Does the use of ketamine or nitroglycerin as an adjuvant to lidocaine improve the quality of intravenous regional anesthesia?

Efficacy and Safety of Adding Ketamine to Lidocaine in Intravenous Regional Anesthesia: A Meta-analysis of Randomized Controlled Trials

PURPOSE

To systematically evaluate the efficacy and safety of adding ketamine (K) to lidocaine (L) for intravenous regional anesthesia (IVRA).

DESIGN

A systematic review and meta-analysis.

METHODS

A comprehensive search of the Cochrane library, Embase, PubMed, Web of Science, and ProQuest databases, and the Google Scholar search engine was conducted from inception to March 2023. All retrieved articles were imported into Endnote X20 software and independently screened by two researchers according to predetermined inclusion and exclusion criteria. The data were analyzed using Revman 5.4 software and the assessed outcomes included the time of sensory and motor block onset, time of sensory and motor block recovery, fentanyl consumption, time of tourniquet pain onset, intraoperative and postoperative visual analog scale scores, and complications.

FINDINGS

A total of 532 patients from 11 randomized controlled trials were included in the meta-analysis. The results showed that the time of sensory (P < .00001) and motor block onset (P < .00001) were shorter in the L + K group than in the L-only group. The time of sensory (P = .01) and motor block recovery (P = .006) and time of tourniquet pain onset (P < .00001) were longer in the L + K group than in the L-only group. There was a significant reduction in fentanyl consumption (P = .0002) in the L + K group compared to the L-only group. Moreover, the visual analog scale scores in the L + K group were significantly lower than the L-only group 10 minutes (P = .04), 20 minutes (P = .0004), 30 minutes (P < .00001), and 40 minutes (P < .0001) after tourniquet inflation, and 5 minutes (P < .00001), 15 minutes (P = .04), 30 minutes (P = .008), 1 hour (P = .002), 2 hours (P < .00001), and 4 hours (P < .00001) after tourniquet deflation. There was no evidence that the use of K as an adjuvant in IVRA increased adverse effects.

CONCLUSIONS

The addition of K to L in IVRA shortened the onset time, prolonged the block time, and reduced intraoperative and postoperative pain without increasing complications.

Development of novel intravenous regional anaesthetic technique for desensitization of hoof in cattle

The cattle having hoof diseases were selected in the study and divided into 2 groups having 6 animals in each group. For induction of intravenous regional anesthesia, tourniquet was placed circumferentially at the metacarpus and just below dewclaw in group 1 and 2, respectively. Mixture of lignocaine and ketamine (L+K) (4 mg/kg and 3 mg/kg b. wt.) was injected in the radial vein in group 1 animals. However, in group 2 animals the dose of L+K was halved (2 mg/kg and 1.5 mg/kg b. wt.) and injected in the dorsal common digital vein III. The anesthetic potency was monitored by observing the HR, PR, RR, systolic pressure, diastolic pressure and SPO2. In group 1 the heart rate decreased significantly at 10 min interval. Peripheral oxygen saturation significantly decreased up to 60 min and 40 minutes in group 1 and 2 animals, respectively. Systolic pressure significantly increased at 60 minute interval in group 1 animals. After removal of tourniquet, systolic pressure and diastolic pressure was significantly increased in group 2. Sensory and motor block onset time was less in group 2 as compared to group 1. Sensory and motor block recovery time was long in group 2 as compared to group 1 animals. It was concluded that novel IVRA technique was more safe as compared to standard IVRA for the hoof anesthesia in cattle because low doses of local anesthetic are required in this technique with early sensory and motor block, and prolonged effect.

Effect of ketamine combined with lidocaine in pediatric anesthesia

Background

We conducted a randomized clinical trial to determine whether adjunctive lidocaine diminishes the incidence of adverse effects in pediatric patients sedated with ketamine.

Methods

This case‐control study involved 586 consecutive pediatric patients necessitating anesthesia. Then systolic blood pressure, heart rate, respiratory rate, and blood oxygen saturation were observed. Alanine aminotransferase (ALT), aspartate aminotransferase (AST), urea nitrogen (BUN), and creatinine (Cr) levels were tested. General dose of ketamine, the time of onset and duration of anesthesia and postoperative recovery, anesthesia effect, and adverse reaction were subsequently compared. High‐performance liquid chromatography was employed to detect ketamine concentration at different time points after administration, and the postoperative cognition function was further evaluated.

Results

Intra‐ and post‐operation, the rising degree of ALT, AST, BUN, and Cr in patients treated with ketamine was higher than those in patients treated with the ketamine‐lidocaine complex. General dose of ketamine, the time of onset and duration of anesthesia, postoperative recovery time, and the incidence rate of adverse reaction in patients treated with ketamine‐lidocaine complex were lower, but the concentration of ketamine was higher compared to the patients treated with ketamine. In patients treated with the ketamine‐lidocaine complex, elimination half‐life of ketamine was prolonged, the area under curve was increased, and the plasma clearance rate was decreased relative to those with ketamine alone.

Conclusions

Ketamine combined with lidocaine may be beneficial in shortening the onset of anesthesia, promoting postoperative awake, prolonging elimination half‐life, increasing area under curve, and decreasing plasma clearance rate and incidence of adverse reactions.

Does the Use of Nitroglycerin Patch Improve Local Anaesthetic Effects in Bier's Block? A Double-Blind Placebo Controlled Study

Aim

The aim of the study was to assess the nitroglycerin patch as a new additive to Bier's block and its impact on the effects and dose of lidocaine.

Methods

Forty patients of each sex belonging to ASA I or II underwent elective tendon repair surgeries of the forearm and hand. The patients were divided into two equal groups as follows: Group C received only lidocaine (1.5 mg/kg, 0.25%) and Group N received lidocaine (1.5 mg/kg, 0.25%) + 5 mg transcutaneous nitroglycerin patch. Onset and recovery times for sensory and motor block, visual analogue scale (VAS) scores for bandage pain, postoperative VAS score, analgesic requirements, patients' satisfaction, and surgeons' opinion were recorded.

Results

Sensory block onset time was shorter in Group N (3.80 ± 1.0) than that in Group C (5.72 ± 1.46), and motor block onset time was shorter in Group N (10.72 ± 1.93) than that in Group C (13.56 ± 1.26). Sensory block recovery time was prolonged in Group N (10.56 ± 1.12) than Group C (6.88 ± 1.45), recovery time of motor block was prolonged in Group N (13.04 ± 1.57) than Group C (11.96 ± 1.72). Bandage pain had lower VAS scores in Group N. Postoperative VAS scores showed significant differences between both groups at the following points of measurement: 30 minutes, 1 hour, and 4 hours after bandage deflation. Postoperative analgesic effect was the longest in Group N (187.20 ± 60.79 min) than Group C (51.60 ± 25.28 min). Patients' satisfaction and surgeons' opinion were better in Group N than Group C.

Conclusion

Supplementation of Bier's block with transcutaneous nitroglycerin patch reduces the lidocaine dose, the sensory and motor block onset times, VAS scores, and analgesic consumption intra- and postoperatively. Length of the block recovery times for the sensory and motor effects, duration of postoperative analgesic effect, and the first time to analgesic requirement improved the quality of Bier's block with better patients' satisfaction and surgeons' opinion and had no adverse effects.

Evaluating the quality of intravenous regional anesthesia following adding dexamethasone to lidocaine

Objectives:

The quality of anesthesia in intravenous regional anesthesia (IVRA) has been evaluated in many studies so far. This study was designed to evaluate the effects of adding the dexamethasone to lidocaine on the quality of IVRA.

Materials and Methods:

A double-blind clinical trial was set up involving 50 hand surgery candidates, 20 to 55 years old, and with American Society of Anesthesiologists class of I and II. Patients were randomly allocated into two groups of 25 cases and received either 3 mg/kg of lidocaine (control group) or 3 mg/kg of lidocaine plus 8 mg of dexamethasone (study group). The onset and recovery times from sensory and motor blocks, the starting time of tourniquet pain, the amount of narcotics needed during patients’ recovery, and probable side-effects were all compared between the two groups.

Results:

No significant differences were detected concerning age, gender, length of surgery and the mean time of starting of tourniquet pain between the two groups. The mean times of both sensory (P = 0.002) and motor (P = 0.004) blocks onset were significantly shorter in the study group. The mean time of recovery from sensory block was significantly longer in the study group (P = 0.01). The average amount of narcotics needed during the recovery was significantly lower in the study group (P = 0.01). No side-effect was detected.

Conclusion:

We conclude that adding the dexamethasone to lidocaine can improve the quality of anesthesia in IVRA.

Ketamine could aggravate central nervous toxicity of lidocaine in rats convulsive model

Previous studies demonstrated that systemic administration of lidocaine could induce central nervous toxicities, including behavioral convulsion as well as cognitive and cellular injury. Ketamine, a general anesthetic, is commonly used as an adjuvant in regional anesthesia with combination of lidocaine. The present was designed to investigate the effects of ketamine in central nervous toxicities of lidocaine. Ketamine (1.2 mg/kg, i.v.) was intravenously injected before and/or after administration of lidocaine in rats. After injection of lidocaine, convulsive behaviors of rats were scored according to the modified Racine scale. Cognitive functions and pathology of hippocampus CA3 pyramid neurons of these rats were evaluated on the one, three, five, and seven days after lidocaine induced convulsion. Both pre- and/or post-administration of ketamine (1.2 mg/kg) could significantly improve lidocaine induced convulsive behaviors of rats (P < 0.01). One, three, five, and seven days after lidocaine induced convulsion, cognitive function and pathology of hippocampus CA3 pyramid neurons of these rats were significantly impaired. In addition, cognitive functions and pathology of neurons of the rats that received ketamine (both pre- and/or post-) were further impaired, compared to the rats without ketamine. We conclude that both pre- and/or post-administration of ketamine could improve lidocaine induced convulsive behaviors. However, cognitive functions and pathology of neurons of these rats are further impaired, compared to the rats without ketamine. This result indicates that ketamine combined with lidocaine might be risky in regional anesthesia.

Addition of ketamine or dexmedetomidine to lignocaine in intravenous regional anesthesia: A randomized controlled study

Introduction:

Ketamine and dexmedetomidine decrease anesthetic requirement and provide analgesia to patients. We designed this study to compare the effect of dexmedetomidine and ketamine when added to lignocaine in intravenous regional anesthesia (IVRA).

Materials and Methods:

Seventy two patients undergoing hand surgery were randomly assigned to three groups to receive IVRA. They received 20 ml of 1% lignocaine and either 1 ml of isotonic saline (Group L, n = 24); or 0.5 mg/kg body weight ketamine (Group LK, n = 24) or 1 mcg/kg body weight dexmedetomidine (Group LD, n = 24). Sensory and motor block onset and recovery time were noted. After the tourniquet deflation, pain and sedation values, time to first analgesic requirement and any side effects were noted.

Results:

Shortened sensory and motor block onset times (69.17 min and 7.83 min respectively, P < 0.0001) and improved quality of anesthesia (satisfaction score = 3, P < 0.05) were found in ketamine group. Visual analog scale scores (3.21 ± 0.41) were comparable while time to first analgesic requirement (166.25 ± 25.89 min, P < 0.0001) was significantly longer in dexmedetomidine group after tourniquet release.

Conclusion:

We conclude that the addition of 1 mcg/kg of body weight dexmedetomidine or 0.5 mg/kg of body weight ketamine to lignocaine for IVRA improves quality of anesthesia and perioperative analgesia without causing side effects. We considered ketamine reduced the time for onset of block, delayed the onset of tourniquet pain, and reduced postoperative analgesic requirement and had a better patient satisfaction than placebo or dexmedetomidine.

The Effect of Adding Magnesium Sulfate to Lidocaine Compared with Paracetamol in Prevention of Acute Pain in Hand Surgery Patients Under Intravenous Regional Anesthesia (IVRA)

INTRODUCTION

This study was done to compare the analgesic effects of "magnesium plus lidocaine", "paracetamol plus lidocaine", and "placebo plus lidocaine" on block characteristics for intravenous regional anesthesia (IVRA) in patients undergoing upper extremity orthopedic surgery.

METHODS

In a double-blind, placebo-controlled randomized clinical trial, 90 patients were selected and entered randomly into three study groups after applying the inclusion and exclusion criteria. Time to start of the sensory and motor block were measured separately and also the duration of these two block types were measured. Post-op pain assessment was measured using a numeric rating scale. Venous samples were checked and compared regarding blood gas and pH measurements.

RESULTS

The time from drug injection to sensory block onset was the shortest in the magnesium plus lidocaine group; the time from drug injection to the time of motor block onset was the shortest in the lidocaine plus magnesium group; the duration of the motor block was the longest in the lidocaine plus magnesium group.

DISCUSSION

Addition of magnesium lidocaine in patients undergoing upper extremity orthopedic operations using IVRA decreases significantly the time gap between drug administration and the start of the block; also, this drug combination increases the IVRA block length, while paracetamol does not have such a significant effect.

Preincisional administration of intravenous or subcutaneous infiltration of low-dose ketamine suppresses postoperative pain after appendectomy

BACKGROUND

Ketamine, an N-methyl-D-aspartate receptor antagonist, can suppress hyperalgesia and allodynia. The purpose of the present study was to evaluate the clinical efficacy of preincisional intravenous or subcutaneous infiltration of ketamine for postoperative pain relief after appendectomy.

METHODS

Ninety patients, aged 18-60 years, scheduled for appendectomy was enrolled in this study. Patients were divided into three groups of 30 each and received subcutaneous infiltration of ketamine 0.5 mg/kg (KS), intravenous ketamine 0.5 mg/kg (KI), or subcutaneous infiltration of normal saline 3 mL (C) before surgery. Visual analog scale (VAS) values and analgesic consumption were evaluated for 24 hours after surgery.

RESULTS

VAS scores were significantly lower at the time of arrival in the recovery room, and at 10, 20, and 30 minutes thereafter in group KI and group KS compared with group C (P < 0.05). VAS scores were not significantly different between group KI and group KS at these intervals. Postoperative VAS scores were significantly lower at 6, 12, 18, and 24 hours in group KI compared with group C (P < 0.05). In group KS, the postoperative VAS score was significantly lower at 6 hours (P < 0.05). VAS scores were significantly lower at 12, 18, and 24 hours after surgery in group KI compared with group KS (P < 0.05).

CONCLUSION

A 0.5 mg/kg dose of ketamine given at approximately 15 minutes before surgery by the intravenous route provided analgesia for 24 hours after surgery in patients undergoing appendectomy.