The Quality of Recovery of Local Anesthesia With Minimal Sedation and Brachial Plexus Block in Hand Surgery: A Randomized Controlled Study

In many hospitals, the widely-accepted benefits of local anesthesia have moved minor hand operations such as carpal tunnel and trigger finger release outside of the main operating room. The proven benefits of local anesthesia include increased efficiency, convenience and patient comfort, reduced costs, lack of pre-operative tests, and decreased operative time. Multiple complex hand operations have been described using lidocaine and epinephrine only, with the patient wide awake during surgery. These include K-wire fixation, flexor tendon repair, tendon transfers, and tendon grafting. For those unfamiliar with this technique, the main concerns are that it is poorly tolerated, does not prevent patient movement, and inadequately controls post-operative pain, which all negatively influence a surgeon's comfort and adoption of this technique. Thus, despite its many advantages, local anesthesia in complex hand surgery is still not widely practiced in North America.

Alternatively, the brachial plexus block is a common method of regional anesthesia used in hand surgery, consisting of anesthetizing the entire upper limb via local anesthesia infiltration of the brachial plexus. This reliable sensorimotor blockade is performed under ultrasound guidance by an anesthesiologist approximately 30 minutes prior to surgery. Although safe and effective to use, its long duration of action, increased need for operating room resources, and unpleasant sensation of a flaccid and insensate upper extremity has prompted research into alternative ultrasound-guided nerve blocks in hand surgery.

Despite prior published data on the use of local anesthesia with epinephrine and brachial plexus blocks in hand surgery, there is a paucity of randomized-controlled, prospective, patient-reported outcome studies comparing these two methods of anesthesia. This study aims to capture patient-reported quality of recovery using a validated, psychometrically tested questionnaire, the Quality-of-Recovery 15. A recent systematic review of the measurement properties of QoR-15 showed good content validity and internal consistency, and concluded that it fulfills requirements for outcome measurement instruments in clinical trials.

Preliminary data was obtained from a pilot study of 11 hand surgery patients who underwent a brachial plexus block and were called 24 hours after surgery to answer the QoR-15 questionnaire. The computed mean QoR score was 118/150 +/- 15, consistent with values reported in the literature. This pilot study allowed for the calculation of a projected sample size for this study, outlined below.

This is a prospective single institution randomized controlled study taking place at the Montreal General Hospital, in Montreal, Canada. The institution is a level I trauma center which performs a minimum of 250 upper extremity surgeries yearly. The study participants are trauma or elective hand surgery patients above 18 years undergoing surgery less than 2 hours in duration distal to the carpal bones.