Tourniquet Tolerance Research Articles

Regional versus systemic dexmedetomidine as an adjuvant to lidocaine for intravenous regional anaesthesia in healthy volunteers: a randomized crossover study

Background Dexmedetomidine enhances the quality and duration of lidocaine intravenous regional anaesthesia (IVRA). However, the two administration routes have not been directly compared regarding effects on tourniquet tolerance time with lidocaine IVRA. Additionally, it remains unclear whether the prolonged tourniquet tolerance stems from the direct peripheral action of dexmedetomidine or indirect systemic analgesic effects. Methods We conducted forearm IVRA in 12 healthy volunteers using a crossover design on two separate study days. One day, the systemic dexmedetomidine group received an intravenous infusion of 0.5 μg/kg dexmedetomidine (20 mL) in one arm, followed by 0.5% lidocaine (25 mL) forearm IVRA in the contralateral arm. On the other day, the regional dexmedetomidine group received an intravenous 0.9% saline infusion (20 mL) in one arm, followed by combined 0.5% lidocaine (25 mL) and 0.5 μg/kg dexmedetomidine forearm IVRA in the opposite arm. After a two-week washout period, participants crossed over to receive the alternate treatment. The primary outcome was tourniquet tolerance time, from initiating IVRA until the patient-reported tourniquet pain numerical rating scale exceeded three. Results The tourniquet tolerance time was longer with regional versus systemic dexmedetomidine (36.9 ± 7.6 min vs 23.3 ± 6.2 min, respectively), with a 13.6 min mean difference (95% CI: 10.8 to 16.4 min, p < 0.001). Regional dexmedetomidine also hastened sensory onset and extended sensory recovery compared to systemic administration. Delayed sedation after tourniquet release occurred in 5 of 12 subjects receiving regional dexmedetomidine. Conclusion The addition of regional dexmedetomidine to lidocaine prolonged tourniquet tolerance time in forearm IVRA to a greater extent compared to systemic dexmedetomidine in healthy volunteers. Trial registration Chinese Clinical Trial Registry, ChiCTR2300067978.

Wide Awake Local Anesthesia No Tourniquet (WALANT) technique improves the efficiency of distal nerve blocks for carpal tunnel release

BackgroundAxillary block is the standard for carpal tunnel release (CTR), providing effective anesthesia, and tolerance of tourniquet. Conversely, distal blocks are less used due to poor tolerance of tourniquet. Wide Awake Local Anesthesia No Tourniquet (WALANT), proposed for hand and wrist surgeries, avoids its use. This study assesses the benefits of the addition of WALANT to distal blocks during endoscopic CTR (eCTR). MethodsThis randomized, open-label, controlled trial prospectively enrolled 60 patients scheduled for eCTR. Patients were randomized to receive distal blocks at the wrist combined to either a high arm tourniquet (Distal block group) or a WALANT in the area of surgery (Distal + Walant group). The primary endpoint was the global pain score summing pain scores related to puncture, local anesthetic injection, pneumatic tourniquet, surgical procedure, tourniquet deflation, and residual sensitivity after surgery. ResultsMean global pain score was significantly reduced in the Distal + Walant group (0.5 ± 1.4 vs. 2.2 ± 2.4; p < 0.001). No need for an additional anesthetic procedure was required in the Distal + Walant group. Even if the quality of visualization was high in both groups, it was better in the Distal block group (5 [5–5] vs. 4 [4–5]; p < 0.001). No rescue tourniquet was necessary for the Distal + Walant group. The rate of hematoma 15 days post-surgery was significantly reduced in the Distal + Walant group (20% vs. 57%; p < 0.01). ConclusionsThe addition of WALANT to distal blocks is adapted for eCTR. This combined technique decreases perioperative pain scores, provides good surgery conditions, and reduces the risk of postoperative hematoma. Clinical trial number and registry URLThe trial was registered on ClinicalTrials.gov (NCT04494100) on July 31, 2020 https://clinicaltrials.gov/ct2/show/NCT04494100?term=CMC+ambroise+pare&cntry=FR&draw=4&rank=28.

Efficacy of femoral periarterial block in preventing thigh tourniquet pain: a randomized controlled trial.

Tourniquet pain, described as a dull, tight, poorly localized aching sensation, is common in conscious patients. Although various pain-reduction methods have been implemented, none are completely effective. Femoral periarterial block (FAB) has been shown to attenuate tourniquet-induced hypertension in patients undergoing general anesthesia. We aimed to test the feasibility of FAB in inhibiting thigh tourniquet pain in orthopedic patients under conscious sedation. Forty-two patients (aged 18-64 years and ASA I-II) scheduled for below-knee orthopedic surgeries with an anticipated tourniquet duration of more than 40 min were recruited and received FAB (Group 1) or not (Group 2). The primary outcome was the occurrence of tourniquet pain. The onset time and severity of the tourniquet pain were recorded. Total doses of sedatives and analgesics administered intraoperatively and hemodynamic changes were documented. The occurrence of local anesthetic systemic toxicity was recorded. Kaplan-Meier time-to-event curves indicated an improved tourniquet tolerance and delayed pain onset. Tourniquet pain occurrence was lower in Group 1 than in Group 2 (30% vs. 95.5%, P=0.02). Tourniquet pain onset was delayed in Group 1 (80[67,84] min vs. 58[51.5,60] min, P<0.01). Fewer patients in Group 1 experienced severe pain (3(15%) vs. 18(81.8%), P<0.01), and less hemodynamic changes (2(10%) vs. 12(54.5%), P<0.01). Local anesthetic systemic toxicity was absent. FAB, applied with regional anesthesia in patients undergoing below-knee orthopedic surgeries, could reduce thigh tourniquet pain, stabilize blood pressure and heart rate, and prolong tourniquet duration.

A prospective randomized, controlled, double blinded study to compare the analgesic efficacy of lidocaine (3 mg/ kg 0.5%) with dexmedetomidine (0.5 mcg / kg) and lidocaine (3mg/ kg 0.5%) with normal saline for intravenous regional anesthesia in patients posted for upper limb surgeries

Intravenous regional anaesthesia may be defined as reversible state of anaesthesia, produced by administration of local anesthetics into the venous system of upper and lower extremities. This technique is simple, effective, cheap and quite safe for operations on limbs especially in emergency situations. The present study involves the comparison of analgesic efficacy of Lidocaine with normal saline vs lidocaine with dexmedetomidine in intravenous regional anesthesia. A total of 120 patients belonging to both sexes of ASA – I or ASA – II and between the age groups of 18 to 50 yrs, admitted for various orthopaedic surgeries on forearm were included in the study. They are prospectively randomised in to two groups: Group L-Lidocaine 3mg/kg 0.5%+1 ml normal saline diluted with normal saline made to 40 ml and Group LD –Lidocaine 3mg/kg0.5%+Dexmedetomidine 0.5μg/kg (diluted to 1ml) diluted with normal saline made to 40 ml. Results analysed and discussed. The addition of 0.5 µg/kg dexmedetomidine to lidocaine for intra venous regional anaesthesia has significant analgesic effect. It shortens the onset of sensory and motor block onset, improved tourniquet tolerance and prolonged postoperative analgesia with stable cardiorespiratory parameters.

Comparison of the Combined Femoral and Lateral Femoral Cutaneous Nerve Block Plus Popliteal Block with Spinal Anesthesia for Thigh Tourniquet Pain During Foot or Ankle Surgery: A Randomized Clinical Trial.

BackgroundA pneumatic thigh tourniquet is routinely used during lower-extremity orthopedic surgeries to provide a bloodless field. When using peripheral nerve blocks, tourniquet-related thigh pain and discomfort limit their routine use as an anesthetic method.ObjectivesThe aim of the present prospective, randomized study was to compare the efficacy of combined femoral nerve/lateral femoral cutaneous nerve block technique and spinal anesthesia on intraoperative thigh tourniquet pain.MethodsWe studied 60 American Society of Anesthesiologists physical status I-II patients scheduled for orthopedic surgery on the foot or ankle using a pneumatic thigh tourniquet. They were randomly divided into two equal groups. The peripheral nerve block group received a combined popliteal, femoral, and lateral femoral cutaneous nerve block under ultrasound-guidance. In both groups, the level of sensory blockade was determined by the pinprick test. The block performance time, anesthetic effect time, intraoperative tourniquet pain scores, the amount of fentanyl and ketamine, surgery duration, and patient’s satisfaction were recorded.ResultsThe patients’ characteristics were comparable in the two groups. The mean duration of block performance and anesthetic effect, intraoperative tourniquet pain scores, and the amount of intravenous analgesics in the peripheral nerve block group were significantly greater than those in the spinal anesthesia group. Patient satisfaction was similar in both groups.ConclusionsSpinal anesthesia is significantly more effective than the peripheral nerve block method in reducing thigh tourniquet pain. A combined femoral and lateral femoral cutaneous nerve block with popliteal block can improve thigh tourniquet tolerance if supplemented with intravenous analgesics.

Efficacy of dexamethasone vs dexmedetomidine as an adjuvant for brachial plexus block- A randomised control trial

The brachial plexus block is an easy and relatively safe procedure for upper limb surgeries though there are different approaches to it, it is a block of roots, divisions and cords of the brachial plexus, out of which supraclavicular approach is most widely used method for anaesthesia and preoperative pain management in surgery below shoulder joint. It is performed at the trunk level where the plexus is presented most compactly. Another advantage is that it can be performed with the patient’s arm in any position to provide excellent anaesthesia for elbow, forearm and hand surgery.Various local anaesthetic agents are used for Brachial Plexus Block but most commonly used drugs are; Bupivacaine, and Lignocaine. Bupivacaine is long acting whereas Lignocaine is short acting drug. Novel adjuncts studied to date include butorphanol, buperonorphine, dexamethasone, Clonidine, Neostigmine, Tramadol, Midazolam, Dexmedetomidine etc.Dexmedetomidine is an anxiolytic sedative and analgesic agent, it is a selective α2 – adrenoreceptor agonist and is approximately 8 times more potent than clonidine. It was superior to clonidine also in quality for anesthesia in tourniquet tolerance, and postoperative analgesia and it is notable for its ability to provide sedation without risk of respiratory depression and can provide cooperative or semi arousable sedation.The mechanism by which αadrenergic receptor agonists produce analgesia is likely to be multifactorial. Peripherally αadrenergic agonists produce analgesia by reducing the release of norepinephrine and αreceptor independent inhibitory effect on nerve fibre action potential. Recent pre-clinical and clinical studies show that the glucocorticoid dexamethasone appears to be effective as adjuvant to local anesthetics since it posses anti-inflammatory and analgesic properties. In addition, perineural injection of steroid does influence post operative analgesia. This study was done to compare the adjuvant effect of dexamethasone and dexmedetomidine, when aded with local anesthetics in Supraclavicular brachial plexus block.It was a prospective randomized control trial conducted for 18 months in LLR hospital Kanpur. 90 patients of ASA grade 1 and 2 aged more than 18 yrs of either sex were included and Thirty patients were randomly divided in each of the three groups and observations were made regarding hemodynamic changes such as HR, MAP, SPO2 and onset of sensory, motor block and duration of motor, sensory effect. Student t test and analysis of variance were the methods used for analysis. Additions of injection dexamethasone and injection dexmedetomidine with lignocaine markedly prolonged duration of sensory and motor block however duration of injection dexmedetomidine was found to be longer as compared to dexamethasone.Dexmedetomidine has longer duration of motor and sensory effect when used as an adjuvent as compared to dexamethasone.

The analgesic efficacy of intravenous regional anesthesia with a forearm versus conventional upper arm tourniquet: a systematic review

BackgroundThe main objective of this review is to perform a systematic review and meta-analysis of the existing evidence related to the analgesic efficacy with the use of conventional, upper arm intravenous regional anesthesia (IVRA) as compared to a modified, forearm IVRA in adult patients undergoing procedures on the distal upper extremity.MethodsMEDLINE, EMBASE and CENTRAL (Cochrane) databases were searched for randomized controlled trials published in English, French, Dutch, German or Spanish language. Primary outcomes of interest including description of quality level of anesthesia and onset of sensory block were assessed for this review. Dosage of the local anesthetic, local anesthetic toxicity and need for sedation due to tourniquet pain were considered as secondary outcomes.ResultsOur literature search yielded 3 papers for qualitative synthesis. Four other articles were added into a parallel analysis of 7 reports that provided data on the incidence of complications and success rate after forearm IVRA. Forearm IVRA was found to be as efficient as upper arm IVRA (RR = 0.98 [0.93, 1.05], P = 0.78), but comes with the advantage of a lower need for sedation due to less tourniquet pain.ConclusionOur results demonstrate that forearm IVRA is as effective in providing a surgical block as compared to a conventional upper arm IVRA, even with a reduced, non-toxic dosage of local anesthetic. No severe complications were associated with the use of a forearm IVRA. Other benefits of the modified technique include a faster onset of sensory block, better tourniquet tolerance and a dryer surgical field.Registration of the systematic reviewA review protocol was published in the PROSPERO register in November 2015 with registration number CRD42015029536.

Effects of dexmedetomidine on responses to tourniquet in patients undergoing lower extremity surgery with peripheral nerve block

Objective To evaluate the effects of dexmedetomidine on responses to tourniquet in patients undergoing lower extremity surgery with peripheral nerve block. Methods Eighty American Society of Anesthesiologists physical status Ⅰ or Ⅱ patients of both sexes, aged 22-63 yr, weighing 47-81 kg, scheduled for elective foot surgery under ultrasound-guided popliteal sciatic nerve block combined with saphenous nerve block, were divided into 2 groups (n=40 each) using a random number table method: control group (group C) and dexmedetomidine group (group D). Dexmedetomidine was intravenously infused for 10 min in a dose of 1 μg/kg in group D, and the equal volume of normal saline was given instead in group C. Blood samples were taken from the internal jugular vein before using the tourniquet (T0) and at 30 and 60 min after releasing the tourniquet (T1-2) for determination of the levels of c-reactive protein (CRP), tumor necrosis factor-alpha (TNF-α), methane dicarboxylic aldehyde (MDA) and superoxide dismutase (SOD) in plasma.The time to responses to tourniquet, tourniquet tolerance time and tourniquet tolerance period were recorded.The occurrence of hypotension, bradycardia and nausea and vomiting was also recorded. Results Compared with the baseline at T0, the concentrations of plasma CRP, TNF-α and MDA were significantly increased and the activity of plasma SOD was decreased at T1, 2 in the two groups (P<0.05). Compared with group C, the concentrations of plasma CRP, TNF-α and MDA were significantly decreased and the activity of plasma SOD was increased at T1, 2, the time to responses to tourniquet, tourniquet tolerance time and tourniquet tolerance period were prolonged, and the incidence of bradycardia was increased in group D (P<0.05). Conclusion Dexmedetomidine can reduce responses to tourniquet in patients undergoing lower extremity surgery with peripheral nerve block. Key words: Dexmedetomidine; Nerve block; Tourniquets; Lower extremity

Comparison of the anesthetic effect of ultrasound-guided brachial plexus block by different approaches in distal radius surgery

Objective To compare the anaesthetic effect of ultrasound-guided brachial plexus block by different approaches (interscalene, axillary, supraclavicular) in distal radius surgery. Methods Ninety adult patients undergoing elective surgery for distal radius fracture open reduction and internal fixation, distal radius fracture after implant removal surgery distal radius fracture, were randomly divided into interscalene group(group A), axillary group(group B) and supraclavicular group (group C) for brachial plexus block under ultrasound-guided(n=30). The performance time and complications were recorded. Besides, the onset time and block execution time of median nerve, ulnar nerve, radial nerve, lateral medial cutaneous nerve, forearm medial cutaneous nerve were evaluated. Results There is no significant difference in performance time(P>0.05) and the onset time of pain block in median nerve, radial nerve, lateral medial cutaneous nerve (P>0.05). As for ulnar nerve and medial antebrachial cutaneous nerve, there were no difference in onset time of pain block between group A[(21±6) min] and group C[(20±5) min] (P>0.05), but they were longer than group B[(8±5) min] (P 0.05), but they were longer than group B[(10±6) min] (P<0.05). The complete suceess rate of group B(90%) were higher than other two groups. We found that two patients in group A and one patient in group C were complicated with phrenic nerve block and one patient in group B showed little tolerance of tourniquet. Conclusions Ultrasound-guided axillary brachial plexus block in the distal radius surgery is recommended because of better blockage of ulnar nerve and medial antebrachial cutaneous nerve and fewer complications. Key words: Ultrasound; Brachial plexus block; Distal radius

Study of Efficacy of Tramadol as an Adjuvant to Lignocaine in Intravenous Regional Anesthesia at a Tertiary Care Teaching Centre

Introduction: Tramadol is a central analgesic with an opioid agonistic activity with some selectivity for µ-receptors. Several studies showed that tramadol is beneficial as an additive to local anesthetics in different regional nerve blocks including infiltration, caudal block, brachial plexus block and IVRA. However, the existing data on its role as an additive for IVRA are conflicting. Therefore, a prospective, randomized controlled trial was conducted to determine efficacy of Tramadol (100mg) as an intra-operative, post-operative and pre-emptive analgesic as an adjuvant to lignocaine in IVRA. Materials and Methods: Present study was carried out in 80 patients undergoing upper arm orthopedic surgery at Sharda Hospital, School of Medical Sciences and Research, Sharda University, Greater Noida, Uttar Pradesh, India. All patients selected were planned for forearm surgeries, of ASA Grade I or II, aged 16-60 years. Patients received 0.5% lignocaine 40 ml in one group and we added Tramadol 100 mg in the other group. All the patients were monitored for onset of effect, quality of anesthesia, post op analgesia after deflation of tourniquet, time of first analgesic drug and number of analgesic drug required in first 24 hrs. Results: Onset of sensory analgesia was significantly earlier in group B (59.7±23.8 sec v/s 196.3±42.7) while onset of motor paralysis was similar in both groups. The post-operative analgesia was significantly longer in group B (304.7 ± 87.9 mins) then group A (12.6 ± 5.1 mins). Accordingly the number of analgesics consumed in post-operative first 24 hours was significantly less in group B (1.2±0.6) then group A (2.9±0.8). Conclusion: Tramadol has favorable effects as an adjuvant to lignocaine for IVRA. Tramadol substantially shortens the onset of sensory block, improves patient’s tolerance of tourniquet, prolongs the duration of analgesia after deflation of tourniquet and reduces the postoperative analgesic consumption.

Efficacy of forearm intravenous regional anesthesia through comparison of concentration and volume of lidocaine at a dose of 2 mg/kg for hand and wrist surgeries

Aim This study aimed to evaluate the efficacy of intravenous regional anesthesia (IVRA) as regards volume versus concentration of lidocaine in surgeries. Patients and methods The study enrolled 46 patients of ASA physical status I and II, aged 18-65 years, undergoing IVRA using lidocaine 2% at a dose of 2 mg/kg plus fentanyl 1 mg/kg diluted with a volume of 25 ml normal saline [the concentration group (group C, n = 23)], or 2 mg/kg lidocaine 2% plus fentanyl 1 mg/kg diluted with a volume of 40 ml normal saline [the volume group (group V, n = 23)]. The total supplemental systemic fentanyl intraoperatively and rescue pethidine consumption during the first 4 h postoperatively were recorded. The success rate of the IVRA block was also recorded. First and second tourniquet pain times, as well as times of onset and recovery of sensory and motor block, were calculated. Visual analogue scale score for evaluation of the pain resulted from the surgical stimulation was recorded. The side effects of the drugs and complications of the technique were also recorded. Results Intraoperative supplemental fentanyl dose was significantly higher in group V compared with group C. The total pethidine consumption during the first 4 postoperative hours showed nonsignificant difference between patients of the two groups, with a mean of 48.27 ± 9.75 mg in group C versus 52.42 ± 13.83 mg in group V. Hemodynamic parameters such as heart rate and mean arterial pressure were comparable in the two groups. The time to first call of analgesia was significantly prolonged ( P Conclusion IVRA with lidocaine at a dose of 2 mg/kg in 25 ml volume of normal saline represented an effective block and reduced the second tourniquet pain, increased the second tourniquet tolerance, and significantly decreased intraoperative supplemental fentanyl in comparison with the same dose in 40 ml volume of normal saline.

Oxygen reduces tourniquet-associated pain: a double-blind, randomized, controlled trial for application in hand surgery.

Why do limb tourniquets cause pain? If ischemia is the mechanism, can supplemental oxygen reduce pain? The Reducing Tourniquet Associated Pain study investigated whether this simple treatment could extend tourniquet tolerance time to facilitate hand surgery under local or regional anesthesia. The Reducing Tourniquet Associated Pain study was a double-blind, randomized, controlled trial of healthy volunteers. Participants received either 50% inhaled oxygen or air placebo via a face mask for 3 minutes before and up to 30 minutes after upper arm tourniquet inflation to 250 mmHg. Pain scores were recorded at 2-minute intervals using a validated 100-mm visual analogue scale. The primary outcomes were (1) difference in visual analogue scale score and (2) difference in time taken to reach visual analogue score of 40 mm or more in oxygen and air groups. Fifty participants enrolled and, after exclusion criteria were applied, 46 were analyzed (oxygen, n = 23; air, n = 23). Oxygen supplementation was associated with a 29 percent mean reduction in pain on visual analogue scoring compared with air placebo over the entire period of inhalation (p = 0.027). Oxygen also extended the time to visual analogue scale score of 40 mm or more by a mean of 6½ minutes compared with air placebo (p = 0.008). Oxygen is a readily available, low-risk, low-cost treatment that significantly reduced tourniquet-associated pain in this study and significantly increased the time taken to reach visual analogue scale score of 40 or more. The authors recommend oxygen to facilitate hand surgery under a tourniquet and when a regional block fails to control tourniquet pain.

English

Traditionally Supraclavicular Brachial plexus block is the commonly performed block for upper extremity surgeries. The Problems associated with this technique include inadequate block, failed block, direct injury to the nerves, pneumothorax, phrenic nerve palsy and vascular puncture etc. Recently lateral approach for supraclavicular brachial plexus block is gaining popularity because of its less complications and high success rate. The aim of the study is to compare the efficacy of lateral approach with conventional approach for supraclavicular brachial plexus block. METHODS: Fifty patients of ASA grade I and II scheduled for upper extremity surgery (below the midarm) were randomly allocated into two groups of 25 each. Group C was randomly allocated to receive supraclavicular brachial plexus block by conventional approach. Group L was randomly allocated to receive supraclavicular brachial plexus by lateral approach. Both the groups were given 10ml of 1.5% lignocaine and 15ml of 0.5% ropivacaine (total volume 25 ml).The parameters assessed were the onset and duration of sensory and motor blockade, time taken for the procedure, need for supplementation of anaesthesia, adverse effects, tourniquet tolerance and success rate. Statistical analysis was done using appropriate tests, (p<0.05) was considered statistically significant. We concluded that lateral approach for supraclavicular brachial plexus block using peripheral nerve stimulator, is a better alternative to conventional approach in terms of higher success rate and lesser

Randomized blinded control trial into tourniquet tolerance in awake volunteers

The ability to tolerate a tourniquet is often the limiting factor to elective and emergent procedures of the upper limb performed under local anaesthesia. This study aims to demonstrate that upper limb tourniquets are more predictably and better tolerated when inflated to 200 mmHg than to the traditional inflation pressure of 250 mmHg in awake, unsedated subjects. Forty healthy volunteers were randomized to have a tourniquet applied at either 200 or 250 mmHg for 20 min. Vital signs and pain scores were measured pre-test, at intervals throughout the time the tourniquet was inflated and post-deflation until the parameters normalized. Grip strength was measured pre-test, immediately post-deflation of the tourniquet and every 2 min until return of normal strength. All subjects were able to tolerate a tourniquet inflated for the allocated 20 min irrespective of the inflation pressure; however, there was a statistically significant lower average pain score in the group where the tourniquet was inflated to 200 mmHg compared with 250 mmHg. There was a quicker return of normal grip strength, although this was not shown to be statistically significant. Tourniquets inflated to 200 mmHg are better tolerated in awake, unsedated subjects that would allow predictably short procedures of the hand, wrist and forearm to be performed under local anaesthesia. It represents a pilot study prior to a further clinical study investigating the efficacy of tourniquets inflated to a lower pressure in maintaining an effective bloodless field.

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

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

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

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

The deleterious effects of exsanguination with a tight bandage on tourniquet tolerance in the upper arm

Tourniquet tolerance is affected by the method of exsanguination. Two commonly used methods, tight elastic bandaging and limb elevation, were tested to determine their effects on upper extremity tourniquet tolerance in 23 healthy adult volunteers. We found that tourniquet tolerance was significantly lower among the bandaging group compared with the limb elevation group (average 19.4 min and 24.1 min, respectively). Overall, the tourniquet tolerance was not affected by hand dominance or arm circumference.

Lateral Approach Of Supraclavicular Brachial Plexus As A Better Alternative To Conventional Supraclavicular Brachial Plexus Block

Purpose: Supraclavicular brachial plexus block technique, blocks the entire arm distally till mid arm level but risk of pneumothorax, phrenic nerve palsy and vascular puncture could be life threatening so to overcome these sequale we compared the lateral approach of supraclavicular brachial plexus block with conventional approach of supraclavicular block. Methods: Patients were randomly allocated in two groups; group 1 (n=50) received conventional approach of supraclavicular brachial plexus block and group 2 (n= 50) received lateral approach of supraclavicular brachial plexus block. Both the group received lignocaine with adrenaline (1:200000) 7 mg/kg and bupivacaine 2 mg.kg -1. The total volume of drug injected was 30 ml. Results: All the patients were assessed in terms of Time of onset of analgesia, Extent of sensory block, Quality of motor blocked, Tourniquet tolerance, Technical difficulty, Total duration of analgesia, Total duration of motor paralysis, and complications. Appropriate statistical analysis was done. Conclusion: We concluded that the Lateral Approach of Supraclavicular brachial plexus block justifies its own routine clinical uses because it has got better compliance of block in relation to onset, duration, extent and success rate. It is less traumatic and causes less adverse effects like puncture of vessels and pleura.

Intravenous regional anesthesia: a review of common local anesthetic options and the use of opioids and muscle relaxants as adjuncts

PurposeTo provide a review of local anesthetic (LA) agents and adjuncts, opioids and muscle relaxants, and their intraoperative effects and postoperative outcomes in intravenous regional anesthesia (IVRA).SourceA search for prospective, double-blind, randomized controlled trials evaluating LA agents, opioids and muscle relaxants as adjuvants for IVRA, was conducted (MEDLINE®, Embase). Intraoperative benefits (onset/recovery of sensory and motor block, intraoperative analgesia, tourniquet pain), postoperative benefits (pain score, analgesic consumption, time to first analgesia), and side effects were recorded. A conclusion for overall benefit was made based on statistical significance and clinical relevance.FindingsThirty-one studies were evaluated, with data collected on 1523 subjects. LA agents evaluated were lidocaine, ropivacaine, and prilocaine. Adjuncts evaluated were opioids ( morphine, fentanyl, meperidine, sufentanil, tramadol) and muscle relaxants (pancuronium, atracurium, mivacurium, cisatacurium). There was good evidence that ropivacaine provided effective IVRA and improved postoperative analgesia. Lidocaine and prilocaine were effective LA agents, however they lacked postoperative benefits. Morphine, fentanyl, and meperidine as sole adjuncts did not demonstrate clinically significant benefits or result in an increased risk of side effects. Sufentanil data was limited, but appeared to provide faster onset of sensory block. Tramadol provided faster onset of sensory block and tourniquet tolerance, however postoperative benefits were not consistent and the risk of minor side effects increased. Muscle relaxants improved the quality of motor block, but at the expense of delayed motor recovery. The combination of fentanyl and muscle relaxants can achieve an equivalent quality of IVRA with 50% reduction in LA dose, but at the expense of a potentially slower onset of sensory block.ConclusionRopivacaine is effective for IVRA and improves postoperative analgesia. Muscle relaxants enhance the motor block and when combined with fentanyl allow for an equivalent quality of IVRA with 50% reduction in LA dose.

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.