Chapter 8: Guidelines for the Provision of Regional Anaesthesia Services 2024

Every anaesthesia department should have a designated clinical lead (see Glossary) for regional anaesthesia services. This lead role should be recognised in job plans and be allocated dedicated time. Regional anaesthesia leads should be involved in multidisciplinary service planning and governance related to regional anaesthesia.²

Anaesthetists should actively engage in planning services with significant regional anaesthesia requirements. They should be actively involved in policy decisions, service improvements and equipment purchasing related to regional anaesthesia.

Every anaesthesia department should aim to provide a high-quality regional anaesthesia service. This should be reflected in the published departmental plans and resources provided to support this aim.

Every anaesthesia department should have sufficient anaesthetists with expertise in regional anaesthesia to provide a timely regional anaesthesia service. When this is not possible, a consultant anaesthetist with expertise in regional anaesthesia should be identified daily to support other anaesthetists with regional anaesthesia procedures

Where indicated patients should be offered the choice of regional anaesthesia either as the sole anaesthetic or in conjunction with general anaesthesia.

Clinical governance is covered in detail in Chapter 1: Guidelines for the Provision of Anaesthesia Services: The Good Department. The principles of governance described in the chapter apply to the provision of regional anaesthesia services.

Every anaesthesia department should have systems to report, investigate, discuss and learn from adverse events occurring during regional anaesthesia.¹⁷

Departments should consider having tools for the collection of data on outcomes and the safety of regional anaesthesia procedures. These data should be regularly discussed at governance meetings to improve the performance of the service.

Hospitals should regularly review local standards and policies related to regional anaesthesia and ensure they are harmonised with national safety standards and guidelines.¹⁸

General policies detailed in Chapter 2: Guidelines for the Provision of Anaesthesia Services for Perioperative Care of Elective and Urgent Care Patients are relevant to the provision of regional anaesthesia services. 

A multidisciplinary team, including all relevant healthcare professionals as appropriate, should develop local policies pertinent to regional anaesthesia.

Local policies should be in agreement with relevant published national guidelines.

Local policy on consent should have a section dedicated to regional anaesthesia.

National guidelines adopted locally should be easily accessible to all staff caring for patients undergoing regional anaesthesia. These include but are not limited to: 

• Regional anaesthesia in patients with abnormalities of coagulation¹⁹
• LocSSIPS (Local Safety Standards for Invasive Procedures) for regional block performed without surgery
• Standardised operating procedure for stop before you block – Prep, Stop, Block²⁰
• Performance of regional techniques by non-physician practitioners^21,22
• Intraoperative supervision of patients during peripheral regional anaesthesia¹⁶
• Postoperative monitoring of patients with regional anaesthesia²³
• Management of nerve injury associated with regional anaesthesia^24,25
• Management of compartment syndrome^26,27
• Management of local anaesthetic toxicity⁵

Children, pregnant women, elderly people, those with comorbidities (e.g.; renal failure, cardiac dysfunction or liver insufficiency) and critically ill patients are at higher risk of Local Anaesthetic Systemic Toxicity (LAST). Clear guidelines on the management of LAST in this population including the administration of lipid emulsion therapy, should be immediately available.⁶

In establishing local guidelines, departments may wish to consult the RA-UK website for examples of good practice in relation to regional anaesthesia. 

The following equipment is required as a minimum standard for the safe delivery of regional anaesthesia:

• Regional anaesthesia needles (spinal, epidural and peripheral nerve block) that have yellow colour coded NRFit connections.
• Syringes and pumps used for bolus or continuous use of local anaesthesia (LA) that are NRFit compatible, yellow colour coded with a visible yellow colour sticker attached close to the patient end.31
• Sufficient portable ultrasound machines with linear and curved probes, probe covers and nerve stimulators that are readily available to avoid any delay in waiting for machine availability.
• A safe supply of oxygen either using wall mounted oxygen outlets or provided by cylinders.
• Appropriate facemasks for oxygen delivery.
• All emergency equipment outlined in Guidelines for the Provision of Anaesthesia Services for the Perioperative Care of Elective and Urgent Care Patients 2024.#ref-28
• Cardiac defibrillator

When performing neuraxial anaesthesia, or where there is any possibility of a regional anaesthetic technique needing to be converted to general anaesthesia, all appropriate equipment for safe induction, maintenance and monitoring of general anaesthesia must be available as outlined in Guidelines for the Provision of Anaesthesia Services for the Perioperative Care of Elective and Urgent Care Patients 2024.²⁸

There should be facilities for hand washing and to ensure asepsis; sterile gowns and gloves, caps, masks and chlorhexidine sprays should be available.²⁸

The standard of monitoring equipment while performing regional anaesthesia should comply with Association of Anaesthetists’ standards of monitoring during anaesthesia and recovery document.³²

Other appropriate monitoring equipment should be available when sedation or general anaesthesia is administered along with regional anaesthesia as outlined in Guidelines for the Provision of Anaesthesia Services for the Perioperative Care of Elective and Urgent Care Patients 2024.

All regional anaesthesia equipment (nerve stimulators, ultrasound machine and infusion pumps) should have user manuals and should be checked prior to use in accordance with the Association of Anaesthetists’ published guidelines alongside regular maintenance and replacement programmes.^33. A planned maintenance and replacement programme should be in place.

All anaesthetists and anaesthetic assistants as well as ODPs should receive systematic training in the use of new regional anaesthesia equipment. Provision and receipt of training should be clearly documented. Staff should not use regional anaesthesia equipment unless appropriately trained. There should be a suitable induction policy for new staff and when new equipment is introduced, with a record of training kept within the department.³⁴

Pharmacy services should be available for advice and dispensing of take-home medication for patients scheduled for day-case regional anaesthesia.

There should be an adequate supply of all commonly used local anaesthetic (LA) agents in different concentrations and formulations in all clinical areas where regional anaesthesia is performed.

There should be facilities for keeping all LA agents in a separate storage unit or cupboard from intravenous infusion solutions, to reduce the risk of accidental intravenous administration of such medication.^35,36,37

Storage units should be located and designed for timely access to LA agents when required, while also maintaining the integrity of the medicines and aiding organisations in compliance with safe and secure storage requirements. ^35,36,37

All local anaesthetic medications and additives prepared for infusions should be clearly labelled and delivered via yellow colour coded syringes (or bags) or tubing in accordance with local medicine management committee guidelines.^35,36,37

All drugs required for safe delivery of anaesthesia, including emergency drugs, should be available.

Lipid emulsion therapy should be easily accessible near all clinical locations where local anaesthetics are being administered.

There must be a system for ordering, storage, recording and auditing of controlled medicines (such as local anaesthetics with opioids for epidural infusions) in all areas where they are used, in accordance with legislation.^38,39

Robust systems should be in place to ensure reliable medicines management, stock review and supply, expiry checks, and access to appropriately trained pharmacy staff to manage any medicine shortages.

All staff involved in the prescribing, dispensing, preparing, administering and monitoring of LA infusions must be appropriately trained with access to resources on safe preparation and administration of LA drugs and access to a pharmacy service for advice.⁴⁰

Electronic or paper copies of patient records should be available at all sites prior to the procedure. Patient data should be updated in a timely manner after performing the regional block.⁴¹

Consent may be obtained by the practitioner performing the regional anaesthetic technique but can also be discussed in advance (eg in the preoperative assessment clinic) by a person not performing the nerve block. The person obtaining consent for a regional anaesthetic procedure should be able to communicate the practicalities of the nerve block, the intended benefits, the risks involved and any alternatives available.

Patients who have a disability or sensory loss and those who need access to an interpreter, advocate or other communication professional should be provided with information in a way they can access and understand.⁴⁴

Shared decision making based on patients’ preferences and informed discussions around risks and benefits are vital in regional anaesthesia practice. Information leaflets (or other forms of information such as online videos) describing benefits, risks and alternatives to regional anaesthesia may be provided at the time of preoperative assessment.

In the elective setting, the option for regional anaesthesia should ideally be discussed with the patient prior to the day of surgery. A ‘patient information leaflet’ may help inform this discussion and, where used, should be written in language easy to understand by the patient, with a translation available if required.

If regional anaesthesia is not considered as an option prior to the day of surgery, consent may be obtained on the day of surgery, provided that adequate time is given in the pre-operative consultation for the patient to understand the information provided, consider alternative options and to ask any questions they may have.

Consent should only be obtained in the anaesthetic room under exceptional circumstances, such as in the case of emergency surgery.

The consent process should include a discussion of the process of the regional anaesthesia technique including whether this will occur while the patient is awake, sedated or under general anaesthesia. All common risks and side effects of the intended block should be outlined together with serious risks.

Patients should be told what to expect following a particular nerve block, including advice on how to protect a limb to prevent damage while it remains insensate and the risk of falls or pressure sores related to a motor block of the lower limb.

All discussions about the intended regional anaesthetic technique should be documented in the patient’s notes. A separate formal, written consent is not required when the nerve block is used to facilitate a surgical procedure, but should be obtained when regional anaesthesia is the sole therapeutic procedure eg. erector spinae plane (ESP) block for rib fractures. In this circumstance, the laterality of the block must also be clearly marked as part of the consent process.

Where regional anaesthesia is an option, this should be offered to and discussed with the patient along with the alternatives

Hospitals should consider providing specific regional anaesthesia lists for awake procedures, staffed by an anaesthetist with a special interest in regional anaesthesia. However, alternative lists for patients unable or unwilling to undergo awake surgery should be available.

Where regional anaesthesia is chosen, and where appropriate, patients should be offered the option of sedation to supplement a regional anaesthetic technique. The relative benefits of undergoing an awake procedure as compared with sedation or general anaesthesia (with or without regional anaesthesia) should be considered.

RA-UK/ Safe Anaesthesia Liaison Group (SALG) national ‘Prep, Stop, Block’ guidance should be followed for all regional anaesthetic procedures involving laterality. Wrong-sided block is defined as a never event by NHS England.⁴⁵

RA-UK recommend that, under certain strict criteria and as defined in RA-UK supervision guidelines, intraoperative patient monitoring may be delegated to a suitably trained health care worker who has been specifically trained in patient monitoring according to Association of Anaesthetists guidelines. This recommendation pertains to awake surgery under peripheral regional anaesthesia but excludes patients undergoing shoulder surgery in the deck chair position.

When using the block room model, where work occurs in parallel, the anaesthetist should be immediately available for the first 15 minutes after siting the block and then immediately contactable and able to attend within 2 minutes for the duration of the procedure.¹⁶

Anaesthetists and other health professionals who care for children having regional anaesthesia techniques, must have received appropriate training and should ensure that at annual appraisals, competence is deemed adequate.^45,51

Equipment suitable for each age group should be available and checked.

Regional anaesthesia should be considered in the pre-operative preparation of patients. Families and patients should be provided with information about the benefits, risks, and side effects of RA techniques in a way that they understand. This includes verbal and written instructions on how to manage pain when the block wears off and what to do and who to contact in the event of a problem or concern when patient is discharged.^52,53

Hospitals should have pathways in place for major surgery that include the use of regional techniques.

Ultrasound equipment should be available, as its use to guide central (e.g. caudal) and peripheral blocks is encouraged to increase efficacy and safety. This is particularly relevant in younger children, infants and neonates where the effect size is inversely proportional to the patient size.⁵

Processes should be recognised that the PREP STOP BLOCK moment will probably occur with the patient under general anaesthesia and therefore the ability to confirm with the patient at this point will be lost; ensuring that this standard operating procedure (SOP) is performed correctly will help to reduce the risk of wrong-sided block.

Guidelines relating to the appropriate maximum doses of local anaesthetic should be considered. It should be recognised that infants and neonates are at increased risk of LAST.²⁷

Staff managing LA infusions (peripheral nerve infusions or epidural infusions) should be appropriately trained in the recognition and management of LAST. The risk of LAST associated with infusions is increased in younger patients and therefore the duration of LA infusions should be considered to reduce this risk.

LA boluses (e.g. epidural top ups) should be performed by appropriately trained individual.

All anaesthetists involved in the care of pregnant and breastfeeding women should be competent to deliver high-quality and safe anaesthetic care in this population.54

Guidelines for anaesthetising pregnant patients should be followed.⁵⁵ Local or regional techniques are preferable where feasible in pregnant and breastfeeding women.^51,52

In pregnant women having non obstetric surgery and regional anaesthesia, the decision to monitor fetal heart rate during surgery is specific to the patient and is often based on institutional guidelines. Informed consent should include consideration of fetal wellbeing, the possibility of caesarean delivery and any risks for mother and child.

Guidelines for the management of pregnant women receiving anticoagulation, and for the recognition and management of complications of regional analgesia/anaesthesia should be available, including access to appropriate imaging facilities if neurological injury occurs.

Guidelines on perioperative care of elderly patients should be available.⁵⁶

Multidisciplinary communication about the nature of surgical intervention is necessary to provide adequate anaesthesia care in this high-risk population and an analgesia plan should be available.

Older patients should be assessed for risk of postoperative cognitive dysfunction and preoperative interventions undertaken to reduce the incidence, severity and duration. While the use of regional anaesthesia alone without sedation might be considered, there is a lack of strong quality evidence suggesting that this practice reduces the overall risk.⁵⁴

In patients deemed to be lacking in capacity, proxy information should be sought to determine what treatment, if any, is in the patient’s best interests and this treatment should be clearly documented.⁵⁴

Experienced anaesthetists should manage patients living with obesity. Regional anaesthesia in this group of patients can be challenging and should be undertaken/supervised by experienced anaesthetists.⁵⁷

Additional specialised equipment might be necessary to perform regional anaesthesia techniques on these patients. Equipment such as extra-long spinal or epidural needles should be available.

Ultrasound equipment should be available, as its use to guide central and peripheral techniques is encouraged to increase success rates.

Critically ill patients are complex and hold unique particularities that makes them more susceptible to side effects and complications of regional anaesthesia techniques. Experienced regional anaesthetists should perform/supervise regional anaesthesia techniques in these patients.

Regional anaesthesia complications in sedated patient are less easily recognisable, and a high index of suspicion is required, which should be recognised in local policies and procedures.  

In the patient receiving epidural analgesia or other continuous LA infusions the site of injection should be checked at least once a day. Patients should be monitored for early signs of complications.

Early multidisciplinary assessment including surgeons, pain services, critical care and physiotherapy should determine the optimal analgesia management for chest wall injuries including provision for early epidural, fascial plane or peripheral nerve blocks in patients with multiple rib fractures.⁵⁸

Establishing pathways that lead to early identification and timely management of injured nerves is key to optimal patient outcome. There should be a clear and accessible pathway for suspected peripheral nerve injuries including a single point of contact to guide further management.⁵⁶

Patients at risk of acute compartment syndrome should be identified on admission to hospital or at the time of surgery, and the condition should be managed within agreed multidisciplinary protocols. Single-shot or continuous peripheral nerve blocks using lower concentrations of local anaesthetic drugs without adjuncts have not been associated with delays in diagnosis provided post-injury or postoperative surveillance is appropriate and effective.27

Patients receiving any regional anaesthesia/analgesia care in a non-theatre location should be cared for by an adequately trained health professional with appropriate supervision.⁵⁹

Guidelines for recognising and managing complications including local anaesthetic toxicity, and intralipid, should be immediately available and should be located in all areas where large amounts of LA is administered.⁶⁰

After performing a fascial plane or peripheral nerve block in the emergency department, patients should be closely monitored (for a minimum of 1 hour) during and after the procedure; for both signs of local anaesthetic toxicity and sedation effects of other analgesia that may have been administered.⁶¹

Hospitals providing care for hip fracture patients should have a formal pathway that includes prompt provision of analgesia with regional block such as Fascia Iliaca Block (FIB) in emergency departments. FIB should be undertaken only by clinicians who have completed a competency assessment in this skill.⁶²

Regional anaesthesia procedure should be clearly documented and easily accessible in the patient’s notes.

Anaesthesia for ophthalmic surgery is a specialised area of anaesthesia. Practitioners should be competent in performing ophthalmic blocks and be able to recognise and manage any complications.

Sharp needle-based blocks (e.g. peribulbar) should only be administered by medically qualified personnel.

Intravenous access should be established prior to performing sharp needle-blocks.

Patients who require regional anaesthesia should undergo preoperative preparation.

Units where ophthalmic surgery is performed should be provided with guidelines, drugs and equipment to deal with complications and emergencies such as cardiac arrest, anaphylaxis and local anaesthesia toxicity.

Medical, surgical and social suitability for day surgery should be assessed as part of pre-operative assessment. This should ideally be within a day-case specific pre-operative assessment service.⁵¹

All components of safe regional anaesthesia service delivery should be adhered to within day surgery environments to the same standards as within an inpatient facility.

Departments should have ‘awake surgery’ pathways, which can increase efficiency of list turnover and may reduce resources required.  A ‘block room’ service delivery model where locally appropriate could facilitate this process.

Policies should acknowledge that patients who undergo surgery under regional anaesthesia without GA may be suitable to bypass the acute/stage 1 recovery area after surgery and may proceed directly to secondary recovery prior to discharge home.⁶³

Locally agreed same-day discharge pathways should consider incorporating local anaesthesia infusion devices and catheters where follow up systems and protocols allow this to be done safely. There should be appropriate staff and patient education in their use and in the detection and management of complications.

Where spinal anaesthesia is used in day-surgery, nursing staff should be trained in the safe mobilisation of patients after spinal anaesthesia prior to nurse-led discharge. Information on post-dural puncture headache and what to do if this occurs should be included in the patients discharge instructions.

Post-operative patient education and written information should be provided prior to discharge as described in section 6: the ‘postoperative period’ section in this document, regarding care of the insensate limb, expected sensation and motor recovery trajectory, pre-emptive analgesia plan, and how and when to seek help.

Staff undertaking day surgery patient follow up or answering patient helpline calls should be aware of local departmental guidance related to peripheral nerve block follow up and initial management of unexpected/persistent neurological dysfunction.