Regional Anesthesia is Much

Better than General Anesthesia

Benefits of Peripheral Nerve Blocks
Improved post operative pain control
Less PONV
Earlier mobilization
Earlier discharge
Better patient satisfaction
Improved postoperative cognitive function
(less sedation)
 Less unanticipated hospital admission
Before We Go On….
 There may be safety concerns in dealing with neural
blockade.
 SAMBA survey published in 2002
 16% never or rarely discharged patients
1. Concern about patient injury
2. Inability to care for themselves
3. Preparation time
4. Physical logistics of placing the blocks
5. Unfamiliarity with techniques
But Should They Be Scared?
 Klein SM et al Anesth Analg.2002;94:65-70
 Retrospective study over 2300 patients received PNB
 7 (0.29%) had a persistent paresthesia that may have been related to
the block.
 All resolved over a period of <3m

 Hausman et al Journal of Clinical Anesthesia (2008) 22, 271–275

 123 with PNB of which 2 patients had nerve problems that resolved over
time
 1 patient with persistent paresthesias after an axillary block which
resolved within one week.
 1 with persistent femoral neuropathy after a femoral nerve block
resolved within 3 m
Back to the Advantages
Improved post operative pain control
Less PONV
Earlier mobilization
Earlier discharge
Better patient satisfaction
Improved postoperative cognitive function
(less sedation)
Less unanticipated hospital admission
 A Comparison of Infraclavicular Nerve Block versus
General Anesthesia for Hand and Wrist Day-case
Surgeries
Hadzic et al anesthesiology 2004;101:127-32
Infraclavicular nerve block vs. fast-track GENA
Criteria INB(25) GENA(25) P value

Pain score >3 3% 43% <0.001

Nausea/vomiting 8% 32% 0.001
Bypass PACU 79% 24% 0.001
Ambulation 82 min 145 min <0.001
Discharge Time 121 min 218 min <0.001
Repeat technique 81% 50% 0.05
(patient satisfaction)
Pain meds. 0 48% <0.001
For Outpatient Rotator Cuff Surgery, Nerve Block
Anesthesia Provides Superior Same-day Recovery over
General Anesthesia Hadzic A et al Anesthesiology 2005;102:1001-7
Interscalene vs .fast track GENA
ISB GA P value
Moderate to severe 0 16%(64) <0.001
pain VAS >3

Nausea 3% (12) 11%(44) 0.02

Vomiting 0 4%(16) 0.05
Ambulation min 84(+/-47) 234(+/-174) 0.001
Home readiness, min 113(+/-55) 270(+/-101) <0.001

Discharge time, min 123(+/-57) 286(+/-100) <0.001

Side effects, quality of pain control and patient satisfaction
Lower Extremities
 Hadzic et al Anesth. Analg 2005;100 :976-81 .
50 patients for outpatient knee arthroscopy.
PNB GA P value
VAS 0-2 84% 52% 0.02
VAS 3-7 12% 32%
VAS 8-10 4% 16%
Nausea 0.001
None 32% 15%
Mod-severe 12% 62%
Ondansetron 12% 60% 0.01
Home readiness t. 131(+/-62) 205(+/-94) 0.001
Discharge t. 162(+/-71) 226(+/-96) 0.002
Poor ability to 25% 56% 0.04
concentrate >8h postop
Unanticipated hospital admission
Hospital admission adds to expense of care and leads to
days of missed work
Most common anesthetic causes are PONV, somnolence,
laryngospasm, dizziness and aspiration
D’Alessio et al Reg Anesth. 1995 Jan-Feb;20(1):62-8
For ambulatory shoulder surgery
 8% of 263 patients receiving GA required unanticipated
admission
 No unanticipated admissions for interscalene block
What about Continuous
Catheters?
Continuous Infraclavicular Brachial Plexus Block for
Postoperative Pain Control at Home
Illfeld B. et al.Anesthesiology 2002;96:1297-1304
Average pain with movement
30 patients received
infraclavicular catheters and 6
5

Pain scale
4 ropivacaine
GA 3 placebo
2
Post-operatively: 1
0
0 1 2 3
15 received ropivacaine POD

Average pain at rest

0.2% at 8 ml/hr
4
15 received placebo 3.5
3

Pain scale
2.5
Infusion was maintained 2
1.5
1
for 3 days. 0.5
0
0 1 2 3
POD

Complications: There were no apparent local anesthetic

or catheter related complications during infusion
 Continuous Interscalene Analgesia for Ambulatory
Shoulder Surgery in a Private Practice Setting
Fredrickson et al. Reg Anesth Pain Med 2008;33:122-128.
300 patients received CISB and GA
Goals was to avoid postoperative narcotics
3 weeks follow-up
13 experienced inadequate pain relief
5 of required additional rescue ropivacaine
3 had catheter reinserted
5 succumbed to oral opioids
Fredrickson et al….
Complications:
1 required antibiotic treatment for catheter site infection
 Neurological sequelae
 Present in 3 patients at 3 weeks
 Remained in only 1 patient at 4 weeks

 All resolved by 6 months

Conclusion:
CISB had a high success rate (avoided use of potent
opioids in 98%)
Low complication rate
Feasibility in a Private Practice?
Essentials
Efficient and Safe
Appropriately trained personnel
 Anesthesiaproviders must be comfortable and
experienced with performing a variety of nerve blocks
Adequate space and personnel
 Area to perform blocks must include adequate monitoring

and personnel to monitor

Structured program and policies
 Appropriate policies, procedures and guidelines must be

in place which address patient instructions for discharge

and easy access for follow-up issues that may arise
Time Efficiency
Hausman et al Journal of Clinical Anesthesia (2008) 22, 271–27
Retrospective study of 238
patients
Time from anesthesia start to
surgery start
 MAC 19 ± 7 min
 PNB 29 ± 11 min
 GA 31 ± 11 min
Time from surgery end to
anesthesia end
 MAC 9 ± 3 min
 PNB 9 ± 3 min
 GA 12 ±4 min
Economic Outcome
Retrospective study of 948 patients undergoing ACL
reconstruction
 Williams B.et al.Anesthesiology 2004;100:697-706

Type of anesthesia:
GA (received ETT or LMA)
GA + nerve block for post op.pain.
Neuraxial anesthesia.
Neuraxial anesthesia with nerve block.
Nerve block only.
Results:
PACU Bypass
 153 patients received PNB-only
 144 of these patients bypassed PACU (94%)
 795 all other patients
 410 of them bypassed PACU (51%)
Patients who stayed in PACU were more likely to have pain,
needed more nursing interventions for management of pain
and PONV.
Unanticipated Hospital Admissions
 Of the 153 patients that received PNB-only, 5 were admitted
unexpectedly (3%)
 Of the 795 patients receiving other anesthetics, 58 were
admitted unexpedctedly (7.3%)
Unanticapted hospital admissions were due to issues with
pain, PONV, somnolence, or urinary retention
Results: (Dollars amount)
PACU bypass was associated with 12% hospital
cost reduction ($420/patient)
Hospital admission was associated with 11%
hospital cost increase ($385/patient)
Assuming that 100% of cases are done with nerve
blocks with PACU bypass rate of 94% and
unplanned admission rate of 3% applied for 3000
ambulatory orthopedic cases/year, estimated
savings will be:
1.2 million $