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Löser B, Petzoldt M, Löser A, Bacon DR, Goerig M. Intravenous Regional Anesthesia: A Historical Overview and Clinical Review. J Anesth Hist 2019; 5:99-108. [PMID: 31570204 DOI: 10.1016/j.janh.2018.10.007] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2018] [Accepted: 10/29/2018] [Indexed: 06/10/2023]
Abstract
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 20th 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.
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MESH Headings
- Anesthesia, Conduction/history
- Anesthesia, Conduction/instrumentation
- Anesthesia, Conduction/methods
- Anesthesia, Intravenous/adverse effects
- Anesthesia, Intravenous/history
- Anesthesia, Intravenous/instrumentation
- Anesthetics, Local/adverse effects
- Anesthetics, Local/history
- Cocaine/administration & dosage
- Cocaine/history
- Contraindications, Procedure
- History, 19th Century
- History, 20th Century
- History, 21st Century
- Humans
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Affiliation(s)
- Benjamin Löser
- Center of Anesthesiology and Intensive Care Medicine, Department of Anesthesiology, University Medicine Rostock, Schillingallee 35, 18057 Rostock, Germany.
| | - Martin Petzoldt
- Center of Anesthesiology and Intensive Care Medicine, Department of Anesthesiology, University Medical Centre Hamburg-Eppendorf, Martinistrasse 52, 20251 Hamburg, Germany.
| | - Anastassia Löser
- Department of Radiotherapy and Radiation Oncology, University Medical Center Hamburg-Eppendorf, Martinistrasse 52, 20251 Hamburg, Germany.
| | - Douglas R Bacon
- Department of Anesthesiology, University of Mississippi, Medical Center, 2500 North State Street, Jackson, MS39216, USA.
| | - Michael Goerig
- Center of Anesthesiology and Intensive Care Medicine, Department of Anesthesiology, University Medical Centre Hamburg-Eppendorf, Martinistrasse 52, 20251 Hamburg, Germany.
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Sertoz N, Kocaoglu N, Ayanoğlu HÖ. Comparison of lornoxicam and fentanyl when added to lidocaine in intravenous regional anesthesia. Rev Bras Anestesiol 2014; 63:311-6. [PMID: 23931243 DOI: 10.1016/j.bjan.2013.06.001] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2012] [Accepted: 07/30/2012] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND AND OBJECTIVES In this study, our goal was to compare intraoperative and postoperative analgesic effects of lornoxicam and fentanyl when added to lidocaine Intravenous Regional Anesthesia (IVRA) in a group of outpatients who underwent hand surgery. METHODS This is a double blind randomized study. A total of 45 patients were included, randomized into three groups. Patients in Group I (L) received 3 mg.kg-1 of 2% lidocaine 40 mL; patients in Group II (LL) received 3 mg.kg-1 lidocaine 38 mL + 2 mL lornoxicam; patients in Group III (LF) received 3 mg.kg-1 lidocaine 38 mL + 2 mL fentanyl. Our primary outcome was fi rst analgesic requirement time at postoperative period. RESULTS Lornoxicam added to lidocaine IVRA increased the sensory block recovery time without increasing side effects and increased fi rst analgesic requirement time at the postoperative period when compared to lidocaine IVRA (p < 0.001, p < 0.001 respectively) and fentanyl added to lidocaine IVRA (p < 0.001, p < 0.001 respectively). In addition, we also found that fentanyl decreased tourniquet pain (p < 0.01) when compared to lidocaine but showed similar analgesic effect with lornoxicam (p > 0.05) although VAS scores related to tourniquet pain were lower in fentanyl group. Lornoxicam added to lidocaine IVRA was not superior to lidocaine IVRA in decreasing tourniquet pain. CONCLUSIONS Addition of fentanyl to lidocaine IVRA seems to be superior to lidocaine IVRA and lornoxicam added to lidocaine IVRA groups in decreasing tourniquet pain at the expense of increasing side effects. However, lornoxicam did not increase side effects while providing intraoperative and postoperative analgesia. Therefore, lornoxicam could be more appropriate for clinical use.
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Affiliation(s)
- Nezih Sertoz
- Ege University, School of Medicine, Department of Anesthesiology and Reanimation, Izmir, Turkey.
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Akdogan A, Eroglu A. Comparison of the effect of lidocaine adding dexketoprofen and paracetamol in intravenous regional anesthesia. BIOMED RESEARCH INTERNATIONAL 2014; 2014:938108. [PMID: 24800256 PMCID: PMC3988948 DOI: 10.1155/2014/938108] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/12/2013] [Accepted: 02/24/2014] [Indexed: 02/07/2023]
Abstract
OBJECTIVE Comparison of dexketoprofen and paracetamol added to the lidocaine in Regional Intravenous Anesthesia in terms of hemodynamic effects, motor and sensorial block onset times, intraoperative VAS values, and analgesia requirements. METHOD The files of 73 patients between 18 and 65 years old in the ASA I-II risk group who underwent hand and forearm surgery were analyzed and 60 patients were included in the study. Patients were divided into 3 groups: Group D (n = 20), 3 mg/kg 2% lidocaine and 50 mg/2 mL dexketoprofen trometamol; Group P (n = 20), 3 mg/kg 2% lidocaine and 3 mg/kg paracetamol; Group K (n = 20), 3 mg/kg 2% lidocaine. Demographic data, motor and sensorial block times, heart rate, mean blood pressure, VAS values, and intraoperative and postoperative analgesia requirements were recorded. RESULTS Sensorial and motor block onset durations of Group K were significantly longer than other groups. Motor block termination duration was found to be significantly longer in Group D than in Group K. VAS values of Group K were found higher than other groups. There was no significant difference in VAS values between Group D and Group P. Analgesia requirement was found to be significantly more in Group K than in Group P. There was no significant difference between the groups in terms of heart rates and mean arterial pressures. CONCLUSION We concluded that the addition of 3 mg/kg paracetamol and 50 mg dexketoprofen to lidocaine as adjuvant in Regional Intravenous Anesthesia applied for hand and/or forearm surgery created a significant difference clinically.
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Affiliation(s)
- Ali Akdogan
- Anesthesiology and Intensive Care Medicine, Karadeniz Technical University, 61080 Trabzon, Turkey
| | - Ahmet Eroglu
- Anesthesiology and Intensive Care Medicine, Karadeniz Technical University, 61080 Trabzon, Turkey
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Comparison of lornoxicam and fentanyl when added to lidocaine in intravenous regional anesthesia. Braz J Anesthesiol 2013; 63:311-6. [PMID: 24565236 DOI: 10.1016/j.bjane.2012.07.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2012] [Accepted: 07/30/2012] [Indexed: 11/21/2022] Open
Abstract
BACKGROUND AND OBJECTIVES In this study, our goal was to compare intraoperative and postoperative analgesic effects of lornoxicam and fentanyl when added to lidocaine Intravenous Regional Anesthesia (IVRA) in a group of outpatients who underwent hand surgery. METHODS This is a double blind randomized study. A total of 45 patients were included, randomized into three groups. Patients in Group I (L) received 3mg.kg(-1) of 2% lidocaine 40 mL; patients in Group II (LL) received 3mg.kg(-1) lidocaine 38 mL + 2 mL lornoxicam; patients in Group III (LF) received 3mg.kg(-1) lidocaine 38 mL + 2 mL fentanyl. Our primary outcome was first analgesic requirement time at postoperative period. RESULTS Lornoxicam added to lidocaine IVRA increased the sensory block recovery time without increasing side effects and increased first analgesic requirement time at the postoperative period when compared to lidocaine IVRA (p < 0.001, p < 0.001 respectively) and fentanyl added to lidocaine IVRA (p < 0.001, p < 0.001 respectively). In addition, we also found that fentanyl decreased tourniquet pain (p < 0.01) when compared to lidocaine but showed similar analgesic effect with lornoxicam (p > 0.05) although VAS scores related to tourniquet pain were lower in fentanyl group. Lornoxicam added to lidocaine IVRA was not superior to lidocaine IVRA in decreasing tourniquet pain. CONCLUSIONS Addition of fentanyl to lidocaine IVRA seems to be superior to lidocaine IVRA and lornoxicam added to lidocaine IVRA groups in decreasing tourniquet pain at the expense of increasing side effects. However, lornoxicam did not increase side effects while providing intraoperative and postoperative analgesia. Therefore, lornoxicam could be more appropriate for clinical use.
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Yurtlu S, Hanci V, Kargi E, Erdoğan G, Köksal BG, Gül Ş, Okyay RD, Ayoğlu H, Turan IÖ. The Analgesic Effect of Dexketoprofen When Added to Lidocaine for Intravenous Regional Anaesthesia: A Prospective, Randomized, Placebo-Controlled Study. J Int Med Res 2011; 39:1923-31. [DOI: 10.1177/147323001103900537] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
Abstract
This prospective, randomized, placebo-controlled study evaluated the effects of dexketoprofen as an adjunct to lidocaine in intravenous regional anaesthesia (IVRA) or as a supplemental intravenous (i.v.) analgesic. Patients scheduled for elective hand or forearm soft-tissue surgery were randomly divided into three groups. All 45 patients received 0.5% lidocaine as IVRA. Dexketoprofen was given either i.v. or added into the IVRA solution and the control group received an equal volume of saline both i.v. and as part of the IVRA. The times of sensory and motor block onset, recovery time and postoperative analgesic consumption were recorded. Compared with controls, the addition of dexketoprofen to the IVRA solution resulted in more rapid onset of sensory and motor block, longer recovery time, decreased intra- and postoperative pain scores and decreased paracetamol use. It is concluded that coadministration of dexketoprofen with lidocaine in IVRA improves anaesthetic block and decreases postoperative analgesic requirements.
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Affiliation(s)
- S Yurtlu
- Department of Anaesthesiology and Reanimation, Zonguldak Karaelmas University, School of Medicine, Zonguldak, Turkey
| | - V Hanci
- Department of Anaesthesiology and Reanimation, Zonguldak Karaelmas University, School of Medicine, Zonguldak, Turkey
| | - E Kargi
- Department of Plastic and Reconstructive Surgery, Zonguldak Karaelmas University, School of Medicine, Zonguldak, Turkey
| | - G Erdoğan
- Department of Anaesthesiology and Reanimation, Zonguldak Karaelmas University, School of Medicine, Zonguldak, Turkey
| | - BG Köksal
- Department of Anaesthesiology and Reanimation, Zonguldak Karaelmas University, School of Medicine, Zonguldak, Turkey
| | - Ş Gül
- Department of Neurosurgery, Zonguldak Karaelmas University, School of Medicine, Zonguldak, Turkey
| | - RD Okyay
- Department of Anaesthesiology and Reanimation, Zonguldak Karaelmas University, School of Medicine, Zonguldak, Turkey
| | - H Ayoğlu
- Department of Anaesthesiology and Reanimation, Zonguldak Karaelmas University, School of Medicine, Zonguldak, Turkey
| | - IÖ Turan
- Department of Anaesthesiology and Reanimation, Zonguldak Karaelmas University, School of Medicine, Zonguldak, Turkey
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Zhou C, Gan J, Liu J, Luo WJ, Zhang WS, Chai YF. The Interaction Between Emulsified Isoflurane and Lidocaine Is Synergism in Intravenous Regional Anesthesia in Rats. Anesth Analg 2011; 113:245-50. [DOI: 10.1213/ane.0b013e31821e9797] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Sen H, Kulahci Y, Bicerer E, Ozkan S, Dagl G, Turan A. The Analgesic Effect of Paracetamol When Added to Lidocaine for Intravenous Regional Anesthesia. Anesth Analg 2009; 109:1327-30. [DOI: 10.1213/ane.0b013e3181b0fedb] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
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Kol IO, Ozturk H, Kaygusuz K, Gursoy S, Comert B, Mimaroglu C. Addition of Dexmedetomidine or Lornoxicam to Prilocaine in Intravenous Regional Anaesthesia for Hand or Forearm Surgery. Clin Drug Investig 2009; 29:121-9. [DOI: 10.2165/0044011-200929020-00006] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2022]
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Sen S, Ugur B, Aydin ON, Ogurlu M, Gezer E, Savk O. The analgesic effect of lornoxicam when added to lidocaine for intravenous regional anaesthesia. Br J Anaesth 2006; 97:408-13. [PMID: 16845131 DOI: 10.1093/bja/ael170] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND The aim of the study was to evaluate the effect of lornoxicam (L) on sensory and motor block onset time, tourniquet pain, and postoperative analgesia, when added to lidocaine in intravenous regional anaesthesia (IVRA). METHODS Forty-five patients undergoing hand surgery were randomly and blindly divided into three groups as to receive either i.v. saline and IVRA with lidocaine 0.5% (Control group, n=15), i.v. saline and IVRA lidocaine 0.5% with lornoxicam (L-IVRA group, n=15), or intravenous lornoxicam and IVRA lidocaine 0.5% (L-IV group, n=15). Sensory and motor blocks onset time, and tourniquet pain was measured after tourniquet application at 5, 10, 20, and 30 min, and analgesic use were recorded during operation. After the tourniquet deflation, at 1, 30 min, and 2, 4 h, visual analogue scales score, the time to first analgesic requirement, total analgesic consumption in first 24 h, and side effects were noted. RESULTS Sensory and motor block onset times were shorter and the recovery time prolonged in the Group L-IVRA compared with the other group (P=0.001). A decreased tourniquet pain, a prolonged time first analgesic requirement [229 (85) min vs 28 (20) and 95 (24) min, P=0.0038) and less postoperative analgesic requirements during 24 h were found in Group L-IVRA compared with the other groups (P<0.05). CONCLUSIONS The addition of lornoxicam to lidocaine for intravenous regional anaesthesia shortens the onset of sensory and motor block, decreases tourniquet pain and improves postoperative analgesia without causing any side effect.
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Affiliation(s)
- S Sen
- Department of Anaesthesiology and Reanimation, Adnan Menderes University, Medical Faculty Aydin, Turkey.
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Merry AF, Webster CS, Holland RL, Middleton NG, Schug SA, James M, McGrath KA. Clinical tolerability of perioperative tenoxicam in 1001 patients – a prospective, controlled, double-blind, multi-centre study. Pain 2004; 111:313-322. [PMID: 15363875 DOI: 10.1016/j.pain.2004.07.013] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2004] [Revised: 07/05/2004] [Accepted: 07/12/2004] [Indexed: 10/26/2022]
Abstract
We investigated adverse events (AEs) associated with perioperative tenoxicam in a double-blind, prospective, randomised study. Patients undergoing surgery, screened for contraindications to non-steroidal anti-inflammatory drug, received tenoxicam (n=750) on 2843 days or placebo (n=251) on 988 days, in courses of 1-12 days. There was no increase in the overall incidence of side effects with tenoxicam (33 vs 38% with placebo: P=0.15), or in major side effects (3.9 vs 2.0% with placebo: P=0.11). Of major side effects possibly or probably related to tenoxicam (2.1 vs 1.2% with placebo: P=0.26), all but one involved post-operative surgical site bleeding. However, in the subgroup of patients undergoing otorhinolaryngology surgery, surgical site bleeding occurred in 18 of 171 (10.5%) patients on tenoxicam and one of 57 (1.8%) on placebo (P=0.026); of these, nine in the tenoxicam group and 0 in the placebo were classified as major (P=0.07). One patient on tenoxicam experienced endoscopically proven duodenal ulceration with malaena. In conclusion, perioperative tenoxicam is well tolerated in comparison with placebo and the incidence of drug-related major AEs (other than post-operative bleeding) is no greater than 1 in 150 in low risk patients, but in patients undergoing otorhinolaryngological surgery there may be an increased risk of post-operative bleeding.
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Affiliation(s)
- Alan F Merry
- Department of Anaesthesiology, School of Medicine, University of Auckland, Private Bag 92-019, Auckland, New Zealand Green Lane Department of Anaesthesia, Auckland City Hospital, Auckland, New Zealand Department of Intensive Care, Blacktown Hospital, Sydney, NSW, Australia Department of Pharmacology, University of Western Australia, and Royal Perth Hospital, Perth, WA, Australia Faculty of Health, Auckland University of Technology, Auckland, New Zealand
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Abstract
In August 1908 Karl August Bier, Professor of Surgery in Berlin, described a new method of producing analgesia of a limb which he named 'vein anesthesia'. Bier first presented his new method of intravenous regional anesthesia (IVRA) at the 37th Congress of the German Surgical Society on 22 April, 1908, only 10 years after his significant communication on spinal anesthesia (1). His method, which now bears his name, consisted of occluding the circulation in a segment of the arm with two tourniquets and then injecting a dilute local anesthetic through a venous cut-down in the isolated segment. Bier had the good fortune to use procaine, the first safe injectable local anesthetic that had been synthesized by Einhorn in 1904.
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Affiliation(s)
- S Brill
- Department of Anesthesiology and Intensive Care, Chaim Sheba Medical Center, Tel. Hashomer, Israel, 52621.
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Hord ED, Oaklander AL. Complex regional pain syndrome: a review of evidence-supported treatment options. Curr Pain Headache Rep 2003; 7:188-96. [PMID: 12720598 DOI: 10.1007/s11916-003-0072-7] [Citation(s) in RCA: 47] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
Complex regional pain syndrome consists of pain and other symptoms that are unexpectedly severe or protracted after an injury. In type II complex regional pain syndrome, major nerve injury, often with motor involvement, is the cause; in complex regional pain syndrome I, the culprit is a more occult lesion, often a lesser injury that predominantly affects unmyelinated axons. In florid form, disturbances of vasoregulation (eg, edema) and abnormalities of other innervated tissues (skin, muscle, bone) can appear. Because of these various symptoms and the difficulty in identifying causative lesions, complex regional pain syndrome is difficult to treat or cure. Complex regional pain syndrome has not been systematically investigated; there are few controlled treatment trials for established complex regional pain syndrome. This article reviews the existing studies (even if preliminary) to direct clinicians toward the best options. Treatments for other neuropathic pain syndromes that may be efficacious for complex regional pain syndrome also are discussed. Some common treatments (eg, local anesthetic blockade of sympathetic ganglia) are not supported by the aggregate of published studies and should be used less frequently. Other treatments with encouraging published results (eg, neural stimulators) are not used often enough. We hope to encourage clinicians to rely more on evidence-supported treatments for complex regional pain syndrome.
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Affiliation(s)
- E Daniela Hord
- Massachusetts General Hospital, 55 Fruit Street, Clinics 3, Boston, MA 02114, USA
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Abstract
BACKGROUND Fracture of the distal radius is a common clinical problem, particularly in older white women with osteoporosis. Anaesthesia is usually provided during manipulation of displaced fractures or during surgical treatment. OBJECTIVES To examine the evidence for the relative effectiveness of the main methods of anaesthesia (haematoma block, intravenous regional anaesthesia (IVRA), regional nerve blocks, sedation and general anaesthesia) as well as associated physical techniques and drug adjuncts used during the management of distal radial fractures in adults. SEARCH STRATEGY We searched the Cochrane Musculoskeletal Injuries Group specialised register (January 2002), the Cochrane Controlled Trials Register (The Cochrane Library Issue 4, 2001), MEDLINE (1966 to October 2001), EMBASE (1988 to 2001 Week 48), Current Controlled Trials (December 2001) and reference lists of articles. SELECTION CRITERIA Randomised or quasi-randomised clinical trials evaluating relevant interventions for these injuries (see Objectives). We excluded pharmacological trials comparing drug dosages and, with one exception, different drugs in the same class. Also excluded were trials reporting only pharmacokinetic and/or physiological outcomes. DATA COLLECTION AND ANALYSIS All trials meeting the selection criteria were independently assessed by the three reviewers for methodological quality. Data were extracted independently by two reviewers. Quantitative data are presented using relative risks or mean differences together with 95 per cent confidence limits. Only very limited pooling of results from comparable trials was possible. MAIN RESULTS The 18 included studies involved at least 1200, mainly female and older, patients with fractures of the distal radius. All studies had serious methodological limitations, notably in the frequent failure to assess clinically important and longer-term outcomes. Five trials provided evidence that, when compared with haematoma block, IVRA provided better analgesia during fracture manipulation and enabled better and easier reduction of the fracture, with some indication of a reduced risk of later redislocation or need for re-reduction. In contrast, haematoma block was quicker and easier to perform and less resource intensive. There was inadequate evidence of relative effectiveness of different methods of anaesthesia only examined within single trials: nerve block versus haematoma block; intravenous sedation versus haematoma block; general anaesthesia versus haematoma block; general anaesthesia versus sedation; and general anaesthesia versus haematoma block and sedation. None of the three trials evaluating three different physical aspects of anaesthesia (injection site of, or extra tourniquet, for IVRA; and technique for brachial plexus block) provided conclusive evidence for the effectiveness and safety of the novel technique. Six trials examined the use of drug adjuncts. The addition of two different muscle relaxants and one analgesic was tested for IVRA; one sedative and hyaluronidase for haematoma block; and clonidine for brachial plexus block. All trials evaluating adjuncts failed to provide evidence on eventual clinical outcome. A seriously flawed study comparing bupivacaine with prilocaine for IVRA gave some insight on the potential confounding effects of treatment by different doctors on patient outcome. REVIEWER'S CONCLUSIONS There was insufficient robust evidence from randomised trials to establish the relative effectiveness of different methods of anaesthesia, different associated physical techniques or the use of drug adjuncts in the treatment of distal radial fractures. There is, however, some indication that haematoma block provides poorer analgesia than IVRA, and can compromise reduction. Given the many unresolved questions over the management of these fractures, we suggest an integrated programme of research, which includes consideration of anaesthesia options, is the way forward.
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Affiliation(s)
- H H Handoll
- University Department of Orthopaedic Surgery, Royal Infirmary of Edinburgh, Little France, Old Dalkeith Road, Edinburgh, UK, EH16 4SU.
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Choyce A, Peng P. A systematic review of adjuncts for intravenous regional anesthesia for surgical procedures. Can J Anaesth 2002; 49:32-45. [PMID: 11782326 DOI: 10.1007/bf03020416] [Citation(s) in RCA: 101] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
PURPOSE To review the use of adjuncts to intravenous regional anesthesia (IVRA) for surgical procedures in terms of their intraoperative effects (efficacy of block and tourniquet pain) and postoperative analgesia. SOURCE A systematic search (Medline, Embase, reference lists) for randomized, controlled and double-blinded studies using adjuncts to IVRA for surgical procedures was conducted. Data were collected on intraoperative effects (onset/offset and quality of block and tourniquet pain), postoperative effects (pain intensity and analgesic consumption) and side effects recorded. Statistical significance as indicated in the original report and likely clinical relevance were taken into account to arrive at a judgment of overall benefit. PRINCIPAL FINDINGS Twenty-nine studies met all inclusion criteria. Data on 1,217 study subjects are included. Adjuncts used were opioids (fentanyl, meperidine, morphine, sufentanil), tramadol, non-steroidal anti-inflammatory drugs (NSAIDs; ketorolac, tenoxicam, acetyl-salicylate), clonidine, muscle relaxants (atracurium, pancuronium, mivacurium), alkalinization with sodium bicarbonate, potassium and temperature. There is good evidence to recommend NSAIDs in general and ketorolac in particular, for improving postoperative analgesia. Clonidine 1 microg/kg also appears to improve postoperative analgesia and prolong tourniquet tolerance. Opioids are poor by this route; only meperidine 30 mg or more has substantial postoperative benefit but at the expense of postdeflation nausea, vomiting and dizziness. Muscle relaxants improve intraoperative motor block and aid fracture reduction. CONCLUSION Using NSAIDs or clonidine as adjuncts to IVRA improves postoperative analgesia and muscle relaxant improves motor block.
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Affiliation(s)
- Andrew Choyce
- Department of Anesthesia, King's College Hospital, Denmark Hill, London, UK
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Estèbe JP. [Locoregional intravenous anesthesia]. ANNALES FRANCAISES D'ANESTHESIE ET DE REANIMATION 1999; 18:663-73. [PMID: 10464534 DOI: 10.1016/s0750-7658(99)80154-3] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE To analyse current data on intravenous regional anaesthesia (IVRA), its benefits and drawbacks. DATA SOURCES Articles were obtained from a Medline search using the following search terms: 'intravenous regional anaesthesia', alone or combined with 'local anaesthetic agents', 'toxicity'. STUDY SELECTION Following articles in English and in French have been selected: main articles, original articles, update and review articles, letters to the editor and recent editorials. DATA EXTRACTION Physiopathological and pharmacological data were extracted for involved mechanisms and means for improving this technique. DATA SYNTHESIS IVRA is a reliable and efficient technique with a lower cost than general anaesthesia and well adapted for limb surgery in the ambulatory patient. Depending on the site of the surgical field, the pneumatic tourniquet is set either on the arm, forearm or wrist for the upper limb or thigh, calf or ankle for the lower limb. When set in periphery, less local anaesthetic agent is required. A wide tourniquet requires a lower inflation pressure than a double cuff tourniquet. A single cuff is as efficient as a dual cuff if shape, size and inflating pressure are appropriate. The limb occlusion pressure (LOP) is the minimal pressure required to occlude blood flow. It is assessed with either a pulse oximeter or Doppler for determination of the lowest cuff inflating pressure. The cuff is inflated to 50 mmHg above LOP. Oozing in the surgical field can be decreased by the re-exsanguination technique. Currently, lidocaine is the only local anaesthetic released in France for IVRA. Addition of a muscle relaxant, a NSAID or clonidine allows the dose of local anaesthetic agent to be decreased and improves postoperative analgesia.
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Affiliation(s)
- J P Estèbe
- Service d'anesthésie-réanimation 2, CHRU de Rennes, Hôpital Hôtel-Dieu, France
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Davis K, McConachie I. Intravenous regional anaesthesia. ACTA ACUST UNITED AC 1998. [DOI: 10.1016/s0953-7112(98)80046-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
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