Perineural Blocks for Postoperative Pain
After Upper Limb Surgery
1st Congress of Slovenian
Association
for Pain Therapy
October 9-10
Bled, Slovenia
S. Gligorijevic MD
City Hospital Waid
Zürich Medical School
University of Zürich
Switzerland
Why is postoperative pain still undermanaged ?

Difficulties to understand the pain pathways lead often to
misconception that postoperative pain is a short, self-limited entity

Goals are frequently not clear

Organisational obstacles

Advances in knowledge do not necessarily lead to the same degree
of progress in patient care
Significant room for further improvement in
postoperative pain management
Newer Developments in Postoperative Pain Management

Drugs
Non-opioids (NSAID’s,coxibs), ketamine, pregabalin,
corticosteroids
Local anaesthetics (ropivacaine, levobupivacaine)
Adjuvants – in techniques such as epidural, perineural, i.v. PCA

Drug delivery systems (transdermal PCA, intranasal, long-acting
epidural morphine, sublingual NSAID, perineural/incisional catheter LA
at home)

Concepts (PROSPECT, multimodal, preemptive)

Web-based guidelines

Outcome debate (cost-effectiveness, risk-benefits, evidence-based)

Organizational issues (APS, role of surgeons, audits)
www.postoppain.org www.esraeurope.org
www.oqp.med.va.gov/cpg/cpg.htm
Pharmacological Options for Postoperative Pain Management
Concept of Multimodal Analgesia
NO
Sites of action of local anaesthetics
Postoperative analgesia - what are the challenges?

Increasing co-morbidity
Ageing population
Obesity
Concurrent medical problems

Changing surgical demands
Early mobilisation / accelerated rehabilitation / day surgery

Decreasing role of epidural analgesia
No major advantages in outcome compared to alternatives
Risk of complications higher than previously reported
Minimal invasive and/or ambulatory surgery

Patients’ preference
Optimal perioperative analgesia
Benefits of PNB,s

Continuous analgesia (during & following the surgery)

Adjustable
to pain
intensity
& duration
you
will
never
ever achieve
Quality of pain relief

single
systemic drug or their
Appropriate for
large number of or
patients
combination
with so
called
multiple
approach
Minimal risks
to patient,
minimal side
effects

Early mobilisation/fast rehabilitation


with
any other
Suitable for pain
of different
origin
Recent Developments of PNB Techniques
Facilitating Factors / Improved Logistics I
 Increased educational efforts
Training programs, RA meetings, videos,
websites, guidelines, cadaver workshops, live
models, companies contribution
 Improved knowledge of anatomy
Anatomical investigations, new text books
 Improved nerve localisation techniques
Peripheral nerve stimulator has dramatically increased
the reliability of nerve location
Recent Developments in PNB Techniques III
Improved nerve localisation techniques
Ultrasound technique: Nerves and
surrounding structures are now visible,
LA spread can be judged during injection
Nerve injury can be avoided ?
Improved equipment
Needles: Sufficient rigid, good penetrating and
gliding needles of appropriate size for specific
blocks
Recent Developments of PNB Techniques IV
 Proper organization of OR schedule
Induction rooms
Holding area
 Enhanced research
Acute pain
Nerve localisation
New approaches
Comparative studies with other methods
Meta - analyses
Peripheral Nerve Blocks Are Not Frequently Used
Pessimist’s view:
 Missed education (need for new skills)
 Time consuming / labor intensive
 Multiple injections (frequently needed)
 Failure rate
 Potential for prolonged neurologic deficit
Serious Complications Related to Regional Anaesthesia
The Two Large Prospective Studies
Auroy Y et al Anesthesiology 1997;87:479-86
Auroy Y et al Anesthesiology 2002;97:1274-80
Peripheral nerve blocks
1997
2002
n = 21.278
n= 50.223
Cardiac arrest
3* (1,4)
1 (0,2)
Death
1
(0,5)
1 (0,2)
Seizure
16**(7,5)
6 (1,2)
4 (1,9)
12 (2,4)
Neurological injury
( n/10. 000 )
* Vagal, after failed bloc ** All seizures preceded by clinical signs
Peripheral Nerve Blocks for
Postoperative Analgesia after
Upper Limb Surgery
Upper Extremity Surgery
What Challenges?
 Shoulder
 Very painful
 Published data that ISB offers benefits for surgery,
analgesia and outcome
 Elbow
 Very painful
 Difficult positioning
 Lack of published data but some evidence that
infraclavicular/axillary BPB offer perioperative
benefits
Brachial Plexus Approaches
Inter
scalene
axillary
Infra
clavi
cular
Hadzic A , 2004
Brachial Plexus Block After Shoulder Surgery
Placement of interscalene catheter
Success rate may vary from 75% - 100%
Modified (“parallel”) approaches increase the success
rate for catheter placement
Boezaart AP, Can J Anesth 1999
Real time ultrasound guidance increases successful
catheter placement
Yang WT, Am J Roentgenol 1998
Pain Control After Shoulder Surgery
 Continuous interscalene block better than opioids ?
Advantages over iv PCA ?

Better analgesia

Reduced opioid requirements/reduced PONV

Higher patient satisfaction (at least for the first 48h)
Tuominen M, 1987. Borgeat A, 1997, 1998, 2000
Lehtipalo S, 1999. Klein SM, 2000. Fredrickson MJ, 2008
Unknown effect on success of physical rehabilitation
or duration of hospitalisation
Cohen NP, J Shoulder Elbow Surg 2000
PCRA (interscalene) vs iv PCA after major shoulder surgery II
RCT, n = 35, surgery under interscalene block

PCRA: 0.2% ropivacaine 5ml/h, bolus 3-4 ml, lockout 20 min

I.V. PCA: nicomorphine 0.5 mg/h, bolus 2-3 mg, lockout 20 min

PONV and pruritus: PCRA 5.5%, i.v. PCA 60% and 20% resp.
PCRA technique provided better pain control, lower incidence of side
effects and higher degree of patient satisfaction
Borgeat A, et al
Anesthesiology 2000 ; 2:102-8
Acute and Nonacute Complications Associated with
Interscalene Blocks and Shoulder Surgery I
Borgeat A, Ekatodramis G, Kalberer F, Benz C. Anesthesiology 2001; 95:875-80
•Prospective evaluation, 521 patients (234 with catheter,
286 single-injection block)
•Tunneled catheters (3-4cm) for 2-5 days
•Single injection of 40 – 50ml Ropivacaine 0,6%
•Continuous infusion Ropivacaine 0,2%  6h after
initial dose
Acute and Nonacute Complications Associated with
Interscalene Blocks and Shoulder Surgery II
Borgeat A, Ekatodramis G, Kalberer F, Benz C. Anesthesiology 2001; 95:875-80
• Puncture related complications:
Painful catheter placement
15 (5,6%)
Pneumothorax 1 (0,2%)
IV injection 1 (0,2%)
Vessel puncture 3 (0,6%)
Pain on injection 109 (21%)
•10th postop.day:
• 9th month:
Pain not clearly related to surgery 74 (14%)
1 symptomatic patient – damage of C6 root after
uneventful block  complete recovery in EMG
Conclusion: Low long-term complication rate
No differences between catheter and single- injection
technique
Peripheral Nerve Blocks After Hand and
Forearm Surgery
Brachial plexus – Axillary approach
• Prospective studies demonstrate excellent analgesia after hand and forearm
surgery with continuous infusion of Bupivacaine 0,2% – 0,25%
• Success rate of catheter insertion 98% - 100%
Ang ET, 1984, Pham-Dang C, 1995, Mezzatesta JP, 1997
Salomen M, Reg Anesth Pain Med 2000
No comparisons with IV PCA or other methods of
systemic analgesia
Distal upper extremity blocks
Indications:
♦ Surgical procedures (ambulatory surgery)
Nerve decompression
Tendon and nerve repair (preserved mobility)
Ganglion, cyst, foreign body removal
AV fistula
Bilateral surgery
♦ Postoperative pain management (selective analgesia)
♦ Evaluation and treatment of chronic pain
♦ Partially successful brachial plexus block
Ulnar Nerve Block at the Elbow
Deep palmar branch
Superficial branch
Injection proximal or
distal to the sulcus
Ulnar n.
Olecranon proces
Medial epicondylle
Nerve Blocks at the Elbow
Median Nerve Block
at the elbow
Radial Nerve
Block
Biceps m.
Median n.
Brachial a.
Radial a.
Med. epicondyle
Nerve Blocks at the Wrist
Median nerve block
Pierce the deep fascia (bone contact)
Inject while withdrawing the needle!
Ulnar nerve block
Median,ulnar and radial nerves
can be consistently seen in the
forearm using ultrasound
McCartney CJL, Daquan X, Constantinescu
C, Abbas Sh, Chan V
Reg Anesth Pain Med 2007;32:434-439
Median nerve catheter for postoperative pain relief after hand
surgery. Continuous infusion of levo-bupi 0,125% - 2-5 ml/h
Elastomeric
Balloon
Pump
Rawal et al
Anesth Analg 1998;86:86-9
PROSPECT, 1966-2006, 112 study -132 excluded
Recommended (grade A):
Anaesthesia 2008;63:1105-1123
Femoral nerve block
( combined with GA or SA pre-/intra-operative)
Spinal block with morphine intrathecal
+
NSAID,s / COX-2 inhibitors ( grade A)
Paracetamol (grade B)
Strong opioids IV for breakthrough pain (grade A)
Cooling and compression techniques (grade B)
Are continuous PNB,s useful for postoperative rehabilitation?
Three days after TSA - cont ISB group (Ropi 0.2%) with increased range of
shoulder motion, most likely resulting from potent analgesia (retrospective
study)
Ilfeld BM Reg Anesth Pain Med 2005
Continuous ISB provides potent analgesia that permits greater passive
Ilfeld BM. Anesthesiology 2006;105:999-1007
shoulder movement
RCT, n=30
Are continuous PNB,s always useful for
postoperative rehabilitation?
Does Patient-Controlled Continuous Interscalene Block Improve Early
Functional Rehabilitation After Open Shoulder Surgery?
Hofmann-Kiefer K et al. Anesth Analg 2008;106:991-996
RCT, n=87
Open rotator cuff repair or acromioplasty
Range of motion and strength of the shoulder &subjective data (Mobility and
muscular strength) pre-and postop
(Constant –Score )
Continuous ISB Improves analgesia but not postoperative
function compared to opioid iv PCA
Possible cause: swelling, stiffness and inflammation of the joint
Drugs for Continuous Perineural Analgesia
Local Anaesthetics
Bupivacaine 0,1 – 0,25 %
Plasma level 0,5 – 1 mcg/ml after interscalene block
Tuominen M, Acta Anaesthesiol Scand 1987
After lumbar plexus block 0,5 – 1,8 mcg/ml
Ganapathy S, Anesth Analg 1999, Aker-Moller E, Acta Anaesthesiol Scnad 1990
Peripheral Nerve Blocks After Hand and Forearm Surgery
Ropivacaine for continuous
plexus block
axillary
Salomen M, Reg Anesth Pain Med 2000
RCT, Single block with Ropivacaine 0,75% 5mg/kg
Postoperative infusion 0,1% or 0, 2% or saline 6 – 11ml/h for 24 h
Results: Postoperative analgesia for 12 – 15h after single injection
Similar VAS scores in all groups with continuous infusion
No analgesics  Group 0,1 %

47 %
Group 0,2 %

45 %
Group S

28 %
Drugs for Continuous Perineural Analgesia
• Ropivacaine has motor block sparing properties
in peripheral nerve blocks?
• Significantly less motor block of the hand with
PC interscalene analgesia and Ropivacaine
0,2% compared with Bupivacaine 0,15%
Borgeat A, Anesth Analg 2001
Which drugs for continuous perineural analgesia ?

ISB after shoulder surgery
Double - blinded comparison levo-bupi 0,125% vs
bupivacaine 0,2% - no difference
Casati A, Borghi B, Fanelli G et al. Anesth Analg 2003;96:253-259
Adjuvants for Peripheral Nerve Blocks
Peripheral effects of opioids ?
1. Evidence and recognition of opioid
receptors on sensory nerve terminals
2. Opioid effects more pronounced in
inflamed tissue
- Increased numbers of nerve
terminals (nerve sprouting)
- Up-regulation of opioid receptors
- Disruption of perineurium
Adjuvants for Peripheral Nerve Blocks
Does the addition of morphine to brachial plexus block improves
analgesia after shoulder surgery?
Flory N, Van Gessel E, Donald F, et al. Br J Anesth 1995; 75:23-26
RCT 40 patients
Interscalene block with
Bupivacaine 0,5 % +Adrenaline
vs. addition of morphine 5 mg
Conclusion:
No significant difference
in quality of analgesia
between the groups
Time from the end of operation to the first
administration of analgesic
Clonidine as the sole analgesic for postoperative
pain administered by axillary approach.
Sia S, Lepri A:Anesth Analg 1999; 88:1109-12
RCT, 45 pts Axillary brachial plexus block, 40 ml 1,5 % lidocaine + catheter.
Postoperative pain relief regimen (3 groups)
Bupivacaine 0,25 %
15 ml
Clonidine 150 mcg + Saline 0,9 %
15 ml
Saline 0,9 %
15 ml
All patients received ketorolac 30 mg im Morphine 5 mg im on request.
Conclusion: Administration of 150 mcg clonidine into brachial
plexus sheath did not produce postoperative analgesia after hand or
forearm surgery
Adjuvants for Peripheral Nerve Blocks
Clonidine
Clonidine as adjuvant in axillary brachial plexus block in
patients with end stage renal disease.
Adnan T: Acta Anaesthesiol Scand 2005
RTC n= 48, double blind
40 ml 1% Lidocaine with or without Clonidine 150 mcg
Conclusion: Clonidine prolongs both motor and sensory
block but cause significantly more hypotension, bradycardia
and sedation compared with control group
Adjuvants for Peripheral Nerve Blocks
Novel Analgesic Adjuncts for Brachial Plexus Block
Murphy DB et al Anesth Analg 2000; 90:1122-28
Systematic review of RCT
Agent
Total outcomes
Systemic control outcomes
10 Opioids
6 supportive
4 negative
4 systemic control
2 supportive, 2 negative
6 no systemic control
4 supportive, 2 negative
6 Clonidine
5 supportive
1 negative
1 systemic control
1 supportive
Actually no substantial differential effect on duration of
analgesia related to the type of LA
(< 1 h with prilocaine and >4h with levo-bupivacaine)
“Man uses his arm and hands constantly and as a result he
exposes his arms and hands to injury constantly”
Little DM. Classical file. Survey of Anesthesiology 1963; 7:280-5
Complications related to peripheral
nerve catheters-what we are afraid of ?
Neurologic Complications of 405
Consecutive Continuous Axillary Catheters
Bradley D et al: Anesth Analg 2003; 96:247-52
Retrospective study
Catheters placed postoperatively for 55 ± 32h,
Infusion rate:10 ± 2ml/h Bupivacaine 0,125% - 0,25% ( in 87,7% )
Results:
Paresthesia with catheter placement
60 pts (14,8 %)
Neurologic deficit non related to surgery
2 pts (0,5 %)
All patients with neurologic deficit had major elbow surgery
Incidence of Serious Adverse Events of CPNB
Capdevilla X. Anesthesiology 2005;103:1035-45
Serious Adverse
Events
Interscalene
(n=256)
Axillary
(n=126)
PCB (n=20)
Femoral
(n=683)
Distal (n=38)
Patients (n)
4
1
3
3
1
Nerve lesions
0
0
0
3 (0,4)
[0,1-0,9)]
0
Acute respiratory
failure
2 (0,8)
[0,2-2,1]
0
0
0
0
Laryngeal & rec.n.
laryngeal paralysis
2 (0,8)
[0,-1,8]
0
0
0
0
Severe hypotension
0
0
3 (15)
[4-31,3]
0
0
Systemic LA toxicity
0
0
0
0
1 (2,5)
[0,3-3,7]
Seizure
0
1 (0,8)
[0.05-1,3]
0
0
0
Abscess
0
0
1 (0,14)
[0.01-0,8]
0
0
No complications related to fascia iliaca (n=94), sciatic (n=32), and
popliteal (n=167)block
n (%)
[95% CI
Acta Anaesthesiol Scand 2007;51:108-114
Axillary 600,interscalene 303, infraclavicular 92, psoas comp.65, femoral 574,sciatic
296, popliteal 355
• Inflammation = redness, swelling, pain (35% catheter culture positive)
• Infection = pus at insertion site (100% positive culture)
• Local inflammation
• Infection
• Surgical drainage
96 pts (4,2%)
73 pts (3,2%)
20 pts (0,9%)
• Staph.epidermidis and Staph aureus in 42% and 58% of catheter tips cultures
• No late complications in any patient. Infection risk increased with duration
• Higher risk for interscalene than for anterior sciatic catheter
Incidence of Local Inflammation and Infection for Different Perineural Catheters
Adapted from Neuburger M et al, Acta Anesthesiol Scand 2007;51:108-114
Number
of
catheters
Catheter
localization
Catheter duration
median (range)
Incidence (%) of
local
inflammation
Incidence
(%) of
infection
Trauma
patients
Borgeat , 2003
700
Interscalene
3,2 (1,5-5)
days
0,7
0,1
No
Cuvillon, 2001
208
Femoral
48 h
4,3
1,4
No
237
1.001
Popliteal
Popliteal
60 (48-90) h
2-4 days
0
0,2
0
0
No
No
Capdevilla, 2005
1.416
Different
2,3(2-5) days
3,0
0,07
Yes
Neuburger, 2007
2.285
Different
4 (1-36) days
4,2
3,2*
30 %
Borgeat,
Borgeat,
2004
2006
*Surgical intervention in 0,9%
When to Use Continuous PNB’s?
 High initial pain level expected (incl. opioid abuse)
 Prolonged postoperative pain(< 48h)
 Early mobilisation - faster rehabilitation
 Elderly patient
 Potential for chronic pain development
 Complications of alternative methods expected
Liu, Kehlet
Incisional Catheters
• Simple, safe, inexpensive
• Catheter placed at correct position under direct vision
• Eliminates risk of inadvertent penetration of vascular or neural structures (vs.
perineural)
• Only area of surgery affected allowing normal use of extremity and early
rehabilitation (vs. perineural)
• Useful for ambulatory and inpatient surgery
Anesth Analg 2006;102:248-57
19 RCT’s (11 double-blind)

Better analgesia for all time periods at 24, 48 and 72 h and all
catheters

Reduction in opioid use

Lower incidence of PONV (21 % vs. 49 %), sedation (27% vs.
52%), and pruritus (10 vs. 27 %) with PNB´s

Improved patient satisfaction (4 RCT’s only)
”CPNB, regardless of catheter location, provided superior
postoperative analgesia and fewer opioid-related side effects
when compared with opioid analgesia”
Advantages of peripheral nerve blocks in
postoperative pain management
♦ High quality of analgesia in all types of pain
♦ Surgical site-targeted (continuous) analgesia
♦ Haemodynamic stability
(postganglionic, unilateral sympathetic block)
♦ Less concerns regarding coagulation and infection problems
♦ Low complication rate (avoidance of potential risk of
alternative methods)
♦ Less intensive ward surveillance
♦ Perineural home infusion
Peripheral nerve blocks and outcome from surgery
We are now asking the right questions
We have some of the right answers
More research is required
Advances in surgical practice will continue to
challenge anaesthetic and analgesic practice
Peripheral nerve block – another point of view
I don’t know much
about outcome,but it
doesn't hurt me!
Thank you for your attention!
Thank you for your
attention!
Potential Economic Benefits of Regional Anaesthesia for Acute Pain Management
Regional anaesthesia appears definitively better
than GA/ opioids for orthopaedic procedures

But, how to realize the benefits?

Advances in surgical techniques & perioperative care have
drastically increased NNT values of analgesic interventions

Lack of trained personnel and resource support – recent
staffing and productivity models are based on GA practice
not considering PACU bypass, same day discharge criteria,
RA-induction room
Wiliams BA, Reg Anesth Pain Med, 2006
Advantages of incisional catheter techniques
• Simple, safe, inexpensive
• Catheter placed at correct position under direct vision
• Eliminates risk of inadvertent penetration of vascular or neural structures (vs
perineural)
• Only area of surgery affected allowing normal use of extremity and early
rehabilitation (vs perineural)
• Useful for ambulatory and inpatient surgery
Why PNB,s for postoperative analgesia?

Decreasing role of neuraxial techniques
No major advantages in outcome ( except orthopedics procedures)
Higher risk of complications than previously reported
Minimal invasive surgery

Increasing co-morbidity
Ageing population
Obesity

Changing surgical demands
Early mobilisation / accelerated rehabilitation
(cont. passive motion concept)
Why regional block for postoperative
analgesia?






Analgesia during and after operation
Sympathetic block
Muscle relaxation
Preservation of consciousness
Abolition of stress response
Reduced morbidity & mortality
Quality of pain relief you will never ever achieve with
any other single systemic drug or their combination or
with so called multiple approach