Short summaries in our own words, with a link to each original. Keep the original posters and cards where you block, and follow your hospital's version where it differs.
WRONG-SITE BLOCK
Prep, Stop, Block
When: Every block, every time, immediately before the needle goes in.
- Prep. WHO Sign In on arrival. The blocker draws up and labels the local anaesthetic and puts the syringe and needle in a tray, which the assistant keeps out of the blocker's reach. Then position, pre-scan if wanted, gloves and skin preparation. The assistant makes sure the surgical site mark can be seen.
- Stop. A two-person check after all preparation is done, immediately before needle insertion. Blocker: "I've completed my prep; let's Stop Before You Block." Assistant: "OK, let's Stop Before You Block." Both check the side against the site mark, and the assistant checks it against the consent form. An awake patient can confirm the side too.
- Block. Only when the side is confirmed does the assistant hand back the tray, and the blocker blocks straight away. Any delay means starting again from the Prep step.
Source: Safe Anaesthesia Liaison Group and Regional Anaesthesia UK, Prep Stop Block (national protocol, 2022). The full educational package, posters and template SOP are free to download from SALG.
EMERGENCY
Local anaesthetic systemic toxicity (LAST)
When: Sudden change in mental state, agitation, loss of consciousness or seizures, or arrhythmia and cardiovascular collapse, during or some time after injection.
- Stop injecting, including any infusion pump. Call for help, tell the team, and ask for the arrest trolley and the lipid rescue pack.
- Airway and breathing: 100% oxygen, secure the airway if needed, avoid hypercarbia (consider mild hyperventilation). Confirm IV access.
- Seizures: small incremental doses of benzodiazepine. Thiopental or propofol with caution. Consider neuromuscular blockade if seizures continue.
- Lipid emulsion 20% (propofol is not a substitute): bolus 1.5 mL/kg over 2–3 min (about 100 mL for 70 kg), then infusion 15 mL/kg/h.
- At 5 and 10 min, repeat the bolus if the circulation is not restored or gets worse. After 5 min, double the infusion to 30 mL/kg/h if needed. Maximum total 12 mL/kg (840 mL for 70 kg).
- Cardiac arrest: CPR to standard protocols plus lipid, but adrenaline 1 microgram/kg or less (not 1 mg) and no vasopressin. Recovery may take more than an hour; consider cardiopulmonary bypass if available.
- No arrest: treat hypotension and arrhythmias in the usual way and consider lipid.
- Afterwards: safe transfer to a monitored area, check daily amylase or lipase for pancreatitis, and report the incident locally and nationally.
Source: Association of Anaesthetists, Quick Reference Handbook card 3-10, Local anaesthetic toxicity (v2, June 2023). Adapted with acknowledgement from the QRH card, which is shared under a Creative Commons CC BY-NC-SA 4.0 licence. The 2010 laminate is withdrawn: keep the 2023 card in your LAST box.
FOLLOW-UP
Nerve injury after a peripheral nerve block
When: New numbness, tingling, weakness or unexplained pain, or a block lasting more than 48 h after a single injection.
- Review within 48 h of the block. Compare with the preoperative examination and ask whether the pattern fits the block you did.
- Document the anaesthetic, surgical and medical records and any symptoms before surgery. Examine all the nerves, skin colour, swelling and pulses. Tell the surgical and anaesthetic consultants.
- Urgent if there is motor weakness, worsening symptoms or a painful deficit: get senior surgical or neurology help the same day. Think of compartment syndrome, compression by a haematoma or dressing, and consider urgent ultrasound or MRI. Decompression may be needed.
- Not urgent (sensory, stable): loosen tight bandages or split the plaster, protect the limb, reassure the patient and review pain relief. Involve the pain team early if there is allodynia or features of CRPS. Review in 2–4 weeks.
- Still there at follow-up: nerve conduction studies and EMG, imaging, and referral to neurology or a peripheral nerve injury service.
Source: Regional Anaesthesia UK and British Orthopaedic Association, algorithm for neurological symptoms after peripheral nerve block (2021). A simplified summary of the RA-UK/BOA algorithm. Use the original flowchart in your department.
EMERGENCY
High or total spinal block
When: After a spinal, epidural or a block near the neuraxis (interscalene, paravertebral, lumbar plexus): rising numbness, arm weakness, difficulty breathing or speaking, hypotension, bradycardia, loss of consciousness.
- Stop any injection or infusion. Call for help. Tell the patient what is happening if they are awake.
- Oxygen and support breathing. Intubate and ventilate if breathing or consciousness fails; give sedation or anaesthesia once intubated, because the patient may be aware.
- Circulation: IV fluids and a vasopressor for hypotension; atropine or glycopyrronium for bradycardia; adrenaline early if severe. In pregnancy, displace the uterus to the left.
- Cardiac arrest: standard life support. If local anaesthetic toxicity is possible, follow the LAST protocol.
- Keep the patient ventilated and supported until the block wears off, then explain and document what happened and report it.
Nerve Blocks summary of standard practice (no single national protocol). Use your hospital's protocol where one exists.
TIME-CRITICAL
Epidural haematoma or abscess: red flags
When: Any patient with an epidural, or after a neuraxial block, especially on antithrombotic drugs.
- Red flags: new or increasing back pain or tenderness, leg weakness that is denser than expected or getting worse, numbness spreading or not wearing off, new bladder or bowel problems, fever with back pain.
- Stop the epidural infusion and reassess the motor block regularly.
- If the block does not start to wear off as expected after stopping the infusion, or any weakness is getting worse, treat it as an emergency: urgent senior review and MRI without delay.
- Call the spinal surgeons straight away if MRI shows compression. The outcome depends on how fast the spinal cord is decompressed.
- Check the timing of antithrombotic drugs (see the table below) and do not remove a catheter or give the next dose until a plan is agreed.
Source: Nerve Blocks summary of standard practice, based on the UK Third National Audit Project (NAP3). Follow your hospital's epidural monitoring and escalation policy.