A Comparative Study Between Arm Intravenous Regional Anesthesia Versus Forearm Intravenous Regional Anesthesia in Patients Undergoing Hand and Wrist Surgery.

The analgesic efficacy of forearm versus upper arm intravenous regional anesthesia (Bier's block): A randomized controlled non-inferiority trial

BackgroundThe main objective of this review is to perform a systematic review and meta-analysis of the existing evidence related to the analgesic efficacy with the use of conventional, upper arm intravenous regional anesthesia (IVRA) as compared to a modified, forearm IVRA in adult patients undergoing procedures on the distal upper extremity.MethodsMEDLINE, EMBASE and CENTRAL (Cochrane) databases were searched for randomized controlled trials published in English, French, Dutch, German or Spanish language. Primary outcomes of interest including description of quality level of anesthesia and onset of sensory block were assessed for this review. Dosage of the local anesthetic, local anesthetic toxicity and need for sedation due to tourniquet pain were considered as secondary outcomes.ResultsOur literature search yielded 3 papers for qualitative synthesis. Four other articles were added into a parallel analysis of 7 reports that provided data on the incidence of complications and success rate after forearm IVRA. Forearm IVRA was found to be as efficient as upper arm IVRA (RR = 0.98 [0.93, 1.05], P = 0.78), but comes with the advantage of a lower need for sedation due to less tourniquet pain.ConclusionOur results demonstrate that forearm IVRA is as effective in providing a surgical block as compared to a conventional upper arm IVRA, even with a reduced, non-toxic dosage of local anesthetic. No severe complications were associated with the use of a forearm IVRA. Other benefits of the modified technique include a faster onset of sensory block, better tourniquet tolerance and a dryer surgical field.Registration of the systematic reviewA review protocol was published in the PROSPERO register in November 2015 with registration number CRD42015029536.

Intravenous regional anesthesia (IVRA) using a forearm tourniquet may be a potentially safer technique compared with using an upper arm tourniquet. Ketorolac is a useful adjuvant to lidocaine for IVRA. In this study, we assessed the analgesic efficacy of administering IVRA lidocaine and ketorolac with either a forearm or upper arm tourniquet for outpatient hand surgery. Upper arm IVRA was established using 40 mL of a solution containing 200 mg of lidocaine and ketorolac 20 mg (0.5 mg/mL). Forearm IVRA was established using 20 mL of a solution containing 100 mg of lidocaine and ketorolac 10 mg (0.5 mg/mL). Onset and duration of sensory block as well as postoperative pain and analgesic use were recorded. The patients who received forearm IVRA had a significantly longer period during which they required no analgesics (701 +/- 133 min) compared with 624 +/- 80 min for the upper arm IVRA ketorolac patients (P = 0.032). Onset of sensory block was similar between the two groups; however, recovery of sensation was significantly longer in the Forearm IVRA (22 +/- 5 min) group compared with the Upper Arm IVRA (13 +/- 3 min) group (P < 0.05). There were no differences in postoperative analgesic use or pain scores between the two groups. We conclude that forearm IVRA with lidocaine and ketorolac provides safe and effective perioperative analgesia for patients undergoing ambulatory hand surgery. This technique results in a longer duration of sensory block and prolonged postoperative analgesia compared with upper arm IVRA while using one-half the doses of both lidocaine and ketorolac. Forearm tourniquet intravenous regional anesthesia (IVRA) with 50% less lidocaine and ketorolac provides for both a longer duration of sensory block and prolonged postoperative analgesia compared with upper arm IVRA.

Aim of the study: to compare between the efficacy of using forearm intravenous regional anesthesia (IVRA) and upper arm IVRA and investigate the effects of nitroglycerine (NTG) compared to fentanyl when added to lidocaine in IVRA in wrist and hand surgery. Patients and Methods: 100 patients divided into 4 equal groups. Patients had upper arm tourniquet and received lidocaine (3 mg/kg) mixed with fentanyl (1 μg/kg) in Group I and NTG (400 μg) in Group III. Patients had forearm tourniquet and received half dose of the aforementioned drugs in Group II and Group IV. Results: there was a rapid sensory and motor block onset and reduction in postoperative diclofenac requirement in group III and group IV compared to group I and group II. Conclusion: Both forearm and upper arm tourniquets showed comperable results. Nitroglycerin was associated with rapid onset of sensory and motor block, and reduction in postoperative diclofenac requirement.

Minidose intravenous regional anesthesia (IVRA) and modified forearm IVRA have been used for closed reduction of forearm fractures and for hand surgery in children. Children (5-17 years old) with forearm fractures presenting to a pediatric emergency department were enrolled in a randomized controlled trial to test if modified forearm and minidose IVRA together would provide improved analgesia with reduced risk of anesthetic toxicity compared with conventional minidose IVRA. Pain was assessed using a visual analog scale (FACES) and an objective pain scale (OPS) score at baseline and at critical times. Spearman rank correlation and repeated-measures analysis of variance were used to compare interobserver pain measures and detect differences between the groups over time. Among the 62 patients in the study, no significant differences were observed between groups in objective measures of blood pressure, oxygen saturation, and heart rate at baseline, 5 minutes after IVRA, during surgical reduction, and 15 minutes after reduction. Nurses reported patients experienced a reduction in pain of 2.5 (SD, 3.1) on FACES and 2.3 (SD, 3.1) on OPS at 5 minutes after sedation (P < 0.001 for both). From time of reduction to 15 minutes after the procedure, FACES score declined 1.7 (SD, 3.4) (P = 0.001), and OPS declined 2.1 (SD, 3.6) (P = 0.002). No significant differences were found between experimental arms. The modified forearm minidose IVRA procedure is an acceptable alternative for the relief of pain that usually accompanies the manipulation and reduction of forearm fractures but does not appear to provide additional pain relief compared with conventional minidose IVRA. Level I, therapeutic study.

Aim This study aimed to evaluate the efficacy of intravenous regional anesthesia (IVRA) as regards volume versus concentration of lidocaine in surgeries. Patients and methods The study enrolled 46 patients of ASA physical status I and II, aged 18-65 years, undergoing IVRA using lidocaine 2% at a dose of 2 mg/kg plus fentanyl 1 mg/kg diluted with a volume of 25 ml normal saline [the concentration group (group C, n = 23)], or 2 mg/kg lidocaine 2% plus fentanyl 1 mg/kg diluted with a volume of 40 ml normal saline [the volume group (group V, n = 23)]. The total supplemental systemic fentanyl intraoperatively and rescue pethidine consumption during the first 4 h postoperatively were recorded. The success rate of the IVRA block was also recorded. First and second tourniquet pain times, as well as times of onset and recovery of sensory and motor block, were calculated. Visual analogue scale score for evaluation of the pain resulted from the surgical stimulation was recorded. The side effects of the drugs and complications of the technique were also recorded. Results Intraoperative supplemental fentanyl dose was significantly higher in group V compared with group C. The total pethidine consumption during the first 4 postoperative hours showed nonsignificant difference between patients of the two groups, with a mean of 48.27 ± 9.75 mg in group C versus 52.42 ± 13.83 mg in group V. Hemodynamic parameters such as heart rate and mean arterial pressure were comparable in the two groups. The time to first call of analgesia was significantly prolonged ( P Conclusion IVRA with lidocaine at a dose of 2 mg/kg in 25 ml volume of normal saline represented an effective block and reduced the second tourniquet pain, increased the second tourniquet tolerance, and significantly decreased intraoperative supplemental fentanyl in comparison with the same dose in 40 ml volume of normal saline.

Comparison of anesthetic effect between 0.375% ropivacaine versus 0.5% lidocaine in forearm intravenous regional anesthesia

Review question/objective The objective of this quantitative systematic review is to determine the effects of ondansetron as an adjunct to lidocaine on the tourniquet pain and postoperative pain of American Society of Anesthesiologists class 1 or 2 adult patients undergoing elective hand surgery with intravenous regional anesthesia. Inclusion criteria Types of participants This quantitative systematic review will consider studies that included American Society of Anesthesiologists 1 or 2 patients aged 18 years or older who used ondansetron as an adjunct to lidocaine for intravenous regional anesthesia in elective hand surgery. Types of intervention(s)/phenomena of interest This quantitative systematic review will consider studies that evaluated the analgesic effectiveness of ondansetron admixed to lidocaine for intravenous regional anesthesia in patients undergoing elective hand surgery. Patients treated with the admixture of ondansetron and lidocaine for Intravenous regional anesthesia will be compared to those who were treated with lidocaine alone. Types of outcomes This quantitative systematic review will consider studies that include the following outcome measures: 1: Tourniquet pain as measured by time to onset of tourniquet pain; 2: Postoperative pain relief as measured by first analgesic requirement time. The first analgesic requirement time is defined as the time which has elapsed after tourniquet release to the first request by the patient for analgesic and is assessed via visual analogue score in two to six hour intervals up to 24 hours postoperatively.

Bilateral forearm intravenous regional anesthesia with prilocaine for botulinum toxin treatment of palmar hyperhidrosis

Background and objectivesDistal upper extremity surgery is commonly performed under regional anaesthesia, including intravenous regional anaesthesia (IVRA) and ultrasound-guided forearm nerve block. This study aimed to investigate if ultrasound-guided forearm nerve block is superior to forearm IVRA in producing a surgical block in patients undergoing carpal tunnel release.MethodsIn this observer-blinded, randomized controlled superiority trial, 100 patients undergoing carpal tunnel release were randomized to receive ultrasound-guided forearm nerve block (n = 50) or forearm IVRA (n = 50). The primary outcome was anaesthetic efficacy evaluated by classifying the blocks as complete vs incomplete. Complete anaesthesia was defined as total sensory block, incomplete anaesthesia as mild pain requiring more analgesics or need of general anaesthesia. Pain intensity on a numeric rating scale (0–10) was recorded. Surgeon satisfaction with hemostasis, surgical time, and OR stay time were recorded. Patient satisfaction with the quality of the block was assessed at POD 1.ResultsIn total, 43 (86%) of the forearm nerve blocks were evaluated as complete, compared to 33 (66%) of the forearm IVRA (p = 0.019). After the forearm nerve block, pain intensity was lower at discharge (-1.76 points lower, 95% CI (-2.92, -0.59), p = 0.0006) compared to patients treated with forearm IVRA. No differences in pain experienced at the start of the surgery, during surgery, and at POD1, nor in surgical time or total OR stay were observed between groups. Surgeon (p = 0.0016) and patient satisfaction (p = 0.0023) were slightly higher after forearm nerve block.ConclusionAn ultrasound-guided forearm nerve block is superior compared to forearm IVRA in providing a surgical block in patients undergoing carpal tunnel release.Trial registrationThis trial was registered as NCT03411551.

Pain relief by different methods in elective hand and wrist surgery is pivotal for patients undergoing elective wrist and hand surgery. To evaluate the effectiveness and duration of peripheral nerve block versus local surgical site anesthetic infiltration among patients undergoing elective wrist and hand surgery. This study was carried out in the Orthopaedic Department of Duhok Emergency Teaching Hospital, Duhok, Kurdistan region, Iraq. All patients who attended the Orthopaedic Department (total number=496) for elective hand and wrist surgery between November 2021 and November 2022 were included in the study, but only 300 patients completed the study protocol after the exclusion of 196 patients. Three methods of nerve block were used for postoperative pain relief.The degree and duration of pain relief were assessed. Patients who underwent ultrasound-guided nerve block had more duration of pain relief when compared to those patients who underwent local surgical site anesthetic infiltration and anatomical landmark nerve block (p<0.01), while patients who underwent local surgical site anesthetic infiltration had better pain relief when compared to those patients who underwent ultrasound-guided nerve block and anatomical landmark nerve block (p<0.01 for the group experiencing mild pain and p=0.12 for the group experiencing moderate pain and p<0.01 for the group experiencing severe pain). Ultrasound-guided nerve block is better for a longer duration of pain relief postoperatively than local surgical site anesthetic infiltration, while local surgical site anesthetic infiltration more effectively controls the severity of pain following elective hand and wrist surgery.

Background Intravenous regional anesthesia (IVRA) is an ideal method of providing anesthesia for minor surgical procedures to the extremities performed on an ambulatory basis. This study aimed to study the effects of adding midazolam, dexmedetomidine, or ketamine as an adjuvant to lidocaine in IVRA during forearm and hand surgeries and examine their benefits and complications. Patients and methods A total of 120 patients were included, aged 40–60 years (American Society of Anesthesiologists physical status I–II), undergoing hand and forearm, from April 2015 to August 2016. Patients were randomly divided into four equal groups. Lidocaine-only group (LL group) received IVRA using 40 ml of lidocaine 0.5% (3 mg/kg). Lidocaine plus midazolam group (LM group) received IVRA using 40 ml of lidocaine 0.5% (3 mg/kg) plus midazolam 50 µg/kg added as an adjuvant. Lidocaine plus dexmedetomidine group (LD group) received IVRA using 40 ml of lidocaine 0.5% (3 mg/kg) plus dexmedetomidine 1 µg/kg added as an adjuvant. Lidocaine plus ketamine group (LK group) received IVRA using 40 ml of lidocaine 0.5% (3 mg/kg) plus ketamine 0.5 mg/kg added as an adjuvant. The time of onset, duration, and quality of analgesia; levels of sensory and motor block; heart rate; mean arterial blood pressure; and visual analog score were recorded. Adverse effects of hematoma, injection pain, skin erythema, sedation, and hallucinations were recorded. Results The onset time of sensory and motor blocks was significantly shorter in the adjuvant groups LM, LD, LK in comparison with the control group LL. The grade of sensory and motor blocks was significantly better in groups LM, LD, and LK in comparison with the LL group. The onset time of tourniquet pain was significantly shorter in the control group LL in comparison with adjuvant groups LM, LD, and LK. There was a significant increase in fentanyl requirements in the control LL group compared with adjuvant LM, LD, and LK groups. The duration of postoperative analgesia was significantly prolonged in adjuvant groups LM, LD, and LK compared with the control LL group. Hematoma, injection pain, cutaneous erythema, and hallucination were reported as postoperative complications. Conclusion The addition of midazolam, dexmedetomidine, or ketamine to lidocaine for IVRA improved the quality of intraoperative and postoperative analgesia with minimal adverse effects and higher patients and surgeon satisfaction.

Intravenous regional anesthesia (IVRA) is used in outpatient hand surgery as an easily applicable and cost-effective technique with clinical advantages. The present study aimed to investigate the effects of addition of systemic tramadol or adjunct tramadol to lidocaine for IVRA in patients undergoing hand surgery. American Society of Anesthesiologists (ASA) I-II patients (n = 60) who underwent hand surgery were included. For this purpose, only lidocaine (LDC), lidocaine+adjunct tramadol (LDC+TRA group), or lidocaine+systemic tramadol (LDC+SysTRA group) was administered to the patients for IVRA and the groups were compared in terms of onset and recovery time of sensory and motor blocks, quality of anesthesia, and the degree of intraoperative and postoperative pain. The onset time of sensorial block was significantly shorter in the LDC+TRA group than that in the LDC+SysTRA group. The motor block recovery time was significantly shorter in the LDC+SysTRA group than that in the LDC+TRA and LDC groups. Administration of tramadol as an adjunct showed some clinical benefits by providing a shorter onset time of sensory and motor block, decreasing pain and analgesic requirement, and improving intraoperative conditions during IVRA. It was determined that systemic tramadol administration had no superiority.

Background: Both the axillary brachial block and elbow block are easy to learn and perform. Elbow block was previously used to as a rescue block to supplement the inadequacy of proximal nerve plexus block. Recently, elbow block is emerging as a primary anesthetic technique for wrist and hand surgeries. However, no such study in Indian scenario exists comparing axillary brachial plexus block and elbow block using ultrasound (US) guidance during wrist and hand surgeries. Aims and Objectives: The present study was designed to compare axillary brachial plexus block and elbow block for hand and wrist surgery in terms of duration of post-operative analgesia (Primary outcome), procedure times, other characteristics of block, patient satisfaction, and adverse events. Materials and Methods: This open-label parallel-group randomized study was performed in 78 adults, aged 18–70 years, ASA I-II, undergoing elective surgeries of wrist and hand. The patients were randomly allocated into two equal groups to receive either axillary brachial plexus block (Group A, n=39) or elbow block (Group B, n=39), both under US guidance. The time to first rescue analgesia was the primary outcome measure. Other outcome measures were different characteristics of nerve blocks, procedure duration, 24-h analgesic consumption, patient’s satisfaction score, and adverse events. Results: The time to first analgesic administration was considerably higher in axillary block compared with elbow block (15 vs. 14 h, P&lt;0.001). However, the post-operative analgesia with elbow block was not clinically insignificant. The onset of blocks was faster with axillary block compared with elbow block (sensory block 15 vs. 24 min, P&lt;0.001; motor block 20 vs. 30 min, P&lt;0.001). Overall, a higher number of patients were more satisfied with elbow block. Conclusion: Using US, elbow block can be a better alternative to axillary block for hand surgeries in terms of sufficient post-operative analgesia, comparatively shorter motor block, and better patient satisfaction.

Objective: In light of the advancement of modern medicine, anesthesiologists and surgeons are increasingly prioritizing patient comfort in diagnostic and therapeutic procedures. A growing body of research revolves around the utilization of ultrasound-guided forearm selective nerve blocks for surgeries involving the distal upper limb. This review aims to provide an overview of regional anesthesia techniques in forearm, hand, and wrist surgeries, laying a theoretical foundation for the prospects of ultrasound-guided forearm selective nerve blocks in optimizing comfort during diagnostic and therapeutic procedures. Methods: A retrospective review of literature sourced from the PubMed database was conducted to comprehensively evaluate and elucidate the advantages and drawbacks of ultrasound-guided forearm selective nerve blocks, brachial plexus blocks, Bier blocks, and wrist blocks. Additionally, a summary was provided regarding the selection of local anesthetics for ultrasound-guided forearm selective nerve blocks. Results: Overall, ultrasound-guided forearm selective nerve block techniques exhibit several advantages over Bier’s block, brachial plexus block, and wrist block for the majority of forearm, wrist, and hand surgeries. These advantages include reduced anesthesia-related time, prolonged duration of analgesia, and minimal impairment of upper extremity motor function. Consequently, these techniques enhance surgical safety and facilitate postoperative recovery. Furthermore, the addition of dexmedetomidine or dexamethasone to ultrasound-guided selective nerve blocks of the forearm could extend the duration of analgesia. Conclusion: Ultrasound-guided forearm selective nerve block is a straightforward and conducive anesthesia method for distal upper limb surgeries, aligning with the principles of fast surgical recovery and enhanced patient comfort during diagnostic and therapeutic procedures. Given its manifold benefits, widespread promotion and adoption of this technique in clinical practice are warranted.