Upper Extremity Blocks for Hand Surgeons: A Literature Review of Regional Anaesthesia Techniques, Efficacy, and Safety

Introduction: Regional anaesthesia (RA) techniques have increased in popularity due to evidence of reductions in acute pain, chronic pain, postoperative nausea and vomiting (PONV), and pulmonary complications. While upper extremity blocks (UEBs) have been the subject of several comprehensive reviews, no review to date has synthesised the information on their use in hand surgery. Methods: A search of PUBMED and Cochrane databases was performed to identify the evidence associated with upper extremity blocks. The results of this search and extant literature on UEBs were examined and the relevant information extracted. Results: Supraclavicular block is associated with transient complications such as Horner's syndrome and phrenic nerve palsy, affecting up to 54% and 50% of patients, respectively. The incidence of pneumothorax in supraclavicular blocks is up to 4%. Infraclavicular, interscalene and axillary blocks have a lower rate of all complications, however, each may require a supplementary block at a different anatomical site as each spares significant regions of the upper extremity. Epinephrine in concentrations of 1:100,000-200,000 is safe for use in digital blocks with no association digital gangrene. Current evidence suggests digital blocks are safe and efficacious when appropriately performed. Conclusion: UEBs are safe and may be administered by an anaesthesia provider or an appropriately trained surgeon. The choice of block is contingent on the anatomical location of the surgical procedure, procedure duration, patient preference, patient co-morbidieis, and the surgeon's experience. Most upper extremity surgeries can be performed using RA. Current evidence illustrates outcome benefits for patients, surgeons, and healthcare institutions utilising RA.

Regional versus systemic dexmedetomidine as an adjuvant to lidocaine for intravenous regional anaesthesia in healthy volunteers: a randomized crossover study

BACKGROUND

Dexmedetomidine enhances the quality and duration of lidocaine intravenous regional anaesthesia (IVRA). However, the two administration routes have not been directly compared regarding effects on tourniquet tolerance time with lidocaine IVRA. Additionally, it remains unclear whether the prolonged tourniquet tolerance stems from the direct peripheral action of dexmedetomidine or indirect systemic analgesic effects.

METHODS

We conducted forearm IVRA in 12 healthy volunteers using a crossover design on two separate study days. One day, the systemic dexmedetomidine group received an intravenous infusion of 0.5 μg/kg dexmedetomidine (20 mL) in one arm, followed by 0.5% lidocaine (25 mL) forearm IVRA in the contralateral arm. On the other day, the regional dexmedetomidine group received an intravenous 0.9% saline infusion (20 mL) in one arm, followed by combined 0.5% lidocaine (25 mL) and 0.5 μg/kg dexmedetomidine forearm IVRA in the opposite arm. After a two-week washout period, participants crossed over to receive the alternate treatment. The primary outcome was tourniquet tolerance time, from initiating IVRA until the patient-reported tourniquet pain numerical rating scale exceeded three.

RESULTS

The tourniquet tolerance time was longer with regional versus systemic dexmedetomidine (36.9 ± 7.6 min vs 23.3 ± 6.2 min, respectively), with a 13.6 min mean difference (95% CI: 10.8 to 16.4 min, p < 0.001). Regional dexmedetomidine also hastened sensory onset and extended sensory recovery compared to systemic administration. Delayed sedation after tourniquet release occurred in 5 of 12 subjects receiving regional dexmedetomidine.

CONCLUSION

The addition of regional dexmedetomidine to lidocaine prolonged tourniquet tolerance time in forearm IVRA to a greater extent compared to systemic dexmedetomidine in healthy volunteers.

TRIAL REGISTRATION

Chinese Clinical Trial Registry, ChiCTR2300067978.

Mini-dose Bier's block vs systemic analgesia in distal radius fractures: a promising reduction in emergency department throughput time

Aim: This study compared the effect of the conventional technique of procedural sedation and the mini-dose intravenous regional anesthesia (IVRA). Patients & methods: 45 patients received IVRA, and 47 received iv. ketamine. The pain score, emergency department (ED) length of stay and patients' satisfaction were compared. Results: The study revealed that not only the levels of hemodynamic parameters but also their stability, and the patient's satisfaction in the IVRA group were significantly better. The patients' pain score and ED length of stay were also significantly decreased in those who received IVRA. Conclusion: Mini-dose IVRA technique contributes to better hemodynamic stability, without prominent adverse events, and leads to significant pain control and improved ED throughput time. Clinical Trial Registration: NCT03349216 (ClinicalTrials.gov).

Forearm and Arm Tourniquet Tolerance

In distal upper extremity surgeries, there can be a choice to use an upper arm or forearm tourniquet. This study examines discomfort and tolerance in healthy volunteers to determine whether one is more comfortable.

Single sterile silicon ring technique for utilization of upper limb intravenous regional anesthesia: A prospective study of patients with operated distal radius fractures

INTRODUCTION

Intravenous regional anesthesia is a well-established method of anesthesia in upper extremity surgery. In this study, we present a modification of the technique using a silicon ring tourniquet in 30 patients undergoing internal fixation for distal radius fractures.

METHODS

A sterile silicone ring wrapped within a stockinette sleeve was applied, and a local anesthetic solution (3 mg/kg lidocaine 0,5%) was injected intravenously. After anesthesia onset, the ring was rolled distally to provide immediate pain and discomfort relief.

RESULTS

The silicone ring achieved adequate exsanguination in all patients. Mean pain VAS score was 2.7 ± 0.9 intraoperatively and 4.3 ± 1.3 during the first hour postoperatively. The onset and termination times of sensory block were 5.8 ± 2.1 and 102 ± 7.8 min, and of motor block 13.8 ± 2.8 and 54.2 ± 4.6 min, accordingly. All patients were satisfied from the procedure.

CONCLUSION

Sterile silicone ring tourniquet application is a simple, safe and effective analgesic and anesthetic technique for the operative treatment of distal radius fractures.

The analgesic efficacy of forearm versus upper arm intravenous regional anesthesia (Bier's block): A randomized controlled non-inferiority trial

STUDY OBJECTIVE

This study aimed to assess if a forearm (FA) intravenous regional anesthesia (IVRA) with a lower, less toxic, local anesthetic dosage is non-inferior to an upper arm (UA) IVRA in providing a surgical block in patients undergoing hand and wrist surgery.

DESIGN

Observer-blinded, randomized non-inferiority study.

SETTING

Operating room.

PATIENTS

280 patients undergoing hand surgery were randomly assigned to UA IVRA (n = 140) or FA IVRA (n = 140).

INTERVENTIONS

Forearm IVRA or upper arm IVRA in patients undergoing hand and wrist surgery.

MEASUREMENTS

The primary outcome was block success rate of both techniques. Block success was defined as no need of additional analgesics. A second, alternative non-inferiority outcome was defined as no need of conversion to general anesthesia. A difference in success rate of <5% was considered non-inferior. Secondary endpoints were tourniquet pain measured with a Numerical Rating Scale (0-10), satisfaction of patients and surgeons, onset time, surgical time and total OR time.

MAIN RESULTS

Non-inferiority of block success rate, defined as no need of additional analgesics or conversion to general anesthesia was inconclusive (5.24%, 95% CI:-4.34%,+14.82%). Non-inferiority of no need of conversion to general anesthesia was confirmed (+0.73%, 95% CI:-0.69%,+2.15%). No differences were observed in onset time (FA: 5 (5, 8) vs UA: 6 (5, 7) min, p = 0.74), surgical time (FA: 8 (5, 12) vs UA: 7 (5, 11) min, p = 0.71), nor total OR stay time (FA: 34 (27, 41) vs UA: 35 (32, 39) min, p = 0.09). Tourniquet pain after 10 min was significantly lower after FA IVRA compared to UA IVRA (FA: 2.00 (0.00, 4.00) vs UA: 3.00 (1.00,5.00) min, p = 0.003).

CONCLUSION

We failed to demonstrate non-inferiority of forearm IVRA with a lower dosage of LA in providing a surgical block without rescue opioids and LA. Non-inferiority of no need of conversion to general anesthesia was confirmed.

The effect of wide-awake anesthesia, intravenous regional anesthesia, and infraclavicular brachial plexus block on cost and clinical scores of patients undergoing hand surgery

The aim of our study was to compare the clinical results and costs of wide-awake local anesthesia no tourniquet (WALANT), intravenous regional anesthesia (IVRA), and infraclavicular brachial plexus block (IC-BPB). The patients were divided into WALANT, IVRA, IC-BPB groups, each with 50 patients. Demographic information, induction time, use of sedation, number of patients who were converted to general anesthesia, time in postanesthesia care unit (PACU), amount of bleeding during surgery, presence of tourniquet pain, hand motor function during surgery, time to onset of postanesthesia pain, discharge time, complications, and anesthesia costs were compared. Sedation was given to 12 IC-BPB patients, 9 IVRA patients and 5 WALANT patients. Of these patients, 6 undergoing IC-BPB, 5 undergoing IVRA and 4 undergoing WALANT were converted to general anesthesia (p = 0.80). PACU time and anesthesia costs were the least in the WALANT group, followed by the IVRA group (p < 0.001, p < 0.001). Intraoperative active voluntary movements were best preserved in the WALANT group; however, bleeding was highest in the WALANT group (p < 0.001, p < 0.001). Tourniquet pain was the higher in the IVRA groups, while postoperative pain in the surgical area developed the fastest in this same group (p = 0.029, p < 0.001). Time to discharge was similar in WALANT and IVRA groups, and the longest in the IC-BPB (p < 0.001) group. There was no difference among the groups in terms of patient satisfaction (p = 0.085, p = 0.242 for the first and second survey question). In the current study, WALANT appears to be a suitable alternative to IVRA and IC-BPB methods, with better preservation of active intraoperative movement, lower cost, and shorter time spent in PACU at the expense of higher bleeding.

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.

Comparison of lidocaine–dexmedetomidine and lidocaine–saline on the characteristics of the modified forearm bier block: A clinical trial

Background and Aims:

Forearm Modified Bier Block (FMBB) reduces local anesthetic systemic toxicity risks compared to the traditional method. This study was designed and implemented to compare the effects of lidocaine–dexmedetomidine (LD) and lidocaine–saline (LS) on the characteristics of the MFBB in distal forearm and hand surgery.

Material and Methods:

In this randomized double-blind trial, which was conducted after obtaining institutional ethical committee approval, 60 patients were enrolled and randomly divided into two groups. In both groups, the analgesic base of the block was 20 mL lidocaine 0.5% that was supplemented by 1 μg/kg dexmedetomidine in the LD group or 1 mL of 0.9% saline in the LS group. Patients were evaluated for the onset and duration of sensory block, time of the first request for postoperative analgesic, and analgesic request frequency during the first 24 h after surgery.

Results:

Sensory block onset in the LD group (7.1 ± 1.4 min) compared to the LS group (8.4 ± 1.4) was faster (P = 0.008). Duration of the sensory block in LD group (49.7 ± 7.2 min) was longer than LS group (33.3 ± 2.6) (P < 0.001). Compared to LS group, time of the first request for postoperative analgesic in LD group was later (P = 0.6), and had lesser analgesic requests during the first 24 h after surgery (P < 0.001).

Conclusion:

Based on our study’s finding, adding dexmedetomidine to lidocaine in the MFBB increases the duration of sensory block.

WALANT versus intravenous regional anesthesia for carpal tunnel syndrome: a randomized clinical trial

BACKGROUND

There are several anesthetic techniques for surgical treatment of carpal tunnel syndrome (CTS). Results from this surgery using the "wide awake local anesthesia no tourniquet" (WALANT) technique have been described. However, there is no conclusive evidence regarding the effectiveness of the WALANT technique, compared with the usual techniques.

OBJECTIVE

To evaluate the effectiveness of the WALANT technique, compared with intravenous regional anesthesia (IVRA; Bier's block), for surgical treatment of CTS.

DESIGN AND SETTING

Randomized clinical trial, conducted at Hospital Alvorada Moema and the Discipline of Hand Surgery, Universidade Federal de São Paulo (UNIFESP), São Paulo (SP), Brazil.

METHODS

Seventy-eight patients were included. The primary outcome was measurement of perioperative pain through a visual analogue scale (VAS). The secondary outcomes were the Boston Questionnaire score, Hospital Anxiety and Depression Scale (HADS) score, need for use of analgesics, operating room times, remission of paresthesia, failures and complications.

RESULTS

The WALANT technique (n = 40) proved to be superior to IVRA (n = 38), especially for controlling intraoperative pain (0.11 versus 3.7 cm; P < 0.001) and postoperative pain (0.6 versus 3.9 cm; P < 0.001). Patients spent more time in the operating room in the IVRA group (59.5 versus 46 minutes; P < 0.01) and needed to use more analgesics (10.8 versus 5.7 dipyrone tablets; P = 0.02). Five IVRA procedures failed (5 versus 0; P = 0.06).

CONCLUSIONS

The WALANT technique is more effective than IVRA for CTS surgery.

Intravenous Regional Anesthesia Using a Forearm Tourniquet: A Safe and Effective Technique for Outpatient Hand Procedures

Background: Bier block provides anesthesia of an entire extremity distal to the tourniquet without necessitating direct injection at the surgical site. This avoids obscuring anatomy with local anesthetic and anesthetizes a wide area, allowing for multiple procedures and incisions. We hypothesize that a low-volume Bier block with forearm tourniquet, rather than a traditional brachial tourniquet, is a safe, well-tolerated, and effective anesthesia technique. Methods: All cases in which adult patients underwent hand procedures using Bier block anesthesia by a single surgeon over a 4-year period were reviewed. Data collected included patient demographics, procedure(s) performed, complications, tourniquet time and settings, procedure and in-room time, and supplemental medications administered. Results: In all, 319 patients were included, 103 from a university hospital and 216 from an ambulatory surgery center. The most commonly performed procedures were carpal tunnel release (205 cases) and trigger digit release (83 cases). Most patients received a 125-mg dose of lidocaine for the Bier block; many also received additional sedatives. Twenty-three patients received no additional medications. No patients required conversion to general anesthesia. One complication (0.3%) occurred, with paresthesias and tinnitus that resolved without intervention. The average tourniquet time was 24 minutes (SD = 4.3 minutes). Patients were discharged at a median of 49 minutes postoperatively, and 9.1% of patients received supplemental analgesics prior to discharge. Conclusions: Regional anesthesia achieved with a forearm tourniquet and intravenous local anesthetic provides adequate pain control, permits timely discharge home, and has a low complication rate. It should be considered for use in outpatient hand procedures.

Opioid-Sparing Pain Management in Upper Extremity Surgery: Part 1: Role of the Surgeon and Anesthesiologist

A multimodal pain management strategy combines complementary medications and techniques, targeting unique pathways, to improve overall analgesic effect and reduce opioid requirements. In this 2-part review, we examine the literature identifying nonopioid analgesic modalities and their targets in the pain pathway as well as anesthetic techniques found to be opioid-sparing in the practice of upper extremity surgery. First, we focus on operative anesthesia and analgesia and areas for future research specific to upper extremity surgery. In part 2, we discuss the nonopioid options available after surgery.

The analgesic efficacy of intravenous regional anesthesia with a forearm versus conventional upper arm tourniquet: a systematic review

Background

The main objective of this review is to perform a systematic review and meta-analysis of the existing evidence related to the analgesic efficacy with the use of conventional, upper arm intravenous regional anesthesia (IVRA) as compared to a modified, forearm IVRA in adult patients undergoing procedures on the distal upper extremity.

Methods

MEDLINE, EMBASE and CENTRAL (Cochrane) databases were searched for randomized controlled trials published in English, French, Dutch, German or Spanish language. Primary outcomes of interest including description of quality level of anesthesia and onset of sensory block were assessed for this review. Dosage of the local anesthetic, local anesthetic toxicity and need for sedation due to tourniquet pain were considered as secondary outcomes.

Results

Our literature search yielded 3 papers for qualitative synthesis. Four other articles were added into a parallel analysis of 7 reports that provided data on the incidence of complications and success rate after forearm IVRA. Forearm IVRA was found to be as efficient as upper arm IVRA (RR = 0.98 [0.93, 1.05], P = 0.78), but comes with the advantage of a lower need for sedation due to less tourniquet pain.

Conclusion

Our results demonstrate that forearm IVRA is as effective in providing a surgical block as compared to a conventional upper arm IVRA, even with a reduced, non-toxic dosage of local anesthetic. No severe complications were associated with the use of a forearm IVRA. Other benefits of the modified technique include a faster onset of sensory block, better tourniquet tolerance and a dryer surgical field.

Registration of the systematic review

A review protocol was published in the PROSPERO register in November 2015 with registration number CRD42015029536.

Evaluation of intravenous regional anaesthesia and four-point nerve block efficacy in the distal hind limb of dairy cows

Background

Intravenous regional anaesthesia (IVRA) and hindfoot four-point nerve block anaesthesia (NBA) are recommended for local anaesthesia (LA) in the distal limb of dairy cows. Two studies were conducted to compare the efficacy, time until onset and stress responses to IVRA and NBA in dairy cows. In the first cross-over designed study, eight healthy unsedated German Holstein cows, restrained in lateral recumbency (LR) on a surgical tipping table, were treated with IVRA and NBA using procaine 2% as a local anaesthetic. Distal limb desensitization was tested by electrical (e-), mechanical (m-) and thermal (t-) nociceptive stimulation 10 min before and 15 and 30 min after LA. Hormonal-metabolic (blood concentrations of cortisol, lactate, non-esterified fatty acids, and glucose) and cardio-respiratory (heart and respiratory rate, mean arterial blood pressure) stress responses to treatment were assessed at predetermined intervals. In the second study, six healthy, unsedated German Holstein cows in LR were treated (crossover design) with IVRA and NBA. Short-interval e-stimulation was measured by the time until complete distal limb desensitization.

Results

In the first study, four of eight cows responded to e-stimulation 15 min after IVRA, while none of the cows treated with NBA responded until the safety cut-off level was reached. E-stimulation revealed complete desensitization of the distal limb 30 min after LA in all cows. Half of the cows did not respond to m- and t-stimulation before LA, so no further evaluation was performed. Stress reactions to IVRA and NBA treatment were similar, but differences may have been masked by stress response to LR restraint. In the second study, complete desensitization was achieved 12.5 min after NBA, while one of the six cows still responded to e-stimulation 20 min after IVRA.

Conclusion

Hindfoot nerve block anaesthesia and intravenous regional anaesthesia induced complete desensitization of the distal hind limb in dairy cows. However, the anaesthesia onset after NBA was significantly faster than that of IVRA, which may be clinically relevant in the field, particularly when distal limb anaesthesia is required for major claw surgeries under time constraints.

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.

Simple Arm Tourniquet as an Adjunct to Double-Cuff Tourniquet in Intravenous Regional Anesthesia

BACKGROUND

Intravenous Regional Anesthesia (IVRA) is a well-known technique for producing analgesia during surgical procedures in the extremities. However, the rapid onset of pain following the deflation of a double-cuff tourniquet during IVRA is a serious disadvantage, leading patient suffering.

OBJECTIVES

The aim of this study was to evaluate the clinical effectiveness of a pneumatic arm tourniquet applied 2 cm above the double-cuff tourniquet in controlling the pain that occurs after its deflation.

PATIENTS AND METHODS

Twenty patients undergoing outpatient hand surgery were operated on under IVRA, using 40 - 50 mL of a solution containing 3 mg/kg of lignocaine. A simple pneumatic tourniquet was applied proximal to the double-cuff tourniquet, 3 min before its deflation, while the procedure was being conducted. The severity of pain on the basis of the Numerical Rating Scale (NRS) was assessed throughout the operation, and continued until an hour after the double-cuff tourniquet was removed.

RESULTS

The mean operation time after the deflation of the double-cuff tourniquet was 20.12 ± 6.1 minutes. Moreover, the mean NRS for the post-deflation time was insignificant (NRS = 2), and only one patient during first 20 minutes received opioids.

CONCLUSIONS

This study showed that a pneumatic arm tourniquet as an adjunct to IVRA provides acceptable analgesia following the deflation of the double- cuff tourniquet for relieving surgical pain.

Pain management strategies in hand surgery

Modern anesthetic agents have allowed for the rapid expansion of ambulatory surgery, particularly in hand surgery. The choice between general anesthesia, peripheral regional blocks, regional intravenous anesthesia (Bier block), local block with sedation, and the recently popularized wide-awake hand surgery depends on several variables, including the type and duration of the procedure and patient characteristics, coexisting conditions, location, and expected length of the procedure. This article discusses the various perioperative and postoperative analgesic options to optimize the hand surgical patients' experience.