Pain Management Strategies in Hand Surgery

Modern anesthetic agents have allowed for the rapid expansion of ambulatory surgery, particularly in hand surgery. The choice between general anesthesia, peripheral regional blocks, regional intravenous anesthesia (Bier block), local block with sedation, and the recently popularized wide-awake hand surgery depends on several variables, including the type and duration of the procedure and patient characteristics, coexisting conditions, location, and expected length of the procedure. This article discusses the various perioperative and postoperative analgesic options to optimize the hand surgical patients’ experience.

Key points

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The choice of intraoperative anesthesia and a postoperative oral pain medication regiment can have a great effect on the patients’ hospital length of stay and recovery experience.
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General anesthesia and regional or local blocks with sedation continue to provide safe, effective perioperative anesthesia and, therefore, have maintained a strong presence in hand surgery.
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Wide-awake hand surgery can be used for a growing number of hand procedures and can avoid the need and cost for preoperative testing and potentially decreases postoperative complications and narcotic consumption.
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New Bier block modifications, including more distal tourniquet placement, allow for the use of less anesthetic making it a safer and more efficient technique.
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There is a shift away from opioid analgesic monotherapies toward combination formulations with complementary mechanisms of oral agents that can achieve greater efficacy and safety profile.
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Bupivacaine liposome formulation has been approved for single-shot surgical wound infiltration and can theoretically lead to pain relief for up to 96 hours postoperatively.