Intravenous Regional Anesthesia Research Articles

Choice of Anesthesia Mode, Neuroprotective Therapy in the Surgical Repair of Extracranial Vessels

Objective: to improve the direct results of carotid endarterectomy, by reducing the number of perioperative complications via the choice of an anesthesia mode and a neuroprotective regimen for possible neurological complications. Subjects and methods. Total intravenous diprivan anesthesia versus regional cervical plexus anesthesia after Pashchuk and inhaled sevorane anesthesia was evaluated in 190 patients with carotid endarterectomy. The parameters of cerebral blood flow and the markers for brain damage were studied. Results. Sevorane anesthesia has been shown to maintain optimal cerebral blood flow, which limits ischemia and reperfusion brain damages and results in fewer postoperative complications. Neurological disorders were an indication for neuroprotective therapy and, according to which, the patients were divided into 2 matched groups. Therapy with mexidol and cytoflavin, which had already become traditional, was used in Group 1. Group 2 patients were given the current neuroprotective agent citicoline (ceraxone) with actovegin. The performed trials showed that the neuroprotective therapy used in Group 2 was more effective (5% significance level) than that in Group 1. Conclusion. Inhalational sevorane anesthesia versus total intravenous diprivan anesthesia and regional cervical plexus anesthesia is characterized by optimal cerebral blood flow values, less neuronal damage, and fewer postoperative neurological complications. Irrespective of the mode of anesthesia, neuroprotective therapy involving ceraxone in combination with actovegin is preferred for the intensive therapy of postoperative neurological disorders. Key words: diprivan, sevorane, neuron-specific enolase, linear cerebral blood flow velocity, carotid endarterectomy, cerebral perfusion pressure, brain-specific protein antibodies, ceraxone.

The Analgesic Effect of Dexketoprofen When Added to Lidocaine for Intravenous Regional Anaesthesia: A Prospective, Randomized, Placebo-Controlled Study

This prospective, randomized, placebo-controlled study evaluated the effects of dexketoprofen as an adjunct to lidocaine in intravenous regional anaesthesia (IVRA) or as a supplemental intravenous (i.v.) analgesic. Patients scheduled for elective hand or forearm soft-tissue surgery were randomly divided into three groups. All 45 patients received 0.5% lidocaine as IVRA. Dexketoprofen was given either i.v. or added into the IVRA solution and the control group received an equal volume of saline both i.v. and as part of the IVRA. The times of sensory and motor block onset, recovery time and postoperative analgesic consumption were recorded. Compared with controls, the addition of dexketoprofen to the IVRA solution resulted in more rapid onset of sensory and motor block, longer recovery time, decreased intra- and postoperative pain scores and decreased paracetamol use. It is concluded that coadministration of dexketoprofen with lidocaine in IVRA improves anaesthetic block and decreases postoperative analgesic requirements.

Hoofbeats

Sir: The maxim, “when you hear hoofbeats, think of horses rather than zebras,” reminds clinicians to focus on the most common diagnoses consistent with presenting symptoms. Trigger finger is a common cause of pain and impaired digital mobility, with a reported lifetime risk of 2.6 percent.1,2 The diagnosis is made clinically and can be aided by palpation of a firm, tendinous nodule on the volar surface that catches on the pulley system. A more rare cause of impaired finger extension is subluxation of the extensor digitorum communis at the metacarpophalangeal joint. Patients present with inability to fully extend the involved digit, often accompanied by pain and catching.3 On attempted finger extension, the extensor tendon exhibits ulnar deviation over the metacarpal head. In this communication, we describe a patient with concomitant trigger finger and extensor tendon subluxation of the same digit, a combination not previously reported in the literature. The workup and management of this clinical “zebra” is presented. A 78-year-old, right-hand-dominant woman presented with several months of progressive inability to extend the middle finger of her left hand. She was nondiabetic and had no previous history of hand trauma, osteoarthritis, or rheumatoid arthritis. On examination, she was unable to extend the index finger metacarpophalangeal joint beyond 45 degrees and had a palpable lump at the A1 level. A diagnosis of trigger finger was made and the patient underwent an uncomplicated open A1 pulley release a few weeks later, with free excursion of the profundus tendon confirmed. The patient recovered without incident, but at the first postoperative visit 2 weeks later, she continued to complain of limited extension of the left middle finger with a catching sensation. Examination of the dorsum of the hand revealed subluxation of the extensor digitorum communis between the metacarpal heads of the ring and middle fingers. The patient was informed that an error in complete diagnosis had been made and that a repair procedure of the extensor mechanism would be needed. Six weeks later, under intravenous regional anesthesia, the extensor indicis proprius tendon was transferred around the extensor digitorum communis tendon of the middle finger to secure it in its normal position in flexion and extension. This was confirmed with active motion in the operating room. At her most recent visit, 10 weeks postoperatively, range of motion was full with the exception of 10 degrees of lag at the middle finger metacarpophalangeal joint, which was improving (Figs. 1 and 2).Fig. 1.: Postoperative photograph demonstrating extension of the middle finger with 10 degrees of residual lag.Fig. 2.: Postoperative photograph demonstrating full flexion of all digits.Our report illustrates the need for comprehensive physical examination even when confronting a common and predictable constellation of findings. An initially thorough examination of the volar and dorsal aspects of our patient's hand would have revealed the coexistence of two causes for her functional limitation. Although a staged repair would still have been performed in this case, both patient and surgeon would have been spared the anxiety of an unsatisfactory outcome to the first operation. Sometimes, hoofbeats do come from zebras. Sashank K. Reddy, M.D., Ph.D. James W. May, Jr., M.D. Massachusetts General Hospital Harvard Medical School Boston, Mass.

Incidence of Regional Pain Syndrome after Carpal Tunnel Release. Is there a Correlation with the Anesthetic Technique?

Complex regional pain syndrome (CRPS) previously known as reflex sympathetic dystrophy refers to a set of signs and symptoms that include pain, increased sweating, and vasomotor instability. Pain is usually triggered by a noxious stimulus in a peripheral nerve, which is disproportionate to the triggering stimulus. Its development after surgery is not uncommon varying with the type of intervention. An incidence of 2.1 to 5% has been reported after carpal tunnel release (CTR). Sympathetic blockade may prevent the onset of CRPS. However, there is no study validating this technique to prevent CRPS after CTR. The objective of the present study was to define the incidence of CRPS after CTR and its relationship with four anesthetic techniques. Patients were randomly distributed to undergo one of the following techniques: general anesthesia, regional intravenous anesthesia with lidocaine, regional intravenous anesthesia with lidocaine and clonidine, or axillary plexus block. Postoperatively, they were followed-up by a nurse who was unaware of the anesthetic technique used, and follow-up was done through electronic patient records for up to 6 months after the anesthesia. During this period signs and symptoms typical of CRPS were investigated and, if positive, treatment was instituted. A descriptive evaluation using the chi-square test was performed. Three-hundred and one patients were investigated. Twenty-five of them developed CRPS, an incidence of 8.3%. Predominance was not observed among the anesthetic techniques used. Other factors such as smoking, profession, and other concomitant diseases were also investigated, and none showed a relationship with the development of post-CTR CRPS. Complex regional pain syndrome has an incidence of 8.3% after CTR surgery without association with the anesthetic techniques investigated.

Complex regional pain syndrome type I as a consequence of trauma or surgery to upper extremity: management with intravenous regional anaesthesia, using lidocaine and methyloprednisolone

Complex regional pain syndrome type I (CRPS-I) is a known complication after surgery or trauma to the upper extremity and is difficult to treat. A simple and easily tolerated method of treatment that includes intravenous regional anaesthetic block with lidocaine and methyloprednisolone is presented. One hundred and sixty-eight patients with CRPS-I of the upper extremity were treated in a 5-year period. At the end of treatment 88% of the patients reported minimal or no pain. After a mean follow-up of 5 years (range 28 months to 7 years) complete absence of pain was reported by 92% of patients. The symptoms of the acute phase of the syndrome were reversed. Early recognition and prompt initiation of treatment is very important for the course of the disease as symptoms can be reversible when treatment starts early. Permanent results with a functional upper extremity and very satisfactory pain relief can be anticipated.

Case report: Sequential bilateral upper extremity intravenous regional anesthesia with chloroprocaine

This case report describes the novel use of sequential bilateral upper extremity intravenous regional anesthesia with 2-chloroprocaine for bilateral endoscopic carpal tunnel decompression. A 49-yr-old female, American Society of Anesthesiologists physical status I, presented for outpatient bilateral carpal tunnel release. Sequential bilateral intravenous regional anesthesia was performed with 0.5% 2-chloroprocaine 30mL per arm using a double upper arm tourniquet. Intraoperative sedation consisted of midazolam and fentanyl. Tourniquet times for the right and left arms were 28 and 19min, respectively. After deflation of each tourniquet, mild limb twitching occurred but resolved immediately after administration of intravenous midazolam. The patient made a rapid recovery, and she was discharged home uneventfully. Bilateral sequential intravenous regional anesthesia with 2-chloroprocaine is effective for upper extremity surgery of short duration. Recommendations to minimize the risk of local anesthetic toxicity are reviewed.

Case reports of novel treatments - proper evaluation before clinical use

Case reports of novel treatments - proper evaluation before clinical use

The Interaction Between Emulsified Isoflurane and Lidocaine Is Synergism in Intravenous Regional Anesthesia in Rats

Our previous studies have demonstrated that emulsified isoflurane (EI) produced epidural anesthesia and blockade of nerve conduction. We designed this study to observe whether EI could produce an anesthetic effect in IV regional anesthesia (IVRA) and to investigate the underlying interaction between EI and lidocaine when they were combined in IVRA. IVRA was evaluated using tail-flick and tail-clamping tests in a rat model. In experiment 1, Sprague-Dawley rats were assigned to 4 groups (n = 10 per group), receiving 0.5 mL of 8%EI, 0.5% lidocaine, 30% Intralipid, or normal saline to observe whether EI could produce an anesthetic effect in IVRA. In experiment 2, for tail IVRA, EC(50) (median effective concentration) of EI alone and EC(50) of lidocaine alone, as well as EC(50) of lidocaine with the addition of Intralipid (0.0% EI) or with the addition of EI at different concentrations (0.4%, 0.8%, and 1.6%) were determined using an up-and-down method. Isobolographic analysis was used to evaluate the interaction between EI and lidocaine. For experiment 1, successful IVRA was observed in 8 of 10 rats with 8% EI, 10 of 10 rats with 0.5% lidocaine, and 0 of 10 rats with 30% Intralipid or normal saline. The anesthetic effect was not different in onset time (1.5 ± 0.9 vs 1.0 ± 0.0 minutes, P = 0.104) or recovery time (15 ± 9 vs 18 ± 12 minutes, P = 0.394) between 8% EI and 0.5% lidocaine. For experiment 2, EC(50) of EI was 4.467% ± 0.375% and EC(50) of lidocaine was 0.183% ± 0.072%; EC(50) of lidocaine was 0.173% ± 0.036% with the addition of Intralipid, and 0.064% ± 0.008%, 0.035% ± 0.005%, and 0.028% ± 0.006% with the addition of 0.4%, 0.8%, and 1.6% EI, respectively. With the addition of EI, the requirement for lidocaine was reduced in a synergistic manner. EI produced IVRA, and a synergistic interaction was found between EI and lidocaine for IVRA in a rat tail model.

Intravenous Lidocaine for Acute Pain Treatment

Lidocaine’s versatility is seen in the many routes by which it can be administered. It is given topically or by infiltration for procedural pain, such as for venous punctures and laceration repairs, and is available in a topical patch formulation for peripheral types of pain, such as postherpetic neuralgia. Lidocaine may be delivered epidurally and by single injection or continuous peripheral nerve block infusion. It has been administered for many years by the intravenous (IV) route for regional anesthesia (Bier block) for surgical procedures and increasingly by brief IV infusion as a third-line option for the treatment of refractory neuropathic and postoperative pain.

Progression of Forearm Intravenous Regional Anesthesia With Ropivacaine

The progression of sensory blockade in the hand following a forearm Bier block with ropivacaine is currently unknown. The hands of 10 healthy adult human subjects were anesthetized with ropivacaine, and their sensitivities to cold and touch were tested until the completion of anesthesia. On average, insensitivity to cold occurred uniformly throughout the hand within 9 mins; however, touch sensation was not complete until approximately 20 mins after injection. The spread of anesthesia occurred in a semisystematic way, spreading proximally and distally from the site of injection (mid-dorsum of the hand), and, at a slower rate, from the dorsum of the hand to the palm.

Use of a temporary forearm tourniquet for intravenous regional anaesthesia: a randomised controlled trial

To investigate the effect of a temporary, additional mid-forearm tourniquet on the quality of intravenous regional anaesthesia. Fifty patients undergoing hand and wrist surgery under intravenous regional anaesthesia (Bier's block) were randomised to receive a temporary mid-forearm tourniquet for 8 min during and after administration of local anaesthetic or to a control group (no tourniquet). The dose of prilocaine was standardised. Onset of block was assessed by response to pinprick in ulnar, radial and median nerve distributions of the hand. Quality of intraoperative anaesthesia was assessed using response to forceps pinch, visual analogue score (VAS) for pain and requirement for supplemental infiltration anaesthesia. Post-operative pain was assessed using VAS. There was no difference between the groups with respect to intraoperative pain VAS (P = 0.19) or post-operative pain VAS (P = 0.69). More patients in the temporary tourniquet group were numb to pinprick testing in the three nerve distributions of the hand at 4 and 8 min after injection of local anaesthetic (P = 0.038). There was no difference in the requirement for supplemental infiltration of local anaesthetic between the groups. Our results suggest that a temporary mid-forearm tourniquet might speed the onset of intravenous regional anaesthesia. Although the advantage is lost by the time surgery starts, the technique might permit the use of a smaller dose of local anaesthetic and may have safety advantages by more rapid movement of anaesthetic out of the venous bed. The technique merits further investigation.

Clonidine as an adjunct to intravenous regional anesthesia: A randomized, double-blind, placebo-controlled dose ranging study

Background:The addition of clonidine to lidocaine intravenous regional anesthesia (IVRA) has been previously reported to improve postoperative analgesia in patients undergoing upper extremity surgery. Our objective was to perform a dose ranging study in order to determine the optimal dose of clonidine used with lidocaine in IVRA.Design & Setting:We performed a double-blinded randomized placebo-controlled study with 60 patients scheduled for elective endoscopic carpal tunnel release under IVRA with 50 ml lidocaine 0.5%. University-affiliated outpatient surgery center. Data collected in operating rooms, recovery room, and by telephone after discharge from surgery center.Materials & Methods:Sixty adult ASA I or II patients undergoing outpatient endoscopic carpal tunnel release under intravenous regional anesthesia.Patients were randomized into five study groups receiving different doses of clonidine in addition to 50 ml 0.5% lidocaine in their IVRA. Group A received 0 mcg/kg, group B 0.25 mcg/kg, group C 0.5 mcg/kg, group D 1.0 mcg/kg and group E 1.5 mcg/kg of clonidine.Intraoperative fentanyl, recovery room pain scores, time to first postsurgical analgesic, total number of acetaminophen/codeine tablets consumed postsurgery, incidence of sedation, hypotension and bradycardia.Results & Conclusions:There was no benefit from any dose of clonidine compared to placebo. There were no clonidine-related side effects seen within the dose range studied. In short duration minor hand surgery, the addition of clonidine to lidocaine-based intravenous regional anesthesia provides no measurable benefit.

Bier′s block using lignocaine and butorphanol

Background:Opioids are most commonly used as adjuncts in intravenous regional anesthesia (IVRA) to improve the quality of intraoperative and postoperative analgesia. There is paucity of literature on the use of butorphanol in IVRA.Aims:The aim of this study was to evaluate the likely benefits of addition of butorphanol to lignocaine in Bier's block in terms of onset and duration of sensory block and also for analgesic requirement in postoperative period.Settings and Design:A randomized double blind study was conducted at Tertiary Care Educational Institute.Patients and Methods:A total of 40 adult ASA I or II patients scheduled to undergo upper limb surgery were randomized in two groups (n=20). Group I received 3 mg/kg of lignocaine alone and group II received 1 mg butorphanol in addition to 3 mg/kg lignocaine. Sensory block onset time and time to recovery from sensory block after tourniquet deflation were noted using the pin prick method. Duration of postoperative analgesia was noted using a visual analogue scale. All the patients were compared for the time to first rescue analgesic consumption and total analgesic consumption in first 24 hours postoperatively.Statistical Analysis Used:The statistical analysis was done using unpaired Student's t-test.Results:Our study showed significant prolongation of postoperative analgesia in group II as noted by the time to first analgesic requirement. Total analgesic consumption in first 24 hours postoperatively was less in group II. Sensory block onset time and time to recovery from sensory block after tourniquet deflation, did not show any significant difference between the two groups.Conclusions:Addition of butorphanol to lignocaine in IVRA significantly prolongs the duration of postoperative analgesia and 24 hours analgesic consumption is less in patients receiving butorphanol along with lignocaine in IVRA. However, there is no effect on sensory block onset time and time to recovery from sensory block.

Complex Regional Pain Syndrome Revived by Epileptic Seizure Then Disappeared Soon during Treatment with Regional Intravenous Nerve Blockade: A Case Report

We present a case of complex regional pain syndrome (CRPS), in which symptoms, including burning pain and severe allodynia, were alleviated by using a regional intravenous nerve blockade (Bier block) combined with physiotherapy, but reappeared following an epileptic seizure. Symptoms disappeared again following control of epileptic discharges, as revealed by single-photon emission computed tomography (SPECT) and electroencephalography (EEG) results. Although systemic toxicity of a local anesthetic applied by Bier block was suspected as a cause of the first seizure, the patient did not present any other toxic symptoms, and seizures repeatedly occurred after Bier block cessation; the patient was then diagnosed as having temporal symptomatic epilepsy. This case suggests that symptoms of CRPS may be sustained by abnormal brain conditions, and our findings contribute to the understanding of how the central nervous system participates in maintaining pain and allodynia associated with CRPS.

The analgesic effect of three different doses of nitroglycerine when added to lidocaine for intravenous regional anesthesia in trauma patients

Nitroglycerine (NTG) has analgesic properties. The aim of the present study was to assess the analgesic effect of three different doses of NTG (200 µg, 300 µg and 400 µg) when added to lidocaine in intravenous regional anesthesia (IVRA) in trauma patients. One hundred patients undergoing hand surgery were randomly allocated to four groups to receive 3 mg/kg 2% lidocaine diluted with saline to a total dose of 40 mL in the control group (Group LS, n = 25) or 200, 300, 400 µg NTG plus 3 mg/kg 2% lidocaine diluted with saline to a total dose of 40 mL in the NTG group (Groups LN1, LN2, LN3 respectively; n = 25 in each group). Before and after the tourniquet application, hemodynamic variables, tourniquet pain, sedation, and analgesic use were recorded. Sensory and motor block onset times were significantly shorter in the LN3 group compared with Groups LN1, LN2, and LS (p<0.05). Sensory and motor block recovery times were statistically prolonged in the LN3 group when compared with Groups LN1 and LS (p<0.05). Postoperative visual analogue scale (VAS) scores were significantly lower at 2, 4, 8, 12, and 24 hours after tourniquet release in Group LN3 compared with Group LS (p<0.05). The addition of 400 µg NTG to lidocaine in IVRA shortens the onset of sensory and motor block in trauma patients and improves the quality of anesthesia and perioperative analgesia better than the addition of 200 µg or 300 µg NTG, without causing side effects.

Quality of lidocaine analgesia with and without midazolam for intravenous regional anesthesia

Midazolam has analgesic effects mediated by gamma aminobutyric acid-A receptors. This study was designed to evaluate the effect of midazolam on anesthesia and analgesia quality when added to lidocaine for intravenous regional anesthesia (IVRA). Forty patients undergoing hand surgery were randomly assigned to two groups to receive IVRA. The control group received 3mg/kg lidocaine 2% w/v diluted with saline to a total volume of 40ml, and the midazolam group received an additional 50μg/kg midazolam. Sensory and motor block onset and recovery times, tourniquet pain, intraoperative analgesic requirements, sedation, and anesthesia quality were recorded. Postoperative pain and sedation scores, time to first analgesic requirements, analgesic use in the first 24h, and side effects were noted. Sensory and motor block onset and recovery times did not differ significantly between groups. Tourniquet pain scores were lower at 10, 15, 20, and 30min (P<0.0001) in the midazolam group. Three (15%) patients in the midazolam group required fentanyl for tourniquet pain compared with thirteen (65%) patients in the control group (P=0.02). Patients in both groups received fentanyl once. Midazolam group showed that significantly less patients required diclofenac for postoperative analgesia (P<0.01) and analgesic-free period during first postoperative 24h was significantly longer (726.8±662.8min vs. 91.0±35.9min, P<0.0001). Postoperative pain scores were lower (P<0.0001) and sedation scores higher (P<0.05) for the first 2h in the midazolam group. Addition of midazolam to lidocaine for IVRA improves anesthesia quality and enhances intraoperative and postoperative analgesia without causing side effects.

Regional intravenous anesthesia in knee arthroscopy

OBJECTIVE:The goal of the study was to investigate the regıonal ıntravenous anesthesıa procedure in knee arthroscopy and to evaluate the effects of adding ketamine over the anesthesia block charactery and tourniquet pain.MATERIAL/METHOD:Forty American Society of Anesthesiologists (ASA) II patients who received knee arthroscopy were enrolled. After monitoring, a peripheral IV line was inserted.The venous blood in the lower extremity was evacuated with a bandage, and the proximal cuff of the double-cuff tourniquet was inflated. The patients were randomly split into two groups. While Group P received 80 ml 0.5% prilocaine, Group PK received 0.15 mg/kg ketamine (80 ml in total) via the dorsum of the foot. We recorded onset time of the sensory block, end time of the sensory block, presence of the motor block, the time when the patient verbally reported tourniquet pain and surgical pain, duration of tourniquet tolerance, fentanyl consumption during the operation, time to first analgesic requirement, methemoglobin values at 60 minutes, operative conditions, 24-hour analgesic consumption, discharge time, and hemodynamic parameters.RESULTS:The body mass index (BMI) of the patients who required general anesthesia was significantly higher than the BMI of other patients. The onset time of the sensory block was shorter for those in Group PK, but the time to first analgesic requirement was longer.CONCLUSION:Regıonal ıntravenous anesthesıa using the doses and volumes commonly used in knee arthroscopy may be an inadequate block among patients with high BMI values. Moreover, the addition of ketamine to the local anesthetic solution may produce a partial solution by shortening the onset of sensory block and prolonging the time until the first analgesic is required.

Toxic reaction related to high dose lidocaine secondary to intravenous regional anesthesia

Lidocaine can be seen systemic intoxication, central nervous system (CNS) and cardiovascular toxicities, due to its common usage and broad safety margin. Lidocaine overdose has been reported with convulsion, cardiac collapse and coma. In present case, a patient underwent surgical excision of wrist mass who erroneously received 1200 mg 10% lidocaine instead of 225 mg 2% dose. Interestingly, the case shows only some mild CNS side effects without any serious adverse effect.

Bilateral forearm intravenous regional anesthesia with prilocaine for botulinum toxin treatment of palmar hyperhidrosis

Treatment of palmar hyperhidrosis with botulinum toxin (BTX) requires effective anesthesia, but previous methods have not provided enough pain relief or have resulted in a prolonged impaired hand function. This is a study of bilateral forearm intravenous regional anesthesia using prilocaine for BTX treatment of palmar hyperhidrosis. In all, 166 patients (100 female and 66 male) were treated bilaterally with intracutaneous BTX type A injections using intravenous regional anesthesia with prilocaine (5 mg/mL). In a subgroup of patients, forearm nerves were studied with neurophysiologic methods and blood concentrations of prilocaine were measured. Pain evaluation with a visual analog scale was accompanied with a questionnaire about the treatment. In all, 95% of the patients answering the questionnaire (response rate 89%) were satisfied with the anesthetic effect. No serious adverse events occurred. There was a fast recovery of motor function (in median 6 minutes) and sensory function (in median 20 minutes). No subclinical signs of sensory nerve damage were found. Recall and reporting bias are potential sources of limitations in this study. Bilateral forearm intravenous regional anesthesia provides an effective and well-tolerated anesthesia during BTX treatment of palmar hyperhidrosis.

The Analgesic Effect of Paracetamol When Added to Lidocaine for Intravenous Regional Anesthesia

The Analgesic Effect of Paracetamol When Added to Lidocaine for Intravenous Regional Anesthesia