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 Table of Contents  
ORIGINAL ARTICLE
Year : 2018  |  Volume : 16  |  Issue : 4  |  Page : 398-404

Lornoxicam versus nitroglycerine as adjuvants to lidocaine in intravenous regional anesthesia by using a single forearm tourniquet


Department of Anesthesia and Intensive Care, Faculty of Medicine, Al-Azhar University, Cairo, Egypt

Date of Submission08-Nov-2018
Date of Acceptance14-May-2019
Date of Web Publication23-Apr-2019

Correspondence Address:
Mohamed Abdel Gawad Abdel Halim
Samanod/Gharbia
Egypt
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/AZMJ.AZMJ_123_18

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  Abstract 


Background Intravenous regional anesthesia (IVRA) is an old anesthetic technique for surgical procedures on the upper and lower limbs. It is a safe and effective type of anesthesia for hand surgery of 1 h duration or less. There are many modifications of IVRA due to tourniquet pain, and intraoperative and postoperative analgesia.
Objective The objective of this study was to assess the effectiveness of lornoxicam and nitroglycerine as adjuvants to lidocaine in IVRA by using single forearm tourniquet in cases of hand surgeries.
Patients and methods Seventy-five patients undergoing hand surgeries where randomly classified into three equal groups: group L received 20 ml of lidocaine 1% with 2 ml normal saline; group LL received 20 ml of lidocaine 1% with lornoxicam 8 mg (2 ml); and group LN received 20 ml of lidocaine 1% with nitroglycerine 100 µg (2 ml).
Results The onset time of sensory and motor blocks was statistically significantly shorter in the nitroglycerine group (3.2±0.2 and 3.7±0.9 min, respectively) than other groups. The onset time of tourniquet pain was delaying in group LL than other groups. There was statistically significant increase in the duration of postoperative analgesia in group LL (90.35±5.72 min) compared with groups LN (48.55±0.52 min) and L (25.7±2.7 min). There were statistically significant increases in patient and surgeon satisfactions in group LN in comparison with groups LL and L.
Conclusion The addition of lornoxicam and nitroglycerine to lidocaine for IVRA improves the speed of onset and the quality of anesthesia, decreases tourniquet pain, and decreases the analgesic requirements during the first 24 h postoperatively without side effects. The addition of lornoxicam to lidocaine was superior in delaying the onset of tourniquet pain and delaying the postoperative analgesia request. The single forearm tourniquet is safe with no obvious side effects.

Keywords: intravenous regional anesthesia, lidocaine, lornoxicam, nitroglycerine, single forearm tourniquet


How to cite this article:
Abdel Halim MG, Hussein AE. Lornoxicam versus nitroglycerine as adjuvants to lidocaine in intravenous regional anesthesia by using a single forearm tourniquet. Al-Azhar Assiut Med J 2018;16:398-404

How to cite this URL:
Abdel Halim MG, Hussein AE. Lornoxicam versus nitroglycerine as adjuvants to lidocaine in intravenous regional anesthesia by using a single forearm tourniquet. Al-Azhar Assiut Med J [serial online] 2018 [cited 2019 Aug 23];16:398-404. Available from: http://www.azmj.eg.net/text.asp?2018/16/4/398/256744




  Introduction Top


Intravenous regional anesthesia (IVRA; Bier’s block) involves intravenous local anesthetic administration into a tourniquet occluded upper or lower limb. The local anesthetic diffuses from the peripheral vascular bed to the nonvascular tissue [1]. IVRA provides effective and safe anesthesia for hand surgery of 1 h duration or less; a lack of adequate postoperative analgesia and tourniquet pain limit its use [2].

The local anesthetic diffuses into the small veins, then into the vasa nervorum and capillary plexus of the nerves and then diffuses into the small nerves in the skin, blocking conduction of the nerve. The tourniquet produces ischemia which contributes to the analgesic action of the local anesthetic by blocking nerve conduction and motor end plate function [3].

Lornoxicam is a NSAID with analgesic, anti-inflammatory, and antipyretic properties. It is available in oral and parenteral formulations [4]. Lornoxicam inhibits prostaglandins synthesis by inhibition of cyclooxygenase (COX), but it does not inhibit 5-lipoxygenase and inhibits the nitric oxide formation. Inhibitory potency ratio of COX-1 to COX-2 for lornoxicam is 0.6 [5],[6].

Nitroglycerine is a vasodilator which has effects on both arteries and veins used to treat congestive heart failure, protection against frequent chest pain caused by a heart condition such as angina and is used as an adjuvant with local anesthesia [7].

Aim

The aim of this study was to assess the effect of lornoxicam and nitroglycerine as an adjuvant to lidocaine in IVRA by using single forearm tourniquet in cases of hand surgeries.


  Patients and methods Top


The study was carried out in Al-Azhar University Hospitals (El-Hussein and Bab-Sharia) from November 2017 to September 2018. After the Research and Ethics Committee approval and written informed consents, patients of American Society of Anesthesiology grades I–III, aged 25–60 years that came for hand surgeries, lasting for less than 90 min were included in this study.

This study was designed as a prospective, comparative, controlled, double-blind, randomized study and was classified into three groups by a randomized table created by a computer software program using sealed envelopes:
  1. Lidocaine only (L) group: patients received IVRA using 20 ml of lidocaine 1% (the control group) with 2 ml normal saline.
  2. Lidocaine plus lornoxicam (LL) group: patients received IVRA using 20 ml of lidocaine 1% plus lornoxicam 8 mg (2 ml).
  3. Lidocaine plus nitroglycerine (LN) group: patients received IVRA using 20 ml of lidocaine 1% plus nitroglycerine 100 µg (2 ml).


Inclusion criteria

Patients aged from 20 to 60 years, American Society of Anesthesiology physical status I–III of both sexes, and scheduled for surgery of the hand.

Exclusion criteria

Patient’s refusal, uncooperative patients, patients with Raynaud’s disease, scleroderma, sickle cell anemia, and lengthy operations.
  1. Primary outcome measures: sensory block assessment and motor block assessment.
  2. Secondary outcomes measures: assessment of hemodynamic changes, the first time to request analgesia, patient satisfaction about the technique, and surgeon satisfaction.


Preoperative assessment

Preoperative evaluation included history, physical examination (systemic and local examination), and investigations (complete blood count, liver function tests, kidney function tests, and coagulation profile).

Materials

  1. Single pneumatic tourniquet (VBM Medizintechnik GmbH, Sulz am Neckar, Germany). The pressure gauge was checked for leaks before the procedure.
  2. Esmarch bandage for exsanguination of the hand.
  3. Two cannulas (20 and 22 G) and two syringes (3 and 20 ml).
  4. Drugs: Lidocaine 2%, nitroglycerine vial, and Lornoxicam vial (Xefo injectable, 8 mg).
  5. Equipment and drugs for general anesthesia and resuscitation (e.g. epinephrine, atropine, succinylcholine, thiopental, airway, laryngoscope, endotracheal tubes, and suction apparatus).


Technique

After application of monitors to the patient, a cannula (20 G size) was placed in the nonoperative hand for fluid infusion and emergency drugs. Another cannula (22 G size) was inserted in a dorsal vein of the operative hand after sterilization by alcohol swab. Single pneumatic tourniquet was placed around the forearm of the operative limb. The arm was elevated for 2 min and exsanguinated with bandage and the cuff was inflated to 200 mmHg. The least time before tourniquet release was 20 min and the maximum time that can be allowed was 60 min.

The ice cubes were used for sensorial block evaluation. Modified Bromage scale was used for assessment of the intensity of motor block. In modified Bromage scale [8], the intensity of the motor block is assessed by the patient’s ability to move their upper extremities as follows: (0=free movement, 1=decreased motor strength with ability to move the fingers only, 2=complete motor block with inability to move the fingers).

The time of the first analgesic need was recorded as the first analgesia time. Mean arterial blood pressure and heart rate were noted at baseline and every 5 min until the end of operation. In the first 8 h, postoperative analgesia in the form of pethidine 30 mg intravenously and paracetamol 1 g intravenously were administered if the visual analog score was greater than or equal to 4. At the end of surgery, the anesthesiologist and the surgeon who were blinded to the study medication were asked about the quality of the operative condition to excellent, good, fair, and poor. Pain was assessed after the release of the tourniquet and recorded by an anesthesiology resident who was blinded to the study medications.

Sample size

Calculation of sample size was based on previous studies. Sample size depended on the prolongation of the duration of postoperative analgesia. A total of 75 patients were needed to detect a difference at the 5% significance level and give the trial 80% power. A total of 25 patients were enrolled in each group.

Statistical analysis

The statistical analysis was done using the statistical package for social sciences, version 20.0 (SPSS for Windows, version 17; SPSS Inc., Chicago, Illinois, USA). Results were expressed as mean and SD. Frequencies were expressed as numbers. One-way analysis of variance was used for three group comparisons and intergroup data were analyzed by χ2-test (categorical) and Student’s t-test (numerical). A P value of 0.05 or less was considered significant for statistical analysis.


  Results Top


A total of 75 patients were enrolled equally into the three groups by a randomized table created by a computer software program using sealed envelopes as shown in the CONSORT flowchart ([Figure 1]).
Figure 1 CONSORT flowchart.

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There were statistically no significant differences between the three groups (P<0.05) as regards the demographic data ([Table 1] and [Table 2]).
Table 1 Demographic data (age, sex and American Society of Anesthesiologists classification)

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Table 2 Type and duration of surgery

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Onset time for the sensory and motor block was statistical significantly shorter in the nitroglycerine group (3.2±0.2 and 3.7±0.9 min, respectively) than other groups L and LL ([Table 3]).
Table 3 Onset of sensory and motor blocks

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Motor block intensity of the groups was statistical significantly in the fourth and sixth minutes which is higher in the nitroglycerine group N and group LL than group L ([Table 4]).
Table 4 Motor block intensity of the groups

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Onset of tourniquet pain was statistical significantly earlier in group L compared with the other groups LL and LN. However, it was significantly delayed in group LL compared with the other two groups ([Table 5]).
Table 5 Onset of tourniquet pain (min)

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Duration of postoperative analgesia was statistically significantly shorter in group L in comparison with adjuvant groups LL and LN. There was a significant increase in the duration of postoperative analgesia in group LL compared with groups LN and L ([Table 6]).
Table 6 Comparison of durations of postoperative analgesia

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There were statistically significant increases in patient satisfaction in adjuvant groups LN and LL compared with the control group ([Table 7]).
Table 7 Comparison of patient satisfaction

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There were statistically significant increases in surgeon satisfaction in adjuvant groups LN and LL compared with the control group ([Table 8]).
Table 8 Comparison of surgeon satisfaction

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Assessment of hemodynamic changes (heart rate, mean arterial blood pressure, peripheral oxygen saturation, and respiratory rate) were recorded in this study ([Table 9],[Table 10],[Table 11],[Table 12]). There were statistically nonsignificant differences between the groups (P=0.05) as regards the hemodynamic changes.
Table 9 Heart rate changes at different time (beats/min)

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Table 10 Mean arterial blood pressure changes (mmHg)

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Table 11 Peripheral oxygen saturation changes (%)

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Table 12 Respiratory rate (rate/min)

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  Discussion Top


IVRA is a simple and effective method, with a high degree of safety and a low incidence of technical failure. IVRA is very suitable for short lasting operations (<1 h) and useful for limb surgeries especially when general anesthesia is highly associated with risks such as difficult intubation or full stomach [9].

The advantages of this technique include cost effectiveness and rapid achievement of anesthesia in the day case anesthesia [10]. Efforts are recently done to optimize the effect of local anesthetics and minimize their side effects by using drug adjuvants including opioids such as meperidine [11], fentanyl, and tramadol [9]; NSAIDs such as tenoxicam and ketorolac [9]; α2 agonists such as dexmedetomidine [12]; clonidine [13], magnesium [14]; and muscle relaxants such as atracurium [9].

Statistical analysis of the demographic data in our study showed no statistically significant differences between groups as regards age, sex, weight, height of the patients, type, and duration of surgery.

In this study, sensory and motor block onset times were statistically significantly shorter in groups LL and LN compared with group L. This could be due to the vasodilator effect of nitroglycerine that helps in the distribution of lidocaine to nerves to make its rapid effect which is in agreement with Sen et al. [15], who reported that addition of nitroglycerine to lidocaine for IVRA shortened the sensory and motor block onset times.

In our study, the addition of lornoxicam 8 mg to lidocaine for IVRA hastens the sensory and motor block onset. It may be due to lidocaine solution (pH≈6.7) which has an alkalinity less than that of lornoxicam (pH≈8.7) which increased the proportion of free bases of lornoxicam and the peripheral analgesic effect by NO–cGMP pathway COX-2 inhibition and potassium channels opening.

This result agrees with the study done by Sen et al. [15], who reported that IVRA with lidocaine 0.5% plus lornoxicam 8 mg has rapid onset of sensory and motor blocks. Koi et al. [16] reported rapid onset of sensory and motor blocks on the addition of lornoxicam to prilocaine for IVRA.

As a result from the study, addition of lornoxicam 8 mg and nitroglycerine to lidocaine 1% for IVRA decreases the analgesic requirements during the first 24 h postoperatively.

The onset time of tourniquet pain was statistical significantly shorter in the control group L in comparison with adjuvant groups LL and LN. These results matched with the study done by Sen et al. [15], who reported that addition of nitroglycerine to lidocaine delayed the onset time of tourniquet pain in IVRA through improving the quality of block as regards onset and offset.

Our study agreement with the study done by Abu Elyazed and Abdel-Ghaffar [17], who reported that addition of nitroglycerine to lidocaine fastened the onset time for sensory and motor blocks and ketorolac was superior in delaying tourniquet pain onset and prolonging postoperative analgesia requirement.

Sen et al. [15] reported that the addition of nitroglycerin to lidocaine improved visual analog score of incisional and tourniquet pain in IVRA through improving the quality of block as regards the onset and offset and grade of blocks.

In our study, there were statistically significant increases in the duration of postoperative analgesia in group LL (90.35±5.72 min) compared with group LN (48.55±0.52 min) and group L (25.7±2.7 min).

In this study, the first time to request analgesia was statistically significantly prolonged in group LL than in groups LN and L. These results were in accordance with the study done by Sen et al. [15] who reported that the addition of nitroglycerine to lidocaine increased the duration of intraoperative analgesia in IVRA through improving the quality of sensory block.

There were statistically significant increase in surgeon and patient satisfaction in adjuvant groups LL and LN compared with the control group. These results matched with the study done by Sen et al. [15] who reported that the addition of nitroglycerine to lidocaine in IVRA improved patient and surgeon satisfaction through improving the quality of block as regards onset, offset, and tourniquet pain.

Chiao et al. [18] reported that the placement of tourniquet on the forearm leads to less pain and few sedation interventions.


  Conclusion Top


The addition of lornoxicam and nitroglycerine to lidocaine for IVRA improves the speed of onset and the quality of anesthesia, decreases tourniquet pain, and decreases the analgesic requirements during the first 24 h postoperatively without side effects. The addition of nitroglycerine to lidocaine hastened the onset time for sensory and motor blocks, but lornoxicam was superior in delaying the onset of tourniquet pain and delaying the postoperative analgesia request. Single forearm tourniquet is safe with no observable side effects.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Miller RD, Terese T, Horlocker , Sandra L, Denise J. Intravenous regional anesthesia; peripheral nerve blocks Chapter 57. 8th edition. Miller’s anesthesia. Saunders; 2014; pp. 1732–1733.  Back to cited text no. 1
    
2.
Brown DL. Atlas of regional anesthesia. 3rd ed. Philadelphia: Elsevier Inc.; 2006. ISBN 13: 978-1-4160-2239-8.  Back to cited text no. 2
    
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Sharma JP, Salhotra R. Tourniquets in orthopedic surgery. Indian J Orthop 2012; 4:377–383.  Back to cited text no. 3
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Skjodt NM, Davies NM. Clinical pharmacokinetics of lornoxicam. A short half-life oxicam. Clin Pharmacokinet 1998; 34:421–428.  Back to cited text no. 4
    
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Balfour JA, Fitton A, Barradell LB. A review of its pharmacology and therapeutic potential in the management of painful and inflammatory conditions. Drugs 1996; 51:639–657.  Back to cited text no. 5
    
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Berg J, Fellier H, Christoph T. The analgesic NSAID lornoxicam inhibits cyclooxygenase (COX)-1/-2, inducible nitric oxide synthase (iNOS), and the formation of interleukin (IL)-6 in vitro. Inflamm Res 1999; 48:369–379.  Back to cited text no. 6
    
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Marsh N, Marsh A. A short history of nitroglycerine and nitric oxide in pharmacology and physiology. Clin Exp Pharmacol Physiol 2000; 4:313–319.  Back to cited text no. 7
    
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Vincent JC. Principles of anesthesiology: spinal anesthesia. 3rd ed. Philadelphia, PA: Lea and Febiger 1993. pp. 1513–1515.  Back to cited text no. 8
    
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Choyce A, Peng P. A systematic review of adjuncts for intravenous regional anesthesia for surgical procedures. Can J Anaesth 2002; 49:32–45.  Back to cited text no. 9
    
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Johnson CN. Intravenous regional anesthesia: new approaches to an old technique. CRNA 2000; 11:57–61.  Back to cited text no. 10
    
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Acalovschi I, Cristea T, Margarit S, Gavrus R. Tramadol added to lidocaine for intravenous regional anesthesia. Anesth Analg 2000; 92:209–214.  Back to cited text no. 11
    
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Memis D, Turan A, Karamanlioğlu B, Pamukcu Z, Kurt I. Adding dexmedetomidine to lidocaine for intravenous regional anesthesia. Anesth Analg 2004; 98:835–840.  Back to cited text no. 12
    
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Reuben SS, Steinberg RB, Maciolek H, Manikantan P. An evaluation of the analgesic efficacy of intravenous regional anesthesia with lidocaine and ketorolac using a forearm versus upper arm tourniquet. Anesth Analg 2002; 95:457–460.  Back to cited text no. 13
    
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Turan A, Memis D, Karamanlioglu B, Guler T, Pamukcu Z. Intravenous regional anesthesia using lidocaine and magnesium. Anesth Analg 2005; 100:1189–1192.  Back to cited text no. 14
    
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Sen S, Ugur B, Aydın ON, Ogurlu M, Gursoy F, Savk O. The analgesic effect of nitroglycerin added to lidocaine on intravenous regional anesthesia. Anaesth Analg 2006; 102:916–920.  Back to cited text no. 15
    
16.
Koi IO, Ozturk H, Kaygusuz K. Addition of dexmedetomidine or lornoxicam to prilocaine in intravenous regional anesthesia for hand or forearm surgery. Clin Drug Investig 2009; 29:121–129.  Back to cited text no. 16
    
17.
Abu Elyazed M, Abdel-Ghaffar M. Nitroglycerin and ketorolac as an adjuvant to lidocaine for intravenous regional anesthesia in patients undergoing forearm and hand surgery. Al-Azhar Assiut Med J 2014; 12:160–176.  Back to cited text no. 17
    
18.
Chiao FB, Chen J, Lesser JB, Resta-Flarer F, Bennett H. Single cuff forearm tourniquet in intravenous regional anesthesia results in less pain and few sedation interventions than upper arm tourniquet. Br J Anaesth 2013; 111:271–275.  Back to cited text no. 18
    


    Figures

  [Figure 1]
 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6], [Table 7], [Table 8], [Table 9], [Table 10], [Table 11], [Table 12]



 

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