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REGIONAL ANESTHESIA VS GENERAL ANESTHESIA FOR AMBULATORY HAND SURGERY

Richard Brull, MD^*, Colin JL McCartney, MBChB FFARCSI FRCA^*, Sherif Abbas, MD^*, Hugo Nova, MD^*, Regan Rawson, RN^*, Vincent WS Chan, MD FRCPC^*, Joel Katz, PhD CPsych^*, Brent Graham, MD FRCSC, Dimitri Anastakis, MD MEd FRCSC FACS and Herbert von Schroeder, MD MSc FRCSC

^* Regional Anesthesia and
Hand Surgery programs, Toronto Western Hospital, University Health Network, 399 Bathurst Street, Toronto, Ontario, Canada M5T 2S8

INTRODUCTION: Regional anesthesia (RA) is associated with superior analgesia and fewer adverse effects compared to general anesthesia (GA) during in-hospital recovery after ambulatory hand surgery [1], but longer duration of benefit is unknown. This study investigates whether RA or GA provides superior analgesia with fewest adverse effects up to two weeks following ambulatory hand surgery.

METHODS: After IRB approval and informed consent, 100 patients undergoing ambulatory hand surgery were randomized to RA (n=50) or GA (n=50). RA comprised of axillary brachial plexus block using 1.5% lidocaine with epinephrine. GA included fentanyl, propofol, and desflurane. All patients received ketorolac. Fentanyl and oral opioid preparations were administered postoperatively as needed. Preoperatively, all patients rated their hand pain (Visual Analog Scale;VAS) and pain-related disability (Pain-Disability Index[2];PDI). Postoperatively, eligibility for bypassing PACU ("fast-track") was determined (Modified Aldrete score[3]), and pain (VAS) and home-readiness scores (Postanesthesia Discharge Scoring System[4]) were recorded. On postoperative days (POD) 1, 7, and 14, patients documented pain (VAS), opioid consumption, nausea/vomiting, weakness and paresthesia in the operative extremity, and satisfaction (VAS). Patients repeated the PDI on POD 14. Intention-to-treat analysis was undertaken by t-test, Mann-Whitney U, or ² with p<0.05 considered significant.

RESULTS: Demographics, medical history, preoperative pain and PDI, and procedure types were similar. More RA patients were fast-track eligible (p<0.001), while duration of stay in PACU was shorter in the RA group (p<0.001). During in-hospital recovery, the time to first analgesic requirement was longer in the RA group (p<0.001), and fentanyl consumption (p<0.001), oral morphine equivalent consumption (p<0.001), and pain (fig.1) were lower in the RA group. More GA patients suffered nausea/vomiting during in-hospital recovery (p<0.05). RA patients achieved home-readiness earlier (p<0.001). On POD 1, 7, and 14, there were no differences in pain (fig.1), opioid consumption, nausea/vomiting, weakness, paresthesia, or satisfaction. There was no difference in PDI on POD 14.

DISCUSSION: During in-hospital recovery, RA provides superior analgesia, fast-track eligibility, and home-readiness compared to GA after ambulatory hand surgery. Neither RA nor GA affects analgesia or adverse effects at home up to two weeks following ambulatory hand surgery.

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1 Anesth Analg 93:1181–4.

2 Arch Phys Med Rehabil 68:438–41.

3 J Perianesth Nurs 13:148–55.

4 J Clin Anesth 7:500–6.

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