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esporaespazioa · 1 year ago

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KAMPAI-k & ZARATAFES-ek aurkezten dute AVUMDULUV musika eta zaratatxoen jaialdia

Honako hauekin

PHLGZ (phlegeton vortex, madrid, abstract technoise, phlgz.bandcamp.com) + KATZA (bilbo, hypnotist ambient, soundcloud.com/ktz) + MYRIAM RZM & CAMILLE ÉMAILLE (dima & mercantour, percussion & body ruidism, myriamrzm.bandcamp.com & camilleemaille.com) + DOPELGANGER (miguel a. garcía & garazi navas, gasteiz & usansolo, lateral elektroacoustics w/accordion, youtu.be/KSEjTwO4vVE) + GABA (enrique garoz de diego & garazi gorostiaga, madrid & galdakao, cosmic horror sounds, gabasonic.wixsite.com/gaba) + PATRICIA ETXEGARAI (iruñea, exhibition & artwork)

2023ko ABUZTUAren 4an, OSTIRALA

KAMPAI ESPAZIOAn (moncada kalea 5, 3º, errekalde, BILBAO) 19: 00etan (18: 30ean irekiko ditugu ateak)

sarrera 7 €-tan

espora & mem kolaboratzaileak

PHLGZ (phlegeton vortex, madril, abstract technoise, https://phlgz.bandcamp.com) J.L. Rey aka Phlegetonen musika elektronikoko proiektua da PHLGZ- Bertan dark techno gehi cyberpunk, IDM glitcheatua eta rave gordinaren elementuak uztartzen ditu, noisez zipriztinduak. Esperimentazio-lubakitik soinu-paisaia asaldatzaile eta inguratzaileak sortzen ditu, non soinu-geruzak gainjartzen eta gurutzatzen diren kaos kontrolatu batean, zibilizazio distopiko bateko dantza-pista baten pultsu hipnotikoa gogora ekartzeko. Musika industrian 20 urte baino gehiagoko esperientzia izanik, Phlegetonek disko ugari kaleratu ditu Wormed, Lifelost edo Utsik musika taldeekin, eta bere musika Europa, Amerika eta Asiako agertokietara eraman du. Ilustratzaile digitala ere bada, eta ikuspegi artistiko paregabea eskaintzen du album eta grafikoen azalen bidez, nazioarteko muturreko metalezko banda askorentzat. +info gehiago hemen: https://linktr.ee/Phlegeton

KATZA (bilbo, hypnotist ambient, https://soundcloud.com/ktz) Katza, PARALELOANen sortzaileetako bat, Bilbon bizi den DJ bat da eta bizitza erdia darama musikaren ertzak aztertzen. Gaur egun askok dantza-musikarekin lotzen badute ere, oso gaztetako punk taldeetan jotzen hasi zen, eta hori nabaritzen da bere aukeraketan. Talde garaikideko musikan, post-punkean, dubean edo DIY bitxikerietan oinarrituta, Katzak batez ere aukeratzen dituen soinuen berehalakotasuna, urgentzia eta emozioa baloratzen ditu.

MYRIAM RZM & CAMILLE ÉMAILLE (dima & mercantour, percussion & body ruidism, https://myriamrzm.bandcamp.com & https://camilleemaille.com) Myriam Rzm (Dima 1975). Sortzailea, performerra, soinu-esperimentatzailea. Eszenan Gora Japon bikotearekin, Magmadam bikote irekiarekin eta diziplina arteko artistekin elkarlanean trebatu da. Gaur egun, "Ruido Proto_Ritual" garatzen du, inprobisazioan oinarritutako zuzeneko bat, DIY/DIT soinu-tresna autofabrikatuekin, bere soinu-performazioko kezketara egokituak, fx eta feedback-pedalekin konbinatuak, mugimenduan dagoen gorputzarekiko ekintzan/elkarreraginean. +gauza gehiago hemen: https://abymenabar.bandcamp.com /; https://crystalmine.bandcamp.com/album/aizu

Camille Émaillek uste du perkusiozko solo emanaldi bat ez dela benetan solo bat. Izan ere, objektuek beren kabuz igortzen dituzte soinuak eta ideiak estimulatzen dituzte beti. Hori dela eta, dagoeneko idatzita dago Émaille-ren jardunak, aldi berean, "aldi berean prekarioa eta ikusgarria den arkitektura bat direla, lotzen duena ukitzen duen dramaturgia ahul eta tirabiratsu bat, gorputzez gorputz argal eta animalia bat, berak maitatzen edo pizten duen soinu-materia batekin". Émaille-k objektu musikal bakoitzaren soinuarekin bilatzen eta ezartzen duen harreman organikoak bere instrumentuak ere eraikiarazten dizkio, eta ulertzen du inprobisazioa egunerokotasunarekin etengabeko harremanean dagoen fluxua dela, inguruan dagoenaz elikatzen dela.

DOPELGANGER (miguel a. garcía & garazi navas, gasteiz & usansolo, lateral elektroacoustics w/accordion, https://youtu.be/KSEjTwO4vVE) Miguel A. Garcíak (elektronika, konposizioa) eta Garazi Navasek (akordeoia, ahotsa) osatzen dute Dopelganger. Konposizio trinkoak, ezinezko hibridoak musika elektroniko esperimentalaren eta opera garaikide-espresionistaren artean, antagonikoak diruditen munduen topatzea eta indartzea arakatu gabeko bazterretara, ezezagunaren eta intentsitate sentsorial zein emozionalaren beldurrik gabe. Garazi Navas Musikenen (Euskal Herriko Goi Mailako Musika Ikastegia) graduatutako soinujole ipurterrea da, eta, gaztea izan arren, proiektu askotan parte hartu du musika garaikidea, klasikoa, tradizionala eta beste estilo batzuetakoa interpretatuz. Miguel A. García (aka Xedh) Bilbon bizi den artista da, musika esperimentalaren eta soinu-artearen arloan lan egiten duena. Bakarka zein hainbat taldetan, herrialde askotan aritu da eta dozenaka artistarekin kolaboratu du estudioan eta zuzenean, eta ehundik gora diskotan agertu da.

GABA (enrique garoz de diego & garazi gorostiaga, madrid & galdakao, cosmic horror sounds, https://gabasonic.wixsite.com/gaba) Enrique Garoz de Diegok eta Garazi Gorostiagak (Euskal Herria-Madril) osatutako proiektua da Gaba. Bikotea 2018an sortu zen Larraskito Klubean eta ordutik aurrera fantasiazko generoan, zientzia fikzioan, naturan eta esoterismoan oinarritutako imajinarioa zabaltzen jarraitu dute. Makineriaren fusioak eta feedbackak, drone, ambient eta musika industrialera amiltzen diren frekuentzien hartzaile, igorle eta sortzaile gisa balio dio bikote honi. Garazi Gorostiaga konpositorea, soinu-artista eta musika-ekoizlea da. Bitarteko analogikoak (sintetizadoreak, sekuentziadoreak, objektu metalikoak…) zein digitalak (dawak) erabiltzen ditu bere piezak sortzeko, eta bere tresna gogokoenetako batzuk dira landa-grabazioak zuzenean manipulatzea eta sintesi granularra. Kike Kaos (Madril, 1979) underground-ean duela bi hamarkada baino gehiagotik errotutako musikaria. Balbulen sintetizadoreekiko eta beste ekipo analogiko batzuekiko zuen grinak musikari izatera eraman zuen. +info gehiago hemen: https://garazigorostiaga.bandcamp.com; https://www.facebook.com/TubeTentacles

PATRICIA ETXEGARAI (iruñea, exhibition & artwork) Lesaka, 1995. Arte Ederrak ikasi zituen Madrilen eta Bilbon. LAV Masterraren IX. edizioa egin zuen LAVen: Sorkuntza eta praktika garaikideko ikus-entzunezko laborategia. Bere lanak erakutsi ditu Madrilgo Cinetecan, Bideodromoan eta Bilboko MEM jaialdian, baita gune autogestionatuetan ere, hala nola Sestaoko Txirbilenean eta Iruñeko La Zurdan. Marrazkilari gisa parte hartu du animaziozko film laburretan Hauazkena taldearekin. Arte garaikidean eta marrazketan lan egin duen heinean, gero eta zinema gehiago behar du forma plastiko berriekin kontatu eta ulertzeko. Sexualitatea, ahultasuna, indarkeria, landa-ingurunea eta ezbeharraren barruko edertasuna dira erabiltzen dituen kontzeptuetako batzuk. +info: http://katana.eus [prozesuan]

KAMPAI&ZARATAFES presentan el AVUMDULUV festival de musika y ruidillos

con

PHLGZ ( phlegeton vortex , madrid , abstract technoise , phlgz.bandcamp.com )

KATZA ( bilbo , hypnotist ambient , soundcloud.com/ktz )

MYRIAM RZM & CAMILLE ÉMAILLE ( dima & mercantour , percussion & body ruidism , myriamrzm.bandcamp.com & camilleemaille.com )

DOPELGANGER ( miguel a. garcía & garazi navas , gasteiz & usansolo , lateral electroacoustics w/ accordion , youtu.be/KSEjTwO4vVE )

GABA ( enrique garoz de diego & garazi gorostiaga , madrid & galdakao , cosmic horror sounds , gabasonic.wixsite.com/gaba )

PATRICIA ETXEGARAI ( pamplona , exhibition & artwork )

será el VIERNES 4 de AGOSTO de 2023 en KAMPAI ESPAZIOA ( moncada kalea 5 , 3º , errekalde , BILBAO ) a las 19:00 ( abrimos puertas a la 18:30 )

entrada por 7€

colaboran espora&mem

PHLGZ ( phlegeton vortex , madrid , abstract technoise , https://phlgz.bandcamp.com ) PHLGZ es el proyecto de música electrónica de J.L. Rey aka Phlegeton, donde fusiona elementos del dark techno más cyberpunk, el IDM glitcheado y rave en crudo, salpicados con brochazos de noise. Desde su trinchera de experimentación, crea paisajes sonoros perturbadores y envolventes, donde las capas de sonido se superponen y entrelazan en un caos controlado, evocando el pulso hipnótico de una pista de baile en una civilización distópica. Con más de 20 años de experiencia en la industria musical, Phlegeton ha lanzado numerosos álbumes con distintas formaciones musicales como Wormed, Lifelost o Utsik, y ha llevado su música a escenarios en Europa, América y Asia. Tambien es ilustrador digital, brindando una visión artística única a través de sus portadas de álbumes y gráficos para numerosas bandas de metal extremo internacionales. +infos en: https://linktr.ee/Phlegeton

KATZA ( bilbo , hypnotist ambient , https://soundcloud.com/ktz ) Katza, co-fundador de PARALELOAN, es un DJ afincado en Bilbao que lleva media vida explorando los márgenes de la música. Aunque hoy en día muchos lo relacionen con la música de baile, comenzó tocando en grupos de punk de muy joven y eso es algo que se nota en sus selecciones. Apoyandose tanto en musica de club contemporanea, como en el post-punk, dub o las rarezas más DIY, Katza valora ante todo la inmediatez, la urgencia y la emoción en los sonidos que selecciona.

MYRIAM RZM & CAMILLE ÉMAILLE ( dima & mercantour , percussion & body ruidism , https://myriamrzm.bandcamp.com & https://camilleemaille.com ) Myriam Rzm (Dima 1975). Creadora, performer, experimentadora sonora. Desarrollada en escena con el dúo Gora Japón, el dúo abierto Magmadam y mediante colaboraciones con artistas transdisciplinares. Actualmente desarrolla "Ruido Proto_Ritual", un directo basado en la improvisación con herramientas sonoras autofabricadas DIY/DIT, adaptadas a sus inquietudes sonoro-performativas, combinadas con pedales de fx y feedback, en acción/interacción con el propio cuerpo en movimiento. +cosas en: https://abymenabar.bandcamp.com ; https://crystalmine.bandcamp.com/album/aizu

Camille Émaille cree que un solo de percusión no es realmente un solo. Porque los objetos emiten sonidos por sí mismos y siempre están estimulando ideas. De ahí que ya se haya escrito c��mo las actuaciones de Émaille son, al mismo tiempo, "una arquitectura a la vez precaria y espectacular que conecta, una dramaturgia tenue y tensa que toca, un cuerpo a cuerpo grácil y animal con una materia sonora que ella amasa o desencadena". La relación orgánica que Émaille busca y establece con el sonido de cada objeto musical le hace construir también sus propios instrumentos y comprender que la improvisación, como flujo en permanente relación con lo cotidiano, se nutre de lo que ya existe a su alrededor.

DOPELGANGER ( miguel a. garcía & garazi navas , gasteiz & usansolo , lateral electroacoustics w/ accordion , https://youtu.be/KSEjTwO4vVE ) Dopelganger es el dúo de Miguel A. García (electrónica, composición) y Garazi Navas (acordeón, voz). Composiciones densas, híbridos imposibles entre la música electrónica experimental y la opera contemporáneo-expresionista, encuentro y potenciación de mundos en apariencia antagónicos hacia rincones inexplorados, sin temor a lo desconocido ni a la intensidad tanto sensorial como emocional. Garazi Navas es una inquieta acordeonista graduada en Musikene (Centro Superior de Música del País Vasco) que, a pesar de su juventud, ha participado en multitud de proyectos interpretando música contemporánea, clásica, tradicional y de otros estilos. Miguel A. García (aka Xedh), es un artista residente en Bilbao que trabaja en el campo de la música experimental y el arte sonoro. Tanto en solitario como en diferentes grupos, ha actuado por un montón de paises y ha colaborado con decenas de artistas en estudio y en directo, apareciendo en más de un centenar de discos.

GABA ( enrique garoz de diego & garazi gorostiaga , madrid & galdakao , cosmic horror sounds , https://gabasonic.wixsite.com/gaba ) Gaba es el proyecto formado por Enrique Garoz de Diego y Garazi Gorostiaga (Euskal Herria - Madrid). El dúo se inicia en el Club Larraskito en 2018 y desde entonces continúan expandiendo su imaginario basado en el género literario fantástico, la ciencia ficción, la naturaleza y el esoterismo. La fusión y retroalimentación de su maquinaria, sirve a este dúo como herramienta receptora, emisora y generadora de frecuencias que se precipitan al drone, al ambient y la música industrial. Garazi Gorostiaga es compositora, artista sonora y productora musical. Utiliza medios tanto analógicos (sintetizadores, secuenciadores, objetos metálicos….) como digitales (daws) para crear sus piezas, siendo algunas de sus herramientas favoritas la manipulación de grabaciones de campo en directo y la síntesis granular. Kike Kaos (Madrid, 1979) escritor maldito y músico arraigado en el underground desde hace más dos décadas. Su pasión por los sintetizadores de válvulas y otros equipos analógicos le llevó a ser un músico maldito también. +cosas en: https://garazigorostiaga.bandcamp.com ; https://www.facebook.com/TubeTentacles

PATRICIA ETXEGARAI ( pamplona , exhibition & artwork ) Lesaka, 1995. Cursa Bellas Artes en Madrid y en Bilbo. Realiza la IX edición de Máster LAV en LAV: Laboratorio audiovisual de creación y práctica contemporánea. Ha mostrado trabajos en Cineteca de Madrid, Bideodromo y Festival MEM de Bilbao, y espacios autogestionados como Txirbilenea de Sestao o La Zurda en Iruña. Ha participado como dibujante en cortometrajes de animación con el grupo Hauazkena. A medida que ha ido trabajando en arte contemporáneo y dibujo, va cada vez necesitando más del cine para poder contar y hacerse entender con nuevas formas plásticas. La sexualidad, la vulnerabilidad, la violencia, el entorno rural y la belleza dentro de lo siniestro son algunos de los conceptos que maneja. +info: http://katana.eus [en proceso]

#zarata #zaratafest #xedh #garazi navas #MYRIAM RZM #dopelganger #katza #gaba #PHLGZ #PATRICIA ETXEGARAI #bilbo #kampai #espora #mem #CAMILLE ÉMAILLE

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juniperpublishersanesthesia · 5 years ago

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Tourniquet Pain after Ultrasound-Guided Axillary Blockade-Juniper Publishers

Abstract

Objective: To analyse tourniquet pain after ultrasound guided axillary block (AXB) as the sole anesthetic technique with no injection of local anaesthetic into the subcutaneous tissue of the posterior half of the axilla to prevent tourniquet pain.

Material/patients and methods: 84 patients older than 18 years ASA I-IV undergoing surgery at hand, wrist, forearm and elbow under ultrasound guided AXB requiring upper arm tourniquet, we studied prospectively. Exclusion criteria included refusal to participate, communication problems, pre-existing neuropathy, coagulopathy or allergy to local anaesthetics. Tourniquet pain was assessed according to visual analogue scale (VAS) every 15 minutes. We also analysed differences in tourniquet pain between sedated and non-sedated patients.

Main results: VAS was 0 during ischemia in 83 patients. One patient reported tourniquet pain. This was mild (VAS = 3) and reported during the first 15 minutes of ischemia. VAS dropped to 0 from then on. The median ischemia time was 62 minutes (IQR 45-86) and the median surgery time was 60 minutes (IQR 40-89.5). Intraoperative sedation was administered to 48.8% of patients. Sedated and non-sedated groups were similar. No statistical differences were found regarding tourniquet pain between both groups (p< 0.05).

Conclusion: Ultrasound guided AXB is sufficient to provide anaesthesia for tourniquet even during prolonged ischemia. However, to ensure prevention of tourniquet discomfort a multiple injection technique that include musculocutaneous blockade should be preferred.

Keywords: Tourniquet pain; Axillary block; Ultrasound-guided peripheral nerve block; Upper limb surgery; Sedation

Background

Regional anaesthesia holds potential advantages when compared to general anaesthesia. Particularly, brachial plexus blockade has demonstrated superior analgesia, reduction of opioid-related side effects and opioid consumption during the first 24 hours after surgery [1]. The axillary blockade (AXB) provides anaesthesia for upper extremity surgery of the elbow, forearm, wrist, and hand [2,3]. It has been shown as effective as supraclavicular (SCB) and infraclavicular (ICB) blocks [4] but its distal location from pleura and phrenic nerve eliminates some of the risks related to those more proximal approaches [5,6].

Ultrasound guidance allows direct observation of nerves, surrounding structures and local anaesthetic (LA) spread. Its use decreases complications and onset time [7,8], improves quality [8] and reduces the volume of LA required [9]. Due to the superficial location of the brachial plexus in the axilla, ultrasound guided AXB provides excellent visibility of both nerves and needle.

The intercostobrachial nerve (T2) is not part of the brachial plexus. It communicates with the medial brachial cutaneous nerve (C8-T1) providing innervation to the skin of the axilla and the medial and posterior aspect of the arm. The block of these nerves to prevent tourniquet pain is widely extended and has been traditionally recommended using an injection of LA into the subcutaneous tissue of the posterior half of the axilla ("semicircular subcutaneous anaesthesia" or "ring block") [1014]. However, its importance in reducing tourniquet pain has never been established and is questioned [2,15,16]. The aim of this study was to assess tourniquet pain after ultrasound guided AXB as the sole anaesthetic technique. Due to the fact that intraoperative sedation could underestimate tourniquet pain, further analyses comparing tourniquet pain in sedated and nonsedated patients were also carried out.

Material and Methods

A prospective observational study of tourniquet pain on patients who received an ultrasound guided AXB was conducted over a four month period (January- May 2013) at Galdakao- Usansolo Hospital. The study was classified as service evaluation and no ethical approval was needed as required no alteration to the routine standard of care, there was no therapeutic or equipment intervention, and no planned change to anaesthetic technique. Written consent from patients was obtained. Inclusion criteria were patients undergoing surgery at or below the elbow under ultrasound guided AXB requiring upper arm tourniquet, age >18 years and ASA (American Society of Anaesthesiologists) status I-IV. Exclusion criteria were refusal to be included, communication problems or inability to cooperate, pre-existing neuropathy, coagulopathy or allergy to LA.

After patient arrival to theatre an intravenous catheter was placed in the upper limb contralateral to the surgical site and ASA standard monitoring were applied. Ultrasound guided AXB were performed by either consultants with expertise in regional anaesthesia or residents supervised by those consultant. A portable ultrasound machine (Sonosite M-Turbo®) and high frequency linear probe was used. Administration of premedication or intraoperative sedation was left to the discretion of the treating anaesthesiologist. The ultrasound probe was applied in the axilla to obtain a short-axis view of the axillary artery. The four terminal nerves (median, ulnar, radial and musculocutaneous nerve) were sought out and their identity confirmed by scanning distally along the arm following the characteristic course that each nerve takes. A 22 gauge needle (Braun Stimuplex D) was used to surround each individual nerve with LA after skin infiltration with lidocaine 1% (Figure 1). The AXB approach (in plane or out of plane) and the type and amount of LA was decided by the anaesthetist who performed the block.

AA: Axillary Artery; RN: Radial Nerve; UN: Ulnar Nerve; MN: Median Nerve; MsN: Musculocutaneous nerve; Conjoint tendon of the latissimus dorsi and teres major

Once the block was finished, a pneumatic tourniquet was applied to all patients on the mid-upper arm over a single wrap of cotton wool padding. The limb was exsanguinated using an Esmarch bandage and the tourniquet cuff inflated between 250- 300mmHg.

The variables collected included age, gender, weigh, ASA status, type of surgery, premedication administered, type and amount of local anaesthetic used to surround each nerve, time between the end of the block and the tourniquet inflation, pressure of the tourniquet, ischemia and surgery time, intraoperative sedation and tourniquet pain. The primary objective was to analyse tourniquet pain assessed according to a 0-10cm visual analogue scale (VAS), whereby '0' represents no pain and '10' represents the worst imaginable pain. Tourniquet pain was measured directly after the tourniquet was inflated and thereafter every 15 minutes (min) until the tourniquet was deflated. VAS evaluations were conducted by the same person who performed the block. As a second objective we analysed differences in tourniquet pain between intraoperative sedated and non-sedated patients.

Statistical analysis

Descriptive analysis of socio-demographic and clinical variables was made by using frequencies and percentages for categorical variables and means and standard deviations for continuous variables. The exception being variables with a high level of deviation. These were represented by median and interquartile range. The differences between sedated and non-sedated patient were evaluated using the Chi-square test (or Fisher exact test when expected values<5) for categorical variables and non-parametric Wilcoxon test for continuous variables. All effects were considered significant at p<0.05. All statistical analyses were performed using SAS for Windows statistical software, version 9.2 (SAS Institute, Inc., Carey, NC).

Results

Over the four month period 84 patients were recruited.Patient characteristics and type of surgery are summarized in Table 1. All patients received premedication prior to the block. Intraoperative sedation was administered to 48.8% of patients. Sedatives used to sedate patients during surgery were propofol and midazolam but one patient received 50 mcg of fentanyl (Table 2). Mepivacaine 1.5% were the LA of choice to surround the four nerves in all patients. Occasionally Ropivacaine 0.2% or Levobupicaine 0.25% were added to provide longer analgesia. The mean total volume of LA used was 34.37±5.37 ml (Figure 2).

The median time since the block was finished until the cuff was inflated was 10min (IQR 5-15). The median surgery time was 60 min (IQR 40-89.5) and the median ischemia time was 62min (IQR 45-86) (Table 3).

Among 84 patients included, 83 scored tourniquet pain as VAS = 0cm during the time tourniquet was inflated. One of these patients complained about pain in the surgery field without pain on the tourniquet site after 180min of surgery and had to undergo general anaesthesia. In this case, a 30min reperfusion period was used after 135min of ischemia and the total ischemia time with the patient awake was 150 min. One patient reported tourniquet pain. In this patient VAS was 3 cm when the cuff was inflated and in the following 15 minutes. He was administered 50mg of fentanyl and 20mg of propofol respectively. Since then VAS reminded 0cm until the tourniquet was deflated 31 minutes later. No more sedatives were administered.

Sedated and non-sedated groups were similar in demographic variables, ASA status, premedication administrated, type of surgery, type and amount of LA used, time of ischemia and surgery and tourniquet pressure. No statistical differences (p< 0.05) were found regarding tourniquet pain between both groups (Table 4).

ASA: American Society of Anaesthesiologists; AXB: Axillary Block; VAS: Visual Analogue Scale;

Results shown as number of patients (%). *mean ± standard deviation (SD). †Median [Interquartile range = p25-p75]. NA = Not applicable. --- = Unknown.

Discussion

Tourniquets are commonly used in upper limb procedures to improve visualisation, reduce bleeding and expedite surgical procedures. Despite its advantages, tourniquet might associate injury that usually involves nerve or other soft tissues and is often complicated by the development of tourniquet pain [17]. Contrary to the old belief that a dermal component represents one of the major causes of tourniquet-related pain, ischemia and compression have been identified as the main sources of noxious stimuli during the maintenance of tourniquet inflation [18-21]. Due to these findings, there is progressively more belief that during AXB a tourniquet is well tolerable without requiring additional dermal anaesthesia [15,16]. Similarly, popliteal blockade is sufficient for tourniquet on the caff with no need of femoral or saphenous block [22]. It is important to highlight the importance of achieving a "complete" AXB [23]. Pain associated to tourniquet has been showed to be significantly reduced when a multiple injection AXB technique is used [24]. S. Sia et al. [25] comparing a triple injection AXB technique (blockade of median, musculocutaneous and radial nerves) and a "selective" approach in which only the nerves involved in surgery were blocked, reported a significant increase of patient requesting intraoperative administration of fentanyl for tourniquet pain in the "selective" group.

Despite the numerous anatomical variations of the four main nerves at the axilla, median, ulnar and radial nerves they all lie very close to the axillary artery [25]. Due to this proximity, the injection of a determinate amount of LA to block one of them could cause blockage of the others. By contrast, musculocutaneous nerve lies far lateral to the axillary artery, in the fascial plane between biceps brachii and coracobrachialis muscle. It innervates the muscles in the anterior compartment of the arm - the coracobrachialis, biceps brachii and the brachialis. To achieve its block the needle has to be redirected but its blockade is essential to prevent tourniquet pain [26]. We identified the four nerves by scanning distally along the arm and observing the nerve tracing. They were surrounded by LA independently. Among 84 patients, 83 reported "no pain" [27]. Only one patient complained about tourniquet discomfort (VAS= 3cm) during the first 15 minutes but VAS dropped to 0 cm from then on. This is more likely to be attributed to a block in progress than to a real need of additional blocks. Time between block finished and cuff inflation was just 3 min in this patient whereas, Tran DQ, et al. [28] concluded that the mean onset time is 18.9 minutes when using 4 injections AXB and lidocaine 1.5% with epinephrine 5mcg/ml.

The use of sedation in regional anaesthesia has been shown to increase patient satisfaction and can also modify pain perception [28,29]. However, there were no differences in tourniquet pain between intraoperative sedated and nonsedated patients in our study.

Tourniquet pain has been related to the duration of inflation [18]. Five of our patients had ischemia for more than 120min but none of them complained about tourniquet pain. JP Estebe et al. [30], reported a tourniquet pain tolerance of approximately 2030 minutes in volunteers. Tolerance was defined in that study when VAS was > 6cm or when volunteers decided their pain tolerance limit was reached. In daily practice, letting patients reach either points is unacceptable. Patients on the operating table suffering a painful experience could lead to anxiety, patient movement and unsuccessful surgery. Therefore if a tourniquet is required for surgery, associated pain should always be prevented and treated.

Fitzgibbons PG et al. [31] carried out a review regarding safe tourniquet use recommended tourniquet pressure of 250mmHg for less than 150min in the upper extremity. We used tourniquet pressure slightly higher and only one patient exceeded a total ischemia time of 150min, however a reperfusion time was used on this patient. Although higher pressures and longer ischemia times than the ones recommended have not demonstrated increased complication [32], tourniquet-related injury resulting from excessive tourniquet inflation pressure or prolonged ischemic time were not an objective of our study and were not followed up. Some of the limitations of this study included a relatively small number of patients, observational methodology and nonrandomized design. Test of sensory and motor blockade were not recorded, but no incomplete blocks were reported. No blinded observer data was collected. Ultrasound guided AXB alone provides enough anaesthesia to cover tourniquet-related pain even during prolonged ischemia. Use of additional dermal blocks are not required, however a multiple injection AXB technique that ensures musculocutaneous blockade should be performed.

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#Tourniquet pain #Axillary block #Upper limb surgery #Sedation

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