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Tsao H, Tang C, Trembath M, Jones P, Snelling PJ. Ultrasound-guided supraclavicular block versus Bier block for emergency reduction of upper limb injuries: a protocol for an open-label, non-inferiority, randomised controlled trial. Trials 2023; 24:366. [PMID: 37254224 DOI: 10.1186/s13063-023-07403-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2023] [Accepted: 05/22/2023] [Indexed: 06/01/2023] Open
Abstract
BACKGROUND Closed reduction of upper limb fractures and/or dislocations are common in the emergency department (ED), which involves physically re-aligning the injured part prior to immobilisation. As this is painful, numerous techniques are available to provide regional anaesthesia to ensure patient tolerance. A Bier block (BB) is typically performed as part of routine care. An alternative technique gaining interest in the ED is ultrasound-guided supraclavicular block (UGSCB), which involves injecting local anaesthetic around the brachial plexus at the supraclavicular fossa under ultrasound guidance. It is unclear whether UGSCB is effective and safe when performed in the ED. METHODS SUPERB (SUPraclavicular block for Emergency Reduction versus Bier block) is a prospective open-label, non-inferiority randomised controlled trial that compares the effectiveness of UGSCB versus BB for closed reduction of upper limb fractures and/or dislocations. Adult patients presenting with an upper limb fracture and/or dislocation that requires emergent closed reduction in the ED will be eligible. After screening, participants will be randomised to either UGSCB or BB. Once regional anaesthesia is obtained, closed reduction of the injured part will be performed and appropriately immobilised. The primary outcome is maximal pain experienced during closed reduction measured via a visual analogue scale (VAS). Secondary outcomes include baseline and post-reduction pain, patient satisfaction, total opioid requirement in ED, ED length of stay, adverse events and regional anaesthesia failure. DISCUSSION Existing evidence suggests UGSCB is effective when performed in the operating theatre by trained anaesthetists. SUPERB will be the first randomised controlled trial to elucidate the effectiveness and safety of UGSCB in the ED. The findings have the potential to provide an alternative safe and effective option for the management of upper extremity emergencies in the ED. TRIAL REGISTRATION This trial has been registered on 21 October 2022 with Australia and New Zealand Clinical Trials Registry (ACTRN12622001356752).
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Affiliation(s)
- Henry Tsao
- Emergency Department, Redland Hospital, Cleveland, QLD, Australia.
- School of Medicine, The University of Queensland, Herston, QLD, Australia.
| | - Christopher Tang
- Emergency Department, Redland Hospital, Cleveland, QLD, Australia
- School of Medicine, The University of Queensland, Herston, QLD, Australia
| | - Mark Trembath
- School of Medicine, The University of Queensland, Herston, QLD, Australia
- Department of Anaesthetics, Royal Brisbane and Women's Hospital, Brisbane, QLD, Australia
| | - Philip Jones
- Department of Emergency Medicine, Gold Coast University Hospital, Southport, QLD, Australia
| | - Peter J Snelling
- School of Medicine, The University of Queensland, Herston, QLD, Australia
- Department of Emergency Medicine, Gold Coast University Hospital, Southport, QLD, Australia
- School of Medicine and Dentistry, Griffith University, Southport, QLD, Australia
- Sonography Innovation and Research Group (Sonar Group), Southport, QLD, Australia
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Karam C, Al Assadi S, Kanazi G, Zeeni C. A sequential allocation study to determine the ED 50 of Dexmedetomidine as an adjuvant to lidocaine intravenous regional anesthesia. BMC Anesthesiol 2022; 22:165. [PMID: 35624418 PMCID: PMC9137144 DOI: 10.1186/s12871-022-01702-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2022] [Accepted: 05/20/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Intravenous regional anesthesia is an easy and reliable anesthetic technique, but its use is limited by tourniquet pain. Clonidine is effective in overcoming this shortcoming when used with intravenous regional anesthesia at a dose of 1 μg/kg. Dexmedetomidine has also been used successfully at a dose of 0.5 μg/kg. OBJECTIVE Based on the potency ratios of clonidine and dexmedetomidine (8 to 1) we hypothesize that a lower dexmedetomidine dose would provide patients with 50 min of pain free tourniquet time. METHODS After informed consent, patients received intravenous regional anesthesia with lidocaine and dexmedetomidine following a sequential allocation scheme. The first patient received a dose of 0.5 μg/kg of dexmedetomidine. The dose was then adjusted in 0.1 μg/kg gradients for the following patients depending on the success of the previous block. If a patient experienced tourniquet pain prior to 50 min, the next patient received a higher dose. If not, the dose was decreased. Recruitment continued until 6 independent crossovers were observed with a minimum of 20 patients. The median effective dose ED50 of dexmedetomidine was calculated using the modified up-and-down method. MAIN OUTCOME MEASURES The median effective dose of dexmedetomidine (ED50) that provides 50 min of tolerance to the tourniquet during a lidocaine intravenous regional anesthesia by a sequential Dixon up-and-down allocation study. RESULTS The ED50 of dexmedetomidine that provided 50 min of tolerance to the tourniquet was 0.30 ± 0.06 μg/kg. CONCLUSION We determined that the dexmedetomidine dose necessary to provide 50 min of pain free tourniquet time during intravenous regional anesthesia was higher than expected based on the relative alpha-2 adrenergic receptor selectivity of dexmedetomidine compared to clonidine. TRIAL REGISTRATION Clinicaltrials.gov: Retrospectively registered ( NCT05342870 ; registration date: 25/04/2022).
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Affiliation(s)
- Cynthia Karam
- Department of Anesthesiology and Pain Management, American University of Beirut Medical Center, PO-Box: 11-0236, Beirut, 1107 2020, Lebanon
| | - Sadek Al Assadi
- Department of Anesthesiology and Pain Management, American University of Beirut Medical Center, PO-Box: 11-0236, Beirut, 1107 2020, Lebanon
| | - Ghassan Kanazi
- Department of Anesthesiology and Pain Management, American University of Beirut Medical Center, PO-Box: 11-0236, Beirut, 1107 2020, Lebanon
| | - Carine Zeeni
- Department of Anesthesiology and Pain Management, American University of Beirut Medical Center, PO-Box: 11-0236, Beirut, 1107 2020, Lebanon.
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Emami SA, Majedi H, Espahbodi E, Sanatkar M. Bier block as a successful management of a patient with intractable complex regional pain syndrome (CRPS) type 1: A case report. Clin Case Rep 2021; 9:e04554. [PMID: 34306705 PMCID: PMC8294144 DOI: 10.1002/ccr3.4554] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2021] [Revised: 06/03/2021] [Accepted: 06/16/2021] [Indexed: 11/10/2022] Open
Abstract
Bier block was successful in the pain management of complex regional pain syndrome (CRPS) type 1.
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Affiliation(s)
- Seyed Ali Emami
- Anesthesiology and Pain DepartmentImam Khomeini Medical CenterTehran University of Medical SciencesTehranIran
- Neuroscience Research CentreNeuroscience InstituteTehran University of Medical SciencesTehranIran
| | - Hossein Majedi
- Anesthesiology and Pain DepartmentImam Khomeini Medical CenterTehran University of Medical SciencesTehranIran
- Neuroscience Research CentreNeuroscience InstituteTehran University of Medical SciencesTehranIran
| | - Ebrahim Espahbodi
- Anesthesiology and Pain DepartmentImam Khomeini Medical CenterTehran University of Medical SciencesTehranIran
- Neuroscience Research CentreNeuroscience InstituteTehran University of Medical SciencesTehranIran
| | - Mehdi Sanatkar
- Anesthesiology and Pain DepartmentImam Khomeini Medical CenterTehran University of Medical SciencesTehranIran
- Neuroscience Research CentreNeuroscience InstituteTehran University of Medical SciencesTehranIran
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Abstract
Background: Bier block provides anesthesia of an entire extremity distal to the tourniquet without necessitating direct injection at the surgical site. This avoids obscuring anatomy with local anesthetic and anesthetizes a wide area, allowing for multiple procedures and incisions. We hypothesize that a low-volume Bier block with forearm tourniquet, rather than a traditional brachial tourniquet, is a safe, well-tolerated, and effective anesthesia technique. Methods: All cases in which adult patients underwent hand procedures using Bier block anesthesia by a single surgeon over a 4-year period were reviewed. Data collected included patient demographics, procedure(s) performed, complications, tourniquet time and settings, procedure and in-room time, and supplemental medications administered. Results: In all, 319 patients were included, 103 from a university hospital and 216 from an ambulatory surgery center. The most commonly performed procedures were carpal tunnel release (205 cases) and trigger digit release (83 cases). Most patients received a 125-mg dose of lidocaine for the Bier block; many also received additional sedatives. Twenty-three patients received no additional medications. No patients required conversion to general anesthesia. One complication (0.3%) occurred, with paresthesias and tinnitus that resolved without intervention. The average tourniquet time was 24 minutes (SD = 4.3 minutes). Patients were discharged at a median of 49 minutes postoperatively, and 9.1% of patients received supplemental analgesics prior to discharge. Conclusions: Regional anesthesia achieved with a forearm tourniquet and intravenous local anesthetic provides adequate pain control, permits timely discharge home, and has a low complication rate. It should be considered for use in outpatient hand procedures.
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Affiliation(s)
- Natalie Vaughn
- Department of Orthopaedic Surgery, Penn State Health Milton S. Hershey Medical Center, Hershey, USA
| | - Niraja Rajan
- Department of Anesthesiology and Perioperative Medicine, Penn State Health Milton S. Hershey Medical Center, Hershey, USA
| | - Michael Darowish
- Department of Orthopaedic Surgery, Penn State Health Milton S. Hershey Medical Center, Hershey, USA,Michael Darowish, Department of Orthopaedic Surgery, Penn State Health Milton S. Hershey Medical Center, 30 Hope Drive, PO Box 859, Hershey, PA 17033, USA.
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Dekoninck V, Hoydonckx Y, Van de Velde M, Ory JP, Dubois J, Jamaer L, Jalil H, Stessel B. The analgesic efficacy of intravenous regional anesthesia with a forearm versus conventional upper arm tourniquet: a systematic review. BMC Anesthesiol 2018; 18:86. [PMID: 30021514 PMCID: PMC6052619 DOI: 10.1186/s12871-018-0550-4] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2018] [Accepted: 06/24/2018] [Indexed: 11/12/2022] Open
Abstract
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.
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Affiliation(s)
- Valerie Dekoninck
- Department of Anesthesiology and Pain Medicine Jessa Hospital, Virga Jesse Campus, Stadsomvaart 11, 3500, Hasselt, Belgium.
| | - Yasmine Hoydonckx
- Department of Anesthesiology and Pain Medicine Jessa Hospital, Virga Jesse Campus, Stadsomvaart 11, 3500, Hasselt, Belgium
| | - Marc Van de Velde
- Department of Cardiovascular Sciences, KU Leuven and Department of Anesthesiology, UZ Leuven, Leuven, Belgium
| | - Jean-Paul Ory
- Department of Anesthesiology and Pain Medicine Jessa Hospital, Virga Jesse Campus, Stadsomvaart 11, 3500, Hasselt, Belgium
| | - Jasperina Dubois
- Department of Anesthesiology and Pain Medicine Jessa Hospital, Virga Jesse Campus, Stadsomvaart 11, 3500, Hasselt, Belgium
| | - Luc Jamaer
- Department of Anesthesiology and Pain Medicine Jessa Hospital, Virga Jesse Campus, Stadsomvaart 11, 3500, Hasselt, Belgium
| | - Hassanin Jalil
- Department of Anesthesiology and Pain Medicine Jessa Hospital, Virga Jesse Campus, Stadsomvaart 11, 3500, Hasselt, Belgium
| | - Björn Stessel
- Department of Anesthesiology and Pain Medicine Jessa Hospital, Virga Jesse Campus, Stadsomvaart 11, 3500, Hasselt, Belgium.,Department of Anesthesiology, Maastricht University Medical Center, Maastricht, The Netherlands
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Haghighi M, Mardani-Kivi M, Mirbolook A, Tehran SG, Saheli NA, Hashemi-Motlagh K, Sahbe-Ekhtiari K. A Comparison between Single and Double Tourniquet Technique in Distal Upper Limb Orthopedic Surgeries with Intravenous Regional Anesthesia. Arch Bone Jt Surg 2018; 6:63-70. [PMID: 29430498 PMCID: PMC5799603] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 11/01/2016] [Accepted: 11/05/2017] [Indexed: 06/08/2023]
Abstract
BACKGROUND Several studies have put an effort to minimize the tourniquet pain and complications after conventional double tourniquet intravenous regional anesthesia (IVRA). We expressed in our hypothesis that an upper arm single wide tourniquet (ST) may serve a better clinical efficacy rather than the conventional upper arm double tourniquet (DT) in distal upper extremity surgeries. METHODS In this randomized controlled trial, 80 patients undergoing upper limb orthopedic surgeries were randomized into two groups. IVRA was administered using lidocaine in both groups. Tourniquet pain was recorded based on visual analogue scale (VAS). In case of pain (VAS>3) in the DT group, the proximal tourniquet was replaced with a distal tourniquet while fentanyl 50µg was injected in the ST group. The onset time of tourniquet pain, time to reach to maximum tourniquet pain and the amount of fentanyl consumption were compared between the two groups. RESULTS No significant difference was seen in demographic characteristics. The onset time of tourniquet pain (VAS=1) in the ST group (26.9±13.2 min) was longer than that of the DT group (13.8±4.8 min) (P<0.0001). The median of time to reach to maximum tourniquet pain (VAS>3) in DT and ST groups were 25 and 40 minutes, respectively; indicating that the patients in ST group reached to pain level at a significantly later time (P<0.0001). The total opioid consumption in the DT group (61 µg) was significantly lower than the ST group (102 µg) (P<0.0001); however, both groups were similar regarding fentanyl consumption before 40 minutes of surgeries. CONCLUSION It seems that in upper limb orthopedic surgeries with less than 40-minute duration, a single tourniquet may serve as a proper alternative opposed to the conventional double tourniquet technique.Level of evidence: II.
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Affiliation(s)
- Mohammad Haghighi
- Anesthesiology Research Center, Guilan University of Medical Sciences, Rasht, Iran Orthopedic Department, Guilan Road Trauma Research Center, Guilan University of Medical Sciences, Rasht, Iran Orthopedic Research Center, Guilan University of Medical Sciences, Rasht, Iran Anesthesiology Department, Anesthesiology Research Center, Guilan University of Medical Sciences, Rasht, Iran Guilan Road Trauma Research Center, Guilan University of Medical Sciences, Rasht, Iran
| | - Mohsen Mardani-Kivi
- Anesthesiology Research Center, Guilan University of Medical Sciences, Rasht, Iran Orthopedic Department, Guilan Road Trauma Research Center, Guilan University of Medical Sciences, Rasht, Iran Orthopedic Research Center, Guilan University of Medical Sciences, Rasht, Iran Anesthesiology Department, Anesthesiology Research Center, Guilan University of Medical Sciences, Rasht, Iran Guilan Road Trauma Research Center, Guilan University of Medical Sciences, Rasht, Iran
| | - Ahmadreza Mirbolook
- Anesthesiology Research Center, Guilan University of Medical Sciences, Rasht, Iran Orthopedic Department, Guilan Road Trauma Research Center, Guilan University of Medical Sciences, Rasht, Iran Orthopedic Research Center, Guilan University of Medical Sciences, Rasht, Iran Anesthesiology Department, Anesthesiology Research Center, Guilan University of Medical Sciences, Rasht, Iran Guilan Road Trauma Research Center, Guilan University of Medical Sciences, Rasht, Iran
| | - Samaneh Ghazanfar Tehran
- Anesthesiology Research Center, Guilan University of Medical Sciences, Rasht, Iran Orthopedic Department, Guilan Road Trauma Research Center, Guilan University of Medical Sciences, Rasht, Iran Orthopedic Research Center, Guilan University of Medical Sciences, Rasht, Iran Anesthesiology Department, Anesthesiology Research Center, Guilan University of Medical Sciences, Rasht, Iran Guilan Road Trauma Research Center, Guilan University of Medical Sciences, Rasht, Iran
| | - Nasim Ashouri Saheli
- Anesthesiology Research Center, Guilan University of Medical Sciences, Rasht, Iran Orthopedic Department, Guilan Road Trauma Research Center, Guilan University of Medical Sciences, Rasht, Iran Orthopedic Research Center, Guilan University of Medical Sciences, Rasht, Iran Anesthesiology Department, Anesthesiology Research Center, Guilan University of Medical Sciences, Rasht, Iran Guilan Road Trauma Research Center, Guilan University of Medical Sciences, Rasht, Iran
| | - Keyvan Hashemi-Motlagh
- Anesthesiology Research Center, Guilan University of Medical Sciences, Rasht, Iran Orthopedic Department, Guilan Road Trauma Research Center, Guilan University of Medical Sciences, Rasht, Iran Orthopedic Research Center, Guilan University of Medical Sciences, Rasht, Iran Anesthesiology Department, Anesthesiology Research Center, Guilan University of Medical Sciences, Rasht, Iran Guilan Road Trauma Research Center, Guilan University of Medical Sciences, Rasht, Iran
| | - Khashayar Sahbe-Ekhtiari
- Anesthesiology Research Center, Guilan University of Medical Sciences, Rasht, Iran Orthopedic Department, Guilan Road Trauma Research Center, Guilan University of Medical Sciences, Rasht, Iran Orthopedic Research Center, Guilan University of Medical Sciences, Rasht, Iran Anesthesiology Department, Anesthesiology Research Center, Guilan University of Medical Sciences, Rasht, Iran Guilan Road Trauma Research Center, Guilan University of Medical Sciences, Rasht, Iran
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