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Role of addition of Dexamethasone and Ketorolac to lignocaine intravenous regional anesthesia (Bier's Block) to improve tourniquet tolerance and post-operative analgesia in hand and forearm surgery

Muhammad Akram,Faheem Mubashir Farooqi,Muhammad Irshad,Syed Faraz Ul Hassan,Syed Muhammad Awais  ( Department of Orthopedic Surgery and Traumatology Unit-1, Mayo Hospital Lahore, Pakistan. )

November, 2015

Abstract

Objective: To compare tourniquet tolerance and postoperative analgesia using lignocaine intravenous regional analgesia alone or with addition of dexamethasone and ketorolac.
Methods: The randomised, prospective study was conducted at Mayo Hospital, Lahore, from June 2013 to June 2014. Patients were divided into three groups: group I received lignocaine; group II received lignocaine and 30mg ketorolac; and group III received lignocaine, 30mg ketorolac and 08mg dexamethasone for intravenous regional anaesthesia. A total of 40ml solution was made by diluting it with normal saline. Motor and sensory block and recovery times were noted. Visual analogue scale was used to assess the severity of surgical and tourniquet pain, and total number of analgesic tablets taken in the first 24 hours after surgery were also recorded.
Results: The 180 patients in the study were divided into three equal groups of 60(33.3%) each, with each group having 30(50%) male and 30(50%) female subjects. In all the three groups, the sensory and motor onset and recovery time was the same (P>0.05). Lower pain scores were reported in groups II and III compared to group I (p<0.001). Patients of group II and III also required fewer analgesic tablets postoperatively and had longer postop time during which no analgesia was given compared to group I (p<0.05).
Conclusion: Bier block using lignocaine, dexamethasone and ketorolac provides better tourniquet tolerance in patients undergoing hand and forearm surgeries when compared to use of lignocaine alone and lignocaine and ketorolac.
Keywords: Bier\'s block, Ketorolac, Dexamethasone, Lignocaine. (JPMA 65: S-128 (Suppl. 3); 2015).


Introduction

In 1908, August Karl Gustav Bier described for the first time about the intravenous (IV) regional anaesthesia for surgeries of hand and forearm.1 For the surgeries of forearm and hand of less than 01 hour it is an effective method of anaesthesia, but does not provide effective postoperative analgesia after tourniquet release. For IV regional anaesthesia, usually local anaesthesia such as lignocaine or prilocaine is administrated.2,3 Various medications like non-steroidal anti-inflammatory drugs (NSAIDs), opioids, dexamethasone, magnesium, neostigmine and tramadol have been administrated along with the local anaesthetic in the Bier block in attempt to improve intraoperative analgesia.4-14
Theoretically, both steroids and NSAIDs should be beneficial in the management of acute surgical pain induced by tissue injury. Different studies have reported an increase in duration of post-operative analgesia after the tourniquet release by adding dexamethasone and ketorolac in Bier block (intravenous regional anaesthesia).9-11
The current study was planned to compare the tourniquet tolerance and post-operative analgesia using lignocaine IV regional analgesia alone or with the addition of dexamethasone and ketorolac in combination or as sole adjunct.


Patients and Methods

The randomised, prospective study was conducted in Unit I of the Department of Orthopaedic Surgery and Traumatology, Mayo Hospital, Lahore, from June 2013 to June 2014. Patients with no co-morbidities and undergoing ambulatory hand and forearm surgeries were included after informed written consent was taken from each patient. Those with history of allergies to any medications used in the study were excluded. Three equal groups of patients were formed. After preoperative assessment, two IV cannulas were inserted: one of 22-G was inserted on the operative hand and the other of wide bore on the other limb for infusion. Ringer Lactate infusion was started and the patient was given 2mg of midazolam intravenously. No other analgesia was given before the surgery. Esmarch bandage was wrapped around the hand and forearm to exsanguinate the operative hand and a rubber tube was used as a tourniquet and was applied on the upper portion of the operative hand and then Esmarch bandage was removed. Group I patients received only 2% lignocaine for Bier\'s block, whereas group II received 30mg ketorolac in addition to 2% lignocaine, and group III received 30mg ketorolac and 08mg dexamethasone additionally. A 40ml solution was made by adding normal saline in the solution. A small gauge needle was used to assess the sensory block onset for every half minute. Sensory onset time was noted as the time passed after injecting the solution till sensory block in all the dermatomes. Patients were asked to move his/her fingers to assess the motor function and time passed from injecting the solution till complete motor block was assessed and noted as the motor block. After achieving complete motor block, another rubber tube was applied distal to first tourniquet and the first tourniquet was removed. This tourniquet was not removed in less than 30 minutes and was not placed for more than 01 hour. Motor and sensory recovery (time elapsed after tourniquet deflation to movement of fingers, and time after the tourniquet deflation to recovery of pain sensation in all dermatomes) were evaluated and recorded. Visual analogue scale (VAS) was used to assess the tourniquet pain and pain at operative site where zero meant no pain, and 10 meant unbearable pain. This took place in the operation theatre during surgery. Opioids analgesia (injection Nalbuphine) was given whenever VAS>03. Patients were instructed to inform the doctor as soon as they felt pain for the first time postoperatively and were given oral analgesia accordingly. The time when patient first required analgesic tablets after the tourniquet deflation was also noted and the total number of analgesic tablets a patient used during the first 24 hours after surgery was also recorded.


Results

The 180 patients in the study were divided into three equal groups of 60(33.3%) each, with each group having 30(50%) male and 30(50%) female subjects. There was no difference among the three groups in demographic variables or duration of surgical procedures or tourniquet times (Table-1).

Motor and sensory block onset and recovery times in all the three groups were also similar (Table-2).

During surgery and postoperatively the patients in groups II and III required significantly less analgesia (Table-3).

Groups II and III had significantly less VAS scores compared to group I (p<0.001), whereas patients in group II reported higher VAS scores compared to group III (Table-4).

Patients in groups I and II had significantly shorter periods of subjective comfort during which they required no analgesia with a median of 122 minutes (interquartile range [IQR]: 34-392) and 524min (IQR: 415-1085) compared to 566 min (IQR: 498-1105) in group I (p<0.001). Furthermore, 8(13.3%) patients in group II and 24(40%) in group III required no additional analgesics during the first 24 hours after tourniquet release, whereas all patients (100%) in group I required oral analgesia. Total numbers of tablets consumed in the first 24 hours after surgery was less in group III compared with groups I (p<0.001) and II (p=0.046) (Table-5).

No patient experienced any complications like bradycardia, hypotension and hypoxia etc.


Discussion

Results showed that addition of ketorolac and dexamethasone in lignocaine for Bier block provided effective peroperative analgesia for patient undergoing hand and forearm surgery. It also provided better tourniquet tolerance and prolonged post-operative analgesia compared to lignocaine alone and lignocaine and ketorolac. The limitations of lignocaine as IV regional anaesthesia are established tourniquet pain and inability to provide effective postoperative analgesia, though it is the commonest drug used for IV regional anaesthesia. In order to prolong the tourniquet tolerance and post-deflation analgesia, different drugs have been combined with lignocaine, but only a2-adrenoceptors and NSAIDs have shown the benefits.4-14
Previously, ketorolac has shown to improve early tourniquet tolerance and prolonged postoperative analgesia when used in addition to lignocaine for Bier block. A study in 1992 for the first time used ketorolac with lignocaine as IV regional anaesthesia.15
Reuben et al, in a study in 1995 reported significant peroperative benefits from ketorolac plus IV regional anaesthesia compared to systemic controls. In their study they found that few patients had a pain score of >3 during the initial first hour after surgery when IV regional anaesthesia was given along with the addition of 60mg of ketorolac compared to the patients who received 60mg IV ketorolac and lignocaine IV regional anaesthesia.9 Our study also showed prolonged tourniquet tolerance, improved postoperative analgesia and less requirement of analgesic tablets during the first 24 hours after surgery in patients of group II.
Reuben et al. also found that use of ketorolac was equally effective whether it was given as an adjunct to IV regional anaesthesia or used as an infiltrate into the surgical site before incision.9,10 The major undesirable side effect, surgical site hematomas with ketorolac as a part of IV regional anaesthesia, was not observed in our study.
The mechanism of analgesia induced by corticosteroids is not clear. But the main action of steroids to provide analgesia is by the peripheral inhibition of phospholipase enzyme, which in return decreases the activities of cyclooxygenase (COX) and lipoxygenase pathways in the inflammatory response.16,17 Some believe that the systemic effects of corticosteroids results in mood elevation, sense of "well-being" and appetite stimulation, resulting in decrease in the pain.18
Some studies have reported that dexamethasone has prolonged duration of analgesia.19-21 In 2001, Coloma et al. reported beneficial effect of a single dose of dexamethasone in patients after having anorectal surgery already receiving prophylactically ketorolac by having early recovery process.22
Bigat et al. published in 2006 the first clinical study in which dexamethasone was added in local anaesthetics for IV regional anaesthesia, reporting that the addition of 8mg of dexamethasone in lignocaine IV regional anaesthesia shortened the time for the first requested analgesia. It also showed that the addition of dexamethasone in lignocaine IV regional anaesthesia prolonged sensory and motor block recovery time.11 On the other hand, our study showed that the addition of dexamethasone in lidocaine and lignocaine plus ketorolac IV regional anaesthesia prolonged the time of patient comfort with no analgesia requested, and, also, it did not affect the sensory or motor block onset or recovery time.
Tourniquet pain is the main source of patient discomfort for Bier block. During the tourniquet inflation, patients experience severe aching sensation which increases with time despite otherwise adequate regional anaesthesia. The actual cause of tourniquet pain is still not clear, but it was suggested that tourniquet pain might arise from ischemia and oxidative stress.23 Some believed that antioxidant therapy might reduce ischemic pain and decrease the dose of analgesia required to block nociception.24,25 Local administration of NSAIDs and glucocorticoids might attenuate tourniquet pain by their antioxidant activities. This is a possible explanation for why patients in groups II and III in our study required no supplemental opioids.
Our findings seem to differ from those of Hartmannsgruber et al, who suggested that the addition of ketorolac to ropivacaine IV regional anaesthesia does not improve tourniquet tolerance.26
Previous studies have demonstrated an enhanced analgesic effect from NSAIDs and steroids, when concentrated at a peripheral site.9-11 Because of these findings, we focused our study on the possible benefits of adding the combination of these drugs locally as a part of IV regional anaesthesia. Although some of the ketorolac and dexamethasone added to the IV regional anaesthesia solution would spread systemically on tourniquet deflation, but it is unlikely that the prolonged analgesia we observed was caused by systemic distribution of these drugs. We suggest that it is plausible that increased and continual levels of NSAIDs and dexamethasone at the site of surgery as part of IV regional anaesthesia results in a longer analgesic period than that for the same dose administered parenterally. We believe that the positive effects of adding these drugs together as a part of ligocaine IV regional anaesthesia might be the result of joint suppression of COX activity.


Conclusion

There was improved tourniquet tolerance, prolonged analgesia and less need of analgesic tablets during the first 24 hours postoperatively when Bier\'s block was given with the addition of dexamethasone and ketorolac to lignocaine.


Acknowledgment

We are grateful to Mr. Ghias-ud-Din, General Secretary of the Society for Welfare of Orthopedically Disabled, for providing free medications for the needy patients, and to Mr. Mumtaz for typing the manuscript.


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