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Over 40% of ambulatory patients experience moderate-to-severe postoperative pain at home following orthopedic procedures.1 Single-injection peripheral nerve blocks with long-acting local anesthetics can provide excellent postoperative analgesia. However, the analgesic benefit of single-injection blocks is typically limited to the duration of the blockade and, subsequently, patients must usually rely on oral opioids to control pain. Unfortunately, opioids are associated with undesirable side effects, such as pruritus, nausea and vomiting, sedation, and constipation. To improve postoperative analgesia following ambulatory surgery, increasing interest has focused on providing perineural local anesthetic infusions, also called, continuous peripheral nerve blocks, to outpatients. This technique involves a percutaneous insertion of a catheter directly adjacent to the peripheral nerve(s) supplying the surgical site. Local anesthetic is then infused via the catheter, providing prolonged, site-specific analgesia.

In 1946, Ansbro first described continuous regional blockade using a cork to stabilize a needle placed adjacent to the brachial plexus divisions to provide a continuous supraclavicular block.2 However, for decades, patients were required to remain hospitalized because the available pumps used to infuse local anesthetic were large, heavy, and technically sophisticated. It was not until 52 years later that outpatient perineural infusion using a percutaneous catheter and a small, lightweight, portable infusion pump was described.3

The first report of continuous infusion of local anesthetics at home was reported by Rawal and colleagues.3 Shortly thereafter, numerous reports or series of ambulatory perineural infusions were published, which described the use of catheters in various anatomic locations, including paravertebral,4 interscalene,5–7 intersternocleidomastoid,8 infraclavicular,6 axillary,9 psoas compartment,9,10 femoral,9,11 fascia iliaca,5 sciatic,9,10 popliteal,6,12 and tibial nerve.6 Ambulatory continuous peripheral nerve blocks in pediatric patients also were reported.13

Klein and colleagues were first to study and quantify the benefits of perineural infusion of local anesthetic.14In their randomized, double-blind, placebo-controlled investigation, patients undergoing open rotator cuff repair who received an interscalene block and perineural catheter preoperatively, were randomized to receive either perineural ropivacaine 0.2% or normal saline postoperatively (10 mL/h). Patients receiving perineural placebo averaged a 3 on a 0–10 visual analog pain scale (VAS), compared with a 1 for subjects receiving ropivacaine. Although a portable pump was used, patients remained hospitalized during local anesthetic infusion of less than 24 h, and catheters were removed by the investigators prior to home discharge.14 Consequently, while these data suggested that perineural infusion may improve postoperative analgesia following hospital discharge, the actual advantages of continuous nerve blocks for patients at home remained unknown.

Data from perineural infusion in outpatients subsequently were provided in four randomized, double-blind, placebo-controlled studies.15–18 Patients receiving perineural local anesthetic achieved significantly lower resting and breakthrough pain scores than did those using exclusively oral opioids for analgesia (Figure 64–1). In addition, they required significantly fewer oral analgesics to achieve their improved ...

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