Skip to main content
SpringerLink
Log in

Complications of Peripheral Nerve Blocks

  • Chapter
Regional Nerve Blocks in Anesthesia and Pain Therapy

Abstract

Anesthesia after most peripheral nerve blocks (PNBs) wears off to complete return to normal nerve function. However, a small percentage of patients develop transient or persisting deficits of motor or sensory performance or a pain syndrome. Similarly, some patients develop systemic toxicity of local anesthetics. These rare but potentially devastating complications should not be surprising since local anesthetics are applied through sharp needles in considerable concentrations close to nerves or blood vessels. The goal of this chapter is to provide a concise overview of the incidence, mechanism of action, and means of prevention of complications associated with the use of PNBs as well as to forecast future developments in preventing such complications.

This is a preview of subscription content, log in via an institution to check access.

Access this chapter

Log in via an institution
Chapter
USD 29.95
Price excludes VAT (USA)
  • Available as PDF
  • Read on any device
  • Instant download
  • Own it forever
eBook
USD 189.00
Price excludes VAT (USA)
  • Available as EPUB and PDF
  • Read on any device
  • Instant download
  • Own it forever
Softcover Book
USD 249.99
Price excludes VAT (USA)
  • Compact, lightweight edition
  • Dispatched in 3 to 5 business days
  • Free shipping worldwide - see info

Tax calculation will be finalised at checkout

Purchases are for personal use only

Institutional subscriptions

References

  1. Auroy Y, Benhamou D, Bargues L. Major complications of regional anesthesia in France: The SOS regional anesthesia hotline service. Anesthesiology. 2002;97:1274–80.

    Article  PubMed  Google Scholar 

  2. Auroy Y, Narchi P, Messiah A, Litt L, Rouvier B, Samii K. Serious complications related to regional anesthesia: Results of a prospective survey in France. Anesthesiology. 1997;87:479–86.

    Article  CAS  PubMed  Google Scholar 

  3. Hadzic A, Vloka J. Kuroda M, et a: The practice of peripheral nerve blocks in the United States: a national survey. Reg Anesth Pain Med. 1998;23:241–6.

    Article  CAS  PubMed  Google Scholar 

  4. Hadzic A, Vloka J. Complications of peripheral nerve blocks. 1st ed. New York: McGrawHill; 2004.

    Google Scholar 

  5. Mackinnon S, Hudson A, Llamas F, Dellon A, Kline D, Dan A, Hunter R. Peripheral nerve injury by chymopapain injection. J Neurosurg. 1984;61:1–8.

    Article  CAS  PubMed  Google Scholar 

  6. Mackinnon S, Dellon A. Classification of nerve injuries as the basis of treatment. In: Mackinnon S, editor. Surgery of the peripheral nerve. New York: Thieme Medical Publishers Inc; 1988. p. 35–63.

    Google Scholar 

  7. Bigeleisen PE. Nerve puncture and apparent intraneural injection during ultrasound–guided axillary block does not invariably result in neurologic injury. Anesthesiology. 2006;105:779–83.

    Article  PubMed  Google Scholar 

  8. Kapur E, Dilberovic F, Zaciragic A, Cosovic E, Vuckovic I, Divanovic KA, Mornjakovic Z, Mirsad B, Borgeat A, Thys DM, Hadzic A. Neurologic and histologic outcome after intraneural injections of lidocaine in canine sciatic nerves. Acta Anaesthesiol Scand. 2006;51(1):101–7.

    Article  PubMed  Google Scholar 

  9. Sala–Blanch X, Pomes J, Matute P, Valls–Sole J, Carrera A, Tomas X, Garcia–Diez AI. Intraneural injection during anterior approach for sciatic nerve block. Anesthesiology. 2004;101:1027–30.

    Article  PubMed  Google Scholar 

  10. Schafhalter–Zoppoth I, Zeitz I, Gray A. Inadvertent femoral nerve impalement and intraneural injection visualized by ultrasound. Anesthesiology. 2004;99:620–30.

    Google Scholar 

  11. Selander D, Sjostrand J. Longitudinal spread of intraneurally injected local anesthetics. An experimental study of the initial neural distribution following intraneural injections. Acta Anesth Scand. 1978;22:622–34.

    Article  CAS  Google Scholar 

  12. Dutton R, Eckhardt 3rd W, Sunder N. Total spinal anesthesia after interscalene blockade of the brachial plexus. Anesthesiology. 1994;80:939–41.

    Article  CAS  PubMed  Google Scholar 

  13. Bhananker S, Domino K. What actions can be used to prevent peripheral nerve injury. In: Evidence–based practice of anesthesiology. Philadelphia: Elsevier Inc; 2004. p. 228–35.

    Google Scholar 

  14. Winnie A. Interscalene brachial plexus block. Anesth Analg. 1970;49:455–66.

    Article  CAS  PubMed  Google Scholar 

  15. Voelckel W, Klima G, Krismer C, Halsonger C, Stadlbauer H, Wenzel V, von Goedecke A. Signs of inflammation after sciatic nerve block in pigs. Anesth Analg. 2005;101:1844–6.

    Article  PubMed  Google Scholar 

  16. Selander D, Edshage S, Wolff T. Paresthesiae or no paresthesiae? Acta Anaesthesiol Scand. 1979;23:27–33.

    Article  CAS  PubMed  Google Scholar 

  17. Winchell SW, Wolfe R. The incidence of neuropathy following upper extremity nerve blocks. Reg Anaesth. 1985;10:12–5.

    Google Scholar 

  18. 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;28:384–8.

    Article  PubMed  Google Scholar 

  19. Karaca P, Hadzic A, Yufa M, Vloka JD, Brown AR, Visan A, Sanborn K, Santos AC. Painful paresthesiae are infrequent during brachial plexus localization using low–current peripheral nerve stimulation. Reg Anesth Pain Med. 2003;28:380–3.

    Article  PubMed  Google Scholar 

  20. Choyce A, Chan VW, Middleton WJ, Knight PR, Peng P, McCartney CJ. What is the relationship between paresthesia and nerve stimulation for axillary brachial plexus block? Reg Anesth Pain Med. 2001;26:100–4.

    Article  CAS  PubMed  Google Scholar 

  21. Urmey WF, Stanton J. Inability to consistently elicit a motor response following sensory paresthesia during interscalene block administration. Anesthesiology. 2002;6:552–4.

    Article  Google Scholar 

  22. Hadzic A, Dilberovic F, Shah S, Kulenovic A, Kapur E, Zaciragic A, Cosovic E, Vuckovic I. Combination of intraneural injection and high injection pressure leads to fascicular injury and neurologic deficits in dogs. Reg Anesth Pain Med. 2004;29:417–23.

    Article  PubMed  Google Scholar 

  23. Tsui B, Li L, Pillay J. Compressed air injection technique to standardize block injection pressures. Can J Anesth. 2006;53:1098.

    Article  PubMed  Google Scholar 

  24. Gebhardt R, Ghelber O, Warters R, Pivalizza E, Szmuk P. Local Anesthetic Injection–Pressure Monitoring during Nerve Blocks with the Compuflo™ Injection Pump. ASA Annual Meeting Abstracts Session. 2006;A1136.

    Google Scholar 

  25. Selander D, Dhuner K, Lundborg G. Peripheral nerve injury due to injection needles used for regional anesthesia. Acta Anaesthesiol Scand. 1977;21:182–9.

    Article  CAS  PubMed  Google Scholar 

  26. Rice A, McMahon S. Peripheral nerve injury caused by injection needles used in regional anaesthesia: Influence of bevel configuration, studied in a rat model. Br J Anaesth. 1992;9:433–8.

    Article  Google Scholar 

  27. Sturrock JE, Nunn JF. Cytotoxic effects of procaine, lignocaine and bupivacaine. Br J Anaesth. 1979;51:273–81.

    Article  CAS  PubMed  Google Scholar 

  28. Myers RR, Kalichman MW, Reisner LS, Powell HC. Neurotoxicity of local anesthetics: altered perineurial permeability, edema, and nerve fiber injury. Anesthesiology. 1986;64:29–35.

    Article  CAS  PubMed  Google Scholar 

  29. Barsa J, Batra M, Fink BR, Sumi SM. A comparative in vivo study of local neurotoxicity of lidocaine, bupivacaine, 2–chloroprocaine, and a mixture of 2–chloroprocaine and bupivacaine. Anesth Analg. 1982;61:961–7.

    CAS  PubMed  Google Scholar 

  30. Powell HC, Kalichman MW, Garrett RS, Myers RR. Selective vulnerability of unmyelinated fiber Schwann cells in nerves exposed to local anesthetics. Lab Invest. 1988;59:271–80.

    CAS  PubMed  Google Scholar 

  31. Kalichman MW, Powell HC, Myers RR. Pathology of local anesthetic–induced nerve injury. Acta Neuropathol (Berl). 1988;75:583–9.

    Article  CAS  Google Scholar 

  32. Li DF, Bahar M, Cole G, Rosen M. Neurological toxicity of the subarachnoid infusion of bupivacaine, lignocaine or 2–chloroprocaine in the rat. Br J Anaesth. 1985;57:424–9.

    Article  CAS  PubMed  Google Scholar 

  33. Ready LB, Plumer MH, Haschke RH, Austin E, Sumi SM. Neurotoxicity of intrathecal local anesthetics in rabbits. Anesthesiology. 1985;63:364–70.

    Article  CAS  PubMed  Google Scholar 

  34. Lambert LA, Lambert DH, Strichartz GR. Irreversible conduction block in isolated nerve by high concentrations of local anesthetics. Anesthesiology. 1994;80:1082–93.

    Article  CAS  PubMed  Google Scholar 

  35. Woolley EJ, Vandam LD. Neurological sequelae of brachial plexus nerve block. Ann Surg. 1959;149:53–60.

    Article  CAS  PubMed Central  PubMed  Google Scholar 

  36. Gentili F, Hudson AR, Hunter D, Kline DG. Nerve injection injury with local anesthetic agents: a light and electron microscopic, fluorescent microscopic, and horseradish peroxidase study. Neurosurgery. 1980;6:263–72.

    Article  CAS  PubMed  Google Scholar 

  37. Selander D, Brattsand R, Lundborg G, et al. Local anesthetics: Importance of mode of application, concentration and adrenaline for the appearance of nerve lesions. Acta Anaesth Scand. 1979;23:127–36.

    Article  CAS  PubMed  Google Scholar 

  38. Partridge BL. The effects of local anesthetics and epinephrine on rat sciatic nerve blood flow. Anesthesiology. 1991;75:243–50.

    Article  CAS  PubMed  Google Scholar 

  39. Myers RR, Heckman HM. Effects of local anesthesia on nerve blood flow: studies using lidocaine with and without epinephrine. Anesthesiology. 1989;71:757–62.

    Article  CAS  PubMed  Google Scholar 

  40. Duchen MR. Effects of metabolic inhibition on the membrane properties of isolated mouse primary sensory neurones. J Physiol. 1990;424:387–409.

    Article  CAS  PubMed Central  PubMed  Google Scholar 

  41. Lundborg G. Structure and function of the intraneural microvessels as related to trauma, edema formation, and nerve function. J Bone Joint Surg Am. 1975;57:938–48.

    CAS  PubMed  Google Scholar 

  42. Tountas CP, Bergman RA. Tourniquet ischemia: ultrastructural and histochemical observations of ischemic human muscle and of monkey muscle and nerve. J Hand Surg [Am]. 1977;2:31–7.

    Article  CAS  Google Scholar 

  43. Iida H, Schmelzer JD, et al. Peripheral nerve ischaemia: reperfusion injury and fiber regeneration. Exp Neurol. 2003;184:997–1002.

    Article  PubMed  Google Scholar 

  44. Iida H, Schmeichel AM, Wang Y, Schmelzer JD, Low PA. Schwann cell is a target in ischemia–reperfusion injury to peripheral nerve. Muscle Nerve. 2004;30:761–6.

    Article  PubMed  Google Scholar 

  45. Coderre TJ, Xanthos DN, Francis L, Bennett GJ. Chronic post–ischemia pain (CPIP): a novel animal model of complex regional pain syndrome–type I (CRPS–I; reflex sympathetic dystrophy) produced by prolonged hindpaw ischemia and reperfusion in the rat. Pain. 2004;112:94–105.

    Article  PubMed  Google Scholar 

  46. Fern R, Harrison PJ. The contribution of ischaemia and deformation to the conduction block generated by compression of the cat sciatic nerve. Exp Physiol. 1994;79:583–92.

    Article  CAS  PubMed  Google Scholar 

  47. Ochoa J, Fouler TJ, Gilliatt RW. Anatomical changes in peripheral nerve compressed by a pneumatic tourniquet. J Anat. 1972;113:433–55.

    CAS  PubMed Central  PubMed  Google Scholar 

  48. Nitz AJ, Matulionis DH. Ultrastructural changes in rat peripheral nerve following pneumatic tourniquet compression. J Neurosurg. 1982;57:660–6.

    Article  CAS  PubMed  Google Scholar 

  49. Mullick S. The tourniquet in operations upon the extremities. Surg Gynecol Obstet. 1978;146:821–6.

    CAS  PubMed  Google Scholar 

  50. Moore MR, Garfin SR, Hargens AR. Wide tourniquets eliminate blood flow at low inflation pressures. J Hand Surg [Am]. 1987;12:1006–11.

    Article  CAS  Google Scholar 

  51. Mohler LR, Pedowitz RA, Myers RR, Ohara WM, Lopez MA, Gershuni DH. Intermittent reperfusion fails to prevent posttourniquet neurapraxia. J Hand Surg [Am]. 1999;24:687–93.

    Article  CAS  Google Scholar 

  52. Dreyfuss UY, Smith RJ. Sensory changes with prolonged double–cuff tourniquet time in hand surgery. J Hand Surg [Am]. 1988;13:736–40.

    Article  CAS  Google Scholar 

  53. Brown DL, Ransom DM, Hall JA, Leicht CH, Schroeder DR, Offord KP. Regional anesthesia and local anesthetic–induced systemic toxicity: seizure frequency and accompanying cardiovascular changes. Anesth Analg. 1995;81:321–8.

    CAS  PubMed  Google Scholar 

  54. Scott B. Acute intravenous tolerance of etidocaine. Acta Anaesthesiol Scand Suppl. 1975;60:117–20.

    CAS  PubMed  Google Scholar 

  55. Scott DB. Evaluation of clinical tolerance of local anaesthetic agents. Br J Anaesth. 1975;47(Suppl):328–31.

    PubMed  Google Scholar 

  56. Scott DB, Lee A, Fagan D, Bowler GM, Bloomfield P, Lundh R. Acute toxicity of ropivacaine compared with that of bupivacaine. Anesth Analg. 1989;69:563–9.

    CAS  PubMed  Google Scholar 

  57. Moore JM, Liu SS, Neal JM. Premedication with fentanyl and midazolam decreases the reliability of intravenous lidocaine test dose. Anesth Analg. 1998;86:1015–7.

    CAS  PubMed  Google Scholar 

  58. Mulroy MF, Neal JM, Mackey DC, Harrington BE. 2–Chloroprocaine and bupivacaine are unreliable indicators of intravascular injection in the premedicated patient. Reg Anesth Pain Med. 1998;23:9–13.

    Article  CAS  PubMed  Google Scholar 

  59. Mahli A, Coskun D, Akcali DT. Aetiology of convulsions due to stellate ganglion block: a review and report of two cases. Eur J Anaesthesiol. 2002;19:376–80.

    Article  CAS  PubMed  Google Scholar 

  60. Korevaar WC, Burney RG, Moore PA. Convulsions during stellate ganglion block: a case report. Anesth Analg. 1979;58:329–30.

    Article  CAS  PubMed  Google Scholar 

  61. Guay J. The epidural test dose: a review. Anesth Analg. 2006;102:921–9.

    Article  PubMed  Google Scholar 

  62. Yoshii WY, Miller M, Rottman RL, Kotelko DM, Wright WC, Stone JJ, Rasmus KT, Rosen PJ. Fentanyl for epidural intravascular test dose in obstetrics. Reg Anesth. 1993;18:296–9.

    CAS  PubMed  Google Scholar 

  63. Leighton BL, Topkis WG, Gross JB, Arkoosh VA, Lee SH, Huffnagle HJ, Huffnagle SL. Multiport epidural catheters: does the air test work? Anesthesiology. 2000;92:1617–20.

    Article  CAS  PubMed  Google Scholar 

  64. Leighton BL, Gross JB. Air: an effective indicator of intravenously located epidural catheters. Anesthesiology. 1989;71:848–51.

    Article  CAS  PubMed  Google Scholar 

  65. Tanaka M, Goyagi T, Kimura T, Nishikawa T. The efficacy of hemodynamic and T wave criteria for detecting intravascular injection of epinephrine test doses in anesthetized adults: a dose–response study. Anesth Analg. 2000;91:1196–202.

    CAS  PubMed  Google Scholar 

  66. Tanaka M, Nishikawa T. The combination of epinephrine and isoproterenol as a simulated epidural test dose in isoflurane–anesthetized adults. Anesth Analg. 1998;86:1312–7.

    CAS  PubMed  Google Scholar 

  67. Tanaka M, Nishikawa T. A comparative study of hemodynamic and T–wave criteria for detecting intravascular injection of the test dose (epinephrine) in sevoflurane–anesthetized adults. Anesth Analg. 1999;89:32–6.

    CAS  PubMed  Google Scholar 

  68. Tanaka M, Nishikawa T. Efficacy of simulated intravenous test dose in the elderly during general anesthesia. Reg Anesth Pain Med. 1999;24:393–8.

    Article  CAS  PubMed  Google Scholar 

  69. Tanaka M, Takahashi S, Kondo T, Matsumiya N. Efficacy of simulated epidural test doses in adult patients anesthetized with isoflurane: a dose–response study. Anesth Analg. 1995;81:987–92.

    CAS  PubMed  Google Scholar 

  70. Ohmura S, Ohta T, Yamamoto K, Kobayashi T. A comparison of the effects of propofol and sevoflurane on the systemic toxicity of intravenous bupivacaine in rats. Anesth Analg. 1999;88:155–9.

    CAS  PubMed  Google Scholar 

  71. Weinberg G, Ripper R, Feinstein DL, Hoffman W. Lipid emulsion infusion rescues dogs from bupivacaine–induced cardiac toxicity. Reg Anesth Pain Med. 2003;28:198–202.

    Article  CAS  PubMed  Google Scholar 

  72. Weinberg GL, Ripper R, Murphy P, Edelman LB, Hoffman W, Strichartz G, Feinstein DL. Lipid infusion accelerates removal of bupivacaine and recovery from bupivacaine toxicity in the isolated rat heart. Reg Anesth Pain Med. 2006;31:296–303.

    Article  CAS  PubMed  Google Scholar 

  73. Weinberg GL, VadeBoncouer T, Ramaraju GA. Garcia–Amaro MF, Cwik MJ: Pretreatment or resuscitation with a lipid infusion shifts the dose–response to bupivacaine–induced asystole in rats. Anesthesiology. 1998;88:1071–5.

    Article  CAS  PubMed  Google Scholar 

  74. Rosenblatt MA, Abel M, Fischer GW, Itzkovich CJ, Eisenkraft JB. Successful use of a 20 % lipid emulsion to resuscitate a patient after a presumed bupivacaine–related cardiac arrest. Anesthesiology. 2006;105:217–8.

    Article  PubMed  Google Scholar 

  75. Bernards CM, Artru AA. Effect of intracerebroventricular picrotoxin and muscimol on intravenous bupivacaine toxicity. Evidence supporting central nervous system involvement in bupivacaine cardiovascular toxicity. Anesthesiology. 1993;78:902–10.

    Article  CAS  PubMed  Google Scholar 

Download references

Author information

Authors and Affiliations

  1. New York School of Regional Anesthesia (NYSORA), St. Luke’s – Roosevelt Hospitals, New York, NY, USA

    Daquan Xu MD, MSc, MPH

  2. Department of Anesthesiology, Ziekenhuis oost-Limburg, Genk, BE, USA

    Admir Hadzic MD, PhD (Professor Anesthesiology, Director NAICE, Director NYSORA, Consultant)

Authors
  1. Daquan Xu MD, MSc, MPH
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Admir Hadzic MD, PhD
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Daquan Xu MD, MSc, MPH .

Rights and permissions

Reprints and permissions

Copyright information

© 2015 Springer International Publishing Switzerland

About this chapter

Cite this chapter

Xu, D., Hadzic, A. (2015). Complications of Peripheral Nerve Blocks. In: Regional Nerve Blocks in Anesthesia and Pain Therapy. Springer, Cham. https://doi.org/10.1007/978-3-319-05131-4_5

Download citation

  • DOI: https://doi.org/10.1007/978-3-319-05131-4_5

  • Publisher Name: Springer, Cham

  • Print ISBN: 978-3-319-05130-7

  • Online ISBN: 978-3-319-05131-4

  • eBook Packages: MedicineMedicine (R0)

Publish with us

Policies and ethics

Search

Navigation