The role of regional anesthesia in patient outcome: ambulatory surgery

Techniques in Regional Anesthesia and Pain Management (2008) 12, 194-198

The role of regional anesthesia in patient outcome: ambulatory surgery Xavier Capdevila, MD, PhD,a Matthieu Ponrouch, MD,b Didier Morau, MD, MScb From the aDepartment of Anesthesiology and Critical Care, Montpellier I University and Montpellier University Hospital, Institut National de la Sante= et de la Recherche Médicale (INSERM), Equipe soutenue par la Région et l’Inserm (ERI)-25, Montpellier, France; and the b Department of Anesthesiology and Critical Care Medicine, Lapeyronie University Hospital, Montpellier, France. KEYWORDS: Ambulatory surgery; Regional anesthesia

The past 10 years have demonstrated real and dramatic growth in the number and complexity of ambulatory surgeries. The remaining real problems are the postoperative pain and the adverse effects due to systemic opioids promoting hospital readmissions and increasing costs. These events limit the expansion of outpatient surgery. Regional anesthesia techniques such as spinal anesthesia and peripheral nerve blocks are ideal techniques for 1-day hospital admission surgical procedures. It is now fully demonstrated that these techniques allow rapid and complete anesthetic blocks, a limitation of adverse events and unplanned hospital admissions, and increase the quality of postoperative pain relief and patient’s outcome if continuous peripheral nerve blocks are used. © 2008 Published by Elsevier Inc.

Ambulatory surgery has gained massive growth in the past 20 years. Seventy-five percent of all surgical procedures performed in the United States are done on an ambulatory basis. In addition, more complex and extensive surgical procedures are now being performed on an outpatient basis. This progress was due to the advent of rapid elimination anesthetics, short-acting sedatives and muscle relaxants, and modern surgical techniques. However, postoperative pain is still a major limiting factor to expanding the type of surgeries performed on a day-case basis. Chung and coworkers1 quantified the failure of outpatient pain management on more than 10,000 outpatients, reporting that 40% to 70% had severe postoperative pain (coded ⬎50 mm on a visual analog scale). As well, Rawal and coworkers2 reported that 35% of day-surgery patients experienced moderate to severe pain at home. These authors demonstrated Address reprint requests and correspondence: Xavier Capdevila, MD, PhD, Department of Anesthesiology (DAR A), Lapeyronie University Hospital, Route de Ganges, 34295 Montpellier Cedex 5, France. E-mail address: [email protected].

1084-208X/$ -see front matter © 2008 Published by Elsevier Inc. doi:10.1053/j.trap.2008.09.004

that regional anesthesia technique really optimized pain relief. Regional anesthesia is the ideal technique for ambulatory surgery but is underutilized in this setting. Dexter and colleagues3 demonstrated this fact when analyzing data from the United States Data for Health Statistics between 1994 and 1996. They reported that only an average of 8% of ambulatory cases were performed under regional anesthesia. We have to choose the best anesthesia technique for outpatient surgery. The patient must go home quickly and safely; side effects that may be tolerated in the patient, such as nausea, vomiting, and pain, become totally unacceptable in the outpatient setting, potentially resulting in delayed home discharge and even unanticipated overnight admission. In this setting, advantages and problems due to regional anesthesia are well known (Table 1). Obviously, regional anesthesia represents a good option for outpatient anesthesia, being associated with less nausea and vomiting than general anesthesia and better postoperative pain relief and patient outcome.4-6

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Table 1 Potential benefits and problems related to RA vs GA in 1-day surgery Advantages to patients ● improved quality of recovery X less postoperative pain (mainly for CPNB) X less postoperative nausea and vomiting X less unplanned hospital admissions ● able to observe the procedure ● communication with surgeon during procedure ● an option to receive no, light, or heavy sedation ● earlier mobilization Advantages to surgeon and staff ● assessment of function before wound closure ● possible to discuss treatment options with patient ● “fast tracking,” i.e., bypassing phase I recovery room ● shortened recovery time ● less requirements in PACU/Phase II recovery room ● fewer unanticipated overnight admissions Potential disadvantages of RA in ambulatory surgery ● takes time and new organization (block insertion, onset, etc.) ● needs active cooperation with patients and surgeons ● risk of complications (nerve damage, transient neurological symptoms, e.g., after lidocaine spinal anesthesia) ● variable failure rate (up to 8-10% with PNB) ● urinary retention with spinals

Spinal anesthesia Spinal anesthesia was one of the choices. The introduction of nontraumatic pencil-point needles with small gauge became an optimum for outpatient anesthesia, providing a fast, reliable, and deep surgical block with simple injection of very small doses of local anesthetics. Spinal anesthesia provides a fast, reliable, and deep surgical block with a simple injection of small amounts of local anesthetics. Problems with using spinal anesthesia in the outpatient setting relate to the effect of spinal block on recovery of motor function after the block, bladder function, and postdural puncture headaches. Recovery of motor function after spinal block is usually evaluated with the Bromage’s scale, and the ability of the patient to flex the ankle, knee, and hip joints is considered as an index of complete motor recovery. A recent study7 compared clinical markers of motor block resolution (Bromage’scale) and objective data of functional balance (computerized force platform method). The results of the study suggested that the standard markers of motor function are poor predictors of functional balance following ambulatory spinal anesthesia, whereas actual ability to deambulate became more important for safe patient discharge. Voiding is usually required before patient discharge. Mulroy and coworkers8 recently evaluated the efficacy and safety of applying an accelerated discharge pathway after spinal block by not requiring the patient to void. Young patients, without a history of voiding dysfunction, were

195 included. Criteria for home discharge included all standard criteria but voiding. If patients voided before fulfilling home discharge criteria, they were discharged. Otherwise they received a bladder ultrasound and when urine volume was less than 400 mL, the patients were discharged; if volume was more than 400 mL, the patients were reassessed after 1 hour and then discharged. These patients were discharged 22 minutes before patients with standard discharge criteria including voiding. None of these patients reported difficulty in voiding after home discharge. This study suggests that waiting for voiding after short-duration spinal anesthesia for surgical procedures at low risk of urinary problems might not be necessary, and could result in prolonged discharge time. Accordingly, the dose and drug used for spinal anesthesia must be balanced in order for the fastest recovery of unassisted ambulation after the procedure, maintaining adequate efficacy of intraoperative nerve block. Lidocaine provides intense and short-lasting spinal block. However, in the last 10 years, the occurrence of transient neurologic symptoms after spinal lidocaine has increased concerns about its use. Freedman and coworkers,9 evaluating the epidemiology and risk factors for transient neurologic symptoms (TNS) after spinal anesthesia in more than 1800 patients, clearly demonstrated that TNS commonly follow lidocaine spinal anesthesia. Lithotomy and surprisingly outpatient procedures were other independent risk factors. TNS is a benign syndrome, usually resolving spontaneously and quickly; however, these symptoms may be particularly concerning to a patient who needs to go back home soon and chooses to perform the procedure on an outpatient basis because of this.10 The use of bupivacaine is recommended. Several agents have been suggested, like mepivacaine, bupivacaine, and, more recently, ropivacaine. Pawloski and coworkers11 reported on the use of two different doses (60 and 80 mg) of mepivacaine for ambulatory spinal anesthesia. It has been reported that the incidence of TNS is only slightly lower or similar to that observed with lidocaine.11 Authors suggested the use of very low doses of local anesthetic (lidocaine or bupivacaine) with an incidence of side effects lower than that previously reported with 50 to 60 mg lidocaine and a time to discharge of 145 minutes.12,13 However, this reduction in doses of local anesthetic also requires the addition of intrathecal opioids (20-25 ␮g fentanyl) to implement analgesia. Very good results have been reported with small doses of long-acting agents, such as bupivacaine (both with plain and hyperbaric solutions) as well as with the new concept of unilateral spinal block.14-17 Recently, ropivacaine has been suggested for outpatient spinal anesthesia, providing some interesting advantages over similar concentrations of bupivacaine related to its shorter duration of sensory and motor blocks.18 It has been recently reported that small doses of ropivacaine could be an acceptable option for outpatient procedures allowing fast recovery of ambulation after the procedure, with discharge times similar to those of small-dose lidocaine.19 This approach provides

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recovery characteristics similar to desflurane anesthesia,20 with lower costs. In some patients, epidural anesthesia may be used with or without general anesthesia. Williams and colleagues10 demonstrated that general–regional anesthesia care is better than general anesthesia alone. Patients with the combined technique showed improved recovery profiles and lower unexpected hospital admission rates, and they required fewer nursing interventions for common postoperative symptoms. Patients receiving epidural anesthesia showed discharge outcomes similar to those patients receiving general anesthesia with femoral nerve block. Postanesthesia care unit bypass (fast-tracking) was more likely in clinical pathway regional anesthesia patients (regional or spinal), when compared with the clinical pathway general anesthesia used.

Peripheral nerve blocks Peripheral nerve blocks (PNB) with long-acting local anesthetics are an attractive anesthetic alternative for outpatient surgery.4,5 These techniques are site-specific, have few side effects, and provide better surgical conditions as well as superior analgesia than systemic opioids. PNB reduce the stress response to surgery, enhance patient satisfaction, and improve patient outcome. PNB are not associated with opiod-related side effects and are not contraindicated in patients receiving anticoagulants. First of all, we have to consider the main problematic point that can happen during a continuous postoperative regional analgesia regimen. The pharmacodynamic muscle dysfunction due to regional anesthesia, mainly a persistent motor blockade after an epidural or a continuous PNB, can be a specific question which depends on concentration (differential blockade) and duration of action of local anesthetics and adjuvants. This problem seems crucial for some types of surgery, due to the establishment of an active rehabilitation program and the patient’s medical history. Muraskin and coworkers21 have recently shown that, during femoral or femorosciatic nerve blocks, a lack of locking of the knee (stiffness) and muscle stability during rotations and direction changes could limit the quality of postoperative rehabilitation. These problems are mainly encountered after a dual femoral and sciatic nerve blockade several hours after the block. However, Williams and colleagues22 reported in a recent study that the use of a femoral–sciatic block was associated with less pain of invasive knee surgery. If no nerve blocks were used, a complex (versus less invasive) knee surgery was associated with a 10-fold greater risk of hospital readmission. The use of femoral nerve block or femoral–sciatic block (versus no blocks) was associated with a 2.5-fold reduction in unplanned admissions. Despite a great number of advantages over systemic opioid postoperative analgesia,23 single-injection PNB interest can be limited due to the duration of long-acting local

anesthetics (10-24 hours).4,5,23 After resolution of PNB, postoperative pain management is often difficult to manage and inadequate in the ambulatory setting. Patients usually have available oral opioids to control their pain. Continuous peripheral nerve blocks (CPNB) are a technology that allows prolonged site-specific local anesthetic delivery in the outpatient setting, profound analgesia, minimal side effects, and avoidance of premature regression of an analgesic block. CPNB can assist anesthesiologists with the ability to extend postoperative analgesia at home, treating patients in a more compassionate way. Case reports or series of ambulatory perineural infusion as well as randomized comparative studies were described for peripheral nerve catheters in various locations.24-31 Klein and coworkers32 involved 40 subjects undergoing major shoulder surgery who received an interscalene block and perineural catheter preoperatively, and were randomized to receive either perineural ropivacaine 0.2% or normal saline postoperatively (10 mL/h). Patients receiving perineural ropivacaine averaged 10 mm on a visual analog pain scale (VAS) of 0 to 100, compared with 30 mm for subjects receiving placebo. Because patients remained hospitalized, the investigators had the opportunity to provide more than oral analgesics; patients had access to intravenous morphine via a patient-controlled anesthesia device. Therefore, patients receiving placebo theoretically received a greater degree of analgesia than that available to ambulatory patients who must rely on oral instead of IV opioids. Recent randomized double-blinded, placebo-controlled trials provided data involving patients discharged at home with CPNB.26,27,29-31 These studies included patients scheduled for moderately painful orthopedic procedures who had infraclavicular, interscalene, or posterior sciatic popliteal perineural catheters. Patients receiving perineural local anesthetic infusions achieved clinically lower resting and breakthrough pain scores while requiring fewer oral analgesics. Patients who received perineural local anesthetic experienced additional benefits related to improved analgesia. Zero percent to 30% of patients with perineural ropivacaine reported insomnia due to pain, compared with 60% to 70% of patients using only oral opioids. Patients receiving perineural ropivacaine infusion awoke from sleep because of breakthrough pain episodes, an average of 0 times on the first postoperative night compared with 2 times for patients receiving perineural saline. Obviously lower opioid consumption in patients receiving perineural local anesthetic resulted in fewer opioid-related side effects. Patients receiving perineural local anesthetic reported satisfaction with their postoperative analgesia of 8.8 to 9.8 compared with 5.5 to 7.7 for patients receiving placebo. The benefits of such analgesia appear to be highlighted by less hospital readmission. Whether these benefits result in an improvement in patients’ health-related quality of life or outcome benefits is only partially studied. Ilfeld and colleagues33 compared an overnight continuous femoral nerve block (cFNB) to a 4-day ambulatory cFNB with ropivacaine 0.2%. The CPNB technique did not increase the ambulation distance the af-

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Figure 1 Percentages of patients without daily activity, with assistance for daily activity, or with complete free activity at home in the three groups of patients. On day 3, 100% of the continuous ⫹ bolus group had a complete free activity at home versus 70% in the continuous infusion group and only 35% in the systemic analgesia regimen group.34 *P ⬍ 0.05 versus both regional anesthesia groups; #P ⬍ 0.05 versus the other two groups.

ternoon after surgery but significantly decreased the time until 3 specific readiness-for-discharge criteria (adequate analgesia, independence from intravenous analgesics, and ambulation of at least 30 meters) are met after total knee arthroplasty in 50 patients. Catheters were removed on postoperative day 4. Patients given 4 days of perineural ropivacaine attained all 3 discharge criteria in 25 hours (21-47 hours), compared with 71 hours (46-89 hours) for those of the control group receiving saline. Capdevila and coworkers34 compared a CPNB infusion of ropivacaine 0.2% to patient-controlled intravenous morphine in 83 patients scheduled for ambulatory orthopedic surgery for functional recovery and postoperative analgesia. Basal– bolus ropivacaine infusion decreased the time to a 10-minute walk, optimized all daily activities (Figure 1), and decreased the amount of ropivacaine used. The morphine group had greater pain scores and consumption of morphine and ketoprofen compared with the ropivacaine group. The incidence of nausea/vomiting, sleep disturbance, and dizziness increased, and the patient satisfaction score decreased in the morphine group. Authors concluded that ambulatory orthopedic surgery using 0.2% ropivacaine delivered as a perineural infusion optimizes functional recovery and pain relief. In conclusion, the benefits of regional anesthesia techniques can be extended from the ambulatory surgery setting into the patient’s home postoperatively via spinal anesthesia for the quality of the anesthetic blockade and for postoperative analgesia via perineural catheter placement.35,36 Obviously, for a successful program, new aspects of the facility’s structures need to be addressed to be sure that regional anesthesia techniques have the potential to decrease the

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