Perioperative Pain Management for Upper Extremity Surgery.

Upper extremity surgeons are currently faced with a daunting array of anesthesia techniques, ranging from traditional general anesthesia to wide-awake surgery, during which patients can watch their surgeons operate in the morning and return to work as soon as that afternoon. This range of options means that surgeons must consider patient-related factors such as disease process and relevant comorbidities, as well as surgery-related factors such as anatomic location, complexity, length of procedure, and postoperative pain expectations. In general, the least invasive technique is favored, but each patient must be considered individually to ensure the best anesthesia choice.

Intravenous regional block is similar to sympathetic ganglion block for pain management in patients with complex regional pain syndrome type I

Sympathetic ganglion block (SGB) or intravenous regional block (IVRB) has been recommended for pain management in patients with complex regional pain syndrome type I (CRPS-I). Forty-five patients were initially selected but only 43 were accepted for the study. The present study evaluated the efficacy of IVRB produced by combining 70 mg lidocaine with 30 µg clonidine (14 patients, 1 male/13 females, age range: 27-50 years) versus SGB produced by the injection of 70 mg lidocaine alone (14 patients, 1 male/13 females, age range: 27-54 years) or combined with 30 µg clonidine (15 patients, 1 male/14 females, age range: 25-50 years) into the stellate ganglion for pain management in patients with upper extremity CRPS-I. Each procedure was repeated five times at 7-day intervals, and pain intensity and duration were measured using a visual analog scale immediately before each procedure. A progressive and significant reduction in pain scores and a significant increase in the duration of analgesia were observed in all groups following the first three blocks, but no further improvement was obtained following the last two blocks. Drowsiness, the most frequent side effect, and dry mouth occurred only in patients submitted to SGB with lidocaine combined with clonidine. The three methods were similar regarding changes in pain intensity and duration of analgesia. However, IVRB seems to be preferable to SGB due to its easier execution and lower risk of undesirable effects.

The Effect of Intravenous Regional Block with Ropivacaine, Ketamine and Clonidine on Complex Reginal Pain Syndrome Type I: A case report / 대한마취과학회지

There is no treatment either to prevent the development of complex regional pain syndromes (CRPS), or to adequately and specifically control established pain. Symptom-based analysis of pain is important for disease progress assessments and treatment outcomes. An intravenous regional block (IVRB) with local anesthetics can contribute to the management of CRPS. We observed that by the IVRB using ropivacaine, ketamine and clonidine, the patient with CRPS type I who was resistant to sympathetic ganglion block and medical treatment with gabapentin, carbamazepine and antidepressant, was relieved of neuropathic pain.

Intravenous Regional Block of Bretylium: Treatment of Reflex Sympathetic Dystrophy / 대한마취과학회지

BACKGROUND: Interruption of efferent sympathetic fibers is the mainstay of therapy in reflex sympathetic dystrophies(RSD) and be accomplished by temporary or permanent anesthetic blockade of sympathetic ganglia, surgical lesions of the sympathetic trunk, intravenous injecton of guanethidine or reserpine, or by systemic administration of adrenergic blocking drugs. In this study, the effects and the side effects of intravenous regional bretylium for the treatment of RSD were studied. METHODS: Seven patients have been administered with 2.0 mg/kg bretylium in 0.25% lidocaine with 100U of heparin three times weekly. A standard intravenous regional technique was used with 250~300 mmHg tourniquet pressure for 30 minutes. Blood pressure and pulse rate were monitored before injection, 1 minute and 5 minutes after injection, immediately before deflation of tourniquet, 1 minute, 5 minutes and 30 minutes after deflation of tourniquet. Pain and temperature evaluations were made before injection and at 1 week after every injection. RESULTS: The increase in skin temperature and decrease in pain score of the affected limb were noted after the use of bretylium in 5 patients out of 7 patients. These clinical effects probably resulted from bretylium,s ability to accumulate in adrenergic nerves and block norepinephrine release. One patient had hypotension immediately after tourniquet deflation. CONCLUSIONS: Intravenous regional bretylium provides significant pain relief for treatment of RSD.