Pain and Regional Anesthesia
For Outpatient Rotator Cuff Surgery, Nerve Block Anesthesia Provides Superior Same-day Recovery over General Anesthesia
Hadzic, Admir M.D., Ph.D.*; Williams, Brian A. M.D., M.B.A.†; Karaca, Pelin Emine M.D.‡; Hobeika, Paul M.D.§; Unis, George M.D.§; Dermksian, Jeffrey M.D.*; Yufa, Marina M.D.#; Thys, Daniel M. M.D.* *; Santos, Alan C. M.D., M.P.H.* *
Background: Both general and nerve block anesthesia are effective for shoulder surgery. For outpatient surgery, it is important to determine which technique provides more efficient recovery. The authors’ goal was to compare nerve block with general anesthesia with respect to recovery profile and patient satisfaction after rotator cuff surgery.
Methods: In this clinical trial, 50 consenting outpatients (aged 18–70 yr) were randomly assigned to receive either fast-track general anesthesia followed by bupivacaine (0.25%) wound infiltration or interscalene brachial plexus block (0.75% ropivacaine), each under standardized protocols. Blinded recovery room nurses assessed the need for pain treatment and rated patient eligibility for bypass of the phase 1 postanesthesia care unit and for discharge home. Patients were followed up for 2 weeks postoperatively. The primary outcome measures were postanesthesia care unit bypass and same-day discharge. Other same-day recovery outcomes included severity of and treatment for pain and time to ambulation. Postoperative outcomes at home included satisfaction with the anesthesia technique and absence of complications (at 2 weeks).
Results: Patients who received nerve block (vs. general anesthesia) bypassed the postanesthesia care unit more frequently (76 vs. 16%; P < 0.001), reported less pain, ambulated earlier, were ready for home discharge sooner (123 vs. 286 min; P < 0.001), had no unplanned hospital admissions (vs. 4 of 25 patients who underwent general anesthesia; P = 0.05), and were more satisfied with their care. No complications were reported in either treatment group.
Conclusions: Nerve block anesthesia for outpatient rotator cuff surgery provides several same-day recovery advantages over general anesthesia.
SHOULDER pain is a common complaint, third only to headache and backache as the most frequent cause for a visit to a physician.1
In one study, gross pathologic changes in the shoulder, such as thinning or tear of the rotator cuff, were observed in 60% of cadavers examined.2
Shoulder pain may result in significant job-related disability, particularly for individuals who lift heavy items or perform activities at shoulder level. Surgery is often advised for patients who do not improve after 6 months of conservative treatment.
Both general anesthesia (GA) and nerve block anesthesia have been used for shoulder surgery. An interscalene brachial plexus block (ISB) can provide complete regional anesthesia for shoulder surgery and has been used as the sole anesthetic by some.3–6
ISB for shoulder surgery is commonly administered in conjunction with GA, with the block performed primarily for postoperative analgesia.7–10
However, there are compelling reasons to avoid GA in outpatients and older patients because of short-term cognitive impairment, postoperative nausea and vomiting (PONV), and delayed recovery. Furthermore, postoperative pain can interfere with initial rehabilitation.11
Opioid analgesics are commonly used for analgesia when nerve blocks are not used. Opioids are effective in relieving postoperative pain at rest but may increase PONV, somnolence, constipation, urinary retention, respiratory depression, and sleep disturbances.5
There have previously been no prospective, randomized studies comparing the use of ISB versus GA for outpatient shoulder surgery. Our hypothesis was that use of nerve block anesthesia would result in improved same-day recovery over GA.
Materials and Methods
The study was approved by the Institutional Review Board of St. Luke’s-Roosevelt Hospital Center, New York, New York. Patients were eligible for participation if they were aged 18–70 yr, had an American Society of Anesthesiologists physical status of I–III, and were scheduled to undergo outpatient open repair of the rotator cuff. Patients were recruited on the day of surgery by a coinvestigator and a research assistant. After obtaining written informed consent, patients were randomized to receive either ISB or fast-track GA (specifically designed for rapid wake up and same-day discharge), using standard protocols.
Data were recorded with respect to anesthesia drugs given and several physiologic parameters during anesthesia (heart rate, blood pressure, and oxygen saturation). Patients were monitored during surgery and recovery according to standard guidelines published by the American Society of Anesthesiologists.††
Interscalene Brachial Plexus Block
Patients assigned to receive ISB were given midazolam (1–2 mg intravenous) and alfentanil (250–500 μg) in the operating room (OR) before block placement. These premedications were used to decrease anxiety and discomfort during block injection while maintaining meaningful patient contact. Blocks were performed by a senior trainee or fellow under the direction of an attending anesthesiologist with extensive experience in ISB.
Supplemental oxygen (5 l/min) was administered by facemask throughout. The ISB was performed using a 22-gauge, 50-mm Stimuplex® block needle (B. Braun Medical Inc., Bethlehem, PA) and a nerve stimulator (Tracer II®; LifeTech Inc., Stafford, TX). The block was performed using a standard technique with the patient supine.12
After the brachial plexus was localized with a current of 0.2–0.4 mA (0.1 ms), 35–40 ml ropivacaine (0.75%) was injected in divided doses.
After injection, surgeons proceeded with surgical preparation without waiting for complete onset of surgical anesthesia. During surgery, ISB patients received an intravenous infusion of propofol (Diprivan®; AstraZeneca Pharmaceuticals LP, Wilmington, DE), titrated to light sleep with easy arousability. No other intraoperative sedatives or opioids were allowed. After surgery, propofol was stopped, and the patient was taken to the phase 1 postanesthesia care unit (PACU).
Interscalene block patients with inadequate surgical anesthesia, or those requiring intraoperative intravenous opioids, were given GA. The research team predetermined that all patients with failed blocks would be analyzed in the ISB treatment group to follow principles of intent to treat.
General anesthesia patients were given preoperative dolasetron (12.5 mg intravenous) for prophylaxis against PONV, midazolam (1–2 mg), and fentanyl (50–100 μg). GA was induced with propofol (1.5–2.0 mg/kg); one dose of rocuronium (1 mg/kg) was given to facilitate intubation. Anesthesia was maintained with desflurane in a 1:1 mixture of nitrous oxide and oxygen. The end-tidal concentration of desflurane was maintained at 3–6%, based on mass spectrometry (Capnomac Ultima ULT1; Datex-Ohmeda, Helsinki, Finland). Fentanyl boluses (25–50 μg intravenous) were administered as deemed necessary by the attending anesthesiologist.
Surgeons prepared the limb as soon as correct placement of the endotracheal tube was confirmed. At the end of surgery, the incision was infiltrated with 5–10 ml bupivacaine (0.25%) followed by an intraarticular injection of 10–15 ml bupivacaine (0.25%). Patients were awakened after a wound dressing and an arm sling had been applied.
After surgery, patients were taken to the phase 1 PACU. Phase 1 PACU nurses were blinded to the anesthetic technique used and had no access to the (automated) anesthesia record. Patients were evaluated using a modified Aldrete score13
by the PACU nurse who made a decision regarding the patient’s eligibility to bypass phase 1 PACU going directly to the phase 2 PACU. Patients could bypass phase 1 PACU only with the following criteria: modified Aldrete score of 9 or greater, no treatment for pain (visual analog scale [VAS] score < 3), and no PONV. If a patient was admitted to phase 1 PACU, his or her vital signs were determined according to PACU policy, and the presence of symptoms (e.g.
, PONV) was recorded.
In phase 2 PACU, patients were assessed at 15-min intervals by the nurses. They determined when patients met discharge-to-home criteria (a score of ≥ 9 on the postanesthesia discharge scoring system).14
There was no minimum time required for patients to remain in phase 2 PACU. Voiding was not required for discharge from the hospital.15
Daily pain scores and overall satisfaction with anesthesia were assessed as single VAS scores (1–10); these scores were then arbitrarily trichotomized as 0–2 (unacceptable), 3–7 (marginal), and 8–10 (acceptable).
The severity of postoperative pain was repeatedly assessed using the VAS at 15-min intervals. If patients reported pain in phase 1 PACU, morphine (1–2 mg intravenous) was administered every 5–10 min until the patient was comfortable (VAS score ≤ 2). The pain management protocol in phase 2 PACU and at home consisted of acetaminophen (325 mg) with codeine (30 mg) every 4 h as needed.
Hospital time intervals (e.g., induction time, OR time, PACU time) were recorded using data from the automated record-keeping system. Data on discharge time were collected from the nursing documentation and verified by research assistants.
The research assistant, who was blinded to the type of anesthetic used, collected patient data by phone at 24 h, 48 h, 72 h, and 2 weeks after surgery. During the first 3 postoperative days, data included highest VAS pain score, daily pill counts, and other parameters of anesthesia recovery (e.g., appetite, self-care, ambulation, interest in daily activities, anxiety). At 2 weeks after surgery, patients were asked about the occurrence of potential complications (e.g., prolonged numbness, radiating pain in the distribution of the brachial plexus, motor weakness), overall satisfaction with anesthesia care, and willingness to have the same anesthetic for a subsequent surgery (if needed).
Sample size estimates were based on time to home readiness and discharge (in minutes) because this variable was of primary interest to the study. It was estimated that a sample size of 18 patients/group would provide 80% power to detect a clinically meaningful difference of 90 min (within-group SD, 60 min) at α = 0.001. The probability of a type I error was set low to accommodate the multiple comparisons that were planned, particularly for the targeted time measures (e.g., time to ambulation, time to intake of fluids and solids). The final sample size was increased to 25 patients/group as an additional assurance that α would not be inflated when demographic and postoperative data were analyzed.
Discrete categoric data are presented as n (%); continuous data are given as mean ± SD. Confidence intervals are reported for the specific aims (PACU bypass and discharge times), and number-needed-to-treat analysis is reported for PACU bypass ineligibility and unplanned hospital admission. Differences in demographic, surgical, anesthetic, and postoperative data were tested by independent Student t
test (continuous data) or by chi-square (categoric data) and Fisher exact tests (where appropriate). For descriptive purposes, P
value differences less than 0.05 are noted in the tables
. All analyses were conducted using the Statistical Package for the Social Sciences (SPSS for Windows, version 11.0.1; Chicago, IL).
Recruitment began in April 2000, and study follow-ups were completed by March 2002. Fifty-four patients were enrolled in the study, with the only refusals to participate occurring after randomization for 4 patients (3 ISB, 1 GA). No patient refused to participate before signing the study consent form. Fifty patients (25 in each group) completed the study on the day of surgery. There were no failed blocks, so intent-to-treat analysis was not applicable. There were no significant differences between groups with respect to sex, age, height, weight, and American Society of Anesthesiologists physical status (table 1
), nor were there any differences in surgical process times (table 2
Main outcome measures were eligibility to bypass phase 1 PACU to phase 2 PACU and eligibility and timing for same-day discharge. More patients who received ISB (76%) were able to bypass phase 1 PACU than those who received GA (16%) (table 3
). Four patients (all in the GA group) were unable to be discharged because of refractory pain and were admitted to the hospital, whereas no patients in the ISB group were (P
= 0.05). Among patients who were discharged, time to home readiness and time to discharge were more than 2.5 h sooner for patients who had received ISB versus
those who had received GA (table 3
). Number-needed-to-treat analysis for the specific aims is shown in table 4
For the secondary aims, moderate/severe pain (VAS > 3) was not reported by any ISB patients, whereas 80% of all GA patients requested treatment with analgesics (P
< 0.001; table 3
). PONV and sore throat were significantly less frequent in the ISB group (P
< 0.05), whereas times to ambulation and oral intake were significantly less in the ISB group (P
< 0.005; table 3
For patients reached by phone at 24, 48, and 72 h, there was no significant difference between groups in pain scores and pill counts (table 5
). The ISB and GA groups did not differ with regard to difficulties with sleep or appetite, self-care, or ambulation within the first 72 h after surgery. However, these findings are statistically underpowered.
Two weeks after surgery, 1 GA patient and 3 ISB patients reported backache (P
= not significant); similar results were reported for headache. There were no reports of prolonged numbness, radiating pain in the distribution of the brachial plexus, or motor weakness. However, these findings are statistically underpowered. Global patient satisfaction with anesthesia care was higher in the ISB than in the GA group, and significantly more patients in the ISB group reported that they would choose the same anesthetic technique again (P
= 0.014 for each; table 6
The change from inpatient to ambulatory surgical care represents a significant advance.16
Rapid recovery, adequate analgesia, prevention of PONV, and timely discharge are essential to a successful ambulatory anesthesia practice.17–19
Our data suggest that from both the hospital’s and the patient’s perspective, there are advantages to using nerve block anesthesia versus
GA for outpatient rotator cuff surgery. Nerve block anesthesia was associated with a greater number of patients being able to bypass phase 1 PACU, fewer unplanned hospital admissions, and faster time to discharge.
Fast tracking/PACU bypass (being able to bypass the more costly and labor-intensive phase 1 PACU to go directly to phase 2 PACU) is frequently used as a benchmark test for success in ambulatory surgery (as is same-day discharge).20,21
In our study, we ensured that all patients were free from pain, nausea, and vomiting before being transferred from phase 1 PACU to phase 2 PACU recovery, regardless of the Aldrete score.22
This is important to prevent shifting of workload from phase 1 to phase 2 nurses.
In other studies, bypass of acute phase 1 PACU recovery has been associated with a $400 cost savings per patient,20
and successful same-day discharge decreases hospital costs by an estimated $400–1,000.20,23
Our findings of more successful PACU bypass and same-day discharge after ISB could be due, in part, to the fact that patients who had received ISB were more alert at the time of arrival to the PACU and had significantly less pain than did patients in the GA group.
None of the patients in the ISB group required treatment for pain before discharge home, whereas 80% of patients in the GA group required pain management despite wound infiltration and intraarticular instillation of local anesthetic by the surgeon. This finding is similar to another study in which continuous interscalene analgesia was superior to continuous wound infiltration with surgically placed incisional/intracapsular catheters.24
Some perceived disadvantages of ISB versus
GA include the additional time required to perform the block, the possibility of block failure, and the potential that patients undergoing blocks ultimately may have more pain when the blocks wear off. None of these disadvantages were apparent in our study, although our sample size was underpowered to determine these specific outcomes. It is possible that OR times could have been even shorter for the ISB group if blocks had been placed in the preoperative area while the OR was being prepared.25
Anesthesia-controlled time for emergence (time from end of the application of surgical dressing until OR exit) has been reported to be shorter after regional anesthesia versus
Applying these findings would help to offset any additional time needed to place the block in the OR before the procedure begins.
Our results of nerve block success differ from those reported in a retrospective study by Weber and Jain.27
In that study, the authors reported that 13% of ISB failed and that 92% of patients receiving ISB required additional opioid analgesics. In addition, potentially severe complications were reported, including seizures, cardiovascular collapse, respiratory distress, and neurologic injuries.27
The difference between our study and that of Weber and Jain could be explained by the fact that the latter used retrospective methodology, whereas our study was blinded and randomized. Second, nerve block performance in our study was limited to a team of university-based anesthesiology trainees medically directed by anesthesiologists with substantial experience with ISB and nerve block anesthesia in general. It has been reported that training in nerve block anesthesia is inadequate in many residency programs.28
Nonetheless, ISB nerve block is successfully used as a sole anesthetic, with a low risk of complications, in institutions where the staff is experienced.4
Postoperative pain is a common reason for unexpected hospital admission or delay in discharge.29
It is possible that a multimodal approach to postoperative pain management (including the addition of antiinflammatory drugs) could have resulted in better analgesia for patients in the GA group.30,31
Unfortunately, multimodal analgesia using newer nonopioid analgesics (specifically, cyclooxygenase-2 inhibitors) is not a universal practice.
Several studies have suggested that use of nerve block anesthesia or local anesthetics may produce a preemptive effect in reducing sensitization of nerve endings after surgical incision, potentially reducing postoperative pain.32,33
A single-injection ISB using a long-acting local anesthetic such as ropivacaine (as in the current study) has been described as providing 12–14 h of analgesia after shoulder surgery.12
More recently, ISB with a continuous infusion of local anesthetic during the postoperative period has resulted in excellent analgesia with minimal opioid requirement as long as the infusion is maintained.5,10,34–38
Postoperative nausea and vomiting remains a common problem after anesthesia; these symptoms commonly result in discharge delays after ambulatory surgery.17,29,39,40
In the current study, patients receiving ISB had a significantly lower incidence of PONV, despite the fact that they did not receive prophylactic dolasetron, an antiemetic, as did patients receiving GA. The odds ratio of experiencing PONV after GA with volatile agents (e.g.
, desflurane, when compared with propofol sedation/anesthesia) has been reported to be 2.7–10.6.41,42
It is probable that the use of volatile anesthetics as the primary maintenance technique, when superimposed on the significant postoperative pain and opioid requirements after shoulder surgery,20
may have predisposed patients to PONV. Using antiemetics with different sites of action may have reduced the risk of PONV in the GA group.42,43
However, in our study, all patients receiving GA who were admitted had a primary reason of refractory pain, not nausea or vomiting.
It may be argued that the advantages of nerve block anesthesia in this study would be less pronounced if another GA technique had been used. However, the GA protocol in this study is commonly accepted as a conventional model for fast-track GA in patients undergoing outpatient shoulder surgery. A systematic analysis of the literature comparing postoperative recovery after propofol-, isoflurane-, desflurane-, and sevoflurane-based anesthesia in adults demonstrated that early recovery was faster in the desflurane and sevoflurane groups. However, PONV was less frequent with propofol.44
In addition, our data may not be reproducible in institutions without extensive expertise in performing peripheral nerve blocks. The training and practice of peripheral nerve blocks varies significantly from institution to institution, and in-depth training is a prerequisite for the success and safety of peripheral nerve blocks.28,45
We assessed our patients’ perception of their recovery using questions about their sleep, appetite, self-care, ambulation, interest in activities, and anxiety after surgery. The functions assessed by our questioning addressed most aspects covered in two validated surveys.46,47
Unfortunately, these validated survey instruments were not available at the time of our study design. Nonetheless, there were no differences between the two anesthetic regimens in these daily functions, although our sample size was underpowered to definitively show no differences between treatment groups.
In summary, under the conditions of our clinical practice, interscalene block with long-acting local anesthetic in outpatients undergoing rotator cuff surgery provided efficient and reliable surgical conditions. Compared with GA with wound infiltration, nerve block anesthesia with a long-acting local anesthetic also resulted in increased eligibility for PACU bypass and same-day discharge, faster same-day recovery, fewer adverse events on the day of surgery, better analgesia immediately after surgery, and greater patient acceptance.
1. Burkhart SS: Reconciling the paradox of rotator cuff repair versus debridement: A unified biomechanical rationale for the treatment of rotator cuff tears. Arthroscopy 1994; 10:4–19
2. Kjellin I, Ho CP, Cervilla V, Haghighi P, Kerr R, Vangness CT, Friedman RJ, Trudell D, Resnick D: Alterations in the supraspinatus tendon at MR imaging: Correlation with histopathologic findings in cadavers. Radiology 1991; 181:837–41
3. Lanz E, Theiss D, Jankovic D: The extent of blockade following various techniques of brachial plexus block. Anesth Analg 1983; 62:55–8
4. Urban MK, Urquhart B: Evaluation of brachial plexus anesthesia for upper extremity surgery. Regional Anesthesia 1994; 19:175–82
5. Ilfeld BM, Morey TE, Wright TW, Chidgey LK, Enneking FK: Continuous interscalene brachial plexus block for postoperative pain control at home: A randomized, double-blinded, placebo-controlled study. Anesth Analg 2003; 96:1089–95
6. Casati A, Vinciguerra F, Scarioni M, Cappelleri G, Aldegheri G, Manzoni P, Fraschini G, Chelly JE: Lidocaine versus ropivacaine for continuous interscalene brachial plexus block after open shoulder surgery. Acta Anaesthesiol Scand 2003; 47:355–60
7. Borgeat A, Dullenkopf A, Ekatodramis G, Nagy L: Evaluation of the lateral modified approach for continuous interscalene block after shoulder surgery. Anesthesiology 2003; 99:436–42
8. Iskandar H, Benard A, Ruel-Raymond J, Cochard G, Manaud B: The analgesic effect of interscalene block using clonidine as an analgesic for shoulder arthroscopy. Anesth Analg 2003; 96:260–2
9. Neal JM, McDonald SB, Larkin KL, Polissar NL: Suprascapular nerve block prolongs analgesia after nonarthroscopic shoulder surgery but does not improve outcome. Anesth Analg 2003; 96:982–6
10. Borgeat A, Tewes E, Biasca N, Gerber C: Patient-controlled interscalene analgesia with ropivacaine after major shoulder surgery: PCIA vs PCA. Br J Anaesth 1998; 81:603–5
11. Ritchie ED, Tong D, Chung F, Norris AM, Miniaci A, Vairavanathan SD: Suprascapular nerve block for postoperative pain relief in arthroscopic shoulder surgery: A new modality? Anesth Analg 1997; 84:1306–12
12. Hadzic A, Vloka JD: Interscalene brachial plexus block, Peripheral Nerve Blocks: Principles and Practice. Edited by Hadzic A, Vloka JD. New York, McGraw-Hill, 2003, pp 109–22
13. Aldrete JA: The post-anesthesia recovery score revisited. J Clin Anesth 1995; 7:89–91
14. Chung F: Recovery pattern and home-readiness after ambulatory surgery. Anesth Analg 1995; 80:896–902
15. Mulroy MF, Salinas FV, Larkin KL, Polissar NL: Ambulatory surgery patients may be discharged before voiding after short-acting spinal and epidural anesthesia. Anesthesiology 2002; 97:315–9
16. Kitz DS, Slusary-Ladden C, Lecky JH: Hospital resources used for inpatients and ambulatory surgery. Anesthesiology 1988; 69:383–6
17. Junger A, Klasen J, Benson M, Sciuk G, Hartmann B, Sticher J, Hempelmann G: Factors determining length of stay of surgical day-case patients. Eur J Anaesthesiol 2001; 18:314–21
18. Pavlin DJ, Rapp SE, Polissar NL, Malmgren JA, Koerschgen M, Keyes H: Factors affecting discharge time in adult outpatients. Anesth Analg 1998; 87:816–26
19. Chung F, Ritchie E, Su J: Postoperative pain in ambulatory surgery. Anesth Analg 1997; 85:808–16
20. Williams BA, Kentor ML, Vogt MT, Vogt WB, Coley KC, Williams JP, Roberts MS, Chelly JE, Harner CD, Fu FH: The economics of nerve block pain management after anterior cruciate ligament reconstruction: Significant hospital cost savings via associated PACU bypass and same-day discharge. Anesthesiology 2004; 100:697–706
21. White PF, Song D: New criteria for fast-tracking after outpatient anesthesia: A comparison with the modified Aldrete’s scoring system. Anesth Analg 1999; 88:1069–72
22. Williams BA: For outpatients, does regional anesthesia truly shorten the hospital stay, and how should we define postanesthesia care unit bypass eligibility? Anesthesiology 2004; 101:3–6
23. Woolhandler S, Himmelstein DU: Costs of care and administration at for-profit and other hospitals in the United States. N Engl J Med 1997; 336:769–74
24. Klein SM, Steele SM, Nielsen KC, Pietrobon R, Warner DS, Martin A, Greengrass RA: The difficulties of ambulatory interscalene and intra-articular infusions for rotator cuff surgery: A preliminary report. Can J Anaesth 2003; 50:265–9
25. Williams BA, Kentor ML, Williams JP, Figallo CM, Sigl JC, Anders JW, Bear TC, Tullock WC, Bennett CH, Harner CD, Fu FH: Process analysis in outpatient knee surgery: Effects of regional and general anesthesia on anesthesia-controlled time. Anesthesiology 2000; 93:529–38
26. Williams BA, DeRiso BM, Figallo CM, Anders JW, Engel LB, Sproul KA, Ilkin H, Harner CD, Fu FH, Nagarajan NJ, Evans JHI, Watkins WD: Benchmarking the perioperative process: III. Effects of regional anesthesia clinical pathway techniques on process efficiency and recovery profiles in ambulatory orthopedic surgery. J Clin Anesth 1998; 10:570–8
27. Weber SC, Jain R: Scalene regional anesthesia for shoulder surgery in a community setting: An assessment of risk. J Bone Joint Surg Am Volume 2002; 84-A:775–9
28. Hadzic A, Vloka JD, Kuroda MM, Koorn R, Birnbach DJ: The practice of peripheral nerve blocks in the United States: A national survey. Reg Anesth Pain Med 1998; 23:241–6
29. Gold BS, Kitz DS, Lecky JH, Neuhaus JM: Unanticipated admission to the hospital following ambulatory surgery. JAMA 1989; 262:3008–10
30. Reuben SS, Fingeroth R, Krushell R, Maciolek H: Evaluation of the safety and efficacy of the perioperative administration of rofecoxib for total knee arthroplasty. J Arthroplasty 2002; 17:26–31
31. Desjardins PJ, Shu VS, Recker DP, Verburg KM, Woolf CJ: A single preoperative oral dose of valdecoxib, a new cyclooxygenase-2 specific inhibitor, relieves post-oral surgery or bunionectomy pain. Anesthesiology 2002; 97:565–73
32. Pasqualucci A, de Angelis V, Contardo R, Colo F, Terrosu G, Donini A, Pasetto A, Bresadola F: Preemptive analgesia: Intraperitoneal local anesthetic in laparoscopic cholecystectomy. A randomized, double-blind, placebo-controlled study. Anesthesiology 1996; 85:11–20
33. Dahl JB, Kehlet H: The value of pre-emptive analgesia in the treatment of postoperative pain. Br J Anaesth 1993; 70:434–9
34. Nielsen KC, Greengrass RA, Pietrobon R, Klein SM, Steele SM: Continuous interscalene brachial plexus blockade provides good analgesia at home after major shoulder surgery-report of four cases. Can J Anaesth 2003; 50:57–61
35. Borgeat A, Schappi B, Biasca N, Gerber C: Patient-controlled analgesia after major shoulder surgery: Patient-controlled interscalene analgesia versus patient-controlled analgesia. Anesthesiology 1997; 87:1343–7
36. Klein SM, Grant SA, Greengrass RA, Nielsen KC, Speer KP, White W, Warner DS, Steele SM: Interscalene brachial plexus block with a continuous catheter insertion system and a disposable infusion pump. Anesth Analg 2000; 91:1473–8
37. Borgeat A, Perschak H, Bird P, Hodler J, Gerber C: Patient-controlled interscalene analgesia with ropivacaine 0.2% versus patient-controlled intravenous analgesia after major shoulder surgery: Effects on diaphragmatic and respiratory function. Anesthesiology 2000; 92:102–8
38. Singelyn FJ, Seguy S, Gouverneur JM: Interscalene brachial plexus analgesia after open shoulder surgery: Continuous versus patient-controlled infusion. Anesth Analg 1999; 89:1216–20
39. Kapur P: The big “little problem.” Anesth Analg 1991; 73:243–5
40. Fisher DM: The “big little problem” of postoperative nausea and vomiting: Do we know the answer yet? Anesthesiology 1997; 87:1271–3
41. Sneyd JR, Carr A, Byrom WD, Bilski AJ: A meta-analysis of nausea and vomiting following maintenance of anaesthesia with propofol or inhalational agents. Eur J Anaesthesiol 1998; 15:433–45
42. Sinclair DR, Chung F, Mezei G: Can postoperative nausea and vomiting be predicted? Anesthesiology 1999; 91:109–18
43. Apfel CC, Korttila K, Abdalla M, Kerger H, Turan A, Vedder I, Zernak C, Danner K, Jokela R, Pocock SJ, Trenkler S, Kredel M, Biedler A, Sessler DI, Roewer N, Investigators I: A factorial trial of six interventions for the prevention of postoperative nausea and vomiting. N Engl J Med 2004; 350:2441–51
44. Gupta A, Stierer T, Zuckerman R, Sakima N, Parker SD, Fleisher LA: Comparison of recovery profile after ambulatory anesthesia with propofol, isoflurane, sevoflurane and desflurane: A systematic review. Anesth Analg 2004; 98:632–41
45. Kopacz DJ, Neal JM: Regional anesthesia and pain medicine: Residency training—the year 2000. Reg Anesth Pain Med 2002; 27:9–14
46. Myles PS, Weitkamp B, Jones K, Melick J, Hensen S: Validity and reliability of a postoperative quality of recovery score: The QoR-40. Br J Anaesth 2000; 84:11–5
47. Myles PS, Hunt JO, Nightingale CE, Fletcher H, Beh T, Tanil D, Nagy A, Rubinstein A, Ponsford JL: Development and psychometric testing of a Quality of Recovery score after general anesthesia and surgery in adults. Anesth Analg 1999; 88:83–90
†† Standards for Basic Anesthetic Monitoring. Available at: http://www.asahq.org/publicationsAndServices/standards/02.pdf
. Accessed January 4, 2005. Cited Here...
This article has been cited 35 time(s).
Turkiye Klinikleri Tip Bilimleri DergisiAnesthesia Management in a Patient Who Underwent Orthopedic Surgery for Thirty Three Times in a Period of Twenty Seven Months: Case ReportTurkiye Klinikleri Tip Bilimleri Dergisi
Canadian Journal of Anesthesia-Journal Canadien D AnesthesieUltrasound-guided regional anesthesia for upper limb surgeryCanadian Journal of Anesthesia-Journal Canadien D Anesthesie
Anesthesia and AnalgesiaA comparison of regional versus general anesthesia for ambulatory anesthesia: A meta-analysis of randomized controlled trialsAnesthesia and Analgesia
Regional Anesthesia and Pain MedicinePotential economic benefits of regional anesthesia for acute pain management: The need to study both inputs and outcomesRegional Anesthesia and Pain Medicine
OrthopadeThe value of regional and general anaesthesia in orthopaedic surgeryOrthopade
Anesthesia and AnalgesiaNeurological complications after regional anesthesia: Contemporary estimates of riskAnesthesia and Analgesia
Journal of Clinical AnesthesiaThe safety and efficacy of regional anesthesia in an office-based settingJournal of Clinical Anesthesia
Canadian Journal of Anaesthesia-Journal Canadien D Anesthesie
Factors affecting recovery and discharge following ambulatory surgery
Canadian Journal of Anaesthesia-Journal Canadien D Anesthesie, 53(9):
Anesthesia and AnalgesiaUltrasound-Guided Axillary Brachial Plexus Block with 20 Milliliters Local Anesthetic Mixture Versus General Anesthesia for Upper Limb Trauma Surgery: An Observer-Blinded, Prospective, Randomized, Controlled TrialAnesthesia and Analgesia
Acta Anaesthesiologica ScandinavicaRegional anesthesia meets ultrasound: a specialty in transitionActa Anaesthesiologica Scandinavica
Regional Anesthesia and Pain MedicineUpper Extremity Regional Anesthesia Essentials of Our Current Understanding, 2008Regional Anesthesia and Pain Medicine
AnaesthesiaPostoperative analgesia for shoulder surgery: a critical appraisal and review of current techniquesAnaesthesia
Annales Francaises D Anesthesie Et De ReanimationAssessment of patient satisfaction after regional anaesthesia in two institutionsAnnales Francaises D Anesthesie Et De Reanimation
Bmc Musculoskeletal DisordersEfficacy and safety of a subacromial continuous ropivacaine infusion for post-operative pain management following arthroscopic rotator cuff surgery: A protocol for a randomised double-blind placebo-controlled trialBmc Musculoskeletal Disorders
Salud I Ciencia
Local anesthetics for regional anesthesia: An update
Salud I Ciencia, 16(3):
Current Drug Targets
Anesthetic and Adjunctive Drugs for Fast-Track Surgery
Current Drug Targets, 10(8):
OrthopadeAnalgesia in shoulder, elbow and hand surgeryOrthopade
Journal of Clinical AnesthesiaFactors impacting on-time transfer to the operating room in patients undergoing peripheral nerve blocks in the preoperative areaJournal of Clinical Anesthesia
Anesthesia and AnalgesiaIs regional anesthesia really better than general anesthesia?Anesthesia and Analgesia
Annales Francaises D Anesthesie Et De ReanimationPeripheral nerve block in orthopaedic surgery: multicentric evaluation of practicing professionnels and impact on the activity of the recovery roomAnnales Francaises D Anesthesie Et De Reanimation
AnaesthesiaRegional anaesthesia in day-stay and short-stay surgeryAnaesthesia
Anesthesia and AnalgesiaPeripheral nerve block techniques for ambulatory surgeryAnesthesia and Analgesia
AnaesthesiaUltrasound in regional anaesthesiaAnaesthesia
Regional Anesthesia and Pain MedicinePreliminary Results of the Australasian Regional Anaesthesia Collaboration A Prospective Audit of More Than 7000 Peripheral Nerve and Plexus Blocks for Neurologic and Other ComplicationsRegional Anesthesia and Pain Medicine
Anesthesia and AnalgesiaThe role of the anesthesiologist in fast-track surgery: From multimodal analgesia to perioperative medical careAnesthesia and Analgesia
Postoperative Pain Control After Shoulder Arthroscopy
Arthroscopy-the Journal of Arthroscopic and Related SurgeryPain Pump Use After Shoulder Arthroscopy As a Cause of Glenohumeral ChondrolysisArthroscopy-the Journal of Arthroscopic and Related Surgery
Journal of Clinical AnesthesiaAnesthesia-controlled time and turnover time for ambulatory upper extremity surgery performed with regional versus general anesthesiaJournal of Clinical Anesthesia
Journal of Bone and Joint Surgery-American VolumeEfficacy of Subacromial Ropivacaine Infusion for Rotator Cuff Surgery A Randomized TrialJournal of Bone and Joint Surgery-American Volume
Current Opinion in AnesthesiologyRegional anesthesia techniques for ambulatory orthopedic surgeryCurrent Opinion in Anesthesiology
© 2005 American Society of Anesthesiologists, Inc.
Publication of an advertisement in Anesthesiology Online does not constitute endorsement by the American Society of Anesthesiologists, Inc. or Lippincott Williams & Wilkins, Inc. of the product or service being advertised.