1 / 17

Ischaemic Arm Block

Ischaemic Arm Block. Dr Peter Jones Emergency Medicine Specialist Auckland City Hospital. IVRA IntraVenous Regional Anaesthesia. >160 IVRA procedures / yr in Auckland ED Bier 1908 Advantages Simple Safe No fatalities recorded in literature Effective anaesthesia Bloodless field

judson
Download Presentation

Ischaemic Arm Block

An Image/Link below is provided (as is) to download presentation Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author. Content is provided to you AS IS for your information and personal use only. Download presentation by click this link. While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server. During download, if you can't get a presentation, the file might be deleted by the publisher.

E N D

Presentation Transcript

  1. Ischaemic Arm Block Dr Peter Jones Emergency Medicine Specialist Auckland City Hospital

  2. IVRAIntraVenous Regional Anaesthesia • >160 IVRA procedures / yr in Auckland ED • Bier 1908 • Advantages • Simple • Safe • No fatalities recorded in literature • Effective anaesthesia • Bloodless field • Muscle relaxation

  3. Indications Any limb procedure Cooperative patient Contraindications Absolute Hypertension Allergy to amide LA Relative Uncooperative patient Not fasted Intoxicated Obtunded IVRA

  4. IVRA Equipment • Resuscitation • Monitoring • Pneumatic tourniquet • Prilocaine • POP stuff • Documentation – procedures sheet • Staffing • Proceduralist • Medicator / Monitoring • Plasterer

  5. IVRA Technique • Label in procedures book • Let radiology know • Consent • Weigh • Record • Why they fell! • Past anaesthetic / Medical / Allergy history • Current CVS status / fasting state • Limb neurovascular status

  6. IVRA Technique • Monitoring • Continuous ECG, SPO2, RR, BP • BP Initially • Same arm / Same cuff • 2 IVs • 18g other arm – resus IV • 22g injured arm – lightly taped • Better anaesthesia if more distally placed • Exanguinate • 1-3min

  7. IVRA Technique • Double cuff • Inflate proximal first • Infuse Prilocaine • Inflate distal cuff • Take out 22g line, apply pressure • Wait 5-10 minutes (anaesthesia achieved) • Perform procedure

  8. IVRAPrilocaine 0.5% plain 3mg/kg = 0.6mL / kgMax 200mg = 40mL • Kinetics • Onset minutes • 10 min to max sensory block • Protein bound 55% • Tissue Binding • Metabolised • amidases – liver/lung/kidney • Post tourniquet • Plasma concentration 4-5mcg/ml • Sensation recovers <10min • T ½ α=3min, β=30min

  9. IVRAPrilocaine 0.5% plain 3mg/kg = 0.6mL / kgMax 200mg = 40mL • Caution • Heart block • Anti-arrythmics • Methaemoglobinaemia • O-toluidine metabolite • <400mg not reported (adults) • Increased risk infants

  10. IVRA Technique(wrist / forearm #) • Reduce # • 1st layer of POP • Repeat xRay • At bedside, cuff still up • Remanipulate if required • Complete POP

  11. IVRA Technique (wrist / forearm #) • Tourniquet off • 20 minute minimum • 90 minute maximum • Deflation / Inflation (reduces peak plasma levels) ?not required • Recheck Neurovascular status • Post procedure instructions / follow up • Complete documentation

  12. IVRA • Common problems • Cant tolerate cuff • Deflate proximal cuff (buys time) • Systemic analgesia • Entonox • Reassurance • Complications <2% • Transient tinnitus, dizziness, bradycardia

  13. Complications The danger of thin skin

  14. Complications Not checking the pulse (her BP was >200mmHg)

  15. Summary • Performed correctly, upper limb IVRA is a safe and effective procedure

  16. Questions? How are we doing this run??

  17. References • Brown EM et al. IVRA (Bier Block): review of 20 years’ experience • Can J Anaesth. 1989 36(3 pt 1):307-10 • Roberts and Hedges: Clinical Procedures in Emergency Medicine 3rd Ed. 1998 (pp 511-515) • Pitkanen MT et al. Comparison of 0.5% articaine and 0.5% prilocaine in IVRA of the arm: a crossover study in volunteers • Reg. Anesth. Pain Med. 1999 (2) 131-5 • Simon MA et al. Comparison of the disposition kinetics of lidocaine and prilocaine in 20 patients undergoing IVRA during day stay surgery • J Clin Pharm Ther. 1997 (2) 141-6 • Simon MA et al IVRA with 0.5% articaine, 0.5% lidocaine, or 0.5% prilocaine. A double blind crossover study • Reg. Anesth. 1997 (1) 29-34

More Related