Anesthesia In Hand Surgery Research Articles

Patient and Surgeon Reported Experiences of Locoregional Anesthesia in Hand Surgery

Introduction Locoregional anesthesia techniques have been increasingly adopted for use in hand surgery in recent years. However, locoregional anesthesia techniques may place patients under significant psychological stress, and there has been limited evaluation of acceptance and satisfaction rates of these techniques.Materials and Methods An observational study was conducted in a single tertiary institution. Data were collected from patients undergoing upper limb surgery procedures with locoregional anesthesia. After completion of surgery, a questionnaire adapted from Evaluation du Vecu de l’Anesthesie LocoRegionale (EVAN-LR), with scores from 1 to 5 on the Likert scale, was conducted on the same day to evaluate patient satisfaction. Responses were also obtained from the operating surgeon to assess satisfaction.Results A total of 101 patients were evaluated as part of the study. All EVAN-LR domains received a mean score >4.5. Responses from surgeons also showed good acceptance of locoregional anesthesia techniques with almost all giving scores ≥4 on the Likert scale.Conclusion The results of this study showed good satisfaction and acceptance of locoregional anesthesia among patients for upper limb procedures. This provides reassurance regarding the quality of care with locoregional anesthesia techniques. It remains important to be aware of potential sources of discomfort such as tourniquet pain to minimize discomfort and maximize patient satisfaction.

Wide awake local anesthesia no tourniquet technique in hand surgery during the COVID-19 pandemic - personal experience

Short-time exposure of the patient to the hospital environment and the significantly lower costs make WALANT technique a “gold-standard” anesthesia in hand surgery during the COVID-19 pandemic. Material and methods: We studied a group of 180 patients treated for acute and chronic conditions during the first 10 months of the COVID-19 pandemic. A statistical analysis was conducted in order to demonstrate the efficacy and usefulness of the WALANT technique. Results: The average length of hospital stay was 118.05 minutes, the mean time of onset of local anesthesia was 12.79 minutes, the average patient waiting time from admission to surgery was 15.72 minutes. We used ANOVA regression, establishing CI 95% and significance F of 95%. A p-value <0.05 was considered statistically significant. Conclusions: Using WALANT technique the length of hospital stays and implicitly the risk of contracting SARS-CoV-2 decreases and also the costs are lower, surgical care is good, and patient satisfaction is high.

Distal hand block

Peripheral nerve blocks in hand surgery. Short operations on the hand. Long operations, polyneuropathy, local anesthesia allergy. Identification of landmarks, skin disinfection, local anesthesia injection, surgery. Postoperative monitoring. We performed 75hand surgeries using distal nerve blocks over 3years (between 2015 and 2018) in our department. In all, 60% (n = 45) of cases belong to the innervation region of the median nerve, 28% of cases (n = 21) belong to the innervation area of the radial nerve and about 5% (n = 4) to the innervation area of the ulnar nerve. In 7% (n = 5) of cases, anesthesia of two neighboring innervation areas was necessary. The distal nerve block provides areliable form of anesthesia in hand surgery with low complication rates.

Study on Epinephrine Used in Local Anesthesia Controversy and certainty

Epinephrine (adrenaline) - C9H13NO3 - was synthesized for the first time by Fredrich Stelz in 1904 from phenylalanine. After a hydrolysis and decarboxylation process, active dopamine is obtained. Following the pathway of other hydroxylation followed by N-methylation, epinephrine synthesis is achieved. Epinephrine has initially been administrated together with procaine in local anesthesia in hand surgery. Epinephrine has been considered to be one of causes of ischemia and necrosis in hand and especially fingers surgery. Over time, studies have shown the efficacy and safety of using lidocaine-associated epinephrine in local hand surgery anesthesia. Numerous advantages regarding the use of lidocaine 1% with epinephrine, solution at a concentration of 1:100,000 have been reported, starting with increasing the duration of anesthesia, avoiding the use of tourniquet, leading to increased patient comfort and to the advantage of a much lower cost in terms of surgery as a whole. Our study group consisted of fifty patients with hand and fingers different patologies. In all cases surgery was performed under local anesthesia using lidocaine 1% with epinephrine, solution at a concentration of 1:100,000. The decrease of doses mentioned in the literature was attempted and in some cases the decrease was up to 30%. There have not been reported any ischemic or necrosis complication in the immediate postoperative period.

Preemptive Analgesia in Thumb Basal Joint Arthroplasty: Immediate Postoperative Pain with Preincision versus Postincision Local Anesthesia

Purpose Currently no guidelines exist for the timing of the injection of anesthetics in surgeries performed under general anesthesia to minimize postoperative pain. To better understand the role of timing of the injection of local anesthesia in hand surgery performed under general anesthesia, we evaluated the effect of pre- versus postincisional local analgesic injection on immediate postoperative pain experience. We hypothesize that the preincisional (preemptive) injection will result in decreased immediate postoperative pain experience and analgesic use when compared with postincisional injection. Methods Consecutive cases of thumb basal joint arthroplasty performed over a 4-year period were retrospectively reviewed. During the first half of the study period, the surgical site was infiltrated with 0.5% bupivacaine at the completion of surgery following closure. During the second half of the study period, the surgical site was infiltrated with 0.5% bupivacaine prior to skin incision. Data collected included patient demographics, immediate postoperative recovery room (PACU) pain scores, and postoperative opioid consumption in morphine equivalents. Results Two-tailed t -test identified no significant difference between the pre- and postincision cohorts relative to PACU entrance pain scores and time spent in the PACU. PACU exit pain scores were significantly lower in the preincision cohort. The mean PACU pain score was also significantly lower in the preincision cohort. PACU opioid consumption, converted into morphine equivalents, was found to be 211 mg in the preincision versus 299 mg in the postincision cohort. Conclusion The preincisional (preemptive) injection of local anesthesia was found to result in lower pain scores during and upon exit of the PACU as compared with the postclosure group. In addition, the preincision cohort also trended toward lower opioid consumption while in the PACU. Consideration should be given to the routine use of preincision injection of local anesthesia to maximize pain relief in a multimodal pain strategy in hand surgical patients. Level of Evidence Therapeutic level III.

Achieving the Optimal Epinephrine Effect with Local Anesthesia in Hand Surgery: Level 2 Evidence

Achieving the Optimal Epinephrine Effect with Local Anesthesia in Hand Surgery: Level 2 Evidence

Putting it all together: recommendations for improving pain management in plastic surgical procedures: hand surgery.

Approaches to upper extremity anesthesia in hand surgery include regional blocks, wide-awake hand surgery with local anesthesia, and stellate ganglion blocks. Retrospective review of the literature from 2000 to 2014 published on the delivery of local and regional anesthesia during hand surgery. Included studies describe techniques of administration and treatment outcomes to identify common practices of pain management in hand surgery. Regional blocks provide sufficient anesthesia for hand surgery and have been found to improve postoperative pain and measured outcome scores. Wide-awake surgery offers many advantages including minimizing anesthetic risk and expense, permitting patient participation in operative evaluation, decreasing hospital time, and improving functional outcomes scores. Pain management in hand surgery can be achieved through regional blocks and wide-awake techniques that do not necessitate general anesthesia in an effort to improve safety, convenience, cost savings, and efficiency.

Transition From Nerve Stimulator to Sonographically Guided Axillary Brachial Plexus Anesthesia in Hand Surgery

Objectives Sonographic guidance for peripheral nerve anesthesia has proven increasingly successful in clinical practice; however, fears that a change to sonographically guided regional anesthesia may impair the block quality and operating room work flow persist in certain units. In this retrospective cohort study, block quality and patient satisfaction during the transition period from nerve stimulator to sonographic guidance for axillary brachial plexus anesthesia in a tertiary referral center were investigated. Methods Anesthesia records of all patients who had elective surgery of the wrist or hand during the transition time (September 1, 2006–August 25, 2007) were reviewed for block success, placement time, anesthesiologist training level, local anesthetic volume, and requirement of additional analgesics. Postoperative records were reviewed, and patient satisfaction was assessed by telephone interviews in matched subgroups. Results Of 415 blocks, 341 were sonographically guided, and 74 were nerve stimulator guided. Sonographically guided blocks were mostly performed by novices, whereas nerve stimulator–guided blocks were performed by advanced users (72.3% versus 14%; P < .001). Block performance times and success rates were similar in both groups. In sonographically guided blocks, significantly less local anesthetics were applied compared to nerve stimulator–guided blocks (mean ± SD, 36.1 ± 7.1 versus 43.9 ± 6.1 mL; P< .001), and less opioids were required (fentanyl, 66.1 ± 30 versus 90 ± 62 μg; P< .001). Interviewed patients reported significantly less procedure-related discomfort, pain, and prolonged procedure time when block placement was sonographically guided (2% versus 20%; P = .002). Conclusions Transition from nerve stimulator to sonographic guidance for axillary brachial plexus blocks did not change block performance times or success rates. Patient satisfaction was improved even during the early institutional transition period.

Transition From Nerve Stimulator to Sonographically Guided Axillary Brachial Plexus Anesthesia in Hand Surgery: Block Quality and Patient Satisfaction During the Transition Period

Sonographic guidance for peripheral nerve anesthesia has proven increasingly successful in clinical practice; however, fears that a change to sonographically guided regional anesthesia may impair the block quality and operating room work flow persist in certain units. In this retrospective cohort study, block quality and patient satisfaction during the transition period from nerve stimulator to sonographic guidance for axillary brachial plexus anesthesia in a tertiary referral center were investigated. Anesthesia records of all patients who had elective surgery of the wrist or hand during the transition time (September 1, 2006-August 25, 2007) were reviewed for block success, placement time, anesthesiologist training level, local anesthetic volume, and requirement of additional analgesics. Postoperative records were reviewed, and patient satisfaction was assessed by telephone interviews in matched subgroups. Of 415 blocks, 341 were sonographically guided, and 74 were nerve stimulator guided. Sonographically guided blocks were mostly performed by novices, whereas nerve stimulator-guided blocks were performed by advanced users (72.3% versus 14%; P < .001). Block performance times and success rates were similar in both groups. In sonographically guided blocks, significantly less local anesthetics were applied compared to nerve stimulator-guided blocks (mean ± SD, 36.1 ± 7.1 versus 43.9 ± 6.1 mL; P< .001), and less opioids were required (fentanyl, 66.1 ± 30 versus 90 ± 62 μg; P< .001). Interviewed patients reported significantly less procedure-related discomfort, pain, and prolonged procedure time when block placement was sonographically guided (2% versus 20%; P = .002). Transition from nerve stimulator to sonographic guidance for axillary brachial plexus blocks did not change block performance times or success rates. Patient satisfaction was improved even during the early institutional transition period.

Continuous cervical epidural anesthesia in hand surgery.

Regional anesthesia, with its known benefits such as increased blood flow, reduced cost, and security, is a method of choice for hand surgery. Recently, the authors have switched from axillary block to continuous cervical epidural anesthesia, which has several advantages such as low cost, a pain-free postoperative period, better control of tourniquet pain, and the avoidance of a motor block so that early active motion is possible. Continuous cervical epidural anesthesia is a safe and reliable method, providing a sensory block with an infusion rate of 4 ml/hr ultracaine (articaine 2 percent), and a motor block when the dosage is increased to 8 ml/hr ultracaine (articaine 2 percent). Postoperatively, only 4 ml/hr ultracaine (articaine 2 percent) is sufficient to provide a sensory block. The method provides both good perfusion and a lower local anesthetic drug dosage than axillary block.

Long-term continuous axillary brachial plexus blockade using an implanted port

Blocking the major nerves at the level of the axilla is the most common technique for providing anesthesia for hand surgery (Fig. 2). Because of the superficial location of the artery and nerves, the simplicity of the technique, and the absence of major complications, there is a wide acceptance of this technique. Before entering the axillary region the brachial plexus cords form three major nerves. With the shoulder abducted, the median nerve lies in front of and slightly above the artery, the ulnar nerve in front and slightly below it, and the radial nerve behind it. The axillary vein lies medial to the artery. The nerves, artery, and vein are enclosed in a fascial sheath, which is part of the same sheath that surrounds the rest of the brachial plexus. The musculocutaneous nerve leaves the sheath of the plexus at the level of the coracoid process and lies within the mass of the coracobrachialis muscle at the level where the axillary block is usually performed. The axillary nerve also leaves the sheath at the level of the coracoid process. This article reviews our experience with continuous axillary blockade using a catheter connected to a port in ten patients suffering from complex regional pain syndrome (CRPS I and II). The technique of insertion and implantation is described as well as relevant anatomy of the brachial plexus. The technique has proved to be useful in relieving pain and discomfort in CRPS patients. Major care is required for using the system, and patients are taught to handle the device themselves. The local anesthetic administered has been 0.25% bupivacaine at 10 mL repeated doses. The system has been used for as long as 16 months without problems. Obstruction of the catheter and infection have been the major complications observed.

Hemodynamic Effects of 0.375% Versus 0.25% Bupivacaine during Cervical Epidural Anesthesia for Hand Surgery

Hemodynamic Effects of 0.375% Versus 0.25% Bupivacaine during Cervical Epidural Anesthesia for Hand Surgery

Balanced Regional Anesthesia for Hand Surgery

In summary, the clinical goal in regional anesthesia for hand surgery is to constantly approach the ideal of a well-conducted, smooth, "balanced regional technique." This begins with the preoperative interview, assurance, and preoperative sedation (po). In the operating room, monitoring (EKG, BP) and safety measures (IV port, nasal oxygen) precede the regional technique. The block is performed with asepsis, minimal "needling," and correct dosages. The complement to neural blockade anxiolytic medication is titrated, thus the balance of IV sedation and regional block is achieved. The patient's symptoms, vital signs, and general comfort should be attended to during the hand surgery. Monitoring is continued in the recovery room, where special attention is given to positioning, cushioning of pressure areas, dressing, analgesia, and specific physical rehabilitation exercises. With a "balanced regional technique," the patient becomes an early participant in his or her own postoperative care and result. This balanced technique reduces the patient's overall operative risk and maximizes the surgical result.

Intravenous regional anaesthesia in hand surgery—experience with 632 cases

Intravenous regional anaesthesia in hand surgery—experience with 632 cases

Intravenous regional anaesthesia in hand surgery—experience with 632 cases

Practical experience in the use of intravenous regional anaesthesia in hand surgery on 632 patients is reported. The safety of the anaesthesia, the efficacy of the procedure and the patient-comfort are well attested in this study. We recommend that its role should be established particularly in busy orthopaedic surgery departments where both elective and emergency work-loads on hand surgery are heavy.

Anesthesia for Hand Surgery

Anesthesia for Hand Surgery

Intravenous regional anesthesia in hand surgery

We have found intravenous regional anesthesia, by the method of expressing the blood, applying a temporary tourniquet, injecting the lidocaine, then placing the second tourniquet on an anesthetized portion of the arm and removing the first tourniquet, to be a very simple and effective way to achieve anesthesia in operations on the hand. The quantities of lidocaine used seem to be well below the toxic amounts by several multiples (this would obtain if the tourniquet should fail). The quantities of lidocaine recovered in the systemic circulation were minute. We did not observe any clear-cut toxic reactions in thirty-six patients. Nerve-conduction studies tended to show that no motor impulses could be transmitted by the median nerve and that anoxia did not seem to play a major role in the production of the anesthesia up to twenty minutes. The usual precautions of availability of oxygen and appropriate drugs should be observed, as is customary when using local anesthetic agents, and the surgeon must be mindful of his selection of cases in regard to necessary operating time, since anesthesia depends on the continuous and uninterrupted presence of the tourniquet.

Intravenous Regional Anesthesia in Hand Surgery

We have found intravenous regional anesthesia, by the method of expressing the blood, applying a temporary tourniquet, injecting the lidocaine, then placing the second tourniquet on an anesthetized portion of the arm and removing the first tourniquet, to be a very simple and effective way to achieve anesthesia in operations on the hand. The quantities of lidocaine used seem to be well below the toxic amounts by several multiples (this would obtain if the tourniquet should fail). The quantities of lidocaine recovered in the systemic circulation were minute. We did not observe any clear-cut toxic reactions in thirty-six patients. Nerve-conduction studies tended to show that no motor impulses could be transmitted by the median nerve and that anoxia did not seem to play a major role in the production of the anesthesia up to twenty minutes. The usual precautions of availability of oxygen and appropriate drugs should be observed, as is customary when using local anesthetic agents, and the surgeon must be mindful of his selection of cases in regard to necessary operating time, since anesthesia depends on the continuous and uninterrupted presence of the tourniquet.