Continuous Peripheral Nerve Blocks: An Update of the Published Evidence and Comparison With Novel, Alternative Analgesic Modalities

Abstract

A continuous peripheral nerve block (CPNB) consists of a percutaneously inserted catheter with its tip adjacent to a target nerve/plexus through which local anesthetic may be administered, providing a prolonged block that may be titrated to the desired effect. In the decades after its first report in 1946, a plethora of data relating to CPNB was published, much of which was examined in a 2011 Anesthesia & Analgesia article. The current update is an evidence-based review of the CPNB literature published in the interim. Novel insertion sites include the adductor canal, interpectoral, quadratus lumborum, lesser palatine, ulnar, superficial, and deep peroneal nerves. Noteworthy new indications include providing analgesia after traumatic rib/femur fracture, manipulation for adhesive capsulitis, and treating abdominal wall pain during pregnancy. The preponderance of recently published evidence suggests benefits nearly exclusively in favor of catheter insertion using ultrasound guidance compared with electrical stimulation, although little new data are available to help guide practitioners regarding the specifics of ultrasound-guided catheter insertion (eg, optimal needle-nerve orientation). After some previous suggestions that automated, repeated bolus doses could provide benefits over a basal infusion, there is a dearth of supporting data published in the past few years. An increasing number of disposable infusion pumps does now allow a similar ability to adjust basal rates, bolus volume, and lockout times compared with their electronic, programmable counterparts, and a promising area of research is communicating with and controlling pumps remotely via the Internet. Large, prospective studies now document the relatively few major complications during ambulatory CPNB, although randomized, controlled studies demonstrating an actual shortening of hospitalization duration are few. Recent evidence suggests that, compared with femoral infusion, adductor canal catheters both induce less quadriceps femoris weakness and improve mobilization/ambulation, although the relative analgesia afforded by each remains in dispute. Newly published data demonstrate that the incidence and/or severity of chronic, persistent postsurgical pain may, at times, be decreased with a short-term postoperative CPNB. Few new CPNB-related complications have been identified, although large, prospective trials provide additional data regarding the incidence of adverse events. Lastly, a number of novel, alternative analgesic modalities are under development/investigation. Four such techniques are described and contrasted with CPNB, including single-injection peripheral nerve blocks with newer adjuvants, liposome bupivacaine used in wound infiltration and peripheral nerve blocks, cryoanalgesia with cryoneurolysis, and percutaneous peripheral nerve stimulation.

Pain Management in Plastic Surgery

“…On the other hand, the addition of opioids often leads to an increased incidence of opioid-related side-effects. Recent data support previous evidence showing that total doses, not concentration/volume, are a major factor affecting clinical effects for continuous infusion of peripheral nerves [33,35,[38][39][40].…”

“…for lower extremity and 6-10 ml/h. for upper extremity along with 2-10 ml small bolus doses with 20-60 min lockout interval [5,[31][32][33][34][35].…”

“…Similar studies doubled the concentration of these drugs (0.25% levobupivacaine compared with 0.25 and 0.4% ropivacaine) showing that analgesia and motor block effects for interscalene catheters were similar at 0.25% levobupivacaine and 0.4% ropivacaine, but better than 0.25% ropivacaine. In a popliteal infusion study, Casati et al also showed that 0.125% levobupivacaine was roughly equivalent to 0.2% of ropivacaine, either from analgesia or motor block sparing effect [33][34][35][36][37][38][39].…”

Ultrasound-guided percutaneous intercostal cryoanalgesia for multiple weeks of analgesia following mastectomy: a case series

“…Importantly, the development of persistent postsurgical pain is associated with the level of pain experienced in the immediate postoperative period; and multiple studies have demonstrated decreased chronic pain with improved analgesia in the 2-3 d following mastectomy [8,9]. Considering the du- Direct comparisons with continuous peripheral nerve blocks are unavailable, but some theoretical benefits of cryoneurolysis include an ultra-long duration of action, no catheter insertion/removal, no required infusion management/oversight, the lack of an infusion pump and anesthetic reservoir to carry, a considerably lower risk of infection, and no risk of local anesthetic toxicity, catheter dislodgement, or fluid leakage [10]. Risks include bleeding, bruising, and-if the ice ball involves the skin-frostbite, alopecia, depigmentation, and/or hyperpigmentation.…”

Continuous Transversus Abdominis Plane Nerve Blocks: Does Varying Local Anesthetic Delivery Method—Automatic Repeated Bolus Versus Continuous Basal Infusion—Influence the Extent of Sensation to Cold?: A Randomized, Triple-Masked, Crossover Study in Volunteers

“…24 The relationship between administration strategy and ensuing effects remains unexamined for TAP catheters. 25 There is real potential for analgesic benefits if intermittent bolus doses improved spread for TAP catheters compared with a basal infusion, as suggested by one trial involving healthy volunteers that found only a 1.5-dermatome distribution after 24 hours of a basal ropivacaine 0.2% infusion (5 mL/h). 26 …”