Sequential supraclavicular brachial plexus block and intravenous regional anaesthesia for upper limb surgery

Abstract

EDITOR: Intravenous regional anaesthesia (IVRA) is a uncomplicated procedure frequently used for surgery of the upper extremities [1,2]. Despite being easy to perform and rapidly bringing about anaesthesia, it has many disadvantages including tourniquet discomfort, ineffective postoperative analgesia necessitating analgesic supplementation after surgery, tissue ischaemia, accumulation of unwanted metabolites together with the local anaesthetic agent itself and increased susceptibility to toxic reactions to local anaesthetics [3,4]. Another common anaesthetic procedure used in hand surgery is the supraclavicular brachial plexus block (SBPB). When using this technique, patients seldom complain of tourniquet discomfort and the analgesia extends into the postoperative period. The main disadvantages of the procedure are as follows: (a) long time interval between the application of the local anaesthetic until the analgesia is sufficient for surgical purposes; (b) possession of expertise for its successful execution; (c) adverse consequences, such as diaphragmatic paralysis and systemic toxicity of the local anaesthetic agents [5,6]. Therefore, we theorized that the combination of these two techniques for regional anaesthesia would improve the quality and duration of the analgesia when compared to each individual technique. In this report, we describe a new practice of regional anaesthesia consisting of SBPB followed by IVRA for upper limb surgery. This study was conducted according to the regulations of HaEmek Medical Center Ethics Committee. Each patient was given a detailed explanation of the anaesthetic technique and instructions on pain scoring using the visual analogue scale (VAS). The study was undertaken in 60 adults, ASA I-II, undergoing elective upper limb surgery. The surgical procedures were carpal tunnel release, suture of the flexor pollicis tendon, trigger finger release, release of Dupuytren's contracture and tendon transfer of the thumb. The exclusion criteria were contraindications for regional anaesthesia, chronic obstructive pulmonary disease and obesity. The patients were randomly divided into three groups each consisting of 20 subjects: Group 1 (12 males and 8 females of average age 47 ± 8 yr) in whom SBPB was used as the method of anaesthesia; Group 2 (12 males and 8 females of average age 45 ± 9 yr) in whom IVRA was used as the method of anaesthesia and Group 3 (10 males and 10 females of average age 42 ± 11 yr) in whom we combined SBPB with IVRA. All patients received oral premedication with 10 mg diazepam and 10 mg metoclopramide 90 min before their arrival to the operating room in case we decided to convert to general anaesthesia. In the operating room non-invasive blood pressure (BP), pulse oximetry and electrocardiogram were continuously monitored in each patient. An intravenous (i.v.) infusion of Ringer's lactate was commenced in the contralateral arm and oxygen was supplemented through a nasal canula. All patients were observed continuously for any signs of adverse reactions to the local anaesthetic agents, such as metallic taste, visual disturbances, numbness of the lips, tinnitus, muscle twitching, and deteriorating consciousness. The time from completion of regional anaesthesia to the skin incision was recorded. Surgery was started after verifying adequate sensory blockade using needle pinpricks in the area of the planned operation. A single tourniquet was used in all procedures with the pressure set at 100 mmHg above the patient's systolic BP. Tourniquet time was limited to 2 h. Upon completion of the surgery, the tourniquet was released gradually permitting a controlled return of circulation. In some cases tourniquet release was requested by the surgeon prior to closure of the wound in order to secure haemostasis. In these circumstances the wound was infiltrated with local anaesthetics. If that was not sufficient, patients received i.v. fentanyl or general anaesthesia consisting of propofol, alfentanil and isoflurane with a laryngeal mask airway as necessary. In each patient, the severity of pain was scored every 15 min during surgery, every 30 min during the immediate postoperative period (a 2 h period during which the patient was in the recovery room) and every 6 h after transfer to the ward. Postoperative pain was treated by 1 g oral dipyrone for mild to moderate pain (VAS ≥ 3) and by 1 mg kg−1 meperidine intramuscularly for severe pain (VAS ≥ 6). SBPB was carried out with a local anaesthetic solution composed of bupivacaine 0.5% 20 mL plus lidocaine 2% 20 mL using the technique described by Winnie [7]. The time from completion of regional anaesthesia to the skin incision was 24 ± 3 min. None of the patients complained of tourniquet discomfort during the surgery. Eight patients needed early release of the tourniquet but did not require supplemental analgesia by either wound infiltration with local anaesthetic, fentanyl supplementation or general anaesthesia. During the immediate postoperative period, none of the patients required supplementary analgesia. Analgesia from the regional block in these patients lasted for up to 22 h with oral dipyrone sufficiently controlling any postoperative pain. All patients were pain free 24 h postoperatively. No toxic reactions to the local anaesthetics were observed during the perioperative and postoperative periods. The only adverse event was the development of Horner's syndrome that was evident for a few hours with spontaneous resolution in 12 patients. IVRA was carried out using a 0.5% solution of lidocaine slowly injected usually over 3 min through an i.v. cannula inserted into one of the dorsal veins of the hand. The dosing rate was fixed at 0.5 mL kg−1 with a maximum injected volume set at 50 mL. The time from completion of regional anaesthesia to the skin incision was 20 ± 3 min. Four patients complained of tourniquet discomfort and mild pain during surgery. Eight patients needed early release of tourniquet. In these patients, the expected loss of analgesia was pre-emptively treated by tissue infiltration with local anaesthetics. In four of these patients, fentanyl supplementation was needed and in one patient we converted to general anaesthesia because of insufficient analgesia. During the 24 h postoperative period pain scores noticeably rose from near zero to values ranging between 2 and 8. Accordingly, these patients were treated with either dipyrone or meperidine over the 24 h postoperative period. Overall, 15 patients complained of pain (VAS ≥ 6) requiring 1-4 doses of meperidine. All patients were pain free 24 h postoperatively. Using the combined SBPB and IVRA technique, regional anaesthesia was initiated using SBPB with bupivacaine 0.25% 20 mL immediately followed by IVRA using 0.25% lidocaine solution at a dosing rate fixed at 0.5 mL kg−1 with a maximum injected volume set at 50 mL. The time from completion of regional anaesthesia to the skin incision was 18 ± 3 min. None of the patients complained of tourniquet discomfort during the surgery. Eight patients needed early release of tourniquet but did not require supplemental analgesia by either wound infiltration with local anaesthetic or fentanyl supplementation. During the immediate postoperative period, none of the patients required additional analgesia. After transfer to the ward, any postoperative pain was effectively controlled by oral dipyrone except in four patients who were treated with 1-2 doses of meperidine. All patients were pain free 24 h postoperatively. Eight patients developed transient Horner's syndrome. Combining two anaesthetic procedures is a common practice to ensure intraoperative success of anaesthesia and improve postoperative analgesia. Examples of this include the combined general and epidural anaesthesia, combined spinal and epidural anaesthesia, and combined regional (nerve block) and general anaesthesia. One could argue that this custom arose due to problems in practice or insecurity of the anaesthesiologist, since either of the two anaesthetic techniques, when correctly executed, should suffice alone. Whatever the reason, the desire for perfection should be encouraged because in most cases it is to the benefit of the patient. Our experiences in this study appear to support this notion. First, the onset time of surgical anaesthesia is short, similar to that obtained if only IVRA was used and shorter than if SBPB was used. Second, none of the patients who had SBPB or the combined procedures complained of tourniquet discomfort. Third, analgesia extended into the postoperative period almost to the same extent as if SBPB alone was used because we noted a reduced need for postoperative analgesia, especially opiates. Although we report a lower incidence of transient Horner's syndrome, a study involving larger patient groups is needed to verify whether this combined technique improves the quality and duration of the analgesia coupled with a lower frequency of adverse consequences and a reduced risk of complications. Z. Crystal Department of Anaesthesiology; HaEmek Medical Center; Afula, Israel M. Barak Department of Anaesthesiology; Rambam Medical Center; Haifa, Israel Y. Katz Department of Anaesthesiology; HaEmek Medical Center; Afula, Israel and The Bruce Rappaport Faculty of Medicine; Technion-Israel Institute of Technology; Haifa, Israel