Continuous Analgesia Research Articles

Is continuous proximal adductor canal analgesia with a periarticular injection comparable to continuous epidural analgesia for postoperative pain after Total Knee Arthroplasty? A retrospective study.

The classic adductor canal block (ACB) is a regional technique that aims to introduce local anesthetic to the saphenous nerve as it traverses the adductor canal. It offers the benefit of preserved quadriceps strength, and is ideal for rehabilitation. Proximal ACB (PACB) allows the operator to place the block away from the surgical site, permitting preoperative placement. Our primary outcome was total opioid consumption; secondary outcomes included the highest numerical rating scale scores and total gait distance at the indicated time intervals. We asked: 1) Does a Continuous Proximal ACB block with Periarticular knee injection (PACB) provide better analgesia than a Continuous Epidural (CSE)?; 2) Do PACB catheter patients do better with physical therapy compared to CSE patients?; 3) Are PACB patients discharged earlier than CSE patients? With IRB approval we performed a retrospective chart review of patients who had underwent primary total knee arthroplasty between October 2015 and September 2016. The selected patients (n = 151) were divided into two groups: CSE group, 72 patients who received a continuous epidural catheter and the PACB group, 79 patients who received at PACB with Periarticular injection. The CSE group received a single-segment combined spinal epidural (CSE) in the operating room. The epidural catheter infusion was started with 0.1% ropivacaine at 8 mL/hour to 14 mL/hour during the post-operative period. The PACB group received a proximal adductor canal catheter with 20 ml of 0.5 % ropivacaine and maintained with ropivacaine 0.2% at 8 ml to 14 ml post operatively. Total opioid consumption, highest numeric rating scores and total gait distance travelled were recorded upon discharge from the PACU and completion of postoperative day (POD) 0, 1, and 2. We found that the median cumulative morphine consumption was significantly higher in the CSE group compared to the PACB group (194 (0-498) versus 126 (0-354) mg, p = 0.012), a difference that was most notable on POD 1 (84 (16-243) versus 60 (5-370) mg, p = 0.0001). Mean hospital length of stay was also shorter in the PACB group (2.6 ± 0.67 versus 3.0 ± 1.08 days, p = 0.01). PACB group used significantly lower morphine consumption compared to the CSE group; they were better participants during physical therapy and achieved longer gait distances. The mean hospital length of stay was also shorter in the PACB group.

Ultrasound/Acidity-Triggered and Nanoparticle-Enabled Analgesia.

Local anesthetics have been extensively employed to treat postoperative pain, but they generally suffer from short acting duration and potential neurotoxicity under high local concentrations, which require the controlled and sustained releasing patterns of treatment drugs. In this work, it is reported, for the first time, the construction of hollow mesoporous organosilica nanoparticles (HMONs)-based nanoplatforms for localized delivery and controlled/sustained release of loaded ropivacaine for local anesthetics, which can be repeatedly triggered by either external ultrasound irradiation or acidity triggering to release the payload, causing on-demand and long-lasting analgesia. Based on the in vivo mouse model of incision pain, the controlled and sustained release of ropivacaine achieves more than six hours of continuous analgesia, which is almost three times longer as compared to single free ropivacaine injection. The low neurotoxicity and high biocompatibility of HMONs for nanoparticle-enabled analgesia are also demonstrated both in vitro and in vivo. This designed/constructed HMONs-based nanoplatform provides a potential methodology for clinical pain management via on-demand and long-lasting pain relief.

Bilateral Continuous Erector Spinea Block Versus Intravenous Analgesia in Cardiac Surgery.

Bilateral Continuous Erector Spinea Block Versus Intravenous Analgesia in Cardiac Surgery.

Ultrasound guided continuous Quadratus Lumborum block hastened recovery in patients undergoing open liver resection: a randomized controlled, open-label trial

BackgroundQuadratus lumborum (QL) block is increasingly being used as a new abdominal nerve block technique. In some studies of mid and lower abdominal and hip analgesia, continuous QL block achieved favorable outcomes as an alternative to continuous intravenous analgesia with opioids. However, the use of continuous QL block for upper abdominal pain is less well characterized. This study aimed to investigate the effects of continuous anterior QL block (CQLB) on postoperative pain and recovery in patients undergoing open liver resection.MethodsSixty-three patients underwent elective open liver resection were randomly divided into continuous anterior QL block (CQLB, n = 32) group and patient-controlled intravenous analgesia (PCIA, n = 31) group. Patients in CQLB group underwent ultrasound-guided anterior QL block at the second lumbar vertebral transverse processes before general anesthesia, followed by postoperative CQLB analgesia. Patients in PCIA group underwent continuous intravenous analgesia postoperatively. Postoperative numerical rating scale (NRS) pain scores upon coughing and at rest, self-administered analgesic counts, rate of rescue analgesic use, time to first out-of-bed activity and anal flatus after surgery, and incidences of analgesic-related adverse effects were recorded.ResultsPostoperative NRS pain scores on coughing in CQLB group at different time points and NRS pain score at rest 48 h after surgery were significantly lower than those in PCIA group (P < 0.05). Time to first out-of-bed activity and anal flatus after surgery in CQLB group were significantly earlier than those in PCIA group (P < 0.05). No significant differences of postoperative self-administered analgesic counts, rate of postoperative rescue analgesic usage, or incidences of analgesic-related adverse effects were found between the two groups (P > 0.05).ConclusionsUltrasound-guided anterior QL block significantly alleviated the pain during coughing after surgery, shortened the time to first out-of-bed activity and anal flatus, promoting postoperative recovery of the patients undergoing open liver resection.Trial registrationThis study has been registered in April 1, 2018 on Chinese Clinical Trail Registry, the registration number is ChiCTR1800015454.

Complications of continuous catheter analgesia for postoperative pain management in a tertiary care hospital. Incidence of technical complications and alternative analgesia methods used

Abstract Background Continuous invasive analgesia remains the gold-standard method for managing acute post-operative pain after major surgery. However, this procedure is not exempt from complications that may have detrimental effects on the patient and affect the post-operative recovery process. Data of the complications of continuous catheter analgesic techniques (CCATs) and their impact on pain relief are scarce in the literature. Material and methods We conducted a prospective longitudinal study and patients who underwent a surgical procedure and received continuous invasive analgesia after surgery were included. Post-operative analgesic strategy, pain scores (NRS), CCAT's characteristics and technical complications were recorded. Patient satisfaction was determined. Descriptive statistics and Student's t-tests were applied for the comparative analyses. Results We collected data from 106 patients. Mean duration of the CCAT was 47.52 ± 21.23 h and 52 patients (49.1%) were controlled in conventional hospitalisation units whereas 54 patients (50.9%) were controlled on intensive or high-dependency care units. The overall incidence of technical complications was 9.43%. The most common complications were catheter displacement (2.38%), inflammation at the IV catheter insertion point (2.38%) and excessive dosing of analgesic drugs (2.38%). Mean NRS scores were ≤3 during the permanence of CCATs. Maximum pain intensity was significantly higher in patients who suffered technical complications (mean ± standard deviation [ x ¯ ± SD ] : 4.4 ± 2.8 vs. 2.9 ± 1.9; p Satisfaction levels with the technique and overall satisfaction with the pain management strategy were negatively impacted by the occurrence of complications. Conclusions The incidence of technical complications of CCATs was 9.43% and had a negative impact in pain control and patient's satisfaction.

Subarachnoid block with continuous TAP catheter analgesia produces less chronic pain and better functional outcome after inguinal hernioplasty: a randomized controlled observer-blinded study

Background and objectivesThe major concern after inguinal hernioplasty is chronic postsurgical pain and impaired quality of life due to central sensitization. Preoperative, intraoperative, and postoperative pre-emptive analgesia using regional techniques...

Continuous caudal analgesia as a safe and effective method for pediatric post - chordectomy analgesia

Continuous caudal analgesia as a safe and effective method for pediatric post - chordectomy analgesia

Complicaciones de la analgesia continua invasiva para el control del dolor agudo postoperatorio en un hospital de tercer nivel. Incidencia de complicaciones técnicas y uso de métodos de analgesia alternativos

BackgroundContinuous invasive analgesia remains the gold-standard method for managing acute post-operative pain after major surgery. However, this procedure is not exempt from complications that may have detrimental effects on the patient and affect the post-operative recovery process. Data of the complications of continuous catheter analgesic techniques (CCATs) and their impact on pain relief are scarce in the literature. Material and methodsWe conducted a prospective longitudinal study and patients who underwent a surgical procedure and received continuous invasive analgesia after surgery were included. Post-operative analgesic strategy, pain scores (NRS), CCAT's characteristics and technical complications were recorded. Patient satisfaction was determined. Descriptive statistics and Student's t-tests were applied for the comparative analyses. ResultsWe collected data from 106 patients. Mean duration of the CCAT was 47.52±21.23hours and 52 patients (49.1%) were controlled in conventional hospitalisation units whereas 54 patients (50.9%) were controlled on intensive or high-dependency care units.The overall incidence of technical complications was 9.43%. The most common complications were catheter displacement (2.38%), inflammation at the IV catheter insertion point (2.38%) and excessive dosing of analgesic drugs (2.38%). Mean NRS scores were ≤3 during the permanence of CCATs. Maximum pain intensity was significantly higher in patients who suffered technical complications (mean±standard deviation [x̅ ± SD]: 4.4 ± 2.8 vs. 2.9 ± 1.9; P<0.05).Satisfaction levels with the technique and overall satisfaction with the pain management strategy were negatively impacted by the occurrence of complications. ConclusionsThe incidence of technical complications of CCATs was 9.43% and had a negative impact in pain control and patient's satisfaction.

Adding sufentanil to ropivacaine in continuous thoracic paravertebral block fails to improve analgesia after video-assisted thoracic surgery: A randomised controlled trial.

The benefit of adding opioid to a local anaesthetic for continuous thoracic paravertebral analgesia after video-assisted thoracic surgery (VATS) is unclear. To analyse the analgesic efficacy of ropivacaine and sufentanil in combination compared with ropivacaine alone after VATS. A randomised, double-blinded, single-centre clinical trial. A tertiary university hospital between March 2010 and April 2014. Ninety patients were recruited, two were not included leaving 88 randomised into two groups. Eighteen patients were excluded from analysis and 70 completed the study. To receive thoracic paravertebral analgesia with either 2 mg ml ropivacaine and 0.25 μg ml sufentanil (ropivacaine + sufentanil group) or 2 mg ml ropivacaine alone (ropivacaine group) for 48 h postoperatively. Infusion rate was set at 0.15 ml kg h in both groups. The primary endpoint was the mean total amount of self-administered morphine by the patients in each group at 48 h postoperatively. The mean ± SD total amount of self-administered morphine was not significantly different between groups (53.1 ± 27.2 mg in the ropivacaine + sufentanil group vs. 58.8 ± 34.3 mg in the ropivacaine group; P = 0.72). No significant differences were found between the two groups in either pain scores at rest or during movement, in opioid-related adverse reactions, in patient satisfaction or length of hospital stay. Adding 0.25 μg ml sufentanil to 2 mg ml ropivacaine in continuous thoracic paravertebral analgesia for VATS did not reduce morphine consumption or pain scores when compared with ropivacaine alone. We cannot recommend its use for routine clinical practice. Further studies analysing different concentrations and infusion rates of sufentanil are needed before a lack of efficacy can be confirmed. Clinical trial registrations: EudraCT: 2009-014832-38. ClinicalTrials.gov: NCT 01082744.

Clinical Comparative study between subcutaneous Continuous Analgesia versus continuous transversus abdominis plane block post caesarian section

Background: post cesarean section pain is associated with a variety of unfavorable post-operative consequences; affect both mother and the newborn, especially the first 48 h after delivery. The pain can be improbable, disrupting mother/child bonding and also affects mental, chest, heart problems, and prolong the hospital stays. Aim of the Work: to compare the efficacy and safety of bilateral continuous transversus abdominis plane (TAP) block versus continuous wound infiltration for pain relief after surgery. Patients and Methods: this study was conducted on forty patients of American Society of Anesthesiologists (ASA) physical status I or II, scheduled for elective CS were enrolled in this controlled study. Information about the study was explained comprehensively both orally and in written form to the patients. All patients gave written informed consents prior to their inclusion in the study. Results: there was no difference between TAP block & CWI as regarding pain during rest but TAP block was more effective during movement than CWI, opioid consumption was much less in TAP group than in CWI group and the time of first analgesia request was earlier in CWI group than in TAP group. Conclusion: both TAP block & CWI provided post-operative analgesia but USG TAP block increased the time to first analgesic request, reduces the total pethidine consumption with hemodynamic stability and decreases the incidence of adverse effects in patient undergoing caesarian section compared to continuous wound infiltration.

Clinical Comparative study between subcutaneous Continuous Analgesia versus continuous transversus abdominis plane block post caesarian section

Clinical Comparative study between subcutaneous Continuous Analgesia versus continuous transversus abdominis plane block post caesarian section

Bloqueio perioperatório do plexo lombar e isquemia cardíaca em pacientes com fratura de quadril: ensaio clínico randomizado

BackgroundPerioperative myocardial ischemia is common among patients undergoing hip fracture surgery. Our aim is to evaluate the efficacy of perioperative continuous lumbar plexus block in reducing the risk of cardiac ischemic events of elderly patients undergoing surgery for hip fractures, expressed as a reduction of ischemic events per subject. MethodsPatients older than 60 years, ASA II–III, with risk factors for or known coronary artery disease were enrolled in this randomized controlled study. Patients were randomized to conventional analgesia using opioid intravenous patient‐controlled analgesia or continuous lumbar plexus block analgesia, both started preoperatively and maintained until postoperative day three. Continuous electrocardiogram monitoring with ST segment analysis was recorded. Serial cardiac enzymes and pain scores were registered during the entire period. We measured the incidence of ischemic events per subject registered by a continuous ST‐segment Holter monitoring. ResultsThirty‐one patients (intravenous patient‐controlled analgesia 14, lumbar plexus 17) were enrolled. There were no major cardiac events during the observation period. The number of ischemic events recorded by subject during the observation period was 6 in the lumbar plexus group and 3 in the intravenous patient‐controlled analgesia group. This difference was not statistically significant (p=0.618). There were no statistically significant differences in the number of cases with increased perioperative troponin values (3 cases in the lumbar plexus group and 1 case in the intravenous patient‐controlled analgesia group) or in terms of pain scores. ConclusionsUsing continuous perineural analgesia, compared with conventional systemic analgesia, does not modify the incidence of perioperative cardiac ischemic events of elderly patients with hip fracture.

Pain control in chronic, refractory CRPS by continuous brachial plexus analgesia.

Each patient underwent a mean of 4.4 (range 2-8) spinal catheter implantations. A rapid and strong analgesic effect was observed immediately after the injection of bupivacaine solution was started: Pain decreased from a mean of 8.3 to 1.6. The duration of maintaining the catheter in the brachial plexus and achieving effective analgesia was 5.3 months (range 2-12). After the removal of the catheter, the pain returned to baseline. No patient achieved a permanent, or at least partial, reduction of pain after completing this therapy.

A prospective randomized trial of continuous paravertebral infusion versus intravenous patient-controlled analgesia after thoracoscopic lobectomy for lung cancer.

Since thoracoscopic lobectomy was introduced in 1990s, it has been regarded as a useful surgical option for early-stage lung cancer because it could reduce operative morbidities as compared with open lobectomy. However, some patients still complain of severe acute pain after thoracoscopic lobectomy, and the incidence of chronic pain was reported up to 30% (1,2). Penetration of the chest wall by trocars, torque at trocar, and compression of the intercostal nerves have all been suggested to cause pain after thoracoscopic lobectomy (3,4). Current analgesic options for acute pain include thoracic epidural analgesia, intravenous patient-controlled analgesia (iv-PCA), thoracic paravertebral block, and continuous paravertebral infusion (c-PVI) of local anesthetics.

Perioperative lumbar plexus block and cardiac ischemia in patients with hip fracture: randomized clinical trial

BackgroundPerioperative myocardial ischemia is common among patients undergoing hip fracture surgery. Our aim is to evaluate the efficacy of perioperative continuous lumbar plexus block in reducing the risk of cardiac ischemic events of elderly patients undergoing surgery for hip fractures, expressed as a reduction of ischemic events per subject. MethodsPatients older than 60 years, ASA II–III, with risk factors for or known coronary artery disease were enrolled in this randomized controlled study. Patients were randomized to conventional analgesia using opioid intravenous patient-controlled analgesia or continuous lumbar plexus block analgesia, both started preoperatively and maintained until postoperative day three. Continuous electrocardiogram monitoring with ST segment analysis was recorded. Serial cardiac enzymes and pain scores were registered during the entire period. We measured the incidence of ischemic events per subject registered by a continuous ST-segment Holter monitoring. ResultsThirty-one patients (intravenous patient-controlled analgesia 14, lumbar plexus 17) were enrolled. There were no major cardiac events during the observation period. The number of ischemic events recorded by subject during the observation period was 6 in the lumbar plexus group and 3 in the intravenous patient-controlled analgesia group. This difference was not statistically significant (p=0.618). There were no statistically significant differences in the number of cases with increased perioperative troponin values (3 cases in the lumbar plexus group and 1 case in the intravenous patient-controlled analgesia group) or in terms of pain scores. ConclusionsUsing continuous perineural analgesia, compared with conventional systemic analgesia, does not modify the incidence of perioperative cardiac ischemic events of elderly patients with hip fracture.

Application of continuous iliac fascial interstitial obstruction in the placement of anaesthesia in the vertebral canal of the elderly femoral fractures and postoperative analgesia

Objective To investigate the effect of continuous iliac fascia space block on the placement of body position and postoperative analgesia in patients with femoral fractures. Methods 60 patients with senile selective unilateral femoral fracture, aged 68-87 years old, weight 49-70kg, ASA grade II-III were selected, and they were randomly divided into iliac fascia block group (A group) and intravenous analgesia group (B group) according to the digital, 30 cases in each group.The two groups underwent lumbar epidural anesthesia, A group received continuous fascia iliaca compartment block 15 min before the the body position.B group was routinely given combination of lumbar and hard anesthesia.After operation, A group was connected with the automatic infusion pump continuous infusion of 0.2% ropivacaine 0.1mL·kg-1·h-1.B group received controlled intravenous analgesia, postoperative given loading dose of dezocine intravenous infusion of 5mg with automatic injection pump for dezocine 0.01mg·kg-1·h-1.When the patients entered the room (T0) and just after the placement of the body position (T1), the heart rate, diastolic blood pressure and systolic blood pressure were measured and recorded.At postoperative 2, 4, 6, 12, 24 and 48h, the VAS scores and pethidine usage during surgery, the adverse reaction were recorded. Results The heart rate, diastolic pressure and systolic pressure at T1 in A group had no significant change compared with T0 (all P>0.05). The heart rate, diastolic pressure and systolic pressure in the control group (B group) at T1 were significantly higher than at T0(t=5.302, 7.369, 5.629, all P<0.05). At T1, T2, T4, T6, T12, T24 and T48, the pain VAS scores in A group were lower than those in B group (t1=66.401, t2=7.719, t4=25.260, t6=13.170, t12=3.837, t24=3.081, t48=6.202.all P<0.05). The study group had no complications such as puncture hematoma, intoxication of local anesthetic and other complications. Conclusion Continuous iliofascial block can provide continuous analgesia for elderly patients with femoral fractures.It is safe and effective, and is easy to perform.It provides favorable conditions for later operative treatment. Key words: Iliac fascia space block; Femoral fracture; Elderly; Postoperative analgesia

LIA with vs. without an additional intraarticular catheter- Results of a RCT

Aims and Objectives: Local infiltration analgesia (LIA) is meanwhile worldwide established and scientifically proven in perioperative treatment of TKA. Single-shot is the mostly used option. However, after the local analgesia has subsided, at the latest after the day of surgery, the pain is usually present and affects rapid mobilization and rehabilitation. Long-acting medications for LIA have not proved to be effective and there are barely data on intra-articular continuous analgesia. We present a randomized controlled trial which compares the LIA with and without additional continuous analgesia using an intraarticular catheter. Materials and Methods: 50 patients with TKA were randomized and included in the study. All patients received the same implant system without patellar resurfacing, without tourniquet or drains. The operation was performed by the same surgeon and postoperative treatment was identical. Both groups received a general anesthesia with laryngeal mask. A group of 25 patients received a single-shot LIA containing 150 ml bupivacaine (0.2%) and morphine (20 mg). The other group, also 25 patients, received the same single-shot LIA and an intraarticular catheter (350 ml) for 3 days with continuous infiltration (8ml/h) of bupivacaine (0.2%) and morphine (20 mg per 200 ml bupivacaine) . The following parameters were recorded preoperatively and postoperatively: VAS, additionally analgetics / opioids. Also included were complications such as infections, postoperative falls and DVT. Results: The average operating time was 46 min. There were no complications or reinterventions. The results were not significantly different during the first day, but for day 2 to 4 VAS was significantly better and additional analgetics / opioids were significantly less (p <0.05) in the group with additional catheters. On days 5 and 6, the results again were comparable. Conclusion: There was a superiority of the additional intra-articular catheter for some days in the perioperative treatment of TKA.

Paraplegia After Accidental Continuous Subdural Analgesia

(Int J Obstet Anesth. 2017;30:61–66) In this case report a healthy 34 year-old woman undergoing her second cesarean section received combined spinal epidural anesthesia for surgery using an 18-G Tuohy epidural needle and a 25-G spinal needle. The spinal injection consisted of 0.75% ropivacaine 1.8 mL. Upon removal of the spinal needle, the epidural needle was rotated 90 degrees cephalad and an epidural catheter was inserted 3 cm into the epidural space. A T6 bilateral sensory level was achieved. The surgery was uneventful; the mother was stable throughout and a healthy was child delivered.

Single-shot pectoral plane (PECs I and PECs II) blocks versus continuous local anaesthetic infusion analgesia or both after non-ambulatory breast-cancer surgery: a prospective, randomised, double-blind trial

BackgroundPectoral plane blocks (PECs) are increasingly used in analgesia for patients undergoing breast surgery, and were recently found to be at least equivalent to single-shot paravertebral anaesthesia. However, there are no data comparing PECs with the popular practice of continuous local anaesthetic wound infusion (LA infusion) analgesia for breast surgery. Therefore, we compared the efficacy and safety of PECs blocks with LA infusion, or a combination of both in patients undergoing non-ambulatory breast-cancer surgery. MethodsThis single-centre, prospective, randomised, double-blind trial analysed 45 women to receive either PECs blocks [levobupivacaine 0.25%, 10 ml PECs I and levobupivacaine 0.25%, 20 ml PECs II (PECs group); LA infusion catheter (levobupivacaine 0.1% at 10 ml h−1 for 24 h (LA infusion group); or both (PECs and LA infusion)]. The primary outcome measure was area under the curve of the pain verbal rating score whilst moving vs time (AUC) over 24 h. Secondary outcomes included total opioid consumption at 24 h. ResultsAUC moving was mean (SD) 71 (34) mm h−1vs 58 (41) vs 23 (20) in PECs, LA infusion, and both, respectively; P=0.002. AUC at rest was also significantly lower in patients receiving both. The total 24 h opioid consumption [median (25–75%)] was 14 mg (9–26) vs 11 (8–24) vs 9 (5–11); P=0.4. No adverse events were observed. ConclusionsThe combination of both pre-incisional PECs blocks and postoperative LA infusion provides better analgesia over 24 h than either technique alone after non-ambulatory breast-cancer surgery. Clinical trial registrationNCT 03024697.

Efficacy and safety of epidural, continuous perineural infusion and adjuvant analgesics for acute postoperative pain after major limb amputation - a systematic review.

Treatment of pain following major limb amputations is often a clinical challenge in a patient population consisting mainly of elderly with underlying diseases. Literature on management of acute post-amputation pain is scarce. We performed a systematic review on this topic to evaluate the efficacy and safety of analgesic interventions for acute pain following major limb amputation. A literature search was performed in PubMed, Cochrane Central Register of Controlled Trials and Cochrane Database of Systematic Reviews using the following key words: [(amputation) AND (pain OR analgesi* OR pain relief)] AND (acute OR postoperative). Randomized controlled studies (RCTs) and observational studies investigating treatment of acute pain following major amputations for any indication (peripheral vascular disease, malignant disease, trauma) were included. The review was performed according to the standards described in the PRISMA statement. The Cochrane quality assessment tool was used to evaluate the risk of bias in the RCTs. Nineteen studies with total of 949 patients were included. The studies were generally small and heterogeneous on outcomes, study designs and quality. There were 16 studies on epidural or continuous perineural analgesia (CPI). Based on five RCTs (n=268) and two observational studies (n=49), epidural analgesia decreased the intensity of acute stump pain as compared to systemic analgesics, during the first 24 h after the operation. Based on one study epidural analgesia caused more adverse effects like sedation, nausea and motor block than continuous perineural local anesthetic infusion. Based on one RCT (n=21) and eight observational studies (n=501) CPI seemed to decrease opioid consumption as compared to systemic analgesics only, on the first three postoperative days, and was well tolerated. Only three trials investigated systemic analgesics (oral memantine, oral gabapentine, iv ketamine). Ketamine did not decrease acute pain or opioid consumption after amputation as compared to other systemic analgesics. Gabapentin did not decrease acute pain when combined to epidural analgesia as compared to epidural analgesia and opioid treatment, and caused adverse effects. The main finding of this systematic review is that evidence regarding pain management after major limb amputation is very limited. Epidural analgesia may be effective, but firm evidence is lacking. Epidural causes more adverse effects than CPI. The results on efficacy of CPI are indecisive. The data on adjuvant medications combined to epidural analgesia or CPI is limited. Studies on efficacy and adverse effects of systemic analgesics for amputation pain, especially concentrating on elderly patients, are needed.