On arrival continuous brachial plexus block provides superior analgesia with reduced persistent postsurgical pain in complex hand injuries: A randomized controlled trial.

Abstract

Background: Patients with complex hand injuries experience extreme pain and frequently witness prolonged preoperative waiting period, which intensifies their agony, especially during wound dressing and debridement, further intensifying pain of acute trauma. Hence, there is a need to study utility of continuous peripheral nerve block in settings of acute trauma emergencies. We hypothesized that, as compared with intravenous systemic analgesics, continuous brachial plexus block would provide superior analgesia in these patients.

Methods: Eighty adults of either sex, with complex unilateral hand injuries (significant soft-tissue loss, crushed hand injury, and metacarpal bone fractures), having moderate-to-severe pain were randomized into two groups of 40 patients each. We excluded patients with sensory deficits, coagulopathy, or vascular injuries of the forearm. In the intervention group (group brachial plexus block [BPB]), patients received continuous infraclavicular brachial plexus block with 20 mL of 0.2% ropivacaine. In control group (group C) patients were administered intravenous analgesics (injection paracetamol [500 mg] 6 hourly with injection diclofenac [50 mg] 8 hourly). We recorded pain scores (Numeric Rating Scale) at regular intervals and total rescue analgesic used. Patients were followed-up on days 15 and 30 following surgery to note persistent postsurgical pain (PPSP). Groups were compared using Student's t test/χ 2 test as applicable. Mann-Whitney U test was used for statistical analysis of skewed continuous variables or ordered categorical data.

Results: Significantly more patients in group BPB reported Numeric Rating Scale score of <4, 1 hour following intervention (100% in group BPB vs. 57.5% in group C; p = 0.00). No patients in group BPB reported pain/discomfort during any interventions, like wound assessment/dressings. On the contrary, 55% (n = 22/40) of patients in group C experienced moderate-to-severe pain ( p = 0.00) and required rescue analgesic. The median preoperative waiting time was significantly less in group BPB (18 [16-18] vs. 48 [24-48] hours; p = 0.00). Significantly more patients in group C reported PPSP on days 15 and 30 (19/40 in group C vs. 6/40 in group BPB; p = 0.03).

Conclusion: On-arrival blocks with catheter technique provide consistent pain relief, with lower PPSP, and hence should be integrated in pain management protocols.

Level of evidence: Therapeutic/Care Management; Level II.