Smarter Decisions,
Better Care

UpToDate synthesizes the most recent medical information into evidence-based practical recommendations clinicians trust to make the right point-of-care decisions.

  • Rigorous editorial process: Evidence-based treatment recommendations
  • World-Renowned physician authors: over 5,100 physician authors and editors around the globe
  • Innovative technology: integrates into the workflow; access from EMRs

Choose from the list below to learn more about subscriptions for a:


Subscribers log in here


Overview of peripheral nerve blocks

INTRODUCTION

Peripheral nerve blocks (PNB) are widely-used for surgical anesthesia as well as for both postoperative and nonsurgical analgesia. PNBs offer distinct benefits over general or neuraxial anesthesia in certain clinical situations [1]. In addition, PNBs provide analgesia that may be superior to other techniques for some patients.  

This topic will discuss aspects of PNBs that are common to multiple blocks. Issues specific to particular blocks are discussed separately. (See "Peripheral nerve block: Techniques".)

USE OF NERVE BLOCKS

Indications — There are no specific indications for peripheral nerve blocks (PNBs). Blocks are often used to avoid the effects of alternative anesthetics or analgesics. The most common rationales for their use are to avoid side effects and complications of general anesthesia (GA), particularly respiratory-related effects, and to provide analgesia while minimizing opioid use.

Examples of circumstances in which PNBs might be preferable to GA as a sole anesthetic include:

Patients at risk of respiratory depression related to GA (eg, obstructive sleep apnea, severe obesity, underlying pulmonary disease, advanced age)

                               

Subscribers log in here

To continue reading this article, you must log in with your personal, hospital, or group practice subscription. For more information or to purchase a personal subscription, click below on the option that best describes you:
Literature review current through: Jun 2014. | This topic last updated: Feb 26, 2014.
The content on the UpToDate website is not intended nor recommended as a substitute for medical advice, diagnosis, or treatment. Always seek the advice of your own physician or other qualified health care professional regarding any medical questions or conditions. The use of this website is governed by the UpToDate Terms of Use ©2014 UpToDate, Inc.
References
Top
  1. Lin E, Choi J, Hadzic A. Peripheral nerve blocks for outpatient surgery: evidence-based indications. Curr Opin Anaesthesiol 2013; 26:467.
  2. Borgeat A, Ekatodramis G, Kalberer F, Benz C. Acute and nonacute complications associated with interscalene block and shoulder surgery: a prospective study. Anesthesiology 2001; 95:875.
  3. Horlocker TT, Wedel DJ, Rowlingson JC, et al. Regional anesthesia in the patient receiving antithrombotic or thrombolytic therapy: American Society of Regional Anesthesia and Pain Medicine Evidence-Based Guidelines (Third Edition). Reg Anesth Pain Med 2010; 35:64.
  4. Bingham AE, Fu R, Horn JL, Abrahams MS. Continuous peripheral nerve block compared with single-injection peripheral nerve block: a systematic review and meta-analysis of randomized controlled trials. Reg Anesth Pain Med 2012; 37:583.
  5. Standards for Basic Anesthetic Monitoring http://www.asahq.org/For-Members/Standards-Guidelines-and-Statements.aspx (Accessed on January 07, 2014).
  6. Walker KJ, McGrattan K, Aas-Eng K, Smith AF. Ultrasound guidance for peripheral nerve blockade. Cochrane Database Syst Rev 2009; :CD006459.
  7. Gelfand HJ, Ouanes JP, Lesley MR, et al. Analgesic efficacy of ultrasound-guided regional anesthesia: a meta-analysis. J Clin Anesth 2011; 23:90.
  8. Casati A, Baciarello M, Di Cianni S, et al. Effects of ultrasound guidance on the minimum effective anaesthetic volume required to block the femoral nerve. Br J Anaesth 2007; 98:823.
  9. McNaught A, Shastri U, Carmichael N, et al. Ultrasound reduces the minimum effective local anaesthetic volume compared with peripheral nerve stimulation for interscalene block. Br J Anaesth 2011; 106:124.
  10. Danelli G, Ghisi D, Fanelli A, et al. The effects of ultrasound guidance and neurostimulation on the minimum effective anesthetic volume of mepivacaine 1.5% required to block the sciatic nerve using the subgluteal approach. Anesth Analg 2009; 109:1674.
  11. Marhofer P, Schrögendorfer K, Wallner T, et al. Ultrasonographic guidance reduces the amount of local anesthetic for 3-in-1 blocks. Reg Anesth Pain Med 1998; 23:584.
  12. Orebaugh SL, Kentor ML, Williams BA. Adverse outcomes associated with nerve stimulator-guided and ultrasound-guided peripheral nerve blocks by supervised trainees: update of a single-site database. Reg Anesth Pain Med 2012; 37:577.
  13. Swenson JD, Bay N, Loose E, et al. Outpatient management of continuous peripheral nerve catheters placed using ultrasound guidance: an experience in 620 patients. Anesth Analg 2006; 103:1436.
  14. Ludot H, Berger J, Pichenot V, et al. Continuous peripheral nerve block for postoperative pain control at home: a prospective feasibility study in children. Reg Anesth Pain Med 2008; 33:52.
  15. Tran de QH, Muñoz L, Russo G, Finlayson RJ. Ultrasonography and stimulating perineural catheters for nerve blocks: a review of the evidence. Can J Anaesth 2008; 55:447.
  16. Casati A, Fanelli G, Koscielniak-Nielsen Z, et al. Using stimulating catheters for continuous sciatic nerve block shortens onset time of surgical block and minimizes postoperative consumption of pain medication after halux valgus repair as compared with conventional nonstimulating catheters. Anesth Analg 2005; 101:1192.
  17. Salinas FV, Neal JM, Sueda LA, et al. Prospective comparison of continuous femoral nerve block with nonstimulating catheter placement versus stimulating catheter-guided perineural placement in volunteers. Reg Anesth Pain Med 2004; 29:212.
  18. Dauri M, Sidiropoulou T, Fabbi E, et al. Efficacy of continuous femoral nerve block with stimulating catheters versus nonstimulating catheters for anterior cruciate ligament reconstruction. Reg Anesth Pain Med 2007; 32:282.
  19. Mariano ER, Afra R, Loland VJ, et al. Continuous interscalene brachial plexus block via an ultrasound-guided posterior approach: a randomized, triple-masked, placebo-controlled study. Anesth Analg 2009; 108:1688.
  20. Fredrickson MJ, Ball CM, Dalgleish AJ, et al. A prospective randomized comparison of ultrasound and neurostimulation as needle end points for interscalene catheter placement. Anesth Analg 2009; 108:1695.
  21. Schnabel A, Meyer-Frießem CH, Zahn PK, Pogatzki-Zahn EM. Ultrasound compared with nerve stimulation guidance for peripheral nerve catheter placement: a meta-analysis of randomized controlled trials. Br J Anaesth 2013; 111:564.
  22. Galindo A, Witcher T. Mixtures of local anesthetics: bupivacaine-chloroprocaine. Anesth Analg 1980; 59:683.
  23. Neal JM, Gerancher JC, Hebl JR, et al. Upper extremity regional anesthesia: essentials of our current understanding, 2008. Reg Anesth Pain Med 2009; 34:134.
  24. Bedder MD, Kozody R, Craig DB. Comparison of bupivacaine and alkalinized bupivacaine in brachial plexus anesthesia. Anesth Analg 1988; 67:48.
  25. Quinlan JJ, Oleksey K, Murphy FL. Alkalinization of mepivacaine for axillary block. Anesth Analg 1992; 74:371.
  26. Capogna G, Celleno D, Laudano D, Giunta F. Alkalinization of local anesthetics. Which block, which local anesthetic? Reg Anesth 1995; 20:369.
  27. Fletcher D, Kuhlman G, Samii K. Addition of fentanyl to 1.5% lidocaine does not increase the success of axillary plexus block. Reg Anesth 1994; 19:183.
  28. Racz H, Gunning K, Della Santa D, Forster A. Evaluation of the effect of perineuronal morphine on the quality of postoperative analgesia after axillary plexus block: a randomized double-blind study. Anesth Analg 1991; 72:769.
  29. Nishikawa K, Kanaya N, Nakayama M, et al. Fentanyl improves analgesia but prolongs the onset of axillary brachial plexus block by peripheral mechanism. Anesth Analg 2000; 91:384.
  30. Cummings KC 3rd, Napierkowski DE, Parra-Sanchez I, et al. Effect of dexamethasone on the duration of interscalene nerve blocks with ropivacaine or bupivacaine. Br J Anaesth 2011; 107:446.
  31. Parrington SJ, O'Donnell D, Chan VW, et al. Dexamethasone added to mepivacaine prolongs the duration of analgesia after supraclavicular brachial plexus blockade. Reg Anesth Pain Med 2010; 35:422.
  32. Movafegh A, Razazian M, Hajimaohamadi F, Meysamie A. Dexamethasone added to lidocaine prolongs axillary brachial plexus blockade. Anesth Analg 2006; 102:263.
  33. Desmet M, Braems H, Reynvoet M, et al. I.V. and perineural dexamethasone are equivalent in increasing the analgesic duration of a single-shot interscalene block with ropivacaine for shoulder surgery: a prospective, randomized, placebo-controlled study. Br J Anaesth 2013; 111:445.
  34. Fredrickson Fanzca MJ, Danesh-Clough TK, White R. Adjuvant dexamethasone for bupivacaine sciatic and ankle blocks: results from 2 randomized placebo-controlled trials. Reg Anesth Pain Med 2013; 38:300.
  35. Pöpping DM, Elia N, Marret E, et al. Clonidine as an adjuvant to local anesthetics for peripheral nerve and plexus blocks: a meta-analysis of randomized trials. Anesthesiology 2009; 111:406.
  36. Abdallah FW, Brull R. Facilitatory effects of perineural dexmedetomidine on neuraxial and peripheral nerve block: a systematic review and meta-analysis. Br J Anaesth 2013; 110:915.
  37. Liu SS, Zayas VM, Gordon MA, et al. A prospective, randomized, controlled trial comparing ultrasound versus nerve stimulator guidance for interscalene block for ambulatory shoulder surgery for postoperative neurological symptoms. Anesth Analg 2009; 109:265.
  38. Fredrickson MJ, Kilfoyle DH. Neurological complication analysis of 1000 ultrasound guided peripheral nerve blocks for elective orthopaedic surgery: a prospective study. Anaesthesia 2009; 64:836.
  39. Sites BD, Taenzer AH, Herrick MD, et al. Incidence of local anesthetic systemic toxicity and postoperative neurologic symptoms associated with 12,668 ultrasound-guided nerve blocks: an analysis from a prospective clinical registry. Reg Anesth Pain Med 2012; 37:478.
  40. Auroy Y, Benhamou D, Bargues L, et al. Major complications of regional anesthesia in France: The SOS Regional Anesthesia Hotline Service. Anesthesiology 2002; 97:1274.
  41. Capdevila X, Pirat P, Bringuier S, et al. Continuous peripheral nerve blocks in hospital wards after orthopedic surgery: a multicenter prospective analysis of the quality of postoperative analgesia and complications in 1,416 patients. Anesthesiology 2005; 103:1035.
  42. Borgeat A, Blumenthal S, Lambert M, et al. The feasibility and complications of the continuous popliteal nerve block: a 1001-case survey. Anesth Analg 2006; 103:229.
  43. Kapur E, Vuckovic I, Dilberovic F, et al. Neurologic and histologic outcome after intraneural injections of lidocaine in canine sciatic nerves. Acta Anaesthesiol Scand 2007; 51:101.
  44. Hadzic A, Dilberovic F, Shah S, et al. Combination of intraneural injection and high injection pressure leads to fascicular injury and neurologic deficits in dogs. Reg Anesth Pain Med 2004; 29:417.
  45. Bigeleisen PE. Nerve puncture and apparent intraneural injection during ultrasound-guided axillary block does not invariably result in neurologic injury. Anesthesiology 2006; 105:779.
  46. Sala-Blanch X, Pomés J, Matute P, et al. Intraneural injection during anterior approach for sciatic nerve block. Anesthesiology 2004; 101:1027.
  47. Mackinnon SE, Hudson AR, Llamas F, et al. Peripheral nerve injury by chymopapain injection. J Neurosurg 1984; 61:1.
  48. Schafhalter-Zoppoth I, Zeitz ID, Gray AT. Inadvertent femoral nerve impalement and intraneural injection visualized by ultrasound. Anesth Analg 2004; 99:627.
  49. Hara K, Sakura S, Yokokawa N, Tadenuma S. Incidence and effects of unintentional intraneural injection during ultrasound-guided subgluteal sciatic nerve block. Reg Anesth Pain Med 2012; 37:289.
  50. Liu SS, YaDeau JT, Shaw PM, et al. Incidence of unintentional intraneural injection and postoperative neurological complications with ultrasound-guided interscalene and supraclavicular nerve blocks. Anaesthesia 2011; 66:168.
  51. Jeng CL, Torrillo TM, Rosenblatt MA. Complications of peripheral nerve blocks. Br J Anaesth 2010; 105 Suppl 1:i97.
  52. Kroin JS, Buvanendran A, Williams DK, et al. Local anesthetic sciatic nerve block and nerve fiber damage in diabetic rats. Reg Anesth Pain Med 2010; 35:343.
  53. Neal JM, Hebl JR, Gerancher JC, Hogan QH. Brachial plexus anesthesia: essentials of our current understanding. Reg Anesth Pain Med 2002; 27:402.
  54. Selander D, Dhunér KG, Lundborg G. Peripheral nerve injury due to injection needles used for regional anesthesia. An experimental study of the acute effects of needle point trauma. Acta Anaesthesiol Scand 1977; 21:182.
  55. Macías G, Razza F, Peretti GM, Papini Zorli I. Nervous lesions as neurologic complications in regional anaesthesiologic block: an experimental model. Chir Organi Mov 2000; 85:265.
  56. Neal JM. Ultrasound-guided regional anesthesia and patient safety: An evidence-based analysis. Reg Anesth Pain Med 2010; 35:S59.
  57. Candido KD, Sukhani R, Doty R Jr, et al. Neurologic sequelae after interscalene brachial plexus block for shoulder/upper arm surgery: the association of patient, anesthetic, and surgical factors to the incidence and clinical course. Anesth Analg 2005; 100:1489.
  58. Neal JM, Bernards CM, Butterworth JF 4th, et al. ASRA practice advisory on local anesthetic systemic toxicity. Reg Anesth Pain Med 2010; 35:152.
  59. Weinberg GL. Treatment of local anesthetic systemic toxicity (LAST). Reg Anesth Pain Med 2010; 35:188.
  60. Cuvillon P, Ripart J, Lalourcey L, et al. The continuous femoral nerve block catheter for postoperative analgesia: bacterial colonization, infectious rate and adverse effects. Anesth Analg 2001; 93:1045.
  61. Gasparini JR, Mello SS, Marques RS, Saraiva RA. Postoperative continuous plexular analgesia. A study on the side effects and risk factors of catheter infection. Rev Bras Anestesiol 2008; 58:602.
  62. Capdevila X, Bringuier S, Borgeat A. Infectious risk of continuous peripheral nerve blocks. Anesthesiology 2009; 110:182.
  63. Compère V, Legrand JF, Guitard PG, et al. Bacterial colonization after tunneling in 402 perineural catheters: a prospective study. Anesth Analg 2009; 108:1326.
  64. Neuburger M, Büttner J, Blumenthal S, et al. Inflammation and infection complications of 2285 perineural catheters: a prospective study. Acta Anaesthesiol Scand 2007; 51:108.