Best Practice & Research Clinical Anaesthesiology

Vol. 16, No. 2, pp. 145±157, 2002

doi:10.1053/bean.2002.0244, available online at http://www.idealibrary.com on

Outcome after regional anaesthesia in the

ambulatory setting ± is it really worth it?

Karen C. Nielsen MD
Assistant Professor

Susan M. Steele MD
Associate Professor

Department of Anesthesiology, Division of Ambulatory Anesthesiology, Duke University Medical Center,

Durham, NC 27710, USA

Regional anaesthesia provides a continuum of perioperative care that includes perioperative

pain management, decreased opioid requirements and decreased post-operative nausea and
vomiting. In addition to these bene®ts, a wide variety of perioperative outcomes can be
enhanced by utilizing regional anaesthesia in the ambulatory setting. Regional anaesthesia has
been shown to improve the cardiovascular, pulmonary, gastrointestinal, coagulative, immuno-
logical and cognitive functions and to be of bene®t in an economic context. These improvements
are particularly advantageous in caring for elderly and high-risk patient populations undergoing
surgery. In addition, regional anaesthesia can facilitate early recovery with excellent post-
operative analgesia and few side-e€ects, which may decrease overall operative costs. This chapter
identi®es important perioperative outcomes that may be positively in¯uenced by the use of
regional anaesthesia in the ambulatory setting.

Key words: perioperative outcomes; regional anaesthesia; ambulatory surgical setting.

Donabedian de®ned patient outcome broadly as `a change in a patient's . . . health status

that can be attributed to antecedent healthcare'.1 Improved patient outcome following a
surgical procedure is the ultimate goal of any anaesthetic. Regional anaesthesia has many
properties that can assist the anaesthesiologist in achieving this goal. Regional
anaesthesia is site-speci®c, long-lasting and ecacious. However, regional anaesthesia
is technically more dicult than general anaesthesia, requires training, has an inherent
failure rate even in experienced hands, and takes time to perform. Therefore, concrete
evidence is required to support its advantages. Regional anaesthesia traditionally has
been associated with superior analgesia. However, a wide variety of patient-related
measurements have demonstrable improvement when regional anaesthesia is used. This
chapter provides an overview of the advantages of regional anaesthesia in the ambulatory
setting. Patient outcomes related to the use of regional anaesthesia are discussed in the

Address correspondence to: Karen C. Nielsen and Susan M. Steele, Department of Anesthesiology, Box 3094,
Duke University Medical Center, Durham, NC 27710, USA
1521±6896/02/$ - see front matter *
c 2002 Elsevier Science Ltd. All rights reserved.
146 K. C. Nielsen and S. M. Steele

following sections: Established evidence of outcome improvement, Possible evidence of

outcome improvement, and Future directions for evaluation of outcome improvement.

ESTABLISHED EVIDENCE OF OUTCOME IMPROVEMENT

Post-operative pain
Pain is one of the most frequent post-operative complications occurring after ambulatory
surgery. Fortier et al2 reviewed over 15 000 consecutive ambulatory surgical procedures.
Pain accounted for 12% of the unanticipated hospital admissions in this study. Of those
being unexpectedly admitted, orthopaedic patients accounted for 60% of cases. Chung
et al3 found that orthopaedic surgery patients had the highest incidence of pain in a
review of over 10 000 ambulatory surgical procedures. The ability to provide adequate
pain management following ambulatory surgery has became a major limiting factor in
determining the types of procedure that can be performed in this setting. Pain also
precipitates several deleterious physiological e€ects leading to post-operative compli-
cations4 (Table 1) that can result in increased morbidity and cost. Severe post-operative
pain is associated with prolonged length of stay and a higher rate of unexpected hospital
admission.5,6
Appropriate pain management is essential after any type of surgery, especially for
surgical procedures performed in the ambulatory setting. Regional anaesthesia provides
long-acting analgesia by placement of local anaesthetic solutions in speci®c sites. Single-
injection nerve blockade can last for 12±18 hours, and continuous catheter techniques
can be used for up to 7±10 days. It has been demonstrated that regional anaesthesia
techniques o€er analgesia superior to that of traditional methods. Singelyn et al7
evaluated the in¯uence of three di€erent analgesic methods on post-operative pain in
patients undergoing total knee arthroplasty. Regional anaesthesia techniques (epidural
and three-in-one block) provided better pain relief than intravenous opioid patient-
controlled analgesia (PCA). Peripheral nerve blockade was as ecient as epidural
analgesia but was associated with fewer side-e€ects. In another comparative study of
e€ects of three analgesic techniques after major knee surgery, regional anaesthesia
techniques (continuous epidural or continuous femoral nerve block) showed
signi®cantly better pain scores at rest and during continuous passive motion compared
with intravenous morphine PCA.8 Similar results were found by Borgeat and colleagues9
when they compared patient-controlled interscalene analgesia and intravenous opioid
analgesia to evaluate post-operative pain after major shoulder surgery. The use of

Table 1. Adverse pathophysiological e€ects of post-operative pain.

Post-operative nausea and vomiting

Post-operative ileus
Immune system impairment
Post-operative fatigue
Post-operative urinary retention
Impaired mobility
Post-operative thromboembolism
Post-operative cognitive de®cit
Respiratory dysfunction ( # alveolar ventilation, # vital capacity, # functional residual capacity,
atelectasia, hypoxaemia, pneumonia)
Sympathetic overactivity (tachycardia, hypertension, " peripheral vasoconstriciton, " myocardial
oxygen consumption, myocardial dysfunction, arrhythmia)
 It is really worth it? 147

patient-controlled interscalene analgesia provided better pain relief than intravenous

opioid PCA. The regional anaesthesia technique was also associated with a signi®cantly
reduced incidence of opioid-related side-e€ects.
Regional anaesthesia provides excellent and prolonged post-operative analgesia that
may also enhance and facilitate patient participation in physical therapy. Because of
improved pain relief and better participation in exercise, this results in a faster recovery
and improvement in perioperative outcomes.8 The use of multimodal analgesia
techniques involving the use of regional anaesthesia in addition to non-opioid
(acetaminophen, and non-steroidal anti-in¯ammatory drugs) and opioid analgesic
drugs can markedly enhance pain relief in the perioperative period10 by reduction of
side e€ects owing to the resulting lower doses and di€erences in side-e€ects pro®les.
Studies reported that multimodal analgesia improved post-operative recovery and
outcome.11,12

Post-operative nausea and vomiting

Post-operative nausea and vomiting (PONV) is a common complication related to
anaesthesia that may lead to delayed discharge, unanticipated hospital admission and
increased health care costs in ambulatory surgical centres. PONV is a distressing
anaesthetic complication for patients which adversely a€ects their post-operative
function and decreases their satisfaction with ambulatory anaesthesia. Carroll et al13
showed that 35% of outpatients discharged from ambulatory surgery centres
experienced PONV severe enough to prevent their return to normal daily activities.
Gold et al14 demonstrated that PONV was the most common anaesthesia-related
complication forcing unplanned hospital admission after outpatient surgery. Carroll
et al15 also estimated that the occurrence of PONV could increase the patient charges
for an ambulatory surgery by approximately US$ 415.
The use of general anaesthesia, systemic opioid use, the surgical stress response and
post-operative pain have all been implicated in the aetiology of PONV. The use of
regional anaesthesia techniques in the ambulatory setting can signi®cantly decrease the
incidence of PONV. An example of this was given by Klein et al16 who demonstrated
that paravertebral blockade (PVB) is associated with a decreased incidence of PONV
when compared to general anaesthesia in patients undergoing plastic surgery of the
breast. Similar results were reported by Coveney et al17 when they compared the use of
PVB and general anaesthesia for major breast cancer surgery in the ambulatory setting.
Patients receiving PVB experienced less PONV than patients receiving general
anaesthesia. Wulf et al18 also found similar results with epidural anaesthesia. They
showed that this technique is associated with a reduced incidence of PONV when
compared to general anaesthesia and intravenous opioid PCA in the perioperative
management of total hip arthroplasty. The use of continuous peripheral nerve blockade
(CPNB) techniques was also associated with a signi®cant reduction of PONV when
Grant et al19 evaluated a series of 228 patients undergoing ambulatory surgery. Williams
et al20 demonstrated that the shift of perioperative care from general to regional
anaesthesia for outpatient knee surgery was associated with a signi®cant reduction in
PONV.
By reducing the incidence of PONV in the ambulatory setting, regional anaesthesia
can result in reduced health care costs. An example of this was the study performed by
D'Alessio et al21 in which the authors reported that interscalene blockade signi®cantly
reduced the incidence of unexpected hospital admissions due to PONV.
148 K. C. Nielsen and S. M. Steele

Length of stay in the post-anaesthesia care unit

Length of stay (total recovery time or time to discharge) in the post-anaesthesia care unit
(PACU) after ambulatory surgery is a major outcome measure with economic signi®-
cance. The main reasons for prolonged post-operative stay are listed in Table 2.22 The
duration of post-operative stay correlates with the incidence of surgical and anaesthetic
complications. The most common causes of recovery delay are post-operative pain,
PONV and drowsiness23; these cause more post-operative nursing interventions in the
PACU, increasing nursing workload and decreasing eciency. Decreased eciency leads
to a potential increase in stang requirements and results in higher health care costs.
The potential impact of regional anaesthesia on length of stay was documented by
Patel et al.24 These authors reported that patients receiving a 3-in-1 block were
discharged in nearly half the time compared to patients receiving general anaesthesia for
arthroscopic knee surgery. This was further supported by Williams et al20 in their
analysis of anaesthesia-controlled time (ACT) for outpatient anterior cruciate ligament
reconstruction. They demonstrated that the use of regional anaesthesia reduced the
time spent in the operating room after completion of surgery and also enabled the
PACU to be bypassed when compared to general anaesthesia. Upper extremity regional
anaesthesia has also been linked to reduced length of stay in the outpatient setting.
Brown et al25 reported that interscalene block for ambulatory shoulder surgery resulted
in shorter hospital stays compared to general anaesthesia. Pavlin et al26 reported their
experience with 1088 patients demonstrating shorter discharge times with peripheral
nerve blockade versus general anaesthesia. Similar results were supported by Collins
et al27 after implementation of a regional anaesthesia programme for outpatient foot
surgery. The reduction in discharge times demonstrated by the studies mentioned
above can facilitate the fast-tracking process by improving discharge times, reducing
stang requirements in the PACU and providing savings in health care costs.

Unanticipated hospital admission

Unanticipated hospital admission is the occurrence of intraoperative or post-operative
complications while the patient is in the ambulatory facility, leading to hospital
admission after outpatient surgery. This is an easily identi®able and important measure
of outcome in the ambulatory surgical setting because it leads to a substantial increase in
health care costs. Hospital admission not only adds to the expense of health care but is
also disruptive for patients and their families and can lead to days of missed work. The
incidence of unanticipated hospital admissions after ambulatory surgery ranges between
0.3 and 9.5%.2 The most common surgical causes for unexpected admission are post-
operative pain, bleeding, surgical misadventure and the need for more extensive
surgery than initially planned. Anaesthetic-related causes are PONV, somnolence,

Table 2. Factors related to prolonged post-operative stay.

Post-operative pain
Post-operative nausea and vomiting
Dizziness
Drowsiness
Cognitive dysfunction
Cardiovascular events
Type of surgery
Anaesthesia technique
 It is really worth it? 149

laryngospasm, dizziness and aspiration. It has been demonstrated that regional

anaesthesia can reduce the unexpected hospital admission rates because of its favourable
side-e€ect pro®le. In a prospective trial, D'Alessio and colleagues21 demonstrated that
8% of the patients receiving general anaesthesia for ambulatory shoulder arthroscopy
required unexpected hospital admission compared to none when patients received an
interscalene block. This was further supported by Williams et al20 who reported that
both regional anaesthesia and a combination of regional and general anaesthesia were
associated with fewer unplanned admissions because of PONV and post-operative pain
when compared to general anaesthesia alone. By providing excellent analgesia, with
decreased opioid consumption and reduced PONV, regional anaesthesia results in fewer
unexpected hospital admissions.14

Unplanned hospital re-admission following discharge

Unplanned hospital re-admission is de®ned as the inpatient admission of an ambulatory
surgery patient, following home discharge, due to complications. Only 1% of those
patients who are discharged home will return to the hospital within 30 days after
ambulatory surgery, demonstrating the relative safety of this practice. Two-thirds of
these patients will require re-admission to the hospital, while a third will require only
a visit to the emergency room.28 For re-admitted patients, the average length of stay is
2.7 days, which is very expensive.29 The most common causes for re-admission to the
hospital are post-operative pain, bleeding, fever, infection and urinary retention.5,29
Emergency room visits and hospital re-admission increase health care costs by 4%
more than the estimated cost of the outpatient procedure.28
Regional anaesthesia can cost-e€ectively reduce post-operative pain and decrease
return hospital visits and re-admissions after ambulatory surgery discharge. In our 3-year
experience in the ambulatory surgical setting using regional anaesthesia techniques in
over 60% of 20 000 cases with approximately 25% of the patients aged 65 years or older
and an ASA physical status of III or IV, less than 0.5% of the patients were re-admitted to
the hospital for potential anaesthetic or surgical complications.

Patient satisfaction
Wu and Fleisher30 classi®ed patient satisfaction as a `non-traditional' patient outcome.
Patient satisfaction is an indicator of the quality of care provided by the facility and a
measure of the e€ect of di€erent anaesthetics on patients. Although there are many
factors that in¯uence patient satisfaction, adverse perioperative events, especially
increased post-operative pain, are strongly associated with decreased levels of patient
satisfaction.31 By providing excellent analgesia, regional anaesthesia techniques may
favourably in¯uence this variable.30 Patient satisfaction with regional anaesthesia has
been examined. Currently, 18 trials have measured patient satisfaction when comparing
regional versus general anaesthesia.32 One of these studies was performed by Doss et al33
who reported that a thoracic epidural with ropivacaine provides greater patient
satisfaction than a general anaesthetic for patients undergoing modi®ed radical
mastectomy. From a total of 18 trials, 13 had focused on a comparison of post-operative
analgesia regimens. The majority of these studies showed that post-operative regional
anaesthesia with local anaesthetic infusion resulted in signi®cantly greater patient
satisfaction when compared with systemic opioids. These studies also showed that
greater patient satisfaction with regional anaesthetic techniques had signi®cantly lower
pain VAS scores.32 Borgeat et al9 have reported higher patient satisfaction following
150 K. C. Nielsen and S. M. Steele

major shoulder surgery when comparing patients who received post-operative patient-
controlled interscalene analgesia and patients who received patient-controlled
intravenous opioids. In addition, Greengrass et al34 reported high satisfaction among
patients following paravertebral blockade for major breast cancer surgery in the
ambulatory setting.
Patient satisfaction in the ambulatory setting is also strongly related to physician±
patient communication and exchange of information. Inadequate education of the
patient is associated with low e€ectiveness of post-operative pain relief.35 Information
about the planned regional anaesthestic, possible complications, post-operative analgesia
and patient recovery expectations should be discussed pre-operatively. A care-team
approach involving anaesthesiologists, surgeons and the nursing sta€ is essential to
provide adequate information about the entire perioperative period. This information
can facilitate the rehabilitation process. Fung and Cohen36 recently reported that the
greatest priority of patients undergoing outpatient surgery is to receive adequate
communication and information on all phases of their care, including pre-operative,
intraoperative, pre-discharge and post-discharge periods.

POSSIBLE EVIDENCE OF OUTCOME IMPROVEMENT

Post-operative sleep disturbances
Sleep deprivation results in psychological and neurological dysfunction, with impair-
ment in behavioural performance and concentration.37 Changes in early post-operative
sleep are characterized by a decrease in total sleep time, elimination of rapid eye
movement (REM) sleep, a marked reduction in the amount of slow-wave sleep, and an
increased amount of non-REM sleep. Rawal et al38 reported that sleep disturbances are
very common in the post-operative period, with 30% of patients waking up during the
night due to inadequate pain control.
Factors that may contribute to sleep disturbances in the post-operative period include
post-operative pain, surgical stress response, age and environmental factors.39,40 As a
result, sleep impairment may lead to decreased post-operative functional level and
quality of life, and to post-operative fatigue. Few studies have been performed to
evaluate the in¯uence of anaesthesia techniques on post-operative sleep. Regional
anaesthesia techniques can be used to reduce surgical stress and to provide superior
analgesia with decreased opioid requirements. These e€ects may lead to improved post-
operative sleep.

Post-operative cognitive dysfunction/cerebral dysfunction/delirium

As the population ages, outpatient surgery is now being performed more frequently on
progressively older patients. These patients have signi®cant coexisting diseases with
numerous anaesthetic implications. The elderly population is also particularly important
because of increased long-term cognitive de®cits after non-cardiac surgery and
anaesthesia.41 A prospective randomized study comparing general versus epidural
anaesthesia for total knee arthroplasty in elderly patients (70 years of age or older)
demonstrated that cognitive performance was worse than the pre-operative baseline in
4±6% of patients 6 months after anaesthesia and surgery.41 A larger randomized
multicentre study reported a cognitive de®cit in 9.9% of patients 3 months after surgery.
Among patients over 75 years of age, 14% had a persistent cognitive dysfunction after
general anaesthesia and surgery.42
 It is really worth it? 151

There are several possible predictors of post-operative cognitive dysfunction,

including advanced age, post-operative pain, opioids, pre-operative cognitive de®cits
and the duration of anaesthesia.42±45 The e€ect of regional anaesthesia versus general
anaesthesia on cognitive function has been studied in several trials.46±48 Few studies
indicated better outcomes for patients undergoing regional anaesthesia. One of these
studies was performed by Hole et al48 who demonstrated that regional anaesthesia was
associated with reduced cognitive deterioration when compared to general anaesthesia
after total hip replacement. However, these studies have been limited by small sample
sizes or by the inclusion of heterogeneous inpatient surgical procedures.
Pain is a signi®cant factor also associated with post-operative cognitive dysfunction.
Duggleby and Lander43 reported that post-operative pain reduces mental status in
elderly patients undergoing total hip arthroplasty. They also suggested that improve-
ment in pain mangement could improve cognitive function in the post-operative period.
In addition to pain, quality of life is also a factor related to cognitive dysfunction. Because
the incidence of post-operative cognitive dysfunction in the elderly patient population is
very high, concerns have been raised about its signi®cant negative impact on quality of
life. This was demonstrated by Hutter and colleagues49 who reported that long-term
cognitive de®cits secondary to subarachnoid haemorrhage were associated with a
reduction in the quality of life.
Regional anaesthesia may positively in¯uence cognitive function by providing superior
analgesia, reducing opioid requirements and improving the quality of life. The role of
regional anaesthetic techniques on cognitive function should be re-evaluated in the
future, especially in the ambulatory patient population. Rasmussen et al50 suggested
novel guidelines for future design and execution of studies within this area that can be
used in the achievement of this goal.

Post-operative functional status and fatigue

The patient's ability to resume pre-operative functional status has become an important
post-operative outcome. However, post-operative functional status is frequently
impaired.51 Swan et al52 demonstrated that patients undergoing ambulatory surgery
experienced a decreased functional level during the ®rst 7 post-operative days and that
only 22% of the patients returned to work (full or part-time) by the seventh day after
surgery. Surgical-stress-induced organ dysfunction, post-operative pain, diculty in
early mobilization, PONV and abnormal eating habits have all been implicated in this
delayed return to normal functional status.51,53 The sedative e€ects secondary to opioid
use can also decrease physical activity post-operatively. Optimal analgesia allows patients
to achieve early mobilization, improves physical therapy participation and results in
better functional results. The advantages of early mobilization are numerous; they
include improvement of pulmonary function, re-establishment of orthostatic re¯exes
and mobilization of extracellular ¯uids.54
Regional anaesthesia techniques provide excellent pain management, thus sparing the
sedative e€ect of opioids and facilitating early post-operative mobilization for a faster
convalescence. It has been demonstrated that continuous epidural analgesia results in an
enhanced rate of rehabilitation following total knee arthroplasty.7,41 Continuous femoral
nerve blockade provides a similar bene®t.8 Regional anaesthesia may also facilitate an
early return to work, potentially generating cost savings for the patient.
Post-operative fatigue is a complex symptom consisting of a decreased ability to carry
out the activities of daily living; it is often related to an element of depression. The
physiological causes of post-operative fatigue are not clear. Early post-operative fatigue
152 K. C. Nielsen and S. M. Steele

may be related to post-operative sleep disturbances, in¯ammatory mediators and the

use of systemic opioids. Late post-operative fatigue appears to be related to decreased
adaptation of the cardiovascular response to exercise, loss of body weight due to
de®cient nutrition and loss of muscular mass and function.55 Regional anaesthesia may
modify the course of post-operative fatigue by improving post-operative sleep. Also, the
excellent analgesia associated with regional anaesthesia may a€ect post-operative fatigue
positively by facilitating early mobilization and return to normal functional status.

Quality of life
Several validated quality-of-life questionnaires are available for assessing physical,
psychological and social variables.56±58 One of the reasons behind the rapid development
of quality-of-life measures in health care has been the growing recognition of the
importance of understanding the impact of health care interventions (e.g. anaesthesia
technique) on patients' lives rather than just on their bodies. As a result, quality-of-life
measures can be taken into account in clinical decision making and research. However,
quality-of-life measurements have not been widely used to assess the e€ect of regional
anaesthesia on patient care. Regional anaesthesia techniques may improve quality of life
by providing superior pain control. Carli et al59 used quality-of-life measurements at
3 and 6 weeks post-operatively in patients undergoing colorectal surgery. They
suggested that regional anaesthesia and analgesia in the post-operative period would
facilitate early recovery. This was further investigated by McNeill et al31 who suggested
that high levels of post-operative pain might a€ect quality-of-life measurements by
interfering with sleep and activity. In addition to pain, deterioration of mental function
after surgery may greatly in¯uence a patient's quality of life.48 In conclusion, regional
anaesthesia may positively a€ect post-operative quality of life by providing excellent pain
control, improving post-operative sleep, facilitating early mobilization and maintaining
cognitive function.

Post-operative immune dysfunction

Several studies describe the e€ects of stressful events on immunological function,
including surgical trauma, anaesthetic drugs, opioids, blood product transfusion and post-
operative pain. These induced alterations in immune function may result in increased
susceptibility to post-operative infection and tumour dissemination. This was supported
by Kutza et al60 who demonstrated that general anaesthesia leads to decreased activity of
natural killer cells. This decreased activity may lead to infection or tumour progression.
Regional anaesthesia may be less immunosuppressive than general anaesthesia.61 Le Cras
et al62 suggested that spinal anaesthesia, but not general anaesthesia, bene®ts patients by
maintaining defence cell numbers thereby promoting cellular immunity and decreasing
the incidence of post-operative infection.
Regional anaesthesia may also preserve perioperative immunological function by
attenuating the surgical stress response. Neural blockade is responsible by pronounced
inhibition of the stress response, in contrast to opioids that have little or no stress-
reducing e€ect.63 In addition, regional anaesthesia may maintain immune function by
decreasing opioid requirements. Opioids alter the function of the immune system by
suppressing cytokine production, thereby inhibiting activation-induced proliferation.64
Finally, regional anaesthesia may conserve immune function by decreasing the need for
blood transfusions. Several studies have focused on the advantages of regional anaesthesia
with respect to decreased intraoperative blood loss and blood transfusion.65±67 However,
 It is really worth it? 153

Stevens et al68 reported that a lumbar plexus block performed in patients scheduled for
total hip arthroplasty provided not only reduced intraoperative but also reduced post-
operative blood loss. Regional anaesthesia may also have an additional bene®t related to
the use of local anaesthetic drugs. It has been reported that local anaesthetics exert anti-
in¯ammatory activity by inhibiting in¯ammatory leukocyte adhesion.69,70

FUTURE DIRECTIONS FOR EVALUATING IMPROVEMENT

IN OUTCOME
Economic outcomes
Comprehensive economic evaluation of any intervention on outcomes is dicult.71
Although there has been no comprehensive examination of costs associated with the use
of regional anaesthesia, these techniques may provide economic bene®ts through
indirect cost containment. Indirect costs include increased length of stay, unexpected
hospital admissions and unplanned hospital re-admission following discharge ± as well as
events leading to patient morbidity and mortality. Yeager et al72 suggested that epidural
analgesia compared to general anaesthesia was associated with a 30% reduction in hospital
charges. Greenberg et al73 analysed the cost of performing monitored anaesthesia care,
general and regional anaesthesia in the ambulatory setting, by using developed models of
cost. Regional anaesthesia was substantially less expensive than general anaesthesia.
Williams et al74 demonstrated the potential bene®ts of utilizing regional anaesthetic
techniques as the primary anaesthetic in their system. In their analysis they demonstrated
that the use of regional anaesthesia reduces the incidence of post-operative side-e€ects
and, hence, the necessity of nursing interventions and unplanned admissions. As a result,
they could reduce overall system costs and bene®t patients. In our practice, the use of
PVB in patients undergoing ambulatory breast cancer surgery has not only signi®cantly
reduced costs but has also achieved a high level of satisfaction among patients.75
Unfortunately, many studies evaluating the economic bene®ts of regional anaesthesia
have failed to consider a patient's timely return to work as an economic indicator. The
study of Swan et al52 was an exception; these authors showed that only 22% of
ambulatory surgical patients returned to full or part-time work by the seventh day after
the operation. This study suggested that a signi®cant portion of the cost reduction
related to the transition of surgical procedures from the inpatient setting to the
outpatient setting might have been merely transferred to the patient and family. Further
research is needed to elucidate the total costs of ambulatory surgery to society; these
costs include home health care costs and loss of work expenses related to patients and
their families.
Rapid turnover of cases is an important goal in the outpatient setting, and frequently
labour-intensive anaesthetic techniques, such as regional anaesthesia, do not gain
acceptance because they require increased operating room time. At our institution, we
try to avoid this by employing a monitored pre-operative holding area which enables
our sta€ to perform these techniques in a safe, well-equipped environment. In fact,
when regional anaesthetic techniques are used, induction rooms obviate induction and
emergence times, thus contributing to an eciently run operating room. This pre-
operative holding area also enhances block success and improves patient satisfaction.
Williams et al20 analysed almost 400 patients undergoing anterior cruciate ligament
reconstruction in an ambulatory facility with a pre-operative holding area. Anaesthesia-
controlled time and turnover times were evaluated with three anaesthetic techniques
(general anaesthesia, peripheral nerve blockade, and a combination of both techniques).
154 K. C. Nielsen and S. M. Steele

Regional anaesthesia was associated with the lowest anaesthesia-controlled time, the
lowest sum of anaesthesia-controlled time and turnover time, and the lowest incidence
of unplanned hospital admission.

Collection of data on regional anaesthesia in the ambulatory setting

The collection of perioperative clinical information is important in assuring high-quality
patient care76 and advancing cost-e€ective, ecient processes in the ambulatory surgery
setting. The bene®ts of regional anaesthesia on patient outcomes as a result of collecting
these data, and subsequent analysis, are a promising avenue of research. However, large
sample sizes will be needed to assess the e€ect that regional anaesthesia may have on
extremely rare outcomes in the ambulatory setting (e.g. mortality and major morbidity).
In our institution we developed a clinical database that includes over 20 000 ambulatory
surgical patients. Data, including pre-, intra- and post-operative variables, are meticu-
lously collected with the aid of computer technology. Because we perform up to 65% of
our cases under regional anaesthesia, these data have been used to evaluate the in¯uence
of regional anaesthesia on patient outcomes and to provide continuous quality
improvement for our ambulatory surgical patients.

SUMMARY

As outpatient surgery continues to grow, and the types of surgery performed in the
outpatient setting become invasive and complex, a wide variety of perioperative
outcomes should be evaluated. Regional anaesthesia techniques o€er numerous
advantages that may be bene®cial and add to the anaesthetic plan for patients undergoing
ambulatory surgery. Undoubtedly, the information presented here suggeststhat regional
anaesthesia is essential for improvement of perioperative outcomes in outpatient
surgery. However, nearly all of the studies evaluating the positive role of regional
anaesthesia in perioperative outcomes involve centroneuraxial techniques ± there are
few outcome studies related to peripheral nerve blockade techniques. Future studies
evaluating the e€ects of peripheral nerve blockade techniques on perioperative
outcomes are needed.

Practice points
. the ultimate anaesthetic goal is to enhance patient outcome. Regional anaesthesia
has many properties that can facilitate the improvement of perioperative patient
outcomes
. regional anaesthesia provides superior analgesia
. regional anaesthesia decreases PONV
. regional anaesthesia reduces post-operative length of stay, unexpected hospital
admission and hospital re-admission
. regional anaesthesia improves patient satisfaction
. regional anaesthesia may positively in¯uence post-operative sleep, cognitive and
immunological function, quality of life and functional status
. more extensive and technically complex surgeries are now performed on an
ambulatory basis by incorporating regional anaesthesia techniques with
preservation of patient safety, comfort and satisfaction
 It is really worth it? 155

Research agenda
. further research is warranted to evaluate the impact of peripheral nerve blockade
techniques on perioperative outcomes in the ambulatory surgical setting
. research on perioperative outcomes in the future should focus on less traditional
outcomes, including quality of life, cognitive function, sleep, immunological
function and patient satisfaction
. accurate economic analysis, evaluating the role of peripheral nerve blocks in the
ambulatory surgical setting, is needed to de®ne the actual economic bene®ts for
the health care system
. large multicentre clinical databases should be used to evaluate rare outcome
variables related to the e€ect of regional anaesthesia in the ambulatory setting

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