Intravenous regional anesthesia using lidocaine and neostigmine for upper limb surgery

Effect of systemic lidocaine on postoperative quality of recovery, the gastrointestinal function, inflammatory cytokines of lumbar spinal stenosis surgery: a randomized trial

Surgery is one of the most frequent and effective intervention strategies for lumbar spinal stenosis, however, one-third of patients are not satisfied with postoperative outcomes. It is not clear whether perioperative systemic lidocaine could accelerate the early postoperative quality of recovery in patients undergoing lumbar spinal stenosis surgery. 66 patients were enrolled in this trial. Lidocaine or placebo was administered at a loading dose of 1.5 mg/kg for 10 min and then infused at 2.0 mg/kg/hour till the end of surgery. Continued infusion by postoperative patient-controlled intravenous analgesia with a dose of 40 mg/hour. The primary outcome was the quality of recovery. Secondary outcomes included the time of the patient's first flatus, catheter removal time, underground time from the end of the surgery, pain score, levels of inflammatory factors (IL-6, IL-10, TNF-α), postoperative nausea and vomiting (PONV), sufentanil rescues, patients' satisfaction scores, and complications of lidocaine. Eventually, 56 patients were in the final analysis with similar age, Body Mass Index (BMI), duration of surgery and anesthesia, and median QoR-15 score (a development and Psychometric Evaluation of a Postoperative Quality of Recovery Score). The difference in median QoR-15 score in placebo versus lidocaine patients was statistically significant (IQR, 106 (104-108) versus 114 (108.25-119.25), P < 0.001). The Numeric Rating Scale (NRS) score at the 12th hour, median sufentanil rescue consumption, IL-6, tumor necrosis factor-alpha (TNF-α) of patients treatment with lidocaine were lower. Nevertheless, patients given lidocaine had high satisfaction scores. Suggesting that lidocaine enhanced the postoperative quality of recovery, met early postoperative gastrointestinal function recovery, provided superior pain relief, lessened inflammatory cytokines, etc., indicating it may be a useful intervention to aid recovery following lumbar spinal stenosis surgery.

Pharmacological and clinical implications of local anaesthetic mixtures: a narrative review

Various techniques have been explored to prolong the duration and improve the efficacy of local anaesthetic nerve blocks. Some of these involve mixing local anaesthetics or adding adjuncts. We did a literature review of studies published between 01 May 2011 and 01 May 2021 that studied specific combinations of local anaesthetics and adjuncts. The rationale behind mixing long- and short-acting local anaesthetics to hasten onset and extend duration is flawed on pharmacokinetic principles. Most local anaesthetic adjuncts are not licensed for use in this manner and the consequences of untested admixtures and adjuncts range from making the solution ineffective to potential harm. Pharmaceutical compatibility needs to be established before administration. The compatibility of drugs from the same class cannot be inferred and each admixture requires individual review. Precipitation on mixing (steroids, non-steroidal anti-inflammatory drugs) and subsequent embolisation can lead to serious adverse events, although these are rare. The additive itself or its preservative can have neurotoxic (adrenaline, midazolam) and/or chondrotoxic properties (non-steroidal anti-inflammatory drugs). The prolongation of block may occur at the expense of motor block quality (ketamine) or block onset (magnesium). Adverse effects for some adjuncts appear to be dose-dependent and recommendations concerning optimal dosing are lacking. An important confounding factor is whether studies used systemic administration of the adjunct as a control to accurately identify an additional benefit of perineural administration. The challenge of how best to prolong block duration while minimising adverse events remains a topic of interest with further research required.

Single sterile silicon ring technique for utilization of upper limb intravenous regional anesthesia: A prospective study of patients with operated distal radius fractures

INTRODUCTION

Intravenous regional anesthesia is a well-established method of anesthesia in upper extremity surgery. In this study, we present a modification of the technique using a silicon ring tourniquet in 30 patients undergoing internal fixation for distal radius fractures.

METHODS

A sterile silicone ring wrapped within a stockinette sleeve was applied, and a local anesthetic solution (3 mg/kg lidocaine 0,5%) was injected intravenously. After anesthesia onset, the ring was rolled distally to provide immediate pain and discomfort relief.

RESULTS

The silicone ring achieved adequate exsanguination in all patients. Mean pain VAS score was 2.7 ± 0.9 intraoperatively and 4.3 ± 1.3 during the first hour postoperatively. The onset and termination times of sensory block were 5.8 ± 2.1 and 102 ± 7.8 min, and of motor block 13.8 ± 2.8 and 54.2 ± 4.6 min, accordingly. All patients were satisfied from the procedure.

CONCLUSION

Sterile silicone ring tourniquet application is a simple, safe and effective analgesic and anesthetic technique for the operative treatment of distal radius fractures.

Intravenous Regional Anesthesia: A Historical Overview and Clinical Review

Intravenous regional anesthesia (IVRA) is an established, safe and simple technique, being applicable for various surgeries on the upper and lower limbs. In 1908, IVRA was first described by the Berlin surgeon August Bier, hence the name "Bier's Block". Although his technique was effective, it was cumbersome and fell into disuse when neuroaxial and percutaneous plexus blockades gained widespread popularity in the early 20^th century. In the 1960s, it became widespread, when the New Zealand anesthesiologist Charles McKinnon Holmes praised its use by means of new available local anesthetics. Today, IVRA is still popular in many countries being used in the emergency room, for outpatients and for high-risk patients with contraindications for general anesthesia. IVRA offers a favorable risk-benefit ratio, cost-effectiveness, sufficient muscle relaxation and a fast on- and offset. New upcoming methods for monitoring, specialized personnel and improved emergency equipment made IVRA even safer. Moreover, IVRA may be applied to treat complex regional pain syndromes. Prilocaine and lidocaine are considered as first-choice local anesthetics for IVRA. Also, various adjuvant drugs have been tested to augment the effect of IVRA, and to reduce post-deflation tourniquet pain. Since major adverse events are rare in IVRA, it is regarded as a very safe technique. Nevertheless, systemic neuro- and cardiotoxic side effects may be linked to an uncontrolled systemic flush-in of local anesthetics and must be avoided. This review gives a historical overview of more than 100 years of experience with IVRA and provides a current view of IVRA with relevant key facts for the daily clinical routine.

Effect of adding dexamethasone to lidocaine on the quality of intravenous regional anesthesia for upper extremity orthopedic operations: A randomized clinical trial

BACKGROUND

Intravenous regional anesthesia (IVRA) is an ideal technique for short surgery on the distal extremities. Different additives have been used to improve lidocaine's block quality.

OBJECTIVE

The aim of this study was to determine the effect of adding dexamethasone to lidocaine on improving the quality of IVRA.

METHODS

This study is a prospective, double-blind randomized study which was done on patients with upper extremity injuries of the distal elbow in Shahid Mohammadi Hospital, Bandar Abbas from October 2014 to December 2015. A total of 110 patients aged 15 to 65 years, with ASA class I and II, with orthopedic injuries distal to the elbow, were randomly divided into two groups. The control group (L) and the intervention group (L+D) received a 40-ml solution of 3 mg/kg lidocaine, and 3 mg/kg lidocaine + 8 mg of dexamethasone respectively. The two groups were compared in terms of onset and recovery time of sensory block in each of the dermatome nerves classified as radial, ulnar, and median, vital signs, patient satisfaction, intraoperative opioid consumption, and request for the first postoperative opioid.

RESULTS

There was no significant difference between the two groups in terms of demographic characteristics. Mean arterial blood pressure was higher in the L + D group (100.39±14.6 mmHg) in comparison to the L group (90.50±11 mmHg) (p=0.002). Need for opioid was reported in 20 (35.7%) patients in the L + D group in comparison to 17 (31.5%) in the L group (p=0.639). The average intraoperative dose of fentanyl was 95±32.04 mcg and 88.44±18.77 mg in L + D and L groups respectively and there was no significant difference between the two groups in this respect (p=0.479). In addition, the average dose of pethidine administered in the recovery room for L + D group (19.34±15.22) mg was significantly higher than in the L group (9.44±12.26 mg) (p=0.001).

CONCLUSIONS

Adding 8 mg dexamethasone to lidocaine has no effect on IVRA solution in upper extremity orthopedic operations and also increases postoperative opioid consumption.

TRIAL REGISTRATION

The trial was registered at the Iranian Registry of Clinical Trials (http://www.irct.ir) with the Irct ID: IRCT2016052928158N1.

FUNDING

The authors received financial support from Hormozgan University of Medical Sciences.

[Intravenous regional anesthesia with long-acting local anesthetics. An update]

Intravenous regional anesthesia is a widely used technique for brief surgical interventions, primarily on the upper limbs and less frequently, on the lower limbs. It began being used at the beginning of the 20th century, when Bier injected procaine as a local anesthetic. The technique to accomplish anesthesia has not changed much since then, although different drugs, particularly long-acting local anesthetics, such as ropivacaine and levobupivacaine in low concentrations, were introduced. Additionally, drugs like opioids, muscle relaxants, paracetamol, neostigmine, magnesium, ketamine, clonidine, and ketorolac, have all been investigated as adjuncts to intravenous regional anesthesia, and were found to be fairly useful in terms of an increased onset of operative anesthesia and longer lasting perioperative analgesia. The present article provides an overview of current knowledge with emphasis on long-acting local anesthetic drugs.