surgery of the upper extremity from the standpoint of local and
Dr Frederic Kresser/F.I.H.S
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
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
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
of pre-medication (according to the degree of the patient's anxiety,
possible allergy, etc.)
be taken into account by the patient whether he/she is under medication
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.
The operative period
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 :
brachial plexus block for surgery of shoulder
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.
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
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
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.
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.
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.
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.