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Year : 2007  |  Volume : 51  |  Issue : 3  |  Page : 247-249  

Continuous perineural catheters for postoperative analgesia: An update

M.D., FICS, FAMS, Senior Professor & Head, Department of Anaesthesiology, R.N.T. Medical College, Udaipur(Raj.), India

Date of Web Publication20-Mar-2010

Correspondence Address:
Pramila Bajaj
25, Pologround, Udaipur(Raj.)
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Source of Support: None, Conflict of Interest: None

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How to cite this article:
Bajaj P. Continuous perineural catheters for postoperative analgesia: An update. Indian J Anaesth 2007;51:247-9

How to cite this URL:
Bajaj P. Continuous perineural catheters for postoperative analgesia: An update. Indian J Anaesth [serial online] 2007 [cited 2020 Aug 14];51:247-9. Available from: http://www.ijaweb.org/text.asp?2007/51/3/247/61154

Recent evidence from randomized controlled tri­als (RCTs) demonstrates that continuous perineural techniques offer the potential benefits of prolonged analgesia with fewer side effects.

RCTs demostrate that use of continuous interscalene analgesia has superior analgesic efficacy to placebo and intraarticular infusions for hospitalized patients[1],[2],[3]. Compared with IV patient-controlled analgesia (PCA) for open shoul­der surgery, RCTs consistently demonstrate that use of continuous interscalene analgesia not only reduced require­ments for postoperative opioids[4],[5] but also provided better analgesia, reduced opioid-related side effects, and provided better patient satisfaction for at least the first 48 h after inpatient surgery. Although a case series of 100 patients suggested enhanced physical rehabilitation after shoulder surgery with continuous interscalene analgesia[6], effects on success of physical rehabilitation or duration of hospital­ization are unknown. Development of portable disposable and electronic pumps has increased interest in continuous perineural analgesia for outpatient upper extremity surgery[7]. RCTs have begun to establish superior efficacy of con­tinuous peripheral catheter techniques for postoperative analgesia after ambulatory surgery. For shoulder surgery, 20 patients were recently randomized to receive continu­ous interscalene analgesia with either 0.2% ropivacaine or saline for 48 h with a disposable infusion pump at 8 mL/h with patient boluses (2 mL) allowed every 15 min. Rescue analgesia was provided with oral opioids. During the infu­sion period, patients receiving ropivacaine had better anal­gesia, used less oral opioid, had less nausea, sedation, and pruritus, and had better sleep patterns[8]. Continuous infra­clavicular analgesia for brachial plexus analgesia has been studied for outpatient upper extremity surgery[9]. Thirty pa­tients were randomized to receive either saline or 0.2% ropivacaine with the same disposable pump. Again during the infusion period, patients receiving ropivacaine had bet­ter analgesia, used less oral opioid, had less nausea, seda­tion, and pruritus and better sleep patterns.

Recent work in ultrasound imaging with high frequency linear arrays demonstrates clear images of brachial plexus anatomy at the interscalene, supraclavicular, infraclavicu­lar, axillary, and mid-humeral approaches. Direct visualisation of neural structure allows visualization of block placement and may improve efficiency of perineural cath­eter placement[10]. For shoulder surgery, the interscalene approach is typically used. However, the classic (Winnie) approach at C6 directs the needle almost perpendicular to the neural bundle. This orientation is satisfactory for single­shot blocks but may increase difficulty of placing a cath­eter parallel to the neural bundle. Recent modifications to improve the parallel orientation of needle/ catheter and neural bundle include the intersternocleidomastoid and modified lateral interscalene approaches. Prospective sur­veys for both of these techniques suggest satisfactory suc­cess rates for catheter placement with the intersternocleidomastoid (63 of 70 patients) and modified lateral approach (602 of 700 patients)[11],[12].

Another recent technical development is the com­mercial release of stimulating catheters. Verification of correct catheter placement has been previously reported with fluoroscopy, ultrasound and computed tomographic (CT) scans. All of these techniques may be cumbersome. The stimulating catheters allow direct and immediate func­tional confirmation of perineural catheter location and may aid in guidance of catheter placement. Preliminary experi­ence in 64 upper extremity perineural stimulating catheters suggests utility of this technique and also that stimulating characteristics of the catheter are different from the needle (1.6mA versus 0.5mA)[13].

Prospective surveys have begun to define potential risks associated with upper extremity perineural catheters. Reports enrolling over 900 patients undergoing continuous interscalene analgesia for 2-5 days observed an approxi­mately 0.7% incidence of catheter site infection and an approximately 0.2% incidence of neurological complica­tions after 6 months[11] .

Prospective clinical trials support the use of continu­ous femoral analgesia after total knee replacement (TKR)[14],[15],[16]­. Continuous femoral analgesia provides comparable or better analgesia with fewer side effects than IV PCA and epidural analgesia for at least the first 48 h after surgery. The improved analgesia provided by continuous femoral nerve blocks resulted in faster short-term functional re­covery of knee flexion during rehabilitation than IV PCA but without significant differences between the two groups after 6-12 wk. Patients undergoing outpatient lower ex­tremity surgery have also been recently studied[17],[18]. Thirty patients were randomized to receive either saline or 0.2% ropivacaine with the same disposable infusion pump via a popliteal fossa catheter. Again during the infusion period, patients receiving ropivacaine had better analgesia, used less oral opioid, had less nausea, sedation, and pruritus, and had better sleep patterns. Use of a popliteal fossa cath­eter may also improve ability to perform outpatient lower extremity surgery. A similar study enrolling 24 patients ob­served similar benefits and was able to discharge more patients on the same day with 0.25% bupivacaine (40%) versus saline infusions (0%)[19] .

Use of high-frequency linear arrays is also helping to improve visualisation of femoral and sciatic nerves. Case series have described the successful use of ultrasound to guide femoral and popliteal blocks, and direct visualisation may also improve catheter placement[20],[21]. Stimulating cath­eters have also been used for continuous femoral and sci­atic catheters (66 patients) with good success and similar stimulating characteristcs as upper extremity placement[13]. However, when compared with nonstimulating catheters in patients undergoing continuous femoral analgesia after major knee surgery (TKR and anterior collateral ligament repair), efficacy of stimulating catheters was not different from regular femoral nerve catheters[22]. Several recent RCTs have examined different techniques for continuous perineural analgesia for TKR. Use of the posterior psoas compartment technique had been proposed to produce better block of the lumbar plexus than the femoral 3-in-1 approach. However, a RCT examining 3-in-1 (femoral) catheters versus psoas compartment (posterior) approach observed no differences in pain scores or analgesic con­sumption[23]. Thus, the techniques appear equivalent with the femoral approach probably being technically easier. Within the femoral approach, a RCT has compared use of a nerve stimulator versus the loss of resistance fascia iliaca technique for placement of non stimulating catheters. The fascia iliaca technique was equally effective and required less time than the nerve stimulator technique[24] .

One prospective survey of 211 femoral catheters noted a 1.4% incidence of infectious complications and a 0.4%incidence of neurological complications after 12 months[25].

Continuous plexus analgesia may be provided with boluses, continuous infusion, PCA, or a combination of back­ground infusion and PCA boluses. Evidence is accumulat­ing that patient-controlled regimens (background infusion plus patient controlled boluses or patient-controlled boluses only) may be advantageous for delivery of continuous plexus an­algesia. RCTs indicate that use of a background infusion +PCA provides superior analgesia, reduces local anaesthetic consumption, and improves patient satisfaction when com­pared with infusion or PCA only administration for continu­ous interscalene, infraclavicular, and popliteal analgesia[26],[27],[28]. RCTs indicate similar findings in femoral catheters for PCA delivery but do not support the addition of a background infusion for femoral analgesia[29] .

   References Top

1.Touminen M, Pitkanen M, Rosenberg PH. Postoperative pain relief and bupivacaine plasma concentrations. Acta Anaesthesiol Scand 1987; 31:276-8.  Back to cited text no. 1
2.Klein SM, Grant SA, Greengrass RA, et al. Interscalene brachial plexus block with a continuous catheter insertion system and a disposable infusion pump. Anesth Analg 2000;91:1473-8.  Back to cited text no. 2
3.Delaunay L, Souron V, Lafosse L, et al. Analgesia after arthroscopic rotator cuff repair : subacromial versus interscalene continuous infusion of ropivacaine. Reg Anesth Pain Med 2005;30:117-22.  Back to cited text no. 3
4.Borgeat A, Tewes E, Biasca N, et al. Patient-controlled interscalene analgesia with ropivacaine after major shoulder sur­gery : PCIA vs. PCA. Br J Anaesth 1998;81:603-5.  Back to cited text no. 4
5.BorgeatA, PerschakH, Bird P, etal. Patient-controlled interscalene analgesia after major shoulder surgery : effects on diaphragmatic and respiratory function. Anesthesiology 2000;92:102-8.  Back to cited text no. 5
6.Cohen NP, Levine WN, Marra G, et al. Indwelling interscalene catheter anesthesia in the surgical management of stiff shoulder: a report of 100 consecutive cases. J shoulder Elbow Surg 2000;9:268-74.  Back to cited text no. 6
7.Ilfeld BM, Enneking FK. Continuous peripheral nerve blocks at home: a review. Anesth Analg 2005;100:1822-33.  Back to cited text no. 7
8.Ilfeld BM, Morey TE, Wright TW, et al. Continuous interscalene brachial plexus block for postoperative pain control at home : a randomized, double blinded, placebo-controlled study. Anesth Analg 2003;96:275-81.  Back to cited text no. 8
9.Ilfeld BM, Morey TE, Enneking FK. Continuous infraclavicular perineural infusion with clonidine and ropivacaine compared with ropivacaine alone: a randomized double-blinded, controlled study. Anesth Analg 2003;97:706-12.  Back to cited text no. 9
10.Chan VW, Perlas A, Rawson R, Odukoya O. Ultrasound-guided supraclavicular brachial plexus block. Anesth Analg 2003;97:1514-7.  Back to cited text no. 10
11.Borgeat A, Dullenkopf A, Ekatodramis G, Nagy L. Evaluation of the lateral modified approach for continuous interscalene block after shoulder surgery. Anesthesiology 2003;85:111-6.  Back to cited text no. 11
12.Pham-Dang C, Gunst JP, Gouin F, et al. A novel supraclavicular approach to brachial plexus block. Anesth Analg 1999;85:111-6.  Back to cited text no. 12
13.Pham-Dang C, Kick O, Collet T, et al. Continuous peripheral nerve blocks with stimulating catheters. Reg Anesth Pain Med 2003;28:83-8.  Back to cited text no. 13
14.Capdevilla X, Barthelet Y, Biboulet P, et al. Effects of perioperative analgesic technique on the surgical outcome and duration of rehabilitation after major knee surgery. Anesthesiol­ogy 1999;91:8-15.  Back to cited text no. 14
15.Singelyn F, Deyaert M, Pendeville E, et al. Effects of patient­controlled analgesia with morphine, continuous epidural analge­sia, and continuous three-in-one block on postoperative pain and knee rehabilitation after unilateral total knee arthroplasty. Anesth Analg 1998;87:88-92.  Back to cited text no. 15
16.Chelly JE, Greger J, Gebhard R, et al. Continuous femoral nerve blocks improve recovery and outcome of patients undergoing total knee arthroplasty. J Arthroplasty 2001;16:436-45.  Back to cited text no. 16
17.Ilfeld BM, Morey TE, Wang RD, Enneking FK. Continuous popliteal sciatic nerve block for postoperative pain control at home: a randomized, double-blinded, placebo-controlled study. Anesthesiology 2002;97:959-65.  Back to cited text no. 17
18.Zaric D, Boysen K, Christiansen J, et al. Continuous popliteal sciatic nerve block for outpatient foot surgery : a randomized, controlled trial. Acta Anaesthesiol Scand 2004;48:337-41.  Back to cited text no. 18
19.White PF, Issioui T, Skrivanek GD, et al. The use of a continu­ous popliteal sciatic nerve block after surgery involving the foot and ankle: does it improve the quality of recovery ? Anesth Analg 2003;97:1303-09.  Back to cited text no. 19
20.Marhofer P, Schrogendorfer K, Wallner T, et al. Ultrasonographic guidance reduces the amount of local anesthetic for 3-in-1 blocks. Reg Anesth Pain Med 1998;23:584-8.  Back to cited text no. 20
21.SinhaA, Chan VW. Ultrasound imaging for popliteal sciatic nerve block. Reg Anesth Pain Med 2004;29:130-4.  Back to cited text no. 21
22.Morin AM, Eberhart LH, Behnke HK, et al. Does femoral nerve catheter placement with stimulating catheters improve effective placement? A randomized, controlled and observer-blinded trial. Anesth Analg 2005;100:1503-10.  Back to cited text no. 22
23.Kaloul I, Guay J, Cote C, Fallaha M. The posterior lumbar plexus (psoas compartment) block and the three-in-one femoral nerve block provide similar postoperative analgesia after total knee replacement. Can J Anaesth 2004;5:45-51.   Back to cited text no. 23
24.Morau D, Lopez S, Biboulet P, et al. Comparison of continuous three-in-one and fascia iliaca compartment blocks for postop­erative analgesia: feasibility, catheter migration, distribution of sensory block, and analgesic efficacy. Reg Anesth Pain Med 2003;28:309-14.  Back to cited text no. 24
25.Cuvillon P, Ripart J, Lalourcey L, et al. The continuous femoral nerve block catheter for perspective analgesia: bacterial coloni­zation, infectious rate, and adverse effects. Anesth Analg 2001;93:1045-9.  Back to cited text no. 25
26.Singelyn F, Seguy S, Gouverneur JM. Interscalene brachial plexus analgesia after open shoulder surgery : continuous versus pa­tient-controlled infusion. Anesth Analg 1999;89:1216-20.  Back to cited text no. 26
27.Ilfeld BM, Morey TE, Enneking FK. Infraclavicular perineural local anesthetic infusion : a comparison of three dosing regimens for postoperative analgesia. Anesthesiology 2004;100:395-402.  Back to cited text no. 27
28.Ilfeld BM, Thannikary LJ, Morey TE, et al. Popliteal sciatic perineural local anesthetic infusion : a comparison of three dos­ing regimens for postoperative analgesia. Anesthesiology 2004;101:970-7.  Back to cited text no. 28
29.Singelyn FJ, Gouverneur JM. Extended "three-in-one" block after total knee arthroplasty: continuous versus patient-con­trolled technique. Anesth Analg 2000;91:176-80.  Back to cited text no. 29


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