DISTAL UPPER EXTREMITY SURGERY
Distal upper extremity surgical procedures generally take place on an outpatient basis. Minor soft tissue operations of the hand (eg, carpal tunnel release) of short duration may be performed with local infiltra-tion or with intravenous regional anesthesia (IVRA, or Bier block). The limiting factor with IVRA is tourniquet tolerance.
For operations lasting more than 1 h or more invasive procedures involving bones or joints, a bra-chial plexus block is the preferred regional anesthetic technique. Multiple approaches can be used to anes-thetize the brachial plexus for distal upper extrem-ity surgery . Selection of brachial plexus block technique should take into account the planned surgical site and location of the pneumatic tourniquet, if applicable. Continuous peripheral nerve blocks may be appropriate for inpatient and select outpatient procedures to extend the duration of analgesia further into the postoperative period or facilitate physical therapy. Brachial plexus blocks do not anesthetize the intercostobrachial nerve dis-tribution (arising from the dorsal rami of T1 and sometimes T2); hence, subcutaneous infiltration of local anesthetic may be required for procedures involving the medial upper arm.
Anesthetic considerations for distal upper extremity surgery should include patient position-ing and use of a pneumatic tourniquet. Most proce-dures can be performed with the patient supine; the operative arm abducted 90° and resting on a hand table; and the operating room table rotated 90° to position the operative arm in the center of the room. Exceptions to this rule often involve surgery around the elbow, and certain operations may require the patient be in lateral decubitus or even prone posi-tion. Because patients are often scheduled for same-day discharge, perioperative management should focus on ensuring rapid emergence and pre-venting severe postoperative pain and nausea .