Regional anesthesia techniques for ambulatory orthopedic surgery

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Regional anesthesia techniques
for ambulatory
orthopedic 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: [email protected]

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

mailto:[email protected]

http://dx.doi.org/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,

rized reproduction of this article is prohibited.

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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-


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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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,


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


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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23

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26

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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.


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.


Regional anesthesia techniques for ambulatory orthopedic surgery

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