Subspecialty

Regional Anesthesia

Precise anatomy, profound analgesia.

Regional anesthesia provides targeted analgesia, reduces opioid exposure, and enables ambulatory surgery. Modern ultrasound guidance has dramatically improved efficacy and safety, but LAST and nerve injury remain ever-present concerns.

Key concepts

LAST

Local Anesthetic Systemic Toxicity — prevent with aspiration, fractionated dosing, max-dose discipline. Treat seizures with benzodiazepine, give 20% lipid emulsion 1.5 mL/kg bolus + 0.25 mL/kg/min.

Common upper extremity blocks

Interscalene (shoulder), supraclavicular (elbow/hand — 'spinal of the arm'), infraclavicular (elbow/hand), axillary (hand).

Common lower extremity blocks

Femoral / adductor canal (knee — adductor preserves quadriceps), popliteal sciatic (foot/ankle), iPACK (posterior knee).

Truncal blocks

TAP, rectus sheath, quadratus lumborum, ESP, PECS I/II, serratus plane — opioid-sparing for abdominal and thoracic surgery.

Anticoagulation

Follow ASRA guidelines for neuraxial/deep blocks. Don't skim — the consequences (epidural hematoma) are catastrophic.

Monitoring

Pulse oximetry
ECG
BP
Lipid emulsion at hand for any block

Common drugs

Ropivacaine 0.2–0.5%Bupivacaine 0.25–0.5%Mepivacaine 1.5%Lidocaine 1–2% (± epi)Dexamethasone (adjunct)

Clinical pearls

1Phrenic nerve palsy occurs in ~100% of interscalene blocks — avoid in severe pulmonary disease.

2Always image the needle tip in plane and confirm circumferential spread.

3Pneumothorax risk: highest with supraclavicular > infraclavicular > interscalene.

References & Further Reading

1
GuidelineOpen source
Horlocker TT, Vandermeuelen E, Kopp SL, et al. Regional Anesthesia in the Patient Receiving Antithrombotic or Thrombolytic Therapy: ASRA Evidence-Based Guidelines (Fourth Edition). Reg Anesth Pain Med. 2018;43(3):263-309.
2
GuidelineOpen source
Neal JM, Neal EJ, Weinberg GL. American Society of Regional Anesthesia and Pain Medicine Local Anesthetic Systemic Toxicity Checklist: 2020 Version. Reg Anesth Pain Med. 2021;46(1):81-82.
3
Textbook
Gropper MA, Miller RD, Cohen NH, et al., eds. Miller's Anesthesia. 9th ed. Philadelphia: Elsevier; 2020.
4
Textbook
Barash PG, Cullen BF, Stoelting RK, Cahalan MK, Stock MC, Ortega R, Sharar SR, Holt NF. Clinical Anesthesia. 8th ed. Philadelphia: Wolters Kluwer; 2017.

Citations are provided to direct further study. Always check the most current edition of guidelines and society recommendations — the information in this chapter is a teaching summary, not primary source material.