Patients' experiences with multiple stimulation axillary block for fast-track ambulatory hand surgery

Background: Ambulatory axillary block by multiple nerve stimulation (MNS) is effective and time efficient, but may be rejected by patients because of block pain. This prospective study assessed patients' anxiety and acceptance of this block, identified which of the components of blocking procedure is most painful (i.v. line insertion, repeated needle passes, local anesthetic injection, or electrical stimulation) and recorded patients' anesthetic preferences for the future hand surgery. Methods: Upon arrival at the day unit, 100 unpremedicated adult patients without previous experience of peripheral nerve stimulation indicated on the visual analog scale (VAS; 0-100) their anxiety about the block. The blocking procedure was then explained step-by-step. After inserting the i.v. line and freezing the skin in axilla, four terminal nerves (musculocutaneous, median, ulnar, radial) were electrolocated using an initial current of 2 mA and a target current of 0.1-0.5 mA. Pain caused by the individual components of blocking procedure was assessed on VAS before the start of surgery. On the day after the operation, the patients reassessed their anxiety for the next axillary block and indicated which anesthetic method (block alone, block plus sedation, or general anesthesia) they would prefer for the future hand surgery. Results: Before the block, 59 patients admitted being anxious about regional block (median anxiety VAS=27), compared with 42 patients (anxiety VAS=10) postoperatively: P <0.01. Median intensity of electrical stimulation pain was significantly higher (VAS=16) than pain of local anesthetic injections (VAS=8), i.v. line insertion (VAS=6) and multiple needle passes (VAS=5). However, only 53 patients categorized electrolocation as painful. Twenty-seven reported discomfort but not pain, and 20 patients described the sensation as 'funny' or 'strange'. None of the patients had surgical pain during operation. Mean duration of surgery was 77 min, and of hospital stay 166 min. Ninety-eight patients would choose the same block for the future hand surgery, 13 of which would like sedation before the block, and two patients did not wish to be awake during any surgery. Ninety-five patients were satisfied with fast-tracking. Conclusions: Fear of block pain is diminished after experiencing the blocking procedure. Electrical stimuli was perceived as painful by 53% of patients, and this pain was more intense than with other block components. The majority of our patients would choose axillary block without sedation for future hand surgery and are satisfied with fast-tracking.