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Brachial plexus blockade is the cornerstone of the peripheral nerve regional anesthesia practice of most anesthesiologists. As part of the American Society of Regional Anesthesia and Pain Medicine's commitment to providing intensive evidence-based education related to regional anesthesia and analgesia, this article is a complete update of our 2002 comprehensive review of upper extremity anesthesia. The text of the review focuses on (1) pertinent anatomy, (2) approaches to the brachial plexus and techniques that optimize block quality, (4) local anesthetic and adjuvant pharmacology, (5) complications, (6) perioperative issues, and (6) challenges for future research.Upper extremity regional anesthesia has been a mainstay of the anesthesiologist's armamentarium since Hall 1 first reported the use of cocaine to block the brachial plexus in 1884. Recognizing that upper extremity neural blockade represents the most frequent use of peripheral nerve blocks in most anesthesiologists' practice, 2 in 2001, the American Society of Regional Anesthesia and Pain Medicine (ASRA) undertook a critical review of all available English-language publications pertinent to this topic. The resulting extensive source document was synthesized into a comprehensive review article 3 that was published in 2002; both the source and the review documents will be updated approximately every 5 years.Rather than publishing only new material that has become available since 2002, the original review article has been completely revised so that readers may continue to view the subject matter in its entirety. New topics in this review include ultrasound-guided brachial plexus block, continuous catheter-based analgesia, and a collection of new images * by medical illustrator, Jennifer Gentry (www.gentryvisualization.com). This review summarizes the essential scholarly work available from the source document, which can be viewed at Copyright © 2009 by American Society of Regional Anesthesia and Pain Medicine Address correspondence to: Joseph M. Neal, MD, 1100 Ninth Ave (B2-AN), Seattle, WA 98101 (anejmn@vmmc.org). The contents of this article are solely the responsibility of the authors and do not necessarily represent the official views of this entity. James P. Rathmell, MD, served as acting editor-in-chief for this article.Financial support: None. NIH Public Access Author ManuscriptReg Anesth Pain Med. Author manuscript; available in PMC 2010 March 1. Published in final edited form as:Reg Anesth Pain Med. 2009 ; 34(2): 134-170. doi:10.1097/AAP.0b013e31819624eb. NIH-PA Author ManuscriptNIH-PA Author Manuscript NIH-PA Author Manuscript www.asra.com. This review article strives (1) to serve as a review of pertinent anatomy, (2) to compare the effectiveness of brachial plexus approaches and techniques, (3) to present available evidence to guide selection of pharmacological agents, (4) to describe the complications inherent to upper extremity anesthesia, (5) to consider pertinent perioperative issues, and (6) to identify informational gaps and empha...

The management of patients with coronary artery stents during the perioperative period is one of the most important patient safety issues clinicians confront. Perioperative stent thrombosis is a life-threatening complication for patients with either bare-metal or drug-eluting stents. Noncardiac surgery appears to increase the risk of stent thrombosis, myocardial infarction, and death, particularly when patients undergo surgery early after stent implantation. The incidence of complications is further increased when dual-antiplatelet therapy is discontinued preoperatively. It is generally agreed that aspirin must be continued throughout the perioperative period, except in circumstances when the risk of bleeding significantly outweighs the benefit of continued anticoagulation, such as procedures performed in a closed space. We present considerations for regional anesthesia, as well as postoperative recommendations as the occurrence of perioperative stent thrombosis appears to be greatest during this period. Immediate percutaneous coronary intervention is the definitive treatment for perioperative stent thrombosis, and 24-h access to an interventional cardiology suite should be readily available. Algorithms for perioperative management of patients with bare-metal and drug-eluting stents are proposed.

BACKGROUND It remains unknown whether local anesthetic concentration, or simply total drug dose, is the primary determinant of continuous peripheral nerve block effects. We therefore tested the null hypothesis that providing different concentrations and rates of ropivacaine, but at equal total doses, produces comparable effects when used in a continuous sciatic nerve block in the popliteal fossa. METHODS Preoperatively, a perineural catheter was inserted adjacent to the sciatic nerve using a posterior popliteal approach in patients undergoing moderately painful orthopedic surgery at or distal to the ankle. Postoperatively, patients were randomly assigned to receive a perineural ropivacaine infusion of either 0.2% (basal 8 mL/h, bolus 4 mL) or 0.4% (basal 4 mL/h, bolus 2 mL) through the second postoperative day. Therefore, both groups received 16 mg of ropivacaine each hour with a possible addition of 8 mg every 30 min via a patient-controlled bolus dose. The primary end point was the incidence of an insensate limb, considered undesirable, during the 24-h period beginning the morning after surgery. Secondary end points included analgesia and patient satisfaction. RESULTS Patients given 0.2% ropivacaine (n = 25) experienced an insensate limb with a mean (sd) of 1.8 (1.8) times, compared with 0.6 (1.1) times for subjects receiving 0.4% ropivacaine (n = 25; estimated difference = 1.2 episodes, 95% confidence interval, 0.3–2.0 episodes; P = 0.009). In contrast, analgesia and satisfaction were similar in each group. CONCLUSIONS For continuous popliteal-sciatic nerve blocks, local anesthetic concentration and volume influence block characteristics. Insensate limbs were far more common with larger volumes of relatively dilute ropivacaine. During continuous sciatic nerve block in the popliteal fossa, a relatively concentrated solution in smaller volume thus appears preferable.

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Premedication with oral clonidine prolonged sensory and motor block from lidocaine spinal anesthesia. The exact mechanism whereby oral clonidine prolongs spinal anesthesia remains to be determined.

Early treatment with Intralipid may help prevent cardiac arrest and speed successful resuscitation efforts.