title: Single-cuff forearm tourniquet in intravenous regional anaesthesia results in less pain and fewer sedation requirements than upper arm tourniquet.
abstract: BACKGROUND
  A limitation of Bier's block or i.v. regional anaesthesia (IVRA) is tourniquet pain. We hypothesized that tourniquet placement on the forearm vs upper arm during IVRA for distal upper extremity surgery may result in less tourniquet pain, lower the need for analgesic interventions, and decrease post-anaesthesia care unit (PACU) admission.
  
  
  METHODS
  Patients for distal upper extremity surgery were randomized into upper or forearm single-cuff tourniquet placement. IVRA was either performed with 15 ml of 2% lidocaine and 20 mg ketorolac in the upper group or 8 ml of 2% lidocaine and 10 mg ketorolac in the forearm group. Vital signs and visual analogue scale (VAS) score were recorded. If VAS score was >4, 50 µg fentanyl was injected. If the patient had VAS scores >6 with fentanyl, deep sedation with propofol was administered.
  
  
  RESULTS
  Twenty-eight subjects were in each group. There were no significant differences in patient characteristics, tourniquet time, or pressure between the groups. Ten patients in the forearm vs 27 in the upper arm group had a VAS score >4. The mean fentanyl use was 30 µg in the forearm group vs 104 µg in the upper arm group. One patient in the forearm group required propofol vs 22 in the upper arm group. PACU bypass to phase 2 recovery occurred 19 times in the forearm group vs zero times in the upper arm group (P<0.0001).
  
  
  CONCLUSIONS
  Our results indicate that the placement of the tourniquet on the forearm resulted in less discomfort, fewer sedation interventions, and greater likelihood of bypassing the PACU when compared with upper arm tourniquet.
authors.affiliation: Department of Anesthesiology, St Luke's Roosevelt Hospital Center and Columbia University College of Physicians and Surgeons, 1000 Tenth Avenue, New York, NY 10019, USA. fchiao@gmail.com
authors.forename: F B
authors.initials: FB
authors.lastname: Chiao
authors.forename: J
authors.initials: J
authors.lastname: Chen
authors.forename: J B
authors.initials: JB
authors.lastname: Lesser
authors.forename: F
authors.initials: F
authors.lastname: Resta-Flarer
authors.forename: H
authors.initials: H
authors.lastname: Bennett
mesh_terms: D000328:Adult; D000368:Aged; D000765:Anesthesia, Conduction / Q000379:methods*; D000771:Anesthesia, Intravenous / Q000379:methods*; D001132:Arm; D005260:Female; D005542:Forearm; D006801:Humans; D008297:Male; D008875:Middle Aged; D010147:Pain Measurement / Q000379:methods; D010149:Postoperative Pain / Q000209:etiology* / Q000517:prevention & control; D014111:Tourniquets / Q000009:adverse effects*; D034941:Upper Extremity / Q000601:surgery*; D055815:Young Adult
keywords: Bier block; regional anaesthesia