title: Importance of vigilant monitoring after continuous nerve block: lessons from a case report.
abstract: BACKGROUND
  Continuous peripheral nerve block achieves good pain control. However, uncontrolled pain despite an effective block in the target areas of the nerve can be an early sign of ischemia. We report a case of iatrogenic injury to the axillary artery during shoulder surgery in a patient who had continuous supraclavicular block and demonstrate how vigilant monitoring helped the diagnosis and resulted in timely management of upper limb ischemia.
  
  
  METHODS
  A 58-year-old female underwent total revision surgery of her right shoulder under continuous supraclavicular block. Postoperatively, she complained of pain along the medial side of her forearm despite clinical evidence of nerve block. Continuous neurovascular monitoring and timely angiography confirmed axillary artery injury, and subsequent vascular repair saved the patient's limb.
  
  
  CONCLUSIONS
  Iatrogenic injuries to vessels or nerves sometimes occur during orthopedic surgical procedures. Regional anesthesia can mask and delay the onset of these symptoms. Postoperative monitoring and the ability to differentiate between the effects of local anesthetics and the body's response to ischemia are important for avoiding postoperative complications. This case report aims to improve awareness about the need for vigilant monitoring of the distal pulses after peripheral nerve blocks.
authors.affiliation: Anesthesiology Institute, Cleveland Clinic Foundation, Cleveland, OH.
authors.forename: Gopakumar Sudhakaran
authors.initials: GS
authors.lastname: Nair
authors.forename: Loran Mounir
authors.initials: LM
authors.lastname: Soliman
authors.forename: Kamal
authors.initials: K
authors.lastname: Maheshwari
authors.forename: Wael Ali Sakr
authors.initials: WA
authors.lastname: Esa
keywords: Autonomic nerve block; axillary artery; pain–postoperative