What is the recommended follow-up care for a patient after a brachial plexus nerve block?

Follow-up Care After Brachial Plexus Nerve Block

After a brachial plexus nerve block, the patient should be monitored for at least 30 minutes following local anesthetic injection, with the anesthetist immediately available for the first 15 minutes and thereafter contactable and able to attend within 2 minutes. 1

Immediate Post-Block Monitoring

First 30 Minutes

• Monitor vital signs including blood pressure, heart rate, respiratory rate, and oxygen saturation
• Assess block effectiveness and distribution
• Monitor for signs of local anesthetic systemic toxicity (LAST), which can peak between 30-90 minutes after injection 1
• Ensure appropriate staff members present can recognize and manage any immediately life-threatening emergencies

Specific Monitoring Parameters

• Neurological assessment: Regularly evaluate sensory and motor function in the affected limb
• Hemodynamic monitoring: Watch for hypotension, particularly in elderly patients who have reduced homeostatic compensation 1
• Respiratory function: Observe for signs of respiratory compromise, especially with interscalene or supraclavicular approaches which may affect the phrenic nerve

Transition of Care

Handover Requirements

• The patient must be conscious and communicating effectively when responsibility is handed over to anyone other than an anesthetist 1
• Monitoring may be delegated to an appropriately trained healthcare worker only after this point
• The anesthetist should remain immediately available for the first 15 minutes following block placement 1
• After the initial 15 minutes, the anesthetist should be contactable and able to attend within 2 minutes 1

Pain Management Following Block Resolution

Anticipating Rebound Pain

• Patients may experience significant "rebound pain" when the block begins to wear off, typically between 12-24 hours post-procedure 2
• Single-shot brachial plexus blocks typically provide 6-8 hours of analgesia 3
• Continuous blocks with catheters may provide longer analgesia (up to 48-72 hours) 1

Analgesic Plan

• Begin oral analgesics before block resolution to prevent rebound pain
• Implement a multimodal approach:
  • Paracetamol (acetaminophen) scheduled regularly
  • NSAIDs/COX-2 inhibitors if not contraindicated 1
  • Opioids as rescue medication 1
• For continuous blocks, follow appropriate infusion protocols (typically ropivacaine 0.2% at 6-14 mL/h) 4

Complications to Monitor For

Early Complications (0-24 hours)

• Local anesthetic systemic toxicity (LAST)
• Hematoma at injection site
• Horner's syndrome (particularly with interscalene approach)
• Respiratory compromise due to phrenic nerve involvement
• Pneumothorax (particularly with supraclavicular approach)

Later Complications (24 hours to weeks)

• Persistent paresthesias or neuropraxias (typically resolve within 2 weeks, but monitor if persisting beyond 4 weeks) 5
• Infection at injection site
• Catheter site complications for continuous blocks

Patient Education and Discharge Instructions

Protection of the Anesthetized Limb

• Instruct on proper positioning and support of the limb while sensory and motor block persist
• Avoid exposure to extreme temperatures
• Protect from pressure injuries, especially over bony prominences

When to Seek Medical Attention

• Signs of infection (redness, swelling, discharge, fever)
• Persistent numbness or weakness beyond expected block duration
• Severe pain unresponsive to prescribed analgesics
• Respiratory difficulties
• Signs of catheter migration or dislodgement (for continuous blocks)

Follow-up Plan

• Routine follow-up at 2 weeks to assess for resolution of any neurological symptoms 5
• Additional follow-up at 4 weeks if symptoms persist

Special Considerations

Elderly Patients

• May require more vigilant monitoring due to reduced physiological reserve
• More susceptible to hemodynamic changes and medication effects 1
• May have increased risk of falls with lower extremity blocks

Continuous Catheter Management

• For continuous infusions, ensure proper catheter site care and dressing maintenance
• Provide clear instructions for home infusion if applicable
• Establish protocol for catheter removal (typically by trained healthcare professional)

By following these guidelines for post-brachial plexus block care, complications can be minimized and patient comfort and safety maximized throughout the recovery period.