Intravenous Regional Block Research Articles

232 Long-term effect of intravenous regional block on skin temperature in complex regional pain syndrome

232 Long-term effect of intravenous regional block on skin temperature in complex regional pain syndrome

Quality Assurance for Interventional Pain Management Procedures

Over the last decade various guidelines for quality assurance in pain medicine have been published for cancer pain, acute postoperative pain and other pain conditions. However, quality assurance for interventional pain management procedures has yet to be addressed. An interventional pain program should at least evaluate 1) efficacy of pain relief; 2) complication rate; and 3) patient satisfaction. This study was designed to monitor the quality of interventional pain management procedures in a university teaching hospital. A prospective survey. From January 1, 2004, to June 30, 2004, the quality of interventional pain management procedures in a university teaching hospital in Miami, Florida was monitored. Questionnaires assessing immediate pain relief, patient satisfaction, and complications were provided to each patient and physician immediately after completion of each procedure. Data was collected before patients were discharged. A total of 566 patients with a mean age of 52.9 years participated in the survey. Interventional pain management procedures included epidural steroid injections, facet joint blocks, transforaminal epidural injections, sympathetic nerve blocks, lumbar discography, nucleoplasty, percutaneous disc decompression, spinal cord stimulator trial, and intravenous regional blocks, etc. Among 528 patients who reported their pain scores before and after procedures, 487 (92%) patients reported various degrees of pain relief immediately following their procedures. The average pain score decreased 4.7 on a o to 10 scale after treatment (p < 0.001). No major complications were reported for this group of patients. Among 442 patients who answered the question regarding satisfaction, 406 (91.8%) were satisfied, or highly satisfied, with the immediate outcome of their procedures. The results of the current study indicate that quality assurance of interventional pain management procedures in terms of immediate pain relief following the procedure, low complication rate, and high patient satisfaction can be achieved through application of a quality assurance program.

Intravenous Regional Block With Lidocaine for Treatment of Complex Regional Pain Syndrome

The goal of this article is to report the successful treatment of a patient with complex regional pain syndrome (CRPS) type 1 involving the hand with the use of an intravenous regional block. The patient was a 35-year-old woman who developed CRPS during conservative therapy for a metacarpal fracture. An intravenous regional block with lidocaine alone, using a two-tourniquet technique, was delivered 10 times for at least 40 minutes. The first five treatments were given twice a week and the next five were delivered weekly. All affected joints, including the wrist, were manipulated without undue force. Functional physical measurements were assessed, including range of motion and performance of fine and gross motor tasks. The visual analog scale scores for pain declined from 10 to 0 after treatment. Use of a pen, a pair of chopsticks, and a hammer improved, and edema decreased. Intravenous regional block with lidocaine was well tolerated and associated with relief in this case of CRPS type 1.

Sedation and Analgesia for Pediatric Fracture Reduction in the Emergency Department

To assess the safety and efficacy of various forms of analgesia and sedation for fracture reduction in pediatric patients in the emergency department, as observed in randomized controlled trials in pediatric populations. Cochrane Controlled Trials Register, CINAHL (Cumulative Index to Nursing & Allied Health Literature), and MEDLINE. The search terms "fractures," "manipulation, orthopedic," "an(a)esthetics," "analgesics," and "hypnotics and sedatives" were used. Studies were included if they were randomized controlled trials studying sedative and/or analgesic regimens for fracture reductions in pediatric patients in the emergency department. The search yielded 915 references. From these, 8 studies including 1086 patients were selected. Interventions studied included intravenous regional blocks (Bier blocks), nitrous oxide, and parenteral combinations. Data on measures of effectiveness and safety were extracted. Ketamine hydrochloride-midazolam hydrochloride was associated with less distress during reduction than fentanyl citrate-midazolam or propofol-fentanyl. Patients receiving ketamine-midazolam required significantly fewer airway interventions than those in whom either fentanyl-midazolam or propofol-fentanyl were used. Data comparing Bier blocks with systemic forms of sedation or analgesia were limited. Ketamine-midazolam seems to be more effective and have fewer adverse events than fentanyl-midazolam or propofol-fentanyl. Data on other forms of analgesia or sedation are too limited to make comparisons. More research is needed to define the regimen that maximizes safety, efficacy, and efficiency for fracture reduction in pediatric patients.

A case of recurrent and migratory complex regional pain syndrome type I: prevention by gabapentin

Complex regional pain syndrome type I (CRPS I) or reflex sympathetic dystrophy (RSD) is a painful and disabling neuropathic pain syndrome. We report a case of a patient who has experienced CRPS I four times with an unidentified cause for all recurrences. The patient responded well to a combination of physiotherapy and intravenous regional sympathetic block in the first two attacks, but not in the fourth one. Gabapentin was effective in the last two attacks. Gabapentin was gradually discontinued 12 months after the last attack and no other recurrence was observed for a follow-up period of 9 months. This case suggests that gabapentin might be considered in the treatment and prevention of CRPS I.

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.

Effects of intravenous regional block with a combination of clonidine, dexamethasone and lidocaine for complex regional pain syndrome type I

Effects of intravenous regional block with a combination of clonidine, dexamethasone and lidocaine for complex regional pain syndrome type I

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.

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.

Intravenous regional sympathetic block: past, present and future?

Intravenous regional sympathetic block is a valued component of the pain clinician's armamentarium for the management of the complex regional pain syndrome type 1. Treatment of this multifaceted condition is multimodal, and despite a lack of convincing supporting evidence from clinical trials, the author makes the case for retaining the technique while recommending both appropriate guidance and further study.

Clinical management of the child with chronic pain

Clinical management of the child with chronic pain

Intravenous regional blocks with guanethidine and prilocaine combined with physiotherapy: two children with complex regional pain syndrome, Type 1

Intravenous regional blocks with guanethidine and prilocaine combined with physiotherapy: two children with complex regional pain syndrome, Type 1

The Effect of Intravenous Regional Block with Ropivacaine, Ketamine and Clonidine on Complex Reginal Pain Syndrome Type I: A case report

There is no treatment either to prevent the development of complex regional pain syndromes (CRPS), or to adequately and specifically control established pain. Symptom-based analysis of pain is important for disease progress assessments and treatment outcomes. An intravenous regional block (IVRB) with local anesthetics can contribute to the management of CRPS. We observed that by the IVRB using ropivacaine, ketamine and clonidine, the patient with CRPS type I who was resistant to sympathetic ganglion block and medical treatment with gabapentin, carbamazepine and antidepressant, was relieved of neuropathic pain.

Neuralgic Amyotrophy: A case report

Neuralgic amyotrophy is an uncommon disorder characterized by acute onset of severe shoulder and upper arm pain followed by marked upper arm weakness. It is easily confused with other neck and upper extremity abnormalities, such as cervical spondylosis and cervical radiculopathy. The diagnosis is based on histroy, clinical findings, electromyography and excluding other disease. Early diagnosis and adequate treatment is important to avoid unnecessary tests and surgery, and prevent complications, especially adhesive capsulitis of the shoulder. 20-year old female patient presented with a history of severe pain involing left shoulder and upper extremity. 1 month after onset of pain suddenly, she noted weakness of left shouler muscles, especially abduction and flexion. At first visit in our clinic, she felt persistant pain for 4 months in the left shoulder, upper extremity and mild pain in the left lower extremity. She diagnosed with neuralgic amyotrophy with complex regional pain syndrome. Her pain managed with epidural block, sympathetic ganglion block, brachial plexus block, stellate ganglion block, intravenous regional block, intravenous local anesthetic infusion, oral analgesics, and exercise therapy. 5 months after the onset of pain, weakness of her shoulder muscles were fully recovered and 9 weaks after caring in our clinic, she had tolerable pain in her extremities and discharged.

The role of radiofrequency in the management of complex regional pain syndrome.

The nomenclature, pathophysiology, and treatment modalities of complex regional pain syndrome (CRPS) are controversial. Thus far there are no specific, scientifically valid treatments for the management of CRPS. The numerous modalities of treatment range from sympathetic ganglion blocks, intravenous regional blocks, administration of a multitude of pharmacologic agents and behavioral interventions, to surgical sympathectomy. Minimally invasive radiofrequency lesioning for managing CRPS is a modality in its developmental stages. This article describes radiofrequency lesioning techniques in managing CRPS.

Treatment of pain in trauma patients with injuries of the upper limb

Since preoperative pain therapy of a trauma patient did not play an outstanding role in the past, this article shall give information about the adequate treatment of such patients, which can be mainly divided into three phases: the prehospitalisation phase with stabilisation of the trauma patient, the early phase of hospitalisation with further stabilisation, diagnosis and surgery, and finally the postoperative phase with corresponding treatment. An optimal analgesic in the prehospitalisation phase should guarantee good analgesic effects, rapid onset and good controllability, simple handling and the opportunity to combine it with other medication. In addition, it should prevent a wide therapeutic range and the absence of side effects. Opioids and ketamine are available for acute pain therapy after trauma. The main opioids used are piritramide and pethidine, with piritramide acting as a sedative at the same time and with pethidine preventing the stronger analgesic effect. The intravenous use of ketamine has become established in trauma patients because of its excellent analgesia at subanaesthetic doses. Especially in multiple trauma patients, the indication for general anaesthesia with intubation should be established on a liberal basis. Nevertheless, for some patterns of injury regional techniques may be advantageous; therefore, this article describes the possible regional procedures (such as intravenous regional anaesthesia or block of peripheral nerves). Concerning the postoperative phase, an individual pain management can be guaranteed by systemic pharmacotherapy and regional catheter techniques, for example the brachial plexus blockade that results in a long period of free pain.

Quantitative sensory changes in humans after intravenous regional block with mepivacaine

Background and Objectives. In previous studies we have demonstrated that after intravenous regional block (IVRA) with dilute mepivacaine, there is a decrease in neurogenic inflammation as well as in post-ischemic hyperemia and steady-state flow, the latter for at least 60 minutes. It is unclear whether these vascular reactions reflect a uniform depression of nerve function in the treated arms. Because the various afferents convey impulses from different types of sensory receptors, we used quantitative sensory testing (QST) to define these effects of IVRA with mepivacaine. Methods. In 16 volunteers, bilateral blocks were performed by simultaneously injecting mepivacaine in one arm and normal saline in the other in a randomized, double-blind manner. Both arms were kept ischemic for 20 minutes, and the pain was rated on a visual analogue scale. Skin temperature and perception threshold values regarding touch (Aβ-fibers), warmth (C-fibers) and cold (Aδ-fibers), and heat pain (C-fibers) were determined before and repeatedly after the blocks. Results. Ischemic pain did not differ between the arms. After reflow, the thresholds for touch, warmth, and heat pain were unchanged. In the mepivacaine-treated arm, the sensibility to cold was significantly decreased 10 and 30 minutes after the block, though there was a slight decrease in skin temperature. Conclusions. There was no uniform depression of nerve function after IVRA. The cold receptors and/or their Aδ-fibers were selectively depressed after the block. In conjunction with earlier findings, this suggests that IVRA with mepivacaine can differentially decrease neurogenic inflammation, with little impairment of sensory function.

Quantitative Sensory Changes in Humans After Intravenous Regional Block With Mepivacaine

Quantitative Sensory Changes in Humans After Intravenous Regional Block With Mepivacaine

Anesthesia and analgesia for the ambulatory management of fractures in children.

The goal of anesthesia in the ambulatory management of fractures in children is to provide analgesia and relieve anxiety in order to facilitate successful closed treatment of the skeletal injury. Numerous techniques short of general anesthesia are available. These methods include blocks (local, regional, and intravenous), sedation (conscious and deep), and dissociative anesthesia (ketamine sedation). Important factors in choosing a particular technique include ease of administration, efficacy, safety, cost, and patient and parent acceptance. Local and regional techniques, such as hematoma, axillary, and intravenous regional blocks, are particularly effective for upper-extremity fractures. Sedation with inhalation agents, such as nitrous oxide, and parenterally administered narcotic-benzodiazepine combinations, are not region-specific and are suitable for patients over a wide range of ages. Ketamine sedation is an excellent choice for children less than 10 years old. With any technique, proper monitoring and adherence to safety guidelines are essential.

Differential effect on vasodilatation and pain after intradermal capsaicin in humans during decay of intravenous regional anesthesia with mepivacaine

Background and Objectives. When given intracutaneously, capsaicin can cause burning pain by central propagation in thin afferents, as well as neurogenic vasodilatation, reflecting antidromic conduction in the same fibers. We wanted to test the hypothesis that an intravenous regional block (IVRA) inhibits these two phenomena to a similar degree. Methods. Sixteen healthy volunteers participated. A bilateral IVRA was performed by simultaneously injecting mepivacaine in one arm and normal saline in the other in a randomized, double-blind manner. Ten minutes after release of the tourniquet, neurogenic inflammation was inflicted in each forearm by intracutaneous capsaicin. Microvascular skin blood flow was measured with a laser Doppler perfusion imager. The area of the flare and the flow therein were measured, taking into account the change in baseline caused by mepivacaine treatment and the postischemic hyperemia. Pain was repeatedly evaluated by visual analog scale. Results. The reactive hyperemia following arterial occlusion was less in the mepivacaine-treated arm 10 minutes after tourniquet release ( P = .026). Intracutaneous capsaicin elicited a flare in both arms. The area of the flare was smaller 10 minutes after capsaicin ( P = .009) in the mepivacaine-treated arm. There was no difference between the arms concerning the mean blood flow within the flare or in ischemic or capsaicin-induced pain. Conclusions. Mepivacaine, given as an IVRA, had no effect on the post-IVRA sensory function of thin afferents but differentially decreased the spread of the capsaicin-induced flare.