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The development of ambulatory surgery and that of peripheral nerve blocks (PNBs) occurred over two separate historic timelines. The performance of outpatient or ambulatory surgeries commenced in the mid-1800s, and its utilization rapidly escalated throughout the next century. By 1980, 16.3% of all surgeries were performed on an outpatient basis. By 1984 this number rose to 30% and the Society for Ambulatory Anesthesia (SAMBA) was born. The total outpatient rate approached 50% by 1990, 60% in 1997, and may have hit 70% in 2003.1,2 During the same span of time, techniques for PNBs were also being discovered. The decades from 1884, (when Koller and Brettauer first instilled ocular cocaine in Heidelberg, Germany3) to 1912 and 1914, (when Kappis and Heidenhein described the interscalene block,4) marked the birth of PNBs. Despite the coexistence of both ambulatory anesthesia and PNB techniques for over a century, they were not typically used concurrently.

As ambulatory surgery acquired today's popularity and widespread use, the scope of surgical procedures similarly expanded to become more invasive and pain-inducing. Suddenly, physicians were faced with a dual challenge: provide short-acting anesthesia thus achieving home-readiness within hours of surgery, concurrent with long-acting postoperative analgesia permitting the patient to remain discharged to the home environment. The differences between these dual desires have proven irreconcilable with modern opiate analgesia. This has been recently documented by Apfelbaum and colleagues, who quantified the shortcomings of ambulatory analgesic regimens. They found that 78% of those queried had felt pain of moderate (52%), severe (22%) or extreme (7%) intensity.5

In response to ambulatory anesthesia's dilemma, PNB techniques offer solutions ideal for an outpatient anesthetic: site-specific surgical anesthesia and a decreased dependency on general anesthesia (GA). In so doing, PNBs buffer the response to surgical stress, better maintain functional residual capacity, defend against loss of immunologic function, and avoid or shorten the period of postoperative ileus.6 By providing effective analgesia, PNBs can reduce patient exposure to opioids and their side effects. This allows for a more rapid discharge of satisfied patients to their home environment, resulting in cost savings for the ambulatory surgery center. As a cornerstone of multimodal analgesia, PNBs with long-acting local anesthetic (LA) help reduce patient readmission for pain or other side effects. Extending the effect of LA through continuous peripheral nerve blocks (CPNBs) further lengthens the period of low side-effect postoperative analgesia in the home environment.

Despite the advances in PNBs and CPNBs, these techniques remain underutilized skills in ambulatory anesthesia. As recently as the year 2000, Dexter and Macario7 revealed that ambulatory surgeries utilized regional anesthesia in only 8% of cases. A 1997 survey by Hadzic and coworkers found that although 98% of anesthesiologists used some regional techniques, less than half of respondents placed at least five PNBs per month.8 A 2001 survey by Klein and colleagues concurred that although interscalene, axillary, and ankle blocks were performed more often, ...

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