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Patient-controlled regional analgesia
Continuous regional analgesia techniques can be provided with continuous infusion alone,
a combination of continuous infusion and patient‐controlled bolus doses or patient‐controlled
bolus doses alone. In a comparison with continuous infusions for ‘3 in 1’ nerve blockade,
patient‐controlled regional analgesia (PCRA) was associated with similar pain scores and
patient satisfaction but reduced consumption of local anaesthetic (Singelyn & Gouverneur,
2000 Level II). A study in patients having open shoulder surgery concluded that a baseline
infusion, with PCRA added to reinforce the block before physiotherapy, was the best choice
(Singelyn et al, 1999 Level II).
The addition of a background infusion to ‘3 in 1’ PCRA (Singelyn & Gouverneur, 2000 Level II)
or femoral nerve PCRA (Singelyn et al, 2001 Level II) did not improve pain relief or alter the
incidence of side effects but could increase total local anaesthetic consumption. The addition
of a background infusion to interscalene brachial plexus PCRA did result in better analgesia
(Singelyn et al, 1999 Level II).
For more information on any differences between the local anaesthetics used for PCRA see
Section 5.1.2.

7.5.2 Intra-articular analgesia
Continuous ropivacaine infusion via interscalene or intra‐articular catheters were compared
following rotator cuff surgery in an outpatient setting. Both study groups had logistical
problems and relatively high pain scores following resolution of the surgical block (Klein et al,
2003 Level II).
Intra‐articular infusions of bupivacaine with adrenaline following shoulder arthroscopy
have been associated with gleno‐humoral chondrolysis in cases series, and their use has
been cautioned against (Hansen et al 2007 Level IV; Bailie & Ellenbecker, 2009 Level IV). The
chondrotoxicity of bupivacaine has been supported by animal experiments (Gomoll et al, 2006).
There is evidence of a small benefit only of intra‐articular local anaesthesia for postoperative
pain relief after anterior cruciate ligament repair (Moiniche et al, 1999 Level I). Femoral nerve CHAPTER 7
block (either single shot or continuous) was more effective than intra‐articular local
anaesthesia following arthroscopic repair (Dauri et al, 2003 Level II; Iskandar et al, 2003 Level II).
Following knee arthroplasty, the use of periarticular and intra‐articular local anaesthetics in
large volumes (eg 170 mL 0.2% ropivacaine) with supplemental doses over 24 hours via an
intra‐articular catheter resulted in lower opioid requirements for up to 24 hours and less
nausea over 5 days compared with systemic morphine (Vendittoli et al, 2006 Level II), improved
analgesia and earlier ambulation compared with femoral nerve block (Toftdahl et al, 2007
Level II), and reduced pain over 32 hours compared with saline (Andersen et al, 2008 Level II).
The technique has been recently been reviewed (Otte et al, 2008).
Following hip arthroplasty, the use of periarticular and intra‐articular local anaesthetics in
large volumes with supplemental doses over 24 hours via an intra‐articular catheter resulted
in improved analgesia for 2 weeks postoperatively and lower opioid requirements for up to
4 days compared with saline (Andersen, Poulsen et al, 2007 Level II) and reduced opioid
consumption and length of hospital stay compared with epidural analgesia (Andersen, Pfeiffer‐
Jensen et al, 2007 Level II). Plasma levels of ropivacaine after this technique have been reported
to be below the toxic range (Vendittoli et al, 2006 Level IV; Bianconi et al, 2003 Level IV).
In clinical practice, morphine injected as a single dose into the knee intra‐articular space
produced analgesia that lasted up to 24 hours, but evidence for a peripheral rather than a
systemic effect was not conclusive (Gupta et al, 2001 Level I; Kalso et al, 2002 Level I). Confounding

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