Skin Anesthesia Research Articles

Robust contact tracing and screening needed for leprosy control and protection of vulnerable children

Leprosy in children is considered as an indicator of active disease transmission in the community. We report about a seven- year-old male from Telangana, India, with anesthetic skin lesions and familial leprosy history. Clinical examination revealed multiple, dry, scaly, hypopigmented, well-defined, raised punched out anesthetic skin lesions all over the body with both ulnar nerves enlarged. On clinical and laboratory examination, the child was diagnosed with borderline-borderline (BB), multibacillary (MB) leprosy, and Type-1 reaction. The child received a weight-adjusted MB multidrug therapy regimen and corticosteroids for type-1 reactions. This case emphasizes the need for contact tracing and screening for early diagnosis of child leprosy to prevent complications like leprosy reactions which are the risk factors for disability.

Sensory cues, behavior and fur-based drying in the rat wetness response.

It never rains in standard lab-confinements; thus we have limited understanding of animal reactions to water and wetness. To address this issue, we sprayed water on different body parts of rats and measured drying and fur temperature by thermal imaging while manipulating behavior, sensory cues and fur. Spraying water on rats resulted in fur changes (hair clumping, apex formation), grooming, shaking, and scratching. Anesthesia abolished behavioral responses, interfered with fur changes, and slowed drying. Spraying water on different body parts resulted in differential behavioral drying responses. Spraying the head resulted in grooming and shaking responses; water evaporated from the head twice as fast as water sprayed on the animal's back or belly. We observed no effect of whisker removal on post-water-spraying behavior. In contrast, local anesthesia of dorsal facial skin reduced post-water-spraying behavioral responses. Shaving of head fur drastically enhanced post-water-spraying behaviors, but reduced water loss during drying; indicating that fur promotes evaporation, acting in tandem with behavior to mediate drying. Excised wet fur patches dried and cooled faster than shaved excised wet skin. Water was sucked into distal hair tips, where it evaporated. We propose the wet-fur-heat-pump-hypothesis; fur might extract heat required for drying by cooling ambient air.

Evidence-based surgery for cesarean hysterectomy secondary to placenta accreta spectrum: A systematic review

ObjectiveIn this systematic review, we aim to propose evidence-based management for perioperative care to improve outcomes at the time of planned cesarean hysterectomy for placenta accreta spectrum, a procedure associated with significant maternal and neonatal morbidity. Data SourcesWe conducted a literature search for studies published in MEDLINE (via Ovid), Embase, CINAHL, and Cochrane/CENTRAL up until February 25, 2022. The search included free-text and controlled-vocabulary terms for cesarean section, cesarean delivery, and hysterectomy. Study Eligibility CriteriaWe included randomized controlled trials, prospective cohort, retrospective cohort, and case-control studies published in English that reported on a perioperative intervention in the performance of a planned CH for PAS. Studies must have included a comparator group. Of the 8,907 studies screened in this systematic review, 79 met the inclusion criteria. Study Appraisal and Synthesis MethodsArticles examining each step or intervention of the CH were grouped together and reviewed qualitatively as a group. Evidence levels and recommendations were made by consensus of all authors according to the terminology of the United States Preventive Services Task Force (USPSTF). We synthesized the results of 79 articles, and provided 28 recommendations. ResultsBased on USPSTF criteria, 21.4 % of the recommendations were level B (n = 6), 39.3 % were C (n = 11), 10.7 % were D (n = 3) and 28.6 % were I (n = 8). The interventions with the highest level of recommendation included delivery at a hospital with high cesarean hysterectomy volume, implementation of a standardized hospital protocol, delivery via a planned procedure, neuraxial anesthesia, and transverse skin incision (all level B recommendations by USPSTF criteria). ConclusionsDevelopment of a standardized hospital protocol, delivery at a center with high CH surgical volume, and utilization of neuraxial anesthesia garnered B evidence levels. Recommendations were limited due to the lack of prospective trials. Further research into the technical aspects of this high-risk procedure is warranted.

The Effect of Preprocedural Low-Dose Ketamine for Pain and Anxiety in Patients during Thoracic Epidural Catheterization.

Background and Objectives: Thoracic epidural catheterization (TEC) can be both uncomfortable and fearful for patients when performed awake with the thought that the procedure may be painful. The aim of this study was to assess the effect of low-dose intravenous ketamine administration on pain and anxiety during the TEC procedure. Materials and Methods: Sixty patients were randomly divided into two groups to receive intravenous (IV) placebo (Group P) and IV low-dose (0.15 mg/kg) ketamine (LDK) (Group K) 3 min before the procedure in a double-blind manner. A visual analog scale (VAS) was used to measure anxiety (VAS-A) and pain (VAS-P) scores. Vital parameters were monitored before premedication (T1), 20 min after premedication (T2), during skin anesthesia (T3), during TEC (T4), and 5 min after TEC (T5). VAS-A values were recorded at T1, T3, T4, and T5 periods, and VAS-P levels were noted at T3, T4, and T5 periods. Results: During TEC (T4), both VAS-P and VAS-A were significantly lower in Group K (p < 0.001). The mean VAS-A value was 10.6 mm lower, and the mean VAS-P value was 9 mm lower in Group K than in Group P at the T4 time point. Additionally, the mean VAS-P value was 7.7 mm lower in Group K compared to Group P at the T3 time point (p < 0.001). Both groups showed a statistically significant difference in VAS-A measurements when compared at their respective time points (p < 0.001). However, only Group P demonstrated a statistically significant difference in VAS-P measurements (p < 0.001). VAS-P values remained stable in Group K. The number of patients who did not recall the procedure was significantly higher in Group K (p < 0.001). Furthermore, the number of patients who would consent to the same procedure in the future was significantly higher in Group K (p = 0.007). Conclusions: A preprocedural LDK (0.15 mg/kg) can effectively prevent anxiety and pain experienced by patients during the TEC procedure. Administration of LDK may provide a more comfortable procedure process without causing ketamine-induced side effects (hemodynamic, respiratory, and psychological).

Challenges in Diagnosing and Treating Subperiosteal Orbital Hematoma Secondary to Sinusitis: A Case.

Subperiosteal orbital hematoma secondary to sinusitis is rare. Thus far, 19 cases of this disease have been reported, of which none involved postoperative skin anesthesia in the region innervated by the supraorbital nerve. In this article, for the first time we report a case of subperiosteal orbital hematoma secondary to sinusitis with skin anesthesia in the area innervated by the supraorbital nerve after surgery.

Effect of topical sildenafil on wound healing and oxidative stress in rats

BackgroundIn this study, the effects of topical sildenafil applications on oxidative damage levels and antioxidative metabolism and their contribution to wound healing and treatment were investigated. Materials and MethodsA total of 24 healthy male rats aged 16–18 weeks, each weighing 200–250 g, were randomly divided into three groups: Group A received a saline solution, Group B received an epithelializing cream, and Group C received sildenafil cream. Following skin preparation and anesthesia, 6 mm diameter punch biopsies created wounds on the rats' backs. The treatment protocol involved daily topical dressing for seven days, after which tissue and blood samples were collected for analysis. Tissue samples underwent histopathological examination, while malondialdehyde (MDA) levels, superoxide dismutase (SOD), glutathione peroxidase (GPx), and catalase activities in wound tissue and blood samples were measured. ResultsThe wound surface area created by the punch decreased in all groups by the end of the seventh day; However, the degree of wound healing differed in favor of the sildenafil cream group. Histopathologically, according to Greenhalgh's Modified Wound Healing Scoring System, all findings were graded. In the Anova test, the differences between glutathione peroxidase, catalase, and malondialdehyde levels in the serum and tissue of rats was statistically significant (P < 0.05), whereas superoxide dismutase levels were not statistically significant (P > 0.05). In the Bonferroni test, the serum CAT levels between groups A and C (P = 0.003), between groups B and C (P = 0.035), and the serum MDA levels between groups A and B (P = 0.018) and between groups A and C (P = 0.001) were found to be significant statistically. By the way, the results between tissue CAT levels in the B and C groups (P = 0.020) and between tissue GPx levels (P = 0.001) in all groups were also significant statistically. ConclusionsThe study findings indicated that topical application of sildenafil led to noteworthy alterations in serum and tissue antioxidative metabolism as well as oxidative damage levels among rats with induced wounds. Sildenafil may be useful in wound treatment; it has been concluded that it is capable of directing new studies to be carried out.

A clinicoepidemiological study of leprosy among children and adolescents in a tertiary care centre in the post elimination era

Leprosy amongst younger age indicates active foci of transmission in the community. Our aim is to analyse the epidemiological profile, clinical spectrum, reactions and deformities of leprosy among children and adolescents. This is a prospective observational study conducted on all newly diagnosed leprosy patients under the age of 19 years for one year. Of 113 newly diagnosed leprosy cases, 38 patients were under 19 years of age. Male-female ratio was 5.3:1. Mean age was 16.6 years. Borderline tuberculoid (BT) was the most common type followed by borderline lepromatous (BL) and Indeterminate (I) leprosy most common manifestation was hypopigmented anaesthetic skin lesion over exposed parts. 79% had multiple nerve trunk involvement of which ulnar nerve was the most common. Reaction and deformity were found to be in 21% and 18.3%. Both were seen only in multibacillary cases and predominantly in 15-19years of age. Risk factors for reactions were male sex, increasing age, labourers, borderline spectrum, skin lesion involving the nerve trunk, multiple nerve involvement and smear positivity. Risk factors for deformities were migrants in lower socio-economic status, increased duration of active disease and delayed diagnosis. Leprosy, a disease of long incubation period, among adolescents may indicate missed cases of childhood leprosy. Training through integrated service in early diagnosis and its complication, introduction of an exclusive type of treatment (MB MDT) for all categories for a shortened duration and newer drugs for reactions, sustained commitment to follow-up care and health education among community is a need at this post elimination era.

ULTRASOUND-GUIDED GENICULAR NERVE BLOCK FOR KNEE OSTEOARTHRITIS: A CASE SERIES.

Knee genicular nerve blocks have been a topic of discussion among various types of treatment for knee osteoarthritis. This study aims to evaluate the pain and function of patients diagnosed with knee osteoarthritis after undergoing ultrasound-guided genicular nerve blockade using pharmacological agents. The study included 36 patients diagnosed with knee osteoarthritis, comprising 17 bilateral cases, totaling 53 knees undergoing UGNB using a mixture of triamcinolone, ropivacaine, and lidocaine under ultrasound guidance. Epidemiological data, pain outcomes measured by the Visual Analog Scale (VAS), and function assessed using the Western Ontario and McMaster Universities (WOMAC) score were evaluated before and after 12 weeks of the procedure. The mean age was 75.5 years (standard deviation of 9.4 years), with a predominance of females and right-sided involvement. There was a mean reduction of 3.0 points in VAS (p < 0.001) and 15.4 points in WOMAC (p < 0.001). Two cases reported only minor and transient complications related to the procedure (skin anesthesia and edema). Ultrasound-guided genicular nerve blockade using pharmacological agents demonstrated pain reduction and improved function with a low complication rate after 12 weeks in patients with knee gonarthrosis. Level of Evidence IV, Case Series.

Association between postinduction hypotension and postoperative mortality: a single-centre retrospective cohort study

PurposeWe aimed to elucidate whether postinduction hypotension (PIH), defined as hypotension between anesthesia induction and skin incision, and intraoperative hypotension (IOH) are associated with postoperative mortality.MethodsWe conducted a retrospective cohort study of adult patients with an ASA Physical Status I–IV who underwent noncardiac and nonobstetric surgery under general anesthesia between 2015 and 2021 at Nagoya City University Hospital. The primary and secondary outcomes were 30-day and 90-day postoperative mortality, respectively. We calculated four hypotensive indices (with time proportion of the area under the threshold being the primary exposure variable) to evaluate the association between hypotension (defined as a mean blood pressure < 65 mm Hg) and mortality using multivariable logistic regression models. We used propensity score matching and RUSBoost (random under-sampling and boosting), a machine-learning model for imbalanced data, for sensitivity analyses.ResultsPostinduction hypotension and IOH were observed in 82% and 84% of patients, respectively. The 30-day and 90-day postoperative mortality rates were 0.4% (52/14,210) and 1.0% (138/13,334), respectively. Postinduction hypotension was not associated with 30-day mortality (adjusted odds ratio [aOR], 1.03; 95% confidence interval [CI], 0.93 to 1.13; P = 0.60) and 90-day mortality (aOR, 1.01; 95% CI, 0.94 to 1.07; P = 0.82). Conversely, IOH was associated with 30-day mortality (aOR, 1.19; 95% CI, 1.12 to 1.27; P < 0.001) and 90-day mortality (aOR, 1.12; 95% CI, 1.06 to 1.19; P < 0.001). Sensitivity analyses supported the association of IOH but not PIH with postoperative mortality.ConclusionDespite limitations, including power and residual confounding, postoperative mortality was associated with IOH but not with PIH.

Adaptogen Technology for Skin Resilience Benefits

(1) Background: Skin undergoes constant changes, providing capabilities to repair and renovate its constituents once damaged and a fundamental shield to contrast environmental stress. Nevertheless, environmental stressors may overcome the skin’s protective potential inducing premature aging and accelerating the appearance of anaesthetic age-related skin aspects. Ultraviolet radiation (UVR) and pollutants (particulate matters, PAHs) contribute to skin aging and functional decline inducing harmful oxidative modifications of macromolecules and stress-related skin disorders. Innovative approaches to preserve skin are needed. (2) Methods: Skin keratinocytes were treated (or not) with a combination of ingredients (Lactobacillus plantarum extract, Withania somnifera root extract and Terminalia ferdinandiana fruit extract; “MIX”) in the presence or absence of stress (oxidative stress or pollution). The effects of the MIX adaptogen technology on (a) cellular resilience, (b) the regulation of cellular functions and (c) regeneration of skin were disclosed through expression proteomics and bioinformatics analyses first, and then through focused evaluations of protein carbonylation as a hallmark of oxidative stress’ deleterious impact and mitochondrial activity. (3) Results: The deleterious impact of stressors was evidenced, as well as the beneficial effects of the MIX through (a) mitochondrial activity preservation, (b) the “vigilance” of the NRF2 pathway activation, (c) NADPH production and protein homeostasis improvements, (d) preserving skin regeneration function and I the contrasting stress-induced oxidation (carbonylation) of mitochondrial and nuclear proteins. (4) Conclusions: The effects of the MIX on increasing cell adaptability and resilience under stress suggested a beneficial contribution in precision cosmetics and healthy human skin by acting as an adaptogen, an innovative approach that may be employed to improve resistance to harmful stress with a potential favourable impact on skin homeostasis.

Open Otoplasty Through Ventral Skin Incision and Abrasion of the Antihelix Under Vision.

Common otoplasties through incisions behind the ear with blind scoring or scratching the anterior perichondrium often leave an irregular surface of the antihelix. To avoid these tiny side effects, a skin incision along the ventral antihelical fold (scapha) is used to thin and fold the flat antihelix under vision. After local anesthesia of the ventral ear skin, an incision along the scapha allows its blunt lifting toward the concha and to expose the cartilaginous antihelix. Its future shape is marked and the thickness of the cartilage is thinned with a dermabrader by approximately half or until one sees the gray of the inner cartilage. The now missing perichondrium causes the antihelix to fold by itself with an absolute smooth surface and is fixed with three absorbable mattress sutures. The technique has been developed in 1985 in Frankfurt and has since been performed on over 1000 patients with optimal results and a low complication rate. The skin flap is so well perfused that no skin necrosis and only 5.7% wound healing problems were experienced. This approach from ventral is safe, timesaving, and avoids contour irregularities of the antihelix often seen after traditional techniques. It can be left to beginners in plastic surgery without hesitation. The fear of hypertrophic scars or even keloids can be dispelled with the fact that ear keloids only occur after wound infection. This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266.

Lidocaine hydrochloride loaded isomaltulose microneedles for efficient local anesthesia of the skin

Lidocaine hydrochloride (LIDH) as an anesthetic is widely used in local anesthesia. Dissolving microneedles (MNs) have great application value in the field of skin anesthesia. However, the limited drug-loading of dissolving MNs is an existing challenge that affects clinical use. In this study, we have screened isomaltulose (ISO) as the proper matrix material for the MNs by using molecular dynamics (MD) simulation. Our findings indicate that ISO has good compatibility with LIDH, and the LIDH-loaded ISO MNs (LI-MNs) have high drug-loading capacity. The drug-loading capacity of LI-MNs could reach 80%, and it could effectively puncture the skin. In addition, the preparation method of customized LI-MNs was established based on three-dimensional (3D) printing technology. It was shown that the administration time of LI-MNs could be controlled within 3 min. Also, the LI-MNs were able to provide the local anesthetic efficacy within 2 min and sustained for more than 2 h. Significantly, LI-MNs had more efficient drug efficacy compared to the topical creams and the majority of existing LIDH-loaded dissolving MNs. They even provided a longer duration of action than the injections. Overall, the LI-MNs with high drug-loading have a promising application prospect.

The Association of Fetal Acidemia With Adverse Neonatal Outcomes at Time of Scheduled Cesarean Delivery

ABSTRACT Up to 30% of term labor deliveries experience fetal acidemia, a condition usually caused by hypoxia that is associated with adverse neonatal outcomes. The American College of Obstetricians and Gynecologists and American Academy of Pediatrics recommend assessing fetal umbilical artery (UA) blood gases at delivery when fetal metabolic status is in question. Although a UA pH of 7.24 to 7.28 is considered normal, the degree of acidemia associated with neonatal death is unclear. Recent data suggest that mild acidemia (UA pH of 7.0–7.2) and certain types of acidemia (metabolic, mixed, or respiratory) also indicate increased risk for adverse outcomes. Most cases of acidemia follow labor when the placental gas exchange is interrupted during contractions. But fetal acidemia is rare in cases of scheduled prelabor cesarean delivery (CD) and not well described in the literature. This study aims to determine if fetal acidemia at the time of scheduled, prelabor CD is associated with neonatal morbidity. This was a retrospective cohort study comparing patients with and without fetal acidemia, defined as a UA pH &lt;7.2. Included were singleton neonates delivered via scheduled CD at a single tertiary care center from June 2004 to December 2014. Excluded were those who delivered before 37 weeks of gestation, were diagnosed with major anomalies, or underwent CD due to labor, rupture of membranes, or nonreassuring fetal status. Also excluded were cases in which data on validated umbilical cord gases were unavailable. The primary outcome was a composite of neonatal outcomes, including neonatal death, encephalopathy, therapeutic hypothermia, seizures, intubation, and respiratory distress. A total of 2081 neonates met the inclusion criteria, with fetal acidemia present at the time of delivery in 252 cases (12.1%). Acidemia occurred more frequently in breech neonates and those born to mothers with gestational diabetes mellitus or obesity. Intraoperative maternal hypotension, use of vasopressor therapy, and increased times from anesthesia induction and skin incision to delivery were also more likely to occur in cases of acidemia. The primary composite outcome was observed in 176 (8.5%) of neonates. This outcome was significantly higher in those with acidemia than those without (7.6% vs 15.1%; adjusted risk ratio [aRR], 2.95; 95% confidence interval [CI], 2.03 to 4.12). Intubation (aRR 3.50; 95% CI, 1.27–9.13) and respiratory distress (aRR, 2.93; 95% CI, 2.00–4.13) also occurred more frequently among those with acidemia. As the rate of UA pH categories decreased, the proportion of neonates with the primary outcome increased: 13.5% morbidity if UA pH was 7.0 to 7.19 versus 42.9% morbidity if UA pH was &lt;7.0. Compared with neonates with a UA pH ≥7.2, the risk for adverse outcomes rose 3.2-fold in those with a UA pH &lt;7.1 (aRR, 3.23; 95% CI, 1.73–5.24) and 6.6-fold in those with a UA pH &lt;7.0 (aRR, 6.64; 95% CI, 3.23–8.96). The primary outcome was observed in 24.7% of neonates with respiratory acidemia, 27.5% with mixed, and 25% with other acidemia. There were no cases of metabolic acidemia. Compared with neonates without acidemia, the risk for adverse outcomes after controlling for confounders increased 2.7-fold in those with respiratory acidemia (adjusted odds ratio, 2.77; 95% CI, 1.74–4.15) and 3-fold in those with mixed acidemia (adjusted odds ratio, 3.08; 95% CI, 1.72–4.93). In conclusion, there was an increased risk of adverse neonatal outcomes in cases with mild fetal acidemia at the time of scheduled CD. Most cases in this study were attributed to respiratory acidemia.

Evaluation of the Physical Treatment Success in Patients with Peripheral Nerve Injury Caused by Firearm

Background: All wars bring high incidence of patients with peripheral nerve injuries, and many of today's knowledge about degeneration, regeneration and surgical treatment in this casuistry come from the period of the global world conflict. Such injuries do not endanger life, but the function of the extremities is threatened, which manifests itself in motor and sensory outbursts, as well as negative psychological implications. Objective: The aims of this article were: a) To present the method of monitoring physical treatment in a patient with a peripheral nerve injury; b) To perform a quantitative analysis of nerve lesions caused by firearms (n = 445);; c) To present the effects of physical treatment for this condition;; d) To analyze the time interval from injury to healing (n = 220);; e) Determine the time from injury until the surgery. Results: Anatomical disruption of axons with complete Waler degeneration. The connective tissue network remains intact and the endoneurium can guide the regenerated nerve fibers to their destination. Spontaneous functional recovery can be expected in 12 to 18 months. Clinical evaluation shows a deficit in the innervation area of damaged axons with muscle atrophy and loss of sensitivity. Nerve recovery can be inhibited by scar formations at the site of injury. Complete interruption of the nerve. Functional recovery is not possible without surgical intervention. Paralysis of mm. atrophy, anesthesia and atrophic skin changes are visible. Conclusion: Rehabilitation is a delicate problem and requires long-term treatment and multidisciplinary cooperation, and is carried out in accordance with the principles of peripheral nerve repair. Factors that facilitate successful regeneration are: a) Pre and post-operative physical treatment; b) Younger age; c) Shorter time since injury (&lt;6 months); d) More distal level of the lesion; e) Absence of factors complicating the injury (infection); and f) The first signs of nerve recovery are the return of sweating and pain.

256 Enlarged pore reduction by targeting parakeratosis and reinforcing dermal extracellular matrix

Enlarged pores is a common anesthetic skin issue mainly driven by excessive parakeratosis, loss of mature collagen and poor extracellular matrix (ECM) renewal. These events conduct to premature ageing with hyperdifferentiation and fragile and coarse dermis. A combination including amino acids, copper, mannose-6-phosphate and lactic acid was designed to counteract the main causes of pores formation. Impact on parakeratosis was evaluated in vitro with genes expression analysis on keratinocytes and using a model of RHE with morphological staining and involucrin immunostaining.

Standardized Quantitative Sensory Testing to Assess Insufficient Recovery of Touch Discrimination in Free Flap Surgery.

With major advances in microsurgical techniques, free tissue transfer has become a widely adopted approach to treat complex soft-tissue defects. However, sensory recovery is poor, leaving the anesthetic skin prone to injuries. Twenty-eight patients with 22 anterior lateral thigh flaps and six latissimus dorsi flaps on their extremities participated in the study. Quantitative sensory testing and two-point discrimination was performed in three test areas and one control on the contralateral unaffected extremity. Physical disability, mental health, quality of life, and characteristics of pain were assessed by the painDetect, Disabilities of the Arm, Shoulder, and Hand, Lower Extremity Functional Scale, and 12-Item Short Form questionnaires, respectively. Somatosensory profiles of all flaps were characterized by an overall loss of nerve function. Small-fiber function was mostly recovered, whereas large-fiber function, and thus touch discrimination, was severely impaired. Mechanical detection thresholds improved over time and from center to the periphery. Reported pain was mild to moderate and correlated with decreased physical function. Standardized quantitative sensory testing provides a useful tool kit to assess the sensory regeneration after surgical treatment of soft-tissue defects. After free tissue transfer, small-fiber function recovers with nerve ingrowth in a centripetal direction from the flap margins to the center, likely by way of collateral axonal sprouting from the undamaged nerves surrounding the flap. Myelinated fibers recover slowly and inefficiently. Therapeutic, IV.

Reliability of analgesia nociception index (ANI) and surgical pleth index (SPI) during episodes of bleeding - A pilot study.

Background and Aims:Analgesia Nociception Index (ANI) and Surgical Pleth Index (SPI) are measures of nociception-antinociception balance during general anaesthesia. The validity of these two monitors during autonomic changes brought about by intraoperative blood loss and noradrenaline infusion has not been studied earlier. The primary objective of the study was to determine the effect of bleeding on ANI and SPI. The secondary objective was to observe the effect of noradrenaline infusion on ANI and SPI and the correlation between ANI and SPI.Methods:In this prospective observational study, 43 patients undergoing surgery for excision of a meningioma or for traumatic brain injury were included. Heart rate, mean arterial pressure, ANI, SPI, response and state entropy were recorded every 5 min from anaesthetic induction till skin closure. ANI and SPI values before bleeding were compared with the values following bleeding. The effect of bleeding and noradrenaline on ANI and SPI were studied using linear mixed effect model.Results:Bleeding increased the values of ANI and the increase was higher in the presence of noradrenaline and it was statistically significant (P = 0.028 and 0.023). SPI was not affected by bleeding or with noradrenaline infusion. ANI and SPI had a poor negative correlation (r = - 0.01).Conclusion:Values of ANI increased significantly during episodes of intraoperative acute blood loss and with co-administration of noradrenaline. SPI seems to be more dependable when compared to ANI under such conditions.

Iontophoretic Transport of Local Anesthesia: A Literature Review

Aim:This study aimed to comprehensively review the literature about the use of iontophoresis for the transportation of local anesthesia to better understand the feasibility of such technique and its benefits compared to other delivery systems. In addition, in the current review we present the challenges compromising the use of this drug delivery system in this area. Material and Methods: This is a literature review which aimed to screen old as well as very recent literature on the technique, methodology, clinical findings, influencing factors of local anesthetics iontophoresis, thus PubMed electronic databases were screened. Indexed articles during the time period extending between 1977 and 2021 were tentatively reviewed. This review was registered by and it only included articles written in English. Research studies conducted in vitro or on animals were excluded in addition to case studies, case series, and pilot studies. Articles that included major forms of bias were also excluded. Pubmed database was screened using the following Mesh terms: Anesthetics, Local / administration &amp; dosage*, Epinephrine / administration &amp; dosage, Ethanol / pharmacology, Humans, Iontophoresis*, Lidocaine / administration &amp; dosage, Regional Blood Flow, Skin / blood supply, Skin / drug effects*Skin / metabolism. Results: A total of 89 studies were screened for possible inclusion after searching for the above mesh terms in PubMed. Eventually, 16 articles were included in this review where 2 studies were related to iontophoretic anesthesia of the ear, 6 were related to skin anesthesia, and 7 related to the oral cavity. The other three studies compared the use of local anesthesia mediated by iontophoresis to other approaches and the change in dosing requirements following iontophoresis administration of local anesthetics. Keywords: Pain management, local anesthesia, drug delivery system, transport, Iontophoresis.

Clinical case of a patient at risk of perioperative recurrence of takotsubo cardiomyopathy

Introduction.Takotsubo syndrome is a new nosological form of acquired cardiomyopathy characterized by transient left ventricular dysfunction in response to physical or psychoemotional stress, clinically and electrocardiographically resembling acute coronary syndrome. Takotsubo cardiomyopathy is a form of stress cardiomyopathy simulating acute myocardial infarction with electrocardiographic and biochemical changes. Despite a large number of publications, there is no definitive understanding of the etiopathogenesis, clinical picture, treatment, as well as measures to prevent the development of takotsubo cardiomyopathy. With the manifestation of takotsubo cardiomyopathy in the perioperative period, the clinical picture may be even less specific, which inevitably leads to diagnostic difficulties. Given that the main trigger of the disease is stress, the development of this disease is an urgent problem of anesthesiology and intensive care. In addition, there is a problem of managing patients with a history of takotsubo cardiopathy, if they need surgical interventions.The aim of the workwas to prove the effectiveness of a number of approaches (premedication with the use of barbiturates and α2-adrenoceptor agonists; monitoring the depth of anesthesia; administration of narcotic analgesics in continuous infusion; use of local anesthetics for skin anesthesia; multimodal anesthesia in the postoperative period) to the perioperative management of patients with a high risk of CT recurrence.Materials and method.We present a clinical case demonstrating the possible tactics of perioperative management of a patient with a history of CT that manifested during anesthesia when a follow-up benefit was needed. The clinical picture is described, the results of instrumental and laboratory investigations indicating a correct CT diagnosis are presented.Results.An individual strategy for perioperative management of the patient was developed and implemented, which made it possible to avoid a CT recurrence. Discussion. The etiopathogenesis of the disease and analysis of the few literature sources on the topic allow us to propose a number of approaches to the perioperative management of patients at risk of recurrence of CT.Conclusions.A number of approaches (premedication with barbiturates and α 2-adrenoceptor agonists; anesthesia depth monitoring; administration of narcotic analgesics in continuous infusion mode; use of local anesthetics for skin anesthesia; multimodal anesthesia in the postoperative period) to perioperative management of patients with high risk of CT recurrence were demonstrated to be successful.

Musculoskeletal manifestations of leprosy.

A 32-year-old lady presented with a 1-month history of recurrent painful nodules over her legs and forearms (Fig. 1A), bilateral symmetric small- and large-joint polyarthritis, swelling of dorsal hands and feet, and dactylitis (Fig. 1B–D). The possibilities of sarcoidosis, tuberculosis, leprosy, SLE, lymphomatoid granulomatosis, and s.c. panniculitis-like T-cell lymphoma were considered. The patient did not have constitutional symptoms, lymphadenopathy, pulmonary or ocular involvement, thickened nerves, or an anaesthetic skin patch, and had no relevant medical family history. A skin biopsy from a nodule showed granulomatous inflammation of foamy macrophages and lymphocytes surrounding the neurovascular bundle (Fig. 1E). Her haemogram, liver and renal function tests, and electrolytes were normal. Her ESR was 42 mm and CRP 24.7 mg/dl, and RF, anti-cyclic citrullinated peptide antibody, ANA, serum angiotensin-converting enzyme levels, and viral markers were negative. A slit skin smear and PCR for Mycobacteriumleprae were positive. A diagnosis of lepra reaction—erythema nodosum leprosum with swollen hands and feet was made. She was treated with prednisolone (40 mg/day) and multidrug therapy (rifampicin, clofazimine and dapsone). All symptoms improved within days to weeks of starting treatment. Musculoskeletal manifestations in leprosy can either present acutely—lepra reaction, swollen hands and feet syndrome, tenosynovitis—or chronically—symmetric polyarthritis as in RA or Charcot’s arthropathy, and can mimic various rheumatic diseases [1]. Arthritis with skin nodules is rarely an initial presentation of Hansen's. Thickened nerves, anaesthetic skin patches, ear lobule infiltration, and anti-cyclic citrullinated peptide antibody levels may help in differentiating [2].