Editor:
There is little data to support the favourable recovery and cost profiles of peripheral nerve block (PNB) over general anaesthesia (GA). Studies have demonstrated that the recovery profile following hand, wrist or shoulder surgery has improved after regional anaesthesia (RA), resulting in a higher degree of patient satisfaction [Reference Pavlin, Chen and Penaloza1–Reference D’Alessio, Rosenblum, Shea and Freitas5]. The purpose of this study was to evaluate the efficacy, recovery profile and perioperative costs of RA compared with those of GA in patients undergoing upper extremity surgery in our day-surgery centre.
Our Institutional Review Board approved this study. All upper extremity surgical procedures performed in our day-surgery centre from September 1999 through August 2000 were reviewed. We generated two study groups: patients who received brachial plexus block and those who received GA. Anaesthetic choice was made collaboratively by anaesthesiologists and patients according to the routine practice at our institution.
In both groups, residents supervised by staff anaesthesiologists provided anaesthesia care. Routine non-invasive monitors were used for all patients. Blocks were placed by the same care team scheduled to provide anaesthesia during surgery. No additional personnel were assigned to facilitate PNB. During block placement, light sedation was provided with midazolam (1–2 mg) and fentanyl (25–250 mcg). The brachial plexus block was administered using a single injection technique with a 22-G, 50 mm, short-beveled tip, insulated needle (Stimuplex®; B. Braun AG, Melsungen, Germany) and a nerve stimulator (Stimuplex®; B. Braun AG, Melsungen, Germany). Mepivacaine 1.5% with sodium bicarbonate 10% v/v was used. In selected PNB patients, sedation was provided during surgery using a propofol infusion at a rate of 10–50 mcg kg−1 min−1. Failed nerve blocks were converted to general anaesthesia. General anaesthesia was administered using either a laryngeal mask (in 80 of 121 patients) or an endotracheal tube (in 41 of 121 patients). Propofol was the induction agent along with a short-acting inhalation agent (sevoflurane or desflurane), fentanyl or sufentanil in titrated doses and cisatracurium, as needed for muscle relaxation. Patients were discharged from the phase-1 recovery using the Modified Aldrete Recovery Scoring System [Reference Aldrete6].
The two groups were analysed and compared based on the following data: (1) anaesthesia preparation time, i.e., the time elapsed from the start of continuous anaesthesia care until the patient was ready for surgery; (2) length of stay in the post-anaesthesia care unit (PACU) from admission to discharge; (3) number of patients who bypassed phase-1 recovery based on a modified Aldrete score of 9 or above [Reference Aldrete6]; (4) number of unplanned admissions; (5) frequency of critical postoperative complications, i.e., persistent pain management issues, intractable nausea and vomiting, postoperative airway obstruction requiring airway manipulation, aspiration and emergence delirium; and (6) all perioperative costs including admission, operating room, PACU, phase-2 recovery and pharmacy and anaesthesia supplies. Charges for surgical supplies and physician fees were excluded.
Data are expressed as a mean ± standard deviation and were analysed using a t-test with Bonferroni’s test or ANOVA when appropriate. Non-parametric data were analysed by χ2-test. Significance is indicated at P < 0.05.
We identified 92 PNB and 121 GA patients (n = 213) who underwent upper extremity day-surgery. The two groups are demographically similar (Table 1), with the exception of a preponderance of male and younger patients in the GA group (P < 0.05) and two ASA IV patients in the PNB group. Painful surgery types were bone, joint and amputation (Table 1), whereas less painful surgery types were vascular and soft tissue, with no difference in case distribution between the groups.
Patient data presented as mean ± SD or numbers of patients.
*P < 0.05.
Eighty-five axillary (91.3%), six interscalene (6.5%) and two supraclavicular (2.2%) blocks were performed. Eight failed blocks (8.7%) were converted to GA (four male and four female), but were retained in the PNB group for data analysis. There was no significant difference in anaesthesia preparation time between the two groups (19 ± 13 min for PNB vs. 15 ± 13 min for GA, P = 0.685). However, average PACU time was 15 ± 36 min in the PNB group vs. 49 ± 32 min in the GA group (P < 0.0001). Seventy patients in the PNB group (76.1%) were fast-tracked to phase-2 recovery vs. two patients (1.7%) from the GA group (P < 0.05).
The frequency of postoperative complications was significantly lower in the PNB group (three patients (3.3%) vs. 14 (11.7%) in the GA group, P < 0.05). Severe or persistent emesis did not occur in the PNB group, but was a problem in four patients (3.3%) in the GA group. One patient (0.8%) in the GA group experienced an airway obstruction that required airway manipulation. No other complication was recorded in either of the two groups. There was a total of eight (6.7%) unplanned admissions, all from the GA group, four (3.3%) owing to intractable nausea and vomiting and four (3.3%) owing to persistent pain management issues. Perioperative costs in the PNB group were $3656 ± 1904 per patient vs. $4780 ± 2721 per patient in the GA group (P < 0.05).
Discussion
This retrospective study has compared objective measurements such as time efficiency, complications, unplanned admissions and perioperative costs of RA vs. GA for upper extremity day-surgery. Investigator bias is reduced as the anaesthesiologist managed the cases according to the standard procedure in our institution in a real-life situation, with no pressure to facilitate one or the other group or to modify a management plan according to his/her preconception. Therefore, it represents a valuable method for evaluating and reporting these types of data, and is similar to the Williams and colleagues study on the economics of nerve blocks [Reference Williams, Kentor and Vogt4].
Inadequate pain control and persistent nausea and vomiting are the two major reasons for unplanned hospital admission after ambulatory surgery [Reference Bardiau, Taviaux and Albert7]. PNB addresses these problems. Although longer anaesthesia preparation time is a potential disadvantage of PNB, only a small, non-significant increase in preparation time for PNB was noted in this study. This finding may be the result of the frequent use of these techniques at our institution, with a resultant inherent efficiency. Furthermore, in the PNB group, a significant decrease in PACU time was noted with more frequent bypass of phase-1 recovery and fewer postoperative complications and associated unplanned admissions, resulting in a significant decrease in perioperative costs. Other studies of RA for upper extremity surgery have also demonstrated shorter recovery times and less complications compared to GA [Reference Hadzic, Arliss and Kerimoglu2,Reference Hadzic, Williams and Karaca3,Reference D’Alessio, Rosenblum, Shea and Freitas5,Reference Aldrete6]. In conclusion, these data support the use of PNB in upper extremity day-surgery and can translate into significant healthcare cost savings.
