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Readiness for Discharge After Foot and Ankle Surgery Using Peripheral Nerve Blocks: A Randomized Controlled Trial Comparing Spinal and General Anesthesia as Supplements to Nerve Blocks

YaDeau, Jacques T., MD, PhD*; Fields, Kara G., MS; Kahn, Richard L., MD*; LaSala, Vincent R., MD*; Ellis, Scott J., MD; Levine, David S., MD; Paroli, Leonardo, MD, PhD*; Luu, Thuyvan H., BS*; Roberts, Matthew M., MD

doi: 10.1213/ANE.0000000000003456
Regional Anesthesia and Acute Pain Medicine: Original Clinical Research Report
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BACKGROUND: Neuraxial anesthesia is often viewed as superior to general anesthesia but may delay discharge. Comparisons do not typically use multimodal analgesics and nerve blockade. Combining nerve blockade with general anesthesia may reduce pain, opioid consumption, and nausea. We hypothesized that general anesthesia (with nerve blocks) would lead to earlier readiness for discharge, compared to spinal anesthesia (with nerve blocks).

METHODS: All patients underwent ambulatory foot and ankle surgery, with a predicted case duration of 1–3 hours. All patients received popliteal and adductor canal nerve blocks using bupivacaine and dexamethasone. No intraoperative opioids were administered. All patients received ondansetron, dexamethasone, ketamine, and ketorolac. Patients, data collectors, and the data analyst were not informed of group assignment. Patients were randomized to spinal or general anesthesia with concealed allocation. Spinal anesthesia was performed with mepivacaine and accompanied with propofol sedation. After general anesthesia was induced with propofol, a laryngeal mask airway was inserted, followed by sevoflurane and propofol. Time until ready for discharge, the primary outcome, was compared between groups after adjusting for age and surgery time using multivariable unconditional quantile regression. Secondary outcomes compared at multiple timepoints were adjusted for multiple comparisons using the Holm–Bonferroni step-down procedure.

RESULTS: General anesthesia patients were ready for discharge at a median of 39 minutes earlier (95% confidence interval, 2–75; P = .038) versus spinal anesthesia patients. Patients in both groups met readiness criteria for discharge substantially before actual discharge. Pain scores at rest were higher among general anesthesia patients 1 hour after leaving the operating room (adjusted difference in means, 2.1 [95% confidence interval, 1.0–3.2]; P < .001). Other secondary outcomes (including opioid use, opioid side effects, nausea, headache, sore throat, and back pain) were not different.

CONCLUSIONS: General anesthesia was associated with earlier readiness for discharge, but the difference may not be clinically significant and did not lead to earlier actual discharge. Most secondary outcomes were not different between groups. The choice of spinal or general anesthesia as an adjunct to peripheral nerve blockade can reflect patient, clinician, and institutional preferences.

From the *Department of Anesthesiology, Hospital for Special Surgery, New York, New York

Healthcare Research Institute, Hospital for Special Surgery, New York, New York

Department of Orthopaedic Surgery, Foot and Ankle Service, Hospital for Special Surgery, New York, New York.

Published ahead of print May 25, 2018.

Accepted for publication April 9, 2018.

T. H. Luu, BS, is currently affiliated with the Department of Medicine, University of Massachusetts Medical School, Worcester, Massachusetts.

Funding: This study was funded by the Hospital for Special Surgery Anesthesiology Department Research and Education Fund, New York, NY. The REDCap electronic data capture tools are funded by the Clinical and Translational Science Center grant (grant number: UL1 TR000457-06) from the National Center for Advancing Translational Sciences, National Institutes of Health, Bethesda, MD.

Conflicts of Interest: See Disclosures at the end of the article.

Institutional review board: Edward C. Jones, MD, MA, Chairman, Institutional Review Board, Hospital for Special Surgery, Caspary Research Bldg, 541 E 71st St, New York, NY 10021. E-mail: jonse@hss.edu.

This study was approved by the hospital institutional review board (IRB #2016-0499), and written informed consent was obtained from all subjects participating in the trial. The trial was registered before patient enrollment at clinicaltrials.gov (NCT02996591; principal investigator: J.T.Y.; date of registration: December 19, 2016).

Reprints will not be available from the authors.

Address correspondence to Jacques T. YaDeau, MD, PhD, Department of Anesthesiology, Hospital for Special Surgery, 535 E 70th St, New York, NY 10021. Address e-mail to yadeauj@hss.edu.

© 2018 International Anesthesia Research Society
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