Effect of combined single-injection femoral nerve block and patient-controlled epidural analgesia in patients undergoing total knee replacement

Multimodal Analgesia for Accelerated Rehabilitation after Total Knee Arthroplasty: A Randomized, Double-Blind, Controlled Trial on the Effect of the Co-Application of Local Infiltration Analgesia and Femoral Nerve Block Combined with Dexmedetomidine

Background: Multimodal postoperative pain regimens are widely used following total knee arthroplasty (TKA). However, there are few studies on the rehabilitation of the co-application of local infiltration analgesia (LIA) and femoral nerve block (FNB) combined with dexmedetomidine (DEX) for patients undergoing TKA. This study aimed to investigate the effect of LIA plus FNB and co-application of perioperative DEX on TKA outcomes. Methods: 95 patients were randomized into two groups. Patients in group B (n = 48) received a single preoperative FNB and LIA. Patients in group A (n = 47) received FNB and LIA, as well as continuous intravenous injection of DEX starting from the induction of anesthesia to postoperative day 2. All patients were allowed patient-controlled analgesia postoperatively. Visual analog scale (VAS) scores, knee range of motion (ROM) degrees, narcotic consumption, length of hospital stay (LOS), complications, Hospital for Special Surgery (HSS) scores and Montreal Cognitive Assessment-Basic (MoCA-B) Scores were recorded. Results: In group A, the mean VAS scores at rest and during movement were lower, the amount of rescue analgesia was decreased, first time of ambulation was reduced, ROM was improved, MoCA-B Scores were increased, LOS was shorter, HSS scores were higher postoperatively compared with group B (all p < 0.05). Conclusion: Our study indicated multimodal analgesia involving a single FNB and LIA combined with DEX accelerates rehabilitation for patients undergoing TKA.

Peripheral nerve block anesthesia/analgesia for patients undergoing primary hip and knee arthroplasty: recommendations from the International Consensus on Anesthesia-Related Outcomes after Surgery (ICAROS) group based on a systematic review and meta-analysis of current literature

BACKGROUND

Evidence-based international expert consensus regarding the impact of peripheral nerve block (PNB) use in total hip/knee arthroplasty surgery.

METHODS

A systematic review and meta-analysis: randomized controlled and observational studies investigating the impact of PNB utilization on major complications, including mortality, cardiac, pulmonary, gastrointestinal, renal, thromboembolic, neurologic, infectious, and bleeding complications.Medline, PubMed, Embase, and Cochrane Library including Cochrane Database of Systematic Reviews, Cochrane Central Register of Controlled Trials, NHS Economic Evaluation Database, were queried from 1946 to August 4, 2020.The Grading of Recommendations Assessment, Development, and Evaluation approach was used to assess evidence quality and for the development of recommendations.

RESULTS

Analysis of 122 studies revealed that PNB use (compared with no use) was associated with lower ORs for (OR with 95% CIs) for numerous complications (total hip and knee arthroplasties (THA/TKA), respectively): cognitive dysfunction (OR 0.30, 95% CI 0.17 to 0.53/OR 0.52, 95% CI 0.34 to 0.80), respiratory failure (OR 0.36, 95% CI 0.17 to 0.74/OR 0.37, 95% CI 0.18 to 0.75), cardiac complications (OR 0.84, 95% CI 0.76 to 0.93/OR 0.83, 95% CI 0.79 to 0.86), surgical site infections (OR 0.55 95% CI 0.47 to 0.64/OR 0.86 95% CI 0.80 to 0.91), thromboembolism (OR 0.74, 95% CI 0.58 to 0.96/OR 0.90, 95% CI 0.84 to 0.96) and blood transfusion (OR 0.84, 95% CI 0.83 to 0.86/OR 0.91, 95% CI 0.90 to 0.92).

CONCLUSIONS

Based on the current body of evidence, the consensus group recommends PNB use in THA/TKA for improved outcomes.

RECOMMENDATION

PNB use is recommended for patients undergoing THA and TKA except when contraindications preclude their use. Furthermore, the alignment of provider skills and practice location resources needs to be ensured. Evidence level: moderate; recommendation: strong.

Assessing outcome in postoperative pain trials: are we missing the point? A systematic review of pain-related outcome domains reported in studies early after total knee arthroplasty

ABSTRACT

The management of acute postoperative pain remains suboptimal. Systematic reviews and Cochrane analysis can assist with collating evidence about treatment efficacy, but the results are limited in part by heterogeneity of endpoints in clinical trials. In addition, the chosen endpoints may not be entirely clinically relevant. To investigate the endpoints assessed in perioperative pain trials, we performed a systematic literature review on outcome domains assessing effectiveness of acute pain interventions in trials after total knee arthroplasty. We followed the Cochrane recommendations for systematic reviews, searching PubMed, Cochrane, and Embase, resulting in the screening of 1590 potentially eligible studies. After final inclusion of 295 studies, we identified 11 outcome domains and 45 subdomains/descriptors with the domain "pain"/"pain intensity" most commonly assessed (98.3%), followed by "analgesic consumption" (88.8%) and "side effects" (75.3%). By contrast, "physical function" (53.5%), "satisfaction" (28.8%), and "psychological function" (11.9%) were given much less consideration. The combinations of outcome domains were inhomogeneous throughout the studies, regardless of the type of pain management investigated. In conclusion, we found that there was high variability in outcome domains and inhomogeneous combinations, as well as inconsistent subdomain descriptions and utilization in trials comparing for effectiveness of pain interventions after total knee arthroplasty. This points towards the need for harmonizing outcome domains, eg, by consenting on a core outcome set of domains which are relevant for both stakeholders and patients. Such a core outcome set should include at least 3 domains from 3 different health core areas such as pain intensity, physical function, and one psychological domain.

The efficiency and safety of fascia iliaca block for pain control after total joint arthroplasty: A meta-analysis

BACKGROUND

This meta-analysis aimed to perform a meta-analysis including randomized controlled trials (RCTs) to assess the efficiency and safety of fascia iliaca block (FIB) for pain control in patients undergoing total joint arthroplasty (TJA).

METHODS

A systematic search was performed in Medline (1966-2017.03), PubMed (1966-2017.03), Embase (1980-2017.03), ScienceDirect (1985-2017.03) and the Cochrane Library. Study evaluated the efficiency and safety of FIB in TJA was selected. Meta-analysis was performed using Stata 11.0 software.

RESULTS

Five randomized controlled trials (RCTs) including 270 patients met the inclusion criteria. The present meta-analysis indicated that there were significant differences between groups in terms of visual analog scale (VAS) score at 12 hours (SMD = -0.544, 95% CI: -0.806 to -0.281, P = .000) and 24 hours (SMD = -0.519, 95% CI: -0.764 to -0.273, P = .000), morphine equivalent consumption at 12 hours (SMD = -0.895, 95% CI: -1.164 to -0.626, P = .000) and 24 hours (SMD = -0.548, 95% CI:-0.793 to -0.303, P = .000). In addition, fewer adverse side effect was identified in FIB groups (RD = -0.139, 95% CI: -0.243 to -0.034, P = .009).

CONCLUSION

The application of fascia iliaca block could significantly reduce VAS scores and morphine consumption at 12 and 24 hours following total knee and hip arthroplasty. In addition, there were fewer adverse effects in FIB groups. Due to the limited quality of the evidence currently available, higher quality RCTs are required.

Use of the cumulative sum method (CUSUM) to assess the learning curves of ultrasound-guided continuous femoral nerve block

BACKGROUND

Although ultrasound is a basic competence for anaesthesia residents (AR) there is few data available on the learning process. This prospective observational study aims to assess the learning process of ultrasound-guided continuous femoral nerve block and to determine the number of procedures that a resident would need to perform in order to reach proficiency using the cumulative sum (CUSUM) method.

METHODS

We recruited 19 AR without previous experience. Learning curves were constructed using the CUSUM method for ultrasound-guided continuous femoral nerve block considering 2 success criteria: a decrease of pain score>2 in a [0-10] scale after 15minutes, and time required to perform it.

RESULTS

We analyse data from 17 AR for a total of 237 ultrasound-guided continuous femoral nerve blocks. 8/17 AR became proficient for pain relief, however all the AR who did more than 12 blocks (8/8) became proficient. As for time of performance 5/17 of AR achieved the objective of 12minutes, however all the AR who did more than 20 blocks (4/4) achieved it.

CONCLUSIONS

The number of procedures needed to achieve proficiency seems to be 12, however it takes more procedures to reduce performance time. The CUSUM methodology could be useful in training programs to allow early interventions in case of repeated failures, and develop competence-based curriculum.

Postoperative pain treatment after total knee arthroplasty: A systematic review

INTRODUCTION

The aim of this systematic review was to document efficacy, safety and quality of evidence of analgesic interventions after total knee arthroplasty (TKA).

METHODS

This PRISMA-compliant and PROSPERO-registered review includes all-language randomized controlled trials of medication-based analgesic interventions after TKA. Bias was evaluated according to Cochrane methodology. Outcomes were opioid consumption (primary), pain scores at rest and during mobilization, adverse events, and length of stay. Interventions investigated in three or more trials were meta-analysed. Outcomes were evaluated using forest plots, Grading of Recommendations Assessment, Development and Evaluation (GRADE), L'Abbe Plots and trial sequential analysis.

RESULTS

The included 113 trials, investigating 37 different analgesic interventions, were characterized by unclear/high risk of bias, low assay sensitivity and considerable differences in pain assessment tools, basic analgesic regimens, and reporting of adverse events. In meta-analyses single and continuous femoral nerve block (FNB), intrathecal morphine, local infiltration analgesia, intraarticular injection of local anaesthetics, non-steroidal anti-inflammatory drugs, and gabapentinoids demonstrated significant analgesic effects. The 24-hour morphine-sparing effects ranged from 4.2 mg (CI: 1.3, 7.2; intraarticular local anaesthetics), to 16.6 mg (CI: 11.2, 22; single FNB). Pain relieving effects at rest at 6 hours ranged from 4 mm (CI: -10, 2; gabapentinoids), to 19 mm (CI: 8, 31; single FNB), and at 24 hours from 3 mm (CI: -2, 8; gabapentinoids), to 16 mm (CI: 8, 23; continuous FNB). GRADE-rated quality of evidence was generally low.

CONCLUSION

A low quality of evidence, small sample sizes and heterogeneity of trial designs prohibit designation of an optimal procedure-specific analgesic regimen after TKA.

Effects of Patient-Controlled Epidural Analgesia and Patient-Controlled Intravenous Analgesia on Analgesia in Patients Undergoing Spinal Fusion Surgery

We compared the outcomes of patient-controlled epidural analgesia (PCEA) and patient-controlled intravenous analgesia (PCIA) in analgesia after spinal fusion surgery. A total of 120 patients who underwent spinal fusion surgeries between April 2013 and April 2015 at Shaanxi Provincial People's Hospital were selected for this study based on defined inclusion criteria. All patients were randomly divided into 2 groups before surgery: PCEA group (n = 65) and PCIA group (n = 55). Visual analog scales (VAS) were used to evaluate the degree of pain. Besides, the active and passive activities of patients during 1- to 3-day recovery period after surgery were recorded. Verbal rating scales were used to measure pain levels after surgery and after surgery. Adverse effects of PCEA and PCIA were monitored, which included nausea, vomiting, pruritus, drowsiness, respiratory depression, and headache. Our results showed no statistically significant differences between PCEA and PCIA in sex ratio, age, height, weight, American Society of Anesthesiologists level, surgery time, number of fusion section, surgery methods, and duration of anesthesia (all P > 0.05). The PCEA group was associated with significantly lower VAS scores, compared with the PCIA group, at 3, 6, 12, 24, and 48-hour postsurgery (all P < 0.05) when surgery-associated pain is expected to be intense. Also, compared with the PCIA group, the PCEA group showed higher frequency of recovery activities on first and second day postsurgery (all P < 0.05). The overall patient satisfaction level of analgesia in the PCEA group was significantly higher than in the PCIA group (P < 0.05). Moreover, the incidence of hypopiesia and skin itching in the PCIA group was higher than in the PCEA group (all P < 0.05). Finally, drowsiness and headache were markedly lower in the PCIA group after surgery, compared with the PCEA group, and this difference was statistically significant (all P < 0.05). Our results provide strong evidence that PCEA exhibits significantly greater efficacy than PCIA for pain management after spinal fusion surgery, with lower VAS scores, higher frequency of recovery activities, and overall higher satisfaction level.

Comparison of pain relief between patient-controlled epidural analgesia and patient-controlled intravenous analgesia for patients undergoing spinal fusion surgeries

INTRODUCTION

This meta-analysis aimed to compare the postoperative analgesic effects of patient-controlled epidural analgesia (PCEA) and patient-controlled intravenous analgesia (PCIA) for patients undergoing spinal fusion surgeries.

METHOD

Relevant articles were identified using computerized and manual search strategies. Statistical analyses were undertaken by the CMA 2.0 statistical software.

RESULTS

Nine cohort studies with a total of 436 patients undergoing spinal fusion surgeries were incorporated in the present meta-analysis. There were significant differences between the PCEA and PCIA groups in the visual analogue scale score of patients undergoing spinal fusion [standardized mean difference = 0.27, 95 % confidence interval (95 % CI) = 0.070-0.470, P = 0.008]. However, no obvious difference was observed in the rate of side effects between the PCIA and PCEA groups (side effects: odds ratio = 0.957, 95 % CI = 0.536-1.708, P = 0.882).

CONCLUSION

Our findings suggested that PCEA may be more effective in relieving pain than PCIA for patients undergoing spinal fusion surgeries.

Femoral nerve blocks for acute postoperative pain after knee replacement surgery

BACKGROUND

Total knee replacement (TKR) is a common and often painful operation. Femoral nerve block (FNB) is frequently used for postoperative analgesia.

OBJECTIVES

To evaluate the benefits and risks of FNB used as a postoperative analgesic technique relative to other analgesic techniques among adults undergoing TKR.

SEARCH METHODS

We searched the Cochrane Central Register of Controlled Trials (CENTRAL) 2013, Issue 1, MEDLINE, EMBASE, CINAHL, Web of Science, dissertation abstracts and reference lists of included studies. The date of the last search was 31 January 2013.

SELECTION CRITERIA

We included randomized controlled trials (RCTs) comparing FNB with no FNB (intravenous patient-controlled analgesia (PCA) opioid, epidural analgesia, local infiltration analgesia, and oral analgesia) in adults after TKR. We also included RCTs that compared continuous versus single-shot FNB.

DATA COLLECTION AND ANALYSIS

Two review authors independently performed study selection and data extraction. We undertook meta-analysis (random-effects model) and used relative risk ratios (RRs) for dichotomous outcomes and mean differences (MDs) or standardized mean differences (SMDs) for continuous outcomes. We interpreted SMDs according to rule of thumb where 0.2 or smaller represents a small effect, 0.5 a moderate effect and 0.8 or larger, a large effect.

MAIN RESULTS

We included 45 eligible RCTs (2710 participants) from 47 publications; 20 RCTs had more than two allocation groups. A total of 29 RCTs compared FNB (with or without concurrent treatments including PCA opioid) versus PCA opioid, 10 RCTs compared FNB versus epidural, five RCTs compared FNB versus local infiltration analgesia, one RCT compared FNB versus oral analgesia and four RCTs compared continuous versus single-shot FNB. Most included RCTs were rated as low or unclear risk of bias for the aspects rated in the risk of bias assessment tool, except for the aspect of blinding. We rated 14 (31%) RCTs at high risk for both participant and assessor blinding and rated eight (18%) RCTs at high risk for one blinding aspect.Pain at rest and pain on movement were less for FNB (of any type) with or without a concurrent PCA opioid compared with PCA opioid alone during the first 72 hours post operation. Pooled results demonstrated a moderate effect of FNB for pain at rest at 24 hours (19 RCTs, 1066 participants, SMD -0.72, 95% CI -0.93 to -0.51, moderate-quality evidence) and a moderate to large effect for pain on movement at 24 hours (17 RCTs, 1017 participants, SMD -0.94, 95% CI -1.32 to -0.55, moderate-quality evidence). Pain was also less in each FNB subgroup: single-shot FNB, continuous FNB and continuous FNB + sciatic block, compared with PCA. FNB also was associated with lower opioid consumption (IV morphine equivalent) at 24 hours (20 RCTs, 1156 participants, MD -14.74 mg, 95% CI -18.68 to -10.81 mg, high-quality evidence) and at 48 hours (MD -14.53 mg, 95% CI -20.03 to -9.02 mg), lower risk of nausea and/or vomiting (RR 0.47, 95% CI 0.33 to 0.68, number needed to treat for an additional harmful outcome (NNTH) four, high-quality evidence), greater knee flexion (11 RCTs, 596 participants, MD 6.48 degrees, 95% CI 4.27 to 8.69 degrees, moderate-quality evidence) and greater patient satisfaction (four RCTs, 180 participants, SMD 1.06, 95% CI 0.74 to 1.38, low-quality evidence) compared with PCA.We could not demonstrate a difference in pain between FNB (any type) and epidural analgesia in the first 72 hours post operation, including pain at 24 hours at rest (six RCTs, 328 participants, SMD -0.05, 95% CI -0.43 to 0.32, moderate-quality evidence) and on movement (six RCTs, 317 participants, SMD 0.01, 95% CI -0.21 to 0.24, high-quality evidence). No difference was noted at 24 hours for opioid consumption (five RCTs, 341 participants, MD -4.35 mg, 95% CI -9.95 to 1.26 mg, high-quality evidence) or knee flexion (six RCTs, 328 participants, MD -1.65, 95% CI -5.14 to 1.84, high-quality evidence). However, FNB demonstrated lower risk of nausea/vomiting (four RCTs, 183 participants, RR 0.63, 95% CI 0.41 to 0.97, NNTH 8, moderate-quality evidence) and higher patient satisfaction (two RCTs, 120 participants, SMD 0.60, 95% CI 0.23 to 0.97, low-quality evidence), compared with epidural analgesia.Pooled results of four studies (216 participants) comparing FNB with local infiltration analgesia detected no difference in analgesic effects between the groups at 24 hours for pain at rest (SMD 0.06, 95% CI -0.61 to 0.72, moderate-quality evidence) or pain on movement (SMD 0.38, 95% CI -0.10 to 0.86, low-quality evidence). Only one included RCT compared FNB with oral analgesia. We considered this evidence insufficient to allow judgement of the effects of FNB compared with oral analgesia.Continuous FNB provided less pain compared with single-shot FNB (four RCTs, 272 participants) at 24 hours at rest (SMD -0.62, 95% CI -1.17 to -0.07, moderate-quality evidence) and on movement (SMD -0.42, 95% CI -0.67 to -0.17, high-quality evidence). Continuous FNB also demonstrated lower opioid consumption compared with single-shot FNB at 24 hours (three RCTs, 236 participants, MD -13.81 mg, 95% CI -23.27 to -4.35 mg, moderate-quality evidence).Generally, the meta-analyses demonstrated considerable statistical heterogeneity, with type of FNB, allocation concealment and blinding of participants, personnel and outcome assessors reducing heterogeneity in the analyses. Available evidence was insufficient to allow determination of the comparative safety of the various analgesic techniques. Few RCTs reported on serious adverse effects such as neurological injury, postoperative falls or thrombotic events.

AUTHORS' CONCLUSIONS

Following TKR, FNB (with or without concurrent treatments including PCA opioid) provided more effective analgesia than PCA opioid alone, similar analgesia to epidural analgesia and less nausea/vomiting compared with PCA alone or epidural analgesia. The review also found that continuous FNB provided better analgesia compared with single-shot FNB. RCTs were insufficient to allow definitive conclusions on the comparison between FNB and local infiltration analgesia or oral analgesia.

Medical management of acute pain in patients with chronic pain

The number of patients with chronic pain has increased over the years, as well as the number of patients who manage chronic pain with opioids. As prescribed opioid use has increased, so has its abuse and misuse. It has also been estimated that the number of people using opioids illicitly has doubled worldwide over the last 20 years. Management of chronic pain with opioids is associated with pathophysiological phenomena such as tolerance, dependence and hyperalgesia. They can become a problem when chronic pain patients present for a surgical procedure. Furthermore, patients who are on opioids on a regular basis require higher amounts during the perioperative period. The perioperative management of the chronic pain patient is difficult and complex. Developing an appropriate plan that can fulfill patients' and surgical team's needs requires skills and experience. The aim of this review is to describe the options available for the optimal perioperative management of acute pain in patients with a history of chronic pain.

Functional outcome after major orthopedic surgery: the role of regional anesthesia redefined

PURPOSE OF REVIEW

Regional anesthesia can provide optimal pain management and stress reduction. This article aims to establish the impact of regional anesthesia in facilitating the recovery process, measured by significant clinical outcomes.

RECENT FINDINGS

The most common outcome assessing the effectiveness of regional anesthesia following major orthopedic procedures has been pain intensity. In recent literature, more precise outcome measures of disability and related to patient's quality of life and ability to return to daily activities have been introduced. Those found in the period of this review and discussed in this article are maximum voluntary isovolumetric contraction, range of motion, walking tests, time up and go, cumulated ambulation score, stair climb test, Short Musculoskeletal Function Assessment, Western Ontario McMaster Osteoarthritis Index, constant Murley score, Knee Society evaluation, Community Health Activities Model Program for Seniors, Short Form 12 and 16. Performance based outcomes have been found to correlate poorly with self-reported outcomes after knee arthroplasty.

SUMMARY

In order to establish the role of regional anesthesia in functional outcome after major orthopedic surgery, assessment of pain control is no longer sufficient. New clinically relevant outcomes must be introduced and used for procedure-specific studies.

Use of a single injection femoral nerve block in the patients of total knee replacement with concomitant epidural analgesia

BACKGROUND

Since central neuraxial analgesia cannot provide adequate post operative pain relief when it is used alone in patients who had undergone Total Knee Replacement Surgery (TKR), an alternative analgesic method is usually advised. The alternatives include either systemic analgesics (opioids, Non Steroidal Anti Inflamatory Drugs, [NSAIDs], etc) or peripheral nerve blocks. When complete analgesia is aimed in such patients, combining the sciatic nerve blocks along with the Femoral Nerve Blocks (FNBs) will be beneficial. But performing femoral and sciatic nerve blocks together in patients with regional or general anaesthesia will be too cumbersome and in this direction, the major clinical trials are yet to decide on their feasibility. Thus, in an attempt to keep the analgesia methods very simple and effective, the physicians may decide on doing a single nerve block when an ongoing epidural analgesia infusion is in situ.

AIM

To evaluate the safety, convenience and the efficacy of a single injection femoral nerve block in patients who had undergone TKR surgeries, who had received concomitant epidural sensory analgesia.

METHODS

The patients who had undergone TKR were inserted with an epidural catheter for continuous analgesia and this was supplemented with an additional single injection femoral block. Postoperatively, each patient was recorded with a Visual Analogue Score (VAS) of pain assessment. The total number of patients who required additional bolus doses of epidural and additional analgesics, the individual patient ratings, and the complications, if any, were noted and analyzed on day 1(D1) and day 2(D2) of the surgery.

RESULTS

The mean time for developing a VAS score of at least 3 was 8.55±1.78 hours. The VAS assessment mean scores were compared to that of D2 and the ratio which was obtained was 0.4±0.32. The mean VAS scores were higher on D2 as compared to those on D1 and they were statistically significant (P<.0001). A categorical score comparison too revealed higher scores on D2 (P<.001). A total of 52% patients required bolus doses of epidural analgesia with bupivacaine on D2 as compared to those on D1 (16%). Additional analgesia on demand was noted in 21% patients on D1 in contrast to 67% patients on D2. The rating of the analgesia as 'excellent' by 29% patients, as 'good' by 46% patients, as 'adequate' by 17% patients and as 'poor' by 8% patients was noted on D1. Similarly, the ratings as 'excellent' by 4% patients, as 'good' by 29% patients, as 'adequate' by 58% patients, and as 'poor' by 8% patients, was recorded for D2, respectively (P<.001).

CONCLUSION

A single injection femoral nerve block provides adequate analgesia for the patients who undergo TKR surgery, when an active epidural is in-situ on the day of the surgery. It keeps the analgesic mode as simple and comfortable and it achieves lower pain scores on the day of the surgery, also with least complications, in patients with an ongoing epidural local anaesthetic infusion.

The role of regional anaesthesia techniques in the management of acute pain

Regional anaesthesia and analgesia techniques are used to effectively manage acute pain after a variety of surgeries. With the rapid growth of ultrasound-guided procedures, anaesthetists are re-examining regional anaesthesia and analgesia and their roles in pain management. In this evolving field previous published data may not reflect current practice. Therefore, a narrative review of recent literature was undertaken to establish the current utility and efficacy of regional anaesthesia and analgesia for the management of acute pain following surgery. Only prospective randomised controlled trials published between March 2009 and March 2011 with outcome measures of analgesia efficacy were included. Sixty-five randomised controlled trials were identified involving 4841 patients. Regional techniques for the management of knee (26%), abdominal (26%) and shoulder (14%) surgery were most frequently studied. The review provides further evidence that regional anaesthesia and analgesia can offer excellent analgesia with acceptable side-effects for the management of postsurgical pain. In addition, the results of this review support the use of ultrasound guidance when performing regional techniques and continuous catheter techniques to prolong analgesia.