Advertisement

Comparison of Postoperative Complications Associated With Anesthetic Choice for Surgery of the Hand

Published:November 14, 2016DOI:https://doi.org/10.1016/j.jhsa.2016.10.007

      Purpose

      There is a recent trend toward performing most hand surgery procedures under local and/or regional anesthesia without sedation. However, little evidence exists regarding the postoperative complications associated with local/regional anesthesia without sedation, especially compared with local/regional anesthesia with sedation or general anesthesia.

      Methods

      Patients who underwent hand procedures as part of the American College of Surgeons National Surgical Quality Improvement Program were identified. Thirty-day postoperative complications were compared among patients who received local/regional anesthesia without sedation, local/regional anesthesia with sedation, and general anesthesia with adjustment for patient and procedural factors.

      Results

      We identified 27,041 patients as having undergone hand surgery from 2005 to 2013. A total of 4,614 underwent local/regional anesthesia without sedation (17.1%), 3,527 underwent local/regional anesthesia with sedation (13.0%), and 18,900 underwent general anesthesia (69.9%). Overall, both local/regional anesthesia with and without sedation were associated with fewer postoperative complications compared with general anesthesia. In patients aged over 65 years, there was an additional benefit of avoiding all forms of sedation; these data showed that treatment with local/regional anesthesia without sedation decreased the odds of sustaining a postoperative complication compared with sedation and general anesthesia.

      Conclusions

      Although the overall risk of postoperative complications remains small in hand surgery, these data suggest that avoiding general anesthesia may decrease the overall risk of sustaining postoperative complications. In addition, for patients aged over 65 years, avoiding any form of sedation may decrease the risk of postoperative complications.

      Type of study/level of evidence

      Prognostic II.

      Key words

      Local or regional anesthesia without sedation has gained considerable popularity in recent years for surgery of the hand.
      • Al Youha S.
      • Lalonde D.H.
      Update/review: changing of use of local anesthesia in the hand.
      Some proponents have suggested using local anesthesia without a tourniquet
      • Lalonde D.
      How the wide awake approach is changing hand surgery and hand therapy: inaugural AAHS sponsored lecture at the ASHT meeting, San Diego, 2012.
      whereas others have suggested employing regional anesthesia without sedation.
      • Chan V.W.S.
      • Peng P.W.H.
      • Kaszas Z.
      • et al.
      A comparative study of general anesthesia, intravenous regional anesthesia, and axillary block for outpatient hand surgery: clinical outcome and cost analysis.
      Both groups suggest that anesthesia without sedation can be used for a large percentage of hand surgery cases. Evidence suggests that administering local or regional anesthesia without sedation has the potential benefits of reducing overall health care spending while increasing perioperative efficiency.
      • Lalonde D.
      How the wide awake approach is changing hand surgery and hand therapy: inaugural AAHS sponsored lecture at the ASHT meeting, San Diego, 2012.
      • Chan V.W.S.
      • Peng P.W.H.
      • Kaszas Z.
      • et al.
      A comparative study of general anesthesia, intravenous regional anesthesia, and axillary block for outpatient hand surgery: clinical outcome and cost analysis.
      • Bismil M.
      • Bismil Q.
      • Harding D.
      • Harris P.
      • Lamyman E.
      • Sansby L.
      Transition to total one-stop wide-awake hand surgery service-audit: a retrospective review.
      • Davison P.G.
      • Cobb T.
      • Lalonde D.H.
      The patient’s perspective on carpal tunnel surgery related to the type of anesthesia: a prospective cohort study.
      • Leblanc M.R.
      • Lalonde J.
      • Lalonde D.H.
      A detailed cost and efficiency analysis of performing carpal tunnel surgery in the main operating room versus the ambulatory setting in Canada.
      Despite the popularity of local and regional anesthesia, little evidence is available on the postoperative outcomes of anesthetic choice for hand surgery. Several reports found a reduction in postoperative complications associated with avoiding general anesthesia, by using either local
      • Nelson R.
      • Higgins A.
      • Conrad J.
      • Bell M.
      • Lalonde D.
      The wide-awake approach to Dupuytren’s disease: fasciectomy under local anesthetic with epinephrine.
      or regional anesthesia.
      • Chan V.W.S.
      • Peng P.W.H.
      • Kaszas Z.
      • et al.
      A comparative study of general anesthesia, intravenous regional anesthesia, and axillary block for outpatient hand surgery: clinical outcome and cost analysis.
      • Hadzic A.
      • Arliss J.
      • Kerimoglu B.
      • et al.
      A comparison of infraclavicular nerve block versus general anesthesia for hand and wrist day-case surgeries.
      Yet, many of these studies failed to differentiate between patients who did or did not receive sedation in addition to local or regional anesthesia. Because sedation has been associated with increased complications in some studies, this distinction is an important factor that is not clearly defined in the current hand surgery literature.
      • Chan V.W.S.
      • Peng P.W.H.
      • Kaszas Z.
      • et al.
      A comparative study of general anesthesia, intravenous regional anesthesia, and axillary block for outpatient hand surgery: clinical outcome and cost analysis.
      • Hadzic A.
      • Arliss J.
      • Kerimoglu B.
      • et al.
      A comparison of infraclavicular nerve block versus general anesthesia for hand and wrist day-case surgeries.
      Furthermore, the available evidence is from small studies lacking the power to determine a significant difference between anesthesia choices.
      The purpose of this study was to compare the risk of sustaining postoperative complications among patients treated with local/regional anesthesia without sedation, local/regional anesthesia with sedation, and general anesthesia for hand surgery.

      Materials and Methods

      Patients who underwent hand surgery between 2005 and 2013 were identified as part of the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP). The ACS-NSQIP is a surgical registry that samples patients from community and academic centers nationwide.

      American College of Surgeons National Surgical Quality Improvement Program. User Guide for the 2013 Participant Use Data File. https://www.facs.org/quality-programs/acs-nsqip/program-specifics/participant-use. Accessed November 3, 2016.

      The program identifies patients undergoing surgical procedures and tracks them for 30 days for the development of postoperative complications. Trained ACS-NSQIP data specialists compile a broad range of patient demographic characteristics and outcomes data from individual medical record review. Previous authors identified a subset of 208 hand-specific Current Procedural Terminology (CPT) codes that are representative of hand surgery in ACS-NSQIP.
      • Lipira A.B.
      • Sood R.F.
      • Tatman P.D.
      • Davis J.I.
      • Morrison S.D.
      • Ko J.H.
      Complications within 30 days of hand surgery: an analysis of 10,646 patients.
      Inclusion in the study was based on the presence of one or more of these 208 hand-specific CPT codes during the study period. Exclusion criteria included any additional CPT coding outside these 208 hand-specific CPT codes, which often represented hand-specific procedures being done in conjunction with other procedures such as a ganglion cyst excision at the same time as total knee arthroplasty. Finally, patients without a recorded anesthesia type were excluded.
      A total of 27,173 patients were initially identified from the ACS-NSQIP database for inclusion in the study. Seventy-eight were excluded for having additional procedures outside hand surgery (0.2%) and 53 were excluded for not having a recorded anesthetic (0.2%). This left 27,041 for inclusion in the study. This study sample represents patients identified by a random sampling selection of all hand surgery procedures conducted at ACS-NSQIP centers.
      The primary outcome measure of the study was the presence or absence of postoperative complications within 30 days of surgery. Postoperative complications of interest to hand surgeons have been previously outlined by authors using the ACS-NSQIP database; these outcomes were used in this study.
      • Schick C.W.
      • Koehler D.M.
      • Martin C.T.
      • et al.
      Risk factors for 30-day postoperative complications and mortality following open reduction internal fixation of distal radius fractures.
      Patients were considered to have had a serious complication if any of the following occurred during the first 30 postoperative days: organ space infection, sepsis, septic shock, deep surgical site infection, wound dehiscence, pulmonary embolism, ventilation greater than 48 hours, unplanned intubation, acute renal failure, cardiac arrest requiring cardiopulmonary resuscitation, myocardial infarction, stroke, coma more than 24 hours, graft/prosthesis/flap failure, or peripheral nerve injury. Patients were considered to have had a complication if any of the following occurred during the first 30 postoperative days: any of the serious complications, deep vein thrombosis, superficial surgical site infection, bleeding transfusions, progressive renal insufficiency, urinary tract infection, or pneumonia.
      The primary independent variable of interest in the study was anesthetic choice. Anesthetic choice was grouped as local/regional anesthesia without sedation, local/regional anesthesia with sedation, and general anesthesia. These categories were determined based on individual review from the medical records performed by ACS-NSQIP study personnel. In addition to anesthetic choice, a variety of baseline demographic data and comorbidities collected by ACS-NSQIP were used to adjust for patient-specific factors in statistical modeling. Demographic data included age and sex. Comorbidity data included body mass index (BMI), diabetes mellitus, congestive heart failure, functional health status (defined by ACS-NSQIP as independent or dependent based on whether the patient required assistance with activities of daily living), hypertension, end-stage renal disease, chronic obstructive pulmonary disease, smoking status, and anemia.
      • Bohl D.D.
      • Shen M.R.
      • Kayupov E.
      • Valle C.J.D.
      Hypoalbuminemia independently predicts surgical site infection, pneumonia, length of stay, and readmission after total joint arthroplasty.
      For each patient, a comorbidity score was calculated using the Charlson comorbidity index (CCI) modified to fit available data.
      • Charlson M.E.
      • Pompei P.
      • Ales K.L.
      • MacKenzie C.R.
      A new method of classifying prognostic comorbidity in longitudinal studies: development and validation.
      Studies demonstrated that such modified CCIs are similar in efficiency and prognosis to the original CCI.
      • Sundararajan V.
      • Henderson T.
      • Perry C.
      • Muggivan A.
      • Quan H.
      • Ghali W.A.
      New ICD-10 version of the Charlson comorbidity index predicted in-hospital mortality.
      • D’Hoore W.
      • Bouckaert A.
      • Tilquin C.
      Practical considerations on the use of the Charlson comorbidity index with administrative data bases.
      The modified CCI we employed was previously employed with the ACS-NSQIP database.
      • Ehlert B.A.
      • Nelson J.T.
      • Goettler C.E.
      • et al.
      Examining the myth of the “July Phenomenon” in surgical patients.
      The comorbidities used to determine the modified CCI were directly available in the dataset and included (followed by corresponding point values): myocardial infarction within the 6 months before to surgery (1), congestive heart failure (1), peripheral vascular disease or rest pain (1), any history of transient ischemic attack or cerebrovascular accident (1), chronic obstructive pulmonary disease (1), diabetes mellitus (1), hemiplegia (2), end-stage renal disease (2), ascites or esophageal varices (3), and disseminated cancer (6). The point values were summed for a total number, to which one point was added for each decade greater than age 40 years.
      Statistical analysis was conducted with significance at α = .05. First, bivariate analysis of variance and Pearson’s chi-square test were used to test for differences between demographics and postoperative outcomes of patients treated with local/regional anesthesia without sedation, sedation, and general anesthesia. To minimize selection bias in study sampling between those receiving differing anesthesia types, we examined predictors of anesthesia type (Table 1). Patients treated with local/regional anesthesia with or without sedation had higher Charlson comorbidity indices and older ages. Patients treated with general anesthesia had longer operative times, were more likely to undergo nonelective and emergent cases, and had slightly higher relative value units associated with surgery and increased BMIs. The higher acuity cases seen with general anesthesia had the potential to bias outcomes. To examine this further, each individual procedure (defined by CPT code) was analyzed separately. This analysis found high variability among differing hand surgery procedures in relation to anesthesia choice and associated postoperative outcomes (Appendix A, available on the Journal’s web site at www.jhandsurg.org).
      Table 1Differences Among Anesthesia Groups
      VariableLocal/Regional Without SedationLocal/Regional With SedationGeneralP Value
      Overall4,6143,52718,900
      Age52.1 ± 17.251.5 ± 17.148.4 ± 17.6<.001
      Sex<.001
       Female2,620 (56.8)2,043 (57.9)9,617 (50.9)
       Male1,994 (43.2)1,484 (42.1)9,283 (49.1)
      BMI26.7 ± 9.427.5 ± 8.827.1 ± 8.8<.001
      Charlson Comorbidity Index
       Modified CCI2.1 ± 1.61.9 ± 1.61.7 ± 1.7<.001
      Work-related value units
       Procedure related value units7.7 ± 3.37.2 ± 3.38.6 ± 3.2<.001
      Average operative time
       Median min54.0 ± 42.540.0 ± 36.363.0 ± 52.2
      Operative setting<.001
       Outpatient4,257 (92.3)3,349 (95.0)15,999 (84.7)
       Inpatient357 (7.7)178 (5.0)2,901 (15.3)
      Elective surgery<.001
       Elective2,695 (92.4)2,612 (92.9)11,056 (82.0)
       Nonelective223 (7.6)197 (7.1)2,422 (18.0)
      Surgical urgency<.001
       Nonemergent4,478 (97.1)3,426 (97.1)17,226 (91.1)
       Emergent136 (2.9)101 (2.9)1,674 (8.9)
      To manage the wide variation in anesthesia choice and associated postoperative outcomes among differing hand surgery procedures and minimize selection bias in anesthesia choice, we used generalized linear mixed modeling to account for clustering in the data. Because the dataset is a combination of 208 different hand-specific procedures, we used a mixed-modeling approach to examine both between-procedure and between-patient variation. A 2-tiered model was employed, with the first tier representing each individual patient and the second tier representing the primary CPT code associated with the procedure. This statistical design allowed for examination of the variable of interest (anesthesia choice) in a large dataset while controlling for variation of the level of acuity of each procedure. We used mixed logistic regression to estimate the association between anesthesia choice and the presence or absence of postoperative complications. Patient-specific factors controlled for in the model included age, sex, BMI, diabetes mellitus, congestive heart failure, functional health status, hypertension, end-stage renal disease, chronic obstructive pulmonary disease, current smoking status, and anemia. These factors were chosen because they have been shown to be accurate markers for overall health status, while avoiding known issues with missing data in ACS-NSQIP.
      • Bohl D.D.
      • Shen M.R.
      • Kayupov E.
      • Valle C.J.D.
      Hypoalbuminemia independently predicts surgical site infection, pneumonia, length of stay, and readmission after total joint arthroplasty.
      Multicollinearity models were conducted to ensure these variables were independent markers of overall health status. Two regression models were run: one with all patients and one with patients aged over 65 years. This study was granted exempt status from our institutional review board owing to the de-identified nature of the data in the ACS-NSQIP national database.

      Results

      A total of 27,041 patients constituted the study population. Of these patients, 4,614 received local/regional anesthesia without sedation (17.1%), 3,527 received local/regional anesthesia with sedation (13.0%), and 18,900 received general anesthesia (69.9%) (Table 1).
      A serious complication occurred in 277 patients (1.0%), whereas any complication occurred in 574 patients (2.1%). The most common postoperative complications were superficial surgical site infection (0.71%), sepsis (0.32%), postoperative transfusion (0.25%), deep surgical site infection (0.21%), and urinary tract infection (0.20%). Patients with general or sedation anesthesia were more likely than patients without sedation to have higher rates of cardiopulmonary complications, sepsis, septic shock, ventilator greater than 48 hours, unplanned intubation, superficial surgical site infection, pneumonia, and transfusion (Table 2).
      Table 2Rates of Postoperative Complications Among Types of Anesthesia
      VariableLocal/Regional Without SedationLocal/Regional With SedationGeneralUnadjusted P Value
      Serious complication
       Organ space infection0.020.060.04.36
       Sepsis0.020.170.42<.001
       Septic shock00.030.18.001
       Deep surgical site infection0.170.120.23.15
       Wound dehiscence0.170.140.12.31
       Pulmonary embolism00.060.02.12
       Ventilator > 24 h000.20<.001
       Unplanned intubation0.040.030.13.04
       Acute renal failure000.05.05
       Cardiac arrest0.040.030.05.44
       Myocardial infarction00.030.05.11
       Stroke0.0400.03.24
      Coma > 24 h000.01.33
       Graft/prosthesis failure0.0700.002
       Peripheral nerve injury0.020.030.01.33
      Any Complication
       Superficial surgical site infection0.430.800.76.02
       Pneumonia0.040.030.15.02
       Urinary tract infection0.170.310.19.15
       Deep venous thrombosis0.020.110.05.11
       Transfusion0.040.060.34<.001
       Progressive renal insufficiency000.03.13
      Cardiopulmonary complications0.170.230.47.25
      Serious complication0.590.601.21.002
      Any complication1.281.762.40<.001
      Data are reported as percentages.
      Among patients of all ages, general anesthesia increased the odds of sustaining a postoperative complication (odds ratio [OR] = 1.59, 95% confidence interval [CI], 1.19–2.13) (Table 3) compared with local/regional anesthesia without sedation. Use of local/regional anesthesia with sedation anesthesia was not associated with an increase in the odds of sustaining a postoperative complication (OR = 1.22; 95% CI, 0.84–1.78) compared with local/regional anesthesia. Increasing age (OR = 1.95; 95% CI, 1.19–3.19), male sex (OR = 1.38; 95% CI, 1.13–1.68), congestive heart failure (OR = 3.43; 95% CI, 1.59–7.40), dependent functional health status (OR = 2.14; 95% CI, 1.50–3.06), end-stage renal disease (OR = 1.63; 95% CI, 1.00–2.65), chronic obstructive pulmonary disease (OR = 1.53; 95% CI, 1.01–2.32), smoking (OR = 1.59, 95% CI, 1.30–1.96), and anemia (OR = 3.38; 95% CI, 2.73–4.20) were all associated with increased odds of postoperative complications.
      Table 3Results of Multivariable Logistic Regression for Any Postoperative Complications in Patients Aged 18 to 90 y
      VariableMultivariable Comparisons
      OR95% CI
      Type of anesthesia
       Wide awakeReference
       Sedation1.220.84–1.78
       General1.591.19–2.13
      Age, y
       16–39Reference
       40–491.511.11–2.04
       50–591.981.49–2.63
       60–691.851.34–2.55
       70–792.321.61–3.36
       80–901.951.19–3.19
      Sex
       FemaleReference
       Male1.381.13–1.68
      BMI
       <18.51.601.14–2.26
       18.5–25Reference
       25–300.920.73–1.18
       30–351.321.01–1.73
       35–401.280.89–1.83
       40–450.870.49–1.54
       45–501.310.58–2.96
       >501.260.54–2.97
      Diabetes
       NoReference
       Yes1.240.93–1.65
      Congestive heart failure
       NoReference
       Yes3.431.59–7.41
      Functional health status
       IndependentReference
       Dependent2.141.50–3.06
      Hypertension
       NoReference
       Yes0.940.75–1.17
      End-stage renal disease
       NoReference
       Yes1.631.00–2.65
      Chronic obstructive pulmonary heart disease
       NoReference
       Yes1.531.01–2.32
      Current smoker
       NoReference
       Yes1.591.30–1.96
      Anemia
       NoReference
       Yes3.392.73–4.20
      In patients aged over 65 years, there was an additional benefit of avoiding all forms of sedation. Patients aged over 65 years who were treated with sedation anesthesia had increased odds of postoperative complications (OR = 3.07; 95% CI, 1.44–6.54) compared with local/regional anesthesia. In addition, patients aged over 65 years who were treated with general anesthesia also experienced increased odds of postoperative complications (OR = 3.26, 95% CI, 1.69–6.28) compared with local/regional anesthesia (Table 4, Fig. 1).
      Table 4Results of Multivariable Logistic Regression for Any Postoperative Complications in Patients Aged Over 65 y
      VariableMultivariate Comparisons
      Odds Ratio95% CI
      Type of anesthesia
       Wide awakeReference
       Sedation3.071.44–6.54
       General3.261.69–6.28
      Age, y
       66–69Reference
       70–791.440.92–2.26
       80–901.180.68–2.06
      Sex
       FemaleReference
       Male1.521.02–2.26
      BMI
       <18.51.730.85–3.51
       18.5–25Reference
       25–300.940.58–1.51
       30–351.240.72–2.13
       35–401.240.60–2.54
       40–450.680.19–2.43
       45–501.450.18–11.38
       >503.100.38–25.45
      Diabetes
       NoReference
       Yes1.010.62–1.64
      Congestive heart failure
       NoReference
       Yes2.560.69–9.56
      Functional health status
       IndependentReference
       Dependent2.051.17–3.60
      Hypertension
       NoReference
       Yes0.940.63–1.41
      End-stage renal disease
       NoReference
       Yes1.550.62–3.87
      Chronic obstructive pulmonary disease
       NoReference
       Yes2.171.22–3.87
      Current smoker
       NoReference
       Yes1.050.58–1.92
      Anemia
       NoReference
       Yes3.872.61–5.74
      Figure thumbnail gr1
      Figure 1Forest plots of odds of sustaining postoperative complications associated with anesthetic choice: for all patients and patients aged over 65 years.

      Discussion

      Anesthetic choice for hand surgery has received increasing attention in recent years.
      • Lalonde D.
      How the wide awake approach is changing hand surgery and hand therapy: inaugural AAHS sponsored lecture at the ASHT meeting, San Diego, 2012.
      Small reports in the hand surgery literature suggested that local
      • Nelson R.
      • Higgins A.
      • Conrad J.
      • Bell M.
      • Lalonde D.
      The wide-awake approach to Dupuytren’s disease: fasciectomy under local anesthetic with epinephrine.
      and regional anesthesia
      • Chan V.W.S.
      • Peng P.W.H.
      • Kaszas Z.
      • et al.
      A comparative study of general anesthesia, intravenous regional anesthesia, and axillary block for outpatient hand surgery: clinical outcome and cost analysis.
      • Hadzic A.
      • Arliss J.
      • Kerimoglu B.
      • et al.
      A comparison of infraclavicular nerve block versus general anesthesia for hand and wrist day-case surgeries.
      are associated with fewer postoperative complications than is general anesthesia. In addition, larger studies in other fields—including orthopedics—have shown a risk reduction in postoperative complications with the use of local or regional anesthesia instead of general anesthesia.
      • Helwani M.A.
      • Avidan M.S.
      • Ben Abdallah A.
      • et al.
      Effects of regional versus general anesthesia on outcomes after total hip arthroplasty: a retrospective propensity-matched cohort study.
      • Pugely A.J.
      • Martin C.T.
      • Gao Y.
      • Mendoza-Lattes S.
      • Callaghan J.J.
      Differences in short-term complications between spinal and general anesthesia for primary total knee arthroplasty.
      • Basques B.A.
      • Bohl D.D.
      • Golinvaux N.S.
      • Samuel A.M.
      • Grauer J.G.
      General versus spinal anaesthesia for patients aged 70 years and older with a fracture of the hip.
      • Rodgers A.
      • Walker N.
      • Schug S.
      • et al.
      Reduction of postoperative mortality and morbidity with epidural or spinal anaesthesia: results from overview of randomised trials.
      Two recently published studies highlighted the benefits of regional anesthesia for hand surgery. Chan et al
      • Chan V.W.S.
      • Peng P.W.H.
      • Kaszas Z.
      • et al.
      A comparative study of general anesthesia, intravenous regional anesthesia, and axillary block for outpatient hand surgery: clinical outcome and cost analysis.
      compared intravenous regional anesthesia, axillary blocks, and general anesthesia for outpatient hand surgery patients. Their findings suggested that regional anesthesia was associated with a more favorable patient recovery than general anesthesia. Furthermore, patients treated with regional anesthesia experienced less postoperative nausea and vomiting, and had shorter postoperative lengths of stay. Overall, the authors found that regional anesthesia was more cost-effective than general anesthesia. Likewise, Galos et al
      • Galos D.K.
      • Taormina D.P.
      • Crespo A.
      • et al.
      Does brachial plexus blockade result in improved pain scores after distal radius fracture fixation? A randomized trial.
      conducted a prospective, randomized trial comparing general and regional anesthesia for distal radius fractures. Those authors found that postoperative pain was reduced in patients treated with regional anesthesia, but that regional anesthesia was associated with “rebound pain” after the block wore off, leading to higher interim pain scores if not treated appropriately.
      Despite the benefits of regional anesthesia shown in those studies, both failed to differentiate between patients treated with regional anesthesia with and without sedation. Both studies used regional anesthesia with tourniquets and provided sedation for tourniquet pain in some cases. Some proponents of local and regional anesthesia have advocated for techniques that avoid tourniquet use to avoid the additional need for sedation.
      • Lalonde D.
      How the wide awake approach is changing hand surgery and hand therapy: inaugural AAHS sponsored lecture at the ASHT meeting, San Diego, 2012.
      The hypothesis behind this thinking is that reducing the need for sedation would reduce postoperative complications, particularly in patients at risk for cardiopulmonary compromise. The current study was designed to test the validity of this hypothesis.
      Data from this large nationwide study suggest that using local/regional anesthesia without sedation instead of general anesthesia reduces the odds of sustaining a postoperative complication after hand surgery by 1.5 times in patients of all ages and by 3.5 times in patients aged over 65 years. For patients aged over 65 years, there is an additional benefit of employing local/regional anesthesia without sedation as opposed to local/regional anesthesia with sedation, as seen by a threefold decrease in the odds of sustaining postoperative complications.
      The findings of Chan et al
      • Chan V.W.S.
      • Peng P.W.H.
      • Kaszas Z.
      • et al.
      A comparative study of general anesthesia, intravenous regional anesthesia, and axillary block for outpatient hand surgery: clinical outcome and cost analysis.
      and Galos et al
      • Galos D.K.
      • Taormina D.P.
      • Crespo A.
      • et al.
      Does brachial plexus blockade result in improved pain scores after distal radius fracture fixation? A randomized trial.
      findings are supported by the current research, which also suggests that using local/regional anesthesia with or without sedation instead of general anesthesia is associated with a reduction in postoperative complications. These findings also suggest that there is an association between reduced postoperative complications and the avoidance of any sedation (either local/regional anesthesia with sedation or general anesthesia) in patients aged over 65 years. This may not be surprising to hand surgeons, because the use of local/regional anesthesia without sedation avoids respiratory sedation and associated respiratory and cardiac postoperative complications.
      This study has limitations. Probably the most notable one is the possible selection bias associated with anesthetic choice. Any outcomes-based study without randomization runs the risk of selection bias, and we sought both to unmask potential bias and control for it in our analysis. Patients who received general anesthesia had slightly longer operative times and higher rates of emergent and nonelective cases. This could potentially account for the higher rates of postoperative complications. Interestingly, an individual analysis of each separate operation showed a high variation in the rates of postoperative complications between procedures. Fracture fixation, for instance, would predictably have a higher complication rate than an elective mass excision. A further look at the data showed that although there were wide variations in risk among surgeries, and higher risk surgeries were more likely to receive general anesthesia, on the level of individual patients, those receiving local/regional anesthesia with or without sedation were actually older and had higher Charlson comorbidity indices. Therefore, we employed a mixed model, which allowed us to expand our 95% CIs to account for the variation between procedures, while isolating the associated risk of anesthetic choice for each patient. We found that there was an effect of anesthetic choice, and that even when accounting for higher acuity cases, avoiding sedation (local/regional anesthesia with sedation or general anesthesia), when possible, is associated with a reduced risk of postoperative outcomes in patients aged over 65 years. As in any retrospective study, the statistical analysis shows only associations, and further prospective or case-control studies are needed to elucidate these findings further. However, this study design allowed for an aggregate analysis of large, population-level data to answer a key question for modern hand surgery.
      There were additional limitations as a result of the database sampling methodology. Trained ACS-NSQIP personnel collect 30-day outcomes, but it is possible that significant outcomes are missed in this sampling methodology. In this case, the findings in this article would be an underrepresentation of the actual effects. Arguably one of the most important limitations was the selection of study outcome measures. We chose to use outcomes measures of postoperative complications that were previously selected in the hand surgery literature to remain consistent between studies.
      • Schick C.W.
      • Koehler D.M.
      • Martin C.T.
      • et al.
      Risk factors for 30-day postoperative complications and mortality following open reduction internal fixation of distal radius fractures.
      However, some opponents may argue that these outcomes are either outside the scope of “normal” hand surgery complications or unlikely to be affected by anesthetic choice. The goal of this study was to provide an overarching view of anesthetic choice outcomes in a population-based cohort. Further studies may choose to examine individual factors or limit outcomes to specific subsets of populations to make further recommendations.
      Although the overall risk of postoperative complications remains small in hand surgery, these data suggest that avoiding general anesthesia may decrease the overall risk of sustaining postoperative complications. In addition, for patients aged over 65 years, avoiding any form of sedation (local/regional anesthesia with sedation or general anesthesia) may decrease the risk of postoperative complications.

      Acknowledgments

      The American College of Surgeons National Surgical Quality Improvement Program and the hospitals participating in the ACS NSQIP are the source of the data used herein; they have not verified and are not responsible for the statistical validity of the data analysis or the conclusions derived by the authors.

      Appendix

      Appendix ADifferences in Anesthesia Choice and Percentage of Patients With Postoperative Outcomes Among CPT Code Procedures
      CPT CodeLocal/Regional, nLocal/Regional, Overall %Sedation, nSedation, Overall %GeneralGeneral, Overall %Complications, %
      208160000310033
      20822000021000
      208240000410050
      20827000041000
      2449513615338323
      244981300379718
      250002412931938276331
      250205577848839
      250234812459062
      2502400003510037
      2502500002310061
      250750000121000
      2507636144819172672
      250771482715137773
      2508531415188214
      2510171371342757
      251051722121550635
      251078144747800
      251102438121928440
      2511149925456231,044521
      2511244224020113571
      251154022724066374
      251163927332275514
      251183826302177531
      251196553272180
      2512051841419684
      251251200048020
      25126333006670
      2513017256946670
      25135220008800
      25136000021000
      252102520161381662
      252152719128106730
      252301341325830
      2524025214392762
      25260231353144842
      252652152159690
      2527015101611118791
      252723160016840
      25274218009820
      252758184933730
      252801452118758
      25290817122626577
      252953726241780574
      25300120004800
      253014244249536
      2531047154414216701
      25312152181148683
      25315000041000
      2532057214918170621
      253321515101074750
      253372726111067640
      2535020266851660
      25393000011000
      25430220008800
      25431292918820
      25440197186240871
      254410021710830
      25442536009640
      25443000011000
      25444000041000
      2544519452521500
      2544652341813590
      2544752119295111,960711
      254493150017855
      2552511123375841
      2552612146766792
      25545171053152872
      25574002334670
      25575258134283882
      25607197118651,450841
      256081481010471,277841
      256092471515091,303772
      2562870193710267712
      2564510151254832
      25652112612307110
      256700000161006
      25676181810830
      256854140025860
      25695141426930
      2590071712348124
      259050000710086
      25907000011000
      259090000610017
      2592032000128047
      25924110000000
      25927929826144523
      259290024036020
      259311330026725
      25999170013937
      26115000011000
      26117112471627607
      2612182261623623
      26123674510772483
      2612536012012020
      261305711141140
      26135192188739
      261451021204218382
      26160000021000
      26170000011000
      26180193277649
      26185000011000
      26205133002670
      262151251252500
      26230000051000
      2623535011723317
      26236001501500
      26250000011000
      26260001100000
      263503412228232811
      263524332176500
      2635668135210412772
      263571013182352657
      263582101518860
      263701581810147821
      26372111008890
      26373492537860
      263902561532803
      26392001910910
      2641054203011186692
      264121621115830
      26415110009900
      26418901610218361652
      264204151422810
      264261120183227485
      26428000031000
      264331321121937603
      26434000071000
      26437112271431630
      2644063217525158534
      264421620243041514
      2644570258129130461
      2644961841223700
      264507444255310
      264552029101439577
      26460821102620535
      2647131552512600
      26474120004800
      264761201203600
      264781721411790
      2648310202439760
      26489229005710
      26492124041314470
      264961115563330
      26497122281534636
      2649871741031740
      26499133002670
      265005284229506
      26502253736880
      2651044011055010
      265201921101160677
      265254127332276511
      265303629201670561
      2653140212212125672
      2653536203620106603
      265363925161098641
      26540102275514226591
      265411312232171661
      2654282071726630
      2654572731216620
      265461311181592751
      265481519141848620
      265510011758317
      26555000031000
      26560150150000
      265610000111000
      26565122171239670
      26567111861045732
      26568218009829
      265870026713333
      26590125003750
      26591000071000
      2659313522810400
      26596000011000
      266080000710014
      2661512110948990821
      26650101291166784
      2666510124569831
      266763651044852
      26685282822850
      2668641341324753
      2671511271229710
      2672775177216293671
      267351011310113577741
      2674652193413181681
      267560000310033
      2676549185520171622
      2677642242210560
      26785712122041682
      26910000041000
      26951000091000
      26952311162221956810
      2698913121514777310
      2984427269966652
      2984613021407444721
      298475151327829
      352077106957816
      6472212129976782
      648217302914619
      6483150123910318782
      64834254937862
      648350000351006
      6483614164569790

      References

        • Al Youha S.
        • Lalonde D.H.
        Update/review: changing of use of local anesthesia in the hand.
        Plast Reconstr Surg Glob Open. 2014; 2
        • Lalonde D.
        How the wide awake approach is changing hand surgery and hand therapy: inaugural AAHS sponsored lecture at the ASHT meeting, San Diego, 2012.
        J Hand Ther Off J Am Soc Hand Ther. 2013; 26: 175-178
        • Chan V.W.S.
        • Peng P.W.H.
        • Kaszas Z.
        • et al.
        A comparative study of general anesthesia, intravenous regional anesthesia, and axillary block for outpatient hand surgery: clinical outcome and cost analysis.
        Anesth Analg. 2001; 93: 1181-1184
        • Bismil M.
        • Bismil Q.
        • Harding D.
        • Harris P.
        • Lamyman E.
        • Sansby L.
        Transition to total one-stop wide-awake hand surgery service-audit: a retrospective review.
        JRSM Short Rep. 2012; 3: 23
        • Davison P.G.
        • Cobb T.
        • Lalonde D.H.
        The patient’s perspective on carpal tunnel surgery related to the type of anesthesia: a prospective cohort study.
        Hand (N Y). 2013; 8: 47-53
        • Leblanc M.R.
        • Lalonde J.
        • Lalonde D.H.
        A detailed cost and efficiency analysis of performing carpal tunnel surgery in the main operating room versus the ambulatory setting in Canada.
        Hand (N Y). 2007; 2: 173-178
        • Nelson R.
        • Higgins A.
        • Conrad J.
        • Bell M.
        • Lalonde D.
        The wide-awake approach to Dupuytren’s disease: fasciectomy under local anesthetic with epinephrine.
        Hand (N Y). 2010; 5: 117-124
        • Hadzic A.
        • Arliss J.
        • Kerimoglu B.
        • et al.
        A comparison of infraclavicular nerve block versus general anesthesia for hand and wrist day-case surgeries.
        J Am Soc Anesthesiol. 2004; 101: 127-132
      1. American College of Surgeons National Surgical Quality Improvement Program. User Guide for the 2013 Participant Use Data File. https://www.facs.org/quality-programs/acs-nsqip/program-specifics/participant-use. Accessed November 3, 2016.

        • Lipira A.B.
        • Sood R.F.
        • Tatman P.D.
        • Davis J.I.
        • Morrison S.D.
        • Ko J.H.
        Complications within 30 days of hand surgery: an analysis of 10,646 patients.
        J Hand Surg. 2015; 40: 1852-1859.e3
        • Schick C.W.
        • Koehler D.M.
        • Martin C.T.
        • et al.
        Risk factors for 30-day postoperative complications and mortality following open reduction internal fixation of distal radius fractures.
        J Hand Surg. 2014; 39: 2373-2380.e1
        • Bohl D.D.
        • Shen M.R.
        • Kayupov E.
        • Valle C.J.D.
        Hypoalbuminemia independently predicts surgical site infection, pneumonia, length of stay, and readmission after total joint arthroplasty.
        J Arthroplasty. 2016; 31: 15-21
        • Charlson M.E.
        • Pompei P.
        • Ales K.L.
        • MacKenzie C.R.
        A new method of classifying prognostic comorbidity in longitudinal studies: development and validation.
        J Chronic Dis. 1987; 40: 373-383
        • Sundararajan V.
        • Henderson T.
        • Perry C.
        • Muggivan A.
        • Quan H.
        • Ghali W.A.
        New ICD-10 version of the Charlson comorbidity index predicted in-hospital mortality.
        J Clin Epidemiol. 2004; 57: 1288-1294
        • D’Hoore W.
        • Bouckaert A.
        • Tilquin C.
        Practical considerations on the use of the Charlson comorbidity index with administrative data bases.
        J Clin Epidemiol. 1996; 49: 1429-1433
        • Ehlert B.A.
        • Nelson J.T.
        • Goettler C.E.
        • et al.
        Examining the myth of the “July Phenomenon” in surgical patients.
        Surgery. 2011; 150: 332-338
        • Helwani M.A.
        • Avidan M.S.
        • Ben Abdallah A.
        • et al.
        Effects of regional versus general anesthesia on outcomes after total hip arthroplasty: a retrospective propensity-matched cohort study.
        J Bone Joint Surg Am. 2015; 97: 186-193
        • Pugely A.J.
        • Martin C.T.
        • Gao Y.
        • Mendoza-Lattes S.
        • Callaghan J.J.
        Differences in short-term complications between spinal and general anesthesia for primary total knee arthroplasty.
        J Bone Joint Surg Am. 2013; 95: 193-199
        • Basques B.A.
        • Bohl D.D.
        • Golinvaux N.S.
        • Samuel A.M.
        • Grauer J.G.
        General versus spinal anaesthesia for patients aged 70 years and older with a fracture of the hip.
        Bone Joint J. 2015; 97-B: 689-695
        • Rodgers A.
        • Walker N.
        • Schug S.
        • et al.
        Reduction of postoperative mortality and morbidity with epidural or spinal anaesthesia: results from overview of randomised trials.
        BMJ. 2000; 321: 1493
        • Galos D.K.
        • Taormina D.P.
        • Crespo A.
        • et al.
        Does brachial plexus blockade result in improved pain scores after distal radius fracture fixation? A randomized trial.
        Clin Orthop. 2016; 474: 1247-1254

      Linked Article