Local anaesthetic delivery regimens for peripheral nerve catheters: a systematic review and network meta‐analysis

Abstract

There are numerous possible techniques for delivering local anaesthetic through peripheral nerve catheters. These include continuous infusions, patient-controlled boluses and programmed intermittent boluses. The optimal delivery regimen of local anaesthetic is yet to be conclusively established. In this review, we identified prospective trials of delivery regimens through peripheral nerve catheters. Our primary outcome was visual analogue scale scores for pain at 48 h. Secondary outcomes were: visual analogue scores at 24 h; patient satisfaction scores; rescue opioid use; local anaesthetic consumption; and nausea and vomiting. Network metaanalysis was used to compare these outcomes. Predefined sub-group analyses were performed. Thirty-three studies enrolling 1934 participants were included. In comparison with continuous infusion, programmed intermittent boluses improved visual analogue pain scores at both 48 and 24 h, the weighted mean difference (95%CI) being À0.63 (À1.12 to À0.14), p = 0.012 and À0.48 (À0.92 to À0.03), p = 0.034, respectively. Programmed intermittent boluses also improved satisfaction scores, the weighted mean difference (95%CI) being 0.70 (0.10-1.31), p = 0.023, and reduced rescue opioid use, the weighted mean difference (95%CI) in oral morphine equivalent at 24 h being À23.84 mg (À43.90 mg to À3.77 mg), p = 0.020. Sub-group analysis revealed that these findings were mostly confined to lower limb and truncal catheter studies; there were few studies of programmed intermittent boluses for upper limb catheters. Programmed intermittent boluses may provide optimal delivery of a local anaesthetic through peripheral nerve catheters. Further research is warranted, particularly to delineate the differences between upper and lower limb catheter locations, which will help clarify the clinical relevance of these findings.

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“…One is trial sequential analysis, which allows an estimation of the volume of evidence (the number of patients in studies) needed to provide a definitive statement about the comparison under scrutiny [12, 13]. The other technique is network meta‐analysis, which makes it possible to extend the analysis to include a wide range of studies, with differing comparators [14]. Network meta‐analysis uses novel statistical techniques to allow comparisons to be drawn between groups which might never have been compared in a piece of research.…”

Optimizing Postoperative Analgesia in the Multiverse of Peripheral Nerve Catheters

“…3,4 Adding to the complexity, the clinical advantages of modern pump technology and the regimens that can be reliably delivered are unclear. 4…”

“…Previous studies comparing bolus with continuous regimens have yielded conflicting results. 3,4,6 Reasons for this are multifactorial and likely reflect anatomic differences at the target site, the techniques used to guide placement (ultrasound vs. nerve stimulation), the choice of local anesthetic and catheter type (stimulating vs. nonstimulating), and the outcomes assessed. The informing evidence base also suffers from substantial trial heterogeneity, small sample sizes, and lack of standardized interventions-all of which hamper our ability to conclude the superiority of any technique.…”

“…Previous studies comparing bolus with continuous regimens have yielded conflicting results. 3,4,6 Reasons for this are multifactorial and likely reflect anatomic differences at the target site, the techniques used to guide placement (ultrasound vs . nerve stimulation), the choice of local anesthetic and catheter type (stimulating vs. nonstimulating), and the outcomes assessed.…”