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Intravenous regional anaesthesia

Intravenous regional anaesthesia . Dr. S. Parthasarathy MD., DA., DNB, MD ( Acu ), Dip. Diab . DCA, Dip. Software statis tics PhD(physiology) Mahatma Gandhi medical college and research institute, puducherry , India . History .

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Intravenous regional anaesthesia

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  1. Intravenous regional anaesthesia Dr. S. Parthasarathy MD., DA., DNB, MD (Acu), Dip. Diab. DCA, Dip. Software statistics PhD(physiology) Mahatma Gandhi medical college and research institute, puducherry, India

  2. History • Intravenous regional anaesthesia (IVRA) was first described by August Bier in 1908. • He observed that when local anaesthetic was injected IV between two tourniquets on a limb, a rapid onset of anaesthesia in between the tourniquets and a slower onset occurred beyond the distal tourniquet. Not popular until the 1960s when it was reintroduced by Holmes.

  3. Original inter cuff IVRA 1st cuff 2nd cuff

  4. Double tourniquet

  5. Indications • surgical interventions on the hand, forearm or elbow that will not exceed 1 hour. • These include manipulation of forearm fractures, excision of wrist ganglia and palmarfasciotomy. • the foot, ankle or lower leg, • for example - for removing plates, screws or foreign bodies

  6. contraindications • To tourniquet • sickle cell disease, Raynaud’s disease or scleroderma • Allergy to local anaesthetics • peripheral vascular disease • Surgery needs tourniquet removal during the procedure

  7. Advantages • Ease of performance • Safety • Onset • Relaxation • Controlled duration • Rapid recovery • Definite -- successful anaesthesia in 96–100%

  8. Disadvantages • Use of tourniquet • Cannot release tourniquet • Exsanguination • Toxic reactions • Duration ??

  9. Technique - equipment • Esmarch bandage • Tourniquet – single or double ?? • Two IV accesses • Routine resuscitative equipment • Local anaesthetics

  10. Preparation • Explanation • IV access both sides • Benzodiazepine premed oral • Vein on the dorsum of hand access before tourniquet • Exsanguination

  11. exsanguination • Esmarch bandage or a Rhys-Davis exsanguinator. • Crepe bandage • elevating the arm for 2–3 minutes while compressing the axillary artery • it must be confirmed that no radial pulse is palpable before IV

  12. Rhys-Davis exsanguinator.

  13. Tourniquet application • The double tourniquet (two tourniquets each 6 cm wide) or • a single one (14 cm wide) is applied on the arm with generous layers of padding, • no wrinkles are formed • tourniquet edges do not touch the skin

  14. Inflation • Proximal touniquet 30 mm above systolic • Better to have it as 200 mmHg • Legs can go upto 300 mmHg

  15. Tourniquet • Discomfort • Minimum time • Release • ?? Test deflation and reinflation • Resuscitation ready • No movement after release

  16. double cuff tourniquet • If using a double cuff tourniquet, the distal cuff should be deflated. • If required for tourniquet pain control, the distal cuff may be inflated, followed by deflation of the proximal cuff. • Check for inflation by palpation of the tourniquet cuff.

  17. Find LOP and inflate • LOP can be defined as the minimum pressure required, at a specific time in a specific tourniquet cuff applied to a specific patient’s limb at a specific location, to stop the flow of arterial blood into the limb distal to the cuff • Inflate 100 mm above LOP

  18. drugs Prilocaine 0.5 % 40 to 50 ml Lignocaine 0.5 % 40 to 50 ml Ropivacaine , Bupivacaine used Legs upto 70 – 80 ml ..dose -- slim?? Preservative free LA Over 90 seconds Chase the LA with NS No adrenaline

  19. Anaesthesia is -- • Anaesthesia is • terribly simple • But sometimes • It is simply terrible

  20. Modified methods • Hand • Legs • Foot • Children • Dose and size of cuff

  21. Complications • CNS symptoms • 2.1 % to 10 % incidence • CVS • 15 % ECG changes ?? • Minimal drop in BP and HR • Dose and preinj. Ischemia • Higher levels of local anaesthetic in blood after axillary and lumbar epidural blocks

  22. Cross section of nerve fibre • Mantle Proximal area Brachial blocks Core = distal or digital- IVRA Mantle Vasanervorum Core

  23. Mechanism • Digits first even in intercuff method • nerves near the elbow (especially the median and ulnar nerves) are known to be closely accompanied by veins, tributaries of which mainly run through the core of each nerve trunk. • nerve trunks are constructed with fibres from the periphery nearest the centre

  24. Difference • centripetal spread of the anaesthetic effect. • Nerve blocks have centrifugal anaesthetic effect because the drug is poured into the nerve from outside

  25. IVRA and additives • Opioids • Relaxants • Ketamine • Clonidine • Neostigmine • Paracetamol • Ketoroloc

  26. IVRA and sympatholytics • Guanithidine 10 – 20 mg with 500 units heparin with 20 – 30 ml physiological saline • Diagnostic sympathetic block • TAO , CRPS etc..

  27. Summary • Easy simple method • 100 % efficacy • Very less complications • Cheap • Adjunct to brachial plexus block ?? • But still infamous

  28. Helping others is ultimate happiness Thank you all

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