Local Anesthetic Solution Research Articles

A Prospective Randomized Study to Assess the Quality of Life in Post-Operative Recovery Phase in Patients Undergoing Surgery for Isolated Vertically Undisplaced Mandibular Parasymphysis Fracture Using Twin Mix Solution.

Trauma is a major cause for facial fractures commonly encountered by maxillofacial surgeons. Mandible is commonly involved in facial trauma resulting in an isolated fracture or associated with other facial bones due to its prominent location in the facial skeleton. This study was undertaken to investigate the quality of life (QoL) post-operatively in patients diagnosed with undisplaced parasymphysis fracture who underwent open reduction and internal fixation (ORIF) under local anesthesia (LA) using the twin mix (TM) solution. A prospective randomized clinical study was conducted among 40 patients aged between 20-55years requiring ORIF for unilateral vertically undisplaced parasymphysis fracture under LA. Group A patients (n = 20) received conventional LA solution with adrenaline, and Group B patients (n = 20) received freshly prepared TM solution for their surgical intervention as a day care procedure. Various parameters such as jaw function, ability to masticate and labialis activity (lower lip pout) were assessed. The data were collected and analyzed applying student's t test, Shapiro-Wilk test using SPSS software. All the 20 patients in Group B who received TM solution exhibited better jaw function and mouth opening with a mean score of (±SD) of 4.55 (±0.944). They also exhibited reduced difficulty in mastication and ability to purse the lower lip on third post-operative day as compared to the patients in Group A. No complications were observed among the patients post-operatively in both the groups of this study. TM solution proves to be superior as compared to the conventional LA solution as the former offers an improved clinical outcomes enhancing the QoL post-operatively in patients undergoing ORIF for undisplaced parasymphysis mandibular fracture.

Safety and efficacy of dexamethasone as an adjuvant to bupivacaine in bilateral transversus abdominis plane block in children undergoing major abdominal surgery

BackgroundThis prospective randomized controlled double-blind clinical study was conducted on 52 patients of both genders divided into two groups (26 patients each). Local anaesthetic solution of isobaric bupivacaine 0.25% (0.3 ml/kg) was prepared. Group A received bilateral transversus abdominis plane (TAP) block with bupivacaine and dexamethasone (0.3 mg/kg) while group B received bilateral TAP block with bupivacaine and volume of saline equal to the amount of dexamethasone given in group A. Patients were observed for FLACC pain scale at the time of discharge from the post-anaesthesia care unit and then every 2 h for 36 h after the operation. This study was conducted to assess the safety and efficacy of adding dexamethasone to bupivacaine on the quality of bilateral US-guided transversus abdominis plane (TAP) block in children undergoing major abdominal surgeryResultsDexamethasone added to local anaesthetic in ultrasound-guided TAP block significantly decreased FLACC score at 8, 10, and 12 up to 24 h postoperatively, The time to the first requested analgesia was prolonged in the dexamethasone group (P = 0.000). The total dose of acetaminophen consumption over 36 h after surgery was also reduced (P = 0.000), but no difference was found regarding the total dose of rectal diclofenac (P = 0.068).ConclusionAdding dexamethasone to isobaric bupivacaine TAP block reduces postoperative pain and analgesic requirements compared to isobaric bupivacaine TAP block alone in children undergoing major abdominal surgery.

Amount of Local Anesthetic Solution Used in Mandibular Third Molar Surgery- A Retrospective Analysis

Mandibular third molar is the most commonly impacted teeth and surgical removal of them is the most common minor oral surgical procedure done under local anesthesia in the outpatient department. For a comfortable patient experience and best surgical results, emphasis should be made on a pain-free procedure. In this study, we aim to analyse retrospectively the amount of local anesthetic solution used during surgical removal of impacted mandibular third molar and to find if any association between the amount of local anesthesia used and Pederson's difficulty Index (PDI) of the impacted teeth. Retrospective observational study conducted among patients reporting to the Department of Oral and Maxillofacial Surgery, Chennai for the surgical removal of impacted mandibular third molar between the study period June 2019 to March 2020. 658 patients who fulfilled the inclusion and exclusion criteria were included in the study. Data regarding patients demography, site of impaction, Pederson Difficulty Index of impacted teeth, amount of local anesthesia used were rewarded. The data were statistically analysed using descriptive statistics in IBM SPSS version 20 software. Study population included 58.4% males and 41.6% females, majority of them in the 3rd decade of life. (53.6%) with mean age 29.1 years. Of 658 impacted teeth analysed 54.4% were moderately difficult followed by minimally difficult 38.4% and very difficult 7.1% according to PDI. A significant association was found between the amount of local anesthesia used and PDI score of impacted teeth. In 64.7% cases 2ml of local anesthesia was sufficient to achieve anesthesia during the procedure. 2ml of local anesthesia is sufficient to achieve adequate anesthetic effect in surgical removal of impacted molar. As PDI increased, the amount of local anesthesia used also increased.

Efficacy of Topical Tranexamic Acid (Cyclokapron) in "Wet" Field Infiltration with Dilute Local Anaesthetic Solutions in Plastic Surgery.

Surgical bleeding may lead to the need for blood transfusion and minimizing blood loss has been a basic principle followed by surgeons for generations. Antifibrinolytic agents are widely used to reduce perioperative haemorrhage. The present study sought to assess the efficacy of directly infiltrated tranexamic acid in ameliorating bruising in participants undergoing cosmetic plastic surgery (liposuction). The study employed a blinded, prospective, randomized, case control design. Thirty-three patients were studied. Tranexamic acid free infiltration tumescent solution (saline, bupivacaine lignocaine and adrenalin) was infiltrated to one flank of patients undergoing liposuction of flanks. The other flank was infiltrated with the same tumescent solution (saline, bupivacaine lignocaine and adrenalin) mixed with tranexamic acid (0.1%). Bruises were photographed one and seven days after surgery and measured for size. The surface area of the bruises was calculated using ImageJ software. We compared the bruised surface are between the tranexamic acid infiltrated flank and non-tranexamic acid infiltrated flank in the same patient. The model employed involved measuring the bruises on each flank of the same patient, with surgery by a single surgeon using the same infiltration and surgical techniques for both sides. The only variable was the difference in tranexamic acid concentration between study and control flanks. We found that use of tranexamic acid consistently resulted in a smaller bruise area on days one and seven after liposuction of flanks. Results were statistically significant. This is the first study examining addition of tranexamic acid to a tumescent infiltration solution-to produce a predictable local concentration of tranexamic acid-in order to maximize surgical site effect and minimize systemic effect. The authors recommend incorporation of tranexamic acid as a routine component along with adrenaline and local anaesthetics in tumescent field infiltration solution 10-15min before commencement of the cosmetic surgery. 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 .

Effect of 2% lignocaine with and without magnesium sulfate for inferior alveolar block in symptomatic mandibular molars

Background and Aim: Magnesium sulphate is used in the field of anaesthesia to increase the quality of anaesthesia. the aim of our prospective randomized, double-blind, controlled clinical trial was to combine MgSO4 with 2% lignocaine in two different concentrations (75 mg and 150 mg) to evaluate the onset, duration and anesthetic efficacy, and postoperative analgesia during routine root canal treatment in patients with symptomatic irreversible pulpitis and symptomatic apical periodontitis.Material and Methods: The study consisted of three groups: 1.5 ml of 2% LA only (group 1), 1.5 ml of 2% LA with 0.15 ml of MgSO4 containing an osmolar concentration of approximately 4.060 mosmol/ml that is equivalent to 75 mg of MgSO4 (group 2). Group 3 consisted of 1.5 ml of 2% LA with 0.3 ml of MgSO4 equivalent to 150 mg of MgSO4. Pre-operative vitals and Heft Parker–Visual Analogue Scale (HP-VAS) pain scores were recorded. The onset of anesthesia, anesthetic efficacy, and duration of anesthesia were evaluated post administration of the local anesthetic solution. The post-operative analgesia was examined at intervals of 2, 6, 12, 24, and 48 h. Results: Both experimental groups showed a significant difference in the onset, duration, and anesthetic efficacy compared to the control group. There was no significant difference between groups 2 and 3 in terms of the onset and anesthetic efficacy, but a significant difference was observed in the duration of anesthesia. Friedman non-parametric test showed significant reduction in pain from the 12th hour in the experimental groups. Conclusion: Present study shows that both 75 mg and 150 mg of MgSO4 in combination with LA are more effective than 2% LA alone. The anesthetic duration achieved with 75 mg of MgSO4 is more than adequate for most of the dental procedures. Pertaining to the post-operative analgesia, both 75 mg and 150 mg did not have significant difference from 24 h onwards.

Randomized controlled study comparing the efficacy of neuraxial blockade by using intrathecal administration of 0.5% hyperbaric bupivacaine 15mg and fentanyl 25mcg - in a single syringe versus separate syringe techniques in inguinal hernia surgeries

Adjuvants premixed with local anaesthetic solution can alter the density of the hyperbaric solution affecting the spread of block. Administering local anaesthetic and adjuvant in a separate syringe may minimize these changes with respect to densities. Hence we aimed to compare the efficacy of the drugs when administered sequentially and as a mixture. To compare the efficacy of neuraxial blockade with pre- mixed fentanyl and 0.5% hyperbaric bupivacaine and sequential administration of fentanyl and 0.5% hyperbaric bupivacaine. After obtaining the institutional ethics committee approval, patients were randomly allocated into Group M = received spinal anesthesia using 15mg of 0.5% bupivacaine heavy and 25mcg fentanyl premixed in the same syringe. Group S = received spinal anesthesia sequentially. Drugs were injected through 25 gauge quincke’s needle in sitting position, inserted at L3-L4 space. Onset of block ,hemodynamics, duration of analgesia and complications were monitored. Group S had slower onset and slow progression of the block with more time taken to regression of the block compared to the group Incidence of hypotension ,bradycardia was less in group S compared to group M. We conclude that administrating adjuvants to local anaesthesia sequentially is better than mixing them in a single syringe in terms of surgical anaesthesia, hemodynamic stability and post operative pain relief.

Onset times and duration of analgesic effect of various concentrations of local anesthetic solutions in standardized volume used for brachial plexus blocks

Visualization of the nerve structures of brachial plexus allows anesthesiologists to use a lower dose of local anesthetics. The content of this low dose is not unequivocal, consequently, the pharmacokinetics of local anesthetics used by various authors are difficult to compare. In this study, the onset times and duration of the analgesic effect of local anesthetic mixture solutions used for brachial plexus blocks are investigated and the quality of anesthesia is compared. 85 unpremedicated American Society of Anesthesiologist physical status I-III, 19-83-year-old patients scheduled for upper limb trauma surgery are assigned to four groups for the axillary-supraclavicular block with lidocaine 1% and bupivacaine 0,5% 1:1 mixture (Group LB) or bupivacaine 0.33% (Group BS) or lidocaine 0,66% (Group LS) or bupivacaine 0.5% and lidocaine 1% 2:1 mixture (Group BL). 0.4 ml/kg was administered to the four groups. The onset time was significantly shorter in the lidocaine group (LS 13.0 ± 1.02) than in the other study groups (LB 16.64 ± 0.89; BS 17.21 ± 0.74; BL 16.92 ± 0.51 min ±SEM, p = 0.002). No differences were observed in the onset times between LB, BS, and BL groups (p > 0.05). Statistical differences were found in the duration of local anesthetics between LB (392.9 ± 20.4), BS (546.4 ± 14.9), LS (172.85 ± 7.8), and BL (458.7 ± 11.9 min ±SEM, p = 0.001). Lidocaine does not shorten the onset times, but significantly decreases the duration of action of bupivacaine when used in mixture solutions. Lidocaine exhibits a good quality of block in the applied dose, while other solutions have excellent quality. Bupivacaine without lidocaine has the longest duration of action to achieve the longest postoperative analgesia.

COMPARATIVE STUDY OF ULTRASOUND GUIDED TRANSVERSUS ABDOMINIS PLANE BLOCK USING BUPIVACAINE WITH AND WITHOUT HYALURONIDASE IN LAPAROSCOPIC BARIATRIC SURGERY

Background: Transversus abdominis plane (TAP) block is atechnique of regional anesthesia, which reduces the pain derived from abdominal wall incisions, decreases general anesthesia requirements, and increases hemodynamic stability. Hyaluronidase is an enzyme considered as the “spreading factor”, facilitating the spread of local anesthetic solutions. It has been shown to produce reliable blockade with better spread and therefore better quality of block when used with local anesthetics.Aim of the work: The aim of this study is to compare the efficacy of Injection of Bupivacaine 0.25% and Injection of Bupivacaine 0.25% with Hyaluronidase 1500 Uin ultrasound guided transversus abdominis plane block.Patients and methods: This double blinded randomized controlled clinical trial study was conducted in the Department of anesthesia, Faculty of Medicine, Ain Shams University and general hospitals during the period from 1st January 2018 to 31stDecember 2018 after being approved by the department ethical Committee. The study population included 60 bariatric patients which were randomly divided into 2 groups (30 patients in each group);Group A: TAP block with Bupivacaine 0.25% 19 ml+1 ml normal saline (loading dose) followed by continuous infusion of Bupivacaine 0.25% at a rate of 4ml/hr.; i.e., 96 ml/24hrs.Group B: TAP block with Bupivacaine 0.25% 19 ml+ Hyaluronidase 1500 U 1ml (loading dose) followed by continuous infusion of Bupivacaine 0.25%+ Hyaluronidase 50 U at a rate of 4ml/hr.; i.e., 96 ml/24hrs.Results: the group of TAP block with Bupivacaine and Hyaluronidase (Group B) had statistically lower NRS 2nd, 4th, 6th, 8th,16th, 22ndand 24th postsurgical day (p=0.28, 0.42,0.018, 0.003, 0.003, 0.004 and 0.041 respectively). Also Group B had statistically lower mean of opioid consumption in 2nd, 4th, 6th, 8th,16th, 22th and 24th postsurgical day with overall lower mean of opioid consumption among group B (p=0.002).Regarding vital data among both groups was non-significant (p≥ 0.2).Conclusion: Our findings support the use of ultrasound guided TAP block using liposomal bupivacaine with hyaluronidase as part of multimodal analgesia for bariatric surgery based on decreased postoperative opioid requirements.

A reliable septum exists between the lateral cord and medial and posterior cords in the costoclavicular region: Clinical and microanatomical considerations in brachial plexus anesthetic blockade.

The ultrasound-guided proximal infraclavicular costoclavicular block (PICB) appears popular but its results are inconsistent. We sought an accurate demonstration of septae formed between the brachial plexus cords. We performed in-plane, lateral-to-medial PICBs on 120 patients and recorded images. Once the most superficial lateral cord component was entered, a 0.4-0.6 mA current was applied to confirm needle placement; 5 ml of local anesthetic (LA) solution was then injected and its spread was observed and recorded. As the needle was advanced, the presence or absence of a hyperechoic linear structure was noted before the deeper compartment was reached, specifically looking for the possible displacement of such a septum. Upon initial scanning, a septum was observed in 67 of the 120 patients (46.2%). However, there was clear displacement of a linear septum between the lateral cord compartment and the medial and posterior cord compartments that prevented spread between the compartments in 94.16% of patients. Piercing the septum evoked motor responses from the medial or posterior cord. The same anatomical regions were studied microanatomically by analyzing cross-sections obtained with the same approach angle as the ultrasound probe. Intraplexus fascial septae that bundled the medial and posterior cords into one compartment and separated them from the lateral cord were demonstrated and confirmed microanatomically. This suggests the need for two separate injections (or two separate catheter placements for continuous peripheral nerve blockade) into the superficial and deep compartments to ensure LA spread around all three cords of the brachial plexus at this level.

Three-step tumescent local anesthesia technique for inguinal hernia repair.

The optimal method of anesthesia for inguinal hernia repair is still controversial. We have developed “three‐step tumescent local anesthesia (TLA) technique” for inguinal hernia repair, and recently showed that this technique is acceptable in view of short‐ and long‐term clinical outcomes. Our study included 273 consecutive cases (290 sides) of elective inguinal hernia repair performed under the newly developed technique between September 2003 and May 2019, and overall clinical outcomes were considered to be safe and feasible. Herein, we report the surgical procedure of “three‐step TLA technique.” Briefly, we rapidly inject the diluted solution of local anesthetic and epinephrine step‐by‐step into the three following closed tissue space. Initially, 80 mL injection into the subcutaneous tissue before skin incision (Step 1). After the external oblique fascia is exposed, injection of 20 mL into the inguinal canal before the external oblique fascia is incised and opened (Step 2). The hernia sac and spermatic cord are then dissected, and the blunt dissection of the preperitoneal space is made by injecting 20 mL under the internal inguinal ring (Step 3), followed by placing a gauze into the preperitoneal space, creating the space for mesh placement. We consider that the most important point of this technique is achieved through the rapid injection of TLA solution into each closed tissue space, which makes for easier dissection, hemostasis, and good pain control.

Hyaluronidase to Reduce Pain from Local Anaesthetic Infiltration for Carpal Tunnel Decompression.

Abstract Aims: The aim of this prospective cohort study is to investigate the effect of hyaluronidase on pain experienced during local anaesthetic infiltration for carpal tunnel decompression. Methods: Two cohorts of twenty consecutive patients each underwent carpal tunnel release by a single surgeon over a five-month period. The first twenty patients received a local anaesthetic solution of lignocaine and adrenaline whilst the second group received a mixture of lignocaine, adrenaline and hyaluronidase (Hyalase®). All consecutive patients booked for simple open carpal tunnel decompression under local anaesthesia were included. Patients with other compressive neuropathies, generalised neuropathies or other concomitant hand pathologies were excluded from the study. The primary outcome measurement was pain experienced during local anaesthetic infiltration. Patients were asked to indicate the level of pain felt using a visual analogue scale (VAS) between 0 (no pain) to 10 (maximum pain they can imagine). Secondary outcome measures were operating time, measured as tourniquet time and early complication rates. Results: Patients administered local anaesthesia with hyaluronidase experienced significantly less pain on infiltration of the proximal palm (p < 0.05) and distal palm (p < 0.05) compared to those that did not receive hyaluronidase. Infiltration of the palm was the most painful part of the procedure for both groups. There was no statistically significant difference in pain reported on initial needle insertion (p = 0.95) or on infiltration of the distal forearm (p = 0.10). No patients in either group required additional local anaesthetic. The mean tourniquet time for the group receiving local anaesthesia without hyaluronidase was 3.79 minutes (range 3 to 5 minutes, SD 0.71) versus to 3.65 minutes (range 3 to 5 minutes, SD 0.67) for the hyaluronidase group. There was therefore no significant difference in operating time between the two cohorts (p = 0.53). No early complications were observed in either groups. Conclusion: This study finds that hyaluronidase is effective at reducing pain during local anaesthetic infiltration for carpal tunnel release. We therefore recommend its routine use.

Efficiency and safety of an anesthetic technique in surgical correction of congenital malformations of the lower parts of the urogenital system in children

Objective: to assess the efficiency and safety of an anesthetic technique in surgical correction of congenital malformations of the lower parts of the urogenital system in children by means of the performance of the comparative analysis of perioperative adverse events and complications, consumption of the inhalation anesthetic sevoflurane and the cost of anesthesia, and also the course of the early postoperative period. Material and methods. Depending on the type of anesthesia, all patients (127 boys) were divided into 3 clinical groups: those operated under multicomponent balanced inhalation anesthesia (group 1, n = 37), under general laryngeal mask anesthesia in combination with caudal blockade with 0.25% bupivacaine solution (group 2, n = 45), under general laryngeal mask anesthesia with caudal blockade with the combination of 0.25% bupivacaine solution and adjuvant (group 3, n = 45). Results. The performed analysis has not revealed any statistically significant distinctions in the assessment of anesthesia complications but it has found some significant distinctions in the consumption of sevoflurane, depth of anesthesia and its cost, as well as the necessity for postoperative anesthesia and introduction of analgesics, which testifies to the efficiency and safety of combined anesthesia and its economic benefit. Conclusion. The most effective, safe, and economically reasonable is the technique of combined anesthesia with the application of caudal blockade with local anesthetic solution and 0.1% adjuvant of morphine solution during surgical correction of congenital malformations of the lower parts of the urogenital system in children.

Comparative area of desensitiztion by three different volumes of local anesthetic solution for paravertebral block

Aim and objectives: Ropivacaine is the drug of choice when we need more sensory block and less motor block. It also has a good safety margin. The anesthesiologists have been using rough formulas to determine the volume of the drug for the desired spread.
 We conducted this study to determine the area distribution of paravertebral block (PVB) using three different volumes of ropivacaine.

Population Pharmacokinetics of Levobupivacaine During Transversus Abdominis Plane Block in Children.

Levobupivacaine is commonly used during transversus abdominis plane (TAP) block in pediatric patients. However, the dosing regimen is still empirical, and the pharmacokinetic properties of levobupivacaine are not considered. Here, the pharmacokinetics of levobupivacaine during an ultrasound-guided TAP block were evaluated to optimize dosing regimen, regarding the between-subject variability (BSV) and the volume of levobupivacaine injected. The clinical trial (prospective, randomized, double-blind study protocol) was conducted in 40 children aged 1-5 years, who were scheduled for inguinal surgery. Each patient received 0.4 mg/kg of levobupivacaine with a volume of local anesthesia solution adjusted to 0.2 mL/kg of 0.2% or 0.4 mL/kg of 0.1% levobupivacaine. Blood samples were collected at 5, 15, 20, 25, 30, 45, 60, and 75 minutes after the block injection. The population pharmacokinetic analysis was performed using the NONMEM software. From the pharmacokinetic parameters obtained, median Cmax, tmax,, and area under the concentration versus time curve were 0.315 mg/L, 17 minutes, and 41 mg/L·min, respectively. BSV of clearance was explained by weight. At the dose regimen of 0.4 mg/kg, none of the infants showed signs of toxicity, but in 13 patients, TAP block failed. After analysis, BSV for absorption rate constant, distribution volume, and clearance were 81%, 47%, and 41%, respectively. Residual unexplained variability was estimated to be 14%. For improved efficiency in the pediatric population, the dose of levobupivacaine should be greater than 0.4 mg/kg. Children's weight should be considered to anticipate any risk of toxicity.

Awake craniotomy in neurosurgery: Shall we do it more often?

BackgroundAwake craniotomy allows intraoperative cortical mapping to prevent injury to the eloquent brain region and minimizes the complications of general anaesthesia. The initial indications include epilepsy surgery and excision of diffuse glioma in eloquent brain region. There have been a remarkable development in the fields of neurosurgery and anaesthesia. AimTo emphasis the role of awake craniotomy in lesions other than diffuse glioma. MethodProspective review of awake craniotomies by the corresponding author over eighteen month’s period. We obtained consent for surgery as routine surgical procedure with emphasis on awake procedure to avoid the possible complications of general anaesthesia. Awake and cooperative patients with suitable lesion location in the brain convexity whose surgery were expected to last not more than four hours had awake craniotomies under scalp nerve block with local anaesthetic solution containing 0.5% xylocaine with adrenaline and 0.125% Bupivacaine. ResultsEight awake craniotomies were done within the period. The age range was 25–92 years. Male: female ratio was 1:1. There were three tumours, one intracerebral abscess, two acute subdural haematoma, a case of intracerebral haematoma secondary to ruptured AVM and craniotomy for removal of posterior left frontal intacerebral metallic object. There was no intraoperative seizures and there was no need to convert to general anaesthesia in any of the cases. A patient with intracerebral haematoma secondary to ruptured arteriovenous malformation (AVM) had excessive primary haemorrhage which was controlled. There was no neurological deficit or seizures and no incidence of wound infection. ConclusionAwake craniotomy is beneficial in a variety of supratentorial brain lesions provided the patient comfort is not compromised. Awake craniotomy in suitable patients, will reduce the possible anaesthetic complications associated with general anaesthesia with endotracheal intubation and need for post-operative intensive care unit admission.

Dexmedetomidine 2 ppm Is Appropriate for the Enhancement Effect of Local Anesthetic Action of Lidocaine in Inferior Alveolar Nerve Block

Local anesthesia is essential for pain management in dentistry. The duration of anesthetic action of the addition of 5.0 and 7.5 ppm of dexmedetomidine (DEX) was significantly longer than the addition of adrenaline, and the mean duration of anesthetic action of the addition of 2.5 ppm DEX was also longer than the addition of adrenaline. We hypothesized that it is possible to safely achieve an equal local anesthesia effect as with 1:80,000 adrenaline, without using adrenaline or felypressin, by the addition of <2.5 ppm DEX to the local anesthetic solution. Nineteen healthy volunteers were randomly assigned by a computer to receive 1.8 mL of 1 of 3 drug combinations (1.8% lidocaine with 1.0 ppm [1.8 μg] DEX, lidocaine with 2.0 ppm [3.6 μg] DEX or lidocaine with 1:80,000 [22.5 μg] adrenaline), to produce inferior alveolar nerve block. Pulp latency and lower lip numbness (for assessing onset and duration of anesthesia) were tested, and sedation level, blood pressure, and heart rate were recorded every 2 minutes for 10 minutes, every 5 minutes from 10 to 20 minutes, and every 10 minutes from 20 to 60 minutes. Pulp latency increased compared with the baseline, from 4 minutes until 60 minutes; there were no significant intergroup differences at any timepoint. Anesthesia onset did not differ between groups. Anesthesia duration did not differ between groups. Blood pressure and heart rate did not change in any group. Sedation score did not indicate deep sedation in any of the groups. DEX at a concentration of 1.0 to 2.0 ppm enhances the local anesthetic action of lidocaine. DEX at 2.0 ppm produces similar enhancement of local anesthesia effect as the addition of 1:80,000 adrenaline.

The impact of cigarette smoking on the efficiency of local anesthesia during simple tooth extraction

Smoking is harmful to all organs of the human body and can affect nerve response to local anesthesia.This study aimed to determine the effect of cigarette smoking on the amount and onset of local anesthesia, as well as the chief complaint (symptomatic and asymptomatic), number of cigarettes, and duration of smoking. Materials and methodsA selective clinical case-control study carried out at the Oral Surgery Clinic of the Teaching Hospital at the College of Dentistry. One hundred and three male patients participated in the study, and they were divided into two groups (55 smokers and 48 nonsmokers). The patients received a local anesthetic agent (2% Lidocaine) in a 1.8 ml dental cartridge. The number of cartridges and the onset time of local anesthesia were detailed for each patient in a special case sheet prepared for this study. ResultsThere was a statistically significant difference between the smoker and nonsmoker groups regarding the amount of local anesthetic solution (p = .041) with a higher amount needed in the smoker group; however, the onset of action showed no significant difference between the two groups (p = 0.983). The symptomatic cases in smokers needed a higher amount of local anesthesia than the asymptomatic cases with a statistically significant difference (p = 0.002). There was no relationship between daily cigarette consumption and the amount of local anesthetic solution (p = .054) and also the onset of local anesthesia (p = .938). The duration of smoking has no significant relationship with onset time (p = .480) and the amount of local anesthesia (p = .418). ConclusionThe amount of local anesthesia used in smoker patients was higher than that in nonsmoker patients, especially if there were symptoms like pain. The duration of smoking and daily cigarette consumption had no effect on the amount and the onset of local anesthesia.

Comparison of speed of onset and analgesic effect of 2% mepivacaine hydrochloride deposited within or outside the neurovascular bundle at the level of the proximal sesamoid bones in horses with naturally occurring forefoot-related lameness.

To compare the speed of onset and analgesic effect of mepivacaine deposited within or immediately outside the neurovascular bundle at the base of the proximal sesamoid bones in horses. 6 horses with naturally occurring forefoot-related lameness. In a crossover study design, horses were randomly assigned to receive 1 of 2 treatments first, with the second treatment administered 3 to 7 days later. Trotting gait was analyzed with an inertial sensor-based motion analysis system immediately before treatment to determine degree of lameness. Afterward, ultrasound guidance was used to inject 2% mepivacaine hydrochloride around the palmar digital nerves of the affected forelimb at the level of the base of the proximal sesamoid bones either within the subcircumneural space or outside the circumneural sheath. After injection, gait was reevaluated at 5-minute intervals for 45 minutes. Mepivacaine deposition outside the circumneural sheath did not resolve lameness in any horse; for 3 horses, the mean time to 70% reduction of initial vertical head movement was 13.3 minutes, and the remaining 3 horses had no such reduction at any point. Mepivacaine deposition within the subcircumneural space resulted in a mean time to 70% reduction of initial vertical head movement of 6.7 minutes and mean time to resolution of lameness of 21.7 minutes. Results suggested that when peripheral nerves of horses lie within a sheath, local anesthetic solution should be deposited within the sheath for an effective nerve block. If local anesthetic solution is deposited outside the sheath, the nerve block may yield erroneous results.

Anesthetic challenges in a large multinodular thyroidectomy at a peripheral hospital

We present a case of large multinodular goiter with retrosternal extension scheduled for thyroidectomy under general anesthesia (GA). We anticipated difficult airway due to tracheal compression as well as perioperative hemodynamic instability. She had had hyperthyroidism previously, which had been treated successfully. We planned and prepared to encounter airway problems in the light of Difficult Airway Society guidelines. After counselling and consent, her upper airways were sprayed with local anesthetic solution. Awake, flexible fiberoptic nasal intubation was performed and GA was induced. She had two episodes of bradycardia and hypotension peri-operatively, which were treated with inj atropine. Tracheostomy was performed in anticipation of tracheomalacia, which was de-cannulated on 3rd postoperative day. She was discharged on 4th post-operative day.Citation: Ikram M, Mahboob S. Anesthetic challenges in a large multinodular thyroidectomy at a peripheral hospital. Anaesth pain &amp; intensive care 2019;23(3):311- 313

Effect of Local Tranexamic Acid on Hemostasis in Rhytidectomy.

Importance: Hematoma is the most common complication in rhytidectomy. Tranexamic acid (TXA) is an antifibrinolytic that may be a useful tool to reduce intraoperative bleeding and postoperative hematoma risk. Objective: To determine whether local TXA reduces intraoperative bleeding and postoperative drain output in rhytidectomy. Design, Setting, and Participants: Retrospective cohort study of patients undergoing deep plane rhytidectomy with platysmaplasty. Beginning January 1, 2019, we began adding 1 cc (100 mg) of TXA to every 10 cc of local anesthetic and tumescent solution. Patients were, therefore, separated into two cohorts: control and TXA. Primary outcomes include postoperative day 1 (POD1) drain output, days to drain removal, percentage drains removed POD1, and percentage POD1 drain output <25 cc. Secondary outcomes include minor hematoma, major hematoma, Nitro-bid use, intraoperative estimated blood loss (EBL), and thromboembolic events. Results: POD1 drain output reduced from 50.4 cc in control group versus 14.8 cc with TXA (p < 0.001). Average day of drain removal reduced from 1.8 days in control group versus 1.2 days with TXA (p = 0.001). Percentage of drains removed on POD1 was increased from 34.4% in control group to 77.3% with TXA (p < 0.001). Percentage of POD1 drain output <25 cc was increased from 21.9% in control group to 95.5% with TXA (p < 0.001). Intraoperative EBL <50 cc increased from 25% in control group to 75% with TXA (p < 0.001). No statistically significant difference was observed between control and TXA in rates of minor hematoma, major hematoma, Nitro-bid use, or thromboembolic events. Conclusions and Relevance: Local TXA used in rhytidectomy significantly reduces intraoperative blood loss, postoperative drain output, and time to drain removal. No significant difference was observed in postoperative complication rates.