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Regional Anesthesia for Hand Surgery
... 13 Concurrently in the United Kingdom, a campaign was being conducted by The Council of the Association of Anaesthetists of Great Britain and Ireland to prevent the use of bupivacaine during Bier's intravenous regional anesthesia (IVRA). 14 Up to this juncture, the agent of choice for IVRA, which was considered relatively safe, 15 was now implicated in the deaths of five patients during the period 1979 to 1982. An editorial that appeared in the British Medical Journal in 1982 signified the comparability of these cases: all five were healthy patients being treated for minor conditions in emergency departments, and all five patients had received bupivacaine during IVRA. ...
... based on the technique introduced by Bier (1908Bier ( , 1910 and subject to modification has been recommended as an alternative to general anaesthesia for operations on the limbs (Rousso et al., 1979;Ware, 1979;Charn et al., 1981), including its use shortly after injury. ...
A simple modification to the method of regional anaesthesia known as Bier's block is presented. This was applied to patients with Colles' fractures. In a controlled trial the technique produced anaesthesia more quickly than the other method.
... regional anaesthesia using a forearm tourniquet produces excellent analgesia of the hand and wrist in the majority of patients. The amount of bupivacaine usually required for this technique (50-75 mg) is small, compared not only with the 150-200 mg generally used (Rousso et al., 1978a), but also with the reduced amount (1.5mgkg"') recommended by Ware (1975) for the conventional technique using an upper arm tourniquet. Therefore, low i.v. ...
A forearm tourniquet for i.v. regional analgesia of the hand, using doses of bupivacainc smaller than in thc conventional
(upper arm) method, produced successful analgesia in 98 of 102 patients. In 63 patients bupivacaine 50mg or less was adequate,
while in 33 the dosage was between 60 and 75mg. No toxic effect was noted. This technique permits surgery of the hand, wrist
and distal forearm.
An unintentionally high blood level of local anesthetic results in an excessive concentration at the central nervous and cardiovascular systems. This may lead to a clinical spectrum of toxicity ranging from mild symptoms to cardiac arrest and death.
Rate of absorption of local anesthetic into the bloodstream is a primary determinant of systemic toxicity and is influenced by local vascularity and extent of local tissue binding.
Presentation and rapidity of onset of local anesthetic toxicity is variable and is dependent on the local anesthetic used and whether the patient is sedated/anesthetized.
Intralipid emulsion is effective at reversing local anesthetic toxicity, although the underlying mechanism is poorly understood.
CPR, ACLS, and low-dose epinephrine are the focus of treatment for local anesthetic toxicity-induced cardiovascular collapse.
Preventative measures (safety checklists, monitoring, appropriate dosing) can help reduce the incidence of local anesthetic toxicity.
Evidence from a large multi-center regional anesthesia database reports a reduction in local anesthetic systemic toxicity of 65 % when ultrasound guidance is used compared with peripheral nerve stimulation alone.
ABSTRACT Objectives: 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 shorter sensory block and motor block onset time, longer motor block recovery time, and decreased analgesic requirement during the 24-hour postoperative period. Conclusions: Despite the longer motor block recovery, the addition of a low dose of mivacurium to lidocaine for IVRA accelerated the sensory and motor blocks onset and improved the postoperative analgesia without important perioperative adverse effects. We demonstrated that the addition of a low dose of mivacurium to lidocaine for IVRA provided a significant clinical benefit by shortening the sensory and motor blocks onset, providing sufficient muscle relaxation, and also reducing postoperative analgesic consumption without any serious adverse effects.
The practice of regional anesthesia has been revitalized of late with the popularization of ultrasound-guided techniques. Advocates must be vigilant for the effects of unintentionally high blood levels of local anesthetic. Systemic local anesthetic toxicity, though rare, is a potentially devastating occurrence. This narrative review summarizes the effects of local anesthetic toxicity. We highlight how these toxic effects have motivated the search for a safe and long-acting local anesthetic. We outline current prevention and treatment options and appraise an emerging therapy in light of unfolding evidence.
A search of the English language literature was conducted using the PubMed database from the National Library of Medicine. Bibliographies of retrieved articles were used to retrieve additional articles.
The advent of multiple safety steps has led to a dramatic reduction in the incidence of local anesthetic toxicity over the past 30 years. Rising plasma levels of local anesthetic lead to a progressive spectrum of neurological and cardiac effects. Seizure activity may herald the onset of myocardial depression and ventricular arrhythmias that are often refractory to treatment. In addition to specific measures, such as lipid emulsion therapy, general supportive measures are warranted, for example, Advanced Life Support Guidelines.
Vigilance during the performance of regional anesthesia and immediate intervention at the earliest sign of toxicity improve the chances of successful treatment.
Our aim was to find out if a modified intravenous regional anaesthetic block technique, used for invasive surgical procedures on the distal forearm and hand, results in a drier operative field than traditional methods. Twenty consenting adult (age > 18) patients who were to have an operation on the distal forearm or hand were randomised into two groups (n=10 in each). The first group was using a traditional bier block, with a double upper arm tourniquet. The second group was using a modified regional anaesthetic block technique, with a single upper arm tourniquet, and a single forearm tourniquet. All operative fields were recorded photographically and judged by the operating surgeon as "wet" or "dry". Analgesic requirements and subjective pain were recorded. Plasma lignocaine concentrations were measured. "Wet" operative fields were seen in 6 of the conventional and 0 of the modified group (p=0.01). Patients in the modified group were more comfortable during the procedures (p=0.004). This benefit was not sustained postoperatively (p=0.57). Plasma lignocaine concentrations were higher in the conventional group (p=0.004). The modified technique was as safe as the conventional technique but has the benefits of a drier surgical field and improved intraoperative comfort for patients.
We report a case in which acute digital hydrofluoric acid burns were treated with regional intravenous perfusion of calcium gluconate to relieve pain and protect from further tissue damage. This is the first documented instance of this technique being used. The conventional treatments for digital hydrofluoric acid burns all have their shortcomings; intravenous regional perfusion of calcium gluconate may be an effective method of treatment for digital hydrofluoric acid burns. © 1992 Informa UK Ltd All rights reserved: reproduction in whole or part not permitted.
Lidocaine 0.5 per cent in a dose of 2 mg X kg-1 was used for intravenous regional analgesia with the tourniquet cuff placed over the forearm. The level of tourniquet cuff pressure employed was the arterial "occlusion pressure" plus 50 mmHg. In 48 normotensive patients successful analgesia was achieved; in seven hypertensive patients, four were pain-free, but the other three required more lidocaine to achieve adequate analgesia. No toxic symptoms and signs were observed. Measurement of serum lidocaine concentrations in 12 patients confirmed the safety of the technique, although small leakage of lidocaine past the inflated forearm tourniquet was detected in some patients.
Five fatalities occurring after intravenous regional anesthesia are mentioned. In all cases, the doctor responsible for the block was the same as the doctor performing the operation. No other anesthesiologist or other doctors were present.
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