Regional anesthesia techniques for ambulatory orthopedic surgery
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Regional anesthesia techniques
for ambulatoryorthopedic surgeryBrian D. O’Donnell and Gabriella Iohom
Department of Anaesthesia and Intensive CareMedicine, Cork University Hospital, Cork, Ireland
Correspondence to Gabriella Iohom, MD, FCARCSI,PhD, Department of Anaesthesia and Intensive CareMedicine, Cork University Hospital, Cork, IrelandTel: +353 21 4922135; fax: +353 21 4546434;e-mail: gabriella.iohom@mailp.hse.ie
Current Opinion in Anaesthesiology 2008,21:723–728
Purpose of review
The purpose of this review is to present advances in the use of regional anesthetic
techniques in ambulatory orthopedic surgery. New findings regarding the use of both
neuraxial anesthesia and peripheral nerve block are discussed.
Recent findings
Neuraxial anesthesia: The use of short-acting local anesthetic agents such as
mepivacaine, 2-chloroprocaine, and articaine permits rapid onset intrathecal anesthesia
with early recovery profiles. Advantages and limitations of these agents are discussed.
Peripheral nerve block: Peripheral nerve blocks in limb surgery have the potential to
transform this patient cohort into a truly ambulatory, self-caring group. Recent trends
and evidence regarding the benefits of regional anesthesia techniques are presented.
Continuous perineural catheters permit extension of improved perioperative analgesia
into the ambulatory home setting. The role and reported safety of continuous catheters
are discussed.
Summary
In summary, shorter acting, neuraxial, local anesthetic agents, specific to the expected
duration of surgery, may provide superior recovery profiles in the ambulatory setting. A
trend towards more peripheral and selective nerve blocks exists. The infrapatellar block
is a promising technique to provide analgesia following knee arthroscopy. Improved
analgesia seen in the perioperative period can be safely and effectively extended to the
postoperative period with the use of perineural catheters.
Keywords
ambulatory continuous perineural analgesia, neuraxial block, peripheral nerve block
Curr Opin Anaesthesiol 21:723–728� 2008 Wolters Kluwer Health | Lippincott Williams & Wilkins0952-7907
IntroductionEfficient ambulatory surgery centers rely on anesthesia
regimens that facilitate early recovery, provide high-
quality analgesia, and have low levels of postoperative
nausea and vomiting (PONV) and low rates of unplanned
hospital admission. Regional anesthesia techniques have
significant advantages over general anesthesia in this
context [1–5].
Recent research into the use of neuraxial anesthesia has
focused on agent selection. Short-acting agents confer
considerable benefits in terms of fast-recovery profiles
and early hospital discharge. Advances in peripheral
nerve block (PNB) techniques, such as ultrasound gui-
dance [6], multistimulation [7], and ambulatory continu-
ous perineural catheters [8], have contributed to a
renewed interest in their use. This review focuses on
regional anesthesia for ambulatory orthopedic surgery.
Neuraxial anesthesia and PNBs will be considered in
separate sections.
opyright © Lippincott Williams & Wilkins. Unauth
0952-7907 � 2008 Wolters Kluwer Health | Lippincott Williams & Wilkins
Neuraxial anesthesiaSpinal anesthesia provides excellent anesthesia for lower
limb orthopedic surgery. Factors limiting the use of spinal
anesthesia in the ambulatory setting include delayed
ambulation due to lower limb muscle weakness [9],
the risk of urinary retention of up to 17% [10,11], and
pain following block regression. Selecting the correct
agent for ambulatory spinal anesthesia is of paramount
importance.
Long-acting agents
Long-acting agents such as bupivacaine and ropivacaine
have the advantage of providing excellent anesthesia at
the expense of delays in post-anesthesia care unit
(PACU) discharge. Reducing the dose of such agents
and adding adjuvants such as fentanyl may permit lower
dosing and faster recovery [12,13]. This reduction in dose
is, however, accompanied by a reduction in the efficacy of
the intrathecal block, particularly with bupivacaine doses
of less than 7.5 mg. The addition of fentanyl is associated
orized reproduction of this article is prohibited.
DOI:10.1097/ACO.0b013e328314b665
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724 Ambulatory anaesthesia
with troubling side effects such as pruritus, and nausea
and vomiting [12].
Capelleri et al. [14] compared the use of hyperbaric
levobupivacaine (5 mg and 7.5 mg) with ropivacaine
(7.5 mg) for day-case knee arthroscopy. Ropivacaine
(7.5 mg) resulted in faster regression of motor and sensory
block than the equipotent (5 mg) levobupivacaine dose
[median (range), 135 (126–154) vs. 162 (148–201) min,
P¼ 0.04].
Van Tuijl et al. [15��] compared the addition of clonidine
to intrathecal bupivacaine in day-case knee arthroscopy.
Three groups randomly received bupivacaine alone,
bupivacaine with 15 mg clonidine, or bupivacaine with
30 mg clonidine. The investigators found that motor
block was prolonged by a mean of 25 min [95% confi-
dence interval (CI) 2–48] and 34 min (95% CI 11–57) in
the 15 and 30 mg clonidine groups compared with the
bupivacaine-only group. They concluded that the
addition of clonidine improved the quality of the spinal
anesthesia and prolonged the duration of motor block. In
a similar study by De Kock et al. [16], the addition of
15 mg clonidine improved the quality of low-dose spinal
anesthesia with ropivacaine (8 mg). Motor or sensory
blockade was not prolonged, and significant added
systemic side effects were not detected. These benefits
have been noted for orthopedic patients by other inves-
tigators [17��,18]. It appears that low-dose intrathecal
clonidine is beneficial in improving the quality of spinal
anesthesia with longer acting amino-amide local anes-
thetic agents.
Short-acting agents
Short-acting agents may have significant benefits in
terms of early mobilization and shorter recovery time.
Their use may, however, be limited by a number of
factors. Lidocaine has been used for ambulatory spinal
anesthesia. Its use is limited by the phenomenon of
painful transient neurological symptoms (TNSs), which
is four times higher than many of the commonly used
agents [19]. Therefore intrathecal lidocaine has all but
been abandoned. Mepivacaine provides another option
with rapid onset and relatively short duration of action;
however, TNSs have been associated with 4% hyper-
baric mepivacaine [20]. YaDeau et al. [21] studied
isobaric 1.5% mepivacaine in patients undergoing
orthopedic lower limb surgery. Intrathecal doses of
45–50 mg produced excellent anesthesia for lower
limb procedures of less than 90 min duration with
combined spinal epidural (CSE) techniques preferred
for surgery of longer than 90 min expected duration.
The rate of TNSs was reported as 6.4% in this study of
1273 patients [21]; therefore, TNSs may be a
limiting factor in the use of mepivacaine for neuraxial
block.
opyright © Lippincott Williams & Wilkins. Unautho
2-Chloroprocaine doses of 30, 40, and 50 mg have been
studied in patients undergoing lower limb surgery [22].
2-Chloroprocaine provided excellent anesthesia when
administered in doses of 40 and 50 mg for procedures
lasting 45–60 min. Patients receiving the 30 mg dose
required analgesic supplementation to complete surgery.
Spinal anesthetic block had regressed by 85 min (40 mg
group) and 97 min (50 mg group) with all patients ambu-
lating independently at a mean of 185 min. Bradycardia
occurred in the 30 mg group only (five patients) and
TNSs did not occur. These authors recommended
40–50 mg of intrathecal 2-chloroprocaine for surgery of
45–60 min expected duration.
In a separate study, Casati et al. [23��] compared 50 mg
of 1% 2-chloroprocaine with 50 mg 1% lidocaine in
patients undergoing knee arthroscopy. 2-Chloropro-
caine provided excellent anesthesia with earlier recov-
ery profiles than lidocaine. The time to unassisted
ambulation was faster [median (range), 103 (70–91)
vs. 152 (100–185) min, P¼ 0.003] and the rate of TNSs
(33% vs. 0%, P¼ 0.042) was lower in the 2-chloropro-
caine group. Two patients in the 2-chloroprocaine group
and one in the lidocaine group, however, required
fentanyl supplementation to complete the procedure.
In a study of their initial 10-month experience, Yoos and
Kopacz [24] described the effective clinical use of 2-
chloroprocaine for ambulatory surgery. This retrospec-
tive review describes the clinical utility of 2-chloropro-
caine for short surgeries with rapid recovery profiles and
early independent ambulation. The authors point to the
phenomenon of unanticipated prolongation of surgery
and the risk of conversion to general anesthesia to
complete surgery.
Articaine is a fast-acting, short-duration, amide local
anesthetic used largely in dental practice. Kallio et al.[25] studied the use of three doses of hyperbaric articaine
(60, 84, and 108 mg) for intrathecal anesthesia in a pro-
spective randomized blinded study. Effective anesthesia
was obtained in all participants. The 108 mg dose was
associated with higher vasopressor use, more intraopera-
tive nausea and vomiting, and a sensory block height
extending frequently above T1. Patients receiving 60 and
84 mg had preferable recovery profiles with complete
motor and sensory block resolution by 150 min (75–
180) and 150 min (75–270), respectively [median
(range)]. TNSs did not occur in any of the 90 patients
studied. They concluded that 60 and 84 mg of articaine
provided effective spinal anesthesia for patients under-
going lower limb surgery of approximately 1 h duration.
Dijkstra et al. [26��] compared the use of 80 mg articaine
with 15 mg bupivacaine. They reported a more rapid
onset at the T12 dermatomal level with articaine
[median (range), 180 (140–257) vs. 234 (170–520) s,
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Regional anesthesia techniques O’Donnell and Iohom 725
P¼ 0.0028]. Recovery from anesthesia was faster
with articaine. Sensory block had regressed by 197 min
(127–241) with articaine compared with 323 min (263–
358) (P< 0.0005). Motor block had regressed by 101 min
(80–129) compared with 307 min (225–350) (P< 0.0005)
in the articaine and bupivacaine groups, respectively.
The articaine group voided urine earlier and achieved
hospital discharge criteria earlier than the bupivacaine
group. The authors conclude that articaine provides
excellent anesthesia for surgery of approximately 1 h
duration and that superior recovery profiles following
articaine anesthesia facilitate earlier recovery and
hospital discharge.
In summary, the search for the ideal intrathecal agent
continues. Short-acting agents have considerable advan-
tages in recovery profiles, and facilitate early ambulation
and home discharge. In choosing a short-acting intrathe-
cal agent, the expected duration of surgery should be less
than 1 h (e.g. knee arthroscopy). For surgeries of longer
than 1 h, there is a real risk of conversion to general
anesthesia thereby negating the beneficial effects of
spinal anesthesia.
Peripheral nerve blockPeripheral nerve blockade facilitates limb surgery on
conscious, ambulatory patients. There are several
benefits of PNB compared with general anesthesia that
directly affect patients, including reductions in post-
operative pain, analgesic use, and PONV [2,3,27]. Ambu-
latory centers may also benefit with earlier hospital dis-
charge, fewer nursing interventions, and lower costs
when PNB is employed [28,29].
Despite these proven benefits, the use of regional anesthe-
sia as a sole anesthetic modality for limb surgery is limited
by a number of factors. Delay to the timely running of a
busy ambulatory surgery list is often quoted as a reason that
general anesthesia is preferred to regional anesthesia. Slow
block onset times and variable block success rates con-
tribute to this perception of delay. Improved block onset
times and success rates have been reported by various
authors with the use of ultrasound guidance [30,31] and/or
multistimulation techniques [7,32��]. Although very much
operator-dependent, these techniques have the potential
to enhance acceptance of regional anesthesia as a valuable
tool in the ambulatory surgery unit.
Peripheral nerve blocks may also be used as adjuncts to
general anesthesia. They improve perioperative analge-
sia, thereby reducing unanticipated admission as a result
of pain or side effects of opiate analgesics. More than 40%
of patients undergoing ambulatory orthopedic surgery
experience moderate to severe pain [33]. Poor analgesia
was associated with longer PACU stay and delayed hos-
opyright © Lippincott Williams & Wilkins. Unauth
pital discharge following ambulatory surgery [34]. There-
fore the use of PNBs to improve perioperative analgesia
may have a significant impact on the patient’s journey
through the ambulatory surgery center.
Single-shot peripheral nerve blocks
The benefits of single-shot PNBs are limited by the
pharmacokinetic profile of the local anesthetic agent used
in the intraoperative and immediate postoperative
period.
Upper limb blocks
The choice of brachial plexus block will be largely deter-
mined by the type of surgery being performed (e.g.
shoulder–interscalene, hand–axillary/infraclavicular).
When used as the sole anesthetic technique for shoulder
surgery, brachial plexus block confers a number of
advantages over general anesthesia. In a randomized
controlled trial, Hadzic et al. [35] compared interscalene
block (ISB) with general anesthesia for ambulatory
shoulder surgery. Patients in the ISB group had
improved analgesia, shorter time to ambulation, and
earlier hospital discharge. Significantly more patients
receiving ISB bypassed phase 1 PACU and none of these
patients required unplanned hospital admission (vs. 4/25
in the general anesthesia group). Patients in the ISB
group were sedated with a propofol infusion, which was
discontinued at the end of surgery and did not influence
the ability to bypass PACU. A noteworthy fact is that the
follow-up relating to pain scores and opiate consumption
at 24, 48, and 72 h revealed no significant difference
between the groups. This observation was also made
by McCartney et al. [3] in a study of axillary brachial
plexus blocks compared with general anesthesia for
ambulatory hand surgery. The true benefits of single-
shot brachial plexus anesthesia are present only in the
immediate perioperative period.
A noticeable trend towards more peripheral and more
selective nerve blocks exists. Discharge from the
ambulatory center with an insensate, immobile upper
limb is somewhat controversial. Ideally, patients would
have a long-acting sensory block and short-acting motor
block. To this end, Bouaziz et al. [36] used the mid-
humeral approach to the brachial plexus to deposit
lidocaine at the musculocutaneous and radial nerves
and bupivacaine at the ulnar and median nerves in
patients undergoing palmar fasciectomy. Excellent
anesthesia was achieved with this technique, enabling
early recovery of proximal upper limb motor function
and extended block in the operative territory. The
use of selective long-acting blocks to extend analgesia
in the surgical territory is feasible and may facilitate
the early discharge of patients from the ambulatory
center.
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726 Ambulatory anaesthesia
It has been shown that ultrasound-guided forearm nerve
blocks (radial, ulnar, and median) to provide sole anesthe-
sia for hand procedures in the emergency department
appeared to be feasible (with high patient satisfaction
after minimal training) [37].
Lower limb blocks
The femoral nerve can be blocked using a targeted
femoral nerve block or a fascia iliaca block. It provides
anesthesia to the anteriomedial thigh, anterior knee, and
medial calf, resulting in broad utility for knee procedures
and making the femoral nerve block the most common
lower extremity single-injection block [38]. The analge-
sic potential of femoral nerve blocks may be enhanced
when they are used for more painful surgical procedures,
such as anterior cruciate ligament (ACL) reconstruction
[39]. Nevertheless, when hamstring graft is used for ACL
repair, as well as for more extensive knee surgery, strong
support for a combination of a sciatic–femoral nerve
block exists [40].
Knee arthroscopy is one of the most commonly per-
formed elective ambulatory lower limb orthopedic
surgeries. The search for the ideal analgesic following
knee arthroscopy continues with reports as to the efficacy
or lack thereof of a multitude of intraarticular agents such
as local anesthetics, opiates, nonsteroidal agents, cloni-
dine, and even the placebo saline [41]. The anterior knee
is supplied by a terminal branch of the femoral/saphenous
nerve – the infrapatellar nerve. Regional anesthesia for
analgesia following knee arthroscopy had focused on
blockade of the femoral nerve. This leads to a motor
block, obliterating the extensor mechanism of the knee
and reducing patient mobility. The infrapatellar nerve is
an entirely sensory nerve supplying the anteromedial
knee and the anterior capsule of the knee. Lundblad
et al. [42�] described the use of high-resolution ultrasound
guidance to identify this nerve and facilitate the depo-
sition of 5 ml 0.5% levobupivacaine adjacent to the nerve.
In a volunteer study, Lundblad et al. successfully
reported the performance of ultrasound-guided infrapa-
tellar block with a mean block onset time of 8.4 min (SD
3.6) and a mean duration of sensory block of 27.5 h (SD
19.1). This simple technique has the potential to be an
excellent regional analgesic adjunct to the anesthetic
technique of choice for knee arthroscopy.
Posterior and lateral popliteal fossa blocks target the
sciatic nerve behind the knee, cephalad to its division
into the tibial and common peroneal nerves. This tech-
nique preserves hamstring function and sensation to the
posterior thigh. This enables crutch walking but requires
the use of a calf tourniquet or supplemental anesthesia for
a thigh tourniquet. It may require supplementation with a
femoral or saphenous nerve block for procedures on the
medial calf or ankle. Overall, popliteal fossa block is safe,
opyright © Lippincott Williams & Wilkins. Unautho
easily achieved, associated with high patient satisfaction,
and thus ideal for foot and ankle surgery [43].
Continuous peripheral nerve blocks
In a placebo-controlled, blinded randomized controlled
trial, Ilfeld et al. [44] studied the use of interscalene
catheters with ropivacaine vs. saline in ambulatory
patients undergoing shoulder surgery under general
anesthesia. Unsurprisingly, following home discharge,
the patients in the ropivacaine group had better analgesia,
used less opiate medication, and had better sleep quality
than those in the placebo group. Thus, the efficacy of
interscalene catheters for analgesia following shoulder
surgery was established.
The postoperative shoulder surgery initiative (POSSI)
evaluated the efficacy and feasibility of the use of ambu-
latory interscalene catheters for analgesia following day-
case shoulder surgery in a center in the United Kingdom
[45�]. Five patients, recruited to phase 1 of the study,
received an interscalene brachial plexus catheter (IBPC),
were admitted overnight following surgery, and were
assessed and discharged early on the first postoperative
day. Five patients were recruited to phase 2 of the
initiative that saw patients discharged on the same day
of surgery. ISBs were placed preoperatively and at the
patient’s request sedation or general anesthesia was
administered for surgery. All IBPCs worked well and
9/10 patients had excellent analgesia for the 72 h duration
of infusion. One of the catheters fell out, necessitating
admission of that patient for pain management. This
simple, elegant study illustrated the utility of IBPCs in
the provision of postoperative analgesia, allowing effec-
tive same day discharge from hospital following major
shoulder surgery.
Capdevila et al. [8] compared perineural analgesia with
intravenous PCA morphine in ambulatory patients
undergoing either shoulder arthroplasty or hallux valgus
surgery. Either an IBPC or a popliteal perineural catheter
(PPC) was placed preoperatively depending on the type
of surgery. Patients receiving perineural analgesia had
improved analgesia and earlier functional recovery on the
first 3 postoperative days. Measures of analgesic con-
sumption, PONV, and sleep disturbance were all higher
in the morphine group with patients less satisfied than
those who received perineural analgesia. Thus, for either
upper or lower limb ambulatory surgery, perineural
catheters provide the distinct advantage of prolonging
analgesia beyond that seen with single-shot blocks and
extend these benefits to the home setting. More recently,
Ilfeld et al. [46��] demonstrated that, following tricom-
partment total knee arthroplasty, a 4-day ambulatory
continuous femoral nerve block (cFNB) decreased the
time to reach specific discharge criteria (adequate analge-
sia, independence from intravenous analgesics, and
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Regional anesthesia techniques O’Donnell and Iohom 727
ambulation of at least 30 m) by an estimated 53% com-
pared with an overnight continuous femoral nerve block.
Although not strictly on the subject of ambulatory
surgery, Capdevila et al. [47] reported on the safety
and efficacy of continuous perineural catheters in the
postoperative setting. Their study on 1416 continuous
PNBs demonstrated low rates of infectious compli-
cations, with only 3% of patients showing local
catheter-related inflammatory signs and transient nerve
injury occurring in three patients (0.21%), which com-
pletely resolved within 10 weeks.
Swenson et al. [48�] report on the safe and effective use of
continuous perineural catheters for postoperative analge-
sia in 620 ambulatory outpatients. They report only two
complications in this heterogenous cohort of patients,
who had both upper and lower limb perineural catheters.
One patient had prolonged motor and sensory common
peroneal nerve dysfunction with symptoms suggestive of
a compressive neuropraxia following the use of a below
knee tourniquet. The other patient had symptoms and
signs of complex regional pain syndrome. Both patients’
symptoms resolved by the 6th postoperative week. Wie-
gel et al. [49��] report on a prospective study of 1389
perineural catheters in 849 consecutive patients. This
cohort had nine cases of superficial catheter-related
inflammation (0.6%), with vascular puncture present in
6% during catheter placement. Major nerve injury
occurred in one patient as a result of retroperitoneal
hematoma. These authors concluded that major injury
is uncommon with the use of femoral and sciatic con-
tinuous catheters. These studies provide substantial
safety data to allay concerns regarding the use of con-
tinuous peripheral nerve blocks.
ConclusionRegional anesthesia is an excellent anesthetic modality
for many different types of ambulatory orthopedic
surgery. Benefits in terms of clinical outcomes such as
pain and PONV are readily found in the peer review
literature. Benefits also exist for the day surgery unit in
reducing the time that patients spend in the PACU,
hastening ambulation, and facilitating early hospital dis-
charge. Neuraxial anesthesia has seen considerable aca-
demic endeavors in terms of the search for the ideal
intrathecal agent for short day-case procedures. Patient
and case selection are of paramount importance in choos-
ing the correct intrathecal agent, especially when shorter
acting agents are considered. Peripheral nerve blockade
for anesthesia and perioperative analgesia has the poten-
tial to transform anesthesia services, providing truly
ambulatory anesthesia when historically general anesthe-
sia was the preferred option. The phenomenon of
rebound pain on block regression can be managed with
opyright © Lippincott Williams & Wilkins. Unauth
the use of ambulatory continuous perineural catheters,
with appropriate home limb care and clinical follow-up.
The experience gained so far with continuous perineural
catheters suggests that they may be used safely and
efficaciously in the ambulatory setting.
In conclusion, regional anesthesia has an important and
ever-expanding role to play in ambulatory orthopedic
surgery. The advent of the ultrasound era, not a focus
of this review, will no doubt see more regional anesthesia
enthusiasts and more patients taking advantage of the
benefits of regional anesthesia in day-case surgery.
References and recommended readingPapers of particular interest, published within the annual period of review, havebeen highlighted as:� of special interest�� of outstanding interest
Additional references related to this topic can also be found in the CurrentWorld Literature section in this issue (p. 812).
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728 Ambulatory anaesthesia
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26
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28 Macaire P, Gaertner E, Capdevila X. Continuous postoperative regionalanalgesia at home. Minerva Anestesiol 2001; 67:109–116.
29 Chan VW, Peng PW, Kaszas Z, et al. A comparative study of generalanesthesia, intravenous regional anesthesia, and axillary block for outpatienthand surgery: clinical outcome and cost analysis. Anesth Analg 2001;93:1181–1184.
30 Williams SR, Chouinard P, Arcand G, et al. Ultrasound guidance speeds theexecution and improves the quality of supraclavicular block. Anesth Analg2003; 97:1518–1523.
31 Sites BD, Beach ML, Spence BC, et al. Ultrasound guidance improves thesuccess rate of a perivascular axillary brachial plexus block. Acta AnaesthesiolScand 2006; 50:678–684.
32
��Casati A, Danelli G, Baciarello M, et al. A prospective randomised comparisonbetween ultrasound and nerve stimulation guidance for multiple injectionbrachial plexus block. Anesthesiology 2007; 106:992–996.
This study demonstrated that multiple injection axillary block with nerve stimulationguidance provided similar success rates and incidence of complication to that withultrasound guidance.
33 Rawal N, Hylander J, Nydahl PA, et al. Survey of postoperative analgesiafollowing ambulatory surgery. Acta Anaesthesiol Scand 1997; 41:1017–1022.
opyright © Lippincott Williams & Wilkins. Unautho
34 Pavlin DJ, Chen C, Penaloza DA, et al. Pain as a factor complicatingrecovery and discharge after ambulatory surgery. Anesth Analg 2002;95:627–634.
35 Hadzic A, Williams BA, Karaca PE, et al. For outpatient rotator cuff surgery,nerve block anesthesia provides superior same-day recovery over generalanesthesia. Anesthesiology 2005; 102:1001–1007.
36 Bouaziz H, Narchi P, Mercier FJ, et al. The use of a selective axillary nerve blockfor outpatient hand surgery. Anesth Analg 1998; 86:746–748.
37 Liebmann O, Price D, Mills C, et al. Feasibility of forearm ultrasonography-guided nerve blocks of the radial, ulnar, and median nerves for handprocedures in the emergency department. Ann Emerg Med 2006;48:558–562.
38 Klein SM, Pietrobon R, Nielsen KC, et al. Peripheral nerve blockade with long-acting local anesthetics: a survey of the Society for Ambulatory Anesthesia.Anesth Analg 2002; 94:71–76.
39 Mulroy MF, Larkin KL, Batra MS, et al. Femoral nerve block with 0.25% or0.5% bupivacaine improves postoperative analgesia following outpatientarthroscopic anterior cruciate ligament repair. Reg Anesth Pain Med 2001;26:24–29.
40 Williams BA, Kentor ML, Vogt MT, et al. Femoral-sciatic nerve blocks forcomplex outpatient knee surgery are associated with less postoperative painbefore same-day discharge: a review of 12000 consecutive cases from theperiod 1996–1999. Anesthesiology 2003; 98:1206–1213.
41 Lavelle W, Lavelle ED, Lavelle L. Intra-articular injections. Anesthesiol Clin2007; 25:853–862.
42
�Lundblad M, Kapral S, Marhofer P, et al. Ultrasound-guided infrapatellar nerveblock in human volunteers: description of a novel technique. Br J Anaesth2006; 97:710–714.
The authors describe a novel and feasible block for perioperative analgesia in out-patient arthroscopic surgery.
43 Hansen E, Eshelman MR, Cracchiolo A 3rd. Popliteal fossa neural blockadeas the sole anesthetic technique for outpatient foot and ankle surgery. FootAnkle Int 2000; 21:38–44.
44 Ilfeld BM, Morey TE, Wright TW, et al. Continuous interscalenebrachial plexus block for postoperative pain control at home: a rando-mized, double-blinded, placebo-controlled study. Anesth Analg 2003;96:1089–1095.
45
�Russon K, Sardesai AM, Ridgway S, et al. Postoperative shoulder surgeryinitiative (POSSI): an interim report of major shoulder surgery as a day caseprocedure. Br J Anaesth 2006; 97:869–873.
The authors investigated the feasibility and acceptance of community-basedcontinuous interscalene brachial plexus blockade to provide effective analgesiafor day-case shoulder surgery.
46
��Ilfeld BM, Le LT, Meyer RS, et al. Ambulatory continuous femoral nerve blocksdecrease time to discharge readiness after tricompartment total knee arthro-plasty: a randomized, triple-masked, placebo-controlled study. Anesthesiol-ogy 2008; 108:703–713.
These study findings favor the use of a 4-day ambulatory cFNB compared with anovernight cFNB following tricompartment total knee arthroplasty. It decreases thetime to reach three important discharge criteria by an estimated 53%.
47 Capdevila X, Pirat P, Bringuier S, et al. Continuous peripheral nerve blocks inhospital wards after orthopedic surgery. Anesthesiology 2005; 103:1035–1045.
48
�Swenson JD, Bay N, Loose E, et al. Outpatient management of continuousperipheral nerve catheters placed using ultrasound guidance: an experiencein 620 patients. Anesth Analg 2006; 103:1436–1443.
The findings of this series suggest that, with adequate instruction and telephoneaccess to healthcare providers, patients are comfortable with managing andremoving continuous peripheral nerve catheters at home.
49
��Wiegel M, Gottschaldt U, Hennebach R, et al. Complications and adverseeffects associated with continuous peripheral nerve blocks in orthopedicpatients. Anesth Analg 2007; 104:1578–1582.
The results of this impressive cohort (398 catheters in 849 consecutive patients)add to the evidence that major complications are rare, but minor adverse effectsassociated with continuous PNBs may be more common.
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