Regional anesthesia for ambulatory surgery

Abstract

Regional anesthesia techniques (peripheral nerve blocks and neuraxial blocks) offer significant advantages in the ambulatory setting. These not only can provide good surgical conditions for intraoperative anesthesia, but also excellent postoperative analgesia. They may be used as (a) the only anesthetic provided, (b) together with sedation, or (c) as a supplement to general anesthesia. Studies show that regional anesthesia lowers the incidence of nausea and vomiting, improves pain scores, and decreases narcotic use. The growth and popularity in regional anesthesia has coincided with dramatically improved intravenous (IV) sedative medications such as propofol, low-dose ketamine, and dexmedetomidine. Monitoring “depth” of anesthesia and better titration techniques for IV sedatives have evolved, whereas regional anesthesia-specific technologies have evolved from peripheral nerve stimulation to ultrasound. Regional anesthesia techniques (peripheral nerve blocks and neuraxial blocks) offer significant advantages in the ambulatory setting. These not only can provide good surgical conditions for intraoperative anesthesia, but also excellent postoperative analgesia. They may be used as (a) the only anesthetic provided, (b) together with sedation, or (c) as a supplement to general anesthesia. Studies show that regional anesthesia lowers the incidence of nausea and vomiting, improves pain scores, and decreases narcotic use. The growth and popularity in regional anesthesia has coincided with dramatically improved intravenous (IV) sedative medications such as propofol, low-dose ketamine, and dexmedetomidine. Monitoring “depth” of anesthesia and better titration techniques for IV sedatives have evolved, whereas regional anesthesia-specific technologies have evolved from peripheral nerve stimulation to ultrasound. Perhaps more than any other specialty, orthopedic surgery lends itself to the practice of regional anesthesia. Nonetheless, general surgery, ophthalmology, and otolaryngology are also leaning towards use of regional anesthesia techniques. Preoperative preparation Patient assessment Patients due for regional anesthesia should basically have the same preoperative assessment and precautions as patients due for general anesthesia. This is both because regional anesthesia has cardiorespiratory risks and complications as well, and also there may be a change of plan intraoperatively, because regional anesthesia may be changed into general anesthesia. Patients receiving regional anesthesia to extremities should be reminded to avoid using the blocked extremity for at least 24 hours. In addition, patients should be warned that protective reflexes and proprioception for the blocked extremity may be diminished or absent for 24 hours. Accepted by the surgeon If the surgeon is unwilling or not cooperative during loco-regional anesthesia, the chance of problems and failure will increase significantly. Sometimes it may simply be a matter of providing the surgeon with better information about the benefits of loco-regional anesthesia or discussing the option of providing adequate sedation in order to let the surgeon work undisturbed. In other cases the surgeon may have valid concerns about muscle relaxation and surgical access, or the surgeon and patient may have made alternative plans in their prior consultations.