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.
Introduction
The growth in both medical technology and the availability of better anesthetic agents has triggered a dramatic growth in ambulatory surgery over the last 2 decades. The rapid onset and termination of effect of modern anesthetic agents as well as a better understanding of their mechanism of action has allowed longer cases to be performed on an ambulatory basis with quicker recovery of patients allowing safe same-day discharge to home. As of 2003, 70% of the surgical procedures in North America were performed on an ambulatory basis, and it now accounts for most surgeries performed in the United States, some European countries, and Australia. Orthopedic surgery, and in particular hand surgical procedures, account for a large portion of these outpatient surgeries and are likely only to increase with time as economic restrictions continue to influence the way we practice. Leblanc and colleagues analyzed the cost and efficiency associated with performing carpal tunnel releases in the main operating room as compared with the ambulatory setting and found that the use of the main operating room for carpal tunnel releases is almost 4 times as expensive and less than half as efficient as when performed in an ambulatory setting.
Even though expense and efficiency are important driving factors, perhaps the main prerequisite for performing ambulatory surgery is postoperative pain that can be controlled with oral analgesics. With the ever-expanding boundaries of what can be done as an outpatient, safe and effective pain control remains an important challenge for surgeons and patients alike. It is estimated that up to 30% to 40% of ambulatory surgical patients suffer from moderate to severe pain during the first 24 to 48 hours after their discharge, which often times will interfere with sleep and daily functioning. Even though this improves with time, postoperative pain remains the most common reason for recurrent office visits and unanticipated hospital admission. Chung and colleagues prospectively studied 1008 consecutive ambulatory surgical patients across 8 surgical specialties and found that in the recovery room or postanesthesia care units (PACUs), orthopedic patients (including hand surgical procedures) had the highest incidence of pain, more than urologic, general surgery, and plastic surgery patients. Furthermore, in a survey by Rawal and colleagues that analyzed postoperative pain, it was found that 37% of hand surgery patients will have moderate to severe pain postoperatively, affecting their function and quality of life.
Traditionally the patient’s pain is managed with general anesthesia (GA) and narcotic medication for surgery, followed by oral medications, including acetaminophen, nonsteroidal antiinflammatory drugs (NSAIDs), opioid-containing oral analgesics (eg, codeine-acetaminophen), or a combination of these. Despite the availability of these analgesic drugs, many patients still do not achieve adequate pain control, often times because adverse gastrointestinal, hemostatic, and renal effects become prohibitive to achieving adequate analgesic concentrations.
Introduction
The growth in both medical technology and the availability of better anesthetic agents has triggered a dramatic growth in ambulatory surgery over the last 2 decades. The rapid onset and termination of effect of modern anesthetic agents as well as a better understanding of their mechanism of action has allowed longer cases to be performed on an ambulatory basis with quicker recovery of patients allowing safe same-day discharge to home. As of 2003, 70% of the surgical procedures in North America were performed on an ambulatory basis, and it now accounts for most surgeries performed in the United States, some European countries, and Australia. Orthopedic surgery, and in particular hand surgical procedures, account for a large portion of these outpatient surgeries and are likely only to increase with time as economic restrictions continue to influence the way we practice. Leblanc and colleagues analyzed the cost and efficiency associated with performing carpal tunnel releases in the main operating room as compared with the ambulatory setting and found that the use of the main operating room for carpal tunnel releases is almost 4 times as expensive and less than half as efficient as when performed in an ambulatory setting.
Even though expense and efficiency are important driving factors, perhaps the main prerequisite for performing ambulatory surgery is postoperative pain that can be controlled with oral analgesics. With the ever-expanding boundaries of what can be done as an outpatient, safe and effective pain control remains an important challenge for surgeons and patients alike. It is estimated that up to 30% to 40% of ambulatory surgical patients suffer from moderate to severe pain during the first 24 to 48 hours after their discharge, which often times will interfere with sleep and daily functioning. Even though this improves with time, postoperative pain remains the most common reason for recurrent office visits and unanticipated hospital admission. Chung and colleagues prospectively studied 1008 consecutive ambulatory surgical patients across 8 surgical specialties and found that in the recovery room or postanesthesia care units (PACUs), orthopedic patients (including hand surgical procedures) had the highest incidence of pain, more than urologic, general surgery, and plastic surgery patients. Furthermore, in a survey by Rawal and colleagues that analyzed postoperative pain, it was found that 37% of hand surgery patients will have moderate to severe pain postoperatively, affecting their function and quality of life.
Traditionally the patient’s pain is managed with general anesthesia (GA) and narcotic medication for surgery, followed by oral medications, including acetaminophen, nonsteroidal antiinflammatory drugs (NSAIDs), opioid-containing oral analgesics (eg, codeine-acetaminophen), or a combination of these. Despite the availability of these analgesic drugs, many patients still do not achieve adequate pain control, often times because adverse gastrointestinal, hemostatic, and renal effects become prohibitive to achieving adequate analgesic concentrations.
Intraoperative analgesia
The choice of analgesia and anesthesia during the surgical procedure can have a great effect on the pain level and chance of successful pain control postoperatively and often dictates both the extent of preoperative evaluation and the postoperative length of stay of patients in the hospital after the procedure. The techniques that are discussed here include GA, peripheral nerve blocks, intravenous (IV) regional blocks, and local anesthesia with or without sedation.
General Anesthesia
GA has a long established history and safe profile. It involves complete anesthetization of patients requiring intubation and artificial ventilation. It has been previously established in the shoulder literature that GA, as compared with peripheral regional blocks (PRBs), results in longer recovery times and slower hospital discharge after surgery. Similarly, Chan and colleagues prospectively examined 3 anesthetic techniques during hand surgical procedures, specifically GA, peripheral (axillary) regional block, and IV regional anesthesia (IVRA), with respect to clinical outcome, time efficiency, and hospital cost. They found that regional anesthesia is associated with a more favorable patient recovery profile than GA, requiring less nursing care in the recovery room and an earlier hospital discharge. These findings were redemonstrated later by McCartney and colleagues in a prospective randomized trial of 100 ambulatory hand surgery patients demonstrating that single-shot axillary PRB significantly reduces pain in the immediate postoperative period, reducing recovery room times and total hospital time and increasing the time to the first analgesic request before discharge. However, when they tracked patient-reported pain beyond the immediate postoperative period, they found no difference in pain level on postoperative day 1 or up to 14 days after surgery when compared with GA.
Peripheral Regional Blocks
Single-injection plexus blocks are currently the most commonly used modality for PRBs in upper extremity surgery. First performed by the American surgeon William Stuart Halsted in 1885, it involves injecting a local anesthetic in the area of the brachial plexus, which can provide analgesic effects from 12 to 24 hours. Depending on the surgical area, this can be administered as an interscalene, supraclavicular, or infraclavicular block. The most common block is the interscalene block that affects the root-trunk level of the brachial plexus and can be used for procedures involving the shoulder, proximal aspect of the humerus, and distal aspect of the clavicle but is inadequate for procedures that are distal to the elbow. The supraclavicular block, that affects the anterior and posterior divisions of the trunks of the brachial plexus, as well as the infraclavicular nerve block that targets the brachial plexus at the level of the cords before the exit of the axillary and musculocutaneous nerves, is well suited for procedures involving the arm, elbow, forearm, and hand. Finally, the suprascapular and axillary nerve blocks have a similar coverage with the interscalene block, and can be an effective option for intraoperative and postoperative pain control for shoulder procedures.
Overall, PRBs can offer cost-effective pain control for patients undergoing upper extremity procedures and have the potential to minimize the need for postoperative narcotic use, shorter hospital stays, and increased patient satisfaction. Nevertheless, several complications have been reported with the use of these blocks, including pneumothorax, recurrent laryngeal nerve blockade, phrenic blockade, peripheral neuropathy, spinal cord damage, and sympathetic chain blockade. With the use of ultrasound guidance, the safety of PRBs has been enhanced and allows for more accurate placement of the blocks with lower anesthetic volumes.
Intravenous Regional Anesthesia
IVRA, more readily known as the Bier block, was first developed by Dr August Bier in 1908 and still remains an effective regional anesthesia technique frequently used for upper extremity surgery. It generally involves placement of a tourniquet above the elbow, exsanguination of the extremity with an Esmarch and tourniquet inflation to ensure arterial occlusion, followed by slow injection of an anesthetic agent (typically lidocaine) into the IV cannula of the surgical hand.
The Bier block technique is intended to provide a bloodless field with rapid onset and high reliability of complete anesthesia, eliminating the need for GA, all while leaving local tissue or anatomic structures undistorted. However, this technique is often associated with tourniquet pain and, therefore, may still require sedation for patient comfort, which is associated with all the well-described side effects of nausea, vomiting, and decreased cognitive function. These side effects, along with failure to provide adequate postoperative analgesia, ultimately impact the time to discharge. In an effort to improve the quality of the block, over the years, various adjuvants have been added to the local anesthetic solution, including opioids, NSAIDs, (alpha) 2 -adrenergic agonists, sodium bicarbonate, and muscle relaxants, with varying degrees of success.
Another concern associated with the Bier block is its potential to cause both local and systemic pharmacologic toxicity as the tourniquet is deflated, and various serious complications including death have been reported in the literature. Guay recently performed a systematic review of the adverse events associated with Bier blocks and described cases of local anesthetic toxicity, compartment syndrome, cardiac arrests, and deaths, as well as seizures that have been reported even with lidocaine at its lowest effective dose (1.5 mg/kg). He concluded that even though serious complications might result from the utilization of the Bier block, their incidence is relatively low; therefore, this technique can be considered a safe method of providing anesthesia during surgery. To minimize these risks, precautionary measures have been described when using this technique. To reduce the bolus effect of the anesthetic agent as it is released into the general circulation, cyclical release of the tourniquet is most times necessary. Additionally, a minimum tourniquet time of 30 minutes is required when using a Bier block, ensuring enough diffusion of the total anesthetic agent before allowing its systemic distribution. This time limitation may make the use of the Bier block impractical for shorter procedures further narrowing its indications in outpatient hand procedures.
In recent years, there has been a renewed interest in reviving and enhancing Bier blocks. Investigators have described modifications to the Bier block technique, such as placing the tourniquet distal to the elbow thereby reducing the amount of lidocaine used to achieve adequate anesthesia and also decreasing the amount of time the tourniquet must remain inflated. Arslanian and colleagues described their experience with forearm Bier block in 121 procedures performed and interviewed patients by telephone 24 hours postoperatively. They report that all patients received adequate anesthesia from the block with no intraoperative or postoperative complications. They were also able to reduce the tourniquet time to about 10.1 minutes using this technique.
Another area of adjustment has been in the choice of anesthetic agent. Mepivacaine, prilocaine, and bupivacaine or the use of adjunctive analgesics, such as ketorolac and combinations thereof, have been described in the literature to provide varying durations of action and blockade. Opioids, including morphine, fentanyl sufentanil, and meperidine, have been added to the Bier block solution with contradictory results. Nonetheless, lidocaine, which is typically given as 0.5% plain lidocaine at a maximum dose of 3 mg/kg, still remains one of the more common anesthetics used for Bier blocks because of its low potential for systemic toxicity.
Wide-Awake Surgery
Wide-awake hand surgery was first introduced by Lalonde about a decade ago, which he termed wide awake local anesthesia no tourniquet (WALANT). It involves injecting a local anesthetic with epinephrine directly into the surgical field without sedation or a tourniquet. Patients are entirely awake. In order to minimize injection discomfort, Lalonde recommends adding bicarbonate to the anesthetic in order to normalize the pH as well as slowly delivering it in a controlled manner using a 27-g or smaller needle.
Epinephrine is a potent vasoconstrictor, which decreases the bleeding in the surgical field, thus, avoiding the need for a tourniquet that is known to cause considerable discomfort, which alone often warrants sedation. This idea became possible after the emergence of recent evidence suggesting that it is safe to inject epinephrine in the human finger, previously thought to potentially lead to digital ischemia and necrosis. Subsequently, negating the need for the tourniquet avoids the need for sedation. Furthermore, lidocaine provides the local anesthesia allowing patients to undergo both simple operations, such as carpal tunnel releases and Dupuytren excisions, as well as more complex surgeries, such as arthroplasties and tendon transfers , circumventing the need for GA, PRB, IVRA, or sedation and, hence, all the risks associated with them. In fact, Lalonde recently claimed that WALANT can be used for up to 95% of all hand surgery procedures. Additional advantages of WALANT include significant cost savings as it forgoes the need for anesthesia, eliminates preoperative history and physicals, and preoperative diagnostic studies, such as blood work. Furthermore, the ability to avoid anesthesia allows patients with significant comorbidities that would otherwise be denied surgery because of the risk of anesthesia to safely undergo hand surgical procedures. An added benefit is that because patients are awake during the procedures, they can receive education about their surgery and postoperative management and can also actively participate in the surgery by actively flexing and extending the digits so the surgeon can evaluate, for example, whether a tendon repair glides freely intraoperatively.
Elimination of anesthesia also means that patients can practically get up after surgery and go home with no need for extensive PACU care, medication administration, and the associated side effects, such as drowsiness, nausea, or vomiting. In a prospective cohort study by Davison and colleagues that compared 100 consecutive carpal tunnel releases (CTR) done with only WALANT with 100 consecutive CTRs done with sedation, they found that 93% of the patients in either group would choose the same method of anesthesia they received again, demonstrating that people would choose the method that they are more familiar with. More importantly, they found that WALANT patients spent less time at the hospital than sedated patients (2.6 hours vs 4.0 hours, respectively) and that only 3% of WALANT patients required preoperative testing (blood work, electrocardiograms, and/or chest radiographs) as compared with 48% of sedated patients. Additionally, preoperative anxiety levels for WALANT patients were lower than for sedated patients even though postoperative anxiety was similar. Narcotics were used by only 5% of unsedated patients as opposed to 67% of sedated patients despite reported adequate pain control by 89% and 90% of patients, respectively. Surprisingly, the postoperative nausea and vomiting incidence was very low for both groups in this study (1% and 7%), unlike most other previous studies.
Postoperative analgesia
Postanesthesia Care Unit
Effective pain management in the PACU can have a big impact on patient satisfaction, time to discharge, and their postoperative experience once patients go home. Morphine and fentanyl are widely used in ambulatory patients to provide analgesia during phase I recovery. Fentanyl has been advocated because of its faster onset time and, therefore, more rapid pain control, potentially avoiding total opioid dose and related side effects. Claxton and colleagues compared the use of IV morphine and fentanyl after painful ambulatory procedures in a prospective randomized trial and demonstrated that morphine produced a better quality of analgesia but was associated with an increased incidence of nausea and vomiting, most of which occurred after discharge. They concluded that the reduced side effects in combination with a short duration of action with fentanyl may facilitate earlier discharge and produce fewer complications after discharge.
Home Analgesia
Oral analgesia is the mainstay of pain control once patients leave the hospital. Medications prescribed should allow patients to perform normal activities of daily living, produce minimal side effects, not interfere with the healing process, and be easy to manage by patients. Depending on the type of procedure performed, breakthrough pain medications might also be indicated to keep pain under control in case the prescribed analgesic is ineffective. Postoperative pain after ambulatory hand surgery is typically managed with a combination of oral medications, including acetaminophen, NSAIDs, and opioid-containing oral analgesics (eg, codeine-acetaminophen). Regardless of the choice of medication, patient education on what to expect, ways to manage pain, and how to use the medications prescribed remains paramount.
Acetaminophen
Acetaminophen is one of the most widely used analgesics worldwide. It is effective, safe, inexpensive, and has a favorable adverse effect profile. Yet, its mechanism of action is poorly understood. There is some evidence that it has a central antinociceptive effect, and some of the proposed mechanisms of action include inhibition of cyclooxygenase-2 (COX-2) or inhibition of putative central COX (COX-3). There is also some evidence that it modulates inhibitory serotonergic pathways and may also prevent prostaglandin production at the cellular level. However, it is known that, unlike NSAIDs, acetaminophen does not irritate gastric mucosa, affect platelet function, or cause renal insufficiency, making it a very versatile medication.
Nonsteroidal antiinflammatory drugs
Prostaglandins, and their role in pain modulation, were first discovered in the 1960s. In 1965, Sir John Vane first demonstrated the in vivo reduction in prostaglandin levels by inhibition of prostaglandin synthetase, now known as COX. Once this enzyme was identified, NSAIDs were developed to inhibit it. Even though some central action has been reported, the generally accepted mechanism of action of NSAIDs today remains the attenuation of prostaglandin synthesis by inhibition of COX enzymes.
NSAIDs are now part of most outpatient surgery pain regimens. Their antiinflammatory properties not only provide pain relief but may also help reduce local edema and minimize the use of more potent medications. The 1998 guidelines for the use of NSAIDs in the perioperative period, issued by the Royal College of Anesthetists, stated that based on the strongest evidence available, ‘‘in situations where there are no contraindications, NSAIDs are the drug of choice after many day-case procedures.’’ Today it is estimated that 20% to 30% of Americans use an NSAID each year, and 1% to 2% use NSAIDs every day.
Despite their success, one of the main concerns with the use of NSAIDs remains their gastrointestinal toxicity, which led to the exploration of ways to reduce their side-effect profile. The two COX isoenzymes were discovered in the late 1980s, with COX-1 largely involved in homeostasis, including the maintenance of gastroprotective mechanisms and renal blood flow, and COX-2, which is upregulated during the inflammatory response. COX-2–selective drugs emerged shortly after the discovery of the isoenzymes, which the World Health Organization has categorized as a new subclass of NSAIDs (coxibs). Despite continuing controversy over the safety of the coxibs with concerns of a higher risk of myocardial infarction, there seems to be no clear differences in the cardiovascular risks of the currently available coxibs and the nonselective NSAIDs when used at the recommended doses. On the other hand, even with a favorable side-effect profile, they perform equally as well as the nonselective NSAIDs. In a recent systematic review by Rømsing and Møiniche, they showed that rofecoxib 50 mg and parecoxib 40 mg have an equipotent analgesic efficacy relative to traditional NSAIDs in postoperative pain after minor and major surgical procedures.
Ketorolac
Ketorolac is a newer NSAID analgesic, considered a central nervous system agent, that was first approved for use by the US Food and Drug Administration (FDA) in 1997. Similar to classic nonselective NSAIDs, when coadministered with an opioid, it exhibits marked opioid-sparing effects, allowing a 25% to 50% reduction in opioid requirement. A randomized double-blinded study by Kinsella and colleagues demonstrated that morphine requirements were 3 times less in the first 24 hours in patients having major orthopedic procedures who had adjuvant ketorolac administered during the postoperative period.
Because it acts by inhibiting the COX pathway, it is, therefore, also a potent inhibitor of platelet aggregation; some concerns were raised with its use in the perioperative period for bleeding. Even though there is a paucity of literature in the use of ketorolac with hand surgical procedures in particular, it has been examined in the spine literature by Chin and colleagues, who found no risk of bleeding complications compared with that of their control group in patients having microdiscectomy after a single intraoperative dose of ketorolac.
For all NSAIDs, careful patient selection is important. Specifically, a history of coronary artery disease, gastrointestinal risk factors such as gastric ulcers, and renal insufficiency has to be taken into consideration before prescribing nonselective NSAIDs, COX-2 selective inhibitors, or ketorolac. After weighing the risks and benefits, NSAIDs, when used at the right dose, remain one of the most effective analgesics and antiinflammatory medications that can safely be used for postoperative analgesia after hand surgical procedures.
Opioids
Even though opioids are routinely used in outpatient surgery in the United States, their role is sometimes questioned because of their well-known side effects of nausea, vomiting, sedation, dizziness, and respiratory depression and the risk of substance dependence. Weak opioids, such as codeine and tramadol, are commonly used and are often times prescribed in combination with acetaminophen. In a controlled trial, postoperative pain management at home using tramadol, metamizole, or acetaminophen as single substances after outpatient hand surgery has been shown to be inadequate for up to 40% of all patients. Consequently, there has been an increasing focus on combining analgesic medications with different mechanisms of action and complementary pharmacokinetic profiles in hopes to not only achieve greater efficacy but also a better safety profile. For example, in a randomized, double-blind, multicenter trial comparing the efficacy and safety of tramadol 37.5 mg/acetaminophen 325-mg combination tablet compared with tramadol hydrochloride (HCL) 50 mg alone in the treatment of postoperative pain following outpatient hand surgery, it was found that analgesic efficacy of the 2 treatments was comparable; but the tramadol/acetaminophen treatment showed a better safety profile than the tramadol monotherapy.
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