Global population aging is a result of the parallel decline in mortality and fertility rates.1 Public health initiatives have also directly contributed to population aging. While the United States (US) population <65 years of age is increasing by 1% per year, the population from ages 65 to 79 years is increasing by >2% per year, and the population 80 years or older is increasing by 3% per year.2 The number of “elderly” persons (>65 years) has tripled over the last 50 years and will more than triple again over the next 50 years (Fig. 1). On a global level, the most rapidly growing age group is that aged 80 years and over (i.e., “oldest-old” or geriatric).
According to the US Census Bureau, the older population (i.e., individuals >65 years of age) numbered 39.6 million in 2009, or 12.9% of the population. By 2030, there will be approximately 72 million older persons, representing 19% of the US population.3 The US National Hospital Discharge Survey reported in 1999 that the 12% of US citizens ages 65 years or older constituted 40% of all hospital discharges and 48% of inpatient care days.3 Thus, the number of surgical and other procedures performed on the elderly has increased dramatically in absolute terms, per hospital discharge, and per capita.
Of the 70+ million operations and diagnostic procedures performed annually in the US, >30% occur at free-standing ambulatory surgical centers not attached to a hospital or emergency department. In these facilities, patients are expected to go home the day of surgery.4 The most common ambulatory surgery procedures on patients >65 years of age are listed in Table 1.
THE RATIONALE FOR AMBULATORY SURGERY IN THE ELDERLY
It is important to consider the potential benefits for this patient population beyond the expected monetary savings to the health care system and reduced risk of nosocomial infections.5 Because it is widely acknowledged that older patients are less able to adapt to unfamiliar environments, allowing elderly patients the opportunity to recover in the comfort of their familiar “home” environment with minimal disruption to their daily routine may actually facilitate the healing process and reduce postoperative discomfort. A study by Canet et al.6 suggested that the avoidance of hospitalization in elderly patients undergoing minor surgery resulted in less cognitive dysfunction in the first postoperative week because of the less stressful conditions associated with the ambulatory (vs. hospital) surgery setting. A study by Castells et al.7 compared clinical and perceived health outcomes (and cost) between ambulatory and inpatient cataract surgery in the elderly. Although the “expected” economic benefits were noted in the ambulatory surgery group, no statistically significant differences were observed between the 2 groups with respect to visual acuity or other clinical and health outcome measures. However, outpatients more frequently reported at least 1 complication in the first 24 hours after surgery than did inpatients (64% vs. 43%). Importantly, there were no differences in complication rates between the 2 groups at later follow-up intervals. These investigators concluded that ambulatory cataract surgery was more cost effective despite the higher risk of early complications in the outpatient group.
In addition to the aforementioned cost savings in comparison with hospital-based care and elimination of the need to adapt to an unfamiliar inpatient routine, other benefits of ambulatory surgery for the elderly surgical population include a reduction in respiratory and intubation-related events and the relative reduction of postoperative complications (e.g., pain, postoperative nausea and vomiting [PONV], nosocomial infection).6 A lower incidence of adverse events in the postanesthesia care unit (PACU) could result in a shorter PACU stay and fewer unanticipated hospital admissions after ambulatory surgery.
PHYSIOLOGIC AND PHARMACOLOGIC EFFECTS OF AGING
Even in the absence of any discernible disease, the aging process results in a progressive functional decline in all major organ systems. Table 2 summarizes how these physiologic changes affect both the pharmacokinetics and pharmacodynamics of commonly used anesthetic and analgesic drugs.8 Organ function peaks in the fourth decade of life, and the functional reserve (the difference between basal and maximal organ function) is well maintained in most individuals until age 60 years.9 However, after age 60, individuals exhibit a wide variation in their functional reserve, as is seen in Figure 2. As part of the preoperative assessment of older patients, it is useful to determine whether a patient is physiologically “young” (i.e., exhibiting only changes associated with normal aging) or “old” (i.e., exhibiting aging effects due to comorbidities in addition to normal aging).
Basal Metabolic Rate (BMR) and Temperature Regulation with Aging
The BMR declines 1%–2% per decade from age 20 to 80 years.10 Aging combined with a decreased level of physical activity contributes to this decrease in BMR. Shivering is less common in older patients because a lower core temperature must be reached to trigger a response,11 placing the elderly at greater risk of perioperative hypothermia.
Cardiovascular Effects of Aging
Advancing age is associated with loss of arterial elasticity and reduced arterial compliance as elastin production declines and collagen is damaged over time, leading to an overall “stiffening” of the heart and vascular system.12 The progressive reduction in nitric oxide production with aging also contributes to vascular stiffening.13 As the aging heart pumps against an increased afterload, the left ventricular wall thickens, leading to ventricular hypertrophy.14 Although these age-related changes in cardiac function preserve systolic function, the decrease in left ventricular compliance impairs early diastolic filling, making the aging heart dependent on late diastolic filling.15 Because late diastolic filling is a function of atrial function, hemodynamic instability can result from the presence of supraventricular arrhythmias.16 Impairment in the ventricular relaxation phase, termed diastolic dysfunction, also predisposes the elderly patient to fluid overload and “flash” pulmonary edema.17
Autonomic Changes with Aging
Autonomic nervous system (ANS) function progresses from parasympathetic predominance at birth to gradually increasing sympathetic activity in early adulthood. Sympathetic activity predominates in later life as parasympathetic activity progressively declines. A concomitant decrease in β-adrenoreceptor responsiveness renders the elderly patient's ANS less capable of responding to stressful stimuli.14 The baroreflex likewise suffers from the age-related decrease in vagal activity, resulting in a reduced capacity to maintain a stable arterial blood pressure in response to acute physiologic changes during the perioperative period.18 The combination of ANS changes and structural changes in the cardiovascular system can increase blood pressure variability.16 The clinical consequences of autonomic aging include increased blood pressure lability, reduced responsiveness to inotropic and chronotropic drugs, and an increased dependence on preload to maintain cardiac output.
Pulmonary Changes with Aging
After the age of 50 years, lung compliance decreases secondary to loss of parenchymal elasticity, loss of chest wall compliance due to calcification of the costo-chondral joints, and decrease in alveolar surface area.19 These changes result in a decrease in vital capacity, expiratory flow, and diffusion capacity, and an increase in residual volume, closing capacity, dead space, and ventilation– perfusion heterogeneity.19 Clinically, elderly patients experience gas exchange abnormalities that require progressively increasing inspired oxygen concentrations.9 Older patients also have impaired respiratory responses to hypoxia and hypercapnia, and an increased sensitivity to the respiratory-depressant effects of opioid analgesics and benzodiazepines.19 Advanced age is an important predictor of postoperative pulmonary complications, including aspiration, pulmonary edema, atelectasis, and pneumonia.20
Renal and Hepatic Effects of Aging
The kidneys lose approximately 10% of parenchymal thickness per decade of life,21 accompanied by a 10% decline in renal blood flow per decade, contributing to a 30%–50% decrease in creatinine clearance between the ages of 20 and 90 years.22 Despite this decline in renal function, serum creatinine levels remain in the normal range because the production of creatinine decreases as a result of the loss of muscle mass, which occurs at a rate similar to the decline in glomerular filtration rate. Liver mass also decreases by 20%–40% during the typical human lifespan, with a concomitant decline in hepatic bloodflow.23 Impaired hepatic and renal function in elderly patients affects the metabolism and excretion of many different anesthetic, analgesic, and muscle-relaxant drugs (Table 2).
Cerebral Effects of Aging
Cerebral atrophy increases and cerebral perfusion decreases after age 60 years, but there is marked heterogeneity in the magnitude of these changes.24 On average, there is a 15% decrease in white matter by the age of 90 years,25 which may predispose the elderly to postoperative cognitive disorders26–28 and increase their sensitivity to the central depressant effects of anesthetic medications. Aging results in an overall loss of neurons in both the cerebral cortex and the spinal cord, and slows conduction velocity in peripheral nerves, resulting in an increased sensitivity to the local anesthetics used in neuraxial and peripheral nerve blocks (PNBs).29 However, a cause-and-effect relationship has not been firmly established between neurodegenerative disorders and anesthesia in the elderly.30
Effects of Aging on Pharmacologic Effects of Anesthetic Drugs
As individuals age, there is a progressive loss of skeletal muscle mass and total body water as muscle is replaced with adipose tissue, especially in women. An increase in adipose tissue leads to an expansion of the “lipid (deep) reservoir” for centrally active anesthetic drugs (e.g., benzodiazepines, volatile agents, opioid analgesics, and sedative-hypnotics [IV anesthetics]), contributing to prolonged elimination half-life values and an increased duration of action of these drugs in the elderly.31 In addition, the reduction in total body water decreases the central volume of distribution for water-soluble drugs, resulting in higher average and peak plasma drug concentrations and an enhanced peak (maximal) effect.22 Older patients with poor nutrition can have a 20% or more decrease in albumin levels. Because many anesthetic drugs are highly bound to albumin (e.g., propofol, diazepam), even modest decreases in albumin levels can increase free-drug concentrations, contributing to increased sensitivity to these drugs in the elderly.
Although oral drug absorption from the gastrointestinal tract is often delayed in the elderly, these changes are of minimal importance in the perioperative setting because the majority of anesthetic and analgesic medications are administered IV. Age-related pharmacokinetic changes in drug distribution, metabolism, and elimination have a significant impact on drug dosing in geriatric patients (Table 2).8,29,31 The mechanisms responsible for the pharmacodynamic changes associated with aging are less well understood. However, the aging of the central nervous system results in neuronal loss and a decline in cognitive reserve, contributing to the enhanced sensitivity of the elderly to centrally active anesthetic drugs. As a result of these age-related changes, the central nervous system– depressant effects of anesthetic drugs (e.g., sedation, hypnosis, cardiorespiratory depression) occur at lower blood and effect-site concentrations in older patients.30 The old adage to “start low and go slow” applies when administering potent anesthetic and analgesic drugs to elderly patients in the ambulatory setting.
Drug Interactions in the Perioperative Period
Polypharmacy, the term used to describe the use of multiple chronic medications, is common among elderly patients undergoing ambulatory surgery procedures. It is estimated that 40% of geriatric patients take 5 or more different drugs per week and 12%–19% use 10 or more drugs in a week.32 An expert panel found that polypharmacy (defined as 5 or more chronic medications) was the only patient characteristic associated with adverse drug reactions in patients over the age of 65 years.33 Combinations of analgesic medications (e.g., opioids, local anesthetics, and anti-inflammatory drugs) can produce enhanced postoperative analgesia as part of a multimodal regimen, but their interactions may contribute to delayed wound healing in the elderly.34,35 Anesthesia providers should be aware of all prescription, “over-the-counter,” and herbal medications taken by elderly outpatients to minimize adverse events from drug interactions in this high-risk surgical population.
PREOPERATIVE PREPARATION AND RISKS OF COEXISTING DISEASES
Strategies for ambulatory surgery in the elderly36 must assess the risks of the proposed operative procedure, the planned anesthesia and analgesia regimen, and the patient's underlying medical condition.37 Risk reduction strategies for the elderly outpatient involve optimization of coexisting diseases.38–40 To minimize perioperative adverse events in the elderly,41 an accurate preoperative assessment of the patient's physical and functional status42,43 allows anesthesiologists an opportunity to implement an appropriate perioperative care plan, including preoperative interventions (e.g., prehabilitation)44–46 and/or prophylactic therapies (e.g., antiemetic prophylaxis of “at-risk” patients).47 Earlier assessment of elderly outpatients scheduled for ambulatory surgery may also identify those patients at risk of developing transient cognitive dysfunction in the postdischarge period.
Preoperative assessment clinics have become a common approach to improving the overall quality of perioperative care for elderly outpatients scheduled for ambulatory surgery procedures. The development of preoperative clinics has progressed from the concept of a comprehensive clinic as originally described by Fisher,48 to the nurse-led preoperative health assessment49 and, most recently, telephone-based evaluations.50 A possible explanation for the move away from routine outpatient preoperative evaluation is the inability to demonstrate a cost–benefit with respect to improved patient outcomes. For example, Lee et al.51 reported that even though preoperative clinic patients were more “optimally prepared” for surgery, their adjusted risk of unanticipated intraoperative events was actually higher than nonclinic-evaluated patients. However, the recognition and optimization of comorbid conditions37—particularly diabetes, cardiovascular disease, pulmonary disorders, hepatic disease, or renal impairment—in advance of surgery is especially important in the elderly because it allows perioperative implementation of preventative measures to reduce adverse events.41,46 In addition, a recent study found emotional and cognitive factors were predictors of postoperative side effects such as pain, nausea, and fatigue.52 This suggests the importance of preoperative evaluation of the psychological state of the elderly patient (e.g., presurgical distress, hearing deficiencies, and cognitive dysfunction).
Ordering routine “screening” laboratory and diagnostic tests for elderly patients undergoing ambulatory surgery has been a long-standing practice. However, a study by Chung et al.53 involving >1000 outpatients (35% of whom were >60 years of age and more than one third had clinically significant cardiovascular disease) found no significant differences in the rates of acute perioperative adverse events or the rates of adverse events <30 days after surgery between those who underwent no preoperative testing and those in the “indicated” testing group.53 Hospital revisits within the first week were actually higher in the indicated testing group. An earlier study by Imasogie et al.54 reported that in elderly cataract surgery patients there was no difference in the incidence of adverse perioperative events between those receiving no preoperative laboratory testing and those undergoing “routine” lab testing. These data suggest that for the majority of older patients with well-controlled (stable) coexisting diseases, routine (screening) lab testing is a waste of time and financial resources.
Diabetic patients should undergo preoperative assessment of their fasting blood glucose level, and their treatment optimized using IV insulin for type I diabetics, and oral hypoglycemic drugs and/or parenteral insulin for type II diabetics. If glucose levels are significantly elevated, a perioperative IV insulin infusion should be used.55 Frequent postoperative assessment of blood glucose levels has also been demonstrated to reduce infectious complications.56
Cardiovascular diseases are common among elderly outpatients presenting for ambulatory surgery, including hypertension, chronic heart failure, arrhythmias, and ischemic heart disease. There is a clear consensus to continue most, if not all, chronic medications up to and including the day of surgery (particularly β-blockers and statins).57,58 However, there is less compelling evidence on continuing calcium channel blockers, and recent guidelines suggest stopping angiotensin converting enzyme inhibitors and angiotensin receptor blocking drugs.57,59 A controversial issue in elderly outpatients is perioperative continuation of antithrombotic drugs and/or platelet inhibitors,60 particularly when regional anesthesia is planned. A comprehensive guideline was recently published by the European Society of Anesthesiologists61 on regional anaesthesia (and supported by other experts in the field),62,63 suggesting that elderly patients continue antiplatelet drug therapy if they are undergoing ambulatory procedures.
Elderly patients with chronic pulmonary diseases should be carefully evaluated to determine whether they have a reversible component to their disease. Those with severe chronic obstructive pulmonary disease should undergo preoperative pulmonary function testing with and without bronchodilators.64 Smoking cessation has been shown to decrease risk of perioperative complications,65 and should be strongly encouraged at least 4 weeks before surgery.66 Undergoing surgery is associated with an increased likelihood of smoking cessation in the elderly, and ambulatory surgery can be a “teachable moment” for smoking cessation.67 Finally, for both smokers and nonsmokers with a reversible component of obstructive disease and/or airway hyperreactivity, a short (48 hour) preoperative course of β2-adrenergic agonist and systemic corticosteroid therapy is recommended.68 The short-term use of steroids has not been found to have an adverse effect on wound healing or infection control.69
Although elderly obese patients with diagnosed and undiagnosed obstructive sleep apnea (OSA) are more frequently presenting for ambulatory surgery,70 neither obesity nor OSA per se is a significant independent risk factor for unplanned admission or adverse events after ambulatory surgery.71,72 Stierer et al. failed to find a relationship between unplanned hospital admission and the diagnosis of OSA or morbid obesity. However, patients with OSA had an increased risk of perioperative events requiring additional anesthetic management.73 A decision regarding the suitability of elderly obese patients with OSA for ambulatory surgery should weigh the invasiveness of the procedure, the choice of anesthesia, the severity of the airway obstruction, the presence of comorbidities, the need for opioid analgesics, and the level of home care.69 An algorithm for evaluating and preparing patients with OSA for ambulatory surgery has been recently published.74
Elderly patients with cirrhosis undergoing major surgery are at increased risk for mortality up to 90 days postoperatively.75 However, no studies have been conducted in the ambulatory population. Preventing acute renal failure in the postoperative period is another important consideration in elderly patients, particularly those with preexisting renal insufficiency, diabetes, and long-standing hypertension.76 Measures used to optimize the patient's clinical condition include careful blood pressure control, avoiding fasting-induced hypovolemia,77 monitoring blood glucose, and estimating creatinine clearance.78
Finally, because many elderly patients are frail (up to 30%) improving functional status may be as important as optimizing medical status. The patient's frailty can be assessed using a validated scale that includes an assessment of weakness, weight loss, exhaustion, low physical activity, and slowed walking speed.79 Functional exercise capacity can be increased through structured training programs,80 and has been shown to improve outcome in elderly patients undergoing major surgery procedures.81
CHOICE OF ANESTHETIC TECHNIQUE
There is a belief that local or regional anesthesia is less likely to lead to complications in elderly patients than is general anesthesia. Although this may be true for very fragile (e.g., ASA III or IV) patients undergoing major surgical procedures,82 in a study involving 800,000 consecutive patients in the Netherlands, advanced age per se was not an independent risk factor for serious morbidity or mortality after ambulatory surgery under general anesthesia.83 In comparing randomized, controlled trials of general and regional anesthesia (i.e., central neuraxial and major peripheral [conduction] nerve blocks) for ambulatory surgery, Liu et al.84 concluded that (1) both central neuraxial block and PNB were associated with prolonged induction times to the start of surgery, reduced pain scores, and decreased need for opioid analgesics in the PACU; (2) central neuraxial block was not associated with enhanced PACU bypassing (fast tracking) or reduced postoperative nausea, and prolonged the time to discharge home; and (3) use of a PNB was associated with decreased PACU stay and reduced PONV, but failed to decrease the time to discharge home.
Although elderly patients may have a higher incidence of transient (early) cognitive dysfunction after general anesthesia in comparison with local–regional techniques,85 there appears to be no causative relationship between general anesthesia and long-term postoperative cognitive dysfunction (POCD). These investigators have also shown that the ambulatory (vs. inpatient) setting is beneficial in reducing POCD after general anesthesia.6 In addition, postoperative delirium (POD) and agitation in the elderly can be minimized by avoiding potential triggering drugs (e.g., centrally active anticholinergics, benzodiazepines, butyrophenones).86 In elderly patients undergoing ambulatory surgery with general anesthesia, the frequency and severity of both postoperative pain87 and nausea88 appear to be lower than in younger outpatients.
In choosing an anesthetic technique it is also important to consider side effects and potential complications associated with local–regional techniques in the elderly (e.g., nerve trauma, tissue ischemia from epinephrine injection with local anesthetics at the incision site).89 In a large French survey of permanent nerve damage due to local– regional techniques, there was a significant association with advanced patient age.90 Spinal and epidural anesthetic techniques can result in perioperative hypotension, postoperative urinary retention, nausea and vomiting, dizziness, and delayed ambulation time.90 When IV sedation is used to supplement local–regional anesthetic techniques, the risks of respiratory depression and hemodynamic instability are similar or even higher than with general anesthesia.91
Drug selection and dosage must be adjusted to make general anesthesia as safe as possible in older outpatients. As was mentioned earlier, interpatient variability is higher in elderly patients than in younger patients with respect to drug pharmacokinetics and pharmacodynamics.11 For example, elderly patients require a lower propofol dose for induction,92 although the propofol maintenance rate is only slightly decreased in comparison with younger patients. However, the onset of propofol's sedative–hypnotic effect may be slower because of the slower blood–brain circulation times in the elderly. In addition, the onset time to maximal cardiorespiratory depression may be delayed in relation to the hypnotic effect.93 Because the elderly have a less-compliant vasculature system and higher incidence of chronic hypertension, they are more prone to develop hypotension after induction of anesthesia.
Elderly patients have up to a 2-fold increase in sensitivity to the ventilatory-depressant effects of opioid analgesics compared with younger patients, and thus require lower doses.94 Benzodiazepines also exert a more potent and prolonged sedative, amnestic, and respiratory-depressant effect in older patients.95 There are very few controlled studies of ketamine in the elderly; however, untoward psychotomimetic reactions (e.g., hallucinations, delirium) appear to be uncommon in the elderly, particularly when ketamine is administered in combination with a benzodiazepine or propofol.96 The α-2 agonist dexmedetomidine can be used as an alternative to opioid analgesics for maintenance of spontaneous ventilation in the fragile elderly patient.97 However, residual sedation after discontinuation of a dexmedetomidine infusion can be problematic in the ambulatory setting.98
There is a 7% increase in the potency of inhalation anesthetics with every decade of age after 30 years.99 The potent, less-soluble inhalation anesthetics may be particularly beneficial in elderly outpatients with compromised coronary circulation because of their recently described preconditioning effects.100 Desflurane offers a more rapid early recovery than isoflurane and sevoflurane, especially after prolonged administration in the elderly.101,102 Desflurane has also been shown to cause less fatigue in the first week after ambulatory anesthesia when compared with a propofol infusion technique for maintenance of anesthesia.103 Despite a continuing controversy regarding its potential to increase PONV and risk of postoperative myocardial infarction, use of nitrous oxide as an adjuvant to the volatile and IV anesthetics can be beneficial for the elderly outpatient because of its rapid elimination and anesthetic and analgesic-sparing effects.104,105
The dose of neuromuscular blocking drugs should be modestly reduced in the elderly because of slower rate of elimination. The ester-based muscle relaxants (e.g., cisatracurium) have a more predictable duration of effect in the ambulatory setting than do the steroidal-based muscle relaxants (rocuronium). However, use of steroidal muscle relaxants allows for the use of the new cyclodextrin reversal drug sugammadex when the standard anticholinesterase reversal drugs fail to adequately reverse the residual neuromuscular blockade.106
The elderly outpatient should have minimal, if any, sedative premedication in the ambulatory setting to avoid prolonging emergence from anesthesia. If midazolam is administered for premedication, a dose of 0.5 to 1 mg IV is recommended. General anesthetic induction with titrated doses of propofol (e.g., increments of 0.5 mg/kg) will minimize acute cardiorespiratory depression. A small dose of a potent opioid analgesic (e.g., fentanyl 0.5 μg/kg IV) may be useful before the insertion of a laryngeal mask or tracheal tube, or before injecting local anesthetics (e.g., PNBs or tissue infiltration) to minimize acute hyperdynamic responses associated with painful stimuli.
The use of an electroencephalogram-based hypnotic brain monitor may be helpful in improving titration of anesthetics during the maintenance period in the elderly because of the high degree of interpatient variability in response to general anesthetics. Use of the bispectral index (BIS) monitor has been shown to facilitate recovery after maintenance of anesthesia with both propofol107 and volatile anesthetics.108 In addition, a preliminary study suggested that avoiding prolonged periods of “deep” hypnosis (i.e., low BIS values) may be associated with decreased morbidity and mortality in the elderly population.109 Although still controversial, Lindholm et al.110 confirmed the statistical relationship between 1-year mortality and low intraoperative BIS (<45), but suggested that the effect was weak in comparison with comorbidity as assessed by the patient's physical status score, preexisting malignancy status, and patient age. A more recent study of elderly patients undergoing cardiac surgery111 found that the cumulative duration of low BIS was independently associated with intermediate-term mortality, with a 29% increased risk of death for every cumulative hour spent with a BIS <45. However, a more recent study by the same group involving patients undergoing noncardiac surgery failed to find evidence that a cumulative BIS value below a threshold of 45 was harmful to patients.112
Spinal and Epidural Anesthesia
The role of neuraxial blockade in ambulatory anesthesia has been described in 2 recent review articles.113,114 A meta-analysis of published comparative trials showed reduced pain scores and decreased need for opioid analgesics in the PACU when outpatients received central neuraxial blockade in comparison with general anesthesia.84 Unfortunately, the advantages of neuraxial block are offset by the longer induction and discharge times and a higher incidence of postoperative bladder dysfunction.86 A nationwide study in Denmark suggested that use of regional (spinal) anesthesia for inguinal hernia repair in patients older than 65 years was associated with an increase in both medical (1.2% vs. 0.6%) and urologic (0.9% vs. 0.1%) complications in comparison with local or general anesthesia.115 However, 2 other studies reported less arterial hypotension in elderly patients undergoing prostate biopsies116 or knee surgery under spinal (vs. general) anesthesia.117 Furthermore, the direct cost of performing a neuraxial block is less than that of general anesthesia.116,118,119
Studies involving ultrashort-acting local anesthetics120,121 and use of small doses of conventional local anesthetics combined with potent opioids116 have demonstrated recovery times after ambulatory surgery that are similar to those found with general anesthesia. However, the prolonged recovery associated with the traditional doses of spinal anesthetics (e.g., lidocaine 50 to 100 mg, tetracaine 5 to 10 mg, or bupivacaine 7.5 to 10 mg)122 is clearly problematic when used for short-stay surgery procedures (e.g., hernia repair, prostate biopsy, and knee arthroscopy). A low dose of bupivacaine (2.5 to 5 mg) has been advocated as an alternative to lidocaine because of the lower incidence of transient neurologic symptoms with bupivacaine.123 Unfortunately, even with this technique, the time to discharge home is unpredictable and remains longer than with general anesthetic techniques.124
Despite the addition of a small dose of fentanyl or sufentanil to reduce the dose of local anesthetic for outpatient procedures, the discharge times remain in the 2- to 4-hour range,125 which is not acceptable in the modern practice of ambulatory anesthesia. Clonidine has also been used as an adjuvant to local anesthetics for spinal anesthesia. Unfortunately, this combination can produce significant hypotension126 and prolonged recovery in the ambulatory setting.127 Prilocaine similarly has a longer discharge time, and one study documented a 23% incidence of urinary retention that can further delay discharge.128 Articaine, an amide-based local anesthetic with characteristics similar to lidocaine, has been investigated for outpatient spinal anesthesia. Although articaine was associated with a faster recovery than was prilocaine,129 it does not appear to offer any significant advantages over 2-chloroprocaine.130 Several recent reports suggest that intrathecal 2-chloroprocaine is associated with recovery times approaching general anesthesia.120,121,131–133 However, intrathecal 2-chloroprocaine is not approved in the US, where it remains controversial.
Spinal anesthesia with ultrashort-acting local anesthetics should reduce the risk of urinary retention and may be no different from general anesthesia. However, elderly male patients with symptoms of prostatic hypertrophy may still be at increased risk of urinary retention after spinal anesthesia even after the use of an ultrashort-acting local anesthetic.134 Advanced age is also associated with an increased risk of hypothermia during spinal anesthesia.135 However, one positive effect of the aging process is a decline in the frequency of postdural puncture headache after spinal anesthesia.
Use of epidural anesthesia with a continuous catheter may provide more precise control of the duration of neuraxial blockade in the ambulatory setting. However, peridural techniques are associated with an unpredictable (lower) dosage requirement in the elderly,136 as well as greater technical difficulty due to common arthritic changes in the elderly spine. Studies suggest that epidural anesthesia is associated with less pain in the early postoperative period, fewer nursing interventions in the PACU, lower overall anesthetic costs, and greater hemodynamic stability.137 However, it is also associated with increased anesthesia time, frequently delayed discharge home after short surgery procedures, and the potential for postoperative urinary retention, particularly in the elderly male outpatient.
Peripheral Nerve Blocks
PNBs possess many of the characteristics of an ideal anesthetic for ambulatory surgery in the elderly, providing site-specific surgical anesthesia and analgesia with few side effects. For inguinal herniorrhaphy, one of the most frequently performed operations in the ambulatory setting, both ilioinguinal–hypogastric and paravertebral blocks have been successfully used in elderly outpatients. The recovery profile after hernia surgery with PNBs is superior to both general and spinal anesthesia.115,118,138–141 In comparison with general anesthesia, a recent meta-analysis suggested that use of paravertebral blocks for breast surgery (at the thoracic level) or inguinal hernia surgery (at the lumbar level) was associated with less pain during the immediate postoperative period, as well as less PONV and greater patient satisfaction.142 Another PNB option for hernia surgery would be the transversus abdominis plane block.143 However, the least invasive block that provides adequate surgical analgesia is recommended in the elderly outpatient.144 Although simple local infiltration anesthesia has been recommended for inguinal hernia repair, the addition of an ilioinguinal block improves both intra- and postoperative analgesia.145,146
Long and short saphenous vein stripping is another common ambulatory surgery procedure in which use of a combined saphenous–popliteal block with short-acting local anesthetics provides better perioperative analgesia and a faster recovery than does spinal anesthesia.147 For upper and lower limb surgery, a wide variety of PNBs have been used.148 For painful shoulder surgery, a single shot or continuous interscalene brachial plexus block is the most common approach.149 However, interscalene block is an invasive procedure with potentially serious complications in the elderly. More “distal” interventions (e.g., infraclavicular nerve block,150 axillary block) may reduce the incidence of adverse events.151 For lower-extremity orthopedic procedures, femoral and popliteal-sciatic PNBs appear to be a better choice than does general or spinal anesthesia.152 The infrapatellar block is another promising PNB technique for knee arthroscopy.153
In comparison with general148,149 and spinal152,153 anesthesia, PNBs offer several advantages for older patients undergoing elective ambulatory surgery, including reduced postoperative pain, decreased need for postoperative opioid analgesics, decreased incidence of PONV, increased chance of a “fast-track” recovery that bypasses the PACU,122 and increased patient satisfaction, particularly when continuous PNB (CPNB) techniques were used.145–152
Unlike parenteral or epidural analgesia, CPNB (perineural) infusions may be used after hospital discharge using a portable infusion pump or disposable elastomeric device to provide local analgesia in the postdischarge period.154 Continuous femoral nerve blocks can facilitate recovery by decreasing disability after orthopedic procedures.155 Techniques for CPNB placement have developed in large part from the single-shot approach, and are now generally performed under ultrasound guidance.156
Richman et al.157 examined 19 studies that enrolled a total of 603 patients receiving postoperative analgesia with a CPNB involving the upper or lower extremity (e.g., interscalene, infraclavicular, femoral, lumbar plexus, or popliteal-sciatic). These investigators concluded that regardless of the location of the catheter, postoperative analgesia was superior in patients who received CPNB in comparison with a placebo or parenteral opioid analgesics. For painful orthopedic procedures, the economic impact of CPNB on ambulatory surgery is increasingly evident158 because more patients can be discharged home on the day of surgery owing to the reduced need for parenteral analgesics.159
Although most patients appreciate the superior pain relief provided by PNB techniques, the dense motor block and altered sensation are potentially dangerous for an elderly patient in an ambulatory setting. In a large prospective study involving 307 patients receiving CPNBs,160 4% could not move their arm or hand for 16 hours after surgery, preventing these patients from participating in active physical therapy. A CPNB involving the femoral nerve can lead to weakness of the quadriceps femoris muscle and interfere with early ambulation, resulting in patients falling and sustaining other injuries.161 Feibel et al.162 reported a 0.7% rate of falling in a series of 1190 patients after total knee arthroplasty with a femoral CPNB. Unfortunately, none of these series included an adequate control group to determine the degree to which the CPNB itself contributed to falling after surgery.163–165 Importantly, a recent analysis166 of 3 multicenter studies involving a total of 171 patients155,167,168 reported 6 patients falling while receiving a postoperative continuous femoral nerve block with 0.2% ropivacaine and none in the control group receiving a perineural saline infusion.
The motor block typically resolves within a few hours after discontinuing the perineural infusion.169 Nevertheless, to avoid potential complications from motor weakness after upper- and lower-extremity surgery, it is recommended that the local anesthetic perineural infusion rate be limited to no more than 4 mL/h of 0.2% solution of bupivacaine, ropivacaine, or levobupivacaine.170 Anesthesiologists should (1) minimize the local anesthetic concentration,160 (2) reduce the volume of supplemental patient-controlled bolus doses, and (3) progressively reduce the “basal” (background) infusion rate to minimize motor blockade while providing an adequate sensory block.161,171 It is also recommended that patients use a knee immobilizer and walker/crutches during ambulation while receiving CPNBs,172 and that physical therapists, nurses, and orthopedic surgeons be educated regarding the possibility of CPNB-induced muscle weakness and the importance of “fall precautions.”
In a series of 620 outpatients who were treated with CPNB placed using ultrasound visualization and managed using a standardized protocol after orthopedic surgery, 2 patients experienced significant neurologic deficits after placement of the catheter in the popliteal fossa.173 Another potential problem is catheter dislodgment and spontaneous removal with ambulation.159 In a national survey involving 2476 patients, the cumulative incidence of catheter dislocation was 4.7%.174 The vast majority of problems related to outpatient perineural catheters can be handled over the telephone. However, there are potential complications of peripheral nerve catheter removal at home.175
Many adjunctive drugs are combined with local anesthetics to speed the onset, prolong the duration, and increase the intensity and success while also decreasing the possibility of local anesthetic toxicity associated with the use of PNB in the ambulatory setting. Although opioid agonists176 and partial agonists (buprenorphine,177 tramadol,178 ketamine,179 neostigmine,180 magnesium,181 dexamethasone182) have all been evaluated, the use of these adjuvants for CPNBs remains unproven.183,184 Current evidence185 only supports the use of epinephrine (to prolong the duration and to delay the systemic absorption of local anesthetic186) or clonidine.187
Although numerous studies and systematic reviews discuss the many advantages of the PNB138 and CPNB149,151,154,156,171,188,189 techniques for patients undergoing painful ambulatory procedures, very few studies have focused exclusively on elderly or cognitively impaired patients.148,152,157,163,164 Additional research is needed to demonstrate clinically meaningful benefits (e.g., shorter time to resumption of normal activities of daily living, reduced incidence of chronic postoperative pain) in the elderly outpatient undergoing ambulatory surgery.
Monitored Anesthesia Care and Local Anesthesia
In elderly patients scheduled for minor surgery or diagnostic procedures, monitored anesthesia care (MAC) is an excellent alternative to general and regional anesthesia because its use is typically associated with minimal changes in physiological and cognitive functioning.190,191 According to the American Society of Anesthesiologists (ASA), MAC refers to those clinical situations in which the patient remains conscious and able to protect the airway for the majority of the procedure.
Most commonly, MAC involves monitoring the cardiorespiratory system and the level of sedation in patients receiving local infiltration anesthesia at the incision site. Incision site and intra-articular local anesthetic infiltration techniques are simple, safe, and inexpensive methods for providing periprocedural anesthesia for a wide variety of surgical and/or diagnostic procedures.192 In addition, use of continuous wound catheters and disposable elastomeric pumps for delivering local anesthetics has been rediscovered as a technique for reducing pain after discharge.193,194
Guidelines for MAC in elderly patients have been published by Ekstein at al.195 Standard monitoring includes pulse oximetry, intermittent noninvasive arterial blood pressure, and continuous display of electrocardiogram and heart rate. Clinical signs of adequate spontaneous ventilation (e.g., maintenance of a patent airway and respiratory rate >10 beats per minute [bpm], hemoglobin oxygen saturation values >90%) must be continuously monitored because of the risk of ventilatory depression in the elderly. In spontaneously breathing patients, the measurement of end-tidal CO2 at the nasal oxygen cannula is useful for monitoring respiratory rate and apnea; however, the measured CO2 value is not reliable.
In elderly patients, the continuous assessment of sedation is important to minimize the risk of inadvertent deep sedation in which responses to verbal commands are not present and protective airway reflexes may be compromised.196 Sedation can be evaluated using the observer assessment of alertness and sedation or Ramsey scale, as well as a BIS monitor.197,198 IV anesthetic drugs (e.g., midazolam, etomidate, propofol, dexmedetomidine) are frequently used for sedation, either by intermittent bolus or by continuous IV infusion. Propofol produces a rapid and controllable sedation, and is associated with predictably rapid recovery of cognitive function and excellent patient acceptance.199,200 Propofol is generally the drug of choice for MAC sedation in the elderly outpatient population.199 However, both etomidate and dexmedetomidine are used in elderly patients at increased risk for cardiovascular depression with propofol.201–203 Although dexmedetomidine has the additional advantage over propofol and midazolam of providing analgesia, recovery from its sedative effects is significantly slower in the elderly population.200,202,203
Sedation may also be obtained by using combinations of sedative–analgesic drugs.204–208 Because elderly patients can be extremely sensitive to the central depressant effects of hypnotics, benzodiazepines, and opioids, the window for titrating these drugs is often small. Because subhypnotic doses of propofol do not reliably produce amnesia,209 small doses of midazolam (0.5 to 1 mg IV) can be administered before propofol sedation to obtain anxiolysis and anterograde amnesia.210 Target-controlled infusion of propofol for moderate sedation does not compromise respiration, but reduces sympathetic activity and baroreflex responses to hypotension.211 Midazolam also provides effective sedation and amnesia, but produces slower recovery than does propofol or dexmedetomidine.210,212 Midazolam combined with an opioid analgesic for brief diagnostic procedures can produce prolonged sedation in elderly patients.213
In comparison with general anesthesia, use of small doses of IV sedative–analgesic drugs for MAC anesthesia minimizes the adverse physiologic effects on major organ systems. More important, MAC techniques result in shorter recovery times than do either general or spinal anesthesia.118,119 As a result of the lower drug costs and early discharge home, MAC techniques are also more cost-effective for elderly surgical patients undergoing superficial operations.
PERIOPERATIVE SIDE EFFECTS AND COMPLICATIONS
Major morbidity and mortality after ambulatory surgery are surprisingly rare, even in the elderly population.38 According to Fleisher et al.,214 in 1997 only 1 in every 180 patients undergoing an outpatient procedure in New York required hospitalization for inadequate pain control or complications such as bleeding, nausea and vomiting, dizziness, adverse reaction to an anesthetic drug, or an irregular heartbeat. In the same study, only 19 of 783,558 outpatients studied died, a rate of 1 in 41,240. Age older than 65 years was one of the independent predictors of immediate hospital admission after ambulatory surgery. These data suggest that older outpatients with increasing comorbidities are at increased risk of admission to an inpatient facility after outpatient surgery.
In a large retrospective outpatient outcome study by Chung et al.,215 27% of the patients were older than 65 years. These investigators reported a 4.0% incidence of adverse events in the operating room, 9.6% in the PACU, and 7.9% in the ambulatory surgery unit. Not surprisingly, adverse cardiovascular events were more common in elderly patients with preexisting cardiovascular diseases. Adverse respiratory events in the elderly were usually associated with obesity, smoking, and asthma. In the previously mentioned study by Chung et al.,215 older patients were 4 times less likely to experience any adverse event; 10-fold less likely to complain about excessive pain, shivering and agitation; and 4-fold less likely to develop symptoms of nausea and vomiting and drowsiness in the PACU than were their younger (<65 years) counterparts. It is possible that the elderly are more tolerant of the various stimuli causing side effects such as pain, nausea, and vomiting, or perhaps they are simply more reluctant to complain to their health care providers. These differences may also relate to the different types of surgery and anesthesia between the elderly and younger ambulatory surgery populations in this study. For example, younger patients were more likely to undergo gynecological and orthopedic procedures, which more frequently cause postoperative pain and require the use of opioid analgesic, a factor that can also contribute to the increased incidence of PONV. In contrast, the elderly most commonly underwent ophthalmic procedures, which cause minimal postoperative pain. The latter explanation is supported by the results of a nationwide survey in Denmark involving older (>65 years) versus young outpatients all undergoing inguinal hernia repair in which the postoperative complication rate was actually significantly higher in the older patients (4.5% vs. 2.7%).115
Postoperative Delirium and Cognitive Dysfunction
More than 50 years ago, clinicians recognized that subtle changes in cognitive functioning occurred in up to 10% of elderly patients undergoing noncardiac surgery.216 POD is an acute temporary change in orientation and cognition, whereas POCD is a more subtle and persistent impairment in cognitive performance, typically assessed by formal testing.217,218 Clinical characteristics for these 2 postoperative cognitive disorders are found in Table 3. The incidence of POD is variable depending on the type of surgery, but is reported to occur in approximately 5%–15% of all elderly patients undergoing noncardiac surgery.219,220 POCD is present in 10%–13% of elderly patients at 3 months after noncardiac surgery.26,221 The socioeconomic and medical implications of both cognitive disorders can be profound.219,220 POD is associated with a longer, more costly hospital course and higher likelihood of death within the first 6 months after surgery or institutionalization.220 POCD is associated with increased mortality,222 risks of leaving the labor market prematurely, and dependency on social transfer (welfare) payments.26
Marcantonio et al.223 studied the risk factors associated with the development of POD. These authors identified 7 key predictors that could be used preoperatively to identify elderly patients at risk of developing delirium: (1) age older than 70 years, (2) self-reported alcohol abuse, (3) poor cognitive status, (4) poor functional status, (5) abnormalities of serum sodium, potassium, or glucose, (6) noncardiac thoracic surgery, and (7) abdominal aneurysm surgery. Current research suggests that decreased preoperative cognitive status and depression can also be useful in identifying patients at high risk for POD.27,28 The etiology of POCD is likely to be multifactorial and includes the patient's preoperative cognitive and physical status, as well as surgical and anesthesia factors. It is accepted that older patients (>60 years old) are at an increased risk for long-term cognitive problems.26 Other reported risk factors for POCD include lower educational level, a history of previous cerebral vascular accident with no residual impairment, and cognitive impairment at hospital discharge.26
It has been suggested that major versus minor surgery potentially contributes to the onset of POCD. In a large-scale study involving patients >60 years old undergoing minor surgery procedures, Canet et al.6 found that older patients had a lower incidence of POCD 1 week after surgery in the ambulatory setting than their counterparts who had undergone similar surgery procedures in an inpatient setting. However, the significant differences reported in the early postoperative period were not apparent at later assessments conducted between 22 days and 6 months after surgery. When compared with an earlier study in which elderly patients underwent major inpatient surgical procedures, the incidence of POCD at 7 days was significantly lower after minor surgery (6.8%) than after major surgery (25.8%) and similar to the incidence in control patients who did not have surgery. These findings suggest that minor operations performed in an outpatient setting have minimal impact on cognition in the elderly population.86
There is controversy as to whether anesthetic type influences cognitive outcomes. Sieber et al.224 randomized patients undergoing hip fracture surgery to spinal anesthesia with either light propofol sedation (depth of anesthesia with BIS ≥80) or deep sedation (i.e., IV general anesthesia with an average BIS of 50). Light sedation was associated with a 50% decrease in the incidence of POD after hip fracture surgery. Patients with better preoperative cognition were more likely to show a benefit from light levels of sedation. Although the results of this study are encouraging, it excluded patients with severe cognitive impairment.
Choice of anesthesia (general versus regional) has not been found to be a significant risk factor for POCD.85,225 A large international study found that the incidence of POCD at 1 week after general anesthesia was 19.7% in comparison with 12.5% after regional anesthesia, and at 3 months, POCD was found in 14.3% versus 13.9%, respectively.225 These investigators concluded that there was no association between general versus regional anesthesia and long-term POCD. Other factors such as inflammatory or metabolic (endocrine) stress responses associated with surgery may be responsible for the late changes that occurred in both anesthetic treatment groups.226 The investigators did note that these findings used the intention-to-treat approach, and if the per protocol approach was used, POCD was found to be significantly less common at 1 week after regional anesthesia. However, no difference was observed at 3 months after either general or regional anesthesia in this older surgical population.
Postoperative Nausea and Vomiting
PONV is less common in elderly surgical patients (Fig. 3).227 However, for some ambulatory procedures (e.g., brachytherapy) a high incidence of PONV has been reported even in low-risk populations (e.g., elderly males).228 It has long been recognized that patient, anesthetic, and surgical factors all contribute to the persistently frequent incidence of emetic symptoms in the ambulatory setting.229 With the increasing emphasis on earlier mobilization and discharge (fast tracking) after minor operations, postoperative factors such as postural hypotension due to inadequate hydration and the use of oral opioid-containing analgesics as rescue analgesics have become more important contributing factors to nausea and vomiting in the postdischarge period.230
Patients undergoing neurological, head or neck, or abdominal (laparoscopic) procedures received antiemetic rescue medication significantly more often in the PACU than patients undergoing integumentary, musculoskeletal, or superficial surgery.231 Female, nonsmoker, history of PONV or motion sickness, anesthesia duration, and intraoperative or postoperative opioid administration were also significantly associated with antiemetic administration after admission to the PACU. Sinclair et al.232 did an extensive analysis of a large outpatient database and identified the following independent predictors of PONV: age, type of anesthesia, gender, type of operative procedure (e.g., gynecologic laparotomy), and duration of surgery. Subsequently, Apfel et al.233 developed a simple scoring system that identified 4 primary predictors of risk: female sex, nonsmoking status, history of PONV or motion sickness, and use of postoperative opioid analgesics. The number of preexisting risk factors that patients presented with before surgery was directly related to the incidence of nausea and vomiting in the postoperative period.
These well-known risk factors have been integrated into guideline-supported treatment algorithms for PONV.234–236 The use of these risk factors as a guide for the management of surgical patients requiring antiemetic prophylaxis has been associated with a lower incidence of PONV in comparison with a nonselective approach to providing prophylaxis.237,238 However, one study involving high-risk patients found a high incidence of PONV despite the frequent use of multiple antiemetic drugs for prophylaxis.239 Interestingly, surgeon experience has been found to influence the incidence of emetic sequelae after ear, nose, and throat surgery.240 The likely explanation is that more highly skilled surgeons have shorter operating times and the duration of surgery has been previously shown to influence the incidence of PONV in the ambulatory setting.229
The original Apfel criteria are less predictive of postdischarge nausea and vomiting (PDNV).241 Administration of opioid analgesics and occurrence of emesis in the PACU are both predictive of PDNV.242 Use of PNBs and/or local infiltration anesthesia (LIA) (i.e., MAC techniques) is associated with a lower incidence of emetic sequelae than is general (volatile) anesthesia.118,119,150 The most important factor for reducing PDNV may be minimizing the perioperative use of opioid analgesics by using a multimodal analgesic approach as described in the next section.243 Thagaard et al. found that 30 mg of IV ketorolac provided better analgesia and antiemesis than did 4 mg of IV dexamethasone or 12 mg IM betamethasone.244 The use of sympatholytic drugs (e.g., esmolol, labetalol), α-2 agonist/antagonists, and even ketamine to control transient autonomic responses during surgery can reduce postoperative emetic sequelae due to their anesthetic and opioid-sparing effects.245–247 The use of propofol (vs inhalation anesthetics) for induction and maintenance of anesthesia reduces the risk of developing PONV in the early postoperative period.248,249 Improving the titration of volatile anesthetics by using a BIS monitor reduced the emetic sequelae after ambulatory surgery and accelerated the recovery process.250,251
Severe pain requiring opioid analgesics, hypotension due to inadequate hydration, premature ambulation and movement, and forcing oral fluids can all increase the risk of PONV.252 For example, a liberal (40 mL/kg) versus restrictive (15 mL/kg) approach to perioperative IV hydration of outpatients undergoing laparoscopic cholecystectomy was found to improve organ function in the postoperative period, reduce emetic sequelae, and shortened the length of stay in the PACU and the time to discharge home.253
A wide variety of antiemetic drugs are available for the prevention and treatment of PONV and PDNV, including antihistamines, sympathomimetics, anticholinergics, dopamine antagonists, serotonin antagonists, and neurokinin-1 antagonists.254 In a large multicenter study comparing 3 commonly used generic antiemetics—namely, ondansetron, dexamethasone, and droperidol—Apfel et al.255 demonstrated that each drug reduced the risk for nausea and vomiting by approximately 25%. Using a multimodal management strategy with routine antiemetic prophylaxis for a high-risk outpatient population, Scuderi et al.256 demonstrated an increase in the level of patient satisfaction in comparison with symptomatic (rescue) treatment.
A prospective observational study of treatments, outcomes, and patterns of care (POST-OP[c]) was conducted239 using the guidelines for managing PONV and PDNV published by the Society for Ambulatory Anesthesia,234 the American Society of Peri Anesthesia Nurses,231 and the ASA.236 Only 61% of clinicians adhered to the ASA guideline recommendations for prophylaxis, even in high-risk patients. When the physicians complied, the incidence of PONV and PDNV was significantly reduced. Nevertheless, in high-risk patients who had received 2 or more prophylactic antiemetic drugs, 29% of the patients vomited in the first 72 hours, almost 60% complained of moderate-to-severe nausea, and another 60% required rescue antiemetic medication, either in the hospital or after being discharged. Importantly, 40% of these patients reported that emetic sequelae interfered with their postoperative recovery.
For elderly outpatients with known risk factors for PONV undergoing highly emetogenic procedures, use of propofol for maintenance of anesthesia or sedation, nonopioid analgesics and routine antiemetic prophylaxis using dexamethasone (4 mg) and low-dose droperidol (0.625 mg) after induction of anesthesia and/or ondansetron (4 mg) at the end of surgery is a cost-effective multimodal therapy for preventing PONV and PDNV.238
Postoperative Pain Management
In an effort to minimize the adverse effects of opioid analgesics in the elderly, “balanced” (or multimodal) analgesic techniques involving the use of smaller doses of potent opioids in combination with nonopioid analgesic drugs including local anesthetics and nonsteroidal anti-inflammatory drugs (NSAIDs) have become increasingly popular during and after ambulatory surgery.243,257 The beneficial role of multimodal analgesia for ambulatory surgery was originally described in younger outpatients undergoing gynecological surgery258 and cholecystectomy procedures.259 Both of these early clinical studies documented the benefits of LIA at the surgical site in combination with NSAIDs for improving recovery. Recent multimodal analgesia studies by White et al.260,261 found additional beneficial effects on recovery after ambulatory surgery by extending the use of either ibuprofen or the more selective NSAID, celecoxib, into the postdischarge period. Few clinical studies have evaluated the efficacy of multimodal analgesia in the elderly undergoing ambulatory surgery. However, the clinical efficacy of multimodal postoperative analgesia in elderly inpatients suggests that similar benefits may result for the elderly outpatients undergoing ambulatory procedures.
The key components of a multimodal analgesic regimen include acetaminophen, NSAIDS, glucocorticoid steroids, local anesthetics, nontraditional analgesic drugs (e.g., ketamine, clonidine, gabapentanoids), and even nonpharmacological techniques.257
Acetaminophen has a long history of safe use for oral analgesia in the elderly.262 When metabolism and excretion of acetaminophen were compared in elderly and younger adults, dosage adjustments were not recommended despite a reduced clearance rate in the elderly.263 Interestingly, there is a report involving doses of 6 g/d in elderly patients without evidence of any adverse effects.264 Both oral (1.5 g) and IV acetaminophen (1 g) are effective before and after ambulatory surgery. Oral acetaminophen, 1 g qid, is effective as part of a multimodal regimen and is well tolerated in the elderly outpatient undergoing an ambulatory surgery procedure.
The efficacy of NSAIDs (e.g., ketorolac) for the prevention of postoperative pain and reducing the opioid analgesic requirement and opioid-related side effects is well documented.265 The potential occurrence of side effects (e.g., gastrointestinal bleeding, thrombotic events) with more extended use of NSAIDs in the perioperative period is a consideration in the elderly.266 The more selective cyclo-oxygenase (COX)–II inhibitors have been shown to reduce, but not eliminate, the risk of gastrointestinal side effects.267
The risk of experiencing an acute cardiovascular event is well established with long-term therapy involving the COX-II selective NSAIDs. However, in a prospective randomized study involving >1000 noncardiac surgery patients, Nussmeier et al.268 reported that COX-II inhibitors were useful adjuncts to opioid analgesics for the treatment of postoperative pain without increasing the risk of cardiovascular events. Additional studies are needed to establish the safety profile of short-term administration of COX-II selective NSAIDs after ambulatory surgery in elderly patients with known atherosclerotic cardiovascular disease. In a meta-analysis assessing the risk of cardiovascular events associated with the perioperative administration of COX-II inhibitors after noncardiac surgery, Schug et al.269 found no increase in the risk of cardiovascular complications even when stratifying for cardiac risk factors.
The COX-II-selective NSAIDs have less effect on platelet function and thus may be associated with a lower risk for postoperative bleeding. However, after general surgery procedures with a low risk of postoperative hemorrhage, the use of traditional nonselective NSAIDs may be a more cost-effective alternative to the COX-II selective NSAIDs.261 These investigators found that ibuprofen (1.2 g/d) compared favorably to celecoxib (400 mg/d) as part of a multimodal pain management strategy after major ambulatory surgery procedures with respect to the patient's quality of recovery scores and satisfaction with their postoperative pain management. The incidence of postoperative constipation was significantly higher in the placebo (control) group (28%) than in the celecoxib (5%) and ibuprofen (7%) groups. There are also concerns about the effects of COX-II-selective NSAIDs on bone healing, based on animal models of bone healing.270 Nevertheless, the benefits of using a combination of NSAIDs and acetaminophen for postoperative pain management have been extensively documented in the literature.271 A recent meta-analysis by Ong et al.272 concluded that the combination of acetaminophen (paracetamol) and an NSAID offers superior postoperative pain control in comparison with either drug alone.
Although the beneficial effect of a single IV dose of dexamethasone (4 to 8 mg IV) in reducing the risk for PONV is well documented,273 a single dose of glucocorticoid steroid also reduces pain after ambulatory surgery procedures.274,275 In outpatients undergoing breast surgery, Hval et al.275 reported that use of a higher dose of dexamethasone (16 mg IV) as part of a multimodal regimen provided prolonged postoperative analgesia lasting up to 72 hours after surgery. Romundstad et al.276 showed that a single dose of methylprednisolone, 125 mg IV, given before breast augmentation surgery had analgesic effects comparable to a parenteral COX-II inhibitor, as well as reduced nausea, vomiting, and fatigue after surgery. However, a preliminary communication by Czarnetzki et al. suggested that postoperative bleeding may be increased in patients receiving dexamethasone for tonsillectomy procedures.277 Interestingly, a meta-analysis involving the use of steroids during coronary artery bypass surgery failed to find any safety concerns with respect to postoperative bleeding. These authors reported that dexamethasone reduced the risk of new onset atrial fibrillation, postoperative bleeding, length of stay, and mortality.278 Because of the slow onset of action and uncomfortable perineal pain occasionally associated with the IV administration of dexamethasone, it should be administered after induction of anesthesia.
The adjunctive administration of local anesthetics during both general anesthesia and MAC is increasingly popular for day-case surgery in the elderly. Open hernia repair is a superficial surgical procedure that can be effectively managed with LIA279 or a combination of local infiltration and a peripheral ilioinguinal–iliohypogastric nerve block.146 In a meta-analysis published in 2005, Ong et al. reported that local anesthetic wound infiltration reduced analgesic consumption and time to first request for a rescue analgesic.280 Intra-articular injection of local anesthetics provides postoperative analgesia after knee arthroscopy.281 However, more recent studies have suggested that local infiltration at the portals is as effective as intra-articular administration, and may reduce the risk of chondro-toxic effects of local anesthetics.282
A variety of adjuncts to local anesthetics have been studied to improve and prolong the duration of local analgesia. The utility of adding epinephrine to prolong local analgesia has been known for many years.283 Limited (and controversial) evidence suggests that intra-articular morphine improves control of pain after knee arthroscopy.284 Adding a small amount of an opioid analgesic to a local anesthetic solution may enhance the success rate and prolong the duration of analgesia after central and peripheral blocks.285,286 However, opioid-related side effects (e.g., nausea, vomiting, pruritis, and urinary retention) are often increased. The addition of a small dose of clonidine to local anesthetic improves and prolongs the duration of local analgesia but may be associated with an increased risk of hypotension, fainting, and sedation in elderly outpatients.287 For LIA, ketorolac is often added to local anesthetics to improve the quality of postoperative analgesia.288–290 However, no major differences were found between systemic and local administration of NSAIDs in patients undergoing hernia repair or anorectal procedures.291,292 Glucocorticoids (e.g., methylprednisolone, dexamethasone) enhance the effects of local anesthetics by improving and prolonging postoperative local analgesia.182
Recent reports suggest major beneficial effects of LIA after major joint replacement surgery,288–290 which has become an ambulatory procedure with the introduction of minimally invasive surgical approaches. The most popular LIA technique involves the periarticular infiltration of a high-volume, low-concentration mixture of ropivacaine (0.2%), ketorolac (30 mg), and epinephrine (10 μg/mL). A volume of 150 to 200 mL is typically injected after the analgesic mixture is diluted with normal saline, to deliver the drug mixture reliably throughout the surgical field. To minimize the risk of local anesthetic toxicity, the total dose of ropivacaine is limited to a maximum of 300 mg.289,293
As was mentioned earlier, the use of continuous local wound infiltration and perineuronal (i.e., CPNB) infusion techniques for postoperative pain management can prolong the local analgesic effects into the postdischarge period. The widespread availability of less costly disposable catheters and drug reservoirs with elastomeric pumps has facilitated the usefulness of this technique after painful upper- and lower-extremity orthopedic procedures in the ambulatory setting.294–296 The meta-analysis by Liu et al. confirmed the efficacy of continuous wound catheters for improving postoperative analgesia, reducing the need for opioid rescue medications and opioid-related side effects, while increasing patient satisfaction.194 With catheter placement guided by nerve stimulation or ultrasound, the safety and efficacy of PNB techniques has improved. However, the risk associated with prolonged local anesthetic blocks (e.g., possible nerve damage, bleeding/hematoma, and catheter infections) and the ability of an elderly patient to manage these systems outside the hospital may be an obstacle to more widespread use in the ambulatory setting. The possibility of “tele-robotic ultrasound-guided blocks” may become an option for practitioners in remote hospitals with limited experience in performing CPNB procedures.297
Recent studies suggest beneficial postoperative effects from a simple perioperative IV infusion of lidocaine (1 to 1.5 mg/kg/h) in older outpatients undergoing laparoscopic colectomy procedures.298 In a recent systematic review, lidocaine infusion was shown to have both intra- and postoperative beneficial effects, including reduced pain, faster resumption of bowel function, and shorter hospital stay.299
Nontraditional Analgesic Drugs and Techniques
Several nontraditional analgesic drugs have been used for improving postoperative pain management. For example, small doses of ketamine have been alleged to reduce early postoperative pain and the development of chronic pain. In a recent study of opioid-dependent patients undergoing spine surgery, Loftus et al. showed that a low-dose ketamine infusion during surgery reduced opioid consumption and pain scores at 24 hours and 6 weeks after the operation.300 Remerand et al. also reported that a 24-hour low-dose ketamine infusion had positive effects as part of a multimodal analgesia regimen, facilitating rehabilitation at 1 month and decreasing chronic pain at 6 months after joint replacement surgery.301
Evidence supports the clinical efficacy of gabapentanoid compounds as part of a multimodal analgesic regimen in the perioperative period. Although Adam et al.302 reported no beneficial effect of a single 600-mg dose of gabapentin administered preoperatively to outpatients who also received a PNB for shoulder extremity surgery,302 Turan et al. reported that gabapentin 1.2 g P.O. given before ear, nose, and throat surgery exhibited both intra- and postoperative analgesic effects.303 Gilron et al. reported that gabapentin 1.2 g/d orally for 3 days after laparoscopic cholecystectomy was as effective as meloxicam 15 mg,304 and Turan et al.305 found that a similar dosing regimen of gabapentin had comparable effects to the COX-II inhibitor rofecoxib in women undergoing abdominal hysterectomy procedures. Buvanendran et al. reported similar short- and long-term benefits with pregabalin when an initial 300-mg dose was administered before surgery, followed by 50 to 150 mg/d for 14 days after surgery.306 Unfortunately, increased postoperative sedation and dizziness may limit the utility of pregabalin in elderly patients undergoing ambulatory surgery.303,306
The perioperative effects of α-2-agonists have long been recognized.246,307 In addition to their intraoperative anesthetic-sparing effect, these compounds can reduce the opioid requirement in the postoperative period in the elderly. The beneficial effects of clonidine premedication include sedation, decreased postoperative pain, and faster emergence from anesthesia.308 Tufanogullari et al. showed that adjunctive use of an intraoperative dexmedetomidine infusion (0.2 to 0.8 μg/kg/h) during laparoscopic bariatric surgery decreased perioperative fentanyl use, postoperative antiemetic requirements, and reduced the length of the PACU stay. However, its use failed to facilitate late recovery (e.g., return of normal bowel function) or improve the patients' overall quality of recovery.309
White et al. have reported beneficial effects of intraoperative esmolol infusion in patients undergoing ambulatory surgery procedures.245,310 The benefits of faster emergence from anesthesia, less postoperative pain, decreased emesis, and earlier discharge have been confirmed by Collard et al.311 and others.312 Although the routine use of longer-acting β-blocking drugs in nonregular users of these drugs has recently been questioned,313 there are no data demonstrating adverse effects related to the intraoperative use of shorter-acting β-blockers in the elderly population undergoing ambulatory surgical procedures.314
The use of “alternative” analgesic therapies could also provide beneficial effects in the elderly ambulatory population because of their simplicity and lack of side effects.315 For example, transcutaneous electrical stimulation and transcutaneous acupoint electrical stimulation have been found to produce opioid-sparing effects and reductions in opioid-related side effects.316,317 Unfortunately, the feasibility of using these techniques in the postdischarge period may be problematic in the elderly population because of technical issues.
In the future, multimodal analgesic regimens will include an even wider variety of central and peripheral-acting opioid and nonopioid analgesic compounds. However, minimal postoperative discomfort should be achievable for the majority of elderly outpatients undergoing ambulatory surgical procedures at the present time if practitioners implement existing evidence-based multimodal analgesic regimens involving both central and peripheral-acting analgesic drugs, as well as nontraditional analgesic therapies.315 The aim of the analgesic technique should be not only to lower the pain scores and opioid analgesic requirement, but more important to facilitate earlier mobilization and rehabilitation of the elderly surgical patient by reducing complications after discharge home. Despite the increased use of multimodal analgesic regimens, a recent study from Sweden reported that 40% of the patients undergoing minor ambulatory surgery procedures (e.g., hernia repair, arthroscopy, cosmetic surgery) experienced pain or mobility problems at 1 week, 28% after 2 weeks, and 20% at 4 weeks postdischarge.318
KEYS TO FUTURE EXPANSION OF AMBULATORY SURGERY FOR THE ELDERLY
There are clear advantages for hospitals, patients, payers, and society-at-large in treating elderly surgical patients on an ambulatory basis. Moreover, a prospective, randomized study comparing patient satisfaction after knee reconstructive surgery performed on an inpatient versus outpatient basis confirmed that older patients preferred the ambulatory setting.319 Therefore, it is important to consider the factors that will be crucial for expanding ambulatory surgery to an aging society in the years ahead.
Although cost containment has been the major driving force for the growth in ambulatory surgery, the economic benefits related to avoiding hospitalization after surgery must be balanced against the additional costs associated with unplanned hospital admissions to treat postoperative complications, as well as the increased need for postoperative medical and social support in extended care facilities and the home environment. In addition to selecting the best anesthetic and analgesic technique on a procedure-selective basis (Table 4), it is necessary to implement evidence-based clinical and social criteria for optimizing preoperative preparation and recovery after ambulatory surgery. When dealing with elderly surgical patients, careful preoperative planning for postoperative home care assumes increased importance. Providing a comfortable setting for the elderly surgical patient is also important because preoperative anxiety (distress) has been found to contribute to the severity of postoperative pain, nausea, and fatigue for up to 1 week after an elective operation.52
A growing body of literature supports the claim that even elderly patients with significant comorbidities, with the exception of acute heart failure,57,320 can successfully undergo ambulatory surgery procedures.38,321 When ambulatory surgery is performed by a skilled perioperative care team, minimizing operative duration and tissue trauma,46,322 age per se and preexisting medical conditions should not preclude an elderly patient from undergoing ambulatory surgery.323 However, there is a clear need for additional data on the influence of the elderly patient's preoperative functional status324 (i.e., ability to maintain basic activities of daily life, degree of autonomy, and cognitive, psychological, and nutritional status) on postoperative outcomes. Whereas there are studies investigating this issue in elderly patients undergoing inpatient procedures,325,326 no studies have been conducted in the ambulatory setting except for the previously mentioned POD/ POCD study.36
It is widely accepted in the anesthesia community that poor baseline functional status in elderly patients increases their risk of an adverse outcome after ambulatory surgery. Worsening functional status caused by perioperative hospitalization, and the consequent loss of autonomy and risk of institutionalization, plays an important role in determining the long-term outcome of surgery.327 The peer-reviewed literature328–331 suggests that bed rest induces functional decline in elderly patients after merely 2 days of hospitalization. Paradoxically, the worse the patient's functional status is preoperatively, the greater the expected benefit of avoiding hospitalization. Nevertheless, there is general agreement that elderly patients scheduled for surgery in an ambulatory unit should be reasonably fit and any underlying medical conditions should be well controlled. Future studies are needed to determine whether it is better to treat frail individuals as outpatients, with the risk of falling and other postsurgical complications after returning to their home, or as an inpatient with the attendant risk of loss of autonomy, POCD, and nosocomial infectious and thrombotic complications, as well as functional decline due to bed rest and hospitalization.
It has recently been reported in the US332 that when copayments for ambulatory care are increased, elderly patients (and especially those of low socioeconomic status with chronic illnesses) often forgo important outpatient care, leading to increased use of hospital and emergency room services. Considering that a lack of financial resources is a worldwide problem, and that copayments are often introduced as a means of reducing costs to hospitals and third-party payers, the long-term effect of these economic factors deserves more careful consideration with the aging surgical population presenting for elective surgery. Technological advancements in surgery and anesthesia will contribute to the future expansion of ambulatory surgery services for elderly patients. With the expected growth in minimally invasive, robotic surgery, and telemedicine, as well as improved anesthetic and analgesic techniques (e.g., ultrasound-guided nerve block procedures, long-acting local anesthetics [depo-bupivacaine]), ambulatory surgery for the elderly will continue to grow. New anesthetic and analgesic drugs (e.g., sugammadex, depo-bupivacaine) have the potential to reduce morbidity by facilitating a faster recovery for elderly patients.333 However, these technological advances must be made available at a reasonable cost to the patient and the health care system.
Several articles334–336 suggest that the use of mobile health systems and home telemedicine can lead to improved follow-up care after ambulatory surgery in the elderly. These systems are based on a mobile phone with built-in camera, which allows patients and their caregivers to send pictures of the surgical wound, blood pressure, heart rate, and pulse oximetry measurements to a hospital server. A trained professional reviews the data to assess the situation and resolve the concerns of the patient and/or their caregiver (e.g., hematomas or blood stained dressing, managing hypertensive or syncopal episodes due to sudden ambulation or arrhythmia). These systems may reduce the incidence of complications and unnecessary emergency room visits. In studies of telemedicine systems, patients reported feeling more secure and were highly satisfied using these systems in their home.334,336 Elderly outpatients undergoing ambulatory procedures can benefit from this emerging technology if it is made more widely available and is intuitively easy to use after discharge by patients and/or their caregivers.
The aging population also has significant implication for the anesthesia and surgical workforce in the future. Etzioni et al.337 analyzed the impact on the demand for specific surgical services. These investigators reported that the numbers of ophthalmologic, cardiothoracic, urological, and general surgery procedures will likely increase at a rate exceeding overall population growth rate (Fig. 4). The ability of ancillary health care workers to manage the postoperative complications and side effects associated with the common ambulatory surgical procedures in the elderly (Table 1) outside the hospital environment will assume greater importance as the population ages.
Formulating a careful plan for postdischarge care on the basis of the patient's functional status should be undertaken during the perioperative period to assure effective communication among the patient, family, and health care providers. An effective organization for providing home health nursing care should be an integral part of the care plan for the elderly surgical population. This plan should identify and resolve age-related communication barriers, while incorporating provisions based on the patient's physical and medical condition and need for psychological support.338 Elderly patients often face isolation from family and long-time friends, hearing and visual impairment, financial constraints, and emotional issues, which present unique challenges in expanding access to ambulatory surgical services for these patients in the future.
In conclusion, as ambulatory surgery continues to expand in our aging society, implementing evidence-based perioperative care programs for the elderly will assume increased importance. A recent study involving “elderly elderly” patients reported that postoperative ambulatory status is an important determinant of mortality in this growing surgical population.339 Given the recent advances in anesthesia, surgery, and monitoring technology, the ambulatory setting offers many potential advantages for the elderly patient requiring elective surgery.
Name: Paul F. White, PhD, MD, FANZCA.
Contribution: This author contributed material and has read and approved several different versions of this manuscript.
Name: Lisa M. White, BA.
Contribution: This author contributed material and has read and approved several different versions of this manuscript.
Name: Terri Monk, MD.
Contribution: This author contributed material and has read and approved several different versions of this manuscript.
Name: Jan Jakobsson, MD, PhD.
Contribution: This author contributed material and has read and approved several different versions of this manuscript.
Name: Johan Raeder, MD, PhD.
Contribution: This author contributed material and has read and approved several different versions of this manuscript.
Name: Michael F. Mulroy, MD.
Contribution: This author contributed material and has read and approved several different versions of this manuscript.
Name: Laura Bertini, MD.
Contribution: This author contributed material and has read and approved several different versions of this manuscript.
Name: Giorgio Torri, MD, PhD.
Contribution: This author contributed material and has read and approved several different versions of this manuscript.
Name: Maurizio Solca, MD.
Contribution: This author contributed material and has read and approved several different versions of this manuscript.
Name: Giovanni Pittoni, MD.
Contribution: This author contributed material and has read and approved several different versions of this manuscript.
Name: Gabriella Bettelli, MD.
Contribution: This author contributed material and has read and approved several different versions of this manuscript. She organized annual anesthesia meetings dedicated to day-surgery for the elderly in Ancoma, Italy from 2008–2010.
This manuscript was handled by: Steven L. Shafer, MD, and Peter S. A. Glass, MB, ChB.
We would like to thank Dr. Matthew Eng for his invaluable assistance with proofreading this manuscript and formatting the figures and tables.
1. Lutz W, Sanderson W, Scherbov S. The coming acceleration of global population ageing. Nature 2008;451:716–9
2. Valvona J, Sloan F. Rising rates of surgery among the elderly. Health Aff 1985;4:108–19
3. Waldo DR, Lazenby HC. Demographic characteristics and health care use and expenditures by the aged in the United States: 1977–1984. Health Care Financ Rev 1984;6:1–29
4. Owings MF, Kozak LJ. Ambulatory and inpatient procedures in the United States, 1996. Vital Health Stat 1998;139:1–119
5. White PF. Past, present, and future. In: White PF, ed. Ambulatory Anesthesia & Surgery. London: WB Saunders, 1997:3–34
6. Canet J, Raeder J, Rasmussen LS, Enlund M, Kuipers HM, Hanning CD, Jolles J, Korttila K, Siersma VD, Dodds C, Abildstrom H, Sneyd JR, Vila P, Johnson T, Munoz CL, Silverstein JH, Nielsen IK, Moller JT. Cognitive dysfunction after minor surgery in the elderly. Acta Anaesthesiol Scand 2003;47:1204–10
7. Castells X, Alonso J, Castilla M, Ribó C, Cots F, Antó JM. Outcomes and costs of outpatient and inpatient cataract surgery: a randomised clinical trial. J Clin Epidemiol 2001;54:23–9
8. Rivera R, Antognini JF. Perioperative drug therapy in elderly patients. Anesthesiology 2009;110:1176–81
9. Prough DS. Anesthetic pitfalls in the elderly patient. J Am Coll Surg 2005;200:784–94
10. Henry CJ. Mechanisms of changes in basal metabolism during ageing. Eur J Clin Nutr 2000;54(suppl 3):S77–91
11. VanSomeren EJ, Raymann RJ, Scherder EJ, Daanen HA, Swaab DF. Circadian and age-related modulation of thermoreception and temperature regulation: mechanisms and functional implications. Ageing Res Rev 2002;1:721–78
12. Jani B, Rajkumar C. Ageing and vascular ageing. Postgrad Med J 2006;82:357–62
13. Brandes RP, Fleming I, Busse R. Endothelial aging. Cardiovasc Res 2005;66:286–94
14. Priebe HJ. The aged cardiovascular risk patient. Br J Anaesth 2000;85:763–78
15. Grobin L. Diastolic dysfunction in the older heart. J Cardiothorac Vasc Anesth 2005;19:228–36
16. Rooke GA. Cardiovascular aging and anesthetic implications. J Cardiothorac Vasc Anesth 2003;17:512–23
17. Lakatta EG. Alterations in the cardiovascular system that occur in advanced age. Fed Proc 1979;38:163–7
18. Monahan KD. Effect of aging on baroreflex function in humans. Am J Physiol Regul Integr Comp Physiol 2007;293:R3–12
19. Sprung J, Gajic O, Warner DO. Review article: age related alterations in respiratory function—anesthetic considerations. Can J Anaesth 2006;53:1244–57
20. Qaseem A, Snow V, Fitterman N, Hornbake ER, Lawrence VA, Smetana GW, Weiss K, Owens DK, Aronson M, Barry P, Casey DE Jr, Cross JT Jr, Sherif KD, Weiss KB. Risk assessment for and strategies to reduce perioperative pulmonary complications for patients undergoing noncardiothoracic surgery: a guideline from the American College of Physicians. Ann Intern Med 2006;144:575–80
21. Gourtsoyiannis N, Prassopoulos P, Cavouras D, Pantelidis N. The thickness of the renal parenchyma decreases with age: a CT study of 360 patients. Am J Roentgenol 1990;155:541–4
22. Aymanns C, Keller F, Maus S, Hartmann B, Czock D. Review on pharmacokinetics and pharmacodynamics and the aging kidney. Clin J Am Soc Nephrol 2010;5:314–27
23. Schmucker DL. Age-related changes in liver structure and function: implications for disease? Exp Gerontol 2005;40: 650–9
24. Akiyama H, Meyer JS, Mortel KF, Terayama Y, Thornby JI, Konno S. Normal human aging: factors contributing to cerebral atrophy. J Neurol Sci 1997;152:39–49
25. Peters A. Structural changes that occur during normal aging of primate cerebral hemispheres. Neurosci Biobehav Rev 2002;26:733–41
26. Monk TG, Weldon BC, Garvan CW, Dede DE, van der Aa MT, Heilman KM, Gravenstein JS. Predictors of cognitive dysfunction after major noncardiac surgery. Anesthesiology 2008;108:18–30
27. Greene NH, Attix DK, Weldon BC, Smith PJ, McDonagh DL, Monk TG. Measures of executive function and depression identify patients at risk for postoperative delirium. Anesthesiology 2009;110:788–95
28. Smith PJ, Attix DK, Weldon BC, Greene NH, Monk TG. Executive function and depression as independent risk factors for postoperative delirium. Anesthesiology 2009;110:781–7
29. Sadean MR, Glass PS. Pharmacokinetics in the elderly. Best Pract Res Clin Anaesthesiol 2003;17:191–205
30. Tang J, Eckenhoff MF, Eckenhoff RG. Anesthesia and the old brain. Anesth Analg 2010;110:421–6
31. Vuyk J. Pharmacodynamics in the elderly. Best Pract Res Clin Anaesthesiol 2003;17:207–18
32. Barnett SR. Polypharmacy and perioperative medications in the elderly. Anesthesiol Clin 2009;27:377–89
33. Hajjar ER, Hanlon JT, Artz MB, Lindblad CI, Pieper CF, Sloane RJ, Ruby CM, Schmader KE. Adverse drug reaction risk factors in older outpatients. Am J Geriatr Pharmacother 2003;1:82–9
34. Gosain A, DiPietro LA. Aging and wound healing. World J Surg 2004;28:321–6
35. Grishko V, Xu M, Wilson G, Pearsall AW. Apoptosis and mitochondrial dysfunction in human chondrocytes following exposure to lidocaine, bupivacaine, and ropivacaine. J Bone Joint Surg Am 2010;92:609–18
36. Steinmetz J, Rasmussen LS. The elderly and general anesthesia. Minerva Anestesiol 2010;76:745–52
37. Gupta A. Strategies for outpatient anaesthesia. Best Pract Res Clin Anaesthesiol 2004;18:675–92
38. Shnaider I, Chung F. Outcomes in day surgery. Curr Opin Anaesthesiol 2006;19:622–9
39. McGory ML, Kao KK, Shekelle PG, Rubenstein LZ, Leonardi MJ, Parikh JA, Fink A, Ko CY. Developing quality indicators for elderly surgical patients. Ann Surg 2009;260:338–47
40. Jakobsson J. Ambulatory anaesthesia: there is room for further improvements of safety and quality of care—is the way forward further simple but evidence-based risk scores? Curr Opin Anaesthesiol 2010;23:679–81
41. Jin F, Chung F. Minimizing perioperative adverse events in the elderly. Br J Anaesth 2001;87:608–24
42. Bryson GL, Chung F, Finegan BA, Friedman Z, Miller DR, van Vlymen J, Cox RG, Crowe M-J, Fuller J, Henderson C. Patient selection in ambulatory anesthesia—an evidence-based review: part I. Can J Anaesth 2004;51:768–81
43. Bryson GL, Chung F, Cox RG, Crowe M-J, Fuller J, Henderson C, Finegan BA, Friedman Z, Miller DR, van Vlymen J. Patient selection in ambulatory anesthesia—an evidence-based review: part II. Can J Anaesth 2004;51:782–94
44. Fleisher LA, Pasternak RL, Herbert R, Anderson GF. Inpatient hospital admission and death after outpatient surgery in elderly patients. Importance of patient and system characteristics and location of care. Arch Surg 2004;139:67–72
45. Lermitte J, Chung F. Patient selection in ambulatory surgery. Curr Opin Anaesthesiol 2005;18:598–602
46. Bettelli G. Anaesthesia for the elderly outpatient: preoperative assessment and evaluation, anaesthetic technique and postoperative pain management. Curr Opin Anaesthesiol 2010;23:726–31
47. Kooij FO, Klok T, Hollmann MW, Kal JE. Decision support increases guideline adherence for prescribing postoperative nausea and vomiting prophylaxis. Anesth Analg 2008;106:893–8
48. Fisher SP. Development and effectiveness of an anesthesia preoperative evaluation clinic in a teaching hospital. Anesthesiology 1996;85:196–206
49. Van Klei WA, Hennis PJ, Moen J, Kalkman CJ, Moons KGM. The accuracy of trained nurses in pre-operative health assessment: results of the OPEN study. Anaesthesia 2004;59:971–8
50. Yen C, Tsai M, Macario A. Preoperative evaluation clinics. Curr Opin Anaesthesiol 2010;23:167–72
51. Lee A, Lum ME, Perry M, Beehan SJ, Hillman KM, Bauman A. Risk of unanticipated intraoperative events in patients assessed at a preanaesthetic clinic. Can J Anaesth 1997;44:946–54
52. Montgomery GH, Schnur JB, Erblich J, Diefenbach MA, Bovbjerg DH. Presurgery psychological factors predict pain, nausea, and fatigue one week after breast cancer surgery. J Pain Symptom Manage 2010;39:1043–52
53. Chung F, Yuan H, Yin L, Vairavanathan S, Wong TD. Elimination of preoperative testing in ambulatory surgery. Anesth Analg 2009;108:467–75
54. Imasogie N, Wong DT, Luk K, Chung F. Elimination of routine testing in patients undergoing cataract surgery allows substantial savings in laboratory costs. A brief report. Can J Anaesth 2003;50:246–8
55. Robertshaw HJ, McAnulty GR, Hall GM. Strategies for managing the diabetic patient. Best Pract Res Clin Anaesthesiol 2004;18:631–43
56. Ata A, Lee J, Bestle SL, Desemone J, Stain SC. Postoperative hyperglycemia and surgical site infection in general surgery patients. Arch Surg 2010;145:858–64
57. The Task Force for Preoperative Cardiac Risk Assessment and Perioperative Cardiac Management in Non-Cardiac Surgery of the European Society of Cardiology (ESC) and Endorsed by the European Society of Anaesthesiology (ESA). Guidelines for pre-operative cardiac risk assessment and perioperative cardiac management in non-cardiac surgery. Eur J Anaesthesiol 2010;27:92–137
58. Smith I, Jackson I. Beta-blockers, calcium channel blockers, angiotensin converting enzyme inhibitors and angiotensin receptor blockers: should they be stopped or not before ambulatory anaesthesia? Curr Opin Anaesthesiol 2010;23:687–90
59. Auron M, Harte B, Kumar A, Michota F. Renin-angiotensin system antagonists in the perioperative setting: clinical consequences and recommendations for practice. Postgrad Med J 2011;87:472–81
60. Mollmann H, Nef HM, Hamm CW. Antiplatelet therapy during surgery. Heart 2010;96:986–91
61. Gogarten W, Vandermeulen E, Van Aken H, Kozek S, Llau JV, Samama CM. Regional anaesthesia and antithrombotic agents: recommendations of the European Society of Anaesthesiology. Eur J Anaesthesiol 2010;27:999–1015
62. Servin FS. Is it time to re-evaluate the routines about stopping/keeping platelet inhibitors in conjunction to ambulatory surgery? Curr Opin Anaesthesiol 2010;23:691–6
63. Hall R, Mazer CD. Review article: antiplatelet drugs: a review of their pharmacology and management in the perioperative period. Anesth Analg 2011;112:292–318
64. Groeben H. Strategies in the patient with compromised respiratory function. Best Pract Res Clin Anaesthesiol 2004;18:579–94
65. Thomsen T, Tønnesen H, Møller AM. Effect of preoperative smoking cessation interventions on postoperative complication and smoking cessation. Br J Surg 2009;96:451–61
66. Lindstrom D, Sadr A O, Wladis A, Tonnesen H, Linder S, Nasell H, Ponzer S, Adami J. Effects of a perioperative smoking cessation intervention on postoperative complications: a randomized trial. Ann Surg 2008;248:739–45
67. Shi Y, Warner DO. Surgery as a teachable moment for smoking cessation. Anesthesiology 2010;112:102–7
68. Silvanus MT, Groeben H, Peters J. Corticosteroids and inhaled salbutamol in patients with reversible airway obstruction markedly decrease the incidence of bronchospasm after tracheal intubation. Anesthesiology 2004;100:1052–7
69. Pien LC, Grammer LC, Patterson R. Minimal complications in a surgical population with severe asthma receiving prophylactic corticosteroids. J Allergy Clin Immunol 1988;82:696–700
70. Gross JB, Bachenberg KL, Benumof JL, Caplan RA, Connis RT, Coté CJ, Nickinovich DG, Prachand V, Ward DS, Weaver EM, Ydens L, Yu S. American Society of Anesthesiologists Task Force on Perioperative Management. Practice guidelines for the perioperative management of patients with obstructive sleep apnea: a report by the American Society of Anesthesiologists Task Force on Perioperative Management of patients with obstructive sleep apnea. Anesthesiology 2006;104:1081–93
71. Sabers C, Plevak DJ, Schroeder DR, Warner DO. The diagnosis of obstructive sleep apnea as a risk factor for unanticipated admissions in outpatient surgery. Anesth Analg 2003;96:1328–35
72. Hofer RE, Kai T, Decker PA, Warner DO. Obesity as a risk factor for unanticipated admissions after ambulatory surgery. Mayo Clin Proc 2008;83:908–16
73. Stierer TL, Wright C, George A, Thompson RE, Wu CL, Collop N. Risk assessment of obstructive sleep apnea in a population of patients undergoing ambulatory surgery. J Clin Sleep Med 2010;6:467–72
74. Seet E, Chung F. Obstructive sleep apnea: preoperative assessment. Anesthesiol Clin 2010;28:199–215
75. Teh SH, Nagorney DM, Stevens SR, Offord KP, Therneau TM, Plevak DJ, Talwalkar JA, Kim WR, Kamath PS. Risk factors for mortality after surgery in patients with cirrhosis. Gastroenterology 2007;132:1261–9
76. Kheterpal S, Tremper KK, Heung M, Rosenberg AL, Englesbe M, Shanks AM, Campbell DA Jr. Development and validation of an acute kidney injury risk index for patients undergoing general surgery: results from a national data set. Anesthesiology 2009;110:505–15
77. Jarnberg PO. Renal protection strategies in the perioperative period. Pract Res Clin Anaesthesiol 2004;18:645–60
78. Cockcroft DW, Gault MH. Prediction of creatinine clearance from serum creatinine. Nephron 1976;16:31–41
79. Makary MA, Segev DL, Pronovost PJ, Syin D, Bandeen-Roche K, Patel P, Takenaga R, Devgan L, Holzmueller CG, Tian J, Fried LP. Frailty as a predictor of surgical outcomes in older patients. J Am Coll Surg 2010;210:901–8
80. Fahlman MM, Topp R, McNevin N, Morgan AL, Boardley DJ. Structured exercise in older adults with limited functional ability. Assessing the benefits of an aerobic plus resistance training program. J Gerontol Nurs 2007;33:32–9
81. Carli F, Zavorsky GS. Optimizing functional exercise capacity in the elderly surgical population. Curr Opin Clin Nutr Metab Care 2005;8:23–32
82. Fischer B. Benefits, risks, and best practice in regional anesthesia: do we have the evidence we need? Reg Anesth Pain Med 2010;35:545–8
83. Arbous MS, Meursing AE, van Kleef JW, de Lange HH, Spoormans HH, Touw P, Werner FM, Grobbee DE. Impact of anesthesia management characteristics on severe morbidity and mortality. Anesthesiology 2005;102:257–68
84. Liu SS, Strodtbeck WM, Richman JM, Wu CL. A comparison of regional versus general anesthesia for ambulatory anesthesia: a meta-analysis of randomized controlled trials. Anesth Analg 2005;101:1634–42
85. Rasmussen LS, Johnson T, Kuipers HM, Kristensen D, Siersma D, Vila P, Jolles J, Papaioannou A, Abildstrom H, Silverstein JH, Bonal JA, Raeder J, Nielsen IK, Korttila K, Munoz L, Dodds C, Hanning CD, Moller JT. Does anaesthesia cause postoperative cognitive dysfunction? A randomised study of regional versus general anaesthesia in 438 elderly patients. Acta Anaesthesiol Scand 2003;47:260–6
86. Deiner S, Silverstein JH. Postoperative delirium and cognitive dysfunction. Br J Anaesth 2009;103(Suppl 1):i41–6
87. Gramke HF, de Rijke JM, van KM, Kessels AG, Peters ML, Sommer M, Marcus MA. Predictive factors of postoperative pain after day-case surgery. Clin J Pain 2009;25:455–60
88. Apfel CC, Greim CA, Haubitz I, Grundt D, Goepfert C, Sefrin P, Roewer N. The discriminating power of a risk score for postoperative vomiting in adults undergoing various types of surgery. Acta Anaesthesiol Scand 1998;42:502–9
89. Gadsden J, Gratenstein K, Hadzic A. Intraneural injection and peripheral nerve injury. Int Anesthesiol Clin 2010;48:107–15
90. Auroy Y, Benhamou D, Bargues L, Eccoey C, Falissard B, Mercier FJ, Bouaziz H, Samii K. Major complications of regional anesthesia in France: the SOS Regional Anesthesia Hotline Service. Anesthesiology 2002;97:1274–80
91. Vila H Jr, Soto R, Cantor AB, Mackey D. Comparative outcomes analysis of procedures performed in physician offices and ambulatory surgery centers. Arch Surg 2003;138:991–5
92. Schnider TW, Minto CF, Shafer SL, Gambus P, Andresen C, Goodale DB, Youngs EJ. The influence of age on propofol pharmacodynamics. Anesthesiology 1999;90:1502–16
93. Kazama T, Ikeda K, Morita K, Kikura M, Doi M, Ikeda T, Kurita T, Nakajima Y. Comparison of the effect-site k(eO)s of propofol for blood pressure and EEG bispectral index in elderly and younger patients. Anesthesiology 1999;90:1517–27
94. Minto CF, Schnider TW, Egan TD, Youngs E, Lemmens HJ, Gambus P, Billard V, Hoke JF, Moore KH, Hermann DJ, Muir KT, Mandema JW, Shafer SL. Influence of age and gender on the pharmacokinetics and pharmacodynamics of remifentanil: I. Model development. Anesthesiology 1997;86:10–23
95. Jacobs JR, Reves JG, Marty J, White WD, Bai SA, Smith LR. Aging increases pharmacodynamic sensitivity to the hypnotic effects of midazolam. Anesth Analg 1995;80:143–8
96. White PF, Vasconez LO, Mathes S, Way WL, Wender LA. Comparison of midazolam and effects of midazolam and diazepam for sedation during plastic surgery. Plast Reconstr Surg 1988;81:703–12
97. Kunisawa T, Hanada S, Kurosawa A, Suzuki A, Takahata O, Iwasaki H. Dexmedetomidine was safely used for sedation during spinal anesthesia in a very elderly patient. J Anesth 2010;24:938–41
98. Makary L, Vornik V, Finn R, Lenkovsky F, McClelland AL, Thurmon J, Robertson B. Prolonged recovery associated with dexmedetomidine when used as a sole sedative agent in office-based oral and maxillofacial surgery procedures. J Oral Maxillofac Surg 2010;68:386–91
99. Eger EI. Age, minimum alveolar anesthetic concentration, and minimum alveolar anesthetic concentration–awake. Anesth Analg 2001;93:947–53
100. Landoni G, Bignami E, Oliviero F, Zangrillo A. Halogenated anaesthetics and cardiac protection in cardiac and non-cardiac anaesthesia. Ann Card Anaesth 2009;12:4–9
101. Chen X, Zhao M, White PF, Li S, Tang J, Wender RH, Sloninsky A, Naruse R, Kariger R, Webb T, Norel El. The recovery of cognitive function after general anesthesia in elderly patients: a comparison of desflurane and sevoflurane. Anesth Analg 2001;93:1489–94
102. Fredman B, Sheffer O, Zohar E, Paruta I, Richter S, Jedeikin R, White PF. Fast-track eligibility of geriatric patients undergoing short urologic surgery procedures. Anesth Analg 2002;94:560–4
103. Raeder JC, Mjaland O, Aasbo V, Grogaard B, Buanes T. Desflurane versus propofol maintenance for outpatient laparoscopic cholecystectomy. Acta Anaesthesiol Scand 1998;42:106–10
104. Tang J, Chen L, White PF, Wender RH, Naruse R, Kariger R, Sloninsky A. Use of propofol for office-based anesthesia: effect of nitrous oxide on recovery profile. J Clin Anesth 1999;11:226–30
105. McKinney MS, Fee JP. Cardiovascular effects of 50% nitrous oxide in older adult patients anaesthetized with isoflurane or halothane. Br J Anaesth 1998;80:169–73
106. Lenz A, Hill G, White PF. Emergency use of sugammadex after failure of standard reversal drugs. Anesth Analg 2007;104:585–6
107. Gan TJ, Glass PS, Windsor A, Payne F, Rosow C, Sebel P, Manberg P. Bispectral index monitoring allows faster emergence and improved recovery from propofol, alfentanil, and nitrous oxide anesthesia. BIS Utility Study Group. Anesthesiology 1997;87:808–15
108. Song D, Joshi GP, White PF. Titration of volatile anesthetics using bispectral index facilitates recovery after ambulatory anesthesia. Anesthesiology 1997;87:842–8
109. Monk TG, Saini V, Weldon BC, Sigl JC. Anesthetic management and one-year mortality after noncardiac surgery. Anesth Analg 2005;100:4–10
110. Lindholm ML, Träff S, Granath F, Greenwald SD, Ekbom A, Lennmarken C, Sandin RH. Mortality within 2 years after surgery in relation to low intraoperative bispectral index values and preexisting malignant disease. Anesth Analg 2009;108:508–12
111. Kertai MD, Pal N, Palanca BJ, Lin N, Searleman SA, Zhang L, Burnside BA, Finkel KJ, Avidan MS. B-Unaware Study group. Association of perioperative risk factors and cumulative duration of low bispectral index with intermediate-term mortality after cardiac surgery in the B-Unaware Trial. Anesthesiology 2010;112:1116–27
112. Kertai MD, Palanca BJ, Pal N, Burnside BA, Zhang L, Sadiq F, Finkel KJ, Avidan MS. The B-Unaware Study group: bispectral index monitoring, duration of bispectral index below 45, patient risk factors, and intermediate-term mortality after noncardiac surgery in the B-Unaware Trial. Anesthesiology 2011;114:545–56
113. Urmey WF. Spinal anaesthesia for outpatient surgery. Best Pract Res Clin Anaesthesiol 2003;17:335–46
114. Mulroy MF, Salinas FV. Neuraxial techniques for ambulatory anesthesia. Int Anesthesiol Clin 2005;43:129–41
115. Bay-Nielsen M, Kehlet H. Anaesthesia and post-operative morbidity after elective groin hernia repair: a nation-wide study. Acta Anaesthesiol Scand 2008;52:169–74
116. Nishikawa K, Yoshida S, Shimodate Y, Igarashi M, Namiki A. A comparison of spinal anesthesia with small-dose lidocaine and general anesthesia with fentanyl and propofol for ambulatory prostate biopsy procedures in elderly patients. J Clin Anesth 2007;19:25–9
117. Kudoh A, Takase H, Takazawa T. A comparison of anesthetic quality in propofol-spinal anesthesia and propofol-fentanyl anesthesia for total knee arthroplasty in elderly patients. J Clin Anesth 2004;16:405–10
118. Song D, Greilich NB, White PF, Watcha MF, Tongier WK. Recovery profiles and costs of anesthesia for outpatient unilateral inguinal herniorrhaphy. Anesth Analg 2000;91:876–81
119. Li S, Coloma M, White PF, Watcha MF, Chiu JW, Li H, Huber P. Comparison of the costs and recovery profiles of three anesthetic techniques for ambulatory anorectal surgery. Anesthesiology 2000;93:1225–30
120. Casati A, Fanelli G, Danelli G, Berti M, Ghisi D, Brivio M, Putzu M, Barbagallo A. Spinal anesthesia with lidocaine or preservative-free 2-chlorprocaine for outpatient knee arthroscopy: a prospective, randomized, double-blind comparison. Anesth Analg 2007;104:959–64
121. Sell A, Tein T, Pitkänen M. Spinal 2-chloroprocaine: effective dose for ambulatory surgery. Acta Anaesthesiol Scand 2008;52:695–9
122. 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
123. Pollock JE. Transient neurologic symptoms: etiology, risk factors, and management. Reg Anesth Pain Med 2002;27:581–6
124. Nair GS, Abrishami A, Lermitte J, Chung F. Systematic review of spinal anaesthesia using bupivacaine for ambulatory knee arthroscopy. Br J Anaesth 2009;102:307–15
125. O'Donnell D, Manickam B, Perlas A, Karkhanis R, Chan VW, Syed K, Brull R. Spinal mepivacaine with fentanyl for outpatient knee arthroscopy surgery: a randomized controlled trial. Can J Anaesth 2010;57:32–8
126. Singh H, Liu J, Gaines GY, White PF. Effect of oral clonidine and intrathecal fentanyl on tetracaine spinal block. Anesth Analg 1994;79:1113–6
127. van Tuijl I, Giezeman MJ, Braithwaite SA, Hennis PJ, Kalkman CJ, van Klei WA. Intrathecal low-dose hyperbaric bupivacaine-clonidine combination in outpatient knee arthroscopy: a randomized controlled trial. Acta Anaesthesiol Scand 2008;52:343–9
128. Kreutziger J, Frankenberger B, Luger TJ, Richard S, Zbinden S. Urinary retention after spinal anaesthesia with hyperbaric prilocaine 2% in an ambulatory setting. Br J Anaesth 2010;104:582–6
129. Hendriks MP, de Weert CJ, Snoeck MM, Hu HP, Pluim MA, Gielen MJ. Plain articaine or prilocaine for spinal anaesthesia in day-case knee arthroscopy: a double-blind randomized trial. Br J Anaesth 2009;102:259–63
130. Förster JG, Kallio H, Rosenberg PH, Harilainen A, Sandelin J, Pitkänen MT. Chloroprocaine vs. articaine as spinal anaesthetics for day-case knee arthroscopy. Acta Anaesthesiol Scand 2011;55:273–81
131. Yoos JR, Kopacz DJ. Spinal 2-chloroprocaine for surgery: an initial 10-month experience. Anesth Analg 2005;100:553–8
132. Kouri ME, Kopacz DJ. Spinal 2-chloroprocaine: a comparison with lidocaine in volunteers. Anesth Analg 2004;98:75–80
133. Hejtmanek MR, Pollock JE. Chloroprocaine for spinal anesthesia: a retrospective analysis. Acta Anaesthesiol Scand 2011;55:267–72
134. 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
135. Frank SM, El-Rahmany HK, Cattaneo CG, Barnes RA. Predictors of hypothermia during spinal anesthesia. Anesthesiology 2000;92:1330–4
136. Visser WA, Lee RA, Gielen MJ. Factors affecting the distribution of neural blockade by local anesthetics in epidural anesthesia and a comparison of lumbar versus thoracic epidural anesthesia. Anesth Analg 2008;107:708–21
137. Mulroy MF, Larkin KL, Hodgson PS, Helman JD, Pollock JE, Liu SS. A comparison of spinal, epidural, and general anesthesia for outpatient knee arthroscopy. Anesth Analg 2000;91:860–4
138. Klein SM, Pietrobon R, Nielsen KC, Steele SM, Warner DS, Moylan JA, Eubanks WS, Greengrass RA. Paravertebral somatic nerve block compared with peripheral nerve blocks for outpatient inguinal. Reg Anesth Pain Med 2002;27:476–80
139. Hadzic A, Kerimoglu B, Loreio D, Karaca PE, Claudio RE, Yufa M, Wedderburn R, Santos AC, Thys DM. Paravertebral blocks provide superior same-day recovery over general anesthesia for patients undergoing inguinal hernia repair. Anesth Analg 2006;102:1076–81
140. Bhattacharya P, Mandal MC, Mukhopadhyay S, Das S, Pal PP, Basu SR. Unilateral paravertebral block: an alternative to conventional spinal anaesthesia for inguinal hernia repair. Acta Anaesthesiol Scand 2010;54:246–51
141. Fanelli G, Borghi B, Casati A, Bertini L, Montebugnoli M, Torri G. Unilateral bupivacaine spinal anesthesia for outpatient knee arthoscopy. Can J Anaesth 2000;47:746–51
142. Thavaneswaran P, Rudkin GE, Cooter RD, Moyes DG, Perera CL, Maddern GJ. Brief reports: paravertebral block for anesthesia: a systematic review. Anesth Analg 2010;110:1740–4
143. Aveline C, LeHetet H, Le Roux A, Vautier P, Cognet F, Vinet E, Tison C, Bonnet F. Comparison between ultrasound-guided transversus abdominis plane and conventional ilioinguinal/iliohypogastric nerve blocks for day-case open inguinal hernia repair. Br J Anaesth 2011;106:380–6
144. White PF. Choice of peripheral nerve block for inguinal herniorrhaphy: is better the enemy of good? Anesth Analg 2006;102:1073–5
145. Ding Y, White PF. Post-herniorrhaphy pain in outpatients after pre-incision ilioinguinal-hypogastric nerve block during monitored anaesthesia care. Can J Anaesth 1995;42:12–5
146. Andersen FH, Nielsen K, Kehlet H. Combined ilioinguinal blockade and local infiltration anaesthesia for groin hernia repair—a double-blind randomized study. Br J Anaesth 2005;94:520–3
147. Vloka JD, Hadzic A, Mulcare R, Lesser JB, Koorn R, Thys DM. Combined popliteal and posterior cutaneous nerve of the thigh blocks for short saphenous vein stripping in outpatients: an alternative to spinal anesthesia. J Clin Anesth 1997;9:618–22
148. Klein SM, Evans H, Nielsen KC, Tucker MS, Warner DS, Steele SM. Peripheral nerve block techniques for ambulatory surgery. Anesth Analg 2005;101:663–76
149. Hadzic A, Williams BA, Karaca PE, Hobeika P, Unis G, Dermksian J, Yufa M, Thys DM, Santos AC. For outpatient rotator cuff surgery, nerve block anesthesia provides superior same-day recovery over general anesthesia. Anesthesiology 2005;102:1001–7
150. Hadzic A, Arliss J, Kerimoglu B, Karaca PE, Yufa M, Claudio RE, Vloka JD, Rosenquist R, Santos AC, Thys DM. A comparison of infraclavicular nerve blocks versus general anesthesia for hand and wrist day-case surgeries. Anesthesiology 2004;101:127–32
151. Faryniarz D, Morelli C, Coleman S, Holmes T, Allen A, Altchek D, Cordasco F, Warren RF, Urban MK, Gordon MA. Interscalene block anesthesia at an ambulatory surgery center performing predominantly regional anesthesia: a prospective study of one hundred thirty-three patients undergoing shoulder surgery. J Shoulder Elbow Surg 2006;15:686–90
152. O'Donnell BD, Iohom G. Regional anesthesia techniques for ambulatory orthopedic surgery. Curr Opin Anaesth 2008;21:723–8
153. Lundblad M, Kapral S, Marhofer P, Lönnqvist PA. Ultrasound-guided infrapatellar nerve block in human volunteers: description of a novel technique. Br J Anaesth 2006;97:710–4
154. Zaric D, Boysen K, Christiansen J, Haastrup U, Kofoed H, Rawal N. Continuous popliteal sciatic nerve block for outpatient foot surgery—a randomized, controlled trial. Acta Anaesthesiol Scand 2004;48:337–41
155. Ilfeld BM, Duke KB, Donohue MC. The association between lower extremity continuous peripheral nerve blocks and patient falls after knee and hip arthroplasty. Anesth Analg 2010;111:1552–4
156. Axley M, Horn JL. Indications and management of continuous infusion of local anesthetics at home. Curr Opin Anaesthesiol 2010;23:650–5
157. Richman JM, Liu SS, Courpas G, Wong R, Rowlingson AJ, McGready J, Cohen SR, Wu CL. Does continuous peripheral nerve block provide superior pain control to opioids? A meta-analysis. Anesth Analg 2006;102:248–57
158. Ilfeld BM, Mariano ER, Williams BA, Woodard JN, Macario A. Hospitalization costs of total knee arthroplasty with a continuous femoral nerve block provided only in the hospital versus on an ambulatory basis: a retrospective, case-control, cost-minimization analysis. Reg Anesth Pain Med 2007;32:46–54
159. White PF, Issioui T, Skrivanek GD, Early JS, Wakefield C. The use of a continuous popliteal sciatic nerve block after surgery involving the foot and ankle: does it improve the quality of recovery? Anesth Analg 2003;97:1303–9
160. Ilfeld BM, Morey LK, Mariano ER, Loland VJ, Stevens-Lapsley JE, Fleisher AS, Girard PJ, Donohue MC, Ferguson EJ, Ball ST. Continuous peripheral nerve blocks: is local anesthetic dose the only factor, or do concentration and volume influence infusion effects as well? Anesthesiology 2010;112:347–54
161. Kandasami M, Kinninmonth AW, Sarungi M, Baines J, Scott NB. Femoral nerve block for total knee replacement—a word of caution. Knee 2009;16:98–100
162. Feibel RJ, Dervin GF, Kim PR, Beaule PE. Major complications associated with femoral nerve catheters for knee arthroplasty: a word of caution. J Arthroplasty 2009;24:132–7
163. Maki BE, Holliday PJ, Topper AK. A prospective study of postural balance and risk of falling in an ambulatory and independent elderly population. J Gerontol 1994;49:M72–84
164. Sieri T, Beretta G. Fall risk assessment in very old males and females living in nursing homes. Disabil Rehabil 2004;26:718–23
165. Morse JM. Enhancing the safety of hospitalization by reducing patient falls. Am J Infect Control 2002;30:376–80
166. Ilfeld BM, Mariano ER, Girard PJ, Loland VJ, Meyer RS, Donovan JF, Pugh GA, Le LT, Sessler DI, Shuster JJ, Theriaque DW, Ball ST. A multicenter, randomized, triple-masked, placebo-controlled trial of the effect of ambulatory continuous femoral nerve blocks on discharge-readiness and analgesia following total knee arthroplasty in patients on general orthopaedic wards. Pain 2010;150:477–84
167. Ilfeld BM, Ball ST, Gearen PF, Le LT, Mariano ER, Vandenborne K, Duncan PW, Sessler DI, Enneking FK, Shuster JJ, Theriaque DW, Meyer RS. Ambulatory continuous posterior lumbar plexus nerve blocks after hip arthroplasty: a dual-center, randomized, triple-masked, placebo-controlled trial. Anesthesiology 2008;109:491–501
168. Ilfeld BM, Le LT, Meyer RS, Mariano ER, Vandenborne K, Duncan PW, Sessler DI, Enneking FK, Shuster JJ, Theriaque DW, Berry LF, Spadoni EH, Gearen PF. Ambulatory continuous femoral nerve blocks decrease time to discharge readiness after tricompartment total knee arthroplasty: a randomized, triple-masked, placebo-controlled study. Anesthesiology 2008;108:703–13
169. Ilfeld BM, Morey TE, Enneking FK. Infraclavicular perineural local anesthetic infusion: a comparison of three dosing regimens for postoperative analgesia. Anesthesiology 2004;100:395–402
170. Ilfeld BM, Morey TE, Wright TW, Chidgey LK, Enneking FK. Interscalene perineural ropivacaine infusion: a comparison of two dosing regimens for postoperative analgesia. Reg Anesth Pain Med 2004;29:9–16
171. Capdevila X, Dadure C, Bringuier S, Bernard N, Biboulet P, Gaertner E, Macaire P. Effect of patient-controlled perineural analgesia on rehabilitation and pain after ambulatory orthopedic surgery: a multicenter randomized trial. Anesthesiology 2006;105:566–73
172. Muraskin SI, Conrad B, Zheng N, Morey TE, Enneking FK. Falls associated with lower-extremity-nerve blocks: a pilot investigation of mechanisms. Reg Anesth Pain Med 2007;32:67–72
173. Swenson JD, Bay N, Loose E, Bankhead B, Davis J, Beals TC, Bryan NA, Burks RT, Greis PE. Outpatient management of continuous peripheral nerve catheters placed using ultrasound guidance: an experience in 620 patients. Anesth Analg 2006;103:1436–43
174. Schulz-Stübner S, Kelley J. Regional Anesthesia Surveillance System: first experiences with a quality assessment tool for regional anesthesia and analgesia. Acta Anaesth Scand 2007;51:305–15
175. Clendenen SR, Robards CB, Greengrass RA, Brull SJ. Complications of peripheral nerve catheter removal at home: case series of five ambulatory interscalene blocks. Can J Anaesth 2011;58:62–7
176. Murphy DB, McCartney CJ, Chan VW. Novel analgesic adjuncts for brachial plexus block. A systematic review Anesth Analg 2000;90:1122–8
177. Candido K, Franco CD, Khan MA, Gonzalez S, Mikat-Stevens M, Pinzur M, Vasic V, Knezevic NN. Buprenorphine added to local anaesthetic for brachial plexus block to provide post operative analgesia in outpatients. Reg Anesth Pain Med 2001;26:352–6
178. Kaabachi O, Ouezini R, Koubaa W, Ghrab B, Zargouni A, Ben Abdelaziz A. Tramadol as an adjuvant to lidocaine for axillary plexus block. Anesth Analg 2009;108:367–70
179. Lee IO, Kim WK, Kong MH, Lee MK, Kim NS, Choi YS, Lim SH. No enhancement of sensory and motor blockade by ketamine added to ropivacaine interscalene brachial plexus blockade. Acta Anaesthesiol Scand 2002;46:821–6
180. Bouaziz H, Paqueron X, Bur ML, Merle M, Laxenaire MC, Benhamou D. No enhancement of sensory and motor blockade by neostigmine added to mepivacaine axillary plexus block. Anesthesiology 1999;91:78–83
181. Gunduz A, Bilir A, Gulec S. Magnesium added to prilocaine prolongs the duration of axillary plexus block. Reg Anesth Pain Med 2006;31:233–6
182. Vieira P, Pulai I, Tsao GC, Manikantan P, Keller B, Connelly NR. Dexamethasone with bupivacaine increases duration of analgesia with ultrasound guided interscalene brachial plexus blockade. Eur J Anesthesiol 2010;27:285–8
183. Eledjam JJ, Deschodt J, Viel EJ, Lubrano JF, Charavel P, d'Athis F, du Cailar J. Brachial plexus block with bupivacaine effects of added alpha-adrenergic agonists: comparison between clonidine and epinephrine. Can J Anaesth 1991;38:870–5
184. Ilfeld BM, Morey TE, Thannikary LJ, Wright TW, Enneking FK. Clonidine added to a continuous interscalene ropivacaine perineural infusion to improve postoperative analgesia: a randomized, double-blind, controlled study. Anesth Analg 2005;100:1172–8
185. Thornton PC, Grant SA, Breslin DS. Adjuncts to local anesthetics in peripheral nerve blockade. Int Anesthesiol Clin 2010;48:59–70
186. Bernards CM, Kopacz DJ. Effect of epinephrine on lidocaine clearance in vivo: a microdialysis study in humans. Anesthesiology 1999;91:962–8
187. Eisenach JC, DeKock M, Klimscha W. Alpha(2)-adrengic agonists for regional anesthesia. A clinical review of clonidine (1984 to 1995). Anesthesiology 1996;85:655–74
188. Swenson JD, Cheng GS, Axelrod DA, Davis JJ. Ambulatory anesthesia and regional catheters: when and how. Anesthesiol Clin 2010;28:267–80
189. Fredrickson MJ, Krishnan S, Chen CY. Postoperative analgesia for shoulder surgery: a critical appraisal and review of current techniques. Anesthesia 2010;65:608–24
190. Sa Règo MM, Watcha MF, White PF. The changing role of monitored anesthesia care in the ambulatory setting. Anesth Analg 1997;85:1020–36
191. Tzabar Y, Asbury J, Millar K. Cognitive failure after general anaesthesia for day case surgery. Br J Anaesth 1996;76:194–7
192. Rawal N. Incisional and intra-articular infusions. Best Pract Res Clin Anaesthesiol 2002;16:321–43
193. Vintar N, Pozlep G, Rawal N, Godec M, Rakovec S. Incisional self-administration of bupivacaine or ropivacaine provides effective analgesia after inguinal hernia repair. Can J Anaesth 2002;49:481–6
194. Liu SS, Richman JM, Thirlby RC, Wu CL. Efficacy of continuous wound catheters delivering local anesthetic for postoperative analgesia: a quantitative and qualitative systematic review of randomized controlled trials. J Am Coll Surg 2006;203:914–32
195. Ekstein M, Gavish D, Ezri T, Weinbroum AA. Monitored anaesthesia care in the elderly. Guidelines and recommendation. Drug Aging 2008;25:477–500
196. Sieber FE, Gottshalk A, Zakriya KJ, Mears SC, Lee H. General anesthesia occurs frequently in elderly patients during propofol-based sedation and spinal anesthesia. J Clin Anesth 2010;22:179–83
197. Ramsey MA, Savege TM, Simpson BR, Goodwin R. Controlled sedation with alphaxolone-alphadolone. BMJ 1974;2:656–9
198. Balci C, Karabekir HS, Kahtaman F, Sivaci RG. Comparison of entropy and bispectral index during propofol and fentanyl sedation in monitored anaesthesia care. J Int Med Res 2009;37:1336–42
199. White PF, Negus JB. Sedative infusion during local and regional anesthesia: a comparison of midazolam and propofol. J Clin Anesth 1991;3:32–9
200. Arain SR, Ebert TJ. The efficacy, side effects, and recovery characteristics of dexmedetomidine versus propofol when used for intraoperative sedation. Anesth Analg 2002;95:461–6
201. Urquhart ML, White PF. Comparison of sedative infusions during regional anesthesia—methohexital, etomidate, and midazolam. Anesth Analg 1989;68:249–54
202. Cicero M, Graneto J. Etomidate for procedural sedation in the elderly: a retrospective comparison between age groups. Am J Emerg Med 2010 (e-pub)
203. Zeyneloglu P, Pirat A, Candan S, Kuyumcu S, Tekin I, Arslan G. Dexmedetomidine causes prolonged recovery when compared with midazolam/fentanyl combination in outpatient shock wave lithotripsy. Eur J Anaesthesiol 2008;25:961–7
204. Horiuchi A, Nakayama Y, Hidaka N, Hichise Y, Kajiyama M, Tanaka N. Low doses propofol sedation for diagnostic esophagogastroduodenoscopy. Results in 10,662 adults. Am J Gatsroenterol 2009;104:1656–7
205. Harris EA, Lubarsky DA, Candiotti KA. Monitored anesthesia care (MAC) sedation: clinical utility of fospropofol. Ther Clin Risk Mang 2009;5:949–59
206. Agostoni M, Fanti L, Arcidiacono PG, Gemma M, Strini G, Torri G, Testoni PA. Midazolam and pethidine versus propofol and fentanyl patient controlled sedation/analgesia for upper gastrointestinal tract ultrasound endoscopy: a prospective randomized trial. Dig Liver Dis 2007;39:1024–9
207. Dere K, Sucullu DK, Budak ET, Yeyen S, Filiz AI, Ozkan S, Dagli G. A comparison of dexmedetomidine versus midazolam for sedation, pain and hemodynamic control, during colonscopy under conscious sedation. Eur J Anaesthesiol 2010;27:648–52
208. Mester R, Easley RB, Brady KM, Chilson K, Toblas JD. Monitored anesthesia care with a combination of ketamine and dexmedetomidine during cardiac catheterization. Am J Ther 2008;15:24–30
209. Smith I, Monk TG, White PF, Ding Y. Propofol infusion during regional anesthesia: sedative, amnesic and anxiolitic properties. Anesth Analg 1994;79:313–9
210. Taylor E, Ghouri AF, White PF. Midazolam in combimation with propofol for sedation during local anesthesia. J Clin Anest 1992;4:213–6
211. Ebert TJ. Sympathetic and hemodynamic effect of moderate and deep sedation with propofol in humans. Anesthesiology 2005;103:20–4
212. Candiotti KA, Bergese SD, Bokesch PM, Feldman MA, Wisemandle W, Bekker AY. Monitor anesthesia care with dexmedetomidine: a prospective, randomized, double-blind, multicenter trials. Anesth Analg 2010;110:47–56
213. Lichtor JL, Alessi R, Lane BS. Sleep tendency as a measure of recovery after drugs used for ambulatory surgery. Anesthesiology 2002;96:878–83
214. Fleisher LA, Pasternak LR, Lyles A. A novel index of elevated risk of inpatient hospital admission immediately following outpatient surgery. Arch Surg 2007;142:263–8
215. Chung F, Mezei G, Tong D. Adverse events in ambulatory surgery. A comparison between elderly and younger patients. Can J Anaesth 1999;46:309–21
216. Bedford PD. Adverse cerebral effects of anaesthesia on old people. Lancet 1955;269:259–63
217. American Psychiatric Association. Diagnostic Criteria from DSM-IV-TR. Washington, DC: American Psychiatric Association, 2000
218. Rasmussen LS. Defining postoperative cognitive dysfunction. Eur J Anaesthesiol 1998;15:761–4
219. Silverstein JH, Timberger M, Reich DL, Uysal S. Central nervous system dysfunction after noncardiac surgery and anesthesia in the elderly. Anesthesiology 2007;106:622–8
220. Rudolph JL, Marcantonio ER. Review articles: postoperative delirium: acute change with long-term implications. Anesth Analg 2011;112:1202–11
221. Moller JT, Cluitmans P, Rasmussen LS, Houx P, Rasmussen H, Canet J, Rabbitt P, Jolles J, Larsen K, Hanning CD, Langeron O, Johnson T, Lauven PM, Kristensen PA, Biedler A, van Beem H, Fraidakis O, Silverstein JH, Beneken JE, Gravenstein JS. Long-term postoperative cognitive dysfunction in the elderly ISPOCD1 study. ISPOCD investigators. International Study of Post-Operative Cognitive Dysfunction. Lancet 1998;351:857–61
222. Steinmetz J, Christensen KB, Lund T, Lohse N, Rasmussen LS. Long-term consequences of postoperative cognitive dysfunction. Anesthesiology 2009;110:548–55
223. Marcantonio ER, Goldman L, Mangione CM, Ludwig LE, Muraca B, Haslauer CM, Donaldson MC, Whittemore AD, Sugarbaker DJ, Poss R, Haas S, Cook EF, Orav EJ, Lee TH. A clinical prediction rule for delirium after elective noncardiac surgery. JAMA 1994;271:134–9
224. Sieber FE, Zakriya KJ, Gottschalk A, Blute MR, Lee HB, Rosenberg PB, Mears SC. Sedation depth during spinal anesthesia and the development of postoperative delirium in elderly patients undergoing hip fracture repair. Mayo Clin Proc 2010;85:18–26
225. Williams-Russo P, Sharrock NE, Haas SB, Insall J, Windsor RE, Laskin RS, Ranawat CS, Go G, Ganz SB. Randomized trial of epidural versus general anesthesia: outcomes after primary total knee replacement. Clin Orthop Relat Res 1996:199–208
226. Evered L, Scott DA, Silbert B, Maruff P. Postoperative cognitive dysfunction is independent of type of surgery and anesthetic. Anesth Analg 2011;112:1179–85
227. Apfel CC, Greim CA, Goepfert C, Grundt D, Usadel J, Sefrin P, Roewer N. Postoperative vomiting. A score for prediction of vomiting risk following inhalation anesthesia. Anaesthesist 1998;47:732–4
228. Keats S. High-dose rate brachytherapy in prostate cancer patients—a study on nausea and vomiting. Urol Nurs 2010;30:195–202
229. Watcha MF, White PF. Postoperative nausea and vomiting. Its etiology, treatment, and prevention. Anesthesiology 1992;77:162–84
230. Chinnappa V, Chung F. Post-discharge nausea and vomiting: an overlooked aspect of ambulatory anesthesia? Can J Anaesth 2008;55:565–71
231. Ruiz JR, Kee SS, Frenzel JC, Ensor JE, Selvan M, Riedel BJ, Apfel C. The effect of an anatomically classified procedure on antiemetic administration in the postanesthesia care unit. Anesth Analg 2010;110:403–9
232. Sinclair DR, Chung F, Mezei G. Can postoperative nausea and vomiting be predicted? Anesthesiology 1999;91:109–18
233. Apfel CC, Laara E, Koivuranta M, Greim CA, Roewer N. A simplified risk score for predicting postoperative nausea and vomiting: conclusions from cross-validations between two centers. Anesthesiology 1999;91:693–700
234. Gan TJ, Meyer TA, Apfel CC, Chung F, Davis PJ, Habib AS, Hooper VD, Kovac AL, Kranke P, Myles P, Philip BK, Samsa G, Sessler DI, Temo J, Tramèr MR, Vander Kolk C, Watcha M. Society for Ambulatory Anesthesia guidelines for the management of postoperative nausea and vomiting. Anesth Analg 2007;105:1615–28
235. ASPAN Task Force. ASPAN′s evidence-based clinical practice guideline for the prevention and/or management of PONV/PDNV. J Perianesth Nurs 2006;21:230–50
236. Practice guidelines for postanesthetic care: a report by the American Society of Anesthesiologists Task Force on Postanesthetic Care. Anesthesiology 2002;96:742–52
237. Pierre S, Corno G, Benais H, Apfel CC. A risk score-dependent antiemetic approach effectively reduces postoperative nausea and vomiting—a continuous quality improvement initiative. Can J Anaesth 2004;51:320–5
238. Glass PS, White PF. Practice guidelines for the management of postoperative nausea and vomiting: past, present, and future. Anesth Analg 2007;105:1528–9
239. White PF, O'Hara JF, Roberson CR, Wender RH, Candiotti KA. POST-OP Study group. The impact of current antiemetic practices on patient outcomes: a prospective study on high-risk patients. Anesth Analg 2008;107:452–8
240. Honkavaara P, Pyykko I. Surgeon's experience as a factor for emetic sequelae after middle ear surgery. Acta Anaesthesiol Scand 1998;42:1033–7
241. White PF, Sacan O, Nuangchamnong N, Sun T, Eng MR. The relationship between patient risk factors and early versus late postoperative emetic symptoms. Anesth Analg 2008;107:459–63
242. Kolodzie K, Apfel CC. Nausea and vomiting after office-based anesthesia. Curr Opin Anaesthesiol 2009;22:532–8
243. White PF. The role of non-opioid analgesic techniques in the management of pain after ambulatory surgery. Anesth Analg 2002;94:577–85
244. Thagaard KS, Jensen HH, Raeder J. Analgesic and antiemetic effect of ketorolac vs. betamethasone or dexamethasone after ambulatory surgery. Acta Anaesthesiol Scand 2007;51:271–7
245. White PF, Wang B, Tang J, Wender RH, Naruse R, Sloninsky A. The effect of intraoperative use of esmolol and nicardipine on recovery after ambulatory surgery. Anesth Analg 2003;97:1633–8
246. Segal IS, Jarvis DJ, Duncan SR, White PF, Maze M. Clinical efficacy of oral-transdermal clonidine combinations during the perioperative period. Anesthesiology 1991;74:220–5
247. Bell RF, Dahl JB, Moore RA, Kalso E. Peri-operative ketamine for acute post-operative pain: a quantitative and qualitative systematic review (Cochrane review). Acta Anaesthesiol Scand 2005;49:1405–28
248. Apfel CC, Kranke P, Katz MH, Goepfert C, Papenfuss T, Rauch S, Heineck R, Greim CA, Roewer N. Volatile anaesthetics may be the main cause of early but not delayed postoperative vomiting: a randomized controlled trial of factorial design. Br J Anaesth 2002;88:659–68
249. Leslie K, Myles PS, Chan MT, Paech MJ, Peyton P, Forbes A, McKenzie D. ENIGMA Trial group. Risk factors for severe postoperative nausea and vomiting in a randomized trial of nitrous oxide-based vs nitrous oxide-free anaesthesia. Br J Anaesth 2008;101:498–505
250. Nelskyla KA, Yli-Hankala AM, Puro PH, Korttila KT. Sevoflurane titration using bispectral index decreases postoperative vomiting in phase II recovery after ambulatory surgery. Anesth Analg 2001;93:1165–9
251. White PF, Ma H, Tang J, Wender RH, Sloninsky A, Kariger R. Does the use of electroencephalographic bispectral index or auditory evoked potential index monitoring facilitate recovery after desflurane anesthesia in the ambulatory setting? Anesthesiology 2004;100:811–7
252. Yogendran S, Asokumar B, Cheng DC, Chung F. A prospective randomized double blinded study of the effect of intravenous fluid therapy on adverse outcomes on outpatient surgery. Anesth Analg 1995;80:682–6
253. Holte K, Klarskov B, Christensen DS, Lund C, Nielsen KG, Bie P, Kehlet H. Liberal versus restrictive fluid administration to improve recovery after laparoscopic cholecystectomy: a randomized, double-blind study. Ann Surg 2004;240:892–9
254. Le TP, Gan TJ. Update on the management of postoperative nausea and vomiting and postdischarge nausea and vomiting in ambulatory surgery. Anesthesiol Clin 2010;28:225–49
255. 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. IMPACT Investigators. A factorial trial of six interventions for the prevention of postoperative nausea and vomiting. N Engl J Med 2004;350:2441–51
256. Scuderi PE, James RL, Harris L, Mims GR 3rd. Multimodal antiemetic management prevents early postoperative vomiting after outpatient laparoscopy. Anesth Analg 2000;91:1408–14
257. Elvir-Lazo OL, White PF. The role of multimodal analgesia in pain management after ambulatory surgery. Curr Opin Anaesthesiol 2010;28:697–703
258. Eriksson H, Tenhunen A, Korttila K. Balanced analgesia improves recovery and outcome after outpatient tubal ligation. Acta Anaesthesiol Scand 1996;40:151–5
259. Michaloliakou C, Chung F, Sharma S. Preoperative multimodal analgesia facilitates recovery after ambulatory laparoscopic cholecystectomy. Anesth Analg 1996;82:44–51
260. White PF, Sacan O, Tufanogullari, Eng M, Nuangchamnong N, Ogunnaike B. Effect of short-term postoperative celecoxib administration on patient outcome after outpatient laparoscopic surgery. Can J Anaesth 2007;54:342–8
261. White PF, Tang J, Wender RH, Zhao M, Time M, Zaentz A, Yumul R, Sloninsky A, Naruse R, Kariger R, Webb T, Fermelia DE, Tsushima GK. The effects of oral ibuprofen and celecoxib in preventing pain, improving recovery outcomes and patient satisfaction after ambulatory surgery. Anesth Analg 2011;112:323–9
262. Toms L, McQuay HJ, Derry S, Moore RA. Single dose oral paracetamol (acetaminophen) for postoperative pain in adults. Cochrane Database Syst Rev 2008;4:CD004602
263. Miners JO, Penhall R, Robson RA, Birkett DJ. Comparison of paracetamol metabolism in young adult and elderly males. Eur J Clin Pharm 1988;35:157–60
264. den Hertog HM, van der Worp HB, van Gemert HM, Algra A, Kappelle LJ, van Gijn J, Koudstaal PJ, Dippel DW. PAIS Investigators. The Paracetamol (Acetaminophen) In Stroke (PAIS) trial: a multicentre, randomised, placebo-controlled, phase III trial. Lancet Neurol 2009;8:434–40
265. White PF, Raeder J, Kehlet H. Ketorolac: its role as part of a multimodal analgesic regimen. Anesth Analg 2012;114:250–4
266. Turajane T, Wongbunnak R, Patcharatrakul T, Ratansumawong K, Poigampetch Y, Songpatanasilp T. Gastrointestinal and cardiovascular risk of non-selective NSAIDs and COX-2 inhibitors in elderly patients with knee osteoarthritis. J Med Assoc Thai 2009;92(suppl 6):S19–26
267. Chan FK, Lanas A, Scheiman J, Berger MF, Nguyen H, Goldstein JL. Celecoxib versus omeprazole and diclofenac in patients with osteoarthritis and rheumatoid arthritis (CONDOR): a randomised trial. Lancet 2010;376:173–9
268. Nussmeier NA, Whelton AA, Brown MT, Joshi GP, Langford RM, Singla NK, Boye ME, Verburg KM. Safety and efficacy of the cyclooxygenase-2 inhibitors parecoxib and valdecoxib after non-cardiac surgery. Anesthesiology 2006;104:518–26
269. Schug SA, Joshi GP, Camu F, Pan S, Cheung R. Cardiovascular safety of the cyclooxygenase-2 selective inhibitors parecoxib and valdecoxib in the postoperative setting: an analysis of integrated data. Anesth Analg 2009;108:299–307
270. Simon AM, O'Connor JP. Dose and time-dependent effects of cyclooxygenase-2 inhibition on fracture-healing. J Bone Joint Surg Am 2007;89:500–11
271. Romundstad L, Stubhaug A, Niemi G, Rosseland LA, Breivik H. Adding propacetamol to ketorolac increases the tolerance to painful pressure. Eur J Pain 2006;10:177–83
272. Ong CK, Seymour RA, Lirk P, Merry AF. Combining paracetamol (acetaminophen) with nonsteroidal antiinflammatory drugs: a qualitative systematic review of analgesic efficacy for acute postoperative pain. Anesth Analg 2010;110:1170–9
273. Henzi I, Walder B, Tramèr MR. Dexamethasone for the prevention of postoperative nausea and vomiting: a quantitative systematic review. Anesth Analg 2000;90:186–94
274. Bisgaard T, Klarskov B, Kehlet H, Rosenberg J. Preoperative dexamethasone improves surgical outcome after laparoscopic cholecystectomy: a randomized double-blind placebo-controlled trial. Ann Surg 2003;238:651–60
275. Hval K, Thagaard KS, Schlichting E, Raeder J. The prolonged postoperative analgesic effect when dexamethasone is added to a nonsteroidal antiinflammatory drug (rofecoxib) before breast surgery. Anesth Analg 2007;105:481–6
276. Romundstad L, Breivik H, Roald H, Skolleborg K, Haugen T, Narum J, Stubhaug A. Methylprednisolone reduces pain, emesis, and fatigue after breast augmentation surgery: a single-dose, randomized, parallel-group study with methylprednisolone 125 mg, parecoxib 40 mg, and placebo. Anesth Analg 2006;102:418–25
277. Czarnetzki C, Elia N, Lysakowski C, Dumont L, Landis BN, Giger R, Dulguerov P, Desmeules J, Tramèr MR. Dexamethasone and risk of nausea and vomiting and postoperative bleeding after tonsillectomy in children: a randomized trial. JAMA 2008;300:2621–30
278. Whitlock RP, Chan S, Devereaux PJ, Sun J, Rubens FD, Thorlund K, Teoh KH. Clinical benefit of steroid use in patients undergoing cardiopulmonary bypass: a meta-analysis of randomized trials. Eur Heart J 2008;29:2592–600
279. Reece-Smith AM, Maggio AQ, Tang TY, Walsh SR. Local anaesthetic vs. general anaesthetic for inguinal hernia repair: systematic review and meta-analysis. Int J Clin Pract 2009;63:1739–42
280. Ong CK, Lirk P, Seymour RA, Jenkins BJ. The efficacy of preemptive analgesia for acute postoperative pain management: a meta-analysis. Anesth Analg 2005;100:757–73
281. Møiniche S, Mikkelsen S, Wetterslev J, Dahl JB. A systematic review of intra-articular local anesthesia for postoperative pain relief after arthroscopic knee surgery. Reg Anesth Pain Med 1999;24:430–7
282. Townshend D, Emmerson K, Jones S, Partington P, Muller S. Intra-articular injection versus portal infiltration of 0.5% bupivacaine following arthroscopy of the knee: a prospective, randomised double-blinded trial. J Bone Joint Surg Br 2009;91:601–3
283. Liu S, Carpenter RL, Chiu AA, McGill TJ, Mantell SA. Epinephrine prolongs duration of subcutaneous infiltration of local anesthesia in a dose-related manner. Correlation with magnitude of vasoconstriction. Reg Anesth 1995;20:378–84
284. Rosseland LA. No evidence for analgesic effect of intra-articular morphine after knee arthroscopy: a qualitative systematic review. Reg Anesth Pain Med 2005;30:83–98
285. Sindjelic RP, Vlajkovic GP, Davidovic LB, Markovic DZ, Markovic MD. The addition of fentanyl to local anesthetics affects the quality and duration of cervical plexus block: a randomized, controlled trial. Anesth Analg 2010;111:234–7
286. Korhonen AM, Valanne JV, Jokela RM, Ravaska P, Korttila K. Intrathecal hyperbaric bupivacaine 3 mg + fentanyl 10 microg for outpatient knee arthroscopy with tourniquet. Acta Anaesthesiol Scand 2003;47:342–6
287. Pöpping DM, Elia N, Marret E, Wenk M, Tramèr MR. Clonidine as an adjuvant to local anesthetics for peripheral nerve and plexus blocks: a meta-analysis of randomized trials. Anesthesiology 2009;111:406–15
288. Essving P, Axelsson K, Kjellberg J, Wallgren O, Gupta A, Lundin A. Reduced hospital stay, morphine consumption, and pain intensity with local infiltration analgesia after unicompartmental knee arthroplasty. Acta Orthop 2009;80:213–9
289. Essving P, Axelsson K, Kjellberg J, Wallgren O, Gupta A, Lundin A. Reduced morphine consumption and pain intensity with local infiltration analgesia (LIA) following total knee arthroplasty. Acta Orthop 2010;81:354–60
290. Spreng UJ, Dahl V, Hjall A, Fagerland MW, Ræder J. High-volume local infiltration analgesia combined with intravenous or local ketorolac+morphine compared with epidural analgesia after total knee arthroplasty. Br J Anaesth 2010;105:675–82
291. Kardash KJ, Garzon J, Velly AM, Tessler MJ. Ketorolac analgesia for inguinal hernia repair is not improved by peripheral administration. Can J Anaesth 2005;52:613–7
292. Coloma M, White PF, Huber PJ Jr, Tongier WK, Dullye KK, Duffy LL. The effect of ketorolac on recovery after anorectal surgery: intravenous versus local administration. Anesth Analg 2000;90:1107–10
293. Kerr DR, Kohan L. Local infiltration analgesia: a technique for the control of acute postoperative pain following knee and hip surgery: a case study of 325 patients. Acta Orthop 2008;79:174–83
294. Boezaart AP. Perineural infusion of local anesthetics. Anesthesiology 2006;104:872–80
295. Fredrickson MJ, Ball CM, Dalgleish AJ. Analgesic effectiveness of a continuous versus single-injection interscalene block for minor arthroscopic shoulder surgery. Reg Anesth Pain Med 2010;35:28–33
296. Chidiac EJ, Kaddoum R, Peterson SA. Patient survey of continuous interscalene analgesia at home after shoulder surgery. Middle East J Anesthesiol 2009;20:213–8
297. Tighe PJ, Badiyan SJ, Luria I, Boezaart AP, Parekattil S. Robot-assisted regional anesthesia: a simulated demonstration. Anesth Analg 2010;111:813–6
298. Kaba A, Laurent SR, Detroz BJ, Sessler DI, Durieux ME, Lamy ML, Joris JL. Intravenous lidocaine infusion facilitates acute rehabilitation after laparoscopic colectomy. Anesthesiology 2007;106:11–8
299. McCarthy GC, Megalla SA, Habib AS. Impact of intravenous lidocaine infusion on postoperative analgesia and recovery from surgery: a systematic review of randomized controlled trials. Drugs 2010;70:1149–63
300. Loftus RW, Yeager MP, Clark JA, Brown JR, Abdu WA, Sengupta DK, Beach ML. Intraoperative ketamine reduces perioperative opiate consumption in opiate-dependent patients with chronic back pain undergoing back surgery. Anesthesiology 2010;113:639–46
301. Remérand F, Le Tendre C, Baud A, Couvret C, Pourrat X, Favard L, Laffon M, Fusciardi J. The early and delayed analgesic effects of ketamine after total hip arthroplasty: a prospective, randomized, controlled, double-blind study. Anesth Analg 2009;109:1963–71
302. Adam F, Ménigaux C, Sessler DI, Chauvin M. A single preoperative dose of gabapentin (800 milligrams) does not augment postoperative analgesia in patients given interscalene brachial plexus blocks for arthroscopic shoulder surgery. Anesth Analg 2006;103:1278–82
303. Turan A, Memi° D, Karamanliođlu B, Yađiz R, Pamukçu Z, Yavuz E. The analgesic effects of gabapentin in monitored anesthesia care for ear-nose-throat surgery. Anesth Analg 2004;99:375–8
304. Gilron I, Orr E, Tu D, Mercer CD, Bond D. A randomized, double-blind, controlled trial of perioperative administration of gabapentin, meloxicam and their combination for spontaneous and movement-evoked pain after ambulatory laparoscopic cholecystectomy. Anesth Analg 2009;108:623–30
305. Turan A, White PF, Karamanlioglu B, Memis D, Tasdogan M, Pamukcu Z, Yavuz E. Gabapentin—an alternative to COX-2 inhibitors for perioperative pain management. Anesth Analg 2006;102:175–81
306. Buvanendran A, Kroin JS, Della Valle CJ, Kari M, Moric M, Tuman KJ. Perioperative oral pregabalin reduces chronic pain after total knee arthroplasty: a prospective, randomized, controlled trial. Anesth Analg 2010;110:199–207
307. Erkola O, Korttila K, Aho M, Haasio J, Aantaa R, Kallio A. Comparison of intramuscular dexmedetomidine and midazolam premedication for elective abdominal hysterectomy. Anesth Analg 1994;79:646–53
308. Dahmani S, Brasher C, Stany I, Golmard J, Skhiri A, Bruneau B, Nivoche Y, Constant I, Murat I. Premedication with clonidine is superior to benzodiazepines. A meta analysis of published studies. Acta Anaesthesiol Scand 2010;54:397–402
309. Tufanogullari B, White PF, Peixoto MP, Kianpour D, Lacour T, Griffin J, Skrivanek G, Macaluso A, Shah M, Provost DA. Dexmedetomidine infusion during laparoscopic bariatric surgery: the effect on recovery outcome variables. Anesth Analg 2008;106:1741–8
310. Coloma M, Chiu JW, White PF, Armbruster SC. The use of esmolol as an alternative to remifentanil during desflurane anesthesia for fast-track outpatient gynecologic laparoscopic surgery. Anesth Analg 2001;92:352–7
311. Collard V, Mistraletti G, Taqi A, Asenjo JF, Feldman LS, Fried GM, Carli F. Intraoperative esmolol infusion in the absence of opioids spares postoperative fentanyl in patients undergoing ambulatory laparoscopic cholecystectomy. Anesth Analg 2007;105:1255–6
312. Lee SJ, Lee JN. The effect of perioperative esmolol infusion on the postoperative nausea, vomiting and pain after laparoscopic appendectomy. Korean J Anesthesiol 2010;59:179–84
313. White CM, Talati R, Phung OJ, Baker WL, Reinhart K, Sedrakyan A, Kluger J, Coleman CI. Benefits and risks associated with beta-blocker prophylaxis in noncardiac surgery. Am J Health Syst Pharm 2010;67:523–30
314. Yu SK, Tait G, Karkouti K, Wijeysundera D, McCluskey S, Beattie WS. The safety of perioperative esmolol: a systematic review and meta-analysis of randomized controlled trials. Anesth Analg 2011;112:267–81
315. White PF. Use of alternative medical therapies in the perioperative period: is it time to get on board? Anesth Analg 2007;104:251–4
316. Chen L, Tang J, White PF, Sloninsky A, Wender RH, Naruse R, Kariger R. The effect of location of transcutaneous electrical nerve stimulation on postoperative opioid analgesic requirement: acupoint versus nonacupoint stimulation. Anesth Analg 1998;87:1129–34
317. Wang B, Tang J, White PF, Naruse R, Sloninsky A, Kariger R, Gold J, Wender RH. Effect of the intensity of transcutaneous acupoint electrical stimulation on the postoperative analgesic requirement. Anesth Analg 1997;85:406–13
318. Brattwall M, Warrén Stomberg M, Rawal N, Segerdahl M, Jakobsson J, Houltz E. Patients' assessment of 4-week recovery after ambulatory surgery. Acta Anaesthesiol Scand 2011;55:92–8
319. Krywulak SA, Mohtadi NG, Russell ML, Sasyniuk TM. Patient satisfaction with inpatient versus outpatient reconstruction of the anterior cruciate ligament: a randomized clinical trial. Can J Surg 2005;48:201–6
320. Hammil BG, Curtis LH, Bennet-Guerrero E. Impact of heart failure on patients undergoing major noncardiac surgery. Anesthesiology 2008;108:559–67
321. Warner MA, Shields SE, Chute CG. Major morbidity and mortality within one month of ambulatory surgery and anesthesia. JAMA 1993;270:1437–41
322. Bettelli G. High risk patients in ambulatory surgery. Minerva Anestesiol 2009;75:259–60
323. White PF, Kehlet H, Neal JM, Schricker T, Carr DB, Carli F. Fast-Track Surgery Study group. The role of the anesthesiologist in fast-track surgery: from multimodal analgesia to perioperative medical care. Anesth Analg 2007;104:1380–96
324. Inouye SK, Peduzzi PN, Robinson JT. Importance of functional measures in predicting mortality among older hospitalized patients. JAMA 1998;279:1187–93
325. Fukuse T, Satoda N, Hijiya K, Fujinaga T. Importance of comprehensive geriatric assessment in prediction of complications following thoracic surgery in elderly patients. Chest 2005;127:886–91
326. Kristjanson SR, Nesbakken A, Jordy MS, Skovlunde E, Audio RA, Johannessen HO, Bakka A, Wyller TB. Comprehensive geriatric assessment can predict complications in elderly patients after elective surgery for colorectal cancer: a prospective observational cohort study. Crit Rev Oncol Hematol 2010;76:208–17
327. Bettelli G. Preoperative evaluation of the elderly patient: comorbidity, functional status and pharmacological history. Minerva Anestesiol (in press)
328. Inouye SK, Bogardus ST, Baker DI, Leo-Summers L, Cooney LM Jr. The hospital elder life program: a model of care to prevent cognitive and functional decline in older hospitalized patients. J Am Geriatr Soc 2000;48:1697–706
329. Brown CJ, Friedkin RJ, Inouye SK. Prevalence and outcomes of low mobility in hospitalized older patients. J Am Geriatr Soc 2004;52:1263–70
330. Hirsch CH, Sommers L, Olsen A, Mullen L, Winograd CH. The natural history of functional morbidity in hospitalized older patients. J Am Geriatr Soc 1990;38:1296–303
331. Wu H, Sahadaven S, Ding YY. Factors associated with functional decline of hospitalized older persons following discharge from an acute geriatric unit. Ann Acad Med Singapore 2006;35:17–23
332. Trivedi AN, Moloo H, Mor V. Increased ambulatory care copayments and hospitalization among the elderly. N Engl J Med 2010;362:320–8
333. McDonagh DL, Benedict PE, Kovac AL, Drover DR, Bristen NW, Morte JB, Monk TG. Efficacy, safety and pharmacokinetics of sugammadex for reversal of rocuronium-induced neuromuscular blockade in elderly patients. Anesthesiology 2011;114:318–29
334. Pérez F, MTón E, Nodal MJ, Viñoles J, Guillen S, Traver V. Evaluation of a mobile health system for supporting postoperative patients following day surgery. J Telemed Telecare 2006;12(suppl 1):41–3
335. Palombo D, Mugnai D, Mambrini S, Robaldo A, Rousas N, Mazzei R, Bianca P, Spinella G. Role of interactive home telemedicine for early and protected discharge one day after carotid endarterectomy. Ann Vasc Surg 2009;23:76–80
336. Martinez-Ramos C, Cerdán MT, López RS. Mobile phone–based telemedicine system for the home follow-up of patients undergoing ambulatory surgery. Telemed J Health 2009;15:531–7
337. Etzioni DA, Liu JH, Maggard MA, Ko CY. The aging population and its impact on the surgery workforce. Ann Surg 2003;238:170–7
338. Burden N. Discharge planning for elderly ambulatory surgical patients. J Perianesth Nurs 2004;6:401–5
339. Kadowaki M, Kono M, Nishiguchi K, Kakimaru H, Uchio Y. Mortality in patients with hip fracture aged over 90 years: a report from a progressively aging island. Arch Gerontol Geriatr 2012;54:113–7
340. Muravchick S. Anesthesia for the geriatric patient. In: Barash PG, Cullen BF, Stoelting RK (eds.). Clinical Anesthesia. 4th ed. Philadelphia: Lippincott-Raven, 2001