1. PURPOSE
To ensure that regional and neuraxial anesthesia are delivered safely, consistently, and with standardized risk controls by defining service governance, privileging and competency (including ultrasound-guided regional anesthesia), correct-side verification, aseptic technique, monitoring requirements, documentation standards, anticoagulation safety processes, continuous catheter management, and prevention/management of local anesthetic systemic toxicity (LAST). This policy supports the CBAHI expectation that perioperative and procedural care follows standardized processes and meets national and cited international standards. (istitlaa.ncc.gov.sa)
2. SCOPE
This policy applies to all regional and neuraxial anesthesia performed in the Operating Rooms (OR), block areas, PACU, and approved remote procedural areas, including:
- Neuraxial techniques: spinal, epidural, combined spinal–epidural (CSE), and neuraxial opioid/adjunct administration associated with these techniques.
- Peripheral nerve blocks (PNB): upper limb, lower limb, truncal, and other single-shot ultrasound-guided or landmark/nerve stimulator techniques.
- Continuous catheter techniques: epidural catheters and peripheral nerve catheters for intraoperative and postoperative analgesia.
- Regional anesthesia performed as primary anesthetic or as analgesic adjunct, with or without sedation.
This policy applies to all clinicians and staff involved in regional/neuraxial anesthesia: anesthesiologists/anesthesia professionals, anesthesia technicians, PACU nurses involved in monitoring regional effects, acute pain service (if present), and any assisting staff.
3. DEFINITIONS
- Regional anesthesia: Anesthetic/analgesic techniques that block nerve conduction in targeted neural structures (neuraxial or peripheral) using local anesthetics with or without adjuvants.
- Ultrasound-guided regional anesthesia (UGRA): Use of ultrasound imaging to identify anatomy and guide needle placement and/or local anesthetic injection.
- Stop-Before-You-Block / Prep-Stop-Block: A standardized pause immediately before needle insertion or injection to verify correct side/site, correct patient, correct block, and readiness, designed to prevent wrong-side blocks. (The Royal College of Anaesthetists)
- Neuraxial hematoma: Bleeding within the spinal canal potentially causing neurological compromise; risk increased with anticoagulants/antiplatelets and traumatic needle placement.
- LAST (Local Anesthetic Systemic Toxicity): Systemic toxicity from local anesthetic exposure, potentially causing neurologic and cardiovascular collapse; requires immediate recognition and lipid emulsion therapy as per guideline checklists. (ASRA Pain Medicine)
- Continuous catheter: Perineural or epidural catheter used to deliver local anesthetic infusion/bolus for ongoing analgesia.
4. POLICY
4.1 Service Governance & Standardization
- 4.1.1 The hospital shall maintain a structured regional/neuraxial anesthesia service aligned with its scope of services and resources, with standardized processes and documentation. (istitlaa.ncc.gov.sa)
- 4.1.2 Regional/neuraxial anesthesia shall be performed only by anesthesia professionals who are credentialed, privileged, and competent for the specific technique and patient population, consistent with CBAHI clinical privileging principles. (istitlaa.ncc.gov.sa)
- 4.1.3 Minimum physiologic monitoring standards for patients receiving anesthesia, including regional anesthesia with sedation or MAC, shall follow recognized standards for evaluation of oxygenation, ventilation, circulation, and temperature when indicated. (asahq.org)
4.2 Correct-Side/Correct-Site Regional Block Safety
- 4.2.1 A block time-out (“Stop-Before-You-Block”) shall be performed prior to all unilateral or laterality-dependent blocks and before neuraxial procedures where laterality/site marking is relevant, in addition to the surgical safety time-out. (The Royal College of Anaesthetists)
4.3 Neuraxial and Peripheral Block Conduct Standards
- 4.3.1 Neuraxial and peripheral blocks shall be performed using aseptic technique, standardized patient selection, standardized documentation, and defined monitoring during and after the block.
- 4.3.2 Continuous catheter infusions shall follow standardized labeling and infusion practices, daily follow-up and complication surveillance, and standardized removal criteria and documentation.
4.4 Anticoagulation Safety
- 4.4.1 Neuraxial and deep peripheral blocks in patients receiving antithrombotic therapy shall follow a standardized anticoagulation safety process consistent with internationally recognized guidelines and local adaptation, including timing considerations for block placement and catheter removal and a defined escalation pathway for complex cases. (rapm.bmj.com)
4.5 LAST Prevention & Management
- 4.5.1 The department shall implement a LAST prevention and management program including dose planning, incremental injection with frequent aspiration where applicable, monitoring and early recognition, immediate access to a LAST rescue kit, and the ASRA LAST treatment checklist and lipid emulsion therapy. (ASRA Pain Medicine)
5. PROCEDURES
5.1 G1 — Regional Anesthesia Service Policy (Privileging, Ultrasound Competency, Documentation Set)
5.1.1 Privileging Framework (Technique-Specific)
- A. Privilege categories shall be defined and granted separately for:
- Spinal anesthesia
- Epidural anesthesia/analgesia
- Combined spinal-epidural (CSE)
- Peripheral nerve blocks—single shot (upper limb, lower limb, truncal)
- Continuous epidural catheter management
- Continuous peripheral nerve catheter insertion and management
- Ultrasound-guided regional anesthesia (UGRA) competency (as a modifier applicable to categories 3–6)
- B. Privileging prerequisites shall include:
- verified training and experience appropriate to the requested privilege,
- demonstrated competence (case logs, proctored cases, skills assessment), and
- ongoing performance evaluation and re-privileging cycle consistent with CBAHI Clinical Privileging principles. (istitlaa.ncc.gov.sa)
- C. Scope restrictions may be applied by: patient age group (adult/pediatric), comorbidity risk, ASA class, setting (OR vs NORA), technique complexity, and catheter management responsibility.
5.1.2 Ultrasound Competency (UGRA)
- A. UGRA requires competence in anatomy recognition, image optimization, needle visualization strategies, safe injection techniques, and complication recognition.
- B. Competency pathway includes:
- formal education (sono-anatomy, physics, safety),
- supervised hands-on training and proctoring, and
- documented competency sign-off for defined block categories.
- C. Institutional granting of UGRA privileges aligns with national/international practice statements emphasizing competence as a prerequisite for safe regional practice. (asahq.org)
5.1.3 Required Documentation Set (Regional/Neuraxial Record Components)
A standardized regional anesthesia note/record shall include, at minimum:
- Patient identifiers; procedure; date/time; location (OR/block area/PACU).
- Indication and intended benefit (primary anesthetic vs analgesia).
- Consent confirmation for regional/neuraxial technique.
- Pre-block assessment summary: relevant comorbidities; airway/sedation plan; baseline vitals; neurologic baseline for limb blocks; anticoagulation status assessment and conclusion.
- Block plan: type of block, laterality, technique (US/nerve stim/landmark), local anesthetic planned (drug, concentration, planned total dose), adjuvants, and maximum dose plan.
- Monitoring applied and sedation plan during block placement.
- Time-out verification performed (Stop-Before-You-Block) and site marking confirmation. (The Royal College of Anaesthetists)
- Aseptic technique confirmation (skin prep, sterile probe cover if UGRA, sterile gloves).
- Needle/catheter details: type, gauge, depth (where relevant), number of attempts, complications (vascular puncture, paresthesia, CSF/blood).
- Injection details: incremental dosing strategy; aspiration results; ultrasound spread description if UGRA; test dose details for epidural when used.
- Block outcome: sensory level/dermatomal distribution; motor effects; adequacy; additional interventions.
- Post-block plan: monitoring requirements, fall precautions, limb protection, catheter infusion orders (if applicable), follow-up plan, and escalation triggers.
- Adverse events documentation and reporting reference if required.
5.1.4 Standard Equipment Requirements (Regional Service)
Minimum availability wherever regional/neuraxial procedures are performed:
- physiologic monitors per anesthesia monitoring standards, (asahq.org)
- oxygen and suction,
- resuscitation equipment (bag-valve-mask, airway adjuncts),
- emergency drugs including vasopressors, and
- LAST rescue kit with 20% lipid emulsion and ASRA checklist at point of care. (ASRA Pain Medicine)
5.2 G2 — “Stop-Before-You-Block” / Correct-Side Block Time-Out Policy
5.2.1 Indications
Stop-Before-You-Block is mandatory for:
- all unilateral peripheral nerve blocks,
- any block where laterality matters (including truncal blocks),
- catheter placements with side/site selection,
- any scenario where patient position/covering/sterile drapes could obscure site verification.
5.2.2 Timing
The pause occurs immediately before needle insertion (or before injection if needle is already positioned), after skin marking and patient positioning but before local anesthetic delivery.
5.2.3 Minimum Elements (Verbalized and Confirmed)
- Correct patient identity (two identifiers).
- Correct procedure and surgical side/site.
- Correct block type planned and intended side/site.
- Visible site mark confirmed (when applicable) and correct limb exposed.
- Allergies confirmed (especially local anesthetic allergy history—rare but must be verified).
- Anticoagulation status reviewed and “safe to proceed” confirmed per local neuraxial/peripheral anticoag policy process. (rapm.bmj.com)
- Planned local anesthetic drug/concentration and maximum dose strategy confirmed.
- Resuscitation readiness confirmed, including LAST rescue kit availability. (ASRA Pain Medicine)
- Team roles clarified (operator, assistant, monitor).
This process reflects national patient safety initiatives to prevent wrong-side regional blocks. (The Royal College of Anaesthetists)
5.2.4 Failure or Discrepancy Management
If any discrepancy exists (missing site mark, uncertainty of laterality, conflicting documentation), the block shall not proceed until resolved through escalation to responsible clinicians and documentation corrected.
5.3 G3 — Neuraxial Block Policy (Spinal / Epidural / CSE: Documentation, Monitoring)
5.3.1 Patient Selection and Pre-Procedure Assessment
- A. Confirm:
- indication (surgical anesthesia, labor analgesia, postoperative analgesia),
- consent,
- baseline neurologic status (lower limb strength/sensation),
- hemodynamic baseline and volume status,
- anticoagulation/antiplatelet status and neuraxial safety clearance per Section 5.6, (rapm.bmj.com)
- infection risk at insertion site and systemic infection status.
- B. Identify high-risk factors requiring escalation or alternative plan: severe aortic stenosis, severe hypovolemia, raised intracranial pressure with mass lesion concern, significant coagulopathy, patient refusal, or inability to cooperate.
5.3.2 Monitoring During Neuraxial Placement
- A. Apply minimum monitoring appropriate to the patient’s condition and sedation level, consistent with anesthesia monitoring standards. (asahq.org)
- B. Establish IV access prior to neuraxial placement.
- C. Ensure resuscitation readiness (vasopressors immediately available; airway support available).
5.3.3 Aseptic Technique
- A. Hand hygiene; sterile gloves; appropriate skin antisepsis; sterile drape.
- B. For catheter techniques: full sterile barrier precautions aligned with infection risk reduction practices; institutional infection control requirements apply. (rapm.bmj.com)
5.3.4 Technique-Specific Standards
- Spinal Anesthesia
- Document needle type/gauge; level/approach; number of attempts; CSF confirmation.
- Incremental and careful dosing based on patient risk; document drug, concentration, dose, and adjuvants.
- Monitor for hypotension and high spinal; treat promptly; document.
- Epidural Anesthesia/Analgesia
- Document level, approach, loss-of-resistance medium used, catheter depth at skin, negative aspiration, test dose strategy (if used per local practice), and initial dosing plan.
- Document catheter labeling and infusion order initiation.
- Combined Spinal-Epidural (CSE)
- Document spinal component and epidural component separately (needle/catheter details, dosing, and confirmation elements).
5.3.5 Post-Placement Monitoring and Assessment
- A. Hemodynamics: frequent BP/HR monitoring after dosing until stable; increase frequency during initial sympathectomy and after boluses.
- B. Block level: document sensory level, motor block assessment, and adequacy.
- C. High spinal surveillance: monitor respiratory effort, level of consciousness, upper limb symptoms, and treat per emergency protocol if suspected.
- D. Neurologic safety: document baseline and ongoing neurologic checks when clinically indicated; establish escalation triggers for suspected hematoma/abscess (new motor weakness, severe back pain, bowel/bladder dysfunction).
- E. Fall precautions: implement lower limb weakness precautions; document nursing instructions.
5.3.6 Neuraxial Complication Escalation
Immediate escalation to anesthesia consultant and surgical team occurs for:
- suspected high spinal,
- persistent hypotension despite initial management,
- suspected local anesthetic toxicity symptoms, (ASRA Pain Medicine)
- suspected neuraxial hematoma/abscess (urgent evaluation pathway).
5.4 G4 — Peripheral Nerve Block Policy (Single-Shot)
5.4.1 Pre-Block Assessment
- A. Confirm: indication, consent, laterality, surgical plan, and expected analgesic benefit.
- B. Document baseline neurovascular status of the limb (motor strength and sensation when feasible).
- C. Review anticoagulation status and classify block bleeding risk (superficial/compressible vs deep/non-compressible); apply Section 5.6. (rapm.bmj.com)
- D. Plan local anesthetic dose; consider patient factors affecting maximum dose (age, frailty, pregnancy, hepatic disease, cardiac disease).
- E. Confirm LAST rescue readiness. (ASRA Pain Medicine)
5.4.2 Monitoring During Block Placement
Apply monitoring consistent with the patient’s sedation level and physiologic status; oxygenation/ventilation/circulation must be continually evaluated during anesthetics including regional anesthesia with sedation. (asahq.org)
5.4.3 Stop-Before-You-Block
Perform and document Stop-Before-You-Block immediately before needle insertion/injection. (The Royal College of Anaesthetists)
5.4.4 Technique and Safety Steps
- A. Use aseptic technique.
- B. When ultrasound-guided:
- identify target and relevant vulnerable structures (vessels, pleura, neuraxis-adjacent structures),
- maintain needle tip visualization strategy,
- inject incrementally with frequent aspiration where applicable, observing spread.
- C. Avoid high injection pressure; stop if severe pain/paresthesia occurs or if injection resistance is unexpected (evaluate needle position).
- D. Document total dose delivered and immediate block assessment.
5.4.5 Post-Block Care
- A. Document sensory/motor effect distribution and adequacy.
- B. Implement limb protection instructions (insensate limb precautions, sling for brachial plexus blocks, fall precautions for femoral/adductor canal blocks).
- C. Provide clear escalation instructions for: progressive dyspnea (possible phrenic nerve effect), signs of LAST, persistent paresthesia/weakness beyond expected duration, or severe pain suggestive of compartment syndrome.
5.5 G5 — Continuous Catheter Policy (Labeling, Infusion Standards, Follow-Up, Removal)
5.5.1 Indications and Authorization
- A. Continuous catheter use must be based on patient and procedure needs (major joint surgery, thoracic/abdominal surgery, severe pain risk) and must be within service capability for follow-up.
- B. Catheter insertion requires the operator to be privileged for catheter techniques and complication management.
5.5.2 Insertion Standards
- A. Perform Stop-Before-You-Block (for peripheral catheters) and document. (The Royal College of Anaesthetists)
- B. Use aseptic technique; for catheter insertion consider full sterile barrier precautions.
- C. Document: catheter type, insertion site, depth at skin, securement method, and any complications.
5.5.3 Labeling and Line Safety
- A. All catheters and infusion lines must be clearly labeled as “Epidural” or “Peripheral Nerve Catheter” with site and date/time of insertion.
- B. Epidural infusions must be physically segregated from IV lines where possible and connected using institution-approved safety connectors/processes.
5.5.4 Infusion Standards
- A. Orders shall specify: drug name, concentration, basal rate, bolus parameters (if any), lockout, maximum dose limits, and monitoring requirements.
- B. Use infusion pumps with appropriate alarm settings.
- C. Document any boluses given (dose, time, response).
5.5.5 Daily Follow-Up and Monitoring
- A. Daily review (by acute pain/regional team or designated anesthesia clinician) shall include:
- analgesia effectiveness and functional goals,
- catheter site inspection (erythema, discharge, tenderness),
- neurovascular assessment of the affected limb(s),
- evaluation for systemic local anesthetic effects,
- infusion settings review and dose safety,
- anticoagulation status update and catheter removal planning. (rapm.bmj.com)
- B. Nursing monitoring instructions shall include:
- motor block assessment frequency relevant to block type,
- fall precautions,
- escalation triggers for increasing motor weakness, new numbness, or severe pain.
5.5.6 Catheter Removal
- A. Removal requires:
- review of anticoagulation timing and safety clearance (neuraxial and deep blocks), (rapm.bmj.com)
- assessment for infection signs,
- documentation of catheter tip integrity if required,
- post-removal neurologic observation instructions and documentation.
- B. If neurologic symptoms occur after catheter removal, urgent escalation and evaluation pathway is initiated.
5.6 G6 — Anticoagulation & Neuraxial Safety Policy (Local Adaptation)
5.6.1 Core Principle
Neuraxial anesthesia and certain deep peripheral blocks can cause catastrophic bleeding complications in anticoagulated patients; therefore timing, risk assessment, and catheter management must follow standardized evidence-based guidance and local adaptation.
International reference frameworks include:
- ASRA (5th edition) evidence-based guidelines on regional anesthesia in patients receiving antithrombotic or thrombolytic therapy, (rapm.bmj.com)
- ESAIC/ESRA joint guideline on regional anesthesia in patients on antithrombotic drugs. (ESRA)
5.6.2 Local Anticoagulation Table Requirement
- A. The department shall maintain a current local neuraxial/peripheral anticoagulation timing table derived from the latest guidance and reviewed at least annually or when major guideline updates occur. (rapm.bmj.com)
- B. The table shall explicitly address:
- neuraxial needle placement timing,
- epidural catheter management and removal timing,
- deep peripheral blocks timing considerations,
- laboratory thresholds if applicable (platelet count, INR), and
- special populations (renal impairment affecting DOAC clearance, elderly/frail).
5.6.3 Pre-Procedure Anticoagulation Safety Process
Before neuraxial or deep block performance, document:
- the exact antithrombotic agent(s), last dose time/date, indication, and renal function status (for DOACs),
- relevant labs where indicated,
- classification of planned block (neuraxial / deep non-compressible / superficial compressible),
- decision outcome: proceed / delay / alternative technique,
- explicit catheter removal plan if catheter is used.
5.6.4 Traumatic Needle Placement or Bloody Tap
- A. If traumatic needle placement occurs, the operator documents details and escalates to anesthesia leadership.
- B. Anticoagulation restart timing is escalated and documented per local table and guideline-based decision.
5.6.5 Post-Procedure Neurologic Surveillance
- A. For neuraxial catheters or high-risk anticoagulated patients, implement enhanced neurologic monitoring instructions.
- B. Immediate escalation occurs for new motor weakness, sensory loss, severe back pain, or bowel/bladder dysfunction—treat as possible neuraxial hematoma until excluded.
5.7 G7 — LAST Prevention & Management Policy (Lipid Rescue Availability + Response)
5.7.1 Prevention (Mandatory Safety Controls)
- A. Dose planning: calculate and document maximum planned dose strategy; adjust for patient risk factors (age extremes, low muscle mass, pregnancy, liver disease, cardiac disease).
- B. Incremental injection: inject in small fractions with pauses; aspirate as appropriate.
- C. Ultrasound guidance and avoidance of intravascular injection where possible; observe spread and avoid injection when needle tip location is uncertain.
- D. Monitor the patient during and after injection—LAST may be delayed.
- E. Avoid simultaneous multiple large-volume blocks without explicit dose aggregation plan.
5.7.2 LAST Rescue Kit Requirements
A LAST rescue kit must be immediately available wherever regional anesthesia is performed, including:
- 20% lipid emulsion,
- ASRA LAST checklist, (ASRA Pain Medicine)
- airway and resuscitation equipment,
- dosing guide and documentation sheet,
- materials for rapid IV access.
5.7.3 Recognition of LAST
Possible early features include tinnitus, metallic taste, perioral numbness, agitation, confusion, seizures; cardiovascular signs can include conduction abnormalities, arrhythmias, hypotension, and cardiac arrest. (rapm.bmj.com)
5.7.4 Immediate Response (Algorithm)
Follow the ASRA checklist principles: call for help; stop local anesthetic; airway/oxygenation/ventilation support; treat seizures; initiate lipid emulsion early; manage cardiovascular instability with guideline-consistent resuscitation adjustments. (ASRA Pain Medicine)
5.7.5 Lipid Emulsion Therapy (20%)
Administer lipid emulsion therapy according to the ASRA LAST checklist (weight-based bolus and infusion approach) and document time/dose/response. (ASRA Pain Medicine)
5.7.6 Post-Event Management
- A. Continue monitoring for recurrence.
- B. Transfer to ICU or higher level of care as clinically indicated.
- C. Complete an incident report and submit case to the departmental safety review and sedation/regional governance process.
6. RESPONSIBILITIES
Anesthesia Department Leadership / Regional Service Lead
Maintains privileging definitions, competency pathways, local anticoagulation table, LAST rescue readiness, audits, and continuous improvement. (istitlaa.ncc.gov.sa)
Regional/Neuraxial Operator (Anesthesia Professional)
Confirms patient suitability, anticoagulation clearance, consent, correct-side verification, monitoring, sterile technique, documentation, and post-block instructions; initiates emergency response for complications.
Anesthesia Technician / Support Staff
Ensures equipment readiness, ultrasound function, sterile supplies availability, and LAST rescue kit availability at point of care.
PACU / Ward Nursing Staff (when managing catheters/blocks)
Implements monitoring instructions, fall precautions, limb protection, catheter checks, and escalation for neurologic or respiratory compromise.
8. COMPLIANCE AND AUDIT
Minimum audit indicators include:
- Stop-Before-You-Block compliance for unilateral blocks. (The Royal College of Anaesthetists)
- Documentation completeness (required regional record fields).
- Anticoagulation clearance documentation rate for neuraxial/deep blocks. (rapm.bmj.com)
- Catheter labeling compliance and daily follow-up completion.
- LAST rescue kit readiness checks and staff familiarity (drills). (ASRA Pain Medicine)
Non-compliance triggers corrective actions, targeted training, workflow redesign, and re-audit.