About PROSPECT
PROSPECT (PROcedure SPECific Postoperative Pain ManagemenT) is a working group, now hosted by the European Society of Regional Anaesthesia (ESRA), that produces procedure-specific analgesic recommendations. Rather than treating “postoperative pain” as a single entity, PROSPECT recognises that the optimal regimen differs by operation — the blocks, systemic agents, and their evidence differ between, say, a thoracotomy and a knee replacement.
What makes PROSPECT distinctive is its methodology: recommendations are based not only on whether an intervention works, but on its procedure-specific risk–benefit balance, incorporating the analgesic effect relative to the baseline multimodal regimen and the invasiveness of the intervention. An intervention that is effective in isolation may still not be recommended if it adds little over simpler measures.
How to read a PROSPECT recommendation
The intervention is supported by procedure-specific evidence and its benefits outweigh the risks and effort in the context of a basic multimodal regimen. These form the backbone of each procedure page on this site.
The intervention either lacks procedure-specific evidence, offers no meaningful benefit over the basic regimen, or carries risks that outweigh its analgesic effect for that operation. Notably, a technique recommended for one procedure may be explicitly not recommended for a similar one (e.g. thoracic epidural in open thoracotomy vs VATS).
A note on grading vs. evidence date. Each PROSPECT review carries a literature search date, which may differ from its year of publication. On this site both are stated where relevant so the currency of the underlying evidence is transparent.
Society Guidelines
Regional anaesthesia practice is shaped by a small number of key societies. Their guidance on technique, anticoagulation, and complication management underpins the recommendations throughout this site.
ESRA
European Society of Regional Anaesthesia & Pain Therapy. Guidelines on regional techniques, anticoagulation, and the PROSPECT programme.
esraeurope.org ↗ASRA
American Society of Regional Anesthesia. Widely used guidance on neuraxial anaesthesia in the anticoagulated patient and on LAST management.
asra.com ↗NYSORA
New York School of Regional Anesthesia. The primary reference for block anatomy, sonoanatomy, and technique descriptions used on this site.
nysora.com ↗Association of Anaesthetists
UK guidance including the Quick Reference Handbook and the widely used management of severe local anaesthetic toxicity guideline.
anaesthetists.org ↗RCoA
Royal College of Anaesthetists — standards, curriculum, and perioperative guidance for UK practice.
rcoa.ac.uk ↗Block Nomenclature (2021)
ASRA–ESRA joint standardised nomenclature for abdominal wall, paraspinal, and chest wall fascial plane blocks.
Reference ↗Local Anaesthetic Reference Guide
A practical reference for the local anaesthetics used in regional blocks. Maximum doses below are widely cited reference values; they are a starting point for calculation, not a target. Always calculate the actual permissible dose on a mg/kg basis for the individual patient and verify against the current SmPC and local formulary.
Maximum doses are not additive-safe. When multiple techniques are combined (e.g. an adductor canal block plus wound infiltration, or bilateral fascial plane blocks), the total local anaesthetic across all injections must be summed and kept within the single safe limit. Absorption is also higher from vascular sites (intercostal, paravertebral) than from fascial planes.
| Agent | Max dose (plain) | Max dose (+adrenaline) | Onset | Duration |
|---|---|---|---|---|
| Lidocaine | 3 mg/kg | 7 mg/kg | Fast | 1–2 h |
| Mepivacaine | ~4.5 mg/kg | 7 mg/kg | Fast–medium | 2–3 h |
| Prilocaine | 6 mg/kg | 8–9 mg/kg (felypressin) | Medium | 1.5–2 h |
| Bupivacaine | 2 mg/kg | 2 mg/kg* | Slow | 4–8 h |
| Levobupivacaine | 2 mg/kg | — | Slow | 4–8 h |
| Ropivacaine | 3 mg/kg | — | Slow–medium | 4–6 h |
*Adrenaline does not meaningfully raise the recommended ceiling for the long-acting amides; its main roles are as an intravascular marker and to prolong block. Concentration conversion: a 1% solution contains 10 mg/mL; 0.5% contains 5 mg/mL; 0.25% contains 2.5 mg/mL.
Local Anaesthetic Systemic Toxicity (LAST)
LAST is the most feared complication of regional anaesthesia. Prevention rests on calculating and respecting dose limits, incremental injection with intermittent aspiration, ultrasound guidance, and vigilance for early features (perioral tingling, tinnitus, agitation, metallic taste) that may precede seizures and cardiovascular collapse.
Lipid emulsion 20% must be immediately available wherever any block is performed. On suspecting LAST: stop injecting, call for help, manage the airway with 100% oxygen, control seizures, and give intravenous lipid emulsion 20% per the Association of Anaesthetists / ASRA protocol. Cardiac arrest from LAST may require prolonged resuscitation.
Clinical Tools
Interactive tools to support these references at the point of care.