Anesth Pain Med 2014; 9: 19-23 ￭Clinical Research￭
A comparison of general anesthesia versus axillary brachial plexus block for hand and wrist surgery in the view of patient satisfaction
Department of Anesthesiology and Pain Medicine, Gachon University of Medicine and Science Gil Medical Center, Incheon, Korea
Mi Geum Lee, Hong Soon Kim, Dong Chul Lee, Wol Seon Jung, and Young Jin Chang
Background: We evaluated whether the analgesic superiority of regional block over general anesthesia improves patient satisfaction. Methods: Patients were anesthetized with either general anesthe- INTRODUCTION sia (GA) (n = 30) or axillary brachial plexus block (BPB) (n = 30). GA was standardized to include induction with propofol and alfen- Both axillary brachial plexus block (BPB) and general tanil and maintenance with desflurane in an oxygen/nitrous oxide anesthesia (GA) have been extensively employed in upper limb mixture. BPB was performed using an axillary perivascular appro- surgery. BPB is preferred over GA due to several analgesic ach, and 1.5% lidocaine 20 ml with epinephrine (1 : 200,000) and 0.5% levobupivacaine 20 ml were injected. Pain scores and num- advantages; superior postoperative analgesia, reduced periope- bers of times pushing the patient-controlled analgesia (PCA) button rative opiate consumption, decreased postoperative nausea and were measured preoperatively and at 2, 6, and 24 hours after the vomiting, shorter post-anesthesia care unit stay, and shorter end of surgery. On the first day after the operation, one of our hospital stay [1-3], and superior postoperative analgesia is one researchers visited the patients to document their opinions of their anesthetic experiences and their satisfaction scores. of the great merits of BPB even taking into account the Results: Group BPB had lower visual analog scale scores at 2 possibility of neurological injury after regional anesthesia [4,5]. hours and 6 hours postoperatively. Numbers of times pushing the There have been few reports on the benefits of BPB PCA button was also lower in Group BPB within the first 2 hours compared to GA from the clinicians’ point of view [6,7], and and between 2–6 hours postoperatively. However, patient satisfac- tion scores were not statistically different between the two groups no previous reports have explored patient satisfaction, thus, the (84 ± 11 vs. 88 ± 12, P = 0.177). aim of this study was to investigate the perioperative analgesic Conclusions: BPB provided superior analgesia after upper limb outcomes and patient satisfaction. surgery compared to GA, but for a complete understanding of patients’ satisfaction, detailed consideration of factors such as sedation would be necessary. (Anesth Pain Med 2014; 9: 19-23) MATERIALS AND METHODS
Key Words: Axillary brachial plexus block, General anesthesia, Patients scheduled for upper limb surgery to the wrist and Pain, Sedation. hand of expected duration of ＜ 90 min, were enrolled in the study, after ethical approval was received and participants provided written informed consent. Patients were 18 years of age or older and American Society of Anesthesiologists (ASA) Received: September 24, 2013. physical status I or II. Exclusion criteria included contraindi- Revised: 1st, October 27, 2013; 2nd, November 4, 2013. Accepted: November 19, 2013. cations to regional anesthesia, multiple injuries, intolerance to Corresponding author: Hong Soon Kim, M.D., Department of Anesthe- non-steroidal anti-inflammatory drugs (NSAIDs), chronic pain siology and Pain Medicine, Gachon University of Medicine and Science history, and pregnancy. Data were collected from January 2012 Gil Medical Center, 1198, Guwol-dong, Namdong-gu, Incheon 405-760, Korea. Tel: 82-2-460-3400, Fax: 82-32-469-6319, E-mail: khs@gilhospital. to March 2013. com The GA group (n = 30) received standardized anesthesia, It was presented The 90th Annual Meeting of the Korean Society of which included lidocaine 0.5 mg/kg, propofol 1.5 mg/kg, Anesthesiologists, November 2013, Kangwon Land Convention Center, μ Jeongseon, Korea. rocuronium 0.6 mg/kg and alfentanil 500 g. A supraglottic
19 20 Anesth Pain Med Vol. 9, No. 1, 2014 airway (i-gelTM, Intersurgical Ltd., Wokingham, England) was block. We considered loss of sensation in a surgical part of inserted based on patient size (＜50 kg, size 3; 50–90 kg, size the hand or wrist and inability to raise the arm as “surgical 4; and ＞ 70 kg, size 5). Anesthesia was maintained with anesthesia”, and we did not include the cases of insufficient oxygen/nitrous oxide (1 : 1) and desflurane 5–7 vol% titrated block (need for an additional injection for ulnar nerve block [1 to effect. An additional dose of either 250 μg (＜60 kg) or patient], and additive intravenous injection of opioid due to 500 μg (≥60 kg) of alfentanil was administered when pain [3 patients]) in this study. We injected midazolam 2–3 patients’ systolic blood pressure increased ＞ 15 mmHg above mg intravenously only in cases in which the doctors requested baseline or in cases of heart rate ＞ 90 beats/min. An intra- it for sedation. A PCA pump was connected to all patients of venous patient-controlled analgesia pump (PCA; Accufuser Plus Group BPB when the patients were transferred to the ward. Ⓡ , Wooyoung Medical Co., Ltd., Seoul, Korea) was connected During the preoperative visit for written informed consent, a before the onset of surgery. The PCA solution contained doctor explained the two anesthetics, and offered the choice of Ⓡ fentanyl citrate (Fentanyl , Guju Pharma Co., Ltd, Seoul, one of the two anesthetics to patients. At the same time, the Ⓡ Korea) 10 μg/kg and ketorolac tromethamine (Keromin , Hana anesthesiologist explained the use of the PCA button, and Pharm Co., Ltd., Seoul, Korea) 1.5 mg/kg mixed with normal recommended to the patients to push the button when they felt saline in a total volume of 100 ml and was administered for pain following the surgery. In the case of patients experiencing Ⓡ two days postoperatively (flow rate 2 ml/hr–bolus 0.5 ml– additional pain even after that, diclofenac (Dicknol , Ⓡ lockout time 15 min). Ondansetron (Ondant , Hanmi Pharm Myungmoon Pharm Co., Ltd., Seoul, Korea) 90 mg was Co., Ltd., Seoul, Korea) 4 mg was also injected intravenously. injected intravenously in both groups. We excluded the cases At the end of surgery, pyridostigmine 0.2 mg/kg and in which patients did not use the PCA due to nausea and glycopyrrolate 0.008 mg/kg were administered, and the i-gel vomiting. was smoothly removed. Before the operation, the patients in both groups received The BPB procedures (n = 30) were performed via a blind, explanations about the documentation of the visual analog scale perivascular approach by either one of two anesthesiology (VAS) scores (preoperatively and at postoperative 2, 6, and 24 residents (each had performed more than 20 transarterial hours) and the numbers of times pushing the PCA buttons (in axillary blocks, and they were closely supervised by experien- three sections: section 1, end of surgery to postop 2 hours; ced regional anesthesia staff). The total volume of the local section 2, postop 2–6 hours; section 3, postop 6–24 hours). On anesthetic mixture was 40 ml (1.5% lidocaine with 1 : the first day after the operation, one of our researchers visited 200,000 epinephrine 20 ml mixed with 0.5% levobupivacaine the ward to collect the above data. At that time, the researcher 20 ml). The technique for performing the BPB was as follows; inquired about the reasons for patient satisfaction or the patient’s arm was extended and abducted exposing the dissatisfaction with their anesthetic method, and asked patients axilla. The elbow was flexed at 90 degrees. The axillary artery to rate their satisfaction level (0–100). The anesthetic was palpated in the proximal axilla with gentle pressure, and procedure, pre-op visit and post-op visit were assigned to punctured using a scalp vein needle until arterial blood was different anesthesiologists in each case. noted in an extension tube open to air. The needle was For each patient, we recorded age, gender, weight, height, advanced until the blood flow ceased. At this point, 17 ml of ASA physical status classification, operation time, type of the drug was injected in 3 ml increments after intermittent surgery, hospital days, number of patients who required negative aspiration. The needle was then withdrawn into the injections of diclofenac. artery such that arterial blood was visualized flowing in the Statistical analyses were performed using the Statistical tubing while open to air. The needle withdrawal was stopped Package for Social Sciences software (SPSS 12.0 for Windows; when the blood flow ceased. At this point, another 17 ml was SPSS Inc., Chicago, IL, USA). Except for the number of injected after negative aspiration. After completion of the patients (n), gender, ASA status and type of surgery, all the block, digital pressure was held over the artery for 5 minutes. measured values were denoted with mean ± SD. All patients were given a proximal subcutaneous injection A Chi-squared test was conducted for the gender, ASA along the medial aspect of the distal axilla with 6 ml of the status, type of surgery and the number of patients who same solution in an attempt to provide tourniquet analgesia. required injections of diclofenac. In addition, a Student’s An alcohol swab was used to evaluate the sensory nerve unpaired t-test was conducted for the comparison of age, Mi Geum Lee, et al：Patient satisfaction with BPB 21
Table 1. Patient Demographic Characteristics and Perioperative Data
Group GA (n = 30) Group BPB (n = 30) P value
Age (yr) 42 ± 13 44 ± 14 0.485 Gender (M/F) (n) 16/14 22/8 0.108 Weight (kg) 67 ± 10 70 ± 11 0.395 Height (cm) 165 ± 8 170 ± 9 0.044* ASA (I/II) (n) 21/9 20/10 0.781 operation time (min) 51.53 ± 23.67 51.9 ± 23.2 0.948 Type of surgery (n) (fracture/non-fracture surgery) 8/22 10/20 0.673 Hospital days (day) 4.27 ± 1.20 4.8 ± 2.8 0.367 Patients of injecting diclofenac (n) 19 10 0.02* Intraoperative alfentanil (μg) 973 ± 362 - - Intraoperative midazolam (mg) - 2.7 ± 0.5 -
Values are numbers of patients and mean ± SD. BPB: Brachial plexus block, ASA: American Society of Anesthesiologists physical status. GA: General anesthesia. *P ＜ 0.05.
Table 2. VAS Scores and Numbers of Times Pushing the PCA Button Preoperatively and within 24 hours from the End of Surgery (VAS at 2, 6, and 24 hours)
VAS Numbers of pushing the PCA button P value P value Group GA Group BPB Group GA Group BPB
Preop 3 ± 3 2 ± 2 0.522 - - - Postop.–2 hr 5 ± 2 0 ± 0 ＜0.001* 2 ± 2 0 ± 0 ＜0.001* 2–6 hr 4 ± 3 1 ± 2 ＜0.001* 2 ± 4 0 ± 1 0.024* 6–24 hr 3 ± 2 3 ± 2 0.906 1 ± 2 4 ± 6 0.013*
Values are mean ± SD. GA: General anesthesia, BPB: Brachial plexus block, PCA: patient-controlled analgesia, VAS: Visual analog scale. *P ＜ 0.05. weight, height, operation time, hospital days, and sequential of patients who required diclofenac was significantly greater in VAS scores. A Wilcoxon signed ranks test was conducted for Group GA than in Group BPB (Table 1). the numbers of times pushing the PCA buttons in the two The preoperative VAS scores were not different between the groups. Significance was assumed at P ＜ 0.05. When the two groups. Group BPB had lower VAS scores at 2 and 6 mean difference and SD of the patient satisfaction between hours after the end of surgery. However, after 6 hours, the group GA and group BPB were taken to be 10 and 11, as VAS scores became similar in both groups. The numbers of was determined based on a preliminary study in 6 patients, 26 times pushing the PCA button were also lower in Group BPB subjects were required for an α value of 0.05 and a power of than in Group GA within the first 2 hours and between 2–6 90%, and 30 subjects were determined necessary in conside- hours, postoperatively, while the opposite was true during the ration of a dropout rate of 10%. postoperative 6–24 hours (Table 2). The patient satisfaction scores of the two anesthetic methods RESULTS were not significantly different between the two groups. The patients’ opinions about the pros and cons of the two The study was conducted with a total of 60 patients in anesthetic methods are also documented in Table 3. Groups GA and BPB, with 30 patients in each group. There were no significant differences in the demographic characte- DISCUSSION ristics except height between the two groups. In Group GA, alfentanil was used for 28 patients (971 ± 362 μg), and mida- As the above results show, BPB decreased the use of zolam was used for 18 patients (2.6 ± 0.8 mg). The number perioperative analgesics (e.g., opioids, NSAIDs) and improved 22 Anesth Pain Med Vol. 9, No. 1, 2014
Table 3. Comparison of Satisfaction between Group GA and Group BPB, and Patients’ Opinions
Group GA Group BPB P value
Patient satisfaction (1–100) 84 ± 11 88 ± 12 0.177 Patients’ opinions Group GA Good: unconsciousness in operation time (n = 22, 73%) Bad: long NPO time (n = 1, 3%) sore throat (n = 6, 20%) dizziness and feeling sleepy (n = 2, 7%) voiding difficulty (n = 2, 7%) severe postoperative pain (n = 3, 10%) Next, I want BPB if I get a sedation (n = 6, 20%) Group BPB Good: no pain immediately after the operation (n = 22, 73%) eating immediately after the operation (n = 3, 10%) Bad: paresthesia, numbness during the procedure (n = 2, 7%) no motor function in long time, feeling of getting excessive anesthesia (n = 1, 3%) pain on axillary site (n = 2, 7%) alertness in BPB procedure and operation time (n = 10, 33%) Next, I want BPB with sedation (n = 10, 33%) Next, I want GA even more acute postoperative pain (n = 4, 13%)
Values are numbers of patients (%) and mean ± SD. GA: General anesthesia, BPB: Brachial plexus block, NPO: Nil per os. postoperative pain compared with GA. Regional anesthetic sedation complained of unpleasant memories of the operating techniques have been known to be superior compared with GA room, which seemed to be directly connected to patient for reducing acute postoperative pain [8], and effective satisfaction. In Group BPB, there were no differences in postoperative pain control is an essential component of the patient satisfaction between patients who received midazolam care of the surgical patient because inadequate pain control (n = 18; 88 ± 15) and patients who did not receive results in increased morbidity or mortality [9]. We observed midazolam (n = 12; 90 ± 8) (P ＞ 0.05). It was considered that patient satisfaction in Group GA was comparable to that that patients harbored fears about consciousness not also during in Group BPB despite inadequate pain control. the operation but also during the BPB procedure itself [10]. During the day 1 postoperative interview, majority of the Performing regional blocks under deep sedation or general GA patients (73%) mentioned that unconsciousness during the anesthesia remains a subject of debate in the anesthesiology procedure made them relieved, and they seemed to be literature due to a higher incidence of nerve injury [11,12]. generous about postoperative pain as a matter of course. Six There are many factors which contribute to patient satisfac- patients who wanted to change the anesthetic method from GA tion as well as a list of dissatisfactions (e.g. consciousness, to BPB due to severe postoperative pain attached a condition pain). These factors include patient tendency (positive or of sedation. Most of the BPB patients (73%) stated that negative), past anesthetic experiences, attitude toward medical experiencing no acute pain was the merit of BPB, but they treatment and so on, so it is difficult to control all described that awareness during the procedure (33%) made confounding variables [10,13,14]. Furthermore, a satisfaction them worry. Ten patients (33%) who had not wanted sedation scale is not an objective indicator of the quality of anesthesia for the current surgery related that the next time they would care, because it is primarily determined by information and want to undergo BPB under sedation. They mentioned that communication between humans with feelings [15]. However, it noisy sounds during the operation, such as drilling or remains the best way to assess the outcome from the point of hammering, and the exchange of words among the medical view of the patient who offers a unique perspective for team during the BPB procedure were as stressful to them as evaluating the nontechnical aspects of medical care [16]. pain, as distinct from the success of regional anesthesia or the Objective questionnaires for identifying satisfaction tend to be main operation [10]. oriented more toward the researchers’ desire for positive results We did not leave BPB patients in an alert state [13]. Therefore, psychometric measures such as establishing intentionally. However, even the patients who did not want content validity, internal consistency and reliability must be Mi Geum Lee, et al：Patient satisfaction with BPB 23 considered, but the task of maintaining the reliability and trial. 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