Awake and Aware
Nerve Blocks on Unconscious Patients a Bad Idea
Administer a nerve block to a patient under general anesthesia? Not a safe practice, say 89.8% of the 106 anesthesia providers we polled, unlike the Wisconsin anesthesiologist embroiled in a deadly malpractice trial (tinyurl.com/lyk2xn3) who says he prefers to give blocks to unconscious patients because they don't flinch when he inserts the needle. That may be true, but a lawsuit claims a man, 62, suffered a fatal heart attack shortly after being administered an interscalene nerve block while still under general anesthesia during rotator cuff surgery. Because he was unconscious, the suit says, he was unable to report the classic symptoms of an intravascular injection ringing in the ears, numbness and tingling around the mouth.
The patient's widow argued that her husband should have been given the option to remain awake while the block was being done. The trial against anesthesiologist Robert Corish, MD, was still ongoing at the time of publication, but some anesthetists offered their own verdicts.
"If one needs a patient to be under general anesthesia to do a brachial plexus block, perhaps they should find a more talented provider for that task," says Gregory Rendelman, CRNA, of the Lebanon (Pa.) VA Medical Center.
In court, Dr. Corish insisted that he isn't alone that the practice is the standard of care for many of his colleagues. Yet only 2% of our survey respondents prefer that patients be unconscious; another 8% decide on a case-by-case basis. "In residency the policy was no nerve blocks in unconscious patients with the possible exception of children or adults incapable of understanding the situation," says Alvin Manalaysay, MD, from St. Louis, Mo. He cautions that "many facilities encourage the practitioner to make procedures as anxiety-free as possible. One has to decide how risky she or he feels today."
It's a risk that should never be taken, argues Mr. Rendelman. "If a provider has not witnessed a patient point out that your needle may have wandered into the wrong territory, either you haven't been doing anesthesia long enough or your patient is under general anesthesia and can't relay that info."
Most anesthesia providers say they prefer to give blocks to patients lightly sedated with a cocktail of midazolam and fentanyl.
"The patient needs to be awake and aware," says Joseph Rodriguez, CRNA, at Banner Boswell Medical Center in Sun City, Ariz. "Their response is an excellent assessment tool for preventing nerve damage." You have to make sure the patient can answer your questions, agrees Fatima Ahmad, MD, associate professor at Loyola University in Maywood, Ill. "Are you OK? Do you have any headache or ringing in the ears? Is there any numbness or weakness in your other arm?"
Others point out that increasingly crisp imaging may help mitigate the dangers of blocking an unconscious patient, but that doesn't mean they're ready to make that leap. "Ultrasound has changed the game," says Hal DeVera, MD, anesthesiologist at the University of California, Davis Medical Center in Sacramento, Calif. "I believe it's safer to have a calm or even anesthetized patient when doing nerve blocks under ultrasound guidance. However, at this point in time, the standard is to have the patient awake or sedated."