CommonRegionalNerveBlocks

QuickGuidedevelopedbyUWHCAcutePainServiceJan2011

Asingleshotnerveblockistheinjectionoflocalanesthetictoblockaspecificnervedistribution.Itcan
beplacedpreorpostoperativelytoprovideanesthesiaand/oranalgesia.Theareaaffectedwillvary
basedonwherethelocalanestheticisinjected.Theonsetanddurationwillvarybasedonthetypeof
block,aswellasthetypeoflocalanestheticused.Inaddition,catheterswithacontinuousinfusionmay
beplacedtoprolonganalgesia.

NursingConsiderations

Itisveryimportanttoprotecttheaffectedareafromharm.Patientswillhaveminimalornosensation
totheblockedarea.Ifacatheterisplaced,amoredilutemedicationwillbeusedthantheconcentrated
solutionusedforplacementoftheblock.Somenumbness/tinglingaswellasdecreasedmotorfunction
isstillcommon.Ifalowerextremityblockisperformed,useextremecautionwhenambulatingthe
patientuntilthenerveblockhaswornoffand/orthenervecatheterhasbeenremoved.**Ifafemoral
nervecatheterisplaced,akneeimmobilizershouldbeusedduringambulation.Theonlyexceptionis
ifphysicaltherapyisworkingwiththepatientanddeterminesthatthequadricepsstrengthissufficient.

**Itisverycommonfornervecatheterstoleak.Inmanycasesthisisjustlocalanesthetictrackingback
alongthecatheter.Aslongasthepatienthasgoodpaincontrol,reinforcethedressing.Ifthepatient
haspoorpaincontrol,contacttheAcutePainService,pagerPAIN(#7246).

Rare,butpossiblecomplicationsfromnerveblocksand/ornervecathetersinclude:infection,bleeding,
vascularpuncture,nerveinjury,falls,shortnessofbreath,orhornerssyndrome.

Hornerssyndromeoccurswhenthenervebetweenthebrainandtheeyeisaffected.Itcanhappen
withanybrachialplexusblock,butismostcommonwiththeinterscaleneorsupraclavicular.Symptoms
includeadroopingeyelid,decreasedpupilsize,anddecreasedsweatingontheaffectedsideoftheface.
Thiswillresolveastheblockwearsoff.

Medications

Avarietyoflocalanestheticsmaybeusedforthenerveblock.Themostcommonincludelidocaine,
ropivacaine,bupivacaine,andmepivacaine.Thetypeofmedicationused,theconcentration,the
volumeadministered,andthelocationoftheblockwillaffecttheonsetandduration.Includedinthis
packetaretheaveragesforeachblocktype.Somepatientsmaystillexperienceshorterorlonger
durationsthanthoselisted.Occasionallyepinephrinemaybeaddedtoanerveblock.Epinephrine
causesvasoconstrictionofthebloodvesselsneartheinjectionsite.Thiscausesdecreaseduptakeof
localanestheticintothevasculature,allowingtheblocktoworkforalongerduration.Opioidsarerarely
usedinanerveblock.**Localanestheticalonewillnotcauseproblemswithnausea/vomiting,or
pruritis.Inaddition,theyarenotcentrallyacting,whichmeansthattheywillnotaffecttheblood
pressure.Ifyourpatientisexperiencinganyofthesesymptomslookforalternatecauses.

Itispossibleforapatienttodeveloplocalanesthetictoxicityfromanerveblockoranervecatheter.It
maybecausedbyaccidentalinjectiondirectlyintoabloodvessel,orvascularreabsorptionfromaround
theinjectionsite.Commonsymptomsoflocalanesthetictoxicityincludenumbnessandtinglingaround
themouth,ametallictaste,orringingintheears.Ifitprogresses,itmayleadtoseizures,arrhythmias,
andevencardiacarrest.ContacttheAPSifyourpatientexperiencesanyofthesesymptoms.


UpperExtremityNerveBlocks

Theinterscalene,supraclavicular,infraclavicular,andaxillarynerveblocksareusedforsurgeriesofthe
upperextremity.Theyallblockthebrachialplexus(abundleofnervestotheupperextremity),butat
differentlocations.Theareacoveredisshownindarkblueonthediagrambelow.Althoughcoverageis
similaramongall4blocks,thetypeofsurgeryandpatientcharacteristicsinfluencewhichblockismost
likelytobeperformed.Forexample,apatientwithahistoryofpulmonarydiseasewouldbelesslikely
toreceiveaninterscaleneorsupraclavicularnerveblock(dependingonthetypeofsurgery)duetothe
riskofrespiratorycompromise.Apatientwithathickneck,havingwristsurgery,wouldbemorelikely
toreceiveaninfraclavicularoraxillarynerveblock.

LocalAnesthetics

Duetothevasculaturenatureofthearea,brachialplexusblocks(interscalene,supraclavicular,
infraclavicular,oraxillary)typicallywearofffairlyrapidly.

1.5% Mepivacaine
1.5% Mepivacaine (+ epinephrine)
2% Lidocaine
2% Lidocaine (+ epinephrine)
0.5% Ropivacaine
0.5% Bupivacaine (+ epi)

Onset
(min)
10-20
5-15
10-20
5-15
15-20
20-30

Anesthesia
(hrs)
2-3
2.5-4
2.5-3
3-6
6-8
8-10

Analgesia
(hrs)
2-4
3-6
2-5
5-8
8-12
16-18

http://www.nysora.com


Interscalene

Theinterscalenenerveblockistypicallyusedforshoulder,clavicle,orupperarmsurgeriesbecauseit
covershigherupontheshoulder.Thedisadvantageisthatpatientswillexperiencephrenicnerve
blockaderesultingindiaphragmaticparalysis.Inmostpatients,thisdoesnotsignificantlycompromise
lungfunction.However,patientswithunderlyinglungdiseaseareathigherriskforrespiratory
compromiseandshouldbemonitoredclosely.Theriskofpneumothoraxispresent,butminimal.

(www.arapmi.org/maraabookproject/Chapt7.pdf)

Supraclavicular

Thesupraclavicularnerveblockisidealforproceduresoftheupperarm,fromthemidhumerallevel
downtothehand.Theareacoveredissimilartotheinterscaleneblock,butdoesnotcovertheupper
partoftheshoulderaswell.Ithasarapidonset,withadenseandpredictablelevelofpaincontrol.
Thereisaslightlyhigherriskofpneumothoraxthantheinterscalenenerveblock.Signsandsymptoms
ofalargepneumothoraxincludesuddencoughandshortnessofbreath.Inaddition,approximately50%
ofpatientswillhavediaphragmatichemiparesis.

(www.arapmi.org/maraabookproject/Chapt8.pdf)


Infraclavicular

Theinfraclavicularnerveblockisidealforoperationstotheelbowandbelow.Ithasalowerriskof
pneumothoraxthanthesupraclavicular,althoughhigherthantheinterscalene.Thisblockhasminimal
riskofblockingthephrenicnerve.

(www.arapmi.org/maraabookproject/Chapt9.pdf)

Axillary

Theaxillaryblockisthemostdistalblockperformedonthebrachialplexus.Becauseofthedistal
location,theaxillaryblockhasminimalriskofrespiratorycompromisefromeitherpneumothoraxor
phrenicnerveblockade.However,theaxillarynerveblockdoesnotcoverthelateralaspectofthe
forearmfromtheelbowtothethumbaswellastheotherblocks.Usuallyablockofthe
mucsulocutaneousnerveisalsoperformedwiththisblock.Thisprovidesulnarcoverage.

(www.arapmi.org/maraabookproject/Chapt10.pdf)
Chest/AbdominalNerveBlocks

Paravertebral

Theparavertebralspaceisadjacenttothevertebralbody.Whenalocalanestheticisinjectedintothis
spaceitblocksoneormorenerverootsastheyexitthespine.Thisleadstounilateralnumbnessofa
specificareaofthebody.Themostcommonindicationisbreastsurgery,butitisusedforchestand
abdominalsurgeries.Theareathatisblockedwilldependonwhichlevelthelocalanestheticisinjected
at.Potentialcomplicationsincludeinadvertentvascularpuncture,hypotension,hematoma,epidural
spreadorintrathecalspread,pleuralpuncture,andpneumothorax.Bilateralblocksmaybeperformed.

(www.arapmi.org/maraabookproject/Chapt12.pdf)

Aparavertebralblockdoesnottypicallyresultinmotorblockofthelowerextremities.The
exceptionisifL2L5areblocked(notcommonlydone).Mostguidelinesrecommendusinga
longeractinglocalanestheticwhenpossible.

Onset (min)Anesthesia (hrs) Analgesia (hrs)

1.5% Mepivacaine (plus HCO3 + epinephrine)10-20
2-3
3-4
2% Lidocaine (plus HCO3 + epinephrine)
10-15
2-3
3-4
0.5% Ropivacaine
15-25
3-5
8-12
0.5% Bupivacaine (plus epinephrine)
15-25
4-6
12-18
0.5% I-Bupivacaine (plus epinephrine)
15-25
4-6
12-18

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TransversusAbdominisPlane

TheTransversusAbdominisPlane(TAP)blockisatechniquewherelocalanestheticisinjectedintoa
potentialspacebetweentheinternalobliqueandtransversusabdominismuscles.Thisplanecontains
thenervesthatprovidesensationtotheanterolateralabdominalwall,approximatelyT10L1,although
insomepatientstheblockwillspreadfurtherupand/ordown.TheTAPBlockistypicallyusedforpain
controlafterlowerabdominalsurgeryincludingbowel,prostate,obstetric,andgynecologicalsurgery.
Potentialcomplicationsincludeintraperitonealinjection,bowelhematoma,transientfemoralnerve
palsy,liverlacerationandlocalanesthetictoxicity.Theoreticallytheseriskshavegreatlydecreasednow
thatmostTAPblocksareplacedunderultrasoundguidance.Moreresearchisneededtoprovethis.

Ifsurgeryenterstheperitonealcavity,thedullvisceralpainfromspasmand/orinflammationmaystill
bepresent.TheTAPblockprimarilycoverstheincisionalpain.Dependingonthetypeoflocal
anestheticused,aTAPBlocktypicallylasts1236hours.TheTAPblockcanproducerelaxationofthe
abdominalwallmuscles,whichcanresultinaflankbulge,whichmaylooklikeahernia.Thismaybe
morepronouncedinpatientswithlowBodyMassIndex(BMI).Anypatientwithsignificantabdominal
distentionfollowingaTAPBlockshouldbeassessedforpossibleinternalbleeding.

http://www.usra.ca/sb_tap

FlankbulgeinapatientafterbilateralTAPblocks
LowerExtremityNerveBlocks

LumbarPlexus

Thelumbarplexuscomprises6nervesthatsupplythelowerextremity.Whenblockedatthelevelofthe
plexus,themajorityofthefrontofthelegiscoveredincludingtheanterolateralandmedialthigh,knee,
andthesaphenousbelowtheknee.Duetotheplacementoftheneedleinthedeepmusclebeds,the
potentialforsystemictoxicityisgreaterthaninmanyotherblocks.Inaddition,theproximityofthe
lumbarnerverootsandepiduralspacecarriesariskofepiduralorspinalspread.Thelumbarplexus
blockismostcommonlyusedtohiparthroscopy,andotherhipsurgeries.

www.nysora.com

Duetotheincreasedvascularitysurroundingthelumbarplexus,thedurationofactionoflocal
anestheticstendstobeslightlylessthanforotherlowerextremitynerveblocks.

Onset (min)

Anesthesia
(hrs)

Analgesia (hrs)

1.5% Mepivacaine (+ epi)

2% Lidocaine (+ epi)
0.5% Ropivacaine
0.5% Bupivacaine (+ epi)

10-20
10-15
15-25
15-25

2-3
2-3
3-5
4-6

3-4
3-4
8-12
12-18
7

http://www.nysora.com
Femoral

Thefemoralnerveisthelargestbranchofthelumbarplexus.Afemoralblockresultsinanesthesiaof
theentireanteriorthighandmostofthefemurandkneejoint.Italsoblockspartofthehipjoint.Itis
usedforsurgeriesontheanteriorthigh,knee,quadricepstendonrepair,andforpostoperativepain
managementafterfemurandkneesurgery,orhipfractures.**Afemoralnerveblockwillcoverthe
frontoftheknee,butprovidesnocoveragetothebackoftheknee.

Femoralnerveblockscanlastforasignificantperiodoftime;thereforeitisveryimportanttoconsider
whatmedicationisbeingused.Themajorsideeffectnotedisquadricepsweakness.

1.5% Mepivacaine
1.5% Mepivacaine (+ epi)
2% lidocaine (+ epi)
0.5% ropivacaine
0.5 Bupivacaine

Onset (min)Anesthesia (hrs)Analgesia (hrs)

15-20
2-3
3-5
15-20
2-5
3-8
10-20
2-5
3-8
15-30
4-8
5-12
15-30
5-15
6-30
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Sciatic

Thesciaticnervesuppliesmotorandsensoryinnervationtotheposterioraspectofthethighaswellas
theentirelowerleg,exceptforthemedialleg,whichissuppliedbythesaphenousnerve(seediagram
below).Thesciaticnerveisthelargestnerveinthebody.Becausethesciaticnerveissolarge,itcanbe
blockedfromseveraldifferentlocationsalongthelowerextremity.Themostcommonapproachesare
thepoplitealandsubgluteal.

Subgluteal approach

Popliteal approach

Afairlysmallamountoflocalanestheticisneededforasciaticnerveblock.Thedurationofasciatic
blockadeislongerthanforanyothernerveblock.

Onset
Anesthesia (hrs)Analgesia (hrs)
(min)
1.5% Mepivacaine (+ HCO3)
10-15 4-5
5-8
2% Lidocaine (+ HCO3)
10-20 5-6
5-8
0.5% Ropivacaine
15-20 6-12
6-24
0.5 Bupivacaine (or I-bupivacaine)15-30 8-16
10-48

http://www.nysora.com

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