Navigating Five Fundamental Regional Anesthesia Challenges

What every outpatient surgery center should know about nerve blocks.

Regional anesthesia is a game changer in outpatient surgery. It promotes quicker recoveries, reduces intra- and postoperative opioid use, and facilitates same-day discharges. But as with any anesthetic technique, it comes with its own potential pitfalls.

To avoid those snags, Rodney Gabriel, MD, MAS, FASRA, an anesthesiologist at UC San Diego Health’s Koman Family Outpatient Pavilion, and Rebecca Johnson, MD, chair of the Committee on Regional Anesthesia and Acute Pain Medicine for the American Society of Anesthesiologists (ASA), share their perspectives on the most common regional anesthesia challenges and how to overcome them.

1. Understand the risks

Regional anesthesia is generally considered safe, but it’s not without risk. “Fortunately, complications are quite rare with regional anesthesia but infection, bleeding and nerve trauma can occur,” says Dr. Johnson. “The risks depend on patient factors and whether the provider is doing a single injection or placing a catheter for continuous pain relief.”

Dr. Gabriel says some patients may experience a vagal response to the procedure itself that presents as hypotension, bradycardia or nausea. While typically manageable, these symptoms can delay surgery and disrupt workflow if not promptly addressed.

Far more serious, though rare, are complications such as intravascular injection, which can lead to local anesthetic systemic toxicity (LAST), seizures or cardiac arrhythmias. These events require immediate intervention and underscore the need for proper technique and preparation.

To add another layer of complexity, post-procedural issues such as nerve injuries or prolonged numbness that result from regional anesthesia may not become apparent until days later. Dr. Gabriel and Dr. Johnson stress the importance of informed consent for regional anesthesia. This ensures that patients fully understand the potential for complications, even if they’re rare, and what to expect if they occur.

Dr. Gabriel says complications are usually temporary, but they can be distressing to the patient. “Blocks that affect the phrenic nerve, especially for shoulder surgeries, can lead to shortness of breath, which is benign in a healthy patient, but dangerous in someone with COPD,” he provides as an example.

2. Precision comes from practice

While advancements such as ultrasound-guided block placement and nerve stimulation have transformed the accuracy of regional anesthesia, technology alone doesn’t guarantee success. Proper nerve block placement remains a highly technical skill that requires focus, repetition and collaboration. In fast-paced outpatient settings, striking the right balance between speed and safety is essential.

“In a high-throughput outpatient setting, you need to resist the urge to rush,” says Dr. Gabriel. “That’s when mistakes happen.”

“You need a solid understanding of anatomy, comfort with ultrasound and situational awareness of the patient’s risk factors,” adds Dr. Johnson. “Combining ultrasound with other modalities such as nerve stimulators can help increase accuracy.” These tools can enhance nerve localization and improve block success, particularly in patients with atypical anatomy, she adds.

Dr. Johnson says it’s vital to standardize regional anesthesia processes through clear protocols and checklists — especially when multiple team members are involved in a procedure. “Everyone involved should know the goals and the plan, from pre-op to PACU,” she says.

Regional anesthesia is not a skill that can be mastered in a single workshop. Providers must continually refine their skills through hands-on experience, ongoing training and mentorship to keep pace with evolving techniques and ensure patient safety.

“It’s not something you master after a workshop or YouTube video,” says Dr. Gabriel. “You need consistent practice to get comfortable seeing nerves and maneuvering the needle under ultrasound.”

“Regional is always evolving,” adds Dr. Johnson. “Go to a specialty conference, attend a regional anesthesia track and ask questions. Not everything is one-size-fits-all.”

3. Choose the right patients

Thoughtful patient selection remains critical to the safety and efficacy of regional anesthesia. The decision to proceed with a nerve block shouldn’t be automatic. It should be based on a thorough evaluation of the patient, the procedure and the setting in which care is delivered.

“If a patient has significant comorbidities such as a high bleeding risk or severe lung disease, we may need to avoid certain blocks altogether, such as the interscalene block,” says Dr. Gabriel.

Even when a continuous block using a catheter could offer extended pain relief at home, not every patient is an appropriate candidate. “We want to make sure they have support at home and that we’re able to follow up with them,” says Dr. Gabriel. “If they’re not comfortable managing a catheter, or there’s no one to help them, we may opt for a single injection instead.”

Dr. Gabriel notes that patients with chronic pain or histories of opioid use often benefit from regional techniques. “If we know someone is going to be especially challenging to manage postoperatively, regional anesthesia, especially a catheter, can be a valuable tool to minimize their opioid use and better control pain.”

Just as important are the capabilities of the surgical facility. Not all outpatient surgery centers are equipped to manage every type of block, notes Dr. Johnson. Limitations in the areas of staffing, follow-up protocols and equipment can impact what’s feasible and safe to do at a particular facility.

“Just because you can place a catheter doesn’t mean you should, especially if you don’t have a way to follow up once the patient leaves,” she says. “Sometimes I know a technique is appropriate but not feasible in the setting I’m working in.”

Surgeon preference also matters. “If the surgeon already has a plan for local infiltration and it works well, I may not need to do a block,” says Dr. Johnson.

4. Communication is everything

No matter how skilled the provider or how advanced the technology, regional anesthesia only succeeds when it’s supported by strong, collaborative communication across disciplines. Dr. Gabriel and Dr. Johnson say trust among anesthesia, surgeons and nursing teams forms the cornerstone of an effective regional anesthesia program, especially in busy outpatient environments that place a premium on efficiency and coordination.

“There can be tension between anesthesia and surgery,” says Dr. Gabriel. “Surgeons may worry about delays or wonder whether the block will work. You need to show them it benefits the patient and builds efficiency over time.”

Establish open lines of communication early on when developing or refreshing a regional anesthesia program. Dr. Johnson makes it a point to proactively engage her surgical colleagues, especially when she is working at a new site or with a new team.

“Even a five-minute conversation before a case can go a long way,” she says. “I ask surgeons what their pain management plan is, and we coordinate from there. Developing those relationships is key, especially when patients have special considerations like past negative anesthesia experiences or nerve deficits.”

5. Expect unanticipated difficulties

MASTERING THE ART Proficiency with regional anesthesia techniques requires practice over an extended period of time.

Even when a nerve block is technically successful, postoperative pain management can be challenging once the anesthetic wears off. Rebound pain, when a patient experiences a sharp return of discomfort after the initial numbness fades, is one of the most common but overlooked complaints associated with regional anesthesia. Fortunately, it’s also one of the most preventable.

“Patients need to understand the block won’t last forever,” says Dr. Johnson. “If they’re not educated in advance, that rebound can be miserable.” She encourages a proactive approach to pain control that includes scheduled doses of NSAIDs and acetaminophen, layered with short courses of opioids when needed. In many cases, patients may benefit from a pain management plan that begins before they feel discomfort.

“We’ve also done a better job incorporating dexamethasone, which can prolong analgesia and reduce the severity of rebound pain, especially in single-injection techniques,” she adds.

Dr. Gabriel echoes the importance of timing, because the transition from numbness to pain can feel abrupt and severe for the patient. “Patients should be encouraged to take their first pain dose before the block fully wears off, especially before going to bed,” he says.

Occasionally, the nerve block may provide incomplete coverage or fail entirely either during surgery or later in recovery. Dr. Johnson notes that doesn’t always mean the block was unsuccessful.

“Sometimes an incomplete block is part of the plan,” she says. “If the patient is under general anesthesia anyway, the block might just be for pain control, not surgical anesthesia.”

However, if the block was intended to be the sole anesthetic and doesn’t provide adequate coverage, the care team must adapt. “You might need to convert to general anesthesia,” says Dr. Gabriel. “If it’s in the PACU and the patient is in pain, we’ll consider replacing the block if it’s in their best interest and risks are minimal.”

Blocking and tackling

Ultimately, the two experts agree that no matter how advanced the tools, success in regional anesthesia depends on mastering the basics, every time.

“When done well, regional anesthesia improves patient comfort, reduces opioid use and supports faster recovery,” says Dr. Gabriel. “To realize those benefits, you need infrastructure: skilled providers, good communication and a shared commitment to patient care.” OSM