We thank Chelly et al. for their interest in our case report that described major ambulatory surgery with continuous regional anesthesia and a disposable infusion pump. Although we appreciate their comments, we believe the use of continuous local anesthetic infusions at home is an investigational area of pain control. As a result, despite their institutional bias, many of the issues they highlight, such as the ideal location of catheter placement, dosing method and regimen, and appropriate patient follow-up, remain to be defined with evidence-based medicine. The case report represents a novel application of available technology to highlight the potential benefit this method could have for outpatient pain management, not a definitive treatment algorithm.
As we attempt to define an appropriate standard of care for ambulatory perineural infusion, vigilance concerning the risk of local anesthetic toxicity occurring outside of the hospital is essential. In our group, we go to great lengths to avoid such complications. The description by Chelly et al. of patients being sent home with brief instructions and a phone number is inaccurate. As we mentioned in the case report, careful patient selection is essential. In addition, at our institution, the standard of care for each patient is to receive 24-h, 7-day, and 3-week follow-up telephone calls, which are tracked in an automated database. Individual patients are also followed-up at home by physician house calls and home healthcare nurses. Deciding the level of care is based on individual clinician judgment on a case-by-case basis.
We agree with Chelly et al. that ambulatory care should provide the same level of care as in-patient care. However, we believe that ambulatory care can provide the same quality of health care as in-patient care, without the same level of nursing and medical intervention suggested by Chelly et al. Removing a continuous local anesthetic catheter at home is one example. Patients routinely remove surgical drains that lie within joint spaces and wounds without the supervision of a physician. Extending this to perineural catheters seems feasible. Furthermore, choosing the appropriate anatomic site for catheter insertion should be based on the site of surgery, patient habitus, and desired postoperative analgesia, not to simply facilitate a clinician’s ease of view of the catheter site.
The rapid growth of ambulatory anesthesia and the evolution of outpatient surgical techniques will demand that we move forward from traditional pain management strategies. This will necessitate incorporation of the numerous successful variations in community practice. Given the 50 h of postoperative analgesia provided with this technique in an ambulatory setting, the success we have seen in placing more than 1,000 continuous local anesthetic catheters for inpatient treatment in our ambulatory care unit, and the success discussed in the literature, we believe further investigation of outpatient continuous local anesthetic catheters is warranted. It is our goal to define the safety and effectiveness of this treatment method by prospective randomized trials performed by a core of professionals interested in developing this field, and not simply by individual or institutional tradition.