Ongoing evidence continues to support the finding that postoperative pain remains the greatest concern for patients presenting for surgery. In fact, recent surveys demonstrate that patients continue to suffer moderate to severe pain postoperatively.

Additionally, patient satisfaction is becoming an increasingly important aspect of health care reimbursements reported via the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey, since the Affordable Care Act established reimbursements based on HCAHPS scores.

Pain after orthopedic surgery may be severe; when uncontrolled, it is the most common reason for readmission after ambulatory orthopedic surgery. Although perineural analgesia is widely considered the gold standard for postoperative pain control for a wide variety of ambulatory orthopedic procedures, a single-injection nerve block with bupivacaine or ropivacaine lasts less than 24 hours. Compared with a single-injection nerve block, continuous peripheral nerve blockade (CPNB) resulted in lower pain scores up to 48 hours postoperatively, decreased opioid use, decreased nausea, and improved patient satisfaction scores. However, CPNB is more costly and takes more time to place compared with a single-injection nerve block, and instituting an ambulatory regional analgesia program requires a dedicated team with 24-hour availability to attend to patient questions and follow-ups. CPNB is also not foolproof and is subject to catheter dislodgement, migration, failure, and leakage. Thus, an ambulatory regional analgesia program is not optimal for each patient or each department of anesthesiology.

In this review, I address options for providing the most optimal analgesia for patients undergoing ambulatory orthopedic procedures and the role local anesthetic additives play in perineural analgesia.

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