Chapter 63

Since the first description of subarachnoid anesthesia by Bier, it has remained the simplest and most effective technique of regional anesthesia. The use of neuraxial techniques in outpatients has been a more recent development, awaiting ready availability of newer needles that reduced the side effect of postdural puncture headache to an acceptable level in the ambulatory setting. The last 10 years have seen a dramatic increase in the use of these techniques in outpatients, for several reasons.

Simplicity and effectiveness should make central neuraxial techniques (either spinal or epidural) ideal in the outpatient setting. Both spinal and epidural anesthesia are more familiar to practitioners than peripheral nerve blocks and are easier to perform because they do not require nerve localization techniques. They can be 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 anesthetic 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 PACU than patients receiving general anesthesia (GA).1–5 Their frequency of postoperative nausea and vomiting (PONV) appears to be at most one-third of that after GA.6 Most importantly, the frequency of phase 1 PACU bypass is high,1,6,7 and discharge times are comparable to even the fastest for GA techniques if appropriate local anesthetic agents and dosages are chosen.8 Modern small-gauge rounded point needles and short-acting drugs have reduced the side effects that were of concern in the past. With propofol infusions available to provide light but transient sedation, the objection to “being awake” during regional techniques has also disappeared, leaving neuraxial techniques as an excellent choice.

This chapter will focus on the advantages, disadvantages, and practical points associated with spinal and epidural anesthesia in the outpatient setting.

Spinal Anesthesia

Spinal anesthesia (SA) is one of the simplest and most reliable of regional anesthesia techniques. The external anatomic landmarks are easily identified. The block can be performed with minimal discomfort, the end-point of cerebrospinal fluid flow is unmistakable, and the onset of anesthesia is more rapid than with any other regional technique. Because of the rapidity of onset, the block can be performed in the operating 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 for the induction of GA. The onset of the sensory blockade 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, ...

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