Local Anesthetic Agents Research Articles

Sacrococcygeal epidural administration of 0.5% bupivacaine in seven cats undergoing pelvic or hind limb orthopaedic procedures

BackgroundEpidural administration of local anaesthetic agents provides good intraoperative antinociception for orthopaedic procedures of the pelvis and the pelvic limb. However, in cats the spinal cord extends approximately to the level of the first sacrococcygeal vertebra, and therefore the sacrococcygeal epidural could be a safer alternative to the lumbosacral epidural in cats. This case series describes perioperative analgesia and the haemodynamic status of seven client-owned cats that received sacrococcygeal epidural injection of 0.5% bupivacaine and underwent orthopaedic hind leg or pelvic surgeries under general anaesthesia.Case presentationEach cat received either 0.2 or 0.3 mL/kg of 0.5% bupivacaine with or without 0.2 mg/kg of morphine in the sacrococcygeal epidural space. Intraoperative antinociceptive response to surgical stimulus and haemodynamic changes were monitored and reported.ConclusionIn these seven anaesthetised cats, 0.2 or 0.3 mL/kg of 0.5% bupivacaine, administered alone or in combination with morphine into the sacrococcygeal epidural space, enhanced antinociception so that intraoperative rescue analgesia was unnecessary in all but one cat. It also reduced the anticipated requirement for postoperative opioid use. However, a high incidence of hypotension was observed in the cats in this report, and hence intraoperative blood pressure monitoring should be considered mandatory in anaesthetised cats following epidural injection of local anaesthetic agents, regardless of injection site.

RANDOMIZED COMPARATIVE STUDY OF ANALGESIC EFFICACY OF BUPRENORPHINE AND CLONIDINE AS ADJUVANTS WITH INTRATHECAL BUPIVACAINE IN PATIENTS UNDERGOING TOTAL ABDOMINAL HYSTERECTOMY.

Introduction: Understanding pain and continued efforts to alleviate pain is utmost priority perioperatively. Most often pain is underestimated in all age groups. This study is intended to evaluate and compare analgesic efcacy of two drug combinations with local anesthetic agent in spinal anesthesia. In this study efcacy of Clonidine-Bupivacaine, Buprenorphine-Bupivacaine and Bupivacaine is studied in patients undergoing total abdominal hysterectomy. This study was a prospective randomized study conducted on 114 patients age Material and Methods: d 35-60 years who underwent total abdominal hysterectomy at Sri Siddhartha Medical College and Research institute for a period of 24 months.After the approval of institutional ethical clearance committee, 114 ASA I and II patients scheduled for elective total abdominal hysterectomy were selected for study. All the patients were evaluated as per the protocol. The anesthetic procedure was explained to the patients in a simple language and informed consent were obtained. The patients were divided into three groups of 38 each using chit in a box technique. Three groups included Bupivacaine 0.5% hyperbaric (Group B), Clonidine and Bupivacaine 0.5% hyperbaric (Group BC), Buprenorphine and Bupivacaine 0.5% hyperbaric (Group BB). Time of onset of sensory blockade, the height of sensory blockade, motor blockade as per Bromage scale were recorded. Total duration of sensory blockade and motor blockade were also noted. Quality of analgesia (visual analogue score), two segment sensory regression time and time to rst rescue analgesia in 24h were documented. Results:The total duration of analgesia was statistically signicant in all three groups. The mean duration of analgesia was 2.436 ± 0.24h in group B, 2.96 ± 0.32h in group BB and 4.35± 0.62h in group BC. The total duration of motor block was found to be statistically signicant between the groups. Mean duration of motor block was 3.10 ± 0.34h in group B , 3.41 ± 0.25h in group BB, 4.48± 0.19h in group BC. The VAS score was found to be statistically signicant between the groups. It was 4.68 ± 0.47 in group B, 4.92 ± 1.07 in group BB and 4.42± 0.50 in group BC. Clonidine is an effective intrathecal Conclusion: adjuvant to Bupivacaine(H) than Buprenorphine in providing post-operative analgesia and the analgesic efcacy of both Clonidine and Buprenorphine as adjuvants with Bupivacaine(H) were better than Bupivacaine(H) alone.

Comparative Evaluation of Reduction in Pain Perception Using 5% Topical LA vs Freezed Cone as a Preparatory Agent for Intraoral Injection in Children and Effect of VRD as Distraction Technique.

To compare freezed cone and 5% lignocaine as a numbing agent before intraoral injection and evaluate the effect of virtual reality distraction (VRD) as a distraction technique in reducing pain perception in children. Around 60 children of 6-11 years old undergoing treatment for the extraction or any pulp therapy of primary tooth were selected. Freezed cone and 5% lidocaine were used to decrease the pain during local anesthesia (LA). VRD was used as a distraction method and to analyze the pain perception, Wong-Baker Faces Pain Rating Scale was used. Each child was randomly assigned to receive ice as a topical anesthetic or lignocaine 5% as a topical anesthetic agent. The pain perception was evaluated after the injection of 2% lignocaine hydrochloride (HCL). The primary researcher evaluated the pain during injection using the sound, eye, motor (SEM) scale. The pain experienced during injection was evaluated using Wong-Baker Faces Pain Rating Scale. In the freezed cone group with the VRD technique, maximum responded to the less pain score. On the contrary, many responded to higher pain scores in the freezed cone group without the VRD technique. It was concluded that the VRD technique can be used for distraction and the frozen ice cone can be an alternative method to reduce the pain perception during LA. Singh R, Gupta N, Gambhir N. Comparative Evaluation of Reduction in Pain Perception Using 5% Topical LA vs Freezed Cone as a Preparatory Agent for Intraoral Injection in Children and Effect of VRD as Distraction Technique. Int J Clin Pediatr Dent 2022;15(5):558-563.

Pain Reduction Using Ropivacaine in Tumescent Solution following Lipoaspiration.

Tumescent solution utilizing dilute epinephrine and a local anesthetic agent injected into a fat compartment has been shown to effectively minimize blood loss and postoperative pain in liposuction. Ropivacaine has a longer duration of action compared to lidocaine and is a potential analgesic in tumescent solution. We sought to explore the effect of using ropivacaine in a tumescent technique with a focus on its efficacy for pain control postoperatively. The formula for the tumescent technique used combined 1 mL of epinephrine with 30 mL of ropivacaine into 500 mL of injectable saline. Tumescent solution was injected manually into fat donor sites of 10 consecutive patients followed by a 20-minute waiting period before beginning fat aspiration with liposuction cannula. Patients were seen immediately following their surgery and on postoperative day 1 and reported their pain using a numerical scale. Data gathered included the amount of ropivacaine used, average pain rating, and the average amount of fat removed. On average, participants reported little to no pain at the donor sites immediately following surgery and on postoperative day 1. Based on the low need for pain medication, we believe that ropivacaine may be successfully used in tumescent solution to reduce postoperative pain.

Does Topical Anesthesia Alter the Outcomes of Vascular Laser Procedures? Review of Vasodynamic Effects and Clinical Outcomes Data.

Topical anesthesia has vasodynamic effects within the skin and therefore has the potential to change the presence of hemoglobin as a chromophore before intense pulsed light (IPL) and vascular laser treatments. It is unclear whether this is clinically relevant. Global consensus on the use of topical anesthetics in this context is lacking. Review the effects of topical anesthetics on the skin microvasculature and the clinical implications of such effects on vascular treatments. PubMed and Medline searches were performed to identify studies examining the vasodynamic effects of topical anesthesia on skin and evaluating differences in efficacy of IPL and vascular laser treatments with or without topical anesthetic use. Published studies reveal variable effects of different topical anesthetic agents on skin microvasculature. Only 3 controlled studies that directly examined the effect of topical anesthesia on clinical outcomes for pulsed dye laser (PDL) treatment of vascular conditions were identified. They did not support a difference in clinical outcomes with or without the use of topical anesthesia before PDL treatment. Although topical anesthetic agents have vasodynamic effects within the skin, there is currently insufficient evidence to advise against their use before light and laser-based vascular treatments.

Enhancing Intradermal Delivery of Lidocaine by Dissolving Microneedles: Comparison between Hyaluronic Acid and Poly(Vinyl Pyrrolidone) Backbone Polymers.

Lidocaine hydrochloride (LiH), an amide-type local anesthetic agent, is commonly used in dermatological procedures. LiH is categorized as a BCS (biopharmaceutics classification system) class III group, which has high solubility and poor permeability. It should be noted that, in this context, LiH is intended as a local anesthetic, so the level of LiH in systemic circulation should be minimized to avoid toxicity and unwanted side effects such as hypotension and bradycardia. This study aimed to formulate and evaluate LiH-loaded dissolving microneedles (DMNs) with different polymer bases. Moreover, an in vitro permeation study using Franz diffusion cells and in vivo study were also performed. LiH-loaded DMNs were prepared using polymer groups of poly(vinyl pyrrolidone) (PVP-K30) and hyaluronic acid (HA). DMNs were created using the micro-molding method with centrifugation. The formulations selected based on the evaluation were F3 (HA 10%) and F5 (PVP-K30 25%). Based on the in vitro permeation study, the amount of drug permeated and deposited in the skin at F3 (HA 10%) was 247.1 ± 41.85 and 98.35 ± 12.86 μg, respectively. On the other hand, the amount of drug permeated and deposited in the skin at F5 (PVP-K30 25%) was 277.7 ± 55.88 and 59.46 ± 9.25 μg, respectively. Our in vivo drug-permeation study showed that only one rat from the PVP-K30 polymer group-with a concentration of 150.32 ng/mL-was detected on rat plasma. Therefore, LiH can be formulated into a DMN and can be deposited in the skin with a safe concentration of the drug permeating into systemic circulation.

Comparison of Recurrence of Wrist Ganglion Following Aspiration and Injection of Steroid Versus Surgical Excision

Objective: To compare the frequency of recurrence after surgical excision versus aspiration and injection of Steroids of wrist ganglion
 Study Design: Comparative cross-sectional study.
 Place and Duration of Study: Department of General Surgery at Combined Military Hospital, Kohat Pakistan, from Sep 2018 to Aug 2019.
 Methodology: Seventy patients reported to the Outpatient Department, Combined Military Hospital, Kohat Pakistan, with complaints of ganglion and wanted treatment. Patients were randomly allocated into two Study Groups 1 and 2, by lottery method. Group-1 was treated by aspiration of the cyst contents followed by Steroid injection, while Group-2 was by excisionof the ganglion surgically under a local anaesthetic agent. The patient was followed up after three months to look for recurrence in both groups.
 Results: The frequency of recurrence was 34.29% in Group-1 and 5.71% in Group-2, (p-value was less than 0.001).
 Conclusion: Surgical excision results in lesser recurrence when compared with simple aspiration and Steroid injection for ganglion of the wrist.

A Curious Case of Methaemoglobinemia

The most frequent cause of raised methaemoglobin is from recreational drug use, with oxidation of the haem molecule leading to methaemoglobinaemia. Our case describes that of a man in his early thirties who presented with shortness of breath, hypoxia and methaemoglobinemia due to ingestion of impure cocaine mixed with local anaesthetic agents, a common cause of acquired methaemoglobinemia. This case report demonstrates the need for clinicians to consider methaemoglobinaemia as a differential diagnosis for patients presenting with hypoxia.

Malignant Hyperthermia in the Dental Setting: A Case Report

Understanding rare diseases, such as Malignant hyperthermia (MH), will help provide optimal care to these patients, especially in dental settings. As MH is a sporadic, inherited disorder, dental clinicians must have sufficient knowledge and information about such a rare disease to manage a patient with such a condition. This article will describe a case with MH, highlighting the patient’s or parents’ concerns about using local anesthetic agents in dental treatment. Keywords: Malignant hyperthermia, CACNA1S, RYR1, Whole exome sequencing, inhalation agents.

Comparison of 25% Dextrose versus Expressed Breast Milk in Reducing Pain while Heel Prick Procedure in Preterm Neonates in a Tertiary Care Hospital, Vadodara, Gujarat, India: A Randomised Clinical Trial

Introduction: Preterm infants undergo repeated painful procedures during a period of rapid brain development and programming of stress systems. Newborn babies including preterm infants do feel pain. Although different interventions, such as skin-to-skin contact, glucose solutions, breastfeeding, and local anaesthetic agents, have been evaluated to reduce infants’ pain, there is no clinical trial available to identify the best method. Aim: To compare the dectrose 25% versus Expressed Breast Milk (EBM) in reducing pain while heel prick procedure in preterm neonates in a tertiary care hospital. Materials and Methods: The present randomised clinical trial was conducted at Neonatal Intensive Care Unit (NICU) of Kashiben Gordhandas Patel Children Hospital, Vadodara, Gujarat, India, from September 2019 to May 2020. Total 125 neonates with Gestational age between 28 weeks to 36 weeks were included in the study. Babies were divided into two groups by randomisation: Group-A: EBM and Group-B: Dextrose 25%. Premature Infant Pain Profile (PIPP) score was calculated from worst state of individual recovery period (0-½ minute, 1-1½ minute, 3-3½ minute) and compared to baseline period PIPP. Results: Mean gestational age on examination in Group-A was 34.48±6.14 weeks and in Group-B were 34.51±5.89 weeks. Out of total 125 preterm babies (Group-A-62, group B-63), 71 (56.8%) were male and 54 (43.2 %) were females. Comparison of PIPP at 1-1½ min of heel prick in EBM and Dextrose 25% group was statistically significant (p-value <0.003) suggestive of continued analgesic effect of dextrose 25% better than EBM and PIPP scores after 3-3½ min of heel prick having no statistically significant difference. (p>0.05) Mean difference between the PIPP score in the dextrose 25% and EBM groups was -1.25 and -1.33 at 0 and 1 minute after procedure (p-value,<0.001), so pain relief was better in dextrose 25% group than EBM group. Conclusion: Dextrose 25% was better effective in reducing mean crying duration than EBM. Dextrose 25% had a better analgesic effect than EBM in 28 to 36 weeks gestational age neonates.

Efficacy of Butorphanol and Tramadol as an Adjuvant to Levobupivacaine for Postoperative Analgesia in Brachial Plexus Block – A Randomized Double-Blind Study

Background: Supraclavicular brachial plexus block has evolved as a safe alternative to general anaesthesia with good postoperative analgesia. In an attempt to hasten the onset of block and increase the duration of postoperative analgesia, various adjuvant drugs are used along with local anesthetic agents. Aim: The present study was undertaken to assess the analgesic efficacy of butorphanol (2mg) and tramadol (100 mg) as an adjuvant to levobupivacaine in supraclavicular brachial plexus block during perioperative period. Study Design: This was a prospective, randomized, double blind study done on 100 adult patients of ASA I-III aged between 18-65 years and scheduled for various upper limb surgeries below the level of elbow. Materials and Methodology: Patients were allocated by computer generated random draw into two groups of 50 each and were administered the study drugs under ultrasonographic guidance. Both groups received 22ml of the study drug (Group B 20 ml 0.5% levobupivacaine + Butorphanol 2mg and Group T 0.5% levobupivacaine + Tramadol 100 mg). Patients were assessed for duration of postoperative analgesia, onset & duration of sensory as well as motor blockade and occurrence of any side effects. Results: Duration of postoperative analgesia was significantly elevated in group B (683±88.58 min), as compared to group T (483.2±45.24 min.) with p<0.001. Onset of sensory and motor blockade was comparable among both groups (p>0.05). Duration of sensory and motor block in group B was significantly longer compared to group T (p<0.001). Hemodynamics were stable and side effects were minimal in both the groups. Conclusion: Butorphanol 2mg when added to 20ml 0.5% levobupivacaine in brachial plexus block, significantly prolongs the duration of postoperative analgesia, sensory and motor block as compared to addition of 100 mg tramadol, with minimal side effects and hemodynamic changes. However, these adjuvants shorten the onset times of sensory and motor block to a similar extent. Keywords: Brachial plexus block, Levobupivacaine, Butorphanol, Tramadol, Analgesia.

Evaluation of Postoperative Analgesia on Addition of Dexmedetomidine to Ropivacaine 0.2% in Femoral Nerve Block in Patients undergoing Open Knee Surgery-A Randomised Single Blinded Study

Introduction: Femoral Nerve Block (FNB) renders marked postoperative analgesia in patients undergoing knee surgery and use of adjuvant to Local Anaesthetic (LA) agent is more advantageous in lengthening duration of sensory effect of block. Aim: To evaluate the effect of addition of dexmedetomidine to 0.2% Ropivacaine in FNB. Materials and Methods: The randomised clinical trial was conducted at Medical College and SSG Hospital, Vadodara, Gujarat, India which included 60 patients of either sex, American Society of Anaesthesiologists (ASA) Grade-I,II,III posted for open knee surgery. Patients were randomly allocated to two groups-Group RD patients received 0.2% ropivacaine 20 milliliter (mL) with dexmedetomidine 2 mL (50 μg) and Group R received 0.2% ropivacaine 20 mL with normal saline 2 mL for FNB. Duration of postoperative analgesia, total requirement of systemic rescue analgesic in 24 hours, vital parameters and complications were observed. Statistical analysis was done with Medcalc 14.8.1 statistical software. A p<0.05 considered as significant. Result: Duration of analgesia was significantly longer in Group RD (484±26.98 min) than in Group R (338±29.40 min), p<0.0001. Mean postoperative cumulative requirement of analgesic (Tramadol) was lesser in Group RD (207±25 milligram (mg)) than in Group R (290±30 mg), p<0.0001. Conclusion: Dexmedetomidine to ropivacaine 0.2% for FNB significantly augments duration of analgesia and reduces requirement of systemic analgesic declining its unfavourable effect.

A comparative analysis of 4% articaine and 2% lignocaine in evaluating the efficacy during pulpectomy procedures in pediatric patients: An observation split mouth technique

A troublesome dental experience usually has a negative influence on the child’s behavior towards any successive dental treatment. An alternative, less traumatic method of achieving pain control is an important contribution to reduce anxiety and emotional outbursts in children. Thus, management of child during any meddling procedure becomes a challenging task. Local anesthetics play a major role in techniques used for controlling pain. Aim: The main aim and objective of the study was to compare and evaluate the efficacy of 4% articaine and 2% lignocaine in reducing pain while performing a pulpectomy in pediatric patients. Material and Methodology: A spilt mouth technique was conducted on 25 subjects aged 3-6 years, who visited the Family Dental Clinic, Kulgam, Jammu and Kashmir for the treatment of their teeth. Subjects with deep carious lesions, grossly decayed or pain on mandibular molars (i.e where ever there was need of local anesthesia) were selected for the study. Topical application of local anesthestic spray followed by 4% articaine infiltration on one side and 2% lignocaine on other. Post treatment pain was assessed using visual analog scale. Statistical analysis: The data collected underwent statistical analysis. Mean, frequencies, standard deviation and standard error was used to describe the descriptive analysis. Continuous variables were compared using student-t test with statistical significant p value of less than 0.05. The graphical representation of the data was done using bar diagrams. Results: Statistically significant results were obtained while comparing pain, duration and onset of action of 4% articaine and 2% lignocaine. Conclusion: Within the limitation it was concluded that 4% Articaine when used was found to be more effective and safe local anesthetic drug to be used in any aspects of dentistry and for all age groups, when compared to the properties of other local common anesthetic agents.

Prospective Study Evaluating the Association between Time since Scorpion Bite and Spinal Anaesthesia Outcomes

Introduction: The drug mainly used in Spinal Anaesthesia (SA) is Local Anaesthetic (LA) agents. It acts via sodium channel by reversibly inhibiting the nerve transmission. Scorpion venom causes mutation in receptors of sodium channel that leads to LA resistance which results in failed SA. Although, there are few studies and many case reports, which shows direct association of scorpion bite with failed SA, but association of duration since, scorpion bite on outcome of spinal anaesthesia is still not known. Aim: To evaluate the association between time since scorpion bite and multiple bites, an outcome of SA on patients posted for elective lower abdominal and lower limb orthopaedic surgeries. Materials and Methods: This monocentric, prospective, single blind observational study was conducted in the Department of Anaesthesia at Rajarshi Dashrath Autonomous State Medical College (RDASMC), Ayodhya, Uttar Pradesh, India. The duration of the study was two years, from December 2019 to December 2021. A total of 33 patients of either gender or age, between 18-70 years were taken and divided them into three groups of 11 each. Groups were divided on the basis of history of duration since scorpion bite/sting. Group A included patients with history of scorpion bite being less than eight months, group B from eight-14 months and group C more than 14 months. SA was provided with 15 mg 0.5% hyperbaric bupivacaine. The pin prick method and Bromage scale were used to detect the onst of sensory (T1), onset of motor (T2), peak of sensory (T3) and peak of motor block (T4). General Anaesthesia (GA) was given if the SA was found inadequate or failed. The mean±Standard Deviation (SD), Student’s t-test and Chi-square test were used for statistical analysis of data. Results: The mean age of the study participants of group A was 49.27 years, group B was 50.27 years and group C was 52.18 years. Demographically, all the three groups were comparable. The authors have found that, block failed completely in group A. There was statistically significant increase of T1, T2, T3 and T4 in group B than group C (p<0.05). Statistically significant difference were not found between single scorpion bite and multiple scorpion bite in group B and group C in terms of SA characteristics T1, T2, T3 and T4 (p>0.05). Conclusion: The present study concludes that, the duration of scorpion bite is a significant factor on the effect of SA in terms of sensory and motor block, but number of stings does not determine the sensory and motor characteristics of SA. The SA should not be given if, the history of scorpion bite is recent (less than eight months).

The impact of Lidocaine gel on TNF-α expression in surgically induced oral mucosal ulcers: an immunohistochemical analysis in rabbits

Background: Besides being a local anesthetic agent lidocaine is a promising anti-inflammatory agent with limited studies on its effect on the mucosa. Aim: Assess the anti-inflammatory effect of lidocaine following surgical induction wound in the oral mucosa as assessed by tumor necrosis factor-α (TNF-α) expression. Materials and methods: The study was conducted on 32 albino rabbits that were categorized into 2 equal groups of 16 rabbits: In the control group an oral wound was surgically induced and left without treatment and in the treatment group an oral wound was surgically induced and received topical Lidocaine gel. Euthanasia of animals was carried out on days 1, 3, 7, and 10, and sample sites were processed for histopathological and immunohistochemical staining for TNF-α. Results: In the histological observations, it was noticed that the healing process was more rapid and convenient in the test group compared to the control group. For Immunohistochemical assessment, the TNF-α started to express clearly at 1 day and gradually decreased and disappeared at 10 days with a superior effect of the lidocaine group over the control group. Conclusion: Lidocaine seems to have anti-inflammatory reactions by lowering TNF-α levels and preventing the production of pro-inflammatory cytokines.

Effects of intrathecal dexmedetomidine coadministered with hyperbaric bupivacaine in the lower abdominal surgery: Results of a double-blind, randomized, and controlled trial between two different doses

Background: Although various adjuvants have been added to local anesthetic agents to potentiate its effect, dexmedetomidine is a relatively new drug with only a fewer studies. Aims and Objectives: The present study has been conducted to compare the efficacy of intrathecal hyperbaric bupivacaine alone with dexmedetomidine of two different doses as adjuvants in spinal anesthesia for the lower abdominal surgery. Materials and Methods: This was a double-blinded, randomized, and controlled trial. Total 120 patients of American Society of Anesthesiologists physical status I and II, 70 male and 50 female, aged between 20 and 60 years, were randomized into three groups receiving 15 mg 0.5% hyperbaric bupivacaine with normal saline, 4 μg (microgram) dexmedetomidine, and 2 μg dexmedetomidine, respectively, administered intrathecally. Results: There was significant difference among all three groups with regard to the onset of sensory block and time to reach the highest level of sensory block. Time to reach T10 dermatome, time to reach Bromage 3 motor block, the mean regression time to S1 dermatome level, the mean regression time to reach Bromage 0, and time to first requirement of rescue analgesia – all these variables showed significance when 4 μg dexmedetomidine additive group was compared with 2 μg dexmedetomidine additive group and bupivacaine alone group. Conclusion: In our double-blinded, randomized, and controlled trial, 4 μg intrathecal dexmedetomidine coadministered with 0.5% hyperbaric bupivacaine showed superior efficacy. Further, larger trials are needed to confirm our findings.

Supra-inguinal Fascia Iliaca Block and the Obturator Nerve Obsession

To the Editor, Anatomic block efficacy of lumbar plexus elements is based upon the involvement of the obturator nerve. However, despite the anatomic location of the obturator nerve and improbable translocation of local anesthetic beyond the confinement of the fascia iliacus plane [1], investigators struggle to study extensively, exhaustively, and try to explicitly describe the means and mechanism to block the obturator nerve [2]. Our anatomical dissections reveal three important dissimilar fascial planes (figure 1a). The quadratus lumborum, the fascia iliaca, and the circum-psoas planes are isolated from each other with tight fascial attachments [Figure 1b], impeding the dissemination of local anaesthetic agents unless inadvertently perforating the fascia. Further exploration revealed the femoral, lateral femoral cutaneous, obturator nerves and the lumbosacral trunk emerge from the lateral and medial of the psoas muscle respectively, and exits the psoas fascia (figure 1a,1b, and 1c) to take their respective course. The obturator nerve might further arise in a separate muscular fold (Figure 1c). However, if the obturator nerve needs to be blocked, two we recommend two alternatives; We presume that with injections deep to the psoas sheath, the plausibility of involvement of all the nerves of the lumbar plexus (lateral femoral cutaneous nerve, femoral nerve, and ON) exists, as reported in a case series [3] and the obturator nerve needs to be blocked separately after a supra-inguinal fascia iliaca block.

Reduction of postoperative pain after infiltration of local anesthetic at the port site and subdiaphragmatic space in laparoscopic cholecystectomy: A cross-sectional study

Introduction: Port site and subdiaphragmatic infiltration of local anesthetics during laparoscopic cholecystectomy (LC) is preferred by surgeons to decrease postoperative pain. LC with local anesthetics infiltration as well as without any local anesthetic both have been standard surgical practice. However, the difference in the reduction of postoperative pain in these two groups is not well known. The objective of the study was to compare the postoperative pain with and without infiltration of local anesthetic at the port site and subdiaphragmatic space in LC.
 
 Methods: A hospital-based cross-sectional study was conducted from 25 April 2021 to 25 October 2021 among 60 patients who underwent elective LC. The patients were divided into two equal groups. The study group received infiltration of 20 ml of bupivacaine (0.5%) at the port site and the subdiaphragmatic space, while the control group did not receive any local anesthetic. The primary outcome measure was the visual analog pain score at 6, 12, 24 and 48hrs postoperatively.
 
 Results: Among 60 patients, the majority were female- 40(66.7%); and 40-50 years age group. The two groups were comparable in terms of age, sex, ASA, BMI and duration of pneumoperitoneum and surgery. Infiltration of a local anesthetic agent produced effective postoperative analgesia in the immediate postoperative hours (6, 12 and 24 hours) and was found to be statistically significant when compared to the no-local anesthesia group.
 
 Conclusion: The intraoperative port site and subdiaphragmatic local infiltration is effective at reducing postoperative pain in the first 12 hours without any adverse events.

Effects of Local Injection of Steroids in Treatment of Posttraumatic Temporalis Muscle Trismus

Trauma to the temporalis muscle sometimes associated with the trismus that may interfere with many daily activities like eating, speech and oral hygiene maintenance, so the treatment is necessary. Aims of study: were to evaluate the effects of local injection of steroids triamcinolone in and around the scar in the temporalis muscle to alleviate the trismus. Materials and methods: Thirty patients presented with trauma in Al-Salam teaching hospital to the temporal region. The procedure done by using local anesthetic agent injected by dental syringe around the scar. Then 1 ml of triamcinolone acetonide injected directly in the scar area and the injection site covered by surgical dressing. Jaw stretching exercise start immediately after injection and daily basis exercises. Two injections interval about 3 weeks repeated in the scar area. The exercise done four times daily for 10 minutes and lasting for four weeks. The improvement of mouth opening checked every five days and mean taken by measuring the inter incisal distance by a ruler. The follow up period continues for 3 months after treatment. Results: There is significant post-operative improvement of mouth opening and the range of inter incisal distance became about 2-4 cm, The patients how start treatment within first two months after trauma show significant improvement in comparison with those who start treatment after 3 months were there is a certain relapse in spite of prolong time and frequency of muscle stretching exercise. Conclusions: Post-traumatic trismus can be treated by early management of local steroid injection along with jaw stretching exercise for masticatory muscle if started in proliferating phase of wound healing.

A Cross-Sectional Study on the Evidence-Based Dentistry, Perception Basis, and Use of Articaine Among Dental Practitioners.

Background: Many dentists use articaine as their choice of local anesthetic agent. However, theuse of articaine is limited to inferior alveolar nerve blocks (IANBs), andliterature data are scarce concerning its perception and choice among various dental practitioners. Aim:The aim of the present study was to assess the extent of articaine use as a local anesthetic in dentistry, its perception basis, and the consistency of evidence of the efficacy and safety of articaine in recent practice. Methods: The present study utilized a survey tool that was given to all the participating dental practitioners, and the participants were given five minutes to fill out the survey questionnaire. The questionnaire was in English and had 14 questions to be answered. The data gathered were statistically assessed to formulate the results. Results: The results of this cross-sectional survey reported that articaine is used as a choice of local anesthetic by more than half of the participating dental practitioners. Sixty percent (n = 480) participants used articaine in their practice, followed by lidocaine, which was used by 33% (n = 264) dental practitioners, mepivacaine by 2% (n = 16) participants, prilocaine by 1% (n = 8) dental practitioners, and other local anesthetics by 4% (n = 32) participants, respectively. Concerning the safety and efficacy of articaine use, 43% used it for all procedures except for IANBs, whereas 20% used it for all procedures, including IANBs. Conclusion: Despite the reported efficacy and safety of articaine as a local anesthetic for all dental procedures, many dental practitioners refrain from using it, especially for IANBs. These data depicta difference between current research evidence and reported clinical practice.