Regional anesthesia

Summary

Regional anesthesia involves the injection of local anesthetic agents around nerves in the peripheral
nervous system or central nervous system to achieve reversible numbing of pain conduction in the
corresponding innervated tissue. Regional anesthesia can be divided into peripheral nerve blocks,
neuraxial anesthesia (i.e., spinal anesthesia, epidural anesthesia), and intravenous regional anesthesia.

Overview

 Goal: used prior to certain medical procedures to reduce pain. [1]

 Types of anesthetic agents: See “Local anesthetic agents.”
 General contraindications to regional anesthesia
o Absolute: allergy to a class of anesthetic
o Relative
 Active inflammation or infection at the injection site
 Coagulopathy
 Neurological deficits in the area of distribution
 Types
o Peripheral nerve blocks
o Neuraxial anesthesia (i.e., epidural anesthesia, spinal anesthesia)
o Intravenous regional anesthesia (Bier block): a local anesthetic agent is injected intravenously
into an extremity that has been separated from the central circulation with a tourniquet and
exsanguinated by compression to provide an anesthetized, bloodless surgical field

Peripheral nerve block

Definition [1]

Injection of local anesthetic agents around nerves in the peripheral nervous system to achieve reversible
numbing of pain conduction in the corresponding innervated tissue

Indications [1]

General

 Nonthoracoabdominal surgery or minor procedures (e.g., closed reductions)

 Wound repair in which infiltration anesthesia may distort the anatomy
 Large area of anesthesia required
 Postoperative pain control

Head, neck, and thorax

 Common nerve blocks of the head, neck, and thorax [1]

Type Targeted nerves Clinical applications

 Individual dental nerves

Maxillary nerve  Superior alveolar nerves  Pain reduction and/or abscess drainage for maxillary

block (i.e., posterior, middle, anterior)  Laceration repair of the upper lip and midface

 Infraorbital nerve

 Pain reduction and/or abscess drainage for

Mandibular nerve  Inferior alveolar nerve
mandibular teeth
block  Mental nerve
 Laceration repair of the lower lip and chin

 Reduction of pain associated with rib

Intercostal block  Intercostal nerve
contusions and fractures

Trigeminal nerve branches and areas of

sensory innervation

Illustrated are the 3 main branches of the

trigeminal nerve (V1–V3), the areas in which
they supply sensory innervation, and their
subsidiary branches. The terminal superficial
branches of V1–V3 are, respectively, the
supraorbital, infraorbital, and mental nerves,
which exit the skull at their eponymous
foramina (marked with red circles). These exit
points are clinically relevant as injection
points for a superficial trigeminal nerve block.
 Upper extremity

Common nerve blocks of the upper extremities [1]

Type Targeted nerves or plexus Clinical applications

 Interscalene plexus

 Supraclavicular plexus  Shoulder reductions and surgery

Brachial plexus block
 Infraclavicular plexus  Arm, forearm, and hand surgery

 Axillary plexus

 Median nerve

Elbow or wrist block  Radial nerve  Hand surgery

 Ulnar nerve

 Finger lacerations

Digital block  Finger reductions

 Digital nerve
See also “Lower extremity.”  Nail bed injuries

 Drainage of digital infections (e.g., paronychia, felon)

Upper extremity peripheral nerve blocks

Dermatomal distributions affected by

selected brachial plexus blocks

Left: The axillary brachial plexus block

anesthetizes the terminal branches of the
brachial plexus, providing reliable anesthesia
to the solid green dermatomes. Depending
on the technique used, the
musculocutaneous nerve (hatched
dermatome) may also be blocked.

Middle: The supraclavicular plexus block anesthetizes the trunks of the brachial plexus, providing
reliable anesthesia to the solid pink dermatomes. The hatched region, innervated by the medial
brachial cutaneous nerve (originating from the brachial plexus) and the intercostobrachial nerve
(originating from the second intercostal nerve), is not reliably blocked.
Right: The interscalene block reliably anesthetizes nerve roots C5–C7 of the brachial plexus (solid blue
dermatomes). Anesthesia to nerve roots C4, C8, and T1 (hatched dermatomes) may vary depending
on the technique used and patient anatomy.

Median nerve

Radial nerve
Ulnar nerve

Lower extremity

Common nerve blocks of the lower extremities [1]

Type Targeted nerves Clinical applications

 Femoral nerve
Femoral block (three-in-
 Obturator nerve
one block)
 Lateral femoral cutaneous nerve  Hip fractures and surgery

 Knee surgery
 Femoral nerve
Fascia iliaca block
 Lateral femoral cutaneous nerve

 Foot surgery
Sciatic block  Sciatic nerve
 Ankle surgery

 Posterior tibial nerve

 Sural nerve

Ankle block  Superficial peroneal nerve  Foot surgery

 Deep peroneal nerve

 Saphenous nerve
 Common nerve blocks of the lower extremities [1]

Type Targeted nerves Clinical applications

 Toe lacerations

 Toe reductions
Digital block  Digital nerve block
 Nail bed injuries

 Drainage of digital infections (e.g., paronychia, f

Lower extremity peripheral

nerve blocks

Dermatomal distributions
affected by femoral and sciatic
nerve blocks

Left: The femoral nerve block

anesthetizes the entire region
innervated by the femoral nerve
(solid red dermatomes).
Depending on the technique
used, the lateral femoral
cutaneous and obturator nerves
may also be blocked (hatched
dermatomes); this variation of
the femoral nerve block is
sometimes referred to as a “3-in-
1 block.”

Right: The sciatic nerve block anesthetizes the entire region innervated by the sciatic nerve and its
branches (blue dermatomes 2–9). Depending on the technique used, the posterior femoral cutaneous
nerve (blue dermatome 1) may also be blocked.
Innervation areas of the
peripheral nerves (leg, ventral
view)
Procedure [1]

 Injection site: varies based on the target nerve

 Approach
o Single injection
o Continuous administration via a catheter
 Technique: varies based on the target nerve
o Place the patient in a position that allows easy access to the target nerves.
o Perform skin preparation and maintain a sterile field.
o Identify the targeted nerve using anatomical landmarks and/or:
 Ultrasound
 Nerve stimulation test
o Inject the local anesthetic agent around the target nerve.

ПОКАЗАТЬ ВИДЕО

Peripheral nerve blocks do not carry the risks associated with general anesthesia (e.g., respiratory
depression, aspiration) and neuraxial anesthesia (e.g., CSF leak syndrome, urinary retention). [1]

Avoid discharging patients after major nerve blocks until sensation and function have returned to
baseline levels to reduce the risk of secondary injury. [1]

Monitor for delayed-onset LAST, especially if high doses of local anesthetic agents were used.

Epidural anesthesia

Definition [2]

 Local anesthetics with or without opioids and alpha-adrenergic agonists are injected into the
epidural space and act on the spinal nerve roots.
 Epidural anesthesia blocks several nerve roots around the site of injection and barely affects the
function of the nerve roots above and below (segmental anesthesia).

Indications [2]

 Used for a variety of surgeries of the lower body (e.g., cesarean delivery, hernia repair,
appendectomy, prostate and bladder surgeries, knee surgery)
 During labor
 Perioperatively
 Chronic pain management (e.g., spinal stenosis, disk herniation)

Contraindications [2]

 Absolute
o Uncorrected hypovolemia
o Increased intracranial pressure
o Infection at the puncture site
 Relative
o Coagulopathy
o Spinal deformities
o Sepsis, systemic bacteremia, amniotic infection syndrome
 o Neurological deficits caused by, e.g., disk prolapse, paraplegic syndrome, and multiple
sclerosis

Procedure [2]

 Injection site
o May be performed at any vertebral level (cervical, thoracic and lumbar spine)
o Needle inserted into the epidural space between the ligamentum flavum and dura mater
 Approaches to inject the local anesthetic
1. Catheter placement, which has the advantage of repeated/continuous administration of
anesthetic drugs (most commonly performed)
2. Single-shot technique

Spread of effect of epidural anesthesia

Epidural anesthesia (1/2): materials and patient positioning

Sterile materials (upper left)

(a) Loss-of-resistance syringe

(b) Syringe with needles for superficial and deep local anesthesia

(c) Epidural needle

(d) Epidural filter with (e) adapter

(f) Epidural catheter

(g) Transparent dressing

(h) Surgical foreceps

(i) Gloves

(j) Surgical swabs

(k) Fenestrated surgical drape

(l) Surgical gown

Nonsterile materials (lower left)

(m) Surgical cap

(n) Surgical mask

(o) Antiseptic

(p) Local anesthetic

(q) Saline solution (to test loss of resistance)

Patient positioning (right): The patient is seated close to the edge of the bed, to bring their back as close
as possible to the clinician performing the procedure. The feet rest on a stool. The patient is asked to
hunch over, which flexes the spine and so widens the space between the spinous processes (without
leaning forward, which increases lumbar lordosis). The arms may rest directly on the thighs or be
propped up on pillows resting on the thighs. An assistant (wearing a surgical cap, mask, and non-sterile
gloves) supports the patient in this position. The injection site and surrounding area should be fully
visible and accessible.
Epidural anesthesia (2/2): procedure

The injection site may be at any vertebral level (cervical, thoracic, and lumbar). This illustration shows a
midline approach, but a paramedian approach is also possible.

(1) Local anesthetic is infiltrated into the subcutaneous tissue (1a) and interspinous ligament (1b).

(2) The epidural needle is inserted, angled slightly cephalad with the bevel orientated cephalad. Once
the needle has been advanced by about 2–3 cm into the interspinous ligament, the stylet is removed
and a loss-of-resistance syringe filled with saline is attached.

(3) The needle is advanced while applying constant, gentle pressure on the syringe plunger. After
passing through the ligamentum flavum and entering the epidural space, a sudden loss of resistance is
felt and the saline is more easily injected (3a); at this point, advancement is stopped.

(4) The syringe is removed and the epidural catheter is inserted through the needle to its correct depth
(puncture depth + 4–6 cm). The tip of the catheter must always be advanced cephalad (4a); therefore,
the bevel of the needle must remain facing cephalad.

(5) The epidural needle is removed, taking care to maintain the epidural catheter at the correct depth.
At this time, aspiration is attempted from the catheter (5a: this should return neither blood nor CSF),
and an epidural filter is attached (5b).

(6) The puncture site is covered with a transparent dressing and the catheter is secured to the patient's
back with adherent dressings. A test dose is then administered.
Spinal anesthesia

Definition

 Local anesthetics with or without opioids and alpha-adrenergic agonists are injected into the
cerebrospinal fluid (CSF) in the lumbar spine and act directly on the spinal cord
 Combined spinal and epidural anesthesia (CSE)
o Combines the advantages of spinal anesthesia (rapid action, motoric block) with the
advantages of epidural anesthesia (favorable post-operative pain management via an
epidural catheter)
o Plays a major role in obstetrics and orthopedics.

Indications

Used for a variety of lower extremity, lower abdominal, pelvic, and perineal procedures (e.g., cesarean
delivery, hip and knee replacement), e.g:

 Cesarean delivery: T4–6 (mamillary line)

 Pelvic, urethral, and renal pelvic surgery: T6–8 (xiphoid)
 Transurethral surgery including stretching of the bladder, vaginal birth, hip surgery: T10 (navel)
 Transurethral surgery without stretching of the bladder: L1 (inguinal ligament)
 Knee and foot surgery: L2/3
 Perineal surgery: S2–5

Procedure

 Injection site
o Injection usually performed below L2 to avoid damage to the spinal cord
o Needle inserted into subarachnoid space between the arachnoid and pia mater
 Approach: almost always single-shot technique

Anatomical structures in lumbar

puncture, spinal anesthesia, and
epidural anesthesia

For lumbar puncture (including spinal

anesthesia) the spinal needle is
typically inserted in the L3-4 or L4-5
interspace and directed toward the
umbilicus.
 Spinal anesthesia (2/2):
procedure

The injection site is usually

at L3/L4 or L4/L5. This
illustration shows a midline
approach, but a paramedian
approach is also possible.

(1) Local anesthetic is

infiltrated into the
subcutaneous tissue (1a) and interspinous ligament (1b).

(2) The introducer needle is inserted (slightly cephalad) into the interspinous ligament.

(3) The spinal needle is inserted through the introducer needle and through the ligamentum flavum,
epidural space, dura- and arachnoid mater into the subarachnoid space (3a). The perforation of the dura
mater may result in an audible and/or palpable click.

(4) The stylet is removed while stabilizing the introducer and spinal needles with the other hand. If
positioned correctly, cerebrospinal fluid (CSF) will drip from the outer opening of the spinal needle (4a).

(5) A syringe with local anesthetic is connected to the spinal needle. A small amount of CSF is aspirated
to ensure correct positioning; this should not be bloody (5a). Following this confirmation, the local
anesthetic is slowly injected, while continuously monitoring the patient for signs of complications.

6) The introducer and spinal needles are removed together, and a sterile plaster is applied (6a).
Spinal anesthesia (1/2): materials and patient positioning

Sterile materials (upper left)

(a) Gloves

(b) Surgical swabs

(c) Fenestrated surgical drape

(d) Surgical gown

(e) Needle for local anesthesia

(f) Introducer needle

(g) Spinal needle

(h) Plaster

(i) 2 ml syringe

(j) 5 ml syringe

Nonsterile materials (lower left)

(k) Surgical cap

(l) Surgical mask

(m) Antiseptic

(n) Local anesthetic.

Patient positioning (right): The patient is seated close to the edge of the bed, to bring their back as close
as possible to the clinician performing the procedure. The feet rest on a stool. The patient is asked to
hunch over, which flexes the spine and so widens the space between the spinous processes (without
leaning forward, which increases lumbar lordosis). The arms may rest directly on the thighs or be
propped up on pillows resting on the thighs. An assistant (wearing a surgical cap, mask, and non-sterile
gloves) supports the patient in this position. The injection site and surrounding area should be fully
visible and accessible.

Spread of effect of spinal anesthesia

Complications

Complications of regional anesthesia [1]

 Nerve injury
 Local anesthetic systemic toxicity
 Hematoma
 Infection
 Secondary injury

Complications of neuraxial anesthesia [3][4][5]

 CSF leak syndrome

 Spinal epidural hematoma and spinal epidural abscess
 Meningitis
 Hypotension
o Pathophysiology: sympathetic blockade causes vasodilation and decreases venous return →
reduced cardiac output
o Clinical features: hypotension, dizziness, lightheadedness, and nausea shortly after
administering anesthetic
o Diagnostics: clinical diagnosis
o Treatment: IV fluid resuscitation + small doses of epinephrine
  Sympathetic block → peripheral vasodilation, bradycardia, and hypotension (Bezold-Jarisch
reflex) → relative hypovolemia
 Postoperative urinary retention
 Back pain
 Anterior spinal artery syndrome
 Conus medullaris syndrome

Total spinal anesthesia [6]

 Definition: complete spinal space affected by local anesthetic drug

 Pathophysiology: drug overdose during spinal block or accidental spinal anesthesia during
epidural block (intrathecal injection) → excessive cranial spread of the local anesthetic drug →
inhibition of the intercostal respiratory muscles and sympathetic block → bradycardia and
hypotension → reduced perfusion of the brainstem → total spinal anesthesia → circulatory and
respiratory arrest
 Clinical features
o Hypotension and cardiac decompensation
o Apnea
o Loss of consciousness
o Mydriasis (dilated pupils), fixed pupils
 Prophylaxis: correct catheter placement
o Negative aspiration test: Aspiration of blood indicates a perforated blood vessel or
intravascular placement of the catheter. Aspiration of CSF may be caused by catheter
insertion into the intrathecal space.
o Intrathecal test dose injection : Numb legs point to a misplaced catheter.
 Therapy
o Immediate intubation unless already performed
o Stabilization of BP via fluid resuscitation and catecholamines

References

1.Roberts JR. Roberts and Hedges' Clinical Procedures in Emergency Medicine and Acute Care. Elsevier;
2018

2.Ronald D. Miller, Manuel Pardo (Jr.). Basics of Anesthesia. Elsevier Health Sciences; 2011

3.Turnbull DK, Shepherd DB. Post-dural puncture headache: pathogenesis, prevention and treatment. Br
J Anaesth. 2003; 91(5): p.718-729. doi: 10.1093/bja/aeg231

4.Clinical Relevance of the Bezold–Jarisch Reflex. http://anesthesiology.pubs.asahq.org/article.aspx?

articleid=1943118. Updated: May 1, 2003. Accessed: February 20, 2017.

5.Schrock SD, Harraway-Smith C. Labor analgesia.. Am Fam Physician. 2012; 85(5): p.447-54. pmid:
22534222.

6.Asfaw G, Eshetie A. A case of total spinal anesthesia. International Journal of Surgery Case Reports.
2020; 76: p.237-239. doi: 10.1016/j.ijscr.2020.09.177.| Open in Read by QxMD

7.Agabegi SS, Agabegi ED. Step-Up To Medicine. Wolters Kluwer Health; 2015