Patient consent for peripheral nerve

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RAUK  Consent  for  peripheral  nerve  blocks  2015  
  

Membership of Working Party

Dr  Anand  Sardesai   Consultant  Anaesthetist,  Cambridge,  UK  

Dr  James  French   Consultant  Anaesthetist,  Nottingham,  UK  

Dr  Amit  Pawa     Consultant  Anaesthetist,  London,  UK  

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RAUK  Consent  for  peripheral  nerve  blocks  2015  
  

Section 1 Introduction

Section 2 Information and the process of consent:

Section 3 Documenting the consent

Section 4 References

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RAUK  Consent  for  peripheral  nerve  blocks  2015  
  

Section  1:  Introduction  

Peripheral  nerve  blocks  are  routinely  performed  by  anaesthetists  to  provide  anaesthesia  and  
analgesia  for  patients  undergoing  limb  surgery.    Like  all  procedures  in  anaesthesia,  nerve  blocks  are  
associated  with  certain  inherent  risks  and  complications.  A  properly  taken  consent  can  help  patients  
make  an  informed  decision  about  undergoing  nerve  blocks  and  will  also  protect  an  anaesthetist  from  
subsequent  criticism  and  litigation.  

In  2006,  The  Association  of  Anaesthetists  of  Great  Britain  and  Ireland  (AAGBI)  published  “Consent  for  
Anaesthesia”  1.    According  to  this  document,  information  about  anaesthesia  should  be  provided  to  
patients  undergoing  elective  surgery  before  they  meet  their  anaesthetist.  This  is  preferably  in  the  
form  of  a  patient  friendly  leaflet  (patient  information  leaflet).  Consent  should  be  obtained  prior  to  a  
patient  coming  to  the  anaesthetic  room,  except  under  exceptional  circumstances.  The  amount  and  
the  nature  of  information  provided  to  the  patient  should  be  aimed  at  helping  the  patient  to  make  an  
informed  decision  about  choosing  one  of  the  available  options.  Patients  should  also  be  given  an  
opportunity  to  ask  questions.  The  discussion  between  patient  and  anaesthetist  should  be  
documented  in  the  notes;  this  documentation  should  cover  what  risks,  benefits  and  alternatives  
were  explained  to  the  patient.  

RAUK  (Regional  Anaesthesia  United  Kingdom)  advise  that  all  the  recommendations  made  in  the  
AAGBI  guideline  apply  to  patients  having  a  nerve  block.    This  RAUK  guideline  contains  additional  
advice  that  is  specific  to  Regional  Anaesthesia.    

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Section  2:  Information  and  the  process  of  consent  for  nerve  block  

2.1.  Information  about  nerve  blocks  can  be  provided  preoperatively  by  an  anaesthetist  and/or  other  
health  care  professionals,  including  surgeons  and  pre-­‐assessment  nurses.    However,  ultimate  
responsibility  for  ensuring  the  adequacy  of  information  provided  to  the  patient  lies  with  the  person  
performing  the  block.  

2.2.  Timing  of  consent  

2.2.1  For  elective  surgery,  information  should  ideally  be  given  prior  to  the  day  of  surgery.    This  could  
be  in  the  form  of  a  ‘Patient  information  leaflet’.    This  can  be  given  to  the  patient  by  the  surgeon  at  
the  time  of  booking  or  by  a  nurse  in  the  pre-­‐assessment  clinic.    However  this  may  not  be  always  
possible.    Information  about  the  nerve  block  can  be  given  on  the  day  of  surgery,  provided  adequate  
time  has  been  given  for  the  patient  to  understand  the  information  and  to  ask  questions.    Consent  for  
peripheral  nerve  blocks  should  not  be  obtained  in  the  anaesthetic  room.  

2.2.2.  For  emergency  surgery  it  will  not  always  be  possible  to  provide  a  patient  information  leaflet  
prior  to  surgery.    The  consent  should  be  obtained  prior  to  the  patient  coming  to  the  anaesthetic  
room.    Under  exceptional  circumstances  it  may  be  necessary  to  obtain  consent  in  the  anaesthetic  
room.      

2.3.  Obtaining  consent  

2.3.1.  Although  information  for  nerve  block  can  be  provided  by  other  health  care  professionals,  
consent  should  ideally  be  obtained  by  the  person  performing  the  block.  

2.3.2.  Consent  for  the  procedure  may  be  obtained  by  a  person  who  is  not  performing  the  block,  
provided  that  he/she  understands  the  processes,  the  risks  involved,  possible  complications,  the  
benefits  of  the  block  to  the  patient  and  any  alternatives  (e.g.  patient  controlled  analgesia).  However,  
the  person  performing  the  block  is  still  responsible  for  ensuring  that  adequate  consent  has  been  
obtained  and  specifically,  that  the  patient  has  consented  for  him/her  to  perform  the  block.      

2.3.3.  If  a  trainee  is  working  under  the  direct  supervision  of  a  Consultant,  then  it  is  the  responsibility  
of  that  consultant  to  ensure  adequate  consent  has  been  obtained  for  the  trainee  to  perform  the  
block,  and  that  risks  are  minimised.  

If  a  trainee  is  not  working  under  the  direct  supervision  of  a  Consultant,  then  it  is  the  responsibility  of  
trainee  to  ensure  adequate  consent  has  been  obtained  and  that  the  indirectly  supervising  consultant  
has  been  informed,  if  appropriate.    Trainees  can  function  autonomously  within  their  level  of  
expertise,  as  defined  by  the  General  Medical  Council2.    If  discussion  has  occurred  with  the  
supervising  consultant,  this  should  be  recorded  and  the  consultant  identified  by  name.      

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2.4.  Patient  information  Leaflets  

2.4.1.  Patient  information  leaflets  are  a  useful  source  of  information.  However  they  may  not  help  the  
patient  remember  all  the  details  of  the  nerve  block3.    They  are  not  a  substitute  for  talking  to  the  
patient  directly  about  the  nerve  block.      

2.4.2.  Patient  information  leaflets  should  be  available  in  the  language  understood  by  the  patient.    If  
this  is  not  possible,  a  translator  should  be  provided.  

2.4.3.  Patient  information  leaflets  can  be  given  to  the  patient  by  any  healthcare  professional,  but  the  
anaesthetist  performing  the  block  should  make  sure  that  the  patient  has  read  and  understood  the  
contents.  

2.4.4.  Whenever  possible,  nationally  approved  patient  information  leaflets  should  be  used.    They  
may  be  modified  to  reflect  local  circumstances.  

2.4.5.  Preoperative  multimedia  information  has  been  shown  to  reduce  the  anxiety  of  patients  
undergoing  surgery  under  regional  anaesthesia  and  improve  patient  experience4.    If  possible,  the  
patient  should  be  shown  a  professionally  approved  video  which  explains  the  block  procedure.  The  
patient  should  be  given  the  opportunity  to  ask  any  questions  relating  to  the  video.      

2.4.6.  Patient  information  leaflets  should  provide  a  prompt  to  the  patient  to  ask  questions  or  express  
any  concerns.  Contact  details  and  “frequently  asked  questions”  and  answers  should  be  provided.    

 2.4.7.  Regular  audit  and  updating  of  the  information  provided  to  the  patient  should  be  carried  out.    
The  audit  may  include  the  quality  of  information  provided  and  usefulness  of  the  information  
provided  to  the  patient.      

2.5.  Content  of  the  consent  process  

2.5.1.  Patients  need  to  know  what  they  are  consenting  for.    They  should  be  told  about  the  benefits  
(e.g.  opioid  sparing,  early  mobilisation,  less  risk  of  nausea  and  vomiting)  to  them  of  undergoing  
nerve  block.    They  also  need  to  be  told  the  alternative  options  to  a  nerve  block  (e.g.  having  a  general  
anaesthetic  for  surgery  or  using  patient  controlled  analgesia  for  pain  relief).  

2.5.2.  The  Patient  should  be  told  about  the  process  of  nerve  blockade,  i.e.,  what  he/she  will  feel  and  
see.    This  includes  use  of  a  nerve  stimulator  (muscle  twitches)  and/or  ultrasound.    If  they  are  going  
to  be  sedated  for  the  block  then  they  should  be  told  about  this.    
 
Patients  should  be  offered  additional  sedation  or  general  anaesthesia,  together  with  a  clear  
explanation  of  the  risks  and  benefits.      
 
2.5.3.  The  risk  of  failure  and  alternative  plans  for  anaesthesia  and  analgesia  should  be  explained  to  
the  patient.  

2.5.4.  Patients  should  be  told  about  any  risk  associated  with  the  nerve  block  or  any  immediate  side  
effect  (e.g.  Horner’s  syndrome  with  interscalene  block)  which  has  an  incidence  of  >1:100  

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2.5.5.  Any  risk  that  can  have  either  short  term  (pneumothorax  following  supraclavicular  block)  or  
long  term  serious  consequences  (permanent  nerve  damage)  should  be  discussed.  

2.5.6.  The  exact  incidence  of  nerve  damage  is  not  known5-­‐8.    The  risk  of  complications  is  influenced  
by  numerous  factors,  including  patient  co-­‐morbidity,  the  experience  of  the  anaesthetist,  the  method  
of  nerve  location  and  the  block  selected.  It  should  be  made  clear  to  the  patient  that  the  exact  
incidence  of  nerve  damage  is  not  known.    In  the  absence  of  clear  figures  we  can  rely  only  on  the  
incidences  quoted  in  the  scientific  literature  and  summarised  in  leaflets  published  by  the  Royal  
College  of  Anaesthetists9,  which  quote  an  incidence  of  approximately  1:10  for  temporary  nerve  
damage  and  a  range  from  1:2000  to  1:5000  for  permanent  nerve  damage.      

2.5.7  If  a  unit  or  an  anaesthetist  has  audit  data  which  indicates  their  local  incidence  of  complications,  
they  may  quote  these  figures.    However,  care  should  be  taken  in  interpretation,  application  and  
explanation  of  uncontrolled  audit  data,  noting  that  statistical  significance  can  only  be  achieved  with  
a  considerable  sample  size  when  assessing  rare  occurrences.      

2.5.8.  For  all  blocks,  patients  should  be  made  aware  of  the  risk  of  thermal  damage  to  the  insensate  
blocked  limb.    They  should  also  be  told  that  they  should  avoid  driving,  using  any  machinery  or  
cooking  while  their  limb  is  insensate.  

2.5.9.  For  lower  limb  blocks  the  patient  should  be  made  aware  of  the  specific  risk  of  falling  and  heel  
pressure  sores.  

2.5.10.  There  are  certain  risks  which  are  block  specific  (e.g.  Horner’s  syndrome  following  
Interscalene  block,  risk  of  pneumothorax  following  periclavicular  blockade).    These  should  be  
discussed  with  the  patient.      

2.5.11.  If  surgery  is  performed  under  block  alone,  then  patients  should  be  made  aware  that  they  
may  have  tourniquet  pain  or  operative  discomfort  even  with  a  fully  functioning  block.    They  should  
also  be  informed  that  they  may  feel  surgical  pain,  but  that  if  this  happens,  the  anaesthetist  or  
surgeon  will  immediately  administer  alternative  effective  analgesia.    

2.5.12.  Patients  should  be  repeatedly  told  to  take  postoperative  pain  relief  well  in  advance  of  block  
resolution.    

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Section  3:  Documenting  consent  

3.1.  It  is  not  necessary  to  obtain  specific  written  consent  for  RA  to  facilitate  a  surgical  procedure,  as  
long  as  written,  signed  consent  has  been  obtained  for  the  surgery.  However,  when  RA  is  proposed  as  
the  sole  therapeutic  procedure  (e.g.  rib  fractures,  chronic  pain  therapy),  specific  signed  consent  
should  be  obtained,  using  the  local  formal  consent  process.      

3.2.  All  the  risks/benefits/alternatives  to  nerve  block  that  have  been  discussed  with  the  patient  
should  be  documented  in  the  patient’s  notes.    If  the  patient  asks  any  questions  related  to  nerve  
blockade,  then  this  discussion  should  also  be  documented.  

3.3.  If  the  patient  has  received  a  patient  information  leaflet,  this  should  be  documented,  as  well  as  
any  discussion  relating  to  it.      

3.4  If  the  patient  has  a  high  risk  of  a  complication  (e.g.,  nerve  damage  in  diabetics),  or  is  at  higher  
risk  than  usual  from  the  effects  of  the  complication  (e.g.,  their  occupation),  care  should  be  taken  to  
specifically  address  these  issues  and  record  the  discussion  in  the  notes.    
 
3.5.  It  should  be  made  clear  in  the  notes  that    

• The  Patient  understood  all  the  information  given    

• The  patient  was  given  the  opportunity  to  ask  questions  and  all  their  questions  were  
answered.  

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Section  4:  References  

1. http://www.aagbi.org/sites/default/files/consent06.pdf  

Consent  for  anaesthesia.  AAGBI  publication  2006  

2. http://www.gmc-­‐uk.org/The_Trainee_Doctor_1114.pdf_56439508.pdf  

General  Medical  council  guidance  for  the  trainee  doctor    

3. Turner  P.  and  Williams  C.  (2002)  Informed  consent:  patients  listen  and  read,  but  what  
information  do  they  retain?  The  New  Zealand  Medical  Journal  Vol  115  No.1164    

4. Jlala  HA,  French  JL,  Foxall  GL,  Hardman  JG,  Bedforth  NM.    Effect  of  preoperative  multimedia  
information  on  perioperative  anxiety  in  patients  undergoing  procedures  under  regional  
anaesthesia.  Br  J  Anaesth.  2010;104:369-­‐374  

5. Liguori  GA.  Complications  of  regional  anesthesia:  nerve  injury  and  peripheral  neural  
blockade.  J  Neurosurg  Anesthesiol  2004;16:84-­‐6.    

6. Auroy  Y,  Benhamou  D,  Bargues  L,  et  al.  Major  complications  of  regional  anesthesia  in  France:  
the  SOS  Regional  Anesthesia  Hotline  Service.  Anesthesiology  2002;97:1274-­‐80.    

7. Liu  SS,  Zayas  VM,  Gordon  MA,  et  al.  A  prospective,  randomized,  controlled  trial  comparing  
ultrasound  versus  nerve  stimulator  guidance  for  interscalene  block  for  ambulatory  should  
surgery  for  postoperative  neurological  symptoms.  Anesth  Analg  2009;109:265-­‐71.    

8. Fredrickson  MJ,  Kilfoyle  DH.  Neurological  complication  analysis  of  1000  ultrasound  guided  
peripheral  nerve  blocks  for  elective  orthopaedic  surgery:  a  prospective  study.  Anaesthesia  
2009;64:836-­‐44.    

9. http://www.rcoa.ac.uk/system/files/PI-­‐RISK12-­‐NERVEBLOCK-­‐2013.pdf  

Royal  College  of  Anaesthetist  document  on  risk  associated  with  anaesthetic,  section  12.  

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