Anestesia Regional y Corta Estancia

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Regional anaesthesia in day-stay and short-stay surgery

S. L. Kopp1

and T. T. Horlocker2

1 Assistant Professor of Anesthesiology, Mayo Clinic College of Medicine, Rochester, Minnesota, USA

2 Professor of Anesthesiology and Orthopedic Surgery, Mayo Clinic College of Medicine, Rochester, Minnesota, USA

Summary

The goals for ambulatory surgery are rapid recovery with minimal side effects, adequate postop-

erative pain control, rapid patient discharge and overall cost containment. The addition of regional

anaesthetic techniques has been shown to decrease nausea, postoperative pain scores and the need

for post-anaesthesia care unit monitoring. The use of regional anaesthesia is increasing as studies

confirm the goals for ambulatory anaesthesia can be met with a combination of regional anaesthesia

and a multimodal pain management regimen.

........................................................................................................

Correspondence to: Dr Sandra L. Kopp

E-mail: [email protected]

The number of ambulatory procedures being performed

is steadily increasing, currently accounting for 5070% of

all surgical procedures in the US [1]. Rapid recovery,

adequate analgesia, minimal postoperative nausea and

vomiting, and rapid discharge become extremely impor-

tant when converting inpatient surgical procedures to

ambulatory procedures. General anaesthesia has histori-

cally been the technique of choice for short, ambulatory

procedures because of the simplicity and overall accep-

tance of the technique. With the introduction of newer,

rapid-acting general anaesthetic agents such as desflurane

and propofol, general anaesthesia continues to be a

popular anaesthetic technique in many ambulatory sur-

gery centers. Although these agents may decrease patients

recovery times, they do not appear to have an impact on

postoperative pain and nausea, two of the most common

causes of delayed recovery and delayed hospital discharge

[2]. The use of multimodal analgesic techniques com-

bined with aggressive anti-emetic prophylaxis may

decrease the disadvantages of general anaesthesia [3].The use of regional anaesthetic techniques for ambu-

latory surgical patients has grown in popularity because of

improved postoperative pain control, less nausea, and

increased alertness. A recent meta-analysis revealed that

peripheral nerve blocks increased post-anaesthesia care

unit (PACU recovery room) bypass, decreased the

visual analogue scale (VAS) pain scores, decreased the

need for postoperative analgesics, decreased the incidence

of nausea, shortened PACU time and increased patients

satisfaction [4]. The regional technique chosen depends

on the surgical site, the anticipated length of the

procedure, ambulation requirements and the desired

duration of postoperative pain control. Techniques such

as local infiltration, neuraxial blockade and peripheral

nerve blocks have all been used successfully in the

ambulatory population. Several studies have reported that

the use of regional anaesthesia or local anaesthetics (LAs)

can provide pre-emptive analgesia and, theoretically, may

decrease sensitisation of nerve endings after surgery and

decrease acute postoperative pain as well as chronic pain

syndromes [5].

Regional anaesthesia for upper extremity

ambulatory surgery

Local infiltration, intravenous regional anaesthesia, bra-

chial plexus blockade and general anaesthesia are the

anaesthetic options for most surgical procedures on the

upper extremity. The upper extremity is well suited toperipheral nerve blockade because the entire arm and

shoulder is innervated by the brachial plexus and blockade

is easily accomplished with a single injection (Table 1).

The differences in surgical outcome after a regional, when

compared with a general, anaesthetic technique in

patients undergoing upper extremity surgery are of

limited duration, perhaps because the procedures are

not as extensive and adequate pain control may be

achieved with conventional analgesics. However, a major

Anaesthesia, 2010, 65 (Suppl. 1), pages 8496 doi:10.1111/j.1365-2044.2009.06204.x.....................................................................................................................................................................................................................

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advance is the placement of indwelling brachial plexus

catheters to provide prolonged analgesia at home, thereby

allowing operations that would have traditionally

required 23 days of hospitalisation to be performed as

day-stay or short-stay surgery. Indeed, both total elbow

and shoulder arthroplasty have been performed as day-

stay procedures with analgesia primarily provided by a

perineural catheter [6, 7].

Shoulder surgery

Injury to the rotator cuff is a common abnormality

requiring surgical repair and is often performed arthro-

scopically as a day-stay procedure. Arthroscopic surgery is

often associated with severe postoperative pain requiring

large doses of opioids [8]. Side effects from opioids

include nausea, vomiting, sedation, constipation, respira-

tory depression and failure to control pain. Although both

general and regional anaesthesia are effective for shoulder

surgery, patients who receive regional anaesthesia for

outpatient rotator cuff repair bypass the PACU more

frequently, report less pain, ambulate earlier, satisfy

discharge criteria sooner, and are more satisfied with

their care than those who receive general anaesthesia [9].The interscalene nerve block is the most commonly

used regional technique for shoulder surgery. Blockade

occurs at the level of the roots as they exit between the

middle and anterior scalene muscles at the C6 level

(identified by the cricoid cartilage). The brachial plexus is

quite spread out at this level, and even with large doses of

LA the lower roots (C8 and T1) may be left unblocked.

This technique does not, therefore, provide adequate

blockade for surgery on the arm or hand. When

compared with general anaesthesia, patients who under-

went an interscalene block had significantly fewer

unplanned hospital admissions (8% vs 0%) [10]. Similarly,

several studies have shown that interscalene blocks

provide superior postoperative analgesia when compared

with suprascapular nerve block, intravenous or oral

opioids, and LA infiltration of the joint capsule by the

surgeon [11]. Shoulder arthroscopy patients are often

encouraged to start passive range-of-motion exercises on

the first postoperative day in order to prevent the

formation of capsular adhesions and to preserve the range

of motion. Even with the longest lasting LA, interscalene

blocks cannot be expected to last longer than 1824 h.

Therefore, patients who are comfortable in the early

postoperative period may experience significant pain at

home when the block recedes. In order to provide

extended analgesia, interscalene catheters have recently

been introduced for the ambulatory population and have

resulted in less pain at home, decreased opioid use and

related side effects, and less sleep disturbance with very

few complications [12, 13].

Arm and hand surgeryExisting data reveal that regional anaesthesia offers several

advantages over general anaesthesia for patients undergo-

ing ambulatory hand surgery, including decreased opioid

consumption, less postoperative nausea and vomiting,

decreased time in the PACU and expedited discharge

from the hospital [14]. Several regional techniques are

used for surgery on the arm and hand, including local

infiltration, intravenous regional anaesthesia, and brachial

plexus blockade.

Table 1 Regional anaesthesia techniques for upper extremity surgery.

Brachial plexus

technique

Level of

blockade

Peripheral nerves

blocked Surgical applications Comments

Axillary Peripheral

nerves

Radial, ulnar,

median

Surgery on forearm and hand;

less used for procedures near

the elbow

Unsuitable for proximal humerus or

shoulder surgery

Requires patient to abduct the arm

Musculocutaneous nerve unreliably blocked

Infraclavicular Cords Radial, ulnar,

median,

musculocutaneous,

axillary

Surgery to elbow, forearm,

hand

No risk of haemothorax or pneumothorax

Relatively rapid onset

Catheter site is easy to maintain

Supraclavicular Distal trunk

proximal cord

Radial, ulnar, median,

musculocutaneous,

axillary

Surgery to mid humerus, elbow,

forearm and hand

Risk of pneumothorax requires caution in

ambulatory patients

Phrenic nerve paresis in 30% of cases

Interscalene Upper and

middle trunks

Entire brachial

plexus, although

inferior trunk

(ulnar nerve) is

inconsistently

blocked

Surgery to shoulder, proximal

and mid-humerus

Phrenic nerve paresis in 100% of patients

for duration of the block

Unsuitable for patients unable to tolerate a

25% reduction in pulmonary function

Adapted from Horlocker TT, Kopp SL, Lennon RL. General and regional anesthesia and postoperative pain control. In: Morrey BF, ed. The Elbowand Its Disorders, 4th edn. Philadelphia: Elsevier, 2009: 144, with permission.

Anaesthesia, 2010, 65 (Suppl. 1), pages 8496 S. L. Kopp and T. T. Horlocker Day surgery......................................................................................................................................................................................................................

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Intravenous regional anaesthesia is a useful technique

for short (< 60 min) surgical procedures below the

elbow. The technique is a relatively simple and safe

method of providing anaesthesia for upper extremity

surgery with published success rates ranging from 9498%

[15]. When compared with general anaesthesia and

axillary brachial plexus block, intravenous regional anaes-

thesia offered the peri-operative clinical benefits of

decreased intra-operative and postoperative costs and

hospital discharge that was nearly 1 h earlier than in those

who had general anaesthesia. The potential disadvantages

include failure due to tourniquet pain and limited

postoperative analgesia [14].

Brachial plexus techniques for arm, forearm and hand

surgery include mid-humeral block, axillary block,

infraclavicular block, and supraclavicular block. Selection

of the appropriate technique is determined by the

innervation of the surgical site, specific patient anatomy

and co-morbidities, the experience of the anaesthetist andthe associated anaesthetic and surgical complications. For

example, patients with significant pulmonary disease are

poor candidates for a supraclavicular approach due to the

potential for pneumothorax and phrenic nerve paresis.

Likewise, an axillary approach may not be adequate for

surgery to the mid- or distal humerus because of the close

proximity of the level of blockade to the site of surgery.

The supraclavicular block is performed at the level of the

trunks where the brachial plexus is compact and wrapped

in a dense fascia before diverging under the clavicle.

Unpredictable blockade of the axillary nerve has limited

the routine use of supraclavicular block in patients

undergoing shoulder surgery. The benefits of the supr-

aclavicular approach include rapid onset of blockade,

reliable anaesthesia for procedures distal to the shoulder

and the ability to perform the block in patients unable to

abduct their arm [16].

When compared with general anaesthesia, infraclavic-

ular brachial plexus blockade is associated with faster

recovery, fewer adverse events and better analgesia in

outpatients undergoing hand and wrist surgery [17].

Although LA is injected at the cord level, when compared

with the multi-stimulation axillary approach, the infra-

clavicular block was found to have a longer onset time and

a greater frequency of an incomplete block, mainlybecause of incomplete blockade of the ulnar nerve [18].

These deficiencies are overcome with injection on a

posterior cord motor response or the use of a multi-

stimulation approach. Infraclavicular block is ideal for

patients who are unable to abduct their arm (as needed for

an axillary block) or those in whom an indwelling catheter

is required due to the ease of catheter site maintenance.

Axillary brachial plexus blockade is the most commonly

used technique for surgery below the shoulder. It is a safe

technique that is rather easy to perform and is ideal for

surgery on the hand, forearm and elbow [19]. Numerous

techniques can be used, including transarterial, paraesthe-

sia, nerve stimulator, fascial click, infiltration technique

and, more recently, ultrasound-guided. Currently, there

are no conclusive data to support the use of one technique

of nerve localisation over another [2023]. However, in

general, multiple-stimulation techniques are associated

with a greater success rate than single injection techniques.

The placement of a brachial plexus catheter before

discharge and the continuous infusion of local anaesthetic

at home can significantly lengthen the period of postop-

erative analgesia. Studies have demonstrated decreased

VAS scores and increased patient satisfaction with the use

of continuous axillary [24] and infraclavicular [17, 25]

blockade in ambulatory patients undergoing surgery to

the hand. Due to the ease of performance and long-

standing safety profile, continuous axillary brachial plexus

block was one of the first catheter techniques to beevaluated in ambulatory patients. Despite the fact that

patients had to administer a bolus of local anaesthetic

when they experienced pain, there were very few

technical problems and high patient satisfaction [24].

Continuous infraclavicular blocks have the advantage of

an immobile insertion point which limits the risk of

dislodgement and facilitates site sterility, both of which

are important in the ambulatory population [26].

Regional anaesthesia for lower extremity

ambulatory surgery

The ideal anaesthetic for lower extremity ambulatory

surgery should be easy to perform, have a fast onset,

provide good operating conditions, allow for a rapid

recovery (ambulation and urinary voiding) and have

minimal side effects. Although general anaesthesia is

commonly used for this patient population, there is

evidence that patients may benefit from either a regional

or combined regional-general anaesthetic technique. In

addition to the intra-operative management of these

patients, postoperative pain control is essential to facilitate

rehabilitation after lower extremity surgery. Techniques

such as neuraxial blockade [27, 28], intra-articular opioids

with and without local anaesthetics [2729], singleinjection or continuous perineural infusion [3032], and

systemic opioids, all have individual advantages and

disadvantages.

Neuraxial blockade for lower extremity surgery

Epidural and spinal anaesthesia have been used success-

fully for lower extremity surgery, although without

making the necessary adjustments in LA selection and

dose, these techniques may have disadvantages in the

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ambulatory population including unpredictable onset and

regression, bilateral lower limb blockade and urinary

retention. Historically, lidocaine has been the LA of

choice for short-acting spinal anaesthesia in ambulatory

patients. With the incidence of transient neurologic

symptoms [33] and, more seriously, cauda equina syn-

drome [34] following intrathecal administration of lido-

caine, alternative techniques have been sought. Selective

spinal anaesthesia, using a minimal dose of intrathecal LA

with the goal of anaesthetising only the nerve roots

supplying the surgical area, and unilateral spinal anaes-

thesia, a one-sided spinal block with an absence of sensory

and motor block on the non-operative side, are both

alternatives to traditional spinal anaesthetic techniques

[35]. By manipulating the patients position based on the

baricity of the LA, it is possible to influence the

distribution of anaesthesia [36]. Lidocaine and bupiva-

caine (with and without the addition of opioids) have

been used to produce selective bilateral spinal anaesthesia,whereas for unilateral spinal anaesthesia, it is necessary to

use hyperbaric bupivacaine. When performing a unilateral

block, maintenance of the required patient position for a

prolonged period (often 1530 min) has been criticised

due to the pre-operative delay. Low dose, lipophilic

intrathecal opioids such as fentanyl (1025 lg) or sufen-

tanil (10 lg) improve the quality of anaesthesia without

delaying home discharge [37]. Low-dose clonidine has

been used in combination with ropivacaine and 2-

chloroprocaine to improve the quality of spinal anaes-

thesia, although due to the risk of sedation, bradycardia

and hypotension, larger doses must be avoided in the

ambulatory population [38].

A recent meta-analysis concluded that although

patients VAS scores and opioid usage in the PACU

were lower following neuraxial anaesthesia, the incidence

of nausea was not decreased, nor was the duration of the

PACU stay shortened, and ultimately discharge from the

hospital occurred 35 min later compared with general

anaesthesia [4]. This result may be skewed because of the

heterogeneous data with respect to the type of surgery

and dose of LA used. Overall, neuraxial anaesthesia may

be safely and effectively used in the ambulatory surgical

population given that an appropriately low-dose of LA

(with or without the addition of lipophilic opioids) isused.

Lower extremity peripheral techniques, which allow

complete unilateral blockade, have traditionally been

underused. In part, this is due to the widespread

acceptance and safety of spinal and epidural anaesthesia.

Furthermore, unlike the brachial plexus, the nerves

supplying the lower extremity are not anatomically

clustered where they can be easily blocked with a

relatively superficial injection of LA. Because of the

anatomic considerations, lower extremity blocks are

technically more difficult and require more training and

practice before expertise is acquired. Many of these blocks

were classically performed using paraesthesia, loss of

resistance or field block techniques that resulted in

variable success. Advances in needles, catheters and nerve

stimulator technology have facilitated the localisation of

nerves and improved success rates. These blocks are safe

and their unilateral nature makes them ideal for the

patient undergoing day-stay or short-stay procedures

since the contralateral limb is immediately available to

assist with early ambulation.

Knee arthroscopy and anterior cruciate ligament

repair

Diagnostic and therapeutic knee arthroscopy procedures

are commonly performed as day-stay procedures. Knee

arthroscopy surgery ranges from the simple, diagnostic

knee arthroscopy to the much more invasive anteriorcruciate ligament (ACL) repair. In addition to general

anaesthesia, virtually all other regional techniques have

been used for knee arthroscopy and ACL repair, includ-

ing intra-articular LAs [39, 40], lumbar plexus (femoral or

psoas) blockade with or without a sciatic block [4144]

and neuraxial anaesthesia (spinal, epidural or combined

spinal-epidural techniques) [4548] (Table 2). Local

infiltration of the arthroscopic portal insertions by the

surgeon combined with intravenous sedation is a rela-

tively simple technique. In a prospective study, 12% of

the patients would have preferred another technique, and

16% of the surgeons found the operating conditions

inadequate, probably due to difficulty in knee manipu-

lation given the lack of muscle relaxation [40].

Of the neuraxial techniques, spinal anaesthesia has the

most rapid onset, and provides dense anaesthesia. Studies

have demonstrated that the discharge times for general

anaesthesia with propofol are similar to those for epidural

analgesia with 2-chloroprocaine, whereas patients who

received a procaine spinal anaesthetic had a longer

recovery time [49]. A recent study concluded that spinal

anaesthesia with low-dose (4 mg) hyperbaric bupivacaine

led to similar home-readiness times compared with

general anaesthesia with desflurane, although pain scores

and the need for postoperative opioids were significantlyless in the spinal group [47]. Unilateral and selective spinal

blockade have also been studied, and are recommended

for knee arthroscopy and ACL repairs. Overall, spinal and

epidural anaesthesia are suitable anaesthetic options for

knee arthroscopy and ACL repair, assuming that an

appropriate technique and dose of LA is used.

Lower extremity peripheral blockade provides anaes-

thesia and prolonged analgesia following moderately

painful lower extremity surgery. The psoas compartment


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block can provide anaesthesia and analgesia to the entire

lumbar plexus and has been used for ambulatory knee

arthroscopy. Due to the relatively low pain scores after

minor knee arthroscopy and the risk profile associated

with psoas blockade (epidural spread, weak hip flexors),

this block may not be justified in the ambulatory

population [41]. The use of, home-going, psoas com-

partment catheters has been introduced, although at

present it has not been widely studied or accepted [50].

The more distal femoral nerve block provides anaesthesia

and analgesia to the anteromedial thigh, anterior knee and

medial calf. This broad coverage combined with the

relative ease of block placement makes the femoral nerve

block one of the most common lower extremity blocks.

As with the psoas approach, the need for a femoral blockfor minor knee arthroscopy procedures has not been

demonstrated in the literature [51]. In contrast, VAS

scores are lower in patients undergoing ACL repair,

which is significantly more painful than arthroscopy,

when a femoral block is performed [42, 51]. The addition

of a sciatic nerve block provided even better postoper-

ative analgesia in this population and resulted in fewer

hospital admissions [51]. The combination of a lumbar

plexus block (psoas or femoral) with a proximal sciatic

nerve block provides complete unilateral anaesthesia and

allows the use of a thigh tourniquet.

Continuous femoral nerve blocks have been used for

arthroscopically-assisted ACL repair and studies have

demonstrated a high degree of patient satisfaction and low

postoperative opioid requirements [52]. For most patients

undergoing ACL reconstruction, a single-injection fem-

oral block will provide adequate postoperative analgesia.

There are patients (extremes of age, chronic opioid users,

multi-ligament reconstruction) in whom a continuous

femoral catheter may offer advantages over a single

injection block [52]. There is also evidence to suggest that

increasing nerve block duration with the use of a femoral

catheter after ACL repair leads to a small but significant

reduction in rebound pain [53].

Foot and ankle surgery

Local, spinal, epidural and, peripheral blocks, and general

anaesthesia, have all been used successfully for foot and

ankle surgery. These procedures often result in moderate

to severe postoperative pain that is often difficult to

control with oral opioid medications. Hence, the greatest

advantage of regional techniques over general anaesthesia

is the prolonged analgesia associated with peripheral

Table 2 Regional anaesthesia techniques for lower extremity surgery.

Block

technique Area of blockade

Peripheral nerves

blocked

Block

duration* Comments

Femoral Femoral, par tial la te ral

femoral cutaneous and

obturator

Lumbar plexus L24 1218 h Provides anaesthesia analgesia to

anteromedial thigh, anterior knee and

medial calf

Need for minor arthroscopy surgery

has not been demonstrated

Deceased VAS when used for ACL repair

Psoas

compartment

Femoral, partial lateral

femoral cutaneous,

obturator, sciatic (S1)

Lumbar plexus

L15 and sciatic S1

1 218 h Anaest hes ia analgesia of entire lumbar

plexus

Due to low pain scores associated with

minor knee arthroscopy procedures the

risk profile may not justify use

Saphenous Medial aspect of lower

leg and foot

L24 (branch of

femoral nerve)

46 h Required for complete anaesthesia

analgesia of foot and ankle

Allows for use of calf tourniquet when

combined with popliteal sciatic nerve

block

Proximal sciatic Posterior thigh and leg

(except saphenous area)

Sciatic L45 and

sciatic S13

1830 h Superior analgesia and fewer hospital

admissions when combined with a femoral

block for patients undergoing ACL repairPopliteal sciatic Posterior lower leg and

foot (except saphenous

area)

Sciatic L45 and S13 1224 h When combined with a saphenous nerve

block anaesthesia analgesia is similar to that of

spinal anaesthesia with fewer side effects

Ankle Forefoot and midfoot Posterior tibial, deep

peroneal, superficial

peroneal, sural, and

saphenous

812 h Relatively simple to perform, high success

rate, few complications

Little or no effect on ambulation

Does not provide anaesthesia for tourniquet

use

*Duration of block performed with long-acting local anaesthetic, e.g. bupivacaine, ropivacaine.

ACL, anterior cruciate ligament; VAS, visual analogue pain scores.


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blockade. Ambulatory procedures on the midfoot and

forefoot are amenable to ankle blockade. Compared with

the more proximal blocks, the ankle block will have little

effect on postoperative ambulation (no foot drop,

hamstring, or quadriceps weakness) while providing a

mean of 11 h of postoperative analgesia if a long-acting

LA is used [54, 55]. Ankle blocks have a high success rate

with few complications, although a complete ankle block

requires LA to be injected around all five nerves supplying

the ankle (posterior tibial, sural, saphenous, deep pero-

neal, superficial peroneal). Despite the relative simplicity,

pain associated with injection of LA during an ankle block

may be significant and require sedation. Because the

block is performed at the ankle level, it does not provide

anaesthesia for a tourniquet placed on the thigh or calf.

However, a calf Esmarch bandage is usually well tolerated

by the patient.

The popliteal sciatic nerve block is a successful nerve

block for surgical anaesthesia as well as long-lastingpostoperative pain control for foot and ankle procedures

[5659]. Posterior and lateral approaches to the sciatic

nerve at the level of the popliteal fossa have both been

shown to provide safe, efficient and reliable anaesthesia

[56, 60, 61]. A popliteal sciatic nerve block combined

with either a saphenous or femoral nerve block allows the

use of a calf tourniquet and provides anaesthesia compa-

rable with neuraxial techniques. However, the peripheral

blocks result in less urinary retention and prolonged

postoperative analgesia [62]. When performed with

long-acting LAs such as ropivacaine or bupivacaine, a

single-injection block can provide 1224 h of analgesia.

Continuous perineural catheters placed in the popliteal

fossa have proven to provide excellent postoperative pain

control for outpatients undergoing moderately painful,

lower extremity orthopaedic surgery, often eliminating

the need for intravenous or oral opioid medications [63

65]. The sciatic nerve is blocked distal to the hamstring

muscles of the posterior thigh, and the patient is able to

retain knee flexion during a continuous infusion (facil-

itating ambulation) [64]. In addition, these patients have

been shown to experience a decrease in sleep disturbance,

oral opioid use and opioid-related side-effects leading to a

very high satisfaction rating [64].

Regional anaesthesia for ambulatory inguinal

hernia repair

Inguinal herniorrhaphy is a common ambulatory proce-

dure that has been successfully performed under a variety

of anaesthetic techniques such as general anaesthesia,

neuraxial anaesthesia, local infiltration, paravertebral

blockade and ilio-inguinal iliohypogastric blockade.

The postoperative side effects and prolonged hospital

stay are often related to the effects of anaesthesia (nausea,

vomiting, urinary retention). The need for urinary

catheterisation following hernia repair is approximately

29% after neuraxial anaesthesia, 8% after general anaes-

thesia and 0% after local infiltration, leading to home

discharge 3 h earlier after infiltration anaesthesia when

compared with general or regional anaesthesia [66].

Spinal anaesthesia for ambulatory hernia surgery

requires a higher level of sensory blockade compared to

that required for lower extremity procedures. Although

the dose of neuraxial LA may be increased to provide the

necessary coverage, this will delay voiding and, ulti-

mately, hospital discharge. As a result, neuraxial block is

typically performed for patients who suffer significant side

effects after general anaesthesia, such as protracted nausea

and vomiting. The use of ilio-inguinal iliohypogastric

nerve block combined with propofol sedation has been

associated with shortened hospital discharge time, lower

pain scores at discharge, and higher patient satisfactioncompared with patients receiving general or spinal

anaesthesia [67]. Paravertebral blocks at the level of

T10-L2 have been shown to provide excellent unilateral

anaesthesia with a low incidence of postoperative nausea

and vomiting and very low analgesic requirements

compared with patients receiving standard peripheral

blocks placed during surgery by the surgeon [68].

Although paravertebral blocks have been used successfully

for hernia surgery, this technique is not without compli-

cations, some of which may be significant in the

ambulatory population, such as pneumothorax or epidural

spread. Although paravertebral block may provide pro-

longed analgesia, the pain from the incision associated

with herniorrhaphy is minor and may not warrant the

invasiveness of a paravertebral technique.

Regional anaesthesia for minor ambulatory

breast surgery

Diagnostic and minor therapeutic breast surgery is

commonly performed in the ambulatory setting and the

anaesthetic technique used should provide a quick

recovery as well as adequate postoperative pain relief

with minimal side effects. Although general anaesthesia is

commonly used, many patients may have undesirable sideeffects such as pain, nausea and vomiting. Interest in

paravertebral blockade for breast surgery is increasing

because the technique provides unilateral and segmental

blockade. Patients undergoing major breast surgery who

underwent thoracic paravertebral blockade reported a

shorter recovery time, experienced less postoperative

pain, required fewer analgesics, tended to mobilise faster

and were discharged from the hospital significantly earlier

than patients receiving general anaesthesia [69]. Although


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paravertebral blocks have been performed for patients

undergoing minor breast surgery, the risks (pleural or

vascular puncture, hypotension, pneumothorax) and

benefits must be carefully weighed. Terheggen et al.

[70] found that although VAS scores in the first 90 min

after surgery were lower in patients undergoing paraver-

tebral blockade; there was no difference in later VAS

scores, postoperative nausea and vomiting, or recovery

time when compared with patients who had general

anaesthesia. Considering the incidence of complications,

the authors concluded that the risk benefit ratio of

paravertebral blockade did not favour their routine use for

minor breast surgery.

Continuous ambulatory perineural infusions

Pain is a common reason for delayed discharge and

unanticipated hospital re-admission. Recently, studies

have demonstrated that continuous perineural LA infu-sion is effective in decreasing pain scores after ambulatory

orthopaedic surgery for the length of the infusion [30, 31,

71]. This technique involves inserting a percutaneous

catheter adjacent to the peripheral nerve supplying the

surgical site. The recent introduction of portable infusion

pumps has allowed patients with perineural catheters to be

safely discharged home with the same level of analgesia

that was historically only available to those patients who

remained inpatients. Several recent investigations have

demonstrated that patients undergoing moderately painful

procedures with postoperative perineural LA infusions

have had lower resting and break-through pain scores and

required fewer oral analgesics [13, 25, 64, 72].

There is a variety of infusion systems ranging from

simple elastomeric, disposable pumps to the more

expensive, mechanical, battery-operated pumps. The

mechanical, re-programmable pumps offer a great deal

of flexibility in programming and bolus dosing but tend to

be much more expensive. Capdevila et al. [71] demon-

strated that disposable, non-mechanical pumps were as

effective as electronic patient-controlled analgesia pumps

for postoperative pain relief, were associated with fewer

technical problems, and consequently led to better patient

satisfaction scores. Studies have determined that a greater

continuous LA infusion rate may provide better paincontrol, less sleep disturbance and increased patient

satisfaction compared with a lower continuous infusion

plus patient-controlled boluses. Despite these advantages,

a limited reservoir pump set to deliver a greater contin-

uous infusion may decrease the overall duration of

analgesia [73].

Despite the potential benefits of regional anaesthesia,

many anaesthetists avoid placing long-acting major con-

duction blocks in the lower extremity (lumbar plexus,

sciatic, popliteal) for fear of patients being discharged

with an insensate lower extremity [74]. Although patient

selection and detailed instructions on limb protection are

essential when discharging patients with a blocked

extremity, a recent study revealed that complications

were very rare [75]. This retrospective review of 2 382

patients discharged with blocked upper and lower

extremities found that patients were extremely satisfied

and only one patient fell when exiting a car and,

fortunately, was not injured. Although falls after lower-

extremity peripheral nerve blocks have not been widely

reported, protocols need to be developed for the care of

these patients, including instruction on the use of assist

devices, knee immobilisers and education of patients and

their families about the risk of falls [76]. It is also

important to provide the patient and carer with written as

well as verbal instructions (Table 3). In addition to

standard postoperative outpatient instructions, patients

with indwelling perineural catheters require informationregarding infusion pump function, block resolution, pain

medication, driving limitations, limb protection, catheter

site care, signs and symptoms of local anaesthetic toxicity

and catheter removal instructions. A plan for break-

through pain is essential since the surgical block has

Table 3 Instructions for patients receiving brachial plexuscatheters for home use.

You are receiving local anaesthetic through a small catheter near your

nerves to help with your pain after surgery. This may not take away

all of your pain but should help greatly. You may take your pain

medicines as prescribed by your doctor. The nurse will review thiswith you. The local anaesthetic will initially make your arm very

numb. Over time, this degree of numbness will decrease, but usually

your arm is not normal until the catheter is removed. Because your

arm or leg will not function normally, YOU SHOULD NOT DRIVE

The doctors and nurses will review the pump instructions with you. If

you have any problems with the pump, call the technical support

number or the number the doctor has given you

Complications that could potentially occur include:

The catheter may fall out. If this occurs, make sure to take some of

your pain medicine and turn the pump off

Fluid may leak around the catheter. You can change or reinforce the

dressing if necessary. This is usually not a problem

The catheter may migrate into a blood vessel and cause high levels

of local anaesthetic. Symptoms of high levels of local anaesthetic may

include:

Drowsiness

DizzinessBlurred vision

Slurred speech

Poor balance

Tingling around lips mouth

Other

You should keep your arm in a sling unless doing therapy

Call your physician for medical assistance if any of the following

symptoms occur:

Unusual drowsiness

Uncontrollable pain

Uncontrollable vomiting


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typically not resolved by the time of discharge. Although

perineural infusions decrease postoperative pain, many

patients will require oral analgesics as part of a multimodal

analgesic regimen.

Multimodal analgesia

Multimodal analgesia is a multidisciplinary approach to

pain management using both pharmacological and non-

pharmacological techniques such as regional anaesthesia,

with the aim of maximising the positive aspects of a

treatment while limiting the associated side effects. The

approach to acute postoperative pain management must

focus on the entire rehabilitation process rather than

focusing specifically on the patients pain. Frequently,

treatment of postoperative pain results in nausea and

vomiting. A combination of peripheral nerve blocks and

multimodal oral analgesics may help increase patient

satisfaction by decreasing both pain and the negative sideeffects associated with traditional pain management.

Non-opioid analgesics

Paracetamol

Paracetamol is an important non-opioid analgesic with

very few side effects (Table 4). A recent Cochrane

systematic review found 40 trials comparing paracetamol

with placebo in patients with moderate to severe

postoperative pain [77]. In postoperative pain manage-

ment, paracetemol 1 g had a number-needed-to-treat

(NNT) of 4.6 for at least 50% pain relief when compared

with placebo. As expected, there was no difference in the

incidence of adverse side effects between paracetamol and

placebo. Paracetamol is an important addition to a

multimodal postoperative pain regimen, although the

total daily dose must be limited to no more than 4 g.

Non-steroidal anti-inflammatory drugs (NSAIDs)

The NSAIDs have a mechanism of action through the

cyclo-oxygenase (COX) enzymatic pathway and ulti-

mately block two individual prostaglandin pathways.

The COX-1 pathway is involved in prostaglandin-E2-

mediated gastric mucosal protection and thromboxane

B2 effects on coagulation. The inducible COX-2

pathway is mainly involved in the generation of

prostaglandins included in the modulation of pain and

fever [78]. The major side effects limiting NSAID use

for postoperative pain control (renal failure, platelet

dysfunction and gastric ulcers or bleeding) are related to

the nonspecific inhibition of the COX-1 enzyme [79].

The advantages of the COX-2 inhibitors are the lack ofplatelet inhibition and a decreased incidence of gastro-

intestinal effects. Prostaglandins are necessary to main-

tain renal homeostasis and, therefore, all NSAIDs have

the potential to cause serious renal impairment. Inhibi-

tion of the COX enzyme may have only minor effects

in the healthy kidney, but can lead to serious side effects

in elderly patients or those with a low-volume condi-

tion (blood loss, dehydration, cirrhosis or heart failure).

Therefore, NSAIDs should be used cautiously in

patients with underlying renal dysfunction, specifically

in the setting of volume depletion due to blood loss

[79].

Table 4 Oral non-opioid analgesics.

Ana lgesic Dose

Dosing

interval

Maximum

daily dose Comment s

Paracetamol 5001000 mg 46 h 4000 mg As effective as aspirin; 1000 mg

more effective than 650 mg

aspirin in some patients

Celecoxib 400 mg initially,

then 200 mg

12 h 800 mg

Aspirin 3251000 mg 46 h 4000 mg Most potent anti-platelet effec t

Ibuprofen 200400 mg 46 h 3200 mg 200 mg equal to 650 mg aspirin

or paracetamol

Naproxen 500 mg 12 h 1000 mg 250 mg equal to 650 mg aspirin,

but with longer duration

Ketorolac 1530 mg 46 h 60 mg(> 65 years);

120 mg

(< 65 years)

Comparable to 10 mg morphine;reduce dose in patients < 50 kg or

with renal impairment; total

duration of administration is 5

days

Tramadol 50100 mg 6 h 400 mg; less in

cases of renal

or hepatic

disease

Adapted from: Lennon RL, Horlocker TT. Mayo Clinic Analgesic Pathway: Peripheral Nerve

Blockade for Major Orthopedic Surgery. Florence KY: Taylor and Francis Group, 2006. By per-

mission of The Mayo Foundation for Medical Education and Research.


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The effect of NSAIDs on bone formation and healing is

another concern that is specific to the orthopaedic

population. Gajraj et al. [80] summarised the limited

available literature in a recent article and concluded that

although the data are conflicting there is evidence from

animal studies that COX-2 inhibitors may inhibit bone

healing. They also noted that it is difficult to extrapolate

animal data into clinical practice, and the adverse effects

of COX-2 inhibitors need to be weighed against the

benefits. Until large human studies are performed it is

reasonable to be cautious with the use of COX-2

inhibitors, especially when bone healing is critical.

Ketorolac is a nonspecific NSAID that can be given

parenterally. A systematic review and meta-analysis of

ketorolac found that opioid usage was decreased by 36%

in surgical patients and an intravenous dose of ketorolac

1030 mg was found to have a similar efficacy to that of

1012 mg of intravenous morphine [81]. Due to the

potential for serious side effects (gastric ulceration andrenal impairment), ketorolac should be used for 5 days or

less in the adult population with moderate to severe acute

pain [79].

Tramadol

Tramadol is a centrally acting analgesic that is structurally

related to morphine and codeine. It works by binding to

the opioid receptors as well as blocking the re-uptake of

both noradrenaline and serotonin. It has gained popularity

due to the low incidence of adverse effects, specifically

respiratory depression, constipation and abuse potential.

Tramadol has been shown to provide adequate analgesia,

superior to placebo and comparable with various opioid

and non-opioid analgesics for the treatment of acute pain

[82]. However, when used as a sole analgesic for patients

undergoing total hip replacement Stubhaug et al. [83]

found no difference in analgesic efficacy compared with

placebo. Due to the low incidence of side effects,

tramadol may be used as an alternative to opioids in a

multimodal approach to postoperative pain, specifically in

patients who are intolerant to opioid analgesics.

Ketamine

Ketamine is a noncompetitive N-methyl-D-aspartate

(NMDA) receptor antagonist that may play a critical role

in the intensity of perceived postoperative pain [84].

Menigaux et al. [85] evaluated postoperative pain scores,

side effects and ability to ambulate in patients undergoing

outpatient knee arthroscopy to determine if a small intra-

operative, intravenous dose of ketamine (0.15 mg.kg)1

)improved outcomes compared with placebo. The authors

concluded that the ketamine group had significantly less

postoperative pain at rest and during mobilisation on days

0, 1 and 2. They also consumed less oral pain medication

and were able to ambulate for a longer period of time on

the first postoperative day.

Opioid analgesics

Opioid analgesics are routinely given to patients for

moderate or severe pain in the peri-operative period

despite their well-known side effects (Table 5). The

Table 5 Oral opioid analgesics.

Analgesic Dose

Dosing

interval Comments

Extended release

oxycodone

1020 mg 12 h Limit to total of

four doses to avoid

accumulation and

opioid-related side

effects

Extended release

morphine

1530 mg 812 h Limit to total of four

doses to avoid

accumulation and

opioid-related side

effects

Oxycodone 510 mg 46 hHydromorphone 24 mg 46 h

Hydrocodone 510 mg 46 h All preparations

contain paracetamol*

Codeine 3060 mg 4 h Combination products*

of codeine paracetamol

and codeine aspirin are

available

*Dose in combination products limited by total paracetamol or aspirin ingestion.

Adapted from: Lennon RL, Horlocker TT. Mayo Clinic Analgesic Pathway: Peripheral Nerve

Blockade for Major Orthopedic Surgery. Florence KY: Taylor and Francis Group, 2006. By per-

mission of The Mayo Foundation for Medical Education and Research.


2010 The Authors



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adverse effects of opioid administration can cause serious

complications in patients undergoing major orthopaedic

procedures. Opioid adverse events in randomised, con-

trolled trials were recently summarised in a systematic

review of postoperative analgesia [86]. The main adverse

events included gastro-intestinal effects (nausea, vomiting,

ileus) (31%), central nervous system effects (somnolence

and dizziness) (30%), pruritus (18%), urinary retention

(17%), and respiratory depression (3%). Due to the

variation in patient pain tolerance, dosing regimens need

to be adjusted frequently in order to maximise the

benefits and minimise the incidence of side effects.

Oral opioids are available in immediate-release and

controlled-release formulations. Although immediate-

release oral opioids are effective in relieving moderate

to severe pain, they must be administered as often as every

4 h. When these medications are prescribed on an as-

needed basis, there may be a delay in the administration,

resulting in a low opioid plasma concentration and asubsequent increase in pain. The US Acute Pain Man-

agement Guideline Panel currently recommends a fixed

dosing schedule for all patients receiving opioid medica-

tions for > 48 h postoperatively (Acute Pain Manage-

ment Guideline Panel, 1992 http://www.ahrq.gov/

clinic/medtep/acute.htm). It is important to note that an

interruption of the dosing schedule, particularly during

the night, may lead to an increase in the patients pain.

A controlled-release formulation of oxycodone (Oxy-

Contin; Purdue Pharma, Norwalk, CT, USA) has been

shown to provide sustained pain relief due to the

maintenance of therapeutic opioid concentrations over

an extended time period. A scheduled dose of controlled-

release oxycodone combined with an as-needed dose of

immediate-release oxycodone for break-through pain

may maximise the analgesia and decrease the associated

side effects.

Conclusions

The number of ambulatory surgery cases is growing

rapidly worldwide. The goals for ambulatory anaesthesia

are rapid recovery with minimal side effects, adequate

postoperative pain control, rapid patient discharge and

overall cost containment. The addition of regionalanaesthetic techniques has been shown to decrease

nausea, decrease postoperative pain scores and decrease

the need for PACU monitoring. The use of regional

anaesthesia is increasing as studies confirm the goals for

ambulatory anaesthesia can be met with a combination of

regional anaesthesia and a multimodal pain management

regimen. The use of peripheral nerve blocks has been

shown to increase the anaesthetic induction time by a

small amount [4], although this may be minimised by the

creation of a separate regional anaesthesia block room

with dedicated and well trained staff [87]. The introduc-

tion of regional anaesthesia into an existing, predomi-

nately general anaesthetic ambulatory practice takes

significant dedication, teamwork and resources, but the

potential cost savings for the hospital and the patient can

be significant [43]. In order for a successful conversion, all

existing policies and procedures must be evaluated and

quality indicators must be benchmarked before, and

reviewed after the conversion. The actual cost savings

after a conversion from primarily general to regional

anaesthesia will be different for each specific practice, and

is based on the number of procedures performed each

year and the initial investment required. Several articles

have been recently published describing in detail the

resource management and economic issues related to the

integration of peripheral nerve blocks into an established

ambulatory surgery center [88, 89].

Conflicts of interest

The authors declare no conflicts of interests.

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Anestesia Regional y Corta Estancia