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Canadian Journal of Anesthesia 51:41-44 (2004)
© Canadian Anesthesiologists' Society, 2004
Regional Anesthesia and Pain

Brachial plexus anesthesia compared to general anesthesia when a block room is available

[L’anesthésie du plexus brachial comparée à l’anesthésie générale quand une salle de bloc est disponible]

Kevin P.J. Armstrong, MD and Richard A. Cherry, MD

From the Department of Anesthesia and Perioperative Medicine, University of Western Ontario, London, Ontario, Canada.

Address correspondence to: Dr. Kevin P.J. Armstrong, Department of Anesthesia and Perioperative Medicine, University of Western Ontario, St. Joseph’s Health Care London, 268 Grosvenor St., London, Ontario N6A 2V4, Canada. Phone: 519-646-6100; Fax: 519-646-6116; E-mail: Kevin.Armstrong2{at}sympatico.ca


   Abstract
TOP
 Abstract
Introduction
 Methods
 Results
 Discussion
 References
 
Purpose: Regional anesthesia is often felt to be beneficial to patient care but detrimental to operating room (OR) efficiency. In this report we compare how a block room (BR) affects OR time (ORT) utilization for brachial plexus anesthesia (BPA) in a busy upper limb practice. We also compare how anesthetic technique, BPA or general anesthesia (GA), impacts on the time to recovery and discharge in patients having outpatient upper limb surgery.

Methods: With the Ethics Committee’s approval, a prospective study using hospital databases was undertaken. All patients presenting for surgery on the upper limb between November 1999 and April 2000 were eligible for analysis. A comparison was made of the various time intervals that comprise a patient’s hospital stay for either GA or BPA. Demographic data (ASA, age, outpatient status), and location of BPA were analyzed.

Results: Use of the BR for BPA significantly reduced the pre-procedure anesthesia ORT when compared to BPA done in the OR (11.4 vs 32.9 min, P < 0.05; GA pre-procedure time was 17.8 min). In the ambulatory patient, BPA alone reduced post procedure anesthesia ORT, postanesthetic care unit, surgical day care unit, and total hospital times when compared to those receiving GA. On average those receiving a BPA spent 1.5 hr less in hospital (P < 0.01). Additionally, fewer admissions (2.4 vs 5.4%) occurred in the BPA group.

Conclusion: The use of a BR reduces the anesthesia ORT associated with BPA. Secondly, BPA improves the recovery time phase of outpatients undergoing surgery on the upper limb.


   Introduction
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 Abstract
 Introduction
Methods
 Results
 Discussion
 References
 
BRACHIAL plexus anesthesia (BPA) is a technique well suited to surgical procedures for the upper limb. Side effects associated with general anesthetics (GA), namely nausea, vomiting, sedation and poor pain control1 are possibly reduced with regional anesthesia (RA).2 The use of BPA is highly variable and is often specific to the institution or anesthesiologist. Inefficient use of operating room time (ORT) is often cited as a reason for avoiding this mode of anesthesia. In this report we illustrate how the use of BPA with a block room (BR) reduces anesthesia ORT use. We also compare the recovery times for patients receiving GA or BPA.


   Methods
TOP
 Abstract
 Introduction
 Methods
Results
 Discussion
 References
 
With the Ethics Committee’s approval, a prospective, six-month study was carried out. Neither randomization nor blinding of patients was attempted. A Canadian, academic, combined plastic/orthopedic practice at St Joseph’s Health Care London (SJHC) was the lone site. This service performs approximately 2,500 upper extremity operations annually. Electronic OR records were generated (Surgi-Server 2000, HBOC Serving Software Group Minneapolis, MN, USA) at the time of surgery. Prior to commencement of data collection specific RA data pages were developed. Primary data included age, American Society of Anesthesiologists (ASA) physical status, BPA technique, BPA start and stop time, BR entry, BR exit, OR entry, procedure start, procedure end, OR exit, postanesthetic care unit (PACU) entry, and PACU exit. Time intervals, which comprise the perioperative time course, were then calculated (time in the BR, time to perform the BPA, pre-procedure anesthesia ORT, procedure time and postprocedure anesthesia ORT). Patients "fast tracked" (BPA only) directly to surgical day care unit (SDCU) were identified. Secondary data included the anesthesiologist, in/out patient status, and delay codes if any. Hospital length of stay (LOS) was determined through examination of health records data. Hospital stay was divided into three phases: 1) the preparation phase (admission to procedure start); 2) the procedure; and 3) the recovery phase (procedure end to discharge from PACU or SDCU).

Database records were checked electronically for breach of case eligibility (procedure codes and text scans of procedure descriptive fields), case duplication, omission of key fields, and incongruent time entries. Outpatients admitted to the hospital or those with a protracted LOS had their chart reviewed to ascertain the reason for admission or to ensure accuracy of time entries.

Between November 1999 and April 2000 all cases performed by any of nine surgeons, and of a specific procedure type, were considered eligible for analysis. These included procedures on the shoulder, humerus, elbow, forearm, wrist and hand. Intravenous RA, monitored anesthesia care, or purely local anesthesia cases were excluded. Cases outside regular hours were included.

Choice of anesthesia for each patient was entirely at the discretion of the attending anesthesiologist. There was no standardization of BPA or GA technique. BPA occurred in the BR or OR based on availability of the patient, house staff, and nursing staff. Each bay of the BR has monitoring capabilities [blood pressure, electrocardiogram, O2Sat]. Supplementary oxygen is available, as is resuscitation equipment and drugs. This BR also serves as a staging area for patients undergoing ophthalmologic procedures as well as other RA activity.

Statistical analysis
Groups were analyzed with t test where appropriate. In the absence of homoscedacity among groups, non-parametric testing (Kruskal-Wallis) was used with post hoc testing (Wilcoxon) to determine statistical difference between multiple groups. A P value of 0.05 was considered to be significant.


   Results
TOP
 Abstract
 Introduction
 Methods
 Results
Discussion
 References
 
Of the 1,023 cases identified as valid for analysis, 319 (31.2%) received a BPA. 16.6% (173) of these were performed under BPA alone while 14.3% (146) had a combined BPA/GA technique. GA accounted for 69.4% of cases. Outpatients represented 75.1% of the BPA group, 45.9% of the GA and 40.4 of the BPA/GA group. BPA technique consisted of an axillary or interscalene block.

Perioperative time course
Anesthesia ORT (pre-procedure, postprocedure and total) as well as recovery times are presented in Table IIGo. BPA use allowed 92 of 173 (53%) outpatients to go directly to SDCU. Analysis of outpatients with similar procedure times (Figure 1Go) revealed that BPA resulted in a shorter PACU stay when compared to GA (P = 0.02). SDCU times were also reduced in the BPA group (Figure 1Go), both for those discharged directly to the SDCU and via PACU. Outpatients receiving BPA spent less time in the hospital and had a lower rate of admission. LOS variability within this subset of patients is greater in those receiving a GA (range 7.8 vs 5.2 hr).


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  		TABLE II A comparison of various operating room time (ORT) intervals, depending on anesthetic technique and/or location
 


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  		FIGURE 1 Composition of outpatient hospital stay for procedures lasting one to three hours

Recovery includes regional anesthesia (RA) patients discharged to postanesthetic care units (PACU) and surgical day care units (SDCU; n = 81). Admitted patients (n = 2) are not included. PACU includes only RA patients discharged to PACU (n = 25). SDCU Reg are patients discharged to SDCU from PACU (n = 56). Error bars indicate 95% confidence intervals.

 

   Discussion
TOP
 Abstract
 Introduction
 Methods
 Results
 Discussion
References
 
We have been able to show that a BR reduces the ORT anesthesiologists use to establish BPA at our centre. Space, anesthesia, and nursing resources are still needed for a BR to function. ORT is perhaps the most valued resource in the surgical model. It therefore stands to reason that where a large volume of RA is conducted a BR would be beneficial. By extension a BR would potentially have a greater benefit to sites with anesthesia training programs or anesthesia assistants.

Our findings, similar to others,3 indicate that the anesthetic technique has an influence on the recovery phase for upper limb procedures. When we controlled for procedure time in outpatients, GA resulted in longer PACU, SDCU, and hospital LOS (Figures 1Go and 2Go). Some of this improvement may result from fast tracking of patients receiving BPA, but is not available to GA patients (all GA patients went to the PACU*). Side-effects associated with GA, namely nausea, vomiting, sedation and poor pain control2 are possibly reduced with BPA4 and may contribute to this finding.



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  		FIGURE 2 Total hospital time for outpatients with a procedure lasting one to three hours

Scattergrams of the total time spent in the hospital for outpatients undergoing surgery on the upper limb. Each data point represents a patient.

 

Limitations of this study are that it lacked randomization and was unblinded. Also, we utilized hospital databases. To reduce erroneous data this project was designed prospectively. Attempts to ensure accuracy at the point of entry and to confirm suspect data were made. As a result we feel the data are accurate.

In conclusion, we confirm that RA together with a BR reduces the anesthesia ORT associated with BPA. We also demonstrate how the use of RA can reduce the recovery time phase in upper limb ambulatory surgery.


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  		TABLE I Demographic data for patients undergoing upper limb surgery, analyzed over a six-month period
 

   Acknowledgments
 
The authors would like thank all those who helped in the completion of this study. In particular Irene Kozac of the SJHC OR data centre and the SJHC OR nursing staff who contributed in data entry and assistance in BPA. Karen Decker from health records SJHC. All anesthesiologists who work at SJHC.


   Footnotes
 
Accepted for publication September 30, 2002. Revision accepted August 29, 2003.

* At the time of this study sevoflurane, desflurane and remifentanil were all available and used but we did not collect data on the composition of either anesthetic technique. Currently we still do not allow fast tracking of GA patients and fast tracking for RA patients is at the discretion of the anesthesiologist. Back


   References
TOP
 Abstract
 Introduction
 Methods
 Results
 Discussion
 References
 
1 Mulroy FM. Outpatients. In: Brown DL (Ed.). Regional Anesthesia and Analgesia. Toronto: W.B. Saunders Company; 1996: 576–86.

2 Chung F, Mezei G. Factors contributing to a prolonged stay after ambulatory surgery. Anesth Analg 1999; 89: 1352–9.[Abstract/Free Full Text]

3 D’Alessio JG, Rosenblum M, Shea KP, Freitas DG. A retrospective comparison of interscalene block and general anesthesia for ambulatory surgery shoulder arthroscopy. Reg Anesth 1995; 20: 62–8.[Medline]

4 Chung F, Ritchie E, Su J. Postoperative pain in ambulatory surgery. Anesth Analg 1997; 85: 808–16.[Abstract]




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This Article
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Right arrow Articles by Armstrong, K. P.J.
Right arrow Articles by Cherry, R. A.

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