Evaluation of a new cutaneous topical anesthesia preparation

Topical anesthetic agents are usually not effective on intact skin because of poor penetration. EMLA is a new topical anesthetic formulation consisting of a eutectic mixture of the local anesthetics lidocaine 5% and prilocaine 5%. We evaluated the ability of this preparation to prevent or ameliorate the pain associated with the percutaneous placement of large IV catheters. Under double-blind randomized conditions, either EMLA or placebo was applied to the dorsum of both hands and an occlusive bandage then placed over each application site. The creams were placed 30, 45 or 60 minutes prior to IV cannulation. A 16-gauge catheter was inserted through each application area. Patients were asked to evaluate the relative degree of pain at each venous puncture site. The EMLA site was preferred when the formulation was applied for 45 to 60 minutes prior to cannula placement (p less than 0.01, confidence limits for the binomial distribution). Cusum analysis confirmed this minimal effective application time. The results indicate that EMLA is an effective cutaneous anesthetic formulation when applied with an occlusive bandage for a minimal time period of 45 minutes.

Dilation of the stump of the esophagus and intestine with Doyen's intestinal clamp followed by application of lidocaine facilitates the stapling anastomoses

To avoid bowel tears on the esophagojejunal or colorectal mechanical anastomoses during insertion of the EEA stapler, we applied a local anesthetic to the stump of the bowel, then gently dilated the bowel with Doyen's intestinal clamp. This approach makes way for use of a larger cartridge and a more satisfactory anastomoses.

Separation of cough and reflex bronchoconstriction by inhaled local anaesthetics

Cough and airway constriction are common features of respiratory diseases. Both can be caused by stimulation of airway nerves. We have studied the effects of airway anaesthesia on these reflexes, stimulated by inhaled capsaicin, in order to determine whether they are controlled by the same sensory nerves. Ten volunteers had capsaicin cough dose responses performed before and at 10 min after inhaling placebo (ascorbic acid in saline), and the topical anaesthetics lignocaine 40 mg, and dyclonine 8 and 4 mg. The effect of the drugs on respiratory resistance (Rrs), measured using a forced oscillation technique, was measured both before and after the inhalation of a dose of capsaicin which caused less than two coughs. Lignocaine (40 mg) and dyclonine (8 mg) caused significant reports of oral anaesthesia but only lignocaine reduced the cough response to inhaled capsaicin, increasing the log dose of capsaicin causing three or more coughs by 162%. None of the treatments altered basal Rrs or its increase after inhaled capsaicin. Thus, the cough and reflex bronchoconstriction caused by inhaled capsaicin have different sensitivities to inhaled local anaesthesia, suggesting that the effect may be mediated by different sensory pathways.

Forty-eight single-shot epidural injections on the same patient

A patient is described who has received 48 single-shot epidurals with plain lignocaine. No complications were encountered at any time. Nuclear magnetic resonance imaging confirmed that no dural damage had occurred.

Ventilatory effects of laparoscopy under epidural anesthesia

This study evaluates the respiratory effects of laparoscopy under epidural anesthesia in seven female patients (ASA physical status I) scheduled for a gamete intrafallopian transfer procedure. Epidural anesthesia was performed with 15-18 mL of 1.5% plain lidocaine using a catheter inserted at the L3-4 level. The upper level of analgesia to pinprick was measured 20 min after lidocaine injection. Ventilatory measurements and arterial blood gas analyses were performed (a) preoperatively, in the horizontal supine position with a T7-9 level of analgesia; (b) in the 20 degrees Trendelenburg position with a T2-5 level of analgesia; (c) during intraabdominal insufflation of CO2 through the laparoscope; and (d) after CO2 exsufflation by manual compression of the abdomen before removal of the laparoscope while in the horizontal position. On-line measurements of VO2, VCO2, VE, VT, F, and PETCO2 were made using a Beckman metabolic cart, while the patients breathed room air through an anesthetic face mask. No significant changes in the ventilatory variables were observed in the Trendelenburg position. In contrast, CO2 insufflation significantly increased VE (from 9.1 +/- 1.0 L/min to 11.8 +/- 2.6 L/min, mean +/- SD), and F (from 16.9 +/- 1.9 breaths/min to 23.1 +/- 3.3 breaths/min, mean +/- SD), whereas VCO2 remained unchanged. PaCO2 remained constant throughout the study. These results suggest that epidural anesthesia may be a safe alternative to general anesthesia for outpatient laparoscopy, as it is not associated with ventilatory depression.

Application of the tumescent technique to hand augmentation

The harvesting of fat for autologous implantation into the hands via the tumescent technique is presented. The tumescent technique, which involves the administration of large volumes of dilute local anesthetic into the donor site, results in low serum concentrations of anesthetic and produces long-lasting anesthesia while providing vasoconstriction and a firmness of the subcutaneous compartment ideal for lipoextraction. The tumescent technique has proven to be an important advance in reduction liposuction surgery. We describe our experience with the tumescent technique as applied to microlipoinjection for hand augmentation of aged and sun-damaged skin.

Outpatient minilaparotomy sterilization with local anesthesia

Three hundred fifty-eight patients underwent interval sterilization by minilaparotomy under local anesthesia and intravenous sedation between December 1984 and October 1987 at the University of Miami Family Planning Center, an out-of-hospital facility. The Osathanondh uterine elevation technique was used. In three cases the operation could not be completed because of technical difficulties. Eighty-five percent of the patients had a post-operative examination. Sixty percent underwent follow-up between 24 and 48 months after surgery and 12% between 12 and 18 months. One patient became pregnant (intrauterine) one year after the operation. From this study it appears that outpatient minilaparotomy sterilization under local anesthesia is safe and effective.

Lumbosacral plexopathy following regional paracervical block anaesthesia

We report a 35 year old lady who developed lumbosacral plexopathy immediately following regional paracervical block anaesthesia for medical termination of pregnancy. There was only partial recovery at one year. The neurological deficit and its mechanisms are discussed.

Prevention of postoperative pain by balanced analgesia

Fourteen patients undergoing colorectal surgery received an intraoperative afferent neural block with combined intrathecal and extradural local anaesthetics plus a balanced postoperative low-dose regimen of extradural bupivacaine 10 mg h-1-morphine 0.2 mg h-1 and systemic piroxicam 20 mg/24 h. Postoperative pain, assessed repeatedly during the initial 48 h, was prevented during rest, mobilization from the supine to the sitting position and during walking, in all but one patient; slight pain was observed intermittently during coughing in four patients.

Influence of local anesthetic solution on postdural puncture headache

A total of 2,511 patients who received spinal anesthesia for cesarean delivery were observed for the development of postdural puncture headache (PDPH); 804 patients received a mixture of tetracaine and procaine, 942 received bupivacaine-glucose, and 765 received lidocaine-glucose. They were observed for the development of PDPH for a minimum of 72 h. PDPH occurred in 9.54% of patients who received lidocaine-glucose during the first 36 h compared with 7.64% of patients who received bupivacaine-glucose and 5.85% of patients who received tetracaine-procaine. The differences between all groups was statistically significant. No differences were found in the percentage of patients who ultimately required epidural blood patch for relief of symptoms after 36 h.

Sciatic block in lower limb surgery

A series of cases is described in which sciatic nerve block (by the lateral approach of Guiardini et al., 1985), with or without femoral nerve blockade, proved useful in the manipulation of tibial and ankle fractures without recourse to general anaesthesia. A case is presented in which this approach was the method of choice.

Alkalinization of 0.5% lidocaine for intravenous regional anesthesia

Although remaining a controversial issue, alkalinization of lidocaine or bupivacaine may shorten the time to onset and increase the duration of the sensory block. The aim of this study was to evaluate the effect of pH adjustment on the sensory and motor blocks during intravenous regional anesthesia (IVRA) with lidocaine. Thirty-one patients scheduled for minor hand surgery performed under IVRA were randomized into two groups: Group 1 (n = 14): 1% lidocaine, 3 mg/kg, diluted with the same volume of physiological saline solution (pH = 6.63 +/- 0.05), and Group 2 (n = 17): 1% lidocaine, 3 mg/kg, diluted with the same volume of 1.4% sodium bicarbonate (pH = 7.34 +/- 0.05). final concentration of lidocaine was thus 0.5% in both groups. Sensory block was assessed by pinprick every 2 minutes in areas corresponding to six terminal nerves: ulnar, median, radial, musculocutaneous, medial cutaneous nerve of arm and intercostobrachial, and medial cutaneous nerve of forearm. The time between release of tourniquet (at the end of surgery) and appearance of pain was recorded. Motor blockade was evaluated by asking the patient to squeeze strongly a blood pressure cuff previously inflated to 40 mmHg. This maneuver was performed before and every 2 minutes after injection. No statistical differences were found between the two groups whatever the parameter studied. In conclusion, there is no advantage (over plain solutions) to using pH-adjusted lidocaine during IVRA for hand surgery.

Anaesthesia of the tympanic membrane: comparison of EMLA cream and iontophoresis

The authors undertook a study to evaluate the effectiveness of two methods for providing local anaesthesia of the tympanic membrane for the purpose of inserting a grommet. The methods compared were the application of EMLA (Eutectic Mixture of Local Anaesthetics) cream and the use of iontophoresis. Both methods seem to provide a satisfactory level of local anaesthesia. It was felt that where multiple procedures were to be performed in one outpatient session the use of EMLA cream might be a more efficient technique.

A new approach to suppress bucking before extubation--lidocaine through modified endotracheal tube

The conventional endotracheal tube was modified with an epidural catheter adhered on the concave aspect of it. The opening of the catheter is at the proximal margin of the cuff. Local anesthetic can be injected into the trachea, then desensitize the tracheal mucosa nearby the cuff. Thirty-four female gynecological patients underwent abdominal total hysterectomy were studied and divided into three groups. In group 1, anesthesia was maintained without special management. In groups 2 and 3, 2 mL gentian violet stained 4% lidocaine solution was administered intratracheally by two different methods 60-120 minutes before the conclusion of the surgery. The peak cuff pressures generated by the awakening patients were 53.8 +/- 2.2 cm H2O (mean +/- SE) in group 1, 47.3 +/- 2.5 cmH2O (Group 2) and 36.4 +/- 1.6 cmH2O Group 3) respectively. Bucking before awakening was also evaluated clinically and showed 100%, 73% and 0% in each group. Intratracheal administration of lidocaine in dose of 2 mL 4% showed significant effect for the suppression of bucking during the recovery of general anesthesia in group 2 and 3 compared with the group 1. Lidocaine administered through the catheter of modified endotracheal tube also resulted in less increase in the peak cuff pressure and even no clinically observed bucking than direct administered through the endotracheal tube. Gag reflex was preserved in all patients and none had suffered from aspiration postoperatively.

Transurethral ureterorenoscopic lithotripsy and retrieval of ureteric calculi under local anaesthesia and sedation

Under strict indications, ureterorenoscopic (URS) lithotripsy was used to treat ureteric calculi in 61 patients under local anaesthesia and sedation in a 2-year period ending November 1988. Assessments of success and discomfort of the procedure were made. Stone retrieval was accomplished in 48 patients (78% success rate) and a mean pain score of 6 was recorded in a scale from 0 to 10. It was concluded that performing URS under local anaesthesia is an acceptable alternative.

A comparison of glucose-free 2% lidocaine and hyperbaric 5% lidocaine for spinal anaesthesia

Fifty patients scheduled to undergo transurethral surgery of the bladder were allocated to receive spinal anaesthesia with either glucose-free 2% lidocaine (80 mg) or hyperbaric 5% lidocaine (80 mg). Onset time, cephalad spread of analgesia, duration of analgesia, duration and intensity of motor block, quality of analgesia, and the patients' ability to walk 5 m and to micturate postoperatively were assessed. Onset and spread of analgesia were fast and comparable in the two groups. At 60 min, the median segmental level of analgesia was T9 and T10 for the 2% and the 5% group, respectively, allowing transurethral surgery to be performed for at least 1 h. In the 2% group the motor block was more pronounced and longer lasting than in the 5% group. Two patients in the 5% group needed general anaesthesia because of pain. The time from injection of the spinal anaesthetic until the patients were able to walk 5 m and to micturate was equal in the two groups, and 89% of all the patients were able to walk and micturate within 4 h. It is concluded that spinal anaesthesia with 80 mg and 2% or 5% lidocaine provides analgesia for transurethral surgery and is characterized by fast recovery of motor and detrusor function.

New technique to anesthetize the prostate for transurethral balloon dilation

Transperineal, digitally guided infiltration of 1 per cent lidocaine solution bilaterally at the base of the prostate gland provides adequate anesthesia for balloon dilation of the prostate; no additional sedation is required.

How to make your patient comfortable and tolerate an indwelling urethral catheter indefinitely

A three-way catheter with openings for local anesthetic application allows patients to tolerate urethral catheters indefinitely.