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| ORIGINAL ARTICLE |
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| Year : 2021 | Volume
: 22
| Issue : 2 | Page : 169-175 |
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The comparison of arm and forearm double tourniquet in terms of the onset and duration of analgesia, tourniquet pain, and the return of sensation and movement in distal upper extremity surgery: A randomized clinical trial
Hesameddin Modir1, Esmail Moshiri1, Amirreza Modir2, Saide Shakeri3, Amir Hosein Moradi4
1 Departments of Anesthesiology and Critical Care, Arak University of Medical Sciences, Arak, Iran
2 student research commitee, Arak University of Medical Sciences, Arak, Iran
3 Department of nursing, School of Paramedical Sciences, Arak University of Medical Sciences, Arak, Iran
4 Department of Orthopedic Surgery, Arak University of Medical Sciences, Arak, Iran
| Date of Submission | 21-Apr-2021 |
| Date of Decision | 24-Apr-2021 |
| Date of Acceptance | 03-May-2021 |
| Date of Web Publication | 29-Sep-2021 |
Correspondence Address:
Dr. Esmail Moshiri
Department of Anesthesiology and Critical Care, Arak University of Medical Sciences, Arak
Iran
 Source of Support: None, Conflict of Interest: None  | Check |
DOI: 10.4103/TheIAForum.TheIAForum_70_21
Aims: The current study aimed at comparing arm and forearm double tourniquet in terms of the onset and duration of analgesia, tourniquet pain, and the return of sensation and movement in distal upper extremity surgery.
Methods: This double-blind clinical trial was performed on 70 patients who were candidates for distal upper extremity orthopedic surgeries. The patients were randomized into two groups of arm and forearm double tourniquet. The onset time and duration of sensory and motor blocks were recorded. The pain level was recorded by visual Analog Scale (VAS) after inflating the tourniquet every 15 min till the end of operation at 15, 30, and 45 min as well as every 30 min for 2 h (at 30, 60, 90, and 120 min.) and at 6, 12, and 24 h after deflating the tourniquet. SPSS version 20 was used to analyze the data.
Results: During 8–24 h after the surgery, the pain in arm double- tourniquet group was less than that in the other group (P < 0.05). There was no statistically significant difference in the time to onset of sensory–motor block between the two groups (P > 0.05). The duration of sensory block in arm double tourniquet was longer than that in forearm double tourniquet group (P = 0.002). In addition, the duration of motor block in arm double tourniquet was also longer than that in forearm double tourniquet group (P = 0.001). The pain level was equal in both the groups at all times except for the time interval of 8–24 h after the operation in arm double tourniquet group. Furthermore, there was no statistically significant difference in the pain level, and the time to onset of sensory–motor block was the same in both the groups as well. However, the duration of sensory–motor block was longer in the arm double tourniquet group, while no complication was found in either group.
Conclusion: Both the techniques are applicable in hand and distal upper extremity surgeries provided that the surgical duration is not too long. Using forearm double tourniquet technique is preferable to arm double tourniquet, but the surgical duration should not exceed 60 min. That is because less amount of anesthetic drugs is needed in forearm double tourniquet technique, hence leading to a decrease in the potential side effects.
Keywords: Distal upper extremity surgery, double tourniquet, motor block, sensory block, tourniquet pain
How to cite this article:
Modir H, Moshiri E, Modir A, Shakeri S, Moradi AH. The comparison of arm and forearm double tourniquet in terms of the onset and duration of analgesia, tourniquet pain, and the return of sensation and movement in distal upper extremity surgery: A randomized clinical trial. Indian Anaesth Forum 2021;22:169-75 |
How to cite this URL:
Modir H, Moshiri E, Modir A, Shakeri S, Moradi AH. The comparison of arm and forearm double tourniquet in terms of the onset and duration of analgesia, tourniquet pain, and the return of sensation and movement in distal upper extremity surgery: A randomized clinical trial. Indian Anaesth Forum [serial online] 2021 [cited 2023 May 30];22:169-75. Available from: http://www.theiaforum.org/text.asp?2021/22/2/169/326983 |
| Introduction | |  |
Introduced first by Karl August Bier in 1908, intravenous regional anesthesia (IVRA) is a simple, safe, and reliable technique which is most commonly used for small surgeries, especially the hand and forearm, and known for its safety and reliability in inducing analgesia and stopping blood flow during extremity surgeries.[1] The rapid onset of analgesia, its high success rate, rapid recovery, and controllable prolonged analgesia have all made it an appropriate technique for outpatient procedures.[1],[2] Regional intravenous anesthesia is based upon exsanguination of the limb, using tourniquet for the isolation of blood in the limb from the systemic circulation and the injection of local anesthetics into the intravenous circulation in the targeted region to be anesthetized.[3] In the Bier block, a local anesthetic is infused into intravenous catheter in the targeted region. In the conventional method, double tourniquet is placed around the limb.[4],[5] An essential step in this technique is the exsanguination of the extremity by an Esmarch bandage before the injection of local anesthetic. For this purpose, the extremity is elevated until the exsanguination of the extremity. Following this, the proximal tourniquet is inflated till the radial pulse disappears, which indicates the suitable tourniquet pressure. At this point, a local anesthetic is injected through the intravenous catheter. For a standard Bier block, a local anesthetic (typically 40–50 mL of 0.5% lidocaine) is injected.[6],[7] Since the inflated tourniquet with a higher pressure than that of systemic blood cannot be tolerated by the patient, when the proximal tourniquet pain becomes severe and intolerable, it is deflated and substituted by the distal tourniquet.[5] The most important limitation of this method is tourniquet pain and rapid development of feelings of pain after deflating the tourniquet, especially in surgeries of prolonged duration.[8]
In general, tourniquets are of two types: the pneumatic (using a gas pump) and Esmarch (rubber bandage). Most of the tourniquets used today belong to the pneumatic type. However, in most cases, it is not very necessary to use tourniquets, but in other cases, such as delicate hand surgeries, the operation is not possible without the application of a tourniquet.[3],[9] On the other hand, various complications following tourniquet application have been reported as follows: increased blood volume during reperfusion following tourniquet use, which makes it difficult for cardiac patients to handle, pulmonary embolism, skin trauma, hypertension, muscle damage, posttourniquet edema, compartment syndrome, nerve damage and even occlusion of coronary and other arteries,[3],[10],[11] and death from pulmonary embolism.[12] Posttourniquet syndrome is a common reaction to prolonged ischemia of the extremity, during which the patient experiences stiffness, muscle weakness, pallor, stiffness, and numbness that will usually resolve in a short time.[13],[14]
Research about complications of tourniquet application for patient satisfaction is very beneficial and patients and practitioners alike have always strived for highly efficacious techniques with minimal side effects.[3],[14] As such, since there has been no comparative study on arm and forearm tourniquet as well as its complications, the current study set out to shed light on comparing arm and forearm tourniquet with regard to onset and duration of analgesia and the return of sensation and movement in distal upper extremity surgeries.
| Methods | | |
A total of 70 patients who were candidates for distal upper extremity surgeries and were of ASA physical status I and II took part in this double-blind clinical trial.
This project is approved by the Ethical Committee of Medical Sciences University (ethics code: IR.ARAKMU.REC.1398.007). Moreover, the study protocol is registered in the Iranian Registry of Clinical Trial centers by clinical trial code number: IRCT20141209020258N119. The informed consent form is received from all eligible subjects after meeting the inclusion criteria. The inclusion criteria were as follows: being of both genders, the age range of 20–50 years, ASA Class 1 and 2, duration of surgery being within 40–90 min, no pregnancy, body mass index of <30, absence of Raynaud's disease, scleroderma, epilepsy, sickle cell anemia, met-hemoglobinemia, history of drug allergy (to the study drugs), lack of excessive blood loss, absence of underlying illnesses such as vascular diseases, hypertension and coagulation disorders, absence of the use of calcium channel blockers or beta-blockers, lack of kidney failure, and substance abuse. The exclusion criteria were as follows: patient dissatisfaction, hemoglobin level of <10, lack of patient's cooperation, and when intraoperative IVRA becomes ineffective for whatever reason.
After recording vital signs and arterial oxygen saturation (SaO2) for the patients, two IV lines were inserted: one into the dorsal vein of the hand which underwent surgery and another into the other hand to inject crystalloid fluids. The patients were then randomized into two groups using the block randomization method. At first, using a block pattern, the sequence of participants' assignments to the groups was determined. The patients were then divided into two groups based on the produced pattern and the order in which they entered the study. [Figure 1] shows the CONSORT flow diagram of participants through each stage of a randomized trial. | Figure 1: CONSORT diagram showing the flow of participants through each stage of a randomized trial
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After the patients' assignment, 2 mg midazolam (Exir Co.) and 1 μg/kg fentanyl (Caspian Tamin Co.) were initially injected as premedication and induce analgesia. Afterward, the patient's arm was raised for 2 min to evacuate the blood followed by Esmarch bandage application. In both the groups of arm and forearm double tourniquet, the proximal cuff of the double tourniquet was inflated to 100 mmHg above the patient's baseline systolic blood pressure, or to 250 mmHg atmospheric pressure, and the Esmarch bandage was removed. Having ensured the absence of pulse by pulse oximetery, the prepared drugs were administered in each group. It should be mentioned that in the arm double tourniquet group, the tourniquet was applied 2.5 cm above the forearm flexor fold, while in the forearm double tourniquet group, it was applied 2.5 cm below the forearm flexor fold.
In arm double tourniquet group, 40 ml of 0.5% lidocaine, approximately 3mg/kg, (Darou Pakhsh Co.) along with 1 μg/kg dexmedetomidine (Exir Co.), totaling a volume of 50 ml, was administered to the patients in the dorsal vein of the organ on which the procedure was to be performed. In addition, in the forearm double tourniquet group, 20 ml of 0.5% lidocaine – approximately 1.5 mg/kg along with 0.5 μg/kg dexmedetomidine, totaling a volume of 25 ml, was administered in the same region as that in the first group.
As to double blinding, the patients were not aware of the group assignments. In addition, the operating surgeon would not notice the particular technique – either arm or forearm tourniquet – since the arm on which the procedure was to be performed was covered by surgical drapes and only an area of 10 cm above the surgical field in both the techniques was available to the surgeon.
The onset of sensory block was determined by a 22G needle (pinprick method) every 30 s. The patient response was tested in sensory dermatomes of the medial and dorsal antebrachial, ulnar, median, and radial nerves. Meanwhile, the level of motor block was assessed by requesting them to bend the wrist and hand fingers up and down (flexion and extension). A complete motor block was achieved when the patient could not perform any voluntary movement of the organ. The onset of sensory block and motor block refers to the time elapsed from the time of administration of study drugs to achieving a complete sensory block and motor block in all dermatomes.
After completion of sensory–motor block, the distal tourniquet was inflated to 250 mmHg, while the proximal tourniquet was deflated and the surgery proceeded. Heart rate (HR), mean arterial pressure (MAP), and SaO2 were recorded before the tourniquet application at 5, 10, 15, and 20 min every 10 min until the end of surgery, after the tourniquet deflation, and during recovery. The tourniquet was not deflated earlier than 35 min and not inflated more than 90 min. If the duration of surgery was longer than 90 min, the patient would undergo general anesthesia and be excluded from the study. After the surgery ended, the tourniquet was emptied with the alternate technique. Later on, the sensory recovery time (i.e., the time elapsed after tourniquet deflation until pain sensation in dermatomes checked with a 22G needle), the motor block recovery time (i.e., the time elapsed after tourniquet deflation until the return of movement in the fingers), and the analgesic requirement time (i.e., the time elapsed after tourniquet deflation until the first time the patient needed pain relief) were recorded accordingly.
The pain level was measured by the Visual Analog Scale (VAS) upon tourniquet inflation at 15, 30, and 45 min and then every 15 min until the end of surgery. If VAS was above 4, 1 μg/kg IV fentanyl was administered to the patient, and the time of receiving the first dose of fentanyl was recorded. Furthermore, the pain level was recorded every 30 min till for 2 h (i.e., at 30, 60, 90, and 120 min) and 4, 8, 16, and 24 h after the tourniquet was deflated. In the postoperative period, if the VAS was above 4, 25 mg of Intramuscular pethidine was administered to the patient. The time and amount of the received drug were recorded as well. In the end, data were analyzed by SPSS version. 20 (IBM SPSS Statistics for Windows, Armonk, NY: IBM Corp, 2017). Independent sample t-test and analysis of variance of repeated measurements were used to analyze data.
| Results | | |
The current study set out to compare arm and forearm double tourniquet with regard to the onset and duration of analgesia, tourniquet pain, and the restoration of sensation and movement in distal upper extremity surgery. Seventy patients who had been randomized into two groups based the block method entered the study. Thirty six of the participants (51.4%) were male and 34 (48.6%) were female. The mean age of the participants was 30.35 ± 6.40. The maximum and minimum age of the participants was 29 and 43, respectively. Moreover, both the groups were similar in terms of age, gender, and body mass index (BMI). There was no statistically significant difference in MAP, HR, SaO2, opioid consumption, and surgical duration in both the groups (P > 0.05). According to the results presented in [Table 1], from 8 to 24 h after the surgery, there was a statistically significant difference in pain scores between the two groups (P < 0.05). However, the pain level in arm double tourniquet group was less than that in the other group at these times. As can be seen in [Table 2], there was no statistically significant difference in time to onset of sensory block between the two groups (P = 581). However, the duration of sensory block in arm double tourniquet group was longer than that in the forearm double tourniquet group (P = 0.002). According to [Table 3], there was no statistically significant difference in time to onset of motor block between the two groups (P > 05). However, the duration of motor block in arm double tourniquet group was longer than that in the forearm double tourniquet group (P = 0.001). | Table 1: Comparison of the mean and standard deviation of pain scores in the two groups
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 | Table 2: Comparing the mean and standard deviation of sensory block scores in the two groups
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 | Table 3: Comparison of mean and standard deviation of motor block scores in the two groups
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| Discussion | | |
On the whole, the results showed during the surgery and even for 8 h after the surgery, the pain level was identical in both the groups. Only from 8 to 24 h after the surgery, there was a statistically significant difference in pain scores between the two groups. Moreover, there was no statistically significant difference in time to onset of sensory and motor block between the two groups. Yet, the duration of sensory block in arm double tourniquet group was longer than that in the forearm double tourniquet group. Likewise, the duration of motor block in arm double tourniquet group was longer than that in the forearm double tourniquet group.
All in all, compared to the forearm double tourniquet group, there were less pain and longer duration of sensory and motor block in arm double tourniquet group. Tourniquets are utilized to minimize the released drug and maximize its density level in the blood.[15] The most outstanding limitation of IVRA pertains to tourniquet pain and rapid progression of pain sensation after removing the tourniquet, especially in procedures of prolonged duration. Despite this, tourniquets reduce intraoperative blood loss and provide bloodless operative fields for the surgeon, leading finally to a reduction in surgical duration.[8]
Dekoninck et al.[16] performed a systematic review of the analgesic efficacy with the use of upper arm IVRA as compared to forearm IVRA. They maintained that forearm IVRA is more effective than an upper arm IVRA. Furthermore, no complications were observed regarding the use of a forearm tourniquet. Among the other benefits of forearm tourniquet application in comparison with forearm one, mention can be made of a faster onset of sensory block, better tourniquet tolerance, and bloodless surgical field.[16] Their results were in line with those of the current study as far as the lack of complications goes. However in the current study, from 8 to 24 h after the surgery, there was less pain in arm double tourniquet group. Furthermore, the results of their study and the current one were not similar as to the comparison of the onset of sensory block. While in the study by Dekoninck et al.,[16] the onset of sensory block was rapid in forearm tourniquet group, in the current study, there was no difference with regard to the onset of sensory block between the two groups.
Song et al.[17] compared forearm tourniquet in IVRA with the arm tourniquet. The onset times of sensory and motor block in forearm tourniquet group were significantly shorter. However, no statistically significant difference was observed in the two groups with regard to onset of tourniquet pain, amount of fentanyl consumption, sensory–motor block, and quality of anesthesia. Furthermore, there was a lower incidence of local anesthetic toxicity in the forearm group. They concluded that the forearm tourniquet was safe and achieved a more rapid onset of sensory and motor blocks.[17] In the current study, from 8 to 24 h after the surgery, there were less pain and longer duration of sensory–motor block in arm double tourniquet group. The difference between the results of the current study and those of Song et al. might be attributed to the large sample size and longer investigation time of the patients in the current study.
Ng et al. compared discomfort levels between upper arm and forearm tourniquet and reported that in the upper arm tourniquet, 24.9% of the patients had mild, 60.5% had moderate, and 14.6% had severe pain, whereas with forearm tourniquet, 99% of patients had mild pain and only 1% had moderate pain. Furthermore, 79% of the patients with forearm tourniquet had no discomfort at all. The average discomfort level for upper arm and forearm tourniquet was 4.72 and 0.39, respectively, which was statistically different. The authors concluded that forearm tourniquet was safe and well tolerated.[18] The results of their study were in tandem with those of the current study in terms of the safety and absence of complications of forearm tourniquet. However, the two studies were different with regard to pain, since in the current study, from 8 to 24 h after the surgery, there were less pain and longer duration of sensory–motor block in arm double tourniquet group. This finding is in contrast with that of the current study. Once again, the difference between the results of the two studies might be ascribed to the longer postoperative investigation time of the participants in the current study.
In 2004, Karalezli et al. conducted a study entitled “results of IVRA with distal forearm application” on 120 patients undergoing hand surgery. They injected a 10 ml solution containing 1.5 mg/kg prilocaine and found that sensory block onset time was 4.5 min with the mean tourniquet time, tourniquet pressure, and tourniquet pain score being 17.6 min 240 mmHg, and 3.8, respectively. They reported no side effects concerning the IVRA technique. Their study indicated that forearm distal tourniquet is safe, rapid, and effective.[19] Their results were in agreement with those of the current study in which it was found that the forearm tourniquet was as effective as the arm tourniquet.
| Conclusion | | |
The findings revealed that the pain level was equal in both the groups at all times except for the time interval of 8–24 h after the operation in arm double tourniquet group, indicating no significant difference in the pain level. Furthermore, the time to onset of sensory–motor block was the same in both the groups as well. However, the duration of sensory–motor block was longer in the arm double tourniquet group, while no complication was found in either group. As such, it can be concluded that both of the aforementioned techniques can be applicable in distal upper extremity surgeries provided that the surgical duration is not too long. Using forearm double tourniquet technique is preferable to arm double tourniquet, but the surgical duration should not exceed 60 min. That is because less amount of anesthetic drugs is needed in forearm double tourniquet technique, hence leading to a decrease in the potential side effects. However, the ultimate decision to use either of these techniques depends on the conditions of the patient and the anesthesiologist's discretion.
Acknowledgments
This article is part of a research project (ethics code: IR.ARAKMU.REC.1398.007) and clinical trial code number: IRCT20141209020258N119. The authors, hereby, would like to express their gratitude to clinical research council in Vali Asr hospital as well as the vice chancellor for research and technology of Arak University of Medical Sciences for their financial and moral support.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
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| 16. | Dekoninck V, Hoydonckx Y, Van de Velde M, Ory JP, Dubois J, Jamaer L, et al. The analgesic efficacy of intravenous regional anesthesia with a forearm versus conventional upper arm tourniquet: A systematic review. BMC Anesthesiol 2018;18:86. |
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[Figure 1]
[Table 1], [Table 2], [Table 3]
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