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

2. Department of Emergency Medicine 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 –Muscle relaxation

3. Department of Emergency Medicine Auckland City Hospital IVRA Indications –Any limb procedure –Cooperative patient Contraindications –Absolute Hypertension Allergy to amide LA –Relative Uncooperative patient Not fasted Intoxicated Obtunded

4. Department of Emergency Medicine Auckland City Hospital IVRA Equipment Resuscitation Monitoring Pneumatic tourniquet Prilocaine POP stuff Documentation – procedures sheet Staffing –Proceduralist –Medicator / Monitoring –Plasterer

5. Department of Emergency Medicine Auckland City Hospital 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. Department of Emergency Medicine Auckland City Hospital IVRA Technique Monitoring –Continuous ECG, SPO 2, 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. Department of Emergency Medicine Auckland City Hospital IVRA Technique Double cuff –Inflate proximal first –Infuse PrilocainePrilocaine –Inflate distal cuff Take out 22g line, apply pressure Wait 5-10 minutes (anaesthesia achieved) Perform procedure

8. Department of Emergency Medicine Auckland City Hospital IVRA Prilocaine 0.5% plain 3mg/kg = 0.6mL / kg Max 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. Department of Emergency Medicine Auckland City Hospital IVRA Prilocaine 0.5% plain 3mg/kg = 0.6mL / kg Max 200mg = 40mL Caution –Heart block –Anti-arrythmics –Methaemoglobinaemia O-toluidine metabolite <400mg not reported (adults) Increased risk infants

10. Department of Emergency Medicine Auckland City Hospital IVRA Technique (wrist / forearm #) Reduce # 1 st layer of POP Repeat xRay –At bedside, cuff still up Remanipulate if required Complete POP

11. Department of Emergency Medicine Auckland City Hospital 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. Department of Emergency Medicine Auckland City Hospital IVRA Common problems –Cant tolerate cuff Deflate proximal cuff (buys time) Systemic analgesia Entonox Reassurance –Complications <2% Transient tinnitus, dizziness, bradycardia

13. Department of Emergency Medicine Auckland City Hospital Complications The danger of thin skin

14. Department of Emergency Medicine Auckland City Hospital Complications Not checking the pulse (her BP was >200mmHg)

15. Department of Emergency Medicine Auckland City Hospital Performed correctly, upper limb IVRA is a safe and effective procedure Summary

16. Department of Emergency Medicine Auckland City Hospital How are we doing this run??? Questions?

17. Department of Emergency Medicine Auckland City Hospital 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 3 rd 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