Local Anesthesia With Minimal Sedation and Brachial Plexus Block in Hand Surgery

The Quality of Recovery of Local Anesthesia With Minimal Sedation and Brachial Plexus Block in Hand Surgery: A Randomized Controlled Study

A major innovation in hand surgery in the last decade is the popularization of Wide Awake Hand Surgery (WAHS). This technique consists of numbing the surgical area with local anesthesia with epinephrine and allowing the patient to actively move their hand intra-operatively to assess the strength and quality of repairs or fixations. Despite its theoretical advantages, the application in clinical practice has seldom spread further than simple hand operations, such as carpal tunnel and trigger finger releases. In many institutions, the current standard of care for hand surgery is the brachial plexus block. The primary objective of the study to directly compare the effects of local anesthesia with minimal sedation, performed by the surgeon, and the brachial plexus block, performed by the anesthesiologist, on patient-reported quality of recovery.

Currently, there are no studies in the surgical literature directly comparing patient-reported quality of recovery, post-operative pain control, or time efficiency between local anesthesia and the brachial plexus block in hand surgery. This lack of information is a major impediment to the acceptance and adoption of a simple yet effective anesthesia technique that may increase patient satisfaction and time efficiency in the operating room. This proposed prospective randomized controlled study will quantitatively compare local anesthesia and brachial plexus block on three fronts: 1) patient-reported recovery at 24-hours post-surgery using the validated Quality of Recovery 15 score (QoR-15), 2) post-operative pain and opioid use at 24-hours post-surgery, and 3) nonsurgical time (defined as the time elapsed from one surgery's end time to the next surgery's start time) as a metric for turnover efficiency. The investigators hypothesize that patients randomized to the local anesthesia group will have a more positive recovery experience, a similar pain profile compared to the brachial plexus block despite common beliefs, and a shorter anesthesia-related and nonsurgical time.

The importance of patient-centered care cannot be understated in a successful and high-quality health care system. The results of this study will provide valuable information regarding the patient experience during their post- operative recovery.

Study Overview

Detailed Description

In many hospitals, the widely-accepted benefits of local anesthesia have moved minor hand operations such as carpal tunnel and trigger finger release outside of the main operating room. The proven benefits of local anesthesia include increased efficiency, convenience and patient comfort, reduced costs, lack of pre-operative tests, and decreased operative time. Multiple complex hand operations have been described using lidocaine and epinephrine only, with the patient wide awake during surgery. These include K-wire fixation, flexor tendon repair, tendon transfers, and tendon grafting. For those unfamiliar with this technique, the main concerns are that it is poorly tolerated, does not prevent patient movement, and inadequately controls post-operative pain, which all negatively influence a surgeon's comfort and adoption of this technique. Thus, despite its many advantages, local anesthesia in complex hand surgery is still not widely practiced in North America.

Alternatively, the brachial plexus block is a common method of regional anesthesia used in hand surgery, consisting of anesthetizing the entire upper limb via local anesthesia infiltration of the brachial plexus. This reliable sensorimotor blockade is performed under ultrasound guidance by an anesthesiologist approximately 30 minutes prior to surgery. Although safe and effective to use, its long duration of action, increased need for operating room resources, and unpleasant sensation of a flaccid and insensate upper extremity has prompted research into alternative ultrasound-guided nerve blocks in hand surgery.

Despite prior published data on the use of local anesthesia with epinephrine and brachial plexus blocks in hand surgery, there is a paucity of randomized-controlled, prospective, patient-reported outcome studies comparing these two methods of anesthesia. This study aims to capture patient-reported quality of recovery using a validated, psychometrically tested questionnaire, the Quality-of-Recovery 15. A recent systematic review of the measurement properties of QoR-15 showed good content validity and internal consistency, and concluded that it fulfills requirements for outcome measurement instruments in clinical trials.

Preliminary data was obtained from a pilot study of 11 hand surgery patients who underwent a brachial plexus block and were called 24 hours after surgery to answer the QoR-15 questionnaire. The computed mean QoR score was 118/150 +/- 15, consistent with values reported in the literature. This pilot study allowed for the calculation of a projected sample size for this study, outlined below.

This is a prospective single institution randomized controlled study taking place at the Montreal General Hospital, in Montreal, Canada. The institution is a level I trauma center which performs a minimum of 250 upper extremity surgeries yearly. The study participants are trauma or elective hand surgery patients above 18 years undergoing surgery less than 2 hours in duration distal to the carpal bones.

Patients who consent to the study will be randomized to receive local anesthesia with minimal sedation (intervention group) or a brachial plexus block (control group) using www.random.org, a random number generating website. The local anesthesia in the intervention group will be administered by the operating hand surgeon or a senior resident under the surgeon's direct supervision as a wrist block and/or digital block. The regional blocks in the control group will be performed as an infraclavicular brachial plexus block by a staff anesthesiologist with extensive experience in ultrasound-guided regional anesthesia.

This study is designed as a prospective non-inferiority study using an alpha of 0.05 for statistical significance and a power of 80%. Using QoR-15 values derived from the pilot study with effect size of 0.54, a power analysis was conducted, yielding a sample size of 44 patients per group, for a total of 88 patients. All quantitative outcome parameters will be evaluated for normal distribution and reported as mean +/- SD or median (IQR). Differences between two groups will be evaluated using unpaired Student's T-Test (if parametric) or Mann-Whitney-U test (if non-parametric).

The patients will be called on the first post-operative day, at least 24 hours after the end of their surgery, by a research assistant blinded to the randomization. As a primary outcome measure, the patient will be asked to answer the questions on the QoR-15 without revealing their surgery or method of anesthesia. The dosage of the medications used and the number of times an opioid medication was taken will be recorded. The nonsurgical time for the local anesthesia and brachial plexus groups will also be directly compared. Nonsurgical time is defined as the time elapsed between the completion of surgical closure on one case until the surgical incision on the next case.

The study will be conducted in accord with the Tri-Council Policy Statement: Ethical Conduct for Research Involving Humans (2014) as well as in respect of the requirements set out by the McGill University Health Centre Research Ethics Board.

Study Type

Interventional

Enrollment (Actual)

105

Phase

  • Not Applicable

Contacts and Locations

This section provides the contact details for those conducting the study, and information on where this study is being conducted.

Study Locations

    • Quebec
      • Montreal, Quebec, Canada, H3G 1A4
        • Montreal General Hospital
      • Montreal, Quebec, Canada, H3G 1A4
        • St-Mary's Hospital

Participation Criteria

Researchers look for people who fit a certain description, called eligibility criteria. Some examples of these criteria are a person's general health condition or prior treatments.

Eligibility Criteria

Ages Eligible for Study

18 years and older (Adult, Older Adult)

Accepts Healthy Volunteers

No

Genders Eligible for Study

All

Description

Inclusion Criteria:

  • Patient age 18 and older
  • Hand surgeries distal to carpal bones
  • Trauma and elective cases
  • Under 2 hours estimated surgical duration
  • Consents to research

Exclusion Criteria:

  • Patient refusal
  • Allergy to local anesthetics
  • Surgery proximal to the carpal bones
  • BMI > 40 kg/m2
  • Non-compressive neurological disease of the upper extremity
  • Daily use of opioids for greater than 2 weeks prior to surgery
  • History of complex regional pain syndrome (CRPS)
  • Patients with high anxiety or severe post-traumatic stress disorder

Study Plan

This section provides details of the study plan, including how the study is designed and what the study is measuring.

How is the study designed?

Design Details

  • Primary Purpose: Supportive Care
  • Allocation: Randomized
  • Interventional Model: Parallel Assignment
  • Masking: Single

Arms and Interventions

Participant Group / Arm
Intervention / Treatment
No Intervention: Brachial plexus block (infraclavicular)
The standard of care at our institution. Performed by experienced regional anesthetists.
Active Comparator: Local anesthesia with minimal sedation
The comparison group. Performed by the operating surgeon.
The operating surgeon will perform a digital or wrist block to numb the surgical area prior to the surgery, instead of using a brachial plexus block.

What is the study measuring?

Primary Outcome Measures

Outcome Measure
Measure Description
Time Frame
Quality of Recovery 15 Questionnaire (QoR-15)
Time Frame: At 24 hours post-surgery
This psychometrically tested and validated 15-items questionnaire measures patient-reported quality of recovery from surgery and anesthesia on the first post-operative day. Each item consists of a question related to the patient's post-operative recovery and is rated by the patient on a 10-point scale, where 0 means "none of the time" and 10 means "all of the time". The total combined score is obtained from the summation of 15 sub-scores and ranges from 0 to 150, and is used to assess and compare the patient's quality of recovery quantitatively between different interventions. A higher number on the score indicates an improved patient recovery experience. This scale has been validated in the ambulatory surgery setting.
At 24 hours post-surgery

Secondary Outcome Measures

Outcome Measure
Measure Description
Time Frame
Block performance time, onset time, and nonsurgical time
Time Frame: Within 24 hours of surgery
To compare local anesthesia to brachial plexus block in hand surgery with respect to performance time, onset time, and nonsurgical time.
Within 24 hours of surgery
Opioid use at 24 hours after surgery
Time Frame: At 24 hours post-surgery
To evaluate patient-reported 24-hours post-operative pain and use of opioid analgesia following local anesthesia versus brachial plexus block.
At 24 hours post-surgery

Collaborators and Investigators

This is where you will find people and organizations involved with this study.

Investigators

  • Principal Investigator: Fanyi Meng, MD, McGill University Health Centre/Research Institute of the McGill University Health Centre

Publications and helpful links

The person responsible for entering information about the study voluntarily provides these publications. These may be about anything related to the study.

Study record dates

These dates track the progress of study record and summary results submissions to ClinicalTrials.gov. Study records and reported results are reviewed by the National Library of Medicine (NLM) to make sure they meet specific quality control standards before being posted on the public website.

Study Major Dates

Study Start (Actual)

August 17, 2018

Primary Completion (Actual)

June 30, 2020

Study Completion (Actual)

June 30, 2020

Study Registration Dates

First Submitted

August 8, 2018

First Submitted That Met QC Criteria

August 14, 2018

First Posted (Actual)

August 15, 2018

Study Record Updates

Last Update Posted (Actual)

April 21, 2021

Last Update Submitted That Met QC Criteria

April 19, 2021

Last Verified

April 1, 2021

More Information

Terms related to this study

Plan for Individual participant data (IPD)

Plan to Share Individual Participant Data (IPD)?

No

IPD Plan Description

There will be no need to share individual participant data based on the objectives set out by our research.

Drug and device information, study documents

Studies a U.S. FDA-regulated drug product

No

Studies a U.S. FDA-regulated device product

No

This information was retrieved directly from the website clinicaltrials.gov without any changes. If you have any requests to change, remove or update your study details, please contact register@clinicaltrials.gov. As soon as a change is implemented on clinicaltrials.gov, this will be updated automatically on our website as well.

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