Br.J. Anaesth. (1976), 48, 485
INTRAVENOUS REGIONAL ANAESTHESIA IN CHILDREN B. FITZGERALD SUMMARY
The technique of intravenous regional anaesthesia is The quality of anaesthesia was graded as: used widely and successfully in the treatment of injuries to the arm and hand in adults (Adams, Dealy (1) Complete, when the manipulation was achieved with no discomfort. and Kenmore, 1964; Sorbie and Chacha, 1965; (2) Partial, when the manipulation was accompanied Dunbar and Mazze, 1967). However, the technique is by some discomfort, not popular in the United Kingdom for the treatment of children, in spite of favourable reports from (3) Failed, when anaesthesia was inadequate for the manipulation, and general anaesthesia had to be elsewhere (Gingrich, 1967; Carrell and Eyring, 1971). employed. This report demonstrates the effective use of the technique in a group of 50 children. The following information was recorded also: PATIENTS AND METHODS
Forty-six children with forearm fractures, two children with supracondylar fractures and two children with elbow dislocations were treated. The age range was 3-12 yr (mean 8 yr). Each child was interviewed, with his or her parents, in the Casualty Department, and the procedure was explained. While the parent comforted the child, a single-cuff pneumatic tourniquet was placed on the upper arm. The systolic arterial pressure and the heart rate were recorded. A "Butterfly" (Abbott) (size 19-25 gauge) needle was inserted into a dorsal hand vein or suitable peripheral arm vein and the arm was elevated. To minimize handling of the injured limb, no attempt was made to exsanguinate it by other methods. The cuff was inflated to approximately 50 mm Hg above the measured systolic pressure. Lignocaine 0.5% 1030 ml was then injected according to age (table I). The volume of lignocaine injected was calculated from the child's weight predicted from age rather than from the actual weight. In each group, the volume corresponded to a maximum dose of 4 mg/kg, thus allowing a safety margin for an underweight child and eliminating the possibility of an overdose in an overweight child (Scott et al., 1972). BRIAN FITZGERALD, M.B., F.R.C.S., Department of Ortho-
paedic Surgery, Royal Hospital for Sick Children, Glasgow. Present address: Department of Orthopaedic Surgery, Western Infirmary, Glasgow G i l .
(a) The time taken to achieve effective anaesthesia after completion of the injection. (b) The duration of anaesthesia after release of the tourniquet. (c) The total tourniquet time. (d) Complications attributable to the release of local anaesthetic agent into the circulation. TABLE
I.
Volume of
lignocaine 0.5% used in each age group Age (yr)
Dose (ml)
3-4 5-7 8-10 11-12
10-15 15-20 20-25 25-30
RESULTS
There were no technical problems associated with the administration of the anaesthetic agent. Anaesthesia was complete in 47 patients, partial in two patients and failed in one patient. The mean time from completion of the injection to adequate anaesthesia was 3.5 min (range 1.5-8 min). The time for full recovery from anaesthesia after release of the tourniquet varied between 2 and 5 min (mean 4 min). The longest tourniquet time was 18 min and none of the
Downloaded from http://bja.oxfordjournals.org/ at Queensland University of Technology on October 14, 2014
Fifty children, aged 3-12 yr, received intravenous regional anaesthesia for the treatment of either simple forearm fractures or elbow injuries. The technique obviated delays in treatment and allowed the child to be discharged from hospital immediately after treatment. There were no complications resulting from anaesthesia, but there was one anaesthetic failure.
BRITISH JOURNAL OF ANAESTHESIA
486 children complained of tourniquet pain. No complications occurred after release of the tourniquet and there were no other complications. DISCUSSION
In this study, intravenous regional anaesthesia was used routinely and with success, in a children's casualty department, to reduce simple forearm fractures and elbow dislocations. A lack of co-operation from these children was anticipated, but, when time was taken to explain the procedure and a parent was present, no undue difficulty was experienced. The quality of anaesthesia was excellent and the failure rate was low. The cause of the one failure was not clear but the child subsequently had an uneventful general anaesthetic. Tourniquet pain may occur during prolonged procedures and requires a two-cuff technique (Holmes, 1963). This technique was not necessary during this study as the longest tourniquet time was 18min. The absence of complications after release of the tourniquet, such as dizziness, convulsions, bradycardia and hypertension (Kennedy et al., 1965), is similar to the experience of Carrell and Eyring (1971) and no other complications were noted. This method obviated the inevitable delays associated with the administration of general anaesthesia in the presence of a full stomach, and prompt treatment was given to a group of children who were both frightened and in pain as a result of their injury. In conclusion, therefore, this technique is considered to be safe, effective and convenient for children and could be considered more often as the first choice anaesthetic technique in suitable cases.
Cinquante enfants de 3 a 12 ans ont recu Panesthesie regionale intraveineuse pour le traitement soit des fractures simples de l'avant-bras soit des blessures aux coudes. Cette technique a permis d'eviter des delais dans le traitement et a autorise les enfants a rentrer chez eux immediatement apres le traitement. II n'y a eu aucune complication par suite de l'anesthesie, mais il y a eu dans un seul cas une insuffisance d'anesthesie.
ACKNOWLEDGEMENTS
ANESTESIA REGIONAL INTRAVENOSA EN NINOS
I wish to thank Messrs N. J. Blockey, D. A. McPherson, M. G. H. Smith and A. N. Connor for permission to study patients under their care. REFERENCES
Adams, J. P., Dealy, E. J., and Kenmore, P. I. (1964). Intravenous regional anaesthesia in hand surgery. J. Bone Joint Surg., 46A, 811. Carrell, E. D., and Eyring, E. J. (1971). Intravenous regional anaesthesia for childhood fractures. J. Trauma, 11, 301.
ANESTHESIE REGIONALE INTRAVEINEUSE CHEZ LES ENFANTS RESUME
INTRAVENOSE LOKALNARKOSE BEI KINDERN ZUSAMMENFASSUNG
Bei 50 Kindern im Alter von 3-12 Jahren wurde intravenose Lokalnarkose bei einfachen Unterarmbruche oder Ellenbogenverletzungen angewandt. Dieses Verfahren ersparte Verzogerung der Behandlung und ermoglichte es, die Kinder unmittelbar nach dem Eingriff nach Hause zu schicken. Obwohl sich keinerlei Komplikationen bezuglich des Narkoseverfahrens ergaben, wirkte bei einem der Patienten die Narkose nicht.
50 ninos comprendidos entre las edades de 3 a 12 anos, recibian anestesia regional intravenosa bien para el tratamiento de fracturas simples de antebrazo o para lesiones de codo. La tecnica elimino retrasos en el tratamiento y permitio que se diera de alta en el hospital al nino inmediatamente despues del tratamiento. No se presentaron complicaciones como resultado de la anestesia, pero se produjo una insuficiencia anestesica.
Downloaded from http://bja.oxfordjournals.org/ at Queensland University of Technology on October 14, 2014
Dunbar, R. W., and Mazze, R. I. (1967). Intravenous regional anesthesia: experience with 779 cases. Anesth. Analg. {Cleve.), 46, 806. Gingrich, E. F. (1967). Intravenous regional anesthesia of the upper extremity in children. J.A.M.A., 200, 135. Holmes, C. M. (1963). Intravenous regional analgesia. Lancet, 1, 245. Kennedy, B. R., Duthie, A. M., Parbrook, G. D., and Carr, T. L. (1965). Intravenous regional analgesia: an appraisal. Br.Med.J., 1,954. Scott, D. B., Jebson, P. J. R., Braid, D. P., Ortengren, B., and Frisch, P. (1972). Factors affecting plasma levels of lignocaine and prilocaine. Br. J. Anaesih., 44, 1040. Sorbie, C , and Chacha, P. (1965). Regional anaesthesia by the intravenous route. Br. Med. J., 1, 957.
INTRAVENOUS REGIONAL ANAESTHESIA IN CHILDREN B. FITZGERALD SUMMARY
The technique of intravenous regional anaesthesia is The quality of anaesthesia was graded as: used widely and successfully in the treatment of injuries to the arm and hand in adults (Adams, Dealy (1) Complete, when the manipulation was achieved with no discomfort. and Kenmore, 1964; Sorbie and Chacha, 1965; (2) Partial, when the manipulation was accompanied Dunbar and Mazze, 1967). However, the technique is by some discomfort, not popular in the United Kingdom for the treatment of children, in spite of favourable reports from (3) Failed, when anaesthesia was inadequate for the manipulation, and general anaesthesia had to be elsewhere (Gingrich, 1967; Carrell and Eyring, 1971). employed. This report demonstrates the effective use of the technique in a group of 50 children. The following information was recorded also: PATIENTS AND METHODS
Forty-six children with forearm fractures, two children with supracondylar fractures and two children with elbow dislocations were treated. The age range was 3-12 yr (mean 8 yr). Each child was interviewed, with his or her parents, in the Casualty Department, and the procedure was explained. While the parent comforted the child, a single-cuff pneumatic tourniquet was placed on the upper arm. The systolic arterial pressure and the heart rate were recorded. A "Butterfly" (Abbott) (size 19-25 gauge) needle was inserted into a dorsal hand vein or suitable peripheral arm vein and the arm was elevated. To minimize handling of the injured limb, no attempt was made to exsanguinate it by other methods. The cuff was inflated to approximately 50 mm Hg above the measured systolic pressure. Lignocaine 0.5% 1030 ml was then injected according to age (table I). The volume of lignocaine injected was calculated from the child's weight predicted from age rather than from the actual weight. In each group, the volume corresponded to a maximum dose of 4 mg/kg, thus allowing a safety margin for an underweight child and eliminating the possibility of an overdose in an overweight child (Scott et al., 1972). BRIAN FITZGERALD, M.B., F.R.C.S., Department of Ortho-
paedic Surgery, Royal Hospital for Sick Children, Glasgow. Present address: Department of Orthopaedic Surgery, Western Infirmary, Glasgow G i l .
(a) The time taken to achieve effective anaesthesia after completion of the injection. (b) The duration of anaesthesia after release of the tourniquet. (c) The total tourniquet time. (d) Complications attributable to the release of local anaesthetic agent into the circulation. TABLE
I.
Volume of
lignocaine 0.5% used in each age group Age (yr)
Dose (ml)
3-4 5-7 8-10 11-12
10-15 15-20 20-25 25-30
RESULTS
There were no technical problems associated with the administration of the anaesthetic agent. Anaesthesia was complete in 47 patients, partial in two patients and failed in one patient. The mean time from completion of the injection to adequate anaesthesia was 3.5 min (range 1.5-8 min). The time for full recovery from anaesthesia after release of the tourniquet varied between 2 and 5 min (mean 4 min). The longest tourniquet time was 18 min and none of the
Downloaded from http://bja.oxfordjournals.org/ at Queensland University of Technology on October 14, 2014
Fifty children, aged 3-12 yr, received intravenous regional anaesthesia for the treatment of either simple forearm fractures or elbow injuries. The technique obviated delays in treatment and allowed the child to be discharged from hospital immediately after treatment. There were no complications resulting from anaesthesia, but there was one anaesthetic failure.
BRITISH JOURNAL OF ANAESTHESIA
486 children complained of tourniquet pain. No complications occurred after release of the tourniquet and there were no other complications. DISCUSSION
In this study, intravenous regional anaesthesia was used routinely and with success, in a children's casualty department, to reduce simple forearm fractures and elbow dislocations. A lack of co-operation from these children was anticipated, but, when time was taken to explain the procedure and a parent was present, no undue difficulty was experienced. The quality of anaesthesia was excellent and the failure rate was low. The cause of the one failure was not clear but the child subsequently had an uneventful general anaesthetic. Tourniquet pain may occur during prolonged procedures and requires a two-cuff technique (Holmes, 1963). This technique was not necessary during this study as the longest tourniquet time was 18min. The absence of complications after release of the tourniquet, such as dizziness, convulsions, bradycardia and hypertension (Kennedy et al., 1965), is similar to the experience of Carrell and Eyring (1971) and no other complications were noted. This method obviated the inevitable delays associated with the administration of general anaesthesia in the presence of a full stomach, and prompt treatment was given to a group of children who were both frightened and in pain as a result of their injury. In conclusion, therefore, this technique is considered to be safe, effective and convenient for children and could be considered more often as the first choice anaesthetic technique in suitable cases.
Cinquante enfants de 3 a 12 ans ont recu Panesthesie regionale intraveineuse pour le traitement soit des fractures simples de l'avant-bras soit des blessures aux coudes. Cette technique a permis d'eviter des delais dans le traitement et a autorise les enfants a rentrer chez eux immediatement apres le traitement. II n'y a eu aucune complication par suite de l'anesthesie, mais il y a eu dans un seul cas une insuffisance d'anesthesie.
ACKNOWLEDGEMENTS
ANESTESIA REGIONAL INTRAVENOSA EN NINOS
I wish to thank Messrs N. J. Blockey, D. A. McPherson, M. G. H. Smith and A. N. Connor for permission to study patients under their care. REFERENCES
Adams, J. P., Dealy, E. J., and Kenmore, P. I. (1964). Intravenous regional anaesthesia in hand surgery. J. Bone Joint Surg., 46A, 811. Carrell, E. D., and Eyring, E. J. (1971). Intravenous regional anaesthesia for childhood fractures. J. Trauma, 11, 301.
ANESTHESIE REGIONALE INTRAVEINEUSE CHEZ LES ENFANTS RESUME
INTRAVENOSE LOKALNARKOSE BEI KINDERN ZUSAMMENFASSUNG
Bei 50 Kindern im Alter von 3-12 Jahren wurde intravenose Lokalnarkose bei einfachen Unterarmbruche oder Ellenbogenverletzungen angewandt. Dieses Verfahren ersparte Verzogerung der Behandlung und ermoglichte es, die Kinder unmittelbar nach dem Eingriff nach Hause zu schicken. Obwohl sich keinerlei Komplikationen bezuglich des Narkoseverfahrens ergaben, wirkte bei einem der Patienten die Narkose nicht.
50 ninos comprendidos entre las edades de 3 a 12 anos, recibian anestesia regional intravenosa bien para el tratamiento de fracturas simples de antebrazo o para lesiones de codo. La tecnica elimino retrasos en el tratamiento y permitio que se diera de alta en el hospital al nino inmediatamente despues del tratamiento. No se presentaron complicaciones como resultado de la anestesia, pero se produjo una insuficiencia anestesica.
Downloaded from http://bja.oxfordjournals.org/ at Queensland University of Technology on October 14, 2014
Dunbar, R. W., and Mazze, R. I. (1967). Intravenous regional anesthesia: experience with 779 cases. Anesth. Analg. {Cleve.), 46, 806. Gingrich, E. F. (1967). Intravenous regional anesthesia of the upper extremity in children. J.A.M.A., 200, 135. Holmes, C. M. (1963). Intravenous regional analgesia. Lancet, 1, 245. Kennedy, B. R., Duthie, A. M., Parbrook, G. D., and Carr, T. L. (1965). Intravenous regional analgesia: an appraisal. Br.Med.J., 1,954. Scott, D. B., Jebson, P. J. R., Braid, D. P., Ortengren, B., and Frisch, P. (1972). Factors affecting plasma levels of lignocaine and prilocaine. Br. J. Anaesih., 44, 1040. Sorbie, C , and Chacha, P. (1965). Regional anaesthesia by the intravenous route. Br. Med. J., 1, 957.
