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decide on a case-by-case basis. "In residency the policy was no nerve
blocks in unconscious patients with the possible exception of chil-
dren or adults incapable of understanding the situation," says Alvin
Manalaysay, MD, from St. Louis, Mo. He cautions that "many facilities
encourage the practitioner to make procedures as anxiety-free as pos-
sible. One has to decide how risky she or he feels today."
It's a risk that should never be taken, argues Mr. Rendelman. "If a
provider has not witnessed a patient point out that your needle may
have wandered into the wrong territory, either you haven't been doing
anesthesia long enough or your patient is under general anesthesia and
can't relay that info."
Most anesthesia providers say they prefer to give blocks to patients
lightly sedated with a cocktail of midazolam and fentanyl.
"The patient needs to be awake and aware," says Joseph Rodriguez,
CRNA, at Banner Boswell Medical Center in Sun City, Ariz. "Their
response is an excellent assessment tool for preventing nerve dam-
age." You have to make sure the patient can answer your questions,
agrees Fatima Ahmad, MD, associate professor at Loyola University in
Maywood, Ill. "Are you OK? Do you have any headache or ringing in
the ears? Is there any numbness or weakness in your other arm?"
Others point out that increasingly crisp imaging may help mitigate
the dangers of blocking an unconscious patient, but that doesn't mean
they're ready to make that leap. "Ultrasound has changed the game,"
says Hal DeVera, MD, anesthesiologist at the University of California,
Davis Medical Center in Sacramento, Calif. "I believe it's safer to have
a calm or even anesthetized patient when doing nerve blocks under
ultrasound guidance. However, at this point in time, the standard is to
have the patient awake or sedated."
— Jim Burger
