Regional Anaesthesia for Bilateral Upper Limb Surgery: A Review of Challenges and Solutions (Report‪)‬

Surgeons are becoming increasingly interested in performing bilateral procedures at the same operation and this poses a challenge to the anaesthetist considering regional anaesthesia. While bilateral lower limb surgery has the easy option of central neuroaxial blockade, this is not a routine option for upper limb surgery. Concerns are raised regarding the large doses of local anaesthetic (LA) required and the risk of serious bilateral adverse effects such as phrenic nerve block or pneumothorax. However, there have been several advances in regional anaesthesia such that these concerns may need to be reconsidered. Within the last decade, ultrasound-guided regional anaesthesia and continuous nerve catheter techniques have become increasingly popular. Use of ultrasound allows imaging of the needle, nerves, surrounding anatomical structures and LA spread. Needle insertion points are no longer constrained by reproducible external anatomical landmarks. Unlike landmark-based techniques, ultrasound allows the needle and LA to be placed where it is less likely to cause unwanted side-effects. Approaches previously less popular, such as the supraclavicular block and individual peripheral nerve blocks, have been undergoing a renaissance. Many anaesthetists are also becoming more confident using smaller doses of LA to achieve similar results (1-3). Continuous nerve catheter techniques allow doses to be titrated and extend the duration of the block well into the postoperative period. No longer do large doses of the long-acting (and potentially more toxic) LA need to be administered as a single bolus. By reducing the risk of toxicity and dose-related adverse effects (3), the option of bilateral blocks could be reconsidered. We now regularly undertake bilateral joint replacements in our area. While the demand for bilateral elective surgery may increase, it is probably in the field of trauma that bilateral regional anaesthesia of the upper limb will have most benefit. Avoidance of general anaesthesia can allow ongoing monitoring such as when there is coexistent head injury (4).