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Safe regional anesthesia begins with a thorough knowledge of anatomy. In Labat's words, "anatomy is the foundation upon which the entire concept of regional anesthesia is built." Studying the anatomy of the major plexuses and peripheral nerves is critical for learning regional anesthesia and avoiding its complications.
Prior to performing regional anesthesia, it is imperative to thoroughly discuss the techniques, and their limitations, with the patient. Assessing which patients are most appropriate for performing these techniques on is important, as some are not suitable candidates (eg, those with major anatomic distortion or serious mental illness).
One of the most important principles for safe regional anesthesia is provision of a comfortable patient environment. If a patient suffers as a result of one's intervention, a basic principle of the practice of anesthesia has been violated.
Resuscitation equipment must be immediately available when performing regional anesthesia, and one must be prepared, at all times, to anesthetize and resuscitate the patient when necessary.
A skilled clinician must be willing to abort their technique in the face of excessive challenge. Dogged persistence is inadvisable. One must seek assistance when faced with difficulties and be prepared to change to an alternative route of anesthesia if persistent failure (more than 3 attempts or 20 minutes) occurs.
Do not perform regional anesthesia procedures in anesthetized adult patients unless the benefits outweigh the risks. If this principle is violated, the reasoning must be documented in the patient's file.
Always be accompanied by a skilled assistant when performing regional anesthesia.
The patient must be adequately monitored at all stages during regional anesthesia. Close monitoring can only be discontinued when the block has adequately resolved.
If neurologic injury is suspected after regional anesthesia, the cause should be determined quickly to minimize injury. Timely advice should be sought from appropriate consultants (neurologists, radiologists).
One must not assume that all patient injury is from regional anesthesia, as other possibilities exist. Do not hesitate to involve other disciplines in the quest to determine the cause of injury.
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No matter how skillful an anesthesiologist may be, adverse perioperative events are inevitable in anesthesia practice. Adverse events have been associated with regional anesthesia since local anesthetics were first introduced by Koller in 18841 and will persist despite advances in technique, skill, and safety mechanisms. It is nearly impossible to address all of the described and potential complications of regional anesthesia; instead, we focus here on those most relevant to current practice.
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Importance of Prevention
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The time-honored statement that "an ounce of prevention is worth a pound of cure" is essential to remember2 when considering the management of adverse outcomes in regional anesthesia practice. It is most effective to prevent and minimize the risk of regional anesthesia complications. Neurologic injury is one of the most dreaded complications associated with all anesthesia techniques, including regional anesthesia, and it is important to realize that once a serious neurologic injury occurs, the chances of ...