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Cochrane Special Collections

Coronavirus (COVID-19): regional anaesthesia to reduce drug use in anaesthesia and avoid aerosol generation

5 January 2021
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Special Collection

First published on 23 March 2020 and updated on an ongoing basis; last updated on 5 January 2021 (changes detailed below); all the reviews in this Special Collection are free to access

This Special Collection is one of a series of collections on COVID-19. It is also available in Simplified Chinese, Farsi, French, GermanJapanese, KoreanMalay, PortugueseRussianSpanish and Thai.

Regional anaesthesia is the term given to a variety of techniques where an anaesthetist injects local anaesthetic around peripheral nerves or the spinal cord to create temporary paraesthesia or paralysis in that part of the body. These techniques can be so effective that they can allow surgery in awake patients, and they provide excellent analgesia allowing for the avoidance of strong opiates and anaesthetic options for patients in whom general anaesthesia may be particularly hazardous.

The COVID-19 pandemic has created unique challenges for anaesthesia. General anaesthesia and manipulation of the airway is an aerosol generating procedure, of which the subsequent aerosolization can potentially infect healthcare workers. Another aspect of the COVID-19 pandemic is the unprecedented demand for anaesthetic drugs for use in critical care, which has reduced the supply of drugs for general anaesthesia. The Royal College of Anaesthetists in the UK have suggested regional anaesthesia as a solution to these problems in their urgent guidance on emergency surgery for procedures such as hip fractures and in guidance to limit drug use in theatre.[1] Therefore the safe and evidence-based practice of regional anaesthesia is increasingly important to maintain reliable anaesthetic services and hopefully limit exposure of healthcare workers to COVID-19.

Independent of the COVID-19 pandemic there are other benefits to regional anaesthesia in standard anaesthetic practice. It provides excellent analgesia after surgery, which allows for the avoidance of strong opiates, and an alternative anaesthetic option for patients in whom general anaesthesia may be particularly hazardous. Regional anaesthesia may also improve recovery and limit some common complications of surgery, such as nausea, vomiting, and ileus, but the evidence for some of these outcomes is less certain.

There is much debate amongst anaesthetists as to when regional anaesthesia should be used, the most effective techniques to provide regional anaesthesia, the safety and effectiveness of local anaesthetics, opiates and adjuncts that can be injected, the value of peripheral nerve blocks versus neuraxial blockade, and the complications that can occur.

This Special Collection presents the available evidence from Cochrane Reviews produced by Cochrane Anaesthesia and aims to better inform these debates and support decision-making when planning regional anaesthesia.

Updated 5 January 2021: added link to translation into Korean and added new Cochrane Clinical Answer for Review 'Femoral nerve blocks for acute postoperative pain after knee replacement surgery'

Regional anaesthesia compared with conventional analgesic techniques

Reviews studying the overall benefits and risks of regional anaesthesia

Neuraxial blockade for the prevention of postoperative mortality and major morbidity: an overview of Cochrane systematic reviews

Various beneficial effects derived from neuraxial blocks have been reported, but it is unclear whether these effects have an influence on perioperative mortality and major pulmonary and cardiovascular complications. This overview summarizes Cochrane Reviews assessing the effects of neuraxial blockade on perioperative rates of death, chest infection, and myocardial infarction. Associated Cochrane Clinical Answer: How does neuraxial blockade compare with general anesthesia and systemic analgesia when used postoperatively?

Local anaesthetics and regional anaesthesia versus conventional analgesia for preventing persistent postoperative pain in adults and children

Regional anaesthesia may reduce the rate of persistent postoperative pain, a frequent and debilitating condition. This review aims to compare local anaesthetics and regional anaesthesia versus conventional analgesia for the prevention of persistent postoperative pain beyond three months in adults and children undergoing elective surgery. Associated Cochrane Clinical AnswerHow does local and regional anesthesia compare with conventional analgesia for women with persistent pain after breast cancer surgery?

Transient neurological symptoms (TNS) following spinal anaesthesia with lidocaine versus other local anaesthetics in adult surgical patients: a network meta‐analysis

Spinal anaesthesia has been implicated as one of the possible causes of neurological complications following surgical procedures. Transient neurological symptoms occurring during the immediate postoperative period are typically observed after the use of spinal lidocaine. Spinal lidocaine does however have a beneficial pharmacokinetic profile, especially for day case surgery. This review determines the prevalence of transient neurological symptoms after spinal anaesthesia with lidocaine. Associated Cochrane Clinical Answer: How do lidocaine and bupivacaine compare with each other and with alternative local anesthetics for adults undergoing spinal anesthesia?

How best to perform regional anaesthesia and which local anaesthetics and adjuncts to use

Reviews that compare different approaches to performing regional anaesthesia or the medications used

Air versus saline in the loss of resistance technique for identification of the epidural space

Epidural block remains one of the main regional anaesthesia techniques, and its success depends on correct identification of the epidural space. For several decades, the decision of whether to use air or physiological saline during the loss of resistance technique for identification of the epidural space has been influenced by the anaesthetist’s personal experience. This review evaluates the efficacy and safety of both air and saline in the loss of resistance technique for identification of the epidural space, as well evaluating complications related to the air or saline injected. Associated Cochrane Clinical AnswerHow does air compare with saline in the loss of resistance technique for identification of the epidural space?

Ultrasound guidance for upper and lower limb blocks

Peripheral nerve blocks can be performed using ultrasound guidance. It is not yet clear whether this method of nerve location has benefits over other existing methods. This review assesses whether the use of ultrasound to guide peripheral nerve blockade has any advantages over other methods of peripheral nerve location. Associated Cochrane Clinical Answer: For people undergoing upper or lower limb block, how does ultrasound guidance, with or without nerve stimulation, compare with an alternative guidance technique?

Hyperbaric versus isobaric bupivacaine for spinal anaesthesia for caesarean section

Bupivacaine is an amide local anaesthetic used in hyperbaric and isobaric forms. These are administered intrathecally into the spine to provide regional anaesthesia for caesarean section. Several trials have compared hyperbaric and isobaric bupivacaine, without conclusively showing the benefit of either. This review aims to determine the effectiveness and safety of hyperbaric bupivacaine compared to isobaric bupivacaine for spinal anaesthesia in women undergoing caesarean section. Associated Cochrane Clinical AnswerFor women undergoing cesarean section, how does hyperbaric bupivacaine compare with isobaric bupivacaine for spinal anesthesia?

Single, double or multiple‐injection techniques for non‐ultrasound guided axillary brachial plexus block in adults undergoing surgery of the lower arm

Regional anaesthesia comprising axillary block of the brachial plexus is a common anaesthetic technique for distal upper limb surgery. This review compares the relative effects (benefits and harms) of three injection techniques (single, double, and multiple) of axillary block of the brachial plexus for distal upper extremity surgery without the use of ultrasound guidance. Associated Cochrane Clinical AnswerWhat are the effects of different injection techniques during non-ultrasound guided axillary brachial plexus block for adults undergoing distal arm surgery?

Dexamethasone as an adjuvant to peripheral nerve block

Peripheral nerve block can be used for anaesthesia or postoperative analgesia. A limitation to its use for postoperative analgesia is that the analgesic effect lasts only a few hours, after which moderate-to-severe pain at the surgical site may result in the need for alternative analgesics. Several adjuvants have been used to prolong the duration of peripheral nerve block, including perineural or intravenous dexamethasone. This review evaluates the comparative efficacy and safety of perineural dexamethasone versus placebo, intravenous dexamethasone versus placebo, and perineural dexamethasone versus intravenous dexamethasone when added to peripheral nerve block for postoperative pain relief. Associated Cochrane Clinical Answers: Can adding perineural or intravenous dexamethasone to peripheral nerve blocks improve outcomes for adults undergoing surgery? and How does perineural dexamethasone compare with intravenous dexamethasone when used as an adjunct to peripheral nerve block in adolescents and adults undergoing surgery?

Adrenaline with lidocaine for digital nerve blocks

Adrenaline combined with lidocaine can prolong digital nerve block and in theory help to provide a bloodless operating field. Extended postoperative pain relief can reduce the need for analgesics and can facilitate hand rehabilitation. Conventionally, adrenaline is avoided at anatomical sites with end arteries because of concerns about arterial spasm, ischaemia and the development of gangrene distal to the site of drug infiltration. This review assesses the safety and efficacy of use of adrenaline combined with lidocaine for digital nerve blocks. Associated Cochrane Clinical Answer: How does lidocaine alone compare with lidocaine plus epinephrine for digital nerve blocks?

 

Liposomal bupivacaine peripheral nerve block for the management of postoperative pain

Poor postoperative pain management is thought to be associated with an increased risk of morbidity and mortality. Liposomal bupivacaine is an analgesic offering a novel method of sustained release. This review assesses the analgesic efficacy and adverse effects of liposomal bupivacaine when used for peripheral nerve block for the management of postoperative pain. Associated Cochrane Clinical AnswerHow does liposomal bupivacaine peripheral nerve block compare with no nerve block or an alternative nerve block for management of postoperative pain?

Orthopaedic surgery

Reviews relating to surgery involving bones and the musculoskeletal system

Regional analgesia for improvement of long‐term functional outcome after elective large joint replacement

Regional anaesthesia is thought to be more effective than conventional analgesia for controlling pain and so enables more rapid mobilization after large joint replacement. It remains unclear whether regional anaesthesia improves functional outcomes in the longer term after large joint replacement. This review assesses the effects of regional anaesthesia on long‐term functional outcomes after elective major joint replacement surgery. Associated Cochrane Clinical AnswerWhat are the effects of regional analgesia for improving long‐term functional outcomes after elective total knee replacement?

Femoral nerve blocks for acute postoperative pain after knee replacement surgery

Total knee replacement is a common operation with significant requirements for postoperative analgesia. Femoral nerve block is frequently utilized as an option to reduce pain and enable mobilization postoperatively. This review evaluates the benefits and risks of femoral nerve block used as a postoperative analgesic technique relative to other analgesic techniques among adults undergoing total knee replacement. Associated Cochrane Clinical Answer: For people post knee replacement surgery, how does femoral nerve block (FNB) compare with opioids, epidural, or local infiltration analgesia?

Nerve blocks or no nerve blocks for pain control after elective hip replacement (arthroplasty) surgery in adults

To facilitate the postoperative rehabilitation of hip replacements, pain must be adequately treated. Peripheral nerve blocks and neuraxial blocks have been proposed to replace or supplement systemic analgesia. This review of compares the relative effects (benefits and harms) of the different nerve blocks that may be used to relieve pain after elective hip replacement in adults. Associated Cochrane Clinical AnswerHow do peripheral nerve blocks compare with no peripheral nerve block for adults undergoing hip replacement surgery?

Anaesthesia for hip fracture surgery in adults

Hip fracture in adults carries a significant morbidity and mortality if surgical treatment is delayed. There is significant debate as to whether regional or general anaesthesia provides the best outcomes for hip fracture repair. This review focuses on comparing outcomes for regional versus general anaesthesia for proximal femoral fracture repair in adults. Associated Cochrane Clinical Answer: How does a neuraxial block compare with general anesthesia in adults undergoing hip fracture surgery?

Peripheral nerve blocks for hip fractures in adults

Various nerve blocks with local anaesthetic agents have been used for analgesia after hip fracture and subsequent surgery. This review focuses on the use of peripheral nerves blocks as preoperative analgesia, postoperative analgesia, or as a supplement to general anaesthesia for hip fracture surgery. Associated Cochrane Clinical Answer: What are the effects of peripheral nerve blocks in people with hip fracture?

Adductor canal blocks for postoperative pain treatment in adults undergoing knee surgery

Peripheral regional anaesthesia techniques are well established for postoperative pain treatment following knee surgery. The adductor canal block is a technique which can be applied as a single shot or by catheter for continuous regional analgesia. This review compares the analgesic efficacy and adverse events of adductor canal block versus other regional analgesic techniques or systemic analgesia for adults undergoing knee surgery. Associated Cochrane Clinical Answer: How does adductor canal block compare with sham treatment or femoral nerve block for adults undergoing knee surgery?

Continuous interscalene brachial plexus block versus parenteral analgesia for postoperative pain relief after major shoulder surgery

Major shoulder surgery is associated with severe postoperative pain with many different analgesic techniques being utilized to enable patient comfort and effective joint mobilization postoperatively. These techniques have included opioid and non‐opioid analgesics, local anaesthetics infiltrated into and around the shoulder joint, and regional anaesthesia. This review evaluates the analgesic efficacy of continuous interscalene brachial plexus block with parenteral opioid analgesia for pain relief after major shoulder surgery. Associated Cochrane Clinical AnswerFollowing major shoulder surgery, how does continuous interscalene brachial plexus block compare with parenteral analgesia for pain relief?

General surgery and vascular surgery

Reviews relating to surgery involving the organs of the abdomen and the major blood vessels

Epidural pain relief versus systemic opioid‐based pain relief for abdominal aortic surgery

Epidural analgesia is thought to offer improved analgesia compared with systemic opioid‐based medications, but its effect on morbidity and mortality is unclear. This review assesses the benefits and harms of postoperative epidural analgesia in comparison with postoperative systemic opioid‐based analgesia for adults undergoing elective abdominal aortic surgery. Associated Cochrane Clinical AnswerHow does epidural pain relief compare with systemic opioid-based pain relief in people undergoing abdominal aortic surgery?

Epidural local anaesthetics versus opioid‐based analgesic regimens for postoperative gastrointestinal paralysis, vomiting and pain after abdominal surgery

Transient gastrointestinal paralysis, nausea, vomiting, and pain are significant clinical problems following abdominal surgery. Anaesthetic and analgesic techniques that reduce pain and postoperative nausea and vomiting, while preventing or reducing postoperative ileus, may reduce postoperative morbidity, duration of hospitalization, and hospital costs. This review compares the effects of postoperative epidural analgesia with local anaesthetics versus postoperative systemic or epidural opioids. Associated Cochrane Clinical AnswerHow does epidural local anesthetics compare with opioid-based analgesia for improving outcomes in adults undergoing abdominal surgery?

Epidural analgesia versus patient‐controlled intravenous analgesia for pain following intra‐abdominal surgery in adults

Intravenous patient‐controlled analgesia (IVPCA) and epidural analgesia, using either continuous or patient‐controlled techniques, are popular approaches for analgesia following intra‐abdominal surgery. Despite several attempts to compare the risks and benefits, the optimal form of analgesia for these procedures is still debated. This review compares and evaluates both forms of epidural analgesia to IVPCA. Associated Cochrane Clinical Answer: For adults with pain following intra-abdominal surgery, how does epidural analgesia compare with intravenous patient-controlled analgesia (IV PCA)?

Cardiothoracic surgery

Reviews relating to surgery involving the heart and chest

Epidural analgesia for adults undergoing cardiac surgery with or without cardiopulmonary bypass

General anaesthesia combined with epidural analgesia may have a beneficial effect on clinical outcomes. However, the use of epidural analgesia for cardiac surgery is controversial due to a theoretical increased risk of epidural haematoma associated with systemic heparinization required during surgery. This review aims to determine the impact of perioperative epidural analgesia in adults undergoing cardiac surgery, with or without cardiopulmonary bypass, on perioperative mortality and cardiac, pulmonary, or neurological morbidity. Associated Cochrane Clinical Answer: How does perioperative epidural analgesia compare with systemic analgesia for adults undergoing cardiac surgery?

Paravertebral block versus thoracic epidural for patients undergoing thoracotomy

Thoracic surgery often results in severe postoperative pain due to dissection through ribs and intercostal muscles. Inadequate analgesia after surgery can impede recovery and increase the risks of developing complications such as atelectasis, pneumonia, and thrombosis, due to ineffective breathing, clearing of secretions, and poor mobilization. Effective management of acute pain following thoracotomy may prevent these complications and reduce the likelihood of developing chronic pain. This review compares the two regional techniques of thoracic epidural and paravertebral block in adults undergoing elective thoracotomy. Associated Cochrane Clinical Answer: How does a paravertebral block compare with a thoracic epidural in people undergoing thoracotomy?

About this Special Collection

References

1. Royal College of Anaesthetists and Association of Anaesthetists. Guidance on potential changes to anaesthetic drug usage and administration during pandemic emergency pressures. https://icmanaesthesiacovid-19.org/drug-demand-supply-guidance (accessed 16/4/2020)

Acknowledgements

This Special Collection was developed by Michael McEvoy and Muataz Amare (Dissemination Fellows, Cochrane Anaesthesia), Andrew Smith (Co-ordinating Editor, Cochrane Anaesthesia), Janne Vendt (Information Specialist, Cochrane Anaesthesia) and Teo Quay (Managing Editor, Cochrane Emergency and Critical Care, and Cochrane Anaesthesia), working with Monaz Mehta (Editor, Cochrane Editorial & Methods Department).

Image credit

Karrastock/GettyImages

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