A modification of the inter-cuff technique of IVRA for use in knee arthroscopy

Abstract

P Pu ur rp po os se e: : To describe a modified approach to intravenous regional anesthesia (IVRA) for operations on the knee joint.C Cl li in ni ic ca al l f fe ea at tu ur re es s: : 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.C Co on nc cl lu us si io on n: : 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. NTRAVENOUS regional anesthesia (IVRA) is a reliable and efficient technique with a lower cost than general anesthesia and well adapted for limb surgery in the ambulatory patient. 1,2 The use of potentially unsafe large doses of local anesthetic made the technique unpopular for operations on the lower extremity. 3 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. ObjectifC Ca as se e r re ep po or rt t A man aged 52 yr weighing 78 kg presented for arthroscopy of the knee joint. He had pain and swelling of the left knee. Preoperative orthopedic examination showed mild genu vara, knee crepitation and synovial thickening. Knee x-ray showed advanced osteoarthritic changes more on the patello-femoral articulation and medial compartment of the knee joint.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

Lower-extremity peripheral nerve blockade: Essentials of our current understanding

“…Clinical experience suggests that lidocaine 0.5% up to 3 mg/kg and 0.6 mL/kg provides consistent surgical anesthesia within 10 minutes An intercuff IVRA technique has been described for knee arthroscopy achieved successfully with 40 mL lidocaine 0.5%. 132 This technique involves inflation of a double-cuffed tourniquet in the thigh after exsanguination, injection of local anesthetic through a foot cannula, then application of a single cuff in the calf, and re-exsanguination of the foot before inflation of the calf tourniquet. This technique allows surgical anesthesia to be most concentrated around the knee joint.…”

Postoperative Pain and Other Acute Pain Syndromes

“…120 Traditional IV regional techniques for the lower extremity using single-or double-tourniquet techniques may carry a high failure rate, 121 requiring supplementation by the surgeon or conversion to GA. Of potential interest, however, is an intercuff technique for IV RA for knee surgery that has been developed in an effort to produce better localization and reduce overall dosing requirements. 122,123 Local anesthetics administered alone in IV regional blocks are not expected to provide meaningful postoperative analgesia. Low doses of muscle relaxants are known to improve motor block, 124 but should be used with caution to avoid adverse respiratory depression upon tourniquet release.…”

Postoperative Pain and Other Acute Pain Syndromes

“…Of potential interest, however, is an intercuff technique for IV RA that has been developed for use in knee surgery in an effort to produce better localization and reduce overall dosing requirements. 249,250 Opioids (other than meperidine, 30 mg or more) are generally considered not to be beneficial when given via the IV regional technique 251 ; systemic side effects of meperidine are manifested at the 30-mg threshold. Tramadol, 100 mg, administered as IV RA with lidocaine is associated with a selflimited rash below the tourniquet and does not necessarily confer an analgesic benefit.…”