When we look at some anesthetists’ performance the first question we need to ask is: Have we defined correctly what a perfect block is? Probably there are as many definitions of a perfect block as anaesthetists in Portugal, but what really matters is how we get away with a patient with a “no so good” block, also called “partial block”.

Good anatomy knowledge is the key to a good block and even more important to a rescue block. Also there are other measures that can be taken during an operation, like for example the use of well-tailored sedation or conscious use of opiates.

During this talk we will review the reasons why blocks aren’t perfect and what steps we must take. We will consider if the patient is awake or sleep and how we need to achieve the full block. It is not the same to deal with a partial block under a general anaesthetic, when a proper assessment of the nerves affected cannot be undertaken or when a patient is awake because he can direct us into the nerve we need to “top up”.

From infiltration by the surgeon if the operation has started, to target blocks with fast acting local anaesthetic will lead to success.

What types of blocks tend to fail? Our audits have shown that, for example supraclavicular blocks tend to produce incomplete blocks if we compare them with other brachial plexus blocks. Which steps should we use to maximize its effectiveness or what tips should we apply to it?

Another important concept is if we have chosen the right block for the right operative site? It is final a complete knowledge of the nerve distribution to apply the correct block. Do we fully understand the implications of the operation? 

We know that nerve can follow different paths all the way down to their terminal branches, up to 60% of the times…. What is the meaning of nerve overlapping? 

But what makes a block work if we are sure we are in the right place? Are there any other factors we should take into account like deep and superficial fascias, real connection between compartments, multiple fascia layers….

All this questions will be discussed and will help us to understand and produce the right perfect rescue block.

Rafael Blanco

CAR meeting November 2009

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