Local Anesthesia With Minimal Sedation and Brachial Plexus Block in Hand Surgery
Primary Purpose
Hand Surgery, Quality of Recovery, Hand Injuries
Status
Completed
Phase
Not Applicable
Locations
Canada
Study Type
Interventional
Intervention
Local anesthesia with minimal sedation
Sponsored by
About this trial
This is an interventional supportive care trial for Hand Surgery focused on measuring hand surgery, quality of recovery, local anesthesia, regional anesthesia, QoR-15
Eligibility Criteria
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
Sites / Locations
- Montreal General Hospital
- St-Mary's Hospital
Arms of the Study
Arm 1
Arm 2
Arm Type
No Intervention
Active Comparator
Arm Label
Brachial plexus block (infraclavicular)
Local anesthesia with minimal sedation
Arm Description
The standard of care at our institution. Performed by experienced regional anesthetists.
The comparison group. Performed by the operating surgeon.
Outcomes
Primary Outcome Measures
Quality of Recovery 15 Questionnaire (QoR-15)
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.
Secondary Outcome Measures
Block performance time, onset time, and nonsurgical time
To compare local anesthesia to brachial plexus block in hand surgery with respect to performance time, onset time, and nonsurgical time.
Opioid use at 24 hours after surgery
To evaluate patient-reported 24-hours post-operative pain and use of opioid analgesia following local anesthesia versus brachial plexus block.
Full Information
NCT ID
NCT03632304
First Posted
August 8, 2018
Last Updated
April 19, 2021
Sponsor
McGill University Health Centre/Research Institute of the McGill University Health Centre
1. Study Identification
Unique Protocol Identification Number
NCT03632304
Brief Title
Local Anesthesia With Minimal Sedation and Brachial Plexus Block in Hand Surgery
Official Title
The Quality of Recovery of Local Anesthesia With Minimal Sedation and Brachial Plexus Block in Hand Surgery: A Randomized Controlled Study
Study Type
Interventional
2. Study Status
Record Verification Date
April 2021
Overall Recruitment Status
Completed
Study Start Date
August 17, 2018 (Actual)
Primary Completion Date
June 30, 2020 (Actual)
Study Completion Date
June 30, 2020 (Actual)
3. Sponsor/Collaborators
Responsible Party, by Official Title
Principal Investigator
Name of the Sponsor
McGill University Health Centre/Research Institute of the McGill University Health Centre
4. Oversight
Studies a U.S. FDA-regulated Drug Product
No
Studies a U.S. FDA-regulated Device Product
No
Data Monitoring Committee
No
5. Study Description
Brief Summary
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.
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.
6. Conditions and Keywords
Primary Disease or Condition Being Studied in the Trial, or the Focus of the Study
Hand Surgery, Quality of Recovery, Hand Injuries, Hand Fracture, Hand Tendon Injury, Anesthesia, Local
Keywords
hand surgery, quality of recovery, local anesthesia, regional anesthesia, QoR-15
7. Study Design
Primary Purpose
Supportive Care
Study Phase
Not Applicable
Interventional Study Model
Parallel Assignment
Model Description
Randomized controlled trial
Masking
Outcomes Assessor
Allocation
Randomized
Enrollment
105 (Actual)
8. Arms, Groups, and Interventions
Arm Title
Brachial plexus block (infraclavicular)
Arm Type
No Intervention
Arm Description
The standard of care at our institution. Performed by experienced regional anesthetists.
Arm Title
Local anesthesia with minimal sedation
Arm Type
Active Comparator
Arm Description
The comparison group. Performed by the operating surgeon.
Intervention Type
Procedure
Intervention Name(s)
Local anesthesia with minimal sedation
Intervention Description
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.
Primary Outcome Measure Information:
Title
Quality of Recovery 15 Questionnaire (QoR-15)
Description
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.
Time Frame
At 24 hours post-surgery
Secondary Outcome Measure Information:
Title
Block performance time, onset time, and nonsurgical time
Description
To compare local anesthesia to brachial plexus block in hand surgery with respect to performance time, onset time, and nonsurgical time.
Time Frame
Within 24 hours of surgery
Title
Opioid use at 24 hours after surgery
Description
To evaluate patient-reported 24-hours post-operative pain and use of opioid analgesia following local anesthesia versus brachial plexus block.
Time Frame
At 24 hours post-surgery
10. Eligibility
Sex
All
Minimum Age & Unit of Time
18 Years
Accepts Healthy Volunteers
No
Eligibility Criteria
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
Overall Study Officials:
First Name & Middle Initial & Last Name & Degree
Fanyi Meng, MD
Organizational Affiliation
McGill University Health Centre/Research Institute of the McGill University Health Centre
Official's Role
Principal Investigator
Facility Information:
Facility Name
Montreal General Hospital
City
Montreal
State/Province
Quebec
ZIP/Postal Code
H3G 1A4
Country
Canada
Facility Name
St-Mary's Hospital
City
Montreal
State/Province
Quebec
ZIP/Postal Code
H3G 1A4
Country
Canada
12. IPD Sharing Statement
Plan to Share IPD
No
IPD Sharing Plan Description
There will be no need to share individual participant data based on the objectives set out by our research.
Citations:
PubMed Identifier
22032599
Citation
Lalonde DH. Reconstruction of the hand with wide awake surgery. Clin Plast Surg. 2011 Oct;38(4):761-9. doi: 10.1016/j.cps.2011.07.005.
Results Reference
background
PubMed Identifier
24286736
Citation
Lalonde D. Minimally invasive anesthesia in wide awake hand surgery. Hand Clin. 2014 Feb;30(1):1-6. doi: 10.1016/j.hcl.2013.08.015. Epub 2013 Nov 9.
Results Reference
background
PubMed Identifier
23411725
Citation
Stark PA, Myles PS, Burke JA. Development and psychometric evaluation of a postoperative quality of recovery score: the QoR-15. Anesthesiology. 2013 Jun;118(6):1332-40. doi: 10.1097/ALN.0b013e318289b84b.
Results Reference
background
PubMed Identifier
27524691
Citation
Soberon JR Jr, Crookshank JW 3rd, Nossaman BD, Elliott CE, Sisco-Wise LE, Duncan SF. Distal Peripheral Nerve Blocks in the Forearm as an Alternative to Proximal Brachial Plexus Blockade in Patients Undergoing Hand Surgery: A Prospective and Randomized Pilot Study. J Hand Surg Am. 2016 Oct;41(10):969-977. doi: 10.1016/j.jhsa.2016.07.092. Epub 2016 Aug 11.
Results Reference
background
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Local Anesthesia With Minimal Sedation and Brachial Plexus Block in Hand Surgery
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