Incidence Of Tourniquet Pain Research Articles

Role of an Intercostobrachial Nerve Block in Alleviating Tourniquet Pain: A Randomized Clinical Trial.

IntroductionTourniquet pain may have cutaneous and ischemic components. It is questionable whether blockade of a sensory nerve will help reduce ischemic pain. In addition, complete anesthesia of the axilla in the intercostobrachial nerve (ICBN) distribution is challenging to execute, and ICBN blockade has an inherently higher failure rate because of its variable anatomic location and source of innervation. We sought to determine the utility of an ICBN block for the prevention of tourniquet pain.MethodsWe conducted a single-center randomized controlled trial at a major academic medical center involving patients scheduled to undergo distal upper extremity surgery under ultrasound-guided supraclavicular brachial plexus block. Forty patients were randomized to receive an additional ICBN block or no ICBN block, with 22 allocated to the intervention and 18 to control. We collected data on the incidence of tourniquet pain and systemic anesthetic requirements.ResultsInitial contingency analysis examining the relationship between ICBN block placement and the development of pain using the two-tailed Fisher exact test failed to show that the presence or absence of ICBN block was associated with the development of tourniquet pain. χ2 analysis failed to show that tourniquet time was significantly related to the development of tourniquet pain.ConclusionsThe overall incidence of tourniquet pain in the setting of a dense supraclavicular brachial plexus block for surgical anesthesia was low even without an ICBN block and even with tourniquet times greater than 90 min. Tourniquet pain was easily managed with small amounts of systemic analgesics.

The Role of Dexmedetomidine as an Additive to Intravenous Regional Anesthesia: A Systematic Review and Meta-analysis.

Background: Intravenous Regional Anesthesia (IVRA) is a reliable and cost-effective anesthetic method for minor surgical procedures to the extremities. Limitations of this block include tourniquet discomfort, short duration of anesthesia, and absence of postoperative analgesia. Dexmedetomidine has been used as an adjuvant to minimize these negative characteristics with inconclusive results.Aim: To perform a systematic review of the existing evidence on the role of dexmedetomidine as an additive to intravenous regional anesthesia in upper limb surgery.Study Design: Systematic Review and Meta-analysis.Methods: The databases searched were MEDLINE, Embase, PubMed, CINAHL, Cochrane Database of Systematic Reviews, Cochrane Central Register of Controlled Trials databases, and clinicaltrials.gov (1990-2019). Seven randomized controlled trials (RCTs) were included. We analyzed the duration of analgesia, onset time of sensory and motor block, intraoperative tourniquet pain scores, the incidence of tourniquet pain, need for rescue analgesia, intraoperative rescue analgesia consumption, sedation scores, postoperative pain scores, and anesthesia quality.Results: Intraoperative analgesia duration (MD 11.08 min; 95% CI 5.42, 16.75; P < .0001) was longer and sensory block onset time (MD −2.10 min; 95% CI −3.345, −0.86; P = .00009) was shorter in the dexmedetomidine group. Anesthesia quality scores (MD 0.58; 95% CI 0.47, 0.70; P < .00001) and postoperative sedation scores (MD 1.03; 95% CI 0.88, 1.24; P < .00001) were significantly higher. There was a significant reduction in intraoperative rescue analgesia consumption (MD −19.70 mg; 95% CI −24.15, −15.26; P < .00001) in the dexmedetomidine group. The risk of tourniquet pain as well as postoperative pain scores were lower in favor of dexmedetomidine. The addition of dexmedetomidine to IVRA slightly increased the risk of sedation. A limitation of our study is that some of the interesting outcomes derive from a small number of RCTs.Conclusion: The addition of dexmedetomidine to IVRA ameliorates the block’s characteristics and carries a low risk of potential side effects.

Dexmedetomidine as an Adjuvant to Lignocaine for Intravenous Regional Anesthesia for Forearm and Hand Surgeries: A Prospective, Randomized, Controlled Study

Objective: Intravenous regional anesthesia (IVRA) is an effective anesthetic technique for surgical procedures of short duration involving the distal parts of the limbs. Intraoperative tourniquet pain is the major restraint of this technique, and to overcome this limitation, various adjuvants to local anesthetics have been used. This study investigated the effect of a fixed low dose of dexmedetomidine as an adjuvant to lignocaine on intraoperative tourniquet pain, onset of block, duration of block, and patient satisfaction. Methods: A total of 100 adult patients with ASA grade I and II who were scheduled for upper limb surgery of approximately 1 hour in duration were randomly divided into two groups (n=50 in each group). Group A received 35 mL of preservative-free lignocaine alone and Group B received 35 mL of preservative-free lignocaine along with 30 μg of dexmedetomidine. The incidence of tourniquet pain, intraoperative fentanyl consumption, duration of onset and recovery of sensory and motor block after tourniquet deflation, postoperative numeric pain rating scale (NPRS) scores, duration of analgesia, and overall patient satisfaction were noted. Result: The incidence of tourniquet pain and intraoperative fentanyl consumption were significantly lower in Group B. The onset and duration of sensory and motor blocks were faster and longer, respectively, in Group B. Postoperative NPRS scores were lower, duration of analgesia was longer, and overall patient satisfaction was better in the dexmedetomidine group. Conclusion: Dexmedetomidine at a dose of 30 μg as a lignocaine adjuvant significantly reduces tourniquet pain and intraoperative fentanyl consumption in IVRA. Dexmedetomidine shortens the onset of block, prolongs the duration of block, and provides a more satisfactory anesthesia than lignocaine alone.

A comparative study on the effect of dexamethasone, dexmedetomidine, and lornoxicam as adjuncts to local anesthetic in intravenous regional anesthesia in forearm and hand surgery

Background Intravenous regional anesthesia (IVRA) is a simple and reliable technique. The ideal IVRA solution should be rapid in onset and offers prolonged analgesia. The aim of this study was to assess the effects of different additives to local anesthetic in IVRA to provide a successful operative anesthesia with minimal analgesic requirements.Patients and Methods 80 patients ASA I–III scheduled for orthopedic and plastic surgeries in the forearm or the hand were randomly categorized into four groups, with 20 patients in each group. All groups received 30 ml of Lidocaine 1 % as IVRA solution in addition to the studied anesthetic adjunct.Group I (LD) received 8 mg dexamethasone in 2 mlGroup II (LP) received 0.5 mcg/kg dexmedetomidine in 2 mlGroup III (LL) received 8 mg lornoxicam in 2 mlGroup IV (LS) received 2 ml normal saline 0.9%Mean arterial pressure and heart rate changes in the four study group changes were noted. Motor and sensory block onset and recovery times (minutes) and postoperative analgesic (gram paracetamol) consumption in the four study groups were recorded. Incidence of tourniquet pain and operative conditions were also assessed.Results The LP group showed a shorter time to onset of sensory block than the other three groups that was statistically significant with p<0.001. Both the LP and LL groups showed statistically significant longer time to recovery of sensory block (min) than the other groups (p<0.001). Both times to onset of motor block (min) and time to recovery of motor block (min) shows statistical insignificance regarding the relation between the 4 groups (p=0.073 and 0.794 respectively). Time to 1st postoperative analgesic request (min) was significantly late and the postoperative paracetamol consumption (gm) was significantly lower in the LP and LL groups than the other groups (p<0.001).Conclusion On studying different additives to lidocaine in IVRA, we found that dexmedetomedine and lornoxicam provide the best patient outcome regarding the onset and recovery of sensory block and prolonged analgesia.

Postoperative Tourniquet Pain in Patients Undergoing Foot and Ankle Surgery.

Background Tourniquets are commonly used to reduce bleeding intraoperatively during orthopedic surgery. There are variable guidelines for ideal tourniquet pressure and duration; the practice of fixed, high tourniquet pressures remains common. The purpose of this study was to assess the correlation between excessive tourniquet pressure and duration and the incidence of tourniquet pain in foot and ankle surgery patients.Methods A retrospective cohort study was conducted on 128 patients who underwent foot and ankle surgery with tourniquet use. Baseline systolic blood pressure (SBP), tourniquet pressure and duration, intraoperative opioid consumption, post-anesthesia care unit (PACU) pain scores, PACU opioid consumption, and PACU length of stay (LOS) were collected. Linear regression analysis was used to test for the statistical correlation between the tourniquet pressure and duration and postoperative pain scores, narcotic use, and PACU LOS.ResultsA tourniquet pressure of 280 mmHg was used in 90% of the cases (N = 128). Only 2.5% of the patients had tourniquet pressures 100-150 mmHg above SBP. The mean tourniquet time was 107.5 minutes ± 39.8. Linear regression showed a significant positive correlation between tourniquet time and morphine equivalents used in the perioperative period (r = 0.410; p < 0.001) and the length of PACU stay (r = 0.250; p = 0.012).Conclusion Prolonged tourniquet times at high pressures, not based on limb occlusion pressure LOP, lead to increased pain and opioid use and prolonged PACU LOS. Basing tourniquet pressures on LOPs could likely improve the safety margin of the tourniquets; however, randomized clinical trials are needed.

A Study on the Efficacy of the Addition of Low Dose Dexmedetomidine as an Adjuvant to Lignocaine in Intravenous Regional Anaesthesia (IVRA).

Intravenous Regional Anaesthesia (IVRA) is a simple, effective method of providing anaesthesia for short duration surgical procedures on the extremities, its chief drawbacks are tourniquet pain, short duration of block and absence of post-operative analgesia. Dexmedetomidine is known to reduce anaesthetic requirements and also provide analgesia to the patient. To evaluate the efficacy of dexmedetomidine as an adjuvant to lignocaine in IVRA with respect to the quality of the block, tourniquet pain and post-operative analgesia. A prospective, randomized, double-blinded study was conducted on 60 patients scheduled for orthopaedic surgery of the upper limb, of American Society of Anaesthesiologist's physical status grades I and II. They were divided into two groups of 30 each. The control group C received 40ml of 0.5% lignocaine with saline and Group D received dexmedetomidine 0.5μg/kg added to 40ml of 0.5% lignocaine. The time taken for the onset and recovery of sensory and motor block, incidence of tourniquet pain, intra-operative and post-operative Visual Analogue Scale (VAS) scores, duration of post-operative analgesia and any side effects were noted. Student t-test was used for evaluation of the demographic data, haemodynamic variables, the onset and recovery times of block, duration of analgesia and intra-operative analgesic consumption and tourniquet pain. Friedman's test was used for intra-operative and post-operative VAS and sedation scores. The onset time of both sensory and motor block were significantly shortened, the recovery of sensory and motor block was prolonged, the incidence of tourniquet pain was comparatively lesser and there was significantly increased duration of post-operative analgesia in the dexmedetomidine group. Haemodynamic parameters were similar in both groups. The addition of 0.5μg/kg of dexmedetomidine as an adjuvant to IVRA effectively enhances the anaesthesia and post-operative analgesia obtained with lignocaine. The low dose of dexmedetomidine was effective and did not cause any major side effects.

The Effect of Body Mass Index on Spinal Anaesthesia for Total Knee Replacement Arthroplasty: A Dose-response Study

The aim of this study was to compare the duration of spinal anaesthesia in obese and non-obese subjects. We also quantified the effect of body mass index (BMI) on spinal anaesthesia by comparing the median effective dose (ED50) of intrathecal hyperbaric bupivacaine required in the two cohorts. One hundred and eight patients undergoing elective total knee replacement arthroplasty under combined spinal-epidural anaesthesia were enrolled as a non-obese group (BMI <27.5 kg/m(2)) or obese (O) group (BMI ≥ 27.5 kg/m(2)). Each group was further subdivided by bupivacaine doses of 6, 7, 8, 9, 10 or 11 mg, respectively. Anaesthesia was deemed successful if a bilateral T12 sensory block occurred within 15 minutes of intrathecal drug administration and epidural supplementation was not required. The ED50 for successful anaesthesia and that for successful block of tourniquet pain were determined separately by probit regression analysis. Although the analgesic duration was prolonged with higher doses of bupivacaine in group O, the ED50 for successful anaesthesia did not differ between groups. However, the incidence of tourniquet pain was lower in group O and the ED50 for block of tourniquet pain was less in group O. This study suggests that bupivacaine dose reduction is not necessary, but analgesic duration may be prolonged in patients with higher BMI. These patients require careful consideration of spinal anaesthetic dose to minimise the risk of unnecessary prolongation of anaesthesia.

Ankle block anesthesia and ankle tourniquets for foot and ankle surgery

Most foot and some ankle surgery is performed in the ambulatory surgery setting. A combination of regional ankle block anesthesia and an ankle tourniquet has several advantages over spinal or general anesthesia and the use of a thigh tourniquet. The ability to anesthetize only the foot and ankle allows for decreased morbidity, increased patient comfort level, and more rapid postoperative recovery. The ankle tourniquet eliminates unnecessary ischemia of the entire lower leg and has not been associated with the high incidence of tourniquet pain that occurs with the thigh tourniquet. It was initially theorized that an ankle tourniquet would cause pressure-induced neural damage. However, the physiological and clinical evidence shows that the ankle tourniquet causes reversible ischemia of the peripheral nerves, which is safe and well-tolerated by the patients. Both the pneumatic tourniquet and Esmarch bandage can be effectively used as an ankle tourniquet. The use of these techniques for a variety of foot and ankle procedures has been highly successful.

Regional anaesthetic technique and the incidence of tourniquet pain

The influence of regional anaesthetic technique on the incidence of lower extremity tourniquet pain was evaluated. We studied 60 patients undergoing orthopaedic procedures of the lower extremity with the use of a pneumatic tourniquet and anticipated inflation of 60 min or longer. Three different anaesthetic techniques were selected by random and draw; spinal anaesthesia (SAB) with plain 0.5% bupivacaine (15 mg) and 0.2 mg epinephrine added, lumbar epidural anaesthesia (EA) with 2% mepivacaine and 1:200,000 epinephrine added, and epidural anaesthesia (AEA) with the same solution alkalinized with bicarbonate. Onset and level of sensory blockade were determined by loss of painful sensation to pinprick. The incidence of tourniquet pain was determined at 15-min intervals or by patient complaint, by an observer unaware of group. Time to onset of pain, amount of treatment (i.v. fentanyl), and sensory level at the time of pain were determined. The SAB was compared with EA and AEA, and EA was compared with AEA. The SAB group was older. The sensory level achieved and duration of tourniquet inflation did not differ among groups. The incidence of tourniquet pain was lower with SAB than with EA and lower with AEA than with EA. There was no difference between SAB and AEA. This study demonstrated a lower incidence of tourniquet pain with spinal anaesthesia than with epidural anaesthesia to the same sensory level. However, this advantage is eliminated if the epidural anaesthetic was performed with an alkalinized local anaesthetic.

Comparison of 0.5% Ropivacaine and 0.5% Bupivacaine for Epidural Anesthesia in Patients Undergoing Lower-Extremity Surgery

Ropivacaine is an amide local anesthetic structurally related to, but appearing less cardiotoxic, than bupivacaine. The authors' investigation was designed in a randomized, double-blind fashion to compare the clinical effectiveness of ropivacaine and bupivacaine in patients undergoing lower-extremity surgery. Forty-five patients were randomized to receive 20 ml of 0.5% ropivacaine or bupivacaine. Intermittent sensory (pinprick) and motor (Bromage score) measurements were made while the block was in effect, and changes in heart rate, blood pressure and amounts of additional analgesics, sedatives and other medications were also recorded. Presence of tourniquet pain and the quality of anesthesia were also assessed. One patient was excluded from analysis; thus, 22 patients each received ropivacaine or bupivacaine. No differences were found in patient or perioperative characteristics between the groups. The quality and extent of sensory and motor blockade between groups were comparable, although bupivacaine was slightly longer acting. Cardiovascular changes, incidence of tourniquet pain, and the amounts of supplemental medications necessary were also similar between groups. The authors found 0.5% ropivacaine and bupivacaine to be clinically similar in both sensory- and motor-blocking characteristics, with the exception that bupivacaine produced a blockade of slightly longer duration. Because ropivacaine is reported to be less cardiotoxic than bupivacaine in animal studies, the similarity of clinical epidural anesthesia may make ropivacaine the preferred agent.

Decreased Incidence of Tourniquet Pain During Spinal Anesthesia with Bupivacaine

In a previous report, the incidence of tourniquet pain was found to be 25% with bupivacaine and 60% with tetracaine (P less than 0.05) spinal anesthesia. On the other hand, tetracaine is more potent than bupivacaine in abolishing the single-compound action potential in vitro in isolated nerves. These conflicting observations may be reconciled if bupivacaine produced greater frequency-dependent conduction blockade of nerve action potentials. This hypothesis was tested in C fibers of isolated, desheathed rabbit vagus nerves. The nerves were supramaximally stimulated at frequencies of 9 or 15 Hz. After a control period, the nerves were exposed to bupivacaine (0.2 mM) or tetracaine (0.02 mM) for 30 minutes. The local anesthetics were then washed out by continuous constant-rate perfusion. The decline and recovery of the first and last action potential amplitudes of the train were measured. Bupivacaine and tetracaine produced similar depression of the first action potential of the 9-Hz and 15-Hz trains. However, bupivacaine caused a delayed recovery of the last action potential of the 15-Hz train but not of the 9-Hz train. These results show that bupivacaine produces greater frequency-dependent conduction blockade of C fibers than does tetracaine. These findings offer a possible explanation as to why spinal anesthesia with bupivacaine results in a lower incidence of tourniquet pain than tetracaine.

Tourniquet Pain During Spinal Anesthesia

The incidence of tourniquet pain was evaluated in 40 patients having orthopedic surgery of the lower extremities during spinal anesthesia using 15 mg of a plain solution of either 0.5% tetracaine or 0.5% bupivacaine. The drugs were administered in a randomized fashion, and measurement of the levels of sensory anesthesia to pinprick and motor blockade as well as the occurrence of tourniquet pain were made by an independent blinded observer. The onset and maximum cephalad spread of sensory anesthesia and the onset and degree of motor block were similar in both groups of patients. However, the duration of sensory anesthesia was significantly longer in patients in whom tetracaine was used. The incidence of tourniquet pain was significantly greater in patients given tetracaine (60%) than in patients given bupivacaine (25%). The occurrence of tourniquet pain was not related to the level of sensory anesthesia, because patients in the tetracaine group had a higher level of sensory anesthesia (mean T6) than did patients in the bupivacaine group (mean T10) at the onset of tourniquet pain. It is speculated that during spinal anesthesia both A and C fibers (mediating fast and slow pain, respectively) are initially equally inhibited. However, as the concentration of local anesthetic in the cerebrospinal fluid declines, C fibers may become unblocked earlier with tetracaine than A fibers, resulting in tourniquet pain in the presence of an otherwise satisfactory spinal anesthetic.

Addition of Glucose to Bupivacaine in Spinal Anesthesia Increases Incidence of Tourniquet Pain

The effect of baricity of 0.5% bupivacaine on the incidence of tourniquet pain when used for spinal anesthesia was evaluated in 60 patients undergoing orthopedic surgery. Three ml of either hyperbaric (8% glucose) or isobaric (glucose-free) solution was used. A standard 7-cm orthopedic tourniquet was applied at the thigh and was inflated to 300 mm Hg for 2 hr or until the patient experienced pain from the tourniquet. During application time, the levels of sensory block to pin prick were similar in the groups. The incidence of tourniquet pain in the glucose-free group (4/30) was significantly lower than in the hyperbaric group (11/30).