Ultrasound-guided axillary brachial plexus block versus distal peripheral forearm nerve block for hand and wrist surgery: a randomised controlled trial

Abstract

Keywords: axillary brachial plexus block; carpal tunnel release; distal peripheral forearm block; hand surgery; operating theatre efficiency; ultrasound-guided regional anaesthesia EditordRegional anaesthesia and local anaesthesia are increasingly recognised as the best options to provide anaesthesia for ambulatory hand and wrist surgery. 1 Ultrasound (US)-guided axillary brachial plexus block is one of the preferred techniques of most anaesthesiologists for distal upper extremity surgery. 2 Disadvantages of this technique include the risk of arterial puncture and slower onset compared with i.v. regional anaesthesia. 1 In recent years, a growing body of literature has investigated the potential of US-guided distal nerve blocks as a primary anaesthetic technique. 3,4 The main advantage of distal peripheral forearm nerve blocks is the preservation of motor function of the digits and the more proximal muscles. 5 Because of the large number of short procedures performed within the field of hand surgery, rapid turnover with reliable regional anaesthesia is required for optimal efficiency. However, block performance time and total anaesthesia-related time, focused on regional anaesthesia for hand surgery, have not been studied in an RCT. This observer-blinded, randomised controlled superiority trial was designed to compare US-guided axillary brachial plexus block and distal peripheral forearm nerve block in patients undergoing hand surgery and carpal tunnel release. The detailed methods are included in the Supplementary material. Briefly, ethical approval (Ethics Committee of the Jessa Hospital, Hasselt, Belgium; B2432020000027), registration (ClinicalTrials.gov, December 16, 2020, NCT04678765), and written informed consent were obtained. The first subject was enrolled after approval of an amendment by the ethical committee of the Jessa Hospital on January 13, 2021. In total, 80 adult patients undergoing unilateral hand surgery (i.e. foreign body removal and abscess incision/drainage of the hand; trigger finger release; tendon repair; and Dupuytren's contracture release surgery, with exclusion of surgery on Digit I, finger amputation, and manipulation of Digits III, IV, and V) or carpal tunnel release with an ASA physical status of 1e3 were enrolled over 10 months from January to October 2021. Exclusion criteria included BMI !40 kg m À2 , puncture site infection, pre-existing peripheral neuropathy, chronic pain syndrome, diabetes mellitus, allergy to study medications, or coagulopathy. Participants were randomly assigned in a 1:1 ratio to US-guided axillary brachial plexus block or US-guided distal peripheral forearm nerve block using sealed envelopes. Nerve blocks were performed in a regional anaesthesia block room by a highly experienced anaesthesiologist. Distal peripheral forearm nerve blocks were performed, as described by Jalil and colleagues, 3 and included a US-guided mid-forearm median and ulnar nerve block with a circumfer-ential subcutaneous infiltration on the radial side of the wrist. Axillary brachial plexus blocks were performed similar to the method described by Tran and colleagues. 6 The primary superiority outcome was total anaesthesia-related time,