Intravenous Regional Anesthesia Research Articles

Comparison of ropivacaine 0.2% and 0.25% with lidocaine 0.5% for intravenous regional anesthesia

Study Objective To compare the anesthetic effects of two different concentrations and doses of ropivacaine (0.2% and 0.25%) with those of a conventional dose of lidocaine 0.5%. Design Prospective, randomized, double-blinded, clinical investigation. Setting Large metropolitan university hospital. Patients 66 adult ASA physical status I and II patients undergoing forearm and hand surgery. Interventions Patients were randomly allocated to three groups to receive intravenous regional anesthesia (IVRA). Study groups were: ropivacaine 0.2% (Group I, n = 22), ropivacaine 0.25% (Group II, n = 22), and lidocaine 0.5% (Group III, n = 22). Measurements Tourniquet tolerance times and regression of sensory analgesia were noted. Verbal numerical pain scores (VNS), cumulative analgesic consumption, and side effects were recorded during surgery and postanesthesia care unit (PACU). Time to first pain medication intake and number of patients receiving analgesics in the PACU were recorded. Main Results Additional tolerance times for the distal tourniquet were significantly higher in the ropivacaine 0.25% group than the other two groups. Regression of sensory anesthesia was fastest in the lidocaine group. During the PACU stay, VNSs were significantly lower in the first 20 minutes in the ropivacaine groups than the lidocaine group. Time to first intake of pain medication in the PACU was soonest in the lidocaine group. The number of patients given analgesics in the PACU was highest in the lidocaine group. The number of patients taking > two tablets of tramadol was significantly lowest in the ropivacaine 0.25% group. No serious side effects were observed in any study group. Conclusion Longer tolerance times for the distal tourniquet, prolonged analgesia after tourniquet release, and lower analgesic requirements postoperatively make ropivacaine 0.2% and 0.25% an alternative to lidocaine for IVRA.

Intravenous Regional Anesthesia Toxicity in Pregnancy

Intravenous Regional Anesthesia Toxicity in Pregnancy

Brachial vein thrombosis after intravenous regional anesthesia for carpal tunnel surgery

Brachial vein thrombosis after intravenous regional anesthesia for carpal tunnel surgery

Alternatives to Sedation for Painful Procedures

Conscious sedation is used frequently to perform procedures that may be undertaken with or without minimal sedation. Fracture manipulation can be performed with minimal discomfort in the awake patient using various techniques-for example, intravenous regional anesthesia, nerve blocks, and hematoma blocks. These have been used for many years and are very safe. They may require some specific equipment (eg, automatic tourniquet) to perform the anesthesia but patients have the same results and are able to go home much quicker because sedation is not used.Use of topical anesthesia for both intact skin and wounds has been used over many years. Its use now should be standard. Nerve blocks can also be used to anesthetize specific areas which may be difficult to use topical anesthesia (eg, lip, hand, etc) or are painful because of injection directly into the wound. These may include infraorbital nerve blocks for lip lacerations, ulna or median nerve blocks for hand injuries, and so on. Other novel approaches to topical anesthesia have seen the use of iontophoresis (again requires specific expensive equipment), jet injection of lidocaine, or "freeze sprays." Each has its own advantages and disadvantages.Femoral nerve block is a useful intervention for analgesia in patients with femoral fractures and can obviate the need for parenteral analgesia and allows excellent analgesia particularly during x-ray examination.Thus, it is important to remember that there are alternatives to conscious sedation which gives good analgesia during the procedure and allows the patient to be discharged sooner.

Anesthesia-controlled time and turnover time for ambulatory upper extremity surgery performed with regional versus general anesthesia

Study Objective To test the hypothesis that regional anesthesia (RA) employing a block room reduces anesthesia-controlled time for ambulatory upper extremity surgery compared with general anesthesia (GA). Design Retrospective cohort study. Setting Outpatient surgery center of a university hospital. Patients 229 adult patients who underwent ambulatory upper extremity surgery over one year. Interventions Upper extremity surgery was performed with three different anesthetic techniques: 1) GA, 2) nerve block (NB) performed preoperatively, or 3) local anesthetic (LA), either Bier block or local anesthetic, administered in the operating room (OR). Measurements Demographic data, anesthesia-controlled time, and turnover time were recorded. Since the data were not normally distributed, differences in anesthesia-controlled time and turnover time were analyzed using the Kruskal-Wallis test and post-hoc testing using one-way analysis of variance on the ranks of the observations, with Tukey-Kramer correction for multiple comparisons. Results Anesthesia-controlled time for NB (median 28 min) was significantly shorter than for GA (median 32 min, P = 0.0392). Anesthesia-controlled time for patients who received LA (median 25 min) was also significantly shorter than GA ( P < 0.0001). However, turnover time did not differ significantly among the three groups. Conclusions Peripheral nerve block performed preoperatively in an induction area or LA injected in the OR significantly reduces anesthesia-controlled time for ambulatory upper extremity surgery compared with GA. Turnover time is unaffected by anesthetic technique. These results may increase acceptance of RA in the ambulatory surgery setting.

Symptomatic Phrenic Nerve Palsy After Supraclavicular Block in an Obese Man

Regional anesthesia has an expanding role in upper extremity surgery. Brachial plexus blocks offer several advantages including providing effective analgesia, reducing narcotic requirements, and facilitating ambulatory care surgery. Despite the popularity of nerve blocks, the surgeon must not forget the complications associated with regional anesthesia. This article describes a case of symptomatic phrenic nerve palsy after supraclavicular brachial plexus block in an obese man. A 46-year-old obese man underwent a left-sided supraclavicular block in preparation for decompression of Guyon's canal for ulnar mononeuropathy at the wrist. The patient experienced acute-onset dyspnea, chest discomfort, and anxiety, and physical examination demonstrated reduced breath sounds in the left hemithorax. Chest radiographs documented elevation of the left hemidiaphragm consistent with an iatrogenic phrenic nerve palsy. The patient was admitted for 23-hour observation and underwent an uncomplicated ulnar nerve decompression under Bier block anesthesia 1 week later. No long-term sequelae have been identified; however, there was a delay in surgical care, admission to the hospital, and transient pulmonary symptoms. We attribute this complication to significant abdominal obesity causing compromised pulmonary reserve and poor tolerance of transient hemidiaphragmatic paresis. In recent studies, waist circumference and abdominal height were inversely related to pulmonary function. We suspect that the incidence of symptomatic phrenic nerve palsy associated with brachial plexus blocks will increase as the prevalence of obesity increases in this country.

Premedication With Dexmedetomidine Alone or Together With 0.5% Lidocaine for IVRA

This study aimed to compare the effects of low and same dose of dexmedetomidine when added to lidocaine for intravenous regional anesthesia (IVRA) and when administered for premedication before IVRA. In this double blind study, 45 patients with ASA physical status I-II were scheduled to undergo carpal tunnel release as an outpatient procedure and were randomly divided into three groups. IVRA was performed with 40 mL of 0.5% lidocaine in the operating room. A single dose of dexmedetomidine 0.5 μg/kg and placebo (saline) solution in a total volume of 20 mL were administered intravenously to group P (n=15) and group S (n=15), respectively, before IVRA. 0.5 μg/kg of dexmedetomidine was added to lidocaine in group A (n=15) during IVRA. The onset and recovery time of sensory and motor block, intraoperative-postoperative visual analog scale (VAS) and Ramsay sedation scores (RSS), analgesic requirement, hemodynamic variables, and side effects were noted. Significantly shortened sensory block onset and recovery time in group P and A, shortened motor block onset time in group P, and decreased intra-postoperative VAS scores and analgesic requirement in groups P and A were found. Intraoperative RSS in group P and postoperative RSS in groups P and A were higher than in group S. Intraoperative and postoperative heart rate and postoperative mean arterial blood pressure (MAP) of group P was significantly lower than groups A and group S, respectively. Both addition of dexmedetomidine to lidocaine and premedication with dexmedetomidine for IVRA similarly improve quality of anesthesia and perioperative analgesia without important side effects.

Adenosine receptor blockade accentuates the responses of muscle sympathetic nerve activity to fatiguing exercise

The role adenosine plays in evoking the exercise pressor reflex in humans remain controversial. Interestingly, animal studies suggest that adenosine can inhibit type 1 vanilloid receptors activity. Thus, we hypothesized that adenosine receptor blockade would accentuate muscle sympathetic nerves activity (MSNA) response to fatiguing exercise in humans. Blood pressure (Finometer), heart rate, and MSNA from peroneal nerve were assessed in 11 healthy young volunteers during fatiguing isometric handgrip, post exercise muscle ischemia (PEMI), and passive muscle stretch during PEMI. The protocol was performed before and after adenosine receptor blockade by local infusion of 40 mg aminophylline in saline via forearm Bier block (regional intravenous anesthesia). In the second experiment, the same amount of saline was infused via the Bier block. After aminophylline, the MSNA and blood pressure responses to fatiguing handgrip, PEMI and passive stretch (all P&lt;0.05) were significantly greater than those in control condition. Saline Bier block had no similar effects on the MSNA and blood pressure responses. These data verified our hypothesis, and suggest that adenosine may act to inhibit MSNA response in exercise pressor reflex. Supported by NIH P01 HL077670, M01 RR010732 and AHA 0635245 N.

Ketamine as an Adjuvant in Lidocaine Intravenous Regional Anesthesia

Ketamine delays and minimizes intraoperative tourniquet pain when added to lidocaine-based intravenous regional anesthesia (IVRA). It is unclear if adding ketamine to the IVRA injectate is more efficacious compared with systemic administration. This study compares intraoperative tourniquet pain, postoperative analgesia, and side effects of systemic versus IVRA ketamine during outpatient hand surgery. We conducted a randomized, double-blind, systemic control study of 40 patients undergoing hand surgery using lidocaine IVRA. In group IVRA, 0.1 mg/kg ketamine in 1 mL of normal saline was added to the IVRA lidocaine, and 1 mL of normal saline was administered via a peripheral IV line. In group systemic, 1 mL of normal saline was added to the IVRA syringe, and 0.1 mg/kg ketamine in 1 mL of normal saline was administered via a peripheral intravenous line. Ten minutes after proximal tourniquet inflation, the distal tourniquet was inflated, and the proximal tourniquet deflated. Tourniquet pain was measured every 10 mins. Need for intraoperative opioids was recorded. Recovery room pain scores, analgesic needs, and sedation scores were compared. Patients were contacted 24 hrs after surgery and reported their analgesic consumption, satisfaction scores, and the occurrence of any unpleasant psychologic effects. Groups IVRA and systemic were comparable in demographic and surgical parameters. There were no differences between groups in intraoperative tourniquet pain scores, intraoperative fentanyl requirements, recovery room pain or sedation scores, postsurgical analgesic needs, or patient satisfaction scores. In comparison to systemic administration, there is no selective benefit to adding ketamine to the IVRA injectate.

Bier'S Block for Emergency Department Management of Distal Radius Fractures

Background Distal radius fractures commonly present to emergency departments (ED). Optimum treatment methods remain unclear and individual hospital practices differ. Objectives To ascertain the number and success rate of manipulation under intravenous regional anaesthesia (IVRA) of distal radius fractures, and to determine the re-manipulation rate. Methods Retrospective observational study of patients undergoing manipulation of distal radius fracture under IVRA in the ED from January 2003 to January 2004. The resuscitation room procedure log, hospital computer records, ED records and theatre records were examined for each patient. Results A total of 84 manipulations were performed. Complete information was available for 74 procedures (73 patients). Manipulation was successful in 73.5% with only 19 out of 73 patients requiring operation. All patients were manipulated under IVRA with middle grade or consultant supervision; and 52 (71.2%) patients were managed entirely as outpatients. Conclusion Our policy of manipulating displaced distal radius fractures under IVRA in the ED has a high success rate and allows the majority of patients to be managed as outpatients. This policy may lead to cost savings from a health service financing perspective.

Addition of Dexmedetomidine or Lornoxicam to Prilocaine in Intravenous Regional Anaesthesia for Hand or Forearm Surgery

Intravenous regional anaesthesia (IVRA) is a simple and cost-effective technique that is ideally suited for surgery involving the distal arm. This study compared the effect of lornoxicam or dexmedetomidine in IVRA with prilocaine in patients who underwent hand or forearm surgery. M ethods: This randomized, double-blind study enrolled 75 patients scheduled for hand or forearm surgery. IVRA was achieved with 2% prilocaine 3 mg/kg in the control group (n=25), 2% prilocaine 3 mg/kg plus dexmedetomidine 0.5 microg/kg in the dexmedetomidine group (n=25), and 2% prilocaine 3 mg/kg plus lornoxicam 8 mg in the lornoxicam group (n=25). In all groups, 0.9% NaCl solution was added to make up a total volume of 40 mL. Sensory and motor block onset and recovery times, haemodynamic variables, visual analogue scale (VAS) pain and sedation scores, duration of analgesia, total analgesic consumption over 24 hours, adverse effects and quality of anaesthesia were recorded. Sensory block onset was shorter and sensory block recovery time longer in the dexmedetomidine group compared with the lornoxicam and control groups (p<0.05). Sensory and motor block recovery times and duration of analgesia for tourniquet were prolonged in the dexmedetomidine and lornoxicam groups compared with the control group (p<0.05). Median VAS scores for tourniquet pain in the dexmedetomidine and lornoxicam groups were lower than that of the control group at 15 and 30 minutes (p<0.05). Postoperatively, the duration of analgesia time was longer and median VAS scores were lower during the first 12 hours in the dexmedetomidine and lornoxicam groups compared with the control group (p<0.05). Total analgesic consumption over 24 hours was lower in the dexmedetomidine and lornoxicam groups compared with the control group (p<0.05). Anaesthesia quality as determined by the anaesthesiologist was better in the dexmedetomidine and lornoxicam group than in the control group (p<0.05). Addition of dexmedetomidine or lornoxicam to prilocaine in IVRA decreased VAS pain scores, improved anaesthesia quality and decreased analgesic requirement. We suggest that addition of dexmedetomidine or lornoxicam at the doses used in this study to IVRA with prilocaine in this setting can be useful without causing adverse effects. No hypotension, bradycardia or hypoxia requiring treatment was seen in any of the patients. Addition of dexmedetomidine had a more potent effect, shortening sensory block onset time and prolonging sensory block recovery time more than lornoxicam.

Modification of the forearm tourniquet techniques of intravenous regional anaesthesia for operations on the distal forearm and hand

Our aim was to find out if a modified intravenous regional anaesthetic block technique, used for invasive surgical procedures on the distal forearm and hand, results in a drier operative field than traditional methods. Twenty consenting adult (age > 18) patients who were to have an operation on the distal forearm or hand were randomised into two groups (n=10 in each). The first group was using a traditional bier block, with a double upper arm tourniquet. The second group was using a modified regional anaesthetic block technique, with a single upper arm tourniquet, and a single forearm tourniquet. All operative fields were recorded photographically and judged by the operating surgeon as "wet" or "dry". Analgesic requirements and subjective pain were recorded. Plasma lignocaine concentrations were measured. "Wet" operative fields were seen in 6 of the conventional and 0 of the modified group (p=0.01). Patients in the modified group were more comfortable during the procedures (p=0.004). This benefit was not sustained postoperatively (p=0.57). Plasma lignocaine concentrations were higher in the conventional group (p=0.004). The modified technique was as safe as the conventional technique but has the benefits of a drier surgical field and improved intraoperative comfort for patients.

Anestesia regional combinada con mascarilla laríngea Proseal en cirugía plástica periférica prolongada

The ProSeal laryngeal mask offers a better interface for controlled ventilation than does a traditional mask because of the ProSeal's improved airway seal and the possibility of draining the digestive tract. Limb reconstructive surgery is normally a long procedure involving the use of grafts or flaps located at a distance from the lesion. Regional anesthesia is therefore of limited use. We report a series of 24 adult patients who underwent peripheral plastic surgery under combined regional and general intravenous anesthesia and in whom the ProSeal mask was used. Data recorded included assessment of the airway and intubation difficulty, disease and duration of the procedure, type of regional anesthesia, respiratory and hemodynamic variables, patient satisfaction, laryngeal complications, and postoperative analgesia. All patients were adequately ventilated. One episode of bradycardia was controlled with atropine. In the immediate postoperative period, no patient presented laryngeal complications and only 1 patient reported significant pain (8 on a visual analog scale). The ProSeal mask was a good choice for use with combined regional-general anesthesia, ensuring control of the airway without causing complications. Analgesia was adequate in most cases.

Buprenorphine significantly prolongs postoperative analgesia in intravenous regional anesthesia: a double blind randomized clinical trial

Background: Recently demonstration of opioid receptors along peripheral sensory nerves especially after painful inflammatory conditions forms the basis of peripheral opioid analgesia. This form of opioid antinociception has the potential to help overcome one of the disadvantages of intravenous regional anesthesia (IVRA) that is lack of postoperative analgesia. The aim of the study was to assess the efficacy of Buprenorphine as an adjunct to lidocaine in (IVRA) for postoperative analgesia. Methods: Seventy-five consenting patients undergoing hand & forearm surgery were randomly allocated into three groups of twenty-five each: group A received 0.5% 40 ml lidocaine for IVRA, group B received 0.5% 40 ml lidocaine for IVRA and Buprenorphine 0.3 mg intramuscularly and group C received 0.5% 40 ml lidocaine with Buprenorphine 0.3 mg for IVRA. Postoperative analgesia was assessed using visual analog scale (VAS) on a 0 to 100 mm scale in the immediate postoperative period and 1 hourly thereafter for 24 hours. Patients were given declofenac 1 mg/kg orally whenever VAS score exceeded 25 or patient demanded analgesic. Results: Onset time for sensory block was longer in group C as compared to group A & B (5.0±1.0 min versus 4.0±0.6 and 4.0±0.4) whereas motor block onset time was comparable in all the three groups. Quality of sensory & motor block was similar in all the groups. Duration of postoperative analgesia was significantly longer in group C (20 ±2 hrs) as compared to 0.7±0.2 and 7±0.6 hrs for group A & B respectively (p=0.001). Analgesic consumption was also significantly lower in group C (56±9 mg versus 201±27 & 120±24 mg for group A & B respectively (p=0.001). incidence of nausea/vomiting and sedation was much higher in group B as compared to other groups (p=0.002). Conclusion: We concluded that addition of Buprenorphine 0.3 mg to lidocaine for IVRA significantly prolongs analgesia without causing systemic side effects.

Evaluation of the Efficacy of Magnesium Sulphate as an Adjuvant to Lignocaine for Intravenous Regional Anaesthesia for Upper Limb Surgery

Several additives have been combined with local anaesthetics for intravenous regional anaesthesia to improve block quality, analgesia and to decrease tourniquet pain. Magnesium sulphate is one potential additive. This prospective, randomised, double-blinded study was conducted in 30 ASA physical status I or II patients undergoing upper limb surgery under tourniquet. In group L, patients received intravenous regional anaesthesia with lignocaine alone (9 ml of 2% lignocaine diluted with normal saline to total volume of 36 ml). Patients in group M received intravenous regional anaesthesia with lignocaine plus magnesium sulphate (6 ml of 25% magnesium sulphate plus 9 ml of 2% lignocaine diluted with normal saline to total volume of 36 ml). Assessment was by observing the response to injection of drug; sensory and motor block and tourniquet pain. The mean time of onset of sensory block was 12.40 and 3.47 minutes in groups L and M respectively (P < 0.001). The average times of onset of motor block in groups L and M were 17 and six minutes respectively (P < 0.001). Of the patients in group M, 66.7% reported moderate to severe pain while the drug was being injected, compared to 20% in group L (P=0.011). There was a statistically significant difference in visual analogue scale for tourniquet pain at 10 and 30 minutes after tourniquet inflation (lower in group M). These findings indicate that magnesium sulphate added as an adjuvant to lignocaine hastens the onset of sensory and motor block and decreases tourniquet pain. However there is increased incidence of transient pain on injection if magnesium sulphate is added.

Centennial of Intravenous Regional Anesthesia. Bier's Block (1908-2008)

The surgeon August Gustav Bier significantly influenced surgery, general medicine, and especially anesthesia. He was the father of spinal anesthesia (1898) and intravenous regional anesthesia (1908). Both anesthetic techniques are still valuable and widely applied in everyday anesthesia practices throughout the world, with a high degree of safety, efficacy, efficiency, and satisfaction. On the occasion of the centennial anniversary of the first use of intravenous regional anesthesia it is appropriate to recall Bier's contribution to the repertoire of anesthesiologists. The evolutionary history of both the injected drugs and the refinements of the technique are elaborated upon.

597: Addition of Midazolam to Lidocaine for Intravenous Regional Anesthesia

597: Addition of Midazolam to Lidocaine for Intravenous Regional Anesthesia

Addition of Dexmedetomidine or Neostigmine to Lidocaine for Intravenous Regional Anaesthesia

Addition of Dexmedetomidine or Neostigmine to Lidocaine for Intravenous Regional Anaesthesia

626: Adding Magnesium Sulfate to Lidocaine for Intravenous Regional Anesthesia

626: Adding Magnesium Sulfate to Lidocaine for Intravenous Regional Anesthesia

379: Addition of Dexmedetomidine or Neostigmine to Lidocaine for Intravenous Regional Anaesthesia

379: Addition of Dexmedetomidine or Neostigmine to Lidocaine for Intravenous Regional Anaesthesia