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opioid‐sparing and improved pain relief, sleep and patient satisfaction (Mariano et al, 2009
Level II). Continuous interscalene nerve blockade compared with placebo following shoulder
arthroplasty also reduced time to discharge readiness and was associated with a greater
degree of shoulder movement (Ilfeld et al, 2006 Level II).
Axillary
There is no consistent evidence that continuous axillary analgesia is better than a single
axillary brachial plexus injection of a long‐acting local anaesthetic. After elective hand surgery
continuous axillary infusions of 0.1%, 0.2% ropivacaine or saline were not sufficient to
adequately treat pain without the addition of adjunct agents (Salonen et al, 2000 Level II).

Infraclavicular
Use of an infraclavicular brachial plexus catheter in patients at home after upper limb surgery
led to better pain relief, patient satisfaction and sleep compared with oral opioid analgesia
(Ilfeld, Morey & Enneking, 2002 Level II).
The incidence of insensate limb was higher when smaller volumes of 0.4% ropivacaine were
used compared with higher volumes of 0.2%, despite no difference in the total amount of local
anaesthetic (mg) used; there was no difference in analgesia but satisfaction scores were higher
in patients who received the 0.2% infusion (Ilfeld, Le et al, 2009 Level II).
Lower limb
Peripheral nerve blocks, including CPNB, after major knee surgery, provided postoperative
analgesia that was comparable with that obtained with epidural techniques but with an
improved side‐effect profile (Fowler et al, 2008 Level I).
Femoral nerve and fascia iliaca blocks
Continuous femoral nerve blockade (often called a ‘3 in 1’ block as a catheter placed in the
CHAPTER 7 and obturator nerves as well as the femoral nerve) provided postoperative analgesia and
femoral nerve sheath may allow local anaesthetic to reach both the lateral femoral cutaneous

functional recovery that was better than IV PCA morphine and comparable with epidural
analgesia following total knee arthroplasty (Singelyn et al, 1998 Level II; Capdevila et al, 1999
Level II; Barrington, Olive et al, 2005 Level II). It decreased nausea and vomiting compared with
morphine and decreased hypotension and urinary retention compared with epidural analgesia
(Capdevila et al, 1999 Level II; Singelyn et al, 1998 Level II). Similar results were reported in a later
study. Although continuous femoral nerve blockade provided pain relief that was comparable
to both IV morphine and epidural analgesia, the incidence of nausea, vomiting, pruritus and
sedation was also reduced compared with morphine and there was again a lower incidence
of urinary retention and hypotension compared with epidural analgesia (Singelyn et al, 2005
Level II).
Femoral nerve block (either continuous or single shot) combined with spinal or general
anaesthesia for total knee arthroplasty led to better analgesia (lower pain intensity scores
especially on movement, reduction in supplemental analgesia use) for up to 48 hours
compared with parenteral opioid‐based techniques (Fischer et al, 2008 Level I). In a later study,
continuous femoral nerve block also led to better pain relief and opioid‐sparing, however
there was a reduction in opioid‐related side effects and patients were able to achieve better
knee flexion in the postoperative period; no functional benefit was seen at 3 months (Kadic et
al, 2009 Level II).
Femoral nerve block (either single shot or continuous) was more effective than intra‐articular
local anaesthesia following arthroscopic anterior cruciate ligament reconstruction (Dauri et al,
2003 Level II; Iskandar et al, 2003 Level II; Dauri et al, 2009 Level II). In day case surgical patients,

196 Acute Pain Management: Scientific Evidence