Distal peripheral nerve blockade for patients undergoing hand surgery: a pilot study

A Comparison of Distal Nerve Blocks and Brachial Plexus Blocks in Terms of Block Success, Block-related Characteristics, Time to Discharge and Patient Satisfaction

Background: Ultrasound-guided brachial plexus blocks (BPB) are used as an anaesthetic method in hand and wrist surgeries. The radial, median and ulnar nerves can also be selectively blocked. The objective of this retrospective cohort study was to compare distal nerve blocks (DNB) and BPB in terms of block success, block-related characteristics, time to discharge and patient satisfaction. Methods: The data of patients who underwent elective hand and wrist surgery under regional anaesthetic procedures between 01.01.2022 and 01.09.2022 were analysed. Standard multimodal analgesia was performed in all groups, in addition to either ultrasound-guided BPB or DNB. Demographic characteristics, American Society of Anaesthesiology (ASA) classes, presence of additional diseases, block and volume applied, block-related data such as block performance time, onset time, initial analgesia times, perioperative additional anaesthetic or analgesic requirement, surgery times, types of surgery, discharge times and the presence of additional complaints were recorded. In addition, the anaesthesia quality score were determined using a 5-point Likert scale. Results: There was no difference between demographic data. Average surgical time was similar between the DNB and BPB groups (46.0 ± 8.92 vs. 59.95 ± 22.04 min, p < 0.05). Block onset time was significantly lower in the DNB group (26.4 ± 2.73 vs. 32.17 ± 2.94 min, p < 0.001). When patients discharged before and after 12 hours were compared, 11/22 of the patients in the DNB group and 4/23 of the patients in the BPB group were discharged in the first 12 hours (p < 0.05). Patient satisfaction scores were similar between groups (14.22 ± 0.86 vs. 13.65 ± 1.11, p > 0.05). Conclusions: In surgeries of the hand and wrist, the radial, median and ulnar nerves can be used individually or in combination as an alternative to proximal BPB. Level of Evidence: Level III (Therapeutic).

Efficacy of ultrasound-guided forearm nerve block versus forearm intravenous regional anaesthesia in patients undergoing carpal tunnel release: A randomized controlled trial

Background and objectives

Distal upper extremity surgery is commonly performed under regional anaesthesia, including intravenous regional anaesthesia (IVRA) and ultrasound-guided forearm nerve block. This study aimed to investigate if ultrasound-guided forearm nerve block is superior to forearm IVRA in producing a surgical block in patients undergoing carpal tunnel release.

Methods

In this observer-blinded, randomized controlled superiority trial, 100 patients undergoing carpal tunnel release were randomized to receive ultrasound-guided forearm nerve block (n = 50) or forearm IVRA (n = 50). The primary outcome was anaesthetic efficacy evaluated by classifying the blocks as complete vs incomplete. Complete anaesthesia was defined as total sensory block, incomplete anaesthesia as mild pain requiring more analgesics or need of general anaesthesia. Pain intensity on a numeric rating scale (0–10) was recorded. Surgeon satisfaction with hemostasis, surgical time, and OR stay time were recorded. Patient satisfaction with the quality of the block was assessed at POD 1.

Results

In total, 43 (86%) of the forearm nerve blocks were evaluated as complete, compared to 33 (66%) of the forearm IVRA (p = 0.019). After the forearm nerve block, pain intensity was lower at discharge (-1.76 points lower, 95% CI (-2.92, -0.59), p = 0.0006) compared to patients treated with forearm IVRA. No differences in pain experienced at the start of the surgery, during surgery, and at POD1, nor in surgical time or total OR stay were observed between groups. Surgeon (p = 0.0016) and patient satisfaction (p = 0.0023) were slightly higher after forearm nerve block.

Conclusion

An ultrasound-guided forearm nerve block is superior compared to forearm IVRA in providing a surgical block in patients undergoing carpal tunnel release.

Trial registration

This trial was registered as NCT03411551.

Low-concentration distal nerve blocks with 0.125% levobupivacaine versus systemic analgesia for ambulatory trapeziectomy performed under axillary block: a randomized controlled trial

BACKGROUND

Trapeziectomy is one of the most painful procedures in ambulatory surgery. This prospective randomized trial aimed to compare postoperative pain control using distal peripheral nerve blocks (dPNB) with a low concentration of a long-acting local anesthetic versus conventional systemic analgesia.

METHODS

Fifty-two patients undergoing trapeziectomy were randomized to receive levobupivacaine 0.125% 5 mL on radial and median nerves at the elbow (dNB group), or not to receive these blocks (control group). In both groups, surgery was performed under axillary block (mepivacaine 1% 20 mL) and the same analgesic regimen was prescribed at discharge. The primary outcome was postoperative pain at 24 and 48 hours after surgery and maximum pain score on the first and second postoperative day. Secondary outcomes were duration of dPNB, rescue analgesia requirements, opioid-related side effects, consumption and effectiveness of antiemetic therapy, and upper limb motor block.

RESULTS

Fifty patients were analyzed. Maximum pain intensity was moderate to severe (dPNB vs. control) in 33.3% vs. 92.3% (P=0.002) on the first day after surgery and 20.8% vs. 80.8% (P<0.001) on the second day. The average duration of analgesia after dPNB was 10 hours and no patient reported motor block. dPNB reduced rescue analgesia requirements and the incidence of postoperative nausea and vomiting (PONV).

CONCLUSIONS

dPNB on target nerves provided better analgesia than systemic analgesia after trapeziectomy performed under axillary block. Opioid consumption and the incidence of PONV were lower in the dPNB group.

Can We Perform Distal Nerve Block Instead of Brachial Plexus Nerve Block Under Ultrasound Guidance for Hand Surgery?

OBJECTIVE

Distal nerve blocks are used in the event of unsuccessful blocks as rescue techniques. The primary purpose of this study was to determine the sufficiency for anesthesia of distal nerve block without the need for deep sedation or general anesthesia. The secondary purpose was to compare block performance times, block onset times, and patient and surgeon satisfaction.

MATERIALS AND METHODS

Patients who underwent hand surgery associated with the innervation area of the radial and median nerves were included in the study. Thirty-four patients who were 18-65 years old and American Society of Anesthesiologists grade I-III and who were scheduled for elective hand surgery under conscious nerve block anesthesia were randomly included in an infraclavicular block group (Group I, n=17) or a radial plus median block group (Group RM, n=17). The block performance time, block onset time, satisfaction of the patient and surgeon, and number of fentanyl administrations were recorded.

RESULTS

The numbers of patients who needed fentanyl administration and conversion to general anesthesia were the same in Group I and Group RM and there was no statistically significant difference (p>0.05). The demographics, surgery times, tourniquet times, block perfomance times, and patient and surgeon satisfaction of the groups were similar and there were no statistically significant differences (p>0.05). There was a statistically significant difference in block onset times between the groups (p<0.05).

CONCLUSIONS

Conscious hand surgery can be performed under distal nerve block anesthesia safely and successfully.

Evaluation and Management of Sleep Disorders in the Hand Surgery Patient

Despite posing a significant public health threat, sleep disorders remain poorly understood and often underdiagnosed and mismanaged. Although sleep disorders are seemingly unrelated, hand surgeons should be mindful of these because numerous conditions of the upper extremity have known associations with sleep disturbances that can adversely affect patient function and satisfaction. In addition, patients with sleep disorders are at significantly higher risk for severe, even life-threatening medical comorbidities, further amplifying the role of hand surgeons in the recognition of this condition.

Distal Peripheral Nerve Blocks in the Forearm as an Alternative to Proximal Brachial Plexus Blockade in Patients Undergoing Hand Surgery: A Prospective and Randomized Pilot Study

PURPOSE

Limited data exist regarding the role of perineural blockade of the distal median, ulnar, and radial nerves as a primary anesthetic in patients undergoing hand surgery. We conducted a prospective and randomized pilot study to compare these techniques to brachial plexus blocks as a primary anesthetic in this patient population.

METHODS

Sixty patients scheduled for hand surgery were randomized to receive either an ultrasound-guided supraclavicular, infraclavicular, or axillary nerve block (brachial plexus blocks) or ultrasound-guided median, ulnar, and radial nerve blocks performed at the level of the mid to proximal forearm (forearm blocks). The ability to undergo surgery without analgesic or local anesthetic supplementation was the primary outcome. Block procedure times, postanesthesia care unit length of stay, instances of nausea/vomiting, and need for narcotic administration were also assessed.

RESULTS

The 2 groups were similar in terms of the need for conversion to general anesthesia or analgesic or local anesthetic supplementation, with only 1 patient in the forearm block group and 2 in the brachial plexus block group requiring local anesthetic supplementation or conversion to general anesthesia. Similar durations in surgical and tourniquet times were also observed. Both groups reported similarly low numerical rating scale pain scores as well as the need for postoperative analgesic administration (2 patients in the forearm block group and 1 in the brachial plexus block group reported numerical rating scale pain scores > 0 and required opioid administration in the postanesthesia care unit). Block procedure characteristics were similar between the 2 groups.

CONCLUSIONS

Forearm blocks may be used as a primary anesthetic in patients undergoing hand surgery. Further research is warranted to determine the appropriateness of these techniques in patients undergoing surgery in the thumb or proximal to the hand.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic II.

Perineural Liposomal Bupivacaine for Postoperative Pain Control in Patients Undergoing Upper Extremity Orthopedic Surgery: A Prospective and Randomized Pilot Study

BACKGROUND

Upper extremity surgery is commonly performed in the ambulatory setting and is associated with moderate to severe postoperative pain.

METHODS

Patients scheduled for upper extremity orthopedic surgery with a peripheral nerve block were randomized to receive either an ultrasound-guided single-injection supraclavicular block or ultrasound-guided median, ulnar, and radial nerve blocks (forearm blocks) performed at the level of the mid to proximal forearm with liposomal bupivacaine (Exparel) combined with a short-acting supraclavicular block. A sham block was performed in an attempt to blind enrollees in the control group. We administered the EuroQol 5D-5L questionnaire preoperatively and on postoperative days 1-3 and considered the results the primary outcome of our investigation. Block procedure times, postanesthesia care unit (PACU) length of stay, instances of nausea/vomiting, need for narcotic administration, and patient satisfaction were also assessed.

RESULTS

We observed no significant differences in postoperative EuroQol scores between the 2 groups and no significant differences in patient demographics, PACU length of stay, or side effects in the PACU. In some instances, the short-acting supraclavicular block resolved in the PACU, and these patients reported higher pain scores and required titration of analgesics prior to discharge.

CONCLUSION

Larger prospective studies are needed to determine the safety and efficacy of liposomal bupivacaine in patients undergoing upper extremity surgery. Liposomal bupivacaine is currently only approved for local anesthetic infiltration use.