Intravenous Regional Anesthesia Research Articles

Treatment of complex regional pain syndrome type I of the hand with a series of intravenous regional sympathetic blocks with guanethidine and lidocaine

The aim of this study was to evaluate the efficacy of guanethidine and lidocaine in the treatment of complex regional pain syndrome (CRPS) type I of the hand. Seventeen patients, aged between 33 and 72 years, suffering from CRPS type I of the hand received two series of intravenous regional sympathetic block (Bier's block) sessions with guanethidine and lidocaine according to the following therapeutic protocol: (1) 5 sessions (once every second day) composed of intravenous regional administration of 15 mg guanethidine and 1 mg lidocaine/kg body weight each and (2) 20 sessions (twice a week) composed of intravenous regional administration of 10 mg guanethidine and 1 mg lidocaine/kg body weight each. Complete disappearance of pain and return of the normal function and movement of the extremity were achieved. No side effects were observed. The above-described therapeutic protocol method resulted in excellent pain relief and full restoration of both function and range of movement of the affected extremity in 17 patients suffering from CRPS type I of the hand.

The cardiovascular complications of intravenous regional anaesthesia.

Abstract In view of the uncertainty over the safety of intravenous regional anaesthesia the heart-rate, blood-pressure, and electrocardiogram were recorded seriany in 100 Bantu gold-miners in whom this form of anaesthesia was used for minor surgical procedures on the extremities. Changes in blood-pressure were infrequent and mild. In 31 patients the heart slowed by more than 10 beats per minute after release of the tourniquet, falling to less than 60 beats per minute in 27. One patient with sinus bradycardia developed sino-atrial block with cardiac standstill of short duration, a second developed an intermittent idioatrial tachycardia and premature atrial beats, and in 3 others sinus bradycardia was complicated by atrial escape beats, nodal rhythm, and premature ventricular beats respectively. These toxic effects were thought to be due either to direct myocardial depression or to increased vagal or decreased sympathetic tone, or to both of these mechanis. It is suggested that the cardiovascular depression caused by large doses of lignocaine may be aggravated by coexisting ischaemic heart disease. The importance of monitoring the patients carefully after release of the tourniquet and having facilities available for resuscitation is stressed.

Safety of Upper Extremity Surgery After Prior Treatment for Ipsilateral Breast Cancer: Results of an American Society for Surgery of the Hand Membership Survey and Literature Review

Lymphedema, infection, and healing delay are among feared complications in patients undergoing upper extremity surgery after prior mastectomy and axillary dissection with or without radiation therapy. Most of these cancer patients are advised to avoid any procedure on their ipsilateral upper extremity including blood pressure monitoring, intravenous punctures, and surgery. As a result, many of these patients hesitate to undergo necessary upper extremity surgery such as arthritis surgery and even carpal tunnel release. Many hand and upper extremity surgeons believe that these precautions are unnecessarily stringent and believe that indicated upper extremity surgeries could be performed safely in these patients. We surveyed 1,200 members of The American Society for Surgery of the Hand and the 606 returned questionnaires were analyzed. More than 95% of the hand surgeons surveyed do not hesitate to perform surgery on an upper extremity in a patient after ipsilateral lymphadenectomy and/or irradiation, decreasing to 85% if there is pre-existing chronic lymphedema; 94% use a tourniquet in a routine fashion (74% use a tourniquet in the presence of existing lymphedema); 46% use a Bier block when clinically indicated (only 21% would use a Bier block in a patient with lymphedema); and 36% are comfortable using an axillary block (25% in the case of lymphedema). Thus, most of the polled surgeons would prefer to perform surgery on these patients under a general anesthetic, but still would use an extremity tourniquet for a bloodless surgical field in their routine manner. The rate of reported complications in these patients was 23% in patients with pre-existing chronic lymphedema and only 3% in patients with no lymphedema. After surgery, 46.2% of the surgeons do not undertake any additional precautions than in their routine practice with all upper extremity surgery patients. However, 53.8% would change their routine practice for such patients and these changes range from placing the surgical tourniquet on the forearm instead of the upper arm, use of perioperative prophylactic antibiotics in all patients irrespective of the type of surgery, use of postoperative compression garments, and specific postoperative hand therapy aimed at the prevention of postoperative edema.

Delivery of BotoxR by iontophoresis

Conflict of interest: None declared. Sir, I read with great interest the case report by Kavanagh and Shams,1 in which Botox was administered by iontophoresis to two patients. My practice is devoted solely to treating patients with hyperhidrosis with Botox, so I believe I have a good perspective to comment on this article. As someone who is a Board Certified Anaesthesiologist and who uses a Bier block for regional anaesthesia, an easily learned and safe technique, I must take issue with the repeated comments by Kavanagh et al. about ‘painful injections’ when giving Botox injections. With a tourniquet applied at the wrist and 12–15 mL of 0·5% xylocaine, a very safe amount, the 50 or so injections can be made virtually pain free. Also, with a properly administered ulnar, median and radial wrist block, adequate anaesthesia can be obtained as well. I think the common method of some practitioners of using ice to numb the hands is as barbaric as using no anaesthesia at all.

Seizures After a Bier Block with Clonidine and Lidocaine: Is Clonidine Really the Culprit?

Seizures After a Bier Block with Clonidine and Lidocaine: Is Clonidine Really the Culprit?

Intravenous Regional Anesthesia Administered by the Operating Plastic Surgeon: Is It Safe and Efficient? Experience of a Medical Center

Intravenous Regional Anesthesia Administered by the Operating Plastic Surgeon: Is It Safe and Efficient? Experience of a Medical Center

Intraoperative Bier’s block as supplement to insufficient axillary block anesthesia in upper extremity surgery

The authors reviewed 52 patients who underwent Bier's block, as supplementary anesthesia for insufficient axillary block in upper extremity surgical procedures. Prior to proceeding to the Bier's block, the mean value of pain using the visual optical analogue scale (VAS) was 7.0. In 48 of the patients supplementation with the Bier's block was sufficient (mean VAS score of 1.0) and all patients were comfortable throughout the procedure. In the remaining four patients supplementation with narcotics and sedatives via the other i.v. line was required. Intraoperative Bier's block provides a safe and effective alternative way of successfully compensating for an insufficient axillary block in upper extremity surgical procedures.

Future of regional anaesthesia

The development and refinement of regional anaesthetic techniques for various types of surgery, mainly obstetric, ophthalmic and orthopaedic surgery, and of continuous regional analgesia continues. Suitable analgesic drug mixtures, and concentrations, will be further tested in order to find the ideal analgesic regimen for each type of surgery and for the individual patient. No new local anaesthetics or equipment for clinical use are expected in the near future. Improvement therefore depends much on how the anaesthesiologists use the present drugs, needles, nerve detection devices, catheters and pumps. During training in regional anaesthesia for the speciality of anaesthesiology and intensive care medicine, it may suffice to concentrate only on certain common techniques such as epidural block, spinal block, axillary brachial plexus block, intravenous regional anaesthesia and femoral nerve block. Rare regional anaesthetic blocks and invasive techniques should be mastered and taught by specially trained regional anaesthesiology experts. In chronic pain, regional anaesthetic blocks with local anesthetics are not expected to play any major therapeutic role. However, nerve blocks can be useful for diagnostic purposes and in order to facilitate rehabilitation in chronic pain syndromes.

Successful Intravenous Regional Sympathetic Blockade (Bier's Block) with Guanethidine and Lidocaine in a Patient with Advanced Buerger's Disease (Thromboangiitis Obliterans)

A 65-year-old man, a heavy smoker with Buerger's disease (thromboangiitis obliterans), presented to this department with persistent severe ischemic rest pain at the fingers of his right hand, not responding to oral treatment with vasodilators and analgesics. Critical blood flow was discovered in the middle, ring, and little finger, with ischemic ulcerations apparent in the fingertips of these 3 fingers. The distal phalanx of the little finger had been amputated 6 months before because of gangrenous necrosis. In an attempt to avoid further disabling amputations, the patient received 3 series of Bier's block sessions with guanethidine and lidocaine according to a specific protocol. Marked increase in finger blood flow was induced even after the first series, and complete disappearance of both fingertip ulcerations and ischemic rest pain was achieved. No side effects were observed. The above-described method in a patient with advanced Buerger's disease resulted in excellent pain relief and full restoration of both blood flow and function of the affected fingers.

Bier Block With Steroid for CRPS

Bier Block With Steroid for CRPS

Carpal tunnel release under intravenous regional anaesthesia with ropivacaine or lidocaine

Carpal tunnel syndrome (CTS) surgery is usually performed utilizing regional anaesthesia techniques such as local infiltration, brachial plexus block and intravenous regional anaesthesia (IVRA). The present investigation aimed to compare the clinical effects of IVRA with lidocaine or ropivacaine. Forty patients undergoing carpal tunnel release were divided into two groups (20 each) and 0.1% ropivacaine or 0.25% lidocaine were administred for IVRA. All patients underwent a standard surgical procedure. The patients were asked about their satisfaction regarding analgesia. After tourniquet deflation, patients were evaluated for any signs of side effects. Verbal numerical pain scores of patients were recorded periodically in the postoperative period. Onset of and recovery from sensory anaesthesia and quantification of analgesic consumption were assessed. According to our results, 0.25% lidocaine and 0.1% ropivacaine provided satisfactory anaesthetic quality with a low toxicity profile. The recovery time from sensory block was longer and analgesic consumption was less with ropivacaine than with lidocaine.

Addition of dexmedetomidine to lidocaine for intravenous regional anaesthesia 1

The aim of this study was to determine the duration of onset and regression time of sensory and motor blocks, the quality of anaesthesia and postoperative analgesia by the addition of dexmedetomidine to local anaesthetic solution in intravenous regional anaesthesia (IVRA). Forty patients scheduled for elective hand surgery participated in this prospective randomized double-blind study. The IVRA was achieved using 3 mg kg(-1) lidocaine diluted with saline to a total volume of 40 mL in the control group or 1 microg kg(-1) of dexmedetomidine + 3 mg kg(-1) lidocaine diluted with saline to a total volume of 40 mL in the dexmedetomidine group. The onset and regression times for sensory and motor blocks were recorded. Qualities of anaesthesia, intraoperative and postoperative analgesic requirements were noted. There was no difference between the groups with respect to sensory and motor blocks onset and regression time. The quality of anaesthesia was better in the dexmedetomidine group than the control group and the difference was statistically significant. Intraoperative and postoperative analgesic requirements were greater in the control group than in the dexmedetomidine group. Addition of dexmedetomidine to local anaesthetic solution in IVRA improved the quality of anaesthesia and decreased analgesic requirements, but had no effect on the sensory and motor blocks onset and regression times.

Ambulatory surgery acute pain management: A review of the evidence

Summary The purpose of this review is to examine the evidence for postoperative analgesic techniques in ambulatory surgery. A search was performed using the title and text words ambulatory surgical procedures and postoperative pain to identify relevant publications on Medline, The Cochrane Library and Embase Anesthesiology Database. The review assesses and compares benefits of local anaesthetic techniques, including local infiltration, intravenous regional anaesthesia, intra-articular anaesthesia, neuraxial block, peripheral nerve block, and continuous infusions. It examines types of peripheral nerve blockade pertinent to ambulatory surgery and indications for its use. It outlines current spinal anaesthesia controversies in ambulatory surgery including transient neurological symptoms and discharge criteria. It examines the role of opioids, non-steroidal-antiinflammatory drugs and non-pharmacological techniques in the management of postoperative pain in ambulatory surgery with a recommended pain management plan.

Peri-Procedural Protocols for Interventional Pain Management Techniques: A Survey of US Pain Centers

Interventional techniques are now an integral part of chronic pain management. As new procedures are arising at a rapid pace, decisions regarding patient safety and comfort are becoming more challenging. No peri-procedural consensus protocol currently addresses issues such as 1. nulla per os (NPO) status, 2. sedation, 3. monitoring, or 4. recovery. In establishing safety guidelines for interventional pain procedures, the knowledge of current peri-procedural protocols is required. To survey interventional pain practices and to obtain current peri-procedural protocols. We faxed a one-page questionnaire to 105 United States pain practices identified using the directory of the American Pain Society. Fifty-seven academic and private pain practices (54%) responded and were included in the analysis. Monitoring devices such as electrocardiogram (EKG), blood pressure, and pulse oximetry are not universally employed for cervical or lumbar spinal procedures. Even procedures that are often performed by anesthesiologists in operating rooms, such as Bier blocks, are not monitored in a uniform manner when performed in pain clinics. Establishment of intravenous access for procedures also varies among practitioners. Most (72%) practices had treated patients with vasovagal reactions over the past 12 months, but only 42% had simulated cardiac arrests to prepare for these situations. While various trends in peri-procedural care are observable, standards of care are not well established. In order to minimize complications associated with interventional pain management techniques, the pain management community should agree on safety guidelines for all procedures, much as these advocated by the American Society of Anesthesiology for surgical anesthetic care.

Intravenous Regional Anesthesia Using Lidocaine and Magnesium

We conducted this study to evaluate the effects of magnesium, when added to lidocaine for IV regional anesthesia (IVRA), on tourniquet pain. Thirty patients undergoing elective hand surgery during IVRA were randomly assigned to two groups. IVRA was achieved with 10 mL of saline plus 3 mg/kg lidocaine 0.5% diluted with saline to a total of 40 mL in group C or with 10 mL of 15% magnesium sulfate (12.4 mmol) plus 3 mg/kg lidocaine 0.5% diluted with saline to a total of 40 mL in group M. Injection pain, sensory and motor block onset and recovery time, tourniquet pain, and anesthesia quality were noted. Patients were instructed to receive 75 mg of IM diclofenac when the visual analog scale (VAS) score was >4, and analgesic requirements were recorded. Sensory and motor block onset times were shorter and recovery times were prolonged in group M (P < 0.05). VAS scores of tourniquet pain were lower in group M at 15, 20, 30, 40, and 50 min (P < 0.001). Anesthesia quality, as determined by the anesthesiologist and surgeon, was better in group M (P < 0.05). Time to the first postoperative analgesic request in group C was 95 +/- 29 min and in group M was 155 +/- 38 min (P < 0.05). Postoperative VAS scores were higher for the first postoperative 6 h in group C (P < 0.05). Diclofenac consumption was significantly less in group M (50 +/- 35 mg) when compared with group C (130 + 55 mg) (P < 0.05). We conclude that magnesium as an adjunct to lidocaine improves the quality of anesthesia and analgesia in IVRA.

Continuous Peripheral Nerve Blocks at Home for Treatment of Recurrent Complex Regional Pain Syndrome I in Children

Recurrent complex regional pain syndrome I is not rare in the pediatric population. The authors conducted this study to evaluate the efficacy of continuous peripheral nerve blocks with elastomeric disposable pumps associated with initial Bier blocks for the treatment of recurrent complex regional pain syndrome I in children. After parental informed consent, 13 children who did not respond to conventional complex regional pain syndrome treatment were included (mean age, 13 yr; range, 9-16 yr). After general anesthesia, peripheral nerve block was performed using 0.5 ml/kg lidocaine, 1%, with epinephrine and 0.5% ropivacaine injected in the peripheral nerve block catheter. Then, a 20-min Bier block was performed using a tourniquet and 0.2 ml/kg lidocaine, 1%; 3 ml/kg hydroxyethyl starch 130/06; and 5 mg/kg buflomedil injected intravenously. A solution of 0.1 ml . kg . h continuous ropivacaine, 0.2%, was infused through the catheter using an elastomeric pump for 96 h. Need for rescue analgesia, occurrence of side effects, and status of motor and sensory block were recorded at hours 1, 6, 12, 24, 48, 72, and 96. Children and parents completed a satisfaction assessment. All of the children had follow-up visits after 2 months. Postoperative analgesia was excellent. The median pain score was 0 for each period studied. Motor blockade was minimal before 12 h (median, 1) and absent thereafter. One child needed rescue analgesia. All children were able to walk easily after the initial 24-h period (walking score, > 4). Children and parents were all satisfied. Children returned home under parental surveillance beginning in the 24th hour. Neither peripheral nerve block nor Bier block caused side effects. After 2 months, none of the children exhibited any clinical symptom of recurrent complex regional pain syndrome. Ambulatory continuous peripheral nerve block associated with an initial Bier block seems to be a significant and novel contribution to treat recurrent pediatric complex regional pain syndrome I. It allows complete pain relief, early mobilization, and rapid return home, representing a psychological advantage for these children.

Role of the sympathetic nervous system in pain

Some chronic pain conditions appear to be sympathetically mediated because interruption of the sympathetic supply results in pain relief. Examples include: complex regional pain syndrome type I and II; visceral pain due to abdominal and pelvic cancers; ischaemic pain or tissue viability from peripheral vascular disease, arterial spasm or frostbite; ischaemic heart disease; post-herpetic neuralgia; erythromelalgia. The sympathetic ganglion can be blocked at several locations. The stellate (cervicothoracic) ganglion can be blocked to reduce pain in the head and upper limb. The lumbar sympathetic chain can be blocked to reduce pain in the lower limb, and the thoracic sympathetic chain to block thoracic pain. The coeliac plexus can be blocked to reduce pain in the upper gastrointestinal tract (e.g. pancreas, liver cancer). The superior hypogastric can be blocked to reduce pain in the pelvic area (e.g. bladder, uterine cancer). Ganglion impar can be blocked to reduce perineal pain such as pelvic floor cancer. Blocks are usually performed using local anaesthetic, preferably a long acting one to maximize duration of effect. Neurolytic blocks can also be carried out using phenol (6% or ethanol 50–100%), most commonly with coeliac and lumbar sympathectomy. An intravenous regional sympathetic block (Bier's block with guanethidine) can be carried out to reduce pain in the upper and lower limb. Guanethidine is injected into an occluded vein, where it is absorbed into the perivascular sympathetic plexus and induces release of noradrenaline. It then prevents the reabsorption of noradrenaline by being preferentially absorbed into the sympathetic nerve itself, so depleting the vesicles of transmitter. A systemic infusion of phentolamine (alpha antagonist) can be used for diagnosis.

Comparison of the Effect of Low-Dose Ropivacaine and Lidocaine in Intravenous Regional Anaesthesia

Comparison of the Effect of Low-Dose Ropivacaine and Lidocaine in Intravenous Regional Anaesthesia

Intravenous Regional Anesthesia of the Penis: A Historical Vignette

Cuban anesthesiologist Dr. Mirta Abad made me aware of a technique that urologist Vicente Osorio Acosta, another anesthesiologist Gabriel Perez Martinez and herself devised in 1968,1 as alternative anesthetic technique for circumcisions in children and adults. After the initial interest on intravenous regional anesthesia of the upper extremity introduced by Bier2 in 1908, there was a lull in its application with a brief reapproachment when Luis Garcia Herreros3 from Mexico in 1946, Enzo Mourigan Canale4 from Uruguay in 1947, and Flavio Kroeff Pires5 from Brasil in 1954, improved and popularized this technique in Latin America using procaine or tetracaine, as anesthetics. Not until a safer and more effective drug (lidocaine) became available that Holmes6 in 1963, reintroduced this anesthetic technique with eventual universal acceptance. Most of the papers included treatment of the upper and lower extremities. The application of this technique to achieve surgical anesthesia in the penis was done by Osorio Acosta, Perez Martinez and Abad when other anesthetic techniques were contraindicated. The authors accomplished this task by placing a rubber band around the base of the penis to produce ischemia; after partial exsanguination, a vein at the base of the organ was entered with a 26 gauge needle connected to a syringe containing the local anesthetic (either 1% procaine in 2 pts., 1% lidocaine in 2 others and 1% mepivacaine in 6 other instances) proceeding to inject from 5 to 10 ml. The needle was removed and pressure applied at the puncture site. Circumcisions were performed, as soon as the excess prepuce was excised, the tourniquet was released, hemostasis was completed by electrocautery and suture of the incision line was performed. Only one out of 10 patients had discomfort while the last sutures were applied, since closure took longer than 10 mins. from the tourniquet release. Apparently, this was the first preliminary report of the application of intravenous regional anesthesia technique in the penis.

Preventing the Development of Complex Regional Pain Syndrome after Surgery

COMPLEX regional pain syndrome (CRPS), previously known as reflex sympathetic dystrophy (RSD), is used to describe a syndrome of pain and sudomotor or vasomotor instability. This pain syndrome usually has an initiating noxious event in the periphery, is not limited to the distribution of a single nerve, and is disproportionate to the inciting event. The Consensus Conference of the International Association for the Study of Pain has subclassified CRPS into two forms: CRPS I (formerly RSD) and CRPS II (formerly causalgia). According to the International Association for the Study of Pain, the diagnosis of CRPS I requires (1) continuing pain, allodynia, or hyperalgesia disproportionate to the injury; (2) evidence at some time of edema, changes in skin blood flow, or abnormal sudomotor activity in the region of pain; and (3) no other conditions that would otherwise account for the degree of pain and dysfunction. Motor disturbances and trophic changes, such as altered nail and hair growth, may be observed in some cases. CRPS II is a pain syndrome that starts after a nerve injury and is not necessarily limited to the distribution of the injured nerve. The diagnostic criteria are the same as those of CRPS I. Patients with CRPS I or CRPS II can have sympathetically maintained pain or sympathetically independent pain. Sympathetically maintained pain, a term introduced in 1986 by Roberts, is pathologic pain that is supported by sympathetic efferent activity, circulating catecholamines, and/or increased sensitivity of -adrenergic receptors. Sympathetically maintained pain is identified by the ability to lessen the pain by sympatholytic blocks or interventions. Sympathetically independent pain has components of pain from sources other than sympathetic innervation and is believed to be most commonly observed in advanced cases of CRPS that do not respond to sympathetic blocks. Patients with CRPS may present with components of only sympathetically maintained pain or sympathetically independent pain or, more commonly, a combination of pain from each. Despite increasing research interest, little is known regarding which patients are at increased risk for development of postoperative CRPS and what the optimal perioperative treatment strategy is for those patients undergoing surgery who have a previous history of CRPS. This review outlines the surgical procedures that are believed to increase risk for development of CRPS and describes pharmacologic and regional analgesic techniques that may be of benefit for preventing the development of CRPS after surgery.