Editorial
Is Regional Anesthesia
Preferable to General
Anesthesia for Outpatient
Surgical Procedures on an
Upper Extremity?
Some time ago, a question similar to the one
posed in the title of this editorial was asked of
anesthesiologists. 1 When asked whether they
would prefer regional or general anesthesia for
themselves if the anesthesiologist was equally
competent in administration of agents for both
regional and general anesthesia, the respon-
dents indicated a preference for regional anes-
thesia. These anesthesiologists chose regional
anesthesia over general anesthesia because they
perceived that it was easy to administer, had a
lower incidence of major complications, provided
excellent operating conditions, and was associ-
ated with fewer problems during recovery and
thus was more pleasant for the patient. Like-
wise, patients who have experienced regional
anesthesia for surgical procedures on an upper
extremity strongly support it. When asked
whether they would choose regional anesthesia
for subsequent procedures, 24 of 25 patients
replied affirmatively.P All these patients had
had prior similar surgical procedures under
general anesthesia. An informal survey of sur-
geons at our institution also indicated a prefer-
ence for regional anesthesia for surgical proce-
dures on an extremity. They noted that their
patients seemed to have superior immediate
postoperative recovery, as indicated by their
ability to ambulate, eat, and drink and by their
general state of alertness. Furthermore, recov-
ery room nurses in our ambulatory surgical
center and our main hospital overwhelmingly
Address reprint requests to Dr. J. L. Seltzer, Department
of Anesthesiology, Thomas Jefferson University Hospital,
111 South 11th Street, Suite G-6460, Philadelphia, PA
19107-5092.
Mayo Clin Proc 66:544-547,1991
prefer regional anesthesia for reasons similar to
those expressed by the surgeons.
Published Comparisons.-In some settings,
regional anesthesia has been shown to be supe-
rior to general anesthesia. Investigators have
attempted to show that overall morbidity is less
with regional anesthesia, a result that has been
verified in high-risk surgical patients." For
patients who underwent abdominal, thoracic, or
major vascular surgical procedures under epi-
dural anesthesia that was continued postopera-
tively for analgesia, the overall complications-
including cardiac and infectious complications-
were significantly decreased. The major contri-
bution to the improved outcome was thought to
be the use ofepidural analgesia in the postopera-
tive period. In earlier investigations to deter-
mine whether regional anesthesia prevented
postoperative pulmonary complications, the site
ofthe incision for abdominal or thoracic surgical
procedures was related to pulmonary complica-
tions, but the anesthetic technique used was
not.v" Studies that have assessed cognitive
function have found no difference between re-
gional and general anesthesia; however, the
testing was done well into the recovery period
and not on the day of operation. Detection of no
differences at 2 days," 1 week," or 3 months"
postoperatively is not surprising. Comparisons
of the immune response indicate that regional
anesthesia might have less of a suppressive
effect than general anesthesia and therefore
may be less likely to contribute to postoperative
infections. 9
The Outpatient Setting.-All currently
available information comparing regional and
general anesthesia deals with surgical proce-
dures in inpatients. The outpatient surgical
setting has somewhat different requirements
for superiority of an anesthetic technique. Fa-
cilities for ambulatory surgical procedures tend
to be high-volume rapid-turnover operating
rooms. The time necessary for induction of
anesthesia becomes important. Thus, ifregional
anesthesia takes considerably longer to induce
544
Mayo cue Proc, May 1991, Vol 66
than general anesthesia, it becomes unaccept-
able. For operative procedures on an upper
extremity, however, the blocks can be performed
in a location outside of the actual operating
room. Moreover, the addition of bicarbonate to
the anesthetic solution appreciably hastens the
development of a solid surgical block. The
immediate recovery period is also important in
outpatient operations. The patient not only
must show cognitive recovery but also must be
able to ambulate. Intuitively, regional anesthe-
sia seems superior to general anesthesia for
procedures on an upper extremity. If only an
extremity is anesthetized, the overall effect on
the patient should be minimal. This assump-
tion, however, is not always true. Frequently,
intravenously administered sedatives are used
along with regional blocks. Because most pa-
tients prefer not to know what is happening in
the operating room, drugs that cause amnesia,
such as midazolamhydrochloride, are often used.
When blocks are only partially effective, large
amounts of a sedative may be given. This exces-
sive sedation may prolong recovery to an extent
greater than general anesthesia. Once the pa-
tient has left the ambulatory facility, the ability
to eat and drink is important because intrave-
nous fluids are no longer provided. Therefore,
nausea and vomiting must be avoided.
Pain.-Postoperative pain is often an ob-
stacle to dismissing a patient from the hospital.
Ifparenteral analgesia is necessary, the patient
may have to be admitted to the hospital. Relief
of postoperative pain should be better with re-
gional anesthesia than with general anesthesia.
In a recent study of patients who underwent
inguinal herniorrhaphies, those who had local
infiltration or regional anesthesia required less
analgesia throughout the entire postoperative
period,"? One evolving concept is that delaying
the onset of pain during and immediately after a
surgical procedure prevents the development of
a vicious cycle oflocal tissue reaction that leads
to pain. This approach tends to lessen the
severity of pain when it does occur and reduces
the overall requirement for analgesia.
Successful Blocks.-In this issue of the
Proceedings (pages 470 to 473), Davis and col-
EDITORIAL 545
leagues examine their experience with regional
anesthesia for surgical procedures on an upper
extremity in the outpatient population. They
demonstrate that this technique is highly useful
and effective. The 93% success rate is commend-
able for peripheral nerve blocks. At our institu-
tion, with nerve blocks being performed by resi-
dents in anesthesiology, we were able to achieve
70 to 80% complete brachial plexus blocks. 11 We
defined success as complete anesthesia of all
three nerve distributions of the hand. Cockings
and associates" reported a success rate of 99%
for an axillary approach to the brachial plexus.
Reports of varied success rates can be attributed
to factors such as the skill of the anesthesiolo-
gist, the actual approach used (paresthesia, trans-
arterial technique, or electrical stimulation of
the nerve), and the volume of the local anesthetic
agent injected.
A high success rate is important in the outpa-
tient setting. Ambulatory surgical centers usu-
ally have rigid schedules, and a failed block
would tend to prolong a case as the surgeon and
anesthesiologist wait for the block to become
more effective. If, after this delay, the block still
is inadequate for performance of a surgical pro-
cedure, general anesthesia must be induced, a
step that entails several additional minutes.
The overall effect is a delay in the remainder of
the surgical schedule. Another approach to a
partially effective block is to provide enough
intravenously administered sedative to allow
the operation to proceed. Frequently, the amount
of sedation superimposed on a partial block is
excessive and may prolong the recovery time.
Rapid recovery is necessary after ambulatory
surgical procedures; therefore, sedation must be
used judiciously.
In the report by Davis and associates, the
highest successful block rate was achieved by
using an approach that involved eliciting a par-
esthesia and passing the needle through the
axillary artery. Other techniques used, in de-
creasing order of successful results, were sim-
ple identification of a paresthesia, an isolated
transarterial approach, and nerve stimulation.
The differences between the success rates for
these approaches, however, were minimal.
546 EDITORIAL
Paresthesias were noted in 284 patients. A
follow-up of outpatient records revealed no post-
operative neuropathy associated with the tech-
nique, an important finding because the pares-
thesia technique has been criticized in the past.
In a prospective study of 290 patients who had
axillary blocks involving a paresthesia, postop-
erative neurologic changes were noted in 8. 13
These changes were thought to be caused by
either direct injury of the nerve by the needle or
injection trauma to the nerve.
Postoperative Hospitalization.-The rate
of postoperative hospitalization reported by
Davis and colleagues (15%)is extremely high for
ambulatory surgical procedures. Preselection of
patients is important for freestanding units
where transfer to a hospital would be an in-
volved process. Because most patients in the
current study were admitted for surgical rea-
sons, the choice of regional anesthesia seems
unimportant; however, 11 patients were admit-
ted for control of pain. The use of a long-acting
local anesthetic agent such as bupivacaine hydro-
chloride could provide anesthesia for up to 18
hours after brachial plexus block. Although a
long-acting block is useful for prolonged analge-
sia, certain cautions must be exercised. The
patient's arm must be well protected with a
padded sling. The patient must be clearly in-
formed that the extremity is vulnerable to injury
as long as it remains anesthetized. A long-acting
block may not be desirable if a cast is used
because pressure points under the cast will not
be identified until the block subsides. Hence, an
ischemic injury to the extremity may ensue.
Nevertheless, in the appropriate situations, a
long-acting block would eliminate the need for
hospitalization for control of pain.
Conclusion.-Although regional anesthesia
seems superior to general anesthesia for outpa-
tient surgical procedures on the extremities,
this point has yet to be proved. Well-designed
prospective studies are needed. The question of
superiority for relief of pain postoperatively,
especially after the block has resolved, needs to
be answered. The quality of postoperative recov-
ery also needs further investigation. Immediate
recovery is influenced by circulatory stability
Mayo Clin Proc, May 1991, Vol 66
and adequate respiratory effects. The study
design must consider the influence of sedative
drugs used during regional anesthesia on these
factors. Sedative drugs may also mask any
superiority regional anesthesia may have in
allowing the patients to ambulate and tolerate
liquids. Differences between general and re-
gional anesthesia in recovery of cognitive func-
tion may also be masked by the intraoperative
sedation. The anesthetic techniques must be
compared to determine whether they are equal
in enabling surgeons to complete their work
efficiently. Studies such as the one reported by
Davis and co-workers in this issue of the Pro-
ceedings are a beginning. Additional investiga-
tions are needed before a definite answer will be
forthcoming about whether regional anesthesia
is preferable to general anesthesia for outpa-
tient surgical procedures on an upper extremity.
Joseph L. Seltzer, M.D.
Department of Anesthesiology
Jefferson Medical College
Thomas Jefferson University
Philadelphia, Pennsylvania
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EDITORIAL 547
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