Bier's block--an improved technique

[Intravenous regional anesthesia]

OBJECTIVE

Intravenous regional anesthesia.

INDICATIONS

Short duration hand operations.

CONTRAINDICATIONS

Open wounds, lengthy operations, local infections, polyneuropathy, Raynaud syndrome, allergy to local anesthetics.

TECHNIQUE

Insertion of an intravenous cannula, attachment of a double lumen cuff, Esmarch's tourniquet, injection of the local anesthetic, stepwise pumping up the tourniquet, surgery, stepwise removal of the tourniquet.

POSTOPERATIVE MANAGEMENT

Postoperative monitoring of the patient after the end of anesthesia.

RESULTS

Over a time period of 2 years (January 2017-December 2018) 90 operations of the hand were carried out with the patient under intravenous regional anesthesia (IVRA). The average age of the patients was 61 years. After surgery the patients were questioned according to the criteria of the quality of recovery‑9 score according to Myles in the German version of Eberhard et al. (2002). The tourniquet could be removed on average 29 min after surgery. No intraoperative or postoperative complications occurred. Therefore, the IVRA represents a reliable and simple form of anesthesia especially for surgery of the hand.

The analgesic efficacy of intravenous regional anesthesia with a forearm versus conventional upper arm tourniquet: a systematic review

Background

The main objective of this review is to perform a systematic review and meta-analysis of the existing evidence related to the analgesic efficacy with the use of conventional, upper arm intravenous regional anesthesia (IVRA) as compared to a modified, forearm IVRA in adult patients undergoing procedures on the distal upper extremity.

Methods

MEDLINE, EMBASE and CENTRAL (Cochrane) databases were searched for randomized controlled trials published in English, French, Dutch, German or Spanish language. Primary outcomes of interest including description of quality level of anesthesia and onset of sensory block were assessed for this review. Dosage of the local anesthetic, local anesthetic toxicity and need for sedation due to tourniquet pain were considered as secondary outcomes.

Results

Our literature search yielded 3 papers for qualitative synthesis. Four other articles were added into a parallel analysis of 7 reports that provided data on the incidence of complications and success rate after forearm IVRA. Forearm IVRA was found to be as efficient as upper arm IVRA (RR = 0.98 [0.93, 1.05], P = 0.78), but comes with the advantage of a lower need for sedation due to less tourniquet pain.

Conclusion

Our results demonstrate that forearm IVRA is as effective in providing a surgical block as compared to a conventional upper arm IVRA, even with a reduced, non-toxic dosage of local anesthetic. No severe complications were associated with the use of a forearm IVRA. Other benefits of the modified technique include a faster onset of sensory block, better tourniquet tolerance and a dryer surgical field.

Registration of the systematic review

A review protocol was published in the PROSPERO register in November 2015 with registration number CRD42015029536.

Regional anaesthesia in trauma

Regional anaesthesia is very effective in alleviating pain due to trauma, and is also used to provide anaesthesia for trauma surgery. It has the advantage of producing localized but complete pain relief, whilst avoiding the side effects of systemic analgesics or anaesthetics. However, regional anaesthetic drugs and techniques have potentially life-threatening complications, which the practitioner must be able to manage. This article discusses the use of regional anaesthesia, and the benefits and disadvantages of specific regional techniques in various traumatic conditions.

Simple Arm Tourniquet as an Adjunct to Double-Cuff Tourniquet in Intravenous Regional Anesthesia

BACKGROUND

Intravenous Regional Anesthesia (IVRA) is a well-known technique for producing analgesia during surgical procedures in the extremities. However, the rapid onset of pain following the deflation of a double-cuff tourniquet during IVRA is a serious disadvantage, leading patient suffering.

OBJECTIVES

The aim of this study was to evaluate the clinical effectiveness of a pneumatic arm tourniquet applied 2 cm above the double-cuff tourniquet in controlling the pain that occurs after its deflation.

PATIENTS AND METHODS

Twenty patients undergoing outpatient hand surgery were operated on under IVRA, using 40 - 50 mL of a solution containing 3 mg/kg of lignocaine. A simple pneumatic tourniquet was applied proximal to the double-cuff tourniquet, 3 min before its deflation, while the procedure was being conducted. The severity of pain on the basis of the Numerical Rating Scale (NRS) was assessed throughout the operation, and continued until an hour after the double-cuff tourniquet was removed.

RESULTS

The mean operation time after the deflation of the double-cuff tourniquet was 20.12 ± 6.1 minutes. Moreover, the mean NRS for the post-deflation time was insignificant (NRS = 2), and only one patient during first 20 minutes received opioids.

CONCLUSIONS

This study showed that a pneumatic arm tourniquet as an adjunct to IVRA provides acceptable analgesia following the deflation of the double- cuff tourniquet for relieving surgical pain.

Anaesthesia for treating distal radial fracture in adults

BACKGROUND

Fracture of the distal radius is a common clinical problem, particularly in older white women with osteoporosis. Anaesthesia is usually provided during manipulation of displaced fractures or during surgical treatment.

OBJECTIVES

To examine the evidence for the relative effectiveness of the main methods of anaesthesia (haematoma block, intravenous regional anaesthesia (IVRA), regional nerve blocks, sedation and general anaesthesia) as well as associated physical techniques and drug adjuncts used during the management of distal radial fractures in adults.

SEARCH STRATEGY

We searched the Cochrane Musculoskeletal Injuries Group specialised register (January 2002), the Cochrane Controlled Trials Register (The Cochrane Library Issue 4, 2001), MEDLINE (1966 to October 2001), EMBASE (1988 to 2001 Week 48), Current Controlled Trials (December 2001) and reference lists of articles.

SELECTION CRITERIA

Randomised or quasi-randomised clinical trials evaluating relevant interventions for these injuries (see Objectives). We excluded pharmacological trials comparing drug dosages and, with one exception, different drugs in the same class. Also excluded were trials reporting only pharmacokinetic and/or physiological outcomes.

DATA COLLECTION AND ANALYSIS

All trials meeting the selection criteria were independently assessed by the three reviewers for methodological quality. Data were extracted independently by two reviewers. Quantitative data are presented using relative risks or mean differences together with 95 per cent confidence limits. Only very limited pooling of results from comparable trials was possible.

MAIN RESULTS

The 18 included studies involved at least 1200, mainly female and older, patients with fractures of the distal radius. All studies had serious methodological limitations, notably in the frequent failure to assess clinically important and longer-term outcomes. Five trials provided evidence that, when compared with haematoma block, IVRA provided better analgesia during fracture manipulation and enabled better and easier reduction of the fracture, with some indication of a reduced risk of later redislocation or need for re-reduction. In contrast, haematoma block was quicker and easier to perform and less resource intensive. There was inadequate evidence of relative effectiveness of different methods of anaesthesia only examined within single trials: nerve block versus haematoma block; intravenous sedation versus haematoma block; general anaesthesia versus haematoma block; general anaesthesia versus sedation; and general anaesthesia versus haematoma block and sedation. None of the three trials evaluating three different physical aspects of anaesthesia (injection site of, or extra tourniquet, for IVRA; and technique for brachial plexus block) provided conclusive evidence for the effectiveness and safety of the novel technique. Six trials examined the use of drug adjuncts. The addition of two different muscle relaxants and one analgesic was tested for IVRA; one sedative and hyaluronidase for haematoma block; and clonidine for brachial plexus block. All trials evaluating adjuncts failed to provide evidence on eventual clinical outcome. A seriously flawed study comparing bupivacaine with prilocaine for IVRA gave some insight on the potential confounding effects of treatment by different doctors on patient outcome.

REVIEWER'S CONCLUSIONS

There was insufficient robust evidence from randomised trials to establish the relative effectiveness of different methods of anaesthesia, different associated physical techniques or the use of drug adjuncts in the treatment of distal radial fractures. There is, however, some indication that haematoma block provides poorer analgesia than IVRA, and can compromise reduction. Given the many unresolved questions over the management of these fractures, we suggest an integrated programme of research, which includes consideration of anaesthesia options, is the way forward.

The use of Bier's block for day case surgery

With the increasing popularity of day case surgery it is important to ensure that safe and appropriate techniques are being used. We retrospectively reviewed a large series of 732 patients who underwent planned day case hand surgery under intravenous regional anaesthesia (modified Bier's block) over a 5-year period. We found a modified Bier's block to be ideally suited to day case surgery with no deaths, minimal morbidity and a success rate in excess of 98%.

The "mini-Bier's block": a new technique for prevention of tourniquet pain during axillary brachial plexus anaesthesia

Tourniquet cuff pain is a significant cause of morbidity following regional anaesthesia of the upper limb. We describe a simple new technique for effectively anaesthetizing the area under a pneumatic tourniquet (the "mini-Bier's block"), which permits comfortable surgery under axillary block anaesthesia even if the local block is incomplete. We report a controlled study of 40 patients in whom statistically significant tourniquet cuff pain relief was obtained in patients receiving an additional low-dose intravenous injection of local anaesthetic localized beneath the cuff. This technique ensures that the safe axillary approach to the brachial plexus can always be used with avoidance of pain from the pressure of the tourniquet cuff.