IS REGIONAL ANESTHESIA APPROPRIATE FOR AMBULATORY SURGERY?

Erwin Kresnoadi, M.D, M.Med.Sc

Department Of Anesthesiology and Reanimation
University of Mataram / West Nusa Tenggara General Hospital
==================================================================
There is continuing debate about whether Regional anaesthesia (RA) or General anaesthesia
(GA) is better for ambulatory surgery. The answer is not straightforward. To implement a successful
RA ambulatory program, it is essential to have a teamwork approach between anaesthetist, surgeon
and ambulatory nurses, conducive to the practice of RA. With this teamwork approach RA can be
very appropriate for ambulatory surgery.
RA whether used alone or in combination with GA offers significant advantages to the
patient. RA provides selective analgesia to the surgical site reducing systemic analgesic requirements
and minimising opioid related side effects such as dizziness and nausea and vomiting. As a
consequence the recovery process can be facilitated, enabling earlier ambulation and discharge home.
RA alone is not appropriate for all ambulatory surgery; therefore careful patient, procedure and
surgeon selection is of key importance.
Practical Implementation of Regional Anaesthetic techniques
To streamline RA there are specific strategies an ambulatory team may pursue. The block
should be performed in a dedicated block room or recovery room with monitoring and oxygen
facilities and adequate time allowed for block onset. Intravenous sedation techniques are useful at
block insertion so that amnesia and anxiolysis can be achieved, however prolonged effects of sedative
agents can potentially delay discharge. Patients can be discharged from ambulatory surgery with
padding and protection of the insensate limb, provided both written and verbal discharge instructions
are given.
Peripheral Nerve Blockade
Upper limb surgery is most suited to peripheral nerve blockade (PNB). For short procedures
(eg carpal tunnel release) intravenous regional anaesthesia provides excellent surgical conditions with
quick recovery of neurologic function. Longer upper extremity procedures (eg rotator cuff repair)
associated with significant postoperative pain is best performed using brachial plexus anaesthesia.
The site of surgery will dictate which approach the clinician should take to the brachial plexus.
Interscalene block, acting at the roots of the brachial plexus, gives a reliable block for shoulder
surgery and provides adequate pain control for early rehabilitation. Infraclavicular block and the more
peripheral axillary approach to the brachial plexus are suitable for elbow and hand surgery
1
respectively. Compared to the traditional paraesthesia technique, nerve stimulation using insulated
needles is now used widely for PNB.
Lower extremity blocks are often under-utilised in ambulatory surgery. Femoral nerve block
provides excellent analgesia for knee surgery and varicose vein stripping, significantly improving
patient satisfaction. Blockade of the sciatic and femoral nerves more distally at the popliteal level,
predominantly used for foot and ankle surgery, has a high success rate with good postoperative pain
relief for up to 24 hours. Ankle block is a simple, safe technique for mid and forefoot surgery.
Addition of adjuvants such as clonidine to long acting local anaesthetics (LA) will prolong
postoperative analgesia produced by PNB.
Whilst its use today has been confined to a clique of adventurous anaesthesiologists,
paravertebral blocks are likely to become the technique of choice for many procedures that are
currently performed under GA. It provides excellent prolonged analgesia (24 hours) following breast
surgery, inguinal, ventral, and umbilical hernia repair. Good anatomical knowledge and appropriate
technique will result in high success rates and minimal complications.
1
Neuraxial Blockade
Epidural anaesthesia is time consuming to perform, and is slower in onset than spinal anaesthesia.
However it may be appropriate when surgical procedures have an unpredictable time course with its
flexibility of additional LA dosing through a catheter (eg cruciate ligament repair or bilateral varicose
vein surgery).
Spinal anaesthesia with its high reliability and fast onset of action is a simpler option to
epidural anaesthesia. The risk of spinal headache has been minimised (1%) with the use of fine gauge,
pencil-point needles. Using short acting LA drugs with lipophilic opioid (fentanyl), the frequency of
urinary retention is acceptably low. Fentanyl appears to increase duration and quality of spinal block
without increasing discharge time.
2
There is a balance between rapid offset of effect with small LA
doses and higher doses of LA which guarantee adequate block height but may result in unacceptable
block duration and side effects such a urinary retention. Lignocaine has the optimal onset and duration
for ambulatory surgery but concern over transient neurological symptoms (pain or sensory
abnormalities in the lower back, buttocks or lower extremities) in up to 20% patients, limit its use.
Low dose bupivacaine (5 10 mg) with 10-25 mcg fentanyl provides excellent anaesthesia with
acceptable discharge times following knee arthroscopy with minimal risk of transient neurologic
syndrome. More recently there have been significant advances in the practice of selective spinal
anaesthesia where the distribution of spinal block is restricted to the operative side. Potential benefits
include fewer cardiovascular side effects, less urinary retention, good patient acceptance and earlier
patient discharge compared to bilateral distribution of spinal anaesthesia; this makes selective spinal
techniques suitable to ambulatory surgery.
3

Mulroy has recently questioned the practice of voiding before discharge in spinal patients
undergoing ambulatory surgery. In a study of 201 patients Mulroy concluded that in healthy patients
of less than 70 years of age with no history of voiding problems who are not undergoing surgery in
2
the perianal or perineal region, or hernia repair, may be discharged safely 2 hours after 6 mg
intrathecal bupivacaine even if they have not voided.
4
However, further large studies should be
performed before these guidelines should be adopted in common ambulatory practice.
Post-operative Analgesia.
Prior to a central neuraxial block wearing off, alternative analgesic options should be
introduced such as wound infiltration or PNB to optimise patients pain relief. Multimodal analgesic
regimes should be commenced at the time of surgery combining LA with non-steroidal anti-
inflammatory drugs and simple oral analgesics. A documented pain management plan will assist the
patient manage rebound pain at home when LA wears off. More recently the use of continuous
infusion catheters has enabled more painful procedures such as major orthopaedic, plastic or vascular
surgery to be performed on a day basis.
5
Catheters can be placed either perineurally or into the wound.
Portable disposable non-electronic pumps preloaded with low concentration local anaesthetic (eg
ropivacaine 0.2%) and preset hourly infusion rates allows practical patient administration at home for
procedures such as major shoulder or knee surgery. Combining a basal infusion rate of LA with a
patient controlled bolus may provide best pain relief with good patient satisfaction.
6
Patients can
remove the catheters themselves however a home nursing service is desirable.
Further clinical studies are required to identify the most cost-effective anaesthetic technique
for ambulatory surgery. PNB in particular offers significant advantages over central neuraxial
blockade, and should be a key area for anaesthetists further education. There is also great enthusiasm
for catheter techniques, but limiting factors are appropriate training, and technical difficulties
associated with catheters and pump technology.
References
1. Klein SM, Bergh A, Steele SM et al. Thoracic paravertebral block for breast surgery. Anesth Analg 2000; 90: 1402-5.
2. Ben-David B, Maryanovsky M, Gurevitch A et al. a comparison of mini-dose lidocaine-fentanyl and conventional-dose lidocaine
spinal anaesthesia. Anesth Analg 2000; 91:865-870
3. Fanelli G, Borghi B, Casati A, Bertini L, Montebugnoli M, Torri G. Unilateral bupivacaine spinal anesthesia for outpatient knee
arthroscopy. Can J Anesth 2000;47: 746-751.
4. Mulroy MF, Salinas FV, Larkin KL, Polissar NL. Ambulatory surgery patients may be discharged before voiding after short-
acting spinal and epidural anesthesia. Anesthesiology 2002;Aug;97(2):315-319.
5. Rawal N, Axelsson K, Hylander J, etal. Postoperative patient-controlled local anaesthetic administration at home. Anesth Analg
1998;86:86-9.
6. Borgeat A, Kalberer F, Jacob H et al. Patient-controlled interscalene analgesia with ropivacaine 0.2% versus bupivacaine 0.15%
after major open shoulder surgery: the effects on hand motor function. Anesth Analg 2001; 92:218-223.
3
MONITORED ANESTHESIA CARE AND REGIONAL ANESTHESIA FOR
AMBULATOR SURGER
Er!i" #re$"oadi% M&D% M&Med&Sc
Department Of Anesthesiology and Reanimation
University of Mataram / West Nusa Tenggara General Hospital

Use of lo!al anestheti! infiltration and peripheral nerve "lo!#s in !om"ination $ith
intravenous analgesi! and sedative drugs is gaining popularity in the am"ulatory setting% &t has "een
estimated that over '() of all outpatient *day+surgery, pro!edures !ould "e performed utili-ing these
te!hni.ues% When patients are undergoing pro!edures under lo!al anesthesia $ith sedation in the
operating room *OR,/ the old terminology used to des!ri"e the !are of these patients $as 0!ons!ious
sedation1%
2
As the term implies/ !ons!ious sedation $as a minimally+depressed level of !ons!iousness
that retained the patient3s a"ility to maintain an air$ay independently and !ontinuously/ and to
respond appropriately to physi!al stimulation and ver"al !ommands% The A4A avoids this term in
their 5ra!ti!e Guidelines of 4edation and Analgesia "y Non+anesthesiologists "e!ause it is impre!ise%
6
The preferred terminology is therefore monitored anesthesia !are *MA7,%
Mo"i'ored a"e$'he$ia care
MA7 is the term used $hen an anesthesiologist monitors a patient re!eiving lo!al anesthesia
alone or administers anestheti! drugs to patients undergoing diagnosti! or therapeuti! pro!edures $ith
or $ithout lo!al anesthesia%
8
The A4A defines MA7 as instan!es in $hi!h an anesthesiologist has
"een !alled on to provide spe!ifi! anesthesia servi!es to a parti!ular patient undergoing a planned
pro!edure/ in !onne!tion $ith $hi!h a patient re!eives lo!al anesthesia or/ in some !ases/ no
anesthesia at all% &n su!h a !ase/ the anesthesiologist is providing spe!ifi! servi!es to the patient/ is in
!ontrol of his or her vital signs/ and is availa"le to administer anestheti!s or provide other medi!al
!are as appropriate%
9
The standard of !are of patients re!eiving monitored anesthesia !are should "e
the same as for patients undergoing general or regional anesthesia and should in!lude a !omplete
preoperative assessment/ intraoperative monitoring/ and postoperative re!overy% :igilant monitoring
is re.uired "e!ause patients may rapidly progress from a 0light1 level of sedation to 0deep1 sedation
*or un!ons!iousness,/ and thus may "e at ris# for air$ay o"stru!tion/ o;ygen desaturation/ and even
aspiration%
Anestheti! drugs are !ommonly administered during pro!edures under MA7 to produ!e
analgesia/ sedation/ and an;iolysis/ $hile providing for a rapid re!overy $ithout side effe!ts%
4ystemi! analgesi!s are used to redu!e dis!omfort asso!iated $ith in<e!tion of lo!al anestheti!s and
prolonged immo"ili-ation/ as $ell as pain $hi!h is not amenda"le to lo!al anestheti!s *e%g%/
endos!opy,%
'
4edative drugs are used to ma#e pro!edures more tolera"le for patients "y redu!ing
4
an;iety and "y providing a degree of intraoperative amnesia and allo$ing to rest% During longer
surgi!al pro!edures/ patients may "e!ome restless/ "ored/ or un!omforta"le $hen for!ed to remain
immo"ile/ therefore sedative+hypnoti! drugs may prove "enefi!ial "e!ause they allo$ patients to rest%
=
5atients3 an;iety !an "e redu!ed "y using "en-odia-epines/ as $ell as "y good preoperative
!ommuni!ation/ #eeping the patient $arm and !overed/ and allo$ing the patient to listen to musi!
during the pro!edure%
>

Many different sedative+hypnoti! drugs have "een used during MA7 *in!luding "ar"iturates/
"en-odia-epines/ #etamine/ propofol and alpha+6 agonists,% &n addition/ a $ide variety of delivery
systems su!h as intermittent "oluses/ varia"le+rate infusions/ target+!ontrolled infusions/ as $ell as
patient+!ontrolled analgesia and/or sedation have "een utili-ed during these pro!edures%
?
The most
!ommonly used sedative drugs are mida-olam *2+6 mg, and propofol *(%'+2 mg/#g follo$ed "y
infusion at 6'+2(( @g/#g/min,% Methohe;ital has also "een used su!!essfully during MA7 "y
intermittent "oluses *2(A6( mg, or as a varia"le+rate infusion *(%2A(%6) solution,%
B
Although residual
sedation appears to "e greater $ith methohe;ital than $ith propofol/ one study found no statisti!al
differen!e in the re!overy times $hen !omparing infusions of methohe;ital *9( @g/#g/min, and
propofol *'( @g/#g/min, during a MA7 te!hni.ue% Ho$ever/ there $as a higher in!iden!e of pain on
in<e!tion in the propofol infusion group%
2(+26
Therefore/ methohe;ital may "e a !ost+effe!tive
alternative to propofol for sedation during MA7% 7areful titration of the &: anestheti! is essential to
a!hieve the desired level of sedation and to ensure prompt re!overy%
8
&n $omen undergoing laparos!opi! tu"al sterili-ation $ith a MA7 te!hni.ue the anestheti!
drug !osts $ere signifi!antly redu!ed !ompared to general anesthesia *C62 vs C9=/ respe!tively,% The
MA7 te!hni.ue $as also asso!iated $ith less time in the OR *8(D9 vs 89D2 min,/ a higher degree
of 0a$a#eness1 on the evening of the day of surgery *9%8D2%9 vs 8%=D2%9,/ as $ell as de!reased
postoperative pain *88) vs ?(), and sore throats *8) vs >(),/ !ontri"uting to a signifi!ant
redu!tion in perioperative !osts%
28
5atel et al
29
reported that the use of MA7 sedation resulted in a =+ to
>+minute de!rease in the OR e;it time !ompared to general anesthesia $ith desflurane/ !ontri"uting to
enhan!ed turnover of !ases% This is an important !onsideration in today3s pra!ti!e environment $ith
the heavy emphasis on 0fast+tra!#ing1 pro!esses%
Avramov et al
2'
des!ri"ed the !om"ined use of alfentanil *(%8A(%9 @g/#g/min, and propofol
*6'/ '(/ or >' @g/#g/min, infusions for MA7% 7on!omitant use of propofol signifi!antly redu!ed the
opioid dose re.uirement *8(A'(), and the in!iden!e of postoperative nausea and vomiting *(A2>)
vs 88), $hen !ompared $ith alfentanil infusion alone% An infusion of remifentanil/ (%(' to (%2'
@g/#g/min/ !an provide ade.uate sedation and analgesia during minor surgi!al pro!edures performed
$ith the patient under lo!al anesthesia $hen administered in !om"ination $ith mida-olam/ 6 to 9 mg%
4E RFgo et al
2=
!ompared the use of intermittent remifentanil "oluses *6' @g, vs a !ontinuous
varia"le+rate infusion *(%(6'A(%2' @g/#g/min, $hen administered to patients undergoing G4WH under
a MA7 te!hni.ue involving mida-olam *6 mg, and propofol *6'A'( @g/#g/min,% 5atients !omfort $as
5
higher during the pro!edure $hen remifentanil $as administered "y a varia"le+rate infusion%
Ho$ever/ these patients also e;perien!ed a higher in!iden!e of desaturation *8() vs (), !ompared
$ith those re!eiving small intermittent "oluses of remifentanil% &n a dire!t !omparison of remifentanil
and propofol administered "y !ontinuous infusion after premedi!ation $ith mida-olam/ there $as a
de!reased level of sedation and a greater degree of respiratory depression $ith remifentanil *versus
propofol, administration% Therefore/ remifentanil infusions must "e !arefully titrated to avoid
e;!essive respiratory depression%
2>
The use of remifentanil in !om"ination $ith lo!al anestheti!s
o"viates the disadvantages of the minimal residual analgesia $hen remifentanil is used during painful
pro!edures%
Given the in!reased ris# of ventilatory depression $hen opioid analgesi!s are !om"ined $ith
sedative+hypnoti!s/ a variety of non+opioid analgesi!s have "een evaluated during MA7% Ietorola!/ a
potent/ parenterally+a!tive N4A&D has "een used "oth as a sole supplement and as an ad<un!t to
propofol sedation during lo!al anesthesia% Use of #etorola! is asso!iated $ith a lo$er in!iden!e of
pruritus/ nausea/ and vomiting than fentanyl% Ho$ever/ $hen used $ith propofol sedation/ #etorola!+
treated patients re.uired higher intraoperative doses of propofol and more supplemental opioid
analgesia !ompared $ith the use of fentanyl% Ho$+dose #etamine *(%6'A(%>' mg/#g, !om"ined $ith
either mida-olam or propofol has also "een administered "efore in<e!tion of lo!al anestheti!s in
outpatients undergoing !osmeti! surgi!al pro!edures%
2?
Ietamine has the advantage over opioid
analgesi!s of produ!ing less ventilatory depression and 5ON: $hile providing "etter intraoperative
analgesia than the N4A&Ds% Joth mida-olam and propofol !an attenuate%
4u"anestheti! !on!entrations of inhaled anestheti!s *e%g%/ N
6
O/ 8(A'() in o;ygen or
sevoflurane (%8+(%=), !an also "e used to supplement lo!al anesthesia%
2B
The primary !on!erns relate
to the ease $hi!h the patient !an drift into an un!ons!ious state/ as $ell as operating room pollution%
The K
6
+agonists redu!e !entral sympatheti! outflo$ and have "een sho$n to produ!e
an;iolysis and sedation%
6(
Iumar et al
62
demonstrated that oral !lonidine *8(( @g, provided effe!tive
an;iolysis for elderly patients undergoing ophthalmi! surgery under lo!al anesthesia and also
de!reased the in!iden!e of intraoperative hypertension and ta!hy!ardia% De;medetomidine/ a more
sele!tive and potent K
6
+agonist/ signifi!antly de!reased an;iety levels and redu!ed the re.uirements
for supplemental analgesi! medi!ations $hen given "efore &: regional anesthesia for hand surgery%
66
When !omparing de;medetomidine $ith mida-olam for sedation/ Aho et al
68
des!ri"ed a faster
re!overy from sedation $hen de;medetomidine $as follo$ed "y reversal $ith the spe!ifi! K
6
+
antagonist atipame-ole% Ho$ever/ the administration of de;medetomidine has "een asso!iated $ith
"rady!ardia/ $hi!h may limit its usefulness during MA7%
66/69
Re(io"al a"e$'he$ia
Regional anesthesia !an offer many advantages for the am"ulatory patient population% &n
addition to limiting the anestheti-ed area to the surgi!al site/ !ommon side effe!ts of general
6
anesthesia *e%g%/ nausea/ vomiting/ di--iness/ lethargy, !an "e avoided%
6'
Lurthermore/ the need for
postanesthesia nursing !are is de!reased if effe!tive analgesia is provided in the early postoperative
period%
6=/6>
&t has "een suggested that regional anesthesia is !ost+ in the outpatient setting "e!ause of
the lo$er in!iden!e of side effe!ts and improved re!overy !ompared $ith general anesthesia%
6?
5roper
patient sele!tion along $ith the s#ill and enthusiasm of the surgi!al and anesthesia teams $ill allo$ an
even $ider variety of pro!edures to "e performed using regional anestheti! te!hni.ues in the future%
Lor short superfi!ial surgi!al pro!edures *M=( min, limited to a single e;tremity/ the
intravenous regional *Jier, "lo!# $ith lido!aine/ (%') / is a simple and relia"le te!hni.ue% This
pro!edure/ $hi!h !an "e used for either upper or lo$er e;tremity surgery/ uses a dou"le tourni.uet to
de!rease tourni.uet pain% &ntravenous regional anesthesia has "een reported to "e the most !ost+
effe!tive te!hni.ue for outpatient hand surgery%
6B

&f more profound and prolonged anesthesia of the upper e;tremity and shoulder is re.uired/ a
regional "lo!# of the "ra!hial ple;us !an "e used *e%g%/ a;illary/ supra!lavi!ular or inters!alene
"lo!#,%
8(
5eripheral nerve "lo!#s are also useful for surgery on the leg% The 0three+in+one "lo!#1
*femoral/ o"turator/ and lateral femoral !utaneous nerves, using a perivas!ular te!hni.ue is useful for
outpatient #nee arthros!opy and anterior !ru!iate ligament repairs/ providing e;!ellent postoperative
analgesia $ith a high degree of patient a!!eptan!e% An#le "lo!#s are also simple and effe!tive
te!hni.ues for surgery on the foot% 5opliteal s!iati! nerve "lo!#s have "een sho$n to provide
e;!ellent postoperative analgesia after foot and an#le surgery%
82
&n pediatri! patients/ peripheral nerve "lo!#s !an "e performed immediately after indu!tion of
general anesthesia to redu!e the anestheti! re.uirement and provide postoperative analgesia%
86
Histori!ally/ !audal anesthesia has "een the most popular te!hni.ue to redu!e postoperative pain in
!hildren undergoing lo$er a"dominal/ perineal/ and lo$er e;tremity pro!edures% Other popular
regional anestheti! te!hni.ues in!lude "lo!#ade of the ilioinguinal and iliohypogastri! nerves to
minimi-e post+herniorrhaphy pain and the use of dorsal penial nerve "lo!# and su"!utaneous ring
"lo!# post!ir!um!ision pain%
88
&nterestingly/ simple $ound infiltration *or instillation, $ith lo!al
anestheti!s may "e as effe!tive as a !audal or ilioinguinal nerve "lo!# in redu!ing pain after inguinal
hernia repair%
89
4tudies also suggest that systemi! #etorola! *2 mg/#g, is as effi!a!ious as !audal
"lo!#ade/ $ith a lo$er in!iden!e of side effe!ts%
8'
4imilarly/ topi!al lido!aine ointment is an effe!tive
alternative to "oth a nerve "lo!# and opioid analgesi!s for post!ir!um!ision pain%
S)**ar+
MA7 is the anestheti! te!hni.ue of !hoi!e for providing !ost+effe!tive anestheti! !are in the
am"ulatory setting% 5eripheral nerve "lo!#s as part of a MA7 sedation te!hni.ue !an further enhan!e
the effi!a!y of this te!hni.ue% The most important fa!tors in a!hieving the desired !lini!al out!ome
are effe!tive lo!al analgesia and the !areful titration of systemi! sedative and analgesi! medi!ations%
7
Re,ere"ce$
2% 4mith &/ White 5LN Monitored anesthesia !areN Ho$ mu!h sedation/ ho$ mu!h analgesiaO P 7lin Anesth ?N>=4/ 2BB=%
6% 7ruise 7P/ 7hung L/ Qogendran 4 et alN Musi! in!reases satisfa!tion in elderly outpatients undergoing !atara!t surgery% 7an P
Anaesth 99N98/ 2BB>%
8% Ne$son 7/ Poshi G5/ :i!tory R et alN 7omparison of propofol administration te!hni.ues for sedation during monitored anesthesia
!are% Anesth Analg ?2N9?=/ 2BB'%
9% Ameri!an 4o!iety of AnesthesiologistsN 5osition on Monitored Anesthesia 7are% Dire!tory of Mem"ers% 5ar# Ridge/ &llinois/
Ameri!an 4o!iety of Anesthesiologists/ 2BB>/ p 928%
'% Ghouri AL/ Taylor G/ White 5LN 5atient+!ontrolled drug administration during lo!al anesthesiaN a !omparison of mida-olam/ propofol and
alfentanil% P 7lin Anesth 9N 9>=+B/ 2BB6%
=% White 5L/ Negus PJN 4edative infusions during lo!al and regional anesthesiaN A !omparison of mida-olam and propofol% P 7lin
Anesth 8N86/ 2BB2%
>% 5ratila MG/ Lis!her MG/ Alagesan R et alN 5ropofol vs mida-olam for monitored sedationN A !omparison of intraoperative and
re!overy parameters% P 7lin Anesth 'N6=?/ 2BB8%
?% Taylor G/ Ghouri AL/ White 5LN Mida-olam in !om"ination $ith propofol for sedation during lo!al anesthesia% P 7lin Anesth 9N628/
2BB6%
B% 4E RFgo MM/ &naga#i Q/ White 5LN The !ost+effe!tiveness of methohe;ital versus propofol for sedation during monitored anesthesia
!are% Anesth Analg ??N >68+?/ 2BBB%
2(% 7ohen MM/ Dun!an 5G/ DeJoer D5 et alN The postoperative intervie$N Assessing ris# fa!tors for nausea and vomiting% Anesth
Analg >?N>/ 2BB9%
22% Hon#avaara 5/ Hehtinen AM/ Hovor#a P et alN Nausea and vomiting after gynae!ologi!al laparos!opy depends upon the phase of the
menstrual !y!le% 7an P Anaesth 8?N?>=/ 2BB2%
26% Jeattie W4/ Hind"lad T/ Ju!#ley DN et alN The in!iden!e of postoperative nausea and vomiting in $omen undergoing laparos!opy is
influen!ed "y the day of menstrual !y!le% 7an P Anaesth 8?N6B?/ 2BB2%
28% Jordahl 5G/ Raeder P7/ Nordentoft P et alN Haparos!opi! sterili-ation under lo!al or general anesthesiaO A randomi-ed study% O"stet
Gyne!ol ?2N28>/ 2BB8%
29% 4mith 7G/ 5in!ha# A7 et alN Desflurane is not asso!iated $ith faster operating room e;it times in outpatients% P 7lin Anesth ?N28(/
2BB=%
2'% Avramov MN/ White 5L% Use of alfentanil and propofol for outpatient monitored anesthesia !areN determining the optimal dosing
regimen% Anesth Analg ?'N'==/ 2BB>%
2=% 4a Rego MM/ Wat!ha ML/ White 5LN The !hanging role of monitored anesthesia !are in the am"ulatory setting% Anesth Analg
?'N2(6(/ 2BB>%
2>% Waters RMN The do$nto$n anesthesia !lini!% Am P 4urg 88N>2/ 2B2B%
2?% Iorttila I/ Ostman 5/ Laure G et alN Randomi-ed !omparison of re!overy after propofol+nitrous o;ide vs thiopentone+isoflurane+
nitrous o;ide anaesthesia in patients undergoing am"ulatory surgery% A!ta Anaesthesiol 4!and 89N9((/ 2BB(%
2B% Gold J4/ Iit- D4/ He!#y PH et alN Unanti!ipated admission to the hospital follo$ing am"ulatory surgery% PAMA 6=6N8((?/ 2B?B%
6(% &ssioui T/ Ilein IW/ White 5L/ et al% 7ost+effi!a!y of rofe!o;i" vs a!etaminophen for preventing pain after am"ulatory surgery%
Anesthesiology B>N B82/ 6((6%
62% Iumar A/ Jose 4/ Jhatta!harya A et alN Oral !lonidine premedi!ation for elderly patients undergoing intrao!ular surgery% A!ta
Anaesthesiol 4!and 8=N2'B/ 2BB6%
66% M!Ien-ie R/ Uy NT/ Riley TP et alN Droperidol/ondansetron !om"ination !ontrols nausea and vomiting after tu"al "anding% Anesth
Analg ?8N262?/ 2BB=%
68% Do-e :A/ 4hafer A/ White 5LN Nausea and vomiting after outpatient anesthesiaN Gffe!tiveness of droperidol alone and in
!om"ination $ith meto!lopramide% Anesth Analg ==N492/ 2B?>%
69% Tang P/ Wat!ha ML/ White 5LN A !omparison of !osts and effi!a!y of ondansetron and droperidol as prophyla!ti! antiemeti! therapy
for ele!tive outpatient gyne!ologi! pro!edures% Anesth Analg ?8N8(9/ 2BB=%
6'% 5hilip JIN Regional anaesthesia for am"ulatory surgery% 7an P Anaesth 8BNR8/ 2BB6%
6=% Mingus MHN Re!overy advantages of regional anesthesia !ompared $ith general anesthesiaN Adult patients% P 7lin Anesth >N=6?/
2BB'%
6>% Jriden"augh HDN Regional anaesthesia for outpatient surgeryN A summary of 26 years3 e;perien!e% 7an Anaesth 4o! P 8(N'9?/ 2B?8%
6?% Green"erg 75N 5ra!ti!al/ !ost+effe!tive regional anesthesia for am"ulatory surgery% P 7lin Anesth >N=29/ 2BB'%
6B% 7han :W/ 5eng 5W/ Ias-as R/ et al% A !omparative study of general anesthesia/ intravenous regional anesthesia and a;illary "lo!#
for outpatient hand surgeryN 7lini!al out!ome and !ost analysis% Anesth Analg B8N22?2/ 6((2%
8(% D3Alessio PG/ Rosen"lum M/ 4hea I5 et alN A retrospe!tive !omparison of inters!alene "lo!# and general anesthesia for am"ulatory
surgery shoulder arthros!opy% Reg Anesth 6(N=6/ 2BB'%
82% 4ingelyn LP/ Aye L/ Gouverneur PMN 7ontinuous popliteal s!iati! nerve "lo!#N An original te!hni.ue to provide postoperative
analgesia after foot surgery% Anesth Analg ?9N8?8/ 2BB>%
86% 5flug AG/ Aasheim GM/ Loster 7N 4e.uen!e of return of neurologi!al fun!tion and !riteria for safe am"ulation follo$ing
su"ara!hnoid "lo!# *spinal anaestheti!,% 7an Anaesth 4o! P 6'N288/ 2B>?%
88% :ater M/ Wandless PN 7audal or dorsal nerve "lo!#O A !omparison of t$o lo!al anaestheti! te!hni.ues for postoperative analgesia
follo$ing day !ase !ir!um!ision% A!ta Anaesthesiol 4!and 6BN2>'/ 2B?'%
89% Reid ML/ Harris R/ 5hillips 5D et alN Day+!ase herniotomy in !hildrenN A !omparison of ilio+inguinal nerve "lo!# and $ound
infiltration for postoperative analgesia% Anaesthesia 96N='?/ 2B?>%
8'% 4plinter WM/ Reid 7W/ Ro"erts DP/ et alN Redu!ing pain after inguinal hernia repair in !hildrenN !audal anesthesia versus #etorola!
tromethamine% Anesthesiology ?>N '96/ 2BB>%
8
AMBULATOR ANESTHESIA - SURGER
Erwin Kresnoadi, M.D, M.Med.Sc
Department Of Anesthesiology and Reanimation
University of Mataram / West Nusa Tenggara General Hospital
==================================================================
I"'rod)c'io"
Am"ulatory surgery a!!ounts for over =() of all ele!tive operative pro!edures performed in
the United 4tates% With the re!ent gro$th in ma<or laparos!opi! and offi!e+"ased surgery/ this
per!entage may in!rease to >() in the future% When surgery is performed outside the !onventional
hospital environment/ it !an offer a num"er of advantages for patients/ health!are providers/ third+
party payers/ and even hospitals%
2
5atients "enefit from day surgery "e!ause it minimi-es !osts/
de!reases separation from their home and family environment/ redu!es surgery $aiting times/
de!reases their li#elihood of !ontra!ting hospital+a!.uired infe!tions/ and appears to redu!e
postoperative !ompli!ations% 7ompared to traditional hospital admissions/ there is less pre+ and
postoperative la" testing and also a redu!ed demand for postoperative pain medi!ation follo$ing
am"ulatory surgery% Unli#e inpatient surgery/ am"ulatory surgery does not depend upon the
availa"ility of a hospital "ed and may permit the patient greater fle;i"ility in sele!ting the time of
their ele!tive operation% Lurthermore/ there is greater effi!ien!y in the utili-ation of the operating and
re!overy rooms in the am"ulatory setting/ !ontri"uting to a de!rease in the overall patient !harges
!ompared to similar hospital "ased !are%
Co*pari$o" o, (e"eral% $pi"al a"d local a"e$'he$ia
The optimal anestheti! te!hni.ue in the am"ulatory setting $ould provide for e;!ellent
operating !onditions/ a rapid re!overy/ no postoperative side effe!ts/ and a high degree of patient
satisfa!tion% &n addition to in!reasing the .uality and de!reasing the !osts of the anestheti! servi!es/
the ideal anestheti! te!hni.ue $ould also improve operating room *OR, effi!ien!y and provide for an
early dis!harge home $ithout side effe!ts% Ho!al anesthesia $ith intravenous *&:, sedation *so+!alled
monitored anesthesia !are SMA7T,/ spinal anesthesia/ and general anesthesia are all !ommonly used
anestheti! te!hni.ues for am"ulatory surgery% Ho$ever/ opinions differ as to the 0"est1 anestheti!
te!hni.ue for these surgi!al pro!edures%
6+2'
Rather than simply generali-ing as to the "est anestheti!
te!hni.ue for am"ulatory surgery/ it is ne!essary to individually analy-e ea!h surgi!al pro!edure% Lor
e;ample/ in an Gditorial in A"e$'he$ia - A"al(e$ia
2=
% Iehlet and White dis!ussed the optimal anestheti!
te!hni.ue for inguinal hernia repair%
&n the !urrent !ost+!ons!ious environment/ it is important to also e;amine the impa!t of
anestheti! te!hni.ues on OR turnover times/ as $ell as the re!overy pro!ess after am"ulatory surgery
9
"e!ause prolonged re!overy times and redu!ed effi!ien!y and produ!tivity !ontri"ute to in!reased !ost of
surgi!al !are%
2(
&n addition/ patient satisfa!tion $ith their perioperative e;perien!e and .uality of re!overy
is improved $hen the anestheti! te!hni.ue !hosen for the pro!edure is asso!iated $ith a lo$ in!iden!e of
postoperative side effe!ts Se%g%/ pain/ di--iness/ heada!hes/ postoperative nausea and vomiting
*5ON:,T%
2(/22
Lor e;ample/ routine use of prophyla!ti! antiemeti! drugs during general anesthesia has
"een found to in!rease patient satisfa!tion in 0at ris#1 surgi!al populations%
2>
Lurthermore/ the use of lo!al
anestheti! infiltration and peripheral nerve "lo!#s de!reases postoperative pain after am"ulatory surgery
pro!edures irrespe!tive of the anestheti! te!hni.ue%
9/2?/2B
The time re.uired to a!hieve a state of home+readiness *0fitness1 for dis!harge home, is
influen!ed "y a $ide variety of surgi!al and anestheti! fa!tors%
6(/62
Ho$ever the ma<or !ontri"utors to
delays in dis!harge after am"ulatory surgery are nausea/ vomiting/ di--iness/ pain and prolonged
sympatheti! and/or motor "lo!#ade% Although the in!iden!e of 5ON: !an "e de!reased "y the use of
prophyla!ti! antiemeti! drugs/
2>
it remains a !ommon side effe!t after general anesthesia and prolongs
dis!harge after am"ulatory surgery%
2(/22
The primary fa!tors delaying dis!harge after spinal anesthesia
are re!overy from the residual motor "lo!#ade and sympatholyti! effe!ts of the su"ara!hnoid "lo!#/
!ontri"uting to delayed am"ulation and ina"ility to void% These side effe!ts !an "e minimi-ed "y the
use of so+!alled mini+dose lido!aine fentanyl spinal anestheti! te!hni.ues%
28/2'
Other !ommon !on!erns
$ith spinal anesthesia in!lude "a!# pain/ post+dural pun!ture heada!he and transient radi!ular
irritation $ith lido!aine%
66/68
Although MA7 is asso!iated $ith the lo$est in!iden!e of postoperative
side effe!ts/
2(/22
the possi"ility of transient nerve palsy is a !on!ern $hen peripheral nerve "lo!#
te!hni.ues are used%
6'/6=

The !ost savings $ith the use of ne$er general anestheti! te!hni.ues are lost if institutional
pra!ti!es mandate minimum lengths of stay in the 5hase 2 unit S5ostanesthesia !are unit *5A7U,T and
do not permit fast+tra!#ing of patients $ho emerge rapidly from anestheti! dire!tly to the 5hase 6
SDay+surgery *0step+do$n1,T unit% 7laims of redu!ed total !osts $ith earlier dis!harge are !ommonly
"ased on the assumption that there is a linear relationship "et$een the !osts of a servi!e and the time
spent providing it% Ho$ever/ sin!e personnel !osts are semi+fi;ed rather than varia"le/ an additional
2'+8( minute stay in the 5A7U may not "e asso!iated $ith in!reased !osts to the institution unless
the fa!ility is $or#ing at or near its !apa!ity%
6>
&n that situation/ a longer stay is potentially asso!iated
$ith a 0"ottlene!#1 in the flo$ of patients through the OR suites and re!overy areas/ re.uiring
overtime payments to the nurses and/or the hiring of additional perioperative personnel% There appears
to "e a mu!h !loser relationship "et$een lo$er !osts and "ypassing of the 5A7U *0fast+tra!#ing1,/ as
the ma<or fa!tor in re!overy !are !osts relates to the pea# num"er of patients admitted to the 5A7U
unit at any time%
6>
Last+tra!#ing !an lead to the use of fe$er nurses and a mi; of less highly trained/
lo$er $age nursing aides and fully+.ualified re!overy room nurses/ and redu!es 0overtime1 personnel
!osts for "usy am"ulatory surgery units% 4horter anesthesia times/ the a"ility to "ypass the 5A7U
10
*5hase 2,/ and a de!reased length of stay in the day+surgery *5hase 6, unit $ill redu!e total
institutional !osts%
6?
4tudies have demonstrated that 0fast+tra!#ing1 am"ulatory surgery patients
de!rease the times to a!tual dis!harge%
6B/8(
The !om"ination of lo$ !osts and high patient satisfa!tion suggests that the highest .uality
*!ost/out!ome, anestheti! may "e a!hieva"le $ith a MA7 te!hni.ue assuming that the surgi!al
pro!edure is amenda"le to this anestheti! approa!h *e%g%/ superfi!ial surgi!al and endos!opi!
pro!edures% Unfortunately/ many pharma!oe!onomi! studies have limited !ost !onsiderations to only
the a!.uisition !osts of the drugs and supplies rather than the total *dire!t U indire!t, e;penses
asso!iated $ith a given anestheti! te!hni.ue% The total !ost should in!lude "oth the a!.uisition !osts
of drugs and the la"or re.uired for managing side effe!ts *e%g%/ 5ON:/ pain/ dro$siness/ "ladder
dysfun!tion,% 4in!e personnel !osts !onstitute a ma<or proportion of e;penses in the OR and re!overy
areas/ anestheti! te!hni.ues $hi!h re.uire more time in the various phases of the perioperative
pro!ess $ill not surprisingly "e more e;pensive%
2(/22
The availa"ility of improved sedation and analgesia te!hni.ues to !omplement lo!al
anestheti! infiltration has in!reased the popularity of performing surgery utili-ing MA7 te!hni.ues%
82
The high patient satisfa!tion $ith lo!al anesthesia/sedation is also related to effe!tive !ontrol of
postoperative pain and the a"sen!e of side effe!ts asso!iated $ith the other !ommonly used general
and spinal anestheti! te!hni.ues% The su!!ess of MA7 te!hni.ues is dependent not only on the
anesthesiologist/ "ut also upon the s#ills of the surgeon in providing effe!tive infiltration analgesia
and gentle handling of the tissues during the intraoperative period% Ho!al anesthesia $ithout any
monitoring or intravenous ad<uvants *so+!alled 0unmonitored1 lo!al anesthesia,/ has "een su!!essfully
used in situations $here lo!al anesthesia is a"le to provide e;!ellent analgesia and patients do not
o"<e!t to "eing a$a#e and a$are of events in the operating room%
86
The importan!e of good surgi!al
s#ills is !riti!ally important "e!ause inade.uate intraoperative !ontrol of pain !an lead to prolonged
surgery times and patient dissatisfa!tion $ith their surgi!al e;perien!e% &n a prospe!tive/ randomi-ed
!omparison of lo!al infiltration $ith spinal and general anesthesia *88,/ surgeons in 4$eden suggested
the te!hni!al diffi!ulties and patient pain $ere 0more intense1 during surgery under lo!al anesthesia%
This finding is !onsistent $ith an earlier report "y Lair!lough et al %
89
Ho$ever/ $ith these surgi!al
provisions/ it is $idely a!!epted that superfi!ial surgi!al pro!edures !an "e performed as safely and
effe!tively under lo!al anesthesia as under any other form of anesthesia% &n fa!t/ the resear!hers in
4$eden !on!luded that 0for most patients/ lo!al anesthesia !an "e re!ommended as the standard
pro!edure for outpatient #nee arthros!opy1%
88
While most studies have suggested that lo!al anesthesia *e%g%/ lo!al infiltration and/or
peripheral nerve "lo!#s, are not only $ell+a!!epted "y patients and surgeons for superfi!ial outpatient
pro!edures *e%g%/ "reast surgery/ #nee arthros!opy/ anore!tal surgery/ and inguinal herniorrhaphy, "ut
is also more !ost+effe!tive than either spinal or general anesthesia/
2(/22/8'
some studies have suggested
that spinal anesthesia is more !ost+ effe!tive than general anesthesia%
'/>
These and other studies have
11
suggested that the use of smaller dosages of lido!aine *2'+8( mg, or "upiva!aine *8+= mg, !om"ined
$ith a potent opioid *e%g%/ fentanyl/ 26%'+6' g/ or sufentanil/ '+2( @g, !ontri"utes to a faster re!overy
of "oth motor and "ladder fun!tion than !onventional doses of the lo!al anestheti! alone% Garlier
dis!harge after spinal anesthesia using the so+!alled mini+dose te!hni.ues $ill !learly improve its
!ost+effe!tiveness in the am"ulatory setting% Unfortunately/ side effe!ts su!h as pruritis and nausea are
in!reased even $hen small doses of fentanyl *or sufentanil, are administered into the su"ara!hnoid
spa!e%
2'
Gven though !entral neuroa;ial "lo!#s !an "e made more !ost+effe!tive "y using smaller
doses of short+a!ting lo!al anestheti!s !om"ined $ith potent opioid analgesi!s/ use of MA7
te!hni.ues for superfi!ial *non+!avitary, am"ulatory surgery pro!edures $ill result in the shortest
times to home readiness/ lo$est pain s!ores at dis!harge/ and smallest in!remental !osts $hen
!ompared to "oth spinal and general anesthesia%
2(/22
Therefore/ in situations $here fast+tra!#ing is
permitted/ the use of MA7 te!hni.ues $ould appear to offer signifi!ant advantages over "oth !entral
neuroa;is "lo!#s *i%e%/ spinal/epidural, and general anestheti! te!hni.ues%
The availa"ility of more rapid and shorter+a!ting intravenous and inhaled anestheti!s/
analgesi!s and ad<un!tive drugs/ as $ell as improved !ere"ral monitoring !apa"ilities/ has fa!ilitated
the re!overy pro!ess after general anesthesia% Lor e;ample/ studies involving the use of 0light1
general anestheti! te!hni.ues $ith a laryngeal mas# air$ay devi!e and lo!al analgesia have
demonstrated that outpatients undergoing superfi!ial surgi!al pro!edures *e%g%/ hernia repair/ "reast
surgery, are a"le to am"ulate $ithin 8( min and !an "e dis!harged home in less than =( min after
!ompletion of their operation *8=+8?,% When tra!heal intu"ation is re.uired Se%g%/ laparos!opi!
pro!edures/ ris# fa!tors for aspiration *e%g%/ dia"eti!s/ mor"idly o"ese/ esophageal dysfun!tion,T/ use
of minimal/ effe!tive doses of ne$er short+a!ting opioid analgesi!s *e%g%/ remifentanil, and
sympatholyti! *e%g%/ esmolol, drugs !an fa!ilitate the early re!overy pro!ess and allo$ patients to
a!hieve earlier dis!harge times after am"ulatory surgery%
8B+96
The use of the more !ostly drugs !an "e
e!onomi!ally <ustified if improvements in re!overy and $or# patterns !an "e demonstrated%
98
Ho$ever/ anestheti! pra!ti!es have advan!ed to the point $here !ost savings from variations in drug
use are only apparent $hen system+$ide improvements are made in the effi!a!y of resour!e
utili-ation *in!luding personnel/ spa!e/ time/ !onsuma"les and !apital investments,%
99
Fa$'.'racki"( co"cep'$
Am"ulatory anesthesia is administered $ith the dual goals of rapidly and safely esta"lishing
satisfa!tory !onditions for the performan!e of therapeuti! or diagnosti! pro!edures $hile ensuring a
rapid/ predi!ta"le re!overy $ith minimal postoperative se.uelae% &f the !areful titration of short+a!ting
drugs permits a safe transfer of patients dire!tly from the operating room suite to the less la"or+
intensive re!overy area $here the patient !an "e dis!harged home $ithin one hour after surgery/
signifi!ant !ost savings to the institution !an "e a!hieved%
99
Jypassing the 5hase & re!overy *i%e%/
12
5A7U, has "een termed 0fast+tra!#ing1 after am"ulatory surgery%
9'
&n addition/ fast+tra!#ing !an also
"e a!!omplished dire!tly from the 5A7U "y !reating a spe!iali-ed area $here re!overy pro!edures
are organi-ed along the lines of a step+do$n unit%
9=
The !riteria used to determine fast+tra!# eligi"ility
has "een made even more stringent than the standard 5A7U dis!harge !riteria in order to redu!e the
need for interventions in areas $ith less nursing personnel% The use of anestheti! te!hni.ues
asso!iated $ith a more rapid re!overy $ill result in fe$er patients remaining deeply sedated in the
early postoperative period
8(/9?
/ de!rease the ris# for air$ay o"stru!tion and !ardiorespiratory
insta"ility/ and redu!e the num"er of nursing interventions%
9B
Jy redu!ing the need for 0intensive1
nursing !are in the early postoperative period using anestheti! te!hni.ues asso!iated $ith a faster
emergen!e from anesthesia/ a $ell+organi-ed fast tra!#ing program !an permit an institution to use
fe$er nurses in the re!overy areas and leads to signifi!ant !ost savings%
'(
The fast+tra!# !on!ept is
gaining $ider a!!eptan!e throughout the $orld%
'2
Gven elderly outpatients !an "e fast+tra!#ed after
general anesthesia if short+a!ting drugs are utili-ed%
9B
&mproved titration of anestheti! drugs using GGG+"ased !ere"ral monitors *e%g%/ "ispe!tral
inde; SJ&4T/ physi!al state inde; S54&T/ auditory+evo#ed potential SAG5T/ and entropy, !an lead to a
faster emergen!e from anesthesia and !an "e useful in predi!ting fast+tra!# eligi"ility%
'9
Although the
early studies involving propofol and the ne$er volatile anestheti!s sevoflurane and desflurane
'8
/
suggested that the anestheti!+sparing effe!t !ould fa!ilitate a faster emergen!e from anesthesia/ these
studies failed to demonstrate a de!rease in the times to dis!harge home "e!ause standard re!overy
pra!ti!es $ere used% Ho$ever/ if outpatients are allo$ed to re!over via a fast+tra!# path$ay/ use of
!ere"ral monitoring !an a!tually redu!e dis!harge times%
''
While the availa"ility of more rapid and shorter+a!ting anestheti! drugs *e%g%/ propofol/
sevoflurane/ desflurane/ remifentanil, has !learly fa!ilitated the early re!overy pro!ess after general
anesthesia/

the preemptive use of non+opioid analgesi!s *e%g%/ lo!al anestheti!s/ #etamine/
nonsteroidal antiinflammatory drugs/ 7OV+6 inhi"itors/ a!etaminophen,
'=
and antiemeti!s *e%g%/
droperidol/ meto!lopramide/ '+HT
8
antagonists/ de;amethasone,
'>
/ $ill redu!e postoperative side
effe!ts and a!!elerate "oth the immediate and late re!overy phases after am"ulatory surgery%
M)l'i*odal approache$ 'o preve"'i"( po$'opera'ive co*plica'io"$
As more !omple; pro!edures are performed utili-ing minimally+invasive surgi!al approa!hes
*e%g%/ laparos!opi! adrenale!tomy/ arthros!opi! #nee and shoulder re!onstru!tions,/ the a"ility to
effe!tively !ontrol postoperative side effe!ts may ma#e the differen!e "et$een performing a given
pro!edure on an inpatient or am"ulatory "asis% Lor routine antiemeti! prophyla;is/ the most !ost+
effe!tive !om"ination !onsists of lo$+dose droperidol *(%'+2 mg, and de;amethasone *9+? mg,%
'?
&nterestingly/ de;amethasone appears to fa!ilitate an earlier dis!harge independent of its effe!ts on
5ON:%
'B/=(
Outpatients at high ris# of 5ON: $ill "enefit from the addition of a '+HT
8
antagonist
*e%g%/ ondansetron/ dolasetron/ granisetron,
=2/=6
or an a!ustimulation devi!e *e%g%/ 4eaJand

/
13
ReliefJand

,%
=8/=9
Droperidol remains the most !ost+efffe!tive antiemeti! assuming side effe!ts !an "e
avoided%
='/==
Although !ontroversy e;ists regarding its potential for !ardia! arrhythmias/ droperidol
has remained a safe and effe!tive antiemeti! for over 8( years%
=>
An aggressive multimodal approa!h
to minimi-e 5ON: !an improve the re!overy pro!ess and enhan!e patient satisfa!tion%
=?
&n addition to
utili-ing !om"ination antiemeti! therapy/ simply insuring ade.uate hydration $ill minimi-e nausea
and other side effe!ts *e%g%/ di--iness/ dro$siness/ thirst, during the postoperative period%
=B
A multimodal *or 0"alan!ed1, approa!h to providing postoperative analgesia is also essential
in the am"ulatory setting%
>(+>6
Not surprisingly/ pain has "een found to "e a ma<or fa!tor !ompli!ating
re!overy and delaying dis!harge after am"ulatory surgery%
>8
The addition of lo$+dose #etamine *>'+
2'( g/#g, to a multimodal analgesi! regimen improved postoperative analgesia and fun!tional
out!ome after painful orthopedi! surgery pro!edures%
>9/>'
Lollo$ing outpatient surgery/ pain must "e
!ontrolla"le $ith oral analgesi!s *e%g%/ a!etaminophen/ i"uprofen/ a!etaminophen $ith !odeine, "efore
patients are dis!harged from the fa!ility% Although the potent rapid+a!ting opioid analgesi!s *e%g%/
fentanyl/ sufentanil, are !ommonly used to treat moderate+to+severe pain in the early re!overy period/
these !ompounds in!rease the in!iden!e of 5ON: and may !ontri"ute to a delayed dis!harge after
am"ulatory surgery%
'=/>8
As a result of the !on!erns regarding opioid+related side effe!ts/ there has
"een an in!reased interest in the use of potent non+steroidal anti+inflammatory agents *e%g%/ di!lofena!/
#etorola!,/ $hi!h !an effe!tively redu!e the re.uirements for opioid+!ontaining oral analgesi!s after
am"ulatory surgery/ and !an lead to an earlier dis!harge home%
>=
Other less e;pensive oral non+
steroidal analgesi!s *e%g%/ i"uprofen/ napro;en,
>>/>?
may "e a!!epta"le alternatives to fentanyl and the
parenteral non+sele!tive N4A&Ds if administered in a pre+emptive fashion% Re!ently/ premedi!ation
$ith the 7OV+6 inhi"itors *e%g%/ !ele!o;i"/ rofe!o;i"/ valde!o;i"/ pare!o;i", has "e!ome more
popular "e!ause they are devoid of potential adverse effe!ts on platelet fun!tion%
>B
Lor routine !lini!al
use/ oral premedi!ation $ith rofe!o;i" *'( mg,/ !ele!o;i" *9(( mg, or valde!o;i" *9( mg, is a simple
and !ost+effe!tive approa!h to improving pain !ontrol and de!reased dis!harge times after am"ulatory
surgery%
?(+?9
The in<e!ta"le 7OV+6 inhi"itor/ pare!o;i"/ may prove useful in the future%
?'/?=
Linally/
a!etaminophen is a very !ost+effe!tive alternative to the 7OV+6 inhi"itors if it !an "e given in a high
enough dose *9(+=( mg/#g po or pr, prior to the end of surgery%
?>/??

One of the #eys to fa!ilitating the re!overy pro!ess is the routine use of lo!al anestheti!s as
part of a multimodal regimen%
'=
Use of lo!al anestheti! te!hni.ues for intraoperative analgesia during
MA7/ as $ell as ad<un!ts to general *and spinal, anesthesia/ !an provide e;!ellent analgesia during
the early postoperative re!overy and postdis!harge periods%
9/2?/2B
Gven simple $ound infiltration and
instillation te!hni.ues have "een sho$n to improve postoperative analgesia follo$ing a variety of
lo$er a"dominal/ peripheral e;tremity and even laparos!opi! pro!edures% A $ide variety of peripheral
e;tremity "lo!#s have also "een utili-ed to minimi-e postoperative pain%
?B/B(
More re!ently/ use of
!ontinuous lo!al anestheti! delivery systems *e%g%/ &+Llo$, have "een found to improve pain !ontrol
14
after ma<or am"ulatory orthopedi! surgery "y e;tending periopheral nerve "lo!#s%
B2+B8
5atient+
!ontrolled lo!al anestheti! delivery has also "een des!ri"ed for improving pain relief after dis!harge
home%
B9
Lollo$ing laparos!opi! pro!edures/ a"dominal pain !an also "e minimi-ed "y the use of a
lo!al anesthesia at the portals and topi!ally applied at the surgi!al site%
B'/B=
4houlder pain is also
!ommon follo$ing laparos!opi! surgery/ and this has "een reported to "e redu!ed $ith
su"diaphragmati! instillation of lo!al anestheti! solutions%
B'
Lollo$ing arthros!opi! #nee surgery/
instillation of 8( ml of "upiva!aine (%') into the <oint spa!e redu!es postoperative opiate
re.uirements and permits earlier am"ulation and dis!harge%
B=
The addition of morphine *2+6 mg,/
#etorola! *2'+8( mg,/ !lonidine *(%2+(%6 mg, and/or triam!inolone *2(+6( mg, to the intraarti!ular
lo!al anestheti! solution !an further redu!e pain after arthros!opi! surgery%
B>+BB
Gle!troanalgesia !an
also "e used as part of a multimodal treatment regimen%
2((
Luture gro$th in the !omple;ity of surgi!al
pro!edures "eing performed on an am"ulatory "asis $ill re.uire further improvements in our a"ility
to provide effe!tive postoperative pain relief outside the surgi!al fa!ility *e%g%/ su"!utaneous opioid
57A/ patient+!ontrolled lo!al anesthesia $ith a disposa"le infusion system/ trans!utaneous analgesi!
delivery systems,%
S)**ar+
Am"ulatory anesthesia has "e!ome re!ogni-ed as an anestheti! su"spe!ialty/ $ith the
institution of formal postgraduate training programs% G;pansion of the spe!ialty of am"ulatory
anesthesia and surgery is li#ely to !ontinue $ith the gro$th in minimally+invasive *so+!alled #eyhole,
surgi!al pro!edures% The rate of e;pansion of am"ulatory anesthesia $ill pro"a"ly vary depending
upon lo!al needs/ the level of an!illary home health!are servi!es/ and e!onomi! !onsiderations *2(2,%
Many re!ently developed drugs have pharma!ologi!al profiles $hi!h are ideally suited for use in the
am"ulatory setting% Use of ne$er anestheti! and analgesi! drugs *e%g%/ desflurane/ sevoflurane/
remifentanil/ pare!o;i", and "rain monitoring systems *e%g%/ J&4/ 54A/ and AG5 devi!es, should
fa!ilitate fast+tra!#ing in the am"ulatory setting/ leading to an early dis!harge after most surgery
pro!edures $ithout !ompromising patient safety% To maintain the high level of patient safety/
mandatory a!!reditation and !redentialing pro!edures are needed for "oth hospital+"ased and free+
standing am"ulatory surgery fa!ilities%
2(6
Given the !hanging pattern of health !are reim"ursement/ it is in!um"ent upon all pra!titioners to
!arefully e;amine the impa!t of ne$ drugs and devi!es on the .uality of am"ulatory anesthesia !are
they are providing to the patient% Luture studies on ne$ drugs and te!hni.ues for am"ulatory
anesthesia need to fo!us not only on su"<e!tive improvements for the patient during the immediate
perioperative period/ "ut also on the overall !ost+effe!tiveness of the !are "eing provided%
6?
These
studies must !ompare the in!reased !ost of ne$er treatments $ith the potential finan!ial savings
15
resulting from earlier dis!harge home/ redu!ed !onsumption of supplemental drugs/ improvements in
patient satisfa!tion/ and perhaps most importantly/ resumption of normal a!tivity% The future
!hallenge that all pra!titioners must fa!e is to provide high+.uality am"ulatory anesthesia !are for
more !omple; surgi!al pro!edures performed in a $ide variety of venues% Linally/ the need to
administer the most !ost+effe!tive anestheti! te!hni.ue for a given am"ulatory surgery pro!edure $ill
li#ely assume in!reased importan!e in the future%
Re,ere"ce$
2% White 5L *Gditor,% Am"ulatory anesthesia and surgery W%J% 4aunders 5u"lishers/ Hondon% 2BB>W pp% 2+B2?%
6% 5atel NP/ Llash"urg MH/ 5as#in 4/ Grossman R% A regional anestheti! te!hni.ue !ompared to general anesthesia for outpatient #nee
arthros!opy% Anesth Analg 2B?=W ='N 2?'+>%
8% Qoung D:% 7omparison of lo!al/ spinal/ and general anesthesia for inguinal herniorrhaphy% Am P 4urg 2B?>W 2'8N '=(+8%
9% Tvers#oy M/ 7o-a!ov 7/ Aya!he M/ et al% 5ostoperative pain after inguinal herniorrhaphy $ith different types of anesthesia% Anesth
Analg 2BB(W >(N 6B+8'%
'% Pan#o$s#i 7P/ He"l PR/ 4tuart MP/ et al% A !omparison of psoas !ompartment "lo!# and spinal and general anesthesia for outpatient
#nee arthros!opy% Anesth Analg 6((8W B>N 2((8+B%
=% Lleis!her M/ Marini 75/ 4tatman R/ et al% Ho!al anesthesia is superior to spinal anesthesia for anore!tal surgi!al pro!edures% Am 4urg
2BB9W =(N ?26+'%
>% 7hilvers 7R/ Good$in A/ :aghadia H/ Mit!hell GW% 4ele!tive spinal anesthesia for outpatient laparos!opyN 5harma!oe!onomi!
!omparison vs general anesthesia% 7an P Anaesth 6((2W 9?N 6>B+?8%
?% Williams 7R/ Thomas N5% A prospe!tive trial of lo!al versus general anaesthesia for arthros!opi! surgery of the #nee% Ann R 7oll
4urg Gngl 2BB>W >BN 89'+?%
B% 7oloma M/ 7hiu PW/ White 5L/ et alN Last+tra!#ing after immersion lithotripsyN general anesthesia versus monitored anesthesia !are%
Anesth Analg 6((( B2N B6+=%
2(% Hi 4/ 7oloma M/ White 5L/ et al% 7omparison of the !osts and re!overy profiles of three anestheti! te!hni.ues for am"ulatory
anore!tal surgery% Anesthesiology 6(((W B8N 266'+8(%
22% 4ong D/ Greili!h NJ/ White 5L/ et al% Re!overy profiles and !osts of anesthesia for outpatient unilateral inguinal herniorrhaphy%
Anesth Analg 6(((W B2N ?>=+?2%
26% Mulroy ML/ Har#in IH/ Hodgson 54/ et al% A !omparison of spinal/ epidural/ and general anesthesia for outpatient #nee arthros!opy%
Anesth Analg 6(((W B2N ?=(+9%
28% Jen+David J/ Maryanovs#y M/ Gurevit!h A/ et al% A !omparison of minidose lido!aine+fentanyl and !onventional+dose lido!aine
spinal anesthesia% Anesth Analg 6(((W B2N ?='+>(%
29% Williams JA/ Ientor MH/ Williams P5/ et al% 5ro!ess analysis in outpatient #nee surgeryN Gffe!t of regional and general anesthesia on
anesthesia+!ontrolled time% Anesthesiology 6(((W B8N '6B+8?%
2'% Jen+David J/ DeMeo 5P/ Hu!y# 7/ 4olos#o D% A !omparison of minidose lido!aine+fentanyl spinal anesthesia and lo!al
anesthesia/propofol infusion for outpatient #nee arthros!opy% Anesth Analg 6((2 B8N 82B+6'%
2=% Iehlet H/ White 5L% SGditorialT Optimi-ing anesthesia for inguinal herniorrhaphy A general regional or lo!al anesthesiaO Anesth Analg
6((2W B8N 28=>+B%
2>% White 5L/ Wat!ha ML SGditorialTN 5ostoperative nausea and vomitingN prophyla;is versus treatment% Anesth Analg 2BBBW ?BN 288>+B%
2?% Harrison 7A/ Morris 4/ Harvey P4% Gffe!t of ilioinguinal and iliohypogastri! nerve "lo!# and $ound infiltration $ith (%')
"upiva!aine on postoperative pain after hernia repair% Jr P Anaesth 2BB9W >6N =B2+8%
2B% Ding Q/ White 5L% 5ost+herniorrhaphy pain in outpatients after pre+in!ision ilioinguinal+hypogastri! nerve "lo!# during monitored
anaesthesia !are% 7an P Anaesth 2BB'W 96N 26+'%
6(% Tong D/ 7hung L/ Wong D% 5redi!tive fa!tors in glo"al and anesthesia satisfa!tion in am"ulatory surgi!al patients% Anesthesiology
2BB>W ?>N ?'=+=9%
62% Marshall 4&/ 7hung L% Dis!harge !riteria and !ompli!ations after am"ulatory surgery% Anesth Analg 2BBBW ??N '(?+2>%
66% 5ollo!# PG/ Neal PM/ 4tephenson 7A/ Wiley 7G% 5rospe!tive study of the in!iden!e of transient radi!ular irritation in patients
undergoing spinal anesthesia% Anesthesiology 2BB=W ?9N 28=2+>%
68% Halpern 4/ 5reston R% 5ostdural pun!ture heada!he and spinal needle design% Metaanalyses% Anesthesiology 2BB9W ?2N 28>=+?8%
69% :lo#a PD/ Had-i! A/ Mul!are R/ et al% Lemoral and genitofemoral nerve "lo!#s versus spinal anesthesia for outpatients undergoing
long saphenous vein stripping surgery% Anesth Analg 2BB>W ?9N >9B+'6%
6'% 5ri!e R% Transient femoral nerve palsy !ompli!ating preoperative ilioinguinal nerve "lo!#ade for inguinal herniorrhaphy% Jr P 4urg
2BB'W ?6N 28>+?%
6=% Rosario DP/ 4#inner 55/ Raftery AT% Transient femoral nerve palsy !ompli!ating preoperative ilioinguinal nerve "lo!#ade for inguinal
herniorrhaphy% Jr P 4urg 2BB9W ?2N ?B>%
6>% De;ter L/ Tin#er PHN Analysis of strategies to de!rease postanesthesia !are unit !osts% Anesthesiology 2BB'W ?6N B9+2(2%
6?% Wat!ha ML/ White 5L% G!onomi!s of anestheti! pra!ti!e% Anesthesiology 2BB>W ?=N 22>(+B=%
16
6B% 7oloma M/ 7hiu PW/ White 5L/ Arm"ruster 47% The use of esmolol as an alternative to remifentanil during desflurane anesthesia for
fast+tra!# outpatient gyne!ologi! laparos!opy surgery% Anesth Analg 6((2W B6N 8'6+>%
8(% 7oloma M/ Rhou T/ White 5L/ Lorestner PGN Last+tra!#ing after outpatient laparos!opyN reasons for failure after propofol/ sevoflurane
and desflurane anesthesia% Anesth Analg 6((2W B8N 226+'%
82% 4a Rego MM/ Wat!ha ML/ White 5L% The !hanging role of monitored anesthesia !are in the am"ulatory setting% Anesth Analg 2BB>W
?'N 2(6(+8=%
86% 7alleson/ Je!h T/ Iehlet H% One+thousand !onse!utive inguinal hernia repairs under unmonitored lo!al anesthesia% Anesth Analg
6((2W B8N 28>8+=%
88% Pa!o"son G/ Lorss"lad M/ Rosen"erg P/ et al% 7an lo!al anesthesia "e re!ommended for routine use in ele!tive #nee arthros!opyO A
!omparison "et$een lo!al/ spinal/ and general anesthesia% Arthros!opy 6(((W 2=N 2?8+B(%
89% Lair!lough PA/ Graham G5/ 5em"erton D% Ho!al or general anaestheti! in day+!ase arthros!opyO Ann R 7oll 4urg Gngl 2BB(W >6N 2(9+
>%
8'% Trieshmann HW% Inee arthros!opyN a !ost analysis of general and lo!al anesthesia% Arthros!opy 2BB=W 26N =(+8%
8=% Tang P/ 7hen H/ White 5L/ et al% Use of propofol for offi!e+"ased anesthesiaN effe!t of nitrous o;ide on re!overy profile% P 7lin
Anesth2BBB 22N 66=+8(%
8>% Tang P/ 7hen H/ White 5L/ et al% Re!overy profile/ !osts/ and patient satisfa!tion $ith propofol and sevoflurane for fast+tra!# offi!e+
"ased anesthesia% Anesthesiology 2BBBW B2N 6'8+6=2%
8?% Tang P/ White 5L/ Wender RH/ et al% Last+tra!# offi!e+"ased anesthesiaN a !omparison of propofol versus desflurane $ith antiemeti!
prophyla;is in spontaneously "reathing patients% Anesth Analg 6((2W B6N B'+B%
8B% 4ong D/ White 5LN Remifentanil as an ad<uvant during desflurane anesthesia fa!ilitates early re!overy after am"ulatory surgery% P 7lin
Anesth 2BBBW 22N 8=9+>%
9(% 4ong D/ Whitten 7W/ White 5LN Remifentanil infusion fa!ilitates early re!overy for o"ese outpatients undergoing laparos!opi!
!hole!yste!tomy% Anesth Analg 6(((W B(N 2222+8%
92% 7oloma M/ 7hiu PW/ White 5L/ Arm"ruster 47N The use of esmolol as an alternative to remifentanil during desflurane anesthesia for
fast+tra!# outpatient gyne!ologi! laparos!opi! surgery% Anesth Analg 6((2W B6N 8'6+>%
96% White 5L/ Wang J/ Tang P/ et alN Gffe!t of intraoperative use of esmolol and ni!ardipine on re!overy after am"ulatory surgery% Anesth
Analg 6((8W B>N2=88+?%
98% Gger G&/ White 5L/ Joget- M4% 7lini!al and e!onomi! fa!tors important to anestheti! !hoi!e for day+!ase surgery%
5harma!oe!onomi!s 6(((W 2>N 69'+=6%
99% De;ter L/ Mar!ario A/ Man"erg 5P/ Hu"ars#y DA% 7omputer simulation to determine ho$ rapid anestheti! re!overy proto!ols to
de!rease the time for emergen!e or in!rease the phase & postoperative !are unit "ypass rate affe!t staffing of an am"ulatory surgery
!enter% Anesth Analg 2BBBW ??N 2('8+=8%
9'% Wat#ins A7/ White 5LN Last+tra!#ing after am"ulatory surgery% P 5erianesth Nurs 6((2W 2=N 8>B+?>%
9=% White 5L/ Ra$al 4/ Nguyen P/ Wat#ins AN 5A7U fast+tra!#ingN an alternative to 0"ypassing1 the 5A7U for fa!ilitating the re!overy
pro!ess after am"ulatory surgery% P 5eriAnesth Nurs 6((8W 2?N 69>+'8%
9>% White 5L/ 4ong DN Ne$ !riteria for fast+tra!#ing after outpatient anesthesiaN a !omparison $ith the modified Aldrete3s s!oring system%
Anesth Analg 2BBBW ??N 2(=B+>6%
9?% 4ong D/ Poshi G5/ White 5L% Last+tra!# eligi"ility after am"ulatory anesthesiaN A !omparison of desflurane/ sevoflurane/ and propofol%
Anesth Analg 2BB?W ?=N 6=>+>8%
9B% Lredman J/ 4heffer O/ Rohar G/ et al% Last+tra!# eligi"ility of geriatri! patients undergoing short urologi! surgery pro!edures% Anesth
Analg 6((6W B9N '=(+9%
'(% Apfel"aum PH/ Wala$ander 7A/ Grasela TH/ et al% Gliminating intensive postoperative !are in same+day surgery patients using short+
a!ting anestheti!s% Anesthesiology 6((6W B>N ==+>9%
'2% Dun!an 5G/ 4handro P/ Ja!hand R/ Ains$orth H% A pilot study of re!overy room "ypass *0fast+tra!# proto!ol1, in a !ommunity
hospital% 7an P Anaesth 6((2W 9?N =8(+=%
'6% Gan TP/ Glass 54/ Windsor A/ et al% Jispe!tral inde; monitoring allo$s faster emergen!e and improved re!overy from propofol/
alfentanil/ and nitrous o;ide anesthesia% Anesthesiology 2BB>W ?>N ?(?+2'%
'8% 4ong D/ Poshi G5/ White 5L% Titration of volatile anestheti!s using "ispe!tral inde; fa!ilitates re!overy after am"ulatory anesthesia%
Anesthesiology 2BB>W ?>N ?96+?%
'9% 4ong D/ :an :lymen P/ White 5L% &s the "ispe!tral inde; useful in predi!ting fast+tra!# eligi"ility after am"ulatory anesthesia $ith
propofol and desfluraneO Anesth Analg 2BB?W ?>N 269'+?%
''% White 5L/ Ma H/ Tang P/ et alN Does the use of ele!troen!ephalographi! "ispe!tral inde; or auditory evo#ed potential inde; monitoring
fa!ilitate re!overy after desflurane anesthesia in the am"ulatory settingO Anesthesiology 6((9W 2((N ?22+>%
'=% White 5LN The role of non+opioid analgesi! te!hni.ues in the management of pain after am"ulatory surgery% Anesth Analg 6((6W B9N
'>>+?'%
'>% White 5L/ Wat!ha ML% 5ostoperative nausea and vomitingN 5rophyla;is versus treatment% Anesth Analg 2BBBW ?BN 288>+B%
'?% Tang P/ 7hen V/ White 5L/ et al% Antiemeti! prophyla;is for offi!e+"ased surgeryN are the '+HT8 re!eptor antagonists "enefi!ialO
Anesthesiology 6((8W B?N 6B8+6B?%
'B% 7oloma M/ Duffy HH/ White 5L/ et al% De;amethasone fa!ilitates dis!harge after outpatient anore!tal surgery% Anesth Analg 6((2W B6N
?'+?%
=(% 7oloma M/ White 5L/ Mar#o$it- 4D/ et al% De;amethasone in !om"ination $ith dolasetron for prophyla;is in the am"ulatory settingN
effe!t on out!ome after laparos!opi! !hole!yste!tomy% Anesthesiology 6((6W B=W 289=+'(%
17
=2% Tang P/ Wang J/ White 5L/ et alN Gffe!t of timing of ondansetron administration on its effi!a!y/ !ost+effe!tiveness/ and !ost+"enefit as
a prophyla!ti! antiemeti! in the am"ulatory setting% Anesth Analg 2BB?W ?=N 6>9+?6%
=6% Rarate G/ Wat!ha ML/ White 5L/ et al% A !omparison of the !osts and effi!a!y of ondansetron versus dolasetron for antiemeti!
prophyla;is% Anesth Analg 6((( B(N 28'6+?%
=8% RErate G/ Mingus M/ White 5L/ et al% The use of trans!utaneous a!upoint ele!tri!al stimulation for preventing nausea and vomiting
after laparos!opi! surgery% Anesth Analg 6((2W B6N =6B+8'%
64. White 5L/ &ssioui T/ Hu P/ et al% 7omparative effi!a!y of a!ustimulation *ReliefJand

, versus ondansetron *Rofran

, in !om"ination
$ith droperidol for preventing nausea and vomiting% Anesthesiology 6((6N B>N2(>'+?2%
='% Tang P/ Wat!ha ML/ White 5LN A !omparison of !osts and effi!a!y of ondansetron and droperidol as prophyla!ti! antiemeti! therapy
for outpatient pro!edures% Anesth Analg 2BB=W ?8N 8(9+28%
==% Hill R5/ Hu"ars#y DA/ 5hillips+Jute J/ et al% 7ost+effe!tiveness of prophyla!ti! antiemeti! therapy $ith ondansetron/ droperidol/ or
pla!e"o% Anesthesiology 6(((W B6N B'?+=>%
=>% White 5LN DroperidolN A !ost+effe!tive antiemeti! for over thirty years% Anesth Analg 6((6W B'N >?B+B(%
=?% 4!uderi 5G/ Pames RH/ Harris H/ Mimms GR% Multimodal antiemeti! management prevents early postoperative vomiting after
outpatient laparos!opy% Anesth Analg 6(((W B2N 29(?+29%
=B% Qogendran 4/ Aso#umar J/ 7heng D/ 7hung L% A prospe!tive/ randomi-ed dou"le+"lind study of the effe!t of intravenous fluid
therapy on adverse out!omes after outpatient surgery% Anesth Analg 2BB'W ?(N =?6+=%
>(% Iehlet HN 5ostoperative pain relief A What is the issueO SGditorialT Jr P Anaesth 2BB9W >6N8?>+9(%
>2% Gri#sson H/ Tenhunen A/ Iorttila IN Jalan!ed analgesia improves re!overy and out!ome after outpatient tu"al ligation% A!ta Anaesth
4!and 2BB=W 9(N 2'2+'%
>6% Mi!halolia#ou 7/ 7hung L/ 4harma 4N 5reoperative multimodal analgesia fa!ilitates re!overy after am"ulatory laparos!opi!
!hole!yste!tomy% Anesth Analg 2BB=W ?6N 99+'2%
>8% 5avlin DP/ 7hen 7/ 5enalo-a DA/ et al% 5ain as a fa!tor !ompli!ating re!overy and dis!harge after am"ulatory surgery% Anesth Analg
6((6W B'N =6>+89%
>9% Menigau; 7/ Guignard J/ Llet!her D/ et al% &ntraoperative small+dose #etamine enhan!es analgesia after outpatient #nee arthros!opy%
Anesth Analg 6((2W B8N =(=+26%
>'% Menigau; 7/ Llet!her D/ Dupont V/ et al% The "enefits of intraoperative small+dose #etamine on postoperative pain after anterior
!ur!iate ligament repair% Anesth Analg 6(((W B(N 26B+8'%
>=% 7oloma M/ White 5L/ Hu"er 5P/ et alN Gffe!t of #etorola! on re!overy after anore!tal surgeryN &ntravenous vs lo!al administration%
Anesth Analg 6(((W B(N 22(>+2(%
>>% Rosen"lum M/ Weller R4/ 7onrad 5H/ et alN &"uprofen provides longer lasting analgesia than fentanyl after laparos!opi! surgery%
Anesth Analg 2BB2W >8N 6''+B%
>?% Raeder P7/ 4teine 4/ :atsgar TT% Oral i"uprofen versus para!etamol plus !odeine for analgesia after am"ulatory surgery% Anesth
Analg 6((2W B6N 29>(+6%
>B% 4outer AP/ Lredman J/ White 5LN 7ontroversies in the perioperative use of nonsteroidal anti+inflammatory drugs% Anesth Analg
2BB9W >BN 22?>+B(%
?(% &ssioui T/ Ilein IW/ White 5L/ et al% The effi!a!y of premedi!ation $ith !ele!o;i" and a!etaminophen in preventing pain after
otolaryngologi! surgery% Anesth Analg 6((6W B9N 22??+B8
?2% &ssioui T/ Ilein IW/ White 5L/ et al% 7ost+effi!a!y of rofe!o;i" versus a!etaminophen for preventing pain after am"ulatory surgery%
Anesthesiology 6((6W B>N B82+>%
?6% Re!art A/ &ssioui T/ White 5L/ et alN The effi!a!y of !ele!o;i" premedi!ation on postoperative pain and re!overy times after
am"ulatory surgeryN a dose+ranging study% Anesth Analg 6((8W B=N 2=82+'%
?8% Wat!ha ML/ &ssioui T/ Ilein IW/ White 5LN 7osts and effe!tiveness of rofe!o;i"/ !ele!o;i" and a!etaminophen for preventing pain
after am"ulatory otolaryngologi! surgery% Anesth Analg 6((8N B=N B?>+B9%
?9% Ma H/ Tang P/ White 5L/ et al% 5erioperative rofe!o;i" improves early re!overy after outpatient herniorrhaphy% Anesth Analg 6((9W
B?N B>(+'%
?'% Tang P/ Hi 4/ White 5L/ et al% Gffe!t of pare!o;i"/ a novel intravenous !y!loo;ygenase+6 inhi"itor/ on the postoperative opioid
re.uirement and .uality of pain !ontrol% Anesthesiology 6((6W B=N 28('+B%
?=% Des<ardins 5P/ Grossman GH/ Iuss MG/ et al% The in<e!ta"le !y!loo;ygenase+6+spe!ifi! inhi"itor pare!o;i" sodium has analgesi!
effi!a!y $hen administered preoperatively% Anesth Analg 6((2W B8N >62+>%
?>% Rusy HM/ Hou!# 74/ 4ullivan HP/ et alN A dou"le+"lind evaluation of #etorola! versus a!etaminophen in pediatri! tonsille!tomyN
analgesia and "leeding% Anesth Analg 2BB'W ?(N 66=+B%
??% Iorpela R/ Ionveno<a 5/ Mereto<a OAN Morphine+sparing effe!t of a!etaminophen in pediatri! day+!are surgery% Anesthesiology
2BBBW B2N 996+>%
?B% Rit!hie GD/ Tong D/ 7hung L/ et al% 4upras!apular nerve "lo!# for postoperative pain relief in arthros!opi! shoulder surgeryN A ne$
modalityO Anesth Analg 2BB>W ?9N 28(=+26%
B(% Mulroy ML/ Har#in IH/ Jatra M4/ et al% Lemoral nerve "lo!# $ith (%6') or (%') "upiva!aine improves postoperative analgesia
follo$ing outpatient arthros!opi! anterior !ru!iate ligament repair% Reg Anesth 5ain Med 6((2W 6=N 69+B
B2% Grant 4A/ Nielsen I7/ Greengrass RA/ et al% 7ontinuous periopheral nerve "lo!# for am"ulatory surgery% Reg Anesth 5ain Med 6((2W
6=N 6(B+29%
B6% &llfeld JM/ Morey TG/ Wang RD/ Gnne#ing LI% 7ontinuous popliteal s!iati! nerve for postoperative pain !ontrol at home%
Anesthesiology 6((6W B>N B'B+='%
18
B8% White 5L/ &ssioui T/ 4#rivane# GD/ et al% Use of a !ontinuous popliteal s!iati! nerve "lo!# for the management of pain after ma<or
podiatri! surgeryN does it improve .uality of re!overyO Anesth Analg 6((8W B>N 28(8+B%
B9% Ra$al N/ A;elsson I/ Hylander P/ et alN 5ostoperative patient+!ontrolled lo!al anestheti! administration at home% Anesth Analg 2BB?W
?=N ?=+B%
B'% 5as.ualu!!i A/ de Angelis :/ 7ontardo R/ et al% 5reemptive analgesiaN &ntraperitoneal lo!al anestheti! in laparos!opi!
!hole!yste!tomy% A randomi-ed/ dou"le+"lind/ pla!e"o+!ontrolled study% Anesthesiology 2BB=W ?'N 22+6(%
B=% 4mith &/ 4hively RA/ White 5L% Gffe!ts of #etorola! and "upiva!aine on re!overy after outpatient arthros!opy% Anesth Analg 2BB6W >'N
6(?+26%
B>% 4tein 7/ 7omisel I/ Haimerl G/ et al% Analgesi! effe!t of intraarti!ular morphine after arthros!opi! #nee surgery% N Gngl P Med 2BB2W
86'N 2268+=%
B?% Reu"en 4/ 7onnelly NR% 5ostoperative analgesia for outpatient arthros!opi! #nee surgery $ith intraarti!ular !lonidine% Anesth Analg
2BBBW ??N >6B+88%
BB% Wang PP/ Ho 4T/ Hee 47/ et al% &ntraarti!ular triam!inolone a!etonide for pain !ontrol after arthros!opi! #nee surgery% Anesth Analg
2BB?W ?>N 2228+=
2((% White 5L/ Hi 4/ 7hiu PWN Gle!troanalgesiaN its role in a!ute and !hroni! pain management% Anesth Analg 6((2W B6N '('+28%
2(2% White 5LN Am"ulatory anesthesia advan!es into the ne$ millennium% Anesth Analg 6(((W B(N 2689+'%
2(6% Rohri!h RP/ White 5L% 4afety of outpatient surgeryN &s mandatory a!!reditation of outpatient surgery !enters enoughO 5lasti!
Re!onstr 4urg 6((2W 2(>N2?B+B6%
19