Cite as: Shah SJ, Ranganath YS. ASRA answers: continuous catheter techniques in regional anesthesia: how long is too long? ASRA Pain Medicine News 2025;50. https://doi.org/10.52211/asra110125.010.

ASRA Answers

Introduction

Continuous nerve catheters (CNCs) serve as important tools for effective acute and chronic pain management, significantly reducing opioid use, improving analgesia, and enhancing recovery. Early recommendations favored catheter removal as early as 48–72 hours to minimize infection risk, but current evidence supports longer durations under appropriate conditions with careful monitoring.^1-5

While infectious complications are rare, catheter duration remains the most important modifiable factor influencing risk when already adhering to recommended practices. A common clinical question remains: When should the catheter be removed? The answer depends not only on duration but also on insertion site, patient (host) factors, and strict adherence to aseptic technique. This article summarizes the current evidence and key studies to support individualized, evidence-based clinical decision-making.

Review of Literature

Early multicenter work by Capdevila (2005) and Neuburger (2007) first quantified infection risk in large surgical cohorts. Both demonstrated that keeping peripheral nerve catheters (PNCs) beyond 48–72 hours increased superficial infection risk (about 3%), though deep infections remained rare.^2,5 Notably, catheter site mattered: Femoral or axillary locations had a higher risk in Capdevila’s series, while interscalene placements carried the highest incidence in Neuburger, underscoring the role of local skin flora. Ruppen’s 2007 meta-analysis, which included 12 studies and 4,628 patients with epidural catheters placed ≥7 days (mean 74 days) in cancer pain populations, reported an overall infection rate of 6.1% and a deep infection rate of 1.2%, rising to 2.8% in cancer subgroups.⁶ Green and Paech (2010) retrospectively analyzed 9,482 obstetric labor epidurals, most lasting ≤24 hours (median: 8–12 hours), and found an overall infection rate of 0.52%, with deep infections (epidural abscess) in only 0.04% (1 in 2,370 cases), highlighting the rarity of serious infection in short-term use in healthy obstetric populations.⁷

Later studies further clarified these trends. Sethna (2010) showed pediatric epidurals lasting 3–11 days carried an overall infection rate of 0.12%, though chronic-pain catheters (>7 days) had a markedly higher rate (3.2%), paralleling adult patterns.⁸ Pediatric data from the PRAN registry (Walker 2015, 2,074 catheters) reinforced the safety of PNCs, reporting 0.9% minor infections and no deep infections. However, infected catheters had a longer median dwell time (4.5 vs. 3 days), emphasizing the importance of duration even in children.⁹ Bomberg et al. (2018), analyzing 44,555 catheters, demonstrated 99% infection-free survival at day 4, 96% at day 7, and 73% at day 15, indicating that while risk rises over time, it remains low in the first week.³ For neuraxial catheters, Bomberg (2016) showed that tunnelling reduced the infection rate from 5.5% to 4.5% and halved moderate and severe infections (0.8% → 0.4%), independent of duration.¹⁰ Vogelsang (2020) demonstrated that rigorous daily inspection and chlorhexidine skin preparation held infections to 0.6%, even without tunnelling, over a median three-day dwell.¹¹ Collectively, these studies confirm that with appropriate aseptic technique and daily monitoring, catheters can safely remain for 4–7 days with low infection risk.

Certain clinical situations demand longer infusions, and several studies support prolonged catheter use with careful monitoring. Perkins (2024) evaluated 484 burn ICU catheters (median 6 days), reporting a 1.2% superficial infection rate with events clustering at or beyond day 6, advocating heightened surveillance after day 5.¹² In ambulatory orthopedics, Gharabawy (2014) reviewed 1,059 outpatient continuous blocks (median 5 days) and found a 1.2% infection rate, all superficial and resolving with removal, demonstrating that extended home use is feasible with patient education and 24-hour support.¹³ Anghelescu (2012) studied 179 pediatric oncology catheters, some maintained up to 81 days, observing only two mild infections (both femoral, ≥10 days), highlighting anatomical risks over duration alone.¹⁴ Buckenmaier (2006) reported on 187 combat trauma patients with median 8-day catheters (range 1-33 days), finding only two superficial infections, thus supporting prolonged use in austere environments.¹⁵ Finally, Verdecchia (2024) described 52 catheters in nine pediatric trauma patients with durations up to 15 days and reported no infections under vigilant monitoring.¹⁶

In summary, data across multiple studies help contextualize duration-related infection risk by catheter type. Neuraxial catheters show an overall infection rate of less than 0.5% during the typical 2–5-day use, with deep infections occurring in fewer than 0.1% of cases. PNCs demonstrate an overall infection rate of about 1% (range 0–3%) for similar dwell times, with deep infections at or below 0.1%. For prolonged use beyond 7 days, infection risk rises; however, studies involving well-monitored patients in oncology and burn settings report deep infection rates of 1%–3%, supporting feasibility with careful oversight.

Controversies and Limitations

Despite accumulating evidence, key controversies remain. Interpretation is limited by variable infection definitions, selective catheter tip culturing, publication bias toward adverse outcomes, and small sample sizes, especially in prolonged catheter use. Catheter colonization—bacterial presence without clinical signs—is common, typically from low-virulence skin flora, and can be as high as 57%. It rarely warrants intervention without symptoms.¹⁷

Proposed additional preventive measures include micropore filters, antiseptic dressings, catheter tunneling, and aseptic drug preparation, though evidence is mixed.¹⁸ Extended antibiotic prophylaxis may lower infections but raises concerns of antibiotic resistance and clostridium difficile infection. Catheter tunneling reduces colonization but may not be routinely necessary due to procedural complexity and discomfort. Chlorhexidine-impregnated dressings show theoretical benefit but lack conclusive clinical support, highlighting the need for further study. Recognizing these limitations underscores the need for continued research and comprehensive registries to guide evidence-based practice.

Conclusion

Most regional nerve catheters placed perioperatively are removed within 3–5 days when infection risk remains low. Infection risk increases with duration, especially beyond 4 days, yet remains acceptable within the first week under vigilant monitoring. Although prolonged catheter use beyond 7 days is uncommon, it may be warranted in select scenarios—such as burns, polytrauma, oncology, or chronic pain—to extend the duration of effective analgesia. Several small studies report extended catheter use for weeks with low complication rates, though data remains limited. Select patients can safely exceed one week—and even several weeks—if strict aseptic insertion and daily monitoring are maintained, and the catheter remains clinically indispensable; however, because infection risk increases with dwell time, any extension beyond 4–5 post-procedure days should proceed only when the risk–benefit profile clearly favors continuation, with removal once analgesic goals are achieved or at the first sign of infection. Duration should inform—not dictate—clinical judgement.

References

1. Provenzano DA, Hanes M, Hunt C, et al. ASRA Pain Medicine consensus practice infection control guidelines for regional anesthesia and pain medicine. Reg Anesth Pain Med 2025;rapm-2024-105651. https://doi.org/10.1136/rapm-2024-105651
2. Capdevila X, Pirat P, Bringuier S, et al. Continuous peripheral nerve blocks in hospital wards after orthopedic surgery: a multicenter prospective analysis of the quality of postoperative analgesia and complications in 1,416 patients. Anesthesiology 2005;103:1035-45. https://doi.org/10.1097/00000542-200511000-00018
3. Bomberg H, Bayer I, Wagenpfeil S, et al. Prolonged catheter use and infection in regional anesthesia: A retrospective registry analysis. Anesthesiology 2018;128:764-73. https://doi.org/10.1097/ALN.0000000000002105
4. Practice advisory for the prevention, diagnosis, and management of infectious complications associated with neuraxial techniques: an updated report by the American Society of Anesthesiologists task force on infectious complications associated with neuraxial techniques and the American Society of Regional Anesthesia and Pain Medicine. Anesthesiology 2017;126:585-601. https://doi.org/10.1097/ALN.0000000000001521
5. Neuburger M, Büttner J, Blumenthal S, et al. Inflammation and infection complications of 2285 perineural catheters: a prospective study. Acta Anaesthesiol Scand 2007;51:108-14. https://doi.org/10.1111/j.1399-6576.2006.01173.x
6. Ruppen W, Derry S, McQuay HJ, et al. Infection rates associated with epidural indwelling catheters for seven days or longer: systematic review and meta-analysis. BMC Palliat Care2007;6:3. https://doi.org/10.1186/1472-684X-6-3
7. Green LK, Paech MJ. Obstetric epidural catheter-related infections at a major teaching hospital: a retrospective case series. Int J Obstet Anesth 2010;19:38-43. https://doi.org/10.1016/j.ijoa.2009.06.001
8. Sethna NF, Clendenin D, Athiraman U, et al. Incidence of epidural catheter-associated infections after continuous epidural analgesia in children. Anesthesiology 2010;113:224-32. https://doi.org/10.1097/ALN.0b013e3181de6cc5
9. Walker BJ, Long JB, De Oliveira GS, et al. Peripheral nerve catheters in children: an analysis of safety and practice patterns from the pediatric regional anesthesia network (PRAN). Br J Anaesth2015;115:457-62. https://doi.org/10.1093/bja/aev220
10. Bomberg H, Kubulus C, Herberger S, et al. Tunnelling of thoracic epidural catheters is associated with fewer catheter-related infections: a retrospective registry analysis. Br J Anaesth2016;116:546-53. https://doi.org/10.1093/bja/aew026
11. Vogelsang H, Lang A, Cevik B, et al. Incidence of infection in non-tunnelled thoracic epidural catheters after major abdominal surgery. Acta Anaesthesiol Scand 2020;64:1312-8. https://doi.org/10.1111/aas.13650
12. Perkins L, Pedroza G, Soghikian M, et al. Continuous peripheral nerve blocks for burn management: a retrospective study of outcomes and complications in 281 burn patients. Reg Anesth Pain Med 2024;rapm-2024-105930. https://doi.org/10.1136/rapm-2024-105930
13. Gharabawy R, Abd-Elsayed A, Elsharkawy H, et al. The Cleveland Clinic experience with supraclavicular and popliteal ambulatory nerve catheters. ScientificWorldJournal2014;2014:572507. https://doi.org/10.1155/2014/572507
14. Anghelescu DL, Harris BL, Faughnan LG, et al. Risk of catheter-associated infection in young hematology/oncology patients receiving long-term peripheral nerve blocks. Paediatr Anaesth2012;22:1110-6. https://doi.org/10.1111/j.1460-9592.2012.03880.x
15. Buckenmaier CC 3rd, Shields CH, Auton AA, et al. Continuous peripheral nerve block in combat casualties receiving low-molecular-weight heparin. Br J Anaesth 2006;97:874-7. https://doi.org/10.1093/bja/ael269
16. Verdecchia N, Praslick A, Visoiu M. Safety assessment of prolonged nerve catheters in pediatric trauma patients: a case series study. Children (Basel) 2024;11. https://doi.org/10.3390/children11020251
17. Cuvillon P, Ripart J, Lalourcey L, et al. The continuous femoral nerve block catheter for postoperative analgesia: bacterial colonization, infectious rate and adverse effects. Anesth Analg2001;93:1045-9. https://doi.org/10.1097/00000539-200110000-00050
18. Nicolotti D, Lotti E, Fanelli G, et al. Perineural catheter infection: a systematic review of the literature. J Clin Anesth 2016;35:123-8. https://doi.org/10.1016/j.jclinane.2016.07.025