Intravenous Regional Anesthesia Research Articles

Intravenous regional anesthesia using lidocaine and neostigmine for upper limb surgery

Study Objective To evaluate the effect of adding neostigmine to lidocaine in intravenous regional anesthesia (IVRA). Design Randomized, double-blinded study. Setting Tertiary-care academic medical institution. Patients 40 ASA physical status I and II patients scheduled for elective or emergency forearm and hand surgery. Intervention Patients were randomized to two groups of 20 patients each. In the control group, IVRA was established using 40 mL of 0.5% lidocaine with one mL of isotonic saline, while neostigmine group patients received 40 mL of 0.5% lidocaine with 0.5 mg neostigmine. Measurements Hemodynamic parameters, onset and recovery times of sensory and motor blocks, and quality of anesthesia achieved with IVRA were recorded. After tourniquet deflation, visual analog pain scores (VAS) were noted every 30 minutes in the first two hours, as were the time to first analgesic request and total analgesic requirement in the 24-hour postoperative period. Main Results In the first 24 hours after surgery, the neostigmine group had significantly lower VAS scores, longer time to first analgesic request, and reduced total analgesic requirement. Intraoperatively, the neostigmine group had significantly shorter sensory and motor block onset times and longer recovery times than the control group. No significant frequency of adverse effects was seen in either group. The quality of intraoperative anesthesia and frequency of tourniquet pain were similar in both groups. Conclusions The addition of neostigmine to lidocaine shortens onset time and improves postoperative analgesia in IVRA for upper limb surgery.

Evaluation of two regional anesthetic methods on the front limb of dogs using hyperbaric bupivacaine

To evaluate the effects of bupivacaine 0.5 and 0.25% in intravenous regional anesthesia (IVRA) and brachial plexus block (BPB), respectively, on anesthesia, motor block and cardiovascular parameters in dogs. Fourteen healthy adult dogs averaging 10 kilograms (kg) of body weight. Animals were randomly assigned to receive one of the two treatments IVRA (n=7) or BPB (n=7). All the animals were sedated with acepromazine (0.1 mg/kg intramuscular). To execute the BPB was used an electrical nerve stimulation. Anesthesia, motor block, sedation, cardiovascular and respiratory effects were measured as effect of the treatment. BPA showed superior efficiency and duration of anesthesia (BPB - 456 +/- 94 minutes vs IVRA - 138 +/- 44) as well as motor block. There only physiologic parameter which change were the systolic pressure in BPB and respiratory rate for both treatments. In dogs the 0.25 % hyperbaric bupivacaine in BPB produces a front limb anesthesia about three times more than the 0.5 % in IVRA, with ptosis of the limb blocked and little interference in the cardiovascular system but with decrease in respiratory rate.

Why Do Bier Blocks Work for Hand Surgery … Most of the Time?

surgical procedures because it provides anesthesia for short procedures and a bloodless field under tourniquet control. It is a safe and cost-effective alternative to general anesthesia, with patients who undergo IVRA leaving the hospital one hour sooner and having less postoperative nausea than those undergoing general anesthesia. 2,3 The success of IVRA for hand surgery is contingent on careful patient selection, maintenance of a bloodless field, and tolerance of the tourniquet. We will discuss why Bier blocks work well for hand surgery, and review some of the recent literature on technical modifications to improve intraoperative hemostasis and tourniquet tolerance. TRADITIONAL METHOD OF IVRA Traditionally, IVRA is performed by first applying a single or double lumen tourniquet to the proximal arm. For surgery less than 20 minutes duration, a single lumen tourniquet is usually chosen, whereas for surgery up to 60 minutes, a double lumen tourniquet provides a more extended period before tourniquet pain occurs. A 20- or 22-gauge cannula is inserted preoperatively into a vein on the dorsum of the hand. The extremity is then elevated and exsanguinated using an Esmarch bandage. Incomplete exsanguination can reduce the quality of anesthesia and hemostasis within the surgical field. The proximal lumen of the tourniquet is then inflated. Local anesthetic (LA) is then injected slowly. A dose of 3 mg/kg 0.5% lidocaine is used frequently. Rapid infusion can exceed the tourniquet pressure and LA may enter the systemic circulation. Surgical-level anesthesia is commonly reached within 5 to 10 minutes. The tourniquet’s proximal lumen remains inflated until the patient becomes uncomfortable. The distal lumen, which is over an anesthetized area, is then inflated, followed by release of the proximal lumen. Gradual release of the distal lumen at the end of the procedure is recommended to prevent systemic LA toxicity for procedures lasting less than 20 minutes. 4

The Addition of Low-dose Mivacurium to Lidocaine for Intravenous Regional Anesthesia

ABSTRACTObjectives: The current study aimed to evaluate low dosage of mivacurium added to lidocaine for intravenous regional anesthesia [IVRA].Methods: The present study used a double-blind methodology. The study group comprised 60 patients with the American Society of Anesthesiologists physical status I and II, who were scheduled to undergo carpal tunnel release as an outpatient procedure. Patients were randomly divided into two groups. In the mivacurium group [Group M; N = 30], intravenous regional anesthesia was achieved using 6 mg of mivacurium with lidocaine 3 mg/kg diluted with saline to a total volume of 40 ml; in the control group [Group C; N = 30] 3 mg/kg lidocaine was diluted with saline to a total volume of 40 ml. The onset and recovery time of sensory and motor blocks, intraoperative–postoperative visual analog scale, and verbal rating scale, tourniquet pain, satisfaction score, analgesic requirement, hemodynamic variables, and side effects were noted.Results: Group M showed significantly shor...

Subcutaneous local anesthesia versus intravenous regional anesthesia for endoscopic carpal tunnel release: a randomized controlled trial

This study compares the effectiveness of subcutaneous infiltration of a local anesthetic agent (LA) versus intravenous regional anesthesia (IVRA) during endoscopic carpal tunnel release. Forty-four patients suffering from severe symptoms restricting normal daily activities-such as persistent loss of feeling in the fingers or hand, or no strength in the thumb in spite of prolonged nonsurgical treatment-and with electromyographically proven carpal tunnel syndrome were enrolled in this study. All underwent endoscopic carpal tunnel release. Twenty-two patients had an endoscopic release of the median nerve under LA (LA Group). The other 22 patients underwent the surgery after intravenous induction of regional anesthesia (IVRA Group). The operating room in-out time and tourniquet time were evaluated in both groups. The patients were also asked to evaluate the pain associated with the tourniquet during surgery using a visual analog scale. The Michigan Hand Outcomes Questionnaire was used to assess the functional outcome preoperatively and at both 2 weeks and 6 months postoperatively. One patient in the LA Group needed an additional application of prilocaine, whereas 3 patients in the IVRA Group needed additional LA and 1 of these required propofol. The tourniquet time and operating room time were significantly lower in the LA Group (p = 0.01 for both). There were no complications related to the endoscopic surgery. The Michigan Hand Outcomes Questionnaire did not show significant differences between the groups at either postoperative follow-up examination. Endoscopic carpal tunnel release with subcutaneous infiltration of LA was well tolerated and effective. Injection-associated problems such as increased thickness of the synovial layer or impaired endoscopic view did not occur.

Local adenosine receptor blockade accentuates the sympathetic responses to fatiguing exercise

The role adenosine plays in evoking the exercise pressor reflex in humans remains controversial. We hypothesized that localized forearm adenosine receptor blockade would attenuate muscle sympathetic nerve activity (MSNA) responses to fatiguing handgrip exercise in humans. Blood pressure (Finometer), heart rate, and MSNA from the peroneal nerve were assessed in 11 healthy young volunteers during fatiguing isometric handgrip, postexercise circulatory occlusion (PECO), and passive muscle stretch during PECO. 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, PECO, and passive stretch (all P < 0.05) were significantly greater than during the control condition. Saline Bier block had no similar effects on the MSNA and blood pressure responses. These data suggest that adenosine receptor antagonism in the exercising muscles may accentuate sympathetic activation during fatiguing exercise.

P2X receptor blockade attenuates the sympathetic response to exercise in humans

Animal studies suggest that ATP may play a role in evoking the muscle reflex via stimulating P2X receptors on sensory neurons. No data about the role of P2X receptors in the muscle pressor reflex in humans has been reported. We hypothesized that P2X receptor blockade attenuates the exercise pressor response in humans. Blood pressure (Finometer), heart rate, and muscle sympathetic nerve activity (MSNA) from peroneal nerve were assessed during fatiguing isometric handgrip, post exercise muscle ischemia (PEMI), and passive muscle stretch during PEMI in 8 young healthy volunteers. The protocol was performed before and after local infusion of vitamin B6 (Pyridoxine Hydrochloride, a non‐specific blocker of P2 receptors) in saline via Bier block. In the second experiment, the same amount of saline was infused via the Bier block. After Vitamin B6, the MSNA responses to fatiguing handgrip (Δ342±78 vs. Δ548±102), PEMI (Δ280±43 vs. Δ451±85) and passive stretch (Δ338±62 vs. Δ559±107 units/min, all P&lt;0.05) were significantly less than those before B6. The blood pressure responses were also significantly (all P&lt;0.05) less than those before B6. Saline Bier block had no similar effects on the MSNA and blood pressure responses. These data verified our hypothesis that P2X receptor blockade attenuates the exercise pressor response in humans. Supported by AHA 0635245 N, NIH P01 HL077670, and M01 RR010732.

A Model of Intravenous Regional Anesthesia in Rats

We developed an IV regional anesthesia (IVRA) model using the tails of rats to allow preclinical evaluation of the safety and efficacy of drugs used in IVRA and analgesia. Three sequential experiments were designed to determine local anesthetic and analgesic effects of drugs injected IV in the tail. The anesthesia was assessed by monitoring the response of the tail-clamp (RTC) test on the tail, whereas the analgesia was assessed by recording the latency in the tail-flick test on the tail. In the first 2 experiments, we studied the effects of different environmental temperatures (15 degrees C, 25 degrees C, and 37 degrees C) and length of tourniquet time on the tail-flick and tail-clamp tests, respectively. Based on the outcomes of these 2 experiments, the pharmacological effects of 1% lidocaine (L group) and 0.5% bupivacaine (B group) were compared with normal saline (NS group) to evaluate this model in experiment 3. In experiment 1, compared with its baseline, tail-flick latency increased rapidly in the 15 degrees C group (P < 0.0001), whereas there were no changes in tail-flick latency in the 25 degrees C group (P = 0.3640) and the 37 degrees C group (P = 0.0641) after the first 20 minutes of tail submersion in a water bath. RTCs in all rats were positive during the entire observation period. In experiment 2, tail-flick latency did not change compared with baseline tail-flick latency after the first 20 minutes of tourniquet application (P = 0.0902), but significantly increased at the 30-, 40-, 50-, and 60-minute intervals (P = 0.0001). RTCs in all rats were positive during the experiment. In experiment 3, local anesthesia was generated in the tail (distal to the tourniquet) in the L and B groups with a similar onset time of anesthesia (approximately 1 minute), but with a longer recovery time of anesthesia and analgesia in the B group (56.0 +/- 22.0 minutes) than the L group (31.0 +/- 19.0 minutes), whereas no anesthetic and analgesic effects were observed in the NS group. A reliable model for studying IVRA and analgesia has been developed in rats.

Intra-arterial regional anaesthesia (iara) - a peripheral experience

Intravenous regional anaesthesia is a simple, safe technique of anaesthesia of extremities for short procedures . The major fear with the use of the technique is local anaesthetic toxicity associated with high volumes of local anaesthetic used. Hence we decided to use reduced volume of local anaesthetic in the peripheral artery to produce satisfactory anaesthesia. A total of twelve patients scheduled to undergo short procedures of upper limb were taken for this study. After exsanguination and tourniquet application on the arm 1.5mg/kg of preservative free lignocaine as 0.5% solution was injected into the cannulated radial artery. The onset of analgesia was 89.92 ± 17.54 seconds. The anaesthesia was satisfactory in all cases except in two patients where there was a minimal discomfort with bony manipulation, which settled with 20 mg of iv pentazocine. The mean duration of surgery was 34.54±4.5 minutes. The mean volume of lignocaine used was only 15.58± 0.95 ml. No significant side effects were noted. We conclude that intra-arterial regional anaesthesia is a useful procedure in patients where there is a fear about local anaesthetic toxicity and the problem of difficult venous access. Key words: Intra-arterial regional anaesthesia, lignocaine DOI: 10.4038/slja.v18i1.1556 Sri Lankan Journal of Anaesthesiology 18(1): 20-22 (2010)

Does the use of ketamine or nitroglycerin as an adjuvant to lidocaine improve the quality of intravenous regional anesthesia?

Aims:To compare and evaluate the effect of adding ketamine or nitroglycerin (NTG) as adjuncts to lidocaine for intravenous regional anesthesia (IVRA) on intraoperative and postoperative analgesia, sensorial and motor block onset times, and tourniquet pain.Settings and Design:A prospective, randomized, double-blind study was carried out.Materials and Methods:Seventy-five patients undergoing hand surgery were divided into three groups as follows: control group receiving lidocaine 2%, LK group receiving lidocaine 2% with ketamine, and LN group administered lidocaine 2% with NTG. Sensory and motor blocks' onset and recovery times were recorded. Visual analog scale (VAS) for tourniquet pain was measured after tourniquet application and it was also used to measure postoperative pain. Analgesic consumption for tourniquet pain and postoperatively were recorded.Results:Sensory block onset times were shorter in the LK (4.4 ± 1.2 minutes) and LN (3.5 ± 0.9 minutes) groups compared with the control group (6.5 ± 1.1 minute) (P < 0.0001) and motor block onset times were shorter in the LK (7.3 ± 1.6 minutes) and LN (3.6 ± 1.2 minutes) groups compared with the control group (10.2 ± 1.5 minutes) (P< 0.0001). Sensory recovery time prolonged in the LK (6.7 ± 1.3 minutes) and LN (6.9 ± 1.1 minutes) groups compared with the control group (5.3 ± 1.4 minutes) (P = 0.0006 and < 0.0001, respectively). Motor recovery time prolonged in the LK (8.4 ± 1.4 minutes) and LN (7.9 ± 1.1 minutes) groups compared with the control group (7.1 ± 1.3 minutes) (P = 0.0014 and 0.023, respectively). The sensory and motor block onset times were also shorter in LN group than in the LK group (3.5 ± 0.9 versus 4.4 ± 1.2 minutes, P=0.004; and 3.6 ± 1.2 versus 7.3 ± 1.6 minutes, P < 0.0001, respectively). The amount of fentanyl required for tourniquet pain was less in adjuvant groups when compared with control group. It was 13.6 ± 27.9 and 27.6 ± 34.9 µg in LK group and LN groups, respectively, versus 54.8 ± 28 µg in the control group. VAS scores of tourniquet pain were higher at 10, 20, 30, 40 minutes in the control group compared with the other study groups (P < 0.0001). It was also higher in LN group compared with LK group at 30 and 40 minutes (P < 0.001). Postoperative VAS scores were higher for the first 4 h in control group compared with the other study groups (P< 0.0001).Conclusions:The adjuvant drugs (ketamine or NTG) 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 in comparison to the control group. Ketamine as an adjuvant produced better tolerance to tourniquet than the other groups. NTG as an adjuvant produced faster onset of sensory and motor blockades in comparison to other groups.

Comparison of the effects of acetaminophen to ketorolac when added to lidocaine for intravenous regional anesthesia

BackgroundThis study was done to evaluate the effect on pain relief when acetaminophen was added to lidocaine for intravenous regional anesthesia (IVRA).MethodsSixty patients undergoing hand or forearm surgery received IVRA were assigned to three groups: Group C received 0.5% lidocaine diluted with 0.9% normal saline to a total volume of 40 ml (n = 20), Group P received 0.5% lidocaine diluted with intravenous acetaminophen 300 mg to a total volume of 40 ml (n = 20) and Group K received 0.5% lidocaine diluted with 0.9% normal saline plus ketorolac 10 mg made up to a total volume of 40 ml (n = 20). Sensory block onset time, tourniquet pain onset time, which was defined as the time from tourniquet application to fentanyl administration for relieving tourniquet pain and amount of analgesic consumption during surgery were recorded. Following deflation of tourniquet sensory recovery time, postoperative pain and quantity of analgesic uses in post-anesthesia care unit were assessed.ResultsSensory block onset time was shorter in Group P compared to Group C (P < 0.05). Tourniquet pain onset time was delayed in Group P when compared with group C (P < 0.05). Postoperative pain and analgesic consumption were reduced in Group P and Group K compared to Group C (P < 0.001).ConclusionsThe addition of acetaminophen to lidocaine for IVRA shortens the onset time of sensory block and delays tourniquet pain onset time, but not with ketorolac. Both acetaminophen and ketorolac reduce postoperative pain and analgesic consumption.

Comparison Between Two Intraoperative Intravenous Loading Doses of Paracetamol on Pain After Minor Hand Surgery: Two Grams Versus One Gram

SummaryBackground: Paracetamol (acetaminophen) is widely used for postoperative analgesia at a recommended dose of 1 g every six hours in adult patients. Increasing the loading dose to 2 g was suggested to improve immediate postoperative analgesia without increased toxicity in healthy adult patients. We tested the hypothesis that a loading dose of 2 g of intravenous paracetamol results in better postoperative analgesia after surgery as compared with a dose of 1 g. Methods: Sixty adult patients scheduled for minor hand surgery under intravenous regional anaesthesia were randomized into two groups. The first group received 1 g of intravenous paracetamol before surgery while the second group received 2 g. Verbal numeric pain score, analgesic consumption, first night sleep quality, and patient’s satisfaction were recorded during the first 24 hours.Results: Verbal numeric pain scores during the first 24 hours after surgery were significantly lower in the 2 g paracetamol group as compared to the 1 g paracetamol group. No differences were found between the two groups with regard to rescue analgesic consumption, sleep quality and patient’s satisfaction.Conclusions: An intraoperative loading dose of 2 g paracetamol improves postoperative analgesia after minor hand surgery as compared to 1 g paracetamol.

Personalized intravenous regional anesthesia

Personalized intravenous regional anesthesia

Management of Local Anesthetic Toxicity

Local anesthetic systemic toxicity (LAST) is a rare but potentially fatal complication of regional anesthesia. The danger of toxic blood concentrations of local anesthetic (LA) has been recognized and reported since the late 1800s after the purification of cocaine, the first LA. Although the practice of regional anesthesia has evolved since the late 1800s, LAST remains a major concern. This fact was highlighted by an alarming editorial by Albright in 1979, accompanying reports of LAST. This study and similar publications prompted the Food and Drug Administration to address administration of LAs by clinicians. The use of bupivacaine for intravenous regional anesthesia was prohibited and bupivacaine 0.75 was precluded from being used in obstetric epidurals. Over the past 25 years, the overall incidence of LAST has decreased dramatically. The decline in LAST is more significant with epidural anesthesia. In 1981, the incidence of LAST was 100/10,000 epidurals. Brown et al in 1995 retrospectively reviewed the Mayo Clinic experience and found an incidence of LAST of 0.1/1000 epidurals and 2.0/1000 brachial plexus blocks. Auroy et al in 1997 prospectively reported an incidence of LAST of 0.13/1000 epidurals and 0.75/1000 peripheral nerve blocks (PNBs). This trend led to a decreased LAST incidence that was confirmed in 2002 by the same team who reported 7 cases of LAST, 1 associated with an epidural, and 6 with PNBs, in 153,083 regional anesthesia procedures recorded. An incidence of 0.98/

Causation and complications

hese are the facts that the authors presented: 1. The patient developed his infection eight weeks after his injections. 2. Despite having an infection that required drainage, the patient had normal range of motion in his metacarpophalangeal joints. 3. The patient refused to be admitted to hospital for “surgical drainage under general anesthesia”, hence, “less thorough surgical debridement under Bier’s block, in the emergency room, was performed.” 4. The extensor tendons were found to be intact at that time. 5. Two days later the patient was revaluated and claimed a one-day history of loss of full extension. On examination his active metacarpophalangeal joint motion was only -30˚ / 90˚.6. Additional surgery was performed that confirmed the rupture of the extensors to the index, long, and ring digits. 7. One week later tendon grafting was performed. 8. One year later the patient’s metacarpophalangeal joint motion was -25˚ / 90˚.The authors claim that this is a “case of rapidly progressive suppurative extensor tenosynovitis, with tendon rupture, following improper administration of local steroids”. By the authors’ own admission, the infection occurred eight weeks after the steroid injections. Eight weeks is a rather long time from alleged bacterial inoculation to clinical infection. Furthermore, when the patient was first examined by the authors he had no tendon ruptures and had normal extension. Using a Bier block for anesthesia, they operated under substandard conditions. The patient lost extension within a day. One week later they attempted to reconstruct his extensors, but the final measurements of digital motion were practically the same as immediately after the rupture. Is the authors’ claim valid? Were the tendon ruptures caused by “improper administration of local steroids” or were they caused by something else? More importantly, is there any sound scientific evidence that the steroid injections resulted in the patient’s final result? Stating that a treatment is ‘improper’ implies that the authors are giving a legal opinion that a malpractice has occurred. Hence, it is worthwhile to consider legal approaches to the causation. The concept of ‘proximate cause’ is used in the United States and is similar to causation under English Law.

Intravenous Regional Anaesthesia With Lignocaine, Fentanyl And Pancuronium – Prospective Randomised Controlled Double Blind Study.

Intravenous Regional Anaesthesia (IVRA) is a simple and effective technique for upper limb distal surgery. However, a relatively large dose of LA is required to induce motor and sensory blockade. Lignocaine 3mg/kg as a 0.5% solution is needed to ensure adequate analgesia. Systemic toxic reactions (convulsions, coma, cardiac arrest) can occur when the tourniquet deflates unexpectedly during the procedure or when it deflated intentionally at the end of short surgery.Therefore we conducted this prospective randomized double blind study to compare and evaluate the effects of addition of fentanyl and pancuronium to reduced dose of LA against the standard practice of 0.5% lignocaine.In this study, 75 patients of both sexes in the age group more than 18 years belonging to ASA 1 and 2 undergoing both elective and emergency surgeries of the forearm and hand were divided randomly into group L, group P and group F with 25 patients in each group.In patients belonging to group L, 40 cc of 3mg/kg of 0.5% lignocaine diluted in normal saline was used for administering IVRA, and in patients of group F 40 cc of 1.5mg/kg of 0.25% lignocaine combined with fentanyl 1mg/kg , and in patients of group P 1.5mg/kg of 0.25% lignocaine combined with fentanyl 1mg/kg and pancuronium 0.5mg was used.The time for onset of sensory blockade in group L was 11.76.± 3.08 minutes , group F was 12.96±3.06 minutes , and group P was 10.20±3.52 minutes which was clinically comparable in all the groups. However the time for onset of motor blockade was significantly delayed in group F (21.1±2.7 minutes) as compared to other two groups: group L (12.5±2.6minutes and group P (11.36±3.5 minutes). The patients in group P were showing significantly excellent muscle relaxation and excellent intraoperative analgesia as compared to other two groups. Post operative analgesia in group P (56.4±2.6minutes ) was significantly longer as compared to group F (46.8 ±4.9 minutes) and group L (39 ± 8 minutes). Our results showed that hemodynamic parameters like pulse rate, blood pressure, respiratory rate were well maintained throughout the intra and post operative period in all the patients of all the groups. There were no major untoward side effects were noticed.Thus from the present study, we conclude that the addition of fentanyl 1mg/kg and pancuronium 0.5mg to 0.25% of lignocaine enhances lignocaine action and results in-Adequate sensory and motor block.Excellent intraoperative analgesia.-Excellent intraoperative muscle relaxation. Thus, using this combination the dose of lignocaine for IVRA can be reduced to a non toxic level for the same quality of analgesia and at the same time not offer any post analgesic benefit as all study patients were required supplement of analgesics post operatively after about 50-60 minutes.. INTRODUCTION Intravenous regional anesthesia was first described by August Gustav Bier in 1908. This technique is a simple, easy to administer, effective and reliable method for anesthesia. It involves intravenous injection of local anesthetics into the limb on which surgery is to be performed after the limb is exsanguinated and a tourniquet has been applied proximally. It is the surest way of obtaining a block with a very minimal failure rate, and has gained immense popularity more so for upper limb surgeries. Besides it is extremely useful for emergency surgeries. Being a regional technique it avoids all the complication of general anesthesia, more so in patients coming for emergency surgery as well as patients belonging to ASA class 3 and 4. However the dose of local anesthetic agent required to induce motor and sensory blockade has the potential to cause systemic local anesthetic toxicity. Therefore various methods have been tried to reduce the dose of Local anesthetic used in Intravenous regional anesthesia ,such as alkalization of the local anaesthetic solution, addition of an opioid, muscle relaxant , non steroidal anti-inflammatory drugs, potassium, and Ketamine 9 with various results. We conducted this prospective randomized double blind Intravenous Regional Anaesthesia With Lignocaine, Fentanyl And Pancuronium – Prospective Randomised Controlled Double Blind Study. 2 of 9 study to know the effect of combining fentanyl 1/kg alone and fentanyl1g/kg plus pancuronium 0.5mg with reduced dose of lignocaine( 0.25%) for Intravenous regional anesthesia. AIMS & OBJECTIVES To study the effect of IVRA with lignocaine 0.5% with lignocaine 0.25% plus fentanyl 1/kg and lignocaine 0.25% plus fentanyl1g/kg plus pancuronium 0.5mg with respect to : Time of onset of sensory block. Time of onset of motor block The degree of muscle relaxation Intraoperative analgesia.

Adverse events associated with intravenous regional anesthesia (Bier block): a systematic review of complications

Study Objective To characterize the complications reported with intravenous regional anesthesia (IVRA). Design Literature search. Setting University-affiliated hospital. Measurements A search was done in the American National Library of Medicine's PUBMED, EMBASE (1980-2007, wk 11), and Medline (from 1950) in March 2007. All complications associated with IVRA were reviewed. Main Results The lowest dose of local anesthetic associated with a seizure was 1.4 mg/kg for lidocaine; 4 mg/kg for prilocaine, and 1.3 mg/kg for bupivacaine. Cardiac arrests and deaths were reported with lidocaine and bupivacaine only. The lowest dose associated with a cardiac arrest was 2.5 mg/kg for lidocaine and 1.6 mg/kg for bupivacaine. Local anesthetic toxicity occurring during tourniquet inflation has been reported, with tourniquet pressure exceeding initial systolic arterial blood pressure by 150 mmHg. Seizures occurring after tourniquet deflation have been reported with a tourniquet time as long as 60 minutes. Ten cases of compartment syndrome are reported. Conclusion Seizures have been reported with lidocaine at its lowest effective dose (1.5 mg/kg).

Ondansetron added to lidocaine for intravenous regional anaesthesia

The aim of this study was to evaluate the effect of ondansetron when added to lidocaine for intravenous regional anaesthesia (IVRA). Thirty patients undergoing hand surgery were randomly assigned to two groups. IVRA was achieved with 3 mg kg lidocaine 2% w/v diluted with saline to a total volume of 40 ml in the control group or with 4 mg ondansetron 2 mg ml plus 3 mg kg lidocaine 2% w/v diluted with saline to a total volume of 40 ml in the ondansetron group. Sensory and motor block onset and recovery times, tourniquet pain score according to a visual analogue scale (VAS), intraoperative analgesic requirements and anaesthesia quality were recorded. Postoperative VAS pain score, time to first analgesic requirements and total diclofenac consumption in the first 24 h were noted. Onset times were slightly but significantly shorter [1.4 min (95% confidence interval (CI) 0.5-2.3) and 1.5 min (95% CI 0.45-2.55)] and recovery times were slightly but significantly prolonged [2.6 min (95% CI 1.66-3.54) and 2.8 min (95% CI 1.83-3.78)] in patients receiving ondansetron. Tourniquet pain scores according to the VAS were slightly but significantly lower at 10, 15, 20 and 30 min, the time to intraoperative analgesic rescue was prolonged (35.0 +/- 7.1 min vs. 18.9 +/- 8.9 min, P = 0.043), a significantly lower number of patients (2 vs. 9) required additional analgesic and significantly less supplemental fentanyl was given [0 microg (0-0) vs. 59 microg (0-76), P = 0.015] in the ondansetron group. First intake of analgesic intake was longer (172 +/- 51 vs. 85 +/- 35 min, P = 0.0001), number of patients (7 vs. 15) requiring postoperative diclofenac was significantly lower and diclofenac requirements [0 mg (0-75) vs. 75 mg (75-150), P = 0.002) was significantly lower in the ondansetron group. Postoperative VAS scores were lower for the first 4 h in the ondansetron group. Addition of ondansetron to lidocaine may improve the quality of IVRA and prolong postoperative analgesia in patients undergoing hand surgery.

Bier's block and regional anaesthesia techniques in hand surgery

Bier's block and regional anaesthesia techniques in hand surgery

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

In this study, we evaluated the effect of paracetamol on sensory and motor block onset time, tourniquet pain, and postoperative analgesia, when added to lidocaine in IV regional anesthesia (IVRA). Sixty patients undergoing hand surgery were randomly and blindly divided into three groups. All groups received IVRA lidocaine (3 mg/kg) diluted with saline to a total volume of 40 mL. Group 1 received IVRA lidocaine plus IV saline, Group 2 received IVRA lidocaine and paracetamol (300 mg) admixture plus IV saline, and Group 3 received IVRA lidocaine plus IV paracetamol (300 mg). Sensory and motor block onset time, tourniquet pain, and analgesic use were assessed during operation. After tourniquet deflation, visual analog scale (VAS) scores at 1, 2, 4, 6, 12, and 24 h, the time to first analgesic requirement, total analgesic consumption in first 24 h, and side effects were noted. Onset of motor block was shorter and recovery of motor and sensory block was significantly longer in Group 2 (P < 0.05). Intraoperative VAS scores at intraoperative 20, 30, and 40 min were significantly lower in Group 2 (P < 0.05). Intraoperative fentanyl consumption (78 +/- 12, 58 +/- 14, 78 +/- 11 microg, respectively) and the number of patients who required fentanyl for tourniquet pain (13 patients, 3 patients, 9 patients, respectively) were significantly less in Group 2 (P < 0.05). Time to postoperative fentanyl administration was also prolonged (15 +/- 6, 25 +/- 5, 15 +/- 4 min, respectively) in Group 2 (P < 0.05). The quality of surgical anesthesia was better in Group 2 (P < 0.05). Postoperative VAS scores and time of initial analgesic requirement were similar among groups; however, the total amount of diclophenac use was less in Group 2 (P < 0.05). The addition of paracetamol during IVRA with lidocaine decreased tourniquet pain, increased anesthesia quality, and decreased postoperative analgesic consumption.