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Intravenous Regional Anesthesia: Assisting

  1. Assess distal neurovascular status (i.e., circulation, sensation, and movement).
  2. Perform hand hygiene and apply gloves.
  3. Assess distal neurovascular status (i.e., circulation, sensation, and movement).
  4. Perform hand hygiene and apply gloves.
  5. Verify the patient's identity in accordance with institutional policy. Ensure consent has been obtained.
  6. Call or participate in a "time-out" before initiating an invasive procedure, in accordance with institutional policy.
  7. Establish IV access distal to site of injury.
  8. Establish a second IV site in an uninjured extremity for emergency access, if needed.
  9. Initiate pulse oximetry and cardiac monitoring.
  10. Apply two or three layers of cast padding at the tourniquet site to protect the skin.
  11. Assess and document vital signs.
  12. Place the patient in a supine position.
  13. Consider IV administration of a sedative to decrease the patient's anxiety and an analgesic to decrease cuff discomfort during the procedure. If the patient exhibits excessive fear or anxiety that prevents cooperation, IVRA could still potentially be used with appropriate sedation and analgesia.
  14. Test the pneumatic tourniquet cuffs by inflating them to 250 mm Hg.
  15. The physician or advanced practice nurse places both pneumatic tourniquets proximal to the injured extremity.
  16. The physician or advanced practice nurse exsanguinates the extremity by elevating the extremity and wrapping it with a tight elastic bandage applied distally to proximally. If the patient's injury precludes the application of an elastic bandage, the extremity is exsanguinated by elevating it and occluding the artery for 5 minutes.
  17. The physician or advanced practice nurse applies digital pressure to occlude the axillary artery (for the arm) or the oral artery (for the leg) and maintains this pressure during cuff inflation. The proximal cuff is inflated to 50 to 100 mm Hg higher than the patient's systolic blood pressure.
  18. With the tourniquet inflated, the physician or advanced practice nurse injects the anesthesia into the IV line of the injured extremity. The anesthetic agent of choice depends on the physician's preference, rapidity of onset, duration and degree of motor block needed, relative toxicity of agent, and spreading power of agent. Dosage should be individualized by patient's weight. Do not use anesthetic agents that contain preservatives. Lidocaine (3 mg/kg) without preservative is a commonly used anesthetic. Opioids, neuromuscular blocker, and nonsteroidal antiinflammatory drugs may also be included to decrease the amount of local anesthetic required. Consultation with anesthesiology should be considered in this event.
  19. Approximately 25 to 30 minutes after the onset of anesthesia or when the patient begins to develop tourniquet pain, inflate the distal cuff 50 to 100 mm Hg higher than the patient's systolic blood pressure. Slowly deflate the proximal cuff so that the local anesthetic does not rush back into the systemic circulation. The area under the distal cuff is already anesthetized and the patient does not experience tourniquet pain.
  20. Monitor vital signs, cardiac rhythm, SpO2, and level of consciousness continuously during the procedure. Monitor the pressure in the pneumatic cuffs.
  21. If the patient has a fracture or dislocation, postreduction films are obtained before the tourniquet is released.
  22. At completion of the procedure, the physician or advanced practice nurse begins tourniquet release. The tourniquet should not be released for at least 30 minutes after the last injection of anesthetic.
  23. Tourniquet is deflated totally and immediately reinflated for 1 minute.
  24. Assess the patient for symptoms of local anesthetic toxicity such as light-headedness, tinnitus, or a metallic taste.
  25. If there are no symptoms of systemic toxicity, the physician or advanced practice nurse deflates the tourniquet totally and immediately reinflates it. Assess the patient for systemic and local anesthetic toxicity.
  26. If there are no symptoms of systemic toxicity after 1 to 2 minutes, the physician or advanced practice nurse deflates the cuff and removes it.
  27. During and after release of the tourniquet, continue to monitor the patient's vital signs, cardiac rhythm, SpO2, level of consciousness, and symptoms of anesthetic toxicity. After tourniquet release, monitor the patient for a minimum of 30 to 60 minutes. Circulation, sensation, and mobility of the patient's injured extremity should also be monitored during this time.
  28. Discard supplies, remove gloves, and perform hand hygiene.
  29. Document the procedure in the patient's record.
A large amount of anesthetic remains within the tissues of the extremity even after tourniquet release. To prevent rapid mobilization into the systemic circulation, the extremity should remain at rest for some time after the procedure.
  1. Verify the patient's identity in accordance with institutional policy. Ensure consent has been obtained.
  2. Call or participate in a "time-out" before initiating an invasive procedure, in accordance with institutional policy.
  3. Establish IV access distal to site of injury.
  4. Establish a second IV site in an uninjured extremity for emergency access, if needed.
  5. Initiate pulse oximetry and cardiac monitoring.
  6. Apply two or three layers of cast padding at the tourniquet site to protect the skin.
  7. Assess and document vital signs.
  8. Place the patient in a supine position.
  9. Consider IV administration of a sedative to decrease the patient's anxiety and an analgesic to decrease cuff discomfort during the procedure. If the patient exhibits excessive fear or anxiety that prevents cooperation, IVRA could still potentially be used with appropriate sedation and analgesia.
  10. Test the pneumatic tourniquet cuffs by inflating them to 250 mm Hg.
  11. The physician or advanced practice nurse places both pneumatic tourniquets proximal to the injured extremity.
  12. The physician or advanced practice nurse exsanguinates the extremity by elevating the extremity and wrapping it with a tight elastic bandage applied distally to proximally. If the patient's injury precludes the application of an elastic bandage, the extremity is exsanguinated by elevating it and occluding the artery for 5 minutes.
  13. The physician or advanced practice nurse applies digital pressure to occlude the axillary artery (for the arm) or the femoral artery (for the leg) and maintains this pressure during cuff inflation. The proximal cuff is inflated to 50 to 100 mm Hg higher than the patient's systolic blood pressure.
  14. With the tourniquet inflated, the physician or advanced practice nurse injects the anesthesia into the IV line of the injured extremity. The anesthetic agent of choice depends on the physician's preference, rapidity of onset, duration and degree of motor block needed, relative toxicity of agent, and spreading power of agent. Dosage should be individualized by patient's weight. Do not use anesthetic agents that contain preservatives. Lidocaine (3 mg/kg) without preservative is a commonly used anesthetic. Opioids, neuromuscular blocker, and nonsteroidal antiinflammatory drugs may also be included to decrease the amount of local anesthetic required. Consultation with anesthesiology should be considered in this event.
  15. Approximately 25 to 30 minutes after the onset of anesthesia or when the patient begins to develop tourniquet pain, inflate the distal cuff 50 to 100 mm Hg higher than the patient's systolic blood pressure. Slowly deflate the proximal cuff so that the local anesthetic does not rush back into the systemic circulation. The area under the distal cuff is already anesthetized and the patient does not experience tourniquet pain.
  16. Monitor vital signs, cardiac rhythm, SpO2, and level of consciousness continuously during the procedure. Monitor the pressure in the pneumatic cuffs.
  17. If the patient has a fracture or dislocation, postreduction films are obtained before the tourniquet is released.
  18. At completion of the procedure, the physician or advanced practice nurse begins tourniquet release. The tourniquet should not be released for at least 30 minutes after the last injection of anesthetic.
  19. Tourniquet is deflated totally and immediately reinflated for 1 minute.
  20. Assess the patient for symptoms of local anesthetic toxicity such as light-headedness, tinnitus, or a metallic taste.
  21. If there are no symptoms of systemic toxicity, the physician or advanced practice nurse deflates the tourniquet totally and immediately reinflates it. Assess the patient for systemic and local anesthetic toxicity.
  22. If there are no symptoms of systemic toxicity after 1 to 2 minutes, the physician or advanced practice nurse deflates the cuff and removes it.
  23. During and after release of the tourniquet, continue to monitor the patient's vital signs, cardiac rhythm, SpO2, level of consciousness, and symptoms of anesthetic toxicity. After tourniquet release, monitor the patient for a minimum of 30 to 60 minutes. Circulation, sensation, and mobility of the patient's injured extremity should also be monitored during this time.
  24. Discard supplies, remove gloves, and perform hand hygiene.
  25. Document the procedure in the patient's record.
  26. A large amount of anesthetic remains within the tissues of the extremity even after tourniquet release. To prevent rapid mobilization into the systemic circulation, the extremity should remain at rest for some time after the procedure.

 

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