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Upper Limb Regional Anaesthesia

This booklet is designed to outline practical considerations when utilising upper limb regional anaesthesia techniques in a day case setting. We have based this upon our own extensive experience at the Queen Elizabeth Hospital as well as up-to-date literature. Hopefully these pages should give you a framework to support your own practice. We have attempted to distil the salient points and in doing so have not gone into the fine details of performing the blocks. As such we do not claim to have provided a textbook of regional anaesthesia. Indeed proficiency in regional anaesthesia takes suitable training, time and dedication. To this point we have listed many useful educational resources in the appendices.

The benefits of upper limb blocks in the day case setting:

The benefits of upper limb blocks in the day case setting

We must stress that to fully reap the benefits of using upper limb blocks in the day-surgery setting one can't simply introduce new techniques seamlessly into an existing list. There must be a cultural shift in the whole patient journey involving the construction of a suitable infrastructure. The provision of an ambulatory upper limb service based on regional anaesthesia works best in a designated setting, either a day-surgery unit or short stay surgical ward. There should be a regular, well-informed and enthusiastic nursing / perioperative team, who are familiar with the concept of regional anaesthesia. Good interpersonal skills between the team and the patient can make the difference between a really well functioning list and one which falters and skips.

Lastly there is also arguably more work for the anaesthetist to do pre, intra and post operatively; we hope you will agree that this workload is worthwhile and adds individual enjoyment to service provision.

List Organisation

List organisation should be discussed in the WHO pre-list briefing at the start of the list.

Pre-operative planning and preparation are essential for lists that employ regional anaesthetic techniques. Time is required to establish a fully effective anaesthetic block. This includes block performance as well as the 'cooking time' - the time required to establish an anaesthetic block. With adequate organisation with the theatre team these time issues can be accommodated and parallel processing can even be employed.

To explain the concept of parallel processing you need to consider the usual progress of perioperative care. Usually an operation follows a serial order in the form of anaesthetic, surgery, and recovery and is known as serial processing. Parallel processing involves the merging of some of these individual stages for multiple patients at any one time. The result can be a marked reduction in ‘anaesthetic time’, quicker transition between patients, an increased time available for teaching / training / performing the regional anaesthesia techniques and ultimately a more efficient process for the patient.

In our institution we start a list with a case, which only needs local infiltration. Whilst the surgeon is doing this case we block the second patient. When the first case is done we move the fully blocked second patient into theatre. We employ a nurse to look after this patient in theatre so that we can get patient three into the anaesthetic room and complete their nerve block. This is repeated as is required. If the block is done before the previous case is completed they are monitored in our first stage recovery.

Parallel processing aims to cut out the anaesthetic component and can save time allowing for more cases per list, similar to a ‘block room’ concept. When planning cases like in the example above, bear in mind who will be anaesthetizing the patient (trainee, fellow, consultant) as well as the experience of the surgeon - they may be quicker or slower than your plan anticipates.

Where general anaesthesia is required you will need to make sure the patient is suitably cared for by another anaesthetist and ODP whilst blocking the next patient. The silver lining to patients needing general anaesthesia is that ‘cooking time’ (the time for a nerve block to become ready for surgery) is not required as you are only after a post-operative analgesic block.

Lastly try not to be over zealous with blocking patients, especially at the end of the day. Time delays do unfortunately occur, leading to the necessity to cancel cases due to a theatre overrun. If you have blocked a patient, you are committed to the operation, which could make you unpopular with the theatre team if this leads to a late finish. Morale is vitally important!

Patient Selection

Patient selection is the key to success during these lists. Many patients who require upper limb surgery have significant comorbidity and general anaesthetic risk attached (rheumatoid arthritis, diabetes mellitus, cervical spine problems etc); many others simply do not want to have a general anaesthetic if at all possible.

Some request to see their surgery (particularly in this day and age of medico-legal practice, or due to previous interventions / investigations with uncertain diagnoses); others will readily accept this if it is offered. A surgeon who is communicative and appropriately informative in the clinic creates an environment of patient acceptance for regional anaesthesia, especially if this is followed up by the pre-assessment and admission nursing team.

A word of warning however. As patients become more likely to request upper limb regional anaesthesia for their procedures (and from our experience this happens increasingly), it becomes far more important to know the contraindications, side-effects and limitations of your techniques, and balance each patient against the potential harm.

Does release of a trigger finger really warrant a full brachial plexus block?

Does the patient with significant bronchiectasis really want a paralysed diaphragm for 18 hours?

The answer can only be determined for any individual patient with the knowledge of the available evidence, the comorbidities of the patient and their wishes / previous experience, and application of your own previous experience and skills.

Patient Preparation

Patients should generally be prepared and informed as for a general anaesthetic. This includes suitable starvation times. Uptake of regional anaesthesia is greater with early discussion and reinforcement; over time the benefits become apparent as patients arrive having discussed their anaesthetic with someone who had something similar. Key influential people to get on board are the surgeon and the pre-assessment nurse. The surgeon can briefly touch on the regional techniques in the initial surgical clinic whilst the pre assessment nurse can reinforce this and give further information including relevant literature.

Hopefully on the day of the operation a regional anaesthetic approach should not be a complete shock to the patient. However we must not be complacent. On the day of the operation we must convey much to the patient whilst maintaining trust and confidence. As well as a typical anaesthetic history and examination you should discuss the risks and benefits of RA, the intraoperative journey and post-operative pain relief (table 2).

Much of the intra and post-operative course will depend on the operation and the respective block. This is covered in detail in chapter 2. Where possible RA techniques can be used alone or with some form of sedation discussed in chapter 3. This may depend on the patient characteristics but also surgical technique. For example, can the patient lie still? This is especially important where a procedure such as shoulder stabilization is being performed.

Some patient concerns may appear trivial, such as ‘hearing drilling noises’, not wanting to ‘see anything’, ‘worried about blood’, ‘can’t sit still for the duration’ etc. Taking these concerns seriously is part of providing a good quality service as well as helping avoiding serious problems intra operatively. Solutions include reassurance, sedation, screening of the surgical site with drapes, and music distraction therapy.

Interestingly the vast majority of patients in our arthroscopic shoulder practice appreciate viewing the arthroscopic images intra-operatively (especially the ones who initially opt for a deep snooze!). Our surgeons then give the patient a guided tour of their shoulder pointing out the pathology and operative interventions that have been or will be done.

In the pre-operative stage it is worthwhile clarifying which pain relief works well for the patient and what they have available at home. The patient's analgesic cache can be supplemented with a ‘To Take Out’ (TTO) prescription which we will cover in chapter 4.

Table 2: Pre-operative patient discussion

Table 2: Pre-operative patient discussion

Equipment Preparation

There will be equipment that you will need for all block lists as well as that which is tailored to the patient and operative needs. It is worthwhile discussing with your ODP what you require at the start of the list. This can be done during the WHO pre-list briefing.

In all areas (anaesthetic room, theatre and recovery) you will require the equipment needed for monitoring blood pressure, pulse and pulse oximetry as well as that required for resuscitation including oxygen and suction. In the anaesthetic room and theatre you should have the equipment needed for monitoring capnography as well as that for providing general anaesthesia. Specific equipment in the anaesthetic room and theatre are covered in tables 3 and 4 respectively.

Table 3: equipment needed in the anaesthetic room

Table 3: equipment needed in the anaesthetic room

Table 4: equipment needed within theatre

Table 4: equipment needed within theatre

Operating Department Practitioner (ODP) preparation

Anaesthetic Room Ergonomics for The ODP

  • Regional anaesthesia anaesthetic rooms often become cluttered and difficult to work in, with trolley, patient, USS machine, sedation pumps, monitoring etc.
  • Consider your usual workspace. Map out where certain items have to be for specific types of block. Note these down / take a picture and work with it.
  • For most brachial plexus blocks we find that the best location for the ODP and nerve stimulator is standing at the head of the patient. This allows proximity to the needle/syringe for injection, and a suitable place for the nerve stimulator.
  • For most patients, the best spot for a drip stand / infusion pump is immediately at the foot end of the trolley. This allows proximity to the drip to avoid decannulation, yet does not impede movement down either side of the trolley.
  • More peripheral upper limb blocks may require an arm board to make the procedure easier.
  • Room preparation is assisted if you have a dedicated block trolley.
  • Use of a ‘block-box’ creates a designated area for everything intended for the regional anaesthetic technique. We use an ‘upcycled’ Stimuplex HNS12 box, with the insides stripped out so the surfaces can be sterilized. All needles, syringes, ampoules and the nerve stimulator can fit into it, and lid will close, with a ‘Stop Before You Block’ poster on the lid. See image 1.1 for example

    Black Box

    Image 1.1 – the ‘Block-Box’

The Block Process

  • The unit must have a policy for ODPs administering the local anaesthetic. This policy should be backed up with training and supervision covering crucial areas of avoidance of nerve injury and toxicity.
  • Familiarity with the various models of nerve stimulator and their idiosyncrasies is important. As an example, the Braun Stimuplex HNS11 does not default to a safe pulse duration setting of 0.1 msec on power up. It remembers the last user’s setting, which could be an unsafe 1 msec. Circuit ‘break’ is indicated in a variety of ways with different models. The HNS12 new models have the ‘SENSe’mode set as the default.
  • Get to know the regional anaesthetists in your hospital. You will find they each have specific things they like / require, and different expectations of your role during the ‘block’.
  • Syringe plunger pressure should be gentle so that injection is slow. If injection is hard, tell the anaesthetist so that he or she can readjust the needle. There is nothing more frustrating for the ‘blocker’ than to give the instruction of a really slow steady injection, and then to find 5 seconds later that 30mls have disappeared into the patient!
  • Familiarise yourself with the ‘feel’ of the system by injecting a syringe filled with tap water through a used needle into the sink.
  • On completion of surgery, ensure the blocked arm is safely padded. Slings, gel pads and blankets are useful for protecting elbows from trolley sides.
  • Allow yourself to be used as a model for any ultrasound demonstrations, and get familiar with your anatomical quirks and foibles – this will also make the blocks clearer.

Arthroscopic Sub-acromial Decompression

What this involves
This involves releasing the coraco-acromial ligament and shaving away any bony spurs on the acromion in an effort to reduce pressure on the rotator cuff tendons. To access the space two (or three ports) are usually inserted one posterior and one lateral.

This operation is notorious for generating post-surgical pain.

Innervation
Essentially all from a C (4) 5 / 6 origin. The suprascapular nerve and, to a lesser extent, axillary nerves constitute the main sensory components for the shoulder complex. The lateral branch of the supraclavicular nerve innervates skin over acromio-clavicular joint and some twigs into joint capsule; and the skin for any cranial aspects of the incision.

Block
In our practice we perform single-shot ultrasound guided blocks of the interscalene brachial plexus (ISB) and supraclavicular nerve.

  • Interscalene brachial plexus block
    • Ropivacaine 0.75% 10-20ml
  • Supraclavicular nerve block
    • Ropivacaine 0.75% 3-5ml
    • This is the nerve not brachial plexus and has been described by Maybin, Townsley &Bedforth (2011) See Image 2.1 for an example

Ropivacaine boasts a faster onset and is our preferred drug for awake surgery. Levo-bupivacaine has a slower onset but longer duration. We usually reserve this for cases which are under general anaesthesia.

Block assessment
With ropivacaine we usually see the onset of the block within the anaesthetic room and surgical anaesthesia is established by the time the patent is positioned, draped and prepped.

Block assessment

Note the cutaneous region of the shoulder where the posterior port is inserted is often spared, as this may receive innervation from T1/2 branches. It is worthwhile pointing this out to the patient ahead of time. Our surgeons check and infiltrate up to 10ml of 1% lidocaine subcutaneously as necessary. This requirement is frequent, being needed in approximately 50% cases.

Alternative block

  • Suprascapular and supraclavicular nerve block

If you want to avoid blockade of the brachial plexus and/or the phrenic nerve this combination of blocks provides excellent analgesia. Patients will need a general anaesthetic but minimal intraoperative opioid. Ultrasound guided suprascapular block can be performed either anteriorly or posteriorly. We perform an anterior ultrasound guided technique which was described by Siegenthaler et al (2012). See Image 2.2 for an example

  • 'Shoulder block'

Recently there has been described the 'shoulder block' which is a combined axillary and suprascapular nerve block. The suprascapular nerve is blocked as above. The axillary nerve is approached posteriorly through the quadrangular space adjacent to the medial humeral circumflex artery. For a detailed description refer to our list of recommended reading - nerveblocks.co.uk.

Image 2.1 supraclavicular nerve
Ultrasound image at the level of C5 & C6. The supraclavicular nerve is found above the deep cervical fascia and the scalene muscles (mauve oval). A needle can be seen approximating the postereolateral aspect of the nerve.

Image 2.1 supraclavicular nerve

Image 2.2 suprascapular nerve
Ultrasound image illustrating the supraclavicular brachial plexus. Green dashed lines represent the borders of the upper, middle and lower trunks. The mauve oval indicates the suprascapular nerve which has originated from the C5 root, and travels separate from the plexus under omohyoid m.

Image 2.2 suprascapular nerve

Arthroscopic rotator cuff repair

What this involves
This involves arthroscopically repairing torn rotator cuff tendons. It is more painful than sub-acromial decompression so a good single shot ISB is vital. In some instances we manage these cases as part of our Post-Operative Shoulder Surgery Initiative (POSSI) - see below. Because it takes longer than sub-acromial decompression and several operative steps require the patient to be absolutely still we will frequently employ sedation if not general anaesthesia.

Block
Usually a single shot ISB and supraclavicular nerve block - see above for more details. In some instances an interscalene catheter is warranted for managing post-operative pain. The indication for this is usually following a discussion with the patient, surgeon and anaesthetist. For more details on catheters see below.

Block assessment
As for subacromial decompression.

Alternative block
As for subacromial decompression. Alternative blocks may not provide the desired post-operative analgesia for day case surgery.

Sedation notes
Discuss the case with the surgeon and the patient. If it looks like the procedure could take some time and you don't think the patient will be able to stay still then general anaesthesia following the ISB is warranted.

Procedures for Frozen Shoulder

Manipulation of shoulder under anaesthesia (MUA)

What this involves
This involves the physical manipulation of the shoulder joint with the aim of improving range of movement. It is usually performed in patients with idiopathic frozen shoulder or in the work up to stabilisation surgery. In the anaesthetic room the surgeon will forcibly abduct, adduct and externally rotate the shoulder, documenting pre and post procedural ranges of movements. After completion a steroid injection is usually performed. The procedure can be particularly painful post operatively, and a regional approach also allows early mobilization to reduce repeat scarring.

Block
ISB - Ropivacaine 0.75% 10-20 ml. A supraclavicular nerve block is not so important with this procedure since cutaneous stimulation is minimal.

Block assessment
As for sub-acromial decompression

Alternative block
Because this is quite stimulating an alternative block for an awake procedure is not advised.

Sedation notes
Even with a decent ISB the procedure is quite stimulating so we will invariably add in sedation and have a quick acting opioid such as alfentanil on stand-by.

Arthroscopic Arthrolysis
A more extensive arthroscopic destruction of the shoulder joint capsule. We routinely place perineural catheters to provide analgesia and allow physiotherapy to occur with good quality analgesia.

Major Shoulder Surgery

What this involves
A number of arthroscopic and open procedures are well known for causing severe pain which lasts for several days. This includes open procedures such as anterior stabilisation and rotator cuff repairs and some arthroscopic work such as acromio-clavicular joint reconstruction. Indeed when a single shot block is used it usually wears off long before the pain is manageable. Around ten years ago as part of multi-disciplinary strategy our Trust developed the Post-Operative Shoulder Surgery Initiative (POSSI). These operations were originally managed in our main theatre complex and patients would require a ward bed for several days where they would receive intravenous opioids. Following the introduction of POSSI we now manage these cases in our day-surgery centre.

As with all types of enhanced recovery, the key elements are patient selection, procedure selection, and preparation. In this context, an additional main component is the ability to provide prolonged quality analgesia, provided using an interscalene catheter and peri-neural infusion.

Block
Interscalene catheter. Please see appendix for our complete technique

Block assessment
Initial assessment as per single shot ISB.

Prilocaine 1% establishes a surgical block within minutes. The surgical anaesthesia subsides after approximately 3-4 hours. During this time we complete the surgery and commence an infusion through the catheter. This allows us to assess the analgesia provided by the catheter and troubleshoot any problems prior to patient discharge.

At the end of surgery we start an infusion via the catheter of 0.2% ropivacaine through an elastomeric pump. For post-operative care see Chapter 4.

Alternative block
If a catheter is not performed we perform a single shot ISB and discharge the patient with facilities for a repeat procedure the following day. This is far from ideal but can be done with a cooperative patient if the need arises.

Sedation notes
As for arthroscopic rotator cuff repair.

Arthroscopic elbow surgery and ulnar nerve release

What this involves
We have grouped these two procedures together as they involve a similar anatomical area and can be blocked by an ultrasound guided supraclavicular (or infraclavicular) brachial plexus block. Ulnar release involves freeing up the nerve as it passes around the elbow (transposition). This in itself is not too painful in the post-operative period but if a medial epicondylectomy is needed pain can be moderate to severe. See image 2.3 for how we position our ulnar release patients.

Innervation
The elbow joint receives sensory ‘twigs’ from all of the main nerves crossing the joint; median, radial and ulnar. Cutaneous innervation may require lateral cutaneous nerves of the arm and forearm, medial cutaneous nerve of the arm, posterior cutaneous nerve of the arm, and the intercostobrachial nerve. Motor block requires the main flexors and extensors of the elbow joint; this can be provided with musculocutaneous, median and radial nerves.

Block
We perform an ultrasound guided supraclavicular brachial plexus block as described by Soares et al. We start with the corner pocket injection to target the inferior trunk. We have found that if this is missed then sparing of the ulnar nerve is almost certainly guaranteed. During the procedure we will move our needle tip to ensure good local anaesthetic spread around the three trunks.

You can keep the needle in one place but from our experience the onset of an anaesthetic block will take longer, and the block is less guaranteed to cover all intended components.

15-25 ml 0.75% ropivacaine

Block assessment
Usually the sign of lifting the plexus up off the first rib with the local anaesthetic results in evidence of an ulnar nerve block by the time we have finished the injection. We allow the block to cook for 30 minutes.

Motor

Upper trunk - flex the forearm
Middle trunk - extend the forearm
Lower trunk - grasp hand.

Sensory

Check with either an ice pack over the surgical site.

There will be sparing of the intercostobrachial nerve. If the surgeon plans to go into this area they can infiltrate a short acting local anaesthetic where necessary. Also patients may experience some tourniquet discomfort over the medial aspect of the upper arm.

Alternative block
Infraclavicular brachial plexus block

We do not routinely perform this block however it is an appropriate technique for this procedure. For more information refer to the appendices.

Axillary brachial plexus block

May provide suitable post-operative analgesia for ulnar nerve decompression surgery; however some cutaneous branches may be missed and require surgical infiltration.

Sedation notes
It is Important to check with the surgeon the position they want the patient in for the operation. In some cases a lateral position is used with the operative arm hanging over the face (see image 2.3). This is quite claustrophobic and we find it usually best to offer the patient a light general anaesthetic technique in addition to the nerve block.

Image 2.3 Elbow surgery being undertaken in the lateral position, with the arm over a support.

Image 2.3 Elbow surgery being undertaken in the lateral position, with the arm over a support.

Trapeziectomy

What this involves
A trapeziectomy is a relatively painful procedure that lends itself to brachial plexus blockade and or blockade of peripheral nerves at the elbow or forearm. In the past we have seen both unplanned admissions and readmissions following this operation under GA.

Block
Axillary, infraclavicular and supraclavicular approaches will all be suitable for this technique. We usually choose either a supraclavicular or axillary approach, as this allows some degree of ‘directing’ the block towards the intended surgical area.

Block assessment
Motor
Median - Flex hand at wrist
Ulnar - Grip hand
Radial - Extend hand at wrist
Sensory
Cold pack over surgical site

We allow this block to cook for 30 minutes. If the block is not evident or is patchy after this time you can do a peripheral nerve block at the elbow or proximal forearm with a rapid acting local anaesthetic (e.g up to 5ml 1% lidocaine) to cover the missed segment. Supplementary blocks need to be at or above the antecubital fossa to ensure that the interosseous nerves are also blocked appropriately.

Alternative block
Mid-humeral blocks
Peripheral blocks at the antecubital fossa +/- general anaesthetic (? Forearm tourniquet)

Sedation notes
Sedation is not normally required though will be offered to all patients.

Palmar Fasciectomy 

What this involves
This involves repair of Dupuytren's contracture and is usually less than 60 minutes for simple disease but can beyond 120 minutes for more complex lesions. The operation usually involves the ulnar nerve territory and employs the use of a tourniquet. Post-operative pain is usually mild to moderate. Occasionally skin grafts may be taken; this may influence type of regional block or requirement for general anaesthesia.

Block
Periclavicular or axillary approaches to the brachial plexus are suitable.

Mid-humeral blocks may be suitable depending on the location of the tourniquet.

A combination of a short-acting proximal plexus block and long-acting distal median and ulnar blocks works really well and avoids patient complaints related to a heavy, densely numb arm.

Block assessment
Assess the block as per trapeziectomy.

We allow this block to cook for 30 minutes. If the block is not evident or is patchy after this time you can do a peripheral nerve block at the elbow or mid-forearm to cover the missed segment.

Alternative
Mid-humeral blocks may be suitable depending on the location of the tourniquet.

Antecubital blocks may be suitable depending on the location of the tourniquet.

Mid-forearm median and ulnar blocks are ideal for this if a general anaesthetic is also intended; these will provide prolonged analgesia with minimal motor blockade.

Sedation notes
We have found that sedation is not normally required though will be offered to all patients.

This chapter looks at the care of the patient whilst you do the block (peri-procedural) and throughout surgery (intra-operative). As you can see from image 3.1 the block and the operation are just one step in the perioperative patient pathway. This chapter will explore these supporting steps in greater detail. Some areas such as the 'Stop Before You Block' check and the WHO surgical checklist are covered in the appendix. We finish the chapter with some trouble shooting tips.

Peri-procedural And Intraoperative Care

Monitoring

During both the block and surgery we monitor blood pressure, electrocardiogram and pulse oximetry. Arguably the most important monitor with awake surgery is verbal contact with the patient i.e. we employ conscious sedation techniques. During a regional technique we usually use a peripheral nerve stimulator in addition to ultrasound guidance. This allows us to:

  • Ensure we have not passed through another nerve on the way to our target (e.g. dorsal scapular nerve on way to brachial plexus)
  • Help make sure our needle tip is not intraneural.
  • Part of our amended Stop Before You Block initiative (See Appendix). We place the electrode on the skin site mark.

In table 3.1 we have distilled the individual monitoring modalities explaining the frequency of recordings required as well as where the monitor needs to be in contact with the patient. This last point is worth bearing in mind for several reasons. With regard to the ECG make sure you place the electrodes away from surgical site. To preempt the surgeon in theatre, have some spare electrodes handy!

We usually place the blood pressure cuff on the lower limb. This allows us to inject medication with no fear of interruption of the drug or risk of extravasation, and minimizes the discomfort of taking a blood pressure reading whilst a propofol infusion is running. It is worthwhile explaining to the patient that it will feel very tight in comparison to a normal blood pressure reading.

Table 3.1: monitoring

Monitoring

Positioning

Ergonomics of the patient position, staff placement and equipment location needs to be thought of well in advance. This ensures maximum efficiency as well as limiting any possible delays because something is not available or attached. See images 3.2 and 3.3.

Image 3.2: Anaesthetic room set up
Note the position of the patient, including the pillow off to one side, as well the ultrasound machine and relevant equipment

Anaesthetic room set up

Image 3.3 Theatre set up
Note how the patient’s head, neck and arm are supported. We attach a metal ‘L-bar’ onto the bed for our drapes to rest on so that they do not cover the patient’s head, and allow the patient to see the operation if they would like. A clear drape is an alternative if your surgeon feels comfortable with this.

Theatre set up

Sedation

We usually offer some form sedation to all of our patients whilst we insert a block and for surgery. It makes the procedure more tolerable and reduces anxiety. This includes pharmacological and non-pharmacological modalities.

Pharmacological

The aim is provide conscious sedation. Verbal contact is especially important during block placement.

  • Propofol via Target Controlled Infusion (TCI)

    This has become our default sedative medication. It is easily titratable, safe and can be continued intra-operatively with little fuss. The beauty of propofol is that if the patient becomes too anxious and requests a general anaesthetic intra-operatively we can simply increase the rate to achieve an effect site concentration (Ce) of between 3-4 mcg/ml. We use intravenous paracetamol to counter the venous ache (Canbay, 2008) and add lidocaine if more is needed.

    Dose:
    Peri-procedural: Ce approx 0.8 mcg/ml. It is unusual to require more, and the disinhibition often results in a moving target.
    Intra-operative: Start at 0.6 mcg/ml Ce. We then titrate by 0.1 mcg/ml according to patient request. A Ce of above 1.0 is likely to result in significant disinhibition and agitation; see below. It is unusual to need a Ce of more than 1.4mcg/ml. Even at these levels, patients usually remember watching their surgery!
  • Midazolam

    We use this for particularly anxious patients or where a GA will be performed post block. Even with 1mg, most patients will not remember anything from their surgery!

    Dose: bolus 1-2mg.

Non-pharmacological

Environment
A serene environment with no confrontation creates a sense of peace and helps to soothe anxieties.

Communication
Clear and friendly communication is vitally important. We tend to have at least one member of staff at the patients side to have a chat, trouble shoot or identify any developing anxiety. With an awake patient during the operation the surgeon can explaining what they are doing.

Music distraction therapy
This is a very good tool intra-operatively for upper limb surgery. We have a selection of music, which we play via headphones. Usually with this we do not have to give any pharmacological agents.

Agitation during sedation

Adequate sedation rests on a knife edge with agitation either side. Agitation may result in a shuffling / wriggling patient, making surgery difficult and causing a ‘beach-chair’ patient to slide, sometimes out of head-support; it will also make it difficult to interpret whether noise or movement are due to incomplete block or disinhibition. For this reason, we suggest a slow increase in sedation rates to maintain true ‘conscious sedation.’

If the patient becomes agitated you need to rule out several causes:

  • Hypoxia or hypercapnia secondary to too deep sedation
  • Haemodynamic instability
  • Pain or discomfort
  • Full bladder (be cautious with fluids)
  • Too warm (especially if using a forced air warming blanket)
  • Disinhibition due to over-sedation

Increasing the sedation may help, however a more effective solution can sometimes be coming down on the sedation or even stop it altogether. With an imbalance in the level of sedation, act early to improve the situation, and consider an early conversion to a GA (whilst in position) if the situation does not improve quickly, to avoid disruption to the surgery.

Remember, we are trying to provide optimal conditions for the operation, for both surgeon and patient. Persisting with or allowing agitation is not beneficial to either party!

Trouble Shooting: What the do when The Block isn't Working

Prior to surgical stimulation

  1. 1. Completely failed block

    Upon block assessment if a regional anaesthetic technique does not block any of the structures that you had intended it has completely failed. You must avoid the temptation to allow surgery to proceed in the hope that the assessment was false. An alternative needs to be sought and usually this involves a general anaesthetic unless you can safely perform a repeat block. In the era of reflective practice it is important to question why your technique has totally failed.

  2. Partially failed block

    If a regional anaesthetic procedure has blocked several intended structures but spared some then it has partially failed. This occurs in as many as 1 in 10 (in some papers and with certain blocks). This is usually identified on block assessment and if found you need to question whether supplementation would be sufficient. If so options include a rescue block of distal nerves using a rapid acting agent (such as lidocaine) or local infiltration by the surgeon.

    IF YOU DOUBT THE ADEQUACY OF THE TECHNIQUE, IT IS NOT APPROPRIATE TO CONTINUE.

Intra operatively
Patient reassurance and close liaison with the surgeon is vital. Get the surgeon to stop and find out where the pain is.

  1. Cutaneous pain

    If the pain is cutaneous this can usually be covered by infiltration of a quick acting local anaesthetic by the surgeon.

  2. Failed block

    If it is clear that deep structures are involved then there are several options. For shoulder or elbow operations you can use a rapid acting opioid. We routinely have alfentanil prepared and ready in theatre. We titrate boluses of 125mcg. The addition of paracetamol and a non-steroidal anti-inflammatory (NSAID) agent can also be useful. Other parenteral agents include clonidine (1mcg/kg) or ketamine (0.5mg/kg). Midazolam may help to reduce anxiety and ablate memory for the remainder of the procedure.

  3. Tourniquet

    Requirement for a tourniquet should be considered prior to any regional anaesthetic technique. Tourniquet ‘pain’ can be covered by the above parenteral agents, although releasing the tourniquet is the only real resolution. Deepening the plane of sedation can be a useful strategy; where necessary you can offer the patient a general anaesthetic.

Trouble Shooting: Haemodynamics

Bradycardia
The combination of proximal brachial plexus anaesthesia and propofol sedation often causes a mild degree of bradycardia, which does not require concern or treatment.

Occasionally severe bradycardia, 2nd / 3rd degree heart block or asystole occur. These severe effects usually have an unclear aetiology, although possibilities include:

  • Underlying myocardial pathology
  • Local anaesthetic myocardial toxic effect
  • Sympathetic / Parasympathetic imbalance
  • Sympathetic chain block
  • Intrathecal / high epidural spread of injectate
  • Bezold-Jarisch type reflex
  • Relative hypoxia

The impact of severe bradycardia is profound, especially with an awake patient in a sitting position, and this requires immediate treatment with atropine. The infusion line will need to be pressured to get the drug to the heart, and some cardiac massage may need to be given to circulate the drug. We routinely draw up and have to hand atropine and glycopyrrolate during shoulder surgery.

Tachycardia
Uncommon within this setting. Usually occurs secondary to anxiety, and resolves with mild sedation.

Consider local anaesthetic toxicity, especially when occurring within 15 minutes of the regional technique performed.

Also consider relative hypotension, especially when moving to a beach-chair position.

Care in Recovery

One of the real valued attributes of a regional anaesthetic is the ability of patients to get their ‘cup of tea’ as soon as they get out of theatre. For most with an anaesthetic block, this means a return to the ward environment direct from theatre; this is the case for most of our regional anaesthetic patients. Patients who have received significant sedation or general anaesthesia may require a short period in recovery. The purpose here is to establish full consciousness, ensure sound physiology, confirm a functioning block and that analgesia has been optimised, and deal with any consequences of the general anaesthetic.

A rapid return to the ward environment helps to ‘normalise’ the ‘patient’ back to ‘person’. This means encouraging normal daily function, avoidance of the sick role, something to eat and drink, encouragement to mobilise and ambulate, especially to the toilet, contacting lift and arranging discharge. Regional anaesthesia patients ambulate and fulfil discharge criteria earlier; a benefit for both unit and patient.

Patent Instructions and Take-Away Prescriptions

Clear verbal and written instructions should be provided related to looking after a limb (or parts thereof) which has received regional anaesthesia. If the patient is provided with a sling, there may be a need for provision of instructions for re-applying the sling. We use a ‘Polysling’, which has multiple Velcro fastening components, and can be complicated.

Examples of the two aforementioned instruction leaflets are found in the appendices.

The patient should be cautioned regarding the risk of injury to the limb whilst it is numb. This has to include both risks from direct heat sources (stoves, fires, irons etc), and the effects of a flammable Polysling (with adherent oxygen molecules) igniting. Smokers need to be specifically cautioned of the danger of a naked flame near a flammable sling, especially with a numb arm.

A suitable quantity of analgesia should be provided and encouraged to take prior from day of surgery, even before the block has begun to wear off. For selected cases we also provide a short supply of oxycodone.

Most of our patients have been visited by the physiotherapy team, either before or after their procedure. Written instructions regarding required exercises are important, as many patients do not fully grasp what is required of them, nor the significance of doing them.

Discharge Criteria

Most patients with regional anaesthesia or analgesia fulfil discharge criteria within an hour of leaving the theatre, not including recovery time. There may be occasional delay if the surgeon requires seeing them before discharge. If a perineural catheter has been left in, the discharge time is usually prolonged, in order to ensure a functional perineural catheter, understanding and compliance with the post-operative analgesic and physiotherapy regime, contact points and follow-up strategy.

Care Following Discharge

Most upper limb procedures suitable for day-surgery under regional anaesthesia require no specific follow-up although we routinely follow-up all patients who have undergone a regional anaesthetic procedure with a phone call usually on day 2. A copy of the form we use is available in the appendices. Patients value this follow-up service, and this enables feedback to the team regarding all standards of peri-operative care, as well as specific questions about the regional anaesthesia and pain management.

Repetitive feedback comments in focused areas allow us to make changes to improve the service ie. feedback we received ascertained that our patients had problems managing the Polysling – we acted to produce a specific sling information leaflet to enable it to be put back on successfully following physiotherapy!

Some major procedures recently relocated to day-surgery may require a specific follow-up phone call and an option of a further analgesic regional anaesthesia technique. We routinely do this for surgery such as arthroscopic rotator cuff repair, or wrist fusion, or for any patient with risk factors for poor or difficult pain control post-operatively.

There are various outcome assessment tools which can provide more specific validated information for a more thorough assessment of quality of recovery. These include the QOR-9 and the QOR-40 (Myles et al 1999 & Myles et al 2000). Although usually used as research tools, they may be relevant for ‘short burst’ type of assessment / proof of quality of care, in response to current performance management criteria.

Other media also provide follow-up tools, including Iwantgreatcare.com

Quality, Safety and Efficiency

What areas to address?
There are so many possibilities that come under the realm of audit and service improvement. The current strategy is to consider quality measures, safety components, and patient feedback / opinion. A key further element of any service delivery is to assess efficiency. Is it good? Is it safe? Is it as efficient as it could be?

Quality, patient satisfaction and quality of recovery.
There are multiple research validated tools available to formally study this, including scores such as the QoR-40 and QoR-9 which were mentioned above. In addition parameters such as admission rates for complications or for pain relief, readmissions for pain relief, and numbers of prolonged blockade should be assessed.

For example in our own practice we identified, and subsequently acted upon, the following patient concerns when looking at the last 1,000 regional anaesthesia procedures:

  • Dislike of having to carry around the ‘lump of meat’
  • Difficulty in getting comfortable for the first post-operative night with blocked arm / sling
  • Difficulty in re-applying the sling if it has been removed
  • Uncertainty regarding physiotherapy
  • Managing pain when the block has worn off

Safety
Auditing safety has previously focused on the identification and reporting of incidents and near-misses, and establishing processes to try and avoid similar events from happening. This has resulted in the development of strategies such as the WHO Safer Surgery Checklist, and the Stop Before You Block campaign. The auditing of these (and other) safety strategies in conjunction with a review of any incidents is one way of looking at the safety component.

Throughput
The primary economic benefits to any Trust for a regional anaesthesia-based upper limb list is the avoidance of admission for the purposes of analgesia and the relocation of in-patient lists into an ambulatory setting. An approximate cost per inpatient bed-night is £400. It is not difficult to see the financial benefit of moving lists into an ambulatory setting; a single in-patient theatre session may allow 2-3 primary joint arthroplasties, each with a tariff value of £6-8,000; 1 day a week moved out of the in-patient theatre setting potentially creates an additional £18-24,000 income (as a conservative estimate); over 52 weeks this equates to £936,000 - £1,248,000.

Obviously this is not the whole economic argument as this is not based on profit; nor service redesign models. Keeping a regular eye on the throughput allows identification of new opportunities to enhance throughput; computation of operation times and identification of inefficiencies; and establishing the best way for an individual unit to optimise their use of time.

Innovations

New Techniques
Following the recent introduction of ultrasound technology, almost any possible approach to the brachial plexus has been described, and all have much to merit / discredit them. New developments include the ability to identify smaller purely sensory nerves such as the supraclavicular nerves, or the cutaneous nerves of the arm / forearm. The general trend towards more peripheral nerve blockade may result in new surgical approaches / perioperative techniques; requiring distal or no tourniquet, and operating with no, or limited, motor block.

Advancing nerve location technology
Current 2D ultrasound has its limitations, and new modalities such as 3D ultrasound, or portable CT imaging technology may yet emerge to be preferable. Development of a probe like transducer which can detect fluctuating electrical current and display its likely location in conjunction with an ultrasound machine image will also greatly help nerve location. The latest development in 2D ultrasound probes is a wireless probe, improving portability and access, and simplifying the often complicated anaesthetic room layout.

New local anaesthetics
Recent developments have included pain fibre specific sodium channel blockers resulting in analgesia with no motor block. The opportunities for such a drug are endless; perineural catheter use is likely to be greatly of benefit. There are also long-acting depot type formulations of both local anaesthetics and opiates which have yet to be evaluated on a large scale.

Movement of a wider range of procedures into the ambulatory setting
Provision of high quality regional anaesthesia services, perhaps in conjunction with prolongation of analgesia using a perineural catheter, may allow more major work to be moved into the day-surgery / overnight care setting. This includes most shoulder, elbow wrist and hand work.

Setting up your Own Service

If this is a new development for the team, it is important to create confidence throughout the process. Firstly, the blocks need to work! Initiation of the service is not the right time to move to low dose techniques, or quirky new approaches recently described.

In our experience it is very useful to have several individuals who can take a degree of ‘ownership’ of this service, and be actively encouraged to insert their own adaptations to all elements of the service. Increasing the number of active participants reduces ‘exclusivity’ and allows a service to continue running in the context of illness / disaster etc. However, too many cooks may spoil the broth!

Some changes will need to happen during a ‘bedding-in’ phase; even if something appears to work to you, the team may feel differently; this simple situation easily translates into confusion and disruption. Be flexible where possible; be open to changes, if they do not directly interfere with your management of the patient.

It is important that written information detailing plans for regional anaesthesia has been provided in addition to these discussions. This information must be accurate, concise, relevant, written in appropriate language, and be thorough enough to provide evidence of information regarding a full explanation of side-effects and complications.

Website

Cambridge Advanced Nerve Blocks
Lipid rescue
I want great care
Some notes on regional anaesthesia

Text Books
Hadzic, A ed. 2012. Hadzic’s Peripheral Nerve Blocks and Anatomy for Ultrasound-Guided Regional Anesthesia (New York School of Regional Anesthesia) Second Edition. New York: McGraw-Hill Medical.

(Some) Key Papers
Canbay O, Celbi N, Arun O, Kargagoz H, Saricaoglu F & Ozgen S.Efficacy of intravenous acetaminophen and lidocaine on propofol injection pain. British journal of anaesthesia 2008; 100: 95-8

Maybin J, Townsley P and Bedforth N. Ultrasound guided supraclavicular blockade: first technical description and the relevance for shoulder surgery under regional anaesthesia. Anaesthesia 2011; 66: 1053 – 1055

Myles PS, Hunt JO, Nightingale CE, Fletcher H, Beh T, Tanil D, Nagy A, Rubinstein A & Ponsford JL. Development and psychometric testing of a quality recovery score after general anaesthesia and survey in adults. Anesthesia and Analgesia 1999; 88: 83-90

Myles PS, Weitkamp B, Jones K, Melick J and Hensen S. Validity and reliability of a postoperative quality of recovery score: the QoR-40. British journal of anaesthesia 2000; 84: 11-15.

Neal JM, Gerancher JC, Hebl J, Ilfeld BM, McCartney CJJ, Franco CD & Hogan QH. Upper extremity regional anesthesia: essentials of our current understanding, 2008. Regional anesthesia and pain medicine 2009; 34: 134-170.

Siegenthaler A, Moriggl B, Mlekusch S, Schliessbach J, Matthias Haug M, Curatolo M and Eichenberger U. Ultrasound-Guided Suprascapular Nerve Block, Description of a Novel Supraclavicular Approach. Regional Anesthesia and Pain Medicine 2012;37: 325-328

Soares LG, Brull R, Lai J & Chan VW. Eight ball corner pocket: the optimal needle position for ultrasound-guided supraclavicular block. Regional anaesthesia and pain medicine 2007; 32: 94-95.

Safety Publications

Local anaesthetic toxicity
Stop before you block campaign
WHO surgical safety checklist

Queen Elizabeth Hospital Documents

Day surgery regional anaesthesia follow up form
Pain relief for shoulder surgery / Looking after arm after a block
POSSI Insertion guide
Post op block instructions
Sling info leaflet