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However, certain local and regional techniques offer specific benefits to patients after day‐stay
or short‐stay surgery; these issues are discussed here. In particular, there has been increasing
interest in the use of ‘single‐dose’ as well as continuous peripheral nerve blockade (CPNB) in
patients discharged home.
Local infiltration
Infiltration of local anaesthetic reduced requirements for opioid analgesics after day surgery
and leads to a lower incidence of nausea and vomiting (Eriksson et al, 1996 Level II; Michaloliakou
et al, 1996 Level II).
After day‐stay hernia repair, wound infiltration with levobupivacaine provided analgesia for
24 hours (Ausems et al, 2007 Level II). Local infiltration was superior to opioid and tenoxicam
after minor laparoscopic surgery (Salman et al, 2000 Level II). Infiltration of the trocar site for
day‐case laparosopic cholecystectomy was more effective if done prior to incision than
postoperatively (Cantore et al, 2008 Level II). However, after day‐case laparoscopic
gynaecological surgery, wound infiltration did not significantly reduce pain or opioid
requirements (Fong et al, 2001 Level II).
Continuous wound infusions with local anaesthetics
There were only limited analgesic benefits for the first postoperative day with the continuous
infusion of local anaesthetic after outpatient inguinal hernia repair (Schurr et al, 2004 Level II;
Lau et al, 2003 Level II).
Single‐dose peripheral nerve blockade
Peripheral nerve blocks (PNBs) are useful in ambulatory surgery as they provide site‐specific
anaesthesia with prolonged analgesia and minimal haemodynamic changes. The decision to
discharge ambulatory patients following PNB with long‐acting local anaesthesia is controversial
as there is always the potential risk of harm to an anaesthetised limb.
A prospective study including 1119 upper and 1263 lower extremity blocks demonstrated that
long‐acting PNBs were safe and that patients could be discharged with an insensate limb (Klein
et al, 2002 Level IV). Provided patients are given verbal and written information regarding the
risks as well as appropriate follow‐up, it would seem reasonable to discharge these patients
with the benefit of prolonged analgesia.
Ilioinguinal and iliohypogastric nerve block
Herniorrhaphy performed under ilioinguinal and iliohypogastric nerve block led to superior CHAPTER 9
pain relief, less morbidity, less urinary retention and cost advantages (Ding & White, 1995
Level II). The analgesic benefit with bupivacaine lasted around 6 hours (Toivonen et al, 2001
Level II).
Paravertebral block
Paravertebral blocks provided better analgesia than more distal nerve blocks after inguinal
herniorrhaphy with earlier discharge, high patient satisfaction and few side effects (Klein et al,
2002 Level II). Their successful use has also been reported after outpatient lithotripsy (Jamieson
& Mariano, 2007 Level IV). While paravertebral blocks after major ambulatory breast surgery
provided good analgesia (Weltz et al, 1995 Level II), after minor breast surgery in a day‐care
setting, the benefits were small and may not justify the risk (Terheggen et al, 2002 Level II).
Upper and lower limb blocks
A single‐dose femoral nerve block with bupivacaine for anterior cruciate ligament
reconstruction provided 20 to 24 hours of postoperative analgesia (Mulroy et al, 2001 Level II).
There was an associated decreased requirement for recovery room stay and unplanned
hospital admission, thereby having the potential to create significant hospital cost savings
Acute pain management: scientific evidence 239