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Hoerner E, Stundner O, Putz G, Steinfeldt T, Mathis S, Gasteiger L. Crystallization of ropivacaine and bupivacaine when mixed with different adjuvants: a semiquantitative light microscopy analysis. Reg Anesth Pain Med 2022; 47:rapm-2022-103610. [PMID: 35738668 DOI: 10.1136/rapm-2022-103610] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2022] [Accepted: 06/13/2022] [Indexed: 11/03/2022]
Abstract
INTRODUCTION Amino-amide local anesthetics precipitate when mixed with some commonly used adjuvants, carrying the risk of perineural or vascular crystal deposition. The aim of this study was to evaluate whether crystallization occurs with routinely used local anesthetic-adjuvant combinations and if a relation with the solution's pH exists. METHODS All substances used in this trial were first visually investigated undiluted under tenfold magnification. Grade of crystallization was assessed using a 6 point grading system.Ropivacaine (0.2%, 0.75% and 1%) and bupivacaine (0.25% and 0.5%) were mixed in a 1:1 solution with the following adjuvants: dexamethasone, dexmedetomidine, clonidine, fentanyl, sodium bicarbonate 8.4% and sodium chloride 0.9%. Subsequently, ropivacaine (0.2% and 0.75%) and bupivacaine (0.25% and 0.5%) were mixed with adjuvants in concentrations commonly used in clinical practice and then serially assessed at several time points up to 1 hour. pH of all substances/combinations was assessed and correlated with crystallization grade. RESULTS All pure substances-except the reference standards sterile water and triamcinolon-showed crystallization grades ranging from grade 1 to grade 4. Addition of adjuvants lead to variable, unpredictable changes in crystal depositions. Addition of sodium bicarbonate 8.4% produced heavy crystallization in all combinations. Grade of crystallization was weakly positively related to the pH of the solution in 1:1 mixtures and clinically relevant concentrations, but not in pure substances. DISCUSSION Our study showed that crystallization is present in pure local anesthetics and may be increased or decreased by admixture of adjuvants. Higher pH of mixtures was weakly associated with more crystallization. Further research is necessary to translate these findings into clinical practice.
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Affiliation(s)
- Elisabeth Hoerner
- Department of Anesthesiology and Intensive Care, Medical University of Innsbruck, Innsbruck, Austria
| | - Ottokar Stundner
- Department of Anesthesiology and Intensive Care, Medical University of Innsbruck, Innsbruck, Austria
- Department of Anesthesiology, Perioperative Medicine and Intensive Care Medicine, Paracelsus Medical University, Salzburg, Austria
| | - Guenther Putz
- Department of Anesthesiology and Intensive Care, Medical University of Innsbruck, Innsbruck, Austria
| | - Thorsten Steinfeldt
- Department of Anesthesiology, Intensive Care and Pain Medicine, BG Unfallklinik Frankfurt am Main, Frankfurt am Main, Hessen, Germany
| | - Simon Mathis
- Department of Anesthesiology and Intensive Care, Medical University of Innsbruck, Innsbruck, Austria
| | - Lukas Gasteiger
- Department of Anesthesiology and Intensive Care, Medical University of Innsbruck, Innsbruck, Austria
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Schäfer M, Mousa SA, Shaqura M, Tafelski S. [Background and current use of adjuvants for regional anesthesia : From research to evidence-based patient treatment]. Anaesthesist 2019; 68:3-14. [PMID: 30645692 DOI: 10.1007/s00101-018-0522-6] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
The discovery of the local anaesthetic effect by blocking sodium ion channels was a milestone in anaesthesia but was soon limited by sometimes life-threatening toxic effects of the local anaesthetics. By developing novel local anaesthetics and also by adding so-called adjuvants, attempts have been made to limit these life-threatening events. This article focuses on the historic background and the current state of the use of these adjuvants for regional anaesthesia. Adding epinephrine, clonidine or dexmedetomidine, but only as a single dose, results in a faster onset, longer duration of action and increased intensity of neuronal blockade of regional anaesthesia. The benefits of adding sodium bicarbonate, on the other hand, are relatively minor and, therefore, clinically negligible. Although increasing evidence in the literature suggests an improvement and prolongation of the analgesic effect after axonal administration of opioids, which can also be given continuously, systemic effects are not fully ruled out due to the increased incidence of central side effects. The partial local anaesthetic effects of opioids cannot always be distinguished from opioid receptor-specific effects. Mechanistic studies postulate a functional coupling of opioid receptors in injured rather than in intact peripheral nerves. Recent studies have identified glucocorticoid and mineralocorticoid receptors predominantly on peripheral nociceptive nerve fibers. This is consistent with numerous clinical reports of a marked prolongation of the local anaesthetic effect. In addition to the known genomic effects of steroids that occur via a change in gene expression of pain-sustaining protein structures, faster non-genomic effects are also discussed, which occur via a change in intracellular signaling pathways. In summary, new insights into mechanisms and novel results from clinical trials will help the anaesthesiologist in the decision to use adjuvants for regional anaesthesia which, however, requires to weigh the individual patient's benefits against the risks.
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Affiliation(s)
- M Schäfer
- Klinik für Anästhesiologie mit S. op. Intensivmedizin, Charité - Universitätsmedizin Berlin, Campus Virchow-Klinikum, Berlin, Deutschland.
| | - S A Mousa
- Klinik für Anästhesiologie mit S. op. Intensivmedizin, Charité - Universitätsmedizin Berlin, Campus Virchow-Klinikum, Berlin, Deutschland
| | - M Shaqura
- Klinik für Anästhesiologie mit S. op. Intensivmedizin, Charité - Universitätsmedizin Berlin, Campus Virchow-Klinikum, Berlin, Deutschland
| | - S Tafelski
- Klinik für Anästhesiologie mit S. op. Intensivmedizin, Charité - Universitätsmedizin Berlin, Campus Virchow-Klinikum, Berlin, Deutschland
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Hwang H, Park J, Lee WK, Lee WH, Leigh JH, Lee JJ, Chung SG, Lim C, Park SJ, Kim K. Crystallization of Local Anesthetics When Mixed With Corticosteroid Solutions. Ann Rehabil Med 2016; 40:21-7. [PMID: 26949665 PMCID: PMC4775754 DOI: 10.5535/arm.2016.40.1.21] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2015] [Accepted: 07/20/2015] [Indexed: 12/03/2022] Open
Abstract
Objective To evaluate at which pH level various local anesthetics precipitate, and to confirm which combination of corticosteroid and local anesthetic crystallizes. Methods Each of ropivacaine-HCl, bupivacaine-HCl, and lidocaine-HCl was mixed with 4 different concentrations of NaOH solutions. Also, each of the three local anesthetics was mixed with the same volume of 3 corticosteroid solutions (triamcinolone acetonide, dexamethasone sodium phosphate, and betamethasone sodium phosphate). Precipitation of the local anesthetics (or not) was observed, by the naked eye and by microscope. The pH of each solution and the size of the precipitated crystal were measured. Results Alkalinized with NaOH to a certain value of pH, local anesthetics precipitated (ropivacaine pH 6.9, bupivacaine pH 7.7, and lidocaine pH 12.9). Precipitation was observed as a cloudy appearance by the naked eye and as the aggregation of small particles (<10 µm) by microscope. The amount of particles and aggregation increased with increased pH. Mixed with betamethasone sodium phosphate, ropivacaine was precipitated in the form of numerous large crystals (>300 µm, pH 7.5). Ropivacaine with dexamethasone sodium phosphate also precipitated, but it was only observable by microscope (a few crystals of 10–100 µm, pH 7.0). Bupivacaine with betamethasone sodium phosphate formed precipitates of non-aggregated smaller particles (<10 µm, pH 7.7). Lidocaine mixed with corticosteroids did not precipitate. Conclusion Ropivacaine and bupivacaine can precipitate by alkalinization at a physiological pH, and therefore also produce crystals at a physiological pH when they are mixed with betamethasone sodium phosphate. Thus, the potential risk should be noted for their use in interventions, such as epidural steroid injections.
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Affiliation(s)
- Hyeoncheol Hwang
- Department of Rehabilitation Medicine, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Korea
| | - Jihong Park
- Department of Rehabilitation Medicine, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Korea
| | - Won Kyung Lee
- Department of Rehabilitation Medicine, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Korea
| | - Woo Hyung Lee
- Department of Rehabilitation Medicine, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Korea
| | - Ja-Ho Leigh
- Department of Rehabilitation Medicine, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Korea
| | - Jin Joo Lee
- Department of Rehabilitation Medicine, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Korea
| | - Sun G Chung
- Department of Rehabilitation Medicine, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Korea
| | - Chaiyoung Lim
- Department of Rehabilitation Medicine, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Korea
| | - Sang Jun Park
- Department of Rehabilitation Medicine, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Korea
| | - Keewon Kim
- Department of Rehabilitation Medicine, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Korea
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Best CA, Best AA, Best TJ, Hamilton DA. Buffered lidocaine and bupivacaine mixture - the ideal local anesthetic solution? Plast Surg (Oakv) 2015; 23:87-90. [PMID: 26090348 DOI: 10.4172/plastic-surgery.1000913] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Abstract
The use of injectable local anesthetic solutions to facilitate pain-free surgery is an integral component of many procedures performed by the plastic surgeon. In many instances, a solution that has both rapid onset and prolonged duration of analgesia is optimal. A combination of lidocaine and bupivacaine, plain or with epinephrine, is readily available in most Canadian health care settings where such procedures are performed, and fulfills these criteria. However, commercially available solutions of both medications are acidic and cause a burning sensation on injection. Buffering to neutral pH with sodium bicarbonate is a practical method to mitigate the burning sensation, and has the added benefit of increasing the fraction of nonionized lipid soluble drug available. The authors report on the proportions of the three drugs to yield a neutral pH, and the results of an initial survey regarding the use of the combined solution with epinephrine in hand surgery.
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Affiliation(s)
- Corliss A Best
- Northern Ontario School of Medicine, Sault Ste Marie, Ontario
| | - Alyssa A Best
- London School of Economics and Political Science, London, United Kingdom
| | - Timothy J Best
- Northern Ontario School of Medicine, Sault Ste Marie, Ontario
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Krasznai AG, Sigterman TA, Willems CE, Dekkers P, Snoeijs MGJ, Wittens CHA, Sikkink CJ, Bouwman LH. Prospective study of a single treatment strategy for local tumescent anesthesia in Muller phlebectomy. Ann Vasc Surg 2015; 29:586-93. [PMID: 25595104 DOI: 10.1016/j.avsg.2014.10.028] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2014] [Revised: 10/23/2014] [Accepted: 10/23/2014] [Indexed: 10/24/2022]
Abstract
BACKGROUND Ambulatory Muller phlebectomy for varicose veins can be performed under local anesthesia. However, subcutaneous injection of local tumescent anesthetics may cause discomfort because of acidity of the solution. Addition of sodium bicarbonate lowers the acidity of anesthetic solutions, which might cause less pain. The objective of this study was to study whether alkalinization of the local anesthetic solution with sodium bicarbonate 1.4% decreases perioperative pain during Muller phlebectomies. METHODS It is a double-blind single-center randomized controlled trial. In all, 101 patients scheduled for ambulatory Muller phlebectomy were randomized to receive either local anesthesia with alkalinized solution (lidocaine 1% and epinephrine in sodium bicarbonate 1.4%) or standard solution (lidocaine 1% and epinephrine in saline 0.9%). Primary outcome was pain during injection of local anesthetics with the use of the Visual Analogue Scale (VAS). Secondary outcomes were peroperative and postoperative pain, use of analgesics, patient satisfaction, return to function, and complications. RESULTS Patients receiving subcutaneous injection of local anesthetics diluted in sodium bicarbonate 1.4% experienced significantly less pain during injection compared with patients treated with standard anesthetic solution (VAS, 1.75 ± 1.8 vs. 3.55 ± 2.2, P < 0.00). Peroperative and postoperative pain, complication rates, use of analgesics, patient satisfaction, return to function, and complications did not differ between the 2 groups (P > 0.10). CONCLUSIONS Alkalinization of local anesthetic solution with sodium bicarbonate 1.4% significantly improves patient comfort during injection of local tumescent anesthesia.
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Affiliation(s)
- Attila G Krasznai
- Department of Surgery, Atrium Medical Centre, Heerlen, The Netherlands
| | - Tim A Sigterman
- Department of Surgery, Atrium Medical Centre, Heerlen, The Netherlands.
| | | | - Peter Dekkers
- Department of Pharmacy, Atrium Medical Centre, Heerlen, The Netherlands
| | | | - Cees H A Wittens
- Department of Surgery, MUMC, Maastricht, The Netherlands; Department of Surgery, Uniklinik Aachen, Aachen, Germany
| | - Cees-Jan Sikkink
- Department of Surgery, Atrium Medical Centre, Heerlen, The Netherlands
| | - Lee H Bouwman
- Department of Surgery, Atrium Medical Centre, Heerlen, The Netherlands
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Gupta S, Mandlik G, Padhye MN, Kini YK, Kakkar S, Hire AV. Combating inadequate anesthesia in periapical infections, with sodium bicarbonate: a clinical double blind study. Oral Maxillofac Surg 2014; 18:325-329. [PMID: 23740399 DOI: 10.1007/s10006-013-0418-1] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2013] [Accepted: 05/15/2013] [Indexed: 06/02/2023]
Abstract
INTRODUCTION Local anesthetics are generally much less effective when administered in inflamed tissues. PURPOSE This study was conducted to validate the addition of sodium bicarbonate in local anesthetics to increase its effectiveness as local infiltrations in teeth associated with periapical infections. METHODS Two hundred subjects requiring extraction of maxillary teeth with periapical infections were enrolled. These subjects were divided in two groups of 100 subjects each. One group received local infiltration with 2 % lignocaine and 1:80,000 adrenaline, and the other group received local infiltration with sodium bicarbonate as an adjunct to the above mentioned local anesthetic solution. All extractions were performed using a consistent intra-alveolar technique by a single operator. Both the patient and the operator were blinded to the contents of local anesthetic solution. Data related to the onset of action of local anesthesia, pain experienced by the patient while undergoing extraction on two scales-"the visual analog scale and the verbal response scale", and any requirement of repeated injections during the procedure was recorded. RESULTS Clinical and statistical data confirmed that the addition of sodium bicarbonate in local anesthetics did increase the efficacy of local anesthesia in inflamed tissues. CONCLUSION It has been observed in this study that the action of sodium bicarbonate in local anesthetics increases the pH levels of these solutions, thus possibly making them more effective in an acidic environment.
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Affiliation(s)
- Savina Gupta
- Padmashree Dr D Y Patil Dental College, Navi Mumbai, Maharashtra, India,
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Foley PL, Ulery BD, Kan HM, Burks MV, Cui Z, Wu Q, Nair LS, Laurencin CT. A chitosan thermogel for delivery of ropivacaine in regional musculoskeletal anesthesia. Biomaterials 2013; 34:2539-46. [DOI: 10.1016/j.biomaterials.2012.12.035] [Citation(s) in RCA: 47] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2012] [Accepted: 12/29/2012] [Indexed: 10/27/2022]
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Welch MN, Czyz CN, Kalwerisky K, Holck DEE, Mihora LD. Double-blind, bilateral pain comparison with simultaneous injection of 2% lidocaine versus buffered 2% lidocaine for periocular anesthesia. Ophthalmology 2012; 119:2048-52. [PMID: 22771049 DOI: 10.1016/j.ophtha.2012.05.029] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2011] [Revised: 05/09/2012] [Accepted: 05/09/2012] [Indexed: 11/18/2022] Open
Abstract
PURPOSE Determine if raising the pH of 2% lidocaine with epinephrine 1:100 000 to a physiologic level decreases pain perception during periocular, subcutaneous anesthesia. DESIGN Double-blind, prospective, randomized study. Simultaneous unilateral injections of buffered and unbuffered lidocaine solutions were given before surgery to patients having bilateral, periocular surgery. PARTICIPANTS Fifty-four consecutive patients (27 male and 27 female; mean age, 68 years; standard deviation, 11 years). INTERVENTION Patients were given simultaneous injections of buffered and unbuffered 2% lidocaine with epinephrine 1:100 000. The needles were inserted simultaneously and the anesthesia was injected for a 20-second count for a total volume of 1.0 ml per injected side. MAIN OUTCOME MEASURES After the simultaneous injections, the patients were asked to rate the pain on each side on a Likert-type visual analog scale of 0 to 10. RESULTS Sixty-five percent of patients preferred the buffered lidocaine with a scaled pain reduction of 0.9 (P = 0.0005). Additionally, for the patients who believed that the buffered solution was less painful, the mean decrease in scaled pain rating was 2, for a 51% reduction in pain level (P = 0.001). No gender differences were noted. CONCLUSIONS Buffering 2% lidocaine with epinephrine 1:100 000 with sodium bicarbonate 8.4% offers a clinically and statistically significant reduction in pain experienced by two-thirds of patients receiving periocular subcutaneous anesthesia.
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Affiliation(s)
- Mark N Welch
- Department of Ophthalmology, Dwight David Eisenhower Army Medical Center, Augusta, Georgia, USA.
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Kashyap VM, Desai R, Reddy PB, Menon S. Effect of alkalinisation of lignocaine for intraoral nerve block on pain during injection, and speed of onset of anaesthesia. Br J Oral Maxillofac Surg 2011; 49:e72-5. [DOI: 10.1016/j.bjoms.2011.04.068] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2010] [Accepted: 04/13/2011] [Indexed: 10/18/2022]
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Han DW, Koo BN, Choi SH, Lee JS, Shin YS, Sharma M, Kim KJ. Neutralized rocuronium (pH 7.4) before administration prevents injection pain in awake patients: a randomized prospective trial. J Clin Anesth 2007; 19:418-23. [PMID: 17967669 DOI: 10.1016/j.jclinane.2007.02.012] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2006] [Revised: 02/11/2007] [Accepted: 02/28/2007] [Indexed: 10/22/2022]
Abstract
STUDY OBJECTIVE To determine (1) the amount of 8.4% sodium bicarbonate (NaHCO(3)) to adjust the pH of rocuronium to 7.4 (neutralization), (2) to show whether neutralizing the pH of rocuronium can prevent pain, and (3) to confirm that rocuronium mixed with NaHCO(3) does not change the physical property and efficacy of rocuronium. DESIGN Prospective studies. SETTING University medical center. PATIENTS 180 ASA physical status I and II women patients undergoing elective gynecologic surgery. INTERVENTIONS AND MEASUREMENTS 60 patients were randomly allocated to group 1 (rocuronium only), group 2 (rocuronium 50 mg mixed with 0.9% NaCl 3 mL), and group 3 (rocuronium 50 mg mixed with 8.4% NaHCO(3) 3 mL). All patients received mixtures equal to 0.04 mg/kg of rocuronium and were asked to evaluate their pain with visual analog scale (VAS) and pain scores. In other settings, the onset time and duration of action of each group of rocuronium were measured. The dose of rocuronium required to produce a 50% twitch depression (ED(50)) was calculated. MAIN RESULTS The amount of 8.4% NaHCO(3) needed to neutralize 50 mg of rocuronium was 3.1 +/- 0.3 mL. VAS scores were lower in group 3 than in groups 1 or 2 (P < 0.05). There were no differences in onset time, duration of action, or ED(50) values among the groups. CONCLUSIONS Rocuronium neutralized with NaHCO(3) prevents intravenous injection pain. The physical and pharmacologic properties of rocuronium mixed with NaHCO(3) immediately before administration are not altered.
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Affiliation(s)
- Dong Woo Han
- Department of Anesthesiology and Pain Medicine, Anesthesia and Pain Research Institute, Yonsei University College of Medicine, CPO Box 8044, Seoul 120-752, Korea
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Ball EL, Sanjay P, Woodward A. Comparison of buffered and unbuffered local anaesthesia for inguinal hernia repair: a prospective study. Hernia 2006; 10:175-8. [PMID: 16424994 DOI: 10.1007/s10029-005-0058-y] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2005] [Accepted: 11/30/2005] [Indexed: 11/29/2022]
Abstract
Bicarbonate buffered local anaesthetic solutions are known to reduce the pain of infiltration. However, its efficacy in reducing the pain of infiltration in patients undergoing inguinal hernia repair has never been tested. This study aims to test the efficacy of bicarbonate buffered solution in reducing the pain of infiltration and pain for the total surgical procedure in a series of patients undergoing elective inguinal hernia repair. Forty consecutive male patients with unilateral, reducible inguinal hernias were studied prospectively. All patients underwent surgery under local anaesthesia, the first 20 with unbuffered solution and the next 20 using buffered solution. Pain scores were obtained for the infiltration in the anaesthetic room and for the total surgical procedure. In addition, satisfaction scores were obtained at the end of the procedure. The mean pain score for the initial infiltration of unbuffered anaesthetic was 3.00 (range 0-5), and for the buffered anaesthetic it was 1.45 (range 0-4), P=0.02. The mean pain score for the entire procedure for the unbuffered group was 3.05 (range 0-6), and for the buffered group it was 1.45 (range 0-5), P=0.02. The patient satisfaction rate was higher with the buffered solution compared to unbuffered solution (P<0.05). There were no complications reported with either solution. Buffered local anaesthetic solution significantly reduces the perceived pain of inguinal hernia repair, both during the infiltration and during the procedure itself. It is safe to administer and it results in a high rate of patient satisfaction.
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Affiliation(s)
- E L Ball
- Royal Glamorgan Hospital, Llantrisant, Wales, UK
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Abstract
The provision of sedation and analgesia is an integral aspect of the care of PICU patients. A careful systems approach to the provision of sedation and analgesia can minimize complications and maximize benefit to patients. Vigilance in monitoring and adherence to published guidelines are important for safety. Physicians must define the goals in clearly devising a plan and tailor the prescription to those goals rather than use a regimented protocol for all patients.
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Affiliation(s)
- D M Polaner
- Department of Anesthesia, University of Colorado School of Medicine, Children's Hospital, Denver, Colorado, USA.
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