{"id":604,"date":"2014-09-01T15:29:16","date_gmt":"2014-09-01T15:29:16","guid":{"rendered":"http:\/\/phosdev.com\/todaysveterinarypractice\/?p=604"},"modified":"2022-04-12T11:48:54","modified_gmt":"2022-04-12T11:48:54","slug":"local-anesthesia-for-the-distal-extremity","status":"publish","type":"post","link":"https:\/\/navc.sitepreview.app\/todaysveterinarypractice.com\/anesthesiology\/local-anesthesia-for-the-distal-extremity\/","title":{"rendered":"Local Anesthesia for the Distal Extremity"},"content":{"rendered":"<p>Local anesthesia techniques are important analgesic tools. The author provides step-by-step instructions in providing IVRA and ring blocks to both dogs and cats.<\/p>\n<hr \/>\n<p>Local anesthetics block nerve impulses caused by painful stimuli, which makes them effective analgesics. Regional and peripheral blocks are versatile and can be applied to most surgical and dental procedures. The objective of this article is to provide practical details that allow a clinician to implement these blocks immediately after assembling the necessary supplies.<\/p>\n<h2><strong><span class=\"bluboldheader\">DISTAL EXTREMITY BLOCKS<\/span><\/strong><\/h2>\n<p>Indications for local anesthesia of the distal limb are listed in\u00a0<strong><span class=\"bold\">Table\u00a0<\/span>1<\/strong>.<\/p>\n<table style=\"height: 189px\" border=\"1\" width=\"499\" cellspacing=\"0\" cellpadding=\"1\">\n<tbody>\n<tr>\n<td class=\"GreenAqua\" colspan=\"2\">Table 1. Indications for Local Anesthesia of the Distal Limb<\/td>\n<\/tr>\n<tr class=\"arial\">\n<td bgcolor=\"#bcefcf\">\n<ul>\n<li>Biopsy<\/li>\n<li>Carpal and tarsal arthrodesis<\/li>\n<li>Foreign-body removal<\/li>\n<li>Fracture repair<\/li>\n<li>Laceration repair<\/li>\n<\/ul>\n<\/td>\n<td bgcolor=\"#9ce8b9\">\n<ul>\n<li>Mass removal<\/li>\n<li>Onychectomy (amputation of distal phalanx)<\/li>\n<li>Ostectomy\/osteotomy of distal radius\/ulna<\/li>\n<li>Toe amputation<\/li>\n<\/ul>\n<\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n<p>Common distal extremity blocks include:<\/p>\n<ol>\n<li>Intravenous regional anesthesia (IVRA)<\/li>\n<li>Metacarpal\/metatarsal ring block<\/li>\n<li>Brachial plexus block<\/li>\n<li>Proximal radial\u2014ulnar\u2014median\u2014musculoskeletal (RUMM) blocks.<\/li>\n<\/ol>\n<p>This article discusses IVRA and ring blocks; see\u00a0<strong><span class=\"bold\">Table 2<\/span><\/strong>\u00a0for a comparison of their benefits. Although with practice RUMM blocks become easy, the latter 2 blocks\u2014brachial plexus and proximal RUMM blocks\u2014are used with greater success if a peripheral nerve locator is used. They require advanced technical skills, and are best learned in a wet laboratory setting before being applied in practice; instruction regarding their use is beyond the scope of this article.<\/p>\n<table border=\"1\" width=\"500\" cellspacing=\"0\" cellpadding=\"1\">\n<tbody>\n<tr>\n<td class=\"GreenAqua\" colspan=\"3\">Table 2. Comparison of Benefits: IVRA &amp; Ring Blocks<\/td>\n<\/tr>\n<tr>\n<td><\/td>\n<td class=\"navyblueheader\" align=\"center\">IVRA<\/td>\n<td align=\"center\">\n<p class=\"navyblueheader\">Ring Blocks<\/p>\n<\/td>\n<\/tr>\n<tr>\n<td class=\"aquabold\" bgcolor=\"#bcefcf\">Efficacy<\/td>\n<td class=\"arial\" bgcolor=\"#9ce8b9\">More effective than ring block for major procedures<\/td>\n<td class=\"arial\" bgcolor=\"#bcefcf\">Less effective than IVRA for major procedures<\/td>\n<\/tr>\n<tr>\n<td class=\"aquabold\" bgcolor=\"#bcefcf\">Location<\/td>\n<td class=\"arial\" bgcolor=\"#9ce8b9\">Ideal for forelimb, distal to elbow<\/td>\n<td class=\"arial\" bgcolor=\"#bcefcf\">Forelimb, distal to carpus<br \/>\nHindlimb, distal to tarsus<\/td>\n<\/tr>\n<tr>\n<td class=\"aquabold\" bgcolor=\"#bcefcf\">Medication<\/td>\n<td class=\"arial\" bgcolor=\"#9ce8b9\">Lidocaine<\/td>\n<td class=\"arial\" bgcolor=\"#bcefcf\">Bupivacaine, lidocaine, or mepivacaine<\/td>\n<\/tr>\n<tr>\n<td class=\"aquabold\" bgcolor=\"#bcefcf\">Duration<\/td>\n<td class=\"arial\" bgcolor=\"#9ce8b9\">Analgesia persists approximately 20 min after tourniquet release<\/td>\n<td class=\"arial\" bgcolor=\"#bcefcf\">Dependent on duration of action of local anesthetic administered<\/td>\n<\/tr>\n<tr>\n<td class=\"aquabold\" bgcolor=\"#bcefcf\">Limitations<\/td>\n<td class=\"arial\" bgcolor=\"#9ce8b9\">Restricted to procedures &lt; 90 min due to tourniquet use<\/td>\n<td class=\"arial\" bgcolor=\"#bcefcf\"><\/td>\n<\/tr>\n<tr>\n<td class=\"aquabold\" bgcolor=\"#bcefcf\">Additional benefits<\/td>\n<td class=\"arial\" bgcolor=\"#9ce8b9\">Reduced blood at surgical site<\/td>\n<td class=\"arial\" bgcolor=\"#bcefcf\">Minimal supplies<br \/>\nQuick to perform<\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n<h2><strong><span class=\"navyblueheader\">INTRAVENOUS REGIONAL ANESTHESIA<\/span><\/strong><\/h2>\n<p>IVRA is a locoregional analgesic technique, which some may know as the\u00a0<span class=\"italic\">Bier block<\/span>, named for the physician who first described this technique nearly a century ago.<\/p>\n<h3><strong><span class=\"aquabold\">Description<\/span><\/strong><\/h3>\n<p>IVRA provides reliable, effective regional analgesia to facilitate fracture repair, toe amputation, and foreign body or mass removal, all under conditions of minimal blood loss. In my experience, it is most easily applied to the forelimb; however, this technique can be used in both forelimbs and hindlimbs of dogs and cats.<\/p>\n<h3><strong><span class=\"aquabold\">Technique Overview<\/span><\/strong><\/h3>\n<p>IVRA is a relatively simple, elegant technique that involves using the patient&#8217;s venous system to distribute local anesthetic medication. Essentially, the technique involves:<\/p>\n<ul>\n<li>Compressing the blood out of the distal limb<\/li>\n<li>Occluding arterial in-flow with a tourniquet<\/li>\n<li>Filling the venous system with an appropriate dose and volume of lidocaine.<\/li>\n<\/ul>\n<p>The tourniquet allows the local anesthetic to remain in situ, with diffusion into the superficial and deep tissues and minimal leakage into systemic circulation.<\/p>\n<h3><strong><span class=\"aquabold\">Sedation\/Anesthesia<\/span><\/strong><\/h3>\n<p>IVRA is typically combined with general anesthesia and reduces inhalant requirements. For minor procedures, such as pad biopsy and foreign body removal, it may be possible to use this technique in sedated animals.<\/p>\n<table border=\"1\" width=\"500\" cellspacing=\"0\" cellpadding=\"1\">\n<tbody>\n<tr>\n<td><strong><span class=\"navyblueheader\">IVRA: Materials &amp; Medications<\/span><\/strong><\/td>\n<\/tr>\n<tr>\n<td><span class=\"aquabold\">MATERIALS\u00a0<\/span><\/td>\n<\/tr>\n<tr bgcolor=\"#bcefcf\">\n<td>\n<ul>\n<li class=\"arial\">Small (20 or 22) gauge catheter and cap<\/li>\n<li class=\"arial\">Self-adhesive elastic bandage material<\/li>\n<li><span class=\"arial\">Tourniquet: pneumatic (preferred)<sup>a<\/sup>\u00a0or nonpneumatic<\/span><\/li>\n<\/ul>\n<\/td>\n<\/tr>\n<tr>\n<td><span class=\"aquabold\">MEDICATIONS<\/span><\/td>\n<\/tr>\n<tr bgcolor=\"#bcefcf\">\n<td>\n<ul>\n<li><span class=\"arial\">Lidocaine\u00a0<\/span>\n<ul>\n<li class=\"arial\">Dose, 3 mg\/kg max, for dogs\/cats<\/li>\n<li class=\"arial\">Volume of 0.5% lidocaine:<sup>b<\/sup>\u00a00.6 mL\/kg<sup>c<\/sup><\/li>\n<\/ul>\n<\/li>\n<li><span class=\"arial\"><em>Do not use bupivacaine<sup>d<\/sup><\/em><\/span><\/li>\n<\/ul>\n<\/td>\n<\/tr>\n<tr>\n<td class=\"arial\"><strong>Notes<\/strong><\/p>\n<ol type=\"a\">\n<li>A pneumatic tourniquet is a blood pressure cuff that can be inflated with a sphygmomanometer, allowing pressure to be maintained.<\/li>\n<li><strong>Important<\/strong>: Lidocaine solution must be labeled for IV administration and contain no additives; (lidocaine in multidose vials designed for SC infiltration may contain a preservative and should never be injected IV).<\/li>\n<li>Dilute 2% lidocaine 1:4 with isotonic crystalloid fluids to create 0.5% lidocaine solution (eg, 1 mL 2% lidocaine plus 3 mL of 0.9% NaCl)<\/li>\n<li>If the tourniquet is released rapidly or prematurely, a bolus of more cardiotoxic bupivacaine may enter the systemic bloodstream.<\/li>\n<\/ol>\n<\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n<h2><strong><span class=\"navyblueheader\">STEP-BY-STEP APPROACH TO IVRA<\/span><\/strong><\/h2>\n<p>This patient has a malignancy affecting digit V, which requires toe amputation.<\/p>\n<p><strong>1.<\/strong> \u00a0Clip hair as indicated for catheter and surgery. Using sterile technique, place a small-gauge IV catheter in the most distal vessel possible. Cap the catheter and secure with tape. Some advocate directing the catheter tip distally, but I place catheters for IVRA using standard proximal tip orientation.<\/p>\n<p><a href=\"https:\/\/todaysveterinarypractice.com\/wp-content\/uploads\/sites\/4\/2014\/09\/1Figure1_IVCath_Shafford_TVP.jpg\"><img fetchpriority=\"high\" decoding=\"async\" class=\"size-medium wp-image-1745 alignnone\" src=\"https:\/\/todaysveterinarypractice.com\/wp-content\/uploads\/sites\/4\/2014\/09\/1Figure1_IVCath_Shafford_TVP-179x300.jpg\" alt=\"1Figure1_IVCath_Shafford_TVP\" width=\"179\" height=\"300\" srcset=\"https:\/\/navc.sitepreview.app\/todaysveterinarypractice.com\/wp-content\/uploads\/sites\/4\/2014\/09\/1Figure1_IVCath_Shafford_TVP-179x300.jpg 179w, https:\/\/navc.sitepreview.app\/todaysveterinarypractice.com\/wp-content\/uploads\/sites\/4\/2014\/09\/1Figure1_IVCath_Shafford_TVP-610x1024.jpg 610w, https:\/\/navc.sitepreview.app\/todaysveterinarypractice.com\/wp-content\/uploads\/sites\/4\/2014\/09\/1Figure1_IVCath_Shafford_TVP-768x1288.jpg 768w, https:\/\/navc.sitepreview.app\/todaysveterinarypractice.com\/wp-content\/uploads\/sites\/4\/2014\/09\/1Figure1_IVCath_Shafford_TVP-916x1536.jpg 916w, https:\/\/navc.sitepreview.app\/todaysveterinarypractice.com\/wp-content\/uploads\/sites\/4\/2014\/09\/1Figure1_IVCath_Shafford_TVP-1221x2048.jpg 1221w, https:\/\/navc.sitepreview.app\/todaysveterinarypractice.com\/wp-content\/uploads\/sites\/4\/2014\/09\/1Figure1_IVCath_Shafford_TVP-scaled.jpg 1526w\" sizes=\"(max-width: 179px) 100vw, 179px\" \/><\/a><br \/>\n<strong>2.<\/strong> \u00a0Identify an arterial pulse distal to anticipated tourniquet location (eg, palmar artery). Later (<span class=\"bold\">Step 5<\/span>), absence of a pulse will help verify that the tourniquet is occluding arterial and venous blood as intended.<\/p>\n<p><b>3.<\/b> \u00a0Exsanguinate the distal limb by tightly wrapping self-adhesive elastic bandage material from the toes (distal) toward the elbow\/tarsus (proximal), covering the catheter as you go (<span class=\"bold\">A<\/span>). For large dogs, it may be helpful to wrap the leg a second time, starting again at the toes and wrapping proximally (<span class=\"bold\">B<\/span>).<\/p>\n<div id=\"attachment_1746\" style=\"width: 310px\" class=\"wp-caption alignnone\"><a href=\"https:\/\/todaysveterinarypractice.com\/wp-content\/uploads\/sites\/4\/2014\/09\/2AFigure2A_Exsangination_Shafford_TVP.jpg\"><img decoding=\"async\" aria-describedby=\"caption-attachment-1746\" class=\"wp-image-1746 size-medium\" src=\"https:\/\/todaysveterinarypractice.com\/wp-content\/uploads\/sites\/4\/2014\/09\/2AFigure2A_Exsangination_Shafford_TVP-300x264.jpg\" alt=\"2AFigure2A_Exsangination_Shafford_TVP\" width=\"300\" height=\"264\" srcset=\"https:\/\/navc.sitepreview.app\/todaysveterinarypractice.com\/wp-content\/uploads\/sites\/4\/2014\/09\/2AFigure2A_Exsangination_Shafford_TVP-300x264.jpg 300w, https:\/\/navc.sitepreview.app\/todaysveterinarypractice.com\/wp-content\/uploads\/sites\/4\/2014\/09\/2AFigure2A_Exsangination_Shafford_TVP-1024x902.jpg 1024w, https:\/\/navc.sitepreview.app\/todaysveterinarypractice.com\/wp-content\/uploads\/sites\/4\/2014\/09\/2AFigure2A_Exsangination_Shafford_TVP-768x677.jpg 768w, https:\/\/navc.sitepreview.app\/todaysveterinarypractice.com\/wp-content\/uploads\/sites\/4\/2014\/09\/2AFigure2A_Exsangination_Shafford_TVP-1536x1354.jpg 1536w, https:\/\/navc.sitepreview.app\/todaysveterinarypractice.com\/wp-content\/uploads\/sites\/4\/2014\/09\/2AFigure2A_Exsangination_Shafford_TVP-2048x1805.jpg 2048w\" sizes=\"(max-width: 300px) 100vw, 300px\" \/><\/a><p id=\"caption-attachment-1746\" class=\"wp-caption-text\">A<\/p><\/div>\n<div id=\"attachment_1747\" style=\"width: 310px\" class=\"wp-caption alignnone\"><a href=\"https:\/\/todaysveterinarypractice.com\/wp-content\/uploads\/sites\/4\/2014\/09\/2BFigure2B_ExsanquinationExtraWrap_Shafford_TVP.jpg\"><img decoding=\"async\" aria-describedby=\"caption-attachment-1747\" class=\"wp-image-1747 size-medium\" src=\"https:\/\/todaysveterinarypractice.com\/wp-content\/uploads\/sites\/4\/2014\/09\/2BFigure2B_ExsanquinationExtraWrap_Shafford_TVP-300x255.jpg\" alt=\"2BFigure2B_ExsanquinationExtraWrap_Shafford_TVP\" width=\"300\" height=\"255\" srcset=\"https:\/\/navc.sitepreview.app\/todaysveterinarypractice.com\/wp-content\/uploads\/sites\/4\/2014\/09\/2BFigure2B_ExsanquinationExtraWrap_Shafford_TVP-300x255.jpg 300w, https:\/\/navc.sitepreview.app\/todaysveterinarypractice.com\/wp-content\/uploads\/sites\/4\/2014\/09\/2BFigure2B_ExsanquinationExtraWrap_Shafford_TVP-1024x870.jpg 1024w, https:\/\/navc.sitepreview.app\/todaysveterinarypractice.com\/wp-content\/uploads\/sites\/4\/2014\/09\/2BFigure2B_ExsanquinationExtraWrap_Shafford_TVP-768x653.jpg 768w, https:\/\/navc.sitepreview.app\/todaysveterinarypractice.com\/wp-content\/uploads\/sites\/4\/2014\/09\/2BFigure2B_ExsanquinationExtraWrap_Shafford_TVP-1536x1305.jpg 1536w, https:\/\/navc.sitepreview.app\/todaysveterinarypractice.com\/wp-content\/uploads\/sites\/4\/2014\/09\/2BFigure2B_ExsanquinationExtraWrap_Shafford_TVP-2048x1740.jpg 2048w\" sizes=\"(max-width: 300px) 100vw, 300px\" \/><\/a><p id=\"caption-attachment-1747\" class=\"wp-caption-text\">B<\/p><\/div>\n<p><strong>4.<\/strong> \u00a0Apply a tourniquet just proximal to the top of the bandage, and note time of tourniquet application.<\/p>\n<ul>\n<li style=\"list-style-type: none\">\n<ul>\n<li><span class=\"blue\">Pneumatic tourniquet (recommended)<\/span>: Inflate cuff pressure to 50 to 100 mm Hg higher than the patient&#8217;s systolic arterial pressure; do not exceed 400 mm Hg.<\/li>\n<li><span class=\"blue\">Nonpneumatic (elastic band) tourniquet<\/span>: Consider placing a protective layer between the skin and band of tourniquet.<\/li>\n<\/ul>\n<\/li>\n<\/ul>\n<p><a href=\"https:\/\/todaysveterinarypractice.com\/wp-content\/uploads\/sites\/4\/2014\/09\/3Figure3_PneumaticTourniquet_Shafford_TVP.jpg\"><img loading=\"lazy\" decoding=\"async\" class=\"size-medium wp-image-1748 alignnone\" src=\"https:\/\/todaysveterinarypractice.com\/wp-content\/uploads\/sites\/4\/2014\/09\/3Figure3_PneumaticTourniquet_Shafford_TVP-300x259.jpg\" alt=\"3Figure3_PneumaticTourniquet_Shafford_TVP\" width=\"300\" height=\"259\" srcset=\"https:\/\/navc.sitepreview.app\/todaysveterinarypractice.com\/wp-content\/uploads\/sites\/4\/2014\/09\/3Figure3_PneumaticTourniquet_Shafford_TVP-300x259.jpg 300w, https:\/\/navc.sitepreview.app\/todaysveterinarypractice.com\/wp-content\/uploads\/sites\/4\/2014\/09\/3Figure3_PneumaticTourniquet_Shafford_TVP-1024x886.jpg 1024w, https:\/\/navc.sitepreview.app\/todaysveterinarypractice.com\/wp-content\/uploads\/sites\/4\/2014\/09\/3Figure3_PneumaticTourniquet_Shafford_TVP-768x664.jpg 768w, https:\/\/navc.sitepreview.app\/todaysveterinarypractice.com\/wp-content\/uploads\/sites\/4\/2014\/09\/3Figure3_PneumaticTourniquet_Shafford_TVP-1536x1328.jpg 1536w, https:\/\/navc.sitepreview.app\/todaysveterinarypractice.com\/wp-content\/uploads\/sites\/4\/2014\/09\/3Figure3_PneumaticTourniquet_Shafford_TVP-2048x1771.jpg 2048w\" sizes=\"(max-width: 300px) 100vw, 300px\" \/><\/a><\/p>\n<blockquote><p><span class=\"aquabold\">Surgical Insight<\/span>: Pneumatic tourniquets are recommended because (1) the pressure is distributed over the wide surface of the cuff and (2) tourniquet pressure can be monitored.<\/p><\/blockquote>\n<p><strong>5.<\/strong> \u00a0Once the tourniquet is applied, remove the bandage and verify that the peripheral pulse is\u00a0<span class=\"italic\">absent<\/span>; do\u00a0<span class=\"italic\">not<\/span>\u00a0proceed if an arterial pulse is present. If pulsatile blood is detected distal to the tourniquet, repeat steps 3 and 4. In the figure, the palmar artery is being used to verify absence of an arterial pulse.<\/p>\n<p><a href=\"https:\/\/todaysveterinarypractice.com\/wp-content\/uploads\/sites\/4\/2014\/09\/4Figure4_VerifyPulse_Shafford_TVP.jpg\"><img loading=\"lazy\" decoding=\"async\" class=\"alignnone size-medium wp-image-1749\" src=\"https:\/\/todaysveterinarypractice.com\/wp-content\/uploads\/sites\/4\/2014\/09\/4Figure4_VerifyPulse_Shafford_TVP-300x219.jpg\" alt=\"4Figure4_VerifyPulse_Shafford_TVP\" width=\"300\" height=\"219\" srcset=\"https:\/\/navc.sitepreview.app\/todaysveterinarypractice.com\/wp-content\/uploads\/sites\/4\/2014\/09\/4Figure4_VerifyPulse_Shafford_TVP-300x219.jpg 300w, https:\/\/navc.sitepreview.app\/todaysveterinarypractice.com\/wp-content\/uploads\/sites\/4\/2014\/09\/4Figure4_VerifyPulse_Shafford_TVP-1024x747.jpg 1024w, https:\/\/navc.sitepreview.app\/todaysveterinarypractice.com\/wp-content\/uploads\/sites\/4\/2014\/09\/4Figure4_VerifyPulse_Shafford_TVP-768x560.jpg 768w, https:\/\/navc.sitepreview.app\/todaysveterinarypractice.com\/wp-content\/uploads\/sites\/4\/2014\/09\/4Figure4_VerifyPulse_Shafford_TVP-1536x1120.jpg 1536w, https:\/\/navc.sitepreview.app\/todaysveterinarypractice.com\/wp-content\/uploads\/sites\/4\/2014\/09\/4Figure4_VerifyPulse_Shafford_TVP-2048x1493.jpg 2048w\" sizes=\"(max-width: 300px) 100vw, 300px\" \/><\/a><\/p>\n<blockquote><p><span class=\"aquabold\">Surgical Insight<\/span>: At low tourniquet pressure, venous outflow is occluded; however, if arterial blood in-flow is not occluded\u2014as indicated by presence of a peripheral pulse\u2014then the distal limb swells due to venous occlusion.<\/p><\/blockquote>\n<p><strong>6.<\/strong> \u00a0Inject lidocaine slowly over 1 to 3 minutes (see\u00a0<span class=\"bold\">IVRA: Materials &amp; Medications<\/span>\u00a0for details on lidocaine dose and preparation); then remove the catheter.<\/p>\n<p><a href=\"https:\/\/todaysveterinarypractice.com\/wp-content\/uploads\/sites\/4\/2014\/09\/5Figure5_LidocaineInjection_Shafford_TVP.jpg\"><img loading=\"lazy\" decoding=\"async\" class=\"alignnone size-medium wp-image-1750\" src=\"https:\/\/todaysveterinarypractice.com\/wp-content\/uploads\/sites\/4\/2014\/09\/5Figure5_LidocaineInjection_Shafford_TVP-300x121.jpg\" alt=\"5Figure5_LidocaineInjection_Shafford_TVP\" width=\"300\" height=\"121\" srcset=\"https:\/\/navc.sitepreview.app\/todaysveterinarypractice.com\/wp-content\/uploads\/sites\/4\/2014\/09\/5Figure5_LidocaineInjection_Shafford_TVP-300x121.jpg 300w, https:\/\/navc.sitepreview.app\/todaysveterinarypractice.com\/wp-content\/uploads\/sites\/4\/2014\/09\/5Figure5_LidocaineInjection_Shafford_TVP-1024x414.jpg 1024w, https:\/\/navc.sitepreview.app\/todaysveterinarypractice.com\/wp-content\/uploads\/sites\/4\/2014\/09\/5Figure5_LidocaineInjection_Shafford_TVP-768x310.jpg 768w, https:\/\/navc.sitepreview.app\/todaysveterinarypractice.com\/wp-content\/uploads\/sites\/4\/2014\/09\/5Figure5_LidocaineInjection_Shafford_TVP-1536x620.jpg 1536w, https:\/\/navc.sitepreview.app\/todaysveterinarypractice.com\/wp-content\/uploads\/sites\/4\/2014\/09\/5Figure5_LidocaineInjection_Shafford_TVP-2048x827.jpg 2048w\" sizes=\"(max-width: 300px) 100vw, 300px\" \/><\/a><\/p>\n<p><strong>7.<\/strong> \u00a0Prep for and perform the procedure. During the procedure, monitor and maintain tourniquet pressure.<span class=\"italic\">\u00a0Limit duration of tourniquet application to<\/span><span class=\"bolditalic\">90 minutes or less.<\/span><\/p>\n<p><a href=\"https:\/\/todaysveterinarypractice.com\/wp-content\/uploads\/sites\/4\/2014\/09\/6Figure6_ToeAmputation_Shafford_TVP.jpg\"><img loading=\"lazy\" decoding=\"async\" class=\"alignnone size-medium wp-image-1751\" src=\"https:\/\/todaysveterinarypractice.com\/wp-content\/uploads\/sites\/4\/2014\/09\/6Figure6_ToeAmputation_Shafford_TVP-243x300.jpg\" alt=\"6Figure6_ToeAmputation_Shafford_TVP\" width=\"243\" height=\"300\" srcset=\"https:\/\/navc.sitepreview.app\/todaysveterinarypractice.com\/wp-content\/uploads\/sites\/4\/2014\/09\/6Figure6_ToeAmputation_Shafford_TVP-243x300.jpg 243w, https:\/\/navc.sitepreview.app\/todaysveterinarypractice.com\/wp-content\/uploads\/sites\/4\/2014\/09\/6Figure6_ToeAmputation_Shafford_TVP-830x1024.jpg 830w, https:\/\/navc.sitepreview.app\/todaysveterinarypractice.com\/wp-content\/uploads\/sites\/4\/2014\/09\/6Figure6_ToeAmputation_Shafford_TVP-768x948.jpg 768w, https:\/\/navc.sitepreview.app\/todaysveterinarypractice.com\/wp-content\/uploads\/sites\/4\/2014\/09\/6Figure6_ToeAmputation_Shafford_TVP-1244x1536.jpg 1244w, https:\/\/navc.sitepreview.app\/todaysveterinarypractice.com\/wp-content\/uploads\/sites\/4\/2014\/09\/6Figure6_ToeAmputation_Shafford_TVP.jpg 1617w\" sizes=\"(max-width: 243px) 100vw, 243px\" \/><\/a><\/p>\n<p><strong>8.<\/strong> \u00a0Slowly and gradually release the tourniquet over a period of 2 to 4 minutes.<\/p>\n<h2><strong><span class=\"navyblueheader\">METACARPAL\/METATARSAL RING BLOCKS<\/span><\/strong><span class=\"navyblueheader\"><br \/>\n<\/span><\/h2>\n<p>The ring block is another simple analgesic technique used for the paw and metacarpal\/metatarsal region.<\/p>\n<p><strong><span class=\"aquabold\">Description<\/span><\/strong><\/p>\n<p>For the forelimbs, the goal is desensitization of the dorsal and palmar branches of the ulnar nerve, the superficial branches of the radial nerve, and the median nerve. For the hindlimbs, the goal is desensitization of the superficial and deep peroneal nerve and the tibial nerve and\/or lateral and plantar nerves.<\/p>\n<p><strong><span class=\"aquabold\">Technique Overview<\/span><\/strong><\/p>\n<p>To create a ring of anesthetic that blocks superficial nerves, local anesthetic is delivered via SC injection in lines over the dorsum and ventrum of the distal limb.<\/p>\n<ul>\n<li>On the forelimb, injection sites are just proximal to the carpus.<\/li>\n<li>On the hindlimb, injection sites are on the dorsal and plantar surfaces, at the level of the tarsometatarsal joint.<\/li>\n<\/ul>\n<p><strong><span class=\"aquabold\">Sedation\/Anesthesia<\/span><\/strong><\/p>\n<p>In sedated animals, consider adding sodium bicarbonate to the local anesthetic medication to minimize the sting associated with SC administration (1 part sodium bicarbonate to 9 parts local anesthetic). In patients under general anesthesia, I do not add bicarbonate to the blocks.<\/p>\n<table border=\"1\" width=\"500\" cellspacing=\"0\" cellpadding=\"1\">\n<tbody>\n<tr>\n<td class=\"navyblueheader\" colspan=\"3\"><strong>Ring Blocks: Materials &amp; Medications<\/strong><\/td>\n<\/tr>\n<tr>\n<td class=\"aquabold\" colspan=\"3\">MATERIALS<\/td>\n<\/tr>\n<tr bgcolor=\"#bcefcf\">\n<td colspan=\"3\">\n<ul>\n<li class=\"arial\">Small (25 or 27) gauge needles<\/li>\n<li class=\"arial\">Syringes<\/li>\n<\/ul>\n<\/td>\n<\/tr>\n<tr class=\"aquabold\">\n<td>MEDICATIONS<sup>a<\/sup><\/td>\n<td>TOTAL DOSE<sup>b,c<\/sup><\/td>\n<td>DURATION<\/td>\n<\/tr>\n<tr>\n<td bgcolor=\"#bcefcf\"><span class=\"arial\">Bupivacaine<br \/>\n<\/span><\/td>\n<td bgcolor=\"#bcefcf\"><span class=\"arial\">Up to 2 mg\/kg (dogs and cats)<br \/>\n<\/span><\/td>\n<td bgcolor=\"#bcefcf\"><span class=\"arial\">4 to 12 H<br \/>\n<\/span><\/td>\n<\/tr>\n<tr>\n<td bgcolor=\"#bcefcf\"><span class=\"arial\">Lidocaine<br \/>\n<\/span><\/td>\n<td bgcolor=\"#bcefcf\"><span class=\"arial\">Up to 8 mg\/kg (dogs)<br \/>\nUp to 6 mg\/kg (cats)<br \/>\n<\/span><\/td>\n<td bgcolor=\"#bcefcf\"><span class=\"arial\">1 to 2 H<br \/>\n<\/span><\/td>\n<\/tr>\n<tr>\n<td bgcolor=\"#bcefcf\"><span class=\"arial\">Mepivacaine<\/span><\/td>\n<td bgcolor=\"#bcefcf\"><span class=\"arial\">5 mg\/kg (dogs and cats)<\/span><\/td>\n<td bgcolor=\"#bcefcf\"><span class=\"arial\">2 to 4 H<\/span><\/td>\n<\/tr>\n<tr>\n<td class=\"arial\" colspan=\"3\"><strong>Notes<\/strong><\/p>\n<ol type=\"a\">\n<li>See\u00a0<strong>Ring Blocks: Medication Choices &amp; Safety Measures<\/strong>.<\/li>\n<li>Total dose is distributed SC between the multiple injection sites.<\/li>\n<li>Doses are\u00a0<strong>not<\/strong>\u00a0for use with the IVRA technique.<\/li>\n<\/ol>\n<\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n<div class=\"orange-box\">\n<h2>Ring Blocks<\/h2>\n<h3>Medication Choices &amp; Safety Measures<\/h3>\n<p>Choice of medication depends on desired duration of nerve blockade.<\/p>\n<ul>\n<li>For long duration analgesia, bupivacaine is recommended because lidocaine and mepivacaine are effective only for shorter periods of time.<\/li>\n<li>Onset and efficacy of blockade depend on (1) proximity to the nerves and (2) volume and concentration of medication (larger volume\/higher concentration are associated with faster onset).<\/li>\n<li>Risk for inadvertent IV administration is minimal, particularly if the anesthetist aspirates before each injection; thus, the local anesthetics listed are appropriate for ring blocks in cats and dogs.<\/li>\n<\/ul>\n<p>To ensure safe administration of medication:<\/p>\n<ul>\n<li>Calculate maximum total dose and label syringes, to prevent toxic adverse effects should inadvertent IV administration of the medication occur.<\/li>\n<li>Draw medications into syringes on the day of the procedure to prevent local anesthetics from adhering to plastic in the syringe.<\/li>\n<\/ul>\n<\/div>\n<h2 class=\"navyblueheader\"><strong>STEP-BY-STEP APPROACH TO RING BLOCKS<\/strong><\/h2>\n<p class=\"navyblueheader\"><strong>1.<\/strong> \u00a0Perform SC injection of medication just proximal to the carpus in the forelimb (<strong><span class=\"bold\">A<\/span><\/strong>) or at the level of the tarsus in the hindlimb (<strong><span class=\"bold\">B<\/span><\/strong>). Before injecting, aspirate to avoid inadvertent IV administration. Inject as the needle is withdrawn to deposit a line of medication that is perpendicular to the long axis of the limb.<\/p>\n<div id=\"attachment_1752\" style=\"width: 310px\" class=\"wp-caption alignnone\"><img loading=\"lazy\" decoding=\"async\" aria-describedby=\"caption-attachment-1752\" class=\"wp-image-1752 size-medium\" src=\"https:\/\/todaysveterinarypractice.com\/wp-content\/uploads\/sites\/4\/2014\/09\/7Figure7_MetacarpalBlock_Shafford_TVP-300x220.jpg\" alt=\"7Figure7_MetacarpalBlock_Shafford_TVP\" width=\"300\" height=\"220\" srcset=\"https:\/\/navc.sitepreview.app\/todaysveterinarypractice.com\/wp-content\/uploads\/sites\/4\/2014\/09\/7Figure7_MetacarpalBlock_Shafford_TVP-300x220.jpg 300w, https:\/\/navc.sitepreview.app\/todaysveterinarypractice.com\/wp-content\/uploads\/sites\/4\/2014\/09\/7Figure7_MetacarpalBlock_Shafford_TVP-1024x750.jpg 1024w, https:\/\/navc.sitepreview.app\/todaysveterinarypractice.com\/wp-content\/uploads\/sites\/4\/2014\/09\/7Figure7_MetacarpalBlock_Shafford_TVP-768x563.jpg 768w, https:\/\/navc.sitepreview.app\/todaysveterinarypractice.com\/wp-content\/uploads\/sites\/4\/2014\/09\/7Figure7_MetacarpalBlock_Shafford_TVP-1536x1126.jpg 1536w, https:\/\/navc.sitepreview.app\/todaysveterinarypractice.com\/wp-content\/uploads\/sites\/4\/2014\/09\/7Figure7_MetacarpalBlock_Shafford_TVP-2048x1501.jpg 2048w\" sizes=\"(max-width: 300px) 100vw, 300px\" \/><p id=\"caption-attachment-1752\" class=\"wp-caption-text\">A<\/p><\/div>\n<div id=\"attachment_1753\" style=\"width: 310px\" class=\"wp-caption alignnone\"><a href=\"https:\/\/todaysveterinarypractice.com\/wp-content\/uploads\/sites\/4\/2014\/09\/8Figure8_MetatarsalBlock_Shafford_TVP.jpg\"><img loading=\"lazy\" decoding=\"async\" aria-describedby=\"caption-attachment-1753\" class=\"wp-image-1753 size-medium\" src=\"https:\/\/todaysveterinarypractice.com\/wp-content\/uploads\/sites\/4\/2014\/09\/8Figure8_MetatarsalBlock_Shafford_TVP-300x216.jpg\" alt=\"8Figure8_MetatarsalBlock_Shafford_TVP\" width=\"300\" height=\"216\" srcset=\"https:\/\/navc.sitepreview.app\/todaysveterinarypractice.com\/wp-content\/uploads\/sites\/4\/2014\/09\/8Figure8_MetatarsalBlock_Shafford_TVP-300x216.jpg 300w, https:\/\/navc.sitepreview.app\/todaysveterinarypractice.com\/wp-content\/uploads\/sites\/4\/2014\/09\/8Figure8_MetatarsalBlock_Shafford_TVP-1024x737.jpg 1024w, https:\/\/navc.sitepreview.app\/todaysveterinarypractice.com\/wp-content\/uploads\/sites\/4\/2014\/09\/8Figure8_MetatarsalBlock_Shafford_TVP-768x553.jpg 768w, https:\/\/navc.sitepreview.app\/todaysveterinarypractice.com\/wp-content\/uploads\/sites\/4\/2014\/09\/8Figure8_MetatarsalBlock_Shafford_TVP-1536x1106.jpg 1536w, https:\/\/navc.sitepreview.app\/todaysveterinarypractice.com\/wp-content\/uploads\/sites\/4\/2014\/09\/8Figure8_MetatarsalBlock_Shafford_TVP-2048x1474.jpg 2048w\" sizes=\"(max-width: 300px) 100vw, 300px\" \/><\/a><p id=\"caption-attachment-1753\" class=\"wp-caption-text\">B<\/p><\/div>\n<blockquote><p><span class=\"aquabold\">Surgical Insight<\/span>: The skin is often tightly adhered to the distal extremity, making injection challenging. Lift up the skin and slide the needle under it to help facilitate injection in this area.<\/p><\/blockquote>\n<p><strong>2.<\/strong> \u00a0Repeat SC needle insertion, aspiration of the syringe, and medication injection to create a circumferential ring of local anesthetic around the limb. The circumferential SC injections shown in the figures demonstrate local anesthetic blockade of superficial nerves in the forelimb and hindlimb of a cat.<\/p>\n<h2><strong>POSTOPERATIVE ANALGESIA<br \/>\n<\/strong><\/h2>\n<p>Local anesthetic techniques, such as IVRA and ring blocks, should be incorporated as part of a multimodal approach to minimizing perioperative pain.<\/p>\n<p>For IVRA, while lidocaine provides excellent in situ anesthesia and analgesia, once the tourniquet is released, the lidocaine&#8217;s effect diminishes after approximately 20 minutes. Therefore, plan to provide postoperative analgesia tailored to the patient&#8217;s anticipated pain.<\/p>\n<p>Duration of local analgesia conferred by ring blocks is dependent upon the local anesthetic used (ie, bupivacaine confers longer duration analgesia). Additional postoperative analgesia benefits the patient, in anticipation of pain extending beyond the duration of the local block.<\/p>\n<h2><span class=\"navyblueheader\"><strong>COMPLICATIONS<\/strong><br \/>\n<\/span><\/h2>\n<p>Visit tvpjournal.com\/resources.asp#resources to find:<\/p>\n<ul>\n<li class=\"bold\"><strong>Table 3<\/strong>. <strong>Minimizing Risks Associated with IVRA and Ring Blocks<\/strong><\/li>\n<li><strong><span class=\"bold\">Local Anesthetic Calculation Cheat Sheet<\/span><\/strong>, which assists with calculating maximum doses of bupivacaine 0.5% solution.<\/li>\n<\/ul>\n<table border=\"1\" width=\"500\" cellspacing=\"0\" cellpadding=\"1\">\n<tbody>\n<tr>\n<td class=\"GreenAqua\" colspan=\"3\" align=\"center\"><strong>Table 3. Minimizing Risks Associated with IVRA &amp; Ring Blocks<\/strong><\/td>\n<\/tr>\n<tr class=\"navyblueheader\">\n<td align=\"center\">POTENTIAL ADVERSE EFFECT<\/td>\n<td align=\"center\">IVRA<\/td>\n<td align=\"center\">RING BLOCKS<\/td>\n<\/tr>\n<tr>\n<td bgcolor=\"#bcefcf\"><span class=\"aquabold\">Tissue or nerve damage<\/span><span class=\"arial\"><br \/>\n<\/span><\/td>\n<td bgcolor=\"#9ce8b9\">\n<ul>\n<li><span class=\"arial\">Limit tourniquet duration to &lt; 90 min<\/span><\/li>\n<li><span class=\"arial\">Monitor tourniquet pressure<br \/>\n<\/span><\/li>\n<\/ul>\n<\/td>\n<td bgcolor=\"#bcefcf\">\n<ul>\n<li><span class=\"arial\">Ensure careful technique<\/span><\/li>\n<li><span class=\"arial\">Use new, small-gauge needles\u00a0<\/span><\/li>\n<li><span class=\"arial\">Do not inject if resistance is met<br \/>\n<\/span><\/li>\n<\/ul>\n<\/td>\n<\/tr>\n<tr>\n<td bgcolor=\"#bcefcf\"><span class=\"aquabold\">Local anesthetic overdose<\/span><span class=\"arial\"><br \/>\n<\/span><\/td>\n<td bgcolor=\"#9ce8b9\">\n<ul>\n<li><span class=\"arial\">Use lidocaine<\/span><\/li>\n<li><span class=\"arial\">Do not use bupivacaine<\/span><\/li>\n<li><span class=\"arial\">Calculate max dose for each patient<br \/>\n<\/span><\/li>\n<\/ul>\n<\/td>\n<td bgcolor=\"#bcefcf\">\n<ul>\n<li><span class=\"arial\">Calculate max dose for each patient\u00a0<\/span><\/li>\n<li><span class=\"arial\">Use dose calculation cheat sheet\u00a0<\/span><\/li>\n<li><span class=\"arial\">Always aspirate syringe before injection<\/span><\/li>\n<li><span class=\"arial\">Label syringes<br \/>\n<\/span><\/li>\n<\/ul>\n<\/td>\n<\/tr>\n<tr>\n<td bgcolor=\"#bcefcf\"><span class=\"aquabold\">Inadequate analgesia during procedure<\/span><span class=\"arial\"><br \/>\n<\/span><\/td>\n<td bgcolor=\"#9ce8b9\">\n<ul>\n<li><span class=\"arial\">Administer IV analgesic (eg, fentanyl, hydromorphone)<br \/>\n<\/span><\/li>\n<\/ul>\n<\/td>\n<td bgcolor=\"#bcefcf\">\n<ul>\n<li><span class=\"arial\">Administer IV analgesic (eg, fentanyl, hydromorphone)<br \/>\n<\/span><\/li>\n<\/ul>\n<\/td>\n<\/tr>\n<tr>\n<td bgcolor=\"#bcefcf\"><span class=\"aquabold\">Venous engorgement<\/span><span class=\"arial\"><br \/>\n<\/span><\/td>\n<td bgcolor=\"#9ce8b9\">\n<ul>\n<li><span class=\"arial\">Ensure absence of peripheral arterial pulse following tourniquet application<br \/>\n<\/span><\/li>\n<\/ul>\n<\/td>\n<td bgcolor=\"#bcefcf\"><span class=\"arial\">n\/a<br \/>\n<\/span><\/td>\n<\/tr>\n<tr>\n<td bgcolor=\"#bcefcf\"><span class=\"aquabold\">Tourniquet-related pain<\/span><\/td>\n<td bgcolor=\"#9ce8b9\">\n<ul>\n<li><span class=\"arial\">If patient shows signs of tourniquet pain\u2014increased heart rate, respiratory rate, and blood pressure unresponsive to analgesic administration\u2014place second tourniquet distal to initial tourniquet; then release proximal tourniquet after second is inflated.<\/span><\/li>\n<\/ul>\n<\/td>\n<td bgcolor=\"#bcefcf\"><span class=\"arial\">n\/a<\/span><\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n<h2><strong><span class=\"navyblueheader\">IN SUMMARY<\/span><\/strong><\/h2>\n<p>Local anesthesia techniques are important analgesic &#8220;tools&#8221; because:<\/p>\n<ul>\n<li>Patients benefit from effective, preventive, site-specific analgesia<\/li>\n<li>Balanced anesthetic protocols allow reduced reliance on inhalants.<\/li>\n<\/ul>\n<p>After reviewing the step-by-step instructions in this article, you should be able to incorporate IVRA and ring blocks into your anesthesia and pain management protocols with confidence.<\/p>\n<p class=\"arial\">IVRA = intravenous regional anesthesia; RUMM = radial\u2014ulnar\u2014median\u2014musculoskeletal<\/p>\n<h3 class=\"references\"><strong>Suggested Reading<\/strong><\/h3>\n<p class=\"references\">Kushner LI, Fan B, Shofer FS. Intravenous regional anesthesia in isoflurane anesthetized cats: Lidocaine plasma concentrations and cardiovascular effects.\u00a0<em>Vet Anesthes Analges<\/em>\u00a02002; 29:140-149.<\/p>\n<p>Skarda RT, Tranquilli WJ. Local and regional anesthetic and analgesic techniques: Cats. In Tranquilli WJ, Thurmon JC, Grimm KA (eds):<em>\u00a0Lumb and Jones&#8217; Veterinary Anesthesia and Analgesia<\/em>, 4th ed. Ames, Iowa: Blackwell Publishing, 2007, pp 595-603.<\/p>\n<p>Staffieri F. Intravenous regional anesthesia. In Campy L, Read MR (eds):\u00a0<em>Small Animal Regional Anesthesia and Analgesia<\/em>. Ames, Iowa: Wiley-Blackwell, 2014, pp 261-271.<\/p>\n<p class=\"references\"><span class=\"italic\"><strong><a href=\"https:\/\/todaysveterinarypractice.com\/wp-content\/uploads\/sites\/4\/2014\/09\/C08_i.jpg\"><img loading=\"lazy\" decoding=\"async\" class=\"alignleft size-full wp-image-6479\" src=\"https:\/\/todaysveterinarypractice.com\/wp-content\/uploads\/sites\/4\/2014\/09\/C08_i.jpg\" alt=\"C08_i\" width=\"100\" height=\"115\" \/><\/a><span class=\"author-bio\">Heidi L. Shafford<\/span><\/strong><\/span><span class=\"author-bio\">, DVM, PhD, Diplomate ACVAA, owns and operates Veterinary Anesthesia Specialists, LLC, based in Portland, Oregon. She provides anesthesia care for patients in the Portland area, leads in-clinic workshops for teams, and lectures extensively to veterinary professionals nationwide. She received her DVM from Colorado State University.<\/span><\/p>\n","protected":false},"excerpt":{"rendered":"<p>After reviewing the step-by-step instructions in this article, you should be able to incorporate IVRA and ring blocks into your anesthesia and pain management protocols with confidence.<\/p>\n","protected":false},"author":187,"featured_media":672,"comment_status":"open","ping_status":"open","sticky":false,"template":"","format":"standard","meta":{"_acf_changed":false,"iawp_total_views":7304,"footnotes":""},"categories":[368],"tags":[13],"class_list":["post-604","post","type-post","status-publish","format-standard","has-post-thumbnail","hentry","category-september-october-2014","tag-peer-reviewed","column-features","clinical_topics-anesthesiology"],"acf":{"hide_sidebar":false,"hide_sidebar_ad":false,"hide_all_ads":false},"yoast_head":"<!-- This site is optimized with the Yoast SEO Premium plugin v24.7 (Yoast SEO v27.3) - 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