Sympathetic Block Procedure Recommendations

Indications and Techniques

The American College of Oncology recommends sympathetic blocks for complex regional pain syndrome (CRPS), phantom limb pain, central pain, visceral pain from pancreatic cancer, and other cancer-related pain 1
Neurolytic sympathetic blocks should be limited to patients with short life expectancy (typically producing a block lasting 3-6 months) 1
The European Society of Anaesthesiology recommends patient preparation with standard aseptic technique similar to neuraxial procedures 2, 3
Blocks should be performed with image guidance - either fluoroscopy or ultrasound, with the lowest effective dose of local anesthetic to avoid systemic toxicity 2, 3

Celiac plexus block is indicated for pain due to pancreatic cancer and upper abdominal visceral pain, and can be performed via anterior or posterior approach under fluoroscopic guidance 1
Echo-endoscopic guidance is an emerging technique for celiac plexus block, placed in the stomach just below the cardia 1
Superior hypogastric plexus block is used for pelvic pain of visceral origin, and neurolytic blocks can be considered for cancer pain in this region 1

The American Heart Association recommends blood pressure and electrocardiogram monitoring, especially in patients with high cardiovascular risk 4
Ultrasound guidance should be used when possible to reduce the risk of local anesthetic systemic toxicity 2, 3
Calculate safe dose of local anesthetic based on patient weight to prevent toxicity 2

Risk of pneumothorax with stellate ganglion block requires proper technique and imaging guidance essential 2
Neurolytic blocks on peripheral nerves can lead to neuritis; use caution in patients with good prognosis 1
For blocks near the head and neck area, consider additional precautions against airborne transmission (particularly relevant during infectious disease concerns) 3

The American Society of Anesthesiologists recommends sympathetic blockade for Complex Regional Pain Syndrome (CRPS) - stellate ganglion block or lumbar sympathetic block as part of multimodal treatment, specifically when there is consistent and increasing duration of pain relief with successive blocks 5, 6
The American Society of Anesthesiologists recommends sympathetic blockade for visceral oncologic pain - celiac plexus block for pancreatic and upper abdominal pain 6
Amides are preferred over esters for sympathetic blockade because esters are degraded by plasma cholinesterase 7

The American Society of Anesthesiologists advises against using sympathetic blocks for long-term treatment of non-CRPS neuropathic pain 5, 6
The American Society of Anesthesiologists advises against performing neuroaxial blocks in patients with anticholinesterase agent toxicity due to the risk of hemodynamic instability from the combination of sympatholytic effect with parasympathetic hyperactivity 7