Anesthesia, Local

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Definition

Local or regional anesthesia involves the injection or application of an anesthetic drug to a specific area of the body, as opposed to the entire body and brain as occurs during general anesthesia.

Description

Regional anesthesia typically affects a larger area than local anesthesia, for example, everything below the waist. As a result, regional anesthesia may be used for more involved or complicated surgical or medical procedures. Regional anesthetics are injected. Local anesthesia involves the injection into the skin or muscle or application to the skin of an anesthetic directly where pain will occur. Local anesthesia can be divided into four groups: injectable, topical, dental (non-injectable), and ophthalmic.

Local and regional anesthesia work by altering the flow of sodium molecules into nerve cells or neurons through the cell membrane. Exactly how the anesthetic does this is not understood, since the drug apparently does not bind to any receptor on the cell surface and does not seem to affect the release of chemicals that transmit nerve impulses (neurotransmitters) from the nerve cells. It is known, however, that when the sodium molecules do not get into the neurons, nerve impulses are not generated and pain impulses are not transmitted to the brain. The duration of action of an anesthetic depends on the type and amount of anesthetic administered.

Types of regional anesthesia include:

• Spinal anesthesia. Spinal anesthesia involves the injection of a small amount of local anesthetic directly into the cerebrospinal fluid surrounding the spinal cord (the subarachnoid space). Blood pressure drops are common but are easily treated.
• Epidural anesthesia. Epidural anesthesia involves the injection of a large volume of local anesthetic directly into the space surrounding the spinal fluid sac (the epidural space), not into the spinal fluid. Pain relief occurs more slowly but is less likely to produce blood pressure drops. Also, the block can be maintained for long periods, even days.
• Nerve blocks. Nerve blocks involve the injection of an anesthetic into the area around a nerve that supplies a particular region of the body, preventing the nerve from carrying nerve impulses to the brain.

Anesthetics may be administered with another drug, such as epinephrine (adrenaline), which decreases bleeding, and sodium bicarbonate to decrease the acidity of a drug so that it will work faster. In addition, drugs may be administered to help a patient remain calm and more comfortable or to make them sleepy.

INJECTABLE LOCAL ANESTHETICS. These medicines are given by injection to numb and provide pain relief to some part of the body during surgery, dental procedures, or other medical procedures. They are given only by a trained health care professional and only in a doctor's office or a hospital. Some commonly used injectable local anesthetics are procaine (Novocain), lidocaine (Dalcaine, Dilocaine, L-Caine, Nervocaine, Xylocaine, and other brands), and tetracaine (Pontocaine).

TOPICAL ANESTHETICS. Topical anesthetics, such as benzocaine, lidocaine, dibucaine, pramoxine, butamben, and tetracaine, relieve pain and itching by deadening the nerve endings in the skin. They are ingredients in a variety of nonprescription products that are applied to the skin to relieve the discomfort of sunburn, insect bites or stings, poison ivy, and minor cuts, scratches, and burns. These products are sold as creams, ointments, sprays, lotions, and gels.

DENTAL ANESTHETICS (NON-INJECTABLE). Some local anesthetics are intended for pain relief in the mouth or throat. They may be used to relieve throat pain, teething pain, painful canker sores, toothaches, or discomfort from dentures, braces, or bridgework. Some dental anesthetics are available only with a doctor's prescription. Others may be purchased without a prescription, including products such as Num-Zit, Orajel, Chloraseptic lozenges, and Xylocaine.

OPHTHALMIC ANESTHETICS. Other local anesthetics are designed for use in the eye. The ophthalmic anesthetics proparacaine and tetracaine are used to numb the eye before certain eye examinations. Eye doctors may also use these medicines before measuring eye pressure or removing stitches or foreign objects from the eye. These drugs are to be given only by a trained health care professional.

— Nancy Ross-Flanigan

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Anesthesia characterized by the loss of sensation only in the area of the body where an anesthetic drug is applied or injected.

Definition

Local, or regional, anesthesia involves the injection or application of an anesthetic drug to a specific area of the body. This is in contrast to general anesthesia, which provides anesthesia to the entire body and brain.

Purpose

Local anesthetics are used to prevent patients from feeling pain during medical, surgical, or dental procedures. Over-the-counter local anesthetics are also available to provide temporary relief from pain, irritation, and itching caused by various conditions such as cold sores, canker sores, sore throats, sunburn, insect bites, poison ivy, and minor cuts and scratches.

Precautions

People who feel strongly that they do not want to be awake and alert during certain procedures may not be good candidates for local or regional anesthesia. However, other medications that have systemic effects may be given in addition to an anesthetic to relieve anxiety and help the patient relax.

Local anesthetics should be used only for the conditions for which they are intended. For example, a topical anesthetic meant to relieve sunburn pain should not be used on cold sores. Anyone who has had an unusual reaction to any local anesthetic in the past should check with a doctor before using any type of local anesthetic again. The doctor should also be told about any allergies to foods, dyes, preservatives, or other substances.

Older people may be more sensitive to the effects of local anesthetics, especially lidocaine. Children may also be especially sensitive to some local anesthetics, and certain types should not be used at all on young children. People caring for these groups need to be aware that they are at increased risk of more severe side effects. Packages should be followed carefully so that the recommended dosage is not exceeded. A doctor or pharmacist should be consulted about any concerns.

Regional Anesthetics

Serious and possibly life-threatening side effects may occur when injectable or inhaled anesthetics are given to people who use street drugs. Doctors and nurses should inform patients about the dangers of mixing anesthetics with cocaine, marijuana, amphetamines, barbiturates, phencyclidine (PCP, or angel dust), heroin, or other street drugs. Some anesthetic drugs may interact with other medicines. When this happens, the effects of one or both of the drugs may change, or the risk of side effects may be greater. In select cases, a urinalysis can help identify drug use.

Patients who have a personal or family history of malignant hyperthermia after receiving a general anesthetic must also be cautious when receiving regional or local anesthetics. Malignant hyperthermia is a serious reaction that involves a fast or irregular heartbeat, high fever, breathing problems, and muscle spasms. All patients should be asked if they are aware of such a risk in their family before receiving any kind of anesthetic.

Although problems are rare, some side effects may occur when regional anesthetics are used during labor and delivery. Anesthetics can prolong labor and increase the risk of requiring a cesarean section. Doctors should discuss the risks and benefits associated with epidural or spinal anesthesia with pregnant patients.

Regional anesthetics should be used only by an experienced anesthesiologist in a properly equipped environment with suitable resuscitative equipment. Although these anesthetics are generally safe when properly selected and administered, severe adverse reactions are still possible. If inadvertent subarachnoid injection occurs, the patient is likely to require resuscitation with oxygen and drug therapy. Careful positioning of the patient is essential to prevent leaking of cerebrospinal fluid.

Patients should not drive or operate machinery immediately following a procedure involving regional anesthesia because numbness or weakness may cause impairment. Doctors and nurses should also warn patients who have had local anesthesia, especially when combined with drugs to make patients sleep or to reduce pain, about operating any type of machinery.

Injectable Local Anesthetics

Until the anesthetic wears off, patients should be careful not to inadvertently injure the numbed area. If the anesthetic was used in the mouth, patients should not eat or chew gum until feeling returns.

Topical Anesthetics

Unless advised by a doctor, topical anesthetics should not be used on or near any part of the body with large sores, broken or scraped skin, severe injury, or infection. They should also not be used on large areas of skin. Some topical anesthetics contain alcohol and should not be used near an open flame or while smoking.

Patients should be careful not to get topical anesthetics in the eyes, nose, or mouth. If a spray-type anesthetic is to be used on the face, it can be applied with a cotton swab or sterile gauze pad. After using a topical anesthetic on a child, the caregiver should make sure the child does not get the medicine in his or her mouth or eyes.

Topical anesthetics are intended for the temporary relief of pain and itching. They should not be used for more than a few days at a time. A doctor should be consulted if:

• Discomfort continues for more than seven days.
• The problem gets worse.
• The treated area becomes infected.
• New signs of irritation such as skin rash, burning, stinging, or swelling appear.

Dental Anesthetics

Dental anesthetics should not be used if certain kinds of infections are present. Package directions should be checked or a dentist, pharmacist, or doctor should be consulted if there is any uncertainty. Dental anesthetics should be used only for temporary pain relief. Consult the dentist if problems such as toothache, mouth sores, or pain from dentures or braces continue or if signs of general illness such as fever, rash, or vomiting develop.

Patients should not eat or chew gum while the mouth is numb from a dental anesthetic to avoid accidentally biting the tongue or the inside of the mouth. In addition, nothing should be eaten or drunk for one hour after applying a dental anesthetic to the back of the mouth or throat, because the medicine may interfere with swallowing and may cause choking. If normal feeling does not return to the mouth within a few hours after receiving a dental anesthetic or if it is difficult to open the mouth, the dentist should be consulted.

Ophthalmic Anesthetics

When anesthetics are used in the eye, it is important not to rub or wipe the eye until the effect of the anesthetic has worn off and feeling has returned. Rubbing the eye while it is numb could cause injury.

Description

Medical procedures and situations that regularly make use of local or regional anesthesia include the following:

• biopsies, in which skin or tissue samples are taken for diagnostic procedures
• childbirth
• scar repair
• surgery on the face (including plastic surgery), skin, arms, hands, legs, and feet
• eye surgery
• surgery involving the urinary tract or reproductive organs

Surgery involving the chest or abdomen is usually performed under general anesthesia. Laparoscopy and hernia repair, however, may be performed under local or regional anesthesia.

Local and regional anesthesia have many advantages over general anesthesia. Most importantly, the risk of unusual and sometimes fatal reactions to general anesthesia is lessened. More minor, but significant, risks of general anesthesia include longer recovery time and the psychological discomfort of losing consciousness.

Regional anesthesia typically affects a larger area than local anesthesia. As a result, regional anesthesia is typically used for more involved or complicated procedures. The duration of action of an anesthetic depends on the type and amount of anesthetic administered.

Regional anesthetics are injected. Local anesthesia involves the injection into the skin or application to the skin surface of an anesthetic directly where pain will occur. Local anesthesia can be divided into four groups: injectable, topical, dental (non-injectable), and regional blockade injection.

Local and regional anesthesia work by altering the flow of sodium molecules into nerve cells (neurons) through the cell membrane. The exact mechanism is not understood, since the drug apparently does not bind to any receptor on the cell surface and does not seem to affect the release of chemicals that transmit nerve impulses (neurotransmitters) from the nerve cells. Experts believe, however, that when the sodium molecules do not get into the neurons, nerve impulses are not generated and pain impulses are not transmitted to the brain.

Regional Anesthesia

Types of regional anesthesia include:

• Spinal anesthesia, which involves the injection of a small amount of local anesthetic into the cerebrospinal fluid surrounding the spinal cord (the subarachnoid space). A drop in blood pressure is a common but easily treated side effect.
• Epidural anesthesia, which involves the injection of a large volume of local anesthetic into the space surrounding the spinal fluid sac (the epidural space), not directly into the spinal fluid. Pain relief occurs more slowly, but is less likely to produce a drop in blood pressure. The block can be maintained for long periods, even for days if necessary.
• Nerve blockades, which involve the injection of an anesthetic into the area around a sensory or motor nerve that supplies a particular region of the body, preventing the nerve from carrying nerve impulses to and from the brain.

Local and regional anesthetics may be administered with other drugs to enhance their action. Examples include vasoconstrictors such as epinephrine (adrenaline) to decrease bleeding, or sodium bicarbonate to lower acidity, which may make a drug work faster. In addition, medications may be administered to help a patient remain calm and more comfortable or to make them sleepy.

Local Anesthesia

Injectable Local Anesthetics

Injectable local anesthetics provide pain relief for some part of the body during surgery, dental procedures, or other medical procedures. They are given only by a trained health care professional and only in a doctor's office or a hospital. Some commonly used injectable local anesthetics are lidocaine (Xylocaine), bupivacaine (Marcaine), and mepivacaine (Carbocaine).

Topical Anesthetics

Topical anesthetics such as benzocaine, lidocaine (in smaller quantities or doses), dibucaine, and tetracaine relieve pain and itching by blocking the sensory nerve endings in the skin. They are ingredients in a variety of nonprescription products that are applied to the skin to relieve the discomfort of sunburn, insect bites or stings, poison ivy, and minor cuts, scratches, and burns. These products are sold as creams, ointments, sprays, lotions, and gels.

Topical dental anesthetics are intended for pain relief in the mouth or throat. They may be used to relieve throat pain, teething pain, painful canker sores, toothaches, or discomfort from dentures, braces, or bridgework. Some dental anesthetics are available only with a doctor's prescription. Others may be purchased over the counter, including products such as Num-Zit, Orajel, Chloraseptic lozenges, and Xylocaine.

Ophthalmic anesthetics are designed for use in the eye. Lidocaine and tetracaine are used to numb the eye before certain eye examinations. Eye doctors may also use these medicines before measuring eye pressure or removing stitches or foreign objects from the eye. These drugs are to be given only by a trained health care professional.

The recommended dosage of a topical anesthetic depends on the type of local anesthetic and the purpose for which it is being used. When using a nonprescription local anesthetic, patients are advised to follow the directions on the package. Questions concerning how to use a product should be referred to a doctor, dentist, or pharmacist.

Aftercare

Most patients can return home immediately after a local anesthetic, but some patients might require limited observation. The degree of aftercare needed depends on where the anesthetic was given, how much was given, and other individual circumstances. Patients who have had their eyes numbed should wear a patch after surgery or treatment until full feeling in the eye area has returned. If the throat was anesthetized, the patient cannot drink until the gag reflex returns. If a major extremity was anesthetized, the patient may have to wait until function returns before being discharged. Some local anesthetics can cause cardiac arrhythmias and therefore require monitoring for a time with an EKG. Patients who have had regional anesthesia or larger amounts of local anesthesia usually recover in a post-anesthesia care unit before being discharged. There, medical personnel watch for immediate postoperative problems. These patients need to be driven home after discharge.

Risks

Side effects of regional or local anesthetics vary depending on the type of anesthetic used and the way it is administered. Any unusual symptoms following the use of an anesthetic requires the immediate attention of a doctor.

Paralysis after a regional anesthetic such as an epidural, spinal, or ganglionic blockade is extremely rare, but can occur. Paralysis reportedly occurs even less frequently than deaths due to general anesthesia.

There is also a small risk of developing a severe headache called a spinal headache following a spinal or epidural block. This headache is severe when the patient is upright, even when only elevated 30°, and is hardly felt when the patient lies down. It is treated by increasing fluids to help clear the anesthetic and enhance the flow of spinal fluid.

Finally, blood clots or abscess can form at the site where an anesthetic is injected. Although they can usually be treated, antibiotic resistance is becoming increasingly common. Such infections must be regarded as potentially dangerous, particularly if they develop at the site of a spinal injection.

A physician should be notified immediately if any of the following occur:

• symptoms of an allergic reaction such as hives (urticaria), which are itchy swellings on the skin, or swelling in the mouth or throat
• severe headache
• blurred or double vision or photophobia (sensitivity to light)
• dizziness or lightheadedness
• drowsiness
• confusion
• an irregular, too slow, or rapid heartbeat
• anxiety, excitement, nervousness, or restlessness
• convulsions (seizures)
• feeling hot, cold, or numb anywhere other than the anesthetized area
• ringing or buzzing in the ears
• shivering or trembling
• sweating
• pale skin
• breathing problems
• unusual weakness or tiredness

Normal Results

Local and regional anesthetics help to make many conditions and procedures more comfortable and tolerable for patients.

Resources

Books

Nettina, Sandra. Lippincott Manual of Nursing Practice, 7th edition. Philadelphia: Lippincott, 2001, pp. 115-117.

Organizations

American Academy of Anesthesiologist Assistants. PO Box 81362, Wellesley, MA 02481-0004. (800) 757-5858. http://www.anesthetist.org.

American Society of Anesthesiologists. 520 N. Northwest Highway, Park Ridge, IL 60068-2573. (847) 825-5586. http://www.asahq.org.

Other

Interview with Harvey Plosker, MD. The Pain Center. 501 Glades Road, Boca Raton, FL 33431.

— Lisette Hilton Sam Uretsky, PharmD

(regional anesthesia), the loss of pain sensation over a specific area of the anatomy without loss of consciousness.

It has been suggested that this article or section be merged with local anesthetic. (Discuss)

Local anesthesia is any technique to render part of the body insensitive to pain without affecting consciousness.

• Local anesthesia, in a strict sense, is anesthesia of a small part of the body such as a tooth or an area of skin.
• Regional anesthesia is aimed at anesthetizing a larger part of the body such as a leg or arm.
• Conduction anesthesia is a comprehensive term which encompasses a great variety of local and regional anesthetic techniques.

Conduction anesthesia allows patients to undergo many surgical procedures without significant pain or distress. In many situations, such as cesarean section), conduction anesthesia is safer and therefore superior to general anesthesia. In other situations, either conduction or general anesthesia are suitable. Anaesthetists sometimes combine both techniques.

Conduction anesthesia is also used for relief of non-surgical pain, also to enable diagnosis of the cause of some chronic pain conditions.

The most common form of conduction anaesthesia is probably local anaesthesia to enable dental procedures.

Techniques

To achieve conduction anesthesia a local anesthetic is injected or applied to a body surface. The local anesthetic then diffuses into nerves where it inhibits the propagation of signals for pain, muscle contraction, regulation of blood circulation and other body functions. Relatively high drug doses or concentrations inhibit all qualities of sensation (pain, touch, temperature etc.) as well as muscle control. Lower doses or concentrations may selectively inhibit pain sensation with minimal effect on muscle power. Some techniques of pain therapy, such as walking epidurals for labor pain use this effect, termed differential block.

Known to block voltage gated sodium channels.

Anesthesia persists as long as there is a sufficient concentration of local anesthetic at the affected nerves. Sometimes a vasoconstrictor drug is added to decrease local blood flow, thereby slowing the transport of the local anesthetic away from the site of injection. Depending on the drug and technique, the anesthetic effect may persist from less than an hour to several hours. Placement of a catheter for continuous infusion or repeated injection allows conduction anesthesia to last for days or weeks. This is typically done for purposes of pain therapy.

Local anesthetics can block almost every nerve between the peripheral nerve endings and the central nervous system. The most peripheral technique is topical anesthesia to the skin or other body surface. Small and large peripheral nerves can be anesthetized individually (peripheral nerve block) or in anatomic nerve bundles (plexus anesthesia). Spinal anesthesia and epidural anesthesia are applied near the spinal cord where the peripheral nervous system merges into the central nervous system.

Clinical techniques include:

• Surface anesthesia - application of local anesthetic spray, solution or cream to the skin or a mucous membrane. The effect is short lasting and is limited to the area of contact.
• Infiltration anesthesia - injection of local anesthetic into the tissue to be anesthetized. Surface and infiltration anesthesia are collectively topical anesthesia.
• Field block - subcutaneous injection of a local anesthetic in an area bordering on the field to be anesthetized.
• Peripheral nerve blocks - injection of local anesthetic in the vicinity of a peripheral nerve to anesthetize that nerve's area of innervation.
• Plexus anesthesia - injection of local anesthetic in the vicinity of a nerve plexus, often inside a tissue compartment that limits the diffusion of the drug away from the intended site of action. The anesthetic effect extends to the innervation areas of several or all nerves stemming from the plexus.
• Epidural anesthesia - a local anesthetic is injected into the epidural space where it acts primarily on the spinal nerve roots. Depending on the site of injection and the volume injected, the anesthetized area varies from limited areas of the abdomen or chest to large regions of the body.
• Spinal anesthesia - a local anesthetic is injected into the cerebrospinal fluid, usually at the lumbar spine (in the lower back), where it acts on spinal nerve roots and part of the spinal cord. The resulting anesthesia usually extends from the legs to the abdomen or chest.
• Intravenous regional anesthesia (Bier's block) - blood circulation of a limb is interrupted using a tourniquet (a device similar to a blood pressure cuff), then a large volume of local anesthetic is injected into a peripheral vein. The drug fills the limb's venous system and diffuses into tissues where peripheral nerves and nerve endings are anesthetized. The anesthetic effect is limited to the area that is excluded from blood circulation and resolves quickly once circulation is restored.
• Local anesthesia of body cavities (e.g. intrapleural anesthesia, intraarticular anesthesia)

Uses in surgery and dentistry

Virtually every part of the body can be anesthetized using conduction anesthesia. However, only a limited number of techniques are in common clinical use. Sometimes conduction anesthesia is combined with general anesthesia or sedation for the patient's comfort and ease of surgery. Typical operations performed under conduction anesthesia include:

• Dentistry (surface anesthesia, infiltration anesthesia, nerve blocks)
• Eye surgery (surface anesthesia with topical anesthetics, retrobulbar block)
• ENT operations, head and neck surgery (infiltration anesthesia, field blocks, peripheral nerve blocks, plexus anesthesia)
• Shoulder and arm surgery (plexus anesthesia, intravenous regional anesthesia)
• Heart and lung surgery (epidural anesthesia combined with general anesthesia)
• Abdominal surgery (epidural/spinal anesthesia, often combined with general anesthesia)
• Gynecological, obstetrical and urological operations (spinal/epidural anesthesia)
• Bone and joint surgery of the pelvis, hip and leg (spinal/epidural anesthesia, peripheral nerve blocks, intravenous regional anesthesia)
• Surgery of skin and peripheral blood vessels (topical anesthesia, field blocks, peripheral nerve blocks, spinal/epidural anesthesia)

Uses in acute pain

Acute pain may occur due to trauma, surgery, infection, disruption of blood circulation or many other conditions in which there is tissue injury. In a medical setting it is usually desirable to alleviate pain when its warning function is no longer needed. Besides improving patient comfort, pain therapy can also reduce harmful physiological consequences of untreated pain.

Acute pain can often be managed using analgesics. However, conduction anesthesia may be preferable because of superior pain control and fewer side effects. For purposes of pain therapy, local anesthetic drugs are often given by repeated injection or continuous infusion through a catheter. Low doses of local anesthetic drugs can be sufficient so that muscle weakness does not occur and patients may be mobilized.

Some typical uses of conduction anesthesia for acute pain are:

• Labor pain (epidural anesthesia)
• Postoperative pain (peripheral nerve blocks, epidural anesthesia)
• Trauma (peripheral nerve blocks, intravenous regional anesthesia, epidural anesthesia)

Uses in chronic pain

Chronic pain of more than minor intensity is a complex and often serious condition that requires diagnosis and treatment by an expert in pain medicine. Local anesthetics can be applied repeatedly or continuously for prolonged periods to relieve chronic pain, usually in combination with medication such as opioids, NSAIDs, and anticonvulsants.

Miscellaneous uses

Topical anesthesia, in the form of lidocaine/prilocaine (EMLA) is most commonly used to enable relatively painless venipuncture (blood collection) and placement of intravenous cannulae. It may also be suitable for other kinds of punctures such as ascites drainage and amniocentesis.

Surface anesthesia also facilitates some endoscopic procedures such as bronchoscopy (visualization of the lower airways) or cystoscopy (visualization of the inner surface of the bladder).

History

The leaves of the coca plant were traditionally used as a stimulant in Peru. It is believed that the local anesthetic effect of coca was also known and used for medical purposes. Cocaine was isolated in 1860 and first used as a local anesthetic in 1884. The search for a less toxic and less addictive substitute led to the development of the aminoester local anesthetic procaine in 1904. Since then, several synthetic local anesthetic drugs have been developed and put into clinical use, notably lidocaine in 1943, bupivacaine in 1957 and prilocaine in 1959.

Shortly after the first use of cocaine for topical anesthesia, blocks on peripheral nerves were described. Brachial plexus anesthesia by percutaneous injection through axillary and supraclavicular approaches was developed in the early 20th century. The search for the most effective and least traumatic approach for plexus anesthesia and peripheral nerve blocks continues to this day. In recent decades, continuous regional anesthesia using catheters and automatic pumps has evolved as a method of pain therapy.

Intravenous regional anesthesia was first described by August Bier in 1908. This technique is still in use and is remarkably safe when drugs of low systemic toxicity such as prilocaine are used.

Spinal anesthesia was first used in 1885 but not introduced into clinical practice until 1899, when August Bier subjected himself to a clinical experiment in which he observed the anesthetic effect, but also the typical side effect of postpunctural headache. Within few years, spinal anesthesia became widely used for surgical anesthesia and was accepted as a safe and effective technique. Although atraumatic (non-cutting-tip) cannulas and modern drugs are used today, the technique has otherwise changed very little over many decades.

Epidural anesthesia by a caudal approach had been known in the early 20th century, but a well-defined technique using lumbar injection was not developed until the 1930s. With the advent of thin flexible catheters, continuous infusion and repeated injections have become possible, making epidural anesthesia a highly successful technique to this day. Beside its many uses for surgery, epidural anesthesia is particularly popular in obstetrics for the treatment of labor pain.

Adverse Effects

Excessive or inappropriately administered doses may result in Local Anesthetic Toxicity. This includes localized effects of nerve damage and systemic effects of heart and respiration depression even death.

External links

• New York School of Regional Anesthesia
• General information and tutorials in peripheral regional anesthesia
• [1] Free online manual of regional anaesthesia- John Hyndman
• Clinical Use of Peripheral Nerve Stimulators and The Neuromuscular Junction

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