Perineural Catheter Research Articles

Continuous adductor canal block for the management of below-knee postamputation stump pain in a diabetic patient

Limb amputation surgery is one of the oldest surgical procedures. Below-knee amputation (BKA) surgery is indicated for advanced critical limb ischemia, diabetic foot sepsis, and major trauma. The majority of unplanned readmission after lower limb amputation surgery occurs mainly due to persistent postamputation stump pain. One of the important causes of postamputation stump pain is stump site infection. A higher rate of infection is seen in diabetic patients. Postamputation stump pain management is challenging due to the presence of mixed nociceptive and neuropathic pain component. Various modalities of treatment to control the stump pain are published in different articles. However, no single technique or drug is found superior to others. Here, we report a case of severe postamputation stump pain after BKA surgery in a diabetic patient with stump site infection. The pain was successfully managed by continuous infusion of analgesics via the adductor canal perineural catheter. After the stoppage of the infusion, the patient did not report any phantom limb pain syndrome during the 6-month follow-up.

Two per cent alcoholic chlorhexidine versus alcoholic five per cent povidone-iodine for the prevention of perineural catheter colonisation: The CHLOVEPI randomised, controlled trial

BackgroundMultimodal analgesia, including a regional technique using perineural catheters (PNCs), is recommended for the treatment of moderate-to-severe acute postoperative pain. Perineural catheters are at risk of bacterial colonisation. In this study, we compared the cutaneous antiseptic efficacy of 2% alcoholic chlorhexidine and povidone-iodine-alcohol for preventing the bacterial colonisation of PNCs in orthopaedic surgery. MethodsWe performed a randomised, controlled trial, comparing two cutaneous antisepsis strategies, one based on 2% alcoholic chlorhexidine and the other on povidone-iodine-5% alcohol, for placed PNCs before orthopaedic surgery. The primary endpoint was the incidence of catheter bacterial colonisation (threshold > 1000 colony-forming units/ml). The secondary endpoints were the incidence of catheter-related infections and the adverse effects of the antiseptic solutions. ResultsFrom November 2016 to May 2018, we included 113 patients in this study. The use of alcoholic chlorhexidine was associated with a lower incidence of catheter colonisation (15.5% (n = 9) versus 32.7% (n = 18); OR: 0.28 [0.09-0.77], p = 0.01). No catheter-related infections or adverse effects of antiseptic solutions were observed in either group. The risk factors associated with colonisation were a duration of catheter use ≥ 3 days (p = 0.04) and obesity (p = 0.005). The most frequently identified bacterium was Staphylococcus epidermidis. ConclusionSkin disinfection with 2% alcoholic chlorhexidine decreases bacterial colonisation rates for placed perineural catheters.

Prolonged regional analgesia in the complex treatment of extensive purulent-necrotic wounds on the background of decompensated arterial and venous insufficiency (case report

Objective:to demonstrate the successful complex treatment of a shin circular wound in a patient with intense pain due to critical limb ischemia and wound infection, which became possible against the background of prolonged peripheral blockade.Materials and methods.A 72-year-old patient with critical ischemia of the right lower extremity was treated for a circular purulent-necrotic wound of the shin leg from November 2016 to April 2017 at the Wounds and Wound Infections Department of FSBI “A. V. Vishnevsky NRC of Surgery” Ministry of Health of Russia. An examination revealed the impossibility of right lower limb arterial insufficiency surgical correction. The patient refused amputation of the lower limb. For the relief of pain, a long-term blockage of the sciatic nerve was used (infusion of ropivacaine 6.0–8.0 mg / hr into the perineural catheter, additional 100 mg ropivacaine boluses were used before performing traumatic daily dressings). The intensity of pain was evaluated on a visual analogue scale (VAS), sought to achieve a pain intensity of not more than 3 points at rest and not more than 4 points on – when moving.Results.Blockade of the sciatic nerve reduced the intensity of pain from 8–10 to 0–3 points, which made it possible to continue treatment. In total, the duration of sciatic nerve catheterization at the stages of treatment was 115 days (18 + 41 + 23 + 32), the maximum duration of one of the peripheral nerve catheterizations was 41 days. Complications associated with nerve catheterization were not observed in the patient. The pain syndrome is stopped, the area of the wound defect is reduced in size. Discharged for outpatient treatment.Conclusion.Long-term peripheral analgesia made it possible to gain time necessary for cleansing the wound surface from necrotic tissues, therapy with drugs that improve arterial blood supply to the limbs, as well as for performing reconstructive and reconstructive operations after the wound process has passed to the reparative stage. Long-term peripheral blockade is a prerequisite for the successful treatment of extensive wounds of the lower extremities caused by insufficient arterial blood supply at the stage of critical limb ischemia, accompanied by intense pain.

Has the future arrived? Liposomal bupivacaine versus perineural catheters and additives for interscalene brachial plexus block.

Single injection interscalene block (ISB) provides effective analgesia for shoulder surgery. However, the duration of these is limited. This review summarizes the effectiveness of three potential means of extending the duration of analgesia: perineural infusion of local anesthetic agents, addition of adjuvant drugs to local anesthetics in single-injection nerve block, and utilization of liposomal bupivacaine in the surgical field or in the block itself. Perineural infusion of local anesthetics with interscalene catheters provides superior pain relief with reduction of postoperative opioids. Both dexmedetomidine and dexamethasone effectively extend the duration of single injection ISB. Liposomal bupivacaine holds promise when injected perineurally in ISB, either as a sole agent or when mixed with standard bupivacaine. Interscalene catheters, adjunctive drugs added to local anesthetics in single-injection interscalene brachial plexus blocks, or liposomal bupivacaine may be used to effectively prolong the duration of analgesia for shoulder surgery patients.

Suture-catheters Compared with Traditional Catheters: Reply.

We agree with Drs. Wardhan and Nimma that the suture-catheter system is simpler in design than conventional through-the-needle catheters and that no system will be perfect in design, ergonomics, or ease of placement.1 However, our experience with the catheter insertion system differs from their suggestion that relative to a straight needle, the suture shape is more difficult to visualize. As our study progressed, we were somewhat surprised to discover that the 19-gauge suture needle visualized at least as well, if not better, than a Tuohy needle of the same gauge. Drs. Wardhan and Nimma note that “lateral forces exerted on [a] straight needle tip leading to curvature may lead to an unpredictable needle trajectory which cannot always be assumed to be straight or even in a single two-dimensional plane.” We concur and suggest that the suture-shaped needle remains within a two-dimensional plane precisely because of its curvature, which appears to greatly strengthen the needle: It is extraordinarily rigid and resists bending laterally (in a direction other than its curvature).Furthermore, as our colleagues note, straight needles often bend, resulting in the end being “obscured by shadows or poor reflection back to the probe.” We agree, and we found that the suture design did not exhibit this weakness, possibly because the gently curved needle is comparatively parallel to the ultrasound probe when it reaches the target nerve.Lastly, we respectfully disagree with our colleagues’ statement that we “struggle to visualize the needle clearly at meager depth of possibly just a few (2 to 4) centimeters as evident in [our] figure 3.” To the contrary, the needle appears clearly for its entire length (within the ultrasound field) in the first two panels of figure 3. Any distortion is an artifact of the static image, which was originally viewed in real-time. This can be best appreciated in the supplemental videos associated with the article, which demonstrate how the suture-catheter can be seen moving through tissue in real time.2We join our colleagues in calling for additional research to provide actionable information for clinicians to optimize benefits—and minimize risks—of perineural catheter delivery systems.Ferrosan Medical Devices (Søborg, Denmark) provided an unrestricted research grant and suture-type perineural catheters used in the original study to the University of California. This institution has also received funding and product for other research projects from Myoscience (Fremont, California), Epimed (Farmers Branch, Texas), InfuTronix (Natick, Massachusetts) and SPR Therapeutics (Cleveland, Ohio). In addition to the above, Dr. Ilfeld’s institution has received funding for a different research project from Heron Pharmaceuticals (San Diego, California).

Dislocation rates of perineural catheters placed either perpendicular or parallel to the femoral nerve: A randomised controlled trial.

Ultrasound has increased the efficacy of femoral nerve catheters but their postoperative dislocation still remains a common problem. Although catheter placement parallel to the nerve seems to reduce dislocation rates in other nerves and plexuses, the possible advantage for femoral nerve catheter placement remains unclear. To compare the dislocation rates of femoral catheters when placed perpendicular or parallel to the femoral nerve. Randomised controlled study. University orthopaedic hospital. Duration of study: October 2018 to June 2019. Eighty patients scheduled for major knee surgery with femoral catheter were enrolled and randomly allocated in two groups. Data from 78 patients could be analysed. The femoral nerve catheters was placed perpendicular to the nerve in Group 1 (n=40), whereas in Group 2 (n=38) parallel to it. For Group 1 the short-axis view of the nerve and an in-plane puncture was used. For Group 2 we used the short-axis view of the nerve and an out-of-plane puncture technique combined with rotation of the transducer to the long-axis view with the needle in-plane. Primary outcome was the catheter dislocation rate in the first 48 h. Secondary outcomes were pain scores and sensory blockade. There was no statistically significant difference between the two techniques regarding dislocation of the catheters at 24 or 48 h (at 48 h, Group 1: 15%, Group 2: 2.6%, P = 0.109). Also pain scores, sensory blockade and rescue doses of ropivacaine did not differ between the groups. However, in Group 2 the technique took longer. Rotating the ultrasound probe to the long-axis in-plane view enabled examination of the catheter position when it was placed parallel to the nerve. The parallel placement of the catheter required more time, but did not significantly improve dislocation rate, pain scores or sensory blockade. Clinicaltrials.gov identifier: NCT03693755.

Suture-method versus Through-the-needle Catheters for Continuous Popliteal-sciatic Nerve Blocks

The basic perineural catheter design has changed minimally since inception, with the catheter introduced through or over a straight needle. The U.S. Food and Drug Administration recently cleared a novel perineural catheter design comprising a catheter attached to the back of a suture-shaped needle that is inserted, advanced along the arc of its curvature pulling the catheter past the target nerve, and then exited through the skin in a second location. The authors hypothesized that analgesia would be noninferior using the new versus traditional catheter design in the first two days after painful foot/ankle surgery with a primary outcome of average pain measured with the Numeric Rating Scale. Subjects undergoing painful foot or ankle surgery with a continuous supraparaneural popliteal-sciatic nerve block 5 cm proximal to the bifurcation were randomized to either a suture-type or through-the-needle catheter and subsequent 3-day 0.2% ropivacaine infusion (basal 6 ml/h, bolus 4 ml, lockout 30 min). Subjects received daily follow-up for the first four days after surgery, including assessment for evidence of malfunction or dislodgement of the catheters. During the first two postoperative days the mean ± SD average pain scores were lower in subjects with the suture-catheter (n = 35) compared with the through-the-needle (n = 35) group (2.7 ± 2.4 vs. 3.4 ± 2.4) and found to be statistically noninferior (95% CI, -1.9 to 0.6; P < 0.001). No suture-style catheter was completely dislodged (0%), whereas the tips of three (9%) traditional catheters were found outside of the skin before purposeful removal on postoperative day 3 (P = 0.239). Suture-type perineural catheters provided noninferior analgesia compared with traditional catheters for continuous popliteal-sciatic blocks after painful foot and ankle surgery. The new catheter design appears to be a viable alternative to traditional designs used for the past seven decades.

Different Approaches of Continuous Fascial Iliaca Compartment Block Under Ultrasound-Guidance for Hip Arthroplasty: Short axis vs long axis in-Plane Techniques

Continuous Fascia iliaca compartment block provides effective analgesia by effective blockade of the femoral and lateral femoral cutaneous (LFC) in patients undergoing hip orthopedic surgeries. We compared analgesic effect of ultrasound-guided continuous fascia iliaca compartment block using either a short-axis in-plane technique or a long-axis in-plane technique for patients undergoing hip arthroplasty.In this prospective double-blind study, twenty-six ASA- I and II patients undergoing hip orthopedic surgeries were enrolled and randomly assigned to receive continuous fascia iliaca compartment block with either a short axis in-plane or a long-axis in- plane technique. The perineural catheter was attached to an electronic infusion pump. Ropivacaine 0.2% was administered through the catheter for 48 hours (4 mL/h). The primary outcome was ropivacaine consumption within 48h in the two groups. Secondary outcomes included the procedural time, success rate of block, postoperative pain score evaluated by NRS score at rest and movement. There was no significant difference in the consumption of ropivacaine during the 48 postoperative hours (P&gt;0.05). Short-axis in-plane group need less procedural time for catheterization insertion than long-axis group. Compared with the short-axis in-plane technique, long-axis in-plane continuous fasicia iliaca compartment block had no ropivacaine-sparing effect on patient-controlled analgesia for hip arthroplasty.

Indigenous technique for continuous perineural catheter insertion and our regime for continuous adductor canal blocks

Indigenous technique for continuous perineural catheter insertion and our regime for continuous adductor canal blocks

Continuous Femoral Catheter for Postoperative Analgesia After Total Knee Arthroplasty.

Introduction:Postoperative pain management in the total knee replacement (TKR) represent a fundamental step for a positive outcome, allowing rapid mobilization, already on the first day. Further, continuous peripheral nerve block techniques have been reported to allow effective and safe control of acute postoperative pain, ensuring the implementation and completion of an accurate and intensive joint rehabilitation program.Aim:The aim of this study was to assess early mobility and compliance of patients that underwent TKR surgery using the femoral block.Methods:For the study, all patients that underwent TKR from 2015 to 2018 with ASA score between II-III was evaluated. Patients underwent vital parameters monitoring and were treated initially with midazolam (0.05mg / kg) e.v. combined sciatic block + femoral perineural catheter positioning using a peripheral nerve stimulation-assisted technique.Results:Intraoperatively, satisfactory analgesia was guaranteed in all patients, associated with a complete muscle relaxation of the affected limb. High patient compliance, associated with good control of acute postoperative pain was obtained in the first 24 hours after surgery (VAS 0- 1). The ROM outcomes were good in all rehabilitation stages, managing to reach 90 degrees bending on the seventh day with an average KSS score of 88-90. Patient satisfaction and impact on quality of life were assessed with the SF-36 showing average scores of 78.Conclusion:Continuous femoral nerve blocking ensures good postoperative analgesia in TKR allowing an early joint mobilization, a rapid functional recovery of the knee and increasing patient compliance during the post-operative rehabilitation program.

The Perineural Local Anaesthetic Catheter After Major Lower Limb Amputation Trial (Placement): A Randomised Controlled Feasibility Study

Introduction - Pain control after major lower limb amputation for peripheral vascular disease is a significant problem, due to the multifactorial nature of post-amputation pain, contra-indication of epidural anaesthesia in many patients and side effects of opioid analgesics and patient frailty. A perineural catheter is a thin plastic tube which may be placed adjacent to the sciatic or tibial nerve at the time of amputation, through which a continuous local anaesthetic infusion can be given. Although low quality observational data suggest that perineural catheter usage reduces postoperative opioid requirements, little data are available regarding their effect on pain. PLACEMENT is a randomised controlled feasibility study to explore the feasibility of running a multi-centre effectiveness trial to assess the impact of perineural catheter usage on short and medium term postoperative outcomes. Methods - Fifty patients undergoing major lower limb amputation (at below or above knee level) for peripheral vascular disease were recruited from two centres. Patients were randomised in a 1:1 ratio to receive standard postoperative analgesia, with or without insertion of a perineural catheter and local anaesthetic infusion for up to 5 postoperative days. The primary effectiveness outcome was pain measured on a verbal rating scale in the first five post-operative days. Secondary effectiveness outcomes included quality of life and the prevalence of phantom limb and chronic stump pain assessed 2 and 6 months after surgery as well as total healthcare costs. Key feasibility outcomes included the proportion of eligible patients successfully recruited and the feasibility of using pain scores as a primary outcome measure as well as a preliminary estimate of the effect size. Full ethical approval has been granted (Wales REC 3 reference number 16/WA/0353). The trial is registered as ISRCTN85710690 with EudraCT number 2016-003544-37 and is funded by Health and Care Research Wales (grant number RfPPb-16-1198). Results - Recruitment commenced on 15th February 2017 and 50 patients were successfully enrolled in the study across two centres by 15th November 2017. Follow-up is due to complete in May 2018, and results of the primary effectiveness and key feasibility outcomes will be available in time for the annual meeting of the European Society for Vascular Surgery, where they will be made publically available for the first time. Conclusion - PLACEMENT is a multi-centre randomised controlled feasibility study which is the first to explore the feasibility of running an effectiveness trial on perineural catheter usage for postoperative pain in amputees. Recruitment is complete and full trial results will be available in time for the annual meeting of the European Society for Vascular Surgery.

Perineural local anaesthetic catheter after major lower limb amputation trial (PLACEMENT): results from a randomised controlled feasibility trial

ObjectivesTo determine the feasibility of undertaking a randomised controlled effectiveness trial evaluating the use of a perineural catheter (PNC) after major lower limb amputation with postoperative pain as the primary...

Peripheral nerve blocks for postoperative analgesia: From traditional unencapsulated local anesthetic to liposomes, cryoneurolysis and peripheral nerve stimulation

Peripheral nerve blocks (PNBs) using local anesthetics either via single injection or continuous perineural catheter have been the mainstay for regional anesthesia and are a vital component of postoperative multimodal opioid-sparing pain management. There are some limitations to PNBs, however, mainly its limited duration of action, but also risk of catheter-associated infection and dislodgements. Furthermore, local anesthetic-based blocks can induce sensory deficits and motor weakness, possibly increasing the risk of falling and/or decreasing the ability to participate in postoperative rehabilitation. In this review, we first discuss various local anesthetic-based PNB techniques for major surgery and then review newer modalities, including liposome bupivacaine, cryoanalgesia, and peripheral nerve stimulation; all of which may offer advantages over single and continuous local anesthetic-based PNBs.

Local Anesthetic Additives for Regional Anesthesia: a Review of Current Literature and Clinical Application

Improving perioperative pain management with regional anesthesia has become prevalent and extremely important, due in part to the opioid epidemic and increased emphasis on enhanced recovery after surgery (ERAS) protocols. Perineural catheters offer extended duration of nerve blockade as compared with single dose of local anesthetic at the cost of increased risk of catheter-related complications like displacement and higher infection rate. Also, many practices lack the infrastructure to manage catheters. We are continuously exploring options to extend block duration without catheters, and local anesthetic additives offer a viable option to prolong the benefits of plain local anesthetics. A recent randomized cross-over study has suggested that the efficacy of local anesthetic additives like dexamethasone on the duration of nerve block remains uncertain despite several supporting systematic reviews and meta-analysis data. This article reviews current literature to provide clinically relevant information about common nerve block additives, describing rationale for their use, effect on block onset, extension of block duration, and safety profiles of the additives.

Ultrasound imaging has a potential to exhibit biotechnical advance in perioperative pain management

The perioperative pain management - instead of the efforts, guidelines and protocols - is underestimated and undertreated. Even in the case of general anaesthesia, the nervous system is overwhelmed by copious quantities of nociceptive stimuli at surgical incision. Stress and pain-modulation processes are triggered which can have significant influence on the outcome. Often the pain-management is discontinued, so a notable part of patients complain about pain in the ward after surgery. Regional anaesthesia conceptually prevents noxious inputs to enter the central nervous system, beyond surgical anaesthesia it is pertinent to achieve excellent analgesia in the immediate postoperative period as well. Based on current literature, this paper provides an overview of the history and role of regional anaesthesia in the multidimensional model of pain. Besides the sensitization caused by nociceptive stimuli - peripheral and central sensitization, descending modulation - there are several biopsychosocial factors involved in pain pathophysiology. Preventing the side effects of general anaesthesia, the ultrasound-guided peripheral nerve blockade is a safe technique with high success rate, rare side effects, achieving long-lasting, excellent analgesia. Continuous perineural catheter placed under ultrasound provides extended pain control. As a part of multimodal analgesia, peripheral nerve blockade prevents central sensitization. After surgery, the pain intensity of patients under peripheral nerve blockade is less, the chronification tendency is decreased, the quality of life and patients' comfort are improved, and the stress-response is attenuated. The greater part of patients are protected from the undesirable side effects of general anaesthesia. Nowadays, it is an unequivocal evidence that the increasingly used peripheral nerve blockades prior to incision are efficient tools in the prevention of chronic postoperative pain. Ultrasound guidance is suitable not only for surgical anaesthesia, but for postoperative pain management as well, however, besides economic factors, the main goal of this technique is to match the best interest of the patients. Orv Hetil. 2019; 160(15): 573-584.

Continuous Bilateral Erector of Spine Plane Block at T8 for Extensive Lumbar Spine Fusion Surgery: Case Report

Supplementary strategies, in combination with conventional analgesia, for pain control after lumbar fusion surgery remain limited. Here, we describe a 79-year-old woman who experienced pain (10/10 on a numeric rating scale) on postoperative day 1 after undergoing L2 to S1 spine fusion. Erector spinae plane (ESP) blocks were performed at T8 and, after a bolus of ropivacaine 0.2% (20 mL) per side, perineural catheters were placed bilaterally. Continuous infusion (5 mL/h) of ropivacaine 0.2% per side was maintained for 48 hours. During this period, 2 boluses (15 mL) per day of ropivacaine 0.2% were administered bilaterally to maintain optimal analgesia. Bilateral ESP catheterizations at T8, placed remotely from the surgical site, may be considered for patients undergoing extensive spinal fusion procedures, because they contribute to significant analgesic improvement, without significant motor block; the effect of the block remains mostly in the posterior rami of spinal nerves and in the posterior bony elements of the vertebrae. The risk for hematoma or bacterial colonization related to catheter placement at T8 level using epidural or ESP techniques is low; nevertheless, a delay in the diagnosis of postoperative epidural hematoma or abscess directly related to the surgical intervention is a potential concern in spine fusion surgery. However, the action of an ESP block is primarily in the posterior rami of the spinal nerves, which makes an eventual neuraxial compression less likely to be masked by an ESP block compared with an epidural block, because an ESP hematoma or infection will not directly impinge on the spinal cord. A 79-year-old woman experienced excruciating pain on post-operative day 1 after undergoing L2 to S1 spine fusion. Bilateral continuous erector spinae plane (ESP) blocks were performed at T8 and, after a bolus of ropivacaine 0.2% (20 mL) per side, a continuous infusion (5 mL/hour) of ropivacaine 0.2% per side was maintained for 48 hours, which provided effective analgesia. During this period, two boluses (15 mL) per day of ropivacaine 0.2% were administered bilaterally to maintain optimal analgesia. ESP catheterizations at T8, placed remotely from surgical site, may be considered in extensive lumbar spinal fusion cases.

Acute Pain Service: A 10-Year Experience.

Pain management after surgery is crucial to decrease perioperative morbidity and mortality. Acute pain services (APS) are multidisciplinary teams that represent a modern strategy to address pain inside hospitals. The APS defines and applies pain treatment protocols specific for each surgery. To evaluate the performance of the APS at our institute, we performed a large retrospective cohort study focusing on complications of epidural analgesia and IV opiates. Data from the 10 years of activity of the APS were collected. Pain was assessed using the VAS at rest (VASr) and during movement (VASm) at each daily visit; the presence of side effects and complications was also assessed. A total of 17,913 adult patients were followed by APS during the study period. Epidural analgesia was used in 7,776 cases (43%), while 9,239 (52%) patients used IV patient-controlled analgesia (PCA). A combination of the 2 was used in 87 patients (0.5%). A total of 456 perineural catheters (2.6%) were placed, while 442 patients(2.5%) used other analgesic techniques. We recorded 163 dural punctures during catheter placement, with no epidural hematoma, epidural abscess, or meningitis, and no permanent modification in sensitive or motor functions. In our large case series, APS was confirmed safe and effective in treating postoperative pain, using both epidural analgesia and IV PCA with morphine.

Outcomes of Ambulatory Upper Extremity Surgery Patients Discharged Home with Perineural Catheters from a Veterans Health Administration Medical Center.

The feasibility and safety of managing ambulatory continuous peripheral nerve blocks (CPNB) in Veterans Health Administration (VHA) patients are currently unknown. We aimed to characterize the outcomes of a large VHA cohort of ambulatory upper extremity surgery patients discharged with CPNB and identify differences, if any, between catheter types. With institutional review board approval, we reviewed data for consecutive patients from a single VHA hospital who had received ambulatory CPNB for upper extremity surgery from March 2011 to May 2017. The composite primary outcome was the occurrence of any catheter-related issue or additional all-cause health care intervention after discharge. Our secondary outcome was the ability to achieve regular daily telephone contact. Five hundred one patients formed the final sample. The incidence of any issue or health care intervention was 104/274 (38%) for infraclavicular, 58/185 (31%) for interscalene, and 14/42 (33%) for supraclavicular; these rates did not differ between groups. Higher ASA status was associated with greater odds of having any issue, whereas increasing age was slightly protective. Distance was associated with an increase in catheter-related issues (P < 0.01) but not additional health care interventions (P = 0.51). Only interscalene catheter patients (3%) reported breathing difficulty. Infraclavicular catheter patients had the most emergency room visits but rarely for CPNB issues. Consistent daily telephone contact was not achieved. For VHA ambulatory CPNB patients, the combined incidence of a catheter-related issue or additional health care intervention was approximately one in three patients and did not differ by brachial plexus catheter type. Serious adverse events were generally uncommon.

Percutaneous peripheral nerve stimulation and other alternatives for perineural catheters for postoperative analgesia

A perineural catheter with a continuous infusion of local anesthetic is an excellent option for postoperative analgesia; however, its limitations include limited duration of action (i.e., 3-7 days) as well as a risk of infection and dislodgement. Furthermore, these blocks may cause dense sensory and motor blockades that under certain circumstances may not be ideal. There is novel evidence that ultrasound-guided percutaneous peripheral nerve stimulation (pPNS) may serve as an alternative approach free of the limitations associated with peripheral nerve blocks. In this review, we discuss the evidence for pPNS on postoperative acute pain management. Subsequently, we briefly discuss additional alternatives to continuous peripheral nerve blocks, including cryoanalgesia and liposomal bupivacaine.

What Pain Levels Do TSA Patients Experience When Given a Long-acting Nerve Block and Multimodal Analgesia?

The pain experience for total shoulder arthroplasty (TSA) patients in the first 2 weeks after surgery has not been well described. Many approaches to pain management have been used, with none emerging as clearly superior; it is important that any approach minimizes postoperative opioid use. (1) With a long-acting nerve block and comprehensive multimodal analgesia, what are the pain levels after TSA from day of surgery until postoperative day (POD) 14? (2) How many opioids do TSA patients take from the day of surgery until POD 14? (3) What are the PainOUT responses at POD 1 and POD 14, focusing on side effects from opioids usage? From January 27, 2017 to December 6, 2017, 154 TSA patients were identified as potentially eligible for this prospective, institutional review board-approved observational study. Of those, 46 patients (30%) were excluded (either because they were deemed not appropriate for the study, research staff were not available, patients were not eligible, or they declined to participate), and another six (4%) had incomplete followup data and could not be studied, leaving 102 patients (66%) for analysis here. Median preoperative pain with movement was 7 (interquartile range [IQR], 5-9) and 13 of 102 patients used preoperative opioids. All patients received a single-injection bupivacaine interscalene block with adjuvant clonidine, dexamethasone, and buprenorphine. Multimodal analgesia included acetaminophen, NSAIDs, and opioids. The primary outcome was the Numerical Rating Scale (NRS) pain score with movement on POD 14. The NRS pain score ranges from 0 (no pain) to 10 (worst pain possible). Secondary outcomes included NRS pain scores at rest and with movement (day of surgery, and PODs 1, 3, 7 and 14), daily analgesic use from day of surgery to POD 14 (both oral and intravenous), Opioid-Related Symptom Distress Scale (which assesses 12 symptoms ranging from 0 to 4, with 4 being the most distressing; the composite score is the mean of the 12 symptom-specific scores) on POD 1, and the PainOut questionnaire on POD 1 and POD 14. The PainOut questionnaire includes questions rating nausea, drowsiness, itching from 0 (none) to 10 (severe), as well as rating difficulty staying asleep from 0 (does not interfere) to 10 (completely interferes). The median NRS pain scores with movement were 2 (IQR, 0-5) on POD 1, 5 (IQR, 3-6) on POD 3, and the pain score was 3 (IQR, 1-5) on POD 14. Median total opioid use (converted to oral morphine equivalents) was 16 mg (4-50 mg) for the first 24 hours, 30 mg (8-63 mg) for the third, and 0 mg (0-20 mg) by the eighth 24-hour period, while the most frequent number of activations of the intravenous patient-controlled analgesia device was 0. Median PainOut scores on POD 1 and POD 14 for sleep interference, nausea, drowsiness and itching were 0, and the median composite Opioid-Related Symptom Distress Scale score on day 1 was 0.3 (IQR, 0.1-0.5). Clinicians using this protocol, which combines a long-acting, single-injection nerve block with multimodal analgesia, can inform TSA patients that their postoperative pain will likely be less than their preoperative pain, and that on average they will stop using opioids after 7 days. Future research could investigate what the individual components of this protocol contribute. Larger cohort studies or registries would document the incidence of rare complications. Randomized controlled trials could directly compare analgesic effectiveness and cost-benefits for this protocol versus alternative strategies, such as perineural catheters or liposomal bupivacaine. Perhaps most importantly, future studies could seek ways to further reduce peak pain and opioid usage on POD 2 and POD 3. Level IV, therapeutic study.