The Addition of Sufentanil, Tramadol or Clonidine to Lignocaine for Intravenous Regional Anaesthesia

Comparison of a single intravenous infusion of alfentanil or sufentanil combined with target-controlled infusion of propofol for daytime hysteroscopy: a randomized clinical trial

Background

The administration of either alfentanil or sufentanil as a single injection, combined with target-controlled infusion (TCI) of propofol, represents a frequently employed anesthetic regimen for daytime hysteroscopy.

Objectives

This study was designed to evaluate and compare the safety and efficacy of alfentanil and sufentanil in the context of daytime hysteroscopy.

Design

A total of 160 patients, scheduled for daytime hysteroscopy, were randomly allocated into two groups: Group A and Group S respectively received alfentanil 10 μg/kg or sufentanil 0.15 μg/kg as a single intravenous injection. Both groups were given propofol with TCI for sedation.

Methods

Monitoring of vital signs was conducted from pre-anesthesia through to 2 h postoperatively. The primary outcome measured was hypoxemia, defined as SpO2 levels below 92% for a duration of 30 s, which necessitated manual positive pressure ventilation. Secondary outcomes included various perioperative complications, such as postoperative nausea and vomiting (PONV) occurring 2 h after surgery, as well as hemodynamic indicators, NRS scores for pain, and other anesthesia-related data. This comprehensive dataset was meticulously documented and subsequently analyzed for comparative purposes.

Results

The analyses revealed that Group A had a significantly lower incidence of hypoxemia (p = 0.002) and PONV (p = 0.021). Additionally, group A demonstrated overall more stable blood pressure and heart rate, as well as higher SpO2 levels.

Conclusion

For daytime hysteroscopy, alfentanil at a dose of 10 μg/kg is safer than sufentanil at a dose of 0.15 μg/kg when combined with propofol TCI.

Trial registration

This study was registered with the Chinese Clinical Trial Registry (The URL of registration is https://www.chictr.org.cn/showproj.html?proj=177784; registration number: ChiCTR2200063939). The date of first registration was September 21, 2022.

Comparison of adjuvant therapy with midazolam, paracetamol, tramadol, or magnesium sulfate during intravenous regional anesthesia with ropivacaine: A randomized clinical trial

Background

Intravenous (IV) regional anesthesia is an easy, safe, reliable, and efficient option for inducing anesthesia during surgeries but with tourniquet-related pain. This study aimed to evaluate midazolam, paracetamol, tramadol, and magnesium sulfate administration as adjuvants with ropivacaine on pain relief and hemodynamic changes in IV regional anesthesia.

Methods

A randomized, double-blind, placebo-controlled trial was conducted in subjects undergoing forearm surgery with IV regional anesthesia. The block randomization method was used to assign eligible participants to each of five study groups. Hemodynamic parameters were assessed before applying the tourniquet, at prespecified time points (5, 10, 15, and 20 min), then and every subsequent 10 min until surgery completion. A Visual Analog Scale was used to assess pain severity at baseline followed by every 15 min until completion of the surgery, and after tourniquet deflation every 30 min to 2 h, and at 6, 12, and 24 h postoperative. Data were analyzed using Chi-square and analysis of variance with repeated data testing.

Results

The shortest onset and the longest duration of sensory block were observed in the tramadol group and the shortest onset of motor block in the midazolam group (P < 0.001). Pain score was estimated to be significantly lower in the tramadol group at the time of tourniquet application and release, and 15 min to 12 h after tourniquet release (P < 0.05). In addition, the lowest dose of pethidine consumption was observed in the tramadol group (P < 0.001).

Conclusion

Tramadol appeared to be able to effectively relieve pain, shorten the onset of sensory block, prolong the duration of sensory block, and achieve the lowest consumption of pethidine.

Dexmedetomidine as an Adjunct for Regional Anesthetic Nerve Blocks

PURPOSE OF REVIEW

This article will review current evidence related to the use of dexmedetomidine as an adjuvant for regional anesthesia.

RECENT FINDINGS

Adjuvants, frequently used during regional anesthesia, act synergistically with local anesthetics thus enhancing the quality of regional anesthesia while minimizing adverse effects. These adjuvants may be administered via different routes including topical, perineural, neuraxial, and systemic. Recent studies indicate that dexmedetomidine prolongs the duration of intravenous regional anesthesia, peripheral nerve blocks, and spinal analgesia. Controversy regarding potential neurotoxicity of perineural dexmedetomidine in patients with diabetic neuropathy requires further evaluation.

Patients' Perspective on Carpal Tunnel Release with WALANT or Intravenous Regional Anesthesia

BACKGROUND

The authors conducted a prospective study to compare patients' intraoperative experience of open carpal tunnel release under "wide awake, local anesthesia, no tourniquet" (WALANT) on the one hand and intravenous regional anesthesia on the other. The authors hypothesized that WALANT would offer a better intraoperative experience than intravenous regional anesthesia.

METHODS

Twenty-four patients with bilateral carpal tunnel syndrome had one hand operated on using WALANT and the contralateral hand with the intravenous regional anesthesia method. At the postoperative second hour, patients completed a questionnaire to quantify their pain levels on a numerical rating scale and compare the operation with dental procedures. They were also asked about their expectations and feelings about reoperation with the anesthesia methods. The results were compared for the two anesthesia methods.

RESULTS

There were no significant differences between numerical rating scale pain values during anesthetic administration or for surgical site pain on the WALANT and intravenous regional anesthesia sides. Patients reported moderate tourniquet pain for intravenous regional anesthesia sides. For WALANT sides, a significantly higher number of patients reported carpal tunnel release to be an easier procedure than dental procedures (91.6 percent WALANT and 37.5 percent intravenous regional anesthesia). For WALANT sides, a significantly higher number of patients reported carpal tunnel release to be an easier procedure than they expected (91.6 percent WALANT and 50 percent intravenous regional anesthesia). For the reoperation, 83.3 percent of patients preferred WALANT, 8.3 percent preferred intravenous regional anesthesia, and 8.3 percent reported no preference.

CONCLUSIONS

WALANT offered a better intraoperative experience. Tourniquet pain, preoperative preparation basics, and the extended anesthesia duration are likely the major drawbacks of the intravenous regional anesthesia method.

Analgesic Effect of Morphine Added to Bupivacaine in Serratus Anterior Plane Block Following Modified Radical Mastectomy. Only a Local Effect? Randomized Clinical Trial

Background

Serratus anterior plane (SAP) block, a novel regional anesthetic procedure, involves the anterolateral chest wall. Opioid receptors have been found on peripheral nerve terminals, so morphine may have a local action.

Objective

This work aimed at exploring the analgesic efficacy of morphine added to bupivacaine in SAPB in patients for whom modified radical mastectomy was conducted and whether it is a mere local effect.

Methods

Forty female patients were planned to have modified radical mastectomy participated in the study. Patients were randomly divided into two groups; Control group (C): received ultrasound-guided serratus anterior plane block with 20 mL of bupivacaine hydrochloride 0.25%; Morphine group (M): received the same in addition to 10 mg morphine sulfate. Intra- and post-operative blood samples were taken for the assessment of morphine serum levels. All patients were assessed for VAS scores during rest and movement (VAS-R and VAS-M). Time to the first request and the total amount of the rescue analgesia were recorded.

Results

In group M, Morphine was not detected in the plasma of all patients. Both VAS-R and VAS-M were significantly higher in group C than in group M (P<0.001) and (P≤0.003), respectively. Time to the first request of rescue analgesia was 8.5 h in group C compared to 20 h in group M (P=0.005) with a median dose of acetaminophen consumption of 2 g in group C compared to 1 g in group M (P=0.006).

Conclusion

Ten mg of morphine, when added to bupivacaine in SAPB, improved postoperative analgesia in patients to whom modified radical mastectomy was conducted. This effect seems to be attributed merely to local mechanisms.

Registration

The registration number of this study is NCT02962024 at www.clinicaltrial.gov.

Effects of Addition of Systemic Tramadol or Adjunct Tramadol to Lidocaine Used for Intravenous Regional Anesthesia in Patients Undergoing Hand Surgery

Intravenous regional anesthesia (IVRA) is used in outpatient hand surgery as an easily applicable and cost-effective technique with clinical advantages. The present study aimed to investigate the effects of addition of systemic tramadol or adjunct tramadol to lidocaine for IVRA in patients undergoing hand surgery. American Society of Anesthesiologists (ASA) I-II patients (n = 60) who underwent hand surgery were included. For this purpose, only lidocaine (LDC), lidocaine+adjunct tramadol (LDC+TRA group), or lidocaine+systemic tramadol (LDC+SysTRA group) was administered to the patients for IVRA and the groups were compared in terms of onset and recovery time of sensory and motor blocks, quality of anesthesia, and the degree of intraoperative and postoperative pain. The onset time of sensorial block was significantly shorter in the LDC+TRA group than that in the LDC+SysTRA group. The motor block recovery time was significantly shorter in the LDC+SysTRA group than that in the LDC+TRA and LDC groups. Administration of tramadol as an adjunct showed some clinical benefits by providing a shorter onset time of sensory and motor block, decreasing pain and analgesic requirement, and improving intraoperative conditions during IVRA. It was determined that systemic tramadol administration had no superiority.

Naloxone added to bupivacaine or bupivacaine-fentanyl prolongs motor and sensory block during supraclavicular brachial plexus blockade: a randomized clinical trial

BACKGROUND

In this study, the effect of naloxone on duration of supraclavicular brachial plexus block was evaluated. It was hypothesized that naloxone can increase the duration of neural blockade.

METHODS

Sixty-eight patients scheduled for surgery under supraclavicular brachial plexus block were randomly assigned to receive 30 ml bupivacaine (Group C); 30 ml bupivacaine with 100 μg of fentanyl (Group F); 30 ml bupivacaine with 100 ng naloxone (Group N); or 30 ml bupivacaine with 100 μg of fentanyl and 100 ng naloxone (Group N + F). Sensory and motor blockade were recorded at 5, 15, and 30 min following the block, and every 10 min following the end of surgery. Duration of sensory and motor block was considered to be the time interval between the complete block and the first postoperative pain and complete recovery of motor functions.

RESULTS

Sensory and motor onset times were the same in all groups. The duration of sensory and motor block in Group C (11.3 ± 1.7 h and 4.56 ± 1.0 h) and Group F (12.8 ± 3.3 h and 5.1 ± 2.0 h) were less than in the other groups (18.1 ± 2.2 h and 6.18 ± 1.0 h in Group N, and 15.8 ± 2.9 h and 6.53 ± 1.1 h in Group N + F, P < 0.0001).

CONCLUSION

Addition of naloxone to bupivacaine in supraclavicular brachial plexus block prolonged the duration of the neural blockade.

Intravenous regional anesthesia: a review of common local anesthetic options and the use of opioids and muscle relaxants as adjuncts

Purpose

To provide a review of local anesthetic (LA) agents and adjuncts, opioids and muscle relaxants, and their intraoperative effects and postoperative outcomes in intravenous regional anesthesia (IVRA).

Source

A search for prospective, double-blind, randomized controlled trials evaluating LA agents, opioids and muscle relaxants as adjuvants for IVRA, was conducted (MEDLINE^®, Embase). Intraoperative benefits (onset/recovery of sensory and motor block, intraoperative analgesia, tourniquet pain), postoperative benefits (pain score, analgesic consumption, time to first analgesia), and side effects were recorded. A conclusion for overall benefit was made based on statistical significance and clinical relevance.

Findings

Thirty-one studies were evaluated, with data collected on 1523 subjects. LA agents evaluated were lidocaine, ropivacaine, and prilocaine. Adjuncts evaluated were opioids ( morphine, fentanyl, meperidine, sufentanil, tramadol) and muscle relaxants (pancuronium, atracurium, mivacurium, cisatacurium). There was good evidence that ropivacaine provided effective IVRA and improved postoperative analgesia. Lidocaine and prilocaine were effective LA agents, however they lacked postoperative benefits. Morphine, fentanyl, and meperidine as sole adjuncts did not demonstrate clinically significant benefits or result in an increased risk of side effects. Sufentanil data was limited, but appeared to provide faster onset of sensory block. Tramadol provided faster onset of sensory block and tourniquet tolerance, however postoperative benefits were not consistent and the risk of minor side effects increased. Muscle relaxants improved the quality of motor block, but at the expense of delayed motor recovery. The combination of fentanyl and muscle relaxants can achieve an equivalent quality of IVRA with 50% reduction in LA dose, but at the expense of a potentially slower onset of sensory block.

Conclusion

Ropivacaine is effective for IVRA and improves postoperative analgesia. Muscle relaxants enhance the motor block and when combined with fentanyl allow for an equivalent quality of IVRA with 50% reduction in LA dose.

Alpha-2-agonists in day case anaesthesia

PURPOSE OF REVIEW

Alpha-2-agonists have long been known to have anaesthetic-sparing, sedative and analgesic properties which are desirable in day case anaesthesia. Their routine use was hampered by a high incidence of undesirable effects, however. In recent years, there have been many attempts to define a role for these unique agents in which their benefits would outweigh their apparent disadvantages.

RECENT FINDINGS

Many recent studies have confirmed the usefulness of alpha-2-agonists in providing sedation and analgesia, although the results have been far from consistent. Some, but by no means all studies have shown advantages over alternative agents, but concerns also remain over acute and possible long-term adverse effects.

SUMMARY

Alpha-2-agonists still have no clearly defined routine role in day surgery. Their most promising application is in limiting recovery agitation in children, but even here, there remain concerns about their routine use.

Dexmedetomidine: clinical application as an adjunct for intravenous regional anesthesia

The selective α-2 adrenoceptor agonist, dexmedetomidine, has been shown to be a useful, safe adjunct in perioperative medicine. Intravenous regional anesthesia is one of the simplest forms of regional anesthesia and has a high degree of success. However, intravenous regional anesthesia is limited by the development of tourniquet pain and its inability to provide postoperative analgesia. To improve block quality, prolong postdeflation analgesia, and decrease tourniquet pain, various chemical additives have been combined with local anesthetics, although with limited success. The antinociceptive effects of α-2 adrenoceptor agonists have been shown in animals and in humans. However, less is known about the clinical effects of dexmedetomidine when coadministered with local anesthetics in patients undergoing intravenous regional anesthesia. This review examines what is currently known to improve our understanding of the properties and application of dexmedetomidine when used as an adjunct in intravenous regional anesthesia.

An ultra-low dose of naloxone added to lidocaine or lidocaine-fentanyl mixture prolongs axillary brachial plexus blockade

INTRODUCTION

In this prospective, randomized, double-blind study, we evaluated the effect of an ultra-low dose of naloxone added to lidocaine and fentanyl mixture on the onset and duration of axillary brachial plexus block.

METHODS

One hundred twelve patients scheduled for elective forearm surgery under axillary brachial plexus block were randomly allocated to receive 34 mL lidocaine 1.5% with 3 mL of isotonic saline chloride (control group, n = 28), 34 mL lidocaine 1.5% with 2 mL (100 microg) of fentanyl and 1 mL of isotonic saline chloride (fentanyl group, n = 28), 34 mL lidocaine 1.5% with 2 mL saline chloride and 100 ng (1 mL) naloxone (naloxone group, n = 28), or 34 mL lidocaine 1.5% with 2 mL (100 microg) of fentanyl and 100 ng (1 mL) naloxone (naloxone + fentanyl group, n = 28). A multiple stimulation technique was used in all patients. After performing the block, sensory and motor blockades of radial, median, musculocutaneous, and ulnar nerves were recorded at 5, 15, and 30 min. The onset time of the sensory and motor blockades was defined as the time between the last injection and the total abolition of the pinprick response and complete paralysis, respectively. The duration of sensory and motor blocks was considered as the time interval between the complete block and the first postoperative pain and complete recovery of motor functions.

RESULTS

Sensory and motor onset times were longer in the naloxone (sensory onset time: 15 +/- 3, and motor onset time: 21 +/- 4) and naloxone + fentanyl group than control or fentanyl groups (sensory onset time: 10 +/- 3 min in control group, 10 +/- 4 min in fentanyl group, and 17 +/- 3 min in naloxone + fentanyl group, motor onset time: 15 +/- 5 min in control group, 14 +/- 7 min in fentanyl group, and 17.3 +/- 3.4 min in naloxone + fentanyl group) (P < 0.001). The duration of time to first postoperative pain and motor blockade was significantly longer in the naloxone (92 +/- 10 and 115 +/- 10 min) and naloxone + fentanyl groups (98 +/- 12 and 122 +/- 16 min) than control (68 +/- 7 and 89 +/- 11 min) and fentanyl groups (68 +/- 11 and 90 +/- 12 min) (P < 0.001). The time to first postoperative pain was significantly longer in the naloxone and naloxone + fentanyl groups than in the control or fentanyl groups (P < 0.001).

CONCLUSIONS

The addition of an ultra-low dose of naloxone to lidocaine 1.5% solution with or without fentanyl solution in axillary brachial plexus block prolongs the time to first postoperative pain and motor blockade but also lengthens the onset time.