Regional anesthesia for outpatient orthopedic surgery

The constant search for increased efficiency and reduction of hospital length of stay has led to an increase number of major orthopedic procedures performed as outpatients and the increase in the associated intensity and duration of acute postoperative pain. Although, it is well established that single peripheral blocks provide adequate anesthesia and excellent immediate postoperative analgesia in patients undergoing minor ambulatory orthopedic surgery, the postoperative acute pain benefit is limited to less than 24 hours. However, many patients required over 24 hours of intensive postoperative analgesia. Furthermore the need for immediate postoperative physical therapy in orthopedics dictates that local anesthetics be chosen on the basis of their safety and ability to produce preferential sensory blocks. As early as 1946, Ansbro proposed the use of continuous nerve blocks to prolong the duration of analgesia of nerve block technique during anesthesia. Continuous nerve blocks have also been used for the acute postoperative pain control of patients undergoing major orthopedic surgery as in-patients. This technique has been proven to be safe and effective in controlling acute postoperative pain and improve functional outcome. The recent introduction of safer local anesthetics producing preferential sensory blocks along with the development of ambulatory pumps has allow to extend the use of these continuous block techniques to ambulatory patients. Recent development also included the use of cox2 inhibitors along with cold maximize postoperative analgesia. This multimodal approach has been proven to be safe and efficacious as much for resting pain than pain associated with exercise.