To the Editor:—
I read with interest the recent article by Hadzic et al. 1and its accompanying editorial by Williams2regarding the role of regional anesthesia in ambulatory surgery. Hadzic et al. reported that the use of infraclavicular block was associated with a significant decrease in discharge time (121 vs. 218 min) compared with “fast-track” general anesthesia among patients undergoing hand or wrist surgery. Williams called for more randomized trials to determine the relative merits of regional anesthesia and “emerging pharmacology and technology” in the ambulatory setting. Although these results are encouraging to believers in regional anesthesia, I have to ask: Does it really take 2–3 h to recover from regional or general “fast-track” anesthesia?
I work with a group of anesthesiologists who provide services to a freestanding orthopedic surgery center. The center has two operating rooms and performs 120–160 cases/month. Patients undergoing hand or wrist surgery may receive monitored anesthesia care with local infiltration by the surgeon, peripheral nerve block (digital, wrist, elbow, or brachial plexus) by the anesthesiologist, intravenous regional anesthesia with additional local infiltration by the surgeon, or general anesthesia with local infiltration by the surgeon. Patients may receive midazolam, fentanyl, and propofol for anxiolysis, analgesia, and sedation. The general anesthetic technique includes propofol induction and nitrous oxide and isoflurane via laryngeal mask airway maintenance. Muscle relaxants are rarely used, and antiemetics are given at the discretion of the anesthetist.
Between April 1 and June 31, 2004, 138 patients had hand or wrist surgery using the above anesthetics. Operative (time from skin incision to completed dressing) and discharge (time from arrival in the postanesthesia care unit until discharge from the facility) times are presented in table 1. Patients were discharged from the facility when they met standardized criteria (Aldrete score3of 10, no significant surgical bleeding, controlled nausea and pain).
The striking differences in discharge times between our facility and that of Hadzic et al. probably have nothing to do with anesthetic technique. Instead, institutional inefficiencies related to size, staffing, and processes serve to prolong patient stay and increase the cost of providing ambulatory surgery in a hospital setting. Among these inefficiencies, I believe one of the most important to be the two-stage recovery process. Instead of having to be admitted and discharged from two separate recovery units, our patients can awaken, recover, and prepare for discharge at a single site, cared for by a single nurse. With this approach, we also can achieve rapid discharge times with more extensive surgeries. During the above-mentioned time, 46 patients underwent open or arthroscopic shoulder surgery lasting 55 ± 25 min. Discharge times ranged from 25 to 165 min (mean, 59 ± 24 min).
Having worked in tertiary care centers, community hospitals, and freestanding facilities, I think that the challenges presented by the latter to the former two are formidable. Although good pain control and absence of adverse effects clearly can facilitate the ambulatory surgical process, the potential for shortening discharge times by altering anesthetic techniques pales in comparison to the savings that could be achieved by more systematic improvements such as eliminating stage 2 recovery. Pilot studies have shown that tertiary care centers can overcome some of these obstacles and achieve results close to ours.4I suggest that it is time for more centers to do the same.
Capitol Anesthesiology, Orthopaedic South Surgery Center, Morrow, Georgia. email@example.com