Search

The supraclavicular block (SCB) and the infraclavicular block (ICB) are introduced to meet upper extremity surgery, where the transducer or the insertion point is placed superiorly and inferiorly at the approximate midpoint of the clavicle, respectively. These two approaches are highly appealing since they clearly exhibited each cord and its associated anatomy. In addition, it directed the needle accurately with real-time imaging by ultrasound guidance. Therefore, it brought higher success rates and fewer complications. Numerous trials have recently been conducted to examine the SCB and ICB regarding the new approach, injection techniques, block dynamics, and complication of hemidiaphragmatic paresis. It was found that both approaches could improve block effectiveness and postoperative analgesia for upper extremity surgery, according to recent studies at the level of the clavicular brachial plexus block. However, there is still a lack of work comparing the clinical performance and effectiveness of both approaches with ultrasonography. This review aims to outline the current available data from clinical trials along with case reports about these two approaches and to describe the findings published in the literature during the previous 5 years. Based on these findings, we attempt to determine whether there exists a one-size-fits-all approach that has the potential to meet upper extremity surgery. [ABSTRACT FROM AUTHOR]

Cervical spinal cord injury (SCI) causing tetraplegia is extremely disabling. In such circumstances, restoration of upper extremity (UE) function is considered the highest priority. The advent of early nerve transfer (NT) procedures, in addition to more traditional tendon transfers (TT), warranted in-depth consideration given the time-limited nature of NT procedures. Potential surgery candidates may not yet have come to terms with the permanence of their disability. A mixed methods convergent design was utilized for concurrent analysis of the Aotearoa/New Zealand upper limb registry data from the clinical assessments of all individuals considering UE surgery, regardless of their final decision. The International Classification of Functioning, Disability and Health (ICF) taxonomy guided data interpretation during the three-phased study series. It was the integration of the findings using the Stewart Model of care drawn from palliative health that enabled the interpretation of higher order messages. It is clear the clinical assessment and selection processes in use require reconsideration given the complexities individuals face following onset of SCI. We draw attention to the higher order cognitive demands placed on individuals, the requirement for SCI peer involvement in decision making and the need for acknowledgment of interdependence as a relational construct when living with tetraplegia. [ABSTRACT FROM AUTHOR]

Background Targeted muscle reinnervation (TMR) is growing in popularity; however, literature evaluating patient characteristics and outcomes is limited. Methods The EMBASE database was queried with the search terms "targeted muscle reinnervation" OR "TMR" AND "outcomes" OR "patient outcomes." Clinical human studies in English were eligible for inclusion, yielding 89 articles. After rigorous exclusion criteria, a total of 13 articles were included in this review. Study data including geographic location, patient demographics, TMR indication, amputation level, number of nerve transfers performed, length of follow-up, and reported outcomes were extracted and analyzed. Results The included articles represent 338 patients (341 limbs). Average patient age was 47.4 years. Indication for amputation included trauma (n = 125), infection (n = 76) cancer/tumor resection (n = 71), ischemia (n = 18), failed Charcot reconstruction (n = 15), failed hardware (n = 9), burn (n = 4), and CRPS (n = 4). Five studies included upper extremity TMR only, two included lower extremity TMR only, and six included both upper and lower extremity TMR. TMR was performed in an immediate or delayed fashion, with an average of 2.2 nerve transfers performed per limb overall. Average length of follow-up was 22.3 months. In three studies, patients with phantom limb pain undergoing delayed TMR were found to have significant or trending toward significant reduction in pain after TMR using numeric rating scale and patient-reported outcomes measurement information system scales. One article reported 9/10 patients with improved or complete resolution of phantom limb pain after delayed TMR. Three studies found that patients undergoing immediate TMR had lower pain scores compared with non-TMR controls. Conclusion While there is evidence that TMR reduces neuroma-related pain and improves the quality of life for amputees, further outcomes studies are needed to study the patient experience with TMR on a larger scale. Establishing standardized, validated patient-reported outcomes assessment tools is critical to future investigation in this field. [ABSTRACT FROM AUTHOR]

Background: Thoracic spinal anaesthesia for upper extremity surgery is rarely performed and exceptional procedure. We report a case in which thoracic spinal anaesthesia (T3–T4 intervertebral space) was performed successfully in a paediatric patient with distal radius fracture ORIF surgery. Case presentation: A 15 years old man with distal radius fracture ORIF was scheduled to undergo remove of implant. His parents did not want to have general anaesthesia because complication of postoperative pulmonary complications, patient has allergy and asthmatic potential. We proposed thoracic spinal anaesthesia with small dose bupivacaine 0.5% hyperbaric (5 mg). Conclusions: Thoracic spinal anaesthesia with small dose bupivacaine 0.5% hyperbaric at the cervical level (C4) may offer an alternative option when general anaesthesia or conventional regional techniques are contraindicated or equipment unavailable to perform peripheral nerve block. [ABSTRACT FROM AUTHOR]

Background: Thoracic spinal anaesthesia for upper extremity surgery is rarely performed and exceptional procedure. We report a case in which thoracic spinal anaesthesia (T3–T4 intervertebral space) was performed successfully in a paediatric patient with distal radius fracture ORIF surgery. Case presentation: A 15 years old man with distal radius fracture ORIF was scheduled to undergo remove of implant. His parents did not want to have general anaesthesia because complication of postoperative pulmonary complications, patient has allergy and asthmatic potential. We proposed thoracic spinal anaesthesia with small dose bupivacaine 0.5% hyperbaric (5 mg). Conclusions: Thoracic spinal anaesthesia with small dose bupivacaine 0.5% hyperbaric at the cervical level (C4) may offer an alternative option when general anaesthesia or conventional regional techniques are contraindicated or equipment unavailable to perform peripheral nerve block. [ABSTRACT FROM AUTHOR]

Introduction: Telemedicine in upper extremity surgery is an evolving modality that provides a viable alternative to the traditional in-person visit for achieving convenient, safe, and cost-effective health care. Our study aimed to identify patient preferences for virtual visits for hand and upper extremity surgery. Methods: An institutional review board approved survey was prospectively administered to all patients >18 years of age, presenting for any complaint to an orthopedic hand and upper extremity clinic at a Level I academic trauma center from September to December 2019. This survey included questions about access and literacy of technology as well as patient preferences regarding virtual visits. The medical record was reviewed to collect demographics, insurance type, and reasons for their visit. Bivariate and multivariate analyses were performed according to survey responses. Results: Two hundred consecutive patients (n) completed surveys. Surveys revealed that >88% of patients own a computer or smartphone, have WiFi access at home, and own a device capable of video chat. In total, 75% of patients reported that they would be moderately or highly comfortable in their ability to use a device for a virtual visit. In bivariate and multivariate analyses, technological literacy and access to a private space to conduct a visit were associated with high interest in virtual visits. Discussion: Telemedicine is a viable alternative to in-person patient visits. Our study demonstrates that most patients are willing and able to participate in a virtual visit for a hand or upper extremity issue. [ABSTRACT FROM AUTHOR]

Background/aim: This study compared ultrasound guided costoclavicular (CC) and lateral sagittal infraclavicular (LS) brachial plexus block in patients undergoing upper extremity surgery. Materials and methods: A total of 80 patients undergoing upper extremity surgery were randomly classified into two groups: Group CC (costoclavicular (n = 40)) and Group LS (lateral sagittal infraclavicular (n = 40)). Both groups received a 25 mL containing a mixture of 1% lidocaine and 0.25% bupivacaine. A blinded observer recorded the block onset time and decided which patients who were admitted to the operation room needed general anesthesia or rescue block or without any iv. narcotics for the surgical procedure. Results: The sensorimotor onset time was found to be faster in the CC group [(15.95 2.97) min] compared to the LS group [(17.72 4.15) min]. There was a statistically significant difference between two groups in terms of sensorimotor onset time (p = 0.031). There was no difference between two groups in terms of the block performance times and post-block motor block dissolution times. Conclusion: The CC approach provides faster onset of sensorimotor blockade than LS approach when the 4 major terminal nerves of the brachial plexus were evaluated. [ABSTRACT FROM AUTHOR]

Background: Advancements in virtual reality (VR) technology have resulted in its expansion into health care. Preliminary studies have found VR to be effective as an adjunct to anesthesia to reduce pain and anxiety for patients during upper gastrointestinal endoscopies, dental procedures and joint arthroplasties. Current standard care practice for upper extremity surgery includes a combination of regional anesthesia and intraoperative propofol sedation. Commonly, patients receive deep propofol sedation during these cases, leading to potentially avoidable risks of over-sedation, hypotension, upper airway obstruction, and apnea. The objective of this study is to evaluate the effectiveness of VR technology to promote relaxation for patients undergoing upper extremity surgery, thereby reducing intraoperative anesthetic requirements and improving the perioperative patient experience.Methods: In this single-center, randomized controlled trial, 40 adult patients undergoing upper extremity orthopedic surgery will be randomly allocated to either intraoperative VR immersion or usual care. VR immersion is designed to provide patients with a relaxing virtual environment to alleviate intraoperative anxiety. All patients receive a peripheral nerve block prior to surgery. Patients in the intervention group will select videos or immersive environments which will be played in the VR headset during surgery. An anesthesia provider will perform their usual clinical responsibilities intraoperatively and can administer anesthetic medications if and when clinically necessary. Patients in the control arm will undergo perioperative anesthesia according to standard care practice. The primary outcome is the difference in intraoperative propofol dose between the groups. Secondary outcomes include postoperative analgesia requirements and pain scores, length of stay in the postanesthesia care unit, overall patient satisfaction and postoperative functional outcomes.Discussion: It is unknown whether the use of VR during upper extremity surgery can reduce intraoperative anesthetic requirements, reduce perioperative complications, or improve the postoperative patient experience. A positive result from this clinical trial would add to the growing body of evidence that demonstrates the effectiveness of VR as an adjunct to anesthesia in reducing intraoperative pain and anxiety for multiple types of procedure. This could lead to a change in practice, with the introduction of a nonpharmacologic intervention potentially reducing the burden of over-sedation while still providing a satisfactory perioperative experience.Trial Registration: ClinicalTrials.gov, NCT03614325. Registered on 9 July 2018. [ABSTRACT FROM AUTHOR]

Aim: To investigate whether a 2% lidocaine addition to 0.5% bupivacaine that is used in a lateral sagittal infraclavicular block, when administered in an upper extremity surgery, decreases the block onset time, drug effect time, and drug activity when compared with bupivacaine alone. Materials and methods: This study was performed on 120 American Society of Anesthesiology classification I-II patients who were 18-65 years old and scheduled to undergo an upper extremity surgery. The group testing in the study was as follows: 20 mL (5 mg/mL) bupivacaine, 10 mL (5 mg/mL) bupivacaine + 10 mL (20 mg/mL) lidocaine, and 20 mL (20 mg/mL) lidocaine were used respectively in the bupivacaine group, bupivacaine + lidocaine group, and lidocaine groups. Results: The block onset time was very long in the bupivacaine group (P < 0.001). Motor block developed the fastest in the lidocaine group and the bupivacaine + lidocaine group (P < 0.001). Motor block regression was the fastest in the lidocaine group and the slowest in the bupivacaine + lidocaine group (P < 0.001). Loss of cold and touch sense was the fastest in the bupivacaine + lidocaine group and the lidocaine group (P < 0.001). Loss of sense of pain was the fastest in the bupivacaine + lidocaine group (P < 0.001). Postoperative analgesia requirement time was the longest in the bupivacaine + lidocaine group (P < 0.001). There were no differences among the satisfaction scores. Conclusion: Lidocaine addition to bupivacaine significantly lowered the block onset time and extended the postoperative analgesia requirement time compared to bupivacaine alone and had no effect [ABSTRACT FROM AUTHOR]

The perioperative management of a patient receiving a bilateral hand transplant is presented. The anesthetic management required careful fluid administration, homeothermic temperature maintenance, and postoperative analgesia. The role of different anesthesia subspecialties is highlighted. [ABSTRACT FROM AUTHOR]

Abstract: Study Objective: To evaluate the effect of adding neostigmine to lidocaine in intravenous regional anesthesia (IVRA). Design: Randomized, double-blinded study. Setting: Tertiary-care academic medical institution. Patients: 40 ASA physical status I and II patients scheduled for elective or emergency forearm and hand surgery. Intervention: Patients were randomized to two groups of 20 patients each. In the control group, IVRA was established using 40 mL of 0.5% lidocaine with one mL of isotonic saline, while neostigmine group patients received 40 mL of 0.5% lidocaine with 0.5 mg neostigmine. Measurements: Hemodynamic parameters, onset and recovery times of sensory and motor blocks, and quality of anesthesia achieved with IVRA were recorded. After tourniquet deflation, visual analog pain scores (VAS) were noted every 30 minutes in the first two hours, as were the time to first analgesic request and total analgesic requirement in the 24-hour postoperative period. Main Results: In the first 24 hours after surgery, the neostigmine group had significantly lower VAS scores, longer time to first analgesic request, and reduced total analgesic requirement. Intraoperatively, the neostigmine group had significantly shorter sensory and motor block onset times and longer recovery times than the control group. No significant frequency of adverse effects was seen in either group. The quality of intraoperative anesthesia and frequency of tourniquet pain were similar in both groups. Conclusions: The addition of neostigmine to lidocaine shortens onset time and improves postoperative analgesia in IVRA for upper limb surgery. [Copyright &y& Elsevier]

We report an incident of delayed onset of true vocal fold paralysis with continuous interscalene brachial plexus block. A 51 year old woman underwent left shoulder manipulation and lysis of adhesions with fluoroscopy and general anesthesia. An interscalene brachial plexus block was performed and a catheter with a continuous infusion pump was placed for postoperative pain control. Following hospital discharge, approximately 8 hours after the initial catheter bolus the patient developed hoarseness, dysphagia, and dyspnea, secondary to left vocal fold palsy. The patient was admitted for observation and the catheter was discontinued with no intubation required. By the next morning, the patient's dysphagia and dyspnea had resolved and her hoarseness improved. [ABSTRACT FROM AUTHOR]

Abstract: The authors reviewed 52 patients who underwent Bier’s block, as supplementary anesthesia for insufficient axillary block in upper extremity surgical procedures. Prior to proceeding to the Bier’s block, the mean value of pain using the visual optical analogue scale (VAS) was 7.0. In 48 of the patients supplementation with the Bier’s block was sufficient (mean VAS score of 1.0) and all patients were comfortable throughout the procedure. In the remaining four patients supplementation with narcotics and sedatives via the other IV line was required. Intraoperative Bier’s block provides a safe and effective alternative way of successfully compensating for an insufficient axillary block in upper extremity surgical procedures. [Copyright &y& Elsevier]

The effectiveness of patient-controlled interscalene analgesia (PCISA) and patient-controlled intravenous analgesia (PCIVA) in the management of postoperative pain in 36 patients was studied. The general anesthetic technique was standardized. After surgery, all patients received 2 mg intravenous morphine. The patients were then randomized to receive either PCISA or PCIVA. The PCISA group received an interscalene block with 20 ml of 1% lidocaine. A catheter was introduced within the interscalene sheath and 20 min after the initial block, patients received a continuous infusion of 0.125 bupivacaine at rate of 4 ml/h supplemented by a bolus dose of 3 ml with a 15-min lockout time. PCIVA was given as a 1 mg morphine bolus and a 7-min lockout time. Pain relief was regularly assessed using a visual analog scale. Side effects and patient satisfaction were noted. The study period ended 48 h after the operation. Pain relief was significantly better controlled in the PCISA group 6, 12, 24, and 30 h after the operation (P<0.05). At 36, 42, and 48 h, no significant difference in pain score between the two groups was observed. Patient satisfaction was greater in the PCISA group (P<0.05). Vomiting and pruritus were observed more frequently in the PCIVA group (P<0.05). No major complications occurred in any of the study patients. The use of the PCISA technique was uncomplicated and provided better pain relief than PCIVA in postoperative analgesia. [ABSTRACT FROM AUTHOR]