Overview
Peripheral nerve blocks involve the injection of local anesthetic around specific peripheral nerves to provide anesthesia and analgesia for surgical procedures. These blocks can be performed with or without ultrasound guidance and are essential for regional anesthesia practice.
Peripheral nerve blocks provide excellent surgical anesthesia and post-operative analgesia while avoiding the side effects of general anesthesia. They are particularly valuable for orthopedic, hand, and foot surgery. Ultrasound guidance has revolutionized the safety and success of these procedures.
Learn more in our comprehensive RxDx Anesthesia Course
Indications
Hand, wrist, elbow, and shoulder procedures
Knee, ankle, foot, and hip procedures
Fracture fixation, joint replacement
Carpal tunnel, tendon repair, digit procedures
Bunionectomy, toe procedures, ankle surgery
Analgesia after surgical procedures
Management of chronic pain conditions
Emergency procedures for trauma
Contraindications
Absolute Contraindications
Relative Contraindications
📋 Equipment Checklist
Check off items as you gather them:
Pre-procedure Preparation
Preparation includes patient assessment (coagulation status, neurological examination), equipment check (ultrasound, nerve stimulator, local anesthetic), informed consent, and understanding the anatomy of the target nerves and surrounding structures.Step-by-Step Procedure
Step 1: Patient Assessment
Assess patient for contraindications, perform neurological examination, check coagulation status, and obtain informed consent. Position patient appropriately.
⚠️ Common Mistakes to Avoid:
- Inadequate assessment
- Missing contraindications
- Poor positioning
💡 Pro Tip:
Always check coagulation status and perform thorough neurological examination before procedure.
Step 2: Equipment Setup
Set up ultrasound machine, prepare nerve stimulator (if used), draw up local anesthetic, and ensure sterile technique.
⚠️ Common Mistakes to Avoid:
- Broken equipment
- Wrong local anesthetic concentration
- Poor sterile technique
💡 Pro Tip:
Always test ultrasound and nerve stimulator before starting. Use appropriate local anesthetic concentration.
Step 3: Nerve Localization
Use ultrasound to identify target nerve, surrounding structures, and optimal injection site. Confirm nerve identity with nerve stimulator if needed.
⚠️ Common Mistakes to Avoid:
- Wrong nerve identification
- Poor ultrasound technique
- Inadequate visualization
💡 Pro Tip:
Use ultrasound guidance whenever possible. Identify nerve, artery, and vein to avoid complications.
Step 4: Needle Insertion
Insert needle under ultrasound guidance, advance toward nerve, and confirm needle position with nerve stimulation or ultrasound.
⚠️ Common Mistakes to Avoid:
- Arterial puncture
- Nerve injury
- Poor needle positioning
💡 Pro Tip:
Use in-plane or out-of-plane technique. Always visualize needle tip to avoid complications.
Step 5: Local Anesthetic Injection
Inject local anesthetic slowly, monitor for signs of intravascular injection, and ensure adequate spread around nerve.
⚠️ Common Mistakes to Avoid:
- Rapid injection
- Intravascular injection
- Inadequate spread
💡 Pro Tip:
Inject slowly with frequent aspiration. Monitor for signs of local anesthetic toxicity.
Step 6: Block Assessment
Assess block success, monitor for complications, and document procedure details.
⚠️ Common Mistakes to Avoid:
- Inadequate assessment
- Poor monitoring
- No documentation
💡 Pro Tip:
Test sensory and motor function. Monitor for complications for at least 30 minutes.
Master PNB with RxDx
Access 100+ procedure videos and expert guidance with the RxDx app
Post-procedure Care
Post-procedure care includes monitoring for complications (nerve injury, local anesthetic toxicity), assessment of block success, management of side effects, and documentation of the procedure details.Complications & Management
| Complication | Incidence | Signs | Management | Prevention |
|---|---|---|---|---|
| Nerve injury | 0.1-1% | Paresthesia, weakness, pain, sensory changes | Neurological consultation, EMG, monitoring | Gentle technique, ultrasound guidance, avoid intraneural injection |
| Local anesthetic toxicity | 0.5-2% | Metallic taste, tinnitus, seizures, cardiovascular collapse | Stop injection, supportive care, lipid emulsion | Calculate safe doses, frequent aspiration, monitoring |
| Hematoma | 1-3% | Swelling, pain, ecchymosis, nerve compression | Compression, monitoring, surgical evacuation if needed | Check coagulation status, gentle technique, ultrasound guidance |
| Infection | <0.1% | Erythema, pain, fever, abscess formation | Antibiotics, surgical drainage if needed | Strict aseptic technique, proper skin preparation |
| Failed block | 5-15% | Inadequate anesthesia, patchy block, patient discomfort | Supplement with local anesthetic, convert to general anesthesia | Proper technique, adequate volume, correct positioning |
| Vascular puncture | 2-5% | Blood aspiration, expanding hematoma, hypotension | Remove needle, apply pressure, monitor | Ultrasound guidance, frequent aspiration, identify vessels |
Clinical Pearls
Use ultrasound guidance whenever possible - it improves success and safety.
Identify nerve, artery, and vein before injection - anatomy is key.
Inject slowly with frequent aspiration - avoid intravascular injection.
Monitor for complications for at least 30 minutes - toxicity can be delayed.
Document procedure details including technique, complications, and outcomes.
Practice sterile technique religiously - infection is rare but serious.
Be prepared for local anesthetic toxicity - have lipid emulsion ready.
Test block success before surgery - inadequate block requires supplementation.
Use appropriate local anesthetic volume - too little causes failed block.
Peripheral nerve blocks provide excellent post-operative analgesia.