Intravenous Regional Anesthesia Research Articles

SAFETY AND EFFICACY OF INTRAOSSEOUS ROPIVACAINE IN LOWER EXTREMITY (SORE) STUDY

IntroductionDay stay surgery for anterior cruciate ligament (ACL) reconstructions is an increasingly common practice and has driven clinicians to come up with postoperative pain regimes that allow same day mobilisation and a safe and timely discharge. There is a paucity of literature surrounding the use of intraosseous (IO) ropivacaine used as a Bier's block to provide both intraoperative and postoperative analgesia in lower limb surgery.MethodsThis patient blinded, pilot study randomised 15 patients undergoing ACL reconstruction to receive either IO ropivacaine 1.5 or 2.0 mg/kg; or 300 mg of ropivacaine as local infiltration (standard of care). Toxic plasma levels of ropivacaine have been defined in the literature and therefore the primary outcome for this study was arterial plasma concentration of ropivacaine as a means to determine its safety profile. Samples were taken via an arterial line at prespecified times after tourniquet deflation. Secondary outcomes that we were interested in included immediate postoperative pain scores using the visual analogue scale (VAS) and perioperative opioid equivalent consumption.ResultsParticipants had a mean age of 27.8 (SD 9.2) years and 87% (13/15) were male. All patients in the intervention group receiving IO ropivacaine had plasma concentrations well below the threshold for central nervous system (CNS) toxicity (0.60 µg/ml). The highest plasma concentration was achieved in the intervention group receiving 1.5 mg/kg dose of ropivacaine reaching 3.59 mg/ml. This would equate to 0.22 µg/ml of free plasma ropivacaine. There were no differences across the three groups regarding pain scores or perioperative opioid consumption.ConclusionsThis study demonstrates that IO administration of 0.2% ropivacaine is both safe and effective in reducing perioperative pain in patients undergoing ACL reconstruction. There may be scope to increase the IO dose further or utilise other analgesics via the IO regional route to improve perioperative pain relief.

Dexmedetomidine Prolongs Lidocaine Intravenous Regional Anesthesia in Rats by Blocking the Hyperpolarization-Activated Cation Current.

Intravenous regional anesthesia (IVRA) using lidocaine provides effective localized analgesia but its duration is limited. The mechanism by which dexmedetomidine enhances lidocaine IVRA is unclear but may involve modulation of hyperpolarization-activated cyclic nucleotide-gated (HCN) channels. Lidocaine IVRA with varying dexmedetomidine concentrations was performed in the tails of Sprague-Dawley rats. Tail-flick and tail-clamping tests assessed IVRA analgesia and anesthesia efficacy and duration. Contributions of α2 adrenergic receptors and HCN channels were evaluated by incorporating an α adrenergic receptor antagonist, the HCN channel inhibitor ZD7288, and the HCN channel agonist forskolin. Furthermore, whole-cell patch clamp electrophysiology quantified the effects of dexmedetomidine on HCN channels mediating hyperpolarization-activated cation current (Ih) in isolated dorsal root ganglion neurons. Dexmedetomidine dose-dependently extended lidocaine IVRA duration and analgesia, unaffected by α2 receptor blockade. The HCN channel inhibitor ZD7288 also prolonged lidocaine IVRA effects, while the HCN channel activator forskolin shortened effects. In dorsal root ganglion neurons, dexmedetomidine concentration-dependently inhibited Ih amplitude and shifted the voltage-dependence of HCN channel activation. Dexmedetomidine prolongs lidocaine IVRA duration by directly inhibiting HCN channel activity, independent of α2 adrenergic receptor activation. This HCN channel inhibition represents a novel mechanism underlying the anesthetic and analgesic adjuvant effects of dexmedetomidine in IVRA.

Pecto-intercostal Fascial Plane Block: A Novel Technique for Analgesia in Patients with Sternal Dehiscence.

Sternal wound complications following sternotomy need a multidisciplinary approach in high-risk postoperative cardiac surgical patients. Poorly controlled pain during surgical management of such wounds increases cardiovascular stress and respiratory complications. Multimodal analgesia including intravenous opioids, non-opioid analgesics, and regional anesthesia techniques, like central neuraxial blocks and fascial plane blocks, have been described. Pecto-intercostal fascial plane block (PIFB), a novel technique, has been effectively used in patients undergoing cardiac surgery. Under ultrasound (US) guidance PIFB is performed with the aim of depositing local anesthetic between two superficial muscles, namely the pectoralis major muscle and the external intercostal muscle. The authors report a series of five cases where US-guided bilateral PIFB was used in patients undergoing sternal wound debridement. Patients had excellent analgesia intraoperatively as well as postoperatively for 24 hours with minimal requirement of supplemental analgesia. None of the patients experienced complications due to PIFB administration. The authors concluded that bilateral PIFB can be effectively used as an adjunct to multimodal analgesia with general anesthesia and as a sole anesthesia technique in selected cases of sternal wound debridement.

Comparison of effectiveness of combination of xylocaine and dexmedetomidine with xylocaine alone in biers block of upper limb.

Objective: To evaluate two groups (combination versus xylocaine alone) in terms of onset of motor block, duration of block, and postoperative analgesia following the release of the tourniquet. Study Design: Quasi Experimental study. Setting: Chaudhary Muhammad Akram Teaching & Research Hospital. Period: 01 June 2023 to 30 Nov 2023. Material & Methods: Quasi experimental study design with a sample of total 80 patients divided into two groups of 40 each (xylocaine alone & combination of xylocaine and dexmedetomidine) were selected by using non probability convenient sampling technique. Results: Combining dexmedetomidine with xylocaine in Bier's block for upper limb surgery demonstrated significant advantages. Group B exhibited faster onset (3.8 min), prolong motor block, and prolonged postoperative analgesia (12.4 hrs) compared to group A (xylocaine alone: 5.2 min onset & shorter postoperative analgesia 6.8 hrs). Dexmedetomidine enhanced post-operative pain control, showcasing its effectiveness in improving outcomes for Bier's block procedures. Conclusion: Dexmedetomidine enhances Bier's block with xylocaine, providing faster onset, extended motor block, and superior post-operative analgesia for upper limb surgery.

Regional versus systemic dexmedetomidine as an adjuvant to lidocaine for intravenous regional anaesthesia in healthy volunteers: a randomized crossover study

Background Dexmedetomidine enhances the quality and duration of lidocaine intravenous regional anaesthesia (IVRA). However, the two administration routes have not been directly compared regarding effects on tourniquet tolerance time with lidocaine IVRA. Additionally, it remains unclear whether the prolonged tourniquet tolerance stems from the direct peripheral action of dexmedetomidine or indirect systemic analgesic effects. Methods We conducted forearm IVRA in 12 healthy volunteers using a crossover design on two separate study days. One day, the systemic dexmedetomidine group received an intravenous infusion of 0.5 μg/kg dexmedetomidine (20 mL) in one arm, followed by 0.5% lidocaine (25 mL) forearm IVRA in the contralateral arm. On the other day, the regional dexmedetomidine group received an intravenous 0.9% saline infusion (20 mL) in one arm, followed by combined 0.5% lidocaine (25 mL) and 0.5 μg/kg dexmedetomidine forearm IVRA in the opposite arm. After a two-week washout period, participants crossed over to receive the alternate treatment. The primary outcome was tourniquet tolerance time, from initiating IVRA until the patient-reported tourniquet pain numerical rating scale exceeded three. Results The tourniquet tolerance time was longer with regional versus systemic dexmedetomidine (36.9 ± 7.6 min vs 23.3 ± 6.2 min, respectively), with a 13.6 min mean difference (95% CI: 10.8 to 16.4 min, p < 0.001). Regional dexmedetomidine also hastened sensory onset and extended sensory recovery compared to systemic administration. Delayed sedation after tourniquet release occurred in 5 of 12 subjects receiving regional dexmedetomidine. Conclusion The addition of regional dexmedetomidine to lidocaine prolonged tourniquet tolerance time in forearm IVRA to a greater extent compared to systemic dexmedetomidine in healthy volunteers. Trial registration Chinese Clinical Trial Registry, ChiCTR2300067978.

Single-center experience of cubital tunnel syndrome surgery performing transposition or internal neurolysis with external decompression under regional intravenous anesthesia technique

Aims: To share the 7-year experience of a single center in the application of regional intravenous anesthesia (RIVA) for surgical treatment of cubital tunnel syndrome (CTS) caused by compression of the ulnar nerve in the elbow region.&#x0D; Methods: A total of 100 patients with CTS who were operated with the RIVA technique at a single center between 2012 and 2019 were retrospectively analyzed. In the RIVA technique, after providing venous drainage in the operated side arm, the double cuff tourniquet was inflated in the upper arm, and anesthesia was provided by administering a 30-40 mL solution of 2% lidocaine (3 mg/kg) diluted in 1% saline through the intravenous catheter. The surgical methods applied (transposition or internal neurolysis with external decompression), demographic data, preoperative and postoperative visual analog scale (VAS) scores for pain were compared.&#x0D; Results: Out of 100 patients, 30 patients underwent surgical transposition (group 1) while internal neurolysis with external decompression was performed in 70 patients (group 2). The mean age of patients in groups 1 and 2 was 66.3±12.1 and 60.6±11.7 years, respectively. Women accounted for 73.3% of patients in group 1 and 87.1% of patients in group 2. The left side was affected in 18 (60%) patients in group 1 and 42 (60%) patients in group 2. In group 1, the mean postoperative 3rd-week VAS score (1.96±0.76) was significantly lower than the mean preoperative VAS score (7.46±0.93; p

Analgesic Techniques for Managing Orthopedic Injuries: A Review for the Emergency Clinician

BackgroundOrthopedic injuries are commonly managed in the emergency department (ED) setting. Fractures and dislocations may require reduction for proper management. There are a variety of analgesic and sedative strategies to provide patient comfort during reduction. ObjectiveThis narrative review evaluates hematoma block, intra-articular injection, intravenous regional analgesia (IVRA) (also known as the Bier block), and periosteal block for orthopedic analgesia in the ED setting. DiscussionAnalgesia is an essential component of management of orthopedic injuries, particularly when reduction is necessary. Options in the ED setting include hematoma blocks, intra-articular injections, IVRA, and periosteal blocks, which provide adequate analgesia without procedural sedation or opioid administration. When used in isolation, these analgesic techniques decrease complications from sedation and the need for other medications, such as opioids, while decreasing ED length of stay. Emergency clinicians can also use these techniques as analgesic adjuncts. However, training in these techniques is recommended prior to routine use, particularly with IVRA. ConclusionsKnowledge of analgesic techniques for orthopedic procedures can assist clinicians in optimizing patient care.

Comparison of lidocaine and its combination with ketamine for distal intravenous regional anesthesia (DIVRA) in bovines

The hoof diseases of cattle can be managed surgically under intravenous regional anesthesia (IVRA). For routine induction of IVRA, a tourniquet is placed circumferentially at the metacarpus/metatarsus. In the present study, hoof diseases of cattle were corrected using a modified IVRA technique. The cattle with hoof ailments were randomly divided into two groups and a tourniquet was placed just distal to the dew claws instead of at the metacarpus/metatarsus in order to decrease the dose of anesthetic. In group I lidocaine (2mg/kg) and in group II a mixture of lidocaine and ketamine (2mg/kg+1.5mg/kg) was injected into the axial digital vein to induce distal intravenous regional anesthesia (DIVRA). The heart rate, respiration rate, systolic and diastolic pressure were unaffected in both groups. Oxygen saturation was significantly (P&lt;0.05) lower between 5 and 60 minutes in group I and between 15and 40 minutes in group II animals. The sensory and motor block onset time was shorter, and the sensory and motor block recovery time was longer in group II animals as compared to group I animals. It was concluded that the DIVRA technique using lidocaine alone and lidocaine admixed with ketamine are suitable for hoof examination and surgery.

Evaluation and Treatment of Acute Trauma Pain in Older Adults.

In the context of an ageing population, the demographic sands of trauma are shifting. Increasingly, trauma units are serving older adults who have sustained injuries in low-energy falls from a standing height. Older age is commonly associated with changes in physiology, as well as an increased prevalence of frailty and multimorbidity, including cardiac, renal and liver disease. These factors can complicate the safe and effective administration of analgesia in the older trauma patient. Trauma services therefore need to adapt to meet this demographic shift and ensure that trauma clinicians are sufficiently skilled in treating pain in complex older people. This article is dedicated to the management of acute trauma pain in older adults. It aims to highlight the notable clinical challenges of managing older trauma patients compared with their younger counterparts. It offers an overview of the evidence and practical opinion on the merits and drawbacks of commonly used analgesics, as well as more novel and emerging analgesic adjuncts. A search of Medline (Ovid, from inception to 7 November 2022) was conducted by a medical librarian to identifyrelevant articles using keyword and subject heading terms for trauma, pain, older adults and analgesics. Results were limited to articles published in the last 10years andEnglish language. Relevant articles' references were hand-screened to identify other relevant articles. There is paucity of dedicated high-quality evidence to guide management of trauma-related pain in older adults. Ageing-related changes in physiology, the accumulation of multimorbidity, frailty and the risk of inducing delirium secondary to analgesic medication present a suite of challenges in the older trauma patient. An important nuance of treating pain in older trauma patients is the challenge of balancing iatrogenic adverse effects of analgesia against the harms of undertreated pain, the complications and consequences of which include immobility, pneumonia, sarcopenia, pressure ulcers, long-term functional decline, increased long-term care needs and mortality. In this article, the role of non-opioid agents including short-course non-steroidal anti-inflammatory drugs (NSAIDs) is discussed. Opioid selection and dosing are reviewed for older adults suffering from acute trauma pain in the context of kidney and liver disease. The evidence base and limitations of other adjuncts such as topical and intravenous lidocaine, ketamine and regional anaesthesia in acute geriatric trauma are discussed.

Mini-dose Bier's block vssystemic analgesia in distal radius fractures: a promising reduction in emergency department throughput time.

Aim: This study compared the effect of the conventional technique of procedural sedation and the mini-dose intravenous regional anesthesia (IVRA). Patients & methods: 45 patients received IVRA, and 47 received iv. ketamine. The pain score, emergency department (ED) length of stay and patients' satisfaction were compared. Results: The study revealed that not only the levels of hemodynamic parameters but also their stability, and the patient's satisfaction in the IVRA group were significantly better. The patients' pain score and ED length of stay were also significantly decreased in those who received IVRA. Conclusion: Mini-dose IVRA technique contributes to better hemodynamic stability, without prominent adverse events, and leads to significant pain control and improved ED throughput time. Clinical Trial Registration: NCT03349216 (ClinicalTrials.gov).

Comparison of Analgesic effect of Dexmeditomidine and Paracetamol as Adjuvant with Lignocaine Hydrochloride for Intravenous Regional Anesthesia

Objective: To compare and evaluate the analgesic effect of Dexmeditomidine and Paracetamol as adjuvant with lignocaine hydrochloride following upper limb surgeries. Study Design: Quasi-experimental study Place and Duration of Study: Combined Military Hospital, Rawalpindi, Allied Hospital, Faisalabad, Fauji Foundation Hospital, Rawalpindi Pakistan Methodology: Sixty ASA physical status I and II patients undergoing upper limb surgery were included in this study. Patients were divided into three groups (n=20) in each group. Regional anesthesia was achieved with 3mg/kg of Lignocaine hydrochloride(L) (02%) in Group A (n=20). Group B received 3 mg/kg of Lignocaine hydrochloride plus Dexmedetomidine (D/L) 0.5 μg/kg. Group C (n=20) received 3 mg/kg of lignocaine hydrochloride plus 300 mg of paracetamol (P/L). Onset and recovery time of Sensory and motor blocks and post-operative pain using visual analogue score was evaluated. Results: Group B showed significantly less sensory block onset time and motor block onset time as compared with Group Aand Group C. Similarly, sensory block recovery time and motor block recovery time were significantly more in Group B compared to other groups. visual analogue score was significantly less in Group B in comparison with Group A and C. First postoperative analgesic request time was significantly longer in the Group B than in Group C. Conclusion: It was concluded that Dexmedetomidine/Lignocaine hydrochloride provides better analgesia compared to paracetamol/Lignocaine hydrochloride in intravenous regional anesthesia.

Comparative Study between Using Lidocaine Alone versus Using Lidocaine Combined with Either Ketamine, Nitroglycerine or Paracetamol for Bier Block in Upper Limb Surgeries Distal to The Elbow: A Prospective Double-Blind Randomized Clinical Trial

Comparative Study between Using Lidocaine Alone versus Using Lidocaine Combined with Either Ketamine, Nitroglycerine or Paracetamol for Bier Block in Upper Limb Surgeries Distal to The Elbow: A Prospective Double-Blind Randomized Clinical Trial

Ultrasound-guided supraclavicular block versus Bier block for emergency reduction of upper limb injuries: a protocol for an open-label, non-inferiority, randomised controlled trial

BackgroundClosed reduction of upper limb fractures and/or dislocations are common in the emergency department (ED), which involves physically re-aligning the injured part prior to immobilisation. As this is painful, numerous techniques are available to provide regional anaesthesia to ensure patient tolerance. A Bier block (BB) is typically performed as part of routine care. An alternative technique gaining interest in the ED is ultrasound-guided supraclavicular block (UGSCB), which involves injecting local anaesthetic around the brachial plexus at the supraclavicular fossa under ultrasound guidance. It is unclear whether UGSCB is effective and safe when performed in the ED.MethodsSUPERB (SUPraclavicular block for Emergency Reduction versus Bier block) is a prospective open-label, non-inferiority randomised controlled trial that compares the effectiveness of UGSCB versus BB for closed reduction of upper limb fractures and/or dislocations. Adult patients presenting with an upper limb fracture and/or dislocation that requires emergent closed reduction in the ED will be eligible. After screening, participants will be randomised to either UGSCB or BB. Once regional anaesthesia is obtained, closed reduction of the injured part will be performed and appropriately immobilised. The primary outcome is maximal pain experienced during closed reduction measured via a visual analogue scale (VAS). Secondary outcomes include baseline and post-reduction pain, patient satisfaction, total opioid requirement in ED, ED length of stay, adverse events and regional anaesthesia failure.DiscussionExisting evidence suggests UGSCB is effective when performed in the operating theatre by trained anaesthetists. SUPERB will be the first randomised controlled trial to elucidate the effectiveness and safety of UGSCB in the ED. The findings have the potential to provide an alternative safe and effective option for the management of upper extremity emergencies in the ED.Trial registrationThis trial has been registered on 21 October 2022 with Australia and New Zealand Clinical Trials Registry (ACTRN12622001356752).

Wide Awake Local Anesthesia No Tourniquet (WALANT) Versus Bier’s Block, in Internal Fixation of Unstable Metacarpal and Phalangeal Fractures of the Hand: A Comparative Study

Hand fractures are a common injury in emergency department, and the majority of these are stable injuries that can be treated conservatively with excellent functional results. When respective injuries are characterized as unstable, surgical reduction and stabilization is necessary. Generally, these operations are conducted under regional or general anesthesia to avoid pain and tourniquet for bloodless surgical fields. Wide Awake local anesthesia no tourniquet (WALANT) procedure is described as a local injection of anesthetic agent and epinephrine without tourniquet application, with scope to allow local anesthesia without other sedation and at the same time hemostasis. The purpose of the study is to compare the functional assessment of the hand function during a period of three months after surgical intervention for unstable metacarpal and phalangeal fractures under WALANT versus Biers block. Material &amp;Methods: Between May 2021 to October 2022, 43 patients with unstable metacarpal and phalangeal fractures underwent open reduction and internal fixation, 21 cases with Biers block(BB) anesthesia and rest with WALANT technique. Metacarpal fractures appeared in 29 cases and phalangeal fractures in 14 patients. Patients were operated within the first week from the injury. According to implants they employed locking plates, screws and Kirschner wires in two groups. Results: At three months postoperatively, Quick Dash Score is better in WALANT group while patients’ satisfaction does not differ between two groups. In WALANT group immediate postoperative median VA Score appeared 2/10, while in the Biers block group appeared 6/10. Patients which underwent WALANT technique were discharged on the same day after operation, while the patients with regional anesthesia the next postoperative day. Mean duration of analgesic use was sorter in WALANT group (2,3 days) than in BB group (5,7 days). Conclusion: Οbjective of surgical treatment of unstable hand fractures (metacarpal-phalangeal) is early mobilization and enhance hand functionality to avoid stiffness and tendon adhesions. Wide Awake local anesthesia no tourniquet technique is an alternative sedative procedure which immediately offers postoperative numerous advantages (low-cost technique, no complication from tourniquet, decrease sensation of intra or postoperative pain) compared with Bier’s block anesthesia. Based on our results we believe that WALANT technique offers many benefits in surgical treatment of hand fractures and is suggested as first choice anesthesiologist procedure.

Usefulness of Intravenous Regional Anesthesia for Upper Extremity Arterial Injury Emergencies in Patients with COVID-19: A Case Series and Literature Review

The medical field has undergone many changes since the start of the coronavirus disease 19 (COVID-19) pandemic. In small- and medium-sized hospitals that lack negative pressure facilities for operating rooms, it is impossible to operate on patients infected with COVID-19. As a result, many patients requiring emergency surgery experience serious complications or die. The authors performed intravenous regional anesthesia (IVRA) and emergency surgery in an isolation room on three patients who needed prompt surgical management for upper extremity arterial injuries but could not enter the operating room due to COVID-19 infection. Anesthesia was successful in all cases. A minor anesthetic complication occurred in one patient, who recovered spontaneously. IVRA is a relatively safe and easy method for anesthesia. Moreover, since the tourniquet is inflated before anesthesia, it is well-suited for patients with arterial injury. The method is simple and therefore easy to perform in an isolation room where space and manpower are limited. IVRA can be a good option in emergency surgery for upper extremity artery injury.

A COMPARITIVE STUDY BETWEEN FENTANYL AND DEXMEDETOMIDINE AS EFFECTIVE ADJUVANTS TO LIGNOCAINE FOR INTRAVENOUS REGIONAL ANAESTHESIA FOR FOREARM SURGERIES IN THE AGE GROUP OF 20-50 YEARS – A PROSPECTIVE STUDY

Aims to compare the efcacy of addition of dexmedetomidine to lignocaine and fentanyl to lignocaine for intravenous regional anaesthesia for forearm surgeries. This prospective randomized study was conducted on 60 patients of age 20-50 years, randomly divided in to two main groups of 30 patients in each group, of ASA I, II and III, scheduled for elective forearm surgeries. Group A received 3mg/kg body weight of lignocaine 2% + 1mcg/kg fentanyl. Group B received 3mg/kg body weight of lignocaine 2% + 1mcg/kg Dexmedetomidine. The following parameters were recorded, onset and duration of sensory and motor blockade, hemodynamic effects, post operative analgesia and side effects between groups. Adding 1mcg/kg fentanyl or 1mcg/kg dexmedetomidine to lignocaine for intravenous regional anaesthesia improves the quality of anaesthesia and perioperative analgesia. Fentanyl reduces the time of onset of block and provided better analgesia

Evaluating the Effects of Lidocaine Alone versus Combination of Lidocaine with Pethidine for the Intravenous Regional Anesthesia in Upper Limb Soft Tissue Surgery

Background: Intravenous regional anesthesia (IVRA) has been used as a common anesthetic technique for several types of operations. However, there are various concerns regarding the efficacy of this anesthetic method. The aim of this study was to evaluate the effects of lidocaine alone versus concomitant use of lidocaine and pethidine for the IVRA in upper limb surgery.&#x0D; Methods: In this randomized, double-blind, controlled clinical, 50 eligible individuals were randomly divided to receive either a combination of 1.5 mg/kg lidocaine 2% and 1.5 mg/kg pethidine or placebo (3 mg/kg lidocaine 2%) for IVRA. After the surgery, the onsets and durations of sensory and motor block, the pain intensity in recovery room, the subjects' first demand of morphine, and the total amount of morphine injected within 24 hours were measured.&#x0D; Results: The combination of lidocaine and pethidine was significantly effective in accelerating the onset of both sensory and motor blocks [(P=0.001), (P=0.001), respectively]. However, no differences were found between groups in sensory and motor block durations after surgery. Intervention with lidocaine plus pethidine caused a significant reduction of the pain intensity in recovery room (P=0.02). Also, concomitant use of lidocaine and pethidine led to a longer time of the first demand of morphine (P=0.04). Moreover, the total amount of morphine injected within 24 hours after surgery was considerably lower in individuals treated by lidocaine plus pethidine (P=0.003).&#x0D; Conclusion: The results of the current study suggest that adding pethidine to lidocaine can be considered as an appropriate approach for better management of IVRA.

Comparison of adjuvant therapy with midazolam, paracetamol, tramadol, or magnesium sulfate during intravenous regional anesthesia with ropivacaine: A randomized clinical trial.

Intravenous (IV) regional anesthesia is an easy, safe, reliable, and efficient option for inducing anesthesia during surgeries but with tourniquet-related pain. This study aimed to evaluate midazolam, paracetamol, tramadol, and magnesium sulfate administration as adjuvants with ropivacaine on pain relief and hemodynamic changes in IV regional anesthesia. A randomized, double-blind, placebo-controlled trial was conducted in subjects undergoing forearm surgery with IV regional anesthesia. The block randomization method was used to assign eligible participants to each of five study groups. Hemodynamic parameters were assessed before applying the tourniquet, at prespecified time points (5, 10, 15, and 20 min), then and every subsequent 10 min until surgery completion. A Visual Analog Scale was used to assess pain severity at baseline followed by every 15 min until completion of the surgery, and after tourniquet deflation every 30 min to 2 h, and at 6, 12, and 24 h postoperative. Data were analyzed using Chi-square and analysis of variance with repeated data testing. The shortest onset and the longest duration of sensory block were observed in the tramadol group and the shortest onset of motor block in the midazolam group (P < 0.001). Pain score was estimated to be significantly lower in the tramadol group at the time of tourniquet application and release, and 15 min to 12 h after tourniquet release (P < 0.05). In addition, the lowest dose of pethidine consumption was observed in the tramadol group (P < 0.001). Tramadol appeared to be able to effectively relieve pain, shorten the onset of sensory block, prolong the duration of sensory block, and achieve the lowest consumption of pethidine.

Intravenous Regional Anesthesia: The Old and Recent Techniques? Review Article

Intravenous Regional Anesthesia: The Old and Recent Techniques? Review Article

Safety and efficacy of intraosseous ropivacaine in lower extremity (SORE) study.

Day stay surgery for anterior cruciate ligament (ACL) reconstructions is an increasingly common practice and has driven clinicians to develop postoperative pain regimes that allow same day mobilization and a safe and timely discharge. There is a paucity of literature surrounding the use of intraosseous (IO) ropivacaine used as a Bier's block to provide both intraoperative and postoperative analgesia in lower limb surgery. This patient blinded, pilot study randomized 15 patients undergoing ACL reconstruction to receive either IO ropivacaine 1.5 or 2.0mg/kg; or 300 mg of ropivacaine as local infiltration. The primary outcome for this study was arterial plasma concentration of ropivacaine. Samples were taken via an arterial line at prespecified times after tourniquet deflation. Secondary outcomes included immediate postoperative pain scores using the visual analogue scale and perioperative opioid equivalent consumption. All patients in the intervention group receiving IO ropivacaine had plasma concentrations well below the threshold for central nervous system (CNS) toxicity (0.60 μg/mL). The highest plasma concentration was achieved in the intervention group receiving 1.5mg/kg dose of ropivacaine reaching 2.93 mg/mL. This would equate to 0.18 μg/mL of free plasma ropivacaine. There were no differences across the three groups regarding pain scores or perioperative opioid consumption. This study demonstrates that IO ropivacaine is both safe and effective in reducing perioperative pain in patients undergoing ACL reconstruction. There may be scope to increase the IO dose further or utilize other analgesics via the IO regional route to improve perioperative pain relief.