach can be used where the needle is inserted, and the tip is placed adjacent to the nerve, and 20 cc to
50 cc of local anesthetic is injected in 5 cc increments. Before injection, however, aspiration should be performed to ensure there is no
blood.
Fascia iliaca block: the patient is placed in a supine position where using ultrasound, the probe is placed transversely to the leg at the
junction of the middle and lateral thirds (between the ASIS and pubic tubercle) to identify the fascia lata, iliacus muscle, and fascia
iliaca. The needle is introduced in-plane inferior to the inguinal ligament and guided beneath the fascia iliaca, and 30 cc of local
anesthetic is injected in 5 cc increments. Before injection, however, aspiration should be performed to ensure there is no blood.
Obturator nerve block: the patient is placed in the supine position with the leg externally rotated. Using an ultrasound probe, it is placed
in the inguinal crease, and the femoral vein is identified. The probe is then moved medially to visualize the pectineus and adductor
longus muscles. The needle is inserted in-plane or out of plane and is directed to the fascial plane between the adductor brevis and
magnus, and 5 cc to 10 cc of local anesthetic is injected. Before injection, however, aspiration should be performed to ensure there is no
blood.
Sciatic nerve block: can be approached anteriorly or posteriorly. The patient is placed in the lateral decubitus position with the hip
flexed at 45 degrees and the knee at 90 degrees for the posterior approach. In the anterior approach, the patient is positioned in the same
manner. Using an ultrasound probe, it is held transverse to the course of the nerve. The nerve is found lateral to the ischial tuberosity
and deep to the gluteus maximus muscle. The needle is inserted in-plane from the lateral aspect of the transducer and positioned with
the tip of the needle adjacent to the nerve. Approximately 20 cc of local anesthetic is injected in 5 cc increments with gentle aspirations
between injections. Before injection, however, aspiration should be performed to ensure there is no blood.
Popliteal nerve block: the patient can be placed in either prone, lateral decubitus or supine. There are two approaches. For the posterior
approach, the biceps femoris and semitendinosus/semimembranosus tendons are palpated. The ultrasound probe is placed transverse to
the thigh and in the popliteal crease. The popliteal artery is used as the landmark, and the tibial nerve is found superficial and lateral to
the popliteal artery. The nerve is then followed cephalad to the point where the common fibular nerve joins the tibial nerve from the
lateral side to form the sciatic nerve. The sciatic nerve is blocked proximal to this to ensure that both the common fibular and tibial
nerves are anesthetized.
Saphenous nerve block: the patient is positioned supine with the leg straight. Using the ultrasound probe, it is placed perpendicularly to
the thigh at the midpoint between the anterior superior iliac spine and the distal end of the femur. The nerve is identified as it exits from
the adductor canal adjacent to the femoral artery. As it is followed distally, it becomes more superficial, traveling with an arterial branch
just deep to the sartorius muscle. Using an in-plane approach 10 cc of local anesthetic is injected deep into the sartorius muscle at the
lateral border of the artery. 

Complications
Potential complications and side effects are dependent upon the type of block performed. However, complications include peripheral nerve injury
(although not common, the rate may be as high as 8% to 10%), hematoma, local anesthetic systemic toxicity, allergic reaction, infection, and a
secondary injury, which includes reduced sensation after nerve block.[4][5][6]

Enhancing Healthcare Team Outcomes

Peripheral nerve blocks are often performed by anesthesiologists, surgeons, and emergency department physicians. However, a dedicated nurse
must monitor the patient's vital signs during the procedure. More important, resuscitation equipment must be in the room before starting the
procedure. A protocol should be established to conduct a peripheral nerve block to ensure patient safety and improve patient outcomes.

Review Questions
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Figure
Supraclavicular Ultrasound-guided, Brachial Plexus Nerve Block. Contributed by StatPearls

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Figure
Live ultrasound guided in plane median nerve block, flexor digitorum superficialis, flexor digitorum profundus. Contributed by
John Pester, DO

Figure
Sural Nerve Block Figures. Contributed by Ryan D'Souza, MD

Figure
Saphenous Nerve Block Image. Contributed by Mark Brady, MD

Figure
Ultrasound guided suprascapular nerve block at level of suprascapular notch. Credit: Eric Helm MD, Department of Physical
Medicine & Rehabilitation, University of Pittsburgh Medical Center

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anatomy, ultrasound-guided peripheral nerve blocks and special considerations. Minerva Anestesiol. 2019 Jul;85(7):763-773. [PubMed:
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Publication Details

Author Information

Authors

Andrew Chang1; Anterpreet Dua2; Karampal Singh; Brad A. White3.

Affiliations

1
University of Miami
2 Augusta University
3
Oklahoma State University Medical Center

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Publication History

Last Update: September 2, 2021.

Copyright
Copyright © 2021, StatPearls Publishing LLC.

This book is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits use,
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provided to the Creative Commons license, and any changes made are indicated.

Publisher

StatPearls Publishing, Treasure Island (FL)

NLM Citation

Chang A, Dua A, Singh K, et al. Peripheral Nerve Blocks. [Updated 2021 Sep 2]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2021 Jan-.

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