Meperidine in Forearm Intravenous Regional Anesthesia?

We appreciate the comment by Drs. Coleman and Chan suggesting that a smaller dose of meperidine (15 mg) may be beneficial when used as a component of IV regional anesthesia (IVRA) lidocaine 0.5% using a forearm tourniquet. Although prolonged analgesia with meperidine doses ≥30 mg can be achieved, we believe the peak plasma meperidine concentrations that result after tourniquet release were large enough to cause the centrally mediated opioid side effects we observed (1). The incidence of these side effects was less frequent with meperidine doses ≤20 mg and was found to be statistically similar to the control group. Perhaps 15 mg of meperidine in IVRA lidocaine using a forearm tourniquet provides effective postoperative analgesia with a lower incidence of side effects. IVRA with a forearm tourniquet provides safe and effective analgesia using smaller doses of lidocaine (2–4). In addition, a forearm tourniquet may be tolerated for a longer (5) or at least equal (6) period of time as an upper arm tourniquet. However, the use of a forearm tourniquet remains controversial. Sanders (7) states that “tourniquets should never be placed distal to the elbow” because of a greater risk of nerve injury and breakthrough bleeding. A forearm tourniquet may not adequately compress the anterior and posterior interosseous arteries located between the radius and ulna, leading to a greater incidence of blood leakage (8). The use of a forearm tourniquet is not recommended for hypertensive patients because of an increased incidence of venous congestion and inadequate analgesia observed with this technique (2). Furthermore, ulnar neuropathy has been reported after the use of a forearm tourniquet (9), perhaps occurring more often than with an upper arm tourniquet. The ulnar nerve can be transfixed between the tourniquet and the ulna, and if the elbow is inadvertently flexed during surgery, a traction neuritis can develop. Although smaller doses of meperidine and lidocaine may be used during IVRA with a forearm tourniquet, this technique should be used with caution. Moreover, the analgesic effects of meperidine in these circumstances have never been investigated. Scott S. Reuben MD Robert S. Steinberg MD, PhD