Elective Hand Surgery Research Articles

A 5-Year Cost-Effectiveness Analysis of Silicone Metacarpophalangeal Arthroplasty in Patients with Rheumatoid Arthritis

There is a paucity of research evaluating the cost-effectiveness of surgical interventions for rheumatoid arthritis patients. Previous reports have challenged the sustainability of improved outcomes after silicone metacarpophalangeal arthroplasty. The authors conducted an economic evaluation of the long-term health outcomes after silicone metacarpophalangeal arthroplasty. The authors performed a 5-year prospective cohort study of 170 patients with rheumatoid arthritis (73 surgical and 97 nonsurgical). Objective functional measurements and patient-rated outcomes using the Michigan Hand Outcomes Questionnaire and the Arthritis Impact Measurement Scale 2 were collected at 3 and 5 years. A cost-effectiveness analysis using direct costs from Medicare outpatient claims data (2006 to 2010) was performed to estimate the incremental cost-effectiveness ratios for both the Michigan and Arthritis Impact Measurement Scale 2 measurements. At 5 years, the authors observed a statistically significant difference in upper extremity outcomes (Michigan Hand Outcomes Questionnaire) between the two groups, with surgical patients having higher outcomes. Costs associated with improved outcomes 5 years after surgery were $787 to $1150 when measured by the Michigan Hand Outcomes Questionnaire and $49,843 to $149,530 when measured by the Arthritis Impact scale. The incremental cost-effectiveness ratios did not substantially increase with their observed surgical revision rate of 5.5 percent (approximately 4 percent increase in incremental cost-effectiveness ratio) or with previously published long-term revision rates of 6.2 percent (approximately 6 percent increase in incremental cost-effectiveness ratio). Short-term improvements in upper extremity outcomes after silicone metacarpophalangeal arthroplasty are maintained over the 5-year follow-up period. These outcomes are achieved at a relatively low cost, even with the addition of potential surgical complications.

Elective hand surgery after axillary lymph node dissection for cancer.

After axillary lymph node dissection (ALND), patients are cautioned against ipsilateral interventional procedures to avoid the theoretical increased risk of postoperative complications, particularly lymphedema. The authors' goal was to evaluate the complications of elective hand surgery after ALND. The authors reviewed patients presenting to their hand clinic from 1998 to 2011, selecting those with a diagnosis of breast cancer or melanoma and a history of previous ALND; the authors excluded those treated nonoperatively and those treated with elective surgery in the contralateral hand. Average age of the 22 patients meeting the criteria (20 with a history of breast cancer, 6 with preexisting lymphedema) was 53.9 years (range, 26.7 to 73.6 years) at the time of ALND and 63.1 years (range, 31.7 to 83.5 years) at the time of hand surgery. Average interval between surgeries was 9.2 years (range, 8 days to 37.3 years). Follow-up averaged 9.2 months (range, 8 days to 41.7 months). Fifteen patients were surveyed for long-term postoperative results (average surgery-to-survey interval, 4.3 years [range, 1 to 11.9 years]). Fifteen patients had uneventful postoperative recoveries, 4 had peri-incisional erythema requiring oral antibiotics, 1 had incisional pain and scarring, 1 had chronic wound-healing issues, and 1 had a dehiscence requiring a return to the operating room. In the 15 patients who completed the follow-up survey, there was no disease exacerbation in the 3 patients with preexisting lymphedema, and there were no new cases of lymphedema. Routine minor hand surgery did not result in lymphedema and did not increase existing lymphedema in these patients with previous ipsilateral ALND, but almost one-third of them had short-term complications in the postoperative recovery period.

The Effect of Anesthesia Type on Nonsurgical Operating Room Time

To determine the effect of local-only anesthesia on nonsurgical time compared with monitored anesthesia care (MAC)/local and general anesthesia. Our hypothesis was that local-only anesthesia cases would have lower nonsurgical times compared with MAC/local and general anesthesia. We retrospectively reviewed the surgical records of 1,179 patients undergoing elective hand surgery. For each case, we recorded the type of anesthesia used (general, MAC/local, or local-only anesthesia) and in-room presurgical time, in-room postsurgical time, and, if relevant, room turnover time. We did not record room turnover times for the first case of the day or for cases after procedures that did not meet inclusion criteria. We also recorded the presence of any anesthesia providers (anesthesiologist vs anesthesia-assistant [certified registered nurse anesthetist]). A total of 566 cases performed on 501 patients met inclusion criteria. Room turnover times were not calculated for 304 cases. The choice of anesthesia had a significant effect on nonsurgical operating room time. Local anesthesia cases had significantly less nonsurgical time compared with general anesthesia and MAC/local. Cases performed under MAC/local anesthesia also had significantly reduced nonsurgical time compared with general anesthesia. The presence of a certified anesthesia assistant had no effect on any time metrics recorded. Choice of local anesthesia, when appropriate, may facilitate rapid operating room turnover and improve overall facility efficiency with lower costs. Therapeutic IV.

Potential advantages of an additional forearm rubber tourniquet in intravenous regional anesthesia: a randomized clinical trial.

Although the usefulness of an additional forearm tourniquet to conventional intravenous regional anesthesia (IVRA) has been reported, the forearm cuff may disturb the surgical field to some degree, especially in wrist surgery. In the present study, we assessed the clinical efficacy of a temporary additional forearm rubber tourniquet to the conventional upper arm tourniquet on the quality of IVRA. The study included 32 ASA physical status I and II adult patients undergoing elective hand surgery who were randomly allocated to either an additional forearm tourniquet group (Group F) or to a conventional upper arm tourniquet group (Group C). Upper arm tourniquet IVRA was established using 40mL of 0.5% lidocaine in Group C. Hypothetically enhanced forearm tourniquet IVRA was established using 10mL of 0.5% lidocaine with an additional forearm rubber tourniquet and then administering 30mL of 0.25% lidocaine after removing the forearm tourniquet in Group F. The sensory and motor block onset and recovery times, onset time of tourniquet pain, intraoperative fentanyl consumption, and incidence of local anesthetic toxicity were recorded. The numerical rating score (NRS) of perioperative and postoperative pain and quality of anesthesia were also assessed. Although the total dose of lidocaine in Group F was less and the sensory and motor block onset times were significantly shorter in Group F than those in Group C (P<0.05), there was no difference regarding sensory and motor block recovery times, onset time of tourniquet pain, intraoperative fentanyl consumption, NRS of perioperative and postoperative pain, and the quality of anesthesia in the two groups (P>0.05). Compared with Group C, the incidence of local anesthetic toxicity (i.e., dizziness, 43.8 vs 6.2%, P=0.02) was significantly decreased in Group F. The combination of the additional forearm and upper arm tourniquets with a smaller amount of local anesthetic achieved more rapid onset of sensory and motor block, a similar quality of anesthesia and a lower incidence of local anesthetic toxicity compared with the conventional technique.

The scope of practice of hand surgery within plastic surgery: the ACAPS national survey to assess current practice and develop educational guidelines.

There is no consensus among plastic surgeons regarding what constitutes the scope of hand surgery practice. Due to this lack, there is a wide variability in what hand surgery procedures plastic surgery resident will see and participate in during the course of training. We assessed what faculty members of plastic surgery training programs felt were contained within the scope of practice of hand surgery. A survey was sent to all members of the American Council of Academic Plastic Surgeons. Respondents reported size of department, faculty fellowship training, hand surgery call coverage, and amount of elective hand surgery within their training program. They also identified what procedures were within the scope of hand surgery. Ninety-three responses were received. Thirty-five respondents were certified or eligible for the surgery of the hand examination. Twenty-five respondents had 0 or 1 surgery-of-the-hand surgeon among their faculty. Thirty-nine departments/divisions performed 10 or fewer elective hand surgeries per week. Seventy-eight percent of groups taking hand call reported that all faculty members took hand call regardless of whether they had hand fellowship training. Although nearly all cover hand and wrist infections, only 49% provide care for distal radius fractures. In many residency programs, hand surgery exposure is in the setting of trauma and emergencies. The inclusion of complex elective hand surgeries within a plastic surgery practice and residency program allows residents to see the full spectrum of hand surgery. This allows them to make an informed decision regarding whether to seek subspecialty training and continue the participation of plastic surgeons in the full spectrum of hand surgery.

Effectiveness of ondansetron as an adjunct to lidocaine intravenous regional anesthesia on tourniquet pain and postoperative pain in patients undergoing elective hand surgery: a systematic review protocol.

Review question/objective The objective of this quantitative systematic review is to determine the effects of ondansetron as an adjunct to lidocaine on the tourniquet pain and postoperative pain of American Society of Anesthesiologists class 1 or 2 adult patients undergoing elective hand surgery with intravenous regional anesthesia. Inclusion criteria Types of participants This quantitative systematic review will consider studies that included American Society of Anesthesiologists 1 or 2 patients aged 18 years or older who used ondansetron as an adjunct to lidocaine for intravenous regional anesthesia in elective hand surgery. Types of intervention(s)/phenomena of interest This quantitative systematic review will consider studies that evaluated the analgesic effectiveness of ondansetron admixed to lidocaine for intravenous regional anesthesia in patients undergoing elective hand surgery. Patients treated with the admixture of ondansetron and lidocaine for Intravenous regional anesthesia will be compared to those who were treated with lidocaine alone. Types of outcomes This quantitative systematic review will consider studies that include the following outcome measures: 1: Tourniquet pain as measured by time to onset of tourniquet pain; 2: Postoperative pain relief as measured by first analgesic requirement time. The first analgesic requirement time is defined as the time which has elapsed after tourniquet release to the first request by the patient for analgesic and is assessed via visual analogue score in two to six hour intervals up to 24 hours postoperatively.

Effect of muscle relaxation on the oxygenation of human skeletal muscle: a prospective in-vivo experiment using an isolated forearm technique.

BackgroundTotal oxygen consumption has been found to be reduced under deep neuromuscular blockade due to a lower rate of metabolism of skeletal muscles. However, the magnitude of this effect in individual muscles has not been investigated. Thus the aim of this study was to compare the oxygenation of paralyzed versus non-paralyzed forearm muscle under tourniquet-provoked ischemia.MethodsAfter ethics approval and written informed consent, 30 patients scheduled for elective hand and wrist surgery were included. Ischemia was provoked by inflation of bilateral upper arm tourniquets and muscle relaxation was achieved via intravenous administration of rocuronium 0.9 mg/kg. Bilateral tourniquets were applied to both upper arms before induction of anesthesia and near infrared spectrometry (NIRS) electrodes applied on both forearms. Muscular ischemia in an isolated (= non-paralyzed, NP) as well as a paralyzed forearm (P) was created by sequential inflation of both tourniquets before and after intravenous administration of rocuronium. Muscle oxygen saturations (SmO2) of NIRS in both forearms and their changes were determined and compared.ResultsData of 30 patients (15 male, 15 female; 41.8 ± 14.7 years) were analyzed. The speed of SmO2 decrease (50% decrease of SmO2 from baseline (median [percentiles]: NP 210 s [180/480s] vs. P 180 [180/300]) as well as the maximum decrease in SmO2 (minimum SmO2 in % (median [percentiles]: NP 20 [19/24] vs. P 21 [19/28]) were not significantly affected by neuromuscular paralysis.ConclusionsNo significant effect of muscle relaxation on NIRS-assessed muscle oxygenation under tourniquet-induced ischemia was found in human forearm muscles.

Addition of dexmedetomidine to a safe intravenous dose of lidocaine for intravenous regional anesthesia

Background Intravenous regional anesthesia (IVRA) is a simple and reliable type of regional anesthesia. However, it has some limitations such as tourniquet pain, lack of postoperative analgesia, and local anesthetic toxicity in case of tourniquet malfunction. Various additives to local anesthetics, such as opioids, NSAID, ketamine, and clonidine, are used. Aim The aim of this study was to evaluate the addition of dexmedetomidine to a safe intravenous dose of lidocaine for IVRA. Patients and methods a total of 50 patients undergoing elective superficial hand surgery were assigned into two groups: the L group and the LD group. In the L group, IVRA was achieved using 2 mg/kg lidocaine 2% alone, diluted with saline to a volume of 25 ml. In the LD group, IVRA was achieved using 2 mg/kg lidocaine 2% along with 0.5 mg/kg dexmedetomidine diluted with saline to a volume of 25 ml. The motor and sensory block onset and recovery times were assessed. Tourniquet pain and sedation score were assessed intraoperatively and postoperatively. The quality of anesthesia and the duration of analgesia were also recorded. Results Sensory and motor block onset times were shorter and recovery times were prolonged in the LD group. The quality of anesthesia was better in the LD group, and the fentanyl dose required intraoperatively was also lower in the LD group. The duration of postoperative analgesia was longer and the doses of lornoxicam required were lower in the LD group. Conclusion A safe intravenous dose of lidocaine can be used for IVRA for superficial hand surgery, and the addition of 0.5 mg/kg dexmedetomidine shortened the onset times for both sensory and motor blockade and improved the quality of anesthesia, with prolonged postoperative analgesia time.

Linear regression analysis of Hospital Episode Statistics predicts a large increase in demand for elective hand surgery in England

SummaryIntroductionWe integrated two factors, demographic population shifts and changes in prevalence of disease, to predict future trends in demand for hand surgery in England, to facilitate workforce planning.MethodsWe analysed Hospital Episode Statistics data for Dupuytren's disease, carpal tunnel syndrome, cubital tunnel syndrome, and trigger finger from 1998 to 2011. Using linear regression, we estimated trends in both diagnosis and surgery until 2030. We integrated this regression with age specific population data from the Office for National Statistics in order to estimate how this will contribute to a change in workload over time.ResultsThere has been a significant increase in both absolute numbers of diagnoses and surgery for all four conditions. Combined with future population data, we calculate that the total operative burden for these four conditions will increase from 87,582 in 2011 to 170,166 (95% confidence interval 144,517–195,353) in 2030.DiscussionThe prevalence of these diseases in the ageing population, and increasing prevalence of predisposing factors such as obesity and diabetes, may account for the predicted increase in workload. The most cost effective treatments must be sought, which requires high quality clinical trials. Our methodology can be applied to other sub-specialties to help anticipate the need for future service provision.

Minimal important changes and differences in elective hand surgery.

Minimal important changes and differences describe the smallest changes and differences between individuals that are relevant to patients following treatment. Minimal important differences may vary between conditions, treatments and lengths of follow-up, and can be calculated in different ways. Minimal important differences for elective hand surgery were reviewed. A total of 99 minimal important differences were identified in 29 articles. The conditions, treatments, outcome measures used and follow-up periods are discussed. The Disabilities of the Arm, Shoulder and Hand had the most estimates of minimal important differences, but these varied. The methods used in the included studies were reviewed and appraised. Most minimal important differences were calculated using retrospective anchors. Future research directions in this area are suggested. II.

Thrombin and Topical Local Anesthetic for Postoperative Pain Management

Local anesthetic is often used for perioperative pain control. Thrombin serves as a carrying medium for sustained release of antibiotics, chemotherapy, and growth factors. We tested the hypothesis that local anesthetic pain relief can be prolonged with the adjunct use of thrombin. A prospective single-blinded clinical study was performed. Patients undergoing elective hand surgery inclusive of carpal tunnel release, excision of ganglion cyst, trigger finger release, and excision of mucous cyst under local block were enlisted. Before closure, patients received 1 of the following combinations: (1) control with oral analgesics, (2) 5 mL of 2% xylocaine, (3) 5 mL of 0.5% bupivacaine, (4) 2.5 mL of 2% xylocaine with 2.5 mL of 0.5% bupivacaine (XB), (5) thrombin with 5 mL of 2% xylocaine (XT), (6) thrombin with 5 mL of 0.5% bupivacaine (BT), and (7) thrombin with 2.5 mL of 2% xylocaine and 2.5 mL of 0.5% bupivacaine (XBT). There were 7 patients in each group, and patient demographics were similar between groups. Outcome measures included postanesthesia care unit (PACU) time, pain level, and number of pain pills required. Compared with oral analgesics alone, mean (SD) postoperative pain levels were reduced by 33.3% (8.9%) by xylocaine, 69.1% (8.7%) by bupivacaine, and 45.7% (9.4%) by XB. When thrombin was added, pain levels were further reduced by 69.9% by XT (P < 0.001), 23.1% by BT (P = 0.071), and 50.5% by XBT (P < 0.001) compared with their nonthrombin counterparts. In addition, PACU time was decreased by 34.8% by XT (P = 0.003) and 19.7% by XBT (P = 0.013) compared with xylocaine and XB, respectively. However, there was no difference in total pain pills needed between xylocaine, bupivacaine, and XB when administered with and without thrombin. The addition of topical thrombin to local anesthetic at the end of elective hand surgery provides for sustained postoperative pain control. Patients in this study who received thrombin and local anesthetic before wound closure had lower pain levels and were discharged from the PACU sooner than those who received local anesthetic alone. Therapeutic level 2.

Intravenous regional anesthesia: effect of magnesium using two different routes of administration

Background Magnesium has been reported as an adjuvant to local anesthetics to improve the quality of intravenous regional anesthesia (IVRA); however, different routes of administration have not been compared before. The aim of this study was to compare between the effect of intravenous infusion of magnesium and the effect when it is added to a local anesthetic on the quality of analgesia and opioid consumption during IVRA in patients undergoing hand surgery. Patients and methods Fifty-nine patients undergoing elective hand surgery were randomly allocated to one of three groups: the R group ( n = 20 patients), which received IVRA using ropivacaine 0.2%; the RM group ( n = 20 patients), which received IVRA using ropivacaine 0.2% and magnesium sulfate 10 mg/kg; and the RMV group ( n = 19 patients), which received IVR using ropivacaine 0.2% and a systemic intravenous single dose of magnesium sulfate 30 mg/kg. The primary outcome measure included morphine consumption in the first 24 h andthe secondary outcome measure included onset of both sensory and motor blockade, tourniquet pain, intraoperative fentanyl consumption, and postoperative pain using the Verbal Rating Scale (VRS). Results Onset times of sensory and motor blockades were shorter in the RM group (10.5 ± 4 and 14 ± 5 min) than in the R group (16.5 ± 6 and 21 ± 6 min) and RMV group (16 ± 5.5 and 20.5 ± 5.3 min). Time to first analgesic requirement was significantly longer in the RMV group (98 ± 12 min) than in the R group (70 ± 11 min) and RM group (75 ± 13 min), whereas the 24 h morphine consumption in the RMV group (14.5 ± 8.7 mg) was significantly lower than that in the RM group (25 ± 10 mg)and Rgroup (27 ± 15 mg). Tourniquet discomfort was significantly lower in the RM group [1 (0-2)] than in the R group [2 (1-4)] and RMV group [3 (1-4)]. Intraoperative fentanyl consumption was lower in the RM group (20.5 ± 9) than in the Rgroup (43.8 ± 9) and RMV group (38 ± 15),whereas VRS was significantly lower in the RM Vgroup at 1, 3, 6, and 12 h ( P < 0.05) in comparison with the other groups. Conclusion The addition of magnesium to ropivacine in the IVRA improved the quality of block and reduced the tourniquet discomfort,and the systemic magnesium administration reduced the postoperative pain and morphine consumption.

Median effective target plasma concentration of remifentainil inhibiting body movement evoked by puncture during brachial plexus block in pediatric patients

Objective To determine the median effective target plasma concentration (Cp50) of remifentainil inhibiting body movement evoked by puncture during brachial plexus block in pediatric patients.Methods Pediatric patients of both sexes,aged 5-12 yr,who grown normally,scheduled for elective forearm or hand surgery,were enrolled in this study.Children were premedicated with oral midazolam 0.2 mg/kg at 30 min before anesthesia.The initial target Cp of remifentainil was 5.0 ng/ml.The target Cp was determined by up-and-down sequential method.Each time Cp increased/decreased by 20％ in the next patient depending on the response of the previous patient to puncture.The ratio between the two successive concentrations was 1.2.The puncture was performed after the target effect-site and plasma concentrations were balanced.Body movement was defined as puncture-induced movement of truncus,limbs and/or head and neck.The Cp50 and 95 ％ confidence interval of remifentainil were calculated by Dixon method.Results Cp50 of remifentainil inhibiting body movement evoked by puncture during brachial plexus block was 3.9 ng/ml,and 95 ％ confidence interval was 3.6-4.2 ng/ml.Conclusion Cp50 of remifentainil inhibiting body movement evoked by puncture during brachial plexus block is 3.9 ng/ml in pediatric patients. Key words: Piperidines; Motor activity; Dose-response relationship, drug; Drug delivery systems; Child; Brachial plexus; Nerve block

Three-dimensional assessment of hand outcome.

Patient reported outcome measures are central to National Health Service quality of care assessments. This study investigated the benefit of elective hand surgery by the simultaneous analysis of pain, function and appearance, using a three-dimensional (3D) graphical model for evaluating and presenting outcome. A total of 188 patients scheduled for surgery completed pre- and postoperative questionnaires grading the severity of their pain, dysfunction and deformity of their hand(s). Scores were plotted on a 3D graph to demonstrate the degree of 'normalisation' following surgery. Surgical groups included: nerve compression (n=53), Dupuytren's disease (n=51), trigger finger (n=20), ganglion (n=17) or other lump (n=21), trapeziometacarpal joint osteoarthritis (n=10), rheumatoid disease (n=5) and other pathology (n=13). A significant improvement towards normality was seen after surgery in each group except for patients with rheumatoid disease. This study provides a simple, visual representation of hand surgery outcome by plotting patient scores for pain, function and appearance simultaneously on a 3D graph.

Effect of local application of dexmedetomidine on the medium effective concentration of ropivacaine for brachial plexus block

Objective To investigate effect of local application of dexmedetomidine on the medium effective concentration (EC50) of ropivacaine for brachial plexus block and the mechanism of the analgesic effect induced by dexmedetomidine.Methods Fifty-two ASA Ⅰ or Ⅱ patients of both sexes,aged 18-50 yr,weighing 50-80 kg,scheduled for elective forearm or hand surgery,requiring ultrasound-guided axillary brachial plexus block,were randomly assigned into 2 groups (n =26 each):control group (group C) and dexmedetomidine group (group D).Axillary brachial plexus block was performed using only ropivacaine in group C.In group D the mixture of ropivacaine and 0.8 μg/kg dexmedetomidine was injected for the block.The effective block was defined as complete loss of pain sensation in the brachial plexus distribution.The volume of local anesthetics was 30 ml.The concentration of ropivacaine was determined by up-and-down technique.The initial concentration was 0.5 ％ and the ratio between the two successive concentrations was 1.2.If the block was effective,the next patient received a lower dose of ropivacaine,or if ineffective,a higher dose was given in the next patient.The EC50 and 95 ％ confidence interval of ropivacaine were determined using the Dixon-Massey method.Results The EC50 (95 ％ confidence interval) of ropivacaine was 0.32％ (0.30％-0.33％) in group D and 0.44％ (0.42％-0.46％) in group C.The EC50 of ropivacaine was significantly lower in group D than in group C (P ＜ 0.05).Conclusion Local application of dexmedetomidine can decrease the EC50 of ropivacaine for brachial plexus block guided by ultrasound,indicating that the mechanism of the analgesic effect induced by dexmedetomidine is related to the local anesthetic-like effect. Key words: Dexmedetomidine ; Amides ; Brachial plexus ; Nerve block ; Dose-response relationship, drug

Usefulness of perfusion index to detect the effect of brachial plexus block

The traditional method to evaluate adequacy of the block for surgery is based on loss of sensory response to stimuli, which requires patient cooperation. Several methods have been described for objective assessment of the nerve block. The aim of the study was to investigate whether perfusion index (PI), a measure of peripheral perfusion from a pulse oximetry finger sensor, is a reliable and objective method for assessing the adequacy of infraclavicular blockade and to describe the time course of PI changes once peripheral nerve block has been achieved during surgery. The study was performed on patients scheduled for elective hand, wrist and forearm surgery under infraclavicular brachial plexus block. The pulse oximetry sensor was affixed to a finger ipsilateral to the side of the infraclavicular block for continuous measurement of PI. The average PI and the average percent change in PI from baseline, at 10, 20 and 30 min from the administration of the block were calculated. Baseline values of PI ranged from 0.6 to 4.7 % in 44 patients for whom infraclavicular block was effective and 1.8 to 2.4 % in 2 patients for whom infraclavicular block failed. Differences were not significant (p = 0.60). In the effective infraclavicular block group, PI rose continuously during the 30-min observation period. At 10 min, PI increased by (mean ± standard deviation) 120 ± 119 % from baseline. At 20 and 30 min, perfusion index increased by 133 ± 125 % and 155 ± 144 % from baseline. All changes from baseline were significant (p < 0.01). The perfusion index is a predictor of infraclavicular block success. The largest changes in PI occur 30 min after the block administration but significant changes in PI were detected 10 min after administration. Perfusion index monitoring may provide a highly valuable tool to quickly evaluate the success of regional anesthesia of the upper extremity in clinical practice.

Effect of dexamethasone added to lidocaine in supraclavicular brachial plexus block: A prospective, randomised, double-blind study

Background:Different additives have been used to prolong brachial plexus block. We performed a prospective, randomised, double-blind study to evaluate the effect of dexamethasone added to lidocaine on the onset and duration of supraclavicular brachial plexus block as this is the most common type of brachial block performed in our institute.Methods:Sixty American Society of Anaesthesiologist's physical status I and II patients undergoing elective hand, forearm and elbow surgery under brachial plexus block were randomly allocated to receive either 1.5% lidocaine (7 mg/kg) with adrenaline (1:200,000) and 2 ml of normal saline (group C, n=30) or 1.5% lidocaine (7 mg/kg) with adrenaline (1:200,000) and 2 ml of dexamethasone (8 mg) (group D, n=30). The block was performed using a nerve stimulator. Onset and duration of sensory and motor blockade were assessed. The sensory and motor blockade of radial, median, ulnar and musculocutaneous nerves were evaluated and recorded at 5, 10, 20, 120 min, and at every 30 min thereafter.Results:Two patients were excluded from the study because of block failure. The onset of sensory and motor blockade (13.4±2.8 vs. 16.0±2.3 min and 16.0±2.7 vs. 18.7±2.8 min, respectively) were significantly more rapid in the dexamethasone group than in the control group (P=0.001). The duration of sensory and motor blockade (326±58.6 vs. 159±20.1 and 290.6±52.7 vs. 135.5±20.3 min, respectively) were significantly longer in the dexamethasone group than in the control group (P=0.001).Conclusion:Addition of dexamethasone to 1.5% lidocaine with adrenaline in supraclavicular brachial plexus block speeds the onset and prolongs the duration of sensory and motor blockade.

Persistent Median Artery and Veins in Patients Undergoing Elective Day Case Hand Surgery

Persistent Median Artery and Veins in Patients Undergoing Elective Day Case Hand Surgery

Efficacy of diltiazem as an adjunct to lignocaine in intravenous regional anesthesia

Background:Various adjuncts have been used with lignocaine to decrease tourniquet pain and prolong post-operative analgesia during intravenous regional anesthesia (IVRA). Calcium-channel blockers potentiate the analgesic effect of local anesthetics. This study was designed to evaluate the efficacy of diltiazem as an adjunct to lignocaine in IVRA with respect to tourniquet tolerance, perioperative analgesia, and quality of anesthesia.Methods:In this prospective, randomized, and double-blind study, 40 patients (American Society for Anesthesiologists grade I/II) undergoing elective hand surgery under IVRA were assigned into two groups of 20 each and administered IVRA either with lignocaine 3 mg/kg (group Lignocaine (L)) or lignocaine 3 mg/kg plus diltiazem 0.2 mg/kg (group Lignocaine-Diltiazem (LD)) with normal saline (total volume-40 ml). Hemodynamic parameters, onset of the complete sensory blockade, motor blockade, and intraoperative (tourniquet pain) and post-operative Visual Analogue Scale scores, total intraoperative and consumption of post-operative fentanyl intraoperative were recorded.Results:Sensory block was established in 2.5±0.688 min in group LD verses 5.60±0.851 min in group L. Motor blockade was established in 8.65±0.933 min in group LD and 13.46±0.604 min in group L. The mean VAS scores >3 were attained early at 30 min (3.1±0.912) in group L. Patients in group L requested early rescue analgesic at 30±8.633 min compared with 49.64±7.958 min in group LD.Conclusions:Diltiazem as an adjunct to lignocaine provided enhanced intraoperative and post-operative analgesia without any significant side effects.

Assessing the Impact of Antibiotic Prophylaxis in Outpatient Elective Hand Surgery: A Single-Center, Retrospective Review of 8,850 Cases

Assessing the Impact of Antibiotic Prophylaxis in Outpatient Elective Hand Surgery: A Single-Center, Retrospective Review of 8,850 Cases