Does motor block related to long-acting brachial plexus blockcause patient dissatisfaction after minor wrist and handsurgery A randomized observer-blinded trialM J Fredrickson13 P J Wolstencroft3 S Chinchanwala34 and M R Boland23

1 Department of Anaesthesiology and 2 Department of Surgery Faculty of Medical and Health Sciences University of Auckland AucklandNew Zealand3 Auckland Southern Cross Hospital Group Auckland New Zealand4 Waitemata District Health Board Auckland New Zealand

Corresponding author Anaesthesia Institute PO Box 109 199 Newmarket Auckland New Zealand E-mail michaelfredricksonyahoocom

Editorrsquos key points

dagger Motor block after regionalanaesthesia may have animpact on patientsatisfaction

dagger The authors comparedshort- or long-actingregional anaesthesia forwrist and hand surgery

dagger Both the groups hadsimilar level of patientsatisfaction

dagger The importance ofstudyingprocedure-specificpatient satisfaction ishighlighted

Background Patient dissatisfaction has been previously associated with motor block inshoulder surgery patients receiving brachial plexus block For elective minor wrist andhand surgery we tested whether a regional block accelerating the early return of upperextremity motor function would improve patient satisfaction compared with a long-acting proximal brachial plexus block

Methods A total of 177 patients having elective lsquominorrsquo wrist and hand surgery underawake regional block randomly received adrenalized infraclavicular lidocaine 2 10ml+ropivacaine 075 20 ml (lsquolong actingrsquo nfrac1490) or adrenalized infraclavicularlidocaine 15 30 ml+long-acting distal median radial and ulnar nerve blocks selectedaccording to the anticipated area of postoperative pain (lsquoshort actingrsquo nfrac1487) A blindedobserver questioned patients on day 1 for numerically rated (0ndash10) subjective outcomes

Results With 95 power there was no evidence for a 1-point satisfaction shift in the shortacting group satisfaction was similarly high for both groups [median (inter-quartilerange)frac1410 (8ndash10) vs 10 (8ndash10) Pfrac14071] and also demonstrated strong evidence forequivalence [mean difference (95 confidence interval)frac142018 (2070 to 035)] Therewas no difference between the groups for weakness- or numbness-related dissatisfaction(low for both groups) or for numerically rated or time to first pain Surgical anaesthesiasuccess was similar between the groups (short acting 97 vs 93 Pfrac14050) althoughmore patients in the short acting group had surgery initiated in le25 min (Pfrac14003)

Conclusions Patient satisfaction is not improved after elective minor wrist and handsurgery with a regional block accelerating the early return of motor function For thissurgery motor block related to a long-acting brachial plexus block does not appear tocause patient dissatisfaction

Clinical Trial Registration number ACTRN12610000749000 httpswwwanzctrorgauregistrytrial_reviewaspxID=335931

Keywords anaesthetic techniques regional brachial plexus anaesthetics local ropivacaine

Accepted for publication 21 May 2012

Our group previously demonstrated an association betweenupper extremity motor block and patient dissatisfactionduring continuous interscalene analgesia for shouldersurgery1 2 Consistent with this evidence many of thesepatients voluntarily report dissatisfaction with being unableto use their hand and fingers as a result of block of thecaudalinferior elements of the brachial plexus Similarly inpatients representing for minor wrist and hand surgeryunder regional anaesthesia we have noted some voluntarily

reporting dissatisfaction from the lsquodead armrsquo sensation asso-ciated with long-acting brachial plexus block

An evolving approach to upper extremity regional anaes-thesiaanalgesia3 4 for wrist and hand surgery involves short-acting brachial plexus block combined with long-acting distalblocks5 In addition to previously published evidence demon-strating that this lsquocombinedrsquo technique accelerates blockonset and improves block consistency5 it also has the theor-etical benefit of promoting the early return of upper

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extremity motor function which might theoretically improvepatient satisfaction

Therefore in patients undergoing elective minor wrist andhand surgery we tested whether substitution of a longacting for a short-acting infraclavicular block (supplementedwith long-acting distalperipheral blocks) would improveearly patient satisfaction

MethodsThe local institutional review board (Northern Y RegionalEthics Committee Hamilton New Zealand) approvedthe trial The primary and secondary endpoints includingthe specific timing of their measurement together with theintended sample size were prespecified before trial com-mencement (ie a priori)6 at the Australian and NewZealand Clinical Trials Registry (ACTRN12610000749000September 2010) A statement regarding the backgroundand rationale for the trial was also made at this time Weenrolled consecutive adult ASA IndashIII patients of all BMIsundergoing elective lsquominorrsquo wrist and hand surgery in theinvestigatorsrsquo practice at the Southern Cross Northern Clinicand North Harbour Hospitals from September 2010 throughDecember 2011 The following patients were excludedthose who refused brachial plexus block or were assessedas requiring a postoperative perineural catheter (eg wristfusion wrist replacement major radial or ulnar osteotomyand suspension arthroplasty) or were likely to receive anabove elbow cast (therefore expected to benefit only margin-ally from the accelerated return of motor function) (Fig 1)Other exclusion criteria were known neuropathy involvingthe arm undergoing surgery and known amide local anaes-thetic allergy Written and oral informed consent wasobtained from all patients the trial was in keeping with theHelsinki declaration and we followed the CONSORT guidelinesfor reporting randomized clinical trials

A research assistant invited the patients to participateand the definitive recruitment was done by the operating in-vestigator The design was a two-centre prospective rando-mized observer-blinded trial

Block technique and randomization5

An operator experienced in ultrasound-guided regional anaes-thesia (MJF and PW) placed all blocks in a dedicated roombeside the operating theatre (see httpwwwultrasoundblockcom) Immediately before block placement all patientsreceived iv sedation up to midazolam 2 mg and alfentanil 05mg Using a computer-generated random number in blocks of20 (wwwrandomorg) a research assistant remote from thestudy procedures implemented random assignment to thelsquolong actingrsquo or lsquoshort actingrsquo group Randomization was notstratified by procedure The groups were concealed by using183 pre-prepared sealed opaque envelopes opened immedi-ately before block placement

All patients first received a single-injection infraclavicu-lar brachial plexus block7 which were performed with 18G Tuohy needles (Portex Kent UK) and a high-resolution

ultrasound machine (SonoSite M-Turbo SonoSite BothellWA USA) Patients were positioned supine with the armadducted and the head turned to the contralateral side Apillow was placed between the shoulder blades to extendboth shoulders and therefore facilitate deltopectoralgroove exposure An 8ndash5 MHz curvilinear probe (SonoSiteC11 Bothell) was placed in the deltopectoral groove witha sagittal orientation and medial-to-lateral position wherethe clearest image of the middle third of the axillaryartery was obtained First the skin subcutaneous tissueand adjacent pectoralis muscles were infiltrated with localanaesthetic under ultrasound guidance Subsequently the18 G Tuohy needle was advanced using in-planeneedle-probe alignment with the bevel facing dorsally toa position posterior to the axillary artery This endpointnecessitates a lsquopoprsquo as the fascia cephaloposterior to theaxillary artery is penetrated At this point all local anaes-thetic was deposited regardless of brachial plexus cordvisualization7 however some needle manipulation in acephalocaudad direction (not extending beyond the cepha-locaudad borders of the axillary artery) was permitted topromote a lsquosaucerrsquo shaped or lsquobubblersquo pattern spreaddorsal to the artery (sometimes described as a lsquodoublebubblersquo sign one bubble represents the artery the otherrepresenting local anaesthetic) The lsquoshort actingrsquo groupreceived 30 ml lidocaine 15 with epinephrine 1200 000followed by an ultrasound-guided distal median radialand ulnar nerve block (using ropivacaine 05) selectedaccording to the anticipated area of postoperative pain(eg wrist arthroscopy median radial and ulnar blockscarpal tunnel and Dupuytrenrsquos release median and ulnarblocks) (Fig 1) The lsquolong actingrsquo group received 30 ml ofa 1020 mixture of lidocaine 2+ropivacaine 075 withepinephrine 1200 000 (ie 30 ml ropivacaine 05) Distalmedian radial and ulnar blocks (using lidocaine 2)were allowed in this group if the operating anaesthesiolo-gist deemed them necessary to speed up onset All distalblocks were performed with the same ultrasoundmachine but a 10ndash5 MHz linear array probe (SonoSiteL38) a 22 G 5 cm B-Plexw needle (Plexufix B|Braun Bethle-hem PA USA) an in-plane needle imaging technique and4 ml local anaesthetic for each nerve

The procedural objective of distal blocks was to place localanaesthetic in proximity in at least two positions (ideallyeach side) around the nerves but specifically avoiding intra-neural injection as follows

(1) Median nerve At the mid-forearm level between theflexor digitorum superficialis muscles and flexor digi-torum profundus muscles8 The arm was abductedand externally rotated with the palm facing upNeedle advancement was in-plane from the radial tothe ulnar side of the forearm

(2) Ulnar nerve At approximately the junction of themiddle and proximal thirds of the forearm just prox-imal to where the nerve diverges from the ulnarartery9 The arm was abducted and externally

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rotated with the palm facing up Needle advancementwas in-plane from anterior to posterior

(3) Radial nerve At approximately the junction of themiddle and distal thirds of the arm just distal to thenerve leaving the spiral groove of the humerus9 10

The arm was adducted and internally rotated withthe forearm resting on the chest Needle advance-ment was in-plane from anterior to posterior

Patients were then taken to the operating theatre and pre-pared for surgery by the application of surgical tourniquet

Anaesthesia and analgesia

A standardized technique was used Multimodal analgesiaconsisted of preoperative oral acetaminophen 1 g and

intraoperative iv parecoxib 05 mg kg21 (maximum 40mg) Most surgery was conducted awake The primarysurgeon (MRB SC) blinded to the treatment group deter-mined whether additional surgical site infiltration or deepsedation was needed in the case of inadequate surgical an-aesthesia Anxious patients received additional midazolamas requested with the intention of remaining responsive toverbal commands throughout the procedure Subjects refus-ing awake surgery received a propofol infusion (targetplasma propofol concentration 20ndash30 mg ml21) with sup-plemental oxygen 1ndash4 litre min21 by a facemask as neces-sary If deep sedation could not be maintained (eginability to maintain a patent natural airway) the patientsreceived general anaesthesia using a laryngeal mask airway

Long acting Short acting

1 Infraclavicular -lidocaine 2 10 ml -ropivacaine 075 20 ml2 plusmnDistal medianradialulnar blocks -lidocaine 2 4 ml per nerve

1 Infraclavicular -lidocaine 15 30 ml2 Distal medianradialulnar blocks -ropivacaine 05 4 ml per nerve

Analysed (n=90)

Lost to follow-up (n=1)

Allocated to intervention (n=92)reg Received allocated intervention (n=91)

reg Did not receive allocated intervention (unanticipated above elbow cast =1 n=1)

Lost to follow-up (n=0)

Allocated to intervention (n=91)reg Received allocated intervention (n=87)

reg Did not receive allocated intervention (unanticipated above elbow cast =1 unanticipated major procedure =3 n=4)

Analysed (n=87)

Allocation (n =183)

Analysis (n=177)

Follow-Up (n=178)

Exclusions (most common)

sum Patient refusal

sum lsquoMajor procedurersquo

sum Anticipated above elbow cast

wrist fusion or replacementradialulnar osteotomysuspension arthroplasty

Randomized (n =183)

Fig 1 Overview of treatment arms

Satisfaction with brachial plexus motor block BJA

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Post-anaesthesia care unit protocol

In the post-anaesthesia care unit (PACU) patients emergingfrom general anaesthesia reporting a numerical rating painscore (NRPS 0ndash10) of more than 2 were given morphine 2mg every 2ndash3 min to achieve an NRPS of le2

Multimodal analgesia was continued after surgery regularacetaminophen (1 g every 6 h) and diclofenac slow release(75 mg every 12 h) and in selected patients PRN tramadolslow release (100 mg every 12 h 50 mg every 12 h if age70 or weight 60 kg) if the NRPS increased to 2despite regular acetaminophen and diclofenac Dischargehome occurred 1ndash4 h after surgery

Data collection

Infraclavicular block procedural time was recorded by the op-erating investigator and was defined as the time from theultrasound probe being placed on the skin before needlepuncture until the needle exited the skin after local anaes-thetic administration Subsequent distal nerve blocks wererecorded but associated procedural time was not The oper-ating investigator recorded the occurrence of inadvertentvascular puncture and asked subjects lsquoHow would you rateyour discomfort during the block on a scale of zero to 10 ifzero is no discomfort and 10 is the worst discomfort imagin-ablersquo and lsquoDid you experience an electric shock-like sensa-tion in the arm during the procedurersquo The operatinginvestigator recorded the surgical start time the need forsurgical infiltration and patient requested sedation orgeneral anaesthesia and whether take home tramadol wasprescribed Block to surgical incision time was defined asthe time from the ultrasound probe being placed on theskin to surgical incision and surgical anaesthesia successas surgery without the requirement for surgical site infiltra-tion or deep sedation administered for intraoperative painPatients who received deep propofol sedation because ofrefusal to undertake awake surgery per se were not desig-nated as having failed surgical anaesthesia The patientrsquosprimary PACU nurse recorded the emergence wristhandNRPS and the requirement for morphine rescue A researchassistant phoned all subjects at 24 postoperative hours andquestioned for overall satisfaction with the pain reliefduring the previous 24 h supplemental tramadol consump-tion time to first pain NRPS (worst and lsquoaveragersquo painduring the previous 24 h) and for numbness- and weakness-related dissatisfaction Numerically rated scales were scored0ndash10 0 no pain no numbness- or weakness-related dissat-isfaction very unsatisfied overall 10 worst imaginable painworst imaginable numbnessweakness-related dissatisfac-tion very satisfied overall Subjects were also asked (yesno) whether they would have this anaestheticanalgesictechnique again for this surgery

Blinding of treatments

All data collection could be considered observer blindedexcept data collected by the operating investigator Forethical reasons placebo distal peripheral nerve block

injections were not used in the lsquolong actingrsquo group thereforepatients were not blinded to the treatment group

Study endpoints

The primary endpoint was numerically rated (0ndash10) painrelief satisfaction assessed at 24 postoperative hours Themain secondary endpoints were time to first pain numerical-ly rated pain and weakness- or numbness-related dissatis-faction during the first 24 h

Statistical analysis

An independent statistician (Richard White) blinded tothe treatment group performed all calculations Categoricaloutcomes were compared using the Fisher exact test(procedure-related paraesthesia number undergoingsurgery within 25 min surgical anaesthesia success propor-tion prescribed and requiring tramadol) Non-normally dis-tributed continuous variables (infraclavicular procedural andblock to surgical incision time) and ordinal outcomes (all nu-merically rated scores) were compared using the MannndashWhitney U-test Many patients had not reported pain at the24 h consultation therefore time to first pain was comparedusing the Log-rank (MantelndashCox) test P-values of 005were considered statistically significant Two-sided testswere used for all study outcomes

Other data were described using appropriate descriptivestatistics [meanstandard deviation (SD) or meanrangefor normally distributed or symmetric variables medianinter-quartile ranges (IQRs) for skewed variables numberproportion for categorical variables] Statistical analyseswere conducted with R 2121 (R Foundation Vienna Austria)

Sample size estimates were based on the demonstrationof an arbitrary 1-point shift in overall patient satisfactionbetween the groups In contrast to NRPS data no previousdata have established what constitutes a clinically relevantpatient satisfaction change the arbitrary 1-point value wasbased on two previous studies demonstrating a similar1-point satisfaction shift1 2 Pooled satisfaction data(nfrac14143) from a previous study revealed an SD of 152 Allow-ing for a 15 adjustment for the use of the t-test when asubsequent non-parametric test was expected we estimatedthat demonstration of a 1-point satisfaction shift with 95power would require 160 patients (unpaired t-test Stat-mate 20 GraphPad Software San Diego CA USA) Weaimed to recruit 180 patients to allow for dropouts

Given the lack of treatment effect shown for the primaryoutcome we performed post hoc power analysis SatisfactionSD was 19 and 16 in the long-acting (nfrac1490) and short-acting(nfrac1487) groups respectively therefore the study had 80and 95 power to detect a shift of 08 and 10 points re-spectively (Statmate 20) A test for equivalence was alsoperformed for the primary outcome by calculating themean difference [95 confidence interval (CI)] betweenthe groups

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ResultsOne hundred and eighty-three patients presenting for elect-ive wrist and hand surgery were recruited during the studyperiod 92 patients were randomized to the long-actinggroup and 91 to the short-acting group (Fig 1) Six patientswere excluded after randomization one patient in eachgroup received an unanticipated above elbow cast threepatients in the short-acting group required a postoperativeperineural catheter for an unanticipated more extensive pro-cedure and one patient in the long-acting group could notbe contacted on day 1 The remaining 177 patients were fol-lowed according to the study protocol Patient and surgicalcharacteristics were similar between the groups (Table 1)

Overall patient satisfaction did not differ between thegroups [median (IQR)frac1410 (8ndash10) vs 10 (8ndash10) Pfrac14071]and demonstrated strong evidence for equivalence meandifference (95 CI)frac142018 (2070 to 035) (Table 2)Tramadol was prescribed in 46 of patients in both groupsRequirement for rescue tramadol numbness- and weakness-related dissatisfaction (both very low for both groups) timeto first pain and numerically rated pain did not differbetween the groups (Table 2) Surgical anaesthesia successwas similar between the groups (short acting 97 vs93) but more patients in the short-acting group underwentsurgery in le25 min (25 vs 14 Pfrac14003) (Table 3) Conscioussedation was requested in 21 and 27 patients in the long-and short-acting groups respectively while deep sedationwas requested in two and three patients respectively

Five patients (3) said that they would not have the sameanaestheticanalgesic technique again for similar surgery onepatient in each group because of the lsquodeadrsquo feeling in the armone patient in the long-acting group because of discomfort

experienced during surgery one patient in the short-actinggroup because of discomfort experienced during block place-ment and one patient in the short-acting group who in retro-spect would have preferred a general anaesthetic

There were three inadvertent vascular punctures all in thelong-acting group and all without significant consequenceNo patient demonstrated symptoms or signs of systemiclocal anaesthetic toxicity

DiscussionAfter minor wrist and hand surgery we found no evidence tosupport the hypothesis of improved patient satisfaction by

Table 1 Patient and surgical characteristics (nfrac14177) Values aremean (range) or n

Long acting(n590)

Short acting(n587)

Sex (malefemale) 4941 3948

Age (yr) 46 (17ndash85) 49 (17ndash88)

Weight (kg) 85 (50ndash141) 80 (55ndash126)

Anaesthesiologist 12 5634 5730

Surgery

Wrist arthroscopydebridement

30 20

Carpal tunnel release 19 16

Ganglionmucous cystexcision

6 16

Dupuytrenrsquos release 3 5

Metacarpaldigital ORIF 9 6

A1 pulleytrigger fingerprocedure

7 11

Plate removal 3 1

Radialulnar collateralligament repair

4 1

Other 9 11

Table 2 Postoperative outcomes (nfrac14177) Values are n ()median or median (IQR) NRS numerical rating score (0ndash10 0 nonumbness- or weakness-related dissatisfaction no pain or verydissatisfied overall 10 worst numbness- or weakness-relateddissatisfaction worst imaginable pain or very satisfied overall)

Long acting(n590)

Shortacting(n587)

P-value

Satisfaction NRS 10 (8ndash10) 10 (8ndash10) 071

Tramadol required 32 (36) 30 (34) 100

Numbness-relateddissatisfaction NRS

2 (0ndash4) 1 (0ndash3) 019

Weakness-relateddissatisfaction NRS

0 (0ndash3) 0 (0ndash2) 076

Time to first pan (h) 135 119 016

lsquoAveragersquo pain NRS 1 (0ndash3) 2 (0ndash3) 042

lsquoWorstrsquo pain NRS 3 (1ndash5) 3 (1ndash5) 080

Table 3 Block placement details (nfrac14177) Values are median(IQR) n or n () NRPS numerical rating pain score (0 no pain 10worst pain imaginable) PACU post-anaesthesia care unit

Long acting(n590)

Short acting(n587)

P-value

Infraclavicularprocedural time (s)

130 (80ndash169)

120 (62ndash150) 033

Procedure-relatedNRPS

1 (0ndash2) 1 (0ndash3) 063

Procedure-relatedparaesthesia

7 8 079

Distal peripheral nerveblock

Lidocaine Ropivacaine

Total 9 87

Median 9 73

Ulnar 5 53

Radial 2 44

Block to surgicalincision time

35 (30ndash50) 35 (25ndash50) 045

Block to surgicalincision le25 min

14 25 003

Surgical anaesthesiasuccess

84 (93) 84 (97) 050

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substituting a long-acting for a short-acting infraclavicularblock (supplemented with long-acting distalperipheralblocks) Patient satisfaction was equally high for bothtechniques

The tested hypothesis arose from our clinical experiencewith continuous interscalene analgesia for shouldersurgery in which some patients report dissatisfaction fromthe inability to move the hand Similarly some patientsrepresenting for wrist and hand surgery under regional an-aesthesia report dissatisfaction from the motor block asso-ciated with a long-acting single injection infraclavicularblock This anecdotal evidence is supported by two previouscontinuous interscalene analgesia studies in which higherpatient satisfaction was associated with reduced motorblock1 2 In a randomized comparison of ropivacaine 02and 04 for continuous interscalene block1 the only out-comes demonstrating a between-group difference were (i)episodes of an insensate or densely blocked extremity and(ii) patient satisfaction The former was higher in the 04group (15 vs 0 Pfrac14005) while patient satisfaction washigher for the 02 group [mean difference (95 CI)frac1413(03ndash24) Pfrac14001] In a randomized comparison of twoprimary bolus doses of ropivacaine for continuous intersca-lene analgesia (20 ml 0375 vs 30 ml 05)2 patient satis-faction was higher for the lower dose [median (IQR)frac1410(10ndash10) vs 9 (8ndash10) Pfrac140007]2 There was a suggestionthat this satisfaction difference was related to motor blockpooled data linear regression analysis showing a positive as-sociation between ropivacaine concentration and handweakness (Pfrac14001) There are several possible explanationsfor the lack of similar findings in the present study First itis possible that the previous statistically significant satisfac-tion outcomes represent type 1 errors such errors beingmore common with multiple secondary rather than pre-specified primary outcomes6 More likely however was thedifference in surgery and block type With continuous inter-scalene analgesia using judicious local anaesthetic doses itis possible to block the shoulder area while sparing thedistal forearm and hand2 A lsquonon-selectiversquo interscaleneblock (ie not selectively confined to the 5th and 6th cervicalroots but also involving the 7th 8th cervical and first thor-acic root) manifests not only as shoulder girdle paralysisbut also elbow wrist and hand paralysis The resulting im-pairment of fine motor function may contribute to patientdissatisfaction In the present study involving wrist andhand surgery both study techniques inevitably resulted indistal forearm hand and finger paralysis The short-actingtechnique of the present study enabled a more rapid returnof proximal arm motor function specifically shoulder move-ment and elbow function It may be that dissatisfaction frombrachial plexus motor block relates more to inability to usethe hand and fingers rather than the proximal arm particu-larly after wristhand surgery when patient expectations arethat the forearm will be immobilized in a cast and supportedwith a sling A final possibility is that lsquoshort actingrsquo techniquemotor block resulting from lidocaine brachial plexus blockmay have reduced the trialrsquos ability to demonstrate a

satisfaction advantage from eliminating the long-acting bra-chial plexus block Inclusion of a treatment arm without anyperipheral nerve block could potentially overcome this limita-tion However compared with general anaesthesia regionalanaesthesia improves early outcome for this surgery(reduced nauseavomiting and sore throat improved anal-gesia earlier ambulation earlier recovery room and hospitaldischarge)11 12 Therefore it would be difficult eliminatingthe effect of these confounders on patient satisfaction withsuch a comparison

Few previous regional anaesthesia studies have usedpatient satisfaction as a primary endpoint13 Indeed thereis controversy regarding how best to assess this outcomeas simple one-dimensional numerical rating instruments typ-ically produce results skewed to the highly satisfied end ofthe scale14 15 Ideally satisfaction is assessed using an in-strument that has undergone psychometric validation16 ndash 18

The use of such an instrument would have increased the val-idity of our findings however the simple numerical ratingscale we used is very similar to a scale shown to demonstrateconvergent validity with a multidimensional psychometrical-ly constructed 40-item questionnaire19 Regardless furthersupport for our conclusions were that numbness- andweakness-related dissatisfaction scores were low for bothgroups

There was a non-significantly higher surgical anaesthesiasuccess rate in the short-acting group (97 vs 93) In add-ition more patients in the short-acting group underwentsurgery within 25 minmdashmaking a statistical chance explan-ation for the trend to higher success less likely Combinedthey support our recent study demonstrating that this ap-proach accelerates upper extremity anaesthesia andimproves block consistency5 It should be noted that the sur-gical start time was not strictly controlled the operatinganaesthesiologist may have intentionally or unintentionallyadvanced or discouraged progression with surgery depend-ing on informal assessment of motor block Based on theresults of our previous study for the lsquocombinedrsquo techniqueour practice is to proceed with surgery immediately afterthe final distal nerve block

The main drawback of using only short-acting local anaes-thetic for brachial plexus block is the limited tourniquet anal-gesia timemdashtypically 90ndash120 min from block placement(30ndash90 min after tourniquet application) Secondlybecause the combined technique involves several blocks(short-acting brachial plexus block and long-acting distalblocks) it is theoretically a more invasive technique Never-theless those who practice in settings requiring rapidupper extremity anaesthesia onset time may consider theadvantages of the short-acting technique outweigh the po-tential problems

In summary this study shows that in patients undergoingminor wristhand surgery there is no satisfaction benefitwhen administering a regional block technique designed toaccelerate the early return of upper extremity motor functionwhen compared with a brachial plexus block incorporatingproximally administered long-acting local anaesthetic For

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this surgery motor block related to a long-acting brachialplexus block does not appear to cause patient dissatisfaction

AcknowledgementWe thank Richard White MA Biostatistics Harvard School ofPublic Health Boston MA USA for performing the statisticalanalysis

Declaration of interestNone declared

FundingThe study was funded by a grant from the New ZealandLottery Grants Board C- The Department of InternalAffairs The New Zealand Government WellingtonNew Zealand

References1 Fredrickson MJ Price DJ Analgesic effectiveness of ropivacaine

02 vs 04 via an ultrasound-guided C5ndash6 rootsuperiortrunk perineural ambulatory catheter Br J Anaesth 2009 103434ndash9

2 Fredrickson MJ Smith KR Wong AC Importance of volume andconcentration for ropivacaine interscalene block in preventing re-covery room pain and minimizing motor block after shouldersurgery Anesthesiology 2010 112 1374ndash81

3 Marhofer P Harrop-Griffiths W Kettner SC Kirchmair L Fifteenyears of ultrasound guidance in regional anaesthesia part 1 BrJ Anaesth 2010 104 538ndash46

4 Marhofer P Harrop-Griffiths W Willschke H Kirchmair L Fifteenyears of ultrasound guidance in regional anaesthesia part 2mdashrecent developments in block techniques Br J Anaesth 2010104 673ndash83

5 Fredrickson MJ Ting FS Chinchanwala S Boland MR Concomitantinfraclavicular plus distal median radial and ulnar nerve block-ade accelerates upper extremity anaesthesia and improvesblock consistency compared with infraclavicular block alone BrJ Anaesth 2011 107 236ndash42

6 Fredrickson MJ Ilfeld BM Prospective trial registration for clinicalresearch what is it what is it good for and why do I care RegAnesth Pain Med 2011 36 619ndash24

7 Fredrickson MJ Wolstencroft P Kejriwal R Yoon A Boland MRChinchanwala S Single versus triple injection ultrasound-guidedinfraclavicular block confirmation of the effectiveness of thesingle injection technique Anesth Analg 2010 111 1325ndash7

8 McCartney CJ Xu D Constantinescu C Abbas S Chan VW Ultra-sound examination of peripheral nerves in the forearm RegAnesth Pain Med 2007 32 434ndash9

9 Kathirgamanathan A French J Foxall GL Hardman JGBedforth NM Delineation of distal ulnar nerve anatomy usingultrasound in volunteers to identify an optimum approach forneural blockade Eur J Anaesthesiol 2009 26 43ndash6

10 Foxall GL Skinner D Hardman JG Bedforth NM Ultrasoundanatomy of the radial nerve in the distal upper arm RegAnesth Pain Med 2007 32 217ndash20

11 Hadzic A Arliss J Kerimoglu B et al A comparison of infraclavi-cular nerve block versus general anesthesia for hand and wristday-case surgeries Anesthesiology 2004 101 127ndash32

12 McCartney CJ Brull R Chan VW et al Early but no long-termbenefit of regional compared with general anesthesia for ambu-latory hand surgery Anesthesiology 2004 101 461ndash7

13 Heidegger T Husemann Y Nuebling M et al Patient satisfactionwith anaesthesia care development of a psychometric question-naire and benchmarking among six hospitals in Switzerland andAustria Br J Anaesth 2002 89 863ndash72

14 Schug SA Patient satisfactionmdashpolitically correct fashion of thenineties or a valuable measure of outcome Reg Anesth PainMed 2001 26 193ndash5

15 Wu CL Naqibuddin M Fleisher LA Measurement of patient satis-faction as an outcome of regional anesthesia and analgesia asystematic review Reg Anesth Pain Med 2001 26 196ndash208

16 Auquier P Pernoud N Bruder N et al Development and validationof a perioperative satisfaction questionnaire Anesthesiology2005 102 1116ndash23

17 Heidegger T Saal D Nuebling M Patient satisfaction with anaes-thesia care what is patient satisfaction how should it be mea-sured and what is the evidence for assuring high patientsatisfaction Best Pract Res Clin Anaesthesiol 2006 20 331ndash46

18 Mui WC Chang CM Cheng KF et al Development and validationof the questionnaire of satisfaction with perioperative anestheticcare for general and regional anesthesia in Taiwanese patientsAnesthesiology 2011 114 1064ndash75

19 Myles PS Williams DL Hendrata M Anderson H Weeks AMPatient satisfaction after anaesthesia and surgery results of aprospective survey of 10811 patients Br J Anaesth 2000 846ndash10

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