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Quantification of Venous Pressures During Intravenous Regional Anesthesia
Alex C. Lesiak, MD, MS1; Christopher M. Viscomi, MD2; Hayk Minasyan, MD3, Borzoo Farhang, DO, MS1; Adam B. Shafritz, MD1; Michel Y. Benoit, MD1
1Department of Orthopaedics and Rehabilitation, University of Vermont, Burlington, VT; 2Department of Anesthesiology, University of Vermont, Burlington, VT; 3Department of Anesthesiology and Perioperative Medicine, UCLA, Los Angeles, CA

Introduction: Intravenous Regional Anesthesia (IVRA) is utilized for upper extremity surgery. Higher tourniquet pressures and longer inflation time increase the risk of soft tissue injury. We investigated the duration and magnitude of elevated venous pressure during IVRA to assess the possibility of safely lowering the tourniquet pressure during surgery.

Materials & Methods: After IRB approval and informed consent, 20 adult patients scheduled for distal upper extremity surgery were studied. Two IV catheters were placed in the surgical arm: the hand for IVRA, and the antecubital fossa, which had a digital pressure transducer for monitoring venous pressure. The limb was elevated, exsanguinated with an Esmarch bandage, and then an upper arm tourniquet was inflated to 300 mm Hg. Local anesthetic (LA) was injected over two minutes (40cc in females, 50cc in males). Venous pressure was recorded prior to injection and every 30 seconds after injection of LA for twenty minutes or until the completion of surgery.

Results: All 20 subjects completed the study without complication. Group demographics were equivalent. No associations were discovered between venous pressures and systemic blood pressure, patients' height, BMI, or age. The mean tourniquet time was 21 minutes (range 16.5-41.5 minutes). Mean peak venous pressure was 75 mmHg, occurring at 1.5 minutes following LA injection. Peak venous pressure was 340 mmHg in one patient and lasted for less than 30 seconds. Mean venous pressure fell below systolic blood pressure after 4.5 minutes in all cases except one. This patient had elevated venous pressures (153-248 mmHg) for 24 of 25 minutes of tourniquet time exceeding systolic blood pressure by 30-130 mmHg. It took 11.5 minutes (range 0-20 minutes) for the mean venous pressure to fall below and remain below 40 mmHg.

Conclusions: Tourniquet pressures during IVRA are critical in the prevention of LA toxicity. We found that the mean peak venous pressure was below systolic blood pressure in only 14 of the 20 subjects, and the peak injection pressure exceeded 300 mmHg in one patient. Another patient's venous pressure remained above systolic blood pressure for 24 of 25 minutes of tourniquet time. Current precautions to prevent LA toxicity may be insufficient in some patients and attempts to lower tourniquet pressures to just above systolic blood pressures soon after IVRA injection may result in toxicity.

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