Eutectic Mixture of Lidocaine and Prilocaine Decreases Movement and Propofol Requirements for Pediatric Lumbar Puncture During Deep Sedation: A Randomized, Placebo-Controlled, Double Blind Trial

Deep sedation/general anesthesia is commonly used in pediatric oncology patients undergoing lumbar puncture (LP). Propofol is often used for sedation, with or without a narcotic. We hypothesized that eutectic mixture of lidocaine and prilocaine (EMLA) would allow for lower cumulative doses of propofol and less movement. We performed a prospective, randomized, double blind, placebo-controlled trial in children undergoing sedation for LP. Standard initial weight-based doses of propofol and fentanyl were administered, with either EMLA cream or a placebo cream applied topically. The primary outcome was the total dose of propofol administered to each patient. We also tracked patient movement and complications. Twenty-seven patients underwent 152 LPs. Patients randomized to EMLA cream (n=75) were significantly more likely to receive a lower dose of propofol (2.94 mg/kg, SE=0.25, vs. 3.22 mg/kg, SE=0.19; P=0.036) and to not require additional propofol doses (probability 0.49, SE=0.08 vs. 0.69, SE=0.06; P=0.001) compared with patients randomized to placebo cream (n=77). In addition, patients with EMLA cream were significantly less likely to demonstrate minor or major movement. EMLA cream results in less movement and less propofol administration in pediatric oncology patients undergoing sedation for LP.

Is prilocaine safe and potent enough for use in the oral surgery of medically compromised patients

Objectives:

To investigate the potency and speed of action of 2% lidocaine and 3% prilocaine for upper teeth extractions.

Methods:

This prospective clinical study was conducted from November 2016 to May 2017. Ninety-six patients, aged between 16 to 70 years old were recruited in this study. Two regimens were randomly administered over one visit. Patients, treatment group I, received 2% lidocaine with 1:00.000 adrenaline. Patients treatment group II received prilocaine 3% and felypressin 0.03 I.U. per ml. The efficacy of pulp anesthesia was determined by electronic pulp testing. At any point of trial (10 minutes), the anesthetized tooth becomes unresponsive for maximal pulp stimulation (64 reading), the extraction was carried out.

Results:

There were no significant differences in the mean onset time of pulpal anesthesia and extraction between the prilocaine and lidocaine buccal infiltration groups (p=0.28). However, clinically, the patients in prilocaine group recorded faster onset time of anesthesia and teeth extraction than those in lidocaine group.

Conclusion:

Prilocaine has a better clinical performance in terms of providing rapid dental anesthesia and earlier teeth extraction than lidocaine but the differences were not significant. Prilocaine with felypressin could be a good choice for patients who have contraindication to the use of lidocaine with adrenaline.

Is prilocaine safe and potent enough for use in the oral surgery of medically compromised patients

OBJECTIVES

To investigate the potency and speed of action of 2% lidocaine and 3% prilocaine for upper teeth extractions.

METHODS

This prospective clinical study was conducted from November 2016 to May 2017. Ninety-six patients, aged between 16 to 70 years old were recruited in this study. Two regimens were randomly administered over one visit. Patients, treatment group I, received 2% lidocaine with 1:00.000 adrenaline. Patients treatment group II received prilocaine 3% and felypressin 0.03 I.U. per ml. The efficacy of pulp anesthesia was determined by electronic pulp testing. At any point of trial (10 minutes), the anesthetized tooth becomes unresponsive for maximal pulp stimulation (64 reading), the extraction was carried out.  Results: There were no significant differences in the mean onset time of pulpal anesthesia and extraction between the prilocaine and lidocaine buccal infiltration groups (p=0.28). However, clinically, the patients in prilocaine group recorded faster onset time of anesthesia and teeth extraction than those in lidocaine group. Conclusion: Prilocaine has a better clinical performance in terms of providing rapid dental anesthesia and earlier teeth extraction than lidocaine but the differences were not significant. Prilocaine with felypressin could be a good choice for patients who have contraindication to the use of lidocaine with adrenaline.

A Randomized Clinical Trial Evaluating Rubber Dam Clamp Pain Reduction from a New Topical Liposomal Anesthetic Gel

PURPOSE

Discomfort during rubber dam clamp often occurs in pediatric dentistry. The purpose of this randomized, triple-blind, clinical trial was to evaluate the effect of pain reduction using a new topical liposomal thermo-sensitive gel (TLTG) or a placebo gel during rubber dam clamp isolation for sealants in children.

METHODS

Eighty-one children (eight to 12 years old) had LTSG or the placebo gel with random assignment placed around the gingival tissue of their permanent mandibular first molars. A clamp was placed after two minutes on the teeth, and intensity of pain was registered using a Wong-Baker FACES scale and an 11-point numerical scale. The data were evaluated using McNemar's test and Wilcoxon signed rank test.

RESULTS

The odds ratio for pain (OR equals 0.7; 95 percent confidence interval equals 0.3 to 1.8) was not statistically significant (P=0.52). However, there was a small difference in the pain intensity between liposomal and placebo groups for both scales (P<0.05).

CONCLUSION

The liposomal thermo-sensitive anesthetic gel may reduce, to a small extent, the pain intensity in children submitted to rubber dam isolation before resin sealant placement.

Anesthetic Efficacy of a Combination of 4% Prilocaine/2% Lidocaine with Epinephrine for the Inferior Alveolar Nerve Block: A Prospective, Randomized, Double-blind Study

INTRODUCTION

Prilocaine plain has a high pH and concentration (4%), which could decrease the pain of injection and increase success. The purpose of this study was to compare pain associated with anesthetic solution deposition and the degree of pulpal anesthesia obtained with the combination of prilocaine and lidocaine versus a lidocaine and lidocaine combination when used for inferior alveolar nerve blocks (IANBs).

METHODS

One hundred eighteen asymptomatic subjects were randomly given a combination of 1 cartridge of 4% prilocaine plain plus 1 cartridge of 2% lidocaine with 1:100,000 epinephrine or a combination of 2 cartridges of 2% lidocaine with 1:100,000 epinephrine for the IANB at 2 separate appointments. Subjects rated the pain associated with anesthetic solution deposition of injection. Mandibular teeth were tested with an electric pulp tester every 4 minutes for 57 minutes. Anesthesia was considered successful when 2 consecutive 80 readings were obtained within 17 minutes and the 80 reading was continuously sustained for 57 minutes. Comparisons for anesthetic success were analyzed using the exact McNemar test, and pain ratings associated with anesthetic solution deposition were analyzed using multiple Wilcoxon matched pairs signed rank tests; both were adjusted using the step-down Bonferroni method of Holm.

RESULTS

Four percent prilocaine plain was significantly less painful upon anesthetic solution deposition. Pulpal anesthetic success was not significantly different between the 2 combinations.

CONCLUSIONS

The combination of 4% prilocaine plain plus 2% lidocaine with 1:100,000 epinephrine did not increase pulpal anesthetic success for IANBs compared with a combination of 2 cartridges of 2% lidocaine with 1:100,000 epinephrine. Pain associated with anesthetic solution deposition from the first cartridge of 4% prilocaine plain was significantly less when compared with the first cartridge of 2% lidocaine with 1:100,000 epinephrine.

Effects of Extracorporeal Shock Wave-Mediated Transdermal Local Anesthetic Drug Delivery on Rat Caudal Nerves

Cavitation plays a substantial role in the clinical effects of extracorporeal shock wave therapy (ESWT). It is also generally accepted as a major mechanism in sonophoresis. To identify the enhancing effect of extracorporeal shock wave-mediated transdermal drug delivery, 24 Wistar rats were randomly assigned to four groups: (i) topical application of a eutectic mixture of local anesthetics (EMLA); (ii) 1-MHz ultrasound; (iii) ESWT pre-treatment combined with EMLA application; (iv) ESWT concurrent with EMLA application on rat tails. The degree of anesthesia was assessed using the amplitude and latency of sensory nerve action potentials within 5 min after a 60-min EMLA application. The results indicated that ESWT pre-treatment and concurrent ESWT accelerated the anesthetic effects of the EMLA cream on the tail nerve (p < 0.05). This finding might indicate that shock wave-mediated transdermal drug delivery is possible during the ESWT period.

Transient Methemoglobinemia in three Neonates due to Maternal Pudendal Anesthesia

Methemoglobin (MetHb) is a form of hemoglobin which contains iron in ferric state. The delivery of oxygen to tissues is impaired and cellular hypoxia develops with an increase in MetHb levels. Methemoglobinemia is a rare but potentially lethal complication of local anesthetics. In this clinical brief, three cases of transient neonatal methemoglobinemia, caused by maternal pudendal anesthesia with prilocaine, are reported.

Topic anaesthesia with a eutectic mixture of lidocaine/prilocaine cream after elective caesarean section: a randomised, placebo-controlled trial

PURPOSE

Aim of the study was to investigate the topical application of a eutectic mixture of lidocaine/prilocaine (EMLA^®) cream after caesarean section (CS) and its effect on postoperative pain, time to mobilisation, and time to discharge.

MATERIALS AND METHODS

A total of 189 pregnant women were enrolled; full data sets were available for 139 of them, who were prospectively randomised to receive either placebo (control group) or EMLA^® cream (study group) on the CS lesion directly as well as 24 h after surgery. Postoperative pain was assessed 24 and 48 h after surgery using the short form of the McGill Pain Questionnaire (SF-MPQ). Additional analgesic pain medication on demand was assessed in both groups.

RESULTS

A total of 62 women were allocated randomly to the study and 77 patients to the control group before primary CS. There were no statistically significant differences regarding demographic and surgical parameters comparing both collectives. In addition, the postoperative total pain scores after 24 h [McGill total: 38.5 (0-102) vs. 50 (0-120) p = 0.0889] as well as after 48 h [24 (0-79) vs. 30.5 (0-92); p = 0.1455] showed no significant differences. Furthermore, time to mobilisation (hours) [9.68 (2.18-51.38) vs. 9.47 (4.18-41.77); p = 0.5919] and time to discharge (hours) [98.6 (54.08-170.15) vs. 98.2 (43.45-195.87); p = 0.5331] were comparable.

CONCLUSION

The postoperative application of EMLA^® cream after CS did not reduce postoperative pain or time to mobilisation or discharge, so that its use in this context has to be seen critically.

Adverse effects of EMLA (lidocaine/prilocaine) cream and efficacy for the placement of jugular catheters in hospitalized cats

EMLA is a lidocaine/prilocaine cream used for topical analgesia in human pediatric patients. The purpose of this study was to establish the safety of EMLA in clinically ill cats, to measure systemic absorption and to determine whether EMLA reduced the need for sedation for the placement of jugular catheters. Thirty-one cats were randomized to either a placebo or EMLA cream group. Cream was applied to a 10 cm2 area over the jugular vein, with 1 h of occlusive dressing. Neither anesthetic was systemically absorbed in any cat, and no adverse clinical signs were observed. Struggling during catheter placement was less in the EMLA-treated cats compared to placebo, but did not reach significance ( P=0.06). Jugular catheters were successfully placed in 60% of EMLA-treated cats and 38% of placebo cats; this difference was not statistically significant and may not justify the added steps of EMLA cream administration for this purpose. However, EMLA does appear to be safe in clinically ill cats, and may be useful for other applications such as for skin mass removal or repeated venepuncture.

Breastfeeding for procedural pain in infants beyond the neonatal period

BACKGROUND

Randomised controlled trials (RCTs) show that breastfeeding newborn infants during painful procedures reduces pain. Mechanisms are considered to be multifactorial and include sucking, skin-to-skin contact, warmth, rocking, sound and smell of the mother, and possibly endogenous opiates present in the breast milk.

OBJECTIVES

To determine the effect of breastfeeding on procedural pain in infants beyond the neonatal period (first 28 days of life) up to one year of age compared to no intervention, placebo, parental holding, skin-to-skin contact, expressed breast milk, formula milk, bottle feeding, sweet-tasting solutions (e.g. sucrose or glucose), distraction, or other interventions.

SEARCH METHODS

We searched the following databases to 18 February 2016: the Cochrane Central Register of Controlled Trials (CENTRAL) (the Cochrane Library), MEDLINE including In-Process & Other Non-Indexed Citations (OVID), Embase (OVID), PsycINFO (OVID), and CINAHL (EBSCO); the metaRegister of Controlled Trials (mRCT), ClinicalTrials.gov (clinicaltrials.gov), and the World Health Organization International Clinical Trials Registry Platform (WHO ICTRP) (apps.who.int/trialsearch/) for ongoing trials.

SELECTION CRITERIA

We included RCTs and quasi-RCTs involving infants aged 28 days postnatal to 12 months and receiving breastfeeding while undergoing a painful procedure. Comparators included, but were not limited to, oral administration of water, sweet-tasting solutions, expressed breast or formula milk, no intervention, use of pacifiers, positioning, cuddling, distraction, topical anaesthetics, and skin-to-skin care. Procedures included, but were not limited to: subcutaneous or intramuscular injection, venipuncture, intravenous line insertion, heel lance, and finger lance. We applied no language restrictions.

DATA COLLECTION AND ANALYSIS

We used standard methodological procedures expected by Cochrane. Two review authors independently considered trials for inclusion in the review, assessed risk of bias, and extracted data. The main outcome measures were behavioural or physiological indicators and composite pain scores, as well as other clinically important outcomes reported by the authors of included studies. We pooled data for the most comparable outcomes and where data from at least two studies could be included. We used mean difference (MD) with 95% confidence interval (CI), employing a random-effects model for continuous outcomes measured on the same scales. For continuous outcomes measured on different scales, we pooled standardised mean differences (SMDs) and associated 95% CIs. For dichotomous outcomes, we planned to pool events between groups across studies using risk ratios (RRs) and 95% CIs. However, as insufficient studies reported dichotomous outcomes, we did not pool such events. We assessed the evidence using GRADE and created a 'Summary of findings' table.

MAIN RESULTS

We included 10 studies with a total of 1066 infants. All studies were conducted during early childhood immunisation. As the breastfeeding intervention cannot be blinded, we rated all studies as being at high risk of bias for blinding of participants and personnel. We assessed nine studies as being at low risk of bias for incomplete outcome data. In addition, we rated nine studies as high risk for blinding of outcome assessment. We scored risk of bias related to random sequence generation, allocation concealment, and selective reporting as unclear for the majority of the studies due to lack of information.Our primary outcome was pain. Breastfeeding reduced behavioural pain responses (cry time and pain scores) during vaccination compared to no treatment, oral water, and other interventions such as cuddling, oral glucose, topical anaesthetic, massage, and vapocoolant. Breastfeeding did not consistently reduce changes in physiological indicators, such as heart rate. We pooled data for duration of cry from six studies (n = 547 infants). Breastfeeding compared to water or no treatment resulted in a 38-second reduction in cry time (MD -38, 95% CI -50 to -26; P < 0.00001). The quality of the evidence according to GRADE for this outcome was moderate, as most infants were 6 months or younger, and outcomes may be different for infants during their 12-month immunisation. We pooled data for pain scores from five studies (n = 310 infants). Breastfeeding was associated with a 1.7-point reduction in standardised pain scores (SMD -1.7, 95% CI -2.2 to -1.3); we considered this evidence to be of moderate quality as data were primarily from infants younger than 6 months of age. We could pool heart rate data following injections for only two studies (n = 186); we considered this evidence to be of low quality due to insufficient data. There were no differences between breastfeeding and control (MD -3.6, -23 to 16).Four of the 10 studies had more than two study arms. Breastfeeding was more effective in reducing crying duration or pain scores during vaccination compared to: 25% dextrose and topical anaesthetic cream (EMLA), vapocoolant, maternal cuddling, and massage.No included studies reported adverse events.

AUTHORS' CONCLUSIONS

We conclude, based on the 10 studies included in this review, that breastfeeding may help reduce pain during vaccination for infants beyond the neonatal period. Breastfeeding consistently reduced behavioural responses of cry duration and composite pain scores during and following vaccinations. However, there was no evidence that breastfeeding had an effect on physiological responses. No studies included in this review involved populations of hospitalised infants undergoing other skin-breaking procedures. Although it may be possible to extrapolate the review results to this population, further studies of efficacy, feasibility, and acceptability in this population are warranted.

Effect of Topical Anesthesia with Lidocaine-prilocaine (EMLA) Cream and Local Pressure on Pain during Infiltration Injection for Maxillary Canines: A Randomized Double-blind clinical trial

OBJECTIVES

This study compared the effect of local pressure and topical lidocaine-prilocaine (EMLA) cream on pain during infiltration injection for maxillary canine teeth.

MATERIALS AND METHODS

A total of 140 volunteer students participated in this split-mouth design randomized clinical trial. The subjects were randomly divided into four groups (n = 35). Before administration of anesthesia, in each group, one side was randomly selected as the experimental and the opposite side as the control. In group 1, finger pressure was applied on the alveolar mucosa on the experimental side and on the tooth crown on the control side. In group 2, 5% EMLA cream and placebo; in group 3, finger pressure and 5% EMLA cream; and in group 4, 5% EMLA cream and 20% benzocaine gel were applied. In all the groups, a buccal infiltration procedure was carried out. Pain during injection was recorded with visual analog scale (VAS). Wilcoxon and McNemar tests were used for statistical analysis of the results. Statistical significance was set at p < 0.05.

RESULTS

The results showed that EMLA reduced the injection pain significantly more than benzocaine (p = 0.02). Also, injection pain was significantly lower with the use of EMLA in comparison to placebo (p = 0.00). Application of local pressure reduced the injection pain, but the difference from the control side was not significant (p = 0.05). Furthermore, the difference between application of local pressure and EMLA was not statistically significant (p = 0.08).

CONCLUSION

Topical anesthesia of 5% EMLA was more effective than 20% benzocaine in reducing pain severity during infiltration injection. However, it was not significantly different in comparison to the application of local pressure.

An Investigation into Dental Local Anaesthesia Teaching in United Kingdom Dental Schools

AIM

To review the current teaching of the use and administration of local anaesthesia in United Kingdom dental schools, along with their local guidelines and protocols.

METHODS

A qualitative and quantitative questionnaire was sent to sixteen UK dental schools to probe the methods of local anaesthetic teaching within each school.

RESULTS

14 of the 16 schools replied and the responses show a variety of practices being taught in the dental schools. 2% Lidocaine 1:80,000 Adrenaline is the first choice local anaesthetic solution for the majority of clinical situations.

CONCLUSION

2% Lidocaine with 1:80,000 Adrenaline remains the gold standard dental local anaesthetic with teaching about its safety and uses in all but a few situations. Most are taught the use of additional aids such as safety syringes and topical anaesthesia. There is variation with regards to the use of alternative anaesthetic agents.

Procedural pain management in the treatment of scleroderma digital ulcers

OBJECTIVES

Digital ulcers (DU) may develop in half of systemic sclerosis (SSc) patients; they are often resistant to treatments. Deep wound debridement is crucial for DU healing, but very difficult to carry out without adequate procedural pain management. Here, we report the results of our experience on procedural pain management in scleroderma DU.

METHODS

The study included 51 DU observed in 32 consecutive SSc patients; procedural pain was treated following a definite schedule: local lidocaine and prilocaine (25 mg of either agent per gram of cream, EMLA 5%) were initially used in all cases, followed by local and oral morphine, according to the severity of pain scored on a 10 cm visual analogue scale (VAS).

RESULTS

At baseline, higher pain VAS was recorded in more severe (p=0.0001) and/or infected DU (p=0.0001). Good compliance to DU debridement was observed in patients with mild pain (VAS ≤4) treated with only EMLA, and in 5 cases with moderate-severe pain (VAS >4) at baseline. While, the majority of DU with moderate-severe pain (34/39) needed a combined therapy with EMLA and local morphine (8/34) or with EMLA, local and oral morphine (26/34). On the whole, pain management during DU debridement required only EMLA application in 33% of cases, EMLA plus local morphine in 16%, while combined EMLA, local and oral morphine were necessary in 51%, generally with more severe and/or infected lesions.

CONCLUSIONS

The present study showed valuable control of procedural pain during DU debridement with sequential, combined analgesic treatment.

An uncommon side effect in a common procedure: a case report of an adverse reaction to prilocaine during a Bier's block

This case report describes a rare side effect during a Bier's block. During local anaesthetic injection, the patient suffered a sudden onset painful petechial rash localised to the upper limb, distal to the tourniquet, without systemic effect. After deflation of the tourniquet, the pain resolved and no systemic effects were seen. The skin changes settled without treatment over one week. The discussion summarises standard technique and precautions required for a Bier's block. It also evaluates risks and complications.

Coating solid dispersions on microneedles via a molten dip-coating method: development and in vitro evaluation for transdermal delivery of a water-insoluble drug

This study demonstrates for the first time the ability to coat solid dispersions on microneedles as a means to deliver water-insoluble drugs through the skin. Polyethylene glycol (PEG) was selected as the hydrophilic matrix, and lidocaine base was selected as the model hydrophobic drug to create the solid dispersion. First, thermal characterization and viscosity measurements of the PEG-lidocaine mixture at different mass fractions were performed. The results show that lidocaine can remain stable at temperatures up to ∼130°C and that viscosity of the PEG-lidocaine molten solution increases as the mass fraction of lidocaine decreases. Differential scanning calorimetry demonstrated that at lidocaine mass fraction less than or equal to 50%, lidocaine is well dispersed in the PEG-lidocaine mixture. Uniform coatings were obtained on microneedle surfaces. In vitro dissolution studies in porcine skin showed that microneedles coated with PEG-lidocaine dispersions resulted in significantly higher delivery of lidocaine in just 3 min compared with 1 h topical application of 0.15 g EMLA®, a commercial lidocaine-prilocaine cream. In conclusion, the molten coating process we introduce here offers a practical approach to coat water-insoluble drugs on microneedles for transdermal delivery.

The use of skin needling for the delivery of a eutectic mixture of local anesthetics

AIM

The use of skin needling is believed to aid the transdermal delivery of drugs, even if it is mostly used for skin collagen induction. The aim of this paper was to use skin needling, combined with a local anesthetic EMLA (eutectic mixture of lidocaine and prilocaine), as a way to enhance transdermal drug penetration and optimize the analgesic effects of common local anesthesia.

METHODS

We recruited 15 patients. For each patient of our study we defined a skin area of 3 cm2 from two forearms: on one side, we used skin needling first and immediately thereafter applied the EMLA in occlusion for 60 minutes; on the other one, we only applied EMLA in occlusion for 60 minutes. Then, pain was induced in each patient's forearm by introducing a 27 G needle into the skin 4 mm deep three times. Lastly, pain sensation measures were registered and a middle value was calculated.

RESULTS

When skin needling is used in conjunction with EMLA applied in occlusion for 60 minutes on skin forearms, the level of pain sensation registered was significantly reduced on a Visual Analogue Scale compared to the application of EMLA alone.

CONCLUSION

The use of skin needling can improve the transdermal delivery of an emulsion-like eutectic mixture of local anesthetics (EMLA) and can introduce the use of this method for delivering topical molecules in dermatology.

Risk of systemic toxicity with topical lidocaine/prilocaine: a review

The eutectic mixture of lidocaine and prilocaine (EMLA, APP Pharmaceuticals, LLC.) is an anesthetic cream frequently used by dermatologists. Although side effects of EMLA are usually mild local skin reactions (ie, edema, pallor, erythema), more severe complications can be encountered including methemoglobinemia, central nervous system toxicity, and cardiotoxicity. This article reviewed the literature regarding risk of systemic toxicity associated with use of EMLA in the pediatric and adult population. All 12 clinical trials evaluating the safety of EMLA in either the pediatric or adult population generally followed dosing and administration guidelines set by the manufacturer and reported clinically insignificant plasma levels of methemoglobin, lidocaine, prilocaine, and their respective metabolites. To date, nine pediatric cases and three adult cases of systemic toxicity associated with EMLA have been published. Possible factors that contributed to the development of systemic toxicity include excessive amount of EMLA, large application area, prolonged application time, diseased and/or inflamed skin (eg, vascular malformations, molluscum contagiosum, eczema, previously abraded skin), age less than 3 months, prematurity, and concomitant use of a methemoglobin-inducing agent. Recommendations are provided on how to safely use EMLA to minimize the risk of systemic toxicity.

Methemoglobinemia induced by lidocaine-prilocaine cream

With growing awareness of the importance of pain control in all procedures, the use of lidocaine-prilocaine cream (EMLA) for all ages is increasing. Lidocaine-prilocaine cream has been implicated as a cause of methemoglobinemia. Diagnostic clues may be oxygen-resistant cyanosis and an oxygen "saturation gap" between arterial blood saturation and pulse oximetry. Treatment with intravenous methylene blue is often effective. Since EMLA is often mistakenly considered risk-free it is routinely applied by medical staff in the emergency room. Subsequent to the case of EMLA-induced methemoglobinemia in an 8 year old girl we wish to alert the medical community to this phenomenon, and in this work review the relevant literature.

Comparison of clinical effects of prilocaine, dexamethasone added to prilocaine and levobupivacaine on brachial plexus block

OBJECTIVE

To determine whether the addition of 8 mg dexamethasone to axillary brachial plexus block would prolong the duration of sensory and motor block in patients undergoing hand and forearm surgery.

METHODS

The prospective, randomised, double-blinded study was conducted at the Eskisehir Osmangazi University Medical School, Turkey, from October 2008 to December 2009. It comprised 45 American Society of Anaesthesiologists grade I and II patients under elective surgery of the hand and forearm. The patients were randomly divided into 3 groups: 5 mg/kg of 2% prilocaine was applied to Group 1; 5 mg/kg of 2% prilocaine +8mg of dexamethasone (2 ml) was applied to Group 2; and 1.5 mg/kg 0.5% levobupivacaine was applied to Group 3. Sensory and motor block onset time as well as the duration of motor and sensory block of those were monitored and recorded. SPSS 15 was used for statistical analysis.

RESULTS

Of the 45 patients, 27 (60%) were men and 18 (40%) were women. There was no significant difference among the groups in terms of demographic data. Based on the duration of motor and sensory block, similar periods of time in Group 1 and Group 2 were noted, whereas this period was statistically different and significantly longer in Group 3 (p < or = 0.001). There were no complications encountered.

CONCLUSION

The addition of dexamethasone to prilocaine prolonged the duration of sensory and motor block. It could be used as an effective adjuvant agent. Levobupivacain could be a more appropriate local anaesthetic in postoperative analgesia and prolonged surgical procedures.

WITHDRAWN: EMLA and Amethocaine for reduction of children's pain associated with needle insertion

An update of this review was initiated by Janice A Lander1 and Barbara Brady‐Fryer2 in 2011, who proposed changing the title to "Three topical anaesthetics for reduction of children's pain associated with venipuncture and intravenous cannulation". At 23 May 2013, The Cochrane Pain, Palliative and Supportive Care Review Group (PaPaS) withdrew this review as the authors were no longer available to complete the update.

1Faculty of Nursing, University of Alberta, Edmonton, Canada
 2Bachelor of Science in Nursing Program, Grant MacEwan University, Faculty of Health Sciences, Health and Community Studies, Edmonton, Canada

The editorial group responsible for this previously published document have withdrawn it from publication.

Topical anesthetics for cosmetic dermatologic procedures

AIM

The aim of our study is to value the vasoconstrictor effect of two most utilized topical anesthetics, the first one containing a mixture 2.5% lidocaine and 2.5% prilocaine and the second one containing 4% liposomal lidocaine, in the treatment of vascular lesion during cosmetic dermatologic procedures.

METHODS

Ten healthy volunteers were enrolled in our department. They showed telangiectasias, measuring between 0.5 and 1 millimeter in diameter on their face and limbs. Five volunteers were randomized to receive topical 4% liposomal lidocaine and five to receive 2.5% lidocaine and 2.5% prilocaine. In all treated areas, the 4% liposomal lidocaine was left for at least 30 minutes and the 2.5% lidocaine and 2.5% prilocaine was left for at least 60 minutes.

RESULTS

Clinically, the volunteers who received the 4% liposomal lidocaine showed minimal vasoconstrictor difference between before and after treatment; while the others who received the 2.5% lidocaine and 2.5% prilocaine showed a major vasoconstrictor effect. Furthermore the 4% liposomal lidocaine cream has the advantage of an anesthetic effect after 30 minutes, rather than 60 minutes for the 2.5% lidocaine and 2.5% prilocaine cream.

CONCLUSION

This study demonstrated that the 4% liposomal lidocaine has relatively minor vasoconstrictor effect when compared to the other anesthetic, and it shows how this type of anesthetic allows a clear vision of the lesion during the dermatologic procedures. Furthermore, this cream achieves an anesthetic effect in 30 minutes rather than the 60 minutes required for the other cream, making the first one more suitable for cosmetic dermatologic procedures and for the emergency.

Effectiveness of nitrous oxide for postpartum perineal repair: a randomised controlled trial

OBJECTIVE

To compare the effectiveness of self-administered 50% nitrous oxide and conventional infiltrative anaesthesia with 1% prilocaine hydrochloride in postpartum perineal repair.

STUDY DESIGN

A total of 100 women were prospectively enrolled and randomised to receive either infiltrative anaesthesia or a self-administered nitrous oxide mixture (Livopan(©)) for pain relief during postpartum perineal suturing. Besides data concerning anaesthesia, characteristics of patients and labour were documented for statistical analysis. Pain experienced during perineal repair was assessed using the short form of the McGill Pain Questionnaire (SF-MPQ).

RESULTS

Forty-eight women received nitrous oxide and 52 underwent perineal suturing after infiltrative anaesthesia. There were no statistically significant differences regarding maternal age, body mass index (BMI), duration of pregnancy and suturing time between the groups. The most frequent birth injury was second-degree perineal laceration in the study group [22/48; 46%] and episiotomy in the control group [18/52; 35%]. Pain experienced during genital tract suturing and patients' satisfaction showed no statistically significant differences between the groups. Thirty-seven women in the study group and 47 in the control group were satisfied with the anaesthesia during perineal repair and would recommend it to other parturients [37/48, 77% vs. 47/52, 90%; p=0.0699).

CONCLUSION

Nitrous oxide self-administration during genital tract suturing after vaginal childbirth is a satisfactory and effective alternative to infiltrative anaesthesia.

[Efficient treatment of breakthrough pain in adults: the importance of timing and medication choice]

Diagnostic or therapeutic procedures can lead to breakthrough pain. Thanks to a wise choice of analgesic medication started in due time, this type of pain can be avoided or decreased. The therapeutic options of this preventive approach are presented according to the expected breakthrough pain type and intensity. Specific situations are presented through case discussions. The main pharmacokinetic information needed to prescribe the right analgesic at the right time is summarized in a convenient table. When associated to non-pharmacological measures such as empathy, patient positioning and high quality procedures, preventive analgesia provides patients the best possible relief from breakthrough pain.

Analgesia for infants' circumcision

Male circumcision (MC) is one of the oldest and most common operations performed all over the world. It can be performed at different ages, using different surgical techniques, for different religious, cultural and medical reasons.Our aim is to examine and compare the various methods of analgesia and different surgical procedures reported in literature that are applied in infant MC. We performed a PubMed, MEDLINE, EMBASE and Cochrane search in the papers published since 2000: 14 studies met the inclusion criteria, most of them showing that a combined pharmacological and non-pharmacological intervention is the best analgesic option, in particular when the dorsal penile nerve block is combined with other treatments. The Mogen surgical procedure seems to be the less painful surgical intervention, when compared with Gomco clamp or PlastiBell device. Only 3 papers studied groups of at least 20 babies each with the use of validated pain scales. Data show a dramatic decrease of pain with dorsal penile nerve block, plus acetaminophen associated to oral sucrose or topic analgesic cream. However, no procedure has been found to definetively eliminate pain; the gold standard procedure to make MC totally painfree has not yet been established.

An alternative local anaesthesia technique to reduce pain in paediatric patients during needle insertion

AIM

Pain control, which is necessary during most dental procedures, is administered by injecting a local anaesthetic. Because the injection itself can be painful, the procedure via which pain is reduced warrants continued investigation. Only a few studies regarding the reaction of children to dental needle insertion without the use of topical anaesthetics have been reported. This study was conducted to evaluate the efficacy of the local anaesthetic procedure without topical application as compared to the conventional insertion technique for alleviating pain in children receiving local anaesthesia injections.

MATERIALS AND METHODS

For the alternative injection procedure, the dentist quickly and gently pulled or pushed the clean and dried loose tissue at the injection site over the tip of the needle to a depth of 1 to 1.5 mm. When the end of the bevel of the needle tip entered the tissue, a few drops of solution were released, after which the needle was advanced to its proper and intended depth to continue anaesthetic release.

RESULTS

There was a significant difference regarding the pain response between the alternative insertion technique (less painful) and the conventional one according to Sound, Eye, and Motor (SEM) scale ratings (P < 0.000). No significant difference was observed in the response between the maxilla and mandible, nor between boys and girls, between the conventional and alternative techniques.

CONCLUSION

This alternative technique can reduce discomfort in paediatric dental patients and allow the clinician to administer a superficial local anaesthesia injection before the needle is advanced into deeper tissue. This technique is simple, quick, devoid of additional costs, and potentially more effective than the conventional needle insertion method.

A prospective randomized trial comparing three different analgesic techniques for pain control during transrectal ultrasound guided prostate biopsy: a single center experience

AIM

The aim of this paper was to optimize pain control during transrectal ultrasound (TRUS) guided prostate biopsy, the efficacy and safety of three different analgesic techniques were compared.

METHODS

Two hundred and forty patients were prospectively randomized into 3 groups before TRUS guided prostate biopsy. Group A received combined periprostatic nerve block (PPNB) and perianal-intrarectal lidocaine-prilocaine (PILP) cream; group B: PILP cream; group C: PPNB. Pain was evaluated using 10-point Visual Analog Scale (VAS).

RESULTS

VAS during TRUS was lower in groups A and B vs. C (mean 1.3,1.4 vs. 5.1, P<0.001); VAS for PPNB was lower in group A and group B vs. C (mean 1.1,1.3 vs. 3.5, P<0.001). VAS for sampling wase lower in group A as compared to B and C (mean 0.6, 3.5 and 1.4, P<0.001). VAS on stratified analysis was significantly lower in groupA vs. B and C in patients <60 years, prostate >50 cc and those with lower anorectal compliance (P<0.001). The overall complication rate was similar in all three groups.

CONCLUSION

The combination of PILP and PPNB provides better analgesia, especially in patients <60 years, prostate volume >50 cc and lower anorectal compliance as compared to two modalities used alone during the sampling part of TRUS guided prostate biopsy with no increase in the complication rate.

The effect of acromioclavicular joint degeneration on orthopedic shoulder tests

OBJECTIVES

This study aims to investigate the effect of acromioclavicular joint (ACJ) degeneration on orthopedic shoulder tests (OST) and to determine complementary role of ACJ injections in the treatment of subacromial shoulder impingements.

PATIENTS AND METHODS

At a secondary care center, 62 patients (56 females, 6 males; mean age 55.8±9.3 years; range 35 to 74 years) with the clinical and radiological diagnosis of shoulder impingement syndrome were enrolled to the study. Two injections were applied to ACJ and subacromial space. Patients were assessed through OSTs (Neer, Hawkins-Kennedy, empty can, full can, external rotation resistance, lift-off and cross-body adduction tests) at baseline and after injection to ACJ and subacromial space. Visual analog scale was used for overall pain.

RESULTS

Two injections and three sets of OSTs were performed on the patients. A significant difference was found in the all OSTs after ACJ injection (p<0.001). Visual analog scale scores improved significantly following both ACJ and subacromial injections (p<0.001).

CONCLUSION

Concomitant ACJ diseases should assessed carefully in the patients with rotator cuff lesions, as it may change the type of management approach.

[Methaemoglobinaemia after using EMLA cream]

BACKGROUND

The use of creams is considered to be generally safe. However, systemic side effects can occur.

CASE DESCRIPTION

A 22-year-old woman came to the emergency department with dyspnea, confusion and 'blue' skin after laser treatment of the upper legs for excessive hair. She had used three tubes of a eutectic mixture of local anaesthetics (EMLA) cream containing lidocaine/prilocaine for analgesia. Her oxygen saturation was 87%, measured with pulse oximetry. Blood gas analysis showed a concentration of oxy-Hb of 79% and a met-Hb of 19%. Our working diagnosis was methaemoglobinaemia as a result of using excessive amounts of EMLA cream. Because the met-Hb concentration decreased spontaneously and the oxy-Hb concentration consequently normalised, we did not administer methylene blue. The patient was discharged symptom-free after several hours of observation.

CONCLUSION

An overdose of EMLA cream, whether or not in combination with laser-induced skin damage, can produce a high systemic o-toluidine concentration. This can lead to methaemoglobinaemia. In such cases, the pulse oximeter is not reliable for measuring the oxygen saturation; therefore, blood gas analysis is necessary for making a diagnosis.

Topical agents or dressings for pain in venous leg ulcers

BACKGROUND

Venous leg ulcers affect up to 1% of people at some time in their lives and are often painful. The main treatments are compression bandages and dressings. Topical treatments to reduce pain during and between dressing changes are sometimes used.

OBJECTIVES

To determine the effects of topical agents or dressings for pain in venous leg ulcers.

SEARCH METHODS

For this third update the following databases were searched: Cochrane Wounds Group Specialised Register (searched 9 May 2012); The Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2012, Issue 4); Ovid MEDLINE (2009 to April Week 4 2012); Ovid MEDLINE (In-Process & Other Non-Indexed Citations May 08, 2012); Ovid EMBASE (2009 to 2012 Week 18); and EBSCO CINAHL (2009 to May 2 2012). No date or language restrictions were applied.

SELECTION CRITERIA

Published or unpublished randomised controlled trials (RCTs) that evaluated the effects of topical agents or dressing for the treatment of pain in venous ulcers were included.

DATA COLLECTION AND ANALYSIS

Two review authors independently performed trial selection, data extraction and risk of bias assessment.

MAIN RESULTS

Six trials (343 participants) evaluated Eutectic Mixture of Local Anaesthetics (EMLA): lidocaine-prilocaine cream for the pain associated with ulcer debridement. The between-group difference in pain measured on a 100 mm scale was statistically significant in favour of EMLA (MD -20.65, 95% CI -12.19 to -29.11). No significant between-group differences in burning or itching were observed.Two trials (470 participants with venous leg ulcers) evaluated ibuprofen slow-release foam dressings for persistent venous leg ulcer pain. Compared with local best practice, significantly more participants in the ibuprofen dressing group achieved the outcome of >50% of the total maximum pain relief score between day 1 and day 5 than participants in the local best practice group (RR 1.63, 95% CI 1.24 to 2.15). The number needed to treat was 6 (95% CI 4 to 12). In the second trial, compared with an identical non-ibuprofen foam dressing, there was no statistically significant difference in the proportion of participants experiencing slight to complete pain relief on the first evening of treatment.Limited data were available to assess healing rates or adverse events.

AUTHORS' CONCLUSIONS

There is some evidence to suggest that ibuprofen dressings may offer pain relief to people with painful venous leg ulcers. EMLA (5%) appears to provide effective pain relief during the debridement of venous leg ulcers. Further research should consider standardised pain assessment methods and assess both the effect on ulcer healing and the impact of long term use of these treatments.

Permanent nerve damage from inferior alveolar nerve blocks: a current update

Permanent nerve involvement has been reported following inferior alveolar nerve blocks. This study provides an update on cases reported to one unit in the preceding six years. Lidocaine was associated with 25 percent of cases, articaine with 33 percent of cases, and prilocaine with 34 percent of cases. It does appear that inferior alveolar nerve blocks can cause permanent nerve damage with any local anesthetic, but the incidences may vary.

Evaluation of EMLA cream for preventing pain during tattooing of rabbits: changes in physiological, behavioural and facial expression responses

BACKGROUND

Ear tattooing is a routine procedure performed on laboratory, commercial and companion rabbits for the purpose of identification. Although this procedure is potentially painful, it is usually performed without the provision of analgesia, so compromising animal welfare. Furthermore, current means to assess pain in rabbits are poor and more reliable methods are required. The objectives of this study were to assess the physiological and behavioural effects of ear tattooing on rabbits, evaluate the analgesic efficacy of topical local anaesthetic cream application prior to this procedure, and to develop a scale to assess pain in rabbits based on changes in facial expression.

METHODOLOGY/PRINCIPAL FINDINGS

In a crossover study, eight New Zealand White rabbits each underwent four different treatments of actual or sham ear tattooing, with and without prior application of a topical local anaesthetic (lidocaine/prilocaine). Changes in immediate behaviour, heart rate, arterial blood pressure, serum corticosterone concentrations, facial expression and home pen behaviours were assessed. Changes in facial expression were examined to develop the Rabbit Grimace Scale in order to assess acute pain. Tattooing without EMLA cream resulted in significantly greater struggling behaviour and vocalisation, greater facial expression scores of pain, higher peak heart rate, as well as higher systolic and mean arterial blood pressure compared to all other treatments. Physiological and behavioural changes following tattooing with EMLA cream were similar to those in animals receiving sham tattoos with or without EMLA cream. Behavioural changes 1 hour post-treatment were minimal with no pain behaviours identifiable in any group. Serum corticosterone responses did not differ between sham and tattoo treatments.

CONCLUSIONS

Ear tattooing causes transient and potentially severe pain in rabbits, which is almost completely prevented by prior application of local anaesthetic cream. The Rabbit Grimace Scale developed appears to be a reliable and accurate way to assess acute pain in rabbits.

Assessment of the efficacy of topical anesthetics using the tactile spatial resolution method

The aim of this study was to compare the purported advantages of 4% tetracaine gel (Ametop gel) and 4% liposomal lidocaine gel (LMX4 gel) with EMLA cream (eutectic mixture of 2.5% lidocaine and 2.5% prilocaine) using an objective and repeatable method. Ametop gel and LMX4 gel were administered under occlusion for 30 min and compared to EMLA cream applied for 30 and 60 min on the intact upper lip skin of 15 volunteers each. The efficacy of the anesthetics was assessed by the spatial resolution method. Measurements were conducted just after removal of the products from the skin, then 20, 40 and 60 min later. Each of the formulations, except for EMLA cream applied for 30 min, decreased tactile spatial discrimination thresholds significantly just after removal from the skin when compared to the output levels (p<0.05). Ametop gel kept significantly good skin anesthesia also 20, 40 and 60 min later (p<0.05). The efficacy of LMX4 gel and EMLA(60) cream decreased to the initial levels after 40-min application. Ametop gel anesthetized the skin in a highly homogeneous manner providing similar effect in most subjects, which was not the case in the EMLA and LMX4 groups. In conclusion, LMX4 gel and Ametop gel appeared to be faster acting than EMLA cream. Our results showed the 30-min application of LMX4 and Ametop gel under occlusion to be equivalent to 60-min administration of EMLA cream. Ametop gel, in contrast to the rest, provides very good anesthesia for up to 60 min. The application of EMLA cream under occlusion over only 30 min cannot guarantee appropriate effects.

TRANSDERMAL ANAESTHESIA FOR PERCUTANEOUS TRIGGER FINGER RELEASE

The purpose of this study was to evaluate the safety and efficiency of transdermal anaesthesia using eutectic mixture of lidocaine and prilocaine (EMLA) in patients undergoing percutaneous trigger finger release and to compare it with lidocaine infiltration.

In this prospective, randomised study percutaneous release of the A1 annular pulley was performed to treat stenosing tenosynovitis (trigger finger syndrome) in 50 patients (50 fingers). The procedure was performed either under transdermal anaesthesia using EMLA applied transcutaneously 120 minutes prior to the operation (Group A, n = 25) or using local infiltration anaesthesia using lidocaine (Group B, n = 25). Pain experienced during administration of anaesthesia and during the operation was assessed using a 10-point Visual Analogue Pain Scale (VAPS), while all patients rated the effectiveness of anaesthesia with a 5-point scale.

There were no significant differences between the two groups in the VAPS during the operation (1.33 ± 0.52 versus 1.59 ± 0.87) and the satisfaction scores (4.6 ± 0.2 versus 4.4 ± 0.3). The VAPS score during the administration of anaesthesia was statistically significantly less in the EMLA group (0 versus 5.96 ± 2.41). All patients were satisfied with the final result of the operation.

Percutaneous trigger finger release can be performed as an office procedure with the use of EMLA avoiding the use of injectable local infiltration anaesthesia.

Analgesia for amniocentesis or chorionic villus sampling

BACKGROUND

Besides risks of miscarriage, pregnant women undergoing amniocentesis or chorionic villus sampling (CVS) are also concerned about pain associated with these procedures. Currently, approaches to analgesia can be categorised in two broad categories - non-pharmacological and pharmacological agents.

OBJECTIVES

To evaluate whether different methods of analgesia have any impact on pain reduction during amniocentesis or chorionic villus sampling (CVS).

SEARCH METHODS

We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (31 August 2011).

SELECTION CRITERIA

All randomised trials comparing different method of analgesia for amniocentesis or CVS. We also include trials with quasi-randomised designs, but analyse and report their results separately.

DATA COLLECTION AND ANALYSIS

Both review authors assessed eligibility and trial quality and performed data extraction.

MAIN RESULTS

We included a total of five randomised studies (involving 805 women) evaluating different methods of analgesia for amniocentesis; there were no studies in women undergoing CVS.One RCT (N = 203) and one quasi-randomised study (N = 220) compared infiltrative local anaesthesia with no anaesthesia and found no statistical difference in experienced pain on the visual analogue scale (VAS) (mean differences (MD) -2.50 and 1.20; 95% confidence interval (CI) -6.98 to 1.98 and -2.67 to 5.07).One study (N = 200) compared light leg rubbing versus no intervention during amniocentesis and found no change in experienced anxiety (MD 0.2; 95% CI -0.63 to 1.03) or VAS pain score (MD 0.3; 95% CI -0.35 to 0.95) during amniocentesis.Another study with 62 patients did not find any benefit of using subfreezing temperature needle during amniocentesis in terms of decreased VAS pain score (MD -0.8; 95% CI -1.8 to 0.2). In addition, there was no difference between anticipated and actual pain (MD 0.4; 95% CI -0.82 to 1.62) (before/after comparison).There was also no difference in VAS pain scores in the study with 120 participants comparing lidocaine-prilocaine analgesic cream to placebo cream before amniocentesis (MD -0.6; 95% CI -1.44 to 0.24).

AUTHORS' CONCLUSIONS

In general, women who undergo amniocentesis could be informed that pain during procedure is minor and that there is currently insufficient evidence to support the use of local anaesthetics, leg rubbing or subfreezing the needle for pain reduction during procedure.

Comparison of the efficacy of articaine and prilocaine local anaesthesia for pulpotomy of maxillary and mandibular primary molars

AIM

The aim of this study was to compare the local anaesthetic efficacy of articaine HCl and prilocaine HCl during an operative procedure after their administration by either mandibular nerve block or maxillary infiltration.

STUDY DESIGN

The study was a double-blind clinical study which comprised 162 children (81 boys and 81 girls), who required a pulpotomy on their primary molars. Pain-related behaviours were used to assess the severity of pain during the injection of either prilocaine HCl or articaine HCl and the operative procedures following either a maxillary infiltration or mandibular nerve block of the two local anaesthetic agents. The frequencies of post-procedural adverse events in the prilocaine and articaine anaesthetised groups were also determined.

RESULTS

Significantly more discomfort (p<0.05) was observed following maxillary infiltration compared to mandibular nerve block. There were no significant differences in the pain-related behaviours scores between the two local anaesthetic agents administered during the dental operative procedures, except for the removal of the coronal pulp. For this latter procedure, the pain-related behaviour score was 1.5- times higher in the prilocain-anaesthetised children than in the articaine-anaesthetised children. The frequencies of post- procedural adverse events in the prilocaine-treated children were similar to those found in the articaine-treated children.

CONCLUSION

We concluded that local anaesthesia following mandibular nerve block is more effective than that following maxillary infiltration in 6-8-year-old children. However, the intensity of pain that was experienced by the children during administration of either prilocaine or articaine and some of the dental procedures after their administration were similar.

Use of a diode laser in an excisional biopsy of two spoonlike neoformations on the tongue tip

The 810 nm diode laser, due to its high affinity with haemoglobin (elective chromatophore) revealed, by itself, as elective instrument for surgical excision of the tongue, an organ highly vascularized and sensitive to the laser cutting action. The advantages for its use, with respect to the traditional cold blade surgery, are its haemostatic effect (which avoids to close wounds by stitches) and, not less important, the decontaminant effect of the laser ray, due to either the thermal raising created on cutting line and/or the specific selective action exerted on the bacterial membrane by its wavelength. Finally, the analgesic effect of the diode laser contributes to consider this kind of procedure more comfortable for the patient who often roundly requires its use.

Care to relieve pain-stress in preterm newborns

BACKGROUND AND AIM OF THE WORK

A variety of non-pharmacological pain-prevention and relief techniques have been studied to evaluate the pain reduction in neonates. The aim of our study was to compare the analgesic effect of sucking a pacifier with the use of eutectic mixture of local anaesthetics (EMLA) during venipuncture in preterm newborns, using physiological and behavioural parameters as indicators of pain.

METHODS

We analysed the reaction to invasive procedures in 17 preterm newborns. Our patients underwent repeated vein draws without pain relief, sucking a pacifier, after the application of EMLA; we also evaluated a group of patients approached for care without pricking. For each infant we recorded the average values of the physiological parameters at rest and after pain stimuli, behavioural conditions (crying or grimaces), number and time required for blood draw.

RESULTS

The maximum heart rate values, respiratory rate, and the maximum respiratory rate values presented a statistically difference only between subjects that underwent vein draws compared to subjects without pricking (p < 0.01). Moreover, the SpO2 parameter presented a significant increase in the control group compared to the others (p = 0.024). Analysis ofbehavioural parameters shows that crying seems significantly related to the duration and number ofvenipunctures (p = 0.000).

CONCLUSIONS

It is clear that pain stress is more closely related to the duration and number of venipuncture than pain relief methods. Our results suggest that limiting the number and duration of vein draws could help to reduce pain stresss in preterm newborns.

Inadvertent brachial plexus anesthesia associated with local anesthetic infiltration during internal jugular venous cannulation: a case report

In the development of neurological complications due to central venous cannulation, the properties of the anatomical region and the experience of the practitioner are important. In this case report, an inadvertent brachial plexus anesthesia after repeated local anesthetic infiltrations during failed attempts of internal jugular venous cannulation by an inexperienced practitioner in cardiovascular intensive care unit is described. The neurological complications due to central venous cannulation are reviewed in the light of actual literature data.

[The surface anesthesia in outpatient pediatric department]

The combination of even parts lidocaine and prilocaine in crème substance was used for surface anesthesia in 73 children, aged 1,5-16 years. Such surgical interventions as molluscum contagiosum eradication, laser wart resection and prepuce synechia dissection were performed. The described anesthetic was highly effective in all areas, but the nasolabial triangle. Resection of warts larger then 0,5 sm required either additional infiltrative anesthesia or step-wise resection. Local allergic reaction was registered in one case, no systemic reactions were noticed. Generally, the used method of surface anesthesia proved to be highly appropriate in pediatric practice.

A prospective, randomized, double-blind comparison of 2% lidocaine with 1:100,000 epinephrine, 4% prilocaine with 1:200,000 epinephrine, and 4% prilocaine for maxillary infiltrations

The purpose of this prospective, randomized, double-blind crossover study was to evaluate the anesthetic efficacy of 2% lidocaine with 1:100,000 epinephrine, 4% prilocaine with 1:200,000 epinephrine, and 4% prilocaine in maxillary lateral incisors and first molars. Sixty subjects randomly received, in a double-blind manner, maxillary lateral incisor and first molar infiltrations of 1.8 mL of 2% lidocaine with 1:100,000 epinephrine, 1.8 mL of 4% prilocaine with 1:200,000 epinephrine, and 1.8 mL of 4% prilocaine, at 3 separate appointments spaced at least 1 week apart. The teeth were pulp-tested in 3-minute cycles for a total of 60 minutes. Anesthetic success (ie, obtaining 2 consecutive 80 readings with the electric pulp tester) and onset of pulpal anesthesia were not significantly different between 2% lidocaine with 1:100,000 epinephrine, 4% prilocaine with 1:200,000 epinephrine, and 4% prilocaine for the lateral incisor and first molar. For both lateral incisor and first molar, 4% prilocaine with 1:200,000 epinephrine and 2% lidocaine with 1:100,000 epinephrine were equivalent for incidence of pulpal anesthesia. However, neither anesthetic agent provided an hour of pulpal anesthesia. For both lateral incisor and first molar, 4% prilocaine provided a significantly shorter duration of pulpal anesthesia compared with 2% lidocaine with 1:100,000 epinephrine and 4% prilocaine with 1:200,000 epinephrine.