Improvement in I.V. Regional Anaesthesia by Re-Exsanguination Before Surgery †

Abstract

A modification of an i.v. regional anaesthesia (IVRA) technique is described in which the arm is re-exsanguinated before surgery (re-IVRA). IVRA and re-IVRA were compared for quality of operative field, sensory and motor block, quality of analgesia and blood concentrations of prilocaine, lignocaine and mepivacaine in a double-blind study in 120 patients undergoing hand surgery. Re-IVRA provided a significantly better surgical field without affecting sensory or motor block. Re-exsanguination improved tolerance of the tourniquet. Plasma concentrations in the re-IVRA group showed some increases, but these were not in the toxic range.

Comparison of mepivacaine and lidocaine for intravenous regional anaesthesia: pharmacokinetic study and clinical correlation

“…In the study of Simon and co-workers, 8 ®ve of the 10 patients showed plasma concentrations of lidocaine greater than 4 mg ml ±1 during the ®rst minute after release of the tourniquet. This is in contrast to ®ndings of Rawal and associates 18 who reported plasma concentrations of lidocaine less than 1 mg ml ±1 at this time. It should be noted, however, that in the ®rst study 8 high-performance liquid chromatography was used for the assessment of plasma drug concentrations in 10 patients, whereas in the second study 18 gas chromatography in 20 patients.…”

“…With respect to mepivacaine, we used a dose of 5 mg kg ±1 with which consistent satisfactory results had been obtained by our group as well as by others. 16 17 According to the study of Rawal and co-workers 18 in which plasma concentrations of mepivacaine, lidocaine, and prilocaine when given at the 3 mg kg ±1 dose peaked within 5 min after tourniquet release, we decided to start measurements of plasma drug concentrations at 5 min following tourniquet de¯ation, with the last measurement at 60 min because in the pharmacokinetic study of Simon and associates 8 less than 1 mg ml ±1 of lidocaine was measured from that time. Although in the case of mepivacaine for IVRA, no previous studies have evaluated plasma concentrations of this agent at 60 min after de¯ation, a pharmacokinetic behaviour similar to that of lidocaine was assumed as in the study of Rawal and co-workers, 18 mepivacaine and lidocaine showed similar pharmacokinetics 5 min after tourniquet release.…”

Comparison of the disposition kinetics of lidocaine and ± prilocaine in 20 patients undergoing intravenous regional anaesthesia during day case surgery

“…Bupivacaine is contraindicated because of poten tial cardiotoxicity, and fatal complications have been reported following intravenous injection (2-5), a situ ation which occurs with this technique when the tourniquet is released, The ideal agent for IVRA should achieve rapid onset of good surgical anesthesia and, above all, be safe. Lidocaine and ( ± )prilocaine both fulfil these criteria, as reported by several authors (7,(12)(13)(14)(22)(23)(24)(25)(26)(27)(28). The flushing and absorption of both lidocaine and prilocaine from the exsanguinated forearm after releas ing the tourniquet was so fast that the maximum plasma concentration was detected in the first sam pling time at 1 min The maximum plasma concen trations of lidocaine were in agreement with those reported earlier (9,29,30) and stayed well below the toxic concentrations of 5 -1 0 |lg/ml, depending on the degree of anaesthesia (31).…”

“…The method is safe provided a suitable local anaesthetic agent is used. Bupivacaine, for instance, is contra indicated because of its cardiotoxicity (2-5), Lidocaine and prilocaine are considered to be very suitable agents for IVRA (6)(7)(8)(9)(10)(11)(12)(13)(14). It is considered to be import ant for patients to leave hospital free of anaesthetic drugs (15,16).…”

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

“…Therefore, the forearm tourniquet increases the safety margin of the technique (16, 17). Rawal et al showed re-exsanguination with an esmarch’s bandage, following the institution of the IVRA, with a brief deflation and reinflation of the tourniquet; they called this procedure re-IVRA, a technique that would result in minimal leakage of the local anesthetic (18). …”