Anaesthesia 2020, 75 (Suppl. 1), e101–e110 doi:10.1111/anae.

14868

Review Article

Advances in regional anaesthesia and acute pain

management: a narrative review
E. Albrecht1 and K. J. Chin2

1 Program Director of Regional Anaesthesia, Department of Anaesthesia, Lausanne University, Hospital, Lausanne,
Switzerland
2 Associate Professor, Department of Anesthesia, Toronto Western Hospital, University of Toronto, Toronto, Canada

Summary
Regional anaesthesia has undergone several exciting advances in the past few decades. Ultrasound-guided
techniques of peripheral nerve blockade have become the gold standard thanks to the associated
improvements in efficacy, ease of performance and safety. This has increased the accessibility and utilisation of
regional anaesthesia in the anaesthesia community at large and is timely given the mounting evidence for its
potential benefits on various patient-centred outcomes, including major morbidity, cancer recurrence and
persistent postoperative pain. Ultrasound guidance has also paved the way for refinement of the technical
performance of existing blocks concerning simplicity and safety, as well as the development of new regional
anaesthesia techniques. In particular, the emergence of fascial plane blocks has further broadened the
application of regional anaesthesia in the management of painful conditions of the thorax and abdomen. The
preliminary results of investigations into these fascial plane blocks are promising but require further research to
establish their true value and role in clinical care. One of the challenges that remains is how best to prolong
regional anaesthesia to maximise its benefits while avoiding undue harm. There is ongoing research into
optimising continuous catheter techniques and their management, intravenous and perineural
pharmacological adjuncts, and sustained-release local anaesthetic molecules. Finally, there is a growing
appreciation for the critical role that regional anaesthesia can play in an overall multimodal anaesthetic strategy.
This is especially pertinent given the current focus on eliminating unnecessary peri-operative opioid
administration.

.................................................................................................................................................................
Correspondence to: K. J. Chin
Email: gasgenie@gmail.com
Accepted: 9 August 2019
Keywords: acute pain; anaesthesia; analgesia; peripheral nerve blocks; postoperative; regional; ultrasound
Twitter: @DrEAlbrecht; @KiJinnChin

Introduction timely as there is growing recognition of the need to re-

Regional anaesthesia has undergone a growing evaluate opioid use as a mainstay of anaesthesia and
renaissance in recent decades. This is primarily due to acute pain management [1]. Regional anaesthesia has
the maturation of ultrasound-guided techniques, which always had a role to play in minimising peri-operative
have placed competence in core block techniques within opioid requirements, but it should no longer be seen as
reach of most anaesthetists. The ubiquity of ultrasound in merely an alternative to general anaesthesia, rather a
anaesthetic environments has further contributed to the complement to an overall multimodal anaesthetic
increased accessibility of regional anaesthesia. This is strategy [2].

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Regional anaesthesia: beyond acute
pain management
The potential benefits of peri-operative
anaesthesia extend beyond acute pain relief. In total hip
and knee arthroplasty, several large retrospective studies
of clinical and administrative databases
demonstrated that, when compared with
anaesthesia, neuraxial anaesthesia is associated with a
reduction in patient mortality, major morbidity (e.g.
pulmonary complications, transfusion requirements) and
economic outcomes such as length of hospital stay [3, 4].
Regional anaesthesia has been advocated in oncological
surgery to reduce the risk of cancer recurrence, based on
mechanistic evidence for the inhibition of tumour cell
seeding and growth by various pathways. These include
effective suppression of the adrenergic and inflammatory
response to surgery, preservation of immune function, a
direct action of systemic local anaesthetics on tumour cell
apoptosis, and indirectly through reduction in the use of
opioids which may have their own pro-metastatic effects
[5]. Although the clinical evidence for benefit remains
equivocal pending the completion of large prospective
randomised studies, regional anaesthesia is still valuable
given the benefits of enhanced patient comfort and
recovery and the absence of evidence for
concerning cancer recurrence. Finally,
anaesthesia may also contribute to a reduced risk of
persistent postoperative pain in a variety of clinical
settings, including breast surgery, thoracotomy and
caesarean section [6]. Optimal efficacy for management
of both acute and chronic postoperative pain is likely to
be obtained with pre-incisional rather than postoperative
nerve blockade [7] and in combination with other peri-
operative multimodal analgesic strategies [8]. This speaks
to the importance of integrating regional anaesthesia and
general anaesthesia where indicated, rather
regarding them as ‘either/or’ options [2].
Regional anaesthesia: advances in
safety and technical performance
Adoption of ultrasound guidance as the de facto gold
standard has also contributed to the safety of regional
anaesthesia, particularly due to the reduced risk of local
anaesthetic systemic toxicity following peripheral nerve
blockade [9]. This can be attributed to associated
reductions in minimum local anaesthetic dose requirements
and accidental vascular puncture. Lipid emulsion has also
been firmly established as an effective treatment for local
anaesthetic systemic toxicity and has reduced the likelihood
of cardiac-related mortality [10].
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A similar impact of ultrasound guidance on the risk of
neurological complications following regional anaesthesia
regional has yet to be conclusively demonstrated; however, this is
unsurprising given the multifactorial aetiology and relatively
low incidence of peri-operative peripheral nerve injury.
have Advances in regional anaesthesia in this regard pertain
general primarily to both an increased understanding of the micro-
architecture of nerves and their surrounding tissues, as well
as the ability to be more selective about where we place the
needle tip and deposit injectate in relation to the nerve. At
the same time, the recognition that ultrasound-guided
regional anaesthesia is a relatively complex procedure has
led to a greater focus on developing effective teaching
strategies and competency assessment tools. It is likely that
a structured educational approach, utilising defined task
metrics, will improve learner performance [11].
In recent years, ‘intracluster’ injections, particularly in
the supraclavicular brachial plexus, have been advocated
by some investigators as advantageous due to a faster
onset and prolonged duration of anaesthesia [12]. It is
theoretically possible to perform a subepineurial but
extrafascicular injection of local anaesthetic that might
result in a faster onset and greater block intensity than a
subparaneural injection (Fig. 1). However, the challenges
harm of accurate needle tip localisation, adequate ultrasound
regional image quality and interpretation of sono-anatomy make it
difficult to ensure that intrafascicular injection will not
occur. Indeed, the nebulous term – intracluster – only
serves to highlight the limitations of ultrasound imaging in
delineating the anatomy of the supraclavicular brachial
plexus. As illustrated in Fig. 2, an intracluster injection
involves plunging the needle tip into the visible ‘cluster’ of
nerve fascicles that constitute the superior, middle or
inferior trunks. What is not usually visible on ultrasound is
the demarcation between paraneurium, epineurium and
than perineurium; or between nerve bundles and individual
fascicles. It is not surprising, therefore, that both cadaveric
[13, 14] and clinical studies [15] have shown that
intracluster injections are associated with a significant
incidence of subepineurial or intrafascicular injection. One
case series of more than 250 patients showed that one out
of six patients receiving an interscalene or supraclavicular
brachial plexus block sustained unintentional nerve
puncture despite the use of ultrasound guidance [15]. It
should further be noted that while intraneural injection
(clinically defined as sonographically visible nerve
swelling) in isolated peripheral nerves, such as the sciatic
and median nerves, may carry less risk of intrafascicular
disruption [16], these findings cannot be extrapolated to
sites with more complex architecture such as the brachial
© 2020 Association of Anaesthetists
Albrecht and Chin | Advances in regional anaesthesia Anaesthesia 2020, 75 (Suppl. 1), e101–e110

Figure 1 Graphical representation of the basic structure of a nerve. The axon (nerve fibre) is the smallest functional unit of a
nerve and may be myelinated, as illustrated, or unmyelinated. The endoneurium is a fine collagenous layer that encases axons.
Axons are organised into bundles called fascicles, and each fascicle is surrounded by a multilayered membrane called the
perineurium. The epineurium is the connective tissue layer that encloses groups of fascicles and delineates the macroscopic
boundary of the nerve. The interfascicular connective tissue is sometimes called the internal or inner epineurium, in which case
the outermost collagen lamina may be termed the external or outer epineurium. Individual nerves and plexuses are usually
further surrounded by layers of connective tissue, which is often organised into a distinct sheath. Reproduced with permission
from KJ Chin Medicine Professional Corporation.

Figure 2 Histological cross-section of the supraclavicular brachial plexus with overlaid images of a 22-gauge needle tip drawn
to scale (a–d), and corresponding ultrasound images. The structural complexity of the plexus is difficult to appreciate on
ultrasound, even with good quality images as shown. At best, the boundaries between the superior trunk (ST), middle trunk (MT)
and inferior trunk (IT) can be distinguished on ultrasound. It is near-impossible to differentiate the paraneurium from the
epineurium and the perineurium, especially as these layers are often closely apposed (see inset). As a result, when placing the
needle tip into the cluster of the inferior trunk (ultrasound 1) or the cluster of the superior trunk (ultrasound 2), it is difficult to be
certain if injection will be subepineural and intrafascicular (a and c), subepineurial but extrafascicular (d), or merely
subparaneural/intrafascial (b). Reproduced with permission from KJ Chin Medicine Professional Corporation. STa, anterior
division; STp, posterior division.

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Anaesthesia 2020, 75 (Suppl. 1), e101–e110
plexus [14], which also has a lower connective tissue:
neural tissue ratio [17].
It is widely accepted that trauma to nerve fascicles,
either by needle puncture or intrafascicular injection, is an
undesirable outcome. As a result, although it is reassuring
to note that accidental low-volume intraneural injection
rarely results in clinically significant neurological deficits
[15], the consensus is that the touted advantages of
deliberate intrafascial or intraneural injections are not
worth the risk, however small, of prolonged postoperative
neurological deficit [18]. There has instead been a push
for safer approaches to regional anaesthesia techniques,
particularly in the brachial plexus, that involve placing the
needle or catheter tip further away from target nerves [19,
20], or engaging in fewer needle passes [21], without
necessarily compromising block efficacy. For example, an
extrafascial approach to interscalene brachial plexus
block produced similar analgesia and a lower incidence
of hemidiaphragmatic paresis (21% vs. 90%) following
shoulder surgery compared with an intrafascial injection,
although onset time was prolonged by 9 min [19].
Another strategy to avoid accidental intraneural injection
is to adopt a needle trajectory that is tangential to the
nerve circumference, making it more likely that
the needle will glance off rather than penetrate the
epineurium [22].
Fascial plane blocks
There has been a rise in popularity of regional anaesthesia
techniques that involve an injection of local anaesthetic into
fascial planes rather than directly around discrete nerves.
These fascial plane blocks have found particular application
in truncal analgesia as simpler and safer alternatives to
thoracic epidural and paravertebral blockade [23, 24]. The
transversus abdominis plane (TAP) block was the first to
enter mainstream practice, beginning as a surface
landmark-guided technique and evolving into what is now
known as the lateral ultrasound-guided TAP block. As the
understanding of abdominal wall anatomy and innervation
advanced, variants on the lateral ultrasound-guided TAP
block approach developed, including the subcostal and
posterior TAP blocks [23]. The site of actual injection into the
TAP plane determines the area of abdominal wall coverage
and thus the clinical indication and expected efficacy for
TAP blocks will depend on the specific approach being
employed [25]. Although TAP blocks have not replaced
thoracic epidurals for analgesia in major abdominal surgery,
the evidence indicates they are modestly effective with
fewer side-effects, particularly hypotension [26, 27].
However, the TAP block may soon be superseded in its role
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Albrecht and Chin | Advances in regional anaesthesia
as a simpler (albeit less effective) alternative to epidural
analgesia by other ultrasound-guided fascial plane blocks
such as the rectus sheath, erector spinae plane (ESP) and
quadratus lumborum (QL) blocks.
The QL block evolved from the posterior TAP block [23]
and itself has proven to be a heterogeneous group of
techniques, with lateral, posterior, anterior (transmuscular),
subcostal and supra-iliac variants described to date [28].
Unlike the lateral and subcostal TAP blocks, which target
branches of the thoraco-abdominal nerves within the fascial
plane sandwiched between transversus abdominis and
internal oblique muscles, the QL block purportedly acts (at
least in part) by injectate spread to the thoracic
paravertebral space. It is unclear at this time if there are
material clinical differences between the different QL block
variants, but cadaveric studies suggest that different
injection sites around the QL muscle do result in different
injectate spread patterns [28]. Clinical evidence for the QL
block is still sparse but early studies indicate that it appears
to provide effective analgesia in lower abdominal surgery,
such as caesarean section [29, 30] or urological procedures
[31]. It may not, however, be sufficient for more extensive
surgery [32] and its relative efficacy with regard to other
truncal block techniques remains to be determined. Certain
variants, for example, the anterior and subcostal QL blocks,
cannot be performed in the supine position and are deeper
blocks with more complex sono-anatomy. These technical
considerations may make them less attractive compared
with TAP or rectus sheath blocks. It is also worth noting that
the QL block, particularly the anterior injection approach,
may result in blockade of the lumbar plexus; this has been
employed therapeutically in hip surgery, but can also cause
accidental leg weakness [33].
Several fascial plane block techniques have been
described for thoracic analgesia, including pectoral nerves
(Pecs) 1 and 2, serratus anterior plane and parasternal
blocks [24]. The Pecs-2 and serratus anterior plane blocks
provide effective analgesia in breast surgery [34] and the
serratus anterior plane block is also finding an increasing
role in thoracic surgery and trauma [24, 35, 36]. A more
recent development is that of paraspinal fascial plane
blocks, such as the ESP [37], the retrolaminar [24] and the
mid-point transverse process to pleura (MTP) blocks [38].
These involve local anaesthetic injection into a
musculofascial plane adjacent to the bony vertebrae (the
transverse processes or the lamina in the ESP block and
retrolaminar block, respectively), rather than directly into
the paravertebral space. Nevertheless, at least part of their
analgesic effect is attributed to spread into the
paravertebral or epidural space; hence the term
© 2020 Association of Anaesthetists
Albrecht and Chin | Advances in regional anaesthesia Anaesthesia 2020, 75 (Suppl. 1), e101–e110

Table 1 Summary of the different methods to prolong the duration of analgesia of regional anaesthetic techniques.
Expected
prolongation vs.
Method single injection Advantages Limitations
Local anaesthetic
adjuncts
6–8 h • Ease of
administration
• Off-label route of administration when administered
perineurally, except for adrenaline
Sustained-release
local anaesthetic
24–72 h • Ease of
administration
• Only approved for interscalene brachial plexus block, TAP
block and surgical infiltration
(liposomal • Lack of robust evidence regarding the expected advantages
bupivacaine) • Two hundred times more expensive than plain bupivacaine
Continuous As long as the • Flexibility and • More complex to perform than single-injection blocks
catheter catheter remains in control of duration • Time and resource-intensive to insert and manage
techniques place and intensity of • Requires organised follow-up (e.g. acute pain service)
analgesia • Associated secondary rate failure is low but not negligible
• Mitigation of
rebound pain
TAP, transversus abdominis plane.

‘paravertebral-by-proxy’ [39]. Although the paraspinal Duration: the challenge to regional

blocks were originally described for thoracic analgesia, they
can be performed at almost any vertebral level to target the
relevant spinal nerve. The ESP block in particular has been
utilised to provide abdominal analgesia by injection at the
T8–10 levels [40, 41], and there are also preliminary reports
of its use in the management of shoulder pain [42, 43] and
hip or proximal lower limb pain [44, 45] at high thoracic or
lumbar vertebral levels.
These blocks have sparked off a new wave of
enthusiasm for regional anaesthesia of the thorax and
abdomen. The attraction lies not only in their apparent
clinical efficacy but also in their relative simplicity and
safety, particularly as the needle tip remains distant from
the pleura and spinal cord. This has expanded the
application of regional anaesthesia to settings such as
cardiac surgery [46] and liver transplant surgery [40],
where concerns regarding coagulation abnormalities
have traditionally been a limitation. The recognition that
the paraspinal blocks, such as the ESP block or the
thoracolumbar interfascial plane block, will also effectively
block dorsal rami of spinal nerves has further led to their
utilisation in thoracic and lumbar spine surgery to provide
opioid-sparing analgesia [47–51]. Notwithstanding this
promising start, more research is needed to fully establish
the role of paraspinal and fascial plane blocks in clinical
practice, particularly with respect to the more-established
techniques of thoracic epidural and paravertebral
blockade [52]. It should also be noted that current
evidence indicates that fascial plane blocks are primarily
analgesic in nature, and unlikely to be a reliable method
of surgical anaesthesia despite isolated case reports to
the contrary [53, 54].
anaesthesia in acute pain management
One of the biggest limitations of regional anaesthesia in
acute pain management is the finite duration of single-
injection techniques. The duration of effective analgesia
depends on the type, the volume and the concentration of
injected local anaesthetic, as well as patient factors such as
diabetic neuropathy [55]; but in general, rarely lasts longer
than 16 h. In surgery expected to produce moderate-severe
postoperative pain, this can result in the phenomenon of
rebound pain [56]. The delayed onset of intense
postoperative pain is particularly problematic in ambulatory
surgery and can significantly increase the need for post-
discharge medical attention [57]. Although patients often
still appreciate the enhanced recovery and opioid-sparing
offered by regional anaesthesia in the immediate
postoperative period [58], optimising the pain experience
in the face of rebound pain remains a challenge to be
addressed. One solution is to prolong the duration of
regional anaesthesia by using pharmacological adjuncts or
sustained-release local anaesthetics in single-injection
techniques, or by employing continuous catheter
techniques instead (Table 1).
Pharmacological adjuncts to prolong the effect of local
anaesthetics
Many different agents have been combined with local
anaesthetics over the years to prolong the duration of
action, some with more success than others (Table 2).
Adrenaline is a common additive that serves as a marker
of intravascular injection and to reduce systemic
absorption but only prolongs the duration of analgesia by
approximately 1 h [59]. Buprenorphine, at perineural

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Anaesthesia 2020, 75 (Suppl. 1), e101–e110 Albrecht and Chin | Advances in regional anaesthesia

Table 2 Characteristics of the different perineural adjuncts. Among these molecules, dexamethasone is highly recommended
due to its favourable risk:benefit profile.
Expected Safety
prolongation Optimal Approved for profile
vs. single dose or perineural (in vitro Intravenous
Method injection concentration Advantages Limitations administration toxicity) alternative

Adrenaline 1h 2.5–5 lg.ml 1

• Approved route
of administration
• Limited
prolongation of
Yes Safe None

• Marker of analgesia
intravascular • Tachycardia
injection
• Hypertension
• Reduces systemic
absorption
Clonidine 2h 150 lg
• None • Sedation No Unsafe None

• Hypotension
• Bradycardia
Dexmed- 6h 50–60 lg
• Reasonable • Sedation No Safe Bolus of

• 1 lg.kg 1
etomidine prolongation of Hypotension
analgesia
• Bradycardia
Dexamethasone 8h 4 mg
• Acceptable
safety profile, one
• Crystallisation when
incubated
No Safe Bolus of
0.11 mg.kg 1
of the longest with ropivacaine but at the
prolongations of expense of a
analgesia rise in blood
glucose levels
by
1.5 mmol.l 1
in both
diabetic and
non-diabetic
patients
Buprenorphine 9h 100–300 lg
• Longest
prolongation of
• Five-fold increase in
postoperative
No Unsafe None

analgesia nausea and

vomiting

doses ranging from 100 to 300 lg, prolongs analgesia by
8.6 h but at the expense of a five-fold increase in
postoperative nausea and vomiting [60]. Alpha-2-agonists,
such as clonidine 150 lg and dexmedetomidine 50–
60 lg, will extend mean analgesic duration by 2 and 6 h,
respectively, but are associated with sedation, hypotension
and bradycardia [61, 62].
Perineural dexamethasone has been widely studied at
doses ranging from 1 to 8 mg [63, 64], and exhibits a dose–
response relationship up to a ceiling of 4 mg [64], at which it
prolongs mean analgesic duration by 8 h [63]. Of note,
dexamethasone incubated with ropivacaine for 15 min
results in crystallisation due to elevated pH
dexamethasone and the incompatibility of ropivacaine with
alkaline solutions; this phenomenon does not occur with
bupivacaine [65]. This serves to highlight that perineural
injection of all these drugs (except adrenaline) remains an
off-label route of administration, even though the current
literature supports an acceptable safety profile for
perineural dexamethasone [63]. Intravenous (i.v.)
1
dexamethasone 0.1 mg.kg is an alternative to perineural
administration; however, it must be noted that the i.v. route
is slightly less effective in extending analgesic duration [66]
and that it also produces a rise in blood glucose levels by an
average of 1.5 mmol.l 1
in both diabetic and non-diabetic
patients [67], with a peak effect at around 4 h [68]. It is worth
noting that a recent publication showed that the i.v.
1
combination of dexamethasone 0.11 mg.kg and
1
dexmedetomidine 1 lg.kg after interscalene brachial
plexus block dramatically increased the duration of
analgesia from 10.9 to 66.3 h after shoulder arthroscopy
[69]. However, this needs to be confirmed by other studies.
Further research is also needed to establish if other
of combinations of i.v. and perineural adjuncts might prolong
local anaesthetic conduction blockade without causing
undue adverse effects.
Sustained-release local anaesthetics
Liposomal bupivacaine is currently the only commercially
available sustained-release formulation of local anaesthetic.
The United States Food and Drug Administration has
approved it for limited applications, namely local infiltration

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Albrecht and Chin | Advances in regional anaesthesia
of surgical sites, TAP and interscalene brachial plexus block;
however, it is not widely available in other countries. With
regard to its use in surgical site infiltration, liposomal
bupivacaine offers superior analgesia compared with
placebo, but there is insufficient evidence to support an
advantage over infiltration with plain bupivacaine or
alternative regional anaesthesia techniques [70]. The role of
liposomal bupivacaine in peripheral nerve blockade
remains undefined [71, 72]. Indeed, when compared with a
placebo solution, administration of liposomal bupivacaine
for femoral nerve block in patients undergoing total knee
arthroplasty showed reduced resting pain scores only
during the first 24 postoperative hours and not beyond [71].
On the other hand, the only study to date to compare
liposomal with plain bupivacaine for interscalene block in
major shoulder surgery reported modest improvements in
worst-reported pain scores during the first postoperative
week (mean 3.6 vs. 5.3) [72]. Liposomal bupivacaine is
approximately 200 times as expensive as plain bupivacaine,
and thus further head-to-head trials, including studies
utilising the adjuncts discussed above as comparators, are
needed before it can be recommended for use.
Continuous catheter techniques
Perineural catheters can be inserted using many of the same
ultrasound-guided approaches as single-injection blocks
and offer advantages including flexibility and control with
regard to block duration and intensity [73]. They can
provide a superior pain experience and mitigate rebound
pain [74], but are by no means a perfect solution.
Continuous catheter techniques are more complex to
perform and resource-intensive to care for. Patients may
experience undesirable side-effects from prolonged
conduction block and are at risk of complications such as
infection and catheter entrapment. There is also a
secondary failure rate associated with catheter migration,
dislodgement, leakage, pump malfunction or suboptimal
dosing regimens [73, 75]. The ongoing investigation into
the superiority of programmed intermittent bolus dosing
over continuous infusion regimens remains inconclusive,
and it may be that any advantages apply only to a subset of
regional anaesthesia techniques [76]. The decision to insert
a perineural catheter should be individualised based on
patient factors, site and type of surgery, anticipated
postoperative pain and local expertise and resources. In
many settings, particularly day-case surgery, a simpler
strategy may be to perform a single-injection regional
anaesthesia technique with adjuncts and a systemic
multimodal analgesic regimen [77].
© 2020 Association of Anaesthetists
Anaesthesia 2020, 75 (Suppl. 1), e101–e110
The future for regional anaesthesia in
acute pain management
It has been almost two decades since ultrasound-guided
regional anaesthesia techniques were introduced, making
regional anaesthesia accessible to the wider community.
Our understanding of the core techniques for peripheral
nerve blockade has been solidified and we are now in an era
of refinement and innovation which promises to increase
the reach of regional anaesthesia. One of the challenges will
be to ensure that novel techniques truly represent advances
in regional anaesthesia and offer concrete advantages with
regard to efficacy and safety in acute pain management
[78]. This will require rigorous research methodology, but
just as importantly, the measurement of relevant outcomes
[79].
The administration of intra-operative opioids has long
been part of ‘balanced anaesthesia’, to relieve pain during
and immediately after surgery. This is, however, one of the
factors implicated in the current opioid epidemic [80] and
has led to a timely re-examination of the traditional
anaesthetic recipe [81]. There is a growing realisation that
opioids are not necessarily an essential ingredient in all
cases. A recent meta-analysis showed that, when compared
with a traditional opioid-inclusive regimen, opioid-free
anaesthesia was associated with similar pain scores in the
first 24 h and a 20% reduction in postoperative nausea and
vomiting [82]. Administration of peri-operative opioids is
also associated with respiratory depression, reduced quality
of recovery, prolonged recovery area length of stay
and increased healthcare costs [81].
Nevertheless, we must be mindful of the human
tendency to swing between extremes of behaviour. An
overzealous pursuit of opioid-free anaesthesia at all costs is
unwarranted [1] and intra-operative anaesthesia must still
incorporate antinociception for the maximal benefit [7].
Regional anaesthesia has a critical role to play in crafting a
multimodal strategy for suppressing nociceptive responses
and sequelae [2]. Future research into regional anaesthesia
should therefore not only focus on the isolated efficacy of
a given technique and its impact on patient-centred
outcomes but should also incorporate an examination of its
contribution in the context of overall anaesthetic
management.
Conclusion
Advances in technology, technique development and
pharmacology over the last decade have significantly
improved efficacy and safety of regional anaesthesia.
Adoption of ultrasound guidance as the gold standard has
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been key to this; however, it remains a skill (albeit a more
accessible one) that must be acquired through training and
practice. There needs to be continued investment into
regional anaesthesia education and a recognition of the
limitations that still exist with regard to imaging nerves and
block needles when promulgating techniques for general
use. The development of fascial plane blocks has been an
important step in increasing the reach of regional
anaesthesia, although more research is needed to clarify
their role in peri-operative pain management. The
expanding use of adjuncts to increase the clinical duration
of local anaesthetics has also provided practitioners with an
alternative to the more complex continuous catheter
techniques for improving the postoperative pain
experience. The role of regional anaesthesia in peri-
operative care and acute pain management is more
important now than it has ever been, and we anticipate that
it will only continue to strengthen in the coming years.
Acknowledgements
The authors acknowledge the invaluable contributions of Dr
M. A. Reina and R. Chin, who supplied the histological
images and artwork for the figures. EA has received grants
from the Swiss Academy for Anaesthesia Research, B. Braun
Medical AG and the Swiss National Science Foundation. EA
has received an honorarium from B. Braun Medical AG. KC
has no competing interests.
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© 2020 Association of Anaesthetists