Avoiding Complications in Regional Anesthesia

  • Richard W. Rosenquist


There is widespread conviction among anesthesiologists that regional anesthesia offers significant advantages over general anesthesia in certain settings. At the same time, there is a fear of complications related to the performance of regional anesthetic techniques that is held with almost equal intensity. Complications related to regional anesthesia have been described by many authors, although our understanding of the numerous factors leading to these complications is limited. Auroy et al.1 described the risk of complications related to regional blocks as lower than 5 in 10,000 patients in their series, which included spinal, epidural, and peripheral nerve blocks. In the case of spinal or epidural hematoma, the relative risk has been described as 1∶220,000 and 1∶150,000, respectively, a rate that approaches the risk of routine general anesthesia.2 However, the risk of neurologic complications after central neuraxial block can be markedly elevated (1∶1,800) in patients with risk factors such as female sex, osteoporosis, or concurrent use of anticoagulants.3 Despite the relatively infrequent occurrence of complications related to regional anesthesia, the fear of complications exceeds their actual occurrence. This may be attributable in part to widespread misperceptions regarding the role of regional anesthesia in producing neurologic injury on the part of patients, surgeons, anesthesiologists, and other healthcare providers. The absence of a clear understanding often leads to blame being assigned to the regional anesthetic without careful assessment and diagnosis of the neurologic deficit to determine its etiology.


Local Anesthetic Regional Anesthesia Needle Insertion Brachial Plexus Injury Peripheral Nerve Block 
These keywords were added by machine and not by the authors. This process is experimental and the keywords may be updated as the learning algorithm improves.


Unable to display preview. Download preview PDF.

Unable to display preview. Download preview PDF.


  1. 1.
    Auroy Y, Benhamou D, Bargues L, et al. Major complications of regional anesthesia in France: The SOS Regional Anesthesia Hotline Service. Anesthesiology 2002;97:1274–1280.PubMedCrossRefGoogle Scholar
  2. 2.
    Horlocker TT, Wedel DJ, Benzon H, et al. Regional anesthesia in the anticoagulated patient: defining the risks (the second ASRA Consensus Conference on Neuraxial Anesthesia and Anticoagulation). Reg Anesth Pain Med 2003;28:172–197.PubMedGoogle Scholar
  3. 3.
    Moen V, Dahlgren N, Irestedt L. Severe neurological complications after central neuraxial blockades in Sweden 1990–1999. Anesthesiology 2004;101:950–959.PubMedCrossRefGoogle Scholar
  4. 4.
    Lee LA, Posner KL, Domino KB, et al. Injuries associated with regional anesthesia in the 1980s and 1990s: a closed claims analysis. Anesthesiology 2004;1001:143–152.CrossRefGoogle Scholar
  5. 5.
    Ekatodramis G, Macaire P, Borgeat A. Prolonged Horner syndrome due to neck hematoma after continuous interscalene block. Anesthesiology 2001;95:801–803.PubMedCrossRefGoogle Scholar
  6. 6.
    Bergman BD, Hebl JR, Kent J, Horlocker TT. Neurologic complications of 405 consecutive continuous axillary catheters. Anesth Analg 2003;96:247–252.PubMedGoogle Scholar
  7. 7.
    Tsao BE, Wilbourn AJ. Infraclavicular brachial plexus injury following axillary regional block. Muscle Nerve 2004;30:44–48.PubMedCrossRefGoogle Scholar
  8. 8.
    Cockings E. Axillary block complicated by hematoma and radial nerve injury. Reg Anesth Pain Med 2000;25:103.PubMedGoogle Scholar
  9. 9.
    Ben-David B, Stahl S. Axillary block complicated by hematoma and radial nerve injury. Reg Anesth Pain Med 1999;24:264–266.PubMedCrossRefGoogle Scholar
  10. 10.
    Nielsen CH. Bleeding after intercostals nerve block in a patient anticoagulated with heparin. Anesthesiology 1989;71:162–164.PubMedCrossRefGoogle Scholar
  11. 11.
    Hsu DT. Delayed retroperitoneal haematoma after failed lumbar plexus block. Br J Anaesth 2005;94:395.PubMedCrossRefGoogle Scholar
  12. 12.
    Aveline C, Bonnet F. Delayed retroperitoneal haematoma after failed lumbar plexus block. Br J Anaesth 2004;93:589–591.PubMedCrossRefGoogle Scholar
  13. 13.
    Weller RS, Gerancher JC, Crews JC, Wade KL. Extensive retroperitoneal hematoma without neurologic deficit in two patients who underwent lumbar plexus block and were later anticoagulated. Anesthesiology 2003;98:581–585.PubMedCrossRefGoogle Scholar
  14. 14.
    Klein SM, D’Ercole F, Greengrass RA, et al. Enoxaparin associated with psoas hematoma and lumbar plexopathy after lumbar plexus block. Anesthesiology 1997;87:1576–1579.PubMedCrossRefGoogle Scholar
  15. 15.
    Aida S, Takahashi H, Shimoji K. Renal subcapsular hematoma after lumbar plexus block. Anesthesiology 1996;84:452–455.PubMedCrossRefGoogle Scholar
  16. 16.
    Aydin ON, Eyigor M, Aydin N. Antimicrobial activity of ropivacaine and other local anaesthetics. Eur J Anaesthesiol 2001;18:687–694.PubMedGoogle Scholar
  17. 17.
    Capdevilla X, Pirat P, Bringuier S, et al. Continuous peripheral nerve blocks in hospital wards after orthopedic surgery: a multicenter prospective analysis of the quality of post-operative analgesia and complications in 1,416 patients. Anesthesiology 2005;103: 1035–1045.CrossRefGoogle Scholar
  18. 18.
    Morin AM, Kerwat KM, Klotz M, et al. Risk factors for bacterial catheter colonization in regional anaesthesia. BMC Anesthesiol 2005;5:1–9.PubMedCrossRefGoogle Scholar
  19. 19.
    Jacobsen RB, Borch JE, Bindslev-Jensen C. Hypersensitivity to local anaesthetics. Allergy 2005;60:262–264.PubMedCrossRefGoogle Scholar
  20. 20.
    Riemersma WA, Schuttelaar ML, Coenraads PJ. Type IV hypersensitivity to sodium metabisulfite in local anaesthetic. Contact Dermatitis 2004;51:148.PubMedCrossRefGoogle Scholar
  21. 21.
    Finucane BT. Allergies to local anesthetics — the real truth. Can J Anaesth 2003;50: 869–874.PubMedCrossRefGoogle Scholar
  22. 22.
    Korman B, Riley RH. Convulsions induced by ropivacaine during interscalene brachial plexus block. Anesth Analg 1997;85:1128–1129.PubMedGoogle Scholar
  23. 23.
    Crews JC, Rothman TE. Seizure after levobupivacaine for interscalene brachial plexus block. Anesth Analg 2003;96:1188–1190.PubMedCrossRefGoogle Scholar
  24. 24.
    Finucane BT. Ropivacaine cardiac toxicity — not as troublesome as bupivacaine. Can J Anaesth 2005;52:449–453.PubMedCrossRefGoogle Scholar
  25. 25.
    Petitjeans F, Mion G, Puidupin M, et al. Tachycardia and convulsions induced by acciden-tal intravascular ropivacaine injection during sciatic block. Acta Anaesthesiol Scand 2002; 46:616–617.PubMedCrossRefGoogle Scholar
  26. 26.
    Mullanu Ch, Gaillat F, Scemama F, et al. Acute toxicity of local anesthetic ropivacaine and mepivacaine during a combined lumbar plexus and sciatic block for hip surgery. Acta Anaesthesiol Belg 2002;53:221–223.PubMedGoogle Scholar
  27. 27.
    Cox B, Durieux ME, Marcus MA. Toxicity of local anaesthetics. Best Pract Res Clin Anaesthesiol 2003;17:111–136.PubMedCrossRefGoogle Scholar
  28. 28.
    Tsui BC, Wagner A, Finucane B. Regional anaesthesia in the elderly: a clinical guide. Drugs Aging 2004;21:895–910.PubMedCrossRefGoogle Scholar
  29. 29.
    Sakura S, Kirihara Y, Mugurama T, et al. The comparative neurotoxicity of intrathecal lidocaine and bupivacaine in rats. Anesth Analg 2005;101:541–547.PubMedCrossRefGoogle Scholar
  30. 30.
    Radwan IAM, Saito S, Goto F. The neurotoxicity of local anesthetics on growing neurons: a comparative study of lidocaine, bupivacaine, mepivacaine, and ropivacaine. Anesth Analg 2002;94:319–324.PubMedGoogle Scholar
  31. 31.
    Kasaba T, Onizuka S, Takasaki M. Procaine and mepivacaine have less toxicity in vitro than clinically used local anesthetic. Anesth Analg 2003;97:85–90.PubMedCrossRefGoogle Scholar
  32. 32.
    Kroin JS, Penn RD, Levy FE, Kerns JM. Effect of repetitive lidocaine infusion on peripheral nerve. Exp Neurol 1986;94:166–173.PubMedCrossRefGoogle Scholar
  33. 33.
    Zink W, Graf BM. Local anesthetic myotoxicity. Reg Anesth Pain Med 2004;29: 333–340.PubMedGoogle Scholar
  34. 34.
    Zink W, Bohl JRE, Hacke N, et al. The long term myotoxic effects of bupivacaine and ropivacaine after continuous peripheral nerve blocks. Anesth Analg 2005;101:548–554.PubMedCrossRefGoogle Scholar
  35. 35.
    Hogan Q, Dotson R, Erickson S, et al. Local anesthetic myotoxicity: a case and review. Anesthesiology 1994;80:942–947.PubMedCrossRefGoogle Scholar
  36. 36.
    Urmey WF, Grossi P. Percutaneous electrode guidance: a noninvasive technique for prelocation of peripheral nerves to facilitate peripheral plexus or nerve block. Reg Anesth Pain Med 2002;27:261–267.PubMedGoogle Scholar
  37. 37.
    Choyce A, Chen V, Middleton W, et al. What is the relationship between paresthesia and nerve stimulation for axillary brachial plexus block? Reg Aneseth Pain Med 2001; 26:100–104.Google Scholar
  38. 38.
    Bollini CA, Urmey WF, Vascello L, Cacheiro F. Relationship between evoked motor response and sensory paresthesia in interscalene brachial plexus block. Reg Anesth Pain Med 2003;2:384–388.Google Scholar
  39. 39.
    Perlas A, Chan VWS, Simons M. Brachial plexus examination and localization using ultrasound and electrical stimulation. Anesthesiology 2003;99:429–435.PubMedCrossRefGoogle Scholar
  40. 40.
    Chan VWS. Ultrasound evidence of intraneural injection. Anesth Analg 2005;101:610–611.PubMedCrossRefGoogle Scholar
  41. 41.
    Hadzic A, Dilberovic F, Shah S, et al. Combination of intraneural injection and high injection pressure lead to fascicular injury and neurologic deficits in dogs. Reg Anesth Pain Med 2004;29:417–423.PubMedGoogle Scholar
  42. 42.
    Benumof JL. Permanent loss of cervical spinal cord function associated with interscalene block performed under general anesthesia. Anesthesiology 2000;93:1541–1544.PubMedCrossRefGoogle Scholar
  43. 43.
    Lonnqvist PA, MacKenzie J, Soni AK, Conacher ID. Paravertebral blockade: failure rate and complications. Anaesthesia 1995;50:813–815.PubMedCrossRefGoogle Scholar
  44. 44.
    Capdevila X, Coimbra C, Choquet O. Approaches to the lumbar plexus: success, risks, and outcome. Reg Anesth Pain Med 2005;30:150–162.PubMedGoogle Scholar
  45. 45.
    Borgeat A, Ekatodramis G, Gaertner E. Performing an interscalene block during general anesthesia must be the exception. Anesthesiology 2001;85:1302–1303.CrossRefGoogle Scholar
  46. 46.
    Choquet O, Jochum D, Estebe JP, et al. Motor response following paresthesia during interscalene block: methodological problems may lead to inappropriate conclusions. Anesthesiology 2003;98:587–588.PubMedCrossRefGoogle Scholar
  47. 47.
    Edmonds CR, Liguori GA, Stanton MA. Two cases of a wrong-site peripheral nerve block and a process to prevent this complication. Reg Anesth Pain Med 2005;30:99–103.PubMedGoogle Scholar
  48. 48.
    Sites BD, Gallagher J, Sparks M. Ultrasound-guided popliteal block demonstrates an atypical motor response to nerve stimulation in 2 patients with diabetes mellitus. Reg Anesth Pain Med 2003;28:479–482.PubMedGoogle Scholar
  49. 49.
    Nielsen DC, Guller U, Steele SM, et al. Influence of obesity on surgical regional anesthesia in the ambulatory setting: an analysis of 9,038 blocks. Anesthesiology 2005;102:181–187.PubMedCrossRefGoogle Scholar

Copyright information

© Springer Science+Business Media, LLC 2007

Authors and Affiliations

  • Richard W. Rosenquist
    • 1
    • 2
  1. 1.Department of AnesthesiaUniversity of IowaIowa CityUSA
  2. 2.Pain Medicine DivisionUniversity of IowaIowa CityUSA

Personalised recommendations