Fractures of the forearm bones that occur around the wrist are common in the elderly. Standard anesthesia for its surgical treatment is regional anesthesia (RA): supraclavicular block, infraclavicular block or axillary block (BAX). However, these techniques have some limitations, such as the postoperative pain management and the non-specificity of the analgesia. Indeed analgesia is not specific to the wrist and extends to the elbow and forearm, preventing rapid recovery of elbow flexion and extension when a long-acting local anesthetic (LA) is used. Recently RA techniques associating proximal anesthetic blocks with distal analgesic blocks have been proposed to serve a dual objective: good anesthesia for surgery and specific analgesia. The hypothesis of this study is that, for the wrist surgery, axillary block using a short-acting LA combined with analgesic blocks at the elbow using a long-acting LA could provide a RA installation time reduction, an optimal surgical comfort, a longer post-operative analgesia duration and a faster recovery from motor block.
This multicenter, prospective, randomized, open-Label study compares two techniques : * BAX (usual technique) : Axillary brachial plexus block (Axillary block) with a long-acting LA (Ropivacaine) * BAX-Asso (experimental technique) : Axillary brachial plexus block (Axillary block) with a short-acting local anesthetic (Lidocaine) + Analgesic block at the elbow with a long-acting local anesthetic (Ropivacaine) Every block will be performed under Ultrasound. BAX will be performed using a multi-injection technique at contact with median (nM), radial (nR), ulnar (nU), musculocutaneous (nMC) and medial antebrachial cutaneous (nCMAB) nerves. 15-30 mL of LA will be injected. Analgesic truncal blocks of the median and radial nerves will be performed at the elbow. 3-7 mL of LA will be injected.
Study Type
INTERVENTIONAL
Allocation
RANDOMIZED
Purpose
OTHER
Masking
NONE
Enrollment
150
axillary block with 15-30 ml Ropivacaine 0,5%.
axillary block with 15-30 ml Lidocaine 1,5% + radial and medial nerve block at the elbow with 3-7 ml Ropivacaine 0,5%.
axillary block with 15-30 ml Ropivacaine 0,5%
radial and medial nerve block at the elbow with 3-7 ml Ropivacaine 0,5%
axillary block with 15-30 ml Lidocaine 1,5%
Clinique du Pré
Le Mans, Pays de la Loire Region, France
Hôpital Privé Paul D'Egine
Champigny-sur-Marne, Île-de-France Region, France
CMC Ambroise Paré
Neuilly-sur-Seine, Île-de-France Region, France
Hôpital Privé Armand Brillard
Nogent-sur-Marne, Île-de-France Region, France
Clinique Bizet
Paris, Île-de-France Region, France
Clinique Jouvenet
Paris, Île-de-France Region, France
Clinique Rémusat
Paris, Île-de-France Region, France
Level of pain when the patient recovers the flexion of the forearm on the arm
Pain VRS ranging from 0 to 10 (0=no pain, 10=worst possible pain)
Time frame: 24 hours
Duration of motor block at the elbow
Time between the performance of regional anesthesia and the elbow flexion recovery
Time frame: 24 hours
Axillary block success
Assess of motor block and sensory perception to pin-prick in the distribution of the five terminal branches at 10, 20, and 30 minutes postinjection. Motor block: complete (2=paralysis), partial (1=paresis), or none (0). Motor function assessed in the following manner: wrist and finger flexion (median nerve), wrist and finger extension (radial nerve), thumb adduction and flexor carpi ulnaris flexion (ulnar nerve), and biceps flexion (musculocutaneous nerve). Sensory block: complete/anesthesia (2=loss of sensation to pinprick), partial/analgesia (1=dull sensation to pinprick), or none (0=sharp sensation to pinprick). Sensory distribution assessed in the following areas: thenar eminence and thumb tip (median nerve), dorsum of hand (radial nerve), fifth digit fingertip (ulnar nerve), lateral aspect of forearm (musculocutaneous nerve) and medial aspect of forearm (medial antebrachial cutaneous nerve). Successful blockade is defined by a sensory-motor score ≥ 3.
Time frame: 40 minutes
Feasibility of the wrist surgery
Usage (or not) of an additional anesthetic procedure to perform the surgery
Time frame: 2 hours
Duration of postoperative analgesia
Time between the performance of regional anesthesia and the first dose of rescue analgesia with opioides.
Time frame: 72 hours
Postoperative morphine consumption
Cumulated dose of oxynorm (mg)
Time frame: 48 hours
Sleep quality
Incidence of sleep disorders
Time frame: Day 2 After Surgery
Complications during block performance
Incidence of vascular puncture, paresthesia, intraneural injection and intravascular passage
Time frame: 15 minutes
Complications immediately after block
Onset of vertigo, nausea or vomiting
Time frame: 2 hours
Postoperative complications
Questionnaire about potential sensory anomalies such as numbness, itching or tingling
Time frame: Day 15 After Surgery
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