Continuous

intravenous

regional anesthesia

This study evaluates the effectiveness of continuous intravenous regional anesthesia for prolonged operations on the upper extremity. The factors evaluated include patient’s sex and age, number of procedures performed, technical complications, first tourniquet

tourniquet on and off times, anesthetic doses, adjunctive drugs used, and side effects. Seventy-two

time averaged 58 minutes.

procedures were done on 34 patients. The

Off time averaged

10 minutes.

Second tourniquet

time averaged 33 minutes, and the mean total tourniquet time was 91 minutes. The mean first anesthetic

dose was 275 mg. Mean second anesthetic

dose was 128 mg. Mean total anesthetic

dose was 402 mg. There were two (6%) technical complications effects. Continuous

intravenous

and two (6%) patients had side

regional anesthesia offers the prolonged anesthesia of brachial

plexus block or genera1 anesthesia

and the safety, reliability,

and ease of intravenous

regional

anesthesia. Continuous intravenous regional anesthesia should be considered an alternative choice of anesthetic method in upper extremity surgery. (J HAND

SURC

1992;17A:82-6.)

Laurence T. Glickman, MD, MSc, FRCSC, Toronto, Ontario, Canada, Susan E. Mackinnon, MD, FRCSC, FACS, St. Louis, MO., T. Vasudera Rao, MD, FRCP, and Steven J. McCabe, MD, FRCSC, Toronto, Ontario, Canada

I

ntravenous regional anesthesia (IVRA) is a commonly used method of upper extremity anesthesia. IVRA was first described by Bier in 1908l but was largely ignored until 1963, when Holmes2 modified and popularized the technique. The main limitation of IVRA is the necessity of tourniquet deflation after a limited period of time. This method of upper extremity anesthesia is applicable to operations that can safely be completed within 1% hours. In 1966, Brown3 described a case report of prolonged IVRA. In this report, Brown left an indwelling cathether in place so that anesthesia could be reestablished

by reinflating the tourniquet and injecting an additional quantity of local anesthesia in the extremity. Brown subsequently described his technique and protocol in 1969 and again in 1989.4* 5 The potential hazards of general anesthesia and brachial plexus block make this alternative method of anesthesia (IVRA) potentially attractive to the reconstructive hand surgeon. The purpose of this study was to evaluate the effectiveness of continuous intravenous regional anesthesia (CIVRA) in prolonged surgery of the upper extremity. Materials

From the Department of Surgery, Division of Plastic Surgery and the Department of Anesthesiology, Sunnybrook Health Science Centre, University of Toronto, Toronto, Ont., Canada, and the Division of Plastic Surgery, Department of Surgery, Washington University School of Medicine, St. Louis, MO. Received for publication 24, 1990.

May 3, 1990; accepted in revised form Oct.

No benefits in any form have been received or will be received from a commercial party related directly or indirectly to the subject of this article. Reprint requests: Susan E. Mackinnon, Washington University School of Medicine, Division of Plastic Surgery, Suite 17424, One Barnes Hospital Plaza, St. Louis, MO. 63110. 311126988

82

THE JOURNAL OF HAND SURGERY

and methods

A prospective study of patients having upper extremity surgery was undertaken. Patients with upper extremity infections, cardiac disease, or those requiring less than 45 minutes of anesthesia were excluded from the study. Procedures on nerves, tendons, bone, soft tissue, or vessels were included. Patients were given the choice of regional or general anesthesia after explanation of these techniques. All patients were adults. Technique. A protocol, adapted and modified from Brown,’ was followed by the anesthesia and surgical teams (Table I). The method requires the scrubbed surgeon or anesthetist to prepare the arm and place a 20gauge angiocatheter in a vein anywhere below the tourniquet. A “U connector” (Parke Davis, Utah) and extension tubing (Professional Medical Products, Ocala,

Vol. 17A. No. 1 January 1992

Continuous intravenous regional anesthesia

83

Fig. 1. CIVRA protocol requires sterile technique. The patient, surgeon,

and anesthetist are shown. After venous access is secured, the extremity is elevated and exsanguinated and the tourniquet inflated. The Esmarch bandage is then removed. The Op-site dressing covering the intravenous line will be trimmed and iidocaine injected

Fla.) are then attached to the catheter and are secured in place with an Op-site (Smith and Nephew, Lachine, Quebec) dressing. The tubing is passed to the anesthetist. The arm is then exsanguinated with an Esmarch or sterile tensor bandage (Fig. l), and a double tourniquet is inflated to 100 mm Hg above the patient’s systolic blood pressure. Plain lidocaine (Astra Pharma Inc., Mississauga, Ontario), 20 to 60 ml of 0.5% concentration, is then slowly injected by the anesthesiologist. After 5 to 10 minutes surgery is begun. When the tourniquet is deflated, hemostasis is obtained. After 5 to 15 minutes the arm is reexsanguinated and half of the original dose (usually 20 ml of 0.5% lidocaine) is injected, and anesthesia is reestablished. In this manner, surgery can be done over an extended period of time. The volume and concentration of anesthetic varied somewhat according to the anesthetist’s preference. Although the protocol was followed in all cases, in two patients the first dose received exceeded by 300 mg that recommended by the manufacturer.

Table I. Continuous anesthesia protocol

intravenous

regional

Test equipment Apply cast padding to arm to protect skin* Place double tourniquet over cast padding Prepare and drape upper extremity Start intravenous line in antecubital vein or dorsal wrist vein Attach “U” connector and extension tubing and secure with Op-site dressing Exsanguinate extremity using Esmarch or sterile tensor bandage Inflate tourniquet to 100 mg Hg above systolic pressure Remove Esmarch bandage Assure absence of radial artery pulsation Slowly inject 40-60 ml of 0.5% lidocaine solution? At the end of 25 to 90 minutes, deflate tourniquet Leave deflated for 5 to 15 minutes. establish hemostasis Raise arm and reapply sterile Esmarch bandage Inflate tourniquet Add 20 to 30 ml of 0.5% lidocaine solution *A proximal tourniquet block may be perfomed before tourniquet inflation. tAnestbesi&gist may vazy the concentration and volume of lidocaine administered and may use supplemental injections of lidocaine if adequate analgesia has not been obtained with the initial bolus doses.

84

The Journal of HAND SURGERY

Glickman et al.

Table II. Procedures performed on 34 patients under CIVRA Number

Median nerve decompression-wrist Neuroma transposition Ulnar nerve transposition-elbow Median nerve decompression-forearm Tenolysisicapsulotomy Radial nerve decompression Tendon transfer Ulnar nerve decompression-wrist Neurolysis (internal) Nerve grafts Microvascular arterial repair TOTAL

13 11 10 8 -I 6 5 4 4 3

I 72

Results Patient

population.

Thirty-four patients had CIVRA. Seventeen men and 17 women were studied. The mean age was 42 years, with a range from 22 to 65 years of age. Procedures. A total of 72 procedures were done on 34 patients for an average number of 2.2 procedures per patient. Six patients had one procedure, 16 patients had two procedures, 11 patients had three procedures, and one patient had four procedures performed (Table II). Tourniquet time. The first tourniquet time averaged 58 minutes, with a range from 23 to 90 minutes. The off time averaged 9 minutes, with a range from 5 to 15 minutes, and the second tourniquet time averaged 33 minutes, with a range from 13 to 80 minutes. The mean total tourniquet time was 91 minutes, with a range from 37 to 170 minutes. Anesthetic agents. Lidocaine was used in all patients. The first dose averaged 274 mg (range, 240 to 450 mg). The second dose averaged 128 mg (range, 50 to 275 mg) . The mean total dose was 40 1 mg (range, 300 to 675 mg). Supplemental medications. Additional agents used included midazolam (Versed, Hoffmann La Roche, Etobicoke, Ontario), diazepam (Valium, Hoffman La Roche, Etobicoke, Ontario) and fentanyl (Sublimaze, Janssen, Piscataway, N. J.). Overall, 80% of patients had additional intravenous sedation during the procedures. Side effects. The side effects included tinnitus in one patient and dizziness in one (6%) patient. No patients experienced bradycardia, nystagmus, dysrythmias, or diplopia.

Technical complications. Technical complications occurred in two patients. One had temporary dislodgement of the catheter and a second patient had a partial tourniquet leak. Two patients had partial blocks and required supplemental local anesthesia. Overall, technical complication rate was 6%. However, all operations were completed without incident. All patients were satisfied and none complained about the technique of anesthesia. Discussion The technique of CIVRA has been adapted and modified only slightly from Brown’s protocols (Table I). Use of a U connecting tube and an Op-site adhesive dressing facilitates the technical aspects of the procedure and ensures that the entire procedure is done using sterile technique. A total of 72 procedures were done on our patients (Table II). An average of two procedures, (such as a median nerve decompression at the wrist and a submuscular ulnar nerve transpositon at the elbow) were performed on each patient. The technique was not used for primary carpal tunnel release alone. Tendon grafts, nerve grafts, ligament reconstructions, and tendon transfers have all been treated successfully using CIVRA. The patient having surgery on a peripheral nerve is especially suited to CIVRA inasmuch as the risk of additional neurologic injury is avoided.6-‘0 Tourniquet times in IVRA are generally limited to 90 minutes, although operations as long as 6 hours have syndromes and been reported. ” Nerve compression ischemic changes in muscle have been well documented after prolonged tourniquet times.‘2-‘4 In our series, the first tourniquet time averaged 58 minutes and was never longer than 90 minutes. The tourniquet was released for an average of 10 minutes. We generally leave the tourniquet down for 5 minutes for each 30 minutes of inflation. The second tourniquet time averaged 32 minutes, and the mean total tourniquet time was 90 minutes. The distinct advantages of releasing the tourniquet before 90 minutes are (1) limiting both pressure and ischemit injury to the underlying nerves and muscles, (2) allowing the surgeon to obtain hemostasis, and (3) providing relief from tourniquet-related pain. Most patients regained sensibility after 8 to 12 minutes, and at this time the arm was reexsanguinated and anesthesia reestablished to either carry on with the procedure or, in some cases, close the incisions. Our longest case (170 minutes) involved excising a median nerve neuroma, doing an internal neurolysis, a nerve graft, and a tendon transfer.

Vol. 17A. No. I January 1992

The average first dose of lidocaine was 274 mg. Like Brown, ‘-zwe generally used half the initial dose for the second tourniquet, and this was sufficient in all but three cases. These patients required “topping up” of their second dose of anesthetic. This is another distinct advantage of having venous access during the block. If needed, additional anesthetic can be injected without disturbing the surgery in progress. Approximately 80% of our patients had supplemental sedation in the form of either a benzodiazepine or a narcotic. This additional relaxation proved to be helpful, especially in anxious patients. No patients complained of excessive sedation or disorientation. Several patients were amnesic of the procedure itself. Toxicity was low in this series and compares favorably with most series.‘. ‘. “-” Two patients complained of either dizziness or tinnitus. No patients had cardiac toxicity or severe central nervous system toxicity despite some patients having large total doses of lidoCaine. Severe complications and even death have been reported in association with IVRA.“.*’ As with any anesthetic procedure, drug expertise is critical. A recent editorial” addresses the concept of “maximum recommended dose” of local anesthetics. This report states that the most common cause of acute systemic toxicity is the accidental direct intravascular injection. and it also stresses that plasma lidocaine levels vary considerably depending on the site of injections.” Toxic plasma level (5 kg/ml) is achieved with a 300 mg intercostal, a 500 mg extradural, a 600 mg brachial plexus. or a 1000 mg subcutaneous injection.” The disadvantages of general anesthesia, the reported complications of brachial plexus block,6~‘0 and the short duration of action of IVRA prompted us to investigate an alternative technique for upper extremity anesthesia. CIVRA has the advantages of IVRA in its technical ease of performance, reliability, safety, rapid onset of analgesia, muscle relaxation, and rapidity of recovery after tourniquet release. Its potential disadvantages are related to the tourniquet and to the possible systemic reactions to the local anesthetic when it is released into the general circulation.‘9 These potential problems can be averted if the technical protocol is strictly adhered to. Like general anesthesia and brachial plexus block, CIVRA provides for prolonged anesthesia, but without the inherent risks of these alternatives. We believe that CIVRA is an excellent anesthetic alternative for procedures performed on the upper extremity.

Continuous

intravenous

regional

anesthesia

85

We thank Gayle M. Burke for manuscript preparation and members of the Department of Anesthesia. Sunnybrook Health Science Centre, especially Drs. R. Jones, M. Ondhia, P. Murphy, and J. Emmett, for their assistance in developing this technique.

REFERENCES 1. Bier A. Ueber einen neven Weg Localanasthesie an der gliedmaassen 2u evzengen. Arch Klin Chir 1908;86: 1007. 2. Holmes CM. Intravenous regional analgesia: useful method of producing analgesia of limbs. Lancer 1963; 1: 245-7. 3. Brown EM, Weissman F. Prolonged intravenous regional anesthesia. Anesth Analg 1966;45:319-20. 4. Brown EM. Continuous intravenous regional anesthesia. Acta Anaesthesiol Stand 1969;36:39-45. 5. Brown EM, McGriff JT, Malinowski RW. Intravenous regional anaesthesia Bier block: review of 20 years experience. Can J Anaesth 1989;36:307- IO. 6. Woolley EF, Vandam LD. Neurological sequelae of brachial plexus nerve block. Ann Surg 1959;149:53-60. 7. Ross S. Scarborough CD. Total spinal anesthesia following brachial plexus block. Anesthesiology 1973:39:45861. 8. Selander D. Edshage S. Wolff T. Paresthesia or no paresthesia? Nerve lesions after axillary block. Acta Anaesthesiol Stand 1979;23:27-3 1. 9. Farrar MD, Scheybani, Nolte H. Upper extremity block: clinical effectiveness and complications. Anaesthesia 1982;37:368. 10. Bamtell C. Raich M. Montero A. A neurological complication following interscalene brachial plexus block. Anaesthesia 1980;35:365-7. Il. lshibashi T, Ouchi Y. Okuda T. New method of local anesthesia for operations on the upper extremity. Jpn J Anaesth 1966;15:239. 12. Moldarer J. Tourniquet paralysis syndrome. Arch Surg 1954;68: 136. 13. Middleton RWD, Vanan JP. Tourniquet paralysis. Aust N Z J Surg 1974;44:124-7. 14. Winchell SW, Wolfe S. The incidence of neuropathy following upper extremity nerve blocks. Reg Anaesth 1985;10:12. 1.5. Kennedy BR, Duthie AM, Parbrook GD. Carr TL. lntravenous regional analgesia: an appraisal. Br Med J 1965;1:954. 16. Sorbie C. Chacha P. Regional anaesthesia by the intravenous route. Br Med J 1965;10:957-60. 17. Dunbar RW, Mazze RI. Intravenous regional anesthesia: Experience with 779 cases. Anesth Analg 1967:46:80613. 18. Thorn-Alguist AM. Intravenous regional anaesthesia: a seven year survey. Acta Anaesthesiol Stand 197 I ; 1S:2332.

The Journal of HAND SURGERY

Gliekman et al.

19. Heath ML. Deaths after intravenous regional anaesthesia. Br Med J 1982;285:913-4. 20. Grice SC, Morel1 RC, Balestrieri FJ, Stump DA, Howard G. Intravenous regional anesthesia: evaluation and prevention of leakage under the tourniquet. Anaesthesia 1986;65:316-20. recommended doses” 21. Scott DB . Editorial-“Maximum of local anaesthetic drugs. Br J Anaesth 1989;63:373-4.

22. Braid DP, Scott DB. The systemic absorption of local analgesic drugs. Br J Anaesth 1965;37:394-404. 23. Tucker GT, Mather LE. Properties, absorption and disposition of local anaesthetic agents. In: Cousins MJ, Bridenbaugh PO, eds. Neural Blockade. Philadelphia: JB Lippincott, 1988:62-3.

Elbow flexion test in the normal population The elbow flexion test was investigated in 204 elbows in 102 normal volunteers. The effects of various wrist and shoulder positions were also studied. In 20 elbows in 15 persons (10%) flexion tests were positive with the wrist and shoulder in neutral position. In 27 elbows in 20 persons (13%) tests were positive with wrist extension and shoulder abduction. (J HAND SURG 1992;17A:86-9.)

Ghazi M Rayan, MD, FACS, Christine Jensen, MS, OTR, and James Duke, PhD, Oklahoma City, Okla.

The elbow flexion

test is often used as a provocative test for diagnosing compression neuropathy of the ulnar nerve at the cubital tunnel. The test is conducted by fully flexing the elbow for 1 minute. Experiencing paresthesias in the distribution of the ulnar nerve constitutes a positive test. Wadsworth’ observed aggravation of symptoms in patients with cubital tunnel syndrome when full elbow flexion was maintained for 5 minutes. Dellon* used the elbow flexion test in a staging system for ulnar nerve compression at the elbow. The purpose of this study was to investigate the incidence of positive elbow flexion test in the normal population and the influence of various positions of the wrist and shoulder on the results.

Departmentof OrthopedicSurgery, and Baptist Medical Center, OklahomaCity, Okla

From the Hand Surgery Section, Received for publication April 15, 1991.

Jan.

15, 1991; accepted

in revised form

No benefits in any form have been received or will be received from a commercial party related directly or indirectly to tbe subject of this article. Reprint requests: G. M. Rayan, homa City, OK 73 112.

MD, 3433 NW 56th. # 850, Okla-

3/l/30634

86

THE JOURNAL OF HAND SURGERY

Materials

and methods

Two hundred four ulnar nerves of 102 adult volunteers were used for this study. There were 40 men and 62 women. Ages ranged from 18 to 89 years. Ninetytwo (90%) of the volunteers were right-handed, nine (9%) were left-handed, and one was ambidextrous. Eight percent of these volunteers had demanding occupations that required heavy or repetitive use of the upper extremity. The remaining volunteers did not have physically demanding occupations. All volunteers were medical personnel or patients who were seen in the orthopedic clinic because of various musculoskeletal disorders other than of the upper extremity. They had no symptoms of ulnar nerve compression. Patients with a history of compression neuropathy, polyneuropathy, systemic disease, or fractures around the elbow were excluded from the study. The volunteers’ response to Tinel’s sign was assessed. The test was performed on both sides by gentle percussion with two fingers over the nerve in the cubital tunnel with the elbow in 90 degrees of flexion. A positive Tinel’s sign was confirmed by the presence of paresthesias in the sensory distribution of the ulnar nerve. Ulnar nerves were examined for instability within the cubital tunnel. The patient was asked to fully flex the elbow. The nerve was inspected and palpated