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Complications of regional anesthesia

J. Eric Greensmith and W. Bosseau Murray
Purpose of review
The use of regional anesthesia, either alone or as an adjunct
to general anesthesia, is at an all-time high. Demonstrated
benets include reduced side effects, more efcient use of
facilities and enhanced patient satisfaction with the
improved postoperative pain relief. New advances in
equipment, techniques and medications have been
incorporated over the past 10years, and especially over the
last 2years. As the number of practitioners and procedures
increase, the number of complications may rise as well.
Recent ndings
The specic issues of nerve damage, treatment of local
anesthetic toxicity with lipid solutions and prevention of
wrong-sided procedures are examined with special
reference to recent publications.
Summary
Specic needle shapes, appropriate pharmacologic
resuscitation from intravascular injection of local
anesthetics and institutional procedures to positively
identify patients and the correct block location are all part of
a strategy to minimize the occurrence of adverse outcomes
and to mitigate the consequences of those adverse events
when they do occur. More importantly, these are changes
that can be instituted immediately with minimal expense to
the institution and great benet to the patient.
Keywords
complications, local anesthetic toxicity, nerve injury,
regional anesthesia, wrong-sited procedure
Curr Opin Anaesthesiol 19:531537. 2006 Lippincott Williams & Wilkins.
Pennsylvania State University College of Medicine, Hershey, Pennsylvania, USA
Correspondence to W. Bosseau Murray, Department of Anesthesiology H-187,
Pennsylvania State University College of Medicine, 500 University Ave, Hershey,
PA 17036, USA
Tel: +1 717 531 4265; fax: +1 717 531 5449; e-mail: wbmurray@psu.edu
Current Opinion in Anaesthesiology 2006, 19:531537
2006 Lippincott Williams & Wilkins
0952-7907
Introduction
Recent national publications document the fact that
perioperative pain is poorly managed. Regional anesthe-
sia has been proposed as a key component of a compre-
hensive multimodal approach to the prevention of
postoperative pain.
The last decade, and particularly the last 5 years, have
witnessed a signicant increase in the use of regional
anesthesia. Purported benets of regional anesthestic
techniques range from reduced mortality and reduced
major morbidity [1], reduction in minor (albeit annoying)
morbidities [2], to enhanced tissue oxygenation, and
improved outpatient pain management [3

,4

].
Sales of regional anesthesia textbooks, videos, interactive
DVDs, regional anesthesia equipment and journals, as
well as visits to regional websites, are at an all-time high.
New developments have been reported in nerve stimu-
lators [5], as well as novel drug delivery technologies
(pumps, deposition release medications [6

], and trans-
cutaneous drug-delivery systems).
The enhanced numbers of practitioners of regional
anesthesia, and a logarithmic growth in procedures per-
formed, similarly increase the potential for complications
and adverse outcomes. This review will examine three
areas of challenge and progress with regards to compli-
cations in the practice of regional anesthesia: direct and
pressure-induced nerve injury, local anesthetic toxicity
and wrong-site regional procedures.
New information regarding direct nerve injury
The public perception of the danger in peripheral neural
blockade largely centers around concerns of direct nerve
injury by the use of a needle, for instance paralysis after a
needle in the back/spine.
Studies by Dag Selander and colleagues in the 1970s [7]
demonstrated that blunt or B bevel needles (see Fig. 1)
are less likely to penetrate a nerve, and thus, less likely to
cause nerve damage, than a long, sharp cutting edge
needle [7]. There was a brief urry of controversy over
this after Rice and McMahons report in 1992 [8] that long
bevel (i.e. sharp) needles were less likely to cause nerve
damage than B-bevel needles an apparent refutation of
Selanders work. This apparent discrepancy is explained
by the methodologic differences wherein Rice and
McMahons in-situ model guaranteed that the nerve
was impaled by the needle whereas Selanders work
531
Copyright Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
(and most biologic scenerios) allow the nerve to move
freely and thus passively slide away from all but the most
resolute needle approaches. Recent application of high-
resolution ultrasound technology conrms, in real time,
Selanders premise [7] that major nerves approached by a
blunt bevel block needle in unconned spaces are rarely
penetrated by the needle and generally slide away from
the needle after any contact. Nerves being blocked in
conned spaces (e.g. the ulnar nerve at the olecranon
fossa, the bular nerve at the head of the bula) may not
enjoy this relative protection due to their lack of mobility
in their anatomic connement. In a recent review, Mar-
hofer et al. [9] suggested that not only can ultrasound
guidance ensure a high block success rate, but also can
nearly eliminate needle complications.
Still, it is apparent that nerves can be penetrated by
needle placement with variable sequelae ranging from
no demonstrable change in function to permanent sen-
sory and motor dysfunction. What accounts for this range
of outcomes for direct nerve injury? Clinical experience
(but not examined in any prospective experimental
fashion) with ultrasound guided blocks suggests that early
recognition of intraneural injection is readily apparent
as the nerve is seen to swell with the rst few milliliters of
local anesthetic injected. Immediate cessation of injec-
tion and repositioning of the needle to an extraneural
location have been associated with the absence of
demonstrable neural decit in the postoperative period
(V. Chan, 2006, personal communication). While this
absence of proof, is not proof of absence, it suggests a
fruitful line of investigation for avoidance of nerve
damage.
Unfortunately, there are several case reports with what
appear to be direct intraneural injections and resultant
permanent dysesthesias in patients who were lightly
sedated or not sedated at all and the patients did
not report any pain in the course of the local anesthetic
injection [10]. Since intraneural injection of local anes-
thetic may give a very brief paresthesia that is rapidly
extinguished by the presence of the local anesthetic
within the nerve [11], it has been suggested that use
of 1 ml of saline should be administered for the initial Raj
test so that any painful intraneural injections would not
be masked by the presence of local anesthetic within the
nerve ber. Since cessation of muscular contraction with
the nerve stimulator occurs rapidly, the small injection of
the Raj test is thought to be due to charge dissipation; the
use of saline in lieu of local anesthetic should still be
predictive of a successful block [12].
Another line of investigation suggests that postregional/
postoperative nerve injury may be a function of periph-
eral nerve ischemia. Among possible contributors to
peripheral nerve ischemia is the addition of low-dose
(5 mg/ml) epinephrine to the local anesthetic mixture.
Selander performed topical endoneural and intrafascicu-
lar injections of saline with various concentrations of
bupivicaine in the presence or absence of epinephrine
in rabbit sciatic nerves in vivo. While intrafascicular
injections inevitably were associated with neuronal
degeneration, endoneurial injections seemed to be
associated with degeneration based on the presence of
epinephrine at 5 mg/ml. Perhaps nerves with a generous
collateral blood supply may be less vulnerable than those
in a watershed area between two tenuous vascular
arcades, such as the sciatic nerve. So at least for the
sciatic nerve, the recommendation has been to forgo
the addition of epinephrine, especially for the use of
long-acting agents such as bupivacaine.
Neural ischemia may also arise from a variety of other
impediments to blood ow, such as a tourniquet occluding
the blood supply to a nerve, hypotension and/or increases
in intraneural pressure that cause temporary cessation of
nutrient blood ow. Hadzic and colleagues [13] demon-
strated in an anesthetized dog model that low pressure
nerve injections both perineurally (into the epineurium)
and intraneurally (within the perineurium) were not
permanently injurious to the nerves in the dogs, whereas
higher pressure injections (11psi) were associated
with severe fascicular injury and persistent neurologic
injury.
In a simulation study designed to examine pressures that
anesthesiologists achieved during regional anesthetic
532 Regional anaesthesia
Figure 1 A comparison of 21 gauge Quincke (upper) and
B-bevel 45- (lower) needles
The B-bevel (lower) needle is blunt enough to make direct nerve
penetration less likely, as per D.E. Selander [7].
Copyright Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
injections, Claudio et al. [14] demonstrated that the vast
majority of anesthesiologists generated pressures greater
than 20 psi and 10%exerted greater than two atmospheres
(30 psi) all well beyond the 11 psi breakpoint for
permanent nerve injury in cases of intraneural injection.
This study went on to illustrate how unreliable the
nebulous parameter of syringe feel is for predicting true
injection pressures.
In truth, all of these factors (and others to be discovered)
may well coexist in cases of nerve injury. Nerves already
compromised by poor vascular supply may be damaged
by needle contact, particularly if entrapped and incapable
of sliding away from a needle with a cutting taper. Any
ensuing injection, especially an intraneural position and/
or injected at high pressure, may bring nutrient blood
ow to a halt. Neural ischemia would be even more
severe if vasoconstrictors were added to the local anes-
thetic. Strategies to minimize complications will work
best when brought to bear on all the risk factors that
potentiate nerve injury risk.
New developments in the treatment of
systemic local anesthetic toxicity
Systemic local anesthetic toxicity and its consequences
are major sources of complications in regional anesthesia.
The two most problematic consequences of toxicity are
seizures and cardiac toxicity. While absolute limits and
weight-scaled limits have been proposed, debated and
refuted in the literature, it is clear that location of [15]
local anesthetic injection is at least as important as the
absolute mass of drug administered.
Relative toxicities of the various ester and amide local
anesthetics have been calculated and expressed as a ratio
to the nerve blocking potency and as a ratio of the cardiac
to central nervous system (CNS) toxicity [16]. Bupivi-
caine, a favored amide local anesthetic, has a narrow CNS
to cardiac toxicity ratio [17]. High doses or rapid increases
in plasma bupivicaine levels can predispose the heart to a
variety of brady-dysrhythmias as well as ventricular
tachycardia and ventricular brillation. Due to the high
afnity of bupivicaine for cardiac sodium channels (as
well as other myocardial sites) [18], bupivicaine cardiac
toxicity can be extremely refractory to all conventional
treatment strategies. Paradoxically, the bupivicaine bind-
ing to sodium channels greatly retards myocardial cellular
metabolism, affording a measure of cellular protection in
the face of ischemia [19]. Thus, bupivicaine is, ironically,
a myocardial preservative. Strategies that rapidly reduce
bupivicaine levels (the functional equivalent of a chelator
or binding agent) or support circulation (cardiopulmonary
bypass) until bupivicaine levels drop by redistribution,
metabolism and clearance may result in an amazingly
well preserved myocardial function despite an asystolic
myocardial arrest.
Bupivicaine is very lipid soluble, suggesting that infusion
of a lipid may serve to chelate (bind) the local anesthetic
and lower free plasma levels of the drug. Isolated heart
experiments show that radiolabled bupivicaine had a
much faster washout rate from the myocardium when a
lipid emulsion was infused through the coronary circula-
tion. Time to recovery of intrinsic rhythm, time to
recovery of baseline pressure and rate pressure product
were all signicantly reduced by intravascular lipid emul-
sion therapy [20

].
In-vivo rat experiments by Weinberg et al. in the late
1990s [21] demonstrated a protective shift in the cardiac
toxic dose of bupivicaine when administered after lipid
infusion. Intravenous lipids remained merely as a theor-
etic antidote to the specter of bupivicaine toxicity until
this year, when the rst case report of a successful human
resuscitation from bupivicaine toxicity using lipids was
published.
In a recent extraordinary case report [22], a 58-year-old,
82 kg male, with a history of coronary bypass surgery was
administered a supraclavicular block for arm surgery.
Ninety seconds after receiving a mixture of 20 ml each
of mepivicaine 1.5% and bupivicaine 0.5%, the patient
began to seize and demonstrated premature ventricular
contractions, followed by ventricular tachycardia that
progressed on to a complete asystolic cardiac arrest.
The seizure was rapidly recognized as due to local
anesthetic toxicity and rapidly truncated with 100 mg
of intravenous propofol. Cardiopulmonary resuscitation
(CPR) was initiated and epinephrine, 1 mg, was adminis-
tered three times, plus a loading dose of amiodarone as
well as vasopressin along with a total of four direct current
countershocks without success. At this point 100 ml of
20% lipid emulsion was given as an intravenous bolus.
The patient received a fth attempt at direct current
debrillation; the patient had one sinus beat followed by
resumption of a normal sinus rhythm at 90 beats per
minute. The patient was eventually discharged home,
neurologically intact. This case is very impressive in that
bupivicaine toxicity if it progressed to the point of
cardiac standstill has been almost uniformly lethal.
A lipid emulsion cheap and readily available may
be our rst effective antidote to this most dreaded of all
regional anesthesia complications.
This case report [22] is accompanied by a leading
editorial [23] emphasizing the clinical importance of
the use of lipids, especially as the basic science and
animal work has such a solid basis.
Wrong-sided and wrong-site procedures
In a eld proudly featuring exceptional achievements of
nerve localization, imaging, nerve stimulation and
reductions in mortality and morbidity, it may seem trivial
Complications of regional anesthesia Greensmith and Murray 533
Copyright Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
and incongruous to discuss the (seemingly) simple con-
cept of wrong-sided procedures [24]. It is not trivial.
Figure 2 shows the number of wrong-site surgeries by
year over the past decade. While there is no comparable
registry for wrong-sided regional anesthetics (yet), it is
probable that the trend would be similar.
In May 2003, the Joint Commission on HealthCare
Organizations (JCAHO) and its corporate members
sponsored a Wrong-Site Summit. More than 50 partici-
pants discussed a root cause analysis of wrong-site pro-
cedures and identied potential barriers to elimination of
those root causes. At this summit, ve key areas were
identied:
(1) preoperative verication;
(2) a dened timeout prior to the procedure;
(3) unambiguous surgical site marking;
(4) special situations and settings outside of the operat-
ing room;
(5) physician buy-in.
JCAHO maintains an extensive website (http://www.
jointcommission.org) with explicit guidelines on the uni-
versal protocol for avoiding wrong side surgery. The
pre-regional anesthetic timeout should be implemented
prior to the surgical timeout and is analogous in
many ways.
Preoperative block placements often occur outside of the
operating room setting and, therefore, are somewhat
removed from the remainder of the preoperative safety
checks. Furthermore, patients are not infrequently
blocked at anatomical locations remote from their surgi-
cal site. A patient having ankle surgery may have a
femoral/sciatic block combination to block both operative
and tourniquet pain. Finally, for some midline or unilat-
eral structures such as partial or total thyroidectomy it
may be appropriate to block the supercial cervical
plexus bilaterally even though the surgery may be
one sided.
Although there are no formal statistical data available on
this point, front/back block combinations seem to be
particularly vulnerable to wrong-sided blocks. The
patient may be positioned prone for a sciatic block of
any approach with the operator standing ipsilateral to the
side to be blocked. When the patient is subsequently
turned supine for a femoral or saphenous nerve block,
operators must switch sides or they are now standing on
the side of the extremity not to be blocked and thus at
risk for a wrong-sided block.
Deschner and colleagues [25], in an abstract at the 2006
American Society of Regional Anesthesia (ASRA) meet-
ing, describe a systematic timeout approach before
sedation of a block procedure is initiated (see Fig. 3).
The mnemonic ECT is used to denote equipment
check, consent check and timeout check for correct,
and labeled block site. Analogous to the pilot preight
checklist, a formal, systematic preprocedural review such
as this is the best systems defense against a wrong-
sided procedure.
At our institution, we have recently instituted the follow-
ing process: the initial event in a patient encounter in the
block room is a timeout/check in. The patients name
band is checked and conrmed with the patient and the
chart. The allergy, anticoagulant and fasting (NPO)
histories are checked, along with the patients under-
standing of what surgery is to be performed. The anesthe-
siologists put their initials on the front and back of the
extremity to be blocked. A circumferential band of 10 cm
(4 inch) wide blue masking tape is placed loosely around
the extremity to be blocked. The patient is positioned
and draped such that the blue band of marking tape is
534 Regional anaesthesia
Figure 2 The increase in the number of reported wrong-site surgeries over the last decade
Number of
events reported
Sentinel trend events:
wrong-site surgeries reported by year
100
90
80
70
60
50
40
30
20
10
0
2005 2004 2003 2002 2001 2000 1999 1998 1997 1996 1995
Adapted from the Joint Commission on HealthCare Organizations (JCAHO) website at http://www.jointcommission.org.
Copyright Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
visible at all times during placement of the regional
anesthetic.
Future trends
New improvements in medications, training, procedural
techniques, neural localization, and safety procedures are
frequently reported. Future trends are always difcult to
predict, and many a prognostication has appeared foolish
in retrospect, but two unrelated areas of basic science
research bear scrutiny.
The rst is use of the high conductance properties of
major nerve tracts to map these nerves transcutaneously
(http://www.nervonix.com). Since nerves have a low
impedance to current ow lower than surrounding
muscle, bone and connective tissue it may be possible
to apply small currents in higher frequency ranges that
take advantage of the conductive properties of individual
nerves and search for an increased current ow down-
stream as the nerve is approached by the stimulating
current.
Secondly, a new facet may be entering the regional
anesthesia/general anesthesia debate in the dual nature
of opiate analgesics specically the ability to ameliorate
acute pain contrasted with the long-term sequelae of pain
sensitization [26]. While it is clear that opiates are unsur-
passed among intravenous and oral medications in the
treatment of pain, there is a growing body of literature to
suggest that these same medications may set up a post-
operative hypersensitivity. It is possible that the concept
of preemptive analgesia may, in fact, be a manifestation
of opiate sparing and a lack of the postoperative sen-
sitization by perioperative narcotic administration [27].
If, in fact, opiates exacerbate the postoperative pain
experience, this will lend a new impetus to the search
for ever more effective means of multimodal analgesia
that are opiate sparing and thus, ultimately, pain
sparing.
Thirdly, a call has been made for more radiological
studies after suspected subdural placement of an epidural
catheter, in an attempt to better understand the physi-
ology. A novel case of rapid onset (6 min) massive sub-
dural anesthesia with cardiovascular collapse was
reported by Wills [28]. The position of the epidural
catheter was radiologically conrmed after successful
resuscitation. We highlight this case because of the rarity
of subdural blocks, and the consequent tendency for
practitioners not to test the height of the block after
the test dose.
Fourthly, although infectious complications of regional
anesthesia have not been a focus of this article, they
remain a dreaded, albeit rare, threat, and readers are
directed to a recent review of this topic [29].
Finally, two recent reviews are commended to the reader.
The rst is a brief review of perioperative nerve dysfunc-
tion by Ridgeway and Herrick [30]. This describes three
key points.
(1) Temporary postoperative paraesthesia is not uncom-
mon, even with no known errors occurring.
(2) The incidence of permanent nerve damage is
approximately one in 5000.
(3) A nerve stimulator will not necessarily prevent
nerve damage.
Patient positioning and surgery are often implicated in
perioperative nerve damage.
The second is a comprehensive review of peripheral
nerve block catheters by Andre Boezaart [31]. This
review includes an extensive review of complications
of perineural blocks under the headings nerve injury,
infection, associated unwanted nerve blockade, compli-
cations due to drug effects, and pain during catheter
placement. The conclusion is that in spite of these rare
complications, it is still valuable to place such nerve
catheters, as this technique is the only one enabling pain
relief not only during periods of immobility, but also
during mobilization and movement of the extremities, for
instance, during physical therapy.
Complications of regional anesthesia Greensmith and Murray 535
Figure 3 The proposedECT protocol to use as a timeout to avoid
errors with regional anesthesia blocks, including wrong-sided
blocks
ECT protocol
E = Equipment check
Block supplies Resuscitation
equipment
Anesthesia consent
T = Timeout procedure
Staff involved
Anesthesiologist
Licensed personnel
Patient
Extremities uncovered
Yes surgical site -- in bold
Chart
Marked site matches
surgical consent
Surgical consent
C = Consent check
Adapted and redrawn from Deschner et al. [25].
Copyright Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Conclusion
Complications in regional anesthesia range from trivial to
life threatening. Incidence and prevalence gures for
morbidity and mortality vary with the procedure and
health status of the patient. Although there are data from
closed claims analyses [32], small randomized trials, as
well as from large individual case series compared with
historic controls [33], it is difcult to get accurate inci-
dence gures with a reliable denominator of procedures
performed.
Using the methodology of surveillance studies that has
proven helpful in infection control research, Schulz-Stub-
ner and colleagues at the University of Iowa have recently
organized the Regional Anesthesia Surveillance System
(http://www.uirass.com) in an effort to assemble large
numbers of patient experiences with regional anesthesia,
such that accurate statements can be made about inci-
dence, type and prevalence of complications. Tim Cook
from the Royal College of Anaesthetists of Great Britain
is organizing a comparable audit of major complications of
neuraxial anesthesia (tcook@rcoa.ac.uk). Out of these
large aggregate experiences, it is hoped that meaningful
trends will become apparent and benchmark statistics can
be derived against which individual practitioners and
institutions can compare their performance.
This brief survey has looked at technical, pharmacologic
and administrative advances to minimize complications
and enhance safety in the practice of regional anesthesia.
As the advantages of regional anesthesia become appar-
ent and the numbers of procedures performed multiply, it
is imperative that we enhance the safety and quality of
the practice in parallel as a duty to our patients.
References and recommended reading
Papers of particular interest, published within the annual period of review, have
been highlighted as:
of special interest
of outstanding interest
Additional references related to this topic can also be found in the Current
World Literature section in this issue (pp. 583584).
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536 Regional anaesthesia
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