Peripheral nerve blocks in the management of postoperative pain: challenges and opportunities

Abstract

Peripheral nerve blocks (PNBs) are increasingly used as a component of multimodal analgesia and may be administered as a single injection (sPNB) or continuous infusion via a perineural catheter (cPNB). We undertook a qualitative review focusing on sPNB and cPNB with regard to benefits, risks, and opportunities for optimizing patient care. Meta-analyses of randomized controlled trials have shown superior pain control and reductions in opioid consumption in patients receiving PNB compared with those receiving intravenous opioids in a variety of upper and lower extremity surgical procedures. cPNB has also been associated with a reduction in time to discharge readiness compared with sPNB. Risks of PNB, regardless of technique or block location, include vascular puncture and bleeding, nerve damage, and local anesthetic systemic toxicity. Site-specific complications include quadriceps weakness in patients receiving femoral nerve block, and pleural puncture or neuraxial blockade in patients receiving interscalene block. The major limitation of sPNB is the short (12-24 hours) duration of action. cPNB may be complicated by catheter obstruction, migration, and leakage of local anesthetic as well as accidental removal of catheters. Potential infectious complications of catheters, although rare, include local inflammation and infection. Other considerations for ambulatory cPNB include appropriate patient selection, education, and need for 24/7 availability of a health care provider to address any complications. The ideal PNB technique would have a duration of action that is sufficiently long to address the most intense period of postsurgical pain; should be associated with minimal risk of infection, neurologic complications, bleeding, and local anesthetic systemic toxicity; and should be easy to perform, convenient for patients, and easy to manage in the postoperative period.

The Effect of Intraoperative Systemic Lidocaine on Postoperative Persistent Pain Using Initiative on Methods, Measurement, and Pain Assessment in Clinical Trials Criteria Assessment Following Breast Cancer Surgery: A Randomized, Double‐Blind, Placebo‐Controlled Trial

“…[1][2][3] Multimodal analgesia approaches have been demonstrated to reduce opioid consumption, improve pain management, and reduce postoperative opioidinduced complications. 4,5 The development of chronic pain (> 3 months) has been linked to the intensity of perioperative pain; therefore, it is conceivable that preemptive multimodal analgesic strategies may also reduce the development of chronic postsurgical pain. [6][7][8] Systemic lidocaine is considered an efficacious multimodal strategy to reduce acute pain.…”

“…It is estimated that persistent postsurgical pain affects 15% to 60% of patients undergoing surgical procedures, and its incidence varies with the surgical procedure . Multimodal analgesia approaches have been demonstrated to reduce opioid consumption, improve pain management, and reduce postoperative opioid‐induced complications . The development of chronic pain (> 3 months) has been linked to the intensity of perioperative pain; therefore, it is conceivable that preemptive multimodal analgesic strategies may also reduce the development of chronic postsurgical pain …”

The European Society of Regional Anaesthesia and Pain Therapy/American Society of Regional Anesthesia and Pain Medicine Recommendations on Local Anesthetics and Adjuvants Dosage in Pediatric Regional Anesthesia

“…However, the risk of drug accumulation after a continuous infusion or several injections is increased. 16 The volume of distribution of ropivacaine is smaller than that of bupivacaine in adults and probably in children.…”

Ultrasound and nerve stimulator guided peripheral nerve blocks of the upper and lower limbs

“…Obezbeđujući značajnu kontrolu bola, doprineli su smanjenju potrošnje opioida u postoperativnom toku. Sve ovo je dovelo do rane rehabilitacije pacijenata, smanjivši broj bolničkih dana, kao i prevenciju ponovnog prijema, što je rezultiralo povećanim zadovoljstvom pacijenata, kao i smanjenjem ukupnih troškova lečenja [2][3][4][5][6][7][8][9] . Uvođenje nervnog stimulatora, a u poslednjih deset godina i ultrazvuka, doprinelo je promenama u svakodnevnoj praksi, omogućivši značajno širu primenu perifernih nervnih blokova, uz danas najviši stepen uspešnosti, ali i sigurnosti za pacijenta 1 .…”