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Anesth Analg 2002;95:457-460
© 2002 International Anesthesia Research Society

REGIONAL ANESTHESIA

An Evaluation of the Analgesic Efficacy of Intravenous Regional Anesthesia with Lidocaine and Ketorolac Using a Forearm Versus Upper Arm Tourniquet

Scott S. Reuben, MD*{dagger}, Robert B. Steinberg, MD PhD*, Holly Maciolek, RN*, and Poornachandran Manikantan, MD*

Department of Anesthesiology, *Baystate Medical Center and {dagger}Tufts University School of Medicine, Springfield, Massachusetts

Address correspondence and reprint requests to Scott S. Reuben, MD, Department of Anesthesiology, Baystate Medical Center, Springfield, MA 01199. Address e-mail to scott.reuben{at}bhs.org


   Abstract
Top
 Abstract
Introduction
 Patients and Methods
 Results
 Discussion
 References
 
Intravenous regional anesthesia (IVRA) using a forearm tourniquet may be a potentially safer technique compared with using an upper arm tourniquet. Ketorolac is a useful adjuvant to lidocaine for IVRA. In this study, we assessed the analgesic efficacy of administering IVRA lidocaine and ketorolac with either a forearm or upper arm tourniquet for outpatient hand surgery. Upper arm IVRA was established using 40 mL of a solution containing 200 mg of lidocaine and ketorolac 20 mg (0.5 mg/mL). Forearm IVRA was established using 20 mL of a solution containing 100 mg of lidocaine and ketorolac 10 mg (0.5 mg/mL). Onset and duration of sensory block as well as postoperative pain and analgesic use were recorded. The patients who received forearm IVRA had a significantly longer period during which they required no analgesics (701 ± 133 min) compared with 624 ± 80 min for the upper arm IVRA ketorolac patients (P = 0.032). Onset of sensory block was similar between the two groups; however, recovery of sensation was significantly longer in the Forearm IVRA (22 ± 5 min) group compared with the Upper Arm IVRA (13 ± 3 min) group (P < 0.05). There were no differences in postoperative analgesic use or pain scores between the two groups. We conclude that forearm IVRA with lidocaine and ketorolac provides safe and effective perioperative analgesia for patients undergoing ambulatory hand surgery. This technique results in a longer duration of sensory block and prolonged postoperative analgesia compared with upper arm IVRA while using one-half the doses of both lidocaine and ketorolac.

IMPLICATIONS: Forearm tourniquet intravenous regional anesthesia (IVRA) with 50% less lidocaine and ketorolac provides for both a longer duration of sensory block and prolonged postoperative analgesia compared with upper arm IVRA.


   Introduction
Top
 Abstract
 Introduction
Patients and Methods
 Results
 Discussion
 References
 
Intravenous regional anesthesia (IVRA) is a safe and effective technique for providing anesthesia as well as a bloodless field during hand surgery. Traditionally, an upper arm tourniquet has been used for these procedures. However, upper arm IVRA does have some disadvantages including the potential for local anesthetic toxicity (1,2), tourniquet pain (3,4), and lack of postoperative analgesia (5–7). Toxicity may be caused by leakage past the tourniquet because of high venous pressures or tourniquet failure (8).

Adverse reactions have also been reported upon tourniquet release, especially when larger doses of local anesthetic are used (1,2). Numerous adjuvant medications (nonsteroidal antiinflammatory drugs, opioids, and muscle relaxants) have been studied in an attempt to minimize the potential of systemic toxicity and to improve postoperative analgesia (5–7,9,10). The application of a forearm tourniquet may offer several advantages to the use of an upper arm tourniquet. Forearm IVRA allows the dose of local anesthetic to be decreased by up to 50% without affecting the quality of analgesia (11). In addition, the forearm tourniquet can be tolerated longer and was consistently rated as less painful when compared with the upper arm tourniquet (12). Finally, using a forearm tourniquet allows for preservation of some motor function of the long flexors and extensors of the wrist and hand, which is useful in certain operations such as tenolysis and fixation of hand fractures (13).

The routine use of a forearm tourniquet has previously been avoided because of the potential risk of nerve injury, incomplete hemostasis, and leakage of local anesthetic into the systemic circulation (3,14,15). However, these theoretical concerns have not been substantiated in any studies. Several investigations revealed that the forearm tourniquet is a safe and effective technique for hand surgery (11,13,16,17). In fact, the use of a forearm tourniquet may be a safer alternative to upper arm IVRA by reducing the local anesthetic dosages to nontoxic levels (11,13).

We have previously shown that IVRA with lidocaine and ketorolac using an upper arm tourniquet provides significant postoperative analgesia after hand surgery (5). The aim of our study was to assess the analgesic efficacy of administering IVRA lidocaine and ketorolac using a forearm compared with an upper arm tourniquet for outpatient hand surgery.


   Patients and Methods
Top
 Abstract
 Introduction
 Patients and Methods
Results
 Discussion
 References
 
Forty patients scheduled for elective hand surgery by a single surgeon gave formal, written consent to participate in this prospective, randomized study approved by our IRB. They were scheduled to undergo carpal tunnel release, tenolysis, or excision of a ganglion cyst under IVRA. After application of routine monitors, patients were assigned to one of two treatment groups using a computer-generated random number table. Patients in the Upper Arm IVRA group had a 14-cm double tourniquet positioned on the upper operative arm, whereas patients in the Forearm IVRA group had the tourniquet positioned 1 cm below the medial epicondyle on the forearm. When required, patients received up to 2 mg of midazolam for sedation; no pre- or intraoperative opioids or other analgesics were given. A 22-gauge Teflon cannula was inserted into the dorsum of the operative hand. The operative extremity was exsanguinated by elevating and wrapping it with a 10-cm Esmarch bandage. The proximal tourniquet was inflated to 100 mm Hg more than systolic blood pressure to a minimum of 250 mm Hg, and the Esmarch bandage was removed. The distal tourniquet was not used for any patient; it was included only as a safety feature. Circulatory isolation of the operative arm was confirmed by inspection of the hand and by absence of the radial pulse. Upper arm IVRA was established using 40 mL of a solution containing 200 mg of lidocaine and ketorolac 20 mg. Forearm IVRA was established using 20 mL of a solution containing 100 mg of lidocaine and ketorolac 10 mg. IVRA solutions were administered slowly via the cannula for 3 min.

After the injection of the IVRA solution, sensory block was assessed at 1-min intervals using a 25-gauge short beveled needle by a blinded observer (PM). Sites used for sensory testing included the thenar eminence (median nerve), hypothenar eminence (ulnar nerve), and the first webspace (radial nerve). In addition, sensory regression was assessed at these same nerve sites at 1-min intervals after tourniquet deflation. Postoperatively, patients had their pain assessed by a blinded observer (HM) at 30 min, 60 min, and 24 h after tourniquet deflation. Pain was assessed using an integer verbal analog pain scale (VAS) between 0 and 10, with 0 representing no pain and 10 representing the worst imaginable pain. IV boluses of fentanyl 25 µg were provided in the postanesthesia care unit whenever the VAS exceeded 3. The total number of fentanyl doses was noted.

Patients were instructed to take one acetaminophen 325 mg/codeine 30 mg (Tylenol No. 3® [McNeil Pharmaceuticals, Raritan, NJ]) tablet every 4 h as required for a VAS >3 while at home. All the patients were contacted by telephone the day after surgery by a blinded observer (HM). The time from tourniquet deflation until the patient first took an acetaminophen/codeine tablet was noted, as was the total number of acetaminophen/codeine tablets required during the first postoperative 24 h.

Demographic data and times (duration of procedure, tourniquet time, time to discharge, and sensory and analgesic duration) were analyzed using analysis of variance. Pain scores and the amount of postoperative analgesics were analyzed by using the Kruskal-Wallis test. If a significant result was obtained, the Wilcoxon’s signed rank test was performed to determine between which groups there was significance; Bonferroni’s correction was made for multiple comparisons. The Mann-Whitney U-test was used to compare the number of fentanyl doses. Significance was determined at the P < 0.05 level. Initial sample size estimation showed that 20 patients should be included in each group to ensure a power of 90% to detect a clinically relevant minimal 20% difference in analgesic duration. Using pooled data from our previous IVRA lidocaine and ketorolac studies (5,18), yielding a mean analgesic duration of 600 min with a SD of 130 min, an {alpha} error of 0.05 was used for this study. All data are presented as mean ± SD.


   Results
Top
 Abstract
 Introduction
 Patients and Methods
 Results
Discussion
 References
 
There were no differences between the two groups in demographic variables, the distribution of surgical procedures, the durations of the operations, or tourniquet times (Table 1).


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  		Table 1. Table 1. Patient Demographics and Surgical Dataa
 
Loss of pinprick sensation was similar between the Upper Arm IVRA (12 ± 3 min) and the Forearm IVRA (13 ± 4 min) groups. Postoperative sensory block at all three nerve sites was significantly longer in the Forearm IVRA (23 ± 5 min) group compared with the Upper Arm IVRA (13 ± 3 min) group (P < 0.05). No patient had prolonged paresthesia, neurologic deficit, or loss of motor function after surgery.

Postoperatively, VAS pain scores at all three time intervals were similar between the two groups (Table 2). No patient required fentanyl in the postanesthesia care unit. There was a trend towards a less 24-h total acetaminophen/codeine tablet consumption in the Forearm IVRA group (3.4 ± 0.8 tablets) compared with the Upper Arm IVRA group (4.6 ± 1.0 tablets), although this was not statistically significant (P = 0.059). Patients in the Forearm IVRA group had a significantly (P = 0.032) longer period of subjective comfort during which they required no analgesics (701 ± 133 min) compared with the Upper Arm IVRA group (624 ± 80 min).


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  		Table 2. Table 2. Postoperative Pain Scores and Treatment
 

   Discussion
Top
 Abstract
 Introduction
 Patients and Methods
 Results
 Discussion
References
 
This study shows that forearm IVRA with lidocaine and ketorolac provides effective perioperative analgesia for patients undergoing ambulatory hand surgery. This technique results in a longer duration of sensory block and prolonged postoperative analgesia while using 50% less lidocaine and ketorolac compared with the upper arm IVRA.

Forearm IVRA has been used infrequently in the past because of concerns of local anesthetic leakage, difficulty maintaining a bloodless field, and possible nerve injury (3,4,15). It was thought that "compression forces of an inflated forearm tourniquet cannot obliterate the anterior and posterior interosseous arteries seated in the deep ‘valley’ between the prominent radius and ulna (15)." It was therefore assumed that tourniquet leakage was inevitable. In addition, concern was expressed that the distal part of the limb is too small to withstand the higher localized pressures with the use of a forearm tourniquet (3). It has also been suggested that proximal tourniquet placement is more likely to transfix the ulnar nerve, resulting in an increased incidence of traction neuritis (19). However, these theoretical concerns have not been substantiated in any studies. In fact, several studies revealed that the forearm tourniquet is a safe and effective technique for hand surgery (11,13,16). A quantitative study showed that forearm IVRA results in tourniquet leakage comparable with upper arm IVRA (20). In addition, a review of more than 1000 patients undergoing surgery using a forearm tourniquet resulted in no significant increase in the incidence of peripheral nerve injury (21).

Our present study supports the finding that forearm tourniquet IVRA is a safe and effective technique that results in no observable complications during outpatient hand surgeries. Furthermore, adequate intraoperative analgesia occurred in all subjects using 50% less lidocaine (100 mg; 1.5 mg/kg) than normally used for IVRA (200 mg; 3 mg/kg) with an upper arm tourniquet (22). Our results are similar to a previous adult volunteer study in which excellent analgesia was provided using a forearm tourniquet with 1.5 mg/kg of lidocaine 0.5% (11).

We also observed a significant postoperative analgesic benefit with forearm IVRA using lidocaine and ketorolac in the same concentrations as for upper arm IVRA. The ketorolac dose chosen for this study was based on our previous investigation (18), which demonstrated the optimal dose of ketorolac to be 0.5 mg/mL using an upper arm tourniquet. Interestingly, our present study revealed that IVRA lidocaine and ketorolac with a forearm tourniquet provides for an enhanced postoperative analgesic benefit compared with an upper arm tourniquet. This was evidenced by the significantly longer time to first request for postoperative analgesics after tourniquet deflation in the Forearm IVRA group. The reason for this enhanced analgesic effect is not known. One possible explanation may be an increased binding of analgesics to local tissues during forearm IVRA. One study has revealed that the quantitative washout of a radiolabeled substance after tourniquet deflation is larger with the use of an upper arm tourniquet (20). This investigation revealed that 20 minutes after tourniquet deflation, a significantly larger percentage of the substance had washed out from the upper arm (82%) compared with the forearm (69%). Therefore, it is possible that lidocaine, ketorolac, or both remains in the tissue of the distal arm for a longer period of time, providing sustained postoperative analgesia with the use of forearm IVRA. This may explain the prolonged postoperative sensory block observed in those patients receiving lidocaine with forearm IVRA (23 ± 5 minutes) compared with upper arm IVRA (13 ± 3 minutes). Similarly, ketorolac administered via forearm IVRA may have provided for an enhanced analgesic effect via increased binding or a reduction in its clearance from the surgical site. The prolonged sensory block observed in our study may be clinically useful to surgeons at the end of the operative procedure. Because recovery of pain sensation is rapid (median, one minute; range, 1–25 minutes) after tourniquet deflation with IVRA lidocaine 0.5% (23), subsequent hemostasis and wound closure may be difficult to achieve. The time from tourniquet deflation for hemostasis and complete wound closure has been reported to range from two to 21 minutes (16). This has led some investigators to recommend routine wound infiltration or metacarpal block immediately before tourniquet deflation (16). Because the forearm IVRA provides for prolonged sensory analgesia, it may reduce or eliminate this need to supplement the IVRA lidocaine block.

Forearm IVRA with ketorolac not only provides enhanced postoperative analgesia, but should also increase the safety margin of this technique. Forearm IVRA allows for a 50% reduction in the doses of both lidocaine and ketorolac. Therefore, this approach reduces the risk of local anesthetic toxicity in the event of tourniquet failure. In addition, because side effects from the perioperative administration of nonsteroidal antiinflammatory drugs are dose-dependent (24), smaller doses of IVRA ketorolac may be safer. Other investigators have noted postoperative hematomas with the use of larger doses of IVRA ketorolac (24). Thus, the administration of small doses of ketorolac used in forearm IVRA may provide for an enhanced margin of safety.

In conclusion, forearm IVRA with lidocaine 100 mg and ketorolac 10 mg provides safe and effective perioperative analgesia for patients undergoing ambulatory hand surgery. This technique provides for both a longer duration of sensory block and prolonged postoperative analgesia compared with the conventional upper arm IVRA. Because forearm IVRA allows for a 50% reduction in the doses of both lidocaine and ketorolac, this technique may also be safer.


   Footnotes
 
Presented, in part, at the International Anesthesia Research Society Meeting, Fort Lauderdale, FL, March 2001.


   References
Top
 Abstract
 Introduction
 Patients and Methods
 Results
 Discussion
 References
 

  1. Heath ML. Deaths after intravenous regional anesthesia. BMJ 1982; 285: 913–4.
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Accepted for publication April 2, 2002.




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Lippincott, Williams & Wilkins Anesthesia & Analgesia® is published for the International Anesthesia Research Society® by Lippincott Williams & Wilkins with the assistance of Stanford University Libraries' HighWire Press®. Copyright 2006 by the International Anesthesia Research Society. Online ISSN: 1526-7598   Print ISSN: 0003-2999 HighWire Press