Regional anaesthesia, also known as nerve block, is used to block the sensation in a specific part of the body during and after surgery.

A reliable method to prevent pain from becoming chronic involves using a regional anaesthetic technique to block a pain stimulus near its origin, thereby eliminating acute pain as a post-operative risk factor. Regional anaesthetic techniques can be divided into two categories; central and peripheral techniques. The central techniques include neuraxial blockade (e.g. epidural anaesthesia, and spinal anaesthesia). The peripheral techniques can be further divided into brachial plexus blocks and single nerve blocks.

The aim of acute pain management is to achieve a comfortable, mobile patient with a sedation score of less than two. Patients often experience pain in the post-operative period which, if uncontrolled, can be associated with increased morbidity. Body systems which can be compromised by inadequate pain control include the respiratory, cardiovascular, neuroendocrine, musculoskeletal and gastrointestinal systems. The psychological effects of pain should also be considered. When left untreated, pain can lead to fear and psychological distress related to the patient’s concerns regarding disability, loss of income, and underlying illness.

Local anaesthetics are widely used for the management of acute pain resulting from surgical procedures and child birth. When local anaesthetics are injected or infused into specific sites, they provide a loss of sensation to that region by reversibly blocking the transfer of peripheral nerve stimulation in that part of the body. The effect may be gained from a local anaesthetic alone, or enhanced by combination with an analgesic (e.g. ropivacaine with fentanyl). Local anaesthetics may also be administered in a continuous infusion, over several days, for effective post-operative pain control.

Long-Acting Local Anaesthetics

Bupivacaine is a long-acting agent, but has a relatively high potential for cardiotoxicity. It is used for minor and major nerve blocks, spinal anaesthesia and epidurals.

Ropivacaine is a long-acting agent that is structurally related to bupivacaine and mepivacine. It was developed as a safer alternative to bupivacaine, and is less cardiotoxic when accidentally administered intravenously. It is used for minor (e.g. field blocks and infiltrations) and major (e.g. brachial plexus) nerve blocks, spinal anaesthesia, epidurals, continuous peripheral nerve blocks (e.g. knee arthroplasty) and wound infiltration. Ropivacaine is the only local anaesthetic indicated for continuous peripheral nerve blocks.

Levobupivacaine is used for minor and major nerve blocks, spinal anaesthesia, epidurals, and wound infiltration; and is also less cardiotoxic than bupivacaine.

Short-Acting Local Anaesthetics

Lignocaine is a short-acting local anaesthetic. It has inherent potency, rapid onset, and a medium duration of action. The addition of a vasoconstrictor agent (e.g. adrenaline) greatly extends the duration of its effect.

Prilocaine has a similar clinical profile to lignocaine in terms of speed of onset and duration of effect. However, it is absorbed more slowly due to its lesser vasodilation effect. It also has less central nervous system toxicity than lignocaine.

Topical Anaesthetics

For topical anaesthesia, a local anaesthetic is applied to an area of the body’s surface in the form of a spray, cream, gel or solution (with the aim of blocking activity in the pain receptors of the superficial nerves that lie immediately below the surface). The choice of local anaesthetic depends on the region which needs to be anaesthetised (refer to Table 1).

Table 1. Forms and Uses of Topical Lignocaine.

Form Use
Topical Lignocaine
Spray, 10% Surface anaesthesia of mucous membranes prior to:

  • Otorhinolaryngology
  • Dental procedures
  • Introducing instruments and catheters into the respiratory and digestive tracts, and
  • Obstetric procedures.
Special Adhesive, 10% Surface anaesthesia of the gums prior to:

  • Injection
  • Scaling, and
  • Fitting new dentures or orthodontic appliances.

Temporary relief of pain associated with removal of teeth.

Ointment, 5% Temporary relief of pain associated with:

  • Minor burns and abrasions of the skin including sunburn, insect bites, pruritus and sore nipples.

Anaesthesia of mucous membranes and anaesthetic lubricant during examination and instrumentation.
Surface anaesthesia of the gums prior to:

  • Injection
  • Deep scaling, and
  • Fitting new dentures.
Topical Solution, 4% Anaesthesia of mucous membranes of the oropharyngeal, tracheal and bronchial areas e.g. endotracheal intubation.
Viscous Solution, 2% Surface anaesthesia and lubrication for exploratory procedures (e.g. gastroscopy and rectoscopy).
Topical Lignocaine/Prilocaine
Cream, 5%
Patch, 1g
Anaesthesia of the skin prior to:

  • Needle or catheter insertions (e.g. vaccinations, and blood sampling)
  • Superficial procedures, and
  • Minor cosmetic procedures.

Anaesthesia of leg ulcers to assist debridement.
Anaesthesia of genital skin prior to superficial surgical procedures or infiltration anaesthesia.

 

Regional anaesthesia offers numerous advantages over conventional general anaesthesia, including faster recovery time, fewer side effects (less nausea and vomiting and fewer thromboembolic events), minimal post-operative pain and no need for an airway device during surgery, or need for an anaesthetist during minor procedures. Hospital stays can be significantly reduced and the overall costs are also reduced.

The disadvantages of regional anaesthesia include a requirement for practice and skill in order to achieve the best results. Toxicity can occur if the local anaesthetic is given intravenously or if an overdose is injected. Some blocks require up to 30 minutes, or more, to be fully effective. Post-operative pain management may not always be effective, requiring the possible use of additional analgesia. There is also a risk of nerve damage, and the area where the nerve block was administered may be sore or tender for a few days.

Various types of regional block procedures are possible to achieve blockade of different regions of the body, for example:

Central blockade:

  • Spinal: suitable for caesarean section and obstetric analgesia, hernia repair, hip and knee surgery, prostate surgery and most procedures on the foot or leg, and
  • Epidural: suitable for labour pain, orthopaedic surgery, caesarean section, thoracic and breast surgery, gynaecological procedures and upper and lower abdominal procedures.

Upper extremities:

  • Brachial Plexus Blockade: Interscalene block, Infraclavicular block, Supraclavicular block, Axillary block
  • Wrist block, and
  • Digital block.

Lower extremities:

  • Sciatic nerve block, and
  • Femoral nerve block.

Intravenous block:

  • Bier’s block.

After the block, verbal communication with the patient will often assist in identifying early signs of local anaesthetic toxicity (e.g. speech disturbances). Cardiovascular signs should be monitored. Rapid tachycardia will be detectable immediately if a solution containing adrenaline is accidentally injected intravenously.

Regional anaesthesia should only ever be conducted in an environment which is fully equipped and adequately staffed to provide safe general anaesthesia, should the need arise.

References:

  1. American Society of Regional Anesthesia and Pain Medicine. ASRA. Pittsburgh, USA. Available from www.asra.com. Accessed 13 April 2014.
  2. Bass C. Regional Anesthesia Lecture, Anesthesia 401 [lecture]. Chapel Hill: University of North Carolina; 2013. Available from www.unc.edu/~rvp/CVDocs/Regional%20Anes%20(Anes%20401).htm. Accessed 5 May 2014.
  3. Bupivacaine (bupivacaine hydrochloride) Australian approved product information. West Ryde: Pfizer Australia Pty Ltd. Approved 13 August 1991, amended 21 May 2012.
  4. Chirocaine (Levobupivacaine) Australian approved product information. Botany: AbbVie Pty Ltd. Approved 07 May 2001, amended 7 December 2012.
  5. Citanest (prilocaine hydrochloride) Australian approved product information. North Ryde: AstraZeneca Pty Ltd. Approved 1 March 2011.
  6. EMLA (lignocaine/prilocaine) Australian approved product information. North Ryde: AstraZeneca Pty Ltd. Approved 29 March 2010.
  7. Maunsell T, Shakallis R, Rudkin G. For the Nursing Professional – Regional anaesthesia and post-operative pain management with local anaesthetics. North Ryde: AstraZeneca Pty Ltd; 2012.
  8. Naropin (ropivacaine hydrochloride) Australian approved product information. North Ryde: AstraZeneca Pty Ltd. Approved 13 April 2011.
  9. Rossi S (editor). Australian Medicines Handbook 2014. Adelaide: Australian Medicines Handbook Pty Ltd; 2014.
  10. SFC Hill. Local/Regional Anesthesia [Lecture]. Fort Brag: Joint Special Operations Medical Training Centre; 2001.
  11. Xylocaine (lignocaine hydrochloride) Australian approved product information. North Ryde: AstraZeneca Pty Ltd. Approved 10 October 2008, amended 20 September 2010.

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