REGIONAL ANAESTHESIA

Regional anaesthesia constitutes the blockade and/or modulationof conduction in nerves supplying
sensation to an anatomical region. Blockade of a nerve or plexus can normally
be performed along its trajectory within the spinal cord, known as a central nerve block; at different
points in a limb; or by infiltration of drug into an area, a technique termed field block. Regional
anaesthesia can be performed on its own, supplemented by sedation or combined with
general anaesthesia. The preparation and assessment of the patient, as well as
he equipment, assistance and monitoring should be the same as for general anaesthesia. This is
particularly true for two reasons:
1. The local anaesthetic procedure may fail or be only partially effective and require ‘conversion’ to
a general anaesthetic.
2. Treatment of toxicity or side-effects may require intubation, ventilation and resuscitation.
General aspects
Advantages
• Avoidance of unconsciousness: Regional anaesthesia does not normally interfere with
consciousness and the ability to protect the airway is maintained.
• Minimum interference with breathing: There is therefore no need to intubate and ventilate and the
disadvantages of these techniques are avoided. However, regional anaesthesia in patients known
to be difficult to intubate can present problems if side-effects then make it necessary to
intubate.
• Postoperative analgesia. Top-up boluses or infusions can provide good quality analgesia for
days. This can reduce opioid consumption and aid early mobilisation. This has obvious benefits in
lung conditions and in the prevention of thromboembolism.
Disadvantages
• Sympathetic blockade: This causes a fall in vascular smooth muscle tone which can lead to a
precipitous drop in vascular resistance, blood pressure, venous return and cardiac output. If not
treated effectively, it can lead to lifethreatening hypotension and end-organ ischaemia, especially
in patients with a fixed cardiac output. These effects can be partially prevented by volume loading
and the use of vasoconstrictors such as ephedrine or phenylephrine; occasionally more aggressive
treatment with potent inotropes may be necessary.
• Toxicity of drug/adverse effect of technique: As discussed above, this may cause loss of airway
control in addition to convulsions and unconsciousness, apnoea and cardiovascular collapse. The
combination of sympathetic block, surgical haemorrhage, incomplete block leading to partial
analgesia, local anaesthetic drug toxicity and oversedation is particularly dangerous.
• Motor block: Although entirely reversible, this can be quite distressing to the patient. It should be
discussed at the preoperative visit.
Indications
Every anaesthetist will assess each case individually and decide how to conduct anaesthesia
based on advantages and disadvantages of general and regional techniques, experience and
training, patient choice and surgical requirements. There is no conclusive evidence that either
technique changes outcome. Some relative indications are:
• significant respiratory impairment;
• obstetrics: pain relief and Caesarian section;
• infraumbilical surgery: urological and orthopaedic procedures;
• analgesia in thoracic and upper abdominal surgery.
Contraindications
• local or generalised infection;
• bleeding diathesis;
• patient disapproval;
• hypovolaemia;
• extreme emergency;
• raised intracranial pressure.
Specific techniques
Intravenous regional anaesthesia (Bier’s block)
A Bier’s block consists of isolating a limb, usually the arm, with a pneumatic tourniquet and
injecting local anaesthetic into a vein. The drug is distributed to the extravascular tissues, including
the nerves. It is suitable for minor surgery to the distal upper limb and is commonly performed for
reduction of wrist fractures. It is often performed in elderly patients, not uncommonly in Emergency
departments after a fall or other accident. Great care must be taken in patient assessment; in
particular, most anaesthetists insist that they are fasted. It is customary that one practitioner
performs the block and cares for the patient while another performs the surgery.
Certain principles are particularly important [21]. Contralateral i.v. access is imperative. The
tourniquet must be tested and known reliably to apply pressures of 50–100mmHg above systolic.
The area just distal to the tourniquet may not be completely anaesthetised; this may cause
discomfort or pain about which the patient must be warned. The anaesthetist must be constantly
vigilant during the procedure, in particular for deflation of the tourniquet and/or signs of drug
toxicity. The tourniquet must not be deflated for at least 20–30 min; this should allow time for
adequate redistribution of local anaesthetic and therefore safe blood levels upon deflation.
Prilocaine is the drug of choice; its safety record, when used appropriately, is good and it has the
widest safety margin. As for all regional anaesthetic techniques, monitoring and resuscitation
facilities should be adequate.
Central nerve blocks
This includes subarachnoid or spinal and extra or epidural blocks; both can be performed with local
anaesthesia and/ or opioids. The most important differential characteristics
are listed in Table 2.11. A caudal block consists of an extradural injection through the sacral hiatus,
delineated by the sacral cornua. Briefly, the technique of performing an epidural involves
the detection of a characteristic loss of resistance as the needle enters the epidural space. A
catheter is then threaded into the space. Before injecting the entire drug dose, it is imperative to
administer a small ‘test dose’ to ascertain extradural and exclude subarachnoid placement.
The administration of opioids by spinal or epidural injections is aimed at reducing local anaesthetic
doses and sideeffects.
Side-effects of central neural opioids include delayed respiratory depression, pruritus, nausea and
urinary retention. Some of the most important complications of central
nerve blocks are:
• Backache: Back pain is more common after extradural anaesthesia in pregnancy, where the
incidence is between 8% and 15%. It is probably due to several mechanisms and a cause–effect
relationship with epidural blocks has not been established.
• Postdural puncture headache: This is caused by cerebrospinal fluid (CSF) escape through a hole
in the arachnoid. It has traditionally been described as a constant, sometimes incapacitating
headache, worse on sitting, straining and often accompanied by photophobia and nausea. A
postdural puncture headache, although very distressing, is not representative of a serious
complication. An epidural, by definition, is not intended to pierce the dura and so a large needle is
used. However, accidental dural puncture will cause significant CSF leak and is associated with a
high incidence of headache, especially in young adults. In contrast, a subarachnoid block is
intended to pierce the arachnoid and is therefore performed with a much smaller needle, often
especially designed to reduce CSF leak; it is normally associated with a small incidence of
postdural puncture headache [22].
• Accidental total spinal block. Essentially this occurs when the arachnoid is inadvertently
punctured while attempting an epidural block; this leads to injection of an excessive amount of local
anaesthetic, intended for the epidural space, into the subarachnoid space. The large dose can
rapidly extend to the brain stem, affecting consciousness and the respiratory and vasomotor
centres. It is a potentially serious complication which requires rapid action, normally in the form of
intubation, ventilation and cardiovascular support.
• Epidural haematoma or abscess. These are both exceedingly rare; they require emergency
neurosurgical assessment and probable surgical decompression without delay.
• Meningitis.
• Arachnoiditis, myelitis, cauda equina syndrome.
TOURNIQUETS
Tourniquets are used to isolate limbs from the circulation and reduce bleeding.
Technique
The limb is exsanguinated by elevation or with the use of an Esmarch bandage. Current cuffs are
usually pneumatic; they must be regularly maintained. The cuff is inflated to about 30–50 mmHg
and 70–100mmHg above systolic pressure for the upper and lower limbs, respectively. Tourniquet
inflation can be very painful. The limb must be appropriately padded; in addition, it is usually
necessary to administer a general or local anaesthetic. During inflation it is essential to
check cuff inflation constantly. Most surgeons and anaesthetists attempt to maintain the cuff
inflated for not longer than 2 h.
Side-effects
In general the frequency and severity of side-effects is proportional to the duration of limb
ischaemia. Ischaemia per se can cause nerve and muscle damage. There can also be
damage to soft tissues. The tourniquet effectively reduces the intravascular compartment; thus the
relative intravascular blood volume is increased. This causes a rise in venous return, which can
increase the cardiac output and blood pressure. Circulatory stasis within the limb predisposes to
thromboembolism. Upon release of the tourniquet, anaerobic metabolites enter into the circulation.
These metabolites, mostly CO2, acids and potassium, cause a general vasodilation, not unlike
reperfusion injury, which can be deleterious in the patient with poor cardiovascular reserve. There
is also reactive hyperaemia which can increase bleeding. Tourniquets are normally contraindicated
in ischaemic peripheral vascular disease and sickle cell states.