REVIEW

CURRENT
OPINION Spinal anesthesia for ambulatory surgery: current
controversies and concerns
Jesse Stewart, Irina Gasanova, and Girish P. Joshi

Purpose of review
General anesthesia is a popular choice for ambulatory surgery. Spinal anesthesia is often avoided because
of perceived delays due to time required to administer it and prolonged onset, as well as concerns of
delayed offset, which may delay recovery and discharge home. However, the reports of improved
Downloaded from http://journals.lww.com/co-anesthesiology by BhDMf5ePHKav1zEoum1tQfN4a+kJLhEZgbsIHo4XMi0hCywCX1AWnYQp/IlQrHD3i3D0OdRyi7TvSFl4Cf3VC4/OAVpDDa8KKGKV0Ymy+78= on 12/07/2020

outcomes in hospitalized patients undergoing total joint arthroplasty have renewed the interest in spinal
anesthesia. This review article critically assesses the role of spinal anesthesia in comparison with fast-track
general anesthesia for the outpatient setting.
Recent findings
The purported benefits of spinal anesthesia include avoidance of airway manipulation and the adverse
effects of drugs used to provide general anesthesia, improved postoperative pain, and reduced
postoperative opioid requirements. Improved postoperative outcomes after spinal anesthesia in hospitalized
patients may not apply to the outpatient population that tends to be relatively healthier. Also, it is unclear if
spinal anesthesia is superior to fast-track general anesthesia techniques, which includes avoidance of
benzodiazepine premedication, avoidance of deep anesthesia, use of an opioid-sparing approach, and
minimization of neuromuscular blocking agents with appropriate reversal of residual paralysis.
Summary
The benefits of spinal anesthesia in the outpatient setting remain questionable at best. Further studies should
seek clarification of these goals and outcomes.
Keywords
ambulatory surgery, anesthesia technique, general anesthesia, perioperative outcomes, spinal anesthesia

INTRODUCTION administer and prolonged onset, as well as concerns

With advances in surgical and anesthetic techni- of unreliability and delayed offset, which may delay
&&

ques, older and sicker patients are increasingly recovery and discharge home [5 ]. However, the
undergoing more extensive surgical procedures in introduction of shorter acting local anesthetics
&&

an outpatient setting. In addition, there is emphasis [5 ] and reports of improved outcomes in hospital-
on enhanced postoperative recovery that facilitates ized patients undergoing total joint arthroplasty
&& &&

early discharge home and early resumption of nor-
&&
mal daily activities [1 ]. The choice of anesthetic
technique can influence not only immediate post-
operative outcomes (e.g., complications in the
recovery room and delayed discharge home) but
also long-term postoperative outcomes (e.g., post-
discharge complications and unplanned visits to the
emergency department and unplanned hospital
admission) [2]. Since the introduction of shorter
acting anesthetic drugs (e.g., propofol, desflurane,
and sevoflurane), general anesthesia has become a
popular choice for patients undergoing ambulatory
&
surgery [3,4 ]. In contrast, spinal anesthesia is often
not used because of perceived delays to the operat-
ing room schedule due to time required to
[6 ,7,8,9 ] have renewed the interest in spinal
anesthesia.
The aim of this article is to critically assess the
role of spinal anesthesia in comparison with fast-
track general anesthesia techniques in adult patients
undergoing ambulatory surgery. In addition, we
present the optimal spinal anesthesia technique
University of Texas Southwestern Medical Center, Dallas, Texas, USA
Correspondence to Girish P. Joshi, MBBS, MD, FFARCSI, Professor of
Anesthesiology and Pain Management, University of Texas Southwestern
Medical Center, 5323 Harry Hines Blvd, Dallas, TX 75390-9068, USA.
Tel: +1 214 648 2623; e-mail: girish.joshi@utsouthwestern.edu
Curr Opin Anesthesiol 2020, 33:746–752
DOI:10.1097/ACO.0000000000000924

www.co-anesthesiology.com Volume 33  Number 6  December 2020

Copyright © 2020 Wolters Kluwer Health, Inc. All rights reserved.


KEY POINTS
 Use of spinal anesthesia avoids airway manipulation
and the adverse effects of drugs used to provide
general anesthesia, improved postoperative pain and
reduced postoperative opioid requirements.
 Spinal anesthesia has been reported to improve
outcomes in hospitalized patients, however, its benefits
in ambulatory settings remain questionable.
 It is not clear whether spinal anesthesia provides
superior postoperative outcomes compared with a fast-
track general anesthesia technique.
 Limitations of spinal anesthesia include prolonged
onset, delayed offset, unreliability, postural
hypotension, and urinary retention, which can delay
patient throughput.
for providing safe and efficient care, while reducing
extended recovery, unplanned hospital transfers,
and acute care or emergency room visits
after discharge.
SPINAL ANESTHESIA: BENEFITS
An ideal anesthetic technique should provide rapid
onset, optimal operating conditions and rapid clear-
headed recovery with no or minimal adverse effects
such as pain, nausea, and vomiting. Furthermore, it
would facilitate early oral intake and ambulation,
thus allowing early discharge home.
Spinal anesthesia has several benefits that make
it desirable for ambulatory surgery. The use of
regional anesthesia such as spinal anesthesia obvi-
ates the need for airway manipulation and avoids
the associated adverse effects of hypnotic-sedatives,
opioids, and muscle relaxants. Avoidance of general
anesthesia may be particularly beneficial in high-
risk patients like the elderly who may be at a high
risk of postoperative cognitive decline [10]. Simi-
larly, patients with comorbid conditions such as
obesity and obstructive sleep apnea may benefit
from avoidance of airway instrumentation and
residual effects of anesthetic drugs used for general
anesthesia. Use of spinal anesthesia may reduce
postoperative pulmonary complications, particu-
larly in high-risk patients such as those with pulmo-
nary disease [11]. In addition, residual analgesia
from spinal anesthesia in the immediate postopera-
tive period allows for titration of nonopioid and
opioid analgesics as the spinal block regresses
&&
[5 ]. Thus, spinal anesthesia is associated with lower
pain scores and opioid requirements in the imme-
diate postoperative period [12]. Compared with gen-
eral anesthesia, spinal anesthesia has been reported
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Copyright © 2020 Wolters Kluwer Health, Inc. All rights reserved.
Spinal anesthesia and ambulatory surgery Stewart et al.
to reduce the incidence of postoperative nausea and
vomiting (PONV) most likely due to reduced intra-
operative and immediate postoperative opioid use
&&
[5 ,13]. In addition, although there is no good
evidence, spinal anesthesia has the potential to
reduce cost of care and facility resource utilization
[14].
An international expert group recommends
neuraxial anesthesia for total knee arthroplasty
(TKA) and total hip arthroplasty (THA), because of
reduced postoperative mortality, pulmonary com-
plications, acute kidney failure, deep venous throm-
&&
bosis, infections, and blood transfusion [9 ].
However, the level of evidence was low for TKA
resulting in a low strength of recommendation.
Of note, the recommendations are primarily sup-
ported by retrospective studies, which may intro-
duce bias including bias regarding the choice of
anesthetic technique (i.e., general anesthesia or spi-
nal anesthesia). Also, there was significant variabil-
ity in the general anesthesia technique and
perioperative analgesic techniques. Furthermore,
perioperative care including surgical and anesthetic
techniques have evolved significantly over time.
Thus, the current applicability of conclusions
remains controversial. Moreover, these recommen-
dations may not be applicable to the ambulatory
setting wherein the patients are younger and health-
ier. In fact, a recent study concluded that utilization
of fast-track general anesthesia techniques was asso-
ciated with low rates of medical and surgical com-
plications with a high rate of patients able to
participate in physical therapy on the day of surgery
&&
[15 ]. A large, multicenter study in patients under-
going anterior cruciate ligament repair found that
the type of anesthesia (i.e., spinal anesthesia versus
general anesthesia versus quadruple nerve blocks)
did not influence postoperative outcomes such as
degree of pain and opioid requirements, delayed
discharge or complications [16]. A large multicenter,
observational study in an ambulatory surgical pop-
ulation performed in French private and public
hospitals found that general anesthesia allowed
for shorter times to micturition and unassisted
ambulation compared with spinal anesthesia; how-
ever, the time to home discharge was similar [17 ].
&&
The authors concluded that spinal anesthesia with
short-acting local anesthetic (i.e., chloroprocaine
and prilocaine) was preferred to general anesthesia
in shorter ambulatory surgical procedures; however,
the median time to discharge was 5 h, which does
not reflect clinical practice [17 ].
&&
Overall, although there are several potential
benefits of spinal anesthesia, there is still substantial
debate as to whether spinal anesthesia provides
superior postoperative outcomes compared with a
www.co-anesthesiology.com 747
Ambulatory anesthesia
fast-track general anesthesia technique, which
includes avoidance of benzodiazepine premedica-
tion, avoidance of deep anesthesia, use of an opi-
oid-sparing approach, and minimization of
neuromuscular blocking agents with appropriate
reversal of residual paralysis.
SPINAL ANESTHESIA: LIMITATIONS
One of the major limitations of spinal anesthesia is
the possibility of a failed spinal, which may be
described as absence of neuraxial blockade or a block-
ade that is insufficient in generating optimal surgical
conditions (i.e., insufficient density, coverage, or
duration). Although the overall failure rate is about
&&
10% [17 ], when performed by experienced practi-
tioners, the failure rate of spinal anesthesia is less
than 1% [18]. However, the potential for failure does
present the anesthesiologist with many challenges,
including repeating the subarachnoid injection or
conversion to general anesthesia. If subarachnoid
injection is repeated, adequate time (about 20 min)
must pass to ensure that the original block is not
delayed. Failure to recognize a slowly developing
block could lead to the development of a high or
total spinal, and consequent cardiorespiratory com-
promise that would necessitate conversion to general
anesthesia. While a high spinal may occur infre-
quently, several factors can mitigate its occurrence
including patient positioning, level of injection, and
selection and dosage of the local anesthetic.
Hypotension is a relatively common occurrence
during spinal anesthesia, but may be treated with
fluid administration and vasoactive medications
(e.g., phenylephrine, ephedrine, norepinephrine,
and vasopressin). However, in high-risk patients,
refractory hypotension may predispose the patient
to significant morbidity such as organ dysfunction
[19] and in rare cases spinal cord ischemia or infarc-
tion [20]. Postoperative postural hypotension may
result in an increased length of stay or unplanned
&
admission [21 ,22]. Dizziness, hypotension, and uri-
nary retention, which can be caused by spinal anes-
thesia, were cited as common reasons for same day
discharge failure after total joint surgery [23]. Simi-
larly, unplanned admission after THA performed
under spinal anesthesia was primarily due to post-
operative nausea and/or dizziness [24].
Another concern with spinal anesthesia is the
potential for prolonged motor weakness, particu-
larly with the use of longer acting local anesthetic
(e.g., bupivacaine), which can delay ambulation and
&&
discharge [5 ]. Postoperative urinary retention
(POUR), defined as the inability to void within 6 h
&&
after surgery [25 ], can occur after spinal anesthesia
as voiding is often the last function to recover after
748 www.co-anesthesiology.com
Copyright © 2020 Wolters Kluwer Health, Inc. All rights reserved.
resolution of motor blockade and regression of sen-
sory blockade beyond the S3 dermatome level [26].
Voiding is often cited as a criterion for discharge
after spinal anesthesia because of the concern for
urinary retention, bladder distention, and urinary
tract infection as well as potential impairment of
renal function [27,28]. Other risk factors for POUR
include advanced age, diabetes mellitus, congestive
heart failure, preoperative urinary symptoms (e.g.,
symptoms of prostate enlargement), type of surgical
procedure (e.g., urological procedures), and surgery
&&
length more than 2 h [25 ,27,28].
Postdural puncture headache (PDPH) is character-
ized by the onset of frontal and/or occipital pain often
radiating into the neck and shoulders and accompa-
nied by other symptoms such as nausea, vomiting,
vertigo, diplopia, tinnitus, and hyperacusis [29,30].
The hallmark of PDPH is its positional nature, wors-
ening when sitting or standing and improving upon
lying down. While the incidence of PDPH appears
unaffected by the choice of local anesthetic [29], the
introduction of a smaller gauge, pencil-point spinal
needle (Whitacre) instead of a larger gauge, cutting
needle (Quincke) has reduced the risk of PDPH to
approximately 1% [31]. Significantly, however, in a
&
study by DelPizzo et al. [32 ] patients 20 years and
younger had almost a three-fold increase in the odds of
developing PDPH when compared with those in the
20–45 age group, suggesting age as an important
factor in anesthetic choice influencing postoperative
outcomes specifically related to the development of
debilitating PDPH.
Cauda equina syndrome (CES) is an infrequent
but well known complication of spinal anesthesia,
characterized by saddle anesthesia, bowel and blad-
der dysfunction and/or paralysis of the lower
extremities [20,33]. In addition, CES has been asso-
ciated with undiagnosed spinal stenosis [20] and is
often attributed to the maldistribution and sacral
pooling of large, supranormal doses of local anes-
thetic [20,31], suggesting either pressure-induced
spinal ischemia or limited local anesthetic distribu-
tion and toxicity as possible causes [20]. While CES
may occur after a single injection of local anesthetic
[20,33], it has often been attributed to the continu-
ous delivery of hyperbaric 5% lidocaine via intra-
thecal microcatheters [31].
Transient neurologic syndrome (TNS) is a local
anesthetic neurotoxicity that is often characterized
by gluteal pain radiating to the lower extremities
after the resolution of sensory and motor blockade
[26]. It has been reported with all intrathecal local
anesthetic, but most commonly occurs with lido-
&&
caine [5 ,26,31]. The incidence of TNS after lido-
caine spinal anesthesia varies between 4 and 37%
[31,34], and the relative risk of developing TNS after
Volume 33  Number 6  December 2020
 Spinal anesthesia and ambulatory surgery Stewart et al.

spinal anesthesia with lidocaine compared with
other local anesthetic (e.g., bupivacaine, prilocaine,
procaine, levobupivacaine, and ropivacaine) was
reported as 4.35 [26]. According to the American
Society of Regional Anesthesia practice advisory, the
risk of TNS is low when using 40–50 mg of 2-chlor-
oprocaine [20]. Other risk factors for TNS include
ambulatory anesthesia and lithotomy and knee
arthroscopy positions [31,35]. It appears unaffected
&&
by baricity, dose, or dilution [5 ,31,34].
Overall, the potential for spinal anesthesia-
related complications can be mitigated with careful
patient and surgical procedure selection and appro-
priate spinal anesthesia technique including use of a
short-acting local anesthetic.
OPTIMAL SPINAL ANESTHESIA
TECHNIQUE
An optimal spinal anesthesia technique would be
reliable and provide a rapid onset of sensory and
motor blockade. In addition, it would have a pre-
dictable duration of action and recovery from motor
blockade and be free from any adverse effects such as
TNS or POUR. Although spinal anesthesia is typi-
cally induced in the operating room, some practi-
tioners may administer it in the preoperative
holding area, so as to avoid delay in surgery start
and allow for enough time to achieve an adequate
level and density necessary for the surgical proce-
dure. One of the concerns with performing spinal
anesthesia in the preoperative holding area is the
need for continual monitoring of cardiorespiratory
function, which would require additional personnel
and adds additional steps to the preoperative work-
flow and especially in the preoperative phase of care.
To prevent PDPH, a small (25–27 ga) pencil-
point needle should be used, and efforts should be
made to reduce the number of insertion attempts,
which could result in the inadvertent extravasation
and subsequent sustained leakage of cerebral spinal
fluid and development of PDPH.
The choice of local anesthetic depends upon the
expected duration of surgery. Although critical, the
optimal local anesthetic type and dose has not been
well defined (Table 1), likely due to the fact that the

Table 1. Overview of local anesthetics for intrathecal use

Structure Dose Volume Duration

Local anesthetic group range (mg) range of action Comments

Lidocaine 5% Amide 50–100 1–2 ml 90–120 min High risk of TNS. No longer licensed in the
United States and the United Kingdom
Mepivacaine 1.5% Amide 30–60 2–4 ml 90–150 min Risk of TNS is similar to lidocaine. Not licensed
in the United States and the United Kingdom
Bupivacaine 0.5 Amide 5–20 1–4 ml for 0.5% and 120–240 min Prolonged duration. 0.75% hyperbaric licensed
and 0.75% 0.75–2 for 0.75% in the United States, whereas 0.5%
hyperbaric licensed in the United Kingdom
Ropivacaine 0.5% Amide 15–20 3–4 ml 120–210 min Does not offer an advantage over bupivacaine.
Not licensed in the United States or the
United Kingdom
Levobupivacaine Amide 12.5–15 2.5–3 ml 390 min; >5 h S-enantiomer of bupivacaine; speed of onset
0.5% for mobilization and quality of block similar to hyperbaric
bupivacaine; isobaric levobupivacaine may
have shorter motor and sensory duration;
isobaric levobupivacaine licensed in the
United Kingdom
Articaine Amide 60–90 2–3 ml 60–90 min Concerns for severe hypotension and
neurotoxicity
Prilocaine 2% Amide 40–60 2–3 ml 60–90 min Similar in onset and offset of lidocaine.
hyperbaric Metabolites may be responsible for
methemoglobinemia
Licensed in the United Kingdom, but not in the
United States
2-Chloroprocaine 1%, Ester 30–60 3–6 ml 40–90 min Licensed in the United States and the United
plain formulation Kingdom
Procaine Ester 100 2 ml 90 min Lower incidence of TNS than lidocaine;
neurotoxicity and intraoperative nausea and
vomiting reported; not licensed for SA in the
United States or the United Kingdom

SA, spinal anesthesia; TNS, transient neurologic symptoms.

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Copyright © 2020 Wolters Kluwer Health, Inc. All rights reserved.

Ambulatory anesthesia
pharmacokinetics and pharmacodynamics of indi-
vidual patients are highly variable and not easily
predicted [31]. Nevertheless, the total dose depends
upon patient characteristics and the type of surgery.
Although lidocaine provides optimal onset and
duration in the ambulatory setting, it has been all
&&
but abandoned due to a high risk of TNS [5 ,36].
Bupivacaine has a very low incidence of TNS (0–1%)
[31]; however, its long duration of action can delay
the ability to ambulate and void, which may further
delay discharge home and/or increase the incidence
of unplanned hospital admissions after ambulatory
surgery. Nevertheless, bupivacaine has been
reported to be appropriate for outpatient total hip
&
and knee arthroplasty [23,37 ]. Both hyperbaric and
isobaric bupivacaine provide effective anesthesia
with no difference in failure rates or adverse effects
[38]. The hyperbaric formulation may offer an
advantage in ambulatory surgery because it offers
a relatively rapid onset and a shorter duration of
motor blockade [38]. Of note, 80–100% block failure
has been reported with the use of ultra-low dose
(<2 mg) of longer acting local anesthetics [39,40].
For surgical procedures over 60–90 min, bupiva-
caine remains the only choice in the United States
&&
[5 ].
Short-acting local anesthetics (e.g., prilocaine,
chloroprocaine, mepivacaine) have been demon-
strated to provide reliable surgical anesthesia and
timely discharge from the hospital. Prilocaine has a
similar predictable onset and offset as lidocaine, but
with a lower incidence of TNS symptoms [26,41]. A
recent systematic review concluded that home read-
iness with prilocaine spinal anesthesia occurs in
about 4 h [26]; however, this is typically longer than
after fast-track general anesthesia. Compared with
prilocaine, chloroprocaine has a shorter duration
and a lower risk of TNS and urinary retention
[41]. A large retrospective review (n ¼ 2746) of
patients undergoing outpatient perianal surgery
concluded that compared with hyperbaric prilo-
caine 2% and hyperbaric mepivacaine 4%, chloro-
procaine 1%, 10–20 mg provided the most favorable
profile related to fast discharge readiness and reli-
able anesthesia with minimal failure rate [42]. In
another study of hospitalized patients undergoing
total joint surgery, chloroprocaine spinal anesthesia
reduced operating times and resulted in a higher
discharge rate on the day of surgery compared with
&
bupivacaine [43 ].
Additives (e.g., opioids) have been used to
improve the quality of surgical anesthesia and
extend the duration of the spinal block, while reduc-
ing the dose of local anesthetic. The use of hydro-
philic opioids (e.g., morphine) is not suitable for
ambulatory surgery due to the risk of delayed
750 www.co-anesthesiology.com
Copyright © 2020 Wolters Kluwer Health, Inc. All rights reserved.
respiratory depression. Lipophilic opioids (e.g., fen-
tanyl and sufentanil) have a more favorable clinical
profile; however, they may increase the incidence of
PONV, pruritus and urinary retention, which can
delay home-readiness. Overall, routine use of intra-
thecal additives is not recommended in the
ambulatory setting.
DISCHARGE CONSIDERATIONS AFTER
SPINAL ANESTHESIA
In addition to routine criteria for discharge from the
post anesthesia care unit (PACU) and from the
ambulatory facility [44], discharge after spinal anes-
thesia includes regression of the motor and sensory
blockade. Motor blockade can be assessed using the
Bromage scale, which describes complete block
(unable to move feet), almost complete block (only
able to move feet), partial block (able to move
knees), and no block (full movement of knees and
feet). Regression of sensory block to L4 level is
considered as recovery of sensory blockade. In addi-
tion, ability to ambulate (i.e., steady gait, no dizzi-
ness, or meets preoperative level) is used for
discharge home. Although ability to void is not a
requirement for discharge home [45], it is com-
monly used with spinal anesthesia, as it is a risk
factor for urinary retention. However, voiding may
not be necessary in low-risk patients (e.g., no history
of urinary retention, nonurologic or pelvic surger-
ies) and use of short-acting local anesthetic [46].
CONCLUSION
One of the key factors for the choice of anesthetic in
the ambulatory setting is rapid readiness for dis-
charge. Patient choice and type of surgery as well
as the availability of shorter acting local anesthetic
may influence the use between spinal anesthesia
and general anesthesia. The purported benefits of
spinal anesthesia include avoidance of airway
manipulation and the adverse effects of drugs used
to provide general anesthesia, improved postopera-
tive pain and reduced postoperative opioid require-
ments. Although spinal anesthesia has been
reported to improve outcomes in hospitalized
patients, its benefits in ambulatory settings in which
patients are relatively healthier remains question-
able. Furthermore, it is not clear whether spinal
anesthesia provides superior postoperative out-
comes compared with a fast-track general anesthesia
technique. Shortcomings of spinal anesthesia
include prolonged onset, delayed offset, unreliabil-
ity, postural hypotension, and urinary retention,
which can delay patient throughput. The time to
home-readiness of 2–4 h after spinal anesthesia is
Volume 33  Number 6  December 2020

clearly unacceptable for busy ambulatory surgery
facilities. Current practice of spinal anesthesia is
heterogenous with wide variability in type and doses
of local anesthetic leading to lack of consensus
regarding the optimal technique. Finally, short-
acting (e.g., chloroprocaine) and intermediate-
acting (e.g., prilocaine and mepivacaine) local
anesthetic are not universally available or approved
by regulatory authorities. Future studies should be
aimed at identifying these factors prior to ambula-
tory surgery under spinal anesthesia.
Acknowledgements
None.
Financial support and sponsorship
None.
Conflicts of interest
G.P.J. has received honoraria from Baxter Pharmaceu-
ticals and Pacira Pharmaceuticals. I.G has received
honoraria from Pacira Pharmaceuticals. J.S has no
conflicts of interest.
REFERENCES AND RECOMMENDED
READING
Papers of particular interest, published within the annual period of review, have
been highlighted as:
& of special interest
&& of outstanding interest
1. Joshi GP, Vetter TR. Unanticipated hospital admission after ambulatory
&& surgery: the devil is in the details. Anesth Analg 2020; 131:494–496.
The editorial discusses unplanned admissions after ambulatory surgery.
2. Sessler DI. Long-term consequences of anesthetic management. Anesthe-
siology 2009; 111:1–4.
3. Joshi GP. Fast tracking in outpatient surgery. Curr Opin Anaesthesiol 2001;
14:635–639.
4. Nilsson U, Jaensson M, Dahlberg K, Hugelius K. Postoperative recovery after
& general and regional anesthesia in patients undergoing day surgery: a mixed
methods study. J Perianesth Nurs 2019; 34:517–528.
The study investigates the differences in recovery after general or regional
anesthesia.
5. Rattenberry W, Hertling A, Erskine R. Spinal anaesthesia for ambulatory
&& surgery. BJA Educ 2019; 19:321–328.
This is a comprehensive review of spinal anesthesia for ambulatory surgery.
6. Wilson J, Farley K, Erens G, Guild G. General vs spinal anesthesia for revision
&& total knee arthroplasty: do complication rates differ? J Arthroplasty 2019;
34:1417–1422.
The retrospective study examines postoperative complications in patients under-
going general versus spinal anesthesia for total knee arthroplasty (TKA).
7. Weinstein SM, Baaklini LR, Liu J, et al. Neuraxial anaesthesia techniques and
postoperative outcomes among joint arthroplasty patients: is spinal anesthe-
sia the best option? Br J Anaesth 2018; 121:842–849.
8. Memtsoudis SG, Poeran J, Zubizarreta N, et al. Do hospitals performing
frequent neuraxial anesthesia for hip and knee replacements have better
outcomes? Anesthesiology 2018; 129:428–439.
9. Memtsoudis S, Cozowicz C, Bekeris J, et al. Anaesthetic care of patients
&& undergoing primary hip and knee arthroplasty: consensus recommendations
from the International Consensus on Anaesthesia-Related Outcomes after
Surgery Group (ICAROS) based on a systematic review and meta-analysis.
Br J Anaesth 2019; 123:269–287.
Consensus recommendations for anesthetic technique in patients undergoing hip
and knee arthroplasty.
10. Weinstein SM, Poultsides L, Baaklini LR, et al. Postoperative delirium in total
knee and hip arthroplasty patients: a study of perioperative modifiable risk
factors. Br J Anaesth 2018; 120:999–1008.
0952-7907 Copyright ß 2020 Wolters Kluwer Health, Inc. All rights reserved.
Copyright © 2020 Wolters Kluwer Health, Inc. All rights reserved.
Spinal anesthesia and ambulatory surgery Stewart et al.
11. Hausman MS, Jewell ES, Endogen M. Regional versus general anesthesia in
surgical patients with chronic obstructive pulmonary disease: does avoiding
general anesthesia reduce the risk of postoperative complications? Anesth
Analg 2015; 120:1405–1412.
12. Liu SS, Strodtbeck WM, Richman JM, Wu CL. A comparison of regional
versus general anesthesia for ambulatory anesthesia: a meta-analysis of
randomized controlled trials. Anesth Analg 2005; 101:1634–1642.
13. Sansonnens J, Taffé P, Burnand B; ADS Study Group. Higher occurrence of
nausea and vomiting after total hip arthroplasty using general versus spinal
anesthesia: an observational study. BMC Anesthesiol 2016; 16:44.
14. Morris MT, Morris J, Wallace C, et al. An analysis of the cost-effectiveness of
spinal versus general anesthesia for lumbar spine surgery in various hospital
settings. Global Spine J 2019; 9:368–374.
15. Stambough JB, Bloom GB, Edwards PK, et al. Rapid recovery after total joint
&& arthroplasty using general anesthesia. J Arthroplasty 2019; 34:1889–1896.
The study reports that outcomes after general anesthesia are similar to that after
spinal anesthesia.
16. Baverel L, Cucurulo T, Lutz C, et al. Anesthesia and analgesia methods for
outpatient anterior cruciate ligament reconstruction. Orthop Traumatol Surg
Res 2016; 102:S251–S255.
17. Capdevila X, Aveline C, Delaunay L, et al. Factors determining the choice
&& of spinal versus general anesthesia in patients undergoing ambulatory
surgery: results of a multicenter observational study. Adv Ther 2020;
37:527–540.
The large observational study evaluated the factors determining the choice of
anesthetic technique in the ambulatory setting. General anesthesia and spinal
anesthesia demonstrated comparable times with discharge.
18. Fettes PDW, Jansson JR, Wildsmith JAW. Failed spinal anaesthesia: mechan-
isms, management, and prevention. Br J Anaesth 2009; 102:739–748.
19. Neal JM. Hypotension and bradycardia during spinal anesthesia: signifi-
cance, prevention, and treatment. Tech Reg Anes Pain Manag 2000;
4:148–154.
20. Neal JM, Barrington MJ, Brull R, et al. The second ASRA practice advisory on
neurologic complications associated with regional anesthesia and pain med-
icine: executive summary. Reg Anesth Pain Med 2015; 40:401–430.
21. Bodrogi A, Dervin GF, Beaulé PE. Management of patients undergoing same-
& day discharge primary total hip and knee arthroplasty. Can Med Assoc J 2020;
192:E34–E39.
This is a review of same-day discharge protocols in primary total hip and knee
arthroplasty.
22. Springer BD, Odum SM, Vegari DN, et al. Impact of inpatient versus out-
patient total joint arthroplasty on 30-day hospital readmission rates and
unplanned episodes of care. Orthop Clin N Am 2017; 48:15–23.
23. Frazer JF, Danoff JR, Manrique J, et al. Identifying reasons for failed same-day
discharge following primary total hip arthroplasty. J Arthroplasty 2018;
33:3624–3628.
24. Coenders MJ, Mathijssen NMC, Vehmeijer SBW. Three and half years’
experience with outpatient total hip arthroplasty. Bone Joint J 2020; 102-
B:82–89.
25. Medairos R, Berger GK, Prebay ZJ, et al. Postoperative urinary retention
&& (POUR) score – can incomplete bladder emptying after surgery be pre-
dicted? Perioper Care Oper Room Manag 2020; 20:100120.
The study provides a risk score for postoperative urinary retention, which could
help determine readiness to discharge prior to voiding.
26. Manassero A, Fanelli A. Prilocaine hydrochloride 2% hyperbaric solution for
intrathecal injection: a clinical review. Local Reg Anesth 2017; 10:15–24.
27. Scott AJ, Mason SE, Langdon AJ, et al. Prospective risk factor analysis for the
development of postoperative urinary retention following ambulatory general
surgery. World J Surg 2018; 42:3874–3879.
28. Mason SE, Scott AJ, Mayer E, Purkayastha S. Patient-related risk factors for
urinary retention following ambulatory general surgery: a systematic review
and meta-analysis. Am J Surg 2016; 211:1126–1134.
29. Turnbull D, Shepherd D. Postdural puncture headache: pathogenesis, pre-
vention and treatment. Br J Anaesth 2003; 91:718–729.
30. Headache Classification Subcommittee of the International Headache So-
ciety. The international classification of headache disorders: 2nd edition.
Cephalalgia 2004; 24(Suppl 1):9–160.
31. Liu SS, McDonald SB. Current issues in spinal anesthesia. Anesthesiology
2001; 94:888–906.
32. DelPizzo K, Luu T, Fields K, et al. Risk of postdural puncture headache in
& adolescents and adults. Anesth Analg 2020; 131:273–279.
The study found age as a risk factor for postdural puncture headache.
33. Grancher JC. Cauda equina syndrome following a single spinal administration
of 5% hyperbaric lidocaine through a 25-guage Whitacre needle. Anesthe-
siology 1997; 87:687–689.
34. Pollock JE, Liu SS, Neal JM, Stephenson CA. Dilution of spinal lidocaine does
not alter the incidence of transient neurologic symptoms. Anesthesiology
1999; 90:445–450.
35. Förster JG. Short-acting spinal anesthesia in the ambulatory setting. Curr
Opin Anesthesiol 2014; 27:597–604.
36. Wulf H, Hampl K, Steinfeldt T. Speed spinal anesthesia revisited: new drugs
and their clinical effect. Curr Opin Anesthesiol 2013; 26:613–620.
www.co-anesthesiology.com 751
Ambulatory anesthesia
37. Ascione F, Braile A, Romano AM, et al. Experience-optimised fast track
& improves outcomes and decreases complications in total knee arthroplasty.
Knee 2020; 27:500–508.
The study describes a fast-track program for patients undergoing TKA under spinal
anesthesia.
38. Uppal V, Retter S, Shanthanna H, et al. Hyperbaric versus isobaric bupiva-
caine for spinal anesthesia: systematic review and meta-analysis for adult
patients undergoing noncesarean delivery surgery. Anesth Analg 2017;
125:1627–1637.
39. Al-Metwalli R. The minimal effective dose of spinal hyperbaric bupivacaine for
successful reliable saddle block for minor perianal surgeries. Ain-Shams J
Anaesthesiol 2015; 8:265.
40. Carron M, Freo U, Veronese S, et al. Spinal block with 1.5 mg hyperbaric
bupivacaine: not successful for anyone. Anesth Analg 2007; 105:1515–1516.
41. Boublik J, Gupta R, Bhar S, Atchabahian A. Prilocaine spinal anesthesia for
ambulatory surgery: a review of the available studies. Anaes Crit Care Pain
Med 2016; 35:417–421.
752 www.co-anesthesiology.com
Copyright © 2020 Wolters Kluwer Health, Inc. All rights reserved.
42. Gebhardt V, Kiefer K, Bussen D, et al. Retrospective analysis of mepivacaine,
prilocaine and chloroprocaine for low-dose spinal in outpatient perianal
procedures. Int J Colorectal Dis 2018; 33:1469–1477.
43. Herndon CL, Martinez R, Sarpong NO, et al. Spinal anesthesia using
& chloroprocaine is safe, effective, and facilitates earlier discharge in selected
fast-track total hip arthroplasty. Arthroplast Today 2020; 6:305–308.
The study compared spinal anesthesia with chloroprocaine versus bupivacaine in
fast-track total hip arthroplasty.
44. American Society of Anesthesiologists Task Force on Postanesthetic Care.
Practice guidelines for postanesthesia care: a report by the American Society
of Anesthesiologists Task Force on postanesthesia care. Anesthesiology
2002; 96:742–752.
45. Joshi GP. New concepts in recovery after ambulatory surgery. Ambul Surg
2003; 10:167–170.
46. Mulroy M, Salinas F, Larkin K, Polissar N. Ambulatory surgery patients may be
discharged before voiding after short-acting spinal and epidural anesthesia.
Anesthesiology 2002; 97:315–319.
Volume 33  Number 6  December 2020