|Year : 2016 | Volume
| Issue : 2 | Page : 290-295
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
Ayman A Rayan MD 1, Hossam I Eldesuky2
1 Department of Anesthesia and Intensive Care, Faculty of Medicine, Menoufia University, Menoufia, Egypt
2 Department of Anesthesia, Zagazig University, Zagazig, Egypt
|Date of Submission||24-Aug-2014|
|Date of Acceptance||12-Apr-2015|
|Date of Web Publication||11-May-2016|
Ayman A Rayan
Department of Anesthesia and Intensive Care, Faculty of Medicine, Menoufia University, 71411 Menoufia
Source of Support: None, Conflict of Interest: None
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.
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 < 0.05) in group C. Block characteristics were significantly better in group C. We did not encounter any serious side effect of any of the drugs used.
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.
Keywords: concentration, efficacy, intravenous regional anesthesia, lidocaine, volume
|How to cite this article:|
Rayan AA, Eldesuky HI. 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. Ain-Shams J Anaesthesiol 2016;9:290-5
|How to cite this URL:|
Rayan AA, Eldesuky HI. 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. Ain-Shams J Anaesthesiol [serial online] 2016 [cited 2021 May 9];9:290-5. Available from: http://www.asja.eg.net/text.asp?2016/9/2/290/182271
| Introduction|| |
Bier's block [intravenous regional anesthesia (IVRA)] is frequently used for operations of the hand, wrist, and forearm using local anesthetic (LA) solution. IVRA is considered a simple and a reliable type of regional anesthesia. It was introduced for the first time by Karl August Bier in 1908. The earliest agent used was procaine, but the technique fell into disrepute as it was cumbersome and procaine had adverse effects. This technique was largely forgotten until 1963, when Holmes used lignocaine instead of procaine in IVRA; this technique subsequently gained popularity [1,2]. Although this technique was widely used due to its simplicity and reliability, it had been limited by tourniquet pain, lack of postoperative analgesia, and LA toxicity . In most of the studies, standard IVRA involved administration of 0.5% lidocaine solution at a dose of 3 mg/kg body weight (0.6 ml/kg) . Opioids were most commonly used as adjuncts in IVRA . The peripheral action of opioids could theoretically be mediated using a peripheral opioid receptor or by their own LA action [6,7]. This study aimed to evaluate the efficacy of IVRA block (Bier's block) as regards volume versus concentration of lidocaine in providing effective anesthesia for hand and wrist surgeries.
| Patients and methods|| |
After obtaining approval from the ethical committee of our hospital and written informed consent of all patients, this prospective, randomized blind study was conducted from May 2013 to August 2014 in King Abdul-Aziz Hospital in Saudi Arabia. Patients scheduled for elective and emergency hand and wrist surgeries were included in this study. The study enrolled 46 patients who were of ASA physical status I and II, aged 18-65 years, and from either sex. Exclusion criteria were as follows: patients' refusal for IVRA technique; chronic use of NSAIDs; coagulopathies; Reynaud's disease; sickle cell disease; cardiac diseases; neurological disorders; use of analgesics, antidepressants, and anxiolytics; neuropathological disease; allergies to study drugs; procedures greater than 1 h; ASA physical status III or IV; pregnancy; and hepatic and renal diseases. Patients received midazolam, intravenously, in incremental doses and according to patients' response. Standard monitoring [ECG, mean arterial pressure (MAP), and pulse oximetry] was used for all patients. Before establishing the anesthetic block, two cannulas were secured: one 22-G cannula in a vein on the dorsum of the operative hand, and the other 20-G cannula in the opposite hand for intravenous infusion of crystalloid. The operative arm was elevated for 3 min and then exsanguinated with an Esmarch bandage. The pneumatic tourniquet was placed around the upper arm. The proximal cuff was inflated to 100 mmHg over the systolic blood pressure of the patient. Circulatory isolation of the operative arm was verified by (i) inspection, (ii) absence of radial pulse, and (iii) loss of pulse oximetry tracing of the ipsilateral index finger. Patients were allocated randomly using computer-generated randomization into two groups (group C and group V). IVRA was achieved using 2 mg/kg lidocaine 2% (20mg/ml) (preservative-free) Hospira, Inc., Lake Forest, IL 60045, USA plus fentanyl 1 mg/kg diluted with normal saline to a total volume of 25 ml in the concentration group (group C, n = 23), or using 2 mg/kg lidocaine 1% plus fentanyl 1 mg/kg diluted with normal saline to a total volume of 40 ml in the volume group (group V, n = 23). Lactated Ringer's solution infusion was initiated at a rate of 150 ml/h through a 20-G intravenous cannula in the nonoperative extremity. All patients received preoperative intravenous sedation 10 min before intravenous block. Midazolam 1 mg intravenous incremental was given according to the patients' response and then IVRA technique was started for all patients.
Intravenous regional anesthesia technique
LA was injected through an indwelling cannula over 90 s by an anesthesiologist, who observed any side effects or complications (LA toxicity) accruing from the study drugs. The patient was informed that the arm would tingle and warm and that the skin would become mottled. The cannula was removed immediately after injection of LA solution, and the bleeding was prevented by exerting pressure on the site for several minutes after removal of the cannula. The concentration of the LA solution after dilution was calculated and recorded. It is important to note that the tourniquet is never deflated until at least 20 min has elapsed from the time of injection of the anesthetic agent. For the procedures between 20 and 40 min duration, a cycled deflation technique was used - that is, the tourniquet was deflated for 5 s, reinflated for 1 min, deflated for another 5 s, reinflated for another minute, and then deflated totally. For procedures that last more than 40 min, the tourniquet is deflated without cycling. LA (lidocaine) plus fentanyl was injected according to the classification of both groups. Surgery was started after loss of pain and touch sensations (testing of the sensation of pain was carried out by pinprick and light touch through comparison of both arms, and motor examination was carried out by testing different movements of the forearm, wrist, hand, and fingers). Surgery was allowed to proceed with the first tourniquet until the patient became pain free. The second tourniquet was inflated and the first was deflated only when the patient felt pain before the end of surgery, or when the first tourniquet inflation time exceeded 30 min. The second tourniquet was deflated when the surgery was complete, with the total duration not exceeding 1.5 h. If the IVRA block was not adequate or failed to achieve at adequate time, an alternative anesthesia plan was implemented with general anesthesia, and the patient was excluded from the study. Baseline data were recorded on a raw data collection sheet. Baseline data included demographic and surgical data. The amount and concentration of lidocaine, the total supplemental intraoperative systemic fentanyl, and total rescue pethidine consumption during the first 4 h postoperatively were recorded. The success rate of the IVRA block in both groups was recorded. Time at first and second tourniquet pain (min), onset and recovery of sensory and motor block (min), and other block characteristics were calculated. Pain from surgical stimulation assessment was evaluated using the 0 to 10 visual analogue scale (VAS) score. The start of the operation was considered at 0 min, followed by 10, 20, 30, and 40 min. Side effects of the drugs and complications of the technique were observed and recorded.
- A 22-G intravenous cannula was secured on dorsal hand vein of the operative arm.
- The operative extremity was elevated for 3 min.
- The operative arm was exsanguinated using an Esmarch bandage.
- The double-cuffed pneumatic tourniquets were placed on the upper arm, and then the distal cuff was inflated to 100 mmHg above systolic pressure and loss of pulse was verified.
- The proximal cuff was inflated and then the distal one was deflated after verifying loss of pulse.
- The Esmarch bandage was removed and then lack of pulse in the operative arm was verified.
Data were analyzed using SPSS statistical package (version 17; SPSS Inc., Chicago, Illinois, USA). Results were presented as mean ± SD, number, and percentage. A power analysis for sample size suggested a minimum of 23 patients in each group, with a mean of 68.33 mg of intraoperative fentanyl in group V and a mean of 23.3 mg fentanyl in group C (reduction >20%) and an SD of 35.44 and 20.65,respectively, with a = 0.05 gave a statistical power of 99.9%. We included 46 patients in both groups. T-tests were used to compare the two groups with respect to age, weight, and intraoperative clinical data (operative time, tourniquet time, onset sensory block, etc.). The Mann-Whitney test was used to compare the two groups as regards intraoperative fentanyl consumption. MAP and heart rate (HR) in the two groups were compared using the paired t-test. A P value less than 0.05 was considered significant.
| Results|| |
The demographic data including age, sex, body weight, the total duration of surgery, and types of surgery were comparable in both the groups, with nonstatistically significant difference (P > 0.05) [Table 1].
Success rate of IVRA was 100% in both groups; only three patients in group V were in need of supplemental local infiltration of bupivacaine of the skin before surgical incision. There was statistically highly significant increase in the concentration of lidocaine (mg/ml solution) in group C in comparison with group V. There was statistically highly significant increase in the total supplemental fentanyl intraoperative in group V in comparison with group C. In contrast, the total rescue pethidine consumption during the first 4 h postoperatively was found to be statistically nonsignificant between patients in group C (48.27 ± 9.75 mg) and those in group V (52.42 ± 13.83 mg) (P = 0.2458) [Table 2].
|Table 2 Amount and concentration of lidocaine, total supplemental fentanyl intraoperative, and total rescue pethidine consumption during the first 4 h postoperatively|
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First call of analgesia time was significantly prolonged (P = 0.0365) in group C. Block characteristics were better, with significant difference between the two groups [Table 3].
Changes in hemodynamic parameters (HR and MAP) were comparable between the two groups (P > 0.05) [Table 4] and [Table 5].
|Table 4 Mean heart rate at different time intervals following Bier's block in both groups|
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|Table 5 Mean arterial pressure at different time intervals following Bier's block in both groups|
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We did not encounter any serious side effect of any of the drugs used, and the difference between the two groups was statistically nonsignificant as regards side effects of the drugs and complications of the technique [three cases complained of hypotension and were treated with 5 mg ephedrine intravenous bolus; three cases suffered from postoperative nausea and vomiting and were treated with ondansetron HCL (Zofran injection, 2 mg/ml) 0.1 mg/kg when three emetic episodes occurred within a 15-min period, and perioral numbness and tinnitus were treated with oxygenation and close monitoring] [Table 6] and [Table 7].
|Table 6 The mean of visual analogue scale score intraoperative (at surgical site)|
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| Discussion|| |
Bier's block provides rapid induction, rapid recovery, and minimal hospital stay and thus it is suitable for day-case anesthesia. IVRA is a useful, reliable, and cost-effective type of anesthesia . It also provides adequate relaxation when used in upper limb surgery . This technique is a popular choice in trauma and emergency services as a large number of fractures and limb injuries result from road traffic accidents. IVRA would be a useful technique in those patients who are ill-prepared for general anesthesia. IVRA is widely used in forearm, hand, and wrist surgeries. The drawback with this technique is the absence of postoperative analgesia . In the current study, increased concentration of lidocaine hastens sensory and motor block onset time. Tourniquet pain is a traditional limitation of IVRA. It manifests itself as a dull and aching pain sensation increasing in severity with duration of inflation despite an adequate regional anesthesia . Even with double tourniquets, pain typically presents by 40 min after initial inflation. Deflation of the tourniquet is followed by resolution of the subjective symptoms. Onset of first tourniquet pain (min) was 24.4 ± 4.16 and 26.15 ± 3.96 in group V and group C, respectively, whereas onset of second tourniquet pain (min) was 29.28 ± 4.31 and 38.34 ± 6.65 in group V and group C, respectively. Shortened sensory and motor block onset times, prolonged sensory and motor block recovery times, prolonged tolerance for the tourniquet, and improved quality of anesthesia were found in group C compared with group V. Onset of sensory block (min) in group C and group V were 5.36 ± 3.2 and 3.53 ± 2.65, respectively (P = 0.0404). The faster sensory and motor block onset times observed in group C is considered an advantage to help the surgery much earlier. The time to onset of sensory block was 5.05 ± 2.10 min in the lidocaine group 3 mg/kg in 40 ml volume in the study conducted by Bansal et al. . We used 2 mg/kg of 1% lidocaine diluted with normal saline to make a total solution of 40 ml, which was different from that used in the studies conducted by Harris et al. , Reuben et al. , and Turan et al. ; they used 3 mg/kg of 2% lignocaine diluted with normal saline to make a total solution of 40 ml. The time to first call analgesia requirements was significantly longer in group C (68.44 ± 34.61 min) in comparison with group V (102.5 ± 67.37 min) during the postoperative period. The time to recovery from sensory block after tourniquet deflation was 12.57 ± 4.72 min in group V compared with 14.25 ± 4.29 min in group C. In comparison with the study conducted by Bansal et al. , the time to recovery from sensory block after tourniquet deflation was 13.60 ± 5.40 min in the lidocaine group, which used 3 mg/kg of 2% lidocaine diluted with normal saline to make a total solution of 40 ml. The primary mode of action of LAs is through the sodium channel and axonal conduction blockade. LAs reversibly block the conduction of nerve impulses by preventing increases in the permeability of nerve membrane to sodium ions. In this study no significant differences were found between the two groups as regards HR and MAP, intraoperatively or during the first 4 h postoperatively. This was in agreement with the study conducted by Mabee . In our study, if the patient complained of pain postoperatively and if the VAS score was found to be 4 or greater, analgesia with 0.5 mg/kg pethidine intravenous was given. The mean time to first rescue analgesic requirement in the V group was 68.44 ± 34.61 min, whereas in group C it was 102.5 ± 67.37 min. This was in agreement with the study conducted by Bansal et al. . The mean time to first rescue analgesic requirement in the lignocaine group was 73.63 ± 61.32 min. In contrast, Turan et al.  reported the time to first postoperative analgesic requirement with lignocaine as 95 ± 29 min. The mean rescue pethidine consumption during the first 4 h postoperatively was 52.42 ± 13.83 mg in group V, whereas in group C it was 48.27 ± 9.75 mg. Side effects and complications due to the drugs used in both groups were comparable and not serious in nature and were managed conservatively. Opioids have long been used as adjuvants in IVRA, although their mode of action remains unclear. Fentanyl has been used in the dose range of 50-200 mg as described by Armstrong et al. . Painful stimuli produced by a surgical incision can lead to a hyperexcitable state in the spinal cord, which can exacerbate the postoperative pain . Once this state has been established, a larger dose of analgesic is usually required. If drugs are administered before the painful stimulus, postoperative pain can be greatly diminished . Various drugs and techniques of their administration have shown varying degrees of success. The technique of using LA with other adjuvants has become even more popular recently, thus improving the duration and quality of analgesia with minimum side effects. This is true for Bier's block. Choyce and Peng  reviewed various adjuncts in IVRA for surgeries. VAS score was statistically significantly decreased in group C during the intraoperative period at 20, 30, and 40 min from the start of operation. Intraoperative fentanyl requirements were significantly less in group C. Side effects and complications due to the drugs used in both groups were not serious in nature and were managed conservatively. However, in the study conducted by Khanna et al. , one of the patients experienced tinnitus, seizures, hallucinations, and respiratory depression after deflation of the tourniquet, and six patients in group L experienced transient dizziness after tourniquet deflation as well. Postoperative nausea and vomiting were observed in two patients in group L in the study conducted by Khanna et al. .
| Conclusion|| |
We conclude that lidocaine at a dose of 2 mg/kg in IVRA in 25 ml volume introduces better outcome, effective block, hastened onset, reduced tourniquet pain, and increased tourniquet tolerance. Overall quality of anesthesia, as well as significant reduction of supplemental fentanyl intraoperative, was significantly better in group C in comparison with the same LA dose in volume 40 ml.
We recommended the use of low volume with higher concentration of lidocaine was effective in providing better block with a good safety profile in both protocols. Further studies need to support the results of IVRA with higher concentration with decrease volume in a lidocaine dose 2 mg/kg faraway from toxic dose of lidocaine with advantage of effective block associated with reduction of the dose of lidocaine.
| Acknowledgements|| |
Conflicts of interest
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[Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6], [Table 7]