Background & Aims
Complex hand injuries are associated with extreme pain that is often inadequately relieved by commonly prescribed intravenous analgesics in trauma bay. These patients frequently witness a prolonged preoperative waiting periods as trauma emergencies are triaged based on life / limb saving surgical indications.These long waiting periods intensify agony of the patient, especially during detailed wound inspection, dressing and debridement. There has been a surge in the use of ultrasound (US) guided single injwe conceptualized a randomized controlled trial to compare continuous brachial plexus analgesia with standard care using intravenous systemic analgesics in patients with complex hand injuries , awaiting a free slot for surgical repair in operating room. Our primary objective was to evaluate pain relief one hour following intervention, with secondary objectives being total analgesic consumption, patient satisfaction and persistent post-surgical pain at 15 and 30 days postoperatively
Methods
Our study enrolled 80 American Society of Anesthesiologists (ASA) physical status I-II patients, 18-60 years of age, with complex unilateral hand injuries.All patients included in the study were explained about the pain scores using an 11-point NRS score that ranged from 0 (“no pain”) to 10 (“worst pain imaginable”) at rest. As an immediate measure to control pain, all patients received injection tramadol 2mg/kg intravenously at time zero before randomisation. Thereafter , patients were randomized to either US-guided infraclavicular BPB (BPB group) or standard regimen. A bolus of 0.2% Ropivacaine injection (maximum volume 20ml) was administered after confirmation of needle placement.Patients in group C received injection paracetamol 500 mg with injection diclofenac 50 mg intravenously administered at regular intervals every sixth hourly and eighth hourly respectively. The selection of drugs and the doses were as per standard protocol of the institute.
Results
The demographics as well as injury characteristics of the cohort , pre-hospital treatment received and numerical rating scale NRS scores on arrival were comparable.The NRS scores were recorded during painful interventions like wound reassessment and dressing , debridement , splinting or radiology in Trauma Triage. None of the patients in brachial plexus analgesia reported pain or discomfort during any of these interventions. On the other hand , patients receiving standard regimen using intravenous analgesics reported discomfort and higher NRS scores during these interventions , with 10% patients experiencing severe pain (p=0.00). Also, breakthrough pain necessitating administration of rescue analgesia was noted in n= 38 / 40 patients in this group. The median time to first rescue analgesia was 7 hours (4-19 IQR) in Group C, with the median cumulative consumption of tramadol 4800 mg prior to surgery.Persistent post-surgical pain (PPSP) was assessed on postoperative days 15 and 30 .. The percentage of patients with PPSP was statistically significantly higher in Group cBPB than Group C
Conclusions
Hand injuries are associated with significant pain. The use of brachial plexus block permits complete resolution of pain and enhances patient comfort. It also allows surgeon to reassess and dress the wound when required. Additionally, there is drift towards earlier surgical intervention as prior placement of catheter saves on operating room time. The decrease in incidence of post -surgical persistent pain is another potential benefit, yet not reported after on arrival nerve blocks. Further studies are also required to understand the effects of early analgesia on physiotherapy and incidence of chronic pain. We also recommend future work on the role peripheral nerve blocks as a component of enhanced recovery pathway as well as a way forward to environmental sustainability
References
1. Wathen, J.E., et al., A randomized controlled trial comparing a fascia iliaca compartment nerve block to a traditional systemic analgesic for femur fractures in a pediatric emergency department. Ann Emerg Med, 2007. 50(2): p. 162-71, 171 e1.
2.Liebmann, O., et al., Feasibility of forearm ultrasonography-guided nerve blocks of the radial, ulnar, and median nerves for hand procedures in the emergency department. Ann Emerg Med, 2006. 48(5): p. 558-62.
3.Stone, M.B., R. Wang, and D.D. Price, Ultrasound-guided supraclavicular brachial plexus nerve block vs procedural sedation for the treatment of upper extremity emergencies. Am J Emerg Med, 2008. 26(6): p. 706-10.
4.Mariano, E.R., et al., A randomized comparison of infraclavicular and supraclavicular continuous peripheral nerve blocks for postoperative analgesia. Reg Anesth Pain Med, 2011. 36(1): p. 26-31.
5. Wilson, J.L., et al., Infraclavicular brachial plexus block: parasagittal anatomy important to the coracoid technique. Anesth Analg, 1998. 87(4): p. 870-3.
Presenting Author
Kajal Jain
Poster Authors
Topics
- Models: Acute Pain