1 Anesthesiology Research Center, Guilan University of Medical Sciences, Rasht, Iran

2 Orthopedic Department, Guilan Road Trauma Research Center, Guilan University of Medical Sciences, Rasht, Iran

3 Orthopedic Research Center, Guilan University of Medical Sciences, Rasht, Iran

4 Anesthesiology Department, Anesthesiology Research Center, Guilan University of Medical Sciences, Rasht, Iran

5 Guilan Road Trauma Research Center, Guilan University of Medical Sciences, Rasht, Iran


Background: Several studies have put an effort to minimize the tourniquet pain and complications after conventional
double tourniquet intravenous regional anesthesia (IVRA). We expressed in our hypothesis that an upper arm single
wide tourniquet (ST) may serve a better clinical efficacy rather than the conventional upper arm double tourniquet (DT)
in distal upper extremity surgeries.
Methods: In this randomized controlled trial, 80 patients undergoing upper limb orthopedic surgeries were randomized
into two groups. IVRA was administered using lidocaine in both groups. Tourniquet pain was recorded based on visual
analogue scale (VAS). In case of pain (VAS>3) in the DT group, the proximal tourniquet was replaced with a distal
tourniquet while fentanyl 50μg was injected in the ST group. The onset time of tourniquet pain, time to reach to maximum
tourniquet pain and the amount of fentanyl consumption were compared between the two groups.
Results: No significant difference was seen in demographic characteristics. The onset time of tourniquet pain (VAS=1)
in the ST group (26.9±13.2 min) was longer than that of the DT group (13.8±4.8 min) (P<0.0001). The median of time to
reach to maximum tourniquet pain (VAS>3) in DT and ST groups were 25 and 40 minutes, respectively; indicating that
the patients in ST group reached to pain level at a significantly later time (P<0.0001). The total opioid consumption in
the DT group (61μg) was significantly lower than the ST group (102μg) (P<0.0001); however, both groups were similar
regarding fentanyl consumption before 40 minutes of surgeries.
Conclusion: It seems that in upper limb orthopedic surgeries with less than 40-minute duration, a single tourniquet
may serve as a proper alternative opposed to the conventional double tourniquet technique.


Main Subjects

1. Chiao FB, Chen J, Lesser JB, Resta-Flarer F, Bennett
H. Single-cuff forearm tourniquet in intravenous
regional anaesthesia results in less pain and fewer
sedation requirements than upper arm tourniquet. Br
J Anaesth. 2013; 111(2):271-5.
2. Choyce A, Peng P. A systematic review of adjuncts
for intravenous regional anesthesia for surgical
procedures. Can J Anaesth. 2002; 49(1):32-45.
3. Frank R, Cowan BJ, Lang S, Harrop AR, Magi E.
Modification of the forearm tourniquet techniques of
intravenous regional anaesthesia for operations on
the distal forearm and hand. Scand J Plast Reconstr
Surg Hand Surg. 2009; 43(2):102-8.
4. Davis R, Keenan J, Meza A, Danaher P, Vacchiano C,
Olson RL, et al. Use of a simple forearm tourniquet as
an adjunct to an intravenous regional block. AANA J.
2002; 70(4):295-8.
5. Farrell RG, Swanson SL, Walter JR. Safe and effective
IV regional anesthesia for use in the emergency
department. Ann Emerg Med. 1985; 14(4):288-92.
6. Johnson CN. Intravenous regional anesthesia:
new approaches to an old technique. CRNA. 2000;
7. Tham CH, Lim BH. A modification of the technique
for intravenous regional blockade for hand surgery. J
Hand Surg Br. 2000; 25(6):575-7.
8. Soleimanha M, Sedighinejad A, Haghighi M, Nabi BN,
Mirbolook AR, Mardani-Kivi M. Hemodynamic and
arterial blood gas parameters during cemented hip
hemiarthroplasty in elderly patients. Arch Bone Jt
Surg. 2014; 2(3):163-7.
9. Haghighi M, Sedighinejad A, Mirbolook A, Naderi
Nabi B, Farahmand M, Kazemnezhad Leili E, et al.
Effect of intravenous intraoperative esmolol on
pain management following lower limb orthopedic
surgery. Korean J Pain. 2015; 28(3):198-202.
10. Soleimanha M, Haghighi M, Mirbolook A, Sedighinejad
A, Mardani-Kivi M, Naderi-Nabi B, et al. A survey on
transfusion status in orthopedic surgery at a trauma
center. Arch Bone Jt Surg. 2016; 4(1):70-4.
11. Sedighinejad A, Haghighi M, Naderi Nabi B,
Rahimzadeh P, Mirbolook A, Mardani-Kivi M, et
al. Magnesium sulfate and sufentanil for patientcontrolled
analgesia in orthopedic surgery. Anesth
Pain Med. 2014; 4(1):e11334-9.
12. Chong AK, Tan DM, Ooi BS, Mahadevan M, Lim AY, Lim
BH. Comparison of forearm and conventional Bier’s
blocks for manipulation and reduction of distal radius
fractures. J Hand Surg Eur Vol. 2007; 32(1):57-9.
13. Karalezli N, Karalezli K, Iltar S, Cimen O, Aydogan
N. Results of intravenous regional anaesthesia with
distal forearm application. Acta Orthop Belg. 2004;
14. Perlas A, Peng PW, Plaza MB, Middleton WJ, Chan VW,
Sanandaji K. Forearm rescue cuff improves tourniquet
tolerance during intravenous regional anesthesia. Reg
Anesth Pain Med. 2003; 28(2):98-102.
15. Arslanian B, Mehrzad R, Kramer T, Kim DC. Forearm
Bier block: a new regional anesthetic technique
for upper extremity surgery. Ann Plast Surg. 2014;
16. Haghighi M, Soleymanha M, Sedighinejad A,
Mirbolook A, Naderi Nabi B, Rahmati M, et al. The
effect of magnesium sulfate on motor and sensory
axillary plexus blockade. Anesth Pain Med. 2015;
17. Odinsson A, Finsen V. The position of the tourniquet
on the upper limb. J Bone Joint Surg Br. 2002;
18. Chan CS, Pun WK, Chan YM, Chow SP. Intravenous
regional analgesia with a forearm tourniquet. Can J
Anaesth. 1987; 34(1):21-5.
19. Edwards SA, Harper GD, Giddins GE. Efficacy of
forearm versus upper arm tourniquet for local
anaesthetic surgery of the hand. J Hand Surg Br. 2000;
20. Graham B, Breault MJ, McEwen JA, McGraw RW.
Occlusion of arterial flow in the extremities at
subsystolic pressures through the use of wide
tourniquet cuffs. Clin Orthop Relat Res. 1993;
21. Pedowitz RA, Gershuni DH, Botte MJ, Kuiper S, Rydevik
BL, Hargens AR. The use of lower tourniquet inflation
pressures in extremity surgery facilitated by curved
and wide tourniquets and an integrated cuff inflation
system. Clin Orthop Relat Res. 1993; 287:237-44.
22. Coleman MM, Peng PW, Regan JM, Chan VW, Hendler
AL. Quantitative comparison of leakage under
the tourniquet in forearm versus conventional
intravenous regional anesthesia. Anesth Analg. 1999;
23. Estebe JP, Le Naoures A, Chemaly L, Ecoffey C.
Tourniquet pain in a volunteer study: effect of
changes in cuff width and pressure. Anaesthesia.
2000; 55(1):21-6.
24. COLE F. Tourniquet pain. Curr Res Anesth Analg.
1952; 31(1):63-4.
25. Gielen MJ, Stienstra R. Tourniquet hypertension and its
prevention: a review. Reg Anesth. 1991; 16(4):191-4.
26. Hodgson AJ. A proposed etiology for tourniquetinduced
neuropathies. J Biomech Eng. 1994;
27. Kam PC, Kavanaugh R, Yoong FF. The arterial
tourniquet: pathophysiological consequences
and anaesthetic implications. Anaesthesia. 2001;
28. Hutchinson DT, McClinton MA. Upper extremity
tourniquet tolerance. J Hand Surg Am. 1993;
29. Sanders R. The tourniquet. Instrument or weapon?Hand. 1973; 5(2):119-23.

30. Barry LA, Balliana SA, Galeppi AC. Intravenous
regional anesthesia (Bier block). Techniq Regional
Anesthesia Pain Manage. 2006; 10(3):123-31.
31. Rosenberg PH, Veering BT, Urmey WF. Maximum
recommended doses of local anesthetics: a
multifactorial concept. Reg Anesth Pain Med. 2004;