Toxicity of local Anesthetics

Local Anesthetics are used in concentration that, under normal clinical conditions, do not cause irreversible nerve damage. However, the combination or relatively high concentration of local anesthetics, intraneural injection, and ephinerphrine, can result in neurotoxicity. The potential for neurotoxicity associated with a local anesthetcs is a function of its potency, concentration, and the length of time the neuronal tissue exposed to the agent. Exposure of the endoneurium to a very high concentration of local anesthetic may contribute to a neurologic deficit. Fortunately, under normal circumstances, the concentration of local anesthetic at the injection site decrease quickly because of dilution by the interstitial fluids and absorption into the blood. For this reason, as long as the local anesthetic is not injected intraneurally, there is no convincing evidence that consentration used clinically present at independent risk factor for neurologic dysfunction.

Neural Ischemia
A good neurologic despite the widespread use of touniquets during extremity surgery demonstrates thap pheripheral nerves are relatively reistant to ischemia of limited duration and magnitude. However, laboratory data unequivocally and ischemia can indeed cause irreversible damage to static nerve in less than 4 hours. A combination of several factors , such as increased pressure due to in advertent intraneural injetion and reduced blood flow due to epinephrine, can result severe neuronal demise. The endoneurial pressure under these circumstance can exceed the capillary perfusion pressure and result in schemia of the nerve fascicles on top of the tissue toxicity of the local anesthetics. The addition of epinephrine can further enhance ischemia because it was has a vasoconstrictive effect and reduces blood flow. Thus, the key to avoidinf neuronal ischemia is avoidance of the combination of intraneural injection, epinephrine, and prolonged apllication of the tourniquet, particularly over the area of nerve block injection.

Methods and Techniques to Decrease the Risk of Nerve Injury After Peripheral Nerve Blocks
Base on the aforementioned evidence, we routinely adhere to the folowing recommendation to derease the risk of complications with peripheral nerve blockcade Aseptic technique Most nerve block techniques are merely percutaneus injections. However, infection are known to occur and can result in significant disability. Since this complication is almost entirely preventable, every effort should be made to adhere to a strictly aseptic technique. Short bevel insulated needles

The short bevel design helps to prevent nerve penetration, Insulated needles are now widely available and result in much more precise needle placement whwn a nerve stimulator is used. Needles of appropriate length for each and every block procedure Excessively long should not be used for nerve blockade. For instance, NEVER insert needles longer than 50 mm in interscalene blockae. In addition, needles of appropriate length can be advanced with far grater precision than excesively long needles. Needle advancement During needle localization, advance and with draw the needle slowly. Keep in mind that nerve stimulators deliver current of very short duration one (1 Hz) or twicw (2Hz) a second and that no current is delivered between the pulses. Fast insertion and withdrawal of the needle may result in failure to stimulate the nerve because the needle may pass near by, or even through, the nerve between the stimuli without eliciting nerve stimuation. Fractionated Injection Inject Smaller doses and volumes of local anesthetics(3-5 mL) with intermitten aspiration to avoid inadvartent intravascular injection. Always observe the patient during the injection of local anesthetic because negative aspiration of blood is not always present with an intravenous injection. This approach ay allow detection of the sign of local anesthetics toxicity before the entire dose is injected. Accurancy of the nerve stimulator Always make sure taht the nerve stimuator is operational, delivering the spesified current, and that the leads are properly connected to the patient and the needle Avoidance of forceful, fast injections Forceful, fast injections are more likely to result in chanelling of local anesthetic to unwated tissue layers, lymphatics vessels, or small veins that may have been cut during needle advancement. Such injection may result in massive channeling of the local anesthetics in the systemiccirculation, with consequent risk of severe CNS and cardiac toxicity. Forceful, fast injetions under excessive pressure also may carry more risk of intrafascicular injection. Limit the injection speed to 15-20mL/minute