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7.4.2 Plexus and other peripheral regional blockade

Significant blood loss rather than neurological deficit seems to be the main risk when plexus or
other regional blocks are performed in patients taking anticoagulant medications (Horlocker et
al 2003). However, a case series of bleeding complications associated with lumbar plexus
blocks and, femoral and sciatic catheters and perioperative anticoagulants suggests that
caution is appropriate (Bickler et al, 2006 Level IV; Horlocker et al, 2003). The previously quoted
evidence‐based ASRA&PM guidelines conclude that recommendations for neuraxial block be
followed for patients receiving deep plexus or peripheral blocks (Horlocker et al, 2010)

Key messages
1. Anticoagulation is the most important risk factor for the development of epidural
haematoma after neuraxial blockade (U) (Level IV).
The following tick box  represents conclusions based on clinical experience and expert
opinion.
 Consensus statements of experts guide the timing and choice of regional anaesthesia and
analgesia in the context of anticoagulation, but do not represent a standard of care and
will not substitute the risk/benefit assessment of the individual patient by the individual
anaesthetist (U).

7.5 OTHER REGIONAL AND LOCAL ANALGESIC
TECHNIQUES

7.5.1 Continuous peripheral nerve blockade
Continuous peripheral nerve blockade (CPNB) extends the duration of postoperative analgesia
beyond the finite period that single injection techniques provide. Important technical issues CHAPTER 7
include the technique used for nerve location, the type of continuous catheter equipment, and
local anaesthetic infusion choice and management.
Compared with opioid analgesia, CPNB (regardless of catheter location) provides better
postoperative analgesia and leads to reductions in opioid use as well as the incidence of
nausea, vomiting, pruritus and sedation (Richman et al, 2006 Level I).
Compared with general anaesthesia, peripheral nerve block (PNB) was associated with
increased induction time, improved analgesia, a decreased requirement for opioids in the
postanaesthesia care unit (PACU); but there was no significant reduction in PACU discharge
time (Liu et al, 2005 Level I). However, it is not clear what proportion of patients received single‐
shot versus CPNB.
Upper limb

Interscalene
Continuous interscalene analgesia improved pain relief and patient satisfaction and reduced
opioid‐related side effects compared with IV PCA (Borgeat et al, 1997 Level II; Borgeat et al, 1998
Level II; Borgeat et al, 2000 Level II). Continuous interscalene analgesia also provided better
analgesia and reduced opioid requirements following shoulder surgery compared with single
injection interscalene blockade (Klein, Grant et al, 2000 Level II; Ilfeld et al, 2003 Level II; Kean et al,
2006 Level II) with higher patient satisfaction (Kean et al, 2006 Level II). Compared with a single‐
injection interscalene block, a 2‐day interscalene infusion at home after shoulder surgery was

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