Synopsis
Select, perform and follow adult peripheral or central neuraxial anaesthesia safely by matching technique, consent, coagulation status, monitoring and rescue planning to the procedure.
- Distinguish peripheral nerve block, fascial-plane block, spinal anaesthesia and epidural anaesthesia: each has different onset, spread, duration, failure pattern and bleeding consequence.
- Before needling, confirm indication, alternatives, consent, side and site, infection, neurological baseline, drug allergies, total local-anaesthetic plan and an agent-specific anticoagulant interval.
- Treat a high neuraxial block as an evolving airway and circulation emergency: call for help, give 100% oxygen, support ventilation, treat hypotension and bradycardia, and reassure an aware patient.
Key red flags
Difficulty breathing, inability to speak normally, arm weakness, bradycardia or hypotension after spinal or epidural dosing suggests a high or total neuraxial block and requires immediate airway and circulatory support.
New severe spinal pain, motor weakness, sensory loss or bladder and bowel dysfunction after neuraxial intervention may represent an epidural haematoma or abscess; urgent neurological assessment and MRI must not wait for routine ward review.
Tinnitus, metallic taste, circumoral paraesthesia, agitation, seizure, conduction disturbance or cardiovascular collapse during or after injection may be local-anaesthetic systemic toxicity.
Never apply one anticoagulant interval to every block: neuraxial and deep non-compressible blocks carry greater bleeding consequence than superficial compressible techniques, and timing changes with agent, dose, renal function and traumatic puncture.
Pain out of proportion, increasing analgesic requirement or pain on passive stretch despite a functioning lower-limb block can indicate compartment syndrome and needs urgent surgical assessment.
A block on the wrong side, wrong site or wrong patient is prevented by an active stop-before-you-block check immediately before needle insertion.
Ascending numbness, hypotension, bradycardia, dyspnoea, arm weakness and impaired consciousness may progress rapidly to apnoea.
New back pain with progressive motor, sensory or sphincter dysfunction is a neurological emergency requiring urgent imaging and surgical discussion.
Disproportionate escalating pain, pain on passive stretch, tense swelling or neurological change requires immediate surgical assessment even when regional analgesia is present.
Reasoning priorities
Determine whether antithrombotic timing is compatible with the exact planned technique.
Check agent, dose, indication, renal function, last administration and catheter plan against current drug-specific guidance; do not infer safety from the medicine class alone.
Worked reasoning
An adult scheduled for major abdominal surgery takes an antithrombotic and requests epidural analgesia.
- Identify the exact drug, dose, indication, renal function, last dose, other haemostatic abnormalities and both the procedural bleeding risk and consequence of neuraxial bleeding.
- Use the current agent-specific neuraxial table for insertion and catheter removal; if the interval is unmet, choose an alternative analgesic technique rather than improvising a shortened gap.
- Record postoperative thromboprophylaxis timing, catheter observations and who authorises removal and restart so that prescriptions cannot inadvertently overlap an unsafe catheter window.
- If traumatic puncture occurs or neurological symptoms develop, stop routine progression, seek senior advice and arrange urgent assessment under the applicable escalation pathway.