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CHAPTER 12

V O L U M E T H I R T Y - F O U R

PRACTICAL REGIONAL
ANESTHESIA FOR
OUTPATIENTS

MEG A. ROSENBLATT, M.D.


ASSOCIATE PROFESSOR OF ANESTHESIOLOGY
DEPARTMENT OF ANESTHESIOLOGY
MOUNT SINAI MEDICAL CENTER
NEW YORK, NEW YORK

EDITOR: ALAN JAY SCHWARTZ, M.D., M.S. ED.


ASSOCIATE EDITORS: JOHN F. BUTTERWORTH IV, M.D.
JEFFREY B. GROSS, M.D.

The American Society of Anesthesiologists, Inc.


© 2006
The American Society of Anesthesiologists, Inc.
ISSN 0363-471X
ISBN 0-7817-9664-4

An educational service to the profession under the auspices of


The American Society of Anesthesiologists, Inc.

Published for The Society


by Lippincott Williams & Wilkins
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Practical Regional Anesthesia
for Outpatients
Meg A. Rosenblatt, M.D.
Associate Professor of Anesthesiology
Department of Anesthesiology
Mount Sinai Medical Center
New York, New York

The advantages that regional anesthesia (RA) confers over general anesthesia (GA),
especially in the outpatient setting, are numerous. Pavlin et al., in a prospective study
of 1,088 patients undergoing ambulatory surgery, found that the most important factor
in determining discharge time from the postanesthesia care unit (PACU) was the anes-
thetic technique (general anesthesia, local, peripheral nerve block, or spinal–epidural
anesthesia).1 This study highlights the anesthesia-related issues that prolong patient
PACU stays, which include pain, nausea and vomiting (PONV), unresolved neuraxial
blocks, and urinary retention. Pain accounted for half of the unanticipated admissions
in one review of 1,996 patients undergoing outpatient orthopedic surgery,2 whereas a
second study found that orthopedic patients are the group of ambulatory patients with
the greatest incidence (16.1%) of pain in the PACU.3 The treatment of pain can increase
PONV and further delay discharge, whereas the nursing care associated with prolonged
PACU stays contributes significantly to overall cost. Peripheral nerve blocks (PNBs)
offer predictable intraoperative anesthesia, analgesia that continues in the postopera-
tive period, the opportunity to bypass phase I recovery, and the avoidance of airway
manipulations. Despite their obvious advantages, PNBs are frequently underused, par-
ticularly in the ambulatory and office-based settings. This Refresher Course discusses
how to choose PNBs appropriate for a patient’s needs, how to modify the block for out-
patient procedures, and how to integrate PNBs into an ambulatory anesthetic practice.

Developing Proficiency in Peripheral Nerve Blocks


Kopacz and Neal, in their review of residency training in the year 2000, found that
40% of residents were receiving an inadequate experience with PNBs.4 Since January
2001, the Residency Review Committee for Anesthesiology of the Accreditation Coun-
cil for Graduate Medical Education has required that residents perform a minimum of
40 peripheral blocks, but has not provided guidelines for the number of any specific
block. Learning manual skills in anesthesia is characterized by rapid increase in suc-
cess during the first 20 attempts. Kopacz described the experience of seven residents
during their first 6 months of training and demonstrated significant improvement over
baseline after 20 spinal and 25 epidural anesthetics, but that 90% success rate was not
consistently achieved until 45 spinal and 60 epidural attempts.5 Konrad, too, reported
a rapid improvement in skill acquisition during the first 20 attempts at epidural and
spinal anesthesia, arterial line insertion, tracheal intubation, and performance of axil-
lary block. After 20 cases, he found a 70% success rate achieved by the 11 CA-1 resi-
dents he followed.6 With seven to nine previous blocks, only 50% of residents were
able to perform an interscalene block autonomously, whereas with >15 blocks, 87.5%

Copyright ©2006 American Society of Anesthesiologists 125


126 ROSENBLATT

reported autonomous success.7 Duke University Health System recently instituted a


teaching model for resident training in regional anesthesia that involves having a
CA-3 resident perform PNBs in a preoperative area, as well as assisting CA-1 or CA-2
residents who were assigned to operating rooms during the performance of their
blocks. They were able to increase the total number of experiences with PNBs from
80 (58–105 per resident) to 350 (range, 237–407).8 Unfortunately, most residencies
cannot offer this number of blocks to their trainees, and thus, many residents finish
training either without being exposed to certain blocks or without the opportunity to
develop proficiency.

Choosing Intelligently
Because the mastery of PNBs frequently does not occur during residency, the suc-
cessful incorporation of blocks into practice requires that an anesthesiologist contin-
ues to acquire skills while often having to work in a rapid turnover environment and
meet high surgeon and patient expectations. It is imperative that he or she critically
evaluates the practice, looking for blocks that fill specific needs and choosing tech-
niques that offer a high likelihood of success. Enlisting the surgeon to introduce the
concept of PNB while they offer patients preoperative instructions will improve
patient acceptance. Local anesthetics should be chosen to minimize onset times and
general anesthesia used to prevent operating room delays. Meticulous follow up until
resolution of all blocks and communication with the surgeons can add to overall sat-
isfaction.

Local Anesthetics and Adjuvants


Local anesthetic agents should be chosen according to the desired duration of
action and the degree of motor blockade required. An insensate extremity in a patient
whose procedure may not produce much postoperative discomfort may be at risk for
injury secondary to the loss of protective reflex of pain or place the patient at risk sec-
ondary to a loss of proprioception; blocks of the longest possible duration are not
always the wisest choice.
Whereas some practitioners combine local anesthetics to decrease onset time while
providing long duration, combining chloroprocaine 2% and bupivacaine 0.5% causes
pH changes that create a block that resembles one produced by bupivacaine alone.
Galindo concluded that mixing local anesthetics leads to unpredictable blockade char-
acteristics.9 Local anesthetic diffuses into the nerve and the rate of diffusion is related
to the concentration; therefore, higher concentrations of local anesthetic result in
more rapid onset of blockade.
The effect of alkalinization of agents on the speed of onset of the block is unclear.
It has been shown to offer no advantage in perivascular blocks with 0.5% bupivacaine10
but improvement in onset and quality of analgesia in axillary blocks with 1.25% mepi-
vacaine11 and in femoral and sciatic blocks with 2% mepivacaine.12 Adding sodium
bicarbonate to lidocaine has been shown to have no effect on the onset of axillary
block,13 and in rats, it has been shown to decrease the intensity and duration of the
block.14 In one study, fentanyl improved the sensory blockade achieved with an axil-
lary block of 1.5% lidocaine, but the pH changes it conferred delayed the onset of anal-
gesia.15 Other studies have not shown efficacy of either fentanyl or morphine in the
PRACTICAL REGIONAL ANESTHESIA FOR OUTPATIENTS 127

improvement of onset or quality of axillary blocks.16,17 Clonidine, an α2-agonist, is


known to prolong the duration of sensory and motor blockade, particularly when
added to local anesthetics of intermediate duration. One study of 56 patients under-
going carpal tunnel release under axillary block with 1% lidocaine and varying amounts
of clonidine showed a reduction in block onset time, but even with doses as small as
30 µg, patients experienced sedation. More than 50% of patients were reported as doz-
ing intermittently at 140 minutes after the block.18

Equipment
Making sure that one is familiar with equipment may sound obvious, but equipment
designed for peripheral nerve stimulation has lately undergone many improvements
and changes. Peripheral nerve stimulators should have the following characteristics:

• Constant current output


• Current meter
• Current intensity control
• Short pulse width
• Stimulating frequency
• Disconnect indicator

Newer models may offer several options for pulse width and stimulating frequen-
cies. Inappropriate choices may lead to patient discomfort or even difficulties in nerve
location.
Ultrasound is becoming a popular modality for the identification of nerves and
nerve plexuses, but because it is a relatively new and somewhat expensive modality
that may not be available for every practitioner. The rest of this discussion is confined
to the use of surface anatomy and peripheral nerve stimulation.

Peripheral Nerve Blocks and When to Use Them


The following is a discussion of some useful blocks and their specific applications
for outpatients.

Midtarsal Ankle Block


First described in 1986 by Sharrock et al.,19 this technique blocks the five nerves to
the forefoot where they are most superficial, thus requiring a small total volume of local
anesthetic (10–15 mL) and offering a high degree of success. It is particularly useful for
podiatric procedures and has the advantage over a traditional ankle block in that the
posterior tibial nerve is anesthetized with the patient in a supine position, using mini-
mal external rotation, and using the posterior tibial artery as a landmark (Fig. 1). The
deep peroneal nerve is blocked on either side of the dorsalis pedis artery, and a super-
ficial ring from the medial malleolus to the base of the fifth metatarsal completes the
block by anesthetizing the saphenous, superficial peroneal and sural nerves (Fig. 2).
The use of a 27-gauge needle minimizes trauma.
Pearls
• Understand the surgical procedure to ensure the correct nerves are blocked
• Use deep but short-acting sedation to place the block
128 ROSENBLATT

FIG. 1. Insertion site of needle to block the posterior tibial nerve, posterior to the medial
malleolus and adjacent to the pulsations of the posterior tibial artery.

• Use long-acting local anesthetics unless procedure is confined to soft tissue;


patients undergoing foot/ankle orthopedic or podiatric procedures can have sig-
nificant postoperative pain

Popliteal Block
The block of the sciatic nerve in the popliteal fossa provides excellent anesthesia for
foot and ankle surgeries, including repair of a ruptured Achilles tendon. The saphenous
nerve must be blocked to provide complete anesthesia below the knee. The inter-
tendinous approach described by Hadzic et al. uses the midpoint between the tendons
of the biceps femoris and semitendinosus muscles 7 cm above the popliteal stop as the
needle insertion point (Fig. 3).20 Using a nerve stimulator, one elicits a dorsiflexion,
plantarflexion, inversion, or eversion response at a current <0.4 mA. A dosage of 40 cc
of local anesthetic is then injected in increments. The block requires approximately
30 minutes to achieve surgical anesthesia.
Collins et al. described the impact of a regional anesthesia analgesia (RAA) program
for outpatient foot surgery. They retrospectively reviewed 50 charts from patients who
had undergone outpatient foot surgery before and after the implementation of the RAA
program that resulted in an increase in the use of ankle or lateral popliteal blocks from
2% to 82%. All patients in the study had GA combined with their block secondary to the
use of a thigh tourniquet. The mean anesthesia time only increased from 12 ± 8.6 min-
utes to 13 ± 7.3 minutes (mean ± standard deviation) with the addition of the block, but
both PACU and discharge lounge patient stays were significantly decreased. There was
a decrease in the number of patients who required greater than one but fewer than four
PRACTICAL REGIONAL ANESTHESIA FOR OUTPATIENTS 129

FIG. 2. Insertion site of the needle to block the deep peroneal nerve adjacent to the dorsalis
pedis artery and the superficial ring that will block the saphenous, superficial peroneal, and sural
nerves.

nursing interventions for analgesic administration. This finding may not have achieved
statistical significance secondary to lack of change in nursing protocols regarding post-
operative management, which included the routine administration of oral analgesics
before discharge from the hospital.21 In an earlier study at the same institution com-
paring lateral popliteal block with subcutaneous infiltration in patients undergoing
osteotomies of the foot, the use of 20 mL bupivacaine 0.5% plain was associated with
1,082 minutes (range, 375–1,930 minutes) of postoperative analgesia in the popliteal
group.22 Popliteal fossa neural blockade with saphenous nerve infiltration has been
described as the sole anesthetic technique for outpatient foot and ankle surgery. In a
study of 48 patients who received this anesthetic for bunionectomy, open reduction
and internal fixation of fractures, ankle ligament repair, Achilles tendon repair, hard-
ware removal, or ankle arthroscopy (all with proximal calf pneumatic tourniquets),
analgesia continued for an average of 10 hours postoperatively. No patients required
postoperative intravenous analgesics and all reported a high level of satisfaction.23 This
technique preserves contralateral leg strength and ipsilateral hamstring function, and
allows immediate postsurgical ambulation with crutches, therefore facilitating early dis-
charge.
Pearls
• Ensure the foot is perpendicular to the long axis of the leg when determining
landmarks
• Use at least 40 mL of local anesthetic to ensure that both the tibial and common
peroneal components are blocked
130 ROSENBLATT

FIG. 3. Landmarks for the intertendinous approach to the popliteal nerve block.

Remember that to ensure complete anesthesia below the knee, the saphenous nerve
must be blocked:
• At the knee
• In the inguinal crease
• Confirm that the surgeon is not planning to use a tourniquet at the level of the
thigh

Femoral (3-in-1) Block


The lumbar plexus gives rise to the femoral, lateral femoral cutaneous (LFC) and
obturator nerves, which provide sensory and motor innervation to the leg above the
knee. When comparing four needle insertion sites for accuracy in locating the femoral
nerve, Vloka found that using the inguinal crease, immediately adjacent to the femoral
artery, yielded a higher success rate (because the femoral nerve was significantly wider
and closer to the fascia lata) than at the level of the inguinal ligament.24 Using a nerve-
stimulating technique, the “patella snap” is sought at a current of £0.4 mA. Frequently,
a contraction across the thigh is elicited, which represents stimulation of the sartorius
muscle. The branches to this muscle may be outside the femoral sheath, and redirec-
tion of the needle laterally and deeper should yield the desired response. A femoral
block with 20 to 25 mL of a long-acting local anesthetic has been shown consistently
to provide superior postoperative analgesia for anterior cruciate ligament repair than
when compared with the use of intraarticular local anesthetics.25,26 The femoral nerve
block can also be used, in combination with a genitofemoral nerve block, to provide
anesthesia for long saphenous vein stripping.27
PRACTICAL REGIONAL ANESTHESIA FOR OUTPATIENTS 131

In 1973, Winnie described a technique of blocking all three nerves of the lumbar
plexus using one injection of local anesthetic into the fibrous sheath surrounding the
femoral nerve,28 Since that time, the efficacy of the block has been disputed. Ritter
studied six cadavers and injected 20-mL and 40-mL aliquots of methylene blue dye. He
found consistent staining of the femoral nerve, occasional staining of the LFC nerves
with the larger volumes of dye, and no staining of the obturator nerves.29 Madej, too,
found an 87.5% success rate in blocking the femoral nerve and 67.5% for the lateral
femoral cutaneous nerve without evidence of obturator block in his study of 40
patients undergoing vastus medialis biopsies for malignant hyperthermia.30 Magnetic
resonance imaging has been used to describe the spread of the anesthetic during this
block. It reveals a lateral, medial, and caudal local anesthetic spread, which correlates
to blockade of the femoral, LFC, and anterior branch of the obturator nerves when
30 mL of local anesthetic is used.31
Pearls
• Performing the block at the level of the inguinal crease allows easy palpation of
the femoral nerve
• If a sartorius twitch is elicited, walk the stimulating needle laterally to elicit one
from the patella tendon

Fascia Iliaca Block


The fascia iliaca block provides more consistent block of the LFC nerve than the 3-
in-1 block, because there is a reported increase in the successful blocking of the LFC
from 62% to 90%.32 (It, too, can solely provide analgesia for patients with hip, femur,
and patella fractures or for postsurgical pain, including anterior cruciate ligament
repair.) It is performed by drawing the inguinal ligament and then trisecting it. Two

FIG. 4. Insertion site of the needle for the fascia iliaca block.
132 ROSENBLATT

centimeters caudal to the junction between the lateral and middle thirds is the loca-
tion of the needle insertion site (Fig. 4). A blunt needle is inserted at a 75° angle to the
skin and advanced. The first “pop” is the needle passing through the fascia lata; the
second, as it passes through the fascia iliaca. The needle angle to the skin is decreased
to 30°, the needle advanced 1 cm, and 30 mL of local anesthetic injected. The local
anesthetic tracks adequately under the fascia between the psoas and iliacus muscles
to block both the femoral and LFC nerves but does not reliably block the obturator
nerve. This block neither requires nerve stimulation nor elicitation of a paresthesia,
and therefore can be performed in the PACU in a patient whose surgical site is encased
in a bulky dressing or knee immobilizer.
Pearls
• Use blunt needles (i.e., at least a 22-gauge pencil-point or short-bevel needle)
• Ensure that your initial puncture has not pierced the fascia lata

Axillary Block
The distribution of local anesthetic in the axillary brachial plexus sheath is incon-
sistent. Whereas Partridge, in his study of 18 cadavers, found incomplete septa divid-
ing the axillary sheath, single injections of dye resulted in staining of the median, radial,
and ulnar nerves. He concluded that there was no support for the need for multiple
injections when performing an axillary block.33 Klaastad, in a study of 13 patients, con-
cluded that there may be little correlation between the spread of methylene blue in
cadavers and what occurs with local anesthetics in humans. He used a catheter tech-
nique and, after stimulating the median nerve, showed irregular areas of local anes-
thetic spread in the cross-section views of his magnetic resonance imaging studies.
Patients with complete filling of the circle also demonstrated incomplete blocks.34
Studies of arm position affecting spread have yielded conflicting results. Yamamoto
found, in a study of 80 patients, that central spread of local anesthetic was facilitated
by injection without abduction of the arm,35 whereas Koscielniak-Nielsen found no
effect of arm position on the circumferential or proximal spread of local anesthesia
after axillary block in 90 patients.36 Proximal spread was not found to be as important
as circumferential spread in providing complete plexus anesthesia.37
A transarterial approach to axillary blockade is technically simple, usually quick to
perform, and associated with a high success rate when large volumes (50–60 mL) of
anesthetic are used.38 The axillary nerve regularly and the musculocutaneous nerve in
more than half of cases exit the neurovascular bundle proximally and should be
blocked individually if a tourniquet will be used or if the procedure is in the sensory
distribution of the musculocutaneous nerve. Multiple injection techniques are suc-
cessful, using smaller amounts of local anesthetic, but require familiarization with the
equipment, longer times to perform, and a high rate of discomfort during block place-
ment (18.3%).39 When using a multiple stimulation technique, the rate of blocking the
musculocutaneous nerve after stimulating the median and radial nerves is only 80%,
so the use of a third stimulation (of the musculocutaneous nerve) may be required.40
Supplemental blocks at the elbow or wrist can convert a partial block into a success-
ful one.
Pearls
• Blockade of the musculocutaneous nerve—5–7 mL within the coracobrachialis
muscle
• Blockade of the intercostobrachial nerve—subcutaneous band of local anesthetic
from site of previous needle insertion posteriorly toward the operating room table
PRACTICAL REGIONAL ANESTHESIA FOR OUTPATIENTS 133

Infraclavicular Block
Infraclavicular block of the brachial plexus provides anesthesia for surgery of the
forearm, wrist, hand, and elbow. One advantage of this block is that it can usually be
performed with the arm in any position, rather than requiring abduction (and it offers
the ability to affix an indwelling catheter on the chest—a more stable and easier loca-
tion to maintain sterility than in the axilla). One approach to this block uses the cora-
coid process as a landmark, and the needle is inserted 2 cm medial and 2 cm caudad
to the tip of the coracoid process (Fig. 5). The distance from the skin to the anterior
wall of the neurovascular bundle has been shown to be 4.24 ± 1.49 cm (2.25–7.75 cm)
in men and 4.01 ± 1.29 cm (2.25 ± 6.5 cm) in women,41 and a motor response of the
wrist or hand at a current of <0.5 mA has been associated with reliable anesthesia and
minimal complications and side effects.42 Borgeat et al. describe a modified approach
of the Raj technique. They abduct the arm and increase it approximately 30° and then
use the surface landmarks of the anterior acromial process, jugular notch, and emer-
gence of the axillary artery. A skin wheal is raised 1 cm caudad below the inferior bor-
der of the clavicle at its midpoint, and the needle is directed laterally toward the emer-
gence of the axillary artery at a 45° to 60° angle to the skin. When they accepted
flexion/extension of the wrist or fingers at currents <0.5 mA, a success rate >97% was
reported.43 Stimulating the individual cord(s) that coincide with the specific region of
the surgery will increase block success. Borene has recently described how following
the direction of the movement of the fifth finger in response to stimulation identifies the
cord that is being stimulated.44

FIG. 5. Insertion site of the needle to perform the coracoid approach to the infraclavicular
block.
134 ROSENBLATT

Pearls
• Do not accept biceps stimulation
• Move the needle caudad and laterally
• Never go medially (toward the lung!)
• Keep the arm adducted

Interscalene Block
Surgery of the shoulder is easily performed with interscalene block anesthesia. Mul-
tiple studies have reported that interscalene anesthesia provides excellent surgical
conditions (analgesia and muscle relaxation), and patients experience less PONV, have
fewer unplanned hospital admissions, and shorter nonsurgical intraoperative and
PACU times than those who have general anesthetics.45,46 In a study of 25 patients who
had previous shoulder surgery with general anesthesia and who chose interscalene
block for a second operation, 24 reported that they would prefer the regional tech-
nique if they required any subsequent procedures.47 This block is associated with 100%
incidence of ipsilateral hemidiaphragmatic paresis,48 which may not make it ideal for
patients with respiratory compromise, and a 17% to 24% incidence of activation of the
Bezold-Jarisch reflex (hypotension and bradycardia), possibly induced by increased cir-
culating epinephrine in the sitting position.49 The overall rate of neurologic compli-
cations associated with interscalene block for shoulder surgery has been reported to
be as high as 14% 10 days postoperatively. Symptoms include paresthesia, dysesthe-
sia, and pain not related to surgery. The majority of these symptoms resolve sponta-
neously, with only 0.2% (one of 520) of patients reporting persistent dysesthesia at
9 months postoperatively.50 It is imperative to accept stimulation of the biceps, triceps,
or deltoid muscles at <0.4 mA, and not to allow a trapezius stimulation with its con-
current upper extremity movement to be an acceptable end point. Interscalene anes-
thesia with 30 mL of 0.5% bupivacaine, 0.5% ropivacaine, and 0.75% ropivacaine were
all associated with mean onset of sensory and motor blocks <6 minutes and similar
recovery characteristics.51
Pearls
• Every attempt should tell you something
• If you elicit phrenic nerve stimulation (diaphragm) you are in the anterior sca-
lene—reinsert needle posteriorly
• If you elicit trapezius muscle stimulation—look for another groove anteriorly
• The surgeon must inject for posterior portals

Intravenous Regional Anesthesia


For procedures of short duration below the elbow, intravenous regional anesthesia
(IVRA) remains an excellent anesthetic, because it has a quick onset and is easy to per-
form. Lidocaine 0.5% remains the agent of choice in the United States (prilocaine is often
favored in other countries), secondary to its low toxicity. Atanassoff did show a small
but significant duration of analgesia after tourniquet deflation when 0.2% ropivacaine
was compared with 0.5% lidocaine for IVRA (median, 20 minutes; range, 15–40 versus
median 1 minute; range, 1–25) without evidence of cardiac arrhythmias in his study of
20 patients.52 When mepivacaine (5 mg/kg) was compared with lidocaine (3 mg/kg) for
IVRA in 42 patients, the mepivacaine provided significantly better intraoperative anal-
gesia but significantly higher blood levels of local anesthetic after tourniquet deflation
PRACTICAL REGIONAL ANESTHESIA FOR OUTPATIENTS 135

after 60 minutes of observation.53 A cost analysis study of anesthetic techniques for out-
patient hand surgery found that IVRA conferred an approximately 30% cost savings over
general anesthesia and brachial plexus blocks, which was secondary to shorter induc-
tion times and lower anesthetic drug and equipment costs.54

Ambulatory Neuraxial Anesthetics


The majority of unilateral lower extremity procedures can be performed with
peripheral nerve blocks, but occasionally, procedures necessitate the use of neuraxial
anesthesia. Spinal anesthetics with pencil-point atraumatic needles have led to
reduced incidence of postdural puncture headaches, but an FDA-approved local anes-
thetic with a favorable recovery profile and low incidence of transient neurologic
symptoms (TNS) is lacking. A dose of 7.5 mg of hyperbaric bupivacaine, although
being associated with a low incidence of TNS, has been shown to provide reliable anes-
thesia for knee arthroscopy while permitting a 161 ± 12-minute time until out of bed
and 186 ± 14 minutes to micturition.55 The use of 45 mg of isobaric mepivacaine yields
similar results, with a 142 ± 37-minute time of motor block duration and 191 ± 29 min-
utes to micturition but 7.4% incidence of TNS.56 Recently, Yoos et al. has described a
10-month experience using 30- or 40-mg doses of spinal 2-chloroprocaine for surgical
procedures £1 hour. They achieved 155 ± 34.7-minute times to ambulation and 207.9
± 69.4-minute times to discharge, and conclude that this is a safe and effective anes-
thetic for ambulatory surgical patients. There were no incidents of TNS in this retro-
spective study.57
The recovery characteristics of epidural anesthesia with 2-chlorprocaine may make
it preferable to spinal anesthesia in the ambulatory setting. In a prospective, random-
ized study comparing the use of spinal, epidural, and general anesthesia for outpatient
knee arthroscopy, epidural anesthesia with 2-chlorprocaine provided similar discharge
times to general anesthesia. The epidural group had both a significantly shorter time
to micturition (80 ± 16 minutes versus 135 ± 51 minutes) and to discharge (92 ± 18 min-
utes versus 146 ± 52 minutes) than the spinal group, who received procaine 75 mg with
10 to 20 µg fentanyl.58

Patient Instructions and Follow Up


Whenever a regional anesthetic is performed, detailed instructions must be given
to the patient offering an expectation of the duration and extent of their block, the
requirement to protect the insensate limb, and the need to begin analgesic medica-
tions before his or her experiencing severe pain. Timely follow up must be conducted
to ensure complete block resolution. Borgeat specifies, in his study following 521
patients after interscalene block, that sulcus ulnaris syndrome, carpal tunnel syn-
drome or complex regional pain syndrome must be excluded in the presence of per-
sistent paresthesia, dysesthesia, or pain not related to the surgery, because specific
interventions may be necessary to treat those conditions.45 Should any persistent neu-
rologic deficit be discovered during a postoperative interview, the patient should be
reassured that it will resolve and that the anesthesiologists’ participation in the fol-
low up is assured. Discussion with the surgeon should include a plan for neurologic
evaluation.
136 ROSENBLATT

Conclusions
The use of PNBs is associated with shortened postprocedure operating room, PACU
and discharge times, the provision of postoperative analgesia, and a high level of
patient satisfaction. Epidural anesthesia with short-acting agents may offer advantages
over spinal anesthesia in the ambulatory setting. Regional anesthetic techniques
should be both encouraged and used for extremity procedures in outpatients.

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