• Reference Number: HEY-675/2023
• Departments: Pain Medicine
• Last Updated: 29 September 2023

Introduction

This leaflet has been produced to give you general information on the treatment of Isolated Limb Block.  Most of your questions should have been answered by this leaflet. It is not intended to replace the discussion between you and the healthcare team, but may act as a starting point for discussion.  If after reading it you have any concerns or require further explanation, please discuss this with a member of the healthcare team.

What is an Isolated Limb Block?

It is a method of treatment which involves blocking certain small nerves carrying pain signals from the affected part of your limb.  Certain drugs are mixed with normal saline or local anaesthetics can be used intravenously to treat certain painful conditions known as Complex Regional Pain Syndrome (CRPS).  This syndrome is thought to be associated with the sympathetic nervous system and controls the regular functions of the body, including the heart rate, blood pressure and skin temperature.

Why do I need an Isolated Limb Block?

An isolated limb block is done to relieve pain in your arms or legs

Can there be any complications or risks?

The limb may temporarily become swollen, warm and red. Sometimes mild ‘pins and needles’ sensations are experienced for the first few days and very occasionally discomfort in the limb due to inflammation of nerves (neuritis) for a few weeks.  There is a potential risk of infection at the injection site and bruising to the skin.

Advice to read before having a pain relief procedure

The following information has been produced to ensure that you are able to have your pain relief procedure. It is essential that you read and follow the advice given below before you come to the hospital. If you do not follow the advice, you may not be able to have your treatment.

Sometimes isolated limb blocks are done under sedation (a drug is given to make you drowsy and relaxed but still conscious). You should not have anything to eat on the morning of your treatment, however you may have a drink (tea or coffee without milk) if you wish up to 2 hours before your appointment time.

Please contact the Pain Service if any of the following apply to you:

• You are diabetic and take medication to control your diabetes. (See below on how to manage treatment sessions booked for the morning or the afternoon).
• You have recently had an admission to hospital.
• You have tested positive for MRSA.
• You have an infection and are currently taking antibiotics.
• If there is any possibility you may be pregnant

Continue your other regular medications including your pain relief, except for anticoagulants (please see below).

If you take Warfarin (Marevan), Clopidogrel (Plavix), Dipyridamole (Persantin Retard), Phenindione, Pradaxa, Xarelto, Apixaban, Sinthrome or Asasantin Retard,  please notify the Pain Clinic at least 10 days before your appointment. You will need to stop taking these drugs at least 1 week prior to the procedure unless your doctor has advised against this.

If you are on new oral anticoagulant medications like dabigatran then you will be required to stop it at least 48 hrs in before the procedure.

This does not cover all blood thinning medications, please notify the Pain Clinic if you are taking any medications which thin your blood or prevent blood clots.

Depending on the reason that you need to take these drugs you may need a short course of blood thinning injections.

You may have to wait a while before your procedure, so please bring something to read or to keep yourself occupied.

Please leave any valuables or jewellery at home. It is essential that after the procedure you arrange for an adult friend or relative to collect you by car or taxi. You will not be able to use the bus or train to travel home.

Hospital transport may be available if there is a medical need. If you think you may be eligible, please contact the Pain Service.

Advice for Diabetic patients only

If you are diabetic and booked to attend treatment in the morning, you should not have breakfast or morning medication but bring the medication with you.

If you are booked for treatment in the afternoon, please have your breakfast and take regular medications before 7.00am. Thereafter, only drink clear fluids (not milk) for up to two hours before the procedure. Please inform the Pain Service staff as soon as you arrive that you are diabetic. The staff will then assess your diabetes and if necessary take appropriate action to monitor and control your blood sugar while you are in our care.

What happens before the procedure?

You will be admitted by the nursing staff; they will ask for and record some information about you. Your blood pressure will be checked and you will be given a gown to put on. The doctor will explain the procedure and ask you to sign a consent form. Please make sure you have understood what has been said and feel free to ask any questions.

What to expect during the procedure

The doctor will insert two thin plastic tubes (cannula) into two separate veins, usually one in the affected limb and one in the back of the hand or arm. One will be to give the necessary drugs (mixed with normal saline or local anaesthetics) into your painful limb (arm or leg) and the other for medication to allow you to relax during the procedure, should you require it.

The affected limb will be protected with soft padding and a cuff similar to a blood pressure cuff will be applied. This will be inflated while your affected limb is raised.

The doctor will then inject the drug through one of the needles on the side of your affected limb. The blood circulation is restricted because of the inflated cuff and so the drug stays in the affected arm or leg.

After approximately 20 – 30 minutes the drug will be fully absorbed and the air is let out of the cuff. You may feel intense heat and pins and needles in your arm/leg at this point but this, along with any giddiness, will wear off quickly.

What happens after the procedure?

You will be taken on the trolley to the recovery area where the nurse will check your blood pressure and pulse. After 30 minutes you will be offered light refreshment and also encouraged to move the affected limb. Once you are mobile, you will able to go home, accompanied by an adult friend or relative.

Please ensure that you have arranged for someone to drive you home after this procedure. Failure to do so will result in your procedure being cancelled. If you have had sedation, we recommend that you arrange for someone to stay with you overnight and that you do not drive for 24 hours.

What to expect afterwards?

You should continue to take all your usual medication / pain relief until the effect of the treatment has been reviewed by the Pain Service.  Some people find that they get relief from their pain but this may wear off.  Others may experience complete relief.  However, there is a chance that the pain will not improve, not change or will get worse.  If you notice a reduction in your pain after this procedure, it is a good idea to gently exercise your arm/leg to reduce muscle stiffness and improve circulation.  The best way to increase your activity is slowly. Try not to overdo things on a good day as this may result in you experiencing more pain the following day.

How long will the pain relief last?

This is highly variable between individuals. Some might notice immediate pain relief where in others it may take up to one to two weeks. However, pain relief may last from a few days to several weeks. Some patients do not get any pain relief from isolated limb branch blocks.

Follow up

An immediate discharge letter will be sent to your doctor detailing your treatment and you will be reviewed either by telephone or seen by the Pain Service in due course.

At this review you will be asked to discuss the Pain Diary you were given at your injection appointment, please have this completed diary to hand at the time of the phone call.

Points to Remember

• You need to arrange for someone to drive you home after this procedure.
•  Please bring your glasses if you need them for reading.
•  Always bring a list of all current medication.
•  Continue taking all your usual medication on treatment day (see advice if you are a diabetic patient).
•  If there is any possibility you may be pregnant, please inform the doctor or nurse.

Additional Information

If you experience unusual symptoms such as a marked increase in pain / swelling around an injection site, fever, severe headache, new symptoms of pins and needles, new muscle weakness in your arms, or you are very concerned about how you feel after the procedure, please contact your doctor.

If you have any queries do not hesitate to contact the Pain Clinic Monday to Friday 9.00am – 4.00pm.

Pain clinic, Hull University Teaching Hospitals NHS Trust, Pain Service Out patients Department East Riding Community Hospital, Hull University Teaching Hospitals NHS Trust, Beverley (01482) 478868

Outside the normal Pain Clinic hours (Monday to Friday 9.00am – 4.00pm) you can contact your own doctor within their working hours.

Out of these hours if you have any queries, contact NHS111 and inform them that you are taking amitriptyline. They will then be able to contact the Pain / Palliative Medicine Consultant on duty for advice.

General Advice and Consent

Most of your questions should have been answered by this leaflet, but remember that this is only a starting point for discussion with the healthcare team.

Consent to treatment

Before any doctor, nurse or therapist examines or treats you, they must seek your consent or permission. In order to make a decision, you need to have information from health professionals about the treatment or investigation which is being offered to you. You should always ask them more questions if you do not understand or if you want more information.

The information you receive should be about your condition, the alternatives available to you, and whether it carries risks as well as the benefits. What is important is that your consent is genuine or valid. That means:

• you must be able to give your consent
• you must be given enough information to enable you to make a decision
• you must be acting under your own free will and not under the strong influence of another person

Information about you

We collect and use your information to provide you with care and treatment. As part of your care, information about you will be shared between members of a healthcare team, some of whom you may not meet. Your information may also be used to help train staff, to check the quality of our care, to manage and plan the health service, and to help with research. Wherever possible we use anonymous data.

We may pass on relevant information to other health organisations that provide you with care. All information is treated as strictly confidential and is not given to anyone who does not need it. If you have any concerns please ask your doctor, or the person caring for you.

Under the General Data Protection Regulation and the Data Protection Act 2018 we are responsible for maintaining the confidentiality of any information we hold about you. For further information visit the following page: Confidential Information about You.

If you or your carer needs information about your health and wellbeing and about your care and treatment in a different format, such as large print, braille or audio, due to disability, impairment or sensory loss, please advise a member of staff and this can be arranged.