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Beyond the hospital: continuous peripheral nerve blocks at home.

PROVIDING extended analgesia after painful surgery remains one of the main barriers to expanding the types of cases performed on an ambulatory basis. This fundamental obstacle also hampers the compassionate care we provide to many current outpatients because they suffer from inadequate analgesia. Chung et al. helped quantify failure of outpatient pain management and noted that after some orthopedic, urologic, and plastic surgeries, the incidence of severe pain postoperatively was between 40 and 70%. Although the introduction of shortacting sedatives, anesthetics, and analgesics has improved the reliability of prompt emergence from anesthesia, postoperative pain and narcotic-related side effects, such as nausea and vomiting, remain major sources of patient dissatisfaction, lead to extended hospital stays, and hamper our ability to progress. Typical regional anesthetic techniques like spinal and epidural blockade that can be used intraoperatively provide little postoperative analgesia to aid recovery in the ambulatory patient. The use of outpatient peripheral nerve blocks is frequently criticized because of the intense pain that may ensue after resolution. As perioperative physicians we are challenged to develop a method of analgesia that is site specific, has few side effects, and can facilitate economic yet compassionate care. Continuous peripheral nerve blocks combined with a simple disposable infusion device that can be used at home may offer a novel solution to part of this problem. In initial nonrandomized reports and comparative trials it has provided excellent analgesia for numerous upper and lower extremity outpatient procedures. In this issue of ANESTHESIOLOGY, Rawal et al. and Ilfeld et al. provide two prospective randomized studies designed to examine the effectiveness of ambulatory continuous peripheral nerve blocks. The results are compelling because both studies found a reduction in pain scores, low opioid consumption, high patient satisfaction, and few logistical obstacles when home continuous peripheral nerve blocks were implemented or compared with standard oral pharmacologic management of postoperative pain. Continuous peripheral nerve catheters have been an integral part of acute and chronic pain management since first being described by Ansboro in 1946. Over the ensuing half-century, numerous clinicians have developed techniques to facilitate catheter placement and manage inpatient treatment. These techniques have been gradually refined, enabling a small group of skilled clinicians to incorporate continuous peripheral nerve catheters into their practice with a high degree of success. Continuous peripheral nerve blocks have been associated with sustained, effective, postoperative analgesia; opioid-sparing, improved rehabilitation; and improved patient well-being with minimal side effects. It is only natural that with the reevaluation of healthcare spending and the increased interest in expanding ambulatory surgery that this method would be tried on an outpatient basis. This is especially true given the economic success and low morbidity and mortality rates that have accompanied the transition of other hospital-based techniques to the ambulatory environment. Making this next transition successfully, on a larger scale, goes beyond the successful placement of individual catheters. It requires further data, improved training, and careful attention to the discharge and follow-up process. Discharging patients with an insensate extremity and relying on the patient to self-administer local anesthetic remains controversial. Concerns about patient injury from an insensate extremity, catheter migration, and the potential for local anesthetic toxicity persist. Despite the encouraging results in these two randomized prospective trials, further data with larger patient samples will be necessary to confirm safety. In both studies in this issue, the investigators instituted several mechanisms to maximize patient safety that have been prevalent in the initial nonrandomized trials of home perineural infusions. Both Rawal et al. and Ilfeld et al. required study participants to display comprehension of the verbal and written instructions they were provided, and both teams required the presence of a chaperon. A common theme in several case reports is the careful attention paid to avoidance of inadvertent vascular catheter placement. This is typically done by injecting a large test dose of local anesthetic with epinephrine via the catheter before discharge to ensure the catheter tip is not misplaced. Perhaps more importantly, both groups used This Editorial View accompanies the following two articles: Rawal N, Allvin R, Axelsson K, Hallén J, Ekbäck G, Ohlsson T, Amilon A: Patient-controlled regional analgesia (PCRA) at home: Controlled comparison between bupivacaine and ropivacaine brachial plexus analgesia. ANESTHESIOLOGY 2002; 96: 1290–6; and Ilfeld BM, Morey TE, Enneking FK: Continuous infraclavicular brachial plexus block for postoperative pain control at home: A randomized, double-blinded, placebo-controlled study. ANESTHESIOLOGY 2002; 96:1297–1304.