Part of your pain-management and recovery will involve the use of a peripheral nerve block. Peripheral nerve blocks are safe and effective procedures and devices that use local anesthetics—injected around specific nerve areas—to numb certain parts of the body. Nerve blocks control post-operative pain and reduce the need for narcotic pain medication. The targeted nerve is often located a short distance from the surgical site.
Peripheral nerve blocks are placed before both inpatient and outpatient surgeries and usually left in place for 2 to 4 days.
Peripheral nerve blocks do not replace the need for anesthesia. They are, however, a very effective method of controlling pain both during and after surgery.
Your anesthesiologist will review your medical history to determine if you are a candidate for a peripheral nerve block. There are rare circumstances where peripheral nerve blocks are contraindicated.
There are several different nerves that can be blocked, and your doctor will discuss which one is best for you, based on your surgical procedure.
Peripheral nerve blocks can be used for operations involving many different parts of the body, including the leg, hip, knee, ankle, foot, toes, arm, shoulder, elbow, wrist, hand, or fingers. They may also be used for surgeries involving the chest/breast area and the abdomen.
The benefits of using peripheral nerve blocks include significantly reduced post-operative pain, reduced need for oral pain medications—reducing their side effects—increased mobility, improved physical therapy participation, and earlier discharge from the hospital.
Although risks and side effects are rare, they do include potential bleeding, possible infection, and local anesthetic toxicity. Peripheral nerve injury is extremely rare. This is especially true with the use of ultrasound technology.
Overall, patients who receive peripheral nerve blocks for post-operative pain control enjoy a greater sense of well-being and recovery. Better pain control leads to better outcomes.
Once your operation is scheduled, you’ll need to have a pre-operative history and physical performed by your primary care doctor within 30 days of your scheduled date of surgery.
In preparation for your upcoming surgery, wear comfortable and loose-fitting clothing to accommodate the surgical area. You may have a sling, cast, or brace when leaving the hospital.
We recommend a zip-up or button-up top if your surgery involves your upper extremity. Sweat pants or loose-fitting shorts are recommended for lower extremity surgery.
You cannot eat, drink, or place anything in your mouth six hours prior to your surgery. This includes candy, chewing gum, breath mints, throat lozenges, and chewing tobacco. Failure to follow these restrictions will result in a delay or cancellation of your surgery.
Taking certain prescribed medications with small sips of water is okay. Make sure you continue taking any medications related to heart rhythm, high blood pressure, and acid reflux, as well as any anti-seizure or narcotic-based pain medications.
However, you must also check with your surgeon if you are taking any non-narcotic pain medication, herbal medicine, anti-inflammatory medication, or blood thinners. Your surgeon will determine if you need to modify your intake or stop taking these medications prior to surgery.
The dosage of your diabetic medications may also need to be adjusted. Follow your primary care doctor’s instructions.
Bring a list of all your medications to the hospital—including prescription and over-the-counter medications.
All jewelry and body piercings must be removed and left at home.
You will need to remove your contact lenses prior to surgery. You may want to wear eyeglasses if you have them.
All valuables should be left at home. However, you should bring a picture ID.
You are not allowed to drive home following surgery and must have someone with you for the next 24 hours. You are also not allowed to drive while you are taking narcotic medications.
Be certain to follow your surgeon’s instructions on when to arrive at the hospital; you must arrive well in advance of your surgery time.
The discomfort associated with the placement of peripheral nerve blocks is mild and temporary. Patients are given a mild sedative in their IV prior to the procedure.
The procedure typically takes 10 to 30 minutes to complete. The portion that may be painful usually lasts only 2 to 3 minutes.
The anesthesiologist uses ultrasound imaging to identify the nerves, muscles, and blood vessels in the area where the peripheral nerve block will be placed.
The skin is then numbed locally with a needle, which may cause a brief stinging sensation.
Another needle is then passed through the numb area and advanced close to the nerve. It is common to feel an ache or pressure at this time, but this quickly subsides.
In some cases, a nerve stimulator may be used to identify and locate the nerve and placement of local anesthetic for the peripheral nerve block. Nerve stimulation causes a muscle-twitching sensation. This is normal, very brief, and not painful.
For continuous nerve blocks, the anesthesiologist will pass a small catheter through the center of the needle, using it as a guide. The catheter will remain in your body and allow us to extend the pain relief of the peripheral nerve block for several days.
After the catheter is inserted, it is advanced just beyond the tip of the needle, and the needle is removed. The catheter is a flexible tube and is not sharp. It is designed to safely remain in your body just below the surface of the skin for several days. Removing the catheter is easy and painless.
Surgical glue is applied to prevent leakage, and a clear plastic dressing is also placed over the insertion site.
A white foam adhesive device is also applied to provide a secure connection between the peripheral nerve catheter and infusion pump at the skin surface.
The infusion pump is labeled with the name and dosage of the medication, along with your anesthesiologist’s contact information.
A peripheral nerve block placement may cause your extremity to feel heavy, also causing a sensation of warmth, numbness, or tingling—particularly on the day of surgery because stronger medications are used to place the peripheral nerve block. However, in subsequent days these feelings will resolve—or wear off—because of milder medications in the infusion pump.
The first 12 to 18 hours Since the local anesthetic originally injected is stronger or more concentrated than the medication in the infusion pump, more profound effects occur during the first 12 to 18 hours.
Peripheral nerve blocks are designed to block the sensory nerves to achieve post-operative pain control. But sometimes movement of your extremity is affected because motor nerves may also be blocked.
Your ability to move the hand or foot of the blocked extremity may be difficult, or you may feel loss of sensation. This is normal and no cause for concern.
You may feel some pain in the surgical area and should supplement with oral prescription pain medication.
Our goal for pain control is mild pain.
Since the initial stronger medications are likely to resolve during the night, patients should take the prescribed pain medications before going to bed, even if you are not experiencing pain.
The medicines you take by mouth are different than the medicine in the pump. This will help your transition from the initial surgical block to the milder block from the infusion pump.
If an interscalene block— which is typically used for shoulder surgery—has been placed, the local medication may temporarily affect your facial nerves.
You may notice a droopy eyelid and a bloodshot eye on the same side of your body where the peripheral nerve block has been placed. Your pupils may also appear unequal. Collectively, these symptoms are referred to as Horner’s Syndrome and will resolve.
You may also experience a hoarse voice and mild shortness of breath. These are all temporary symptoms and no cause for alarm.
You can contact an anesthesiologist at any time if you have questions or concerns. Contact information is located on the catheter and in your discharge instructions.
Your surgeon will prescribe the appropriate safety device for use at home. This may include an immobilizer, brace, sling, crutches, or a walker. This device will protect you and minimize risk of falling or injuring your extremity.
You must follow your surgeon’s post-operative orders relating to weight-bearing, use of extremity, and the use of braces or assist devices.
For upper extremity blocks, your arm will be placed in a sling prior to going home.
Your post-operative instructions will include information about any possible restrictions for physical activity after surgery. Follow your surgeon’s discharge instructions regarding physical therapy exercises.
Because the peripheral nerve catheter contains metal, it will need to be removed if an MRI is required during this time period.
It is normal to have decreased feeling or movement with a continuous nerve block. However, once the initial block has resolved, moving the extremity may be much easier, and numbness or tingling may have subsided.
In 18 to 72 hours
t is normal to have decreased feeling or movement with a continuous nerve block. However, once the initial block has resolved, moving the extremity may be much easier, and numbness or tingling may have subsided.
Prescribed pain medication will need to be used during this time period as a supplement to the peripheral nerve block infusion, along with other surgeon recommendations such as cold therapy and elevation of the extremity.
While the infusion continues, safety measures must be continued—such as crutches, an immobilizer, brace, walker, or a sling.
Your pressurized On-Q infusion pump delivers local anesthetic continuously at a programmed rate determined by your anesthesiologist.
A black arrow on the Select-A-Flow dial points to the number that corresponds to the rate of your infusion. The rate is programmed in milliliters per hour. Do not make any rate changes without the direction of your anesthesiologist.
The Rate Changing Key is removable. If it comes off, it can be easily inserted back into place.
The pump is pressurized and does not need elevation to function properly.
In addition to infusing continuously, the pump selected by your anesthesiologist may have a bolus feature. This feature—On-Demand—allows additional medication to be safely delivered by the patient, as needed, for breakthrough pain.
The On-Demand button locks into place when fully depressed. The extra dose of medication—or bolus—which is stored inside of the On-Demand canister, will be delivered over a short period of time. If the On-Demand button does not lock into the depressed position, contact your anesthesiologist at the pager number provided.
Once the bolus is administered, which usually takes several minutes, the button springs back to the initial position, and the canister begins refilling. If the On-Demand button does not spring back after 30 minutes, contact your anesthesiologist.
The Refill Indicator, which is a yellowish line located in the clear window on the side of the On-Demand canister, will be at different levels depending on how full or empty the canister is.
After delivering a bolus, the line will be at the bottom indicating that a bolus has just been delivered. After approximately one hour, the canister should be refilled and the line will then be at the top. The bolus is then ready to be used again if needed.
If the On-Demand button is depressed when the Refill Indicator is not at the top, only a partial bolus will be delivered.
Your On-Q infusion pump may have a white clamp on the tubing between the Select-A-Flow dial and the pump itself. It must remain open for your device to function properly.
Your pump will be stored in a small storage pouch with an adjustable strap.
If pain issues develop, check that there are no kinks in the tubing and that the white clamp is open. It will resemble an open safety pin.
Your pump will get smaller over time. It will likely take 36 to 48 hours before you notice any change in size. Initially you will notice that there is a more wrinkled appearance.
Your pump will last 2 to 4 days and is dependent on the type of On-Q pump selected, the settings, and the On-Demand bolus usage—if available.
The pump is empty and can be removed when it resembles an apple core and the sides are flattened.
The infusion pump and catheter can be thrown away. No special disposal precautions are necessary.
You cannot shower until the nerve catheter infusion is complete and the catheter is removed. The nerve catheter site should remain clean and dry.
Small amounts of drainage or leakage at the insertion site can occur and are no cause for alarm.
Contact your anesthesiologist only if pain significantly increases or leakage becomes problematic.
Add more adhesive dressing or surgical tape to reinforce edges that may be peeling, but do not remove any of the original dressings until the nerve catheter is to be removed. Doing so may cause unintended removal of the catheter.
The infusion pump delivers local anesthetic continuously at a programmed rate to block nerve transmission and reduce pain.
There are infusion pumps which can safely deliver extra medication via a bolus or injection button, which can be depressed by the patient as needed.
Before you leave the hospital, you and your post-operative care giver will be thoroughly instructed on your type of infusion pump and how it functions.
Removing your catheter is a simple procedure. Remove the adhesive dressing that is covering the peripheral nerve catheter. The peripheral nerve catheter is often removed when the adhesive is peeled from the skin.
If the catheter remains in place after the dressing has been removed, simply grip the catheter near the insertion site and pull the catheter out. The catheter should come out easily and without any discomfort.
If the catheter cannot be easily removed, or if you experience pain, stop the removal process and contact your anesthesiologist. Do not manipulate the catheter any further. Never cut the catheter under any circumstances.
It is not uncommon to have a small amount of bleeding or drainage at the catheter insertion site. This can be controlled with light pressure and a band-aid.
The catheter should be inspected to confirm complete removal. Be sure that you see a silver tip.
Any remaining effects of the peripheral nerve block, such as numbness or tingling, heaviness, or decreased ability to move the extremity should be resolved within 24 to 36 hours. If any of these effects remain beyond 36 hours after removal, please contact your anesthesiologist.