SLR - October 2018 - Rebecca S. Herman
Reference: YaDeau JT, Fields KG, Kahn RL, LaSala VR, Ellis SJ, Levine DS, Paroli L, Luu TH, Roberts MM. Readiness for Discharge After Foot and Ankle Surgery Using Peripheral Nerve Blocks: A Randomized Controlled Trial Comparing Spinal and General Anesthesia as Supplements to Nerve Blocks. Anesth Analg. 2018 Sep;127(3):759–766.Scientific Literature Review
Reviewed By: Rebecca S. Herman, DPM
Residency Program: SUNY Downstate Medical Center, Brooklyn, NY
Podiatric Relevance: The majority of elective podiatric surgeries are performed in ambulatory surgery centers. Discharge time is a key metric to understanding efficiency in the ambulatory setting. Anesthesia modality can greatly affect recovery process and timeliness. The major decision in anesthesia modality centers is the use of spinal or general anesthesia. When used without a nerve block (isolated anesthesia), spinal anesthesia outperforms general anesthesia in the areas of postoperative nausea and vomiting, pain level and dose of analgesic administration. However, spinal anesthesia is also associated with longer stays in postoperative ambulatory care units. Peripheral nerve blockades have become a popular adjunct to spinal or general anesthesia for their rapid recovery, decrease in postoperative pain and decrease in opioid use. This trial investigates the timeliness of discharge with spinal or general anesthesia in conjunction with nerve blocks.
Methods: This is a single-center randomized controlled trial of 36 patients who underwent general or spinal anesthesia to supplement combined popliteal and adductor canal block. Patients included were 18–75, eligible for thigh tourniquet during surgery and undergoing elective foot and ankle ambulatory surgery lasting between one and three hours. Ankle blocks were not included. All patients received popliteal and adductor canal nerve blocks with dexamethasone and bupivicaine prior to undergoing either spinal or general anesthesia. To determine criteria meant for discharge, a postanesthesia discharge scoring system was utilized by trained staff assessing patients every 15 minutes for ability to ambulate with assistance, ability to dorsiflex nonoperative foot and intact sensation to legs. The primary outcome was timeliness to meet criteria for discharge to home. Follow-up, postoperative nausea, vomiting and pain were also assessed.
Results: On average, patients who underwent general anesthesia met criteria for discharge 39 minutes before spinal anesthesia patients. However, they were not physically discharged earlier. Both groups included a significant amount of patients with discharge well after meeting criteria for discharge. Initial pain scores were higher at one hour after surgery for patients undergoing general anesthesia. There were no significant difference between the two groups identified for nausea, vomiting, pain and surgical bleeding.
Conclusions: Despite the advantages that spinal anesthesia confers, many podiatric surgeons performing elective cases are hesitant to utilize spinal anesthesia in conjunction with peripheral nerve blocks due to prolonged discharge. The study confirmed that general anesthesia in combination with peripheral nerve blockade leads to earlier readiness for discharge; however, it did not influence discharge time. Clinical judgment and efficiency to discharge patient depends on quality of PACU staff and hospital or ambulatory surgical center. In the proper clinical setting, the results of this study may facilitate a more efficient ambulatory surgical center. The major limitation in this study is the small sample size, which may hinder the validity and reproducibility of this study. This trial highlights the impact (or lack thereof) on the decision to use general anesthesia or spinal anesthesia with supplementation of peripheral nerve blockade in time to discharge, postoperative nausea and vomiting, and postoperative pain level.