Overview

Regional anesthesia involves the injection of local anesthetic near nerves to block pain sensation in specific regions of the body. It includes neuraxial techniques (spinal, epidural) and peripheral nerve blocks.

Regional anesthesia provides excellent pain control, reduces opioid requirements, and may improve surgical outcomes. It is essential for orthopedic surgery, obstetrics, and chronic pain management.

Learn more in our comprehensive RxDx Anesthesia Course

Indications

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Orthopedic Surgery

Upper and lower extremity procedures

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Obstetric Anesthesia

Labor analgesia and cesarean section

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Thoracic Surgery

Paravertebral blocks for thoracotomy

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Abdominal Surgery

Transversus abdominis plane blocks

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Chronic Pain

Diagnostic and therapeutic nerve blocks

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Ambulatory Surgery

Outpatient procedures with early discharge

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Trauma Surgery

Emergency procedures with pain control

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Pediatric Surgery

Selected procedures in children

Contraindications

Absolute Contraindications

✗ Patient refusal
✗ Severe coagulopathy (INR >1.5, platelets <50,000)
✗ Local infection at injection site
✗ Severe neurological disease
✗ Allergy to local anesthetics

Relative Contraindications

✗ Anticoagulation therapy
✗ Anatomical abnormalities
✗ Previous nerve injury
✗ Severe cardiovascular disease
✗ Pregnancy (for certain blocks)
✗ Severe anxiety or inability to cooperate

📋 Equipment Checklist

Check off items as you gather them:

Pre-procedure Preparation

Preparation includes patient assessment (coagulation status, neurological examination), equipment check (needles, local anesthetic, ultrasound), informed consent, and understanding the anatomy and technique.

Step-by-Step Procedure

Step 1: Patient Assessment

Assess patient for contraindications, perform neurological examination, and obtain informed consent.

⚠️ Common Mistakes to Avoid:

  • Inadequate assessment
  • Missing contraindications
  • Poor consent

💡 Pro Tip:

Always check coagulation status and perform thorough neurological examination.

Step 2: Equipment Setup

Prepare ultrasound, needles, local anesthetic, and ensure sterile technique.

⚠️ Common Mistakes to Avoid:

  • Broken equipment
  • Poor sterile technique
  • Wrong medications

💡 Pro Tip:

Always test equipment before starting. Use appropriate local anesthetic.

Step 3: Patient Positioning

Position patient appropriately for the specific block and ensure comfort.

⚠️ Common Mistakes to Avoid:

  • Poor positioning
  • Patient discomfort
  • Inadequate access

💡 Pro Tip:

Position patient comfortably. Good positioning is crucial for success.

Step 4: Skin Preparation

Clean skin with antiseptic solution and apply sterile drapes.

⚠️ Common Mistakes to Avoid:

  • Poor skin preparation
  • Inadequate sterile field
  • Contamination

💡 Pro Tip:

Use proper antiseptic technique. Sterility is essential.

Step 5: Nerve Localization

Use ultrasound or nerve stimulation to identify the target nerve.

⚠️ Common Mistakes to Avoid:

  • Poor visualization
  • Wrong nerve identification
  • Inadequate localization

💡 Pro Tip:

Take time to identify the nerve correctly. Ultrasound is very helpful.

Step 6: Needle Insertion

Insert needle under ultrasound guidance or with nerve stimulation.

⚠️ Common Mistakes to Avoid:

  • Wrong needle direction
  • Too deep insertion
  • Nerve trauma

💡 Pro Tip:

Advance needle slowly and carefully. Watch for paresthesias.

Step 7: Local Anesthetic Injection

Inject local anesthetic around the nerve with frequent aspiration.

⚠️ Common Mistakes to Avoid:

  • Intravascular injection
  • Wrong volume
  • Poor distribution

💡 Pro Tip:

Aspirate frequently and inject slowly. Monitor for toxicity.

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Post-procedure Care

Post-procedure care includes monitoring for complications (nerve injury, infection), assessing block effectiveness, and managing any side effects or complications.

Complications & Management

Complication Incidence Signs Management Prevention
Local anesthetic toxicity 0.1-1% Seizures, arrhythmias, cardiovascular collapse Stop injection, lipid emulsion, supportive care Frequent aspiration, appropriate doses, monitoring
Nerve injury 0.1-0.5% Persistent numbness, weakness, pain Neurological consultation, EMG, rehabilitation Gentle technique, proper needle size, avoid intraneural injection
Infection 0.1-0.3% Redness, swelling, fever, pain Antibiotics, drainage if needed, monitoring Strict aseptic technique, proper skin preparation
Hematoma 0.5-2% Swelling, pain, bruising, compression symptoms Compression, monitoring, surgical consultation if severe Check coagulation status, gentle technique
Failed block 5-15% Inadequate analgesia, patient discomfort Supplemental analgesia, reattempt if appropriate Proper technique, adequate volume, correct localization
Pneumothorax 0.1-1% Chest pain, dyspnea, decreased breath sounds Chest X-ray, oxygen therapy, chest tube if large Proper technique, avoid deep insertion, ultrasound guidance

Clinical Pearls

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Ultrasound guidance improves success rates and reduces complications.

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Always aspirate before injection - intravascular injection is dangerous.

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Use appropriate local anesthetic doses - toxicity can be life-threatening.

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Take time to identify nerves correctly - accuracy is more important than speed.

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Monitor for complications post-block - especially in the first 24 hours.

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Practice sterile technique religiously - infections are serious complications.

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Have lipid emulsion available - it's the antidote for local anesthetic toxicity.

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Document block details carefully - including technique and complications.

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Use appropriate needle size - too large can cause trauma.

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Regional anesthesia is a skill that requires regular practice and maintenance.