I read with interest the article by Hadzic et al.  1about the use of interscalene block compared with general anesthesia for outpatient rotator cuff surgery. Although I agree that there are advantages to using nerve block anesthesia for outpatient shoulder surgery, I believe the comparator group receiving general anesthesia in the current Clinical Investigation1was a recipe for failure. I am not surprised by the 16% hospital admission rate for refractory pain observed in those patients receiving general anesthesia. I would hope with our current understanding of the pathophysiology of acute pain that we as anesthesiologists will offer our patients more effective perioperative analgesic techniques. I was surprised that the current clinical investigation failed to use nonopioid analgesics, including nonsteroidal antiinflammatory drugs, in a multimodal approach to perioperative pain management as outlined by the recent American Society of Anesthesiologists Practice Guidelines for acute pain management in the perioperative setting state.2A more aggressive preventive multimodal pharmacologic approach3including the use of nonsteroidal antiinflammatory drugs, acetaminophen, intraarticular local anesthetics, opioids, and α2agonists and postoperative cold therapy may have resulted in a less dramatic benefit compared with interscalene block. Failure to do so may result in inadequate analgesia for our patients, as demonstrated in the current study by Hadzic et al.  1 

Baystate Medical Center and the Tufts University School of Medicine, Springfield, Massachusetts. scott.reuben@bhs.org

Hadzic A, Williams BA, Karaca PE, Hobeika P, Unis G, Dermksian J, Yufa M, Thys DM, Santos AC: For outpatient rotator cuff surgery, nerve block anesthesia provides superior same-day recovery over general anesthesia. Anesthesiology 2005; 102:1001–7
Ashburn MA, Caplan RA, Carr DB, Connis RT, Ginsberg B, Green CR, Lema MJ, Nickinovich DG, Rice LJ: Practice guidelines for acute pain management in the perioperative setting: An updated report by the American Society of Anesthesiologists Task Force on Acute Pain Management. Anesthesiology 2004; 100:1573–81
Reuben SS, Gutta SB, Maciolek H, Sklar J: Effect of initiating a multimodal analgesic regimen upon patient outcomes after anterior cruciate ligament reconstruction for same-day surgery: A 1200-patient case series. Acute Pain 2004; 6:87–93