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Regional anaesthetic techniques for management of postoperative pain

Perioperative regional anaesthesia and analgesia techniques using local anaesthetics can provide effective analgesia and attenuate adverse perioperative pathophysiology, which can potentially translate into decreased morbidity and improved convalescence. A variety of regional techniques can be used for a wide spectrum of surgical procedures. This chapter takes up the evidence-based recommendations of regional techniques in general and also the recommended blocks for specific surgical procedures.

Regional techniques and postoperative analgesia

ANZCA, chapters 7.2-7.5 p182-204.

  • For all types of surgery, epidural analgesia (regardless of catheter location) provides better postoperative pain relief compared with parenteral (including i.v. PCA) opioid analgesia.
  • Thoracic epidural analgesia improves bowel recovery after abdominal surgery (including colo­rectal surgery), it also reduces the incidence of postoperative myocardial infarction if it is extended for more than 24 h.
  • Epidural local anaesthetics improve oxygenation and reduce pulmonary complications com­pared with parenteral opioids
  • Intrathecal morphine offers improved analgesia and opioid-sparing for up to 24 hours, especially following abdominal surgery.
  • Anticoagulation is the most important risk factor for the development of epidural haematoma. Immediate decompression (within 8 hours of the onset of neurological signs) increases the likelihood of partial or good neurological recovery
  • Compared with opioid analgesia, continuous peripheral nerve blockade (regardless of catheter location) provides better postoperative analgesia, reduced opioid use and decreased risk of nausea, vomiting, pruritus and sedation
  • Continuous local anaesthetic wound infusions lead to reductions in pain scores (at rest and with activity), opioid consumption, postoperative nausea and vomiting, and length of hos­pital stay; patient satisfaction is higher and there is no difference in the incidence of wound infections.
  • Intraarticular local anaesthetics reduce postoperative pain to a limited extent only. Intraarticular morphine does not improve analgesia after knee arthroscopy. Intraarticular bupivacaine infusions have been associated with chondrolysis and their use has been cautioned against.

Recommendations for regional blocks for specific surgical procedures

Surgical procedure Recommended block Reference
A = German guideline recommendations
B = Prospect recommendations
C = Australian and New Zealand College recommendations
D = French Society recommendations
p = page numbers
Thoracotomy Thoracic epidural A, B
Paravertebral A, B
Intercostal block (if epidural or paravertebral not possible) B
Single bolus spinal morphine (if epidural or paravertebral not possible) B
Shoulder Surgery* Interscalene block I A4.6.2.3, C –p207, D-p408
Subacromial catheter D-p407
Breast surgery (non-cosmetic) Paravertebral block B
Catheter wound infusion D-p407
Intrapleural C-p207
Laparoscopic cholecystectomy Epidural (only high-risk patients) B
Wound infiltration B, A4.3.5.1, D-p407
Major abdominal Epidural A
Colon resection Thoracic epidural B
Preperitoneal infusion of la B
Spinal morphine (if epidural not possible) B
Laparoscopic colon resection Epidural (only in high-risk patient) B
Pre-closure wound infiltration B
Abdominal vascular surgery Thoracic epidural A
Extra-transperitoneal kidney surgery Thoracic epidural A
Hysterectomy Epidural (only in high-risk patient) B
Single-shot spinal morphine B
Wound infiltration B
Wound catheter infusion D-p407
Caesarean section Wound catheter infusion D-p407
Radical prostatectomy Epidural A4.3.11.1
Trans urethral resection of prostate Spinal morphine A
Inguinal surgery Inguinal n block/field block, infiltration B, A4.3.6.1, D-p407
Inguinal, scrotal, genital in children Caudal block A &
Proctological surgery Pudendal block A
Penis surgery Penile block A4.3.12.2
Caudal block A4.3.12.2
Scoliosis surgery/ laminectomy Local application of la (intraoperative) A4.5.2.2,
Epidural A4.5.2.2
Iliac crest surgery Local application of la + opioid A4.5.4.3
Amputation Peripheral or epidural catheter (pre, -intra- and postoperative) A4.4.5.2
Continuous infusion into stump A4.4.5.3
Hip replacement Femoral block or posterior or lumbar plexus block B,A4.6.5.3
Single bolus spinal morphine B, A4.6.5.3
Intraoperative, high volume wound Infiltration (LIA technique) B
Epidural A
Total knee replacement Single shot femoral B
Femoral catheter infusion C-chapter 7.5.1 p196
Single shot spinal morphine B
Local infiltration analgesic (LIA technique) B
Sciatic and/or femoral catheter, or epidural A4.6.9.3
Tonsillectomy, craniotomy Oral, maxillo-facial, thyroid Wound infiltration A4.

Supplementary reading

  1. Kehlet H, Andersen LÖ. Local infiltration analgesia in joint replacement: the evidence and recommendations for clinical practice. Acta Anaesthesiol Scand 2011;55:778-784
  2. Raeder J, Spreng UJ. Local-infiltration anaesthesia (LIA):postoperative pain management revisited and appraised by the surgeons? Acta Anaesthesiol Scand 2011;55:772-774
  3. Rawal N. Local Infiltration Analgesia and other multicomponent techniques to improve postoperative outcome- are we comparing oranges and apples? Reg Anesth Pain Med. 2012;36:417-420