Combined Vascular & Skeletal Trauma

Table of Contents

1 Objectives

2 Overview

3 Diagnosis

4 Management

5 The decision to amputate

6 Management Algorithm
      6.1 1. Resuscitation
      6.2 2. Risk factors for amputation
      6.3 3. Amputation technique
      6.4 4. Hards signs of vascular injury
      6.5 5. Investigation
      6.6 6. Fasciotomy
      6.7 7a. Damage control
      6.8 7b. Definitive repair
      6.9 8. Vascular shunts
      6.10 9. Skeletal stabilization
      6.11 10. Exclusion of clinically significant vascular injury
      6.12 11. Wound management
      6.13 12. Secondary amputation
      6.14 13. Limb salvage

7 References

8 Authors & Contributors

Objectives

 

1. Understand the clinical manifestations of vascular injury and the diagnostic approaches to confirm or exclude vascular injury in complex extremity trauma.

2. Know the appropriate prioritization of management of vascular injury, skeletal injury, and soft tissue and nerve and tendon injury in complex extremity trauma

3. Be familiar with the criteria for early amputation in complex extremity trauma.

 

Overview

Complex extremity trauma involving both arterial and skeletal injuries remains challenging. This combination of injuries is rare, comprising only 0.2% of all military and civilian trauma, and only 0.5%-1.7% of all extremity fractures and dislocations. Vascular and trauma surgeons are more likely than orthopedic surgeons to encounter these injuries, as 10%-70% of all extremity arterial injuries are associated with skeletal trauma. In past years, the great majority of complex extremity injuries in the civilian sector have been caused by blunt trauma, although in some recent series penetrating trauma has caused a majority of these injuries. Combat injuries of this type from military series usually are due to high velocity penetrating trauma.

Combined arterial and skeletal extremity trauma imparts a substantially higher risk of limb loss and limb morbidity than do isolated skeletal and arterial injuries. Debakey and Simeone documented this in WWII battle casualties, in which all injured arteries were ligated, reporting amputation in 60% of all combined injuries and 42% in isolated arterial injuries. Although McNamara and coworkers(65) reported a substantial improvement in limb salvage from isolated arterial injuries in the Vietnam War, combined injuries still had a 10-fold greater rate of limb loss(23% vs 2.5%). These authors also documented a higher incidence of failed vascular repair among combined extremity injuries (33%) than among isolated extremity arterial injuries(5%). Romanoff and coworkers reported more than a 3-fold increase in limb loss in combined combat extremity trauma compared to isolated arterial injuries (36% vs 11%) in the hostilities in Israel. This trend has continued into recent years in the civilian sector, even in the most experienced trauma centers, where amputation rates approaching 70% still are reported from combined arterial and skeletal extremity trauma, while less than 5% of limbs currently are lost following isolated arterial or skeletal trauma. Limb loss most commonly is attributed to delay in diagnosis and revascularization in most published series of this unique trauma. Major nerve damage, extensive soft tissue injury which disrupts collaterals and prevents adequate vessel coverage, infection, and compartment syndrome are other reasons for such a high rate of loss of these severely compromised limbs.

 

Diagnosis

Prompt diagnosis is essential if rapid treatment and optimal limb salvage is to be achieved in these complex extremity injuries. This requires that a high index of suspicion of arterial trauma be applied to every injured extremity by noting whether any hard signs are present (i.e. active hemorrhage, large, expanding or pulsatile hamatoma, bruit or thrill over wound, absent distal pulses, and signs of distal ischemia�the 5 P�s: pain, pallor, paralysis, paresthesias, poikilothermy, or coolness). The presence of hard signs in any blunt or complex extremity trauma requires immediate arteriography due to the relatively low incidence of surgically significant arterial injury in this setting. This is best done by the surgeon as a percutaneous hand-injected study in the trauma center, or on the operating table, to minimize time delay while achieving excellent accuracy.

 

Popliteal artery injury	Popliteal artery injury
Popliteal artery injuries following leg fractures with hard signs of vascular injury (reduced or absent distal pulses). Both angiograms were done as one-shot percutaneous angios and patients were then operated on immediately.

The absence of hard signs excludes major arterial injury with sufficient accuracy to allow further diagnostic workup to be avoided. Since most complex extremity trauma does not manifest hard signs, avoiding the considerable expense of arteriography in this population has substantial economic advantages.

 

Superficial femoral artery injury – intimal flap	Resolution at 6 weeks	Popliteal artery injury – nonocclusive	Resolution at 1 week
Blunt supracondylar femur fracture with asympomatic superficial femoral artery nonocclusive intimal flap identified on ER angiography. Non-operatively observed. 6 weeks later, after ORIF, repeat angiogram documents complete resolution of arterial injury.		Undisplaced tibial plateau fracture from gunshot wound with no hard signs. Angiogram shows non-occlusive intimal injury of the popliteal artery. The injury was observed and repeat angiogram one week later documents complete resolution.

This principle holds true even for the especially high-risk injury of posterior knee dislocation, in which setting routine arteriography has been advocated in all cases, due to a substantial risk of popliteal artery disruption and its associated high rate of limb loss. However, those published studies that compare the clinical manifestations of patients with posterior knee dislocation with outcome show no surgically significant arterial injuries in that majority of patients who have no hard signs (Table 1), confirmed by follow-ups of up to 2 years. Again, most cases present without hard signs, allowing major resource savings at no harm to the patient by using only physical findings to exclude arterial injury. Arteriography is indicated only in that minority of patients with knee dislocation presenting with hard signs, to exclude the need for surgery in those 30% of patients who do not have an arterial injury. Immediate surgery without imaging may be undertaken if the clinical picture clearly indicates vascular injury(i.e. absent pulse, cold ischemic foot).

Table 1: Relation of Physical Findings of Vascular Injury to Outcome Following Knee Dislocation
Author	No. KD	Hard Signs Present		Hard Signs Absent
		No. (%) a	Surgery (%)	No. (%) a	Surgery(%) b
Kaufman et al	19	4 (21)	4 (100)	15 (79)	0
Treiman et al	115	29 (25)	22 (75)	86 (75)	0
Dennis et al	38	2 (13)	2 (100)	36 (87)	0
Kendall et al	37	6 (16)	6 (100)	31 (84)	0
Miranda et al	32	8 (25)	6 (75)	24 (75)	0
Martinez et al	23	11 (48)	2 (18)	12 (52)	0
Hollis et al	39	11 (28)	7 (64)	28 (72)	0
Stannard et al	134	10 (8)	9 (90)	124 (93)	0
Total	437	81 (18)	58 (72)	356 (82)	0

There is no clear role for noninvasive testing in the initial evaluation of complex extremity injuries (Doppler pressures or signals, duplex U/S), due to a paucity of studies of their use in this category of trauma, and uncertainty over its accuracy in the presence of severe tissue disruption and large bulky dressings. Further study is necessary to clarify this. Again, the physical exam quite clearly answers all questions of management in this setting, as absent pulses mandates ruling out vascular injury, and present pulses in the absence of other hard signs reliably excludes vascular injury as well as any imaging modality. Noninvasives add nothing and may lead the examiner astray, as Doppler flow signals may be transmitted by collaterals around a completely occluded or transected vessel, while a pulse caot. Thus, Doppler flow signals DO NOT exclude a vascular injury. The presence or absence of a pulse is all that is necessary to decide on the next step in diagnosis.

Management

Appropriate prioritization of the management of the vascular and skeletal injuries is a major determinant of limb salvage. Initial fracture stabilization and fixation has been advocated in past years, due to concerns that an established vascular repair will be disrupted by subsequent orthopedic manipulation, as long as there is no overt ischemia. However, published evidence has refuted such concerns, showing minimal disruption of initial vascular repairs, and no adverse impact of prompt revascularization on outcome. Also, substantial tissue damage still can occur in the absence of clinical signs of ischemia, as our understanding of compartment syndrome has made clear. Further, clinical studies have shown a substantially higher rate of limb salvage among combined vascular and skeletal extremity injuries in which revascularization is performed first, compared with those in which it is delayed until the skeleton is addressed.

ER Arteriogram	Popliteal artery – End to end anastomosis	Completion arteriogram
Undisplaced, stable blunt tibial plateau fracture with no distal pulses. ER angiogram identified the popliteal artery injury. Immediate exploration and repair with end to end anastomosis, followed by internal fixation. Completion angiogram documents two vessel flow to foot. Prophylactic fasciotomy was performed.

 

In fact, definitive vascular repair should be delayed in cases of unstable or severely comminuted fractures or dislocations, segmental bone loss, or severe soft tissue destruction and contamination, due to the risk of undue tension or slack on the repaired vessel when the limb is fixed at its proper length, and to the possibility of disruption from skeletal manipulation. But this should not ever delay immediate restoration of perfusion to the extremity, which can be accomplished rapidly by temporary intraluminal shunting until skeletal stabilization and soft tissue debridement has been completed. Alternatively, immediate definitive vascular repair should be the means of initial revascularization in the setting of uncomplicated and stable skeletal injuries in which minimal subsequent manipulation and length discrepancy is anticipated.

 

Arteriogram	Popliteal artery injury	Shunt in place
Comminuted supracondylar femur crush fracture with no pulses. On-table angio in the operating room documented popliteal artery injury, leading to immediate vascular exploration. Transected popliteal artery was isolated, controlled, and shunted to restore distal flow while ex-fix placed to stabilize joint. Definitive arterial repair was then performed.

External fixation of the skeleton is preferred when rapid stabilization is necessary, in open, comminuted and unstable fractures, or in the presence of severe soft tissue disruption and contamination. Internal fixation has been used successfully in this setting, and is preferred if the patient�s condition permits.

The consensus of authorities now favors limb revascularization as the first priority in all combined extremity trauma. How the revascularization is accomplished(i.e. definitive repair or temporary shunting) is a matter of judgement based on the nature of the skeletal and soft tissue injuries and the condition of the patient. Only with a cooperative multidisciplinary effort, with close communication between the trauma, orthopedic and plastic surgeons, can the outcome of these injuries be optimized.

 

Elbow fracture-dislocation	Shunt in brachial artery
Saphenous vein repair	Completion arteriogram
Blunt elbow fracture-dislocation with brachial artery transection and large soft tissue degloving. Transected brachial artery was shunted and a cross-elbow ex-fix placed to stabilize the joint. Then a reversed saphenous vein graft arterial repair was performed. The completion angio documents two vessel flow to hand.

 

In addition to prompt diagnosis with on-table arteriography, liberal use of a number of surgical adjuncts has improved limb salvage following combined arterial and skeletal extremity trauma. Intra-operative completion arteriography is important to document patency of the repair, as any technical errors could easily result in limb loss in these severely compromised limbs. Four compartment fasciotomy should be applied liberally and prophylactically in this setting due to the high risk of compartment syndrome following reperfusion. Extra-anatomic bypass, and pedicled or free-tissue flap coverage should be considered in the setting of severe contamination and soft tissue injury or loss to protect the vascular repair. Careful attention to all of these considerations, as well as to avoiding unnecessary surgery for nonocclusive arterial lesions, and meticulous postoperative surveillance, has led to dramatic improvements in limb salvage, with amputation rates even in this challenging setting falling below 10% in a small number of recent studies.

The decision to amputate

Among the most difficult challenges in the management of complex extremity trauma is the decision as to whether and when amputation is indicated. Recent advances in the ability to salvage limbs have led to prolonged and aggressive reconstruction efforts following injuries which would have undergone amputation in the past. Such heroic efforts actually may harm patients in terms of prolonging hospitalization and time lost from work, as well as increasing sepsis, operative procedures, and even mortality. These outcomes are especially undesirable if amputation or severe limb dysfunction ultimately occur anyway.

Although it is often difficult to predict soon after injury which extremities will require amputation, there are injuries of such destruction and severity that a decision for immediate, or primary, amputation can be made easily. These are injuries in which it is obvious that attempts at revascularization are futile due to the extent of soft tissue and skeletal trauma, major nerves are transected, or other life-threatening injuries are present which prevent any attention to the limbs. Gustilo III-C injuries (comminuted open tibial-fibular fractures with arterial injury) are an example of limb trauma generally mandating immediate amputation.

However, most complex extremity injuries are not that clear cut. In these cases, immediate revascularization should be performed, along with important surgical adjuncts such as shunts, fasciotomy, or extra-anatomic bypass, the skeleton should be stabilized promptly by either traction or external fixation, and then the extremity should be observed over the next 24-48 hours to determine what level of function and tissue viability returns. Nerve transectioever should be assumed, but only determined by direct visualization, as vascular insufficiency or muscle damage alone may cause profound deficits that can be confused with nerve damage. If revascularization fails, tissue loss is severe or worsens, systemic sepsis or crush syndrome develops, or profound neurologic or functional deficits persist, amputation then should be performed. If improvement occurs, limb salvage may proceed, but should be assessed just as critically at each successive stage to minimize unnecessarily prolonged, costly and futile efforts.

 

Mangled Upper Extremity	Crush to lower leg
Mangled upper extremity treated by immediate amputation.	Comminuted tibia & fibula fractures from crush injury in a 64 year old diabetic male with no distal pulses and acute ischemic changes. Underwent immediate below-knee amputation.

A number of scoring systems have been developed to objectify this difficult decision that is so often clouded by subjective and wishful thinking, often at the patient�s expense. Although none have been found to be prospectively useful in predicting amputation or the degree of functional impairment, they do focus attention on those factors which most closely correlate with outcome, and which must be a part of the treatment decision.

High-Risk Factors for Ultimate Limb Loss or Severe Dysfunction

·        Gustilo III – C skeletal injuries

·        Transected tibial or sciatic nerve

·        Transection of 2 of 3 upper extremity nerves

·        Prolonged ischemia (> 6-12 hours)

·        Shock and life-threatening associated injuries

·        Below-knee arterial injury

·        Extensive soft tissue loss

·        Crush injury

·        Multiple fractures

·        Elderly with medical comorbidity

·        Severe contamination

·        Patient preference

Another major consideration in this decision is whether the injury is in the upper or lower extremity, as the former is less likely to require amputation, being more tolerant of deficits in protective sensation, motor function, weight-bearing concerns, and length discrepancy, and prostheses tend to be less satisfactory.

This decision must be a matter of clinical judgement based on each individual case, and it must always involve a consensus of the entire health care team, including the trauma, orthopedic, vascular and plastic surgeons, rehabilitation specialist, psychologist, nursing, and most importantly the patient and family. The sophistication of limb prostheses, prompt return to work, short hospitalizations and lower costs and morbidity following early amputation are often preferable to salvage efforts which may take months or years and still fail. The ultimate goal is to return the patient to a comfortable, self-sufficient and productive life as quickly as possible.

 

Management Algorithm

1. Resuscitation

Resuscitation and management of all life-threatening injuries must take priority over any extremity problems. Only active extremity hemorrhage must be controlled at this time by direct pressure, tourniquet, or direct clamping of visible vessels (in that order of preference) as a life saving measure. Blind clamping in wounds is discouraged and potentially harmful to limb salvage.

Once attention is directed to the extremity, neurovascular injury must be assumed in all injured extremities until definitively excluded as the first diagnostic priority. Vascular injury must be found and treated within 6 hours to maximize the chance of limb salvage, as it is the major determinant of limb salvage.

2. Risk factors for amputation

• Gustilo III-C injuries � comminuted, open tib-fib fractures with vascular disruption.

• Sciatic or tibial nerve, or two of the three major upper extremity nerves, anatomically transected

• Prolonged ischemia (>4-6 hours)/muscle necrosis
• Crush or destructive soft tissue injury

• Significant wound contamination
• Multiple/severely comminuted fractures/segmental bone loss

• Old age/severe co-morbidity
• Lower vs. upper extremity
• Apparent futility of revascularization/failed revascularization

These factors have been applied over the course of the last two decades in several scoring systems to predict primary amputation. Although the scoring systems have validated these factors to be associated with a worse prognosis for limb salvage, none have adequate prospective reliability to permit a definitive decision for amputation to be made solely based on a score alone.

3. Amputation technique

If early amputation is deemed necessary, a �guillotine-type� amputation should be performed at an appropriate level above the destructive wound. Marginally viable soft tissue should be preserved and the open wound copiously irrigated and d�brided of contaminating debris. The amputation stump should be dressed with a bulky absorbent dressing and protective splint if amputation is below the knee and/or elbow. Early return to the operating room for further wound debridement and definitive management should be anticipated.

If the need for amputation is not clear on initial presentation, limb salvage should be attempted and the extremity observed carefully for the next 24-48 hours for soft tissue viability, skeletal stability, and sensorimotor function.

4. Hards signs of vascular injury

• Active hemorrhage
• Large, expanding or pulsatile hematoma
• Bruit or thrill over the wound(s)

• Absent palpable pulses distally
• Distal ischemic manifestations (pain, pallor, paralysis, paresthesias, poikilothermy, or coolness)

5. Investigation

The presence of any one or more hard signs mandates immediate arterial imaging to confirm or exclude vascular injury. Most hard signs in this setting (as much as 87%) are NOT due to vascular injury, but rather to soft tissue and bone bleeding, traction of intact arteries to lose pulses, or compartment syndrome. When imaging is not possible, immediate surgical exploration of the vessel at risk must be done. If these measures exclude surgically significant vascular injury (i.e. no occlusion, extravasation, transection) then the treatment of soft tissue and skeletal injuries may proceed. *How this reperfusion is achieved depends on the patient�s hemodynamic status, physiologic parameters, skeletal stability, wound characteristics, and resource availability.

6. Fasciotomy

A 2-incision, 4 compartment fasciotomy of the distal extremity should be performed liberally in complex extremity trauma at the time of initial revascularization due to the high risk of compartment syndrome. If it is elected not to do this immediately, observation must include the frequent direct measurement of compartment pressures due to the poor sensitivity of the clinical examination for the presence of compartment syndrome.

7a. Damage control

A definitive vascular repair should be avoided, and there should be consideration for placement of a temporary intraluminal shunt in the proximal and distal ends of the injured vessel after distal thrombectomy and regional or systemic heparinization (if not contraindicated) in the following settings:

• Hemodynamic instability, coagulopathy, acidosis, hypothermia of the patient

• Unstable skeleton
• Major wound contamination/infection or soft tissue deficits precluding wound coverage

• Requirement for any definitive repair more complex than lateral suture or end to end anastomosis (i.e. extra-anatomic bypass, interposition graft)

• Austere environment with no resources for definitive management

• Other life threatening injuries requiring urgent management

If tourniquet control or ligation of injured extremity vessels are the only means of controlling life-threatening hemorrhage, and reperfusion is not possible due to the nature of the wound or the environment, then immediate evacuation is necessary to achieve revascularization within 6 hours if limb salvage is to be attempted.

7b. Definitive repair

Definitive repair should be performed provided:

• Hemodynamic and physiologic stability of patient

• Stable skeleton
• Clean wound with adequate viable soft tissue

• Availability of necessary time and resources

• No other injuries requiring more urgent management

8. Vascular shunts

Many commercial plastic intraluminal shunts are available. However plastic IV tubing, or connecting tubing that accompanies many closed suction drains, is sufficient if irrigated with heparinized saline before use. The ends of the tubing are placed in the proximal and distal segments of the injured artery, secured by a silk suture tied around the vessel over the shunt and then also tied directly on the shunt itself to prevent dislodgement. Alternatively, shunt clamps are available to clamp the vessel over the shunt. Flow through the shunt should be monitored regularly by palpating distal arterial pulsation and/or using a Doppler device to detect flow signals through the shunt or distal vessel. If flow ceases, the shunt and distal vessel must be thrombectomized with a Fogarty catheter and reinserted. If not contraindicated, systemic heparinization may facilitate shunt flow.

9. Skeletal stabilization

Only skeletal stabilization by splint or external fixation should be done after reperfusion in those settings found in 7a above. Definitive internal fixation of skeletal extremity injuries should be delayed until conditions in 7b above are reached, and after definitive vascular repair is performed.

10. Exclusion of clinically significant vascular injury

The absence of any hard sign in an injured extremity excludes a surgically significant vascular injury as reliably as any imaging modality. If all hard signs are absent, no vascular imaging or exploration is necessary, and treatment of skeletal and soft tissue injuries may proceed immediately.

11. Wound management

Wounds should be inspected frequently and any dead/necrotic tissue should be d�brided and dressings changed accordingly.

12. Secondary amputation

Amputation after initial attempts at limb salvage should be considered if risk factors for limb loss persist. However, the patient�s family, as well as involved surgical specialists, should be informed and involved in this decision whenever possible. Efforts to avoid excessive morbidity, cost, procedures, and hospital stay for limbs that will ultimately be amputated or without function should be avoided. Any adverse impact of the extremity on the patient�s health, i.e. sepsis, rhabdomyolysis, hyperkalemia, ARDS, or other life-threatening problems mandate immediate secondary amputation.

13. Limb salvage

Continue limb salvage efforts and monitor patient closely for changes that may warrant secondary amputation.

NURSING DIAGNOSIS: Risk for peripheral neurovascular dysfunction: fractured extremity

related to trauma to or excessive pressure on the nerves or blood vessels as a result of the injury; displaced bone fragments; blood accumulation and edema at fracture site; and improper alignment, application of skin traction device, or traction on the injured extremity.

Desired Outcome

The client will maintaiormal neurovascular function in the injured extremity as evidenced by: palpable pedal pulses capillary refill time in toes less than 3 seconds extremity warm and usual color ability to flex and extend knee, foot, and toes absence of numbness and tingling in leg and foot no increase in pain in extremity or buttock.

 

Nursing Actions and Selected Purposes/Rationales

1. Assess for and report signs and symptoms of neurovascular dysfunction in the injured extremity:

1. diminished or absent pedal pulses
2. capillary refill time in toes greater than 3 seconds

3. pallor, cyanosis, or coolness of the extremity

4. inability to flex or extend knee, foot, or toes

5. numbness or tingling in leg or foot

6. increased pain in extremity or buttock (new or increased pain that occurs during passive movement is a symptom of compartment syndrome).

2. Implement measures to prevent neurovascular dysfunction in injured extremity:

1. maintain traction as ordered
2. place a trochanter roll or sandbag firmly against lateral aspect of injured hip and upper thigh (should extend from the iliac crest to midthigh) in order to help maintain proper alignment

3. do not attempt to realign injured leg unless specifically ordered (an attempt to align extremity may cause further trauma to the nerves and blood vessels)

4. make sure skin traction device (e.g. elastic wraps, foam boot with Velcro strap) is applied properly (if necessary to reapply, obtain assistance so that one person can maintain traction on the leg during the reapplication process)

5. make sure that excessive or prolonged pressure is not exerted on Achilles tendon and medial and lateral aspects of knee and ankle

6. do not turn client on injured side unless specifically ordered (may cause further displacement of fracture and decrease blood flow to area).

3. If signs and symptoms of neurovascular dysfunction occur:

1. assess for and correct improper positioning of the injured extremity and traction device and external cause of excessive pressure

2. notify physician if the signs and symptoms persist or worsen

3. prepare client for surgical intervention (e.g. internal fixation, insertion of hip prosthesis).

Nursing Diagnosis

• Pain related to fracture, soft tissue damage, muscle spasm, and surgery
• Impaired physical mobility related to fractured hip
• Impaired skin integrity related to surgical incision
• Risk for impaired urinary elimination related to immobility
• Risk for disturbed thought process related to age, stress of trauma, unfamiliar surroundings, and drug therapy
• Risk for ineffective coping related to injury, anticipated surgery, and dependence
• Risk for impaired home maintenance related to fractured hip and impaired mobility

VII. Nursing Management

Prevent infection
– Cover any breaks in the skin with clean or sterile dressing.

Provide care during client transfer.
– Immobilize a fractured extremity with splint in the position of the deformity before moving the client; avoid strengthening the injured body part if a joint is involved.
– Support the affected body part above and below fracture site when moving the client.

Provide client and family teaching.
– Explain prescribed activity restrictions and necessary lifestyle modification because of impaired mobility.
-Teach the proper use of assistive devices, as indicated.

Administer prescribed medications, which may include opioid or nonopioid analgesics and prophylactic antibiotics for an open fracture.

Prevent and manage potential complications.
– Observe for symptoms of life-threatening fat embolus, which may include personality change, restlessness, dyspnea, crackles, white sputum, and petechaie over the chest and buccal membranes. Assist with respiratory support, which must be instituted early.
– Observe for symptoms of compartment syndrome, which include deep, unrelenting pain; hard edematous muscle; and decreased tissue perfusion with impaired neurovascular assessment findings.
– Monitor closely for signs and symptoms of other complications.

Patient education regarding different factors that affect fracture healing
Factors that enhance fracture healing
• Immobilization of fracture fragments
• Maximum bone fragment contact
• Sufficient blood supply
• Proper nutrition
• Exercise: weight bearing for long bones
• Hormones: growth hormone, thyroid, calcitonin, vitamin D, anabolic steroids

Factors that inhibit fracture healing
• Extensive local trauma
• Bone loss
• Inadequate immobilization
• Space or tissue between bone fragments
• Infection
• Local malignancy
• Metabolic bone disease (Paget’s disease)
• Irradiated bone (radiatioecrosis)
• Avascular necrosis
• Intra-articular fracture (synovial fluid contains fibrolysins, which lyse the initial clot and retard clot formation)
• Age (elderly persons heal more slowly)
• Corticosteroids (inhibit the repair rate)

Restoring Form and Function to Upper Extremities

In the fall of 2007, AG, a 36-year-old East Bay musician, was driving home with his wife when they rolled their 10-year-old sedan. AG’s left arm was extended through the driver’s side window, and as the car rolled, his elbow slammed against the pavement and ripped open. The impact cracked off a large piece of his ulna, damaged his ulnar nerve and left a large, soft tissue defect.

After emergency room physicians at an East Bay hospital stabilized AG, they transferred him to UCSF Medical Center, where a team of surgeons — including orthopaedic surgeon Lisa Lattanza, M.D., chief of the Hand and Upper Extremity Service, and plastic surgeons David S. Chang, M.D., and David M. Young, M.D. — reconstructed AG’s severely damaged elbow.

Lattanza began the process with an open reduction and internal fixation that required a large tricortical iliac crest graft. As she worked through that phase of the operation, other members of the team harvested a sural nerve from the leg and a free flap from the rectus abdominis. The team then performed the microvascular surgery required to complete a nerve graft and to connect the blood vessels from the free flap to those in the arm.

Today, AG is healing well and has begun playing music again. “It’s been very rewarding to see him regain strength and range of motion,” says Lattanza.

Addressing a Spectrum of Concerns

AG’s case clearly illustrates the many factors necessary for successful reconstructive surgery of the upper extremities. One factor is having a full surgical team available with all of the necessary expertise. “Without a full team of surgeons who have complementary skill sets, the surgery would have taken much longer and involved more risk,” says Lattanza.

For example, at UCSF Medical Center, Lattanza and her new colleague Mohana Amirtharajah, M.D., typically handle the large, bony defects, while plastic surgeon Scott Hansen, M.D., often works on the soft tissue portion of these cases. All three are trained to handle nerve injuries, although in complex cases they often call ieurosurgeon Nicholas Barbaro, M.D., who leads the UCSF Nerve Injury Clinic, where Lattanza consults as part of a multidisciplinary team.

The Hand and Upper Extremity Service team also includes hand surgeon Mathias Masem, M.D., and Bryan Werner, M.D., a physiatrist specializing ionoperative treatment of upper extremity problems.

Experience also is essential for addressing the overlapping concerns that characterize complex reconstructions. “As one example, with a very large bone graft you need to have enough experience to correctly assess what needs to be restored, how to shape the bone to fit, and when there is extensive joint destruction, how to complete an interposition arthroplasty,” says Lattanza.

In addition, in many cases, restoring motion can pose a difficult challenge, depending on the specific nerve and tissue damage. Lattanza describes the case of a man who suffered a work-related crush injury that left him with a soft tissue defect, a broken radius and nerve damage in his forearm.

After initial treatment at San Francisco General Hospital for the severe trauma, the patient came to Lattanza, hoping to regain motion that had been lost due to post-traumatic synostosis of the radius and ulna, as well as to severe muscle loss. Lattanza removed the extra bone growth from the synostosis and then reconstructed the biceps, which restored active elbow and forearm motion.

“Volume is the difference in these complex cases,” says Hansen. He notes, for example, that outcomes for gracilis free muscle transfers that restore finger movement tend to be better when surgeons have extensive microsurgery experience. “In the last year, the division has done over 100 free tissue transfers, and my job is often to provide healthy, well-vascularized soft tissue coverage while minimizing donor site morbidity.”

One newer technique that Hansen sometimes employs is perforator flap reconstruction. “We use magnification to dissect perforating vessels and preserve the muscle,” says Hansen. “It can be a tedious and time-consuming procedure, but it’s effective. We will even do very small free flaps — one millimeter and less.”

Understanding the Range of Injury

Successful outcomes also can involve more than technique; they can require understanding the way upper extremity injuries play themselves out over the course of a lifetime.

For example, Lattanza’s work with both children and adults helped her in the case of a patient who, as a young child, had suffered a traumatic radial head fracture and elbow dislocation. Unfortunately, the original procedure had failed to stabilize the elbow. When the young woman — a still active rugby player at age 25 — arrived in Lattanza’s office, she presented with elbow pain and inability to rotate her forearm.

“The pain and lack of motion were limiting her daily activity and her ability to play her sport,” says Lattanza. With a radial head implant, proper reconstruction of the elbow ligaments and a shortening of the ulna at the wrist, Lattanza was able to restore the normal relationships among the elbow, forearm and wrist.

Finally, a well-planned postsurgical rehabilitation is essential for optimal recovery. “Sometimes as early as post-op day one, we will use continuous passive motion machines to keep the elbow from stiffening,” says Lattanza. “The motion is sometimes limited by the flap — and operative reconstructioeeds to render the parts stable so motion can resume — but early movement helps control edema, restore function and prevent scar formation.”

What are the most common indicators for considering complex reconstructive surgery?

• Any injury of the hand and upper extremity that combines bone loss, soft tissue loss, nerve defect or a combination of these factors

• Acute and chronic elbow instability
• Post-traumatic contracted elbow
• Nerve injuries of the upper extremity requiring repair, graft or tendon transfers

• Complex congenital anomalies of the upper extremity

• Arthritic conditions of the upper extremity requiring joint replacement or resurfacing

• Tendon repair and reconstruction

Microvascular reconstruction in burn and electrical burn injuries of the severely traumatized upper extremity.

Sauerbier M, Ofer N, Germann G, Baumeister S.

Source

Department of Hand, Plastic, and Reconstructive Surgery, Burn Center, BG Trauma Center Ludwigshafen, Plastic and Hand Surgery of the University of Heidelberg, Ludwigshafen, Germany. [email protected]

Abstract

BACKGROUND:

As the versatility and variability of free flaps have significantly increased during recent years, so have the indications for free tissue transplantation in burn reconstruction expanded.

METHODS:

The authors report retrospectively the results of 42 free flaps for upper extremity reconstruction in 35 severely burned patients using 13 different free flaps. This experience enabled the authors to establish reconstructive principles pertinent to the type of injury (burn versus high-voltage injuries) and the timing of reconstruction procedures.

RESULTS:

In high-voltage injuries (n = 17), early free flap coverage with muscular flaps was the most frequently used type of reconstruction. The reconstruction site was predominately the forearm. In burn injuries, free flap coverage was performed during a later stage of the treatment course. Reconstruction with cutaneous or fascial flaps was the preferred method. The elbow and dorsum of the hand underwent defect coverage in most circumstances. For reconstruction of complex or large defects (n = 6), combined “chimeric” flaps were used. Overall, the flap failure rate was 12 percent (n = 5). Interestingly, there was a relationship between flap failure rate and timing of the procedure. Four of five flap failures occurred within 5 to 21 days after trauma, and all five flap failures occurred between 5 days and 6 weeks. No flap failure occurred during secondary reconstruction.

CONCLUSIONS:

The authors’ data demonstrate that burn and high-voltage injuries are distinct entities, each requiring custom-tailored reconstructive solutions for limb salvage. Even if the authors’ flap failures all occurred during the first 6 weeks, it should not be forgotten that this type of coverage is the only alternative to amputation in selected cases.

Analgesia for day‐case surgery

1. N. Rawal

+ Author Affiliations

1.      Department of Anaesthesiology and Intensive Care, Örebro Medical Centre Hospital, S‐701 85 Örebro, Sweden

1. ^†LMA^® is the property of Intavent Limited.

 

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Abstract

Br J Anaesth 2001; 87: 73–87

Key words

• Keywords: surgery, day‐case; analgesia, postoperative

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Recent advances in anaesthetic and surgical techniques, along with escalating healthcare costs, have resulted in an ever‐increasing number of surgical procedures being performed on a day‐case basis world‐wide. The cost‐effectiveness of day‐case surgery is well recognized. Day‐case surgery constituted 60–70% of all surgery performed in North America in the 1990s,22 but in other parts of the world the numbers are lower. However, as outcome data become available confirming the safety of day‐case surgery, it is anticipated that even more procedures will be performed on a day‐case basis. Recent surgical advances include the use of endoscopic approaches for procedures such as micro‐discectomy, tubal interrupt and carpal tunnel release. Major day‐care surgery procedures (e.g. knee and shoulder reconstructions, laparoscopic‐assisted vaginal hysterectomies, gastric fundoplications, splenectomies and adrenalectomies) are being performed at many centres. Even pulmonary lobectomy, prostatectomy, carotid endarterectomy and minor craniectomy procedures are being performed on a same‐day (or 23 h admission) basis.94 Major advances in anaesthetic techniques include the use of anaesthetic agents of short duration and increasing use of regional anaesthetic techniques. It is expected that the number, diversity and complexity of operations performed in the outpatient setting will continue to increase.

Most day‐case surgery procedures are associated with relatively minor surgical trauma, so discharge of these patients frequently depends on recovery from anaesthesia. Top priorities for successful outpatient surgery are the four ‘A’s: alertness, ambulation, analgesia and alimentation. Excessive fatigue, nausea, vomiting or unrelieved pain will delay discharge; these symptoms are the most common reasons for unanticipated hospital admission. Since the proportion of surgery done on an outpatient basis is increasing, and since early discharge and patient satisfaction are important goals, pain management is receiving greater attention.

Rapid recovery after the use of new, short‐acting anaesthetic agents has led to the concept of fast‐tracking and by‐passing the post‐anaesthetic care unit (PACU).5 However, the success of fast‐tracking will depend to a considerable extent on effective postoperative pain management routines with simple methods such as oral analgesics. The potential cost saving of outpatient surgery may be negated by unanticipated hospital admission for poorly treated pain.30 In this review, the terms ‘ambulatory surgery’, ‘day‐case surgery’ and ‘out‐patient surgery’ are used synonymously to indicate that the patient is discharged on the day of surgery without overnight hospital stay.

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Severity of pain after day‐case surgery

The problem of postoperative pain after discharge has generally been poorly studied.22 Postoperative pain is one of the most common complaints after surgery and continues to be a challenge for anaesthetists. Contrary to the common belief that day surgery is followed by mild pain, recent studies have shown that under‐treatment of pain is common. About 30–40% of discharged outpatients may suffer from moderate to severe pain during the first 24–48 h.12 74 This pain decreases with time but may be severe enough to interfere with sleep and daily functioning.29 79 Lengthy surgical procedures and certain types of operation (orthopaedic, urological, anorectal, hernia repair, breast augmentation, laparoscopic cholecystectomy, ENT, dental) tend to be associated with severe pain and therefore require more analgesia.12 43 74

As in adults, most studies of analgesia in paediatric day‐case surgery have focused on the immediate postoperative course and largely ignored the risk of severe pain at home, when it becomes the responsibility of the parent.96 Studies have shown that more than half of children experience clinically significant pain after discharge.29 44 50 Despite the high frequency of under‐treated postoperative pain, the overwhelming majority of patients express satisfaction with pain control.12 74 Patient satisfaction regarding postoperative analgesia is a complex issue. Satisfaction ratings are often related to psychosocial aspects of care such as communication rather than to technical aspects. Several factors may account for the low level of dissatisfaction in spite of moderate to severe pain, including poor follow‐up of patients, reluctance of patients to report postoperative complications, effect of memory on recalling past experience of pain and acceptance of pain as an inevitable consequence of surgery.12

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Impact of pain after day‐case surgery

Severe postoperative pain causes extreme discomfort, sleep deprivation and suffering. Along with postoperative nausea and vomiting (PONV), it is the main cause of delayed discharge, contact with the hospital after discharge, unanticipated hospital admission30 and increased costs. Pain after day‐case surgery may last several days and can have implications for return to work and for community health services. Currently, the majority of patients undergoing day‐case surgery are healthy. However, elderly patients and those with concurrent disease are increasingly being included. The physiological effects of pain may be particularly harmful in patients with ischaemic heart disease or chronic respiratory problems.

The intensity of acute postoperative pain may be important for predicting the development of chronic pain after leg amputation, breast surgery and thoracotomy.47 In day‐case surgery, chronic pain is a significant problem after open groin hernia repair; the reported incidence varies from 0 to 12%. The intensity of early postoperative pain may be an important predictor of the development of chronic pain.18

Changes in children’s behaviour have been seen after both day‐case and inpatient surgery. The changes are mostly transient but in some children they persist for several weeks, months or even years. A recent multicentre survey showed a 47% incidence of problematical behavioural changes; the main predictors were age (highest incidence in children <3 years of age), pain at home and a previous difficult experience of healthcare.52 The authors emphasized the importance of effective prevention and treatment of pain. postoperative pain also seems to be a clear predictor of PONV in children.53

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Choice of anaesthetic technique and peri‐operative analgesia

Safety, rapid recovery and minimal postoperative problems are essential in selecting surgical procedures and anaesthesia techniques for day‐case surgery. The choice of anaesthetic technique can affect postoperative morbidity at home.53 Several new drugs have significant advantages in terms of rapid onset, excellent analgesia and amnesia, good surgical conditions and early recovery. These drugs include sedative–hypnotics such as propofol, analgesics such as remifentanil, alfentanil, ketorolac and tenoxicam, muscle relaxants such as mivacurium, rocuronium, rapacuronium and inhalational agents such as desflurane and sevoflurane. These inhalation agents provide rapid and smooth induction, quick adjustments during maintenance and rapid recovery with few side‐effects.

The nature, technique, extent and duration (>90 min) of surgery and the anaesthetic technique affect the incidence of postoperative morbidity at home.22 38 53 Asking the surgeon to decompress the abdomen rigorously after laparoscopic sterilization reduces the need for postoperative opioids.24 Gas‐less and abdominal wall lift techniques reduce the incidence of PONV.49 Patients undergoing laparoscopic, orthopaedic or general surgery are at a much greater risk of developing persistent symptoms. Certain drugs and anaesthetic techniques are similarly associated with a greater incidence of morbidity.38 The risk of postoperative sore throat can be reduced by using the laryngeal mask airway (LMA^†) rather than endotracheal intubation.10 Succinylcholine may not be a suitable choice for day‐case patients, because myalgias associated with its use may delay the resumption of normal activity. Day‐case surgery patients are said to be at greater risk of succinylcholine‐induced postoperative myalgia than hospitalized patients. The reported incidence of succinylcholine‐induced myalgia varies among studies, from 45% to 85%. Pre‐treatment with small doses of a non‐depolarizing muscle relaxant before succinylcholine administration has been reported to minimize postoperative myalgia. However, despite this intervention, various incidences of myalgia, ranging from 20% to 70%, have been reported.60 In children, PONV increases, even after a single dose of morphine,93 and decreases after administration of propofol.11 The use of regional blocks57 or non‐steroidal anti‐inflammatory drugs (NSAIDs)59 during anaesthesia has reduced the need for postoperative opioids, so their value may be not only in improvement of pain control but also in the reduction of PONV.53

The role of opioids in day‐case surgery is controversial because of their well‐known side‐effects, especially nausea and vomiting. At equi‐analgesic doses, the emetic effects of all opioids appear to be similar. It is emphasized that pain itself is a major cause of nausea and vomiting and opioids may be anti‐emetic when given to relieve pain.2 Although patients who receive an opioid are more likely to experience PONV, average recovery times are not significantly prolonged by the use of intra‐operative opioids per se. Several studies have demonstrated early ambulation and discharge after fentanyl or alfentanil‐based anaesthetic techniques.101 However, there is good evidence that avoidance of opioids virtually abolishes the postoperative complaints of nausea and vomiting that preclude oral intake of fluids after surgery. The ultra‐short‐acting opioid, remifentanil, is associated with a predictable and rapid recovery that is relatively independent of the duration of infusion. However, remifentanil has a limited role in day‐case surgery because its advantages of rapid postoperative recovery and no respiratory depression are negated by the requirement for a longer‐acting opioid or alternative analgesic as soon as the remifentanil infusion is stopped. To quote from a recent editorial by Leach, ‘There seems little logic in using a drug such as remifentanil intraoperatively to suppress the surgical response to painful stimulus, only to allow the patient to regain his senses, acknowledge that pain is severe and then obtund consciousness once more with large doses of a long‐acting opioid’.54 Furthermore, a recent study showed that intraoperative remifentanil can cause acute opioid tolerance leading to increased postoperative pain and opioid consumption.33

With modern general anaesthetic techniques, recovery after surgery can be both rapid and complete. However, in many day‐care patients, regional anaesthetic techniques might be preferable. Regional anaesthesia can reduce or avoid the hazards and discomforts of general anaesthesia, including sore throat, airway trauma and muscle pain. Regional anaesthesia, whether by epidural, spinal, peripheral nerve blocks or field block techniques, offers a number of advantages to outpatients undergoing surgery. These techniques provide analgesia without sedation, earlier discharge and prolonged postoperative analgesia. Local or regional anaesthesia can be used alone, in combination with sedation techniques or as part of balanced analgesia with general anaesthesia. Decreased requirements for opioids reduce the incidence of postoperative nausea (Table 1).

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Table 1

Advantages of local/regional anaesthesia (adapted from reference 81, with permission)

A controversial issue in day surgery is whether regional anaesthesia offers significant benefits over general anaesthesia for ambulatory surgery. Published data are conflicting. However, the indications for regional anaesthesia vary from one institution to another.81 All general and regional anaesthesia techniques have advantages and disadvantages. Thus, in a comparative study of spinal, epidural and propofol anaesthesia for knee arthroscopy, propofol anaesthesia was associated with shortest stay in the operating room but greatest postoperative pain and drug costs. Mepivacaine epidural block resulted in the longest stay and most prolonged postoperative analgesia. Spinal anaesthesia was the least expensive but one patient (3.3%) developed post‐spinal headache.25 Acceptance of the technique by surgeon and patient, and the expertise of the anaesthesiologist, are crucial. It is essential that each unit audits its own complication rates, recovery room times and patient opinions to determine the relevance of regional or general anaesthesia. Day surgery performed under local anaesthesia is often the simplest, safest and cheapest. It is surprising how little sedation patients require if the atmosphere is conducive and the surgeon handles the tissues gently.38 81 Of particular importance is the ability of regional anaesthesia to provide a predictable intra‐ and postoperative course, thus aiding a smooth transition from surgery to recovery with anticipated early discharge. This is in contrast to the use of general anaesthesia with the associated risks of delayed discharge because of complications, particularly nausea, vomiting and pain. Indeed, unanticipated admission for these complications is almost exclusively a problem in patients receiving general anaesthesia.81

Regional anaesthesia does have some disadvantages (Table 2). It may take longer and it requires active co‐operation of patient and surgeon. Induction may be associated with minor discomfort and there is a risk of complications specific to each block and to the local anaesthetic drug used. Furthermore, not all patients are suitable for regional anaesthesia. Difficulties in performing the block and movement during surgery can be a problem in the very anxious patient. Heavy sedation in such patients may negate the positive aspects of regional anaesthesia. If the block fails, the surgeon may be able to supplement with additional local anaesthetic and the anaesthetist must be on stand‐by to convert to general anaesthesia immediately.81

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Table 2

Disadvantages of local/regional anaesthesia (adapted from reference 81, with permission)

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Day‐case regional anaesthesia for perioperative pain

A number of regional anaesthetic techniques can be used for day‐case surgery. These techniques involve little physiological trespass, compared with general anaesthesia, and so they are particularly suited to the ever‐growing population of high‐risk elderly patients presenting for day‐case procedures. At completion of surgery, infiltration of the wound using a long‐acting local anaesthetic (e.g. 0.25% bupivacaine) provides prolonged postoperative analgesia. For ocular surgery, peribulbar, retrobulbar or topical blocks can be performed safely, effectively and with few complications.

In children, the use of regional anaesthesia techniques before the start of surgery (but after the child has been put to sleep) will reduce the requirements for general anaesthetic drugs during surgery, which may result in a more rapid recovery, less nausea and vomiting, and earlier alimentation and discharge. Caudal block is easy to perform and provides excellent analgesia for perineal or inguinal surgery. Sympathetic effects on the circulatory system are rare. Blocks may be performed on the ilioinguinal nerve, iliohypogastric nerve, the dorsal nerve of the penis, the brachial plexus, femoral nerve or digital nerves. Ring blocks of the wrist or ankle and local infiltration are simple and effective.

Intravenous regional anaesthesia

Intravenous regional anaesthesia (IVRA) is one of the most common regional techniques world‐wide.37 69 It is very easy to perform: the only technical skill necessary is the ability to perform venipuncture (although skill in resuscitation is also required if complications occur). IVRA is most suitable for short duration (<45–60 min) surgical procedures in distal extremities (forearm, hand, ankle and foot). Good surgical anaesthesia can be achieved rapidly after the injection of local anaesthetic and recovery is fast after the release of the tourniquet. No other regional anaesthetic technique provides such a control over the onset, duration and recovery of block. The published success rates range from 94% to 100%. Adjuvants such as opioids, NSAIDs and muscle relaxants have been used to improve the quality of block and postoperative analgesia, but the results are generally unimpressive. The main problems of the technique are related to the requirement for a tourniquet, and include restricted area of anaesthesia, pain associated with the tourniquet, and risk of local anaesthetic toxicity due to accidental release of the tourniquet. Some recent studies suggest that the use of ropivacaine may provide prolonged postoperative analgesia.8 21 Although ropivacaine is less toxic than bupivacaine, its use is not recommended for IVRA because it is much more toxic than the commonly used prilocaine and chloroprocaine.37 72

Peripheral nerve blocks

Peripheral nerve blocks provide excellent analgesia over a limited field and with minimal systemic effects. The blocks are generally easy to perform, inexpensive and very safe. Peripheral blocks are possible for nearly all kinds of surgery (Figure 1). Even in situations where the block is ineffective for surgery, the catheter can often be used for postoperative pain management. The technique is under‐used both for surgery and for postoperative pain treatment. Peripheral nerve blocks have extended the indications for day‐case surgical procedures such as major shoulder surgery and knee reconstruction. Comparative studies of interscalene block and general anaesthesia for day‐case shoulder arthroscopic surgery showed that 8% of the patients receiving general anaesthesia required unanticipated admission compared with none in the patients receiving interscalene block.17 26 Details about different blocks and techniques are beyond the scope of this review; they can be found in standard books.

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Fig 1 Possible peripheral nerve blocks for surgery and postoperative analgesia.

Upper extremity blocks for day surgery

Several techniques are available to provide efficient regional anaesthesia of the upper limb for day‐case surgery. The technique chosen should be appropriate for the intended surgery. The timing of the block is important. It is not advisable to squander operation‐room time on waiting for the block to work. Special block rooms outside the operating rooms should be available to (i) handle the high volumes and rapid turnover of patients; (ii) perform the blocks well in advance of the scheduled surgery allowing sufficient ‘soak time’ (≥20 min) for the local anaesthetic to work; and (iii) recognize early any technical failure so that the decision to proceed with rescue block or general anaesthesia can be made quickly once the patient arrives in the operating room. The block should have residual analgesia in the postoperative period, minimizing the need for systemic analgesics. The limb with residual motor block should be protected appropriately until complete resolution of the block. Criteria for fast‐track discharge should be established to minimize patient’s recovery and discharge times. In some institutions, patients are allowed to leave before regression or resolution of the block. A telephone follow‐up the next day monitors patient satisfaction and any post‐surgical complications.62 During surgery, a tranquil environment should be provided for the patient by allowing them to watch a video, listen to music, or sleep lightly, with judicious use of midazolam if necessary.

Many techniques are available to block the brachial plexus; the most commonly used are interscalene block for shoulder surgery, supraclavicular or interscalene block for upper arm surgery, axillary or intraclavicular block for elbow or forearm surgery and axillary or peripheral nerve block for wrist and hand surgery. The medial, ulnar and radial nerves may be blocked using consistent anatomic landmarks at the elbow or wrist and small volumes of local anaesthetic.

Peripheral nerve blockade can also be used to supplement patchy brachial plexus anaesthesia or provide anaesthesia to a specific site in which surgery is limited and of short duration.

Both bupivacaine and ropivacaine appear to be as efficacious as long‐acting local anaesthetics for brachial plexus block.48 Opioid and non‐opioid adjuncts have been added to local anaesthetic solutions in an attempt to improve or prolong analgesia during brachial plexus blockade. Although several studies have reported that analgesia lasts longer when opioids such as morphine, sufentanil and buprenorphine are added to local anaesthetic, other studies found no advantages.62 Clonidine 0.5 µg kg^–1 is reported to prolong anaesthesia and analgesia, but higher doses (e.g. 300 µg) can cause sedation and hypotension, both of which are undesirable in day‐surgery patients.14

Lower extremity blocks for day surgery

A combined block of the lower extremity offers many advantages over spinal or epidural anaesthesia, such as less hypotension, no urinary retention or post‐spinal headache, and fewer concerns regarding bleeding risk in patients taking anticoagulants. For knee surgery, the extent of sensory and motor blockade achieved with a combination of a sciatic and a dorsal lumbar plexus nerve block is comparable to that achieved with a central nerve block. For surgery below the knee, popliteal sciatic nerve block alone or combined with a saphenous nerve block is a reasonable choice; for foot surgery an ankle block is probably the best method. The choice of local anaesthetic depends on duration of the surgery, but attention should be paid to the possibility of systemic toxicity because combined proximal nerve blocks of the lower extremity frequently require doses that are close to the maximum recommended doses. The arguments against peripheral nerve blocks are that they take longer, it is impossible to block all nerves of the lower extremity from one injection site, and there is a certain proportion of failed blocks, even in experienced hands. However, acceptance of peripheral blocks by patient (and surgeon) can be increased by selection of appropriate blocks, patient education and follow‐up routines.31

Intra‐articular analgesia

Intra‐articular drug administration has gained popularity because of its simplicity and efficacy in achieving anaesthesia for diagnostic and operative arthroscopy and for providing postoperative analgesia. Although the knee joint has been examined most commonly, arthroscopy of other joints such as shoulder, ankle, wrist, metatarsophalyngeal and temporomandibular joints is being increasingly practised.27 Intra‐articular instillation of local anaesthesia during arthroscopic procedures has been used by many orthopaedic surgeons to provide pain relief after surgery. However, there are conflicting reports in the literature about its therapeutic role. A systematic review of 20 controlled trials with data from about 900 patients showed evidence for a postoperative analgesic effect in 12 of the 20 studies of intra‐articular administration of local anaesthetic following arthroscopic knee surgery. However, the evidence was not compelling and, in most cases, analgesia was short lived. Nevertheless, the authors concluded that the technique may be of clinical significance in day‐case surgery.61 The use of intra‐articular morphine is effective in the management of pain after arthroscopic knee surgery86 and anterior cruciate ligament repair.45 A systematic review of 36 randomised control trials showed that intra‐articular morphine may have some effect in reducing postoperative pain intensity and consumption of analgesics.46 However, most of the studies had significant problems in design, data collection and statistical analysis. The authors emphasized the need for better methodological quality trials to decide conclusively if intra‐articular morphine analgesia is clinically useful. There is some evidence that intra‐articular NSAIDs have a clinically relevant peripheral analgesic action.83 Current evidence suggests that intra‐articular multimodal regimens may provide improved effects on postoperative pain and convalescence.10 34 83

Central neural blockade: epidural, spinal or combined spinal epidural?

Spinal and epidural anaesthesia are effective alternatives to general anaesthesia in ambulatory surgery, with some investigators demonstrating advantages of fewer side‐effects and earlier discharge times. However, this remains a controversial issue, as some clinicians are concerned about delayed patient recovery. Selection of short‐acting local anaesthetic drugs is therefore appropriate. Combinations of local anaesthetics, short‐acting opioids and non‐opioids may be used to allow lowest possible effective dose of local anaesthetic to provide early postoperative ambulation and discharge.

The choice of a central block depends on patient request, surgical considerations and anaesthetic benefits. For surgical procedures with patients lying face down, there may be a problem with airway control and general anaesthesia unless endotracheal intubation is used. Anaesthetic benefits with central blocks are most evident in the postoperative phase. The patient may be wheeled out immediately after surgery. Residual block protects the patient from initial pain and there is some evidence that regional anaesthesia also protects the patient from pain after the block has worn off. Patients are in less need of postoperative opioids for pain relief and there is less tendency for nausea or vomiting after central blocks.32 68 This is a major benefit in day‐case surgery, both in terms of better patient comfort and faster discharge. The risk of major neurological complications is very small. However, the patient should be informed about the symptoms of epidural haematoma or abscess formation, because these complications have been reported after discharge of day patients.67 68

Epidural anaesthesia with a short‐acting local anaesthetic such as lidocaine provides about 60–90 min of anaesthesia with possible discharge 4–6 h after the block. However, it has some drawbacks. It is more time consuming to perform and there is a delay in onset of block. Ræder describes a technique aimed at reducing the time required to achieve an adequate epidural block: the total dose of local anaesthetic is injected as a bolus into the epidural needle, the test dose is eliminated and the surgical site prepared before the block is evident.68

Spinal anaesthesia is the most common central block in a day‐surgery setting. Spinal block has distinct advantages over epidural anaesthesia, with less time required to achieve an adequate block, lower incidence of incomplete sensory and motor block and pain during surgery.81

The spinal technique is easy to perform and has a very high success rate and an enviable safety record.9 The out‐patient spinal anaesthetic is typically of rapid onset, predictable duration, minimal side‐effects and reliable offset.39 Spinal anaesthesia provides excellent surgical conditions for orthopaedic surgery on lower extremities, for gynaecological, urological and perirectal procedures and for lower abdominal procedures such as inguinal hernia. A 17‐nation European survey of 105 hospitals showed that almost 40% of all ambulatory surgery in the participating hospitals was performed under regional blocks. Spinal and epidural blocks were used in 25–30% of hospitals. However, there was a great difference between European countries: these blocks were well accepted in Scandinavian countries, Germany and Switzerland, whereas Austria, Greece and Ireland restricted the use of these blocks in day‐case surgery.69 A recent Swedish survey showed that spinal block was used routinely in 85% and epidural block in 28% of the 109 day surgery units in the country (Rawal N, unpublished data).

Lidocaine is used most frequently, though recent studies have shown that transient neurological symptoms (TNS) can occur in 16–40% of outpatients.35 56 66 Alternative local anaesthetic drugs such as bupivacaine in small doses (5–10 mg) and ropivacaine are associated with a very low incidence of TNS but are not always appropriate for day‐case surgery.39 Adjuvants such as fentanyl 10 µg can improve the success rate of low‐dose hyperbaric bupivacaine (e.g. 5 mg) spinal anaesthesia without prolonging discharge time.13 TNS should be taken into account when considering the choice of local anaesthetic, especially when the lithotomy position or knee arthroscopy is planned.39 In a recent study, mepivacaine 60–80 mg was shown to be a suitable anaesthetic choice for ambulatory spinal anaesthesia with respect to anaesthetic, as well as recovery profiles. A postoperative follow‐up did not show TNS in any of the 60 patients who received spinal mepivacaine as part of combined spinal–epidural (CSE) for anterior cruciate ligament repair.64

A former barrier to outpatient spinal administration, namely post‐dural puncture headache, has been largely eliminated with the introduction of conical‐tipped needles that result in less dural trauma. Comparative studies of spinal and general anaesthesia have dispelled the myth that spinal anaesthesia results in operating room inefficiency. Novel manipulations of baricity and dose have resulted in significant reductions in unwanted motor block using conventional spinal anaesthesia.39 66

For surgical procedures involving one lower limb, a unilateral spinal block has been shown to minimize the haemodynamic effects of spinal anaesthesia. The technique involves the lateral decubitus position, low‐dose hyperbaric local anaesthetic solution, low speed of intrathecal injection and directional pencil‐point spinal needles.19 Unilateral spinal block for ambulatory surgery needs further evaluation.

Selective spinal anaesthesia (SSA) using lower doses of intrathecal agents with or without intrathecal or systemic adjuvants has been used to provide spinal anaesthesia with greater selectivity and rapid return of function. It has been demonstrated that SSA provides pinprick analgesia suitable for surgery while light touch, proprioception, motor and sympathetic function are preserved.91

CSE anaesthesia combines the rapidity, density and reliability of subarachnoid block with the flexibility of continuous epidural block.77 Although, at first sight, CSE techniques appear to be more complicated than epidural or spinal block alone, intrathecal drug administration and siting of the epidural catheter are both enhanced by the combined, single‐space, needle‐through‐needle method. CSE is an effective way to reduce the total drug dosage required for anaesthesia and analgesia, thus making a truly selective blockade possible.77 In contrast with epidural anaesthesia, the other leading central neuraxial technique, CSE, has a lower failure rate and a faster onset time.40 The practicality of CSE has been questioned. CSE is well‐established for inpatient surgery and obstetrics but is still in its infancy in day‐case surgery. By providing the ‘safety net’ of an epidural catheter, CSE allows use of the lowest effective dose of local anaesthetic.65 90 For ambulatory knee surgery, CSE allowed Urmey and colleagues to reduce the dose of spinal lidocaine from 80 mg to 40 mg.90 Similarly, Pawlowski and others used CSE to identify appropriate doses of spinal mepivacaine in order to eliminate the risk of TNS.64 The security of an epidural catheter allows minimal dosing of local anaesthetic and therefore more precise predictability of day surgery spinal anaesthesia.

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Strategies for postoperative pain management

Optimal postoperative pain control for day‐case surgery should be effective and safe, produce minimal side‐effects, facilitate recovery and be easily managed by patients at home. Analgesic techniques should permit ‘normal’ activities and additional analgesic supplements should be provided to cover any painful activity. Rescue analgesia should be provided if the prescribed analgesic is ineffective. The use of pre‐packaged take‐home analgesics specific to the type of surgery and breakthrough medication can lead to improved pain control, mobility and sleep.58

Pain assessment and documentation

Pain intensity must be assessed and reassessed frequently and documented on the bedside chart (‘making pain visible’). The day‐care facility should define a maximum acceptable pain score and train the personnel to treat pain promptly if it exceeds a certain level. At our institution, a hospital‐wide policy of keeping pain levels at ≤3 on the 10‐point visual analogue scale (VAS) has been functioning satisfactorily since 1991 for surgical day‐case and inpatients. Pain intensity is assessed and documented every 3 h for inpatients and at least every hour for day‐case surgery patients.71 It is important to assess pain and efficacy of analgesia at rest and during activity. A practical scheme is to assess pain at rest in early recovery, and at rest and during activity at and after discharge. In situations where communication is difficult, a verbal or observer (nurse) scoring system can be used82 (Figure 2). It may be difficult to determine whether small children are in pain after surgery because such children are unable to express their feelings in words. If a child’s pain is treated at home, parents have to estimate the level of pain and therefore need to be informed appropriately. Pain assessment tools have been formulated and validated for parents to use at home.20 95 Documenta tion of pain scores also allows the day surgery unit (DSU) to perform regular audits to confirm that pain management techniques are not causing problems at home.

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Fig 2 Pain scoring systems (modified from reference 82).

Pain management in the PACU

postoperative pain control should be started intra‐operatively by supplementing general anaesthesia with short‐acting opioids, NSAIDs or regional anaesthesia. This should aid smooth recovery. When opioids are used in the recovery period, rapid and short‐acting drugs such as fentanyl and alfentanil should be administered i.v. and titrated to desired effect.

Regional analgesia performed in conjunction with general anaesthesia is becoming an increasingly important component of paediatric postoperative pain management. A variety of regional blocks can be performed simply and quickly in paediatric day‐surgery patients.

The possible differences in PONV between different opioids have not been demonstrated in controlled trials: no difference in adverse effects was noted between morphine, pethidine (meperidine) and fentanyl (in adults) using PCA97 or between i.v. morphine and i.v. fentanyl in the PACU.23 Incidence of nausea and vomiting increases significantly in the period after discharge, because morphine can act as an emetic stimulus on the trip home, resulting in delayed vomiting. Discharge may also be delayed by PONV and sedation. Combinations of analgesics that act by different mechanisms result in additive or synergistic analgesia, allowing total doses of drugs to be reduced and so reducing side‐effects. Such techniques, using a combination of opioid, NSAID, paracetamol and local anaesthetic, are superior to any single modality. Regular and frequent assessment of pain intensity is important. Differences between analgesic methods may only become evident when pain is assessed during activity, so pain should be assessed both at rest and during activity.82

Choice of analgesic after discharge

Oral analgesics are the mainstay of continuing pain control at home, and it is important to encourage patients to take analgesics pre‐emptively and regularly, starting before the effect of the local anaesthetic has worn off.81 For mild pain, simple analgesics such as paracetamol may be sufficient. Patients with mild to moderate pain in day surgery benefit from combinations of NSAIDs and weak opioids in addition to regional or local anaesthesia. Patients’ responses to drugs vary, so rescue analgesia for postoperative pain beyond acceptable levels may be needed. Strong opioids are generally avoided because of their well‐known side‐effects, including the risk of respiratory depression.

Paracetamol is the most commonly used analgesic world‐wide because it is effective, cheap and safe. It is often combined with other drugs, such as weak opioids and NSAIDs, as part of a balanced analgesic approach. The effectiveness of paracetamol is often underestimated because this drug is often not administered correctly. Paracetamol has a dose‐related potency for postoperative pain in paediatric surgery.51 Earlier dosing with paracetamol 10–15 mg kg^–1 ‘as necessary’ failed to provide therapeutic plasma concentrations and so was ineffective.96 In children, a loading dose of 40 mg kg^–1 (or greater) is currently recommended followed by regular dosing of 90 mg kg^–1 day^–1 to maintain therapeutic plasma concentrations.3 96 98

The currently recommended doses for rectal and oral administration of paracetamol are the same. However, the rectal dose should be higher than the oral dose, because of poor and erratic absorption of paracetamol from suppositories.3 51

Weak opioids, such as codeine and dextropropoxyphene, are the most commonly used oral opioids, usually in combination with paracetamol. Tramadol is believed to have a potency equal to that of pethidine28 without causing significant respiratory depression. Its main drawback is a high incidence of nausea and vomiting. Our recent controlled comparison between tramadol, metamizol and paracetamol in patients undergoing day‐case hand surgery showed that none of the study drugs provided effective analgesia in all patients. The percentage of patients who required rescue dextropropoxyphene at home was 42% with paracetamol, 31% with metamizol and 23% with tramadol. However, tramadol was associated with the greatest frequency and severity of adverse effects such as nausea and dizziness and, consequently, with the greatest dissatisfaction. Metamizol and paracetamol provided good analgesia in 70% and 60% of the patients, respectively, with low incidence of side‐effects.78

NSAIDs are now the basis of most day‐surgery analgesic regimes. As well as providing effective analgesia, their anti‐inflammatory effects may help reduce local oedema and minimize the use of more potent drugs and their accompanying side‐effects. Several advantages are offered by NSAIDs in the peri‐operative period. They are effective as the sole analgesic in a high proportion of cases of mild to moderate pain. When combined with opioids, they can enhance the quality of opioid‐based analgesia and often diminish opioid requirements by about 25%. Some studies have shown that they may reduce opioid‐related side effects.

NSAIDs are frequently used to treat mild to moderate pain and as a component of multimodal regimens for moderate to severe pain. In 1998, the Royal College of Anaesthetists issued guidelines for the use of NSAIDs in the peri‐operative period. Based on the strongest evidence available, it is stated that ‘In situations where there are no contraindications, NSAIDs are the drug of choice after many day‐case procedures.’80 However, controversy still surrounds the use of NSAIDs because of their significant gastrointestinal, haematological and renal side effects. Systematic reviews have not found any important differences between different NSAIDs but have found differences in toxicity related to increased doses and possibly to the NSAID itself. It has been proposed that the anti‐inflammatory properties of NSAIDs are mediated through cycloxygenase 2 (COX‐2) inhibition, whereas adverse effects occur as a result of their effects on COX‐1. The World Health Organization has categorized COX‐2‐selective drugs as a new subclass of NSAIDs (coxibs). The two coxibs currently available, rofecoxib and celecoxib, appear to be as effective as non‐selective NSAIDs in suppressing inflammation and providing analgesia, while reducing the incidence of endoscopy‐verified ulcers to levels similar to those seen with placebo.55 Parecoxib is a new COX‐2‐specific agent that is given i.v. or i.m. The role of COX‐2‐specific NSAIDs in postoperative pain management will become clearer when the results of ongoing clinical trials become available. Overall, the benefits of NSAIDs greatly outweigh their risks. Choice of drug will depend on availability, desired route of administration (oral, rectal, i.v.), duration of analgesia and cost.

In general, there is a great need for powerful non‐opioid analgesics in future day surgery and they may either be prescribed alone or be used to reduce opioid requirements. It may prove more convenient and less unpleasant to give these drugs by the i.v. route rather than by i.m. or rectal administration.

Regional techniques at home

Administration of local anaesthetic into the surgical wound is effective and safe but the analgesia lasts only a few hours. We have described a technique using an elastometric balloon pump, which allows the patient to self‐administer local anaesthetic analgesia at home.75 The technique involves placement of a multihole, thin (22‐gauge) epidural or Perifix brachial plexus catheter (B. Braun, Melsungen, Germany) subcutaneously into the surgical wound, subacromially, intra‐articularly or in the axillary brachial plexus sheath (depending on the surgical site). The catheter is tunnelled 4–5 cm subcutaneously by the surgeon and firmly secured on to the skin by sterile tape. Axillary brachial plexus catheters are placed and secured in position by anaesthetists. The catheters are introduced 3–5 cm within the sheath and secured to the skin with transparent dressing and tape.

Using aseptic technique, the catheters are connected to a 50 or 100 ml elastomeric (balloon) pump (Figure 3) with the appropriate concentration and volume of local anaesthetic drug (‘Home Pump’; I‐Flow Corporation Lake Forest, CA, USA). The balloon pump is filled with a volume of local anaesthetic to provide 10 doses for postoperative pain management. After the operation, when the patient feels pain, he starts the local anaesthetic infusion by opening the clamp. The patient stops the infusion by closing the clamp after the prescribed time (usually 6 min), or earlier if he is satisfied with pain relief (Figure 3). When the patient no longer requires analgesia, he removes the tape, pulls out the catheter and discards the pump. In most cases, the patient gives himself the first dose in the PACU.

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Fig 3 Self‐administration of local anaesthetic solution by a patient. On opening the clamp (left), the solution starts running into the catheter. After the prescribed time (usually 6 min), the patient closes the clamp (confirmed by a clicking sound) to stop the infusion (right). The patient is encouraged to use a timer as a reminder to close the clamp. (Reprinted from reference 73 with permission from Lippincott–Williams and Wilkins.)

In brachial plexus catheters, 0.125% bupivacaine or ropivacaine was used, whereas 0.25% was used in all other catheters. The 0.125% solution was used to reduce or avoid the risk of possible injury caused by excessive motor block. The maximum volume of local anaesthetic allowed for each administration was 2.5 ml for maxillofacial surgery, 5–10 ml for surgical wounds and 10 ml for other procedures. An appropriately sized pump (50 or 100 ml) filled with local anaesthetic to provide 10 doses at home was given to the patient before discharge. The patient was told not to use the pump more than once an hour. Follow‐up consisted of evaluation of pain relief at home, pump function, use of rescue medication and overall satisfaction or dissatisfaction with the technique.

Pain relief was graded as good to excellent by 90% of patients. Onset of analgesia was experienced within 5 min, and the duration of analgesia after each administration of local anaesthetic varied from 2 to 8 h. Patient follow‐up did not reveal any infection or any other major problem with the technique, and patient satisfaction was very high. Nearly 700 patients undergoing a variety of surgical procedures have been treated with patient‐controlled regional anaesthesia (PCRA) at our hospital without any major complications.

Recent controlled trials have demonstrated the efficacy and safety of incisional catheter PCRA in patients undergoing Caesarean section,100 abdominal hysterectomy99 and inguinal hernia repair.92 Our controlled comparison between 0.125% ropivacaine and 0.125% bupivacaine for axillary brachial plexus PCRA at home demonstrated the feasibility, efficacy and safety of this technique for treating pain outside the hospital. Both drugs provided effective analgesia, but patient satisfaction was better with ropivacaine PCRA.76 White cell counts, bacterial culture of the catheter tips and wound inspection have not shown any evidence of infection.92 99

The main concern with the balloon pump device is the risk of local anaesthetic toxicity if the patient neglects to close the clamp. This can be prevented with newer devices which allow a continuous infusion of local anaesthetic at a pre‐set rate. For example a 100 ml elastomeric pump (‘Pain Buster’; I‐Flow Corporation, Lake Forest, CA, USA) can provide adequate analgesia at home for 2 days when the local anaesthetic is infused at a rate of 2 m h^–1. However, this is not PCRA. Newer, lightweight pumps with appropriate safety features including lock‐out possibilities and disposable cassettes for local anaesthetic solutions are also available to provide safe PCRA in the patients’ home environment (Microject; Sorensen Medical, UT, USA). Further studies are necessary to establish the efficacy and safety of this promising new technique at home after ambulatory surgery. Studies are also necessary to evaluate the optimal concentration and volume of local anaesthetic and the possible role of adjuvant drugs. Adequate patient information is important (Table 3).

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Table 3

Patient instructions for post‐operative PCRA at home

Role of patient (and parent) information

Preoperative preparation of patients

Postoperative pain is often associated with anxiety; it has been demonstrated that patient education and preoperative preparation can reduce postoperative pain.36 Successful postoperative pain control depends on the knowledge and demands of the patient. A questionnaire survey for evaluating the general public’s perception of postoperative pain revealed that almost half of patients were prepared to suffer pain rather than complain.84 Patients should be informed about the need to treat pain and about the various ways of managing pain. The information should be given verbally and in writing. Day patients with severe pain at home do not always take their medication as prescribed and may even mix in their own analgesics. Clear instructions are therefore mandatory. On admission to DSU, pain management should be discussed with the patient and the pain assessment scoring explained. Patient preferences, for example with regard to the use of suppositories or central neuraxial blocks, should be respected.

Analgesia needs to be tailored to the severity of pain associated with the procedure. Drugs are chosen on the basis of their availability, freedom from side‐effects, convenience of administration and safety. Patients’ responses to drugs vary, so rescue analgesia for pain beyond acceptable levels may be needed. Pre‐packaged analgesics should be provided for anticipated mild, moderate or severe pain. A follow‐up call the next day reassures the patient and provides feedback about analgesic efficacy. Regular audit of the postoperative pain service is essential.82

For patients undergoing surgery with regional anaesthetic techniques, patient education during the pre‐operative clinic visit is essential to improve patient acceptance of the use of regional anaesthesia. Audiovisual material and an information pamphlet are helpful tools, giving patients time to make an intelligent decision and to be psychologically prepared for the block. Patient education will also help to allay apprehension about being awake during the surgery and to address the fear of pain during block.

Local anaesthetics such as bupivacaine should be chosen for their long‐lasting effect. All surgeons should be encouraged to use bupivacaine for wound infiltration. However, patients should be warned that the effects will wear off and that they should take another analgesic before this happens, particularly before going to bed on the first night after surgery. Patients must meet standard discharge criteria following day surgery with local or regional anaesthesia. Patients who have undergone central neural blockade should have return of motor and sensory function and preferably void before discharge. Those who have residual numbness after limb anaesthesia should be advised about limb protection17 (Table 4).

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Table 4

Day‐case surgery: infomation given before discharge

Prevention and treatment of pain and PONV at home remain a challenge in children undergoing day‐case surgery. The parents of a child recovering at home have to estimate the intensity of pain and treat postoperative pain. A general instruction to parents to give the child some medication for pain at home as needed is not enough. To ensure successful pain management at home, it is important to give parents appropriate information. It is also important to train doctors and nurses to provide proper information on treating pain and to determine the outcomes of training programmes. Since hospital personnel often recommend over‐the‐counter pain medicines, we should also direct attention to pharmacists’ knowledge of pain treatment in children and their ability to provide information for parents. Staff training programmes to provide adequate information about postoperative pain medication for the parents can be highly beneficial.85

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Future perspectives in day‐case surgery and pain management

Advances in day‐case anaesthesia and development of minimally invasive surgical techniques can be expected to continue. Day‐case surgery has presented a new set of challenges and goals for the anaesthetist. Newer inhalational agents and improved anaesthetic drugs with minimal emetic sequelae and new drug delivery techniques may improve the outcome of day‐case surgery in the future. Widespread use of improved sedation and regional anaesthesia will also evolve. Further development of target infusion anaesthesia will smooth the maintenance of day‐case anaesthesia.15 Although the requirement for alternative analgesia immediately after cessation of infusion limits the usefulness of remifentanil in day‐case surgery, further advances in opioid therapy may become available with the introduction of trefentanil and mirfentanil. The former has characteristics intermediate between those of alfentanil and remifentanil.16 63 Patient‐controlled approaches to newer opioid drug delivery systems, such as transdermal iontopheresis7 or intranasal87 or transmucosal6 delivery also need to be evaluated for their suitability and safety in patients discharged after day‐case surgery. Based on current trends, it is fair to predict an increased use of local or regional anaesthesia alone, in combination with sedation anaesthesia or as part of a multimodal technique with general anaesthesia. As more extensive and painful procedures, such as cholecystectomy, knee reconstructions, shoulder procedures, hysterectomy and laminectomy, are being performed as day surgery, there will be a pressing need to introduce far better drugs to alleviate PONV and pain.

Spinal and epidural blockade are widely practised in several countries. Discharge times of 2–3 h after short‐acting local anaesthetics or low‐dose local anaesthetic drug combinations are not unrealistic.30 Patient acceptance will increase if the benefits of these procedures are explained by enthusiastic surgeons and anaesthetists. It is no longer valid to oppose spinal anaesthesia on account of post‐lumbar puncture headache. This may be reduced to less than 1% by the use of 26‐ or 27‐gauge pencil‐point spinal needles.39 Further improvements ieedle and catheter technology will make central neuraxial blocks safer. The trend towards increasing use of peripheral nerve blocks42 will accelerate as newer catheter systems (e.g. Stim‐Kath, Epimed) become available which allow successful placement by nerve stimulation technique.1 The recent introduction of less toxic long‐acting local anaesthetics ropivacaine and levobupivacaine have improved the safety of regional techniques. A variety of opioid and non‐opioid adjuvants to local anaesthetic drugs are under investigation. Other future directions in the use of regional anaesthesia for day‐case surgery include the development of local anaesthetic encapsulated in lipophilic membranes, which allows sustained release of local anaesthetic and thus prolonged analgesia lasting several days after single injection techniques.

Although the concept of fast‐tracking is well accepted in day‐case surgery, the issue of at‐home recovery is generally neglected. Almost all literature concerns the early postoperative period while the patient is in hospital. At‐home recovery and return to normal daily activities are of greater interest to the patient, his family and society. The following questions need to be addressed. What is the natural course of recovery after different surgical procedures? When is cognitive function restored to baseline? When do patients resume usual at‐home activities? What is the relationship between hospital costs and costs to society?

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Conclusions

Day surgery is a cost‐effective, quality approach to surgery that has expanded rapidly in recent years. Multiple factors have contributed to this transition, including economic forces, improved anaesthetic and surgical techniques, better pre‐operative planning, better patient education and an enhanced ability to deliver adequate analgesia in the outpatient setting. Many procedures that used to be performed on an in‐patient basis under general anaesthesia are now performed on a day basis under local or regional anaesthesia alone or combined with sedation techniques.

Regional anaesthesia offers many advantages for the day‐case surgery patient. Patients can remain alert and, with proper techniques and agents, are able to be rapidly discharged with minimal side‐effects and optimal pain control. Local and regional anaesthesia, alone or as part of general anaesthetic technique, offer major benefits to the ambulatory surgery patient. In general, peripheral nerve blocks are under‐used for ambulatory surgery. The use of regional techniques will depend on local tradition, the day‐surgery facility, patient and surgeon co‐operation and skill of the anaesthetists. In many institutions, neuraxial blocks such as epidural, spinal, and CSE are controversial regional techniques for day‐case surgery. However, by appropriate patient selection, choice of equipment, drugs and adjuvants, the anaesthetist can tailor neuraxial blocks to a specific type and duration of surgery.

The success of day‐case surgery depends, to a large extent, on both effective control of postoperative pain and minimization of side‐effects such as sedation, nausea and vomiting. Inadequate analgesia after surgery is a problem: it has been demonstrated that one‐third of patients suffer moderate to severe postoperative pain as a result of inadequate analgesia. Under‐treatment is still one of the most common errors in the treatment of pain in children. Day‐surgery analgesia must allow the patient to be discharged safely and without delay. Additionally, after the patient has been discharged, he must not require close medical or nursing supervision, either for the administration of analgesia or for safety reasons. Side‐effects that might be regarded as minor in the inpatient may contribute to unexpected admissions in the day‐case setting. Prolonged recovery may disrupt patient flow and increase institutional costs per patient. The unplanned overnight hospital admission rate may well reflect the quality of care in day‐case surgery.

The growth of day‐case surgery requires both a rapid return to street fitness and the provision of analgesia appropriate to the nature of the surgery undertaken. Balanced analgesia in day‐case surgery commonly involves intra‐operative administration of short‐acting opioids such as fentanyl, and wound infiltration with local anaesthetic at the end of surgery supplemented in the postoperative period by an oral, non‐opioid analgesic. Recent improvements in our pharmacological knowledge concerning pain medication have made it possible to provide more individualized pain treatment for adults and children.

Dispensing appropriate analgesia with clear instructions for the patient is crucial. Giving patients pre‐packed analgesics for anticipated mild, moderate or severe pain, with clear directions has the potential for improving patient comfort at home. After discharge, patient follow‐up is essential to monitor effectiveness of pain treatment. Day‐surgery units should standardize and audit their analgesic treatments for mild, moderate and severe pain. New portable PCRA systems are becoming available which can provide effective and safe analgesia at home for several days. Small disposable pumps, pre‐loaded with local anaesthetic, with pre‐set hourly infusion rates or self‐administered bolus infusions provide effective analgesia at home.

 

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