Regional Anesthesia

(Appendix E)

Regional anesthesia (e.g., local anesthetic such as ropivacaine or lidocaine injected adjacent to a large, extremity nerve bundle or on either side of a finger or toe) is a useful technique that can markedly reduce or eliminate limb pain without risk of opioid or benzodiazepine side-effects of respiratory depression, sedation, and hypotension. There are, however, serious potential morbidities (and mortality from proximal injections or injection directly into blood vessels) that may occur.

For these reasons, this guideline has attempted to balance the overall risks and potential benefits of this intervention by recommending optimal procedure technique (e.g., use of ultrasound), a limited number of block sites, and the safest medication and dose combination. It should be noted that even with optimal technique, the risk of systemic toxicity (e.g., seizure or cardiac arrest) is not eliminated. Toxicity occurs either with direct injection of anesthetic into the systemic blood circulation or by absorption over the first 15–20 minutes after injection. Close monitoring MUST be available during this time.

Regional anesthesia should only be used by trained individuals. There should be documentation of competency. Three techniques exist:

1. Ultrasound-guidance: used to visualize targeted nerves, needle placement, and the spread of local anesthetic in real time.
2. Nerve stimulation: requires an assistant, a nerve stimulator, specialized needles, and cannot be reliably applied in cases of partial or complete amputations, given the inability to elicit motor response in severed muscles.
3. Blind or anatomical technique: should be reserved for distal nerve blocks only (i.e. fingers or toes).

   (Appendix E)

   Regional anesthesia (e.g., local anesthetic such as ropivacaine or lidocaine injected adjacent to a large, extremity nerve bundle or on either side of a finger or toe) is a useful technique that can markedly reduce or eliminate limb pain without risk of opioid or benzodiazepine side-effects of respiratory depression, sedation, and hypotension. There are, however, serious potential morbidities (and mortality from proximal injections or injection directly into blood vessels) that may occur.

   For these reasons, this guideline has attempted to balance the overall risks and potential benefits of this intervention by recommending optimal procedure technique (e.g., use of ultrasound), a limited number of block sites, and the safest medication and dose combination. It should be noted that even with optimal technique, the risk of systemic toxicity (e.g., seizure or cardiac arrest) is not eliminated. Toxicity occurs either with direct injection of anesthetic into the systemic blood circulation or by absorption over the first 15–20 minutes after injection. Close monitoring MUST be available during this time.

   Regional anesthesia should only be used by trained individuals. There should be documentation of competency. Three techniques exist:

   1. Ultrasound-guidance: used to visualize targeted nerves, needle placement, and the spread of local anesthetic in real time.
   2. Nerve stimulation: requires an assistant, a nerve stimulator, specialized needles, and cannot be reliably applied in cases of partial or complete amputations, given the inability to elicit motor response in severed muscles.
   3. Blind or anatomical technique: should be reserved for distal nerve blocks only (i.e. fingers or toes).