PAIN
The role of regional
anaesthesia in the
management of acute
pain
Laura Perry
James Stimpson
Abstract
Regional anaesthesia is a powerful tool in the management of acute
pain and offers additional advantages, although there are caveats.
For certain sub-groups of patients the advantages are greater than
others; either in avoidance of opioid-based analgesic regimes, or ben-
ets related to the direct use of local anaesthetics. The future role of
regional anaesthesia in the context of acute pain is expanding, and
key directions are focussing its role as part of a multimodal enhanced
recovery package, and also the role of local anaesthetics in perioper-
ative cancer care.
Keywords Acute pain; adjuvants; complications; local anaesthetics;
regional anaesthesia
Royal College of Anaesthetists CPD Matrix: 1D02, 2E01, 2G01
The traditional model of escalating analgesia according to the
World Health Organization pain ladder is internationally
accepted and provides a stepwise systematic approach to phar-
macologically managing pain of increasing severity. At each step
of this process a consideration must be given to the use of
adjunctive drugs. One key approach which is often excluded
from such descriptions of the adjunctive approaches is that of
regional anaesthesia. However, with increasing severity of pain,
the ability of regional anaesthesia to effectively manage it be-
comes more pronounced, whilst being able to minimize the side
effects associated with more extensive opioid use. (Figure 1)
This article aims to explore the role of regional anaesthesia and
analgesia within the context of acute pain.
Regional anaesthesia is the application of local anaesthetic
to tissues or around nerves to provide a temporary reversible
blockade of nerve transmission; this may render a part or parts of
the body insensate or provide motor or autonomic blockade.
Laura Perry is a Specialist Registrar with an Interest in Regional
Anaesthesia at the Queen Elizabeth Hospital, Kings Lynn, Norfolk,
UK. Conicts of interest: none declared.
James Stimpson is a Consultant Anaesthetist and Lead in Regional
Anaesthesia at the Queen Elizabeth Hospital, Kings Lynn, Norfolk,
UK. Conicts of interest: Dr Stimpson has received honoraria to
deliver educational material for the University of East Anglia, and
teaches on courses organised by B-Braun.
ANAESTHESIA AND INTENSIVE CARE MEDICINE --:-
Please cite this article in press as: Perry L, Stimpson J, The role of regional anaesthesia in the management of acute pain, Anaesthesia and
intensive care medicine (2016), http://dx.doi.org/10.1016/j.mpaic.2016.06.005
Learning objectives
After reading this article, you should be able to:
C describe the rationale for regional anaesthesia (RA) in acute
pain
C
C
describe the advantages and disadvantages of RA
contrast RA with alternatives
C describe key patient groups for whom RA may be particularly
beneficial
C appreciate additional benefits of using RA in an acute pain
setting
Postoperative, or surgical pain, describes a set of conditions
where there is a known quantity of tissue injury, and therefore a
reasonably predictable estimate of pain severity can be made. In this
context, the stepwise model outlined above may be used from top-
down, including the use of adjuncts such as regional anaesthesia.
Regional anaesthesia in comparison to systemic
pharmacotherapy
Successful regional anaesthesia completely ablates (or signifi-
cantly reduces) afferent nociceptive traffic from the area of tissue
injury/surgery. This makes it a very powerful tool in reducing
unwanted side effects from strong opioid-based analgesia and
other adjuncts.
Specific advantages and disadvantages of regional anaesthesia
are outlined in Table 1.
Complications associated with regional anaesthesia
Every intervention or procedure performed in medicine carries
some risk with it and regional anaesthesia is no different. The
risk of complication will be very dependent on the expertise of
the anaesthetist and to a lesser extent the anatomy of the patient.
There are some complications that can be expected with nearly
every block, for example motor blockade, phrenic and stellate
ganglion nerve block when performing an interscalene approach
to the brachial plexus. This is simply due to the proximity of
unrelated nerves to the targeted sensory nerves.
Other complications that Regional Anaesthesia e United
Kingdom suggests mentioning to patients during the consent
process are infection, haematoma, local anaesthetic toxicity and
nerve injury.
Nerve injury can be temporary (up to 10% in the days
following the nerve block) or permanent (1.5:10,000). The exact
aetiology of neuronal injury is varied; but is increased in pa-
tients with pre-existing neuropathy, and prolonged exposure of
the nerve to high concentrations of local anaesthetic agents. The
risk of nerve injury due to intraneural injection can be mini-
mized with sound knowledge of the anatomy, use of a fascial
plane as end-point for injection rather than the nerve structure,
use of ultrasound and nerve stimulator for dual monitoring
during procedure, and using a pressure-monitoring device to
ensure pressure during injection is as low as possible. Table 2
identifies advantages and disadvantages of regional anaes-
thesia in comparison to other analgesic strategies.
1 2016 Published by Elsevier Ltd.

Figure 1 Demonstrating the relationship of pain severity to the WHO
analgesic ladder and the potential benet from regional anaesthesia.
Complex patients/comorbidities
The patient with severe respiratory disease
Unwanted side effects limit the effectiveness of opioid-based
analgesic regimes in severe respiratory disease. Regional anaes-
thesia allows the provision of analgesia whilst allowing compli-
ance with respiratory physiotherapy, an effect particularly
pronounced following major abdominal or thoracic surgery, or
following thoracic trauma, including extensive rib fractures. This
benefit may reduce the high mortality especially associated with
thoracic trauma in the older person.
However, techniques such as interscalene brachial plexus
block, or a high intrathecal block, may compromise respiratory
function; care must be used to choose the correct technique to
obtain the benefits without the complications.
The older patient
Due to alteration in pharmacodynamics with ageing, such as
increased time to elimination, older patients may be more sus-
ceptible to the unwanted side effects of systemic analgesics, such
as constipation, nausea and vomiting, confusion, drowsiness and
respiratory depression.1 It is recommended opioids be used with
caution and at smaller doses in this age group.
Regional anaesthesia has demonstrable benefits for the older
person with a fractured neck of femur, where patients with
femoral nerve blocks had less delirium, earlier mobilization and
less systemic opioid. Emerging evidence suggests a mortality
benefit in this group, and femoral nerve blocks or fascia iliaca
blocks are now recommended. This benefit is also clearly
demonstrated with epidural analgesia in the older person
following major surgery.
The paediatric patient
Children often need to undergo elective or emergency surgical
procedures, but have a varying level of understanding of pain
and the reasons for it. Regional anaesthesia has been clearly
ANAESTHESIA AND INTENSIVE CARE MEDICINE --:-
Please cite this article in press as: Perry L, Stimpson J, The role of regional anaesthesia in the management of acute pain, Anaesthesia and
intensive care medicine (2016), http://dx.doi.org/10.1016/j.mpaic.2016.06.005
PAIN
shown to provide beneficial effects beyond that of surgical site
infiltration; continuous catheter techniques can be safely used to
prolong the analgesia for a required duration safely. Although
these techniques are performed under general anaesthesia, the
complication rate is no higher than that in the adult population,
and is significantly lower than the use of neuraxial approaches.
Caution must be used with the site and total dose adminis-
tered of local anaesthetic to avoid local anaesthetic toxicity.
The opioid-tolerant patient
Patients with a history of chronic pain treated with opiates, or
patients who have recreationally abused opiates may get limited
analgesic benefits from this class of drugs due to tolerance,
thought to be caused by changes to opiate receptor type, location
and functionality. This can make them very difficult to manage
when presenting with acute pain, and these patients may be
susceptible to be under-analgesed, or have escalating analgesic
requirements. There is also a threat from mis-prescription of the
patients standard opioid regime, and either under- or over-
dosing.
Regional anaesthesia in this setting provides the additional
analgesic needs whilst allowing the patient to maintain their
usual opioid dosing to avoid withdrawal phenomenon.
The patient with cancer
Regional anaesthesia has been shown in multiple trials to be
linked to an improved outcome in reducing cancer recurrence.
Breast cancer remission was found to be 94% in a group of
patients who had paravertebral blocks compared with 77% in a
group who had morphine for analgesia.2 A similar effect has
been seen in prostate and ovarian cancer with epidural vs gen-
eral anaesthetic and opioids3,4 and there is also evidence that
regional technique may improve long-term outcomes following
melanoma surgery.5 However, no relationship between epidural
use and outcome has been shown with bowel cancer and this
area of investigation is still really in its infancy.6 The relation-
ship between cancer outcomes and regional techniques is
Advantages and disadvantages of regional anaesthesia
in acute pain management
Advantages Disadvantages
Exceptional analgesia Requires skills, training and
equipment
Avoidance of Invasive procedure
opioids/others
May avoid general Limited duration only
anaesthetics
Reduction in May cause motor block
sensitization
Preventive for Site-specific side effects
chronic post-surgical pain (motor block etc)
(especially after thoracotomy,
abdominal, breast surgery)
Complication rate (nerve
damage, infection, haematoma
Table 1
2 2016 Published by Elsevier Ltd.
 PAIN

anaesthetic functioning to block sodium channel expression on

Comparison of regional anaesthesia with other acute dormant malignant cells.
pain management options
The patient undergoing major surgery
Analgesic method Advantages Disadvantages
Kehlet has expounded upon the benefits of regional anaesthesia
Regional anaesthesia Effective, targeted Skills, training and in reducing the stress response to surgery.7 Minimizing this
Preventive for CPSP equipment response is a key component of enhanced recovery schemes,
Invasive alongside a multimodal analgesic regime. Especially with regard
Paracetamol Few side effects Rare but harmful to major abdominal surgery, the use of regional anaesthesia
toxicity techniques reduces intraoperative blood loss, minimizes risk of
NSAIDs Anti-inflammatory, Peptic ulceration transfusion, reduces systemic opioid requirements, decreases
anti pyretic and Renal dysfunction nausea, allows a speedier return of gut motility and allows earlier
analgesic action mobilization.
Opioids Effective analgesics Constipation Use of peripheral nerve blocks or local infiltration analgesia
Many available Nausea/vomiting for lower limb arthroplasty has hugely reduced the duration of
preparations and Urinary retention stay of patients requiring hip or knee replacements, in compari-
routes Sedation son with either systemic analgesia or epidural.
Respiratory
depression
Can regional anaesthesia prevent the transition from
Delayed gut motility
acute to chronic pain?
Regional anaesthesia can also help prevent the development of
post-GI surgery
inappropriate pain signalling, causing central sensitization and
Ketamine Effective for opioid Dysphoria
the onset of chronic pain.8 This is of great importance as the
resistant pain Hallucinations
impact of chronic pain on a personal and economic level can be
Non-respiratory
substantial.9
depressant
Preventive for CPSP
Gabapentinoids Reduce opioid side Not effective for all
Drugs and adjuvants
effects acute pain
The local anaesthetics generally used for regional anaesthesia are
NNT 11 (sole agent)
amides, which include lidocaine, bupivacaine and ropivacaine.
NNT 6 (reduction
They act through binding to the inside of sodium channels within
rescue analgesia)
cells and preventing depolarisation by Na influx, and therefore
inhibit propagation of pain signals from the site of injury to the
Drowsiness
spinal cord. The three drugs listed have different onset and
GI disturbance
duration of action that can be used in different situations as
Lidocaine IV Effective Toxicity risk
required. Table 3 highlights some key features of these drugs.
Requires continuous
Adjuvant drugs can also be used to prolong the block; these
monitoring
Clonidine Effective Hypotension
include steroids, clonidine and ketamine all of which show some
Reduces nausea Bradycardia
evidence of extending the duration of analgesia.
Eases withdrawal
Opioids have a role in increasing the density of the block and
states
prolonging its action, but may also increase the risk of side
Dexamethasone Effective but with Hyperglycaemia
effects.
small effect Unfounded concerns
Adrenaline can be used as an adjuvant both to demonstrate
intravascular injection and to prolong and action of the local
re-infection
anaesthetic by causing vasoconstriction. It has also been postu-
Nefopam Effective for opioid Tachycardia
lated that adrenaline has an independent analgesic action
resistant pain
through a2 adrenergic receptors.
Magnesium Anti-IL-6 and TNF-a Vasodilation
effect Smooth muscle
Opioid reduction relaxation
Novel routes and new concepts
effect
In the last 15 years the increased availability and use of ultra-
sound has allowed the development of a number of new block
From ANZCA Acute Pain Management: Fourth Edition. techniques, such as the PECS I (blocking the pectoral nerves
CPSP, chronic post-surgical pain; GI, gastrointestinal; IL-6, interleukin-6; NNT,
between pectoralis major and minor at the level of the third rib
number needed to treat; TNF-a, tumour necrosis factor-a.
with 10 ml injectate), PECS II (a PECS I, plus blocking intercostal
Table 2 nerves T2-4 and long thoracic nerve by adding 20 ml injectate
deep between pectoralis minor and serratus anterior) and the
thought to be due mainly to two factors, suppression of the serratus plane block for breast surgery;10 the transversus
neuroendocrine response to stress and avoidance of or reduction abdominis plane (and latterly the quadratus lumborum block)
in immunosuppressant analgesics such as morphine. There may block for abdominal surgery, individual peripheral nerve blocks
also be a direct action of the systemic concentration of local for upper limb and lower limb work to target the sensory

ANAESTHESIA AND INTENSIVE CARE MEDICINE --:- 3 2016 Published by Elsevier Ltd.

Please cite this article in press as: Perry L, Stimpson J, The role of regional anaesthesia in the management of acute pain, Anaesthesia and
intensive care medicine (2016), http://dx.doi.org/10.1016/j.mpaic.2016.06.005

Properties of the most commonly used local anaesthetics in the UK
Drug Onset of action Duration, without
(minutes) adrenaline (hours)
Lidocaine 5e10 2e4
Bupivacaine 10e30 18e24
Levobupivacaine 15e30 18e24
Ropivacaine 10e15 14e18
Table 3
components rather than a full plexus block. Ultrasound use has
also allowed reduction in dose and volume of local anaesthetic
required to achieve the analgesic effects.
Continuous catheter techniques for continued analgesia have
gained huge popularity, particular in America. These methods
require insertion of a catheter adjacent to the intended nerve, and
use a weak concentration of local anaesthetic to provide a pref-
erential pain fibre block of nociception, whilst allowing motor
function. In the UK they are most commonly performed at the
femoral nerve for analgesia after hip fracture, and the inter-
scalene brachial plexus for major shoulder surgery.
Time differential blocks are a relatively new phenomenon that
can be used to anaesthetize the same part of the body for
different lengths of time. For example, with hand surgery, a
short-acting axillary brachial plexus block to cover tourniquet
pain, combined with longer acting forearm blocks allows a pa-
tient to minimize the unwanted side effect of a densely motor
blocked arm, yet still have extended analgesia into the first
postoperative day.
Economics and opportunity
By performing surgery as a day case there are two savings: the
saving of costs of an overnight stay for that patient (approx. 400
per patient night) and the availability of time in main theatre for
alternative surgery. Surgery that would have previously required
inpatient stay for pain management (e.g. shoulder replacement)
can be carried out as day surgery and patients discharged with
indwelling catheters for continued analgesia. The increased main
theatre time availability can generate additional tariff income for
the hospital. As well as producing a financial benefit for the
hospital, this also increases patient satisfaction, as most patients
prefer to return to their homes as soon as possible following
surgery.
Discharge home with an active nerve block or indwelling
catheter requires further patient education and may not be suit-
able for all, but it can be very successful in the right
circumstances.
Refinement of regional anaesthetic techniques to spare motor
function can be useful in accelerating rehabilitation. For
example, following knee replacement surgery an adductor canal
nerve block will preserve the function of the quadriceps muscles,
ANAESTHESIA AND INTENSIVE CARE MEDICINE --:-
Please cite this article in press as: Perry L, Stimpson J, The role of regional anaesthesia in the management of acute pain, Anaesthesia and
intensive care medicine (2016), http://dx.doi.org/10.1016/j.mpaic.2016.06.005
PAIN
Max dose, Special features
without
adrenaline
(mg/kg)
3 Caution with dose especially with 2%
(20 mg/ml)
2 The most cardiotoxic due to myocardial
binding
2
3 Less motor block when used in equal
concentration as
bupivacaine
whilst still providing analgesia to the anterior knee, allowing
physiotherapy within hours of surgery. The field of enhanced
recovery is developing all the time to reduce length of stay for
patients and help to streamline their journey through surgery.
Regional anaesthesia as part of a combined analgesic approach is
evolving all the time to help increase the types of procedures that
can be managed in this way. A
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4 2016 Published by Elsevier Ltd.
 PAIN

FURTHER READING of Pain Medicine 2015. Available at: http://www.anzca.edu.au/

ANZCA Acute Pain Management: Scientic Evidence; 4th edition. resources/college-publications/pdfs/APMSE4_2015_Final.pdf
Edited by Schug S, Palmer G, Scott D, Halliwell R, Trinca J. (Last accessed 24 Feb 2016).
Australian and New Zealand College of Anaesthetists and Faculty

ANAESTHESIA AND INTENSIVE CARE MEDICINE --:- 5 2016 Published by Elsevier Ltd.

Please cite this article in press as: Perry L, Stimpson J, The role of regional anaesthesia in the management of acute pain, Anaesthesia and
intensive care medicine (2016), http://dx.doi.org/10.1016/j.mpaic.2016.06.005