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Colombian Journal of Anestesiology

Print version ISSN 0120-3347

Rev. colomb. anestesiol. vol.39 no.3 Bogotá July/Oct. 2011

https://doi.org/10.5554/rca.v39i3.247 

Artículo de Revisión

 

Peripheral Nerve Blocks

 

Félix Arturo Salazar Pérez*, Geovanny Rodríguez Sánchez**

* Residente III de Anestesiología y Reanimación, Universidad Colegio Mayor Nuestra Señora del Rosario, Hospital Occidente de Kennedy. Bogotá, Colombia. Correspondencia: Calle 47B sur No. 23B-70, int 22 Apto 344 Bogotá, Colombia. Correo electrónico: fe_ar@yahoo.com.ar

** Anestesiólogo instructor de Anestesiología y Reanimación, Universidad Colegio Mayor Nuestra Señora del Rosario. Jefe del Departamento de Anestesiología, Hospital Occidente de Kennedy, Bogotá, Colombia. Correo electrónico: grodriguezsa@hotmail.com

Recibido: septiembre 20 de 2010. Enviado para modificaciones: febrero 13 de 2011. Aceptado: mayo 18 de 2011.


SUMMARY

Background. Technological advances and the development of several new techniques have helped expand the use of peripheral nerve blocks in different situations. This paper is designed to review several issues related with the tecniques to perform peripheral nerve blocks.

Methods. The literature search and selection was done in PubMed, Cochrane, Scielo, LILACS; it was expanded on the basis of the references found in texts reviewed by the author; the search was done using the MeSH terms included as keywords.

Results. Physiology of neural conduction, functioning of the peripheral nerve stimulator, anatomy of the several neural structures, drugs, and techniques are showed.

Key Words: Peripheral nerves, anesthesia, autonomic nerve block, anesthesia and analgesia. (Source: MeSH, NLM).


Introduction

As a result of new breakthroughs in devices for peripheral nerve localization, regional anesthesia has become one of the most widely used techniques, with a growing number of followers (1-5).

Patients receiving peripheral blocks have a lower incidence of complications (6-8) when compared with other techniques. This enables the use of this technique in other areas such as multimodal anesthesia and analgesia, management of acute postoperative pain, and management of chronic pain. Associated factors such as sedation, knowledge of the anatomy (4,5),adequate selection of the technique to be used, and of the local anesthetic (1,2), are critical.

Materials and methods

The literature search and selection was done in PubMed, Cochrane, Scielo, LILACS; it was expanded on the basis of the references found in texts reviewed by the author; the search was done using the MeSH terms included as key words.

This paper is designed to review several issues related with the tecniques to perform peripheral nerve blocks.

Peripheral nerve blocks

Blocks were developed early on in the history of anesthesia. Halsted and Hall in the 1880's used a cocaine injection that produced a sensory block in the ulnar, musculocutaneous, supratrocheal and infraorbital regions. In 1885, James Leonard recommended the use of a peripheral tourniquet in order to arrest circulation and prolong the action of cocaine. In 1903, Braun added epinephrine to the local anesthetic and gave it the name of “chemical tourniquet”. In 1914, the term conduction was introduced in anesthesia to refer to nerve conduction, and nerve stimulation principles were described for the first time. In 1920, Labat published the book Regional Anesthesia, technique and application, where he described anesthetic techniques and different approaches for peripheral nerve blockade (1).

Several technologies are now available to help localize nerve structures in order to improve the percentage of success and effectiveness (1,3). A peripheral nerve stimulator or an ultrasound probe may be used to localize the nerve to be blocked, resulting in lower volumes of local anesthetic and improved success and efficacy rates (1,3,8-10). Clinical trials showing superiority of one localization device over another are scant at the present time (1).

Peripheral nerve blockade consist of the injection of a local anesthetic close to a nerve or peripheral nerve bundle in order to inhibit the excitatory transmembrane action potential that transmits a nociceptive stimulus along different nerve fibers towards the central nervous system, modulating pain perception (2,3).

Table 1 shows the characteristics of the nerve fibers according to their physiology, anatomy and function.

Regional anesthetic techniques offer advantages over other techniques, including improved pain relief, and less respiratory (12) and gastrointestinal (13) complications (11), among others. Following major orthopedic surgery, peripheral nerve blocks and catheters provide analgesia and contribute to early rehabilitation (14,15), resulting in rapid return to daily activities (1,16).

In outpatient procedures (50 % of surgical patients in the United States) (14,16-18) and in hospitalized patients, it is associated with less postoperative nausea and vomiting, resulting in shorter stays in the post-anesthetic care unit (PACU) (16,19). However, up until the last decade, this technique was used in less than 30 % of all surgical procedures (16).

Materials and equipment for nerve blocks (Table 2)

Adequate history and clinical examination (thorough preoperative assessment): It is critical to ask about a history of peripheral and diabetic neuropathy, blood dyscracias, muscleskeletal disorders; past surgeries and pharmacological interventions, for example, platelet anti-aggregation agents and anticoagulants.

A systems review must focus on determining functional class and capacity, cardiovascular, respiratory and neurological symptoms; the clinical exam, including vital signs, must focus on the assessment of the airway, the cardiovascular system, and a physical neurological examination, all this in order to determine any contraindications for a peripheral nerve block.

Adherence to the minimal monitoring standards of the American Society of Anesthesiology (ASA): Blood pressure, pulse oxymetry, heart rate, electrobioscopy with DII and/or V5 aplileads, capnography. Additional monitoring will depend on the patient's condition, the anesthetic technique and the type of procedure. Markers and rule of thumb for adequate identification of anatomical landmarks (3-5).

Asepsis and antisepsis elements (20): Hand washing or glycerine alcohol, use of aseptic solutions and surgical soap, protective barriers and biosafety elements. The use of sterile drapes, gauze, syringes and needles is recommended. The occurrence of hazardous biological accidents must be avoided. (20,21).

The peripheral nerve stimulator is a technical device used for peripheral nerve localization; it triggers depolarizaton of a nerve fibre that conducts a transmembrane action potential (TAP). The nerve stimulator provides an external current flow that is negative in relation to the TAP when axons are at rest (1,3,9,22). This evokes a motor response mediated by the stimulation of a muscle group that receives nervous input from the target nerves. The application of an external electric current flow requires specific intensity and duration that are dependent on the type of nervous fiber (3) (Table 1). The nerve stimulator allows to determine the location of the fiber by applying an electric current that enters through a needle connected to an electrode. The most popular device in Colombia is the B/ Braun Stimuplex® dig R. It is 11 cm long x 7 cm wide and 3 cm thick and weighs approximately 300 g. The instructions for use are printed on one of the sides of the device (9) (Figure 1).

The use of the nerve stimulator increases the success rate (3) and reduces complications (1- 3,9,10,22-26). Needles for the peripheral nerve stimulator come in different sizes and must be selected in accordance with the type of nerve block; the use of teflon-coated needles is recommended (3,9).

Drug selection: the selection of the local anesthetic will depend on the type of block, the surgical procedure, the physical condition of the patient, and the pharmacological characteristics. Several local anesthetics are available in our setting: 1 % and 2 % lidocaine, 0.5 % bupivacaine, and 0.75 % levobupivacaine. These can be used to prepare different types of solutions such as 0.5 % lidocaine plus 0.25 % bupivacaine, etc.

There are no current trials with significant statistical power regarding the onset, duration and quality improvement of peripheral nerve blocks following the addition of different substances to the blockade solutions (1,2). Tables 3 and 4 show some of the characteristics pertaining to onset, duration, concentration and dose of the local anesthetics used.

Drugs for sedation and analgesia: Drugs such as midazolam, fentanyl, remifentanil, dexmedetomidine and/or propofol may be used (27,28) at doses that achieve effective site concentrations appropriate for sedation and analgesia, with a bispectral or enthropy ratio between 60 and 80 (27). Drug selection for sedation and premedication depends on the type of block, the procedure, the patient's physical status and the pharmacological characteristics of the medications (29).

Fully-equipped procedure room: Anesthesia machine, oxygen source, resuscitation elements and airway devices, venous lines and all the elements required for other anesthetic techniques.

Peripheral nerve block procedures

They consist of three phases: Before, during (3) and after peripheral nerve block. The initial phase before performing the block includes: Assessment and education of the patient and family members regarding the technique and the anesthetic risk; obtaining the informed consent; verification of the fasting state; review of the chart and of any paraclinical tests required. The anesthesia and basic patient monitoring equipment must be checked.

The peripheral nerve block phase (3) includes localization, approach, injection and anesthesia:

• The localization phase includes patient positioning, anatomical landmark identification and puncture.

• After the puncture is made, the motor response is evoked during the approach. Adequate knowledge of the neural anatomy and physiology as well as of the stimulus that triggers nerve propagation and the transmembrane excitatory action potential emerging from the nociceptors is required (1,3,6,9,11,30,31).

The good functioning of the nerve stimulator must be checked (9) using the battery charge test and verifying circuit integrity. The positive electrode should not be more that 40 cm away from the negative electrode in order to ensure circuit integrity during the procedure (9).

Additional techniques used for localizing the peripheral nerve include the fascial pop when the needle passes through the different structures (transfascial block or femoral three-in-one), evoked paresthesias, perivascular and transarterial approaches (axillary block with multiinjection technique)) (3,32-34), ultrasound, CT scan, fluoroscopy and nuclear magnetic resonance (NMR) (1,3,6,7). Table 5 shows the main techniques for approaching peripheral nerve blocks.

The recommended output current ranges between 1.0-5 mA initially, with a frequency of 1-2 Hz over 100-200 milliseconds. The intensity of the evoked motor response must range between 0.3-0.5 mA, and the distance between the nerve and the needle must be between ± 2-3 mm (3,9).

• The injection phase must take place only after the motor response is established and consists of a slow injection of a titrated dose of local anesthetic or local anesthetic solution, after a test dose, using suction in order to rule out intravascular placement. It is critical to monitor clinical signs of cardiotoxicity (1-3) such as ventricular arrhythmias, prolonged QT interval, direct myocardial effects such as inotropism or negative chronotropism, bradycardia and hypotension. Clinical signs of neurotoxicity must also be monitored, including seizures, psychomotor excitation, tinnitus, metallic taste in the mouth, and lip paresthesias (1). The motor response will be lost after the injection of the initial two centimeters of the anesthetic (3) and the injection must continue. Aller gies may also occur, mainly with amino ester anesthetics (1).

• During the anesthesia phase there is inhibition of the proprioceptive transmission, giving rise to a regional block of the anatomical structures that receive sensory input from the target nerve. Monitoring must be maintained in order to look out for systemic signs of toxicity. Blockade quality and the level of anesthesia must be measured. The patient must be positioned in such a way as to avoid risks caused by thermoelectric contact and pressure areas that may cause neurapraxia associated with neurological damage.

If required, ocular protection must be provided. The anesthesist must be knowledgeable of the surgical technique and the anatomical structures that lie close to the surgical site, and warn the surgical team about the use of tourniquets or about situations that may induce nerve damage (8).

The after phase of the block: Begins upon completion of the procedure and continues during patient transfer and monitoring at the PACU; the patient must be handed over, with orders for oxygen supplementation and information about the anesthetic and surgical techniques, and any relevant event such as intraoperative bleeding. Vital signs and patient recovery must be checked, and discharge from the PACU must be ordered only after determining the absence of surgical or anesthetic complications. In cases of outpatient procedures, the anesthetist may choose to gather basic information such as address and telephone number in order to ensure home follow-up or to remain informed about the patient's recovery.

Tables 6 and 7 show the main indications, advantages and disadvantages and contraindications for performing peripheral nerve blocks.

Peripheral nerve block complications

• Peripheral nerve block complications: May be general, secondary to the application of the local anesthetic, or secondary to the access techniques (1).

• General complications secondary to the application of the local anesthetic: Inadequate block (1,4), hematoma formation, cardiotoxicity (1,8), infection, transient neuropathy and, to a lesser degree, permanent neuropathy, associated with the intraneural injection of the local anesthetic (1). The rate of complications in obese patients is not increased (35).

• Complications associated with intrascalene block: Hemidiaphragmatic paresis (HDP) due to phrenic blockade occurs in 100 % of cases (1,6,8); the incidence of Horner's syndrome (stellate ganglion blockade) is 30 % - 50 % (1,8); laryngeal nerve block occurs in 6 % - 30 % of cases (1,8); and there have also been reports of spinal, subdural and epidural placement of the local anesthetic with total spinal or massive peridural anesthesia (8). Additional complications include hemodynamic changes of unclear origin in 12 % - 24 % of cases (8,36), associated with shoulder surgery performed with the patient in a sitting position (18). Intravascular placement in vertebral arteries leading to early seizures has also been reported.

• Supraclavicular block complications: The incidence of pneumothorax is 0.5 % - 6 % (1,8), with symptoms appearing after 24 hours occasionally in the form of pleural pain, although they do not warrant routine post-block chest X-ray. Horner's syndrome occurs in 40 % - 60 % of cases, and neuropathy is rare (1). HDP has been reported in 50 % of cases of supraclavicular blocks together with a 25 % - 32 % reduction in spirometry values. This requires special attention in patients with lung function abnormalities.

• Infraclavicular brachial plexus block: The incidence of pneumothorax and the risk of intravascular injection are lower. The incidence of peripheral neuropathy is 0-16/10,000 (95 % CI) (8) in infraclavicular blocks, mainly with transient manifestations. HDP has been reported in up to 25 % of cases (8).

• Axillary approach: It is associated with a low rate of complications such as intravascular injection, hematoma, infection or indequate blockade (inability to block the four main upper limb nerve branches, namely, musculocutaneous, median, radial and ulnar nerves) (1,4).

• Bier's block: Cardiac and neural toxicity manifestations may occur due to intravascular injection of the local anesthetic; the use of intravenous bupivacaine is not recommended (1,37). Other complications may include tourniquet-induced nerve damage.

• Psoas approach for lumbar plexus block: It is associated with a higher risk of peridural placement (9 % - 16 %) (1,38-40) when volumes greater than 20 ml are used. Neurological injury may occur with spinal or intravascular administration of the anesthetic. The paravertebral approach may give rise to sympathetic blockade (1). Femoral blocks are associated with intravascular placement and hematoma. Nerve damage is rare (1).

• Obturator nerve block: Complications associated with this block include intravascular placement, hematoma and neurological damage due to intraneural placement (1,41-44).

• Sciatic nerve blocks: The complications are associated with the access technique and include muscle trauma, sympathetic blockade (26), intravascular placement (gluteal approach) and nerve damage with infrequent transient residual dysesthesias (34,35,45-49). Surgical procedures of the hip and knee may be associated with neurapraxia (8).

The complications of the sciatic and popliteal (posterior and lateral) approaches and foot-neck blocks include peripheral neuropathy and intravascular placement (1).

Conclusions

The use of peripheral nerve blocks has become popular as a result of new technological developments that help localize nerve structures, thus increasing blockade effectiveness and reducing anesthetic complications, and prolonging the therapeutic window. At the present time there are not enough clinical trials demonstrating the superiority of one technological device over another. There is a need to develop good knowledge of the physiological principles of nerve conduction, the functioning of the nerve stimulator and the anatomy of the peripheral nerves and bundles. This paper offers guidelines to enhance safety in regional anesthesia and ensure adequate performance of the anesthesia procedure. The authors recommend conducting studies with a higher level of scientific evidence in the future.

References

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14. Capdevila X, Dadure C, Brinquier S, et al. Effect of patient-controlled perineural analgesia on rehabilitation and pain after ambulatory orthopedic surgery. A multicenter randomized trial. Anesthesiology. 2006;105:566-73.

15. Hadzic A, Karaca PE,Hobeika P, et al. Peripheral nerve blocks result in superior recovery profile compared with general anesthesia in outpatient knee arthroscopy. Anesth Analg. 2005;100:976-81.

16. Mulroy M. Practical regional anesthesia: making it work in the real world. Documento presentado en: 60th annual refresher course lectures, ASA Inc. 17- 21 de octubre del 2009. New Orleans, US.

17. Hadzic A, Vloka JD, Kuroda MM, et al. The practice of peripheral nerve blocks in the United States: a national survey. Reg Anesth Pain Med. 1998;241-6.

18. Cullen DJ, Kirby RR. Beach chair position may decrease cerebral perfusion; catastrophic outcomes have occurred. APSF Newsletter. 2007;22:25-7.

19. Apfel C. Posoperative care, postoperative nausea and vomiting. En: Miller R, Lars MD, Eriksson I, et al. Miller's Anesthesia 7th ed. Philadelphia: Elsevier; 2009;86.

20. Marino P. Practicas preventivas en el enfermo grave, control de las infecciones en la UCI. En: Marino P. El libro de la UCI. España: Lippincott Williams & Wilkins; 2008;3:39-59.

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25. Dingemans E, Williams SR, Arcand G, et al: Neurostimulation in ultrasound-guided block -a prospective randomized trial. Anesth Analg. 2007;104:1275.

26. Gaertner E, Lascurain P, Venet C, et al. Continuous parasacral sciatic block: A radiographic study. Anesth Analg. 2004;98:831.

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36. Borgeat A, Ekatodramis G, Kalberer F, et al. Acute and nonacute complications associated with interscalene block and shoulder surgery. A prospective study. Anesth Analg. 2001;95:875-80.

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1. Wedel D, Wedel J. Anesthesia management; nerve blocks. En: Miller R, Lars MD, Eriksson I, et al. Miller's Anesthesia 7th ed. Philadelphia: Elsevier; 2009;52.         [ Links ]

2. Berde Ch, Strichartz G. Anesthetic pharmacologic, local anesthetics. En: Miller R, Lars MD, Eriksson I, et al. Miller's Anesthesia 7th ed. Philadelphia: Elsevier; 2009;30.         [ Links ]

3. De Andrés J, Alonso-Iñigo JM, Sala-Blanch X, et al. Nerve stimulation in regional anesthesia: theory and practice. Best Pract Res Clin Anesthesiol. 2005;19:153-74.         [ Links ]

4. De Franco C. Applied anatomy of the lower extremity. En: de León-Casasola O. Techniques in regional anesthesia and pain management. Philadelphia: Elsevier; 2008. p. 140-145.         [ Links ]

5. De Franco C, Clarck L. Applied anatomy of the upper extremity. En: de Leon-Casasola O. Techniques in regional anesthesia and pain management. Philadelphia: Elsevier.; 2008. p. 134-9.         [ Links ]

6. Admir H. Peripheral nerve blocks - principles and Practice. New York : Mc GrawHill; 2009.         [ Links ]

7. Mulroy M. Peripheral nerve blockade. En: Barash PG, Cullen BF, Stoelting RK. Clinical anesthesia, 6th Ed. Philadenphia: Lippincott Williams & Wilkins; 2009;38.         [ Links ]

8. Neal J, Gerancher JC, Hebl J, et al. Upper extremity regional anesthesia: essentials for your practice. Documento presentado en: 60th annual refresher course lectures, ASA Inc, ©. 17-21 de octubre del 2009. New Orleans, US.         [ Links ]

9. Jaramillo J. Anestesia regional, uso de neuroestimulador de nervio periférico. Curso de Anestesia Regional. Bogotá: SCARE;2008.         [ Links ]

10. Gray AT. Ultrasound-guided regional anesthesia: Current state of the art. Anesthesiology. 2006;104:368.         [ Links ]

11. Auroy Y, Benhamou D, et al, Major complications of regional anesthesia in France. The SOS regional anesthesia hotline service. Anesthesiology. 2002;97:1274-80.         [ Links ]

12. Ballantyne JC, Carr DC, de Ferranti, et al. The comparative effects of postoperative analgesic therapies on pulmonary outcome: cumulative meta-analyses of randomized, controlled trials. Anesth Analg. 1998;86:598-612.         [ Links ]

13. Steinbrook. Epidural anesthesia and gastrointestinal motility. Anesth Analg. 1998;86:837-44.         [ Links ]

14. Capdevila X, Dadure C, Brinquier S, et al. Effect of patient-controlled perineural analgesia on rehabilitation and pain after ambulatory orthopedic surgery. A multicenter randomized trial. Anesthesiology. 2006;105:566-73.         [ Links ]

15. Hadzic A, Karaca PE,Hobeika P, et al. Peripheral nerve blocks result in superior recovery profile compared with general anesthesia in outpatient knee arthroscopy. Anesth Analg. 2005;100:976-81.         [ Links ]

16. Mulroy M. Practical regional anesthesia: making it work in the real world. Documento presentado en: 60th annual refresher course lectures, ASA Inc. 17- 21 de octubre del 2009. New Orleans, US.         [ Links ]

17. Hadzic A, Vloka JD, Kuroda MM, et al. The practice of peripheral nerve blocks in the United States: a national survey. Reg Anesth Pain Med. 1998;241-6.         [ Links ]

18. Cullen DJ, Kirby RR. Beach chair position may decrease cerebral perfusion; catastrophic outcomes have occurred. APSF Newsletter. 2007;22:25-7.         [ Links ]

19. Apfel C. Posoperative care, postoperative nausea and vomiting. En: Miller R, Lars MD, Eriksson I, et al. Miller's Anesthesia 7th ed. Philadelphia: Elsevier; 2009;86.         [ Links ]

20. Marino P. Practicas preventivas en el enfermo grave, control de las infecciones en la UCI. En: Marino P. El libro de la UCI. España: Lippincott Williams & Wilkins; 2008;3:39-59.         [ Links ]

21. Centers for Disease Control and Prevention. Guidelines for hand hygiene in health-care settings: recommendations of the healthcare infection control practices advisory committee and the HICPAC/SHEA/ APIC/IDSA Hand Hygiene Task Force. MMWR. 2002;51:1-45.         [ Links ]

22. Power I, Kam P. Physiology of exitable cells. En: Pagel P. Principles of physiology for the anesthesist. 2da ed. UK: Hodder Arnold And Hachette UK Company; 2008.         [ Links ]

23. Weinberg GL, Neal JM, Bernards CM, et al. ASRA practice advisory on the systemic toxicity of local anesthetics. Reg Anesth Pain Med. 2010;35:152-61.         [ Links ]

24. Marhofer P, Greher M, Kapral S. Ultrasound guidance in regional anaesthesia. Br J Anaesth. 2005;94:7.         [ Links ]

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