Anesthesiology

Excision of extensor tendon sheath of the wrist (de Quervain's procedure)

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What the Anesthesiologist Should Know before the Operative Procedure

De Quervain's procedure is a minor surgical intervention to excise the fibro-osseous sheath surrounding the extensor tendons of the thumb. The procedure can be done either endoscopically or open. It is considered elective out-patient surgery and typically follows failure of conservative therapy (e.g., nonsteroidal anti-inflammatory drugs, splinting, activity modification, corticosteroid injections, or a combination).

Diagnosis is suggested by a positive Finkelstein's test and exacerbation of pain over the first dorsal compartment with rapid ulnar deviation of the wrist initiated by the examiner's grasping of the patient's thumb.

Appropriate anesthetic techniques include local anesthesia with monitored anesthesia care, regional anesthesia techniques in the form of intravenous regional anesthesia or nerve blocks of the brachial plexus or terminal peripheral nerves, and rarely general anesthesia.

The procedure is characterized by low intra- and postoperative pain levels frequently well controlled by over-the-counter non-steroidal anti-inflammatory drugs.

What is the risk of delay in order to obtain additional preoperative information?

De Quervain's procedure is typically a scheduled elective procedure performed on an outpatient basis.

Emergent: Not applicable.

Urgent: Not applicable.

Elective: This is a minor surgical procedure that is limited to the base of the thumb. A tourniquet may be applied to the upper arm, forearm, or, occasionally, the proximal wrist, according to surgeon's preference.

2. Preoperative evaluation

Because De Quervain's tenosynovitis is caused by a thickening of the tendon sheath resulting from repetitive use, there are generally no definite associated medical conditions.

Medically unstable conditions warranting further evaluation: These include any new-onset changes or acute exacerbations of the patient's baseline physiologic status.

When delaying surgery may be indicated: If the patient exhibits signs of acute illness, presents with worsening of preexisting conditions, or has not adhered to recommended fasting guidelines since this surgical procedure is elective.

3. What are the implications of co-existing disease on perioperative care?

De Quervain's tenosynovitis is not associated with any specific comorbidities. However, patients who present for this operative procedure may also suffer from a wide variety of other illnesses.

Perioperative evaluation: The preoperative evaluation of these patients should be comprehensive and cover all major organ systems including airway evaluation.

Perioperative risk reduction strategies: Patients with chronic pain syndromes who undergo elective surgery can be expected to experience greater acute postoperative pain compared to patients without chronic pain. These patients should continue their outpatient analgesic regimen throughout the perioperative period, with the exception of aspirin or other nonsteroidal anti-inflammatory agents (unless indicated for an intracoronary stent, in which case a discussion with the patient's cardiologist is warranted).

Patients with coronary heart disease on beta blocker medications or patients with obstructive pulmonary disease who use inhalers regularly should continue these treatments throughout the perioperative period as well.

Patients with obstructive sleep apnea presenting for outpatient surgery should be encouraged to undergo this procedure, avoiding general anesthesia, and to bring their continuous positive airway pressure (CPAP) equipment with them to the surgery center, if applicable.

b. Cardiovascular system

Acute/unstable conditions

Patients with acute coronary syndrome should have elective surgery delayed and seek definitive diagnosis and treatment according to the AHA/ACC Guidelines.

Baseline coronary artery disease or cardiac dysfunction – goals of management

Patients with long-standing cardiac disease, especially those patients on beta blockers, should continue their normal medication regimen during the perioperative period. For patients with severe cardiac disease, regional anesthesia (e.g., intravenous regional anesthesia, brachial plexus block, or terminal nerve blocks) may be the preferred anesthetic over general anesthesia to avoid hemodynamic swings during induction.

c. Pulmonary

Chronic obstructive pulmonary disease and obstructive sleep apnea

Patients with chronic obstructive pulmonary disease (COPD) who are on chronic medical therapy should continue their usual regimen during the perioperative period. For patients with severe COPD, respiratory drive may be dependent on hypoxia; therefore, high concentrations of oxygen during supplemental oxygen delivery may impair ventilatory drive. Patients with COPD may benefit from regional anesthesia techniques over general anesthesia to maintain the patient's normal respiratory function.

Patients with obstructive sleep apnea (OSA) also benefit from the avoidance of general anesthesia. These patients should be encouraged to bring their own CPAP equipment with them on the day of surgery, if applicable.

Reactive airway disease (asthma)

Patients with reactive airway disease should continue usual medical therapy throughout the perioperative period. To avoid exacerbating underlying reactive airways via tracheal intubation, these patients may benefit from regional anesthesia techniques as the primary anesthetic when undergoing De Quervain's procedure.

d. Renal-GI:

Not specific to this procedure or underlying disease. Patients taking diuretics should not take them on the day of surgery. Patients with chronic renal insufficiency, including those on dialysis, should not receive medications perioperatively with active metabolites. A patient with a history of gastroesophageal reflux disease (GERD) taking proton pump inhibitors should continue these medications perioperatively.

e. Neurologic:

Patients with preexisting neurologic conditions may be concerned about the remote risk of nerve injury related to certain regional anesthesia procedures. Unfortunately, the clinical data regarding potential "double crush syndrome" is lacking, and clinicians are advised to discuss potential risks and benefits of each anesthetic technique with the individual patient and surgeon to determine the most appropriate anesthetic technique. Local anesthesia, infiltrated at the site of surgery, or intravenous regional anesthesia may be preferred.

Acute issues

Any acute central or peripheral nervous system disorder should prompt cancellation of surgery and further evaluation.

Chronic disease

Patients with preexisting central nervous system disorders or peripheral neuropathies may be concerned about potential worsening of symptoms secondary to regional anesthesia. There is no strong evidence for or against the use of regional anesthesia in this setting and, often, patients with chronic neurologic diseases represent a patient population that may be at high risk for complications related to general anesthesia. Each patient's condition and the risks and benefits of each anesthetic option must be considered on an individual basis.

f. Endocrine:

Patients on medications to manage diabetes, thyroid disorders, and other endocrine abnormalities should be counseled on proper medication management in a preanesthetic evaluation clinic, if available.

Oral hypoglycemic agents should be held on the day of surgery. Patients on an insulin regimen can continue long-acting agents and hold fast-acting agents perioperatively because the surgical procedure is brief.

g. Additional systems/conditions which may be of concern in a patient undergoing this procedure and are relevant for the anesthetic plan (e.g., musculoskeletal in orthopedic procedures, hematologic in a cancer patient)

Patients with sickle cell disease should not have surgery under a pneumatic tourniquet, as limb ischemia may precipitate a sickle cell crisis.

4. What are the patient's medications and how should they be managed in the perioperative period?

Because De Quervain's procedure is a relatively short outpatient surgery, most medications can be continued in the perioperative period, with few exceptions (e.g., short-acting insulin, nonsteroidal anti-inflammatory drugs, and other anticoagulants).

Consultation with an anesthesiologist prior to surgery should provide the patient with some guidance regarding medication management.

h. Are there medications commonly seen in patients undergoing this procedure and for which should there be greater concern?

These may include medications specific to diseases associated with surgery. Many patients undergoing De Quervain's procedure have been on nonsteroidal anti-inflammatory drugs chronically. These medications may be associated with increased bleeding risk and are often stopped several days before scheduled elective surgery.

Each surgeon may have a different preference regarding the discontinuation of these medications and should convey his or her preference to the patient.

i. What should be recommended with regard to continuation of medications taken chronically?

Cardiac: Continue use of beta blockers perioperatively. Hold ACE (angiotensin-converting-enzyme) inhibitors and angiotensin receptor blocks on the day of surgery.

Pulmonary: Continue use of inhalers perioperatively.

Renal: N/A

Neurologic: Continue any long-acting analgesics, except nonsteroidal anti-inflammatory drugs.

Antiplatelet: Use of aspirin and other nonsteroidal anti-inflammatory drugs are often held several days prior to elective surgery, but their management should be directed by the surgeon.

Psychiatric: Continue any psychiatric medications per routine, including the morning prior to surgery.

j. How to modify care for patients with known allergies -

A thorough history of medication and environmental allergies should be obtained during preanesthetic evaluation. Medications known to be antigens should be avoided.

k. Latex allergy- If the patient has a sensitivity to latex (e.g., rash from gloves, underwear, etc.) versus anaphylactic reaction, prepare the operating room with latex-free products.

Medication vials with latex tops require removal of these tops prior to aspiration of the drug into the syringe. The practitioner performing regional anesthesia procedures should wear nonlatex sterile gloves.

l. Does the patient have any antibiotic allergies - Common antibiotic allergies and alternative antibiotics

Patients with minor allergy to penicillins may be nonresponsive to cephalosporins. Cefazolin, a first-generation cephalosporin, is effective antibacterial prophylaxis against common skin flora. For patients truly allergic to cephalosporins, clindamycin or vancomycin also offers coverage for these bacteria.

m. Does the patient have a history of allergy to anesthesia?

Malignant hyperthermia (MH)

Documented: Avoid all trigger agents such as succinylcholine and inhalational agents:

  • Proposed general anesthetic plan: Consider local anesthesia or a regional anesthetic technique such as peripheral nerve blocks or intravenous regional anesthesia (Bier block).

  • Ensure that an MH cart is available: (MH protocol)

  • Family history or risk factors for MH: Consider local anesthesia or a regional anesthetic technique such as peripheral nerve blocks or intravenous regional anesthesia (Bier block).

Local anesthetics/ muscle relaxants: Consider local anesthesia or a regional anesthetic technique such as peripheral nerve blocks or intravenous regional anesthesia (Bier block).

5. What laboratory tests should be obtained and has everything been reviewed?

Patients undergoing scheduled elective De Quervain's procedure will only require pertinent laboratory tests based on their medical history. A patient on anticoagulation or history of bleeding may require a hemoglobin measurement. A patient on diuretics for hypertension should have electrolytes checked.

Common laboratory normal values will be same for all procedures.

  • Hemoglobin levels: This should be checked if the patient has a history of anemia or is at risk for bleeding due to anticoagulation.

  • Electrolytes: This should be checked if the patient is on diuretics or has a history of liver, kidney, or endocrine disease.

  • Coagulation panel: This should be checked if the patient is on certain anticoagulants (e.g., warfarin or heparin) or has severe liver dysfunction.

  • Imaging: The patient may have specific diagnostic tests related to the operative extremity for surgical planning. A chest X-ray is often performed for patients over 50 years old or those with known cardiopulmonary disease.

  • Other tests: An ECG is performed for patients over 50 years old, who are undergoing elective surgery, and those with known cardiopulmonary disease. Other tests of cardiac function (e.g., stress echocardiography or perfusion imaging) may be indicated for the patient with myocardium at risk.

Intraoperative Management: What are the options for anesthetic management and how to determine the best technique?

Anesthetic options for De Quervain's procedure include local anesthetic administration by the surgeon along with monitored anesthesia care, a variety of regional anesthesia techniques, and general anesthesia.

Because the site of surgery is not extensive, especially with endoscopic procedures, it is very likely that a patient will be eligible for local anesthesia or regional anesthesia. However, a patient taking antiplatelet medications or other anticoagulants may not be the ideal candidate for certain regional anesthesia techniques when noncompressible bleeding is a significant risk.

a. Regional anesthesia

Regional anesthesia options include intravenous regional anesthesia and nerve blocks of the brachial plexus or distal peripheral nerves often combined with monitored anesthesia care.

Tourniquet coverage is an important factor to consider when choosing the most appropriate regional anesthesia technique. For surgical site and tourniquet coverage of an upper arm tourniquet, a brachial plexus block at the supraclavicular, infraclavicular, or axillary levels. For more distal tourniquet applications, or with intravenous sedation as a supplement, patients may be successfully anesthetized under De Quervain's procedure after specifically anesthetizing the radial, median, and lateral antebrachial cutaneous nerve distributions.

Intravenous regional anesthesia (Bier block)

Benefits: Specific to the site of surgery and can provide effective anesthesia for soft tissue procedures of short duration; does not require special regional anesthesia training since local anesthetic solution will be injected intravenously; procedural time is brief and only entails placement of an additional peripheral intravenous catheter in the operative hand.

Drawbacks: A double-tourniquet is recommended although two single tourniquets can be applied side-by-side; anesthesia is dependent on local anesthetic trapping via the pneumatic tourniquet so this technique is limited by the patient's tourniquet pain tolerance; does not empirically provide postoperative analgesia unless adjuvants are included in the local anesthetic solution.

Peripheral nerve block

Benefits: Specific to the site of surgery; can provide postoperative analgesia and improve the quality of recovery by minimizing the need for opioid analgesics and even general anesthesia.

Drawbacks: Requires an appropriate level of skill and training in order to perform these nerve blocks safely as well as designated equipment (e.g., needles, catheters, nerve stimulator, ultrasound machine); brachial plexus blocks will result in a completely anesthetized upper limb for a very limited surgical site; blocks of terminal branch nerves require multiple injections; adds potential risks of hematoma at the site of needle insertion, site infection, and peripheral nerve injury.

Issues: The practice of peripheral nerve blockade does require sufficient time for performance and anesthetic onset, and this time is often in short supply in a busy ambulatory surgical practice.

b. General anesthesia

General anesthesia can be employed for patients undergoing this procedure with volatile anesthetics alone, intravenous agents alone (e.g., propofol), or a combination. The airway may be managed by mask, laryngeal mask, or endotracheal intubation.

  • Benefits: Does not require special training in regional anesthesia or additional equipment; effectively prolongs tourniquet tolerance.

  • Drawbacks: Not specific to site of surgery; may increase the risk of postoperative nausea and vomiting when volatile anesthetics are used; potential for dental or oral trauma from airway manipulation with or without laryngoscopy.

  • Other issues: Induction and emergence of general anesthesia require additional time which may produce delays given the anticipated short surgical duration.

  • Airway concerns: None specific to this procedure or underlying disease.

c. Monitored anesthesia care

Monitored anesthesia care (MAC) is an effective anesthetic technique for this procedure when combined with regional anesthesia or local anesthesia administered by the surgeon. Anesthetic agents amenable to MAC in this setting include the benzodiazepines, short-acting opioids (e.g., fentanyl, alfentanil), propofol, and dexmedetomidine.

  • Benefits: Does not require special training in regional anesthesia or equipment if local anesthetic is administered by the surgeon; does not significantly increase the risk of postoperative nausea and vomiting unless an opioid-based technique is used; avoids airway manipulation.

  • Drawbacks: May not be effective in blunting tourniquet pain when surgical duration is more than 30 minutes.

  • Other Issues: None.

6. What is the author's preferred method of anesthesia technique and why?

For uncomplicated endoscopic procedures, my anesthetic of choice for this procedure is surgeon administered local with opioid-free monitored anesthesia care. For more extensive open procedures or patients with a history of chronic opioids use, a regional nerve block combined with monitored anesthesia care is reasonable.

What prophylactic antibiotics should be administered?

First-generation cephalosporins (e.g., cefazolin) are effective prophylaxis against the majority of skin bacterial flora.

What do I need to know about the surgical technique to optimize my anesthetic care?

Surgical options include either an open or endoscopic procedure. For the open procedure, a small incision of less than 2 cm is made over the base of the dorsal thumb. Endoscopic procedures require a significantly smaller incision to accommodate the endoscope. A pneumatic tourniquet is commonly employed to prevent intraoperative bleeding and is applied on the upper arm, forearm, or wrist. Knowing where a surgeon plans to place the pneumatic tourniquet can influence the choice of anesthetic technique.

Provide a relaxed patient and stable work environment; specifically, prevent movement of the operative hand.

What are the most common intraoperative complications and how can they be avoided/treated?

Intraoperative bleeding from a nonfunctioning tourniquet. To avoid this complication, perform proper exsanguination with an Esmarch wrap prior to tourniquet inflation above (commonly 100 mmHg over) the patient's systolic blood pressure. Confirm inability to palpate the patient's radial pulse in the operative extremity.

Complications

  • Cardiac: None specific to this procedure or disease.

  • Pulmonary: None specific to this procedure or disease.

  • Neurologic: Trauma to the superficial branch of the radial nerve can produce neuropathic pain in the distribution of this nerve that can be transient, or even permanent; prolonged use of a pneumatic tourniquet has also been associated with peripheral nerve injury from ischemia.

a. Neurologic:

None specific to this procedure or disease; prolonged use of pneumatic tourniquet has been associated with transient, and even permanent, peripheral nerve injury from ischemia.

Unique to procedure: Trauma to the superficial branch of the radial nerve can produce neuropathic pain in the distribution of this nerve that can be transient or even permanent.

b. If the patient is intubated, are there any special criteria for extubation?

No.

c. Postoperative management

What analgesic modalities can I implement?

If peripheral nerve blocks are employed, long-acting local anesthetic solutions (e.g., bupivacaine, ropivacaine) can be used to provide postoperative analgesia or approximately 1 day. For cases performed under monitored anesthesia care, the surgeon can infiltrate the surgical site with long-acting local anesthetic solution. If using an intravenous regional anesthesia technique, adjuvants such as ketorolac, alpha agonists, and ketamine have demonstrated efficacy in providing postoperative analgesia following anesthetic resolution.

What level bed acuity is appropriate?

This procedure is commonly performed on an outpatient basis.

What are common postoperative complications, and ways to prevent and treat them?

Incomplete decompression requiring repeat surgery. Subluxation of the released extensor tendons may result from a widely released first dorsal compartment. Prevention is not guaranteed, but surgical adjustments such as performing a limited resection (<3 mm) in the thickest segment of the dorsal compartment or reconstructing a loose sheath over the exposed tendons may reduce the incidence of subluxation. Trauma to the superficial branch of the radial nerve can produce neuropathic pain in the distribution of this nerve that can be transient, or even permanent, and may be avoided with careful, deliberate blunt dissection.

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