Application of the traditional intravenous regional anaesthesia (IVRA) method with the help of an under-knee tourniquet for short-term foot and ankle surgeries.

Dear Editor,

Intravenous regional anaesthesia (IVRA) was first defined by Karl August Bier in 1908.[1] It has been modified many times until now, and today, it is generally preferred for upper extremity surgeries with the double-cuff method. Traditional IVRA is not preferred for lower extremity surgeries because of the need for a high volume of local anaesthetics.[2] A limited number of studies for the lower extremity are directed to analgesia rather than anaesthesia of the lower extremity.[3]

Some authors have reported that the use of an under-knee tourniquet does not increase the risk of local anaesthetic leakage from the interosseous space; it allows a lower dose to obtain a comparable level of anaesthesia and is as safe as an over-knee tourniquet.[4] We believe that this innate plasticity of IVRA may be optimised by alternative adaptations for the lower extremity. An additional tourniquet at the below-knee level may limit the distribution of local anaesthetic. With relevant modifications, the local anaesthetic amount can be decreased to safe levels and side effects may be reduced.

A 32-year-old male patient weighing 80 kg was operated on the first and second metatarsal bones. We planned to remove the Kirschner wire (K-wire) and apply a plate to the first metatarsal bone. As he had a post-spinal headache caused by the previous surgery, spinal anaesthesia was not preferred, and a proximal tourniquet was planned. The patient was in the supine position. Midazolam 0.03 mg/kg was administered. A single-cuff pneumatic tourniquet was placed over the proximal femur. An additional intravenous (IV) access was obtained from the dorsum of the foot. The tourniquet pressure was increased to 300 mmHg in the extremity after blood had been drained appropriately. A blood pressure cuff was placed 10 cm above the ankle to the non-circulatory extremity. A hand-adjustable blood pressure cuff was maintained at a pressure which was 100 mmHg above the systolic blood pressure. 30 cc mixture was prepared by adding 10 cc contrast, 10 cc 2% lidocaine, and 10 cc isotonic NaCl. This local anaesthetic mixture was applied 1 mL every 3 sec. Lipid Rescue Kit was kept ready for possible local anaesthetic toxicity based on the protocol determined by the American Society of Regional and Pain Medicine (ASRA). During this process, the distribution of local anaesthetics was followed by serial radiological evaluations. Analgesia was confirmed with the pinprick test and the blood pressure cuff was removed at the fifth minute. Additional radiological images were obtained to visualize the upward movement of the contrast agent.

When the radiological images of the patient were examined after the injection of local anaesthetic solution superficial veins became prominent first. The solution, whose upward movement was prevented, moved retrograde. There was no passage through the intraosseous area. Small venous beds also became visible as the fullness of superficial veins increased. After the removal of the temporary tourniquet, contrast agent moved to intraosseous area through deep veins. Contrast agent diffused upwards from the intraosseous area with the help of deep venous valves. Visibility of vascular beds was reduced after diffusion movements [Figures 1–5].

Figure 1

Injection of local anaesthetic solution

Figure 5

Removal of the temporary tourniquet

Imaging of superficial veins

Retrograde movement

Any passage through the intraosseous area

During the operation, the patient's pain was assessed using the visual analogue scale (VAS). The VAS score at the first 5 min was observed as 3. The patient who had no pain in the surgical incision area was restless due to compression sensation around tourniquet and this condition was considered as tourniquet discomfort. The pain due to tourniquet relieved after addition of fentanyl at a dose of 1 mcg/kg. The surgery was ended at the twenty-fifth minute of the tourniquet The patient was monitored for any toxic symptoms in post anaesthesia care unit for 2hr subsequently.

Nowadays, traditional IVRA is rarely preferred because regional anaesthesia methods and imaging methods have developed at a rapid pace. Especially in lower extremity surgeries, it may create difficulties related to regional approaches in cases of application difficulty and low success. Other difficulties to apply regional anaesthesia methods currently include increased comorbid factors due to prolonged life expectancy and sedentary living style.[5] In these circumstances, it should be remembered that IVRA can be easily applied, affects haemodynamic parameters less than general anaesthesia, its morbidity is low and requires less hospitalisation period.[6]

Ischaemia plays an important role in the total conduction block after 15 to 45 minutes when saline is injected instead of local anaesthetics under conditions similar to that of clinical IVRA, leading to complete sensory blockage of the limb and skin.[7] Although rescue analgesic was required initially due to tourniquet discomfort, no additional analgesic requirement was needed subsequently.

We think that IVRA may be used as an alternative approach to regional approaches and low dose sedo-analgesia may be used to control discomfort that may occur until the development of the real tourniquet pain. Studies with larger samples are required to decide the optimal approach.

Patient consent

Written informed consent for the procedure and future publishing was obtained from the patient.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.