title: Adjuvant Agents in Regional Anesthesia in the Ambulatory Setting.
abstract: OBJECTIVE
  A majority of surgical practice has involved ambulatory centers with the number of outpatient operations in the USA doubling to 26.8 million per year. Local anesthesia delivery provides numerous benefits, including increased satisfaction, earlier discharge, and reduction in unplanned hospital admission. Further, with the epidemic of opioid mediated overdoses, local anesthesia can be a key tool in providing an opportunity to reduce the need for other analgesics postoperatively.
  
  
  RESULTS
  Adjuvants such as epinephrine and clonidine enhance local anesthetic clinical utility. Further, dexmedetomidine prolongs regional blockade duration effects. There has also been a significant interest recently in the use of dexamethasone. Studies have demonstrated a significant prolongation in motor and sensory block with perineural dexamethasone. Findings are conflicting as to whether intravenous dexamethasone has similar beneficial effects. However, considering the possible neurotoxicity effects, which perineural dexamethasone may present, it would be prudent not to consider intravenously administered dexamethasone to prolong regional block duration. Many studies have also demonstrated neurotoxicity from intrathecally administered midazolam. Therefore, midazolam as an adjuvant is not recommended. Magnesium prolongs regional block duration but related to paucity of studies as of yet, cannot be recommended. Tramadol yields inconsistent results and ketamine is associated with psychotomimetic adverse effects. Buprenorphine consistently increases regional block duration and reduce opioid requirements by a significant amount. Future studies are warranted to define best practice strategies for these adjuvant agents. The present review focuses on the many roles of local anesthetics in current ambulatory practice.
authors.affiliation: Department of Anesthesiology, Mayo Clinic, Phoenix, AZ, USA.
authors.forename: Veerandra
authors.initials: V
authors.lastname: Koyyalamudi
authors.affiliation: Department of Anesthesiology, LSUHSC-Shreveport, Shreveport, LA, USA.
authors.forename: Sudipta
authors.initials: S
authors.lastname: Sen
authors.affiliation: Department of Anesthesiology, LSUHSC-Shreveport, Shreveport, LA, USA.
authors.forename: Shilpadevi
authors.initials: S
authors.lastname: Patil
authors.affiliation: Department of Anesthesiology, LSUHSC-Shreveport, Shreveport, LA, USA.
authors.forename: Justin B
authors.initials: JB
authors.lastname: Creel
authors.affiliation: Department of Anesthesiology, LSUHSC-Shreveport, Shreveport, LA, USA.
authors.forename: Elyse M
authors.initials: EM
authors.lastname: Cornett
authors.affiliation: Department of Anesthesiology, LSUHSC-Shreveport, Shreveport, LA, USA. cfox1@lsuhsc.edu.
authors.forename: Charles J
authors.initials: CJ
authors.lastname: Fox
authors.affiliation: Department of Anesthesiology, LSUHSC-NO, New Orleans, LA, USA.
authors.forename: Alan D
authors.initials: AD
authors.lastname: Kaye
mesh_terms: D000759:Adjuvants, Anesthesia / Q000627:therapeutic use*; D000554:Ambulatory Care Facilities; D000779:Anesthetics, Local / Q000008:administration & dosage*; D006801:Humans
chemical_list: D000759:Adjuvants, Anesthesia; D000779:Anesthetics, Local
keywords: Adjuvants; Ambulatory; Analgesia; Pain; Peripheral nerve; Regional blockade