Optimising Hand Surgery during COVID-19 Pandemic.

Background: With the emergence of the COVID-19 pandemic, most health-care personnel and resources are redirected to prioritize care for seriously-ill COVID patients. This situation may poorly impact our capacity to care for critically injured patients. We need to devise a strategy to provide rational and essential care to hand trauma victims whilst the access to theatres and anaesthetic support is limited. Our center is a level 1 trauma center, where the pandemic preparedness required reorganization of the trauma services. We aim to summarise the clinical profile and management of these patients and highlight, how we modified our practice to optimize their care. Methods: This is a single-centre retrospective observational study of all patients with hand injuries visiting the Department of Plastic Surgery from 22nd March to 31st May 2020. Patient characteristics, management details, and outcomes were analysed. Results: A total of 102 hand injuries were encountered. Five patients were COVID-19 positive. The mean age was 28.9 ± 14.8 years and eighty-two (80.4%) were males. Thirty-one injuries involved fractures/dislocations, of which 23 (74.2%) were managed non-operatively. Seventy-five (73.5%) patients underwent wound wash or procedure under local anaesthetic and were discharged as soon as they were comfortable. Seventeen cases performed under brachial-plexus block, were discharged within 24 hours except four cases of finger replantation/ revascularisation and one flap cover which were discharged after monitoring for four days. At mean follow-up of 54.4 ± 21.8 days, the rates of early complication and loss to follow-up were 6.9% and 12.7% respectively. Conclusions: Essential trauma care needs to continue keeping in mind, rational use of resources while ensuring safety of the patients and health-care professionals. We need to be flexible and dynamic in our approach, by utilising teleconsultation, non-operative management, and regional anaesthesia wherever feasible.

Tissue Oxygen Saturation Change on Upper Extremities After Ultrasound-Guided Infraclavicular Brachial Plexus Blockade; Prospective Observational Study.

Background and Objective: The aim of this study was to investigate whether tissue oxygen saturation (StO2) is a reliable and objective method for assessing the adequacy of infraclavicular block and to describe the time course of StO2 changes. Materials and Methods: In this prospective observational study, StO2 was measured in 40 patients planned for elective hand surgery under infraclavicular block. Noninvasive StO2 monitoring was used prior to ultrasound-guided infraclavicular brachial plexus block and during the first 30 min of the blockade. Sensory and motor blocks were evaluated every 5 min followed by pinprick testing and Bromage scale. Results: Preanesthetic median StO2 values of the blocked side and nonblocked side were similar (p = 0.532), whereas the postanesthetic values of the blocked side were higher. At the fifth minute and the following minute, measurements compared to the nonblocked side (p < 0.001). The median StO2 values increased significantly, which increased by 4.5% at 5 min, by another 5.5% at 30 min, and by an average of 1% from 5 to 30 min compared to the baseline values in the blocked side. The responses of the patients to the questions probed in the pinprick test and Bromage scale were fully compatible with the data obtained by the near-infrared spectroscopy (NIRS) method. Conclusions: StO2 monitoring may provide a useful instrument for rapid evaluation of the success of regional anesthesia in the upper extremity.

Individual duration of axillary brachial plexus block is unpredictable: a prospective double centered observational study.

BACKGROUND: The duration of effect for axillary plexus block using ropivacaine is highly variable. The available literature does not offer any plausible means of predicting time of block offset for individual patients, making it difficult to give accurate information and plan postoperative analgesics. This study was designed to identify factors influencing axillary plexus block offset time. METHODS: A total of 92 patients participated in this prospective double centred observational study. All patients were scheduled for axillary plexus block with ropivacaine 0.75% and subsequent block duration was recorded. RESULTS: Mean time of axillary plexus block offset was 13.5 hours, with a range of 4.8 to 25.4 hours. No statistical significant differences in offset time was seen with regard to gender, age, body weight, BMI and ASA-classification. A trend for increasing duration of blocks associated with increasing age was observed. No statistically significant difference was identified in block duration between blocks performed with nerve stimulator guidance versus ultrasound guidance. Similarly, neither dose nor volume of ropivacaine 0.75% was identified as a factor influencing block duration. CONCLUSIONS: This prospective study demonstrates a large inter individual variation in time of axillary plexus block offset using ropivacaine 0.75%. The lack of association between offset time and both demographic and block performance factors, makes predictability of individual duration of axillary plexus blocks in clinical practice extremely difficult. We suggest that all patients should be made aware of such variability in duration prior to block placement.

Effect of local anesthetic concentration, dose and volume on the duration of single-injection ultrasound-guided axillary brachial plexus block with mepivacaine: a randomized controlled trial.

BACKGROUND: In what way volume, concentration and dose affect block duration is controversial. The purpose of the present study is to investigate the effect of dose, volume and concentration of mepivacaine on the duration of sensory and motor blockade in ultrasound-guided single shot axillary brachial plexus blockade. METHODS: In this parallel group randomized trial conducted in the Sint Maartenskliniek Nijmegen, 45 adult patients undergoing minor orthopaedic forearm, wrist or hand surgery were randomized to 3 groups. Group A: 20 mL mepivacaine 1.5 %, Group B: 30 mL mepivacaine 1 % and Group C: 30 mL mepivacaine 1.5 %. Randomization was computer-generated, with allocation concealment by opaque sequentially numbered sealed envelopes. Patients and observers were blinded to group allocation. PRIMARY OUTCOME MEASURE: duration of sensory block. RESULTS: Forty-five patients were randomized, four patients were excluded and replaced, and 15 patients in each group were included in the analysis. Mean (95 % CI) sensory and motor block duration was 256 (230-282) and 254 (226-282) minutes in Group A, 226 (209-243) and 220 (200-240) minutes in Group B and 270 (249-291) and 264 (244-284) minutes in Group C. Duration of sensory and motor block duration differed significantly between groups (p = 0.012 and p = 0.016 respectively). Post-hoc analysis showed a significantly reduced sensory and motor block duration in Group B when compared to Group C of 44 min. No local anesthetic systemic toxicity was reported. CONCLUSIONS: When using mepivacaine for axillary brachial plexus block, a higher dose and concentration was associated with a longer duration of sensory and motor blockade, but not a higher volume. TRIAL REGISTRATION: The Netherlands National Trial Register NTR3648 . Registered October 3, 2012.