Peripheral Nerve Blocks for Outpatient Surgery

The rapid expansion of surgical case variety and complexity has resulted in the inability of GA to provide quality care for all ambulatory patients. This has been evidenced by frequent readmissions for pain and PONV. In contrast, the successes of ambulatory PNBs referenced in this chapter support their emerging role. For upper extremity procedures, the use of PNB has demonstrated improved analgesia, faster patient discharge readiness, and decreased opioid-related side effects compared with that for GA. For surgery involving lower extremity procedures of greater complexity the benefits of dense analgesia from PNB become more apparent. The use of lower extremity PNB appears to be critical to same-day discharge and lower rates of readmission in patients undergoing more invasive same-day surgery on the lower extremity. The use of multimodal analgesia with long-acting LA provides extended analgesic benefit. The addition of CPNB can significantly expand this benefit at home. However, the slow onset time associated with long-acting LA and the time needed to place continuous catheters can adversely affect ambulatory efficiency. Although effective strategies do exist to diminish this impact, timely administration of RA may still be challenging and represent an impediment to use in some institutions. Developing additional solutions to this obstacle will be important in broadening the use of PNB in the ambulatory population. Another potential impediment results from patient anxiety and apprehension regarding RA. Reassurance about the use of sedation for PNB placement and intraoperative course should alleviate this problem. Selection of appropriate patients for PNBs and CPNBs and detailed discharge instructions are important for continuing the track record of safety with these techniques. Ongoing positive patient experiences with RA will beget future successes. Whether ambulatory anesthesiologists will be prepared for this success remains to be determined. Improvements in residency training and intensive workshops for current practitioners will likely be necessary to keep up with future demand for outpatient PNBs.