Explain the historical context of spinal anaesthesia in the ambulatory setting. Describe the ideal characteristics of an ambulatory spinal anaesthetic. Recognise the central role of prilocaine and 2chloroprocaine in the ambulatory setting. Select the right drug for the right patient and the right procedure. Ambulatory surgery places high demands on anaesthetic technique. In this setting, rapid onset and offset of anaesthesia, rapid recovery of protective reflexes, mobility and micturition, and good control of postoperative pain and nausea are required. Since the inception of ambulatory surgery, the favoured anaesthetic technique has been general anaesthesia with short-acting drugs. Concerns about the time to perform spinal anaesthesia and the risks of prolonged motor block and urinary retention have limited its use. Whilst in the UK, 'ambulatory surgery' refers solely to patients being discharged from the hospital shortly after surgery, in the USA this term may also apply to admissions for up to 23 h. In this article, we will consider ambulatory surgery to mean that the patient is discharged home before midnight on the day of surgery. Spinal anaesthesia has become increasingly popular for inpatient surgery, but, until recently, its use has been limited in ambulatory surgery by the lack of a safe, licensed short-acting local anaesthetic agent. An ideal intrathecal agent for ambulatory surgery should have a rapid onset of motor and sensory blockade, predictable regression within an acceptable time frame, and a low incidence of adverse effects. Historically, lidocaine was the preferred agent in this setting, providing a dense block with rapid recovery, but the identification of a high incidence of transient neurologic symptoms (TNS) has effectively excluded it from use. 1,2 Until recently, the only local anaesthetic preparations licensed for intrathecal use have been hyperbaric William Rattenberry FRCA is a specialty trainee in anaesthesia whose interests include quality improvement and regional anaesthesia.

Background: Paravertebral blocks are one of the possible postoperative pain management modalities after laparotomy. Adjuvants to local anesthetics, including alpha agonists, have been shown to lead to better pain relief and increased duration of analgesia. Objectives: The aim of this study is to examine the effect of adding dexmedetomidine to bupivacaine for ultrasound-guided paravertebral blocks in laparotomy. Methods: In this double-blind, randomized controlled trial (RCT), we enrolled 42 patients scheduled for T6 to T8 thoracic paravertebral block (TPVB) for analgesia after laparotomy. The patients were randomly assigned into two groups of BD (bupivacaine 2.5 mg/mL 20 mL plus dexmedetomidine 100 µg) and B (bupivacaine 20 mL alone). Following surgery, intravenous fentanyl patient-controlled analgesia was initiated. The numerical rating scale (NRS) for pain, sedation score, total analgesic consumption, time to first analgesic requirement, side effects (such as nausea and vomiting), respiratory depression, and patients’ satisfaction during the first 48 hours of evaluation were compared in the two groups. Results: Pain scores and mean total analgesic consumption at the first 48 hours in the BD group were significantly lower than Group B (P = 0.03 and P < 0.001, respectively). The time of first analgesic request was significantly longer in BD group (P < 0.001). Sedation scores and side effects did not differ significantly between the two groups. Conclusions: Adding dexmedetomidine to bupivacaine for TPVB after laparotomy yielded better postoperative pain management without significant complications.

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Background: Chronic residual pain after total knee arthroplasty (TKA) is one of the challenges of postoperative pain management. Duloxetine, by controlling neuropathic pain, and pregabalin, by affecting nociceptors, can effectively manage postoperative pain. Objectives: This study aimed to compare the effect of perioperative oral duloxetine and pregabalin in pain management after knee arthroplasty. Methods: In this clinical trial, 60 patients scheduled for TKA under spinal anesthesia were randomly assigned to one of three groups A (pregabalin 75 mg), B (duloxetine 30 mg), and C (placebo). Drugs were administered 90 minutes before, 12, and 24 hours after surgery. The visual analog scale (VAS) score for pain, the first analgesic request time, postoperative analgesic consumption (i.v. paracetamol), and WOMAC score six months after surgery were recorded. Results: The VAS score and analgesic consumption 48 hours after TKA in groups A and B significantly decreased compared to the placebo (P < 0.05). The first analgesic request time was longer in groups A and B than in group C (P < 0.05). While the differences were statistically significant, they are most likely not clinically significant. The WOMAC score before and six months after arthroplasty did not differ between the groups (P > 0.05). Conclusions: Perioperative oral pregabalin and duloxetine similarly reduce pain and the need for analgesic consumption within 48 hours after TKA but do not affect knee mobility status.

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