Sorry, ESI may be useful in inpatients with tunnelled catheters. Infection rates as high as 31% (but generally lower). BPB case reports only.
Many have adopted epidural infusion techniques as next- line therapy for patients failing intermittent blocks with moderate evidence for efficacy of epidural clonidine. This
34procedure is technically easy to perform, with level 3 evi- dence supporting epidural clonidine infusion as outlined earlier. Some centers have utilized the plexus infusions described earlier, but the epidural techniques are more common. The main drawback to these infusion tech- niques is the rate of infection, which remains to be defined by further prospective study on infusion techniques in CRPS patients.
IVRA
IVRA has been used for years to empirically treat CRPS [317]. Numerous IVRA medications alone and in combi- nation have been reported to have efficacy in treating CRPS. IVRA with guanethidine, lidocaine, bretylium, cloni- dine, droperidol, ketanserin, or reserpine have been described and reviewed critically by Perez et al., Forouza- nfar et al., and Kingery [46,134,197].
Perez et al. undertook a meta-analysis of the highest quality (blinded, with re-evaluation of included trials, sta- tistical methodology, and inclusion only of trials meeting strict inclusion criterion such as randomization, blinding, sample size, dropout rate, and others), finding 11 accept- able trials of sympathetic suppressors, nine being IVRA studies and six concerning guanethidine in particular [197]. Perez et al. applied a quantitative analysis of effect size that compares the difference in pain relief between experimental and control groups, with a correction factor applied for trial size. This method has become acceptable in meta-analysis to analyze aggregate treatment effect from numerous studies. Their aggregate analysis showed lack of proven effect of IVRA and lack of proven effect more specifically of guanethidine IVRA (thus level 1 evi- dence for lack of proven effect of these therapies).
SCS if lesser options fail.