Background and Objectives. To evaluate the usefulness, safety, and efficacy of the combined plexus brachial, spinal, and epidural blocks in free toe to hand transplantations.

Methods. Design: Prospective, case series. Setting: Tampere University Hospital, Finland. Patients: Fifteen adult patients for toe to hand microvascular transplantation under combined regional anesthesia with bupivacaine. Interventions: The efficacy of the blocks, complications, and patient satisfaction were recorded in the study form. Measurements and Main

Results. The duration of operations varied between 8 and 18 hours. No major complications occurred. Vasodilatation in the operated hand was maintained during the entire operation as well as in the postoperative period, and the surgical results were satisfactory. The mean skin temperature was 5°C higher in the blocked extremity compared to the opposite hand. In every patient the skin temperature of the transplant was over 32.4°C after the operation. Blood pressure, heart rate, temperature and oxygen saturation were well maintained during the entire procedure. All patients were satisfied with their anesthesia. Back pain occurred in 11 patients and in two it was considered severe. One patient may have had a systemic toxic reaction (shivering) due to high plasma levels of bupivacaine, but the symptom was transient.

Conclusion. Combined regional anesthesia is an alternative to general anesthesia in prolonged microsurgical operations and it appears to improve perfusion of the transplanted extremity.