Ambulatory surgery of the upper extremity from the standpoint of local and regional anaesthesia.

Dr Frederic Kresser/F.I.H.S

Pre-operative period
Operative period
Post-operative period

Introduction

Ambulatory anaesthesia is designed to meet the needs of ambulatory surgery, so that the patient can return home in no more than 12 hours after the surgical intervention. Ambulatory anaesthesia is conducted by an anaesthetist-reanimator.
In France, around 27% of anaesthesia is ambulatory. The pre-anaesthetic appointment is essential to determine whether the patient will receive this type of anaesthesia. This decision is made both by the anaesthetist and the surgeon.

It is important to use techniques that allow rapid recovery of the main vital functions, as well as the fewer number of side effects possible.
The surgery of upper extremity (and/or hand) in particular, seems to meet these demands :


The patient to be operated on will undergo these stages :

The pre-op period

The selection of operations and patients is of great significance. This selection will first be made by the surgeon, and later confirmed by the anaesthetist-reanimator during the compulsory pre-anaesthetic appointment. (this appointment should be held several days before the surgical operation, except for emergency cases)

The anaesthetist-reanimator will conduct a questionnaire and make a clinical exam to the patient, who will be given documentation with information and recommendations. The patient is also likely to be prescribed pre-op exams.

Later, the patient and his/her family will receive a brief explanation of the anaesthetic technique selected for the operation. Both parties, the patient and his/her family, provide the final consent.

Finally, the following items will be arranged :

duration of the pre-op fast.
The selection of pre-medication (according to the degree of the patient's anxiety, possible allergy, etc.)
indications to be taken into account by the patient whether he/she is under medication
more `prosaic` considerations such as : basic hygiene rules, advice on clothing, solution to the means of transport, etc.

The pre-anaesthetic appointment will be held in the ambulatory offices the morning of the operation date. Its aim is to verify whether all the indications above have been followed and respected.
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The operative period

The anaesthetic environment : the technical facilities at the Victor Hugo Clinic are: an operating room, a post-op monitoring room, and surgery recovery rooms where the patient will rest during his/her short stay before returning home.
Each room is equipped with a relaxation stretcher or a bed, fluids (oxygen and suction) The patient will have a warning device in case of need. A nurse will permanently visit the room to check upon the clinical conditions of the operated patients.
The local and regional anaesthesia is performed in a reanimation room. A pulse oximeter allows to check the patient during the anaesthesia and his/her transfer to the operating room.
The operating room has a ventilator for anaesthesia, a defibrillator and a complete monitoring equipment (saturometer, capnometer, electrocardiographies, etc.) The operative and postoperative monitoring offered to the patient, is the same as the one used in patients that undergo general anaesthesia.

Local and Regional anaesthesia techniques : in our unit anaesthesia is classified as follows :

plexus anaesthesia : 60%
brachial anaesthesia : 35%
other local and regional anaesthesia : 5%

For the Local and Regional anaesthesia, our team utilises a neuronal simulator which allows to locate, in a very selective manner, the nerve structures, without establishing direct contact with the nerves, in order to decrease the nerve connection risk to reduce patient's discomfort.

All the material is utilised only one time.
The need to achieve success of all local and regional anaesthesia, has led us to use only the techniques we know for certain are beneficial. Therefore, we have ruled out some techniques which are considered too dangerous (e.g. intravenous local anaesthesia)

    blocs plexiques :
interscalenic brachial plexus block for surgery of shoulder
infraclavicular, axillary and/or humerus tunnel block, for the region of elbow to hand surgery.

    brachial blocks (also medial radial and ulnar nerves) :
at the elbow level
at the wrist level
for short length surgery at the hand level

    some intratecal anaesthesia of the flexor sheath for a short length surgery at the fingers level.

Anaesthetic drugs : it is an adequate concentration of substances which when in contact with a muscular or nerve structure, temporarily and reversibly block the nerve supply to a part of the body.
There is a wide range of products available. Thus, the anaesthetist can choose the appropriate drug depending upon the length of the operation, the technique chosen. The current therapeutic options allows to choose from various drugs such as.

Lidocaine, Carbocaine, Mepivacaine, Ropivacaine, etc

These drugs are used alone or in combination with other drugs. The addition of a adjuvant - Adrenaline or Clonidine - allows to extend the effect of local anaesthetics (this is used when there are no contraindications regarding the patient's clinical condition or the type of surgery)

Surgical Operation : the patient is taken to the operating room by the stretcher-bearer. The medical file accompanies the patient so as not only to verify that the preoperative guidelines have been respected, but also to write the postoperative prescriptions. The patient's observation is guaranteed by the monitoring above mentioned.
Even though the anaesthetics might be "working" normally, the anxiety of the patient, or the operating table, may make the patient need an additional sedative. Most often, sedation means the injection of a low dose of benzodizapine. We always consider the risk of using a very strong sedative.

Transfer to the postoperative observation room: length of observation varies. It depends upon the type of anaesthesia performed , length of operation, eventual pain, and pace of patient's recovery.
If the patient has pain, it is necessary to relieve it immediately, because the later it is relieved, greater is the number of required doses to calm the patient. Besides, a sharp pain may cause nausea and vomiting.

The patient will be transferred to the surgery recovery room, provided he/she responds to a certain number of clinical parameters under a scores system. The most frequently used is the Aldrete, which measures motor function, breathing, 02 saturation, blood pressure and consciousness.

Once the patient is in the room, he/she will be given a light meal. According to the surgeon and/or anaesthetist's prescription, the nurse will administer analgesics to replace the local and regional anaesthetics when it wears off. A sling will keep the upper extremity elevated. Therefore, the return of the motor function is expected without running any risk.
Before the patient is discharged, he/she will have a medical examination performed. The patient's authorisation to leave the institute is signed by the anaesthetist or the surgeon. Sometimes, it is required that the patient stay overnight , either because the operation lasted longer than expected and ended at the end of the day, or because the observation conditions at the patient's home are not the required ones. The patient and his/her companion will get instructions in a written and oral form. The patient is told that during the 24 first hours, he/she might undergo some minor discomfort namely: pains, nausea, vomiting, headaches, dizziness, tiredness, drowsiness, etc. These symptoms should wear off within 24/28 hours after the surgical procedure. In the documentation given to the patient, there is a telephone number to contact a doctor from the team anytime.

Returning home
The patient must return home accompanied. The way back home should be made by private car or a special vehicle (taxi, ambulance, LSV -Light Sanitary Vehicle-, etc) Under no circumstances should the patient return home by his/her own means, or by public transport. Once the patient is at home, he/she should not be alone, especially during the night after the procedure. The support of the treating doctor is essential, provided he/she is aware of the situation before the operation, he/she is entitled to give adequate advice, or stay with the patient.

Postoperative follow-up
The first postoperative appointment often takes place between one and five days after the surgical operation, depending on the type of operation, the pathology, the field and patient's location. The patient has the possibility of contacting the surgical team on duty anytime.
Any information of significance concerning the anaesthesia or the surgery during the operative stages is recorded in a computerised medical file which allows doctors to have precise knowledge of the evolution of the procedure, the distribution of techniques used, or the incidence of side complications.


Conclusion

Most patients require local and regional anaesthesia. In our Centre, 70% of our patients are benefited with such requirement.
Surgery of Upper extremity at the FIHS, is performed in accordance with the guidelines above.