Efficacy of forearm tourniquet for local intravenous regional anesthesia in bilateral hand surgery

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1 Research and Oinion in Anesthesia & Intensive Care Volume 2 Efficacy of forearm tourniquet for local intravenous regional anesthesia in bilateral hand surgery Eslam N, Gehan F. Ezz Deartment of Anesthesia and Intensive Care, Faculty of Medicine, Zagazig University ABSTRACT A rosective randomized study was done to study the efficacy of forearm tourniquet for local anesthetic rocedure on both hands, 40 atients of bilateral caral tunnel syndrome received local intravenous anaesthesia of 15% xylocaine 1% in one side with midforearm tourniquet. The tourniquet was inflated to ressure of mmhg above systolic ressure tourniquet, not released till 20 minutes at least assed. The same was done on the other hand. All atients received 0.05 mg/kg midazolam and 1 µg/kg fentanyl as general anaesthesia before giving the local anaesthetics. Time of oeration did not exceed 15 minutes in each hand. We concluded that use of forearm tourniquet was well tolerated in all atients excet in 2 cases. INTRODUCTION The use of tourniquets and injected agents to induce localized anesthesia was first-introduced by Angul- Bier in He used an Esmarch bandage to exsanguinate the arm and injected rocaine between two tourniquets to quickly roduce anesthetic and analgesic effect(1). Though it roved effective, IVRA remained relatively unoular until C. McK. Holmes reintroduced in 1963(2). Today, the tourniquet is common due to its economy, raid recovery, reliability and simlicity(3,4). The safe and effective alternative to general anaesthesia in many cases of distal limb surgeries either in oerating room or emergency deartment(5). Caral tunnel release is often erformed as an outatient rocedure, although general anaesthesia is widely used in this surgery, other anesthetic technique, like brachial lexus block, IV regional, local infiltration and distal blocks can be used. Local infiltration may cause median nerve injury and may interfere with surgical rocedure secially with endoscoic techniques. Also, distal nerve blocks may cause neurological comlications(6). The extent of anesthetized area achieved by brachial lexus block is not necessary for a minor surgical incision. Regarding IV regional anesthesia, it is still an easy technique in site of its severe comlications if safety recautions are not taken(1). IVRA has roven to be very simle,safe and effective over very years and large numbers of atients, when erformed according to established rotocols with safe, accurate and reliable tourniquets instruments and cuffs than have been thoroughly tested rior to use(7). The aim of the work is to study the efficacy of forearm tourniquet in regional anesthesia for bilateral hand surgery. PATIENTS AND METHODS After obtaining written informed consent, 40 female atients of ASA hysical status I-II aged between years old of kg body weight, scheduled for caral tunnel syndrome of both hands divided into 2 grous; grou I of intravenous regional anesthesia and grou II of local infiltration anesthesia. All atients in both grous injected by 1 µg/kg fentanyl and 0.05 mg/kg midazolam after inserting 2 of 22 gauge intranveous catheter in each hand. In grou I, neumatic tourniquet was laced on the mid-forearm of one side to be blocked after exsanguinating the arm with Esmarch bandage. The tourniquet was inflated to ressure of 100 mmhg above the atient systemic blood ressure, then 15 ml of 1% xylocaine was injected, skin incision was started 5 minutes after injection of LA. During the oeration visual analogue score for ain in all time of oeration, ulse, blood ressure, more sedation if ain occurs, evaluated, atients and surgeon satisfaction for the rocedure, tolerability to tourniquet all time of oeration was evaluated from the start to the end of the rocedure. The tourniquet of the 1st oerated hand was not removed till at least 20 minutes was assed after injection of local anaesthetic or till oeration comleted on the same hand. Then, after that if cannula of this hand is needed, we releases the tourniquet after 20 minutes. After 20 minutes was assed, start oerating the 2nd hand and use this cannula. The same was done on the 2nd hand and tourniquet of this hand was removed till also 20 minutes assed after the end of surgery in this hand. In grou II, the tourniquet was laced after exsanguinations and wraing of the arm with soft cloth 10 ml of 1% xylocaine was injected in the tunnel of each hand searately. Skin incision was started after 5 minutes of injection of LA, the same is done in the 2nd hand after the 1st 7

2 Research and Oinion in Anesthesia & Intensive Care Volume 2 was oerated, and tourniquet in this grou can be removed after surgery in each hand. Also, ulse, blood ressure, more sedation, atients and surgeon satisfaction for the rocedure, tolerability to tourniquet all time of oeration was evaluated from the start to the end of the rocedure. Comlications that occur also evaluated allover the oeration. RESULTS NO significant differences between 2 grous were found on the demograhic variable evaluated (age, sex and ASA). There was a significant increase in systolic blood ressure with ain ( = 0.05) occurred in 2 cases in grou I as comared to grou II shows the same increase in systolic in 6 cases. The same increase in systolic in 6 cases. The ain which cause the increase in systolic result from non-tolerability to tourniquet. Pain scored by VAS used from the start of the rocedure in grou I and grou II show a significant difference ( = ) in all cases suffering from mid-forearm tourniquet; 2/20 in grou I and 6/20 in grou II. Pulse and blood ressure shows an increase with ain in relation to each other. As a result of ain, atients need more sedation or general anaesthesia ( = ) show high significant difference to need to sedation is 2 cases in grou I (2/20) and 6 cases in grou II (6/20) the same significance occurs ( = ). The satisfaction of atient surgeon to the rocedure show a significance in grou I ( = ) excet 2 cases suffer from mid-forearm tourniquet, ain in comarison to 6 cases suffering from tourniquet used in local infiltration in grou II and so, the atients and surgeon refuse to continue the rocedure. Tolerability to bilateral mid-forearm tourniquet show a significance in all cases in grou I excet 2 cases ( = ) as comared to grou II (6 cases) non-tolerability to tourniquet used in local infiltration occurred and need more sedation and general anaesthesia. At the end of rocedure, no comlications occur in 2 grous, no intraoerative recorded ain during the rocedure in other cases, excet those who suffer from ain during the rocedure. Table (1): Grou I Grou II T Age (year) Mean ± SD 40.8 ± ± Range ASA Mean ± SD 1.5 ± ± Range Weight (kg) Mean ± SD 77 ± 7.9 Range ±

3 Research and Oinion in Anesthesia & Intensive Care Volume 2 Table (2): Grou I Grou II T Pulse Mean ± SD 81.4 ± ± Range (NS) Systolic ressure Mean ± SD ± ± Range Diastolic ressure Mean ± SD 68.7 ± ± Range (NS) Table (3): Sedation in grou I Pain (VAS) Sedation Table (4): Satisfaction to rocedure in grou I yes Satisfaction to rocedure no

4 Research and Oinion in Anesthesia & Intensive Care Volume Table (5): Tolerability to bill mid-forearm tourniquet in grou I VAS to ain Tolerability to bill mid-forearm tourniquet Table (6): Relations in grou I Pain r Pulse 0.7 Systolic blood ressure 0.8 Diastolic blood ressure 0.9 There is ositive significant correlation between ain and ulse, systolic, diastolic ressure (when ain increases, ulse and ressure increase). 01

5 Research and Oinion in Anesthesia & Intensive Care Volume 2 Table (7): Sedation in grou II Pain (VAS) Sedation Table (8): Satisfaction to rocedure in grou II yes Satisfaction to rocedure no Table (9): Tolerability to torn quit in grou II Tolerability to torn quit

6 Research and Oinion in Anesthesia & Intensive Care Volume 2 Table (10): Relations in grou II Pain r Pulse 0.8 Systolic blood ressure Diastolic blood ressure 0.8 There is ositive significant correlation between ain and ulse, systolic, diastolic ressure (when ain increases, ulse and ressure increase). Table (11): Pain Grou I Grou II KW Mean ± SD 1.5 ± ± Range ` 1 3 KW: Kruskal-Wallis DISCUSSION Placement of tourniquet on forearm results in less discomfort than uer arm lacement for atients having hand surgery under Bier block anesthetics. In our rocedure, we use bilateral mid-forearm tourniquet to get the benefit of less discomfort of mid-forearm tourniquet and increase the effect of local anaesthetic in bilateral hand surgery. Several advantages of forearm-tourniquet have been suggested. Hatchinson and McClinton(8) reorted a study in which the forearm tourniquet was tolerated for an average of 45% longer and was less ainful than the conventional arm tourniquet. Other studies have suggested that forearm tourniquet might be more effective in achieving anaesthesia(9). In our study, the rocedure was done bilaterally in each hand consequently. In the first grou, the tourniquet is laced on the 1st hand lift at least 20 minutes was assed since injection of local anaesthesia or till the oeration was comleted on the 2nd hand. Tourniquet of 2nd hand removed after also 20 minutes. So, we do bilateral hand surgery with more tolerability to mid-forearm tourniquet in this grou, 18 from 20 atients. Tolerate the bilateral tourniquet in comarison to 14 rom 20 in grou II where we use the tourniquet over the site of skin incision and ain was more tolerated in grou I (2/20) than grou II (6/20). This study is suorted by Tram and Vin(9) using forearm tourniquet during the induction of Bier's block achieved good anaesthesia undergoing elective hand surgery. In our study, alication of bilaterial midforearm tourniquet, give the benefits of using midforearm tourniquet bilaterally and can do hand and wrist surgery within short time, in the same sitting, to decrease cost and decrease stress of more sittings in cases of bilateral hand injury. Pain resulting from non-tolerability to tourniquet cause increase in systolic blood ressure ( = 0.05), and there was ositive significant correlation between ain, ulse, systolic and diastolic blood ressure in both grous. Two cases in grou I (VAS 5, 6) ( = ) showed non-toelrability to tourniquet and 6 cases (VAS was 6) in grou II ( = ). Those atients need more sedation and general anaesthesia (fentanyl and 01

7 Research and Oinion in Anesthesia & Intensive Care Volume 2 midazolam) ( = ). also, atients and surgeon refuse to continue the rocedure without increasing sedation, and become unsatisfied from the rocedure ( = ). Our study suorted and confirmed by AKS by Chong et al.(10). Forearm-based Bier's block intravenous regional anaesthesia is safe and effective alteration to conventional Bier's block(1). We are suorted by other studies as the use of midforearm tourniquet was more cost-effective and suitable in the office and surgical center setting(11). CONCLUSION Use of forearm tourniquet was well tolerated in all atients excet in 2 cases. REFERENCES 1- Gebhard RE, Al-Samsam T, Greg J, et al. Distal nerve blocks at the wrist for outatient caral tunnel surgery after intraoerative cardiovascular stability and reduce discharge time. Anesth. Analg. 2002; 95: Altissimi M and Mancini GB. Surgical release of the median nerve under local anesthesia for caral tunnel syndrome. J Hand Surg (Br) 1988; 13: Robert SJR and Hedges JR (editors). Clinical rocedures in emergency medicine, 2nd ed. Philadelhia; Saunders 1991; Wood SH and Logan AM. A local anaesthetic technique for endoscoic caral tunnel release. J Hand Surg (Br) 1999; 24: Farnell RG, Swanson SL and Walter JR. Safe and effective regional anesthesia for use in the emergency deartment. Ann Emerg Med 1985; 14: Brown DL. Distal uer extremity block. In: Brown DL, ed. Atlas of Regional Anesthesia. Philadelhia: WB Saunders Co 1992; ordin S, McEwen JA, Kragh JF Jr, et al. Surgical tourniquets in orthoaedics. J Bone Jt Surg 2009; 91A: Hatchinson DT and McClinton MA. Uer arm and forearm tourniquet tolerance. Journal of Hand Surgery 1994; 19B: Tham CH and Lim BH. A modification of the technique for intravenous regional blockade for hand surgery. Journal of Hand Surgery 2000; 25B: Chong AKS, Tan DMK, Oo BS, et al. Comarison of forearm and conventioanl Bier's blocks for maniulation and reduction of distal radius fractures. Journal of Hand Surgery 2007; 32E: Chiao FB, Bennett H, Lesser JB, et al. Placing forearm versus uer arm tourniquet for Bier block anesthesia results in les stourniquet ain: Fewer sedation requirements and greater byass of the ost-anesthesia care unit. American Society of Anesthesiologists Annual Meeting

Original Article INTRODUCTION. Abstract

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