Perineural catheters for continuous peripheral nerve blocks: a narrative review

Narrative review of perineural catheters

Article information

Anesth Pain Med. 2025;20(1):5-13

Publication date (electronic) : 2025 January 25

doi : https://doi.org/10.17085/apm.24192

Seokha Yoo

, Hansol Kim

, Jin-Tae Kim

Department of Anesthesiology and Pain Medicine, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Korea

Corresponding author: Jin-Tae Kim, M.D., Ph.D. Department of Anesthesiology and Pain Medicine, Seoul National University Hospital, Seoul National University College of Medicine, 101 Daehak-ro, Jongno-gu, Seoul 03080, Korea Tel: 82-2-2072-3295 Fax: 82-2-747-8363 E-mail: jintae73@gmail.com

Received 2024 December 27; Revised 2025 January 6; Accepted 2025 January 6.

Abstract

Continuous peripheral nerve blocks using perineural catheters are increasingly used because they are the only well-established techniques that can provide prolonged analgesia. Although the novel indications and benefits of each type of continuous peripheral nerve block have been well described in several review articles, there is a lack of recent publications focusing on the use of perineural catheters. Numerous clinical challenges are associated with the use of catheters for pain management. This narrative review discusses the currently available perineural catheter designs, catheter fixation methods, perineural catheter-related complications, and management strategies.

Keywords: Anesthesia, regional; Anesthetic, Local; Block, nerve; Catheter, indwelling; Catheter-related infections; Peripheral nerve injuries

INTRODUCTION

Since the early 21st century, with the widespread adoption of ultrasound in clinical practice, regional anesthesia techniques, including peripheral nerve blocks, have proliferated. Initially, the procedures involved a single injection of local anesthetic around the target nerve. However, the limited duration of analgesia led to a desire to prolong the effect of local anesthetics, and with the commercial availability of perineural catheters, continuous peripheral nerve blocks were increasingly performed. As the understanding of the relevant anatomy advanced, a variety of fascial plane blocks have been introduced, and catheters for continuous peripheral nerve blocks are currently inserted perineurally as well as into the interfascial space. This provides analgesia similar to the epidural blockade, which has long been the standard of care for postoperative pain management after thoracoabdominal surgery [1-3].

One effort to extend the analgesic duration of peripheral nerve blocks was the development of liposomal bupivacaine, which was first approved by the U.S. Food and Drug Administration (FDA) in 2011 [4]. However, several recent publications have demonstrated the failure of clinically relevant prolongation of analgesia with liposomal bupivacaine [5-9], with a significant discrepancy between studies sponsored by the manufacturer and those that did not [10]. These findings suggest that a continuous peripheral nerve block using catheters remains the most effective method for providing prolonged analgesia to surgical patients.

This narrative review does not address the current literature on each of the continuous peripheral nerve blocks that have already been reviewed in other excellent publications [11,12]. Instead, we focus on the catheter, which is essential for all continuous peripheral nerve blocks. We examine commonly used catheter types, securing techniques, perineural catheter-related complications, and the management of these catheters to provide guidance for clinicians who wish to start performing continuous peripheral nerve blocks.

CATHETER TYPES

Nerve block catheters can be classified into two primary designs based on the relationship between the catheter and needle: catheter-through-needle and catheter-over-needle. In addition, a ‘catheter-and-needle-in-one’ design, termed a suture-method catheter, has recently been developed, although this requires further studies. Fig. 1 shows schematics of the three catheter designs.

Fig. 1.

Schematic images of currently available catheter designs. (A) Catheter through the needle. (B) Catheter over the needle. (C) Needle insertion with a suture-method catheter. (D) Suture-method catheter placement after hub removal.

Catheter-through-needle

The catheter-through-needle technique, in which a flexible catheter is inserted through a larger-diameter needle, is a classic design for catheter insertion devices and has long been used for epidural catheterization. This technique is straightforward and familiar to the operator, as it is commonly used in several anesthetic procedures such as central line catheterization. However, a size discrepancy between the smaller catheter and needle hole can result in potential complications, such as local anesthetic leakage or catheter displacement at the insertion site. Methods such as the use of skin adhesive [13-15] or subcutaneous tunneling [16,17] have been proposed to address these drawbacks. However, these additional steps prolong the procedure time and may cause complications such as accidental cutting of the catheter [18].

In this technique, the catheter is inserted through the needle, and the tip of the catheter is extended farther than the needle tip after the needle reaches the target location, often placing the catheter tip slightly farther than the point initially reached by the needle. Therefore, although this technique allows greater control over the catheter tip placement, precise catheter tip placement requires careful manipulation of the catheter under ultrasound guidance.

Catheter-over-needle

Similar to an intravenous cannula, a catheter-over-needle design features a catheter larger in diameter than the puncture hole created by the needle. This design was briefly used for continuous spinal anesthesia to reduce cerebrospinal fluid leakage in the late 20th century [19] and was reintroduced in the field of regional anesthesia in the early 2010s. Several studies have demonstrated that catheter-over-needle techniques can reduce local anesthetic leakage at the insertion site as well as catheter dislocation owing to a tight seal between the catheter and the surrounding tissue [20-25]. Additionally, the catheter-over-needle design has been reported to shorten procedure time, although operators may require experience to become proficient with recently introduced assemblies [22,24].

Unlike the catheter-through-needle technique, this design uses a catheter mounted over a needle, eliminating the need to advance the catheter farther than the needle tip during insertion. Once the needle was withdrawn, the tip of the catheter remained in its exact position.

Suture-method catheter

This catheter is the most recently developed design, in which the catheter is attached to a suture-like curved needle so that it passes adjacent to the target nerve after being inserted into the skin and then exits at another site. This design has several advantages, including facilitating initial placement, securing both entry and exit sites, and repositioning a dislodged catheter at both ends in both directions, unlike other designs that can only be repositioned by retraction [26]. In addition, using the same needle and catheter diameters in this system can theoretically reduce local anesthetic leakage [27]. Although few studies have investigated the suture-method catheter, it has been reported to provide non-inferior postoperative analgesia [28] and can be easily repositioned after displacement compared with a traditional catheter design [29].

However, the suturing method has several drawbacks. Because of the inherent invasiveness of advancing the needle farther than the target nerve and through the skin, the entire needle trajectory should be carefully evaluated before catheter insertion to avoid damage to the target nerve [27]. Furthermore, precise placement of a curved needle tip requires expertise, and the presence of two skin puncture sites may increase the risk of infectious complications. Future research is required to evaluate the potential risks and benefits of suture-method catheters compared with traditional catheter designs.

CATHETER FIXATION METHODS

Unlike single-injection peripheral nerve blocks, continuous peripheral nerve blocks involve continuous administration of local anesthetics through a perineural catheter to provide prolonged analgesia. However, catheter dislocation can disrupt the distribution of the local anesthetic around the target nerve, resulting in inadequate analgesia and patient dissatisfaction. Several fixation methods have been used in clinical practice to prevent catheter dislodgement. However, there is still no standard of care. Although several factors may affect catheter dislocation rates, including the type of catheter, catheter insertion technique (in-plane or out-of-plane), direction of catheter insertion (parallel or perpendicular to the target nerve), and patient movement [30], we focused on methods of catheter fixation that may help prevent catheter dislocation in this review (Table 1).

Table 1.

Evidence Regarding Catheter Fixation Methods

The first attempt to prevent catheter dislodgement was subcutaneous tunneling of the catheter using a Tuohy needle [16]. After placement of the interscalene catheters, the authors subcutaneously inserted a Tuohy needle directly above the suprasternal notch and then superolaterally toward the catheter entry point. The proximal end of the catheter was then threaded through the Tuohy needle, which was removed, leaving the catheter tunneled subcutaneously. Another study reported the use of an 18 G intravenous cannula as the channel for this technique to reduce potential injury to the vascular structures or small cutaneous nerves [17]. Subcutaneous tunneling has been reported to reduce the incidence of catheter dislodgement by strengthening the force against pulling [31] as well as the infection rate [32], similar to the fact that tunneled central venous catheters can prevent catheter-related sepsis [33]. However, this has the risk of needlestick injuries to the operator [34], catheter damage [35], and catheter kinking during the tunneling procedure. However, subcutaneous tunneling has the advantage of being less affected by the characteristics of the catheter insertion site, including sweat, oozing, or the presence of hair. Although subcutaneous tunneling remains underutilized [36], it has been recommended for pediatric regional anesthesia, particularly for caudal or epidural blockade [37]. Various techniques have been proposed to minimize the potential risks associated with subcutaneous tunneling [36,38,39]; however, the evidence supporting these approaches is still lacking.

Another well-established method for securing perineural catheters is the application of an adhesive such as 2-octyl cyanoacrylate (such as Dermabond^® Topical Skin Adhesive, Ethicon). The 2-octyl cyanoacrylate adhesive polymerizes within minutes of application to the skin and forms a waterproof bond with the keratin in the epidermis, thereby creating a complete seal over the catheter insertion site. Although this seal may result in skin abrasion during catheter removal [13], the application of a 2-octyl cyanoacrylate adhesive is an effective method for preventing peri-catheter leakage and reducing catheter dislodgement [14,15]. A similar adhesive, Histoacryl^® (B. Braun, Melsungen), has been introduced for securing epidural catheters [40], but has not yet been studied for application in perineural catheters. Other liquid adhesives, including Mastisol^® or topical benzoin, have been tested for securing perineural catheters, but were less effective than 2-octyl cyanoacrylate adhesive for preventing catheter dislodgement [41,42].

Anchoring devices for affixing the catheter hub have also been widely used to secure perineural catheters. It has been reported to provide greater dressing strength than a transparent film dressing alone, albeit in a simulation study [43]. Several recent catheter needle assemblies have specific anchoring devices for their own designs; however, if not, a specific anchoring device such as StatLock^TM (BD) can be used as an alternative. Notably, combining different techniques for securing perineural catheters has been shown to improve dressing [42], which has also been reported to keep catheters stable in clinical practice [44].

Fixation at the contact point between the skin and catheter is important; however, patient movement can alter the distance between the target nerve and skin, potentially causing a change in the position of the catheter tip. For example, passive leg movements can alter the distance from the skin to the adductor canal by up to 1 cm, which may contribute to catheter dislodgement and block failure in patients undergoing continuous adductor canal block [45]. Because early mobilization is an essential component of enhanced recovery programs, proper securing of perineural catheters is imperative to ensure adequate analgesia through continuous peripheral nerve block.

COMPLICATIONS RELATED TO PERINEURAL CATHETERS

In addition to catheter dislodgement and leakage at the insertion site, which are associated with the secondary failure of continuous peripheral nerve blocks, perineural catheters carry the risk of several complications. Mechanical damage to the catheter during insertion or withdrawal may result in catheter retention [46-48], a serious issue. Perineural catheters often contain coiled wire that can be heated during magnetic resonance imaging [49]. In addition, hematoma formation can occur with perineural catheters, although its incidence is rare and typically limited to patients receiving anticoagulants [50,51]. In addition, continuous peripheral nerve blocks may obscure the early signs of compartment syndrome by masking ischemic pain, a critical initial symptom, potentially delaying diagnosis and treatment [52,53]. Continuous local anesthetic infusion via perineural catheters may cause concerns regarding local anesthetic systemic toxicity; however, existing literature suggests that local anesthetic systemic toxicity is rare with continuous peripheral nerve blocks [54,55].

Catheter-related infection is also a complication of continuous peripheral nerve blocks, because the perineural catheter may act as a direct route for pathogen penetration. The reported incidence of infection ranges 0–3%; however, the majority have an incidence of < 1% [56-58]. Notably, a recent registry analysis showed a total incidence of 2.9% with perineural catheters, with a significantly increased risk over time, especially after 4 day [59]. Several risk factors for catheter-related infection have also been identified, such as prolonged intensive care unit stay, immunodeficient status, diabetes, block site (axillary and femoral), the absence of antibiotic prophylaxis, and frequent changing of the dressings [56,60,61]. Although severe infections requiring surgical intervention are extremely rare, it is recommended to immediately remove infected catheters with mild or moderate signs of infection that may progress to severe infection [59]. Skin disinfection and strict aseptic techniques should be used during catheter placement to prevent catheter-related infections.

Neurological injury is a serious complications of peripheral nerve block, despite its very low incidence. Previous studies have reported that the incidence of long-term neurological dysfunction after peripheral nerve blocks is approximately 2–4/10,000 (0.02–0.04%), irrespective of whether the block is a single-injection or continuous [62,63]. Potential risk factors include intraneural injection, patient positioning during surgery, tourniquet-induced ischemia, pre-existing neurological deficits, and specific types of nerve blocks such as interscalene brachial plexus block [63-65]. Notably, a continuous peripheral nerve block is not associated with an increased risk of neurological injury [60]. A recent study on the complications of continuous peripheral nerve blocks reported an incidence of neurological complications of 0.29%, with a long-term sequela rate of 0.13% [58], which was higher than the previously reported incidence. However, several studies have demonstrated that the association between neurological complications and the use of perineural catheters is not evident [60,65]. In addition, owing to the low incidence of neurological complications, most studies were conducted in a retrospective design, potentially leading to a risk of selection bias and difficulty in determining causality. Prospectively collected large databases, including anesthesia quality improvement programs or national safety reporting systems, may help develop evidence regarding the incidence of such rare complications [63].

CATHETER MANAGEMENT

Once the perineural catheter is placed, a proper management protocol is critical to prevent complications such as catheter-related infection. Although no guidelines regarding the maximum duration of perineural catheters currently exist, prolonged catheterization is associated with an increased risk of infection [59,60]. However, a prospective study reported that perineural catheters were placed for up to 36 day without infection [57], and in one case report, a tunneled femoral nerve catheter was placed for 88 day [66]. Several orthopedic procedures are shifting to ambulatory settings; therefore, the duration of catheter placement should be determined individually based on the analgesic requirements and risk factors for infection. Notably, catheters with mild or moderate signs of infection should be promptly removed, as leaving them in place can lead to progression to severe infection [59].

Interestingly, repeated changes in catheter dressings have been associated with an increased risk of infection in patients receiving continuous peripheral nerve blocks [67]. As most institutions cover perineural catheters with a transparent dressing film, it is recommended to carefully inspect the catheter insertion site and change the dressing only when necessary. Notably, anesthesiologists should apply rigorous aseptic protocols during the procedure, including hand hygiene; wearing masks, sterile gowns, and gloves; skin disinfection; and sterile draping.

CONCLUSION

Continuous peripheral nerve blocks will continue to be increasingly used considering the limited options available for prolonging the duration of analgesia. Clinicians can select various types of catheters based on the benefits and disadvantages of each as well as their personal preferences. Several catheter-securing methods have been developed; however, an optimal fixation method has not yet been constructed. A combination of various techniques can help prevent catheter leakage and dislodgement. Despite its low incidence, some complications such as infection or neurological injury may result in serious outcomes and long-term sequelae. Therefore, careful catheter placement using strict aseptic techniques should be implemented during continuous peripheral nerve blocks.

Notes

FUNDING

None.

CONFLICTS OF INTEREST

No potential conflict of interest relevant to this article was reported.

DATA AVAILABILITY STATEMENT

Data sharing is not applicable to this article as no new data were created or analyzed in this study.

AUTHOR CONTRIBUTIONS

Writing - original draft: Seokha Yoo. Writing - review & editing: Hansol Kim, Jin-Tae Kim.

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Authors	Year	Block type or region	Intervention	Comparator	Primary outcome	Results	Notes
Chalacheewa et al. [15]	2021	Femoral nerve block	Skin adhesive (Dermabond^®)	Sterile strips	The incidence of peri-catheter leakage	The application of skin adhesive reduced peri-catheter leakage (0% vs. 93%) and catheter displacement (6.7% vs. 93.3%) after 24h compared to the fixation with sterile strips.
Kumar et al. [42]	2021	Thigh	Transparent film dressing, Skin adhesive (Dermabond^®), sterile strips, liquid adhesive (topical benzoin), adhesive spray	Combination of each method	The force required to dislodge the catheter	The combination of transparent film dressing, skin adhesive, sterile strips, and adhesive spray provided the strongest fixing force.	Healthy volunteer study (n = 6)
Auyong et al. [41]	2017	Interscalene brachial plexus block	Skin adhesive (Dermabond^®)	Liquid adhesive (Mastisol^®)	The incidence of catheter tip-to-nerve apposition	Fixation using skin adhesive improved maintenance of catheter tip-to-nerve apposition (90.6%) compared to liquid adhesive (64.7%).
Borg et al. [43]	2016	Thigh	Anchoring device (StatLock^TM)	Transparent film dressing alone	The weight to disrupt or remove dressing	Using an anchoring device provided stronger fixing force compared to transparent film dressing alone.	Simulation cadaver study (n = 20)
Leng et al.	2015	Thigh	Subcutaneous tunneling	No tunneling	Change in distance from the catheter tip to the center of the target nerve	Catheter tunneling did not affect migration of perineural catheter.	Simulation cadaver study (n = 20)
Byrne and Freeman [31]	2014	Shoulder	Single-tunneling, double-tunneling	No tunneling	The force required to displace the catheter by 1 cm	Catheter tunneling significantly increased the force required for catheter displacement (double-tunneling led to a further significant increase).	Porcine animal study
Gurnaney et al. [14]	2011	NA	Skin adhesive (Dermabond^®)	Transparent film dressing alone	The incidence of local anesthetic leakage	Catheter sealed with skin adhesive reduced the incidence of local anesthetic leakage (0.56% vs. 3.87%).	Before-and-after study (n = 1,644)