Local Anaesthetic Techniques

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Local Anaesthetic Techniques

Local anaesthetic techniques are used for both operative anaesthesia and for postoperative analgesia. They are becoming more popular as a result of advances in drugs, equipment and improved techniques of anatomical localization, including nerve stimulation and ultrasonic location. In addition, there is a greater appreciation of the need to improve postoperative pain control using techniques that not only reduce pain but have the ability to abolish it and potentially improve outcome. This chapter outlines the basic principles of patient management and the methods used in the performance of a variety of blocks which are commonly undertaken by the trainee anaesthetist. Regional techniques for obstetrics and dental surgery are described in other chapters.

FEATURES OF LOCAL ANAESTHESIA

Regional anaesthetic techniques may be used alone or in combination with sedation or general anaesthesia, depending on individual circumstances. Advantages of regional techniques include:

image Avoidance of the adverse effects of general anaesthesia. These may range from relatively minor postoperative nausea and vomiting, sore throat or myalgia to major issues such as respiratory impairment, awareness, airway complications or aspiration pneumonitis. In addition, the management of many patients with significant medical co-morbidity such as diabetes, obesity, or chronic pulmonary disease, can be improved or simplified. In elderly patients, acute perioperative cognitive impairment may be limited by reducing or avoiding psychoactive drugs and maintaining contact with their surroundings.

image Postoperative analgesia. Local anaesthetic techniques can be used to provide effective prolonged postoperative analgesia whilst avoiding the systemic effects of other analgesic drugs, especially opioids. This can be provided using long-acting agents or by utilizing continuous catheter techniques, either neuraxial or peripheral. Some patients may be distressed by the accompanying numbness and motor block, but adequate preoperative explanation should minimize this concern. In addition, it is important that both nursing staff and patient are aware of the risk of tissue damage to any blocked area whether from direct trauma or indirect pressure from poor positioning or prolonged immobility. Simple techniques such as supporting the arm in a sling after brachial plexus block may help prevent injury and encourage earlier mobilization.

image Preservation of consciousness during surgery. The ability to assess neurological status continuously may be an advantage in patients with a head injury, diabetes or those undergoing carotid endarterectomy. Patient positioning may be safer, more comfortable and damage to pressure areas or joints avoided if the patient is awake. Airway and neck manipulation can be avoided; this may be especially important in a patient with severe rheumatoid arthritis or an unstable cervical spine. The awake patient undergoing caesarean section under regional anaesthesia is able to protect her own airway and experience the birth of the child.

image Sympathetic blockade and attenuation of the stress response to surgery.

image Improved gastrointestinal motility and reduced nausea and vomiting. This can allow earlier feeding and more rapid mobilization and discharge.

image Simplicity of administration.

There are now several studies suggesting that the net effect of these features may lead to a reduction in the incidence of major postoperative respiratory complications, though claims of other pathophysiological benefits remain unproven.

However, some patients may be unhappy at the prospect of being awake during surgery. In this situation the combination of a regional block with target-controlled intravenous sedation or general anaesthesia may be valuable. Similarly, this combination works well for prolonged surgery, where patient positioning may be compromised by generalized discomfort or where operation at several sites is necessary.

COMPLICATIONS OF LOCAL ANAESTHESIA

The incidence of complications may be minimized by ensuring adequate supervision and training in local anaesthetic techniques and by exercising care in the performance of each block. Many anaesthetists recommend performing all blocks in the awake (or lightly sedated) patient. The advantages of this are:

Sufficient expertise and equipment must always be available to deal with potential complications. Complications common to many techniques are discussed in this section; more specific problems are considered later.

Local Anaesthetic Toxicity

LA toxicity usually results from accidental intravascular injection, an excessive dose of local anaesthetic or faulty technique, particularly during performance of Bier’s block.

Hypotension

There are several possible mechanisms by which a local anaesthetic technique may cause hypotension. The anaesthetist must always remember that surgical factors may be responsible.

Neurological Complications

Carefully performed blocks rarely result in neurological complications. Risk factors include obesity, diabetes and the perioperative use of potent anticoagulants. The incidence of neurological complications resulting from central neuraxial blocks is likely to be less than 4 per 10 000 or 0.04%.

Neuritis with persisting sensory changes and/or weakness may result from trauma to the nerve, intra-neural injection or bacterial, chemical or particulate contamination of the injected solution. Injection of the incorrect solution has caused some of the most severe neurological complications. To avoid this, all drugs must be checked personally and labelled by the anaesthetist immediately before injection.

Anterior spinal artery syndrome may follow an episode of prolonged, severe hypotension and results in painless permanent paraplegia. Adhesive arachnoiditis has been described after subarachnoid and epidural blockade and may lead to permanent pain, weakness and bladder or bowel dysfunction. It is suspected that this complication results from injection of the incorrect solution. Haematoma or abscess formation in the spinal canal after subarachnoid or epidural anaesthesia results in weakness and sensory loss below the level of spinal cord compression. It is associated with intense back pain and is a neurosurgical emergency which demands immediate decompression to avoid permanent disability.

GENERAL MANAGEMENT

Patient Assessment and Selection

Careful preoperative evaluation is as important before a local anaesthetic technique as it is before general anaesthesia, and the same principles of preoperative management apply. Therapy to improve the patient’s condition before surgery should be commenced if appropriate. It is inappropriate to proceed with surgery under local anaesthesia for the sake of convenience in the poorly prepared patient. A decision should be made on the need for immediate surgical intervention before the anaesthetic technique is chosen.

The preoperative visit should be used to establish rapport with the patient. A clear description of the proposed anaesthetic technique should be given in simple terms, but there is rarely a need for excessive detail. Patients require an explanation of the reasons for selecting a regional technique along with its advantages and potential disadvantages, but there should be no attempt at coercion to accept a particular technique.

Potential problems related to the intended block should be anticipated and sought. Anatomical deformities or pain affecting patient positioning may render some blocks impractical. A history of allergy to amide local anaesthetics is rare, but is an absolute contraindication, as is infection at the site of needle insertion. For most blocks, recent anticoagulant therapy and bleeding diatheses are also absolute contraindications, and the use of major blocks in patients with distant infection or receiving low molecular weight heparin, rivaroxaban or potent anti-platelet drugs such as clopidogrel, requires careful consideration. The use of non-steroidal anti-inflammatory drugs is not generally considered to be a contraindication to neuraxial block unless combined with other anticoagulant agents. The decision to perform spinal or epidural anaesthesia and the timing of catheter removal in a patient receiving antithrombotic therapy should be made on an individual basis, weighing the small, but definite risk of spinal haematoma against the benefits of regional anesthesia for a specific patient. The patient’s coagulation status should be optimized at the time of spinal or epidural needle/catheter placement and indwelling catheters should not be removed in the presence of therapeutic anticoagulation because this seems to significantly increase the risk of spinal haematoma. Close monitoring is vital to allow early evaluation of neurological dysfunction and allow prompt intervention where necessary.

Sympathetic blockade with consequent vasodilatation may lead to profound hypotension in patients with significant aortic or mitral stenosis because of the relatively fixed cardiac output. Hypovolaemia must be corrected before contemplating subarachnoid or epidural anaesthesia.

There is no evidence that neuromuscular disorders or multiple sclerosis are adversely affected by local anaesthetic techniques, but most anaesthetists use regional anaesthesia in such patients only if there are obvious benefits to be gained; any perioperative deterioration in the neurological condition may be associated by the patient with the local anaesthetic procedure. Raised intracranial pressure is a contraindication to central neuraxial blockade but peripheral techniques may be considered.

Selection of Technique

Local anaesthetic drugs may be administered by:

If regional anaesthesia has been selected primarily to provide analgesia during and after surgery under general anaesthesia, a more peripheral technique may be more appropriate to provide a more selective motor and sensory blockade with less functional impairment.

Because a local anaesthetic technique renders only part of the body insensible, it is essential that the method employed is tailored to, and sufficient for, the planned surgery. Account must be taken of the duration of surgery, its site (which may be multiple, e.g. the need to obtain bone grafting material from the iliac crest) and the likelihood of a change of procedure in mid-operation. The problem of multiple sites of surgery may be met by one block which covers both sites, or by more than one regional anaesthetic procedure where indicated. The duration of anaesthesia may be tailored to the anticipated duration of surgery by selection of an appropriate local anaesthetic agent, or may require the use of a technique which allows further administration of drug.

Resuscitation Equipment

A full range of resuscitation equipment must be immediately available and in working order whenever a local anaesthetic technique is used. This includes:

An intravenous cannula must be sited before any local anaesthetic block is performed, in case emergency therapy is required.

Regional Block Equipment

Regional anaesthesia may be used with basic equipment, but some special items increase the success rate and reduce the risk of complications.

Needles

The use of very fine spinal needles (26G) has significantly reduced the incidence of post-spinal headache as has the use of pencil-point 25G Whitacre and 24G Sprotte needles (Fig. 24.1A). The 27G Whitacre needles appear to be associated with the lowest incidence of post-spinal headache but confident and successful use of these needles requires greater expertise than is needed for the use of larger needles. For peripheral blocks, short-bevelled needles allow greater tactile appreciation of fascial planes and appear to reduce the likelihood of nerve damage. A variety of insulated needles are available for plexus and peripheral nerve blockade using a nerve stimulator (Fig. 24.1B). Ultrasound needle visibility may be improved by using echogenic needles which have ‘corner stone’ reflectors positioned at the distal end of the cannula shaft (Fig. 24.11C).

A recent patient safety initiative aimed at reducing drug administration errors, has recommended the development and evaluation of spinal needles and catheter infusion systems with non-Luer connectors that cannot therefore attach to intravenous equipment or standard syringes. This should help prevent wrong route intrathecal injection and stop the accidental intravenous administration of drugs intended for epidural or regional block.

Immobile Needle Technique

For plexus and major nerve blocks, local anaesthetic drug is drawn into labelled syringes and connected to the block needle by a short length of tubing (Fig. 24.2). This allows the anaesthetist to hold the needle steady while aspiration tests are performed and syringes changed. The system must be primed to prevent air embolism and also to avoid image artefact when using ultrasound-guidance.

Catheters

Continuous administration of local anaesthetic drugs has been made possible by the development of high-quality catheters, which are introduced through a needle (or occasionally over a needle; Fig 24.1A) and may be left in position for hours or even days. Careful fixation is essential to maintain the position of the catheter in the postoperative period. Catheters, in particular spinal (subarachnoid) catheters, should be labelled clearly to prevent accidental overdosage.

Nerve Stimulators

Few anaesthetists now aim to deliberately elicit paraesthesiae when performing a major nerve block; many still use the nerve stimulator (Fig. 24.2) but an increasing number now use ultrasound-guidance. It is important to explain to the patient the sensation elicited by nerve stimulation. It causes little discomfort unless the contracting muscle crosses a fracture site, when duration of stimulation should be kept to the absolute minimum necessary to confirm needle position. The incidence of paraesthesia with short-bevelled insulated needles is very low because of their ability to stimulate without direct neural contact. They are also more likely to displace nerves rather than penetrate them.

Stimulators that deliver a constant current and give a digital display of the current used are readily available. One lead is attached to an electrocardiogram (ECG) electrode on the patient’s skin, and the other to the needle. After skin puncture, the stimulator is set to a frequency of 1 Hz and an initial current of 1–2 mA. Most stimulators have a visual display to confirm a complete circuit when needle touches patient. If this fails, connections should be checked or the ECG electrode replaced. Failure to confirm a complete circuit could result in unwanted paraesthesiae or potential nerve injury from repeated needling.

As the nerve is approached, motor fibre stimulation causes muscle contraction in the appropriate distribution. The current is reduced until maximal contraction is still present at a current of, optimally, around 0.5 mA. At this point, a gentle aspiration test is performed and 2 mL of local anaesthetic solution slowly injected. Muscle contraction should cease immediately due to nerve displacement. If it does not, and an insulated needle is being used, the tip may have moved, be beyond the nerve or placed intravascularly; gentle aspiration should be repeated, the needle withdrawn slightly and the procedure repeated. Severe pain on injection suggests intraneural injection, in which case the needle should be repositioned. When the correct position has been found, the remainder of the anaesthetic solution should be injected slowly with repeated aspiration tests. Performance of the block in the awake patient allows better assessment of early intravascular toxicity and intraneural injection in addition to encouraging gentle and careful technique.

Ultrasound

The most significant recent change in the practice of regional anaesthesia has been the introduction of ultrasound guidance. A variety of high quality scanners and probes are now available and vast improvements in image quality have contributed greatly to advances with these techniques. The ultrasound transducer functions as both a transmitter and receiver with the beam reflected, refracted and scattered after it encounters structures of different acoustic impedance, returning to the transducer to produce the target image. Production of a clear target image as well as location and safe needle guidance in real time, requires sound cross-sectional anatomical knowledge along with excellent technical skills, which develop only following adequate training and repetitive hands-on practice. Transducers can be either linear or curved array, with higher frequency probes (8–12 MHz) generally used to produce superficial images of high resolution, such as would be required for interscalene or axillary block. Lower frequency probes (4–7 MHz) provide improved penetration to visualize deeper structures but with reduced resolution. Using the curved array probe for deeper blocks will provide a broader field of view for appreciation of surrounding anatomical structures and landmarks, for example during performance of a subgluteal sciatic block or an infraclavicular brachial plexus block. Most nerves exhibit a distinctive ‘honeycomb’ appearance on scanning, a combination of nerve fascicles and connective tissue, which varies in appearance depending on the individual nerve, its location and the angle of incidence of the probe. More proximal nerve roots, such as with interscalene imaging, tend to appear hypoechoic or dark, due to reduced amounts of connective tissue compared with the axilla and peripherally. As well as visualizing the target nerve structures, ultrasound guidance is useful to identify other important structures such as blood vessels and pleura in order to avoid complications and also allows visualization of local anaesthetic spread. Needle advancement can be tracked in real time, allowing subtle adjustment of needle position to ensure optimal local anaesthetic distribution.

Supplementary Techniques

A local anaesthetic may be the only drug administered to the patient, or it may form part of a balanced anaesthetic technique. During surgery, patients may be awake, or sedated by i.v. or inhalational means. Intermittent boluses of midazolam, or target-controlled infusion of propofol are commonly used. General anaesthesia may be used as a planned part of the procedure. A combination of regional and general anaesthesia may be useful to obtain advantages from both, particularly for prolonged procedures or where positioning is difficult because of additional trauma or significant arthritis.

When a surgical tourniquet is used, the chosen block must extend to the tourniquet site unless the procedure is brief. Discomfort from prolonged immobility on a hard table is relieved by the administration of an opioid either as a premedicant or i.v. during surgery. This type of discomfort is not relieved by sedative drugs, which often result in the patient becoming agitated, confused and uncooperative. An i.v. infusion of remifentanil is being used increasingly for this purpose although this technique is not for the beginner and requires careful respiratory monitoring, preferably by continuous nasal capnography in addition to pulse oximetry.

After-Care

Clear instructions should be given to the nurses caring for the patient.

After day-case surgery, the patient must be in a safe condition at the time of discharge. Plexus blockade with a long-acting agent is inappropriate because of the risk of the patient injuring the anaesthetized limb, but is suitable for postoperative pain relief in supervised inpatients following major surgery, particularly when the limb is immobilized or conversely when continuous passive mobilization is required. Patients who have received central nerve blockade should have routine nursing observations at least until the block has worn off.

Continuous infusion techniques are suitable for use only by experienced anaesthetists. When used correctly, administration by infusion is safer than repeated bolus injection of drug, but regular observations are essential and the nursing staff must have an adequate level of knowledge to appreciate possible complications. An anaesthetist must be available within the hospital at all times.

INTRAVENOUS REGIONAL ANAESTHESIA

Ideally, intravenous regional anaesthesia (IVRA) (Bier’s block) should be the first local anaesthetic technique learnt by a trainee, because its technical simplicity allows the trainee to concentrate on acquiring the skills of patient management. In practice, however, this technique is being used increasingly by Emergency Department staff and less frequently by anaesthetists, who often prefer to block the brachial plexus. Bier’s block is simple, safe and effective when performed correctly using an appropriate drug in correct dosage. Deaths from IVRA have resulted from incorrect selection of drug and dosage, incorrect technique and the performance of the block by personnel unable to treat toxic reactions. The drug involved in these deaths, bupivacaine, was not the most suitable agent and is now contraindicated. The lessons to be learned from these deaths are applicable to all local anaesthetic techniques, and emphasize that expert guidance is essential even when learning the most basic blocks.

Method

Intravenous regional anaesthesia involves isolating an exsanguinated limb from the general circulation by means of an arterial tourniquet and then injecting local anaesthetic solution intravenously. Analgesia and weakness occur rapidly and result predominantly from local anaesthetic action on peripheral nerve endings.

An orthopaedic tourniquet of the correct size is applied over padding on the upper arm. All connections must lock, and the pressure gauge should be calibrated regularly. An intravenous cannula is sited in the contralateral arm in case administration of emergency drugs is required. An indwelling cannula is inserted into a vein of the limb to be anaesthetized. A vein on the dorsum of the hand is preferred; injection into proximal veins reduces the quality of the block and increases the risk of toxicity. Exsanguination by means of an Esmarch bandage improves the quality of the block and increases the safety of the technique by reducing the venous pressure developed during injection. In patients with a painful lesion (e.g. Colles’ fracture), elevation combined with brachial artery compression is adequate. The tourniquet should be inflated to a pressure 100 mmHg above systolic arterial pressure.

In an adult, 40 mL prilocaine 0.5% is injected over 2 min with careful observation that the tourniquet remains inflated. Analgesia is complete within 10 min, but it is important to inform the patient that the feeling of touch is often retained at this time. The anaesthetist must be ready to deal with toxicity or tourniquet pain throughout the surgical procedure. The tourniquet should not be released until at least 20 min after injection, even if surgery is completed. This delay allows for diffusion of drug into the tissues so that plasma concentrations do not reach toxic levels after release of the tourniquet. The technique of repeated reinflation and deflation of the cuff during release has little effect on plasma concentrations and is not necessary.

CENTRAL NERVE BLOCKS

Spinal anaesthesia is a term that may be used to denote all forms of central nerve blockade, although it usually refers to intrathecal administration of LA. The term subarachnoid block (SAB) avoids ambiguity. The technique of SAB is basically that of lumbar puncture, but knowledge of factors which affect the extent and duration of anaesthesia, and experience in patient management are essential. Epidural nerve block may be performed in the sacral (caudal block), lumbar, thoracic or cervical regions, although lumbar block is used most commonly. Local anaesthetic solution is injected through a needle after the tip has been introduced into the epidural space, or may be injected through a catheter placed in the space.

Physiological Effects of Subarachnoid Block

Respiratory System

Low SAB has no effect on the respiratory system and the technique is an important part of the anaesthetist’s armamentarium for patients with severe respiratory disease. However, motor blockade extending to the roots of the phrenic nerves (C3–5) causes apnoea and blocks which reach the thoracic level cause loss of intercostal muscle activity. This has little effect on tidal volume (because of diaphragmatic compensation), but there is a marked decrease in vital capacity resulting from a significant decrease in expiratory reserve volume. The patient may experience dyspnoea, and difficulty in taking a maximal inspiration or in coughing effectively. A thoracic block may lead to a reduction in cardiac output and increased ventilation/perfusion imbalance, resulting in a decrease in arterial oxygen tension (PaO2). Awake patients with a high spinal block should always be given oxygen-enriched air to breathe.

Cardiovascular System

The cardiovascular effects are proportional to the height of the block and result from denervation of the sympathetic outflow tracts (T1–L2). This produces dilatation of resistance and capacitance vessels and results in hypotension. In awake patients, vasoconstriction above the height of the block may compensate almost completely for these changes, thereby maintaining arterial pressure, but general anaesthetic agents may reduce this compensatory response, with consequent profound hypotension. Hypotension is exacerbated by:

Prevention of Hypotension

Both the incidence and the degree of hypotension are reduced by limiting the height of the block and, in particular, by keeping it below the sympathetic supply to the heart (T1–4).

It is common practice to attempt to minimize hypotension during SAB or epidural anaesthesia by preloading the patient with 500–1000 mL of crystalloid solution i.v. before or during the performance of the block. These volumes are usually ineffective even in the short term, may risk causing pulmonary oedema in susceptible individuals either during the procedure or when the block wears off, and may lead to postoperative urinary retention. Appropriate fluid should be given to replace blood and fluid losses and prevent dehydration.

Bradycardia may occur because of:

Careful patient positioning, maintenance of a normal circulating volume and the use of pharmacological agents (see later), if required, should minimize the incidence of hypotension.

SAB has no direct effect on the liver or kidneys, but reductions in hepatic and renal blood flow occur in the presence of hypotension and reduced cardiac output associated with high spinal blocks.

Indications for Subarachnoid Block

Blockade is produced more consistently and with a lower dose of drug by the subarachnoid route than by epidural injection. Duration of analgesia is usually limited to 2–4 h depending on surgical site and may be prolonged by catheter techniques. Catheter techniques may also be used to establish block height more carefully in more compromised patients. SAB is most suited to surgery below the umbilicus and in this situation the patient may remain awake. Surgery above the umbilicus using SAB is less appropriate and would necessitate addition of a general anaesthetic, in order to abolish the unpleasant sensations from visceral manipulation resulting from afferent impulses transmitted by the vagus nerves.

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