 |
 |
I'd agree that using a single cuff is painful for the patient if the cuff release is delayed in order to get a check X ray. When I was the volunteer in the atracurium study we only had a single cuff available... very uncomfortable at 30 mins. I sometimes give a talk to the radiographers and if I get the opportunity I put the cuff on one of them, so that they understand the importance of getting a check X ray quickly! Having said that I would routinely rotate the cuff at 15 mins after manipulation if a check X ray was to be done. Much better for the patient. Couldn't find a lot on double cuffs on Medline probably because papers were done before Medline starts in the 1960's. See below Title Comparison of the effect of EMLA cream, subcutaneous ring anaesthesia and a double cuff technique in the prevention of tourniquet pain. Source BJA: British Journal of Anaesthesia. 70(4):394-6, 1993 Apr. Abstract We have examined the effect of EMLA on tourniquet pain and compared it with those of subcutaneous ring anaesthesia (SRA), a double cuff technique and a single cuff (control) during i.v. regional anaesthesia. The durations of analgesia (mean 57.3 (SD 16.6) min) and tolerance (72.3 (13.9) min) to tourniquet inflation in the EMLA group were comparable to those in the SRA group (54.1 (16.2) min and 68.3 (19.0) min), but significantly (P < 0.05) greater than those in the control group (30.0 (10.7) min and 45.6 (14.0) min). The double cuff technique was the most effective method, with 91.5 (14.9) min duration of analgesia. We conclude that EMLA provided a significant analgesic effect on tourniquet pain compared with the control group, but a relatively limited analgesic effect compared with a double cuff technique. ----- Original Message ----- From: "Black, John" <[log in to unmask]> To: <[log in to unmask]> Sent: Tuesday, October 01, 2002 12:51 PM Subject: Haematoma blocks > I think Paul has made the key point in the method that blocking the ulna > aspect of the wrist (infiltrating just distal to the ulna styloid including > the radio-carpal joint) as well as the fracture site and WAITING 15 minutes > or so is key the success. I use up to 2 mg/kg of 1 % lignocaine for its > speed of action - using bupivacaine takes significantly longer. Despite this > once the fracture has been reduced and held in a cast, analgesia is usually > less of an issue. > > It is important that the wrist x-rays are readily available for inspection > so that the precise position of the fracture site can be determined in the > swollen wrist. I use a 23 G needle followed by a 21 G needle and infiltrate > slowly. In elderly patients impacted fractures are rarely problematic as the > bones are usually osteoporotic. > > Despite intuition, we have NOT had any problems with infection and there is > nothing in the literature to support an excess of bony infection with this > method of block. Lack of muscular relaxation has not compromised > satisfactory reduction if satisfactory local anaesthesia has been achieved, > and patients can be instructed to relax if need be. I do happen to make note > of any verbal/non verbal clues from the patient re efficacy of the block > throughout the procedure. > > The major issue I have with Bier's block is freeing up the necessary > resources (resus room type environment) for this procedure to be safely > performed. I have also been struck by how painful the cuff is for many > patients when a single cuff technique is used (as has been encouraged for > use in the ED to reduce the risk of the wrong cuff being deflated during the > procedure). > > I would be interested to know from Jason precisely what type > instruction/method etc the doctors who performed haematoma blocks received > in his study. > > John Black > Oxford > > > -----Original Message----- > From: Paul Ransom [mailto:[log in to unmask]] > Sent: 30 September 2002 09:21 > To: [log in to unmask] > Subject: Re: Bier Blocks > > > Given up on Bier blocks by now, thanks to time constraints. Haematoma > blocks so much faster. My experience is that failure rate in haematoma > blocks as opposed to Biers concerns inadequate dosage of anaesthetic, and > most likely omitting to inject over the ulnar side of the wrist aswell, as > there will usually be damage here too. So, two injection sites usually, > but I can (nearly) always get excellent anaesthesia with this site. I use > marcaine, on the basis that this is what I would want for myself. > Sometimes,when the department is busy, or a long wait in x-ray, I will put > in the block on first sight, and give it a tweak, and so just get back an > x-ray in POP, if it is clinically obvious this is a Colles. Patients > usually happy to be out of the department in under an hour, if lucky. > As for the haematoma, not always possible to get into this, if there is > more of an impaction. Can't say that I've noticed any decrease in analgesia > since not routinely aspirating x mls of blood back. > > Paul Ransom > A&E Brighton >