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INTRAVENOUS ANALGESIA with CHLOROPROCAINE
TRANSARTERIAL BRACHIAL PLEXUS BLOCK

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INTRAVENOUS ANALGESIA with CHLOROPROCAINE

Case Report
Four variations of IVRA
Equipment
Drugs
The syringes
The doses
How to proceed ?
Indications
Contraindications to IVRA
Advantages
Drawbacks
Complications
Pearls
Costs

The administration of intravenous chloroprocaine in an isolated limb by means of an ischaemic cuff is called intravenous regional anaesthesia (IVRA). IVRA is ideally suited to operations of the hand, forearm, elbow, and foot.

Case Report :

A 60 year-old, 130 kg (280 lb) man arrives at 11 PM in the emergency room with a big abcess of the hand. He is not fasting, smokes one pack a day, has other comorbidities (Hypertension, Obesity, Sleep Apnea,…). The surgeon wants to incise and drain the abcess ; he has a long list the next morning. The operating theater is available and the team is ready. The anaesthetist is on his own. The recovery room is closed until the next morning.
Which technique is best ? In contrast to common opinion, I decided to do an IVRA with two cuffs on the arm which allows to put a third sterile cuff on the forearm during the procedure if the operation is longer than anticipated. After inflation of the proximal cuff, I injected intravenously: chloroprocaine 0.5 % 120 cc + Ketorolac 30 mg + Bicarbonate (see "The doses" below). After 20 minutes, I inflated the distal cuff on the arm (and deflated the proximal one). A third cuff on the forearm was not necessary. At midnight, surgery was all over. The patientt left the hospital 30 minutes later and was asked to come back the next dax for dressing change.
In contrast to common opinion, a regional technique for infections of the upper limb, such as IVRA, is a very good choice. A TAB would have been another option (see below).

Four variations of IVRA with the same equipment :

1. The mini-technique : one single cuff on the forearm.
2. The two separated cuffs technique : one on the arm, the other on the forearm.
3. The two cuffs technique, both of them on the arm.
4. The foot technique, both cuffs on the ankle or calf.
   

                      

Equipment (for suppliers, see below) :

1. Cuffs must be of very good quality . One of average size for the arm (red laces : 18 in. ; 46 cm) and a smaller one for the forearm or the arm (yellow laces : 14 in. ; 35 cm).
   
2. A reliable two-way stopcock, like the metallic Braem one.
   
3. A standard manometer.
4. An Esmarch rubber bandage.
5. Two intravenous cannulae : one for venous cannulation distal to the cuff (22 G on the hand ; 24 G on the foot) and one for cannulation in the opposite arm in the event of complications (optional for the mini-technique).
   

Drugs required :

1. Chloroprocaine 0.5 % is the only local anaesthetic agent I use.
2. Bicarbonate 8.4 % to prevent the discomfort at the beginning of the injection and to facilitate the local anesthetic effect.
3. Toradol (Ketorolac) for postoperative analgesia.
   

The syringes are injected in the following order :

1. One 25 cc syringe: chloroprocaine 0.5 % 20 cc + Bicarbonate 8.4 % 5 cc.
2. One 21 cc syringe : chloroprocaine 0.5 % 20 cc + Toradol 1 cc (30 mg).
3. The next ones of 20 cc : pure chloroprocaine 0.5 %.
   

The doses of chloroprocaine 0.5 % are the following :

1. Mini-technique (one cuff on forearm): 0.5 cc to 1 cc/kg (2.5 to 5 mg/kg).
2. The two-cuffs technique: 1 to 1.3 cc/kg (5 to 6.5 mg/kg).
3. The highest doses are recommended for infections !
4. For surgery on the foot, up to 80 cc in adults.

How to proceed ?

Preparation :

1. Monitor : Blood Pressure measurement and Oxygen saturation.
2. Check the manometer : pressure must be 100 mmmHg above the
   patient’s systolic blood pressure.
3. Bilateral venous cannulation.
4. Inform the patient. Give IV sedation if required.
   

IVRA itself :

1. First tourniquet : on the forearm for the mini-technique at a 3-digit distance from the elbow ; on the arm for the two cuffs technique.
2. Exsanguinate the limb with an Esmarch rubber band, all the way down to the tourniquet. If it is too painful (fractures…), simply elevate the
   limb for a few minutes with compression of the brachial artery.
   
   
3. Inflate the cuff to 100 mmHg above the systolic blood pressure
   (250 mmHg)
4. Injection of the anaesthetic with the patient’s arm in a comfortable position. Inform the patient that the limb will feel a little strange : temperature change, tingling in the fingers, mottled in appearance. Then, remove the IV cannula and apply pressure on the puncture site.
5. Lower cuff : put it either just besides the uppermost one for surgery on the elbow/forearm ; or on the forearm for surgery on the wrist/hand.
   

Surgical procedure :

1. Disinfection and draping.
2. During the procedure. When two tourniquets are used, inflate the
   lower one after 30 to 45 minutes depending on patient’s tolerance
   and then deflate the uppermost one.
3. Inform the patient that the hand will feel a little strange..
4. At the end of the procedure. Deflate the lower tourniquet. For very
   short procedures using the mini-technique, the minimum theoretical
   inflation time is 20 minutes for the amides, like lidocaine. However,
   for esters, like chloroprocaine, the cuff can be deflated after 10 min.
   Check blood pressure, pulse and oxymetry one more time. Tell the
   patient he is going to feel tingling in the fingers for 15-20 minutes.
   

Indications :

1. Mini-IVRA : all procedures on hand or wrist of less than 45 minutes.
2. Double cuff on the calf : for foot procedures of less than 60 minutes.
3. Double cuff on the upper limb : all procedures of less than 90 minutes.
4. In contrast to common opinion, IVRA is very effective for infections at the condition that high doses are used.
5. Pediatrics : IVRA well tolerated at the age of 6 or older. Put anaesthesia cream (EMLA) on both hands for IV cannulae. Explain carefully.
   

Contraindications to IVRA :

1. Absolute : Allergy to Toradol. Just use chloroprocaine and bicarbonate.
2. Relative : Allergy to local anaesthetics : none with IV chloroprocaine (very rarely, weals disappearing quickly). Psychological : to be discussed with the patient.
   
3. Theoretical : plasma esterase deficiency. In our practice, the limb always gets back to normal in a few minutes.

Advantages :

1. The anaesthetist can work on his/her own, with no extra-hands, with no induction room.
2. Patients should not be starved.
3. Can be used in the presence of aspirin or clopidogrel.
4. Simplicity (can be learned very quicly ; follow directions carefully !).
5. Save time.
6. Very effective method.
7. Patient’s satisfaction.
8. Recovery time. In all cases, limb back to normal in minutes due to chloroprocaine very short half-life. Most patients leave the hospital 30 min. after the procedure.
9. Low cost (see below).
10. Works by diffusion ; therefore, no tissular lesion, except a small hematoma at the site of the cannula.

Drawbacks :

1. Tourniquet pain. Time limitations : 45 min. for the single cuff ; 60 min. for the foot ; 90 min. for the double cuff on the upper limb. Give propofol IV if necessary.
2. Cuff tolerance is variable. Even children are amenable to IVRA alone. To be combined with sedation and additional analgesia if necessary.
3. At cuff deflation, tingling in the fingers for 15-20 minutes. No residual analgesia.
4. Registration : chloroprocaine not registered for IV use in some countries.

Complications :

1. Dizziness during injection (rare): very short-lasting (1 to 2 min.) with a mild increase in heart rate (due to chloroprocaine bypassing the tourniquet). Just reassure the patient ! At deflation, very rare.
2. Vagal reaction due to stress and/or tourniquet pain.. Give Atropine 0.5 mg IV ; have a second dose ready. Reassure the patient. Rare.
3. Theoretical : shivering/convulsions. Never observed.

Pearls :

1. IV cannulation for IVRA can be inserted at the level of the elbow if no vein can be found more distally. The injectate flows backwards.
2. Cuffs must be of very good quality. Ensure that they do not leak. Monitor cuff pressure.
3. Sterile cuff can be placed on the forearm, as a third cuff, if procedure longer than expected (double cuff on arm technique).
4. Surgeon must be aware that a small dose of lidocaine subcutaneously may be necessary at incision (rare).
5. Obesity : give an intermediate dose first, then test the analgesia. Give more if inadequate.

Suppliers and costs :

1. Non-sterile cuffs : VBM simple manchette with silicone balloon. Intermediate size (14 in.) : about 130 US dollars ; big size (18 in.) : about 160 US dollars. Sold by Laubscher (www.laubscher.ch). E-Mail : info@laubscher.ch.
2. Sterile cuffs : VBM Brassard simple Dispo Cuff, sterile, 18 in. : about 20 US dollars (www.laubscher.ch). E-Mail : info@laubscher.ch
3. Two-way metallic stopcock : about 230 US dollars. Sold by H.P. Braem AG, article n° 100600. Direct contact by phone : - 41-71 866 1933 (ga@hpbraem.ch)
4. Chloroprocaine 0.5 % (Ivracain) 5 amp x 20 ml : about 30 US dollars. Sold by Sintetica S.A (www.sintetica.com). E-Mail : info@sintetica.com.

Reference :

Van Zundert A. et al . Centennial of Intravenous Regional Anesthesia. Bier’s Block (1908-2008). Reg Anesth Pain Med 2008 ; 33 : 483-489.