Efficacy and safety of different doses of ropivacaine for laparoscopy-assisted infiltration analgesia in patients undergoing laparoscopic cholecystectomy: A prospective randomized control trial

BACKGROUND

Wound infiltration analgesia provides effective postoperative pain control in patients undergoing laparoscopic cholecystectomy (LC). However, the efficacy and safety of wound infiltration with different doses of ropivacaine is not well defined. This study investigated the analgesic effects and pharmacokinetic profile of varying concentrations of ropivacaine at port sites under laparoscopy assistance.

METHODS

In this randomized, double-blinded study, 132 patients were assigned to 4 groups: Group H: in which patients were infiltrated with 0.75% ropivacaine; Group M: 0.5% ropivacaine; Group L: 0.2% ropivacaine; and Group C: 0.9% normal saline only. The primary outcome was pain intensity estimated using numeric rating scale (NRS) at discharging from PACU and at 4 hours, 6 hours, 8 hours, and 24 hours after infiltration. Secondary outcomes included plasma concentrations of ropivacaine at 30 minutes after wound infiltration, rescue analgesia requirements after surgery, perioperative vital signs changes, and side effects.

RESULTS

The NRS in Group C was significantly higher at rest, and when coughing upon leaving PACU and at 4 hours, 6 hours, 8 hours, and 24 hours after infiltration (P < .05) and rescue analgesic consumption was significantly higher. Notably, these parameters were not significantly different between Groups H, Group M and Group L (P > .05). Intra-operative consumption of sevoflurane and remifentanil, HR at skin incision and MAP at skin incision, as well as 5 minutes after skin incision were significantly higher in Group C than in the other 3 groups (P < .01). In contrast, these parameters were not significantly different between Groups H, Group M and Group L (P > .05). The concentration of ropivacaine at 30 minutes after infiltration in Group H was significantly higher than that of Group L and Group M (P < .05). No significant differences were observed in the occurrence of side effects among the 4 groups (P > .05).

CONCLUSIONS

Laparoscopy-assisted wound infiltration with ropivacaine successfully decreases pain intensity in patients undergoing LC regardless of the doses used. Infiltration with higher doses results in higher plasma concentrations, but below the systematic toxicity threshold.

Combination Preemptive Peripheral Nerve Block in Limb Surgery. A Prospective Study

Background and objectives: Patients often suffer from moderate to severe pain during the early recovery period in orthopedic surgery. We investigated the impact of a single-shot preoperative peripheral nerve block (PNB) on post-anesthesia recovery parameters and interleukin (IL)-6 level during limb surgery. Materials and Methods: A prospective randomized controlled study was conducted, and patients scheduled for limb surgery were recruited. Sixty patients were randomly assigned to either the PNB group or control group, who received morphine as a primary analgesic. The peak verbal numeric rating scale (NRS) score in the post-anesthesia care unit (PACU) was evaluated as a primary outcome. We also recorded rescue analgesics requirement and wake-up time from anesthesia in the PACU. In addition, the change of plasma IL-6 level after incision was measured. Results: Fifty-two patients completed the study, 27 and 25 cases in the PNB and control group, respectively. Preemptive PNB significantly reduced peak NRS score in the PACU compared to control group. Lower rescue analgesics requirement and rapid wake-up from anesthesia were also noted in PNB group. The IL-6 concentration increased less in the PNB group at 2 h after incision. Conclusions: Preemptive PNB attenuates IL-6 expression 2 h after incision and improves pain management in the PACU. PNB was considered as an essential part of pain management in limb surgery.

How to minimize the pain of local anesthetic administration

Expertise in the delivery of effective local analgesia is critical to the success of in-office procedures. Here's how to optimize patient outcomes and satisfaction.

Infiltrative local anesthesia with articaine is equally as effective as inferior alveolar nerve block with lidocaine for the removal of erupted molars

AIM

The aim of this study is to assess the efficacy of 4% articaine with 1:100,000 adrenaline given as buccal and lingual infiltration in adult patients undergoing erupted mandibular first and second molar teeth extraction versus inferior alveolar nerve block technique using 2% lignocaine with 1:80,000 adrenaline.

MATERIALS AND METHODS

A total of 100 patients undergoing extraction of mandibular posterior teeth were divided into two equally matched groups for the study, out of which 50 patients were given 4% articaine with 1:100,000 adrenaline as buccal and lingual infiltration and 50 patients were given 2% lignocaine with 1:80,000 adrenaline using classic direct inferior alveolar nerve block with lingual and buccal nerve block. Efficacy of anesthesia was determined using a numeric analog scale (NAS) ranging from 0 indicating no pain to 10 indicating the worst pain imaginable. The NAS was taken by a different operator to avoid bias.

RESULTS

The pain scores in both groups were analyzed using the Mann-Whitney U test, and a p value of 0.338 was obtained which is not statistically significant. Hence, no significant difference in the pain score was established between both groups. The adverse effects of both the local anesthetics if any were noted.

CONCLUSION

From this study, we concluded that the use of 4% articaine with 1:100,000 adrenaline is as effective as inferior alveolar nerve block with lignocaine but without the risk of attendant adverse effects of inferior alveolar nerve block technique.

Failure rate of inferior alveolar nerve block among dental students and interns

OBJECTIVES

To report the failure rate of inferior alveolar nerve block (IANB) among dental students and interns, causes of failure, investigate awareness of different IANB techniques, and to report IANB-associated complications.  

METHODS

A 3-page questionnaire containing 13 questions was distributed to a random sample of 350 third to fifth years students and interns at the College of Dentistry, King Saud University, Riyadh, Saudi Arabia on January 2011. It included demographic questions (age, gender, and academic level) and questions on IANB failure frequency and reasons, actions taken to overcome the failure, and awareness of different anesthetic techniques, supplementary techniques, and complications.  

RESULTS

Of the 250 distributed questionnaires, 238 were returned (68% response rate). Most (85.7%) of surveyed sample had experienced IANB failure once or twice. The participants attributed the failures most commonly (66.45%) to anatomical variations. The most common alternative technique used was intraligamentary injection (57.1%), although 42.8% of the sample never attempted any alternatives. Large portion of the samples stated that they either lacked both knowledge of and training for other techniques (44.9%), or that they had knowledge of them but not enough training to perform them (45.8%). 

CONCLUSION

To  decrease IANB failure rates for dental students and interns, knowledge of landmarks, anatomical variation and their training in alternatives to IANB, such as the Gow-Gates and Akinosi techniques, both theoretically and clinically in the dental curriculum should be enhanced.

A National Survey of Undergraduate Suture and Local Anesthetic Training in the United Kingdom

BACKGROUND

Suturing is a skill expected to be attained by all medical students on graduation, according to the General Medical Council's (GMC) Tomorrow's Doctors. There are no GMC recommendations for the amount of suture training required at medical school nor the level of competence to be achieved. This study examines the state of undergraduate suture training by surveying a sample of medical students across the United Kingdom.

METHODS

We distributed a survey to 17 medical schools to be completed by undergraduates who have undergone curricular suture training. The survey included questions relating to career intention, hours of curricular suture training, hours of additional paid training, confidence in performing various suture techniques and knowledge of their indications. We also asked about the students' perceived proficiency at injecting local anesthetic and their overall opinion of medical school suture training.

RESULTS

We received responses from 705 medical students at 16 UK medical schools. A total of 607 (86.1%) medical students had completed their scheduled curricular suture training. Among them, 526 (86.5%) students reported inadequate suture training in medical school and 133 (21.9%) students had paid for additional training. Results for all competence markers were significantly lower than the required GMC standards (p < 0.001). Students who had paid for additional training were significantly more confident across all areas examined (p < 0.001).

CONCLUSIONS

Our study identified a deficiency in the curricular suture training provided to the medical students surveyed. These findings suggest that medical schools should provide more opportunities for students to develop their suturing skills to achieve the GMC standard.

[Technical features of intraligamental intraseptal anesthesia]

Based on personal clinical experience the authors provide clinical guidelines for periodontal anesthesia. The by-step protocol for intraligamentary and intraseptal anesthesia is presented. The basic mistakes in technique and possible complications are described. Recommendations for a local anesthetic choice and dosage for different groups of teeth are given.

Clinical efficacy of tetracaine anesthetic paste

Benzocaine, the most commonly used topical anesthetic in dentistry, often fails to eliminate the pain associated with injections. One type of anesthetic used frequently in medicine with success is tetracaine, but minimal research has been done regarding the application of tetracaine in dentistry. This study sought to evaluate the effectiveness and safety of tetracaine anesthetic paste (TAP), a newly formulated topical anesthetic. For this study, TAP was applied to the maxillary mucobuccal fold of one side of the arch and benzocaine paste was applied to the opposite side prior to injection of anesthetic. Patients then reported the level of pain experienced on each side and were evaluated for any adverse reactions. The results showed no difference in effectiveness between TAP and benzocaine paste, and no adverse reactions were reported. Because of the safety and effectiveness of tetracaine extraorally, further research is warranted on its intraoral use.

REGIONAL ANALGESIA FOR POST-OPERATIVE PAIN MANAGEMENT--INITIAL EXPERIENCE IN A LOW RESOURCE SETTING

OBJECTIVE

The aim of this study is to demonstrate the use of some regional anaesthetic techniques in effective postoperative pain control in a low resource setting. We also wanted to find out the potential benefits and prospects of regional techniques to achieve effective postoperative analgesia.

DESIGN

This study was a prospective observational study in which 25 patients presenting for various orthopaedic and general surgical procedures were recruited randomly.

SETTING

Ahmadu Bello University Teaching Hospital (ABUTH), Zaria, Nigeria from December, 2008 to May, 2009.

SUBJECTS

Eligible patients were males and females aged 21-55 years. These included emergency and elective cases.

RESULTS

The age range was 21-55 years with a mean age of 34 years. Of the 25 patient studied, 14 of them were men and 11 women constituting 56% and 44% respectively. Our study shows that Hausa/Fulani ethnic group made up 75% of the study population. Intraoperatively, the anaesthetic techniques used were general anaesthesia (only) in 13 patients (52%), Regional techniques consisting of spinals, epidurals, combined spinals and epidurals and brachial plexus blocks in nine patients (36%) and three (12%) of the patients had a combination of general anaesthesia (GA) and regional anaesthesia (RA). For post-operative pain management, nine patients (36%) had continuous brachial plexus block using intermittent injections, 13 (52%) patients had epidural catheters with intermittent top-up injections and three (12%) patients received combined spinal and epidural with an epidural catheter left in-situ for intermittent top-ups. The drugs used for top-ups included 0.125% plain bupivacaine (15 patients), 0.125% plain bupivacaine + 2.5 mcgs/ml Fentanyl (10 patients) in 10 ml aliquots. The outcome was good in most patients with 19 patients (82.4%) experiencing only mild pain (numeric pain score 0-3). Onset of post-operative pain was 13-18 hours in most (52%) of patients with majority of patients (80%) requiring only a single dose of opioid in 24 hours. There was no incidence of infection at site of catheter insertion one week after the procedure.

CONCLUSION

Regional techniques if used properly can provide superior pain control in the post-operative period. There is reduction in the requirements of opioids in the immediate post-operative when regional techniques are used for pain management. We need to encourage the use of these techniques especially in our setting where resources are sparse and potent analgesics are not always available.

[Oxygen provision of the brain during carotid endarterectomy in the settings of general and local anaesthesia]

Based on the indices of cerebral oximetry, analysed herein is efficiency of oxygen support of the brain in various types of anaesthesiological provision (total and general anaesthesia) in patients presenting with atherosclerosis of the brachiocephalic arteries during carotid endarterectomy. It was shown that at the expense of preserving the mechanism of autoregulation, the use of local anaesthesia provides higher efficiency of cerebral perfusion than general anaesthesia which is evidenced by the values of cerebral oximetry exceeding 60% at all stages of the operation. Dynamics of cerebral oxygenation during occlusion of the carotid arteries in the setting of local anaesthesia suggests high reactivity of the cerebral vessels in this cohort of patients and hence preservation of the cerebrovascular reserve in them.

Morphometric analysis of the skull of the Sahel goat breed: basic and clinical anatomy

The work reports morphometric analysis of the skulls of the Sahel breed of goat. The calculated metric data (mean +/- SD) included the condylobasal length, 16.94 +/- 1.39 cm, while the orbital circumference was 11.30 +/- 0.48 cm. The foramen magnum height and width were 1.82 +/- 0.11 cm and 1.85 +/- 0.15 cm respectively while the foramen magnum index was 89.81 +/- 8.71. Animals above one year of age had significantly higher values for orbital length including horizontal and vertical diameters, overall skull length, basal length, and neurocranium height than animals aged one year and below. The cornual process length, maximum orbital circumference and horizontal diameter obtained in this study were higher than those reported for other Nigerian goat breeds in the literature. The data for the distances from the facial tuberosity to the infraorbital canal, from the mental foramen to the lateral extent of the alveolar root of the lower incisor, as well as from the mandibular foramen to the base of the mandible and that from the mental foramen to the caudal border of the mandible, which are important clinically in the estimation of craniofacial measurements that will aid regional anaesthesia, were however similar to those reported earlier for the Red Sokoto and West African Dwarf breeds implying that a uniform craniometric estimation for associated regional nerve blocks can be attempted for these goat breeds.

Local differences in the position of the mental foramen

The mental foramen has been reported to vary in position in different ethnic groups. Repeated failures during injections and operative procedures involving the mental foramen suggest the presence of local differences in a given population. The aim of the present study was to investigate possible local differences of the mental foramen in Eastern Anatolian individuals in the Turkish population. The present investigation is based on the examination of 70 adult mandibles. The study consisted of three measurements, to include the relations of the mental foramen to the following: 1) the lower teeth; 2) the body of mandible; 3) the mandibular symphysis and posterior border of the ramus of the mandible. The most common position of the foramen was in line with the longitudinal axis of the second premolar tooth (relation IV), at the midpoint of the mandibular body height and at 1/3.5 of the distance from the mandibular symphysis to the posterior border of the ramus. Local differences of the mental foramen may occur in a population. Prior to surgery knowledge of the most common location of the foramen peculiar to a local population may enable effective mental block anaesthesia to be provided.

Tumescent liposuction: standard guidelines of care

DEFINITION

Tumescent liposuction is a technique for the removal of subcutaneous fat under a special form of local anesthesia called tumescent anesthesia. PHYSICIAN'S QUALIFICATIONS: The physician performing liposuction should have completed postgraduate training in dermatology or a surgical specialty and should have had adequate training in dermatosurgery at a center that provides training in cutaneous surgery. In addition, the physician should obtain specific liposuction training or experience at the surgical table ("hands on") under the supervision of an appropriately trained and experienced liposuction surgeon. In addition to the surgical technique, training should include instruction in fluid and electrolyte balance, potential complications of liposuction, tumescent and other forms of anesthesia as well as emergency resuscitation and care.

FACILITY

Liposuction can be performed safely in an outpatient day care surgical facility, or a hospital operating room. The day care theater should be equipped with facilities for monitoring and handling emergencies. A plan for handling emergencies should be in place with which all nursing staff should be familiar. A physician trained in emergency medical care and acute cardiac emergencies should be available in the premises. It is recommended but not mandatory, that an anesthetist be asked to stand by.

INDICATIONS

Liposuction is recommended for all localized deposits of fat. Novices should restrict themselves to the abdomen, thighs, buttocks and male breasts. Arms, the medial side of the thigh and the female breast need more experience and are recommended for experienced surgeons. Liposuction may be performed for non-cosmetic indications such as hyperhidrosis of axillae after adequate experience has been acquired, but is not recommended for the treatment of obesity.

PREOPERATIVE EVALUATION

Detailed history is to be taken with respect to any previous disease, drug intake and prior surgical procedures. Liposuction is contraindicated in patients with severe cardiovascular disease, severe coagulation disorders including thrombophilia, and during pregnancy. Physical evaluation should be detailed and should include assessment of general physical health to determine the fitness of the patient for surgery, as well as the examination of specific sites that need liposuction to check for potential problems.

PREOPERATIVE INFORMED CONSENT

The patient should sign a detailed consent form listing details about the procedure and possible complications. The consent form should specifically state the limitations of the procedure and should mention whether more procedures are needed for proper results. The patient should be provided with adequate opportunity to seek information through brochures, computer presentations, and personal discussions. Preoperative laboratory studies to be performed include Hb%, blood counts including platelet counts, bleeding and clotting time (or prothrombin and activated partial thromboplastin time) and blood chemistry profile; ECG is advisable. Liver function tests, and pregnancy test for women of childbearing age are performed as mandated by the individual patient's requirements. Ultrasound examination is recommended in cases of gynecomastia.

PREOPERATIVE MEDICATION

Preoperative antibiotics and non-sedative analgesics such as paracetamol are recommended. The choice of antibiotic and analgesic agents depends on the individual physician's preference and the prevailing local conditions.

TYPE OF ANESTHETIC EMPLOYED

Lidocaine is the preferred local anesthetic; its recommended dose is 35-45 mg/kg and doses should not exceed 55 mg/kg wt. The recommended concentration of epinephrine in tumescent solutions is 0.25-1.5 mg/L. The total dosage of epinephrine should be minimized and should not exceed 50 microg/kg.

SURGICAL TECHNIQUE/PROCEDURE

t is always advisable not to combine liposuction with other procedures to avoid exceeding the recommended dosage of lignocaine. However, such combinations may be attempted if the total required dose of lignocaine does not exceed the maximum dose indicated above. The recommended cannula size for liposuction is not to be larger than 3.5 mm in diameter. The recommended volume of fat removed is in proportion to the fat content and/or size and/or weight of the patient being treated. It is recommended that the volume of fat removed not exceed 5000 mL in a single operative session. arge volume liposuctions or mega-liposuctions are not recommended.

INTRAOPERATIVE AND POSTOPERATIVE MONITORING

Baseline vital signs including blood pressure and heart rate, are recorded pre- and postoperatively. Pulse oximeter monitoring is essential in all cases.

POSTOPERATIVE CARE

Postoperative antibiotics should be selected by the physician and taken for five days. Postoperative antiinflammatory drugs such as Cox 2 Inhibiters may be given for 5-7 days; specialized compression garments, binders, and tape help to reduce bruising, hematomas, seromas, and pain. Generally, compression is recommended for two weeks although this is variable according to the needs of the individual patient.

Topical anaesthesia before nasendoscopy: a randomized controlled trial of co-phenylcaine compared with lignocaine

OBJECTIVE

To evaluate the relative effectiveness of co-phenylcaine (lignocaine 5% with phenylephrine) and lignocaine 5% sprays when administered prior to rigid nasendoscopy.

DESIGN

Randomized, double blind controlled study.

SETTING

Teaching hospital otolaryngology unit.

PARTICIPANTS

Thirty patients requiring routine outpatient rigid nasendoscopy were administered five puffs of either co-phenylcaine or lignocaine 5% spray which had been randomly assigned to either the first or the second visit. Ten minutes later nasendoscopy was performed. Immediately after nasendoscopy the ease of performance of the procedure and the quality of the view achieved was rated on a visual analogue scale by the endoscopist and the patients recorded the level of pain experienced on a visual analogue scale. Two weeks later, the patients returned for a repeat nasendoscopy, receiving the alternate spray.

MAIN OUTCOMES MEASURES

Ease of performance and quality of view of achieved by endoscopists and pain experienced by patients, both measured with visual analogue scales.

RESULTS

The ease of passage of the endoscope and quality of the view obtained was found to be greater after the administration of co-phenylcaine [visual analogue scores 84 (95% CI: 80-89) than after lignocaine and 77 (95% CI: 73-81) (P < 0.01)]. The two sprays produced similar levels of topical anaesthesia.

CONCLUSIONS

Nasendoscopy can be performed with minimal discomfort after the administration of either co-phenylcaine or lignocaine 5% sprays. The vasoconstricting action of co-phenylcaine increases the ease of passage of the endoscope and quality of the view obtained by the endoscopist.

Bupivacaine in the emergency department is underused: scope for improved patient care

AIMS

To determine patterns of local anaesthetic use, knowledge and perceived use of local anaesthetic by emergency department doctors, and barriers to bupivacaine use.

METHODS

This was a multifaceted, observational study undertaken at two large metropolitan emergency departments. It comprised a retrospective chart review of patients who had been given local anaesthetic in the emergency department, an examination of ordering records of local anaesthetics in the emergency department, and a cross-sectional survey of emergency department doctors.

RESULTS

The charts of 95 patients were reviewed. Most (93.7%) injuries were lacerations and the most common site was the hand (41.4%). 88 (92.6%), 4 (4.2%) and 3 (3.2%) patients were given lignocaine, prilocaine (Bier's blocks) and bupivacaine (digital blocks), respectively. Four (4.2%) cases were identified for which bupivacaine was likely to have been a better alternative than the lignocaine used. These were finger/hand injuries likely to be associated with considerable prolonged pain. The emergency department pharmacy records indicated that 30 times more lignocaine than bupivacaine was ordered in 2004-5. 30 (88.2%) of 34 doctors completed the survey. Knowledge of local anaesthetic pharmacology was variable: 33% and 66% did not know that bupivacaine was more cardiotoxic and that lignocaine was more painful, respectively. The main barriers to bupivacaine use were "habit" of using lignocaine (46.7%), cardiac toxicity (40%) and slower onset (30%).

CONCLUSION

Bupivacaine seems to be underused in some appropriate circumstances. Accordingly, there is scope for improvement in patient care through critical evaluation of local anaesthetic practice. This is particularly necessary because barriers to bupivacaine use are often non-clinical (habit, availability, familiarity) rather than clinical (toxicity, onset time).

Anaesthesia-related maternal mortality

Complications of anaesthesia leading to death in young pregnant women might be prevented if more experienced personnel could be entrusted with the job. The contribution of anaesthesia to maternal mortality in the United Kingdom is 1.7 per million pregnancies with almost similar incidence from United States. The commonest single factor responsible for anaesthesia-related death is difficult or failed intubation. A pregnant woman with a potentially difficult airway should receive aspiration prophylaxis (mechanical or pharmacological) as soon as operative delivery is anticipated. Anaesthetists should make a plan that comes into effect as soon as failure to view the larynx or to intubate the trachea becomes evident. Unsuspected difficult airway can be managed if the skill of the anaesthetists is of high standard. Pulmonary aspiration is one cause of death in obstetric anaesthesia. Regurgitation and vomiting prevention can minimise pulmonary aspiration. In regional anaesthesia, local anaesthetics toxicity is another cause of concern. This should be tackled with some safe local anaesthetics. Preventing a high spinal or epidural block involves ways to detect inadvertent injection of local anaesthetic into the cerebrospinal fluid. Postoperative care after anaesthesia in obstetric cases is very important.

Costs and quality in loco-regional anesthesia

Quality can be considered to be a strategic element in the political process of planning and implementation of health and social care, resulting in a form of guarantee for the public through encouraging constructive competition between providers and reducing wasting and poor management. This should also be applied to managing loco-regional anesthesia. Competition is constant between treatments currently available together with a focus on quality and costs. This brings about strict controls on health care costs which should then be based on the evaluation of the results obtained in terms of health. It is obvious that costs for materials, time spent for an intervention, staff employed and structures required to carry it out are unavoidable. Quality is that treatment which maximises the patient's well-being following evaluation of the expected risks and benefits involved in the overall treatment. Acute pain is suffered by surgical patients either due to pre-existing disease, surgical intervention or due to a combination of both these situations. There is a high incidence of postoperative pain. In fact, more than 75% of postoperative patients report to have suffered moderate to severe pain. The same results have been reported in pediatrics and oncology: these results should always encourage the application of clinical quality, taking into consideration the costs involved when carrying out loco-regional anesthesia which aims at improving patient's outcome when undergoing surgical intervention.

Local Anesthesia Reduces Pain Associated with Transrectal Prostatic Biopsy

INTRODUCTION

To test the hypothesis that periprostatic block could completely relief prostatic biopsy-associated pain.

MATERIALS AND METHODS

Patients scheduled for transrectal ultrasound guided prostate biopsy were randomized (1:1:1 ratio) to no analgesia (group A), endorectal enema of 1% lidocaine gel (group B) or transrectal periprostatic block (group C). All patients underwent 10 core TRUS-guided biopsy. After the procedure, a ten visual analogue pain score (VAS) from 0 = no discomfort to 10 = severe pain was administered to the biopsied patients and a global estimation of pain associated with the procedure was obtained. The study design included interim analysis of pain score after the first 60 patients were enrolled. Kruskal-Wallis test for unpaired data was used for statistical analysis. Data are presented as mean, median (range).

RESULTS

Sixty patients were enrolled between May 2003 and December 2003 and all patients were evaluable. Mean and median age was 68.5 and 69 (range 53-82) years, respectively. Mean and median PSA was 86.8 and 9 ng/ml (range 0.58-4.111), respectively. No major side effects were observed. Patients in group A scored at VAS a median 4, mean 5.5 +/- 2.3 (range 3-10). Patients in group B scored a median 4, mean 5.5 +/- 2.7 (range 3-10) (p = 0.237). Patients receiving periprostatic injections of carbocaine (group C) scored a median 0, mean 0.5 +/- 0.8 (range 0-2). The level of pain reported by this group of patients was significantly different from those reported by patients who performed prostatic biopsy without anesthesia or with intrarectal anesthetic jelly (p = 0.00001). In the periprostatic block group 65% of patients referred no pain after the procedure (VAS = 0) while all patients in the other groups experience some degree of pain.

CONCLUSION

The use of bilateral periprostatic block is a very effective and useful technique, well tolerated by the patient, which almost completely abolishes the pain and discomfort associated with the prostatic biopsy procedure.

Comparison of subtenon anaesthesia with peribulbar anaesthesia for manual small incision cataract surgery

PURPOSE

To compare the safety and efficacy of subtenon anaesthesia with peribulbar anaesthesia in manual small incision cataract surgery using a randomised control clinical trial.

METHOD

One hundred and sixty-eight patients were randomised to subtenon and peribulbar groups with preset criteria after informed consent. All surgeries were performed by four surgeons. Pain during administration of anaesthesia, during surgery and 4 h after surgery was graded on a visual analogue pain scale and compared for both the techniques. Sub-conjuntival haemorrhage, chemosis, akinesia after administration of anaesthesia and positive pressure during surgery were also compared. Patients were followed up for 6 weeks postoperatively.

RESULTS

About 146/168 (86.9%) patients completed the six-week follow-up. Thirty-one out of 88 (35.2%) patients of peribulbar group and 62/80(77.5%) of subtenon group experienced no pain during administration of anaesthesia. There was no significant difference in pain during and 4 h after surgery. Subtenon group had slightly more sub-conjunctival haemorrhage. About 57 (64.8%) patients of the peribulbar group had absolute akinesia during surgery as compared to none (0%) in sub-tenon group. There was no difference in intraoperative and postoperative complications and final visual acuity.

CONCLUSION

Sub-tenon anaesthesia is safe and as effective as peribulbar anaesthesia and is more comfortable to the patient at the time of administration.

Bupivacaína racêmica, levobupivacaína e ropivacaína em anestesia loco-regional para oftalmologia: um estudo comparativo

BACKGROUND AND OBJECTIVE

Racemic bupivacaine, used in peribulbar anesthesia owing to its high potential to promote motor blockade, presents a smaller safety margin for cardiotoxicity in relation to ropivacaine and levobupivacaine. The objective of this study was to compare the degree of motor blockade and alteration of intraocular pressure (IOP) produced by racemic bupivacaine, levobupivacaine and ropivacaine in peribulbar block.

METHOD

Ninety seven patients, ASA physical status I and II, submitted to peribulbar anesthesia, were randomly allocated into three groups: group A-(n=16) receiving racemic bupivacaine 0.75% with epinephrine 1:200.000; group B -(n=16) levobupivacaine 0.75% with epinephrine 1:200.000; group C -(n=15) ropivacaine 0.75%. A single inferior injection peribulbar anesthesia was performed with 7 ml of the anesthetic solution plus 280 UI of hyaluronidase. The IOP and the degree of motor blockade were registered five minutes before injection and 1,2,3,4,5 and 10 minutes after it. The motor blockade was evaluated according to Nicoll's scale. For statistical analysis, Wilcoxon's test, simple frequency analysis, and Student-t test were used. p<0.05 was considered significant.

RESULTS

There were no significant differences between groups with respect to the degree of motor blockade. The IOP variation between the groups was not clinically significant.

CONCLUSIONS

Considering the advanced age of most of these patients and the high concentrations of local anesthetics used in peribulbar blockade, the use of ropivacaine and levobupivacaine produces motor blockade as effective as racemic bupivacaine while minimising risks for cardiotoxicity.

Topical anesthesia with sedation in phacoemulsification and intraocular lens implantation combined with 2-port pars plana vitrectomy in 105 consecutive cases

BACKGROUND AND OBJECTIVE

To evaluate the efficacy of topical anesthesia as an alternative to peribulbar or retrobulbar anesthesia in phacoemulsification and intraocular lens implantation combined with our modified 2-port pars plana vitrectomy technique (phacovitrectomy).

PATIENTS AND METHODS

Phacovitrectomy using topical anesthesia (4% lidocaine drops) was prospectively performed in 105 eyes with cataract and varied vitreoretinal pathology. In 75 eyes (71.4%), phacovitrectomy was combined with argon laser photocoagulation (endolaser). Preoperative and intraoperative sedation of varying degrees was necessary. Subjective pain and discomfort were graded from 1 (no pain or discomfort) to 4 (severe pain and discomfort).

RESULTS

All patients had grade 1 pain and discomfort during most of the procedure. All patients had grade 2 (mild) pain and discomfort during pars plana sclerotomies, external bipolar cautery, and conjunctival closure. No patient required additional retrobulbar, peribulbar, or sub-Tenon's anesthesia.

CONCLUSION

This technique avoids the risk of globe perforation, retrobulbar hemorrhage, and prolonged postoperative akinesia of the eye. With appropriate case selection, topical anesthesia is a safe and effective alternative to peribulbar or retrobulbar anesthesia in phacovitrectomy.

A reappraisal of thyroid surgery under local anaesthesia: back to the future?

BACKGROUND

Thyroid surgery is usually performed under general anaesthesia. However, for a selected group of patients, local anaesthesia may be preferable. The aim of this study was to review the authors' experiences with local anaesthesia with regard to the safety and outcome of this approach.

METHODS

A total of 65 consecutive patients who underwent primary thyroid surgery were accrued prospectively into this study from May to December 1999. A field block with 0.5% bupivacaine and adrenaline in 1:200 000 dilutions was given in all cases. In addition, light sedative and narcotics were given as necessary to achieve patient comfort and cooperation. The pain experienced during surgery was recorded using a visual analogue scoring system on a scale of 1-10.

RESULTS

Unilateral thyroid resection was performed in 58 patients, isthmectomy in four patients and bilateral thyroid resection in three patients, two of which were in their second trimester of pregnancy diagnosed with papillary thyroid cancer. There were 55 women and 10 men with an average age of 38.2 years (range: 18-67 years). No conversion to general anaesthetic was needed, and the mean operating time was 80 min. The postoperative recovery was quick with this technique and, of interest, 22 (33.9%) patients were discharged within 6 h following the surgery. Overall 62 (95.4%) patients were discharged in the first 24 h and three (4.6%) patients after 24 h. There were no significant postoperative complications encountered except for wound infection in two (3.1%) patients.

CONCLUSIONS

Thyroid surgery under local anaesthesia can be performed safely in a selected group of patients. It offers an effective alternative approach to general anaesthesia and is associated with low morbidity and high levels of patient satisfaction.

Local anaesthetic techniques in ophthalmic surgery

This article, which won third place in the Alison Bell Writer's Award this year, reports the findings of a literature review that explored the use of local anaesthetic techniques used in ophthalmic surgery. The author describes the various ophthalmic procedures that can take place under local anaesthetic and asks whether there is a need for an anaesthetist to be present for such lists. Issues such as patient monitoring requirements and intravenous access are also discussed, emphasising the importance of the nurse's role in informing, supporting and comforting the patient through what can be a stressful experience.

[Drugs that alter hemostasis and regional anesthetic techniques: safety guidelines. Consensus conference]

Patients about to undergo surgery are often taking drugs that alter hemostasis and affect anesthesia, particularly when neuroaxial techniques are used for subarachnoid or epidural anesthesia. The aim of this paper is to provide safety guidelines for regional anesthesia in patients receiving hemostasis-altering drugs, in order to reduce the risk of bleeding. We offer a detailed discussion of patients treated with inhibitors of platelet aggregation (emphasizing that such treatment alone is not a contraindication for neuroaxial blockade although certainly guidelines must be followed), unfractionated heparin (anesthesia should be started at least 4 hours after administration of this drug or 30 minutes before, provided pulmonary arterial pressure is normal), low molecular weight heparin (which should be administered 12 hours before or 12 hours after the anesthetic technique), and oral anticoagulants (provision of regional anesthesia depends mainly on International Normalized Ratio monitoring). We also stress that removal of catheters should follow criteria similar to those listed above, that the risk of complications due to bleeding increases considerably in association with these drugs, and that adequate neurological monitoring is essential during postoperative recovery. Overall, the final decision to use regional anesthesia in patients receiving drugs that alter hemostasis must be made on an individual basis after assessment of benefit and risk.

Liposuction in cosmetic dermatology

Liposuction is one of the most frequently performed cosmetic procedures in the world today. The central role of dermatologists in evolving many of the procedural methods now used is discussed. Tumescent anaesthesia and the associated tumescent technique proper allow liposuction to be performed safely and effectively in an outpatient setting. An overview of the technique and applications is presented.

When one liter does not equal 1000 milliliters: implications for the tumescent technique

BACKGROUND

Tumescent anesthesia has revolutionized the practice of liposuction. Inherent to the tumescent technique is the use of large volumes of dilute solutions of lidocaine with epinephrine instilled into subcutaneous fat deposits. Precise formulation of the tumescent anesthesia is essential to liposuction technique.

OBJECTIVES

To determine the actual volumes of fluids contained in intravenous (IV) 1 L bags of saline used for tumescent anesthesia, to calculate volumes supplied in 50 cc stock solutions of 1% lidocaine, and to measure the amount of fluid retained by peristalic pump tubing used for infiltration.

METHODS

The amount of saline contained in fifteen 1 L saline bags from three different manufacturers was calculated using graduated cylinder methodology. The volume of tumescent anesthesia retained by peristaltic pump tubing was calculated by expelling the contents of the filler tubing and measuring it. The actual amount of 1% lidocaine contained within fifteen 50 ml "stock" 1% lidocaine bottles from different manufacturers and with different lot numbers was calculated by transferring the contents into graduated cylinders.

RESULTS

One liter IV bags of physiologic saline contained an average volume of 1051 ml (range 1033-1069 ml). The 50 ml bottles of 1% lidocaine with epinephrine contain an average of 54 ml of anesthetic (range 52.5-55 ml). Infusion tubing for use with peristaltic pumps may retain 46-146 ml of tumescent anesthesia.

CONCLUSION

One liter IV bags of normal saline contain more than 1 L, having an average volume of 1051 ml. Common methods of preparation of 0.05% lidocaine with 1:1,000,000 epinephrine and sodium bicarbonate can increase the total amount of fluid in the tumescent anesthesia to 1112 ml for 0.05% solutions and preparation of a 0.1% solution contains an average volume of 1162 ml. The fluid contained in each bag may be increased over labeling by as much as 11-16%. Final concentrations of lidocaine in tumescent anesthesia may be reduced due to extra fluids. A 0.05% lidocaine solution may have a final lidocaine concentration of 0.045% and a 0.1% lidocaine solution may have an actual concentration of 0.086%. Lidocaine concentrations may be reduced by as much as 10-14%. Extra anesthesia fluid is also contained within stock 50 ml bottles of 1% lidocaine. Dermatologic surgeons should be aware of extra fluid possibly contained within tumescent anesthetic preparation, be aware of the extra anesthesia supplied in standard 1% lidocaine bottles, and possible decreased concentration of lidocaine within the final tumescent anesthesia.

The advantages and disadvantages of Bier's blocks and haematoma blocks for Colles' fractures in A&E

In the author's current area of practice the use of either the Bier's block or haematoma block for manipulating distal radial fractures seems to have been based mostly on the A&E consultant's preference. The purpose of this literature review was to determine if there was sufficient evidence on the advantages and disadvantages of each method of regional anaesthesia to advocate the general use of one and the exclusion of the other. When reviewing the literature the author specifically looked in to three key areas to answer this question: 1) the patient's perception of pain experienced during and after the manipulation; 2) patient safety i.e. the documented risks of the anaesthetic type used; and 3) the success of the manipulation as determined by repeat radiographs immediately after the application of a plaster of Paris cast.

Randomized double-blind study of the clinical duration and efficacy of Nesacaine-MPF 2% and 3% in peribulbar anesthesia

PURPOSE

To compare 2 commercially available concentrations of Nesacaine-MPF (2-chloroprocaine) to determine the time to onset of adequate motor blockade, the quality of surgical anesthesia, and the duration of motor blockade in the extraocular muscles after peribulbar anesthesia for cataract surgery.

SETTING

Tampa Eye and Specialty Surgery Center, Tampa, Florida, USA.

METHODS

This double-blind, randomized, single-center study comprised 40 patients scheduled to receive peribulbar anesthesia before cataract surgery. Patients were given 5 mL of Nesacaine-MPF 2% or 3% before surgery. Beginning at the end of the injection, assessments of ocular and eyelid movement were made every 2 minutes until adequate motor blockade was achieved or 25 minutes elapsed. Ocular assessments were made immediately after completion of surgery, 60 minutes after the end of the initial injection, and at 15 minute intervals thereafter until full recovery. Assessments of the quality of anesthesia achieved by the patient during surgery were made by the surgeon.

RESULTS

The 3% solution provided significantly faster onset of surgical anesthesia than the 2% solution (mean 3.9 minutes +/- 2.2 [SD] versus 6.0 +/- 3.6 minutes) (P = .02) but also required more time for recovery from anesthesia (98.9 +/- 18.7 minutes versus 84.8 +/- 20.6 minutes) (P = .02). All patients had adequate surgical anesthesia. Duration of ocular motor function was brief enough so that all patients could be sent home without an eye patch. Both concentrations were safe for use in this procedure.

CONCLUSION

Both Nesacaine-MPF 2% and 3% produced safe and effective peribulbar anesthesia in all patients; however, the 3% solution provided better duration of clinical anesthesia.

Topical anaesthesia for cataract surgery

First, do no harm. We believe that the analgesia provided by topical anaesthetic is adequate for small-incision cataract surgery and does not compromise the safety of the surgery. In addition, the lack of amaurosis is ideal for day-case surgery, which itself is increasingly popular. If preventable, why not prevented? The greatest attraction of topical anaesthesia is its complete absence of the complications described for injectional local anaesthetic techniques. We therefore recommend that our colleagues consider topical anaesthetic for patients undergoing small-incision cataract surgery under local anaesthesia. Our policy for the past 3 years has been to use only topical or general anaesthetics for cataract surgery.

Laparoscopic tubal ligation in a minimally invasive surgical unit under local anesthesia compared to a conventional operating room approach under general anesthesia

OBJECTIVE

This study was done to compare costs, operating and recovery times, safety, and patient acceptance between (a) minimally invasive laparoscopic tubal ligation under sedation and local anesthesia and (b) conventional laparoscopic operating-room-based tubal ligations under general anesthesia.

METHODS

Fourteen women desiring sterilization were randomized between tubal ligation under sedation/local analgesia versus general anesthesia. Procedures were performed by supervised residents previously unfamiliar with the minimally invasive technique. Hospital charges were used as a surrogate for cost. Operating or procedure room times, surgical complications, and recovery times were recorded. Patient acceptance was assessed using satisfaction surveys administered in the recovery room and again 1 week postoperatively.

RESULTS

The cost of minimally invasive tubal ligation was significantly lower than for the conventional technique ($1,615+/-$134 vs $2,820+/-$110, p < 0.001). Surgical times were not different between the two procedures: 40.4+/-15 min for the conventional technique versus 32.9+/-10 min for minimally invasive surgery. However, the total in-room time required in the operating room significantly exceeded that for the procedure room technique (84+/-10 min vs 60+/-2 min, p < 0.05). Likewise, recovery time for the general anesthesia technique was longer (48+/-6 min vs 14+/-7 min, p < 0.03). No complications were encountered with either surgical method. Patient satisfaction for pain, fatigue, and days of missed work was similar between the two groups.

CONCLUSIONS

The use of minimally invasive surgery to perform tubal ligation is advantageous over conventional laparoscopic tubal ligation under general anesthesia with regard to cost and time utilization. The minimally invasive technique appears to be easy to learn, safe, and well tolerated.