Chapter 17

• The greatest immediate risk of nerve blocks is systemic toxicity from inadvertent intravascular injection. Delayed toxicity can follow the initial injection when rapid or excessive amounts of local anesthetics are absorbed systemically.
• Good surgical anesthesia is obtained only when local anesthetic is injected in close proximity to the nerve or nerves that are to be blocked.
• A perineural injection may produce a brief accentuation of the paresthesia, whereas an intraneural injection produces an intense, searing pain that serves as a warning to immediately terminate the injection and reposition the needle.
• Surgical anesthesia of the upper extremity and shoulder can be obtained following neural blockade of the brachial plexus (C5–T1) or its terminal branches at several sites.
• The interscalene approach is most optimal for procedures on the shoulder, arm, and forearm. Injection at the interscalene level tends to produce a block that is most intense at the C5–C7 dermatomes and least intense in the C8–T1 dermatomes.
• The axillary approach to the brachial plexus is most optimal for procedures from the elbow to the hand. This approach tends to produce the most intense block in the distribution of C7–T1 (ulnar nerve).
• Infraclavicular blocks provide good homogeneous anesthesia to the brachial plexus and can be used for procedures involving the hand, forearm, elbow, and upper arm and are quite conducive for placement of an indwelling catheter for postoperative analgesia.
• Intravenous regional anesthesia, also called a Bier block, can provide intense surgical anesthesia for short surgical procedures (< 45–60 min) on the forearm, hand, and even the leg.
• A femoral nerve block is very useful in numerous procedures involving the thigh and knee, such as skin grafting, knee arthroscopy, and patellar surgery, or as an adjunct to procedures distal to the knee that require anesthesia to the medial aspect of the lower leg (saphenous distribution).
• There has been a recent surge of interest in fascia iliaca blocks. Because it does not require a nerve stimulator, it can be performed very quickly, it is not very stimulating, and patients often do not require sedation. It is useful in procedures involving the hip, thigh, and knee.
• Blockade of the sciatic nerve is useful for many surgical procedures involving the hip, knee, or distal lower extremity. The nerve can be successfully blocked at numerous sites along its course.
• A popliteal nerve block is very useful for foot and ankle surgery and can result in complete anesthesia of the limb distal to the knee if a separate saphenous nerve block (terminal nerve of the femoral nerve) is also included.
• Paravertebral nerve blocks are being increasingly used as an effective technique for postoperative analgesia following mastectomy, inguinal hernia repair, and several procedures involving the chest and body wall.

Advancement in needle delivery devices, safer local anesthetics, and development of indwelling catheters for postoperative perineural infusion have led to a transformation in regional anesthesia; the focus has shifted from providing intraoperative regional anesthesia to providing intraoperative anesthesia and postoperative regional analgesia.

Fundamental to the success of regional anesthesia is the ...

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