Section D: Specific Technique

Outcome Issues in
Ambulatory Anesthesia
 Neuraxial Techniques for
Ambulatory Anesthesia

Michael F. Mulroy, MD
Francis V. Salinas, MD

Central neuraxial techniques should be the simplest and most effective

applications of regional anesthesia (RA) in the outpatient setting. Both
spinal and epidural anesthesia are 1) more familiar to practitioners than
are peripheral nerve blocks, 2) generally simpler to perform because they
do not require nerve localization techniques, and 3) performed rapidly
and without assistance. Neuraxial techniques are effective for lower
abdominal, perineal, and lower extremity surgery, and are among the best
choices for practitioners who are just starting to incorporate regional
techniques in an outpatient practice. They also provide optimal outcomes
in most of the important aspects of outpatient anesthesia. Patients with
neuraxial blocks have lower pain scores on admission to the postanesthesia
care unit (PACU) compared with patients receiving general anesthesia
(GA).1–5 Their frequency of postoperative nausea and vomiting (PONV)
appears to be one third of that after GA.6 Most important, the frequency of
fast-track eligibility is high,1,6,7 and discharge times may be competitive with
even the fastest of general anesthetic techniques if appropriate drugs and
dosages are chosen. Additionally, modern equipment and drug choices
have reduced the side effects that were of previous concern. With propofol
infusions available to provide light but transient sedation, the objection to
‘‘being awake’’ has also disappeared, leaving neuraxial techniques a clearly
superior choice.
This chapter focuses on advantages, disadvantages, and practical
points of spinal and epidural anesthesia in the outpatient setting.

General Considerations

Advantages
Spinal anesthesia (SA) is one of the simplest and most reliable of RA
techniques. The anatomic landmarks are easily identified. The block can
be performed with minimal discomfort, the end point is unmistakable, and
the onset of anesthesia is more rapid than with any other RA technique.
129
130 n Mulroy and Salinas

Because of the rapidity of onset, the block can be performed in the op-
erating room without the requirement for additional personnel or a block
room. The efficient performance of the block does not add substantially to
operating room time any more than the induction of GA. The onset of the
local anesthetic is sufficiently rapid to attain surgical anesthesia by the time
the positioning and preparation of the patient are completed. A variety of
local anesthetic agents are available that can provide a wide range of
duration of surgical anesthesia. The risk of nausea can be reduced if
systemic opioids are avoided. Likewise, nausea/vomiting2,8,9 and residual
somnolence associated with general anesthetics or heavy premedication
can be avoided, allowing a rapid return to full alertness in the discharge
area. SA is also a technique with a high degree of patient familiarity because
of its use in obstetrics and thus is more likely to be accepted by many
patient populations. In addition, it generally uses the lowest milligram
dose of local anesthetic and has the least potential for systemic toxicity.
Epidural anesthesia (EA) shares many of the advantages of SA, partic-
ularly the familiarity to the clinician, the simplicity of landmarks, and ease
of performance of the block. It has the additional advantage of allowing
a continuous catheter to be placed in the epidural space, which creates
the potential for tailoring both the height and duration of the block. Al-
though it is a more flexible technique, this advantage is attained at the
price of a slower onset of surgical anesthesia.
The combination of spinal and epidural (CSE) anesthesia is also a useful
technique in the outpatient setting. The procedure is technically more
challenging; once the epidural space is identified, the spinal needle must
be introduced through the epidural needle and advanced further into the
subarachnoid space. After the spinal anesthetic is injected, the spinal
needle is withdrawn and the epidural catheter is inserted and taped in
place. This technique requires more time and technical skill, but CSE
provides the advantages of the rapid onset and dense block of SA with the
flexibility of an indwelling catheter to allow incremental and repeated
injections to achieve the desired height and duration of surgical anes-
thesia. This technique has been used effectively for extracorporeal shockwave
lithotripsy procedures, in which the duration of treatment may be un-
predictable. It has also been used for knee arthroscopies when low doses of
SA are used to provide the shorter duration, but may not always provide
reliable height or duration of blockade.10 Although the technique com-
bines some of the disadvantages of both neuraxial procedures, it also
maximizes the advantages and positive aspects of both SA and EA.

Drawbacks
There are potential disadvantages of neuraxial anesthesia. SA is
typically a single-injection blockade, and thus careful attention must be
paid to selection of the appropriate local anesthetic agent and dose. If the
 Neuraxial Techniques n 131

surgical duration was underestimated or becomes prolonged for un-

expected reasons, supplemental GA may be needed. The ‘‘single-injection’’
aspect of SA frequently induces clinicians to give ‘‘just a little bit more’’
drug to ensure adequate height and duration; however, this tendency must
be resisted, because the downside of this dosing pattern is a prolonged
recovery and discharge time.6
Postdural puncture headache (PDPH) remains a risk with SA. Newer
pencil point, smaller-gauge needles have significantly reduced this fre-
quency to less than 3%.11 It is even less frequent in patients over the age
of 40. Although PDPH does not result in long-term neurologic damage
and usually is not a prolonged inconvenience for the patient, it must be
acknowledged in the discussion of SA with the outpatient. If it is inconve-
nient for a patient to return for an epidural blood patch or essential that
the patient not have this debility, alternative anesthetic techniques should
be considered.
The most recent concerns about SA for outpatients have revolved
around potential toxicity of local anesthetic drugs. A major concern was
the reporting of permanent neurologic damage associated with very high
doses of concentrated lidocaine injected through spinal microcatheters.
This has not been a problem with standard doses of the local anesthetics
used for single-injection spinal anesthetics, although all anesthetics
injected in the subarachnoid space are potentially neurotoxic.12 A more
common, relevant concern has been the symptoms of neurologic irritation
associated primarily with lidocaine. This syndrome of ‘‘transient neuro-
logic symptoms’’ (TNS) consists of a burning type of back pain radiating
into the buttocks or legs that appears 12 to 24 hours after the resolution
of spinal blockade and can persist for 1 to 6 days.13 TNS occurs approxi-
mately 15% to 30% of the time with the highest frequency after lidocaine
SA. Obese outpatients are more susceptible, especially those having
procedures performed in the lithotomy or knee arthroscopy positions.14
Although there are no sensory or motor deficits associated with this
syndrome,15 and to date no persistent neurologic deficits, it is nevertheless
a significant source of morbidity in some patients. Many practitioners have
sought alternatives to lidocaine to reduce the incidence of TNS (see
subsequently).
EA also has some potential drawbacks in the outpatient setting. As
previously mentioned, the slower onset of blockade, compared with spinal
injection, may cause a slight delay. However, if anesthesia is performed in
a block room outside the operating room, the onset of anesthesia with
drugs such as chloroprocaine is so rapid that there is little delay in the
onset of surgery, and the use of EA may even promote operating room
efficiency.16 Other drawbacks associated with EA include the greater risk
for postdural headache if an unintentional dural puncture occurs. Because
the potential for headache is directly related to the size of the needle, the
use of the larger-gauge epidural needles may represent a greater risk,
132 n Mulroy and Salinas

although the incidence of postdural puncture headache and an un-

intentional dural puncture in experienced hands should be less than 0.5%.
EA involves the use of larger doses of local anesthetic drugs and thus may
represent a greater potential for systemic toxicity. The careful use of safety
steps is just as appropriate in the outpatient as in the inpatient.17
Another limitation of both neuraxial techniques is the absence of
residual analgesia. Multiple randomized comparisons of neuraxial tech-
niques with GA show that early pain is significantly less with the regional
techniques,1–3,18,19 but once the block has resolved, some alternative mode
of analgesia must be provided for the patient. This is often accomplished
by the use of local anesthetic infiltrated into the wound or even a supple-
mental peripheral nerve block (such as a femoral nerve or ankle block).
The need for additional analgesia may not be an issue after relatively less
painful procedures such as diagnostic knee arthroscopy. Nevertheless, the
possibility for breakthrough pain must be considered in the planning of
the central neuraxial anesthesia for the outpatient.
A common concern is the potential for difficulty with urination after
neuraxial blockade. With higher doses of longer-acting local anesthetics,
the bladder is distended beyond its normal cystometric capacity during the
prolonged duration of neural blockade and is frequently unable to return
to normal function once the sensory blockade dissipates.20 Fortunately,
with the short duration central neuraxial blockades that are usually used
in the outpatient setting, bladder function returns normally after resolu-
tion of the blockade. Patients can be successfully discharged home after
short-duration spinal anesthetics with procaine, chloroprocaine, lidocaine,
and even low doses of bupivacaine.21 The use of certain additives such
as epinephrine may impede this recovery.22,23 The requirement for post-
operative voiding is not essential with short-acting drugs or low-dose
bupivacaine SA techniques.

Local Anesthetic and Adjuvant Choices

Chloroprocaine
For epidural injection, 2-chloroprocaine (2-CP) has been the standard
drug for the outpatient setting because of its short duration (resolution
within 2 hours with a narrow variation). 2-CP provides discharge times that
are competitive with short-acting GA techniques.24,25 The onset of blockade
is sufficiently rapid that if the block is performed in a preoperative holding
area, the patient usually has adequate surgical anesthesia by the time the
transition to the operating room and the positioning and preparation is
performed. The major drawback with 2-CP as the epidural agent has been
the issue of back pain associated with this drug. Back pain appears to be
dose-related.26 The use of single-injection techniques, limited to less than
25 mL, decreases the incidence of back pain. The introduction of
 Neuraxial Techniques n 133

preservative-free preparations also appears to have eliminated the risk of

neurotoxicity that was previously associated with this drug when un-
intentional high-dose subarachnoid injection was performed.
2-CP had originally been introduced for SA in the 1950s, and the
advent of the new preservative-free solutions has allowed its reintroduction
for subarachnoid use. Recent experience suggests that 40 to 60 mg of 2-CP
when used intrathecally provides excellent surgical anesthesia for 1 hour.
Kopacz and colleagues confirmed in volunteers that 2-CP provides effec-
tive surgical anesthesia for approximately 60 minutes with resolution of
blockade in approximately 2 hours,27 with significantly faster resolution
than either procaine28 or bupivacaine.29 The current preparation is slightly
hyperbaric. The duration of anesthesia can be potentiated by the addition
of fentanyl. Initial experience with this drug have to date not identified
a problem of TNS.30 Some concern has been raised about potential neu-
rotoxicity of this drug in an animal model in extremely high doses
(equivalent to 1000 mg in a 70-kg man),31 but this level of toxicity does not
appear to be any greater than that previously seen in the same model with
lidocaine or prilocaine.32 Although the current subarachnoid use will
probably not undergo the formal review process to become an ‘‘approved’’
indication by the U.S. Food and Drug Administration, initial experience
suggests that 2-CP is likely a worthy alternative for lidocaine.30

Procaine
An older alternative for short-duration SA has been the aminoester
drug procaine. This drug is available in a commercial 10% solution, which
should be diluted by at least 50% before injection. Procaine can be made
hyperbaric, isobaric, or hypobaric by the addition of appropriate additives.
It has been used in doses of 75 to 100 mg for procedures such as knee
arthroscopy and hernia repair with good results, with surgical duration
and discharge times equivalent to those found with 50 mg of lidocaine,33,34
but longer than chloroporcaine.28 The addition of fentanyl to procaine
appears to produce a higher frequency and severity of itching than is
found with the other local anesthetics.35 Nevertheless, procaine is a useful
alternative to lidocaine in the United States today. Procaine is not reliable
as an epidural anesthetic.

Lidocaine
The traditional ‘‘short-acting’’ local anesthetic for outpatient SA has
been lidocaine. In dosages in the 50-mg range, this local anesthetic
provides 60 to 90 minutes of surgical anesthesia, with a predictable
resolution within 2.5 hours, which allows for an acceptable discharge home
after most outpatient procedures on the lower abdomen and lower ex-
tremity. For patients having procedures not in the lithotomy or arthroscopy
positions, the incidence of TNS is <15% and is relatively mild, making
134 n Mulroy and Salinas

lidocaine still a standard choice of drug for such procedures.13 It can also
be diluted with sterile water and injected as a hypobaric solution in the
prone jackknife position in a 40-mg dose to provide excellent surgical
anesthesia for most anorectal procedures.36
Although diluting the concentration of lidocaine does not reduce the
frequency of TNS,37 there has been enthusiasm for the use of small doses of
lidocaine potentiated by small doses of fentanyl to provide anesthesia for
lithotomy or knee procedures. Vaghadia and colleagues have used 20 mg
of lidocaine with fentanyl for SA for gynecologic laparoscopic surgery and
have reported no instances of TNS in several of their case series.9,38,39 Ben-
David studied a group at high-risk group for TNS (patients undergoing
knee arthroscopy) and reported an incidence of only 3% TNS with a 20-mg
dose of lidocaine potentiated by fentanyl.40 Subsequently, Ben-David has
increased his dosage to 25 mg, but others have been unable to confirm this
low incidence of TNS in this high-risk population.41 Although many prac-
titioners have changed to using a low dose of lidocaine, many have looked
for other alternatives such as procaine and 2-CP.
Lidocaine has also been used for EA in the outpatient setting. Its duration
of action is approximately 30 minutes longer than that of chloroprocaine,24
and thus epidural lidocaine may be more suitable for surgical procedures in
the 60- to 90-minute range.

Mepivacaine
Mepivacaine is an aminoamide local anesthetic similar in structure to
lidocaine with a slightly greater potency and duration of action. Mepivacaine
has been used successfully for SA for knee arthroscopies in 40-mg doses with
discharge time slightly longer than lidocaine. There are conflicting reports
about the frequency of TNS associated with this drug, with some authors
claiming a reduced incidence and others finding an equivalent frequency of
TNS after mepivacaine (vs. lidocaine). Because of these conflicting findings
and the equivalence in duration, mepivacaine does not appear to be a
competitive alternative to lidocaine at the current time.

Prilocaine
Although prilocaine is not available in the United States as a local
anesthetic for spinal use, it has produced effective SA in clinical trials and
a lower incidence of TNS than seen with lidocaine.

Bupivacaine
Bupivacaine is a more potent and longer-acting aminoamide local
anesthetic, and has received some interest as a potential alternative to
lidocaine for outpatient SA because of the lower incidence of TNS. Unfor-
tunately, in addition to a longer duration, bupivacaine also has a wider
 Neuraxial Techniques n 135

variability in the duration of anesthetic action. Liu et al showed in a series

of volunteers that each additional milligram of bupivacaine added to SA
provides approximately an average 10-minute prolongation of surgical an-
esthesia but 20-minute prolongation of discharge time.42 More importantly,
the standard deviation of the readiness for discharge time was almost an
hour, which can translate into unacceptably long discharge times for some
outpatients when doses greater than 6 mg are used. This wide standard
deviation has also been confirmed at low doses.43 Because of the variability
in the height of the block as well as the duration, the low dose of bupivacaine
is not as predictable for outpatient surgical procedures. Nevertheless, many
practitioners are willing to accept this variability and potentially prolonged
block in exchange for the very low rate of TNS associated with this drug,
which is at 3% or less in clinical trials. The low TNS rate and shorter
discharge times with 2-CP (as well as procaine) may make the latter drug(s)
a better alternative.29

Ropivacaine and Levobupivacaine

The aminoamide ropivacaine has been studied for outpatient anes-
thesia. Although it is effective as a subarachnoid local anesthetic, it appears
to be less potent than bupivacaine by approximately 50%.44–46 Although
this drug has enjoyed popularity because of its reduced risk of cardiac
toxicity in large doses and of less motor blockade when used on peripheral
nerve blockade, these 2 advantages are not clinically relevant in its use in
a subarachnoid space. Levobupivacaine has also been studied47 and is
equivalent to bupivacaine, but its additional cardiac safety is not a relevant
factor in SA. None of the longer-acting aminoamides are useful for EA in
the outpatient.

Adjuvants
Additives have been used with SA over the years to prolong the
duration or to intensify blockade and thus allow a lower dose of the local
anesthetic drug itself.
Changing the baricity of an SA solution by the addition of either sterile
water or dextrose can allow greater control of the spread of local anesthetic
to specific areas. Hypobaric solutions diluted with water are particularly
useful for rectal surgery performed in the prone jackknife position. The
most common baricity with SA is hyperbaric. The addition of glucose to
standard local anesthetics tends to concentrate the anesthetic effect within
the dependent portion of the subarachnoid space. In most patients, this
means that the SA predictably rises to the level of T4–T6 when the patient is
promptly turned supine after injection, because the thoracic curvature
becomes the most dependent portion of the spinal canal in the supine
position. The use of a hyperbaric technique, however, is more useful in
limiting the spread to one side and to the lower lumbar and sacral fibers. If
136 n Mulroy and Salinas

the patient is kept in the lateral position with the operative side dependent
for 10 to 15 minutes, predominantly ‘‘unilateral’’ SA ensues, allowing lower
doses of local anesthetic and faster same-day discharge.2,48–51 The block
frequently crosses over to the opposite side when the patient is finally
turned supine, although it is less dense and of shorter duration on the
opposite side. The use of such a lower dose allows for more rapid recovery
and less chance of urinary retention, but the additional time required to
perform this unilateral technique presents a challenge in a rapid-turnover
ambulatory surgical setting. In this context, the RA induction room is of
tremendous benefit for the safe and efficient placement of ipsilateral
hyperbaric SA for patients undergoing lower extremity surgery.
Epinephrine was, but is no longer, the classic drug additive for SA.
Epinephrine provides prolongation and potentiation for all local anes-
thetics. It has been shown to be safe in standard doses of 100 to 200 ^g, but
it is associated with a significant increase in the time to voiding in patients
receiving both bupivacaine and lidocaine.20,22 Epinephrine also produces
an unusual flu-like syndrome when added to chloroprocaine.52 In general,
epinephrine does not appear to be a useful additive for outpatient spinal
anesthesia unless used in extremely low doses53 and is probably best
avoided altogether.
Fentanyl has been used extensively as an additive in outpatient SA.
Fentanyl prolongs and intensifies the block produced by lidocaine and
chloroprocaine without a delay in urination; thus, intrathecal fentanyl
may be a useful adjunct for the outpatients.23,43,53,54 Unfortunately, fenta-
nyl is associated with pruritus; 100% of volunteers receiving lidocaine or
chloroprocaine SA with fentanyl experienced itching. In the clinical set-
ting, where other factors such as surgical pain and systemic opioids are
added, the itching appears to be reported less frequently by patients.
Patients receiving lidocaine SA with fentanyl appear to have an incidence
of approximately 25% of mild pruritus. When fentanyl is added to
bupivacaine, the incidence appears to double, but again the symptoms
remain mild. When fentanyl is added to procaine, itching becomes more
noticeable and unpleasant, and may even require systemic treatment.35
The itching usually responds to small doses of nalbuphine or diphenhy-
dramine. Nevertheless, the use of fentanyl is extremely effective in reduc-
ing the total dose of local anesthetic and allowing a shorter discharge
time.43 Longer-acting intrathecal opioids such as morphine have not been
shown to be useful in the ambulatory setting.
Clonidine is an alpha-2 agonist that potentiates local anesthetics in the
subarachnoid space and on peripheral nerves. Doses of 15 to 45 ^g are
effective without side effects, but larger doses may produce bradycardia
and sedation.55,56 The addition of 15 ^g to chloroprocaine SA, for example,
prolongs motor and sensory block without systemic side effects.56 Unfor-
tunately, in the United States, the drug is marketed in relatively expensive
large-dose vials in contrast to the European market where it is available in
 Neuraxial Techniques n 137

more practical smaller incremental dosages. For that reason, it has not
attained great popularity in the United States but is worth considering for
potentiation of SA. Another additive that has been tested is neostigmine, but
it is associated with severe intractable nausea, which makes it unacceptable
as an additive at the present time.57

Specific Surgical Procedures Suitable for

Neuraxial Anesthesia

Hernia Repair
Inguinal herniorrhaphy is one of the most common procedures
performed on an outpatient basis. Neuraxial anesthesia provides excellent
anesthesia and motor relaxation for this operation.58 SA with procaine or
lidocaine in a hyperbaric solution (to give cephalad spread to the T4–T6
level) can provide high enough block with appropriate discharge,
although the need for a higher surgical level of anesthesia with this block
increases the risk of prolonged blockade and delayed discharge because of
the higher dosages used. Although postoperative voiding is not usually
a problem after short-acting or low-dose bupivacaine, patients with hernia
repairs frequently have urinary retention simply because of the post-
operative pain and reflex inhibition of the voiding pathway. Generous use
of local anesthetic infiltration during and after the procedure may help
prevent this, but many centers still require hernia patients to void before
discharge regardless of the anesthetic technique. EA offers an alternative
for this surgical procedure because of the segmental band and the
opportunity to use short-acting drugs such as 2-CP.

Anorectal Procedures
Intrathecal anesthesia limited to specific dermatomal fibers is an ideal
application of SA. For lithotomy procedures, a traditional ‘‘saddle-block’’
technique with hyperbaric 2-CP or procaine in small doses (20–30 mg) is
appropriate. Because of the risk of TNS, lidocaine may not be an ideal
choice. For the prone jackknife position, procaine, chloroprocaine, and
lidocaine can also be made hypobaric.36 Again, provision for adequate
postoperative analgesia should be made by generous injection of local
anesthetics during the procedure by the surgeon.

Laparoscopy
Although laparoscopic procedures of the upper abdomen are not
tolerated well with regional techniques, pelvic laparoscopy appears to be
suitable with neuraxial blockade in some hands. Vaghadia and colleagues
have shown the successful use of low-dose SA for outpatient gynecologic
138 n Mulroy and Salinas

laparoscopy. For this situation, 25 mg lidocaine combined with 20 ^g fen-

tanyl produces adequate sensory anesthesia with minimal motor blockade,
which was well tolerated by their patients.59 Such a blockade provides rapid
resolution and discharge and a high degree of patient satisfaction. This
SA dosing strategy requires a gentle and skilled surgeon capable of per-
forming the operation with less extensive distention of the peritoneum. If
such a partnership can be arranged, patients appear to benefit from this
technique.

Knee Surgery and Foot Surgery

These are excellent situations to use neuraxial techniques, with good
surgical conditions and rapid recovery reported with spinal2,5,33,60,61 and
epidural techniques3,4,34,62 for the knee. Foot surgery requires more sacral
anesthesia and thus EA may not be as useful. These procedures are dis-
cussed at length elsewhere in this symposium issue.

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