A continuous peripheral nerve block (CPNB) or peripheral nerve catheter (PNC) is essentially an indwelling tubular device inserted via a needle through the skin, with orifices at each end for injection and delivery of local anesthetic around nerve or within a fascial plane known to contain traversing neural elements. Since its development, there has been a multitude of iterations and modifications, creating what is now an essential device in the prevention and treatment of postoperative pain after major surgery. The use of catheters for the infusion of local anesthetic extends back to 1931, when Dr. Eugen Aubrel, a Romanian professor of obstetrics and gynecology, used a silk ureteral catheter to deliver a continuous lumboaortic plexus block for the first stage of labor. Subsequently, the indwelling Lemmon needle was developed by Dr. William Lemmon and later modified by Drs. Robert Hingson and Waldo Edwards to provide a method of delivering continuous caudal anesthesia via a malleable stainless-steel needle attached to a syringe via long tubing.
After reports of the limitations associated with the modified Lemmon needle were published, including migration and breakage of the needle, Dr. Edward Tuohy applied the ureteral catheter to continuous spinal anesthesia in the 1940s. At the time, the catheter was delivered via a 15-gauge Barker needle, which upon removal was sequentially sterilized but not reused more than ten times per Dr. Tuohy’s recommendation. He subsequently developed the Tuohy needle, which is still in use today. Nylon catheters later replaced their silk predecessors after a case of meningitis was reported by Dr. Samuel Manalan in that same decade.
Several modifications to needle size, type, and technique were made over the following years until Dr. Manuel Curbelo, a Cuban anesthesiologist who had visited the Mayo Clinic three years prior, described an adaptation of the Tuohy needle to achieve peridural passage of an indwelling catheter in 1949 to provide anesthesia for surgeries below the neck. Drs. Charles Flowers, Louis Hellman, and Robert Hingson collaborated later that year to describe the use of a continuous epidural catheter, threaded through a 16-gauge Tuohy needle into the second lumbar interspace, for vaginal and cesarean deliveries, another technique which remains in use today, with minor modifications. The continuous peripheral nerve block was first described in 1946 by F. Paul Ansbro for upper extremity surgeries1. By 1951, Sarnoff and Sarnoff reported using a continuous nerve block to treat intractable hiccups, demonstrating the diversity of experimentation with regional anesthesia during that fruitful period in the history of anesthesia.4
Regarding the current practice in management of perineural catheters, there are several considerations and potential complications which must be accounted for in addition to the standard principles used to guide management of all nerve blocks. The indications for use of PNCs are essentially the same regarding surgical anesthesia, with the addition that the catheter allows for continuous delivery of dilute local anesthetic for extended postoperative analgesia. This is useful for cases where postoperative pain is expected to be persistently high and will be inadequately controlled on intravenous and/or oral analgesics. PNCs are also useful in situations where standard dosing of opioid analgesics is contraindicated or poorly tolerated (e.g. opioid tolerant or active substance abuse, severe PONV, severe OSA). In addition, continuous regional techniques have been used to treat vasospasm (Raynaud’s phenomenon, digital injury/reimplantation), CRPS, phantom limb pain, terminal cancer pain, and trigeminal neuralgia. While there are several useful clinical applications for CPNB, the most rigorously tested of these is for perioperative pain control. There remains a paucity of level-I studies evaluating the effectiveness of PNCs in these other applications, however there are several trials underway to this effect. Given the increased risk for potential complications from an indwelling device, PNCs are typically preserved for cases when single-shot nerve blocks along with other non-invasive analgesics will be inadequate and the benefit of placing a catheter outweighs the potential risks. Absolute contraindications to placement of a PNC are few and include patient refusal, allergy to local anesthetic, or inability to cooperate with procedure. Relative contraindications include active infection or preexisting nerve deficit in the intended site or distribution, and coagulopathy, especially when the planned block is in a non-compressible location.
References
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