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PubMed2004

Adding dexmedetomidine to lidocaine for intravenous regional anesthesia.

UNLABELLED: Dexmedetomidine is approximately 8 times more selective toward the alpha-2-adrenoceptors than clonidine. It decreases anesthetic requirements by up to 90% and induces analgesia in patients. We designed this study to evaluate the effect of dexmedetomidine when added to lidocaine in IV regional anesthesia (IVRA). We investigated onset and duration of sensory and motor blocks, the quality of the anesthesia, intraoperative-postoperative hemodynamic variables, and intraoperative-postoperative pain and sedation. Thirty patients undergoing hand surgery were randomly assigned to 2 groups to receive IVRA. They received 40 mL of 0.5% lidocaine and either 1 mL of isotonic saline (group L, n = 15) or 0.5 microg/kg dexmedetomidine (group LD, n = 15). Sensory and motor block onset and recovery times and anesthesia quality were noted. Before and after the tourniquet application at 5, 10, 15, 20, and 40 min, hemodynamic variables, tourniquet pain and sedation, and analgesic use were recorded. After the tourniquet deflation, at 30 min, and 2, 4, 6, 12, and 24 h, hemodynamic variables, pain and sedation values, time to first analgesic requirement, analgesic use, and side effects were noted. 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 LD. Visual analog scale scores were significantly less in group LD in the intraoperative period and 30 min, and 2, 4, and 6 h after tourniquet release. Intra-postoperative analgesic requirements were significantly less in group LD. Time to first analgesic requirements was significantly longer in group LD in the postoperative period. We conclude that the addition of 0.5 microg/kg dexmedetomidine to lidocaine for IVRA improves quality of anesthesia and perioperative analgesia without causing side effects. IMPLICATIONS: This study was designed to evaluate the effect of dexmedetomidine when added to lidocaine for IV regional anesthesia. This is the first clinical study demonstrating that the addition of 0.5 microg/kg dexmedetomidine to lidocaine for IV regional anesthesia improves quality of anesthesia and intraoperative-postoperative analgesia without causing side effects.

Adrenergic alpha-Agonists↗

PubMed2001

Day surgery for mucosal-hemorrhoidal prolapse using a circular stapler and modified regional anesthesia.

PURPOSE: In 1993, prolapse reduction using the circular stapler for the treatment of hemorrhoidal disease was proposed. The procedure is characterized by minimal postoperative pain. In this study we evaluated the above technique using regional anesthesia to identify the advantages and feasibility of stapled hemorrhoidectomy, with special focus on the efficacy of same-day discharge. METHODS: From December 1997 to November 1999, we performed 70 consecutive reduction corrections of mucosal hemorrhoidal prolapse using the circular stapler with regional anesthesia (a technical modification of Marti's posterior perineal block). Our series included 41 males and 29 females with a mean age of 43.4 (range, 25-74) years. Three patients were affected by second-degree hemorrhoids and 67 by third-degree hemorrhoids. RESULTS: Sixty-two patients were discharged three hours after the operation in good general condition and without pain, whereas eight patients were discharged the day after for early complications, consisting of two cases of early bleeding, three cases of urinary retention, and three cases of persistent severe pain requiring prolonged medical treatment. CONCLUSION: Our study shows that, in selected cases, it is possible to perform day surgery for patients with hemorrhoidal disease using a circular stapler device when combined with regional anesthesia.

Adult↗

PubMed1987

Regional anesthesia for ambulatory foot and ankle surgery.

Regional anesthesia provides significant advantages for the patient and practitioner involved in ambulatory foot and ankle surgery. Reliable techniques for administering regional ankle blocks emphasizing their importance in the practice of ambulatory surgery are presented.

Ambulatory Surgical Procedures↗

PubMed2001

Alpha 2 agonists in regional anesthesia and analgesia.

Clonidine is a partial alpha 2 adrenergic agonist that has a variety of different actions including antihypertensive effects as well as the ability to potentiate the effects of local anesthetics. It can provide pain relief by an opioid-independent mechanism. It has been shown to result in the prolongation of the sensory blockade and a reduction in the amount or concentration of local anesthetic required to produce perioperative analgesia. Different routes for the administration of regional anesthesia, including intravenous, intrathecal and epidural ones, as well as the addition of clonidine for peripheral neural blockade, have been described. It has been also used for intra-articular administration. The latest articles describing the use of clonidine in regional anesthesia are discussed. Most authors agree that the use of clonidine for regional neural blockade in combination with a local anesthetic results in increased duration of sensory blockade with no difference in onset time. The addition of clonidine to the local anesthetic opioid mixtures seems to produce analgesia of longer duration, more rapid onset and higher quality. The higher doses of clonidine were associated with a more cephalad spread of the spinal blockade and increased sedation and hypertension. When clonidine is added to a fentanyl-bupivacaine mixture for epidural labor analgesia, it seems to provide satisfactory analgesia of a longer duration than that produced by the fentanyl-bupivacaine combination alone. Similar results were found when epidural analgesia using levobupivacaine with clonidine was used in patients undergoing total hip arthroplasty. Less clear results were seen when clonidine was used for caudal anesthesia in a pediatric patient population. The addition of clonidine to intravenous regional anesthesia resulted in prolongation of the tourniquet time and improvement of postoperative analgesia. However, the latter was found to be short-lived. In another study, the effects of clonidine used for intra-articular administration in combination with morphine were investigated. These authors found a significantly higher rate of satisfaction in the group of patients receiving clonidine plus morphine. Although several recent studies have shown certain benefits from the use of clonidine for regional anesthesia, further investigations are necessary to clarify its role.

Journal Article↗

PubMedDate not supplied

Perioperative pain management education: a short structured regional anesthesia course compared with traditional teaching among medical students.

BACKGROUND AND OBJECTIVES: Previous research has demonstrated that a brief course on pain management improved knowledge and attitudes toward analgesic use among medical students. The purpose of this study is to compare a structured clinical instruction course on regional anesthesia techniques for perioperative pain management with traditional teaching given to senior medical students. METHODS: During a 1-month clerkship in anesthesiology, 40 fourth-year medical students were randomly and equally divided into 2 groups. The study group received a 2-hour structured course on regional anesthesia techniques for pain management, whereas the control group received a 1-hour lecture tutorial on regional anesthesia techniques for perioperative pain management and 1 hour of bedside teaching on acute pain management. Each student completed an objective structured clinical examination (OSCE) 2 weeks after completion of the course. RESULTS: The study group performed better on each of the 11 items of the OSCE and on the total performance scores (mean +/- SD of 36.2 +/- 7.3 for study group versus 14.8 +/- 8.4 for the control group; P < .05). All students rated the clinical course highly valuable (4.7 +/- 0.5). CONCLUSION: A structured clinical instructional course on regional techniques for perioperative pain management given to fourth-year medical students can significantly improve their understanding and knowledge compared with traditional teaching.

Anesthesia, Conduction↗

PubMed1999

Impact of a regional anesthesia analgesia program for outpatient foot surgery.

PURPOSE: To examine the effects of a Regional Anesthesia and Analgesia (RAA) program for outpatient foot surgery in an outpatient unit. METHODS: The RAA program was implemented in our Surgical Day Care Center (SDCC) in 1992-93. Fifty charts were randomly selected for each of two periods, 1990 (pre-program) and 1995 (post-program). One surgeon operated on all patients. Preoperative, intraoperative and postoperative information collected included demographic data, block type, analgesic requirements, nursing visits and complications. A time analysis of the perioperative course was also performed. RESULTS: The use of regional block increased from 2% to 82% as a result of the RAA program. This was not accompanied by a change in operating room efficiency (anesthetic time, preparation time, exit time). Patient stay in the PACU and discharge lounge was reduced by a mean difference of 7 min (Upper 95% CI = 24 min) and fentanyl consumption in the OR was reduced by 35 microg (95% CI = -8, -62 microg). The number of patients who required > 1 < 4 nursing visits for analgesia administration in the PACU decreased from 17 to 9 after program implementation. CONCLUSIONS: Regional anesthesia is more likely to be offered to outpatients if it is introduced as a formal RAA program. Such a program did not have a negative impact on operating room efficiency and was beneficial in reducing patient stay in the PACU and discharge lounge. Facility discharge processes may need to be modified to obtain the maximum benefits from such RAA programs.

Adolescent↗

PubMed1998

The dose-response relationship of ketorolac as a component of intravenous regional anesthesia with lidocaine.

UNLABELLED: Ketorolac (K) is a useful addition to lidocaine for i.v. regional anesthesia (IVRA). However, the minimal dose of K that is effective for this purpose has not been established. We added 0, 5, 10, 15, 20, 30, and 60 mg of K to 0.5% lidocaine IVRA for either carpal tunnel release or tenolysis. Pain was assessed in the postanesthesia care unit by using a visual analog scale. The duration of analgesia (time to first request for pain relief) and the use of Tylenol No. 3 tablets (T3) were measured. A linear dose-response relationship was observed between the dose of K and the duration of analgesia (r = 0.988) up to 20 mg of K. Similarly, the number of T3 tablets used was inversely related to the dose of K (r = 0.960) over the same range. There were no significant differences among the groups who received 20, 30, or 60 mg of K. We conclude that 20 mg of K is the optimal dose for inclusion with 0.5% lidocaine for IVRA under the conditions of our study. IMPLICATIONS: The antiinflammatory drug ketorolac is a useful addition to lidocaine for i.v. regional anesthesia. This study showed that 20 mg of ketorolac is equally effective as 60 mg in this context. However, smaller doses provided less effective pain relief, and a linear dose-response relationship was demonstrated.

Acetaminophen↗

PubMed1987

[Therapy of paradoxical reactions to midazolam in regional anesthesia].

Many patients fear being awake in the operating room, and the acceptance of regional anesthesia is often made dependent on the promise of adequate sedation. With the introduction of the short-acting benzodiazepine (bzdp) midazolam, it seemed possible to achieve induction and maintainance of sleep throughout an operative procedure. This substance may, however, occasionally result in a "paradoxical reaction" (PR) characterized by agitated excitement, mental confusion, and uncooperativeness. We have treated this condition successfully with physostigmine, as documented here in two case reports where a possible interaction between promethazine and midazolam may have been responsible for the PR. The symptoms resemble some of those seen in the central anticholinergic syndrome, as further implied by the therapeutic effect of physostigmine, but an etiological difference may exist. A direct anticholinergic effect of bzdp's is described only following excessive doses. An indirect effect may result from the impact on GABA-receptors, which have been identified as structurally related to the bzdp receptors. Physostigmine itself is not bound at the bzdp receptor, but has been shown to block the binding of bzdp's to their receptors and to reverse sedation from midazolam, perhaps through an indirect stimulatory effect. Previous case reports have indicated the effect of physostigmine in reversing PR following various bzdp's. Without treatment, a PR during regional anesthesia frequently makes general anesthesia necessary in order to immobilize the patient sufficiently to make surgery possible.(ABSTRACT TRUNCATED AT 250 WORDS)

Adult↗

PubMed2002

An evaluation of the analgesic efficacy of intravenous regional anesthesia with lidocaine and ketorolac using a forearm versus upper arm tourniquet.

UNLABELLED: Intravenous regional anesthesia (IVRA) using a forearm tourniquet may be a potentially safer technique compared with using an upper arm tourniquet. Ketorolac is a useful adjuvant to lidocaine for IVRA. In this study, we assessed the analgesic efficacy of administering IVRA lidocaine and ketorolac with either a forearm or upper arm tourniquet for outpatient hand surgery. Upper arm IVRA was established using 40 mL of a solution containing 200 mg of lidocaine and ketorolac 20 mg (0.5 mg/mL). Forearm IVRA was established using 20 mL of a solution containing 100 mg of lidocaine and ketorolac 10 mg (0.5 mg/mL). Onset and duration of sensory block as well as postoperative pain and analgesic use were recorded. The patients who received forearm IVRA had a significantly longer period during which they required no analgesics (701 +/- 133 min) compared with 624 +/- 80 min for the upper arm IVRA ketorolac patients (P = 0.032). Onset of sensory block was similar between the two groups; however, recovery of sensation was significantly longer in the Forearm IVRA (22 +/- 5 min) group compared with the Upper Arm IVRA (13 +/- 3 min) group (P < 0.05). There were no differences in postoperative analgesic use or pain scores between the two groups. We conclude that forearm IVRA with lidocaine and ketorolac provides safe and effective perioperative analgesia for patients undergoing ambulatory hand surgery. This technique results in a longer duration of sensory block and prolonged postoperative analgesia compared with upper arm IVRA while using one-half the doses of both lidocaine and ketorolac. IMPLICATIONS: Forearm tourniquet intravenous regional anesthesia (IVRA) with 50% less lidocaine and ketorolac provides for both a longer duration of sensory block and prolonged postoperative analgesia compared with upper arm IVRA.

Adult↗

PubMed2003

Why patients choose regional anesthesia for orthopedic and trauma surgery.

BACKGROUND: While both surgeons' and anesthesiologists' preference of regional over general anesthesia is increasing, the patients' preference remains limited. Little is known about why patients choose regional anesthesia. The aim of our study was to answer this question with regard to orthopedic and trauma surgery. METHODS: The study was carried out prospectively from 1999 to 2001 and included 238 patients scheduled for arthroscopy of the lower limb or other orthopedic or trauma surgery. All patients were informed about regional and general anesthesia in a pre-anesthesia interview and subsequently chose the method they preferred. RESULTS: Curiosity was the main reason why patients chose regional anesthesia for arthroscopy ( n=155, p<0.0001). For all other types of orthopedic or trauma surgery ( n=83), patients chose regional anesthesia to avoid postoperative pain ( p<0.01) and/or the side-effects of general anesthesia ( p<0.0001). Younger ( n=128) and low-risk ( n=184) patients chose regional anesthesia because they were curious ( p<0.01 and p<0.001, respectively), while older ( n=110) and unhealthier patients ( n=56) did so for safety ( p<0.01 and p<0.001, respectively). CONCLUSIONS: Patients choose different types of regional anesthesia for different reasons. While spinal anesthesia and femoral and sciatic block were chosen for curiosity reasons, brachial plexus block was chosen to avoid the side effects of general anesthesia. The patients' choice of regional anesthesia for orthopedic and trauma surgery is significantly influenced by the type of surgery, age, and health.

Adult↗

PubMed1993

Intravenous regional anesthesia in the treatment of forearm and wrist fractures and dislocations in children.

OBJECTIVE: To evaluate the efficacy and safety of intravenous regional anesthesia in the treatment of unilateral closed fractures and dislocations of forearm or wrist in children. DESIGN: A prospective study over 6 years. SETTING: The study was undertaken in the well-equipped emergency department of a community general hospital for ambulatory patients. PATIENTS: One hundred and thirty-nine children between the ages of 4 and 18 years with unilateral closed fractures and dislocations of forearm or wrist. INTERVENTION: All children received premedication with a combination of meperidine and promethazine (0.5 mg/kg intramuscularly) and regional upper limb anesthesia with 0.5% lidocaine solution (3 mg/kg intravenously) after inflation of an arm tourniquet. MAIN OUTCOME MEASURES: The relief of pain, allowing closed reduction with intravenous regional anesthesia, and the incidence of complications. RESULTS: All patients had complete relief of pain allowing successful closed reduction in 133 patients (96%); tourniquet pain occurred in 10 patients (7%). There were no symptoms of lidocaine toxicity. There were no neurovascular or compartment syndrome complications. CONCLUSIONS: Intravenous regional anesthesia for the treatment of fractures and dislocations of forearm and wrist in children was found to be simple, safe and effective.

Adolescent↗

PubMedDate not supplied

Fetal effects of prophylactic ephedrine and maternal hypotension during regional anesthesia for cesarean section.

The purpose of this study was to evaluate the effects of a prophylactic intravenous bolus of ephedrine on the incidence and severity of maternal hypotension and on neonatal outcome. Term healthy parturients (n = 122) scheduled for elective repeat cesarean section under regional anesthesia were studied. Ninety-two women received 10 mg ephedrine as a prophylactic intravenous bolus prior to intrathecal epidural local anesthesia. Thirty parturients who served as controls did not receive prophylactic ephedrine. Maternal blood pressures, Apgar scores, and umbilical cord blood acid-base status were evaluated. Sixty-three of 92 women (69%) who received intravenous prophylactic ephedrine prior to regional anesthesia developed hypotension compared to 21 (70%) controls. The mean (+/- SD) lowest systolic blood pressure was similar in both groups (95.6 +/- 12.9 vs. 96 +/- 8.9 mmHg; P = 0.86). The mean (+/-SD) fetal pH was significantly lower with prophylactic ephedrine than controls (7.24 +/- 0.07 vs. 7.28 +/- 0.05; P = 0.001). The frequency of umbilical artery blood pH < 7.20 was 10.6% for the ephedrine group vs. 3.2% for controls (P = 0.024). Among newborns of hypotensive mothers, the frequency of umbilical artery blood pH < 7.20 was 30.2% and 4.6% for the ephedrine and control groups, respectively (P = 0.018). Intravenous prophylaxis with ephedrine did not significantly decrease the frequency of hypotension in women receiving regional anesthesia and resulted in a greater proportion of umbilical artery blood pH values < 7.20.

Anesthesia, Epidural↗

PubMed2002

Complications of regional anesthesia: an overview.

Perhaps the clearest picture of the numbers and types of injuries from regional anesthesia is provided by the ASA Closed Claims Project database. In reviewing these data, it is valuable to keep in mind, of course, that the lack of a denominator makes the calculation of incidence impossible. For the decade of the 1990s, 308 claims were associated with regional anesthesia (versus 642 claims associated with general anesthesia). The percentage of these claims for patient death (10%) continued its steady decline from more than 20% in the 1970s and 13% in the 1980s. The primary reason for death remains cardiac arrest associated with neuraxial blockade, though this now represents only 30% of the deaths as opposed to 61% in the 1970s and 40% in the 1980s. There were 71 permanent disabling injuries among the 308 claims. The most common of these (23%) was associated with nerve blocks of the eye (13 retrobulbar, 3 peribulbar), and typically the injury entailed loss of vision. Second in frequency (21%) were pain-management related claims involving, for example, neuraxial opiates or neurolytic blocks. Third in frequency (20%) were nerve injuries associated with neuraxial and peripheral blocks followed by epidural hematomas (13%).

Anesthesia, Conduction↗

PubMed2006

Ultrasonographic guidance in pediatric regional anesthesia Part 1: Theoretical background.

Recent findings support the use of ultrasonographic guidance in pediatric regional anesthesia. This review article illustrates basic knowledge in physics of ultrasound and ultrasonographic appearance of neuronal structures, which are prerequisites for the safe application of this technique in daily clinical practice. A critical view on education and ethics in science should emphasize future developments in ultrasonography for pediatric regional anesthesia.

Anesthesia, Conduction↗

PubMed1976

[Regional anesthesia in geriatric surgery. Possibilities and limitations: (author's transl)].

Modern anesthetic techniques are superior to regional anesthesia for most operative procedures. Yet because of new advances in techniques and methods and sound pathophysiological knowledge, there are some operations for which regional anesthesia has distinct advantages over general anesthesia. This is the case, for example, in geriatric surgery. Here, the technical simplicity and short amount of time required give spinal anesthesia marked advantages over general anesthesia. Post-spinal headaches and slight falls in blood pressure have become rarer due to technical innovations and can reasonably be accepted.

Age Factors↗

PubMed2006

[Levobupivacaine for regional anesthesia. A systematic review].

Levobupivacaine [S(-)bupivacaine], the levorotatory S-enantiomer of racemic bupivacaine, is commercially available in the U.S. and in most European countries. We performed a systematic review (MEDLINE database) and identified 88 articles on the clinical application of levobupivacaine in more than 3,000 patients. The use of levobupivacaine is described for epidural, caudal, and spinal anesthesia, for peripheral nerve blocks, for ophthalmic and dental anesthesia, for different pediatric indications and for intravenous regional anesthesia. In these regional techniques, levobupivacaine was used for all common indications in a wide range of clinical settings. Epidural levobupivacaine was combined with fentanyl, morphine, sufentanil, epinephrine, and clonidine, spinal levobupivacaine was combined with sufentanil, fentanyl, and epinephrine. In most studies, levobupivacaine was compared to bupivacaine and/or ropivacaine.

Amides↗

PubMed2006

The analgesic effect of nitroglycerin added to lidocaine on intravenous regional anesthesia.

We evaluated the analgesic effect of nitroglycerine (NTG) when added to lidocaine in IV regional anesthesia. Thirty patients undergoing hand surgery were randomly assigned to two groups. The control group (group C, n = 15) received a total dose of 40 mL with 3 mg/kg of lidocaine diluted with saline, and the NTG group (group NTG, n = 15) received an additional 200 mug NTG. Hemodynamic variables, tourniquet pain measured before and 1, 5, 10, 20, and 30 min after tourniquet inflation, and analgesic requirements were recorded during the operation. After the tourniquet deflation, at 1 and 30 min and 2 and 4 h, visual analog scale (VAS) score, time to first analgesic requirement, total analgesic consumption in the first 24 h after operation, and side effects were noted. Shortened sensory and motor block onset time (3.2 +/- 1.1 versus 4.5 +/- 1.2 min; P = 0.01 and 3.3 +/- 1.6 versus 5.2 +/- 1.8; P = 0.009 in group NTG and group C, respectively), prolonged sensory and motor block recovery times (6.8 +/- 1.6 versus 3.1 +/- 1.2 min P < 0.0001 and 7.3 +/- 1.3 versus 3.6 +/- 0.8 P < 0.0001 in group NTG and group C, respectively), shortened VAS scores of tourniquet pain (P = 0.023), and improved quality of anesthesia were found in group NTG (P < 0.05). VAS scores were lower in group NTG after tourniquet release and in the postoperative period (P = 0.001). First analgesic requirement time was longer in group NTG (225 +/- 74 min versus 39 +/- 33 min) than in group C (P < 0.0001). Postoperative analgesic requirements were significantly smaller in group NTG (P < 0.0001) but the side effects were similar in both groups. We conclude that the addition of NTG to lidocaine for IV regional anesthesia improves sensory and motor block, tourniquet pain, and postoperative analgesia without side effects.

Adult↗

PubMed2006

Complications of regional anesthesia.

PURPOSE OF REVIEW: The use of regional anesthesia, either alone or as an adjunct to general anesthesia, is at an all-time high. Demonstrated benefits include reduced side effects, more efficient use of facilities and enhanced patient satisfaction with the improved postoperative pain relief. New advances in equipment, techniques and medications have been incorporated over the past 10 years, and especially over the last 2 years. As the number of practitioners and procedures increase, the number of complications may rise as well. RECENT FINDINGS: The specific issues of nerve damage, treatment of local anesthetic toxicity with lipid solutions and prevention of wrong-sided procedures are examined with special reference to recent publications. SUMMARY: Specific needle shapes, appropriate pharmacologic resuscitation from intravascular injection of local anesthetics and institutional procedures to positively identify patients and the correct block location are all part of a strategy to minimize the occurrence of adverse outcomes and to mitigate the consequences of those adverse events when they do occur. More importantly, these are changes that can be instituted immediately with minimal expense to the institution and great benefit to the patient.

Anesthesia, Conduction↗