Ultrasound-guided nerve blocks (UGNBs) have become an integral part of emergency medicine practice, offering targeted analgesia while reducing reliance on opioids. Yet, in the rush to master anatomy, technique, and ultrasound visualization, clinicians may overlook the broader context of pain management. A nerve block should not exist in isolation; rather, it should function as one component of a structured, multimodal pain strategy that spans from patient arrival through disposition.^1,2

We recommend approaching every block — and the patient’s overall pain control — through three deliberate phases:

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1. Pre-block analgesia
2. Intra-procedural safe anesthetic deposition
3. Post-block pain planning

Thinking about pain across these stages allows clinicians to provide safe, durable analgesia while anticipating and addressing common pitfalls at each phase.

Pre-Block Analgesia: Foundational Pain Management

Optimal pain control begins well before the needle touches the skin. Patients in acute pain deserve early administration of systemic analgesics. When not contraindicated, acetaminophen and nonsteroidal anti-inflammatory drugs (NSAIDs) should be initiated promptly to reduce baseline discomfort and overall nociceptive input. In some cases, this early intervention may also reduce the anesthetic dose or volume required for effective blockade.

For patients with more severe pain, small doses of intravenous opioids or ketamine can improve comfort and facilitate positioning for the block. In our experience, ketamine 0.2–0.3 mg/kg diluted in 50 mL of normal saline and administered over 15 minutes is effective for reducing pain and procedure-related anxiety. This mirrors a familiar principle seen with lumbar punctures and other bedside procedures: early analgesia and anxiolysis often determine procedural success and patient satisfaction.^3,4 patients scheduled for shoulder arthroscopy received ultrasoundguided single-shot Interscalene Brachial Plexus Block preoperatively and were randomized to receive either intravenous esketamine (0.5 mg/kg bolus + 0.25 mg/ kg/h infusion).

Finally, informed consent should include a brief explanation of the block’s purpose, expected duration, and potential risks. The clinician should clarify that the goal is multimodal pain control and not surgical anesthesia. This helps align expectations and reassure patients before the procedure.

Intra-Procedural Management: Precision and Safety

During the procedure, the clinician’s focus shifts to technical execution and patient safety. Patients undergoing blocks that require larger anesthetic volumes (generally >10–15 mL) or are performed near vascular structures should have intravenous access and continuous cardiac monitoring, maintained during the procedure and for approximately 30 minutes afterward.

The maximum safe anesthetic dose should be calculated in advance, particularly when using long-acting agents such as bupivacaine or ropivacaine. We recommend using an anesthetic dosing calculator or electronic health record-embedded tools to minimize dosing errors.