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(Williams et al, 2004 Level III‐3). After complex outpatient knee surgery, femoral‐sciatic nerve
block provided better pain relief than femoral nerve block alone, and both techniques reduced
unplanned hospital admissions to a similar extent (Williams et al, 2003 Level IV).
Interscalene plexus block provided safe and effective analgesia after ambulatory shoulder
surgery (Bishop et al, 2006 Level IV; Faryniarz et al, 2006 Level IV). For hand and wrist surgery,
infraclavicular nerve blocks with propofol sedation, compared with general anaesthesia
followed by local anaesthetic wound infiltration, resulted in less postoperative pain, less
nausea, earlier ambulation and earlier hospital discharge. (Hadzic et al, 2004 Level II).
Continuous peripheral nerve blockade
Patients may suffer intense pain following resolution of a peripheral nerve block although
it maximises pain relief in the first 12 to 24 hours (Chung et al, 1997 Level IV). CPNB using
perineural catheters and continuous infusions of local anaesthetic led to sustained
postoperative analgesia (Ilfeld, Morey, Wang et al, 2002 Level II; Ilfeld, Morey & Enneking, 2002
Level II; Zaric et al, 2004 Level II), was opioid‐sparing (Ilfeld, Morey, Wang et al, 2002 Level II; Ilfeld,
Morey & Enneking, 2002 Level II; Ilfeld et al, 2003 Level II) and resulted in less sleep disturbance
(Ilfeld, Morey, Wang et al, 2002 Level II; Ilfeld, Morey & Enneking, 2002 Level II) and improved
rehabilitation (Capdevila et al, 1999 Level II). Patients achieved discharge criteria significantly
earlier in a number of ambulatory settings: after total shoulder arthroplasty with use of
continuous interscalene blocks (21 vs 51 hours) (Ilfeld et al, 2006 Level II); after hip arthroplasty
with use of continuous lumbar plexus block (29 vs 52 hours) (Ilfeld, Ball et al, 2008 Level II); and
after total knee arthroplasty with the use of continuous femoral nerve blocks (25 vs 71 hours)
(Ilfeld, Le et al, 2008 Level II). These benefits have the potential to reduce hospital costs (Ilfeld et
al, 2007 Level III‐3).
Compared with a single‐injection interscalene block, a 2‐day interscalene infusion at home
after shoulder surgery was opioid‐sparing and improved pain relief, sleep and patient
satisfaction (Mariano et al, 2009 Level II).
Patient‐controlled delivery of the infusion improved analgesia and function more than a
continuous infusion and even more so compared with IV morphine PCA (Capdevila et al, 2006
Level II).
CHAPTER 9 (Swenson et al, 2006 Level IV; Fredrickson et al, 2008 Level IV) and paediatric patients (Ganesh et al,
The safety and efficacy of CPNBs in an ambulatory setting has been confirmed in adult

2007 Level IV; Ludot et al, 2008 Level IV).
Inadvertent intravascular catheter placement should be excluded prior to patient discharge
using a test dose of local anaesthetic and adrenaline (epinephrine) (Rawal et al, 2002). Patients
and their carers should be given extensive oral and written instructions about management,
side effects and care of the local anaesthetic catheter, and have 24‐hour a day telephone
access to an anaesthesiologist during the postoperative period while CNPB is in use (Swenson et
al, 2006), as 30% of patients make unscheduled phone calls regarding catheter infusions
despite been given adequate written and verbal instructions (Ilfeld, Morey & Enneking, 2002
Level II). A review of 620 outpatients with CPNB (including popliteal fossa, fascia iliaca and
interscalene) showed that 4.2% required assistance by the anaesthesiologist after discharge
from hospital for problems relating to issues such as patient education, inadequate analgesia
and equipment malfunction; only one patient was unable to remove their catheter (Swenson et
al, 2006 Level IV), although patients may have significant anxiety about catheter removal at
home (Ilfeld et al, 2004 Level IV).
Detailed reviews of the use of CPNBs for ambulatory surgery have been published (Cheng et al,
2008; Ilfeld & Enneking, 2005).

240 Acute Pain Management: Scientific Evidence