CURRENT STATUS OF REGIONAL ANESTHESIA FOR ADULT OUTPATIENTS n6m14mr
Dermot Fitzgibbon MB, BCh, FFARCSI
From the Department of Anesthesiology, University of Washington School of Medicine,
Seattle, Washington
Address reprint requests to
Dermot Fitzgibbon, MB, BCh, FFARCSI
Department of Anesthesiology
University of Washington
School of Medicine
1959 N.E. Pacific Street
Seattle, WA 98195
BENEFITS OF REGIONAL ANESTHESIA
The challenge of anesthesia for ambulatory patients is to provide for rapid
return to street readiness with the most effective postoperative analgesia and
minimal undesirable side effects. Regional anesthesia, with its selective local
action and relatively simple equipment, offers an excellent anesthetic choice
in an outpatient facility. In addition to limiting the anesthetized area to
the surgical site, the common side effects of general anesthesia (e.g., nausea,
vomiting, lethargy) are reduced, the risks and side effects of endotracheal
intubation are minimized, patient recovery time may be decreased, and improved
analgesia is provided in the postoperative period. a7i a46i
A number of studies a51i a82i have evaluated the efficacy of ambulatory regional
anesthesia. Urmey et al a82i prospectively recorded data on ambulatory surgery
patients at an orthopedic speciality hospital where regional anesthesia was
the first-line standard care; the various types of anesthesia administered are
listed in Table 1 (Table Not Available) . Only 4.4% of patients who had regional
anesthesia required admission compared with 12% of general anesthetics. Discharge
times were similar for general, spinal, or epidural anesthesia (average of 3
hours); patients who had peripheral nerve blocks were discharged in approximately
2 hours. Failure of regional anesthesia, necessitating general anesthesia, occurred
in only 1% of cases. The authors concluded that regional anesthesia in an ambulatory
center is effective in all but a small percentage of patients. Osborne a51i
evaluated outcome for 6000 consecutive procedures in a major public teaching
hospital day surgery unit. Anesthesia-related complications were more frequent
with general anesthesia (1:114) than with regional anesthesia (1:180) or local
anesthesia plus sedation
712
TABLE 1 -- ANESTHETIC TECHNIQUES FOR AMBULATORY ORTHOPEDIC PROCEDURES
From Urmey WF, Stanton J, Sharrock NE: Initial one-year experience of a 97.3%
regional anesthesia ambulatory surgery center. Reg Anesth 18:69, 1993; ©
Churchill Livingstone, with permission.
(Not Available)
(1:780). Recovery with regional or local anesthesia was significantly shorter
than after general anesthesia.
Despite the potential advantages cited regional anesthesia should not be considered
universally appropriate. Factors that contribute to a successful regional anesthetic
include the appropriate selection of patients, anesthetic technique, and local
anesthetic, use of sedative and hypnotic agents, and the skill of the anesthesiologist.
Prior screening of patients through preanesthesia testing (PAT) clinics is very
useful in determining the acceptability of patients for a regional anesthetic.
Very young or excessively anxious patients may be poor candidates. Similarly,
obese patients may present technical problems, especially for central neuraxial
blocks. Patients of American Society of Anesthesiologists (ASA) physical status
III or IV may be particularly good candidates for ambulatory regional anesthesia
compared to general anesthesia, especially if their systemic diseases are medically
stable.
SELECTION OF TECHNIQUE AND LOCAL ANESTHETIC
Outpatient regional techniques require some modification from standard inpatient
procedures. Ideally, an outpatient regional technique should be rapid in onset
and result in few if any acute or delayed complications (e.g., pneumothorax).
The additional time needed to perform many regional blocks, as well as the time
needed for the anesthetic to take effect, is a potential drawback when procedures
are short and turnover between cases is rapid. Use of blocks that require more
time than the procedure itself to perform should be limited to those situations
where specifically indicated for medical reasons or the patient expresses a
strong preference for a specific technique. Blocks that significantly impair
the ability to ambulate and void should be tailored to the anticipated usual
duration of surgery by appropriate selection of both local anesthetic agent
and technique to minimize both recovery and discharge time. Prolonged analgesia
from a block (e.g., foot, arm, or hand blocks) may be beneficial in some instances,
particularly if the ability of the patient to perform various activities is
not significantly impaired; however, prolonged anesthesia may provoke anxiety
or be considered unpleasant or irritating by many patients when
713 it persists for many hours after hospital discharge and should be discussed
with patients before instituting such a block.
Local anesthetic agents are commonly classified according to their relative
potency and duration of action as follows: low potency and short duration (e.g.,
chloroprocaine), moderate potency and duration (e.g., lidocaine and mepivacaine),
high potency and long duration (e.g., tetracaine, bupivacaine, and etidocaine).
Selection of specific blocks are discussed later. Selecting the appropriate
local anesthetic for a given regional anesthetic requires consideration of a
number of factors, including potency, speed of onset, duration of action of
local anesthetics, site and duration of surgery, the degree of muscle relaxation
required, and the duration of analgesia desired. Duration of anesthesia with
a given agent varies with the site of injection and frequently with the total
mass of drug injected. a70i Thus, bupivacaine injected into the epidural space
lasts approximately 2 to 3 hours whereas the same dose injected into the brachial
plexus may last 10 to 11 hours. Vasoconstrictors, such as epinephrine, are added
to increase the duration of action, provide an indication of intravascular injection,
and reduce peak serum levels of local anesthetic. The extent to which epinephrine
prolongs the duration of anesthesia depends on the specific local anesthetic
used and the site of injection. Vasoconstrictors do not prolong the duration
of action of all local anesthetics in all situations (Table 2) (Table Not Available)
. Epinephrine prolongs the duration of action of all agents for peripheral nerve
blocks except ropivacaine. a33i It also prolongs the duration of action of epidural
chloroprocaine, lidocaine, and mepivacaine. The local anesthetic properties
of the intrinsically more potent and longer acting agents (bupivacaine, etidocaine,
tetracaine) are influenced less by the addition of epinephrine, particularly
when such agents are used epidurally. Epinephrine does not markedly prolong
the duration of motor block by epidural bupivacaine or etidocaine; however,
it does extend the sensory block by these epidural agents. a71i The effects
of epinephrine added to agents used for spinal anesthesia are discussed later.
The optimal dose of epinephrine is one that would produce maximal increase in
the duration of a local anesthetic agent and minimal hemodynamic effects. Kennedy
et al a36i showed that a supraclavicular brachial plexus block with 30 mL of
1.6% lidocaine has virtually no hemodynamic effects whereas the same agent with
epinephrine 1:200,000 produced a dose-related increase in cardiac rate, cardiac
output, and stroke volume that persisted for 90 minutes and decreases in peripheral
resistance and concomitant changes in mean arterial pressure that persisted
for 120 minutes. Absorbed epinephrine produces predominantly beta-adrenergic
effects with little evidence of alpha-adrenergic effects at
TABLE 2 -- DURATION OF ACTION OF LOCAL ANESTHETICS AND EFFECT OF EPINEPHRINE
Adapted from Ellis JS: Local anesthetics. In Kirby, Gravenstein: Clinical Anesthesia
Practice. Philadelphia, WB Saunders, 1994.
(Not Available)
714 doses up to 400 mug. Furthermore, epinephrine produced a dose-related increase
in mean duration of anesthesia, but only up to a concentration of 1:200,000,
above which the cardiocirculatory changes continued to increase without any
further increase in the duration of anesthesia. The optimal dose of epinephrine
in the above study was a 1:200,000 solution or 5 mug/ml concentration. If the
use of epinephrine is desirable it should be added to the local anesthetic just
before the local anesthetic is used. The reason for this is that commercial
solutions of epinephrine containing epinephrine are buffered to a lower pH than
the standard solution of that agent in an effort to oxidation of the epinephrine.
Such acidification moves the pH farther from the pKa of that solution, reducing
the availability of the free base and the rate of diffusion of the local anesthetic.
The speed of onset of local anesthetics is primarily related to the agent selected
and the site of injection. Thus, agents such as chloroprocaine have a more rapid
onset in the epidural space than agents such as lidocaine and bupivacaine, and
lidocaine and mepivacaine have a more rapid onset than bupivacaine when used
for peripheral nerve blocks. Efforts to increase the speed of onset of local
anesthetics by the addition of bicarbonate have yielded contradictory results
and appear to be minimally effective.
SEDATION/ANALGESIA
Many patients undergoing surgery with local or regional anesthesia prefer to
be sedated. Small doses of short-acting drugs should be carefully titrated.
Midazolam is an excellent agent for the moderately-anxious patient. The amnesia
it produces does not correlate with the apparent level of sedation; fully conscious
patients may have no recall of perianesthetic events. Low-dose propofol infusions
also appear to be excellent agents for intraoperative sedation. a84i Adequate
intraoperative sedation can usually be achieved with infusion rates of 25 to
100 mug/kg-1 /min-1 . When intraoperative amnesia is desired in addition to
a rapid recovery, administration of small titrated doses of midazolam (0.5-3
mg intravenously) prior to the propofol infusion may offer advantages over either
drug alone. Many outpatients find the use of local anesthetic techniques acceptable
alternatives to both general and regional anesthesia when adequate sedation
and anxiolysis are provided. The addition of a short-acting opioid (e.g., fentanyl,
alfentanil) is especially useful if paresthesia are sought or nerve stimulation
performed during a regional technique and obtundation is undesirable.
UPPER EXTREMITY BLOCKS
Brachial plexus anesthesia is suitable for many upper extremity procedures,
most notably for orthopedic surgery. The axillary approach is suitable for forearm
and hand surgery whereas the interscalene approach is useful for shoulder and
more proximal upper extremity surgeries. Intravenous regional anesthesia (Bier
block) provides adequate anesthesia of the hand and forearm for procedures of
limited duration (less than 1 hour).
Axillary Brachial Plexus Block
The axillary approach is safe and effective for outpatients. a19i Localization
of the plexus may be based on elicitation of paresthesias, palpation of a click
as
715 the surrounding fascial sheath is pierced, piercing the axillary artery, or
observation of motor responses to direct electrical stimulation of nerves. Although
there is some controversy regarding the most reliable method of performing a
successful axillary block, block of at least two nerves appears to be important
to improving the success rate. a42i Urban et al a79i prospectively evaluated
508 patients who received either interscalene or axillary brachial plexus blocks
for upper extremity surgery. They noted that major immediate complications were
infrequent, with only one mild seizure in the axillary block group and evidence
of intravascular injection in only two of the patients in the interscalene group;
however, 23% of patients in the axillary group complained of pain, tenderness,
or bruising in the axilla on the first day of surgery, and in 2 patients the
pain persisted for 2 weeks. Paresthesia occurred in 19% of patients in the axillary
group on the first postoperative day, and 7% of patients continued to have paresthesias
2 weeks after surgery. Similar problems of bruising and persistent numbness
associated with axillary blocks were reported by Cooper et al. a13i
Interscalene Brachial Plexus Block
Despite its common use for open shoulder surgery, interscalene block is less
widely accepted as a viable anesthetic technique in the fast turnover setting
of ambulatory surgery. a66i Its major advantage is that it provides very effective
postoperative analgesia as well as providing satisfactory anesthesia for surgery
or arthroscopy of the shoulder. The block can also be used for surgery on the
upper arm; however, the lower part of the brachial plexus, and in particular,
the medial cutaneous nerve of the arm, intercostobrachial nerve, and the ulnar
nerve are frequently missed by this approach. In situations where anesthesia
of the medial aspect of the arm or forearm are required, additional block of
the intercostobrachial nerve or supplementation by the axillary approach is
required. The interscalene approach to the plexus is generally unsuitable for
outpatient hand surgery. D'Alessio et al a16i reported on the use of interscalene
block for ambulatory surgery. Compared with general anesthesia, the block required
significantly less total nonsurgical intraoperative time use and resulted in
fewer unplanned admissions for therapy of severe pain, sedation, or nausea and
vomiting. A failure rate of 8.7% was observed. No airway problems other than
hoarseness due to recurrent laryngeal nerve block were noted. Postoperatively,
patients who had the block proceeded more rapidly through PACU and phase 2 recovery
than comparable patients who received general anesthesia (72 minutes ±
24 versus 102 minutes ± 40, for regional versus general; P = 0.0001).
A number of different nerves (phrenic, recurrent laryngeal, and cervical sympathetic)
may be blocked in addition to the roots of the brachial plexus when using the
interscalene approach. Side effects commonly observed from block of these nerves
are relatively minor and well tolerated. Involvement of the recurrent laryngeal
and cervical sympathetic nerves is rarely significant, but patients may experience
hoarseness, dysphagia, and blurred vision, and should be cautioned against drinking
or eating while hoarseness and dysphagia are present. Reversible diaphragmatic
paralysis has been reported to occur in up to 100% of cases. a83i In addition,
greater than 25% mean reductions in functional residual capacity and FEV1 have
also been associated with the block. a81i Complete or incomplete paralysis of
a hemidiaphragm is usually well-tolerated, but spirometric studies have documented
altered respiratory capacity for several hours. a83i a53i Urmey et al a80i have
listed respiratory considerations for interscalene brachial plexus block.
716
LOCAL ANESTHETIC CHOICE FOR UPPER EXTREMITY BLOCK
Agents commonly used for peripheral nerve blocks, including brachial plexus
blocks, are listed in Table 3 . In general, agents of intermediate potency exhibit
a more rapid onset than the more potent agents. Etidocaine may be an exception
because it produces a block of relatively rapid onset. a71i Mepivacaine provides
a greater degree of motor block with a longer duration of sensory anethesia
than lidocaine when used for brachial plexus block. a86i The variation in duration
of anesthesia after brachial plexus block is also considerably greater than
that observed after other types of regional anesthesia. As such, it is prudent
to forewarn patients about to receive a brachial plexus block of the possibility
of prolonged sensory and motor block, particularly when agents such as bupivacaine
and etidocaine are used. When numbness is persistent after an upper extremity
block, the patient's discharge need not be delayed until the block has resolved.
Instructions can be given in the care of the extremity to prevent injury while
sensation is lacking. Patients should also be instructed on the use of short-acting
opioids and nonsteroidal anti-inflammatories prior to complete resolution of
the block, and on regular use thereafter if significant postoperative pain is
anticipated. Patients should be reassured that sensation will return after discharge
and be given a contact telephone number or person if persistent beyond the expected
duration.
Intravenous Regional Anesthesia
Surgical anesthesia during intravenous regional anesthesia (IVRA) is produced
by multiple and complementary mechanisms, including block of peripheral small
nerves and nerve endings (initial effect), block of nerve trunks at a proximal
site (main anesthetic component), ischemia, and compression of nerve trunks.
a63i The block can be used for various upper extremity operations, including
both soft-tissue and orthopedic procedures, primarily in the hand and forearm.
a5i It has also been used for foot procedures with a calf tourniquet. a38i The
agent most commonly used for an upper extremity block is 0.5% lidocaine, approximately
40 mL for upper extremity procedures, and 0.25% lidocaine 50 to 60 mL for lower
extremity procedures. Because of the risk of toxic reactions, bupivacaine is
not a suitable agent. Although chloroprocaine, because of its extremely short
serum half-life, might appear to be the ideal choice for IVRA, it is contraindicated
because it can cause phlebitis on intravenous injection. a31i IVRA is a safe
and effective way to provide anesthesia for surgery distal to the elbow of less
than 1 hour's duration. A limiting feature of the technique is the onset of
tourniquet pain. Clinical investigations involving unmedicated unanesthetized
volunteers
TABLE 3 -- LOCAL ANESTHETICS USED FOR PERIPHERAL NERVE BLOCKS
Agent Concentration Duration (minutes)
2-Chloroprocaine 2%-3% 30-75
Lidocaine 1%-2% 50-120
Mepivacaine 1%-2% 120-300
Bupivacaine 0.25%-0.5% 300-720
Etidocaine 0.5%-0.75% 300-720
717 have shown that upper extremity tourniquet inflation can be tolerated for 29
to 34 minutes in motivated, healthy subjects. a3i a15i The use of a double tourniquet
reduces but does not eliminate this problem. Onset of analgesia and anesthesia
after injection is rapid, so surgery or manipulation may begin within 5 to 10
minutes. Lidocaine typically produces sensory loss earliest on the radial forearm
and in the first dorsal web space. The onset of fingertip anesthesia is variable
and unpredictable, as is decrease in motor function. a78i Supplementation of
IVRA with a digital nerve block may be used if digital anesthesia is inadequate.
Normal sensation and motor power return rapidly after tourniquet release. In
some situations rapidity of recovery with loss of analgesia may be considered
a disadvantage. Infiltration of the wound with long acting local anesthetic
or peripheral nerve block by the surgeon prior to cuff release and application
of dressings may overcome this problem in the early postoperative period. Recently,
Reuben et al a61i studied the effects of IVRA using ketolorac 60 mg and 38 mL
of 0.5% lidocaine, and noted that patients who had received ketoralac experienced
less postoperative pain (both in PACU and in the first 24 hours), and concluded
that ketorolac improves IVRA with 0.5% lidocaine, both in terms of controlling
intraoperative tourniquet pain and by diminishing postoperative pain.
ABDOMINAL, PERINEAL, AND LOWER EXTREMITY BLOCKS
Lumbar epidural anesthesia is suitable for pelvic, lower abdominal, and lower
extremity (excluding foot) surgery. The onset and quality of sensory and motor
block of the fifth lumbar and first sacral roots by epidural anesthesia are
often delayed or incomplete, with a failure of the S1 segment sensory block
in up to 46% of patients when using lidocaine hydrochloride and epinephrine.
a28i Spinal anesthesia is superior to epidural anesthesia for lower extremity
and perineal surgery, and is useful for lower extremity, urologic, and herniorrhaphy
procedures in the ambulatory setting. Anesthesia and analgesia for mid- and
forefoot surgery can be satisfactorily achieved with peripheral nerve blocks
of the ankle and foot. Complete analgesia lasting from 10 to 25 hours after
surgery has been described with ankle blocks using bupivacaine 0.5%. a67i Details
on how to perform this block are provided by Schurman. a69i
Spinal Anesthesia
The advantages of spinal anesthesia for ambulatory surgery include ease of administration,
rapid onset, and high reliability. Potential disadvantages include the possibility
of postdural puncture headache, urinary retention, and transient radicular irritation
with lidocaine. In North America three local anesthetics are commonly used to
produce spinal anesthesia: lidocaine, tetracaine, and bupivacaine (Table 4)
. Lidocaine produces short-to-intermediate-acting anesthesia and is ideally
suited for ambulatory regional anesthesia. The only mixture of lidocaine currently
approved by the Food and Drug Administration (FDA) for subarachnoid use is a
5% solution made hyperbaric in 7.5% dextrose. Recently, observations have been
made that 5% hyperbaric lidocaine may cause back and bilateral leg pain. Pinczower
et al a55i described the problem in nine patients who received hyperbaric lidocaine
for spinal anesthesia in an ambulatory setting. The dose of lidocaine ranged
from 40 to 100 mg. The pain was described as either sharp or cramping with or
without associated back pain. None of these patients
718
TABLE 4 -- LOCAL ANESTHETICS USED FOR SPINAL ANESTHESIA
Agent Concentration Usual Dose Baricity Duration (minutes)
Lidocaine 5% in 7.5% glucose 50-100 mg Hyperbaric 45-80
2% 40-60 mg ? Hypobaric 60-100
Bupivacaine 0.75% in 8.25% glucose 9-15 mg Hyperbaric 90-240
0.5% 15 mg Isobaric 90-240
Tetracaine 0.5% in 5% glucose 10-20 mg Hyperbaric 150-300
0.5% 10-20 mg Isobaric 150-300
0.1% 7.5-10 mg Hypobaric 150-300
demonstrated objective neurologic deficits. In all cases, the symptoms resolved
fully within 1 week. Tarkkila et al a76i estimate that approximately 10% of
patients who receive hyperbaric 5% lidocaine may experience these problems.
Because of concerns of neurotoxicity relating to either a high lidocaine or
dextrose concentration, a41i a68i a76i the manufacturing company now recommends
dilution of the mixture with equal volume of cerebrospinal fluid (CSF) prior
to subarachnoid injection. A number of studies suggest equal if not greater
efficacy with lower concentrations of lidocaine. a43i a77i Liew a43i reported
on the use of 25 mg of 0.5% lidocaine for minor outpatient gynecologic procedures;
93% of patients developed a block to T10. The mean duration of sensory block
was 32.5 minutes, and all patients had complete resolution of motor block within
1 hour. Bupivacaine 0.75% in 8.25% dextrose is useful for procedures lasting
2 to 2.5 hours, althought the time to spontaneous voiding may be considerably
longer. a23i Although subarachnoid bupivacaine without a vasoconstrictor possesses
an anesthetic profile similar to tetracaine without a vasoconstrictor, differences
do exist between the drugs. The depth and duration of motor block is probably
greater with tetracaine a11i making it less desirable for outpatient anesthesia.
Bupivacaine, when compared with tetracaine, has been reported to cause less
hypotension a4i and to have a lower incidence of lower extremity tourniquet
pain. a12i
The effect of epinephrine on subarachnoid anesthesia is confusing. Chambers
a9i noted that different doses of epinephrine (100-300 mug) added to hyperbaric
lidocaine did not prolong the duration of anesthetic block to any clinically
useful effect, but time to full recovery was delayed by 40 to 50 minutes; similar
effects were observed with subarachnoid bupivacaine. a8i Chiu a10i showed that
200 mug of epinephrine added to 50 mg of hyperbaric lidocaine delayed the ability
to void urine by approximately 1 hour, and may delay discharge. Moore et al
a47i studied the effect of epinephrine added to lidocaine for lower extremity
surgery using the occurrence of intraoperative pain as an end-point rather than
thoracic dermatome sensory regression. The duration of anesthesia prior to the
occurrence of pain was 87 minutes ± 16 minutes for the plain lidocaine
group and 128 minutes ± 23 minutes for the lidocaine with epinephrine
group. Epinephrine may have a differential vasoconstrictive effect at different
levels. Kozody et al a40i showed that 200 mug of intrathecal epinephrine caused
dural vasoconstriction, implying that epinephrine prolongs a lidocaine block
primarily in the lumbosacral area. Thus, some prolongation of lower extremity
anesthesia may be achieved by the addition of epinephrine but at a potential
cost of delayed recovery and discharge. For routine lower extremity or perineal
surgery the author recommends the use of 50 to 60 mg 5% lidocaine in 7.5% dextrose
diluted in equal volumes with CSF and injected without epinephrine. If prolongation
of lower extremity anesthesia is necessary (greater than 60 minutes) the author
719 recommends the addition of 200 mug of epinephrine to lidocaine or the use of
bupivacaine 8 to 12 mg without epinephrine. Subarachnoid tetracaine with epinephrine
is not recommended for ambulatory surgery.
RECOVERY AFTER SPINAL ANESTHESIA
The generally accepted sequence of return of function after spinal block is
motor, sensory, and sympathetic; however, several studies have found recovery
of sympathetic activity may occur before complete regression of the motor or
sensory spinal block, a18i a62i although Axelsson a2i demonstrated that motor
strength in the lower extremities was restored 40 to 140 minutes on average
before restoration of detrusor strength after subarachnoid injections of bupivacaine
and tetracaine. Pflug a54i considered the ability to urinate a final indication
of reversal of sympathetic paralysis because an intact, functioning sympathetic
nerve supply to the bladder and urethra is necessary for this function. Suitable
criteria for ambulation after spinal anesthesia include normal perianal (S4-5)
pinprick sensation, plantar flexion of the foot, and proprioception of the big
toe. Discharge criteria after spinal anesthesia include normal sensation, ability
to walk, and ability to urinate. Patients should be instructed not to lift heavy
objects or strain for 24 hours.
POSTDURAL PUNCTURE HEADACHE
The use of spinal anesthesia in younger patients for ambulatory procedures has
been discouraged by reports of a high incidence of postdural puncture headaches
(PDPH). a25i Outpatients appear to have a higher risk of PDPH than inpatients.
a25i a49i In ambulatory surgery the possibility of PDPH assumes more prominence
because it may impair the ability to return to normal activities shortly after
the procedure. For patients planning to travel long distances soon after surgery,
the occurrence of a severe headache in a geographical area remote from the hospital
may be difficult to manage. Headache following dural puncture is typically delayed
in onset and postural in nature. PDPH presumably occurs when a slow leak of
CSF leads to contraction of the subarachnoid space and compensatory expansion
of the pain-sensitive intracerebral veins. A variety of factors are involved
in the incidence of PDPH, including age, sex, needle diameter, and needle tip
design. a26i a48i Patients younger than 45 years old are at greater risk from
a higher incidence and severity of headache requiring treatment. Efforts have
been made to reduce the incidence of PDPH by changing the size and design of
the needle. In a meta-analysis of PDPH and spinal needle design, Halpern a30i
showed a reduction in the incidence of PDPH when noncutting needles rather than
cutting needles were used, unless the discrepancy in needle diameter was very
large. There was also a reduction in PDPH when a small-diameter spinal needle
compared with a larger diameter needle of the same type was used. Quincke point
needles may cause persistent dural tears whereas blunt or noncutting spinal
needles (Whitacre, Sprotte) may spread dural fibers and decrease CSF loss after
dural puncture, thereby reducing the incidence of PDPH. a65i The use of 22-
and 25-gauge Quincke needles in young patients cannot be encouraged as few studies
with large patient numbers have demonstrated a PDPH incidence under 10%. a75i
Although the incidence of headache significantly decreases with the smaller
diameter needles, such as 27-gauge and 29-gauge, a22i technical difficulties
may be increased. a17i a44i The incidence of PDPH in young
720 patients with a 25-gauge Whitacre needle varies between 0.6% and 3.0%. a6i a7i
The incidence of headache after a 24-gauge Sprotte is probably similar, a21i
a64i although Wiesel et al a85i report an incidence of 15.2% with 24-gauge Sprotte
needles in patients under 45 years old. Needle size is less of a factor in the
incidence of PDPH when noncutting needles are used compared with Quincke-type
needles. a14i a27i Smith et al a72i recently compared the use of 25- and 27-gauge
Whitacre needles in obstetric patients and observed increased technical difficulties
with the use of the smaller gauge needles. The possibility of a lower incidence
of PDPH with the 27-gauge needle was unproven in this study. Campbell et al
a7i noted that 25-gauge Whitacre and 24-gauge Sprotte needles were comparable
with respect to ease of insertion and incidence of PDPH, but that the Whitacre
needles were substantially cheaper than the Sprotte needles.
Based on these studies and on other currently available information, the author
recommends the routine use of 25-gauge Whitacre needles for young patients in
the ambulatory setting as the incidence of PDPH does not appear to be significantly
different with either Sprotte needles or the smaller gauge Whitacre needles,
and the cost-savings may be significant with 25-gauge Whitacre. Although advances
in needle tip design may have reduced the incidence of PDPH, the problem still
persists, and a higher incidence should be expected in the younger outpatient
age groups. Alternative methods of regional anesthesia for outpatient anesthesia
should be considered if either the risk of PDPH is unacceptable to the patient
or access to appropriate medical care or advice is difficult should this problem
arise. If PDPH occurs and does not respond to conservative approaches, an epidural
blood patch on an outpatient basis can be highly effective. a59i Patients are
instructed to rest quietly for 1 hour after injection of autologous blood. Patients
can be discharged but should subsequently avoid straining and should maintain
good oral fluid intake at home.
Epidural Anesthesia
Effective use of epidural local anesthesia requires an understanding of local
anesthetic potency and duration and a realistic estimate of the length of the
procedure. A variety of different agents are used for epidural anesthesia (Table
5) . 2-Chloroprocaine (2-CP), an amino ester local anesthetic, is a short-acting
agent that allows efficient matching of surgical procedure length and duration
of epidural analgesia. It is available in 2% and 3% concentrations, with the
latter preferable for surgical anesthesia.
Kopacz a39i noted that the duration of sensory anesthesia after epidural injection
of 20 mL of 3% 2-CP and 1.5% lidocaine was significantly shorter (133 minutes
± 28 minutes for 2-CP, 182 minutes ± 38 minutes for lidocaine)
than
TABLE 5 -- LOCAL ANESTHETIC DRUGS USEFUL FOR OUTPATIENT EPIDURAL ANESTHESIA
Drug Concentration Typical Volume (mL) Duration (minutes) *
Chloroprocaine 2%-3% 15-24 30-90
Lidocaine 1.5%-2% 15-24 60-90
Mepivacaine 1.5%-2% 15-24 90-120
*Solution contains 1:200,000 concentration of epinephrine.
721 after 1.5% mepivacaine (247 minutes ± 42 minutes). In addition, discharge
times were significantly shorter for 2-CP (269 minutes ± 62 minutes)
and lidocaine (284 minutes ± 62 minutes) than for mepivacaine (357 minutes
± 71 minutes). Each of these solutions contained 5 mug/mL epinephrine.
Deck et al a20i compared the effects of epidural 3% 2-CP and 1.5% lidocaine
without epinephrine. Patients receiving 2-CP had significantly faster times
to block resolution, ambulation, and discharge than those receiving lidocaine.
Patients receiving 2-CP had resolution of block (120 minutes ± 15 minutes
versus 190 minutes ± 44 minutes) and were discharged sooner (127 minutes
± 16.8 minutes versus 195 minutes ± 43.8 minutes) than patients
in the lidocaine group. The implication of these studies are that moderate epidural
doses of 3% 2-CP without epinephrine may be the epidural solution of choice
for ambulatory epidural anesthesia.
Prolonged and sometimes permanent neurologic deficits have been reported after
inadvertent subarachnoid injections of 2-CP during attempted epidural anesthesia.
a59i The combination of a low pH and the presence of sodium bisulfite may have
been responsible for the neurotoxic reactions. a29i 2-CP itself does not appear
to be neurotoxic. Partly because of these reports, the preparation of the drug
has undergone an evolution resulting in 2-CP preparations with different additives.
Earlier preparations of the drug contained methylparaben. In 1987, a new preparation
that was free of both methylparaben and sodium bisulfite was marketed under
the brand name Nesacaine-MPF (Nesacaine methylparaben free, Astra Pharmaceutical,
Westborough, MA); however, this preparation contains disodium ethylenetetraacetic
acid (EDTA), which has been associated with a syndrome of prolonged backache
following regression of epidural anesthesia with Nesacaine-MPF. a24i a50i
2-CHLOROPROCAINE BACK PAIN
In 1989, Fibuch a24i published the first of several reports describing a syndrome
of prolonged backache following regression of epidural anesthetic with EDTA
containing Nesacaine-MPF. Orkin a50i reported a 40% incidence of backache following
2-CP epidural anesthesia in ambulatory patients. Stevens a73i found a 100% incidence
of back pain after large doses of 2-CP. The pain typically begins during regression
of sensory anesthesia. It is described as being deep, aching, or burning in
character. The pain is poorly localized to the lumbar region and severe in intensity.
It is not easily treated with conventional analgesics and may last 24 hours
or more. It has not been reported to cause either a chronic pain syndrome or
any lasting neurologic sequelae. This syndrome of severe back pain was not reported
prior to the addition of EDTA; therefore, EDTA has been the leading suspect
in the cause of back pain. One possibility is that EDTA leaking into the lumbar
musculature may result in localized hypocalcemia and tetanus. a24i Other possible
contributing factors include the low pH (2.5-3.5) of 2-CP as 2-CP is more acidic
than the other commonly used local anesthetics. Stevens a74i concluded that
large doses (> 40 mL) of 2-CP that contains EDTA resulted in a high incidence
of back pain. Use of a lower volume (< 25 mL) significantly reduced the incidence
of back pain. Treatment with epidural fentanyl (100 mug) has provided prompt
relief. a73i
If 2-CP is planned for epidural use, a block might prudently first be established
with 1.5% lidocaine (to exclude inadvertent subarachnoid injection and avoid
potential neurotoxic effects from 2-CP) and then maintained with 2-CP. For short
procedures, epinephrine should be avoided. The minimal volume of 2-CP necessary
should be used. The use of epidural bupivacaine is not recommended for ambulatory
surgery due to its unnecessarily prolonged duration.
722
KNEE SURGERY
Arthroscopic procedures on the knee joint form a large proportion of outpatient
surgical procedures. The surgery may be solely diagnostic, and in this situation
may last less than 30 minutes. Therapeutic procedures (e.g., meniscectomy) may
last 2 to 3 hours. The knee is innervated by L3, L4, and L5 nerve roots anteriorly
and the first two sacral roots posteriorly. A number of different regional anesthetic
techniques have been used for knee surgery (Table 6) . Randel a57i considered
epidural anesthesia superior to spinal or general anesthesia for outpatient
knee arthroscopy. Patel et al a52i noted favorable operating conditions and
good postoperative analgesia with a 3-in-1 femoral nerve block, a lateral cutaneous
nerve block of thigh, and 10 mL 0.25% bupivacaine as supplementary intra-articular
anesthesia, if required. A variety of analgesic techniques have been evaluated
and advocated for managing postoperative pain after arthroscopic knee surgery.
These techniques have largely focused on the use of intra-articular anesthetics,
intra-articular opioids, and systemic nonsteroidal anti-inflammatory agents.
Although studies have shown various degrees of success, intra-articular injections
of local anesthetics and opioids are currently popular for postoperative analgesia.
Intra-articular 0.25% bupivacaine, usually in doses of 20 mL, is associated
with significantly improved early (1-6 hours) postoperative analgesia, and generally
does not appear to be effectively maintained thereafter. a1i a35i Conflicting
results exist regarding the efficacy of intra-articular morphine with some studies
revealing effective analgesia for up to 48 hours a34i a37i
TABLE 6 -- REGIONAL ANESTHETIC TECHNIQUES FOR KNEE SURGERY
Technique Agents Advantages Disadvantages
Epidural Lidocaine 1.5% ± 2-CP Faster recovery time compared with spinal
or general anesthesia. a57i Relatively slow onset time; wet tap; patchy block.
Spinal Lidocaine, bupivacaine Rapid onset; dense block. PDPH; unpredictable
duration of surgery.
Nerve block (3-in-1, sciatic) Lidocaine + epinephrine Prolonged postoperative
analgesia; no impairment of voiding. Slow onset; inability to ambulate.
Femoral nerve block + intra-articular injection Bupivacaine 0.25% + epinephrine
Prolonged postoperative analgesia; no impairment of voiding; early discharge.
Some difficulty with ambulation; ? patchy anesthesia.
Local anesthesia (skin + intra-articular) Lidocaine 0.5% + epinephrine Use of
epinephrine should eliminate need for tourniquet; ? postoperative analgesia.
Minor procedures only; potential for large doses of local anesthetic.
723
TABLE 7 -- LOCAL ANESTHETIC AGENTS USED FOR INFILTRATION TECHNIQUES
Agent Concentration Duration without Epinephrine (minutes) Duration With Epinephrine
(minutes)
Lidocaine 0.5-1.0 30-60 120-360
Mepivacaine 0.5-1.0 45-90 120-360
Bupivacaine 0.25-0.5 120-240 180-420
Etidocaine 0.5-1.0 120-180 180-420
and others failing to demonstrate any clinical effect. a32i a56i Reuben a60i
recently evaluated the effect of intravenous and intra-articular ketorolac (60
mg) with intra-articular bupivacaine (30 mL 0.25%) in patients undergoing elective
arthroscopic meniscal surgery. Intra-articular ketorolac in combination with
bupivacaine significantly decreased postoperative pain, decreased analgesic
requirements, and increased analgesic duration after arthroscopic knee surgery.
Patel et al a52i suggest that a 3-in-1 femoral nerve block may be extremely
useful for outpatient knee arthroscopy, providing both excellent postoperative
analgesia and a high degree of patient acceptance.
LOCAL ANESTHESIA
Local infiltration of the operative site with dilute solutions of local anesthetics
is a simple and safe technique for outpatients. Because the injection of local
anesthetics can be associated with significant discomfort, the use of intravenous
sedative and analgesic drugs (so-called "conscious sedation") has
become very popular among surgeons. a45i A variety of surgical procedures, including
vasovasotomy, circumcision, hydrocele and spermatocele repairs, cystoscopy,
inguinal herniorrhaphy, plastic and reconstructive surgery, and breast biopsy
with needle localization, are suitable for local infiltration. In addition,
local anesthetic supplementation (e.g., infiltration with 0.25% bupivacaine)
decreases incisional pain in the recovery room and potentially hastens recovery
time. a46i Agents commonly used for local infiltration are listed in Table 7
.
CONCLUSION
Regional anesthesia is ideally suited for many types of adult outpatient surgery.
It requires appropriate choice of both anesthetic agent and technique. Central
neuraxial anesthesia provides ideal anesthetic conditions for many procedures,
and to avoid delays in time to discharge caused by either prolonged motor block
or inability to void urine, the use of short-acting agents without epinephrine
(lidocaine for subarachnoid, 2-CP for epidurals) is recommended. A variety of
methods for improved postoperative analgesia is now available to minimize both
patient discomfort and impairment of function. Increased use of regional anesthesia
and analgesia in the ambulatory setting may result in greater satisfaction for
both patient and physician alike.