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From the Department of Anaesthesia, Faculty of Medicine, King Faisal University, Al-Khobar, Saudi Arabia.
Address correspondence to: Dr. Hany A. Mowafi, Department of Anesthesiology, King Fahd University Hospital, PO Box 40081, Al-Khobar 31952, Saudi Arabia. Phone: (+) 966-54-995792; Fax: (+) 966-3-8823650; E-mail: hany_mowafi{at}hotmail.com
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Abstract |
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Clinical features: A 52-yr-old male presenting for knee arthroscopy was anesthetized by IVRA using only 40 mL of lidocaine 0.5%. After performing IVRA in the routine way an additional below knee tourniquet was used and inflated after local anesthetic exsanguination towards the knee. Operation was performed without the need for further analgesic.
Conclusion: The technique allowed the use of a small anesthetic volume for IVRA on the lower limb, thus decreasing the potential risk of local anesthetic toxicity.
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Introduction |
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We describe a case of knee arthroscopy that was performed successfully under IVRA using 40 mL of 0.5% lidocaine isolated between two tourniquets applied above and below the knee.
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Case report |
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On the preanesthetic visit the patient requested a regional technique and gave no history of medical problems except previous multiple level lumbar disc surgery. The proposed IVRA technique, which had been approved by the departmental Ethical Committee, was fully explained to him and his consent was taken. The patient was given 10 mg diazepam orally 90 min before surgery.
The patient was placed on the operating table. An iv access was secured in the right forearm and routine monitors were applied. A double cuffed tourniquet was arranged over a soft padding above the knee joint and an 18-G plastic cannula was inserted on the dorsum of the foot (Figure 1a
). The lower limb was exsanguinated with a rubber bandage (Figure 1b).The tourniquet was then inflated to 270 mmHg which is 100 mmHg above the limb occlusive pressure (LOP) as determined by photoplethysmograpic pulse wave amplitude4 of the big toe. The Esmarch bandage was removed and 40 mL of 0.5 % lidocaine were injected through the plastic cannula.
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) and the distal segment was re-exsanguinated using a rubber bandage (Figure 1d). The distal tourniquet was also inflated to 270 mmHg. Examination of the patient showed complete anesthesia in the inter-cuff segment around the knee joint and patchy anesthesia in the distal segment. After preparing the surgical site the procedure was performed. Arthroscopy confirmed the diagnosis of osteoarthritis and subcondylar drilling of the femur and tibia was done. During the 45 min procedure no further analgesia was required and the patient was given 5 mg of midazolam iv as a sedative. At the conclusion of surgery, the distal tourniquet was deflated first then the proximal one. The patient was discharged on the same day of surgery with no complications.
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Discussion |
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The cuff pressure of the above knee tourniquet was set to 100 mmHg above the LOP as described before in the literature.6 The distal below-knee cuff was inflated arbitrarily at the same pressure aiming at isolating the injected local anesthetic between the two cuffs.
The inter-cuff block, as named by Hannington-kiff,7 is not new. The original method introduced by Bier in 19088 used two tourniquets, one above and one below the elbow or the knee. He performed a cut-down to cannulate a large vein in the region of the elbow or knee. Hannington-kiff, in 1990, revisited the technique and used it to perform surgery on the upper limb. Our modification uses veins distally on the dorsum of the foot and therefore avoids the technical difficulty of cannulating veins around the knee joint. Another disadvantage of the Hannington-kiff inter-cuff method is that the injection is made near the tourniquet and any rapid local rise in the iv pressure may defeat the cuff. In our modification, as in the currently popular method of IVRA, the injection is made at a distance from the cuff with less hydraulic challenge to the tourniquet.
In addition to the small volume of local anesthetic used, the release of the distal tourniquet before the proximal one at the end of surgery may add safety to the technique as the local anesthetic will recirculate again in the empty veins of the lower limb.
A potential extension of the technique is the use of small volumes with a high concentration of local anesthetic isolated in the same way at the elbow or the knee to perform surgery on hands or feet. Lai et al.9 showed that 2% lidocaine injected between two tourniquets applied above and below the elbow produces analgesia rapidly in the inter-cuff area and slowly on the forearm and hand developing from finger tips upwards. They concluded that the principal site of action of lidocaine depends on the concentration; a lower concentration acts on the sensory nerve endings and a higher concentration acts on both nerve trunks and sensory nerve endings.
In conclusion, in this case, knee arthroscopy was performed safely and effectively using small volumes of local anesthetic with the described modification of IVRA. The technique should be less toxic when the tourniquet is released compared to current IVRA technique. Further studies are required to confirm the efficacy and safety of this approach and to explore the possible modifications with different surgical procedures.
Revision received May 13, 2002. Accepted for publication December 3, 2001.
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References |
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2 Chilvers CR, Kinahan A, Vaghadia H, Merrick PM. Pharmacoeconomics of intravenous regional anaesthesia vs general anaesthesia for outpatient hand surgery. Can J Anaesth 1997; 44: 1152–6.
3 Henderson CL, Warriner CB, McEwen JA, Merrick PM. A North American survey of intravenous regional anesthesia. Anesth Analg 1997; 85: 858–63.[Abstract]
4 Blanc VF, Haig M, Troli M, Sauve B. Computerized photoplethysmography of the finger. Can J Anaesth 1993; 40: 271–8.[Abstract]
5 Brown EM, McGriff JT, Malinowski RW. Intravenous regional anaesthesia (Bier block): review of 20 years’ experience. Can J Anaesth 1989; 36: 307–10.
6 Davies JA II, Hall ID, Wilkey AD, Smith JE, Walford AJ, Kale VR. Intravenous regional analgesia. The danger of the congested arm and the value of occlusion pressure. Anaesthesia 1984; 39: 416–21.[Medline]
7 Hannington-kiff JG. Bier’s block revisited: intercuff block. J R Soc Med 1990; 83: 155–8.[Abstract]
8 Hilgenhurst G. The Bier block after 80 years: a historical review. Reg Anesth 1990; 15: 2–5.[Medline]
9 Lai YY, Chang CL, Yeh FC. The site of action of lidocaine in intravenous regional anesthesia. Ma Zui Xue Za Zhi 1993; 31: 31–4.[Medline]
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