The American Society of Regional Anesthesia and Pain Medicine (ASRA) Practice Advisory on Neurologic Complications in Regional Anesthesia and Pain Medicine includes an evidence- and expert opinion-based section on performing procedures on anesthetized or heavily sedated patients. This practice advisory is based on existing scientific literature, pathophysiological principles, and expert opinion. The advisory panel examined the ability of anesthetized or heavily sedated patients to recognize and report intravascular injection of local anesthetic or impending neurologic injury. The advisory panel also considered whether or not the ability to recognize and report symptoms could actually affect the occurrence of nerve injury or local anesthetic systemic toxicity. The advisory contains recommendations pertaining to both adult and pediatric patients.
◊ Reviewed by P.A. Lönnqvist, MD, PhD
Professor of Paediatric Anesthesiology & Intensive Care, Inst. of Physiology & Pharmacology, Karoliniska Institute, Stockholm, Sweden;
Senior Consultant, Dept. of Paediatric Anaesthesia & Intensive Care, Karolinska University Hospital, Stockholm, Sweden
The present communication represents a clear and structured review of currently available evidence regarding the burning issue of whether or not regional anesthetic blocks should be performed in anesthetized or heavily sedated patients. The members of the ASRA expert panel and authors of the current recommendations are well-known researchers and clinicians within the field of regional anesthesia.
The discussion clearly differentiates the two major complications of regional anesthesia, systemic toxicity and direct nerve injury. Regional anesthesia in anesthetized or heavily sedated patients should not be avoided simply because patients are not able to report early symptoms of local anesthetic toxicity. However, apart from the pediatric population performing blocks in anesthetized or heavily sedated adults is generally not recommended.
Unfortunately, the issue of whether ultrasound guidance does provide protection and sufficient certainty to allow the performance of peripheral nerve blocks in anesthetized/heavily sedated adults is left open due to the current lack of evidence. The panel’s caution regarding this is understandable but due to the very topical character of this issue one could have hoped for a more comprehensive discussion and a bolder recommendation. However, one should respect the professionalism and adequate conservatism of the panel regarding this topic.
Will these recommendations alter the practice of most anesthesiologists?
Since the recommendations are based on current literature, of which most will be well-known to the majority of anesthesiologists who are involved in regional anesthesia, I would expect that the impact on current practice is small. Having said that, I still believe that these recommendations will provide a very useful framework for teaching as well as for departmental guidelines on how regional anesthesia should be performed. Guidelines also support the widespread practice of regional anesthesia in anesthetized pediatric patients but warn that it should be performed in only selected adult patients after careful assessment of the risk-to-benefit ratio for each individual patient.
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