Anaesthesia, 2010, 65 (Suppl. 1), pages 84–96 doi:10.1111/j.1365-2044.2009.06204.

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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: kopp.sandra@mayo.edu

The number of ambulatory procedures being performed satisfaction [4]. The regional technique chosen depends
is steadily increasing, currently accounting for 50–70% of on the surgical site, the anticipated length of the
all surgical procedures in the US [1]. Rapid recovery, procedure, ambulation requirements and the desired
adequate analgesia, minimal postoperative nausea and duration of postoperative pain control. Techniques such
vomiting, and rapid discharge become extremely impor- as local infiltration, neuraxial blockade and peripheral
tant when converting inpatient surgical procedures to nerve blocks have all been used successfully in the
ambulatory procedures. General anaesthesia has histori- ambulatory population. Several studies have reported that
cally been the technique of choice for short, ambulatory the use of regional anaesthesia or local anaesthetics (LAs)
procedures because of the simplicity and overall accep- can provide pre-emptive analgesia and, theoretically, may
tance of the technique. With the introduction of newer, decrease sensitisation of nerve endings after surgery and
rapid-acting general anaesthetic agents such as desflurane decrease acute postoperative pain as well as chronic pain
and propofol, general anaesthesia continues to be a syndromes [5].
popular anaesthetic technique in many ambulatory sur-
gery centers. Although these agents may decrease patients’
Regional anaesthesia for upper extremity
recovery times, they do not appear to have an impact on
ambulatory surgery
postoperative pain and nausea, two of the most common
causes of delayed recovery and delayed hospital discharge Local infiltration, intravenous regional anaesthesia, bra-
[2]. The use of multimodal analgesic techniques com- chial plexus blockade and general anaesthesia are the
bined with aggressive anti-emetic prophylaxis may anaesthetic options for most surgical procedures on the
decrease the disadvantages of general anaesthesia [3]. upper extremity. The upper extremity is well suited to
The use of regional anaesthetic techniques for ambu- peripheral nerve blockade because the entire arm and
latory surgical patients has grown in popularity because of shoulder is innervated by the brachial plexus and blockade
improved postoperative pain control, less nausea, and is easily accomplished with a single injection (Table 1).
increased alertness. A recent meta-analysis revealed that The differences in surgical outcome after a regional, when
peripheral nerve blocks increased post-anaesthesia care compared with a general, anaesthetic technique in
unit (PACU – recovery room) bypass, decreased the patients undergoing upper extremity surgery are of
visual analogue scale (VAS) pain scores, decreased the limited duration, perhaps because the procedures are
need for postoperative analgesics, decreased the incidence not as extensive and adequate pain control may be
of nausea, shortened PACU time and increased patients’ achieved with conventional analgesics. However, a major

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84 Journal compilation  2010 The Association of Anaesthetists of Great Britain and Ireland
Anaesthesia, 2010, 65 (Suppl. 1), pages 84–96 S. L. Kopp and T. T. Horlocker Æ Day surgery
. ....................................................................................................................................................................................................................

Table 1 Regional anaesthesia techniques for upper extremity surgery.

Brachial plexus Level of Peripheral nerves

technique blockade blocked Surgical applications Comments

Axillary Peripheral Radial, ulnar, Surgery on forearm and hand; Unsuitable for proximal humerus or
nerves median less used for procedures near shoulder surgery
the elbow Requires patient to abduct the arm
Musculocutaneous nerve unreliably blocked
Infraclavicular Cords Radial, ulnar, Surgery to elbow, forearm, No risk of haemothorax or pneumothorax
median, hand Relatively rapid onset
musculocutaneous, Catheter site is easy to maintain
axillary
Supraclavicular Distal trunk – Radial, ulnar, median, Surgery to mid humerus, elbow, Risk of pneumothorax requires caution in
proximal cord musculocutaneous, forearm and hand ambulatory patients
axillary Phrenic nerve paresis in 30% of cases
Interscalene Upper and Entire brachial Surgery to shoulder, proximal Phrenic nerve paresis in 100% of patients
middle trunks plexus, although and mid-humerus for duration of the block
inferior trunk Unsuitable for patients unable to tolerate a
(ulnar nerve) is 25% reduction in pulmonary function
inconsistently
blocked

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

advance is the placement of indwelling brachial plexus compared with general anaesthesia, patients who under-
catheters to provide prolonged analgesia at home, thereby went an interscalene block had significantly fewer
allowing operations that would have traditionally unplanned hospital admissions (8% vs 0%) [10]. Similarly,
required 2–3 days of hospitalisation to be performed as several studies have shown that interscalene blocks
day-stay or short-stay surgery. Indeed, both total elbow provide superior postoperative analgesia when compared
and shoulder arthroplasty have been performed as day- with suprascapular nerve block, intravenous or oral
stay procedures with analgesia primarily provided by a opioids, and LA infiltration of the joint capsule by the
perineural catheter [6, 7]. surgeon [11]. Shoulder arthroscopy patients are often
encouraged to start passive range-of-motion exercises on
Shoulder surgery the first postoperative day in order to prevent the
Injury to the rotator cuff is a common abnormality formation of capsular adhesions and to preserve the range
requiring surgical repair and is often performed arthro- of motion. Even with the longest lasting LA, interscalene
scopically as a day-stay procedure. Arthroscopic surgery is blocks cannot be expected to last longer than 18–24 h.
often associated with severe postoperative pain requiring Therefore, patients who are comfortable in the early
large doses of opioids [8]. Side effects from opioids postoperative period may experience significant pain at
include nausea, vomiting, sedation, constipation, respira- home when the block recedes. In order to provide
tory depression and failure to control pain. Although both extended analgesia, interscalene catheters have recently
general and regional anaesthesia are effective for shoulder been introduced for the ambulatory population and have
surgery, patients who receive regional anaesthesia for resulted in less pain at home, decreased opioid use and
outpatient rotator cuff repair bypass the PACU more related side effects, and less sleep disturbance with very
frequently, report less pain, ambulate earlier, satisfy few complications [12, 13].
discharge criteria sooner, and are more satisfied with
their care than those who receive general anaesthesia [9]. Arm and hand surgery
The interscalene nerve block is the most commonly Existing data reveal that regional anaesthesia offers several
used regional technique for shoulder surgery. Blockade advantages over general anaesthesia for patients undergo-
occurs at the level of the roots as they exit between the ing ambulatory hand surgery, including decreased opioid
middle and anterior scalene muscles at the C6 level consumption, less postoperative nausea and vomiting,
(identified by the cricoid cartilage). The brachial plexus is decreased time in the PACU and expedited discharge
quite spread out at this level, and even with large doses of from the hospital [14]. Several regional techniques are
LA the lower roots (C8 and T1) may be left unblocked. used for surgery on the arm and hand, including local
This technique does not, therefore, provide adequate infiltration, intravenous regional anaesthesia, and brachial
blockade for surgery on the arm or hand. When plexus blockade.

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S. L. Kopp and T. T. Horlocker Æ Day surgery Anaesthesia, 2010, 65 (Suppl. 1), pages 84–96
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Intravenous regional anaesthesia is a useful technique technique that is rather easy to perform and is ideal for
for short (< 60 min) surgical procedures below the surgery on the hand, forearm and elbow [19]. Numerous
elbow. The technique is a relatively simple and safe techniques can be used, including transarterial, paraesthe-
method of providing anaesthesia for upper extremity sia, nerve stimulator, fascial click, infiltration technique
surgery with published success rates ranging from 94–98% and, more recently, ultrasound-guided. Currently, there
[15]. When compared with general anaesthesia and are no conclusive data to support the use of one technique
axillary brachial plexus block, intravenous regional anaes- of nerve localisation over another [20–23]. However, in
thesia offered the peri-operative clinical benefits of general, multiple-stimulation techniques are associated
decreased intra-operative and postoperative costs and with a greater success rate than single injection techniques.
hospital discharge that was nearly 1 h earlier than in those The placement of a brachial plexus catheter before
who had general anaesthesia. The potential disadvantages discharge and the continuous infusion of local anaesthetic
include failure due to tourniquet pain and limited at home can significantly lengthen the period of postop-
postoperative analgesia [14]. erative analgesia. Studies have demonstrated decreased
Brachial plexus techniques for arm, forearm and hand VAS scores and increased patient satisfaction with the use
surgery include mid-humeral block, axillary block, of continuous axillary [24] and infraclavicular [17, 25]
infraclavicular block, and supraclavicular block. Selection blockade in ambulatory patients undergoing surgery to
of the appropriate technique is determined by the the hand. Due to the ease of performance and long-
innervation of the surgical site, specific patient anatomy standing safety profile, continuous axillary brachial plexus
and co-morbidities, the experience of the anaesthetist and block was one of the first catheter techniques to be
the associated anaesthetic and surgical complications. For evaluated in ambulatory patients. Despite the fact that
example, patients with significant pulmonary disease are patients had to administer a bolus of local anaesthetic
poor candidates for a supraclavicular approach due to the when they experienced pain, there were very few
potential for pneumothorax and phrenic nerve paresis. technical problems and high patient satisfaction [24].
Likewise, an axillary approach may not be adequate for Continuous infraclavicular blocks have the advantage of
surgery to the mid- or distal humerus because of the close an immobile insertion point which limits the risk of
proximity of the level of blockade to the site of surgery. dislodgement and facilitates site sterility, both of which
The supraclavicular block is performed at the level of the are important in the ambulatory population [26].
trunks where the brachial plexus is compact and wrapped
in a dense fascia before diverging under the clavicle.
Regional anaesthesia for lower extremity
Unpredictable blockade of the axillary nerve has limited
ambulatory surgery
the routine use of supraclavicular block in patients
undergoing shoulder surgery. The benefits of the supr- The ideal anaesthetic for lower extremity ambulatory
aclavicular approach include rapid onset of blockade, surgery should be easy to perform, have a fast onset,
reliable anaesthesia for procedures distal to the shoulder provide good operating conditions, allow for a rapid
and the ability to perform the block in patients unable to recovery (ambulation and urinary voiding) and have
abduct their arm [16]. minimal side effects. Although general anaesthesia is
When compared with general anaesthesia, infraclavic- commonly used for this patient population, there is
ular brachial plexus blockade is associated with faster evidence that patients may benefit from either a regional
recovery, fewer adverse events and better analgesia in or combined regional-general anaesthetic technique. In
outpatients undergoing hand and wrist surgery [17]. addition to the intra-operative management of these
Although LA is injected at the cord level, when compared patients, postoperative pain control is essential to facilitate
with the multi-stimulation axillary approach, the infra- rehabilitation after lower extremity surgery. Techniques
clavicular block was found to have a longer onset time and such as neuraxial blockade [27, 28], intra-articular opioids
a greater frequency of an incomplete block, mainly with and without local anaesthetics [27–29], single
because of incomplete blockade of the ulnar nerve [18]. injection or continuous perineural infusion [30–32], and
These deficiencies are overcome with injection on a systemic opioids, all have individual advantages and
posterior cord motor response or the use of a multi- disadvantages.
stimulation approach. Infraclavicular block is ideal for
patients who are unable to abduct their arm (as needed for Neuraxial blockade for lower extremity surgery
an axillary block) or those in whom an indwelling catheter Epidural and spinal anaesthesia have been used success-
is required due to the ease of catheter site maintenance. fully for lower extremity surgery, although without
Axillary brachial plexus blockade is the most commonly making the necessary adjustments in LA selection and
used technique for surgery below the shoulder. It is a safe dose, these techniques may have disadvantages in the

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86 Journal compilation  2010 The Association of Anaesthetists of Great Britain and Ireland
Anaesthesia, 2010, 65 (Suppl. 1), pages 84–96 S. L. Kopp and T. T. Horlocker Æ Day surgery
. ....................................................................................................................................................................................................................

ambulatory population including unpredictable onset and anatomic considerations, lower extremity blocks are
regression, bilateral lower limb blockade and urinary technically more difficult and require more training and
retention. Historically, lidocaine has been the LA of practice before expertise is acquired. Many of these blocks
choice for short-acting spinal anaesthesia in ambulatory were classically performed using paraesthesia, loss of
patients. With the incidence of transient neurologic resistance or field block techniques that resulted in
symptoms [33] and, more seriously, cauda equina syn- variable success. Advances in needles, catheters and nerve
drome [34] following intrathecal administration of lido- stimulator technology have facilitated the localisation of
caine, alternative techniques have been sought. Selective nerves and improved success rates. These blocks are safe
spinal anaesthesia, using a minimal dose of intrathecal LA and their unilateral nature makes them ideal for the
with the goal of anaesthetising only the nerve roots patient undergoing day-stay or short-stay procedures
supplying the surgical area, and unilateral spinal anaes- since the contralateral limb is immediately available to
thesia, a one-sided spinal block with an absence of sensory assist with early ambulation.
and motor block on the non-operative side, are both
alternatives to traditional spinal anaesthetic techniques Knee arthroscopy and anterior cruciate ligament
[35]. By manipulating the patient’s position based on the repair
baricity of the LA, it is possible to influence the Diagnostic and therapeutic knee arthroscopy procedures
distribution of anaesthesia [36]. Lidocaine and bupiva- are commonly performed as day-stay procedures. Knee
caine (with and without the addition of opioids) have arthroscopy surgery ranges from the simple, diagnostic
been used to produce selective bilateral spinal anaesthesia, knee arthroscopy to the much more invasive anterior
whereas for unilateral spinal anaesthesia, it is necessary to cruciate ligament (ACL) repair. In addition to general
use hyperbaric bupivacaine. When performing a unilateral anaesthesia, virtually all other regional techniques have
block, maintenance of the required patient position for a been used for knee arthroscopy and ACL repair, includ-
prolonged period (often 15–30 min) has been criticised ing intra-articular LAs [39, 40], lumbar plexus (femoral or
due to the pre-operative delay. Low dose, lipophilic psoas) blockade with or without a sciatic block [41–44]
intrathecal opioids such as fentanyl (10–25 lg) or sufen- and neuraxial anaesthesia (spinal, epidural or combined
tanil (10 lg) improve the quality of anaesthesia without spinal-epidural techniques) [45–48] (Table 2). Local
delaying home discharge [37]. Low-dose clonidine has infiltration of the arthroscopic portal insertions by the
been used in combination with ropivacaine and 2- surgeon combined with intravenous sedation is a rela-
chloroprocaine to improve the quality of spinal anaes- tively simple technique. In a prospective study, 12% of
thesia, although due to the risk of sedation, bradycardia the patients would have preferred another technique, and
and hypotension, larger doses must be avoided in the 16% of the surgeons found the operating conditions
ambulatory population [38]. inadequate, probably due to difficulty in knee manipu-
A recent meta-analysis concluded that although lation given the lack of muscle relaxation [40].
patients’ VAS scores and opioid usage in the PACU Of the neuraxial techniques, spinal anaesthesia has the
were lower following neuraxial anaesthesia, the incidence most rapid onset, and provides dense anaesthesia. Studies
of nausea was not decreased, nor was the duration of the have demonstrated that the discharge times for general
PACU stay shortened, and ultimately discharge from the anaesthesia with propofol are similar to those for epidural
hospital occurred 35 min later compared with general analgesia with 2-chloroprocaine, whereas patients who
anaesthesia [4]. This result may be skewed because of the received a procaine spinal anaesthetic had a longer
heterogeneous data with respect to the type of surgery recovery time [49]. A recent study concluded that spinal
and dose of LA used. Overall, neuraxial anaesthesia may anaesthesia with low-dose (4 mg) hyperbaric bupivacaine
be safely and effectively used in the ambulatory surgical led to similar home-readiness times compared with
population given that an appropriately low-dose of LA general anaesthesia with desflurane, although pain scores
(with or without the addition of lipophilic opioids) is and the need for postoperative opioids were significantly
used. less in the spinal group [47]. Unilateral and selective spinal
Lower extremity peripheral techniques, which allow blockade have also been studied, and are recommended
complete unilateral blockade, have traditionally been for knee arthroscopy and ACL repairs. Overall, spinal and
underused. In part, this is due to the widespread epidural anaesthesia are suitable anaesthetic options for
acceptance and safety of spinal and epidural anaesthesia. knee arthroscopy and ACL repair, assuming that an
Furthermore, unlike the brachial plexus, the nerves appropriate technique and dose of LA is used.
supplying the lower extremity are not anatomically Lower extremity peripheral blockade provides anaes-
clustered where they can be easily blocked with a thesia and prolonged analgesia following moderately
relatively superficial injection of LA. Because of the painful lower extremity surgery. The psoas compartment

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S. L. Kopp and T. T. Horlocker Æ Day surgery Anaesthesia, 2010, 65 (Suppl. 1), pages 84–96
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Table 2 Regional anaesthesia techniques for lower extremity surgery.

Block Peripheral nerves Block

technique Area of blockade blocked duration* Comments

Femoral Femoral, partial lateral Lumbar plexus L2–4 12–18 h Provides anaesthesia ⁄ analgesia to
femoral cutaneous and anteromedial thigh, anterior knee and
obturator medial calf
Need for minor arthroscopy surgery
has not been demonstrated
Deceased VAS when used for ACL repair
Psoas Femoral, partial lateral Lumbar plexus 12–18 h Anaesthesia ⁄ analgesia of entire lumbar
compartment femoral cutaneous, L1–5 and sciatic S1 plexus
obturator, sciatic (S1) Due to low pain scores associated with
minor knee arthroscopy procedures the
risk profile may not justify use
Saphenous Medial aspect of lower L2–4 (branch of 4–6 h Required for complete anaesthesia ⁄
leg and foot femoral nerve) analgesia of foot and ankle
Allows for use of calf tourniquet when
combined with popliteal sciatic nerve
block
Proximal sciatic Posterior thigh and leg Sciatic L4–5 and 18–30 h Superior analgesia and fewer hospital
(except saphenous area) sciatic S1–3 admissions when combined with a femoral
block for patients undergoing ACL repair
Popliteal sciatic Posterior lower leg and Sciatic L4–5 and S1–3 12–24 h When combined with a saphenous nerve
foot (except saphenous block anaesthesia ⁄ analgesia is similar to that of
area) spinal anaesthesia with fewer side effects
Ankle Forefoot and midfoot Posterior tibial, deep 8–12 h Relatively simple to perform, high success
peroneal, superficial rate, few complications
peroneal, sural, and Little or no effect on ambulation
saphenous 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.

block can provide anaesthesia and analgesia to the entire nerve block provides complete unilateral anaesthesia and
lumbar plexus and has been used for ambulatory knee allows the use of a thigh tourniquet.
arthroscopy. Due to the relatively low pain scores after Continuous femoral nerve blocks have been used for
minor knee arthroscopy and the risk profile associated arthroscopically-assisted ACL repair and studies have
with psoas blockade (epidural spread, weak hip flexors), demonstrated a high degree of patient satisfaction and low
this block may not be justified in the ambulatory postoperative opioid requirements [52]. For most patients
population [41]. The use of, home-going, psoas com- undergoing ACL reconstruction, a single-injection fem-
partment catheters has been introduced, although at oral block will provide adequate postoperative analgesia.
present it has not been widely studied or accepted [50]. There are patients (extremes of age, chronic opioid users,
The more distal femoral nerve block provides anaesthesia multi-ligament reconstruction) in whom a continuous
and analgesia to the anteromedial thigh, anterior knee and femoral catheter may offer advantages over a single
medial calf. This broad coverage combined with the injection block [52]. There is also evidence to suggest that
relative ease of block placement makes the femoral nerve increasing nerve block duration with the use of a femoral
block one of the most common lower extremity blocks. catheter after ACL repair leads to a small but significant
As with the psoas approach, the need for a femoral block reduction in rebound pain [53].
for minor knee arthroscopy procedures has not been
demonstrated in the literature [51]. In contrast, VAS Foot and ankle surgery
scores are lower in patients undergoing ACL repair, Local, spinal, epidural and, peripheral blocks, and general
which is significantly more painful than arthroscopy, anaesthesia, have all been used successfully for foot and
when a femoral block is performed [42, 51]. The addition ankle surgery. These procedures often result in moderate
of a sciatic nerve block provided even better postoper- to severe postoperative pain that is often difficult to
ative analgesia in this population and resulted in fewer control with oral opioid medications. Hence, the greatest
hospital admissions [51]. The combination of a lumbar advantage of regional techniques over general anaesthesia
plexus block (psoas or femoral) with a proximal sciatic is the prolonged analgesia associated with peripheral

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88 Journal compilation  2010 The Association of Anaesthetists of Great Britain and Ireland
Anaesthesia, 2010, 65 (Suppl. 1), pages 84–96 S. L. Kopp and T. T. Horlocker Æ Day surgery
. ....................................................................................................................................................................................................................

blockade. Ambulatory procedures on the midfoot and stay are often related to the effects of anaesthesia (nausea,
forefoot are amenable to ankle blockade. Compared with vomiting, urinary retention). The need for urinary
the more proximal blocks, the ankle block will have little catheterisation following hernia repair is approximately
effect on postoperative ambulation (no foot drop, 29% after neuraxial anaesthesia, 8% after general anaes-
hamstring, or quadriceps weakness) while providing a thesia and 0% after local infiltration, leading to home
mean of 11 h of postoperative analgesia if a long-acting discharge 3 h earlier after infiltration anaesthesia when
LA is used [54, 55]. Ankle blocks have a high success rate compared with general or regional anaesthesia [66].
with few complications, although a complete ankle block Spinal anaesthesia for ambulatory hernia surgery
requires LA to be injected around all five nerves supplying requires a higher level of sensory blockade compared to
the ankle (posterior tibial, sural, saphenous, deep pero- that required for lower extremity procedures. Although
neal, superficial peroneal). Despite the relative simplicity, the dose of neuraxial LA may be increased to provide the
pain associated with injection of LA during an ankle block necessary coverage, this will delay voiding and, ulti-
may be significant and require sedation. Because the mately, hospital discharge. As a result, neuraxial block is
block is performed at the ankle level, it does not provide typically performed for patients who suffer significant side
anaesthesia for a tourniquet placed on the thigh or calf. effects after general anaesthesia, such as protracted nausea
However, a calf Esmarch bandage is usually well tolerated and vomiting. The use of ilio-inguinal ⁄ iliohypogastric
by the patient. nerve block combined with propofol sedation has been
The popliteal sciatic nerve block is a successful nerve associated with shortened hospital discharge time, lower
block for surgical anaesthesia as well as long-lasting pain scores at discharge, and higher patient satisfaction
postoperative pain control for foot and ankle procedures compared with patients receiving general or spinal
[56–59]. Posterior and lateral approaches to the sciatic anaesthesia [67]. Paravertebral blocks at the level of
nerve at the level of the popliteal fossa have both been T10-L2 have been shown to provide excellent unilateral
shown to provide safe, efficient and reliable anaesthesia anaesthesia with a low incidence of postoperative nausea
[56, 60, 61]. A popliteal sciatic nerve block combined and vomiting and very low analgesic requirements
with either a saphenous or femoral nerve block allows the compared with patients receiving standard peripheral
use of a calf tourniquet and provides anaesthesia compa- blocks placed during surgery by the surgeon [68].
rable with neuraxial techniques. However, the peripheral Although paravertebral blocks have been used successfully
blocks result in less urinary retention and prolonged for hernia surgery, this technique is not without compli-
postoperative analgesia [62]. When performed with cations, some of which may be significant in the
long-acting LAs such as ropivacaine or bupivacaine, a ambulatory population, such as pneumothorax or epidural
single-injection block can provide 12–24 h of analgesia. spread. Although paravertebral block may provide pro-
Continuous perineural catheters placed in the popliteal longed analgesia, the pain from the incision associated
fossa have proven to provide excellent postoperative pain with herniorrhaphy is minor and may not warrant the
control for outpatients undergoing moderately painful, invasiveness of a paravertebral technique.
lower extremity orthopaedic surgery, often eliminating
the need for intravenous or oral opioid medications [63–
Regional anaesthesia for minor ambulatory
65]. The sciatic nerve is blocked distal to the hamstring
breast surgery
muscles of the posterior thigh, and the patient is able to
retain knee flexion during a continuous infusion (facil- Diagnostic and minor therapeutic breast surgery is
itating ambulation) [64]. In addition, these patients have commonly performed in the ambulatory setting and the
been shown to experience a decrease in sleep disturbance, anaesthetic technique used should provide a quick
oral opioid use and opioid-related side-effects leading to a recovery as well as adequate postoperative pain relief
very high satisfaction rating [64]. with minimal side effects. Although general anaesthesia is
commonly used, many patients may have undesirable side
effects such as pain, nausea and vomiting. Interest in
Regional anaesthesia for ambulatory inguinal
paravertebral blockade for breast surgery is increasing
hernia repair
because the technique provides unilateral and segmental
Inguinal herniorrhaphy is a common ambulatory proce- blockade. Patients undergoing major breast surgery who
dure that has been successfully performed under a variety underwent thoracic paravertebral blockade reported a
of anaesthetic techniques such as general anaesthesia, shorter recovery time, experienced less postoperative
neuraxial anaesthesia, local infiltration, paravertebral pain, required fewer analgesics, tended to mobilise faster
blockade and ilio-inguinal ⁄ iliohypogastric blockade. and were discharged from the hospital significantly earlier
The postoperative side effects and prolonged hospital than patients receiving general anaesthesia [69]. Although

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S. L. Kopp and T. T. Horlocker Æ Day surgery Anaesthesia, 2010, 65 (Suppl. 1), pages 84–96
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paravertebral blocks have been performed for patients sciatic, popliteal) for fear of patients’ being discharged
undergoing minor breast surgery, the risks (pleural or with an insensate lower extremity [74]. Although patient
vascular puncture, hypotension, pneumothorax) and selection and detailed instructions on limb protection are
benefits must be carefully weighed. Terheggen et al. essential when discharging patients with a blocked
[70] found that although VAS scores in the first 90 min extremity, a recent study revealed that complications
after surgery were lower in patients undergoing paraver- were very rare [75]. This retrospective review of 2 382
tebral blockade; there was no difference in later VAS patients discharged with blocked upper and lower
scores, postoperative nausea and vomiting, or recovery extremities found that patients were extremely satisfied
time when compared with patients who had general and only one patient fell when exiting a car and,
anaesthesia. Considering the incidence of complications, fortunately, was not injured. Although falls after lower-
the authors concluded that the risk ⁄ benefit ratio of extremity peripheral nerve blocks have not been widely
paravertebral blockade did not favour their routine use for reported, protocols need to be developed for the care of
minor breast surgery. 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
Continuous ambulatory perineural infusions
important to provide the patient and carer with written as
Pain is a common reason for delayed discharge and well as verbal instructions (Table 3). In addition to
unanticipated hospital re-admission. Recently, studies standard postoperative outpatient instructions, patients
have demonstrated that continuous perineural LA infu- with indwelling perineural catheters require information
sion is effective in decreasing pain scores after ambulatory regarding infusion pump function, block resolution, pain
orthopaedic surgery for the length of the infusion [30, 31, medication, driving limitations, limb protection, catheter
71]. This technique involves inserting a percutaneous site care, signs and symptoms of local anaesthetic toxicity
catheter adjacent to the peripheral nerve supplying the and catheter removal instructions. A plan for break-
surgical site. The recent introduction of portable infusion through pain is essential since the surgical block has
pumps has allowed patients with perineural catheters to be
safely discharged home with the same level of analgesia Table 3 Instructions for patients receiving brachial plexus
that was historically only available to those patients who catheters for home use.
remained inpatients. Several recent investigations have
demonstrated that patients undergoing moderately painful You are receiving local anaesthetic through a small catheter near your
procedures with postoperative perineural LA infusions 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
have had lower resting and break-through pain scores and medicines as prescribed by your doctor. The nurse will review this
required fewer oral analgesics [13, 25, 64, 72]. with you. The local anaesthetic will initially make your arm very
There is a variety of infusion systems ranging from numb. Over time, this degree of numbness will decrease, but usually
your arm is not normal until the catheter is removed. Because your
simple elastomeric, disposable pumps to the more arm or leg will not function normally, YOU SHOULD NOT DRIVE
expensive, mechanical, battery-operated pumps. The The doctors and nurses will review the pump instructions with you. If
mechanical, re-programmable pumps offer a great deal you have any problems with the pump, call the technical support
number or the number the doctor has given you
of flexibility in programming and bolus dosing but tend to Complications that could potentially occur include:
be much more expensive. Capdevila et al. [71] demon- The catheter may fall out. If this occurs, make sure to take some of
strated that disposable, non-mechanical pumps were as your pain medicine and turn the pump off
Fluid may leak around the catheter. You can change or reinforce the
effective as electronic patient-controlled analgesia pumps dressing if necessary. This is usually not a problem
for postoperative pain relief, were associated with fewer The catheter may migrate into a blood vessel and cause high levels
technical problems, and consequently led to better patient of local anaesthetic. Symptoms of high levels of local anaesthetic may
include:
satisfaction scores. Studies have determined that a greater Drowsiness
continuous LA infusion rate may provide better pain Dizziness
control, less sleep disturbance and increased patient Blurred vision
Slurred speech
satisfaction compared with a lower continuous infusion Poor balance
plus patient-controlled boluses. Despite these advantages, Tingling around lips ⁄ mouth
a limited reservoir pump set to deliver a greater contin- Other
You should keep your arm in a sling unless doing therapy
uous infusion may decrease the overall duration of Call your physician for medical assistance if any of the following
analgesia [73]. symptoms occur:
Despite the potential benefits of regional anaesthesia, Unusual drowsiness
Uncontrollable pain
many anaesthetists avoid placing long-acting major con- Uncontrollable vomiting
duction blocks in the lower extremity (lumbar plexus,

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90 Journal compilation  2010 The Association of Anaesthetists of Great Britain and Ireland
Anaesthesia, 2010, 65 (Suppl. 1), pages 84–96 S. L. Kopp and T. T. Horlocker Æ Day surgery
. ....................................................................................................................................................................................................................

typically not resolved by the time of discharge. Although incidence of adverse side effects between paracetamol and
perineural infusions decrease postoperative pain, many placebo. Paracetamol is an important addition to a
patients will require oral analgesics as part of a multimodal multimodal postoperative pain regimen, although the
analgesic regimen. total daily dose must be limited to no more than 4 g.

Non-steroidal anti-inflammatory drugs (NSAIDs)

Multimodal analgesia
The NSAIDs have a mechanism of action through the
Multimodal analgesia is a multidisciplinary approach to cyclo-oxygenase (COX) enzymatic pathway and ulti-
pain management using both pharmacological and non- mately block two individual prostaglandin pathways.
pharmacological techniques such as regional anaesthesia, The COX-1 pathway is involved in prostaglandin-E2-
with the aim of maximising the positive aspects of a mediated gastric mucosal protection and thromboxane
treatment while limiting the associated side effects. The B2 effects on coagulation. The inducible COX-2
approach to acute postoperative pain management must pathway is mainly involved in the generation of
focus on the entire rehabilitation process rather than prostaglandins included in the modulation of pain and
focusing specifically on the patient’s pain. Frequently, fever [78]. The major side effects limiting NSAID use
treatment of postoperative pain results in nausea and for postoperative pain control (renal failure, platelet
vomiting. A combination of peripheral nerve blocks and dysfunction and gastric ulcers or bleeding) are related to
multimodal oral analgesics may help increase patient the nonspecific inhibition of the COX-1 enzyme [79].
satisfaction by decreasing both pain and the negative side The advantages of the COX-2 inhibitors are the lack of
effects associated with traditional pain management. platelet inhibition and a decreased incidence of gastro-
intestinal effects. Prostaglandins are necessary to main-
Non-opioid analgesics tain renal homeostasis and, therefore, all NSAIDs have
Paracetamol the potential to cause serious renal impairment. Inhibi-
Paracetamol is an important non-opioid analgesic with tion of the COX enzyme may have only minor effects
very few side effects (Table 4). A recent Cochrane in the healthy kidney, but can lead to serious side effects
systematic review found 40 trials comparing paracetamol in elderly patients or those with a low-volume condi-
with placebo in patients with moderate to severe tion (blood loss, dehydration, cirrhosis or heart failure).
postoperative pain [77]. In postoperative pain manage- Therefore, NSAIDs should be used cautiously in
ment, paracetemol 1 g had a number-needed-to-treat patients with underlying renal dysfunction, specifically
(NNT) of 4.6 for at least 50% pain relief when compared in the setting of volume depletion due to blood loss
with placebo. As expected, there was no difference in the [79].

Table 4 Oral non-opioid analgesics.

Dosing Maximum
Analgesic Dose interval daily dose Comments

Paracetamol 500–1000 mg 4–6 h 4000 mg As effective as aspirin; 1000 mg

more effective than 650 mg
aspirin in some patients
Celecoxib 400 mg initially, 12 h 800 mg
then 200 mg
Aspirin 325–1000 mg 4–6 h 4000 mg Most potent anti-platelet effect
Ibuprofen 200–400 mg 4–6 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 15–30 mg 4–6 h 60 mg Comparable to 10 mg morphine;
(> 65 years); reduce dose in patients < 50 kg or
120 mg with renal impairment; total
(< 65 years) duration of administration is 5
days
Tramadol 50–100 mg 6h 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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Journal compilation  2010 The Association of Anaesthetists of Great Britain and Ireland 91
S. L. Kopp and T. T. Horlocker Æ Day surgery Anaesthesia, 2010, 65 (Suppl. 1), pages 84–96
. ....................................................................................................................................................................................................................

The effect of NSAIDs on bone formation and healing is Tramadol has been shown to provide adequate analgesia,
another concern that is specific to the orthopaedic superior to placebo and comparable with various opioid
population. Gajraj et al. [80] summarised the limited and non-opioid analgesics for the treatment of acute pain
available literature in a recent article and concluded that [82]. However, when used as a sole analgesic for patients
although the data are conflicting there is evidence from undergoing total hip replacement Stubhaug et al. [83]
animal studies that COX-2 inhibitors may inhibit bone found no difference in analgesic efficacy compared with
healing. They also noted that it is difficult to extrapolate placebo. Due to the low incidence of side effects,
animal data into clinical practice, and the adverse effects tramadol may be used as an alternative to opioids in a
of COX-2 inhibitors need to be weighed against the multimodal approach to postoperative pain, specifically in
benefits. Until large human studies are performed it is patients who are intolerant to opioid analgesics.
reasonable to be cautious with the use of COX-2
inhibitors, especially when bone healing is critical. Ketamine
Ketorolac is a nonspecific NSAID that can be given Ketamine is a noncompetitive N-methyl-D-aspartate
parenterally. A systematic review and meta-analysis of (NMDA) receptor antagonist that may play a critical role
ketorolac found that opioid usage was decreased by 36% in the intensity of perceived postoperative pain [84].
in surgical patients and an intravenous dose of ketorolac Menigaux et al. [85] evaluated postoperative pain scores,
10–30 mg was found to have a similar efficacy to that of side effects and ability to ambulate in patients undergoing
10–12 mg of intravenous morphine [81]. Due to the outpatient knee arthroscopy to determine if a small intra-
potential for serious side effects (gastric ulceration and operative, intravenous dose of ketamine (0.15 mg.kg)1)
renal impairment), ketorolac should be used for 5 days or improved outcomes compared with placebo. The authors
less in the adult population with moderate to severe acute concluded that the ketamine group had significantly less
pain [79]. postoperative pain at rest and during mobilisation on days
0, 1 and 2. They also consumed less oral pain medication
Tramadol and were able to ambulate for a longer period of time on
Tramadol is a centrally acting analgesic that is structurally the first postoperative day.
related to morphine and codeine. It works by binding to
the opioid receptors as well as blocking the re-uptake of Opioid analgesics
both noradrenaline and serotonin. It has gained popularity Opioid analgesics are routinely given to patients for
due to the low incidence of adverse effects, specifically moderate or severe pain in the peri-operative period
respiratory depression, constipation and abuse potential. despite their well-known side effects (Table 5). The

Table 5 Oral opioid analgesics.

Dosing
Analgesic Dose interval Comments

Extended release 10–20 mg 12 h Limit to total of

oxycodone four doses to avoid
accumulation and
opioid-related side
effects
Extended release 15–30 mg 8–12 h Limit to total of four
morphine doses to avoid
accumulation and
opioid-related side
effects
Oxycodone 5–10 mg 4–6 h
Hydromorphone 2–4 mg 4–6 h
Hydrocodone 5–10 mg 4–6 h All preparations
contain paracetamol*
Codeine 30–60 mg 4h 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

92 Journal compilation  2010 The Association of Anaesthetists of Great Britain and Ireland
Anaesthesia, 2010, 65 (Suppl. 1), pages 84–96 S. L. Kopp and T. T. Horlocker Æ Day surgery
. ....................................................................................................................................................................................................................

adverse effects of opioid administration can cause serious creation of a separate regional anaesthesia block room
complications in patients undergoing major orthopaedic with dedicated and well trained staff [87]. The introduc-
procedures. Opioid adverse events in randomised, con- tion of regional anaesthesia into an existing, predomi-
trolled trials were recently summarised in a systematic nately general anaesthetic ambulatory practice takes
review of postoperative analgesia [86]. The main adverse significant dedication, teamwork and resources, but the
events included gastro-intestinal effects (nausea, vomiting, potential cost savings for the hospital and the patient can
ileus) (31%), central nervous system effects (somnolence be significant [43]. In order for a successful conversion, all
and dizziness) (30%), pruritus (18%), urinary retention existing policies and procedures must be evaluated and
(17%), and respiratory depression (3%). Due to the quality indicators must be benchmarked before, and
variation in patient pain tolerance, dosing regimens need reviewed after the conversion. The actual cost savings
to be adjusted frequently in order to maximise the after a conversion from primarily general to regional
benefits and minimise the incidence of side effects. anaesthesia will be different for each specific practice, and
Oral opioids are available in immediate-release and is based on the number of procedures performed each
controlled-release formulations. Although immediate- year and the initial investment required. Several articles
release oral opioids are effective in relieving moderate have been recently published describing in detail the
to severe pain, they must be administered as often as every resource management and economic issues related to the
4 h. When these medications are prescribed on an as- integration of peripheral nerve blocks into an established
needed basis, there may be a delay in the administration, ambulatory surgery center [88, 89].
resulting in a low opioid plasma concentration and a
subsequent increase in pain. The US Acute Pain Man-
Conflicts of interest
agement Guideline Panel currently recommends a fixed
dosing schedule for all patients receiving opioid medica- The authors declare no conflicts of interests.
tions for > 48 h postoperatively (Acute Pain Manage-
ment Guideline Panel, 1992 – http://www.ahrq.gov/
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 2010 The Authors
Journal compilation  2010 The Association of Anaesthetists of Great Britain and Ireland