Intravenous Regional Anesthesia Research Articles

Peri- and postanalgesic properties of lidokain, lornoxicam, and nitroglycerine combination at intravenous regional anesthesia.

Background. This study was conducted to compare and evaluate the effect of adding lornoxicam or nitroglycerine as adjuncts to lidocaine in intravenous regional anesthesia (IVRA). Methods. 60 patients were randomly separated into three groups, lidocaine group (group L), lidocaine + lornoxicam group (group LL), and lidocaine + lornoxicam + transdermal nitroglycerine group (group LL-N). Hemodynamic parameters, sensory and motor blocks onset, and recovery times were recorded. Analgesic consumption for tourniquet pain and postoperative period were recorded. Results. Sensory block onset times and motor block onset times were shorter in the LL-N and LL groups compared with L group. Sensory block recovery time and motor block recovery time were prolonged in the LL and LL-N groups compared with group L. The amount of fentanyl required for tourniquet pain was less in group LL and group LL-N when compared with group L. VAS scores of tourniquet pain were higher in group L compared with the other study groups. Postoperative VAS scores were higher for the first 4 hours in group L compared with the other study groups. Conclusion. The adjuvant drugs (lornoxicam or TNG) when added to lidocaine in IVRA were effective in improving the overall quality of anesthesia, reducing tourniquet pain, increasing tourniquet tolerance, and improving the postoperative analgesia.

Does Low‐Level Laser Therapy Enhance The Efficacy of Intravenous Regional Anesthesia?

The use of intravenous regional anesthesia (IVRA) is limited by pain resulting from the application of tourniquets and postoperative pain. To assess the efficacy of low-level laser therapy added to IVRA for improving pain related to surgical fixation of distal radius fractures. The present double-blinded, placebo-controlled, randomized clinical trial involved 48 patients who were undergoing surgical fixation of distal radius fractures. Participants were randomly assigned to either an intervention group (n=24), who received 808 nm laser irradiation as 4 J⁄point for 20 s over ipsilateral three nerve roots in the cervical region corresponding to C5-C8 vertebrae, and 808 nm laser irradiation as 0.1 J⁄cm2 for 5 min in a tangential scanning mode over the affected extremity; or a control group (n=24), who underwent the same protocol and timing of laser probe application with the laser switched off. Both groups received the same IVRA protocol using 2% lidocaine. The mean visual analogue scale scores were significantly lower in the laser-assisted group than in the lidocaine-only group on all measurements during and after operation (P<0.05). The mean time to the first need for fentanyl administration during the operation was longer in the laser group (P=0.04). The total amount of fentanyl administered to patients was significantly lower in the laser-assisted group (P=0.003). The laser group needed significantly less pethidine for pain relief (P=0.001) and at a later time (P=0.002) compared with the lidocaine-only group. There was no difference between the groups in terms of mean arterial pressure and heart rate. The addition of gallium-aluminum-arsenide laser irradiation to intravenous regional anesthesia is safe, and reduces pain during and after the operation.

Comparison the effects of prilocaine and the addition of dexketoprofen and dexamethasone to prilocaine for intravenous regional anesthesia

The aim of this study was to compare the anesthetic and analgesic effects of prilocaine alone, prilocaine added dexketoprofen and dexamethasone during intravenous regional anesthesia (IVRA). Forty five patients undergoing forearm or hand surgery were randomly assigned to one of three groups to receive (Group P) 3 mg/kg 0.5% prilocaine; (Group PDK) 3 mg/kg 0.5% prilocaine plus 50 mg dexketoprofen; (Group PDM) 3 mg/kg 0.5% prilocaine plus 8 mg dexamethasone in total 40 ml volume for IVRA. The onset and duration of sensory and motor blocks, hemodynamic datas, duration of analgesia and tourniquet, time to first analgesic requirement, visual analog scale (VAS), total analgesic consumption in 24 hours and patient satisfaction score were assessed and recorded. Time to onset of sensory block was found to be longer in Group P (p<0.05), though no significance was found according to sensory block recovery times amoung groups. Time to onset of motor block was found to be longer and recovery time of motor block was found to be shorter in Group P (p<0.05). Time to first analgesic requirement was found to be longer in Group PDK,and was found to be high in Group PDM than Group PDK(p<0.05). The VAS scores was found to be high and patient satisfaction scale was found to be low in Group P (p<0.05). The addition of dexketoprofen and dexamethasone to prilocaine during IVRA improves the quality of both anesthesia and analgesia moreover dexketoprofen provides beter postoperative analgesia during the first 24 hour after surgery.

Efficacy of ketamine as an adjunct to lidocaine in intravenous regional anesthesia.

This study aims to compare and evaluate the effect of adding ketamine as an adjunct to lidocaine for intravenous regional anesthesia (IVRA) on intraoperative and postoperative analgesia, the onset and recovery times of sensory and motor block, and tourniquet pain. Forty patients undergoing surgery of the hand or forearm under IVRA were randomly assigned to receive lidocaine 3 mg/kg (group 1) or lidocaine 3 mg/kg plus ketamine 50 mg (group 2) diluted to 40 mL with normal saline. Assessment parameters included the onset and recovery times of sensory and motor block, tourniquet pain, intraoperative hemodynamics, surgeon and patient satisfaction, postoperative pain, time of first analgesic request, total analgesic consumption, and adverse effects in the first 24 hours postoperatively. Groups 1 and 2 were comparable in demographic and surgical parameters. There were no differences between groups in intraoperative hemodynamics, onset and recovery times of sensory and motor block, or surgeon satisfaction index. Compared with group 1, group 2 patients showed less tourniquet pain, prolonged time to first request for postoperative rescue analgesia (5.5 ± 1.3 vs 20.4 ± 3.7 hours, P < 0.001), lower postoperative diclofenac consumption (120.00 ± 45.23 vs 55.1 ± 0.00 mg, P < 0.001), lower scores for postoperative pain as measured by the Verbal Rating Scale, higher patient satisfaction index, and a nonsignificant difference in the incidence of postoperative adverse effects between groups. The addition of ketamine to lidocaine in patients receiving IVRA significantly reduced intraoperative and postoperative analgesic requirements and improved patient satisfaction without causing significant adverse effects.

A comparative double blind study of tramadol and fentanyl as adjuvants to lignocaine for intravenous regional anesthesia for forearm orthopedic surgeries

Introduction: IVRA is safe, technically simple, and cost effective technique compared to general anaesthesia with success rates of 94 to 98% for upper and lower limb surgeries. It also provides bloodless field during surgery. To overcome these disadvantages various adjuvants have been tried. We compared Fentanyl and tramadol as adjuvants to lignocaine for IVRA for upper limb surgeries. Material and Method: After approval from institutional ethical committee, 60 patients of either sex belonging to ASA grade I and II, in the age range of 20 to 60 years scheduled to undergo upper limb orthopaedic surgery either elective or emergency were included in the study. All the patients were administered intravenous regional anaesthesia (IVRA) after obtaining written informed consent. Patients enrolled in the study were divided into 2 groups of 30 each by a computer generated Randomization program. Group LF-received 40 ml of 0.5% Lignocaine with Fentanyl 1 ug/kg. Group LT-received 40 ml of 0.5% Lignocaine with Tramadol 1 mg/kg. Double tourniquet technique was used. The arm was exsanguinated with Eschmark bandage and proximal cuff was inflated followed by injection of the study drug. Parameters observed were time of onset of sensory and motor block, intraoperative conditions post operative analgesia and adverse effects. Data was expressed as mean ± SD (Standard Deviation) of statistical analysis. Statistical Analysis was done by using Discriptive and Inferencial statistics using chi-square test and students unpaired t-test. The software used in analysis were SPSS 17.0 version and Graph Pad Space Prism 5.0 and results were tested at 5% level of significance. Results: Patients were comparable demographically. Mean values of onset of sensory blockade was 6.76 ± 1.30 min in Group LT and 7.13 ± 0.81 min in Group LF.

Adding metoclopramide to lidocaine for intravenous regional anesthesia in trauma patients

Background:Metoclopromide have local anesthetic properties. The main object of performing the present study was to evaluate the analgesic effect of metoclopromide 10 mg when added to lidocaine for intravenous regional anesthesia (IVRA) of upper extremities in trauma patients.Materials and Methods:Ninety patients undergoing upper limb producer were randomly allocated to the three groups to receive 3 mg/kg 2% lidocaine diluted with saline to a total dose of 40 ml (Group L, n = 30) or 10 mg metoclopromide plus 3 mg/kg 2% lidocaine diluted with saline to a total dose of 40 ml (group LM, n = 30) or 3 mg/kg 2% lidocaine diluted with saline to a total dose of 40 ml plus 10 mg metoclopromide intravenously (Group IM, n = 30).Results:Our study showed that the onset times for sensory and motor block were significantly shorter in Group LM compared with Group L and Group IM (4.5 ± 0.7 vs. 5.0 ± 0.7 and 5.0 ± 0.6, respectively, P = 0.006 for sensory block; 6.3 ± 0.7 vs. 5.1 ± 0.9 and 5.9 ± 0.6 respectively, P = 0.000 for motor block). The postoperative VAS scores were significantly less at 1, 5, 10, 15, and 30 minutes after tourniquet release in Group LM compared with Group L and Group IM (P < 0.05).Conclusion:The results of our study showed that adding 10 mg metoclopromide to lidocaine for IVRG in trauma patients reduced intraoperative and postoperative analgesic use till 24 hours and improve quality of anesthesia.

Bier Block Regional Anesthesia and Casting for Forearm Fractures

Bier block regional anesthesia was first described in 1908; however, it is uncommonly used for fears of cardiac and neurological complications. Although recent studies have documented safe usage in an adult population, no study to date has investigated its use in a pediatric setting. In addition, most emergency departments feel that splint placement is safer than casting after acute forearm fracture reduction in the pediatric population. However, to our knowledge there is no such study that documents the complication rates associated with immediate casting. The goal of this study was to assess the safety and efficacy of Bier block regional anesthesia and immediate cast application after closed reduction of pediatric forearm fractures. A retrospective review was conducted of patients treated for forearm fractures in a 2-year period at a major metropolitan pediatric hospital. Rates of complications and length and costs of the 2 procedures were analyzed. A total of 600 patients were treated with Bier block regional anesthesia and 645 were treated with conscious sedation for displaced fractures of the forearm in the 2-year study period. No complications requiring admission were seen in either group. No patient experienced compartment syndrome or a need for readmission secondary to cast application. 2.2% and 4.3% (P=0.0382) of patients in the Bier block and sedation groups, respectively, needed their cast bivalved secondary to swelling. The average time from initiation of procedural sedation to discharge was 1 hour and 42 minutes, whereas the time to discharge from initiation of Bier block regional anesthesia was 47 minutes (P<0.0001). The average cost for a patient treated with procedural sedation was $6313, whereas the average cost for the Bier block regional anesthesia group was $4956. Bier block regional anesthesia is a safe, efficient, and cost-effective method of reducing pediatric forearm fractures. Immediate cast application can be used without fear of major complications. Level III--retrospective review.

A randomized, double blind comparison of pethidine and ketoprofen as adjuvants for lignocaine in intravenous regional anaesthesia

Background and objectivesA review of all the adjuncts for intravenous regional anaesthesia concluded that there is good evidence to recommend NonSteroidal Anti-Inflammatory agents and pethidine in the dose of 30mg dose as adjuncts to intravenous regional anaesthesia. But there are no studies to compare pethidine of 30mg dose to any of the NonSteroidal Anti-Inflammatory agents. MethodsIn a prospective, randomized, double blind study, 45 patients were given intravenous regional anaesthesia with either lignocaine alone or lignocaine with pethidine 30mg or lignocaine with ketprofen 100mg. Fentanyl was used as rescue analgesic during surgery. For the first 6h of postoperative period analgesia was provided by fentanyl injection and between 6 and 24h analgesia was provided by diclofenac tablets. Visual analogue scores for pain and consumption of fentanyl and diclofenac were compared. ResultsThe block was inadequate for one case each in lignocaine group and pethidine group, so general anaesthesia was provided. Time for the first dose of fentanyl required for postoperative analgesia was significantly more in pethidine and ketoprofen groups compared to lignocaine group (156.7±148.8 and 153.0±106.0 vs. 52.1±52.4min respectively). Total fentanyl consumption in first 6h of postoperative period was less in pethidine and ketoprofen groups compared to lignocaine group (37.5±29.0mcg, 38.3±20.8mcg vs. 64.2±27.2mcg respectively). Consumption of diclofenac tablets was 2.4±0.7, 2.5±0.5 and 2.0±0.7 in the control, pethidine and ketoprofen group respectively, which was statistically not significant. Side effects were not significantly different between the groups. ConclusionBoth pethidine and ketoprofen are equally effective in providing postoperative analgesia up to 6h, without significant difference in the side effects and none of the adjuncts provide significant analgesia after 6h.

Anestesia regional intravenosa con anestésicos locales de larga duración. Actualización

Intravenous regional anesthesia is a widely used technique for brief surgical interventions, primarily on the upper limbs and less frequently, on the lower limbs. It began being used at the beginning of the 20th century, when Bier injected procaine as a local anesthetic. The technique to accomplish anesthesia has not changed much since then, although different drugs, particularly long-acting local anesthetics, such as ropivacaine and levobupivacaine in low concentrations, were introduced. Additionally, drugs like opioids, muscle relaxants, paracetamol, neostigmine, magnesium, ketamine, clonidine, and ketorolac, have all been investigated as adjuncts to intravenous regional anesthesia, and were found to be fairly useful in terms of an increased onset of operative anesthesia and longer lasting perioperative analgesia. The present article provides an overview of current knowledge with emphasis on long-acting local anesthetic drugs.

Single-cuff forearm tourniquet in intravenous regional anaesthesia results in less pain and fewer sedation requirements than upper arm tourniquet

Background A limitation of Bier's block or i.v. regional anaesthesia (IVRA) is tourniquet pain. We hypothesized that tourniquet placement on the forearm vs upper arm during IVRA for distal upper extremity surgery may result in less tourniquet pain, lower the need for analgesic interventions, and decrease post-anaesthesia care unit (PACU) admission. MethodsPatients for distal upper extremity surgery were randomized into upper or forearm single-cuff tourniquet placement. IVRA was either performed with 15 ml of 2% lidocaine and 20 mg ketorolac in the upper group or 8 ml of 2% lidocaine and 10 mg ketorolac in the forearm group. Vital signs and visual analogue scale (VAS) score were recorded. If VAS score was >4, 50 µg fentanyl was injected. If the patient had VAS scores >6 with fentanyl, deep sedation with propofol was administered. ResultsTwenty-eight subjects were in each group. There were no significant differences in patient characteristics, tourniquet time, or pressure between the groups. Ten patients in the forearm vs 27 in the upper arm group had a VAS score >4. The mean fentanyl use was 30 µg in the forearm group vs 104 µg in the upper arm group. One patient in the forearm group required propofol vs 22 in the upper arm group. PACU bypass to phase 2 recovery occurred 19 times in the forearm group vs zero times in the upper arm group (P<0.0001). ConclusionsOur results indicate that the placement of the tourniquet on the forearm resulted in less discomfort, fewer sedation interventions, and greater likelihood of bypassing the PACU when compared with upper arm tourniquet.

Comparison of Lornoxicam and Fentanyl when added to Lidocaine in Intravenous Regional Anesthesia

Background and objectivesIn this study, our goal was to compare intraoperative and postoperative analgesic effects of lornoxicam and fentanyl when added to lidocaine Intravenous Regional Anesthesia (IVRA) in a group of outpatients who underwent hand surgery. MethodsThis is a double blind randomized study. A total of 45 patients were included, randomized into three groups. Patients in Group I (L) received 3mg.kg-1 of 2% lidocaine 40mL; patients in Group II (LL) received 3mg.kg-1 lidocaine 38mL + 2mL lornoxicam; patients in Group III (LF) received 3mg.kg-1 lidocaine 38mL + 2mL fentanyl. Our primary outcome was first analgesic requirement time at postoperative period. ResultsLornoxicam added to lidocaine IVRA increased the sensory block recovery time without increasing side effects and increased first analgesic requirement time at the postoperative period when compared to lidocaine IVRA (p < 0.001, p < 0.001 respectively) and fentanyl added to lidocaine IVRA (p < 0.001, p < 0.001 respectively). In addition, we also found that fentanyl decreased tourniquet pain (p < 0.01) when compared to lidocaine but showed similar analgesic effect with lornoxicam (p > 0.05) although VAS scores related to tourniquet pain were lower in fentanyl group. Lornoxicam added to lidocaine IVRA was not superior to lidocaine IVRA in decreasing tourniquet pain. ConclusionsAddition of fentanyl to lidocaine IVRA seems to be superior to lidocaine IVRA and lornoxicam added to lidocaine IVRA groups in decreasing tourniquet pain at the expense of increasing side effects. However, lornoxicam did not increase side effects while providing intraoperative and postoperative analgesia. Therefore, lornoxicam could be more appropriate for clinical use.

Comparação de Lornoxicam e Fentanil Adicionados à Lidocaína em Anestesia Regional Intravenosa

In this study, our goal was to compare intraoperative and postoperative analgesic effects of lornoxicam and fentanyl when added to lidocaine Intravenous Regional Anesthesia (IVRA) in a group of outpatients who underwent hand surgery.This is a double blind randomized study. A total of 45 patients were included, randomized into three groups. Patients in Group I (L) received 3 mg.kg-1 of 2% lidocaine 40 mL; patients in Group II (LL) received 3 mg.kg-1 lidocaine 38 mL + 2 mL lornoxicam; patients in Group III (LF) received 3 mg.kg-1 lidocaine 38 mL + 2 mL fentanyl. Our primary outcome was fi rst analgesic requirement time at postoperative period.Lornoxicam added to lidocaine IVRA increased the sensory block recovery time without increasing side effects and increased fi rst analgesic requirement time at the postoperative period when compared to lidocaine IVRA (p < 0.001, p < 0.001 respectively) and fentanyl added to lidocaine IVRA (p < 0.001, p < 0.001 respectively). In addition, we also found that fentanyl decreased tourniquet pain (p < 0.01) when compared to lidocaine but showed similar analgesic effect with lornoxicam (p > 0.05) although VAS scores related to tourniquet pain were lower in fentanyl group. Lornoxicam added to lidocaine IVRA was not superior to lidocaine IVRA in decreasing tourniquet pain.Addition of fentanyl to lidocaine IVRA seems to be superior to lidocaine IVRA and lornoxicam added to lidocaine IVRA groups in decreasing tourniquet pain at the expense of increasing side effects. However, lornoxicam did not increase side effects while providing intraoperative and postoperative analgesia. Therefore, lornoxicam could be more appropriate for clinical use.

Procedural sedation and analgesia for reduction of distal forearm fractures in the paediatric emergency department: A clinical survey

Distal forearm fractures frequently require reduction in children. We set out to survey how such fractures are currently reduced at Paediatric Research in Emergency Departments International Collaborative (PREDICT) sites. A survey was completed by paediatric emergency physicians at PREDICT sites. Survey questions covered departmental guidelines and resources and individual practice, agents used and limitations of fracture management using case vignettes. One hundred eleven of 145 (77%) possible surveys were returned. All 12 PREDICT sites have guidelines for the use of nitrous oxide and 11 of 12 for ketamine. Guidelines for other agents are less common and highly variable. The most frequently used procedural sedation and analgesia (PSA) agents were ketamine (27%), nitrous oxide alone (19%) or in combination with intranasal fentanyl (18%) and Bier's block (11%). Most respondents indicated tolerance without reduction in fractures with angulation less than 20° (59%) and 10° (71%) in a 5- and 10-year-old patient, respectively. Most physicians (74%) would reduce up to a 25° angulated fracture in the ED with more displaced fractures being referred to theatre. The 44% of respondents listed the lack of an image intensifier in the ED as a limitation in their ability to reduce fractures. Paediatric distal forearm fractures are commonly reduced in the surveyed EDs, most commonly under ketamine or nitrous oxide. Areas of improvement include better defined cut-offs for fracture reduction and for referral to theatre, improved differential efficacy of PSA agents, standardised guidelines for PSA and introduction of image intensifiers into more EDs.

Study of 0.5% Lidocaine Alone and Combination of 0.25% Lidocaine with Fentanyl and Vecuronium in Intravenous Regional Anesthesia for Upper Limb Surgeries

Justificativa e objetivosA anestesia regional intravenosa (ARIV) para cirurgias de membros superiores com a tradicional alta dose de lidocaína pode levar a efeitos colaterais potencialmente letais. A fim de evitar esses efeitos, muitas técnicas modificadas de ARIV foram experimentadas com o uso de uma dose baixa de lidocaína, relaxante muscular e opioide. MétodosO presente estudo foi feito com 60 pacientes não medicados previamente, com classificação ASA 1-2, para comparar as características sensoriais e motoras, os parâmetros cardiorrespiratórios e os efeitos colaterais durante o período intraoperatório e de deflação póstorniquete entre os pacientes que receberam 40mL de lidocaína a 0,5% (n=30) e aqueles que receberam uma combinação de 40mL de lidocaína a 0,25% com 0,05mg de fentanil e 0,5mg de vecurônio (n=30) em ARIV para cirurgias ortopédicas de membros superiores. Os resultados foram analisados com o uso do teste t de Student pareado para identificar a significância estatística. Resultado: A diferença entre os dois grupos em relação ao tempo médio de início e completo bloqueio sensitivo e motor foi estatisticamente significante. Porém, houve completo bloqueio sensitivo e motor em ambos os grupos 15 minutos após a injeção da solução anestésica. ConclusãoEmbora a pequena demora observada no início e na obtenção completa dos bloqueios sensitivo e motor possa, teoricamente, atrasar o início da cirurgia em 10–15 minutos, clinicamente esse tempo seria gasto na preparação do campo cirúrgico. Portanto, essa combinação pode ser usada com segurança e eficácia em anestesia regional intravenosa para cirurgias ortopédicas de membros superiores com menor possibilidade de toxicidade anestésica local.

Study of 0.5% Lidocaine Alone and Combination of 0.25% Lidocaine with Fentanyl and Vecuronium in Intravenous Regional Anesthesia for Upper Limb Surgeries

Background and objective: Intravenous regional anesthesia (IVRA) for upper limb surgeries with traditional high dose of lidocaine can lead to life threatening side effects. In order to avoid these potential life threatening side effects, many modified techniques of IVRA have been attempted by using a low dose of lidocaine, muscle relaxant and opioid. MethodThe present study is carried out in sixty unpremedicated ASA Class 1 and 2 patients to compare the sensory and motor characteristics, cardio-respiratory parameters and side-effects during intra-operative and post-tourniquet deflation period between the patients who received 40mL of 0.5% lidocaine alone (n = 30) and those who received a combination of 40mL of 0.25% lidocaine with 0.05mg fentanyl and 0.5mg vecuronium (n = 30) in IVRA for upper limb orthopedic surgeries. The results were analyzed for statistical significance using a paired student t test. ResultsThe difference between the two groups regarding the mean time of onset and complete sensory and motor block was statistically significant. But 15minutes after the injection of anesthetic solution, there was complete sensory and motor block in both groups. ConclusionAlthough the short delay observed in the onset and attainment of complete sensory and motor block may theoretically delay the start of surgery for 10-15minutes but clinically that time will be spent in the preparation of surgical field. So this combination can be used safely and effectively in intravenous regional anesthesia for upper limb orthopedic surgeries with reduced chance of local anesthetic toxicity.

English

INTRODUCTION: IVRA is a simple, reliable, and effective technique with rapid onset of action, rapid and prompt recovery after tourniquet release. It provides good analgesia, adequate muscle relaxation, & bloodless operative field. It is widely applicable to patients of different ages and physical status for operations & cost effective. Lignocaine though preferred local anesthetic agent has limitation of short duration of anesthesia & inability to provide postoperative analgesia various additives were added to it. In this study we compared efficacy of clonidine as an adjuvant to lignocaine with plain Lignocaine. MATERIAL & METHOD: Patients undergoing upper arm surgery were included in this study & are divided in two groups. The proximal circulatory isolation of arm was done by placing a pneumatic tourniquet around arm. In group C IVRA was given by 1ug/kg clonidine & 0.5% preservative free lignocaine in a dose of 200mg diluted up to 40 ml & in group L 0.5% preservative free lignocaine 200 mg diluted up to 40 ml. Tourniquet was deflated at least 30 mines after injection of drug. AIMS & OBJECTIVES: To compare onset and quality of sensory analgesia, Onset and quality of motor blockade, onset & severity of tourniquet pain, Complications like hypotension b thus the name, “Bier block”. Dr. Bier described a complete anaesthesia and motor paralysis after intravenous injection of Prilocaine into a previously exsanguinated limb. It is a simple, reliable, and effective technique with rapid onset of action, and prompt recovery after tourniquet release. It provides good analgesia, adequate muscle relaxation, & bloodless operative field, widely applicable to patients of different ages and physical status for operations & cost effective. Poor postoperative analgesia, limited duration of anaesthesia (<90 minutes), the potential for local anesthetic toxicity, nerve damage and compartment syndrome are the disadvantages of intravenous regional anaesthesia.

Choice of loco-regional anesthetic technique affects operating room efficiency for carpal tunnel release

Intravenous regional anesthesia (Bier block) is indicated for minor procedures such as carpal tunnel release but must be performed in the operating room. We hypothesize that preoperative peripheral nerve blocks decrease anesthesia-controlled time compared to Bier block for carpal tunnel release. With IRB approval, we reviewed surgical case data from a tertiary care university hospital outpatient surgery center for 1 year. Unilateral carpal tunnel release cases were grouped by anesthetic technique: (1) preoperative nerve blocks, or (2) Bier block. The primary outcome was anesthesia-controlled time (minutes). Secondary outcomes included surgical time and time for nerve block performance in minutes, when applicable. Eighty-nine cases met criteria for analysis (40 nerve block and 49 Bier block). Anesthesia-controlled time [median (10th-90th percentiles)] was shorter for the nerve block group compared to Bier block [11 (6-18) vs. 13 (9-20) min, respectively; p = 0.02). Surgical time was also shorter for the nerve block group vs. the Bier block group [13 (8-21) and 17 (10-29) min, respectively; p < 0.01), but nerve blocks took 10 (5-28) min to perform. Ultrasound-guided nerve blocks performed preoperatively reduce anesthesia-controlled time compared to Bier block and may be a useful anesthetic modality in some practice environments.

Efficacy of diltiazem as an adjunct to lignocaine in intravenous regional anesthesia

Background:Various adjuncts have been used with lignocaine to decrease tourniquet pain and prolong post-operative analgesia during intravenous regional anesthesia (IVRA). Calcium-channel blockers potentiate the analgesic effect of local anesthetics. This study was designed to evaluate the efficacy of diltiazem as an adjunct to lignocaine in IVRA with respect to tourniquet tolerance, perioperative analgesia, and quality of anesthesia.Methods:In this prospective, randomized, and double-blind study, 40 patients (American Society for Anesthesiologists grade I/II) undergoing elective hand surgery under IVRA were assigned into two groups of 20 each and administered IVRA either with lignocaine 3 mg/kg (group Lignocaine (L)) or lignocaine 3 mg/kg plus diltiazem 0.2 mg/kg (group Lignocaine-Diltiazem (LD)) with normal saline (total volume-40 ml). Hemodynamic parameters, onset of the complete sensory blockade, motor blockade, and intraoperative (tourniquet pain) and post-operative Visual Analogue Scale scores, total intraoperative and consumption of post-operative fentanyl intraoperative were recorded.Results:Sensory block was established in 2.5±0.688 min in group LD verses 5.60±0.851 min in group L. Motor blockade was established in 8.65±0.933 min in group LD and 13.46±0.604 min in group L. The mean VAS scores >3 were attained early at 30 min (3.1±0.912) in group L. Patients in group L requested early rescue analgesic at 30±8.633 min compared with 49.64±7.958 min in group LD.Conclusions:Diltiazem as an adjunct to lignocaine provided enhanced intraoperative and post-operative analgesia without any significant side effects.

Should aspirin be stopped before carpal tunnel surgery? A prospective study

To determine whether patients taking aspirin during carpal tunnel release had an increase of complications. Between January 2008 and January 2010, 150 patients underwent standard open carpal tunnel release (CTR) under intravenous regional anaesthesia. They were divided into three groups: groups 1 and 2 were made of 50 patients each, on aspirin 100 mg/d for at least a year. In group 1 the aspirin was never stopped. In group 2 it was stopped at least 5 d before surgery and resumed 3 d after. Group 3 acted as a control, with 50 patients who did not take aspirin. The incidence of clinically significant per- or post-operative complications was recorded and divided into local and cardio-cerebro-vascular complications. Local complications were then divided into minor and major according to Page and Stern. Local haematomas were assessed at 2 d (before resuming aspirin in group 2) and 14 d (after resuming aspirin in group 2) postoperatively. Patients were reviewed at 2, 14 and 90 d after surgery. There was no significant difference in the incidence of complications in the three groups. A total of 3 complications (2 major and 1 minor) and 27 visible haematomas were recorded. Two major complications were observed respectively in group 1 (non stop aspirin) and in group 3 (never antiaggregated). The minor complication, observed in one patient of group 2 (stop aspirin), consisted of a wound dehiscence, which only led to delayed healing. All haematomas were observed in the first 48 h, no haematoma lasted for more than 2 wk and all resolved spontaneously. A major haematoma (score > 20 cm(2)) was observed in 8 patients. A minor haematoma (score < 20 cm(2)) was recorded in 19 patients. All patients at 90 d after surgery were satisfied with the result in terms of relief of their preoperative symptoms. Major and minor haematomas did not impair hand function or require any specific therapy. Our study demonstrates that continuation of aspirin did not increase the risk of complications. It is unnecessary to stop aspirin before CTR with good surgical techniques.

The analgesic effect of nitroglycerin added to lidocaine on quality of intravenous regional anesthesia in patients undergoing elective forearm and hand surgery

To evaluate the effect of nitroglycerine (NTG) on sensory and motor block onset and recovery time as well as the quality of tourniquet pain relief, when added to lidocaine (LID) for intravenous regional anesthesia in elective forearm and hand surgery. A randomized double-blinded clinical trial was performed on 40 patients that were randomly allocated into two groups received lidocaine 3 mg/kg with NTG 200 µg or received only lidocaine 3 mg/kg as the control. There was no difference between the two study groups in hemodynamic parameters before tourniquet inflation, at any time after inflation and after its deflation. There was no difference in the mean of pain score over time between the two groups. The onset time of sensory and motor blockades was shorter in the group received both LID and NTG. The mean recovery time of sensory blockade was longer in the former group. The frequency of opioid injections was significantly lower in those who administered LID and NTG. The adjuvant drug of NTG when added to LID is effective in improving the overall quality of anesthesia, shortening onset time of both sensory and motor blockades, and stabling homodynamic parameters in hand and forearm surgery.