A COMPARATIVE STUDY OF THE EFFECTS OF DIFFERENT DRUGS …

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Manjunath et al. World Journal of Pharmacy and Pharmaceutical Sciences

A COMPARATIVE STUDY OF THE EFFECTS OF DIFFERENT

DRUGS USED TO SUPPLEMENT THE LOCAL ANESTHETIC IN

INTRAVENOUS REGIONAL ANESTHESIA (BIER'S BLOCK) FOR

SURGICAL PROCEDURES OF THE UPPER LIMB

*Dr. Trifa Assadlah Faidlah and Ali Mohammed Kareem

College of Medicine University of Sulaimani.

ABSTRACT

Background: block) is used for anesthesia for surgical procedures on

the upper limb, it is a reliable, simple and safe method for providing

anesthesia with low incidence of side effects. It is recommended as an

alternative to general anesthesia for operations on the hands, forearms

and arms. An intravenous cannula is inserted, the limb is

exsanguinated, a tourniquet applied and the veins filled with local

anesthetic. Intravenous regional anesthesia (Bier's Objective: To

perform the intravenous regional anesthesia by using minimal dose of

local anesthetic (lidocaine) with additive drugs (dexamethasone, atracurium) to decrease the

toxicity of lidocaine and improve the quality of anesthesia, analgesia and muscle relaxation

perioperatively. Study design: This study is clinical trials comparative study. Setting: This

study was performed in Teaching and Emergency Hospitals in Sulimani city eriod of January

2007 to September 2007, it is approved by Suliamani Ethical mittee. uk a Laas ASA I and II

status, average ages of 18-65 years of both gender were omly into three groups, thirty patients

in each group, neither prepared nor me measures: ents the onset of action, time to motor and

sensory recovery and gesia were measured, comparison among them is done and the epain

intensity scale was evaluated. sults shows that the addition of (8 mg) dexamethasone to

lidocaine 1e to sensory recovery and perioperative analgesia in group B (12.48 + is longer

than in group A (plane lidocaine) (11.55 + 1.35, 52.50 ess than0.05). nonstrates that the

addition of (1 mg) of atracurium to lidocaine n (complete motor and sensory block) in group

C (4.40 + soup A (4.99 + 0.13) (p value is less than 0.05), while the 4 perioperative analgesia

in group A (14.06 + 0.79, 52.50 5 + 1.66, 50.8 + 13.6) (p value is more0.05) Conclusions: It

is concluded that the addition of (8 mg) of dexamethasone to supplement a“ intravenous

WORLD JOURNAL OF PHARMACY AND PHARMACEUTICAL SCIENCES

SJIF Impact Factor 7.421

Volume 8, Issue 7, 1595-1611 Research Article ISSN 2278 – 4357

*Corresponding Author

Dr. Trifa Assadlah Faidlah

College of Medicine

University of Sulaimani.

Article Received on

18 May 2019,

Revised on 08 June 2019,

Accepted on 28 June 2019

DOI: 10.20959/wjpps20197-14232


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regional anesthesia is advisable to improve the quality of anesthesia an in provide better

perioperative analgesia and the addition of a minimum dose of atracurium (1 mg) will speed

the onset of action, provide good intraoperative muscle relaxation and optimize the operative

condition with minimizing the potential toxicity of the local anesthetic.

KEYWARDS: Bier's block, simple descriptive pain intensity scale, dexamethasone and

atracurium.

1.1 INTRODUCTION

1.1.1 Intravenous regional anesthesia (Bier’s block) +

Many procedures in the upper limb can be performed on awake patients using intravenous

regional anesthesia (IVRA). This not only avoids the risks and unplea which sometimes

associated with general anest benefits such as reduced blood loss often lasts longer t! several

hours after the surgery, in addition; some patien they are awake during surgery. a Intravenous

regional anesthesia providing anesthesia for minor surgica minutes), it is suited to operations

of the dista knee), such as reduction of radial or ulna fracture, carpa wrist ganglion, foreign

body removal and palmer faciotomy. santness such as nausea and vomiting hesia but may

also provide specific han the providing pain relief for ts feel more in control when is a

reliable, simple and safe method for procedures of relatively short duration (60-90 arm or leg

(i.e. below the elbow or | tunnel syndrome, excision of (2,3)

1.1.2 Technique: Intravenous regional anesthesia (Bier‟s block) is unique regional local

anesthetic blocked via the venous system, it presumed the nerve roots by back diffusion from

the Intravenous regional anesthesia (Bier technique as it relies on the nerves being that the

local anesthetic gain access to veins. echnique involves total isolation and drainage of the

venous network in the n Esmarch bandage and tourniquet. The former empties the veins

whilst ents further influx of blood. (a specially designed double tourniquet is s cannula is

inserted in the affected arm as distally as possible Po the contra lateral one for injection of

drugs (sedatives ang d, the proximal tourniquet is inflated to a safe level (usually nd using

sterile technique. (7) ssthetic agent which is the lidocaine was used 40 ml of 0.5 % ient and

safe anesthesia. The dosage used should allow for eins are then filled with local anesthetic.

“ses in to the small veins surrounding the nerves and then id cz pillary plexus of the nerves

leading to a core to mantle in the nerves involved. Local anesthetic then diffusesn, blocking

their conduction. contributes to the analgesic action of on and motor end plate function, —

will be analgesia to pinprick he speed of onset and the (10) The tourniquet produces


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ischemia, which the local anaestetic by blocking nerve conducti twenty minutes after

tourniquet application alone there without the injection of any local anesthetic however, t

density of anesthesia are greater with injection of local anesthetic. short time; the tourniquet

is left inflated Satisfactory anesthesia was obtained in a ion of the anesthetic agent in to the

for a minimum of 30 minutes after inject extremity, ('!? As the more proximal tourniquet

become un inflated and then the proximal tourniquet is deflated. comfortable, the distal

tourniquet is (12)

1.1.3 Advantages of intravenous regional anesthesia are

Speed of onset and rapid recovery.

Reliability (in the absence of local infection and with adequate equipment).

Muscle relaxation.

Technical simplicity. ‟13,14”

The only expertise required is ability to cannulate the vein and a vigorous technique.

Extremely high (>95%) success rate, higher than any other block. (15)

1.1.4 Disadvantages of intravenous regional anesthesia are

• Not suitable for deep operations as analgesia is not sufficiently intense.

• Tips of fingers are often missed, an additional ring block may then be necessary.

• The tourniquet may become extremely uncomfortable and thus limit the duration of surgery

(using a second tourniquet together with the judicious use of adjuvant drugs may overcome

this problem).

• Surgical time is limited to about one hour due to the tourniquet which must not be released

during the procedure. <16)

• Poor postoperative analgesia.

• The potential of systemic local anesthetic toxicity.

• Nerve damage secondary to direct compression of the tourniquet.

• Compartment syndrome and loss of the limb (very rare).(l7)

• Tourniquet paralysis may result from: (a) excessive pressure (b) insufficient pressure

resulting in passive congestion of the part with hemorrhagic infiltration of the nerve (c)

keeping the tourniquet too long (d) application of the tourniquet without considering local

anatomy. <7)

Intravenous regional anesthesia is generally a safe technique, the most important

complication to be recognized is a leaking or accidentally deflated tourniquet cuff this will


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result in large volume of local anesthetic being rapidly introduced in to the circulation. The

patient may develop dizziness, nausea, vomiting, tinnitus, perioral tingling, muscle twitching,

loss of consciousness and convulsions. Avoidable deaths have occurred.[IX]

1.1.5 Intravenous regional anesthesia is contraindicated in: Severe Raynaud‟s disease

(intermittent arteriolar spasm of the distal limbs after cold or emotional stimuli).; Sickle cell

disease (IVRA is relatively contraindicated, unless meticulous exsanguinations of the limb

takes place prior to cuff inflation). e Crush injury to the limb, [VRA may provoke further

tissue damage secondary to hypoxia. e Age: young children are generally not amen

combination with sedation and additional ana e Allergy to local anesthetic. Patient refusal. „!”

able to IVRA alone, however, in Igesia it can be used successfully.

1.1.6 Relative contraindications of intravenous regional anesthesia

Severe hypertensive or peripheral vascular disease.

Local infection.

Skeletal muscle disorders or Paget's disease (loc systemic circulation via venous channels

in bone In this study, intravenous regional anesthesia is performed by using three caine,

atracurium and dexamethasone. al anesthetic may spread to the (20)

1.1.7. lidocaine (Xylocaine): hydrochloride or lignocaine, the first modern amide local

ynthesized by Lofgren and Lunquist in 1943 and was clinically n (1-3 hours). for all sorts of

regional anesthetic blocks including intravenous dental anesthesia and therapeutic blockade

in concentrations 0t intended for blocks of long duration, e.g. via intermittent bolus

oductioneae Lidocaine has a membrane — stabilizing effects on both cardiac a at tissue, it is

used to control cardiac arrhythmia and to interrupt a status epilepticus, =H a lidocaine use in

anesthesia can be explained by the fact that it alters Cee Ob neurons by blocking the fast

voltage gated sodium channels in the cell mem Pra: With sufficient blockade, the membrane

of presynaptic neuron will not, depolanze and so fail to transmit an action potential leading to

its anesthetic effects. Lidocaine is hepatically metabolized and renally excreted with only

10% unmodified. The maximum safe dose is approximately 3-5 mg iz ee epinephrine), with

epinephrine 7 mg /kg to decrease the vascular uptake. ae Systemic exposure to excessive

quantities of lidocaine mainly result in central nervous system and cardiovascular system

adverse effects, central nervous effects occur at low concentration and additional

cardiovascular effects present at higher concentration, though cardiovascular collapse may


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also occur with low concentration. Central nervous system effects may include central

nervous system excitation (nervousness, tingling around the mouth, tinnitus, dizziness,

blurred vision, seizure) followed by depression (drowsiness, loss of consciousness,

respiratory depression and apnea), cardiovascular effects include hypotension bradycardia,

arrhythmia and/ or cardiac arrest, some of which may be due to hypoxaemia secondary to

respiratory depression. 7°

1.1.7.2 Atracurium

A benzyl isoquinolonium ester. It is an intermediate acting relaxant which is dly broken-

down by the body. s makes atracurium very predictable as wears off rapidly compared with

laxants. °” lecular weight of 1243, pH solution 3.5 stored at 4 celisus in the drug deteriorates

at room temperature, it is a highly specific ae rzing muscle relaxant, which was designed to

undergo lown, °°! ovascular system; although atracurium produces few direct e absence of

vagal blocking activity makes the patient vulnerable ng anesthesia. Histamine release may

occur if atracurium is ipitated in the syringe or vein or injected immediately after : system;

bronchospasm can occasionally occur ease. °” Pies 5. Z; A „ ns gnificant and the drug is

widely used in obstetrics. °*).

Rohavin t Distribution, metabolism and excretion

Atracurium is broken-down to inactive metabolites by minor ester hydrolysis and

Spontaneous Hoffman degradation (major pathway) to laudanosine. This metabolite has been

shown to cause seizure in animal models (>17 mcg/ml). There is little change in its effects in

patients with renal or liver failure. When used for long operation, it is very predictable. ©”).

1.1.7.2.2 Dose, administration and use

A dose of 0.3-0.6 mg/kg will provide relaxation for 20-40 minutes supplemental doses should

be 5-10 mg. Atracurium precipitates in an alkaline pH and it should never be mixed with

thiopentone, always flush the vein with saline if using the two drugs at induction.

1.1.7.2.3 Factors that altered the response to atracurium

Neuromuscular blockade can be prolonged with: electrolyte disturbances, hypothermia,

myasthenia gravis, Eaten lamberts syndrome, respiratory acidosis, furosemide, phenytoin,

theophylline, carbamazepine, sepsis, major burns and __ peripheral neuropathies. __-__It

produces more rapid recovery that the older non depolarizing agents and easily 2versed 20-25

minutes after administration of a dose of 2x ED95 (0.45 mg /kg). g does not have any direct


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cardiovascular effect, but may release histamine / 3 of that released by tubocurium) and

therefore produce a local wheal and 1 the injection site, especially if a small vein is used.

This may b y a slight fall in arterial pressure. ° roid similar to normal steroid hormone

produced by the adrenal -inflammatory, metabolic and immunosuppressant effects. It helps,

redness, itching and allergic reactions, so it treats severe allergies, hma, arthritis and other

conditions, decreases nausea and vomiting notherapy drugs, kills some types of cancer cells

and decreases injury or illness. °°?” bound to the plasma proteins and distributed via the

blood, it is and excreted by the kidneys.

It has many side effects: an allergic reaction, hypertension, sudden weight gain, insomnia,

nausea, vomiting, stomach upset, fatigue, dizziness, muscle weakness or joint pain, problems

with diabetes control or increased hunger or thirst, acne, increased hair growth, thinning of

the skin, cataract, glaucoma, moon face, change in behavior, hallucination and osteoporosis.

cy) A single large dose of this medication is unlikely t over dose is more likely to be caused

by a chronic over dose aperiod of time. °” o cause symptoms or death, an —large doses taken

over.

1.1.8 Tourniquets

er by the use of a tourniquet. The t that must be used with proper t is luxury, while in others

such Operations on the extremities are made easi tourniquet is a potentially dangerous

instrumen knowledge and care. In some procedures, a tourniquet as delicate operation on the

hand, it is a necessity. A pneumatic tourniquet is safer than an Esmarch tourniquet or the

Martin sheet rubber bandage. A pneumatic tourniquet with a hand pump and an accurate

pressure gauge is probably the safest, but a constantly regulated pressure tourniquet is quite

satisfactory if it is properly maintained and checked. When a sphygmomanometer cuff is

used, it should be wrapped with gauze alii bandage „According to Cren show et al., wide

tourniquet cuffs are none effective at lower sure than are narrow ones. demonstrated that

curved tourniquet on conical extremities require er arterial occlusion pressure than straight

(rectangular) tourniquet, sht tourniquet on conical thighs should be avoided specially in or

obese individuals. uets should be kept in good repair and all valves and gauges checked. The

Esmarch tourniquet is still in use some areas and it is cal of the elastic tourniquets. „”

1.2 Aim of the Study

The aim of the study is to improve the quality of the apeional aes ee a inimum toxic level of

local anesthetics by the pe pepoance Of tis by usin plain anesthesia (Bier‟s block) for surgical


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procedures in the upper limb by) making lidocaine, lidocaine with additive

Simecicarnerigsgge, airacurium), comparison between these two groups with a group of plain

lidocaine.

PATIENTS AND METHODS

7 This study was performed at Teaching and Emergency hospitals in Sulaimani ty in period

from January 2007 to September 2007. It was approved by Sulaimani Ethical Committee.

Ninety patients of ASA I and Il, ages 18-65 years of either gender were included in this

study, All patients had been admitted for surgical procedures in the upper limb (hand, wrist

and forearm) which is lasting 60-90 minutes. e Adequately informed about the procedure and

have consented to it. e Patients with open wounds or crush injuries in the upper limb were

excluded from this study. e Patients were not premedicated and randomly allocated in to three

groups, thirty patients in each.

Forty five patients were an emergency cases, subjected to upper limb (hand ed; had full

stomach, they, forearm) trauma; they were unprepared, not premedicat were a good candidate

for intravenous regional anesthesia (Bier‟s block), after obtaining an informed consent that

includes understanding all the risks and benefits with considering the surgeon preference and

physiological and mental state of the_ patient, the procedure was performed for them.:

received 40 ml (3mg/kg) of 0.5% lidocaine solution. Surgical hand. of pain is done by simple

descriptive pain intensity scale which snts words (mild, moderate, severe) to describe their

degree of e perioperative analgesia was assessed and their need for rugs also evaluated.

2.1 The equipments required for intravenous regional anesthesia

Double tourniquet or reliable sphygmomanometer.

Esmarch bandage.

Local anesthetic solution.

Resuscitation equipment and drugs.

Before beginning to perform the block, the patient's blood pressure should be measured. en

inserted in a distal vein in the he hand), and another cannula which may require _ An

intravenous cannula or butterfly needle is th limb scheduled for surgery (e.g. in the dorsum of

t placed on the other hand for cases of any complications, occur, intravenous drug

administration.„ “After the limb is exsanguinated (blood removed) before tourniquet is


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inflated, this is done by tightly wrapping the distal part of the limb with Esmarch rubber

bandage, before inflating the tourniquet, or elevation of the arm for 20-30 seconds whilst

applying firm digital pressure on the brachial artery, this will allows venous blood to drain

from the limb whilst preventing further arterial blood entering.*”

The tourniquet (cuff of the sphygmomanometer) is then inflated to a pressure 50 _mmHg or

more above the patient's systolic pressure. The local anesthetic solution is then injected

slowly into the cannula of the surgical hand and the patient warned that e limb may start to

feel hot and that the skin will take on a mottled appearance, Igesia rred within 3-4 minutes

and after that the surgery commenced. Even if mpleted within a few minutes, on no account

the tourniquet deflated) minutes has passed since the injection of the local anesthetic or ffects

may occur, the pressure in the tourniquet was constantly ained at least 50 mmHg above the

patient's systolic blood 1 expected to be prolong, that will lead to pain due to pressure cuff of

sphygmomanometer) this reduced by the use of a double 1e two tourniquets are placed on the

patient's arm, initially, the ne is applied and the local anesthetic agent injected when the the

distal (lower) tourniquet is placed and then the proximal d or loosed and normal ee sca a ae

procedure, the tourniquet is deflate Be of ured; es, the tourniquets is reinflated or tighten

again 20-30 seconds, ee of local anesthetic from the limb and hence the incidence of side

ased. In any event, the patient warned that they may experience tinnitus, flation of the

tourniquet.„*dizziness or transient drowsiness following de ES Monitoring of the patient is

done for the vital signs (heart rate, blood pressure _Tespiratory rate) and sings of

complications of drugs on cardiovascular, respiratory and central nervous systems. tients to

flex and extend the wrist Motor function was assessed by asking the pa‟ en no voluntary

movement was and fingers; complete motor block was noted wh possible. Sensory block was

assessed by a pinprick test performed with a needle every 30 seconds. e was evaluated in the

dermatomal sensory distribution of the and radial nerves. median, ction of the study drug

until Patient respons e was the time elapsed medial and lateral ante brachial coetaneous,

ulnar, Sensory block onset time was noted as the time from inje sensory block in all

dermatomes, and motor block onset tim: injection of the study drug to complete motor

block.°” aa1yuL 19}deyD


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RESULTS

3.1 Descriptive statistical analysis in form of mean, range and SD was calculated. The data of

this study were analyzed by t-test for the differences between two groups and distinguished

whether the differences were significant or not.

3.2 The demographic data of patients in all groups were demonstrated in (table 1) which

shows the difference in the onset of action in the three groups (A=4.9940.136, B=5,30+1.36,

C=4.40+0,89).

Table. (3.1): Patients and demographic data, mean, range and SD.

Table. (3.2): Statistical comparison between group A and group B.


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Table. (3.3): Statistical comparison between group A and group C.

Table (3.4): Statistical comparison between group B and group C.

The onset of action in group C (4.40+0.89) was faster than in group A id group B (5.30

+1.37), (p value less than 0.05).

Overy in group A showed no significant differences with (p value more than 0.05).

perioperative analgesia in group B is significantly 2.49) as compared with that of group A

(11.54+1.34, 05). The time of perioperative analgesia in group A and C was statistically not

The time taken for motor and sensory recovery with perioperative analgesia was ignific: antly

longer in group B (13.70+1.89, 12.48+1.90, 62.10+12.49) than in group 22: (12.25+1.66,

5.26+1.17, 50.77£13.59),(p value was less than 0.05).


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Fig. (3.1): Onset of action.

Onset of action: time of complete motor and sensory block in minutes.

A: Plane lidocaine Group.

B: Lidocaine+dexamethasone group.

C: Lidocaine+atracurium group.

Fig. (3.4): Time to motor recovery.

Time to sensory recovery: the time from the release of tourniquet till the return of sensation

(duration of sensory block after the release of tourniquet) in minutes.

Fig. (3.3): Time to sensory recovery.


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Fig. (3.4): Perioperative Analgesia.

Perioperative analgesia the block (the time from the injection of the drugs till the return of

sensatior) in minutes.

DISCUSSION

To avoid some of $ anesthesia. such as known impossible intubation, severe sephreig de ne

problems are expected. patients who specifically request regional anesthesia, situations where

general anesthesia is} not available (rare); to provide high quality postoperative pain relief; as

part of 7 postoperative multimodal rehabilitation programme to enable carly return to

function; intravenous regional anesthesia (Bier's block) is most commonly performed on the

upper extremity for forearm and hand surgery of up to 90 minutes in duration it is reliable

and safe and has a high degree of patient satisfaction “”

The potential complications of a Bier block include the risk of excessive, toxic doses of local

anesthetic reaching the systemic circulation with accidental deflation of the tourniquet “, this

risk ean be minimized by the following: The tourniquet should not be released until at least

20 minutes after injection: even if the surgery is completed, this delay allows for diffusion of

drug into the tissues, so that plasma concentrations do not reach toxic levels after release of

the tourniquet; slow deflation may also provide a safety margin, as the local anesthetic drug is

released into the circulation in a biphasic manner. there is initial fast release of 30%, but 50%

may still be present in the limb 30 minutes later. “'°** Using adjunct drugs to supplement the

local anesthetic to decrease the need of the top-up dose, so, minimizing the potential toxicity

improving the quality of analgesia and muscle relaxation perioperatively; also decrease the

need of intraoperatively sedation thus allow a constant communication with the patient is

essential to detect early symptoms of toxicity. he patients simple descriptive pain intensity

scale score was 1 discomfort despite the use of double tourniquet especially ich last more


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than 40 minutes; 19 patients of them received am Smeg intravenously with monitoring of

their vital signs‟ complications noted in this group. d 40m lidocaine(0.5%) plus 8mg

dexamethasone I (side effects of this drug occur after a long- term doses are harmless while

short courses are well d with toxicity, “°*7) nsory recovery and perioperative analgesi 2 lan

0.05). i ™.

DISCUSSION

There was one case who developed hypotension after the release of tourniquet, and treated by

intravenous fluids then returned to normal level blood pressure after 10 minutes.; This study

make a comparison between the supplement of dexamethasone to lidocaine and the addition

of atracurium to lidocaine; with plane lidocaine. This study demonstrates that the addition of

(8 mg) dexamethasone to lidocaine makes the time to sensory recovery and perioperative

analgesia in group B (12.48 + 1,90, 62.1 + 12.5) is longer than in group A (plane lidocaine)

(11.55 + 1.35, 52.50 £15.7), (p value less than 0.05).

This study also demonstrates that the addition of (1 mg) of atracurium to lidocaine makes the

onset of action (complete motor and sensory block) in group C (4.40 + 0.89) is faster than in

group A (4.99 + 0.13) (p value is less than 0.05), while the time to motor recovery and

perioperative analgesia in group A (14.06 + 0.79, 52.50 + 15.7) is longer than in group C

(12.25 + 1.66, 50.8 + 13.6), (p value more than 0.05). tween group B and group C

(comparison between the that of atracurium on lidocaine in intravenous regional the onset of

action in group C (4.40 + 0.89) is). (p value is less than 0.05), while the time to memeroup C

(12.25 + 1.66, 5.27+ 1.17, 50.8.

CONCLUSIONS AND RECOMMENDATIONS

5.1 CONCLUSIONS

Th ae poe ae mg) dexamethasone to supplement the local anesthesia for will improve the

perioperative analgesia, prolong the sensory and motor i: mee 3 recovery time and reducing

the simple descriptive pain scale scoring. Thea ate Riceieeigne e a minimum dose of

atracurium (1 mg) to supplement the local or Bier's block speed the onset of complete motor

and sensory block and improve the muscle relaxation intraoperatively.

5. 2 RECOMMENDATIONS

• Itis advisable to perform the intravenous regional anesthesia Oe oer surgical procedures

of the upper limb to avoid some risks of genera fee ee Further studies are recommended


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with other adjuvant to the local anesthe minimize the potential toxicity. ¢ More and

careful study is essential to evaluate the effects of gns petee a dexamethasone and

atracurium concurrently in the surgical hand to imp the quality of intravenous regional

anesthesia.

REFERENCES

1. Wallace A, Guardini R, Ellis S. Standard intravenous regional anesthesia, BMJ, 1982;

285: 654-6.

2. Colleen Ec. The Bier block for intravenous regional anesthesia, technical and literature

review. Anesthesia and analgesia, 1970; 49: 645-40.

3. Johnson CN. Intravenous regional, new approach to an.

4. W.F. Casey, consultant anesthetist, Gloncester Shine, World Federation Of Sociaties of

Anesthesiologist. Intravenous regional anethsia (Bier‟s block), 1992; 1: 1-2.

5. Gentili M Bonnet F, Bernard JM. Adding clonidine to lidocaine for intravenous regional

anesthesia prevent tourniquet pain. Anesthesia and analgesia, medline, 1999; 88: 1327-30.

6. F.Rodola, S.Vagnoni, S.Inglelti. An update on intravenous regional anesthesia of the arm.

European Review for medical and pharmacological sciences, 2003; 7: 131-138.

7. Glic Kman Lt, Mackinnon SE, Rao TV, Me Cabe SJ: J hand surgery 17-A: 83, 1992.

Campbell‟s Operative Orthopaedics, Wysiwyg://frame5.frame

0.2/http://,27.0.0.1:1080/ram:2002.

8. Haasio J, Hippala S, Rosenberg PH. Intravenous regional anesthesia of the arm.

Anesthesia, 1989; 44: 19-21.

9. Gordh T. Xylocaine-a new local anesthetic. Anesthesia, 1949; 4: 4-10.

10. Prithri Pr et al. The site of action of intravenous regional anesthesia. Anesthesia and

analgesia, current researches, vol.51, No5, Sept.-Oct. 1972-776-7786.

11. Esteb Jp, Le Naunre A, Chemaly L, Eccffey C.Tourniquet pain in a volunteer study.

Anesthesia, 2000; 55: 21-6.

12. Tuncal B, Karc A, Bacakoglu AK, et al. Controlled hypotension and minimal inflation

pressure, a new approach for pneumatic tourniquet application in upper limb surgery.

Anesthesia and analgesia, 2003; 97: 1529-32.

13. Cobb AG, Houghton GR. Local anesthetic infilteration versus Bier‟s block for colles

fractures. BMJ., 1985; 291: 1683-4.

14. Healy, E.J Cohen, P.J. Wylia and Churchill-Davidson‟s practice of anesthesia 6 ed. 1995

(160, 156, 157, 167).


1609


15. Abdulla Wy, Fadhil NM. Anew approach to intravenous regional anesthesia, 1992; 75:

597-601.

16. B Nicolls J, Berrington and sonosite.Anesthesia and analgesia, 2005; 401: 297.

17. A Lan R.Aitkenhead. Text book of anesthesia 4th

ed., 2001; 229.

18. Valli H, Rosen berg pH, KyHa, Numinen M. Arterial hypertension associated with the

use of a tourniquet with either general or regional anesthesia. Acta Anesthesia Scand,

1987; 31: 299-83.

19. Heath ML. Death after intravenous regional anesthesia. BMJ., 1982; 285: 913-4.

20. John Oyston. Intravenous regional anesthesia. Anesthesia and analgesia, 2001; 7184-395.

21. Terry Dvolka. Intravenous regional anesthesia, New York School of anesthesia.


22. Kari Harrison. What is lidocaine. Molecule of the month for June 2007.

23. Robert K. Stoelling. Pharmacology and physiology in anesthetic practice 2nd

ed. 1991:

208.

24. Corino B, Vasallo H. Local anesthetics mechanismof action and clinical use. Grunns and

Stralton. New York, 1976; 4-5.

25. Thomson PD, Melmon KL, Richardson JA et al. Lidocaine pharmacokinetics in advance

heart failure, liver diease and renal failure in human. Ann Inten Med., 1973; 78(4):

499-508, PMID.

26. Memis D, Turan A. Karamanhoglu et al. Adding dexmedetomidine to lidocaine for

intravenous regional anesthesia. Anesthesia and analgesia, 2004; 98: 835-40.

27. Faccenda KA, Finucaue BT. Complicatios of regional anesthesia, incidence and

prevention. Drug safety, 2001; 24: 413-42.

28. Tsui BCH, Wagner, Finucane B. Regional anesthesia in the Elderly. A clinical guide.

Drugs Aging, 2004; 21: 895-910.

29. Patrick Neligan. Local anesthetics. Source Mather Drugs, 1979; 18: 185-205.

30. McGlone R, Heyes, Harris P. Anesthesia and analgesia, 1988; 5(2): 79-85.

31. Elhakim M, Sadek RA. Addition of atracurium to lidocaine for intravenous regional

anesthesia. Acta Anesthesiol. Scand, 1994; 38: 54-4.

32. Vicker M.D, Morgan M, Spencer, P.S.J and Read M.S. Drugs in anesthetic and intensive

care practice 8th

ed. 1999-275.

33. Edward G, Morgan and Magid S., Mikali. Muscle relaxant in clinical anesthesia 2nd

1996:

160-164.


1610


34. Playfor, S.D. Thomas A.D., Choonel. Duration of action of atracurium when given by

infusion to critically ill children, pediatric anesthesia, 2000 Jan; 10(1): 77-81.

35. Grallenstien, J.S. Paulus, DA. Neuromuscular function, clinical monitoring 2nd

ed.

Philadeliphia: Lippencott, 1987; 213-27.

36. Stenlake, J.B Waigh, R.B, Urwin J et al. Atracurium: conception and inception BJ.

Anesthesia, 1983; 55: 35-105.

37. Holtle K, Werner MU, lacouture PG, Kehlet H. Dexamethasone prolongs local analgesia

after subcutaneous infiteration of bupivacaine microcapsules in human volunteers.

Anesthesiology, 2002; 96: 1331-5.

38. Kopacz Dj, Lacouture PG, WuD et al. The dose response and effects of dexamethasone

on bupivacaine microcapsules for intercostal blockade (T9 to Til) in healthy volunteer.


39. Castillo J, Curely J, Hotz J et al. Glucocorticoides, steroids prolongs rat sciatic nerve

blockade in vivo from bupivacainemicrospheres. Anesthesiol, 1996; 85: 1157-66.

40. Lee‟s synopsis of anesthesia, 13th

ed. Edited by N.J.H. Davis, N.J. Cashman, 2005; 4:

401-429.

41. A.R. Aitkenhead, G.Smith, text book of anesthesia 4th

ed. 2001; 43: 559.

42. Lorraine M. Sdrales, Ronald D.Miller, anesthesia review, 2001; 13: 194.

43. G.Edward Morgan, J., M.D., Maged S. Mikhail, M.D. Appleton and Lange, clinical

anesthesiology 2nd

ed. 2006; 17: 342.

44. James Duke, M.D., anesthesia secrets, 3rd

ed., 2006; 71: 451.

45. Lippincott‟s Illustrated reviews, 3rd

ed., 2006; 17: 342.

46. Padmaja Udaykumar, text book of medical pharmacology, 2004; 64: 406.

47. Johansson A, Hao J, Sjolund B. Local corticosteroid application blocks transmission in

normal nociceptive C-fibers. Acta Anesiol. Scand, 1990; 34: 335-8 PM1D.

48. Zekiye Bigat, Neval Boztug, Necmiye Hadimioglu, Nihan Cete, Nesil coskunfirat and

Ertugrul Ertok. Dose dexamethasone improve the quality of intravenous regional

anesthesia and analgesia. Anesth. and analgesia, 2006; 102(2): 605-9.

49. Movafeqh A, Razazia M, Hajimao hamadi F and Mey Sarnie A.Anesthesia and analgesia,

2006 Jan; 102(l): 263-7.

50. Kurt N, Kurt I, Aygunes B, oral H Tulunay M, Eur J. Anesthesiol, 2002 Jun; 19(7):

522-5.


1611


51. Turan A, Karaman Lyoglu B, Memis D, Kaya, Pamukcu Z. Intravenous regional

anesthesia using prilocaine and neostigmine. Anesthesia and analgesia, 2002; 95:

1419-1422.

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