Can bilateral hand regional anaesthesia be performed safely in an adult patient?

Bilateral Hand Regional Anaesthesia: Safety and Feasibility

Yes, bilateral hand regional anaesthesia can be performed safely in adult patients using peripheral nerve blocks, provided you stay within safe local anaesthetic dose limits and avoid bilateral interscalene approaches. 1

Key Safety Principles

Local Anaesthetic Dosing Strategy

• Ultrasound guidance and nerve catheter techniques have reduced dose requirements for effective blocks, allowing bilateral procedures while remaining within recommended safe dose limits 1
• Space the blocks apart in time to prevent peak absorption rates from coinciding, further reducing systemic toxicity risk 1
• Peripheral nerve blocks for the hand have the highest incidence of systemic toxicity (7.5 per 10,000) among regional techniques, making dose management critical 2
• The incidence of systemic toxicity has decreased from 0.2% to 0.01% over the past 30 years with improved techniques 2

Block Selection for Bilateral Hand Surgery

• Peripheral nerve blocks (axillary, infraclavicular, or distal blocks) are preferred over bilateral interscalene approaches 1
• Bilateral interscalene blocks remain contraindicated due to inevitable bilateral phrenic nerve paralysis, even with low local anaesthetic doses 1
• Axillary blocks are performed most frequently and are safer than supraclavicular approaches 2
• Multiple peripheral nerve blocks in the upper limb (median, ulnar, radial at wrist or forearm level) are suitable alternatives for hand-specific procedures 3

Clinical Implementation

Technique Considerations

• Ultrasound guidance should be prioritized whenever possible, as recommended during the COVID-19 pandemic and beyond for drug-sparing strategies 4
• Experienced clinicians should perform blocks in higher-risk scenarios (including bilateral procedures), as fewer attempts correlate with reduced bleeding complications 4
• Success requires meticulous attention to detail and careful safety precautions; regional anaesthesia should not be attempted by inexperienced, unsupervised practitioners 3

Risk Assessment

• Pain on injection and paraesthesiae are danger signals of potential nerve injury and must not be ignored 2
• Permanent neurological injury from peripheral nerve blocks is rare (1.9 per 10,000), with transient injuries being more common 2
• There is no scientific evidence that performing blocks under general anaesthesia increases nerve injury risk compared to awake patients, though this remains debated 5

Common Pitfalls to Avoid

• Do not perform bilateral interscalene blocks due to bilateral phrenic nerve paralysis risk 1
• Do not exceed maximum safe local anaesthetic doses when performing bilateral blocks; calculate total dose carefully 1
• Do not rush the procedure; spacing blocks 15-30 minutes apart allows staggered absorption and reduces peak plasma levels 1
• Do not ignore patient concerns; approximately 8-10% of patients may prefer general anaesthesia despite successful regional technique 3

Coagulation Considerations

• Any coagulation abnormality is a relative contraindication requiring risk-benefit assessment 4
• Peripheral nerve blocks at compressible sites carry lower bleeding risk than neuraxial or deep blocks 4
• Experienced clinicians should be involved in decisions about regional anaesthesia in patients with abnormal coagulation 4