REGIONAL ANESTHESIA AND PAINMANAGEMENT Section Editor Phillip 0. Bridenbaugh
A New Approach to Intravenous Regional Anesthesia Walied Y. Abdulla,
MD, SCD,
and Nihal M. Fadhil, MSC
Departments of Anesthesiology, College of Medicine, University of Basrah, Basrah, Iraq, and University of Heidelberg, Heidelberg, Germany
In an attempt to reduce the dose of local anesthetic during intravenous (IV) regional anesthesia of the upper limb, we combined 100 mg of lidocaine with 0.05 mg of fentanyl and 0.5 mg of pancuronium. The study was designed in a randomized, double-blind fashion to determine the efficacy of this approach in providing analgesia and relaxation during surgery and to evaluate its safety after immediate deflation of the tourniquet following IV drug injection. Eighty unpremedicated patients, ASA physical status I or 11, were assigned to the following groups: group A (n = 15) received 100 mg of lidocaine diluted in 40 mL of NaCl IV; groups B-D (n = 15 in each group) received 100 mg of lidocaine diluted in NaC1, with the addition of 0.05 mg of fentanyl (group B) or 0.5 mg of pancuronium (group C), or both (group D) to a total volume in all groups of 40 mL. Patients in groups A-D underwent elective operations on the forearm, wrist, and hand; for evaluation of safety, in 20 volunteers (group E) the tourniquet was immediately released after IV injection of the three drugs at the previously
I
n intravenous (IV) regional anesthesia, with the tourniquet conventionally placed over the upper arm, a relatively large dose of local anesthetic is required to induce appropriate sensory blockade. For lidocaine, 3 mg/kg administered as a 0.5% solution ensures adequate analgesia and relaxation when used for upper limb surgery. However, toxic reactions, including convulsions, coma, cardiorespiratory depression, a n d even cardiac arrest have been reported (1-8). Toxicity may be due to leakage past the tourniquet after injection caused by either tourniquet failure o r buildup of excessively high venous pressure distal to the tourniquet (9-11). In view of the possible central nervous system a n d cardiovascular toxicity, use of a n alternative approach to IV regional anesthesia with fewer side effects would be desirable. Lidocaine is considered one of the least toxic local anesthetics (12) a n d i n t he usual IV dosage of 1-2 mg/kg is safe a n d effective for treating ventricular Accepted for publication June 1, 1992. Address correspondence to Dr. Walied Abdulla, Neue Strasse 56, 0-4350 Bernburg, Germany. 01992 by the International Anesthesia Research Society 0003-2999/92/$5,00
described doses. The analgesic effect was more profound in group D compared with groups A-C. In group D, 9 of 15 patients had excellent analgesia. In six patients, pain was experienced at the beginning of surgery, but 5 min thereafter patients remained pain free. In group B, analgesia was obtained successfully in only 26.6% of cases compared with group A with 13.3%. Skeletal muscle relaxation was profound in groups C and D compared with groups A and B. Signs indicating toxicity were not encountered after release of the tourniquet in these groups. In group E, the volunteers complained of minor events, such as mild dizziness and transient visual disturbances. In one case, vomiting and hypotension with a systolic arterial blood pressure of 90 mm Hg occurred 5 min after release of the tourniquet. In conclusion, this approach to IV regional anesthesia with the combination of lidocaine, fentanyl, and pancuronium offers adequate analgesia and relaxation during upper limb surgery. (Anesth Analg 1992;75:597401)
arrhythmias (13) or attenuating the cardiovascular response to endotracheal intubation (14). O n the other hand, analgesia was insufficient when a similar dose of lidocaine administered a s a 0.25% solution was used alone for IV regional anesthesia with the tourniquet placed on the upper ar m (15). O u r clinical trials indicated that the addition of 0.05 m g of fentanyl a n d 0.5 m g of pancuronium to 100 mg of lidocaine improves the quality of analgesia and relaxation during various surgical procedures on the upper limbs. O u r double-blind study was designed to establish the efficacy of this new approach to IV regional block in controlling analgesia and relaxation during surgery. Furthermore, its safety was evaluated immediately after deflation of the tourniquet following IV drug injection.
Methods Informed consent was obtained from each patient, a n d the study was approved by the Hospital Human Investigation Committee. Eighty unpremedicated patients (46 male and 34 female), ASA physical status I
Anesth Analg 1992;75:597401
597
598
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ABDULLA AND FADHIL
or 11, were assigned in a randomized, double-blind fashion to the following groups: group A ( n = 15) received 100 mg of lidocaine diluted in 40 mL of NaCl IV; groups l3-D ( n = 15 in each group) received 100 mg of lidocaine diluted in NaCl with the addition of 0.05 mg of fentanyl (group 8)or 0.5 mg of pancuronium (group C), or both (group D), to a total volume in all groups of 40 mL. In group E ( n = 20), volunteers received 100 mg of lidocaine, 0.05 mg of fentanyl, and 0.5 mg of pancuronium, and the tourniquet was immediately released after IV injection of the drugs. Patients in groups A-D underwent various elective operations on the forearm, wrist, and hand 10 min after IV injection. Once the patient was in the operating room, a plastic intravenous cannula (20 gauge) was inserted in a distal vein of the affected hand, preferably on the dorsum. An infusion of IV fluid was commenced on the contralateral arm on which a blood pressure cuff was also applied. A bipolar lead I1 of the electrocardiogram was continuously monitored from the start of the procedure. The limb was then elevated for 5 min, and an Esmarch bandage was applied from the fingers proximally to reach a double-cuffed tourniquet applied on the upper arm. The proximal cuff was first inflated to 250-300 mm Hg with a constantpressure pneumatic inflator. The Esmarch bandage was then removed, and 40 mL of a solution was injected intravenously. Once anesthesia was started in the limb, the distal cuff on the analgesic part was inflated, and the proximal one was deflated. Surgery was begun 10 min after injection of the drugs in groups A-D, whereas the tourniquet was immediately released after injection of the drugs in group E. All patients were monitored in the standard manner. Intraoperative degree of analgesia was evaluated by the patient as well as by an observer using two different pain scores (16,17). Scores were assigned to the patient at 5-min intervals during surgery (Table 1). The subjective pain score (17) was explained to each patient on the day before surgery. To enhance its sensitivity, key descriptive phrases and pictures depicting facial expressions of pain or its absence were associated with the numbers on the score. For example, a 10 on the score was described as ”pain is excruciating,” whereas 0 was described as “no pain,” with the midsection labeled as “moderate.” Patients were instructed on the use of numerical responses to standard questions that would be asked of them with regard to skin incision and closure and intraoperative levels of pain associated with the surgical area. These instructions were reinforced preoperatively by the anesthesia staff on the day of surgery. Although different staff interviewed the patients, all instructions and questions were standardized.
ANESTH ANALG 1992;75:597401
Table 1. Objective Pain Scoring System Score
Description
0
Excellent
1
Good
2
Incomplete
3
Failure
4
Excruciating
Feature Patient was completely pain free and lying quietly Patient was satisfied but experienced minor pain for a short period during surgery Patient had significant pain relief but experienced minor pain during most of the time of surgery Patient had no pain relief during most of the time of surgery Surgery under general anesthesia
Sensation was tested by multiple pinpricks on the affected arm and by monitoring of neuromuscular blockade using train-of-four stimulation by applying four supramaximal stimuli (2 Hz) at intervals of 0.5 s over a period of 2 s at the ulnar nerve with surface electrodes. Complete neuromuscular blockade was determined by the disappearance of muscle twitch responses to train-of-four stimulation and was assessed by tactile and visual evaluation without recording equipment. Testing for statistical significance was done using two-factor analysis of variance followed by the MannWhitney test and 2 analysis. A P value < 0.05 was considered significant.
Results In all groups, there were no significant differences in age, body weight, height, gender, and general health. Likewise, surgical procedures performed on forearm, wrist, and hand in groups A-D were similar in type and included soft tissues, nerves, tendons, bone, and joints (Table 2). In addition, no significant difference in injection-release interval was found. Intraoperative degree of analgesia was assessed similarly by the patient and the observer (Table 3, Figure 1). The analgesic effect was significant in group D compared with groups A-C. In 9 of 15 patients, analgesia was excellent. In six patients, minor pain was experienced only after start of surgery, and for 5 min thereafter patients were pain free and remained so 10 min postoperatively (Table 3). Pain sensation to pinprick in group D was abolished 5-10 min after drug injection and returned immediately after release of the tourniquet. In group A, analgesia was good in only two subjects and was incomplete in two others. Analgesia failed in eight subjects, mainly 10 min after start of surgery. Three subjects were changed to general anesthesia, two of them 10 min and the third 15 min after start of surgery owing to excruciating pain that could not be
REGIONAL ANESTHESIA AND PAIN MANAGEMENT ABDULLA A N D FADHIL NEW APPROACH TO IV REGIONAL ANESTHESIA
ANESTH ANALG 1992;75:597-601
599
Table 2. Clinical Characteristics of the Five Study Groups Group A ( n = 15) Gender (M/F) 8/7 36 5 18 Age ( Y d Weight (kg) 64 11 Height (cm) 163 2 7 Duration of 32 2 11 ischemia (min) Operation 4IExcision of ganglion (No./type) YWound excision l/Removal of foreign body 2iBone graft 2/Amputation 1iFracture fixation 2/Manipula tion
*
Group B (n = 15)
Group C (n = 15)
Group D ( n = 15)
Group E (n = 20)
916 34 ? 17 69 2 12 168 t 11 31 2 9
10/5 38 ? 18 67 +- 13 163 2 10 34 t 13
9/6 40 t 21 69 -t 10 168 -t 8 36 2 13
10/10 40 2 17 62 ? 10 164 _t 10 -
2/Excision of ganglion 3/Wound excision 2/Mass excision URelease of carpal tunnel ZAmputation 2/Repair of tendon 3lManipulation
ZExcision of ganglion 3/Wound excision l/Removal of foreign body lmrainage of abscess UFracture fixation ZRelease of contracture 2/Wrist exploration 1iTendon transfer 21Manipulation
3/Excision of ganglion 3lWound excision l/Mass excision l/Bone graft 2IAmputation l/Fracture fixation 2lRepair of tendon llWrist exploration IIManipulation
M, male; F, female. Mean ? SD.
Table 3. Objective Assessment of Level of Analgesia in Four Study Groups Study group“
Level of analgesia
Successful analgesia
Excellent
Good
Incomplete
Failure
0 0 0 9
2
2 1 7 0
8 8 5 0
A
B C
D
4 1 6
Excruciating
“0.
(“/.)I
2 (13.3) 4 (26.6) 1 (6.6) 15 (100)
“n = 15 in each group
tolerated. In group B, analgesia was obtained successfully in 26.6%of subjects (Table 3). Analgesia was complete in four patients, and one patient with incomplete analgesia experienced minor pain during most of the surgery. Failure of analgesia was reported in eight cases, and general anesthesia was initiated in two patients 10-15 rnin after start of surgery. In group C, good analgesia was achieved in only one subject; it was incomplete in seven and failed in five others. In two patients, general anesthesia was necessary (Table 3). Operations on patients who had little pain relief for most of the surgery could be completed under IV block with the help of 5-10 mg of diazepam with or without IV meperidine. Neuromuscular blockade was profound in groups C and D compared with groups A and B. Complete abolition of twitch response and absence of spontaneous movements on command in groups C and D were achieved within 4-5 min after drug injection. Muscle power returned within 5-10 min after release of tourniquet. With regard to safety, questioning of patients undergoing surgery did not reveal any toxic symptoms. In group E, all volunteers complained of mild
dizziness; four developed visual disturbances starting 1 min and lasting 5-7 min after the release of the tourniquet. In another volunteer, vomiting and hypotension with systolic arterial blood pressure of 90 mm Hg occurred 5 min after release of tourniquet and returned to normal 5 min later without any IV fluid or drug administration. This volunteer’s hemoglobin was 8.6 g/dL. In six subjects, there was some difficulty in moving the affected arm. This disappeared within 15 min. Another subject experienced heaviness in the eyelids and had difficulty opening his eyes. Sinus tachycardia developed in five subjects at 2 min and subsided by itself 5-10 min after release of tourniquet. In other five subjects, tachypnea was recorded 2 min after release of tourniquet and subsided 10 min later, except in one volunteer who remained tachypneic for 20 min and had chronic bronchitis and emphysema.
Discussion Our preliminary investigation demonstrates the efficacy of the modified IV block developed at our institution, with the tourniquet conventionally placed
600
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ABDULLA AND FADHIL
Pain Score
Group A: Lidocaine 0.25% - - _Group B: Lidocaine + Fentanyl
+ Pancuronium Group D: Lidocaine + Fentanyl + Pancuronium
Group C: Lidocaine
-
/ 1
1
1
S
2
1
5
1
1
1
0
1
1
5
1
E
1
R
2
1
5
1
1
1015
Time (minutes) Figure 1. Subjective pain assessment in study groups A-D. R, release of tourniquet. E, end of surgery; S , start of surgery.
over the upper arm and with a dose of lidocaine comparable to the size of the bolus dose used for treating ventricular arrhythmias (13) or before endotracheal intubation (14). Analysis of data shows that the differences among the groups were clearly significant in group D. The patients rated their analgesia as good or excellent, and successful analgesia was achieved with a dose of no more than 100 mg of lidocaine. So far, adequate analgesia has been observed only with 0.5% lidocaine, suggesting that more dilute solutions do not appear to provide adequate analgesia (8,12,15). Accordingly, in group A with 0.25% lidocaine, heavy sedation or general anesthesia was required in eight patients. This high failure rate may have been reduced if our patients had been premedicated. The addition of 0.05 mg of fentanyl in group B significantly increased the quality of analgesia compared with group A, preserving the benefit of a low dose of local anesthetic. An additional advantage noted in our study using an upper arm tourniquet was complete muscle relaxation, which was very useful in certain operations such as those for tendolysis and proper fixation of bone fractures. The regional administration of muscle relaxants has been used for experimental, therapeutic, and diagnostic purposes (18,19). The possible mechanism by which fentanyl enhances the action of lidocaine on peripheral nerve blockade is unclear. Although no in vivo studies have demonstrated a measurable local anesthetic effect of fentanyl, in vitro studies have shown that perineural
ANESTH ANALG 1992;75597401
fentanyl depresses the action potential in nerve fibers of different types (20,21). Recordings of fastconducting A fibers and slow-conducting C fibers before and after exposure to 50 and 100 pg/mL of fentanyl indicate that a high concentration of fentanyl may partially suppress conduction in peripheral nerves and apparently does not diffuse well through a nerve sheath (20). Thus, it is unlikely that fentanyl per se would cause conduction blockade in vivo in peripheral nerves that are enclosed within a nerve sheath. Opioids are much more effective at blocking dull pain (C fibers) than acute pain (A-delta fibers). This agrees with the observation that the addition of fentanyl (50 pg/mL) to stable bupivacaine block significantly augments the effect, particularly of C fibers (21). Thus, labor and surgical pain are not completely blocked by opioids alone. The depressant effect of fentanyl on the action potential of A and C fibers in desheathed peripheral nerves is probably not related to the presence of opiate receptors in these nerves, because pretreatment with naloxone failed to inhibit the decrease in action potential produced by fentanyl (20). This also agrees with the observation that there is a virtual absence of opiate receptors in spinal ventral roots and in peripheral nerves (22). In- this regard, evidence has been presented by various investigators that opiates may have a dual mechanism of action (23,24). The primary clinical effect is related to interaction with opiate receptors after epidural or intrathecal administration. On the other hand, fentanyl may cause some depression of nerve transmission similar to that produced by local anesthetics. This fact suggests that fentanyl may possess weak local anesthetic properties. It is possible that the addition of local anesthetics to fentanyl enhances its weak local anesthetic effect to such an extent that a clinical response can be observed as in group B. The success rate in group B would probably have been even higher in premedicated patients. However, the combination of the three drugs used in group D in our study improved the quality of analgesia and relaxation in such a way that upper limb surgery could be accomplished with success in all cases. The safety of this modification was confirmed in group E by the absence of serious symptoms and signs of toxicity after release of tourniquet pressure immediately after injection of the drugs. In group E, only mild side effects attributable to the technique were noted. One person complained of transient hypotension associated with nausea after immediate deflation of the tourniquet. Thus, the low lidocaine dose used in group D represents a negligible risk in the event of accidental release of tourniquet pressure, with a further decreased risk with the addition of fentanyl and pancuronium, owing to the smaller dose of lidocaine used.
ANESTH ANALG 1992;75:597-601
REGIONAL ANESTHESIA AND PAIN MANAGEMENT ABDULLA AND FADHIL NEW APPROACH TO IV REGIONAL ANESTHESIA
Therefore the combination of these drugs may prove to be a useful adjunct to IV regional anesthesia.
References 1. Albright GA. Cardiac arrest following regional anesthesia with etidocaine or bupivacaine. Anesthesiology 1979;51:285-7. 2. Anonymous. Regional IV analgesia (editorial). JAMA 1965;193: 300. 3. Davies ]AH, Gill SS, Weber JCP. Intravenous regional analgesia using bupivacaine. Anesthesia 1981;36:331-4. 4. Davis NI, de Jong RH. Successful resuscitation following massive bupivacaine overdose. Anesth Analg 1982;61:624 5. Heath ML. Deaths after intravenous regional anesthesia. Br Med J 1982;285:9134. 6. Henderson AM. Adverse reaction to bupivacaine: complications of IV regional analgesia. Br Med J 1980;2:1043. 7. Kennedy BR, Duthie AM, Parbrook GD, Carr TL. Intravenous regional analgesia. Br Med J 1965;1:954-6. 8. Mazze RI, Dunbar RW. Intravenous regional anesthesiareport of 497 cases with a toxicity study. Acta Anaesthesiol Scand 1969;36:27-34. 9. Duggan J, McKeown DW, Scott DB. Venous pressures generated during IV regional anaesthesia. Br J Anaesth 1983;55:1158-9. 10. Grice SC, Morel1 RC, Balestrieri FJ, Stamp DA, Howard C. Intravenous regional anesthesia: evaluation and prevention of leakage under the tourniquet (abstract). Anesthesiology 1985; 63:A221. 11. Rosenberg PH, KaIso EA, Touminen MK, Linden HB. Acute bupivacaine toxicity as a result of venous leakage under the tourniquet cuff during a Bier block. Anesthesiology 1983;58: 95-8. 12. Brown EM, McGriff JT, Malinowski RW. Intravenous regional
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anaesthesia (Bier block): review of 20 years’ experience. Can J Anaesth 1989;36:307-10. 13. Gianelly R, von der Groeben JO, Spivack AP, Harrison DC. Effect of lidocaine on ventricular arrhythmias in patients with coronary heart disease. N Engl J Med 1967;277:121.59. 14. Asfar SN, Abdulla W. The effect of various administration routes of lidocaine on hemodynamics and ECG rhythm during endotracheal intubation. Acta Anaesthesiol Belg 1990;41:17-24. 15. Urban BJ, McKain CW. Onset and progression of intravenous regional anesthesia with dilute lidocaine. Anesth Analg 1982; 61:834-8. 16. Celleno D, Capogna G. Epidural fentanyl plus bupivacaine 0.125 per cent for labor: analgesic effects. Can J Anaesth 1988;35:375-8. 17. Scott J, Huskisson EC. Graphic representation of pain. Pain 1976;2:175-84. 18. Plotz J, Schreiber W, Braun J. Mehrphasige neuromuskulare Blockade wahrend und nach regionaler Anwendung von Succinylcholin beim Menschen. Anaesthesist 1981;305434. 19. Torda TAG, Klongmus DH. The regional use of muscle relaxants. Arch Surg 1967;94:199-201. 20. Gissen AJ, Gugino LD, Datta S, Miller J, Covino BC. Effects of fentanyl and sulfentanyl on peripheral mammalian nerves. Anesth Analg 1987;66:1272-6. 21. Power I, Brown DT, Wildsmith JAW. Effect of fentanyl on nerve condition. Br J Anaesth 1988;61:507-8. 22. Fields HL, Einson PC, Keigh BK, Gilbert RFT, Iverson LL. Multiple opiate receptor sites on primary afferent fibers. Nature 1980;284:351-3. 23. Dodson BA, Miller KW. Evidence for a dual mechanism in the anesthetic action of an opioid peptide. Anesthesiology 1985; 62:615-20. 24. Finegan BA, Sewedd RDE, Roth SH. Receptor and nonreceptor effects of opiod anesthetics (abstract). Anesthesiology 1984;61:A360.
A New Approach to Intravenous Regional Anesthesia Walied Y. Abdulla,
MD, SCD,
and Nihal M. Fadhil, MSC
Departments of Anesthesiology, College of Medicine, University of Basrah, Basrah, Iraq, and University of Heidelberg, Heidelberg, Germany
In an attempt to reduce the dose of local anesthetic during intravenous (IV) regional anesthesia of the upper limb, we combined 100 mg of lidocaine with 0.05 mg of fentanyl and 0.5 mg of pancuronium. The study was designed in a randomized, double-blind fashion to determine the efficacy of this approach in providing analgesia and relaxation during surgery and to evaluate its safety after immediate deflation of the tourniquet following IV drug injection. Eighty unpremedicated patients, ASA physical status I or 11, were assigned to the following groups: group A (n = 15) received 100 mg of lidocaine diluted in 40 mL of NaCl IV; groups B-D (n = 15 in each group) received 100 mg of lidocaine diluted in NaC1, with the addition of 0.05 mg of fentanyl (group B) or 0.5 mg of pancuronium (group C), or both (group D) to a total volume in all groups of 40 mL. Patients in groups A-D underwent elective operations on the forearm, wrist, and hand; for evaluation of safety, in 20 volunteers (group E) the tourniquet was immediately released after IV injection of the three drugs at the previously
I
n intravenous (IV) regional anesthesia, with the tourniquet conventionally placed over the upper arm, a relatively large dose of local anesthetic is required to induce appropriate sensory blockade. For lidocaine, 3 mg/kg administered as a 0.5% solution ensures adequate analgesia and relaxation when used for upper limb surgery. However, toxic reactions, including convulsions, coma, cardiorespiratory depression, a n d even cardiac arrest have been reported (1-8). Toxicity may be due to leakage past the tourniquet after injection caused by either tourniquet failure o r buildup of excessively high venous pressure distal to the tourniquet (9-11). In view of the possible central nervous system a n d cardiovascular toxicity, use of a n alternative approach to IV regional anesthesia with fewer side effects would be desirable. Lidocaine is considered one of the least toxic local anesthetics (12) a n d i n t he usual IV dosage of 1-2 mg/kg is safe a n d effective for treating ventricular Accepted for publication June 1, 1992. Address correspondence to Dr. Walied Abdulla, Neue Strasse 56, 0-4350 Bernburg, Germany. 01992 by the International Anesthesia Research Society 0003-2999/92/$5,00
described doses. The analgesic effect was more profound in group D compared with groups A-C. In group D, 9 of 15 patients had excellent analgesia. In six patients, pain was experienced at the beginning of surgery, but 5 min thereafter patients remained pain free. In group B, analgesia was obtained successfully in only 26.6% of cases compared with group A with 13.3%. Skeletal muscle relaxation was profound in groups C and D compared with groups A and B. Signs indicating toxicity were not encountered after release of the tourniquet in these groups. In group E, the volunteers complained of minor events, such as mild dizziness and transient visual disturbances. In one case, vomiting and hypotension with a systolic arterial blood pressure of 90 mm Hg occurred 5 min after release of the tourniquet. In conclusion, this approach to IV regional anesthesia with the combination of lidocaine, fentanyl, and pancuronium offers adequate analgesia and relaxation during upper limb surgery. (Anesth Analg 1992;75:597401)
arrhythmias (13) or attenuating the cardiovascular response to endotracheal intubation (14). O n the other hand, analgesia was insufficient when a similar dose of lidocaine administered a s a 0.25% solution was used alone for IV regional anesthesia with the tourniquet placed on the upper ar m (15). O u r clinical trials indicated that the addition of 0.05 m g of fentanyl a n d 0.5 m g of pancuronium to 100 mg of lidocaine improves the quality of analgesia and relaxation during various surgical procedures on the upper limbs. O u r double-blind study was designed to establish the efficacy of this new approach to IV regional block in controlling analgesia and relaxation during surgery. Furthermore, its safety was evaluated immediately after deflation of the tourniquet following IV drug injection.
Methods Informed consent was obtained from each patient, a n d the study was approved by the Hospital Human Investigation Committee. Eighty unpremedicated patients (46 male and 34 female), ASA physical status I
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597
598
REGIONAL ANESTHESIA AND PAIN MANAGEMENT NEW APPROACH TO IV REGIONAL ANESTHESIA
ABDULLA AND FADHIL
or 11, were assigned in a randomized, double-blind fashion to the following groups: group A ( n = 15) received 100 mg of lidocaine diluted in 40 mL of NaCl IV; groups l3-D ( n = 15 in each group) received 100 mg of lidocaine diluted in NaCl with the addition of 0.05 mg of fentanyl (group 8)or 0.5 mg of pancuronium (group C), or both (group D), to a total volume in all groups of 40 mL. In group E ( n = 20), volunteers received 100 mg of lidocaine, 0.05 mg of fentanyl, and 0.5 mg of pancuronium, and the tourniquet was immediately released after IV injection of the drugs. Patients in groups A-D underwent various elective operations on the forearm, wrist, and hand 10 min after IV injection. Once the patient was in the operating room, a plastic intravenous cannula (20 gauge) was inserted in a distal vein of the affected hand, preferably on the dorsum. An infusion of IV fluid was commenced on the contralateral arm on which a blood pressure cuff was also applied. A bipolar lead I1 of the electrocardiogram was continuously monitored from the start of the procedure. The limb was then elevated for 5 min, and an Esmarch bandage was applied from the fingers proximally to reach a double-cuffed tourniquet applied on the upper arm. The proximal cuff was first inflated to 250-300 mm Hg with a constantpressure pneumatic inflator. The Esmarch bandage was then removed, and 40 mL of a solution was injected intravenously. Once anesthesia was started in the limb, the distal cuff on the analgesic part was inflated, and the proximal one was deflated. Surgery was begun 10 min after injection of the drugs in groups A-D, whereas the tourniquet was immediately released after injection of the drugs in group E. All patients were monitored in the standard manner. Intraoperative degree of analgesia was evaluated by the patient as well as by an observer using two different pain scores (16,17). Scores were assigned to the patient at 5-min intervals during surgery (Table 1). The subjective pain score (17) was explained to each patient on the day before surgery. To enhance its sensitivity, key descriptive phrases and pictures depicting facial expressions of pain or its absence were associated with the numbers on the score. For example, a 10 on the score was described as ”pain is excruciating,” whereas 0 was described as “no pain,” with the midsection labeled as “moderate.” Patients were instructed on the use of numerical responses to standard questions that would be asked of them with regard to skin incision and closure and intraoperative levels of pain associated with the surgical area. These instructions were reinforced preoperatively by the anesthesia staff on the day of surgery. Although different staff interviewed the patients, all instructions and questions were standardized.
ANESTH ANALG 1992;75:597401
Table 1. Objective Pain Scoring System Score
Description
0
Excellent
1
Good
2
Incomplete
3
Failure
4
Excruciating
Feature Patient was completely pain free and lying quietly Patient was satisfied but experienced minor pain for a short period during surgery Patient had significant pain relief but experienced minor pain during most of the time of surgery Patient had no pain relief during most of the time of surgery Surgery under general anesthesia
Sensation was tested by multiple pinpricks on the affected arm and by monitoring of neuromuscular blockade using train-of-four stimulation by applying four supramaximal stimuli (2 Hz) at intervals of 0.5 s over a period of 2 s at the ulnar nerve with surface electrodes. Complete neuromuscular blockade was determined by the disappearance of muscle twitch responses to train-of-four stimulation and was assessed by tactile and visual evaluation without recording equipment. Testing for statistical significance was done using two-factor analysis of variance followed by the MannWhitney test and 2 analysis. A P value < 0.05 was considered significant.
Results In all groups, there were no significant differences in age, body weight, height, gender, and general health. Likewise, surgical procedures performed on forearm, wrist, and hand in groups A-D were similar in type and included soft tissues, nerves, tendons, bone, and joints (Table 2). In addition, no significant difference in injection-release interval was found. Intraoperative degree of analgesia was assessed similarly by the patient and the observer (Table 3, Figure 1). The analgesic effect was significant in group D compared with groups A-C. In 9 of 15 patients, analgesia was excellent. In six patients, minor pain was experienced only after start of surgery, and for 5 min thereafter patients were pain free and remained so 10 min postoperatively (Table 3). Pain sensation to pinprick in group D was abolished 5-10 min after drug injection and returned immediately after release of the tourniquet. In group A, analgesia was good in only two subjects and was incomplete in two others. Analgesia failed in eight subjects, mainly 10 min after start of surgery. Three subjects were changed to general anesthesia, two of them 10 min and the third 15 min after start of surgery owing to excruciating pain that could not be
REGIONAL ANESTHESIA AND PAIN MANAGEMENT ABDULLA A N D FADHIL NEW APPROACH TO IV REGIONAL ANESTHESIA
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Table 2. Clinical Characteristics of the Five Study Groups Group A ( n = 15) Gender (M/F) 8/7 36 5 18 Age ( Y d Weight (kg) 64 11 Height (cm) 163 2 7 Duration of 32 2 11 ischemia (min) Operation 4IExcision of ganglion (No./type) YWound excision l/Removal of foreign body 2iBone graft 2/Amputation 1iFracture fixation 2/Manipula tion
*
Group B (n = 15)
Group C (n = 15)
Group D ( n = 15)
Group E (n = 20)
916 34 ? 17 69 2 12 168 t 11 31 2 9
10/5 38 ? 18 67 +- 13 163 2 10 34 t 13
9/6 40 t 21 69 -t 10 168 -t 8 36 2 13
10/10 40 2 17 62 ? 10 164 _t 10 -
2/Excision of ganglion 3/Wound excision 2/Mass excision URelease of carpal tunnel ZAmputation 2/Repair of tendon 3lManipulation
ZExcision of ganglion 3/Wound excision l/Removal of foreign body lmrainage of abscess UFracture fixation ZRelease of contracture 2/Wrist exploration 1iTendon transfer 21Manipulation
3/Excision of ganglion 3lWound excision l/Mass excision l/Bone graft 2IAmputation l/Fracture fixation 2lRepair of tendon llWrist exploration IIManipulation
M, male; F, female. Mean ? SD.
Table 3. Objective Assessment of Level of Analgesia in Four Study Groups Study group“
Level of analgesia
Successful analgesia
Excellent
Good
Incomplete
Failure
0 0 0 9
2
2 1 7 0
8 8 5 0
A
B C
D
4 1 6
Excruciating
“0.
(“/.)I
2 (13.3) 4 (26.6) 1 (6.6) 15 (100)
“n = 15 in each group
tolerated. In group B, analgesia was obtained successfully in 26.6%of subjects (Table 3). Analgesia was complete in four patients, and one patient with incomplete analgesia experienced minor pain during most of the surgery. Failure of analgesia was reported in eight cases, and general anesthesia was initiated in two patients 10-15 rnin after start of surgery. In group C, good analgesia was achieved in only one subject; it was incomplete in seven and failed in five others. In two patients, general anesthesia was necessary (Table 3). Operations on patients who had little pain relief for most of the surgery could be completed under IV block with the help of 5-10 mg of diazepam with or without IV meperidine. Neuromuscular blockade was profound in groups C and D compared with groups A and B. Complete abolition of twitch response and absence of spontaneous movements on command in groups C and D were achieved within 4-5 min after drug injection. Muscle power returned within 5-10 min after release of tourniquet. With regard to safety, questioning of patients undergoing surgery did not reveal any toxic symptoms. In group E, all volunteers complained of mild
dizziness; four developed visual disturbances starting 1 min and lasting 5-7 min after the release of the tourniquet. In another volunteer, vomiting and hypotension with systolic arterial blood pressure of 90 mm Hg occurred 5 min after release of tourniquet and returned to normal 5 min later without any IV fluid or drug administration. This volunteer’s hemoglobin was 8.6 g/dL. In six subjects, there was some difficulty in moving the affected arm. This disappeared within 15 min. Another subject experienced heaviness in the eyelids and had difficulty opening his eyes. Sinus tachycardia developed in five subjects at 2 min and subsided by itself 5-10 min after release of tourniquet. In other five subjects, tachypnea was recorded 2 min after release of tourniquet and subsided 10 min later, except in one volunteer who remained tachypneic for 20 min and had chronic bronchitis and emphysema.
Discussion Our preliminary investigation demonstrates the efficacy of the modified IV block developed at our institution, with the tourniquet conventionally placed
600
REGIONAL ANESTHESIA AND PAIN MANAGEMENT NEW APPROACH TO IV REGIONAL ANESTHESIA
ABDULLA AND FADHIL
Pain Score
Group A: Lidocaine 0.25% - - _Group B: Lidocaine + Fentanyl
+ Pancuronium Group D: Lidocaine + Fentanyl + Pancuronium
Group C: Lidocaine
-
/ 1
1
1
S
2
1
5
1
1
1
0
1
1
5
1
E
1
R
2
1
5
1
1
1015
Time (minutes) Figure 1. Subjective pain assessment in study groups A-D. R, release of tourniquet. E, end of surgery; S , start of surgery.
over the upper arm and with a dose of lidocaine comparable to the size of the bolus dose used for treating ventricular arrhythmias (13) or before endotracheal intubation (14). Analysis of data shows that the differences among the groups were clearly significant in group D. The patients rated their analgesia as good or excellent, and successful analgesia was achieved with a dose of no more than 100 mg of lidocaine. So far, adequate analgesia has been observed only with 0.5% lidocaine, suggesting that more dilute solutions do not appear to provide adequate analgesia (8,12,15). Accordingly, in group A with 0.25% lidocaine, heavy sedation or general anesthesia was required in eight patients. This high failure rate may have been reduced if our patients had been premedicated. The addition of 0.05 mg of fentanyl in group B significantly increased the quality of analgesia compared with group A, preserving the benefit of a low dose of local anesthetic. An additional advantage noted in our study using an upper arm tourniquet was complete muscle relaxation, which was very useful in certain operations such as those for tendolysis and proper fixation of bone fractures. The regional administration of muscle relaxants has been used for experimental, therapeutic, and diagnostic purposes (18,19). The possible mechanism by which fentanyl enhances the action of lidocaine on peripheral nerve blockade is unclear. Although no in vivo studies have demonstrated a measurable local anesthetic effect of fentanyl, in vitro studies have shown that perineural
ANESTH ANALG 1992;75597401
fentanyl depresses the action potential in nerve fibers of different types (20,21). Recordings of fastconducting A fibers and slow-conducting C fibers before and after exposure to 50 and 100 pg/mL of fentanyl indicate that a high concentration of fentanyl may partially suppress conduction in peripheral nerves and apparently does not diffuse well through a nerve sheath (20). Thus, it is unlikely that fentanyl per se would cause conduction blockade in vivo in peripheral nerves that are enclosed within a nerve sheath. Opioids are much more effective at blocking dull pain (C fibers) than acute pain (A-delta fibers). This agrees with the observation that the addition of fentanyl (50 pg/mL) to stable bupivacaine block significantly augments the effect, particularly of C fibers (21). Thus, labor and surgical pain are not completely blocked by opioids alone. The depressant effect of fentanyl on the action potential of A and C fibers in desheathed peripheral nerves is probably not related to the presence of opiate receptors in these nerves, because pretreatment with naloxone failed to inhibit the decrease in action potential produced by fentanyl (20). This also agrees with the observation that there is a virtual absence of opiate receptors in spinal ventral roots and in peripheral nerves (22). In- this regard, evidence has been presented by various investigators that opiates may have a dual mechanism of action (23,24). The primary clinical effect is related to interaction with opiate receptors after epidural or intrathecal administration. On the other hand, fentanyl may cause some depression of nerve transmission similar to that produced by local anesthetics. This fact suggests that fentanyl may possess weak local anesthetic properties. It is possible that the addition of local anesthetics to fentanyl enhances its weak local anesthetic effect to such an extent that a clinical response can be observed as in group B. The success rate in group B would probably have been even higher in premedicated patients. However, the combination of the three drugs used in group D in our study improved the quality of analgesia and relaxation in such a way that upper limb surgery could be accomplished with success in all cases. The safety of this modification was confirmed in group E by the absence of serious symptoms and signs of toxicity after release of tourniquet pressure immediately after injection of the drugs. In group E, only mild side effects attributable to the technique were noted. One person complained of transient hypotension associated with nausea after immediate deflation of the tourniquet. Thus, the low lidocaine dose used in group D represents a negligible risk in the event of accidental release of tourniquet pressure, with a further decreased risk with the addition of fentanyl and pancuronium, owing to the smaller dose of lidocaine used.
ANESTH ANALG 1992;75:597-601
REGIONAL ANESTHESIA AND PAIN MANAGEMENT ABDULLA AND FADHIL NEW APPROACH TO IV REGIONAL ANESTHESIA
Therefore the combination of these drugs may prove to be a useful adjunct to IV regional anesthesia.
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