A comparison of infraclavicular nerve block versus general anesthesia for hand and wrist day-case surgeries.
BACKGROUND
General anesthesia (GA) and brachial plexus block have been used successfully for surgery on the upper extremities. Controversy exists as to which method is more suitable in outpatients undergoing hand and wrist surgery. The authors hypothesized that infraclavicular brachial plexus block (INB) performed with a short-acting local anesthetic would result in shorter time to discharge home as compared with "fast-track" GA.


METHODS
After obtaining written informed consent, 52 patients (aged 18-65 yr, American Society of Anesthesiologists physical status I-III) were randomly assigned to receive either an INB or GA under standardized protocols (INB = 3% 2-chloroprocaine + HCO3 + epinephrine 1:300000, followed by propofol sedation; GA = 12.5 mg dolasetron, propofol induction, followed by laryngeal mask airway insertion and desflurane for maintenance; 0.25% bupivacaine for wound infiltration). At the conclusion of the procedure, nurses blinded to the study goals and the anesthetic technique used a modified Aldrete score to decide whether patients could bypass the postanesthesia care unit. Additional data were collected regarding time to postoperative pain, ambulation, home readiness, and incidence of adverse events.


RESULTS
More patients in the INB group (79%) met the criteria to bypass the postanesthesia care unit compared with patients in the GA group (25%; P < 0.001). Compared with patients in the GA group, fewer patients in the INB group had pain (visual analog scale score > 3) on arrival to the postanesthesia care unit (3% vs. 43%; P < 0.001). None of the patients in the INB group requested treatment for pain while in the hospital, compared with 48% of patients in the GA group (P < 0.001). Patients in the INB group were able to ambulate earlier (82 +/- 41 min) compared with those in the GA group (145 +/- 70 min; P < 0.001). Time to home readiness and discharge times were shorter for patients in the INB group (100 +/- 44 and 121 +/- 37 min) compared with those in the GA group (203 +/- 91 and 218 +/- 93 min; P < 0.001). Adverse events (e.g., nausea, vomiting, sore throat) occurred less frequently in patients undergoing INB as compared with those undergoing GA.


CONCLUSIONS
Infraclavicular brachial plexus block with a short-acting local anesthetic was associated with time-efficient anesthesia, faster recovery, fewer adverse events, better analgesia, and greater patient acceptance than GA followed by wound infiltration with a local anesthetic in outpatients undergoing hand and wrist surgery.
Hadzic
Admir
A
Department of Anesthesiology, St Luke's-Roosevelt Hospital Center, College of Physicians and Surgeons of Columbia University, New York, New York 10025, USA. ah149@columbia.edu
Arliss
Jeffrey
J
Kerimoglu
Beklen
B
Karaca
Pelin Emine
PE
Yufa
Marina
M
Claudio
Richard E
RE
Vloka
Jerry D
JD
Rosenquist
Richard
R
Santos
Alan C
AC
Thys
Daniel M
DM
D000293:Adolescent; D000328:Adult; D000368:Aged; D000556:Ambulatory Surgical Procedures; D000700:Analgesics / Q000008:administration & dosage / Q000627:therapeutic use; D000762:Anesthesia Recovery Period; D000768:Anesthesia, General / Q000009:adverse effects; D000779:Anesthetics, Local; D001917:Brachial Plexus; D005260:Female; D006225:Hand / Q000601:surgery*; D006801:Humans; D008297:Male; D008875:Middle Aged; D009407:Nerve Block / Q000009:adverse effects; D019637:Orthopedic Procedures; D010149:Postoperative Pain / Q000188:drug therapy / Q000453:epidemiology; D010351:Patient Discharge; D017060:Patient Satisfaction; D011183:Postoperative Complications / Q000453:epidemiology; D013997:Time Factors; D014953:Wrist / Q000601:surgery*
D000700:Analgesics; D000779:Anesthetics, Local