Local and regional anesthesia, in contrast to systemic, general anesthesia, involves the reversible numbing of a specific region of the body to prevent any sensation of pain. Pain may be blocked on different levels of its signal transduction pathway, e.g., at the site of origin, along the nerves, or in the brain. Accordingly, local and regional anesthesia can be divided into local topical and infiltration anesthesia, regional peripheral nerve blocks (PNB), and neuraxial anesthesia (e.g., spinal and epidural). Local anesthesia can be combined with general anesthesia, allowing the doses of anesthetic and analgesic drugs to be reduced during surgery, and may eliminate the need for other measures to achieve sufficient anesthesia (depending on the timeframe of surgery, risk profile, patient's consent). In general, local anesthesia carries less risk than general anesthesia, as essential body functions (e.g., respiration) are not affected. However, specific complications (e.g., bleeding, infection) and contraindications (e.g., patient's refusal, allergies) to local anesthesia must be considered. The drugs used for anesthesia can be found in the article .
Local and regional anesthesia are used prior to certain medical procedures to reduce pain; see “Indications” in .
- Types of anesthetic agents and their pharmacology: See “L.”
- Local anesthesia: topical or infiltrative
- Intravenous regional anesthesia (e.g., Bier block anesthesia): a local anesthetic is injected intravenously to perform surgery on the extremities
- Neuraxial: See and .
- Definition: : Local anesthesia reversibly blocks nerve endings and pain conduction near the site of administration (limited area).
- Indications: See “ .”
- Topical anesthesia: application of gels, ointments, sprays, or patches → anesthetic agent gets absorbed through the skin or mucosa
Infiltration anesthesia: injection of local anesthetic directly into a painful area or one to be operated on
- Hygiene is crucial and depends on the specific intervention!
- Sufficient infiltration of the target area (e.g., wound margins of a cut) by injecting the local anesthetic drug from all sides with as few punctures as possible (avoid vascular infiltration by aspirating before injecting!)
- Injection site: injected locally subcutaneously and/or submucosally wherever required (e.g., wound margins of a cut)
The effect of local anesthetic drugs is very limited in inflamed tissues (e.g., abscess)! The acidic environment of inflamed tissues leads to protonation of the anesthetic drug, which in turn reduces its lipophilicity and prevents the spread of the drug to the site of action.
- Definition: Local anesthetic is injected near a specific nerve or nerve bundle.
- Surgery of the upper extremities
- Interscalene block
- Supraclavicular plexus block
- Vertical infraclavicular plexus block
- Axillary brachial plexus block
- Surgery of the lower extremities
- Surgery of the scalp, neck, and trunk
- Block of selected peripheral nerves (e.g., digital nerve block): technique to anesthetize the digits to perform surgery on the fingers or toes.
- Surgery of the upper extremities
- Relative contraindication: coagulopathy
- Injection site: depends on the nerves that need to be blocked
- The patient is placed in a position that is tolerable for him or her and allows the practitioner to access the relevant nerve easily (e.g., to apply an axillary plexus block, the hand is placed underneath the head with the arm abducted and bent.)
- Hygiene: hand disinfection, sterile gloves, sterile face mask, utensils for wipe disinfection of the puncture site afterward, (if catheter is inserted, also sterile gown and sterile fenestrated drape)
- Identification of the relevant nerve guided by specific landmarks and/or:
- Two approaches to inject the local anesthetic drugs are available:
Peripheral nerve blocks are preferred over general anesthesia in patients with respiratory problems and preferred over epidural/spinal anesthesia in patients who are at high risk for urinary retention or other side effects of these procedures.
- Definition: local anesthetics with or without opioids and alpha-adrenergic agonists are injected into the epidural space and act on the spinal nerve roots.
- Injection site
- Approaches to inject the local anesthetic:
- Catheter placement, which has the advantage of repeated/continuous administration of anesthetic drugs (most commonly performed)
- Single-shot technique
- Absolute contraindications
- Relative contraindications
- Pain at the injection site
- Dural puncture
- Spinal-epidural hematoma
- Epidural abscess
- Pathophysiology: sympathetic blockade causes vasodilation and decreases venous return → reduced cardiac output
- Clinical features: hypotension, dizziness, lightheadedness, and nausea shortly after administering anesthetic
- Diagnostics: clinical diagnosis
- Treatment: IV fluid resuscitation + small doses of epinephrine
- Local anesthetics with or without opioids and alpha-adrenergic agonists are injected into the cerebrospinal fluid (CSF) in the lumbar spine and act directly on the spinal cord
- Combined spinal and epidural anesthesia (CSE)
Indications: : used for a variety of lower extremity, lower abdominal, pelvic, and perineal procedures (e.g., cesarean delivery, hip and knee replacement)
- C-section: Th4–6 (mamillary line)
- Pelvic, urethral, and renal pelvic surgery: Th6–8 (xiphoid)
- Transurethral surgery including stretching of the bladder, vaginal birth, hip surgery: Th10 (navel)
- Transurethral surgery without stretching of the bladder: L1 (inguinal ligament)
- Knee and foot surgery: L2/3
- Perineal surgery: S2–5
- Contraindications: See “Contraindications” in “Epidural anesthesia” above.
- Bleeding complications (e.g., hematoma) → nerve compression → neurological symptoms depending on the localization and degree of the hematoma
- Infections: local inflammation/abscess formation
- Allergic reactions
- Toxic reactions
- Local tissue toxicity
- Systemic toxicity (see “Side effects” in )
- Septic/aseptic meningitis
- Sympathetic block → peripheral vasodilation, bradycardia, and hypotension (Bezold-Jarisch reflex) → relative hypovolemia
- Urinary retention and overflow incontinence : treat with indwelling catheter for 24 hours if postvoid residual volume > 50 ml and/or the patient is unable to empty the bladder voluntarily
- Back pain
Total spinal anesthesia: complete spinal space affected by local anesthetic drug
- Pathophysiology: drug overdose during spinal block or accidental spinal anesthesia during epidural block (intrathecal injection) → excessive cranial spread of the local anesthetic drug → inhibition of the intercostal respiratory muscles and sympathetic block → bradycardia and hypotension → reduced perfusion of the brainstem → total spinal anesthesia → circulatory and respiratory arrest
- Clinical features
- Prophylaxis: correct catheter placement
We list the most important complications. The selection is not exhaustive.