Local Anesthetic Solution Research Articles

Effect of Buffered Local Anesthesia on Perioperative Pain During Arteriovenous Fistula Surgery: A Randomized Control Trial.

Objective: This prospective, pilot randomized double-blind study aimed to compare the effects of buffered and non-buffered xylocaine solutions on injection pain and anesthesia effectiveness in patients undergoing arteriovenous fistula surgery.Material and methods: A total of 100 adult patients meeting inclusion criteria undergoing arteriovenous fistula surgery were included in the study. They were split into two groups at random. The control group received 1% xylocaine dissolved in 5 ml distilled water, while the intervention group received sodium bicarbonate mixed with 1% xylocaine solution as a local anesthetic. The patients were asked to rate the pain of first and subsequent injections on a visual analog scale (VAS). Besides, the need for extra analgesia was investigated. The mean and standard deviation of the data was determined.Results: During both the first and subsequent injections, the alkalinized local anesthetic group showed substantially lower VAS scores. In the alkalinized local anesthetic group, anesthesia satisfaction was also more than three times higher. Furthermore, the non-alkalinized group's mean analgesic requirement was higher than the intervention group.Conclusion: Our findings support the effectiveness of the alkalinized local anesthetic solution in minimizing injection pain and increasing anesthesia duration and overall patient's surgical experience in terms of anesthesia satisfaction score.

Effect of verapamil as an adjuvant to Levobupivacaine in supraclavicular brachial plexus block

Background: The quest for searching newer and safer anaesthetic agents has always been one of the primary needs in anaesthesiology practice. Levobupivacaine, the pure s (-) enantiomer of bupivacaine, has strongly emerged as a safer alternative for regional anaesthesia than its racemic sibling. Also, many adjuvants have been used with local anaesthetics to reduce the time of onset and prolong the duration of analgesia in brachial plexus blocks. However, few studies are there using verapamil as an adjuvant with Levobupivacaine.Aims: The primary aim of the study is to know the effect of verapamil (5mg) as an adjuvant to Levobupivacaine in supraclavicular brachial plexus block.Methods: A Descriptive, Observational study was carried out in 80 ASA Grade I and II patients, undergoing upper limb surgeries under supraclavicular brachial plexus block using ultrasound machine. Local anaesthetic solution was prepared as following. 30ml 0.5% Levobupivacaine + 2ml Verapamil (5mg). The effect of Verapamil as an adjuvant to Levobupivacaine in Supraclavicular Brachial Plexus Block with regards to onset and duration of motor and sensory block, duration of analgesia, need for rescue analgesia and number of rescue analgesia in first 24 hours after surgery was evaluated. Data analysis was done with the help of SPSS Software ver 13.Results: Mean onset time for motor block in our study group was 9.19 ± 1.86minThe mean duration of motor block in our study group was 470.25 ± 42.00 minThe mean onset time for sensory block in our study group was 6.48 ± 2.55 minThe mean duration of sensory block in our study group was 494.88 ± 37.67 minThe mean duration of analgesia in our study group was 517.88 ± 48.24The mean no of reuse analgesia required in the first 24 hours after surgery was 3Conclusion: Verapamil (5 mg) 2 ml can be effectively and safely used as an adjuvant to Levobupivacaine (0.5%) 30ml in Supraclavicular Brachial Plexus Block. However, due to paucity of studies in literature, there is still scope for further study using different calcium channel blocking drugs or in different dosage strengths.

A modern approach to pain relief in labour

Until now, there are opposite points of view on the problem of pain in labour. The side effects of pain during labour can significantly affect the general condition of the woman and the fetus, the course of labour, and the prognosis. Pain relief in labour is based on the use of various pharmacological and non-pharmacological methods that reduce the level of psychological anxiety, relieve tension, and also block the conduction of pain impulse. For pain relief in labour, the full range of currently available pharmacological and non-pharmacological methods cannot be used, since many of them, simultaneously with pain relief, negatively affect the fetus and the process of childbirth. The use of neuraxial analgesia with local anaesthetic solutions at low concentrations is a safe method of pain relief during labour.

Extending the limits of vaginal hysterectomy under local anesthesia and conscious sedation

In this video we present the surgical management of a 58-year-old woman presenting with a large prolapsed myomatous uterus treated with vaginal hysterectomy (VH) and pelvic floor repair (PFR) (uterosacral ligament suspension and posterior colporraphy) under local anesthesia and conscious sedation. The patient underwent VH and PFR by using an infiltration of a local anesthetic solution of lidocaine, ropivacaine and adrenaline in combination with intravenous (iv) conscious sedation. Debulking techniques, such as intramyometrial coring, uterine bisection, myomectomy and wedge resection, were used to facilitate VH. The final weight of the removed uterus was 870g. This video demonstrates that performing a surgically challenging VH under local anesthesia is feasible. Vaginal uterine morcellation can be performed to debulk the enlarged uterus so that hysterectomy can be accomplished under local anesthesia. The use of local anesthesia may safely be offered as an alternative to patients undergoing a complex vaginal hysterectomy and reconstructive surgery.

Effects of vasopressin on anesthetic response time and circulatory dynamics of lidocaine

This study aimed to investigate the hypothesis that vasopressin extends the anesthetic response time of lidocaine and does not affect the circulatory dynamics. Rats were sedated with isoflurane; subsequently, breathing was maintained through mechanical ventilation. We infiltrated the first molar area of the upper left jaw with saline (NS, test solution), 2% lidocaine (L), 0.025 IU vasopressin-supplemented 2% lidocaine, 0.05 IU vasopressin-supplemented 2% lidocaine, 0.1 IU vasopressin-supplemented 2% lidocaine, and 0.2 IU vasopressin-supplemented 2% lidocaine (VL4). Further, anesthetic response times were measured up to 30 min using electric pulp testing methods (n = 4). The anesthetic response times of NS, L, and VL4 were measured up to 45 min with the aforementioned results as reference values (n = 7). The circulatory dynamics of NS, L, VL4, and 0.2 IU vasopressin (V) were measured up to 45 min using a non-invasive blood pressure measuring device. VL4 extended the anesthetic response times of lidocaine compared to L (p < 0.05). Further, V and VL4 significantly increased the systolic and diastolic blood pressure and significantly decreased the pulse rate (p < 0.05). VL4 is not a suitable addition to the local anesthetic solution used in dentistry. Further study is needed to determine vasopressin concentration that extends the anesthetic effect without affecting the circulatory dynamics.

Clinical efficacy of 0.75% ropivacaine vs. 2% lignocaine hydrochloride with adrenaline (1:80,000) in patients undergoing removal of bilateral maxillary third molars: a randomized controlled trial.

BackgroundLignocaine with adrenaline is routinely used as a local anesthetic for dental procedures. Adrenaline was added to increase the duration of anesthesia. However, epinephrine containing a local anesthetic solution is not recommended in conditions such as advanced cardiovascular diseases and hyperthyroidism. Recently, ropivacaine has gained popularity as a long-acting anesthetic with superior outcomes. The goal of this study was to assess and compare the effectiveness of 0.75% ropivacaine alone and 2% lignocaine with adrenaline (1:80,000) in the removal of bilateral maxillary wisdom teeth using the posterior superior alveolar nerve block technique.MethodsThis was a single-blind, randomized, split-mouth, prospective study assessing 15 systemically sound outpatients who needed bilateral removal of maxillary third molars. We randomly allocated the sides and sequences of ropivacaine and lignocaine with adrenaline administration. We evaluated the efficacy of both anesthetics with regard to the onset of anesthesia, intensity of pain, variation in heart rate, and blood pressure.ResultsThe onset of anesthesia was faster with lignocaine (138 s) than with ropivacaine (168 s), with insignificant differences (p = 0.001). There was no need for additional local anesthetics in the ropivacaine group, while in the lignocaine with adrenaline group, 2 (13.3%) patients required additional anesthesia. Adequate intraoperative anesthesia was provided by ropivacaine and lignocaine solutions. No significant difference was observed in the perioperative variation in blood pressure and heart rate.ConclusionRopivacaine (0.75%) is a safe and an adrenaline-free local anesthetic option for posterior superior alveolar nerve block, which provides adequate intraoperative anesthesia and a stable hemodynamic profile for the removal of the maxillary third molar.

To evaluate and compare the compressive strength of root dentin exposed to calcium hydroxide, mixed with various vehicles for a period of 30 days - An in vitro study.

Background:Long-term use of intracanal medicaments such as calcium hydroxide (CH) reduces the fracture resistance of dentin.Aim:This study aimed to evaluate and compare the compressive strength of root dentin exposed to CH, mixed with various vehicles after 30 days of placement.Settings and Design:Sixty single-rooted extracted human permanent premolars were collected, and complete instrumentation was done. Samples were divided into six groups.Materials and Methods:In Group I, no medicament was placed. In Group II, Group III, and Group IV, the root canals were filled with CH powder mixed with normal saline, distilled water, and local anesthetic solution. In Group V and Group VI, the root canals were filled with Metapaste and RC-Cal. Access cavities were sealed using IRM and were stored for 30 days. Teeth sectioned to obtain a 5 mm thick dentin cylinder subjected to compressive loading to evaluate the fracture resistance using a universal testing machine.Statistical Analysis:Results were analyzed using one-way ANOVA and multiple comparisons using Bonferroni test.Results:Highest mean compressive strength was recorded in Group I followed by Group II, Group IV, Group VI, Group III, and Group V.Conclusions:CH when used as a root canal dressing material will reduce the compressive strength of the teeth irrespective of the form of CH and vehicle.

Comparison of the effects of articaine and bupivacaine in impacted mandibular third molar tooth surgery: a randomized, controlled trial.

BackgroundThe aim of this randomized, triple-blind trial was to determine the anesthetic, analgesic, and hemodynamic effects of articaine and bupivacaine in the extraction of impacted mandibular third molar teeth.MethodsTwenty-six patients who underwent removal of bilaterally symmetric mandibular third molars were randomly assigned to articaine and bupivacaine groups in a split-mouth design. The onset of anesthetic action, intraoperative comfort, total amount of solution used, duration of postoperative anesthesia and analgesia, rescue analgesic use, postoperative pain, intraoperative bleeding, and hemodynamic parameters were evaluated.ResultsIn the articaine group, the onset of anesthetic activity was faster, intraoperative comfort was greater, and effective anesthesia required less local anesthetic solution. The bupivacaine group showed a significantly longer duration of postoperative anesthesia and analgesia, in addition to lower visual analog scale values at 6 and 48 hours postoperatively. There were no significant differences between the two solutions regarding rescue analgesic medication use, intraoperative bleeding, or hemodynamics.ConclusionArticaine showed greater clinical efficacy than bupivacaine in intraoperative anesthesia, achieving faster onset of anesthetic action and greater patient comfort while also requiring less reinforcement during surgery. However, bupivacaine was superior in terms of postoperative anesthesia, reducing postoperative pain due to its residual anesthetic and analgesic effects. Both anesthetic solutions led to similar hemodynamics at low doses in mandibular third molar surgery.

Effect of Subcutaneous Adrenaline/Saline/Lidocaine Injection on Split-Thickness Skin Graft Donor Site Wound Healing.

Subcutaneous injection of tumescent solution, which contains local anesthetic, adrenaline, and saline, before split-thickness skin graft harvesting, shows a significant hemostatic effect. This method can reduce the initial bleeding from the donor site. The aim of this study is to assess the benefits of controlling the bleeding from donor sites by tumescent injection. A randomized, controlled trial was performed to compare the wound healing of split-thickness skin graft donor sites treated with or without tumescent injection. This randomized, controlled trial examined donor site healing days as the main measure of outcome. postoperative pain, donor site ulceration, and scar quality were evaluated as secondary outcome measures. Patients planned for split-thickness skin graft harvest were randomly assigned to receive either pre-harvest subcutaneous injection of local anesthetic, adrenaline, and saline solution (tumescent solution) (Group 1) or post-harvest application of adrenaline solution-soaked gauze to the skin graft donor sites (Group 2). Donor sites were treated with calcium alginate dressings after graft harvesting. On the 10th postoperative day, the dressings were removed and donor site healing were measured. Follow-up evaluation of scar quality was performed 6 months after surgery. Postoperative pain was evaluated on the 1st day after operating. Forty-five patients (26 males; average age 61.8 years) completed the late follow-up evaluation (6 months postoperatively), with 26 patients in group 1 and 19 in group 2. There were no significant differences between the two groups in any of the outcome measures. Tumescent technique provides sufficient hemostasis in split skin graft donor sites, especially the initial bleeding just after graft harvesting, without any negative effects. Larger series should be studied to evaluate the effect in donor site wound healing.

Comparison of two different methods for labor analgesia depending on the mode of epidural infusion administration (continuous or intermittent)

Introduction: The use of a local anesthetic solution with opioids as a continuous epidural infusion administration during labor is controversial. It is considered to prolong the second stage of labor and to increase the total delivered dose of anesthetic, without improving the analgesia in comparison with the usage of the same solution in intermittent bolus doses, periodically. This study is designed to compare these two techniques. Materials and methods: In this study, 60 parturient women were included. Labor analgesia started with a single bolus dose of 10 mL ropivacaine 0.1% administered epidurally in both groups. Group A was, subsequently, given epidurally Ropivacaine 0.15% with Fentanyl 2 μgr/mL in continuous infusion with a rate of 10 mL/h throughout labor, while Group B was given the same dose per hour but in two bolus doses of 5 mL administered every 30 min. In both groups, we had the possibility of additional bolus doses of 5 mL of the same solution with a lock out interval of 20 min. The total dosage received, the duration of the 2nd stage of labor, the method of delivery (assisted or not, Cesarean section), the motor activity (using the Bromage scale) and the pain intensity (using the VAS 1–10, every 20 min) were evaluated. Results: No statistically significant differences were observed in the duration of labor (one way ANOVA), in the Bromage score and in the method of delivery between the two groups (x2 test). No differences were also observed in the recordings of pain intensity between the two groups (two-way ANOVA for repeated measurements), but in some specific instances Group A presented higher VAS score, although the total dosage of local anesthetic received was greater in this group compared to group B (180 mL vs. 162 mL, p = 0.04). Conclusions: The use of intermittent epidural bolus doses compared to a continuous infusion technique is associated with lower total consumption and periodically better pain management.

Comparison of lignocaine versus articaine local anesthetic solutions in periodontal therapies administered by computerized anesthetic delivery system

Objectives: To compare the depth and duration of anesthesia experienced by the patient between lignocaine and articaine anesthetic solutions and to evaluate pain perception and intraoperative anxiety by computer-controlled injection while administering these anesthetic solutions. Materials and Methods: The clinical trial was designed as a randomized, single-center, double-blinded, parallel arm, and comparative study. Examiner and study patients were blinded to treatment assignment during the study. Patients were divided into three groups based on treatment to be performed (Root Planing 30, Curettage 30, and Surgery 20) and were anesthetized with articaine in one quadrant and lignocaine in another quadrant by computer-controlled anesthetic device (WAND®). The duration of anesthesia was self-reported by the patients and was calculated by paired t-test. The pain and anxiety scores were calculated on Wong Baker's Facial Pain/Anxiety Scale' by Chi-square test. Results: Articaine had longer duration of anesthesia than lignocaine in all the three groups (P

Single-insertion technique for anesthetizing the inferior alveolar nerve, lingual nerve, and long buccal nerve for extraction of mandibular first and second molars: a prospective study.

ObjectivesAppropriate and accurate local anesthetic (LA) techniques are indispensable in the field of oral and maxillofacial surgery to obtain a satisfactory outcome for both the operating surgeon and the patient. When used alone, the inferior alveolar nerve block (IANB) technique requires supplemental injections like long buccal nerve block for extraction of mandibular molars leading to multiple traumatic experiences for the patient. The aim of this study was to anesthetize the inferior alveolar, lingual, and long buccal nerves with single-needle penetration requiring a minimal skillset such as administering a conventional IANB through introduction of the Benny Joseph technique for extraction of mandibular molars.Materials and MethodsThis was a prospective study conducted in the Department of Oral and Maxillofacial Surgery, Kunhitharuvai Memorial Charitable Trust (KMCT) Dental College, Calicut, India. The duration of the study was 6 months, from June to November 2017, with a maximum sample size of 616 cases. The LA solution was 2% lignocaine with 1100,000 adrenaline. The patients were selected from a population in the range of 20 to 40 years of age who reported to the outpatient department for routine dental extraction of normally positioned mandibular right or left first or second molars.ResultsOf the 616 patients, 42 patients (6.8%) required re-anesthetization, a success rate of 93.2%. There were no complications such as hematoma formation, trismus, positive aspiration, and nerve injuries. None of the cases required re-anesthetization in the perioperative period.ConclusionThe Benny Joseph technique can be employed and is effective compared with conventional IANB techniques by reducing trauma to the patient and also requires less technique sensitivity.

ОПРЕДЕЛЕНИЕ КОНЦЕНТРАЦИИ РОПИВАКАИНА В ВЕНОЗНОЙ КРОВИ ПРИ ПРОВЕДЕНИИ ДЛИТЕЛЬНОЙ АНАЛЬГЕЗИИ ПОСЛЕОПЕРАЦИОННОЙ РАНЫ

Aim. Determinations of concentrations of total ropivacaine in venous blood with use of the selected scheme of prolonged analgesia of the postoperative wound after cesarean operation. Materials and Methods. The study involved 47 female patients after cesarean operation in whom during suturing of the laparotomy wound a multiperforated catheter was installed under aponeurosis of the abdominal muscles for a prolonged postoperative analgesia. With use of infu-sion pump, 0.2% ropivacaine solution was introduced at constant speed 4 ml/h with the total amount 200.0 ml. Blood was taken by puncture of the peripheral vein in control points in 30 min, 24 hours and 48 hours after the start of injection of the solution. The quantitative determination of the concentration of the total ropivacaine of venous blood plasma (free and bound with plasma proteins) was conducted using gas chromatograph with mass-selective detector. Results. The highest concentrations of the total ropivacaine of venous blood were recorded in 48 hours Me (Q1; Q3)=0.053 (0.043; 0.071) which was significantly lower than minimal potentially toxic concentrations. Also not a single case of appearance of clinical signs of systemic toxicity of local anesthetics was recorded. No statistically reliable correlation was found between body mass, height, body mass index and concentration of total ropivacaine in blood. Conclusion. The given study permitted to confirm safety of the selected scheme of introduction of the solution of local anesthetic, since no potentially toxic concentrations of the total ropivacaine were reached in venous blood in a single patient included into the study.

Ultrasound-guided pectoral nerve block for pain control after breast augmentation: a randomized clinical study

Background and objectivePectoral nNerve (PECS) block type-1 is an Ultrasound (US)-guided interfacial block that can be performed for postoperative analgesia management after breast surgery. In the procedure, a local anesthetic solution is injected into the interfacial area between the Pectoralis Major muscles (PMm) and Pectoralis minor muscles (Pmm). The present study compared PECS block type-1 administered preoperatively or postoperatively for postoperative analgesia after breast augmentation surgery. MethodsThe patients were randomly divided into three groups (n = 30 in each): a preoperative PECS block group (Pregroup), postoperative PECS block group (Postgroup), and control group (Group C). Opioid consumption and Visual Analogue Scale (VAS) scores were evaluated at postoperative period. ResultsThe pains scores in the Pregroup were significantly lower than those in the control group. Although there was no significantly difference in the VAS scores of the Postgroup and control group at postoperative 1 hour, the scores in the Postgroup were significantly lower than those in the control group at all the other evaluated times (p < 0.05). The VAS scores in the Pregroup were significantly lower than those in the Postgroup 8 hours after the surgery. Opioid consumption was significantly lower in the Pregroup as compared with that in the other two groups (p < 0.05). The use of rescue analgesia in the Pregroup was significantly lower than that in the other groups (p < 0.05). ConclusionPerforming PECS block type-1 preoperatively reduced VAS scores and opioid consumption after breast augmentation.

Efeito do volume da solução anestésica local aplicada no bloqueio retrobulbar na cirurgia de catarata na duração da anestesia e no conforto do paciente

Abstract Objective: To compare the use of 2 different local anesthetic solution (LAS) volumes of 1.5 mL and 3 mL in retrobulbar block in patients undergoing cataract surgery in terms of anesthesia, akinesia, and pain levels. Methods: 80 patients between 18-90 years old, ASA I-II-III, were included in the study. For retrobulbar anesthesia, 1.5 mL LAS was applied to one group (Group LV), and 3 mL LAS to the other group (Group HV). The patients' ocular and eyelid motion scores were evaluated and recorded in the first, third, fifth, and tenth minutes after the block, and at 30-minute intervals for 4 hours post-operatively. One day later, the first hour of analgesic need and the number of times they took analgesic agents were asked and recorded. In addition, side effects were questioned and recorded. Results: The 39 (48.75%) patients were male and 41 (51.25%) patients were female. The criteria determined in terms of ocular motor score after the retrobulbar block (ocular motor score≤4) were met in 92.5% of patients in Group LV in all patients in Group HV, and the time to fulfill the determined criteria in Group HV was found to be significantly lower compared to Group LV (p=0.004). The movements of the eye in all direction except the inward movement recovered in Group LV in a significantly shorter time than Group HV (p=0.004). There was no significant difference in pain levels and side effects between the groups (p=0.34). Conclusions: After 1.5 mL LAS administration in retrobulbar block, adequate akinesia was not achieved in about one tenth of patients, but no significant difference was found between 1.5 mL and 3 mL LAS volumes in analgesic efficacy and side effects.

Endovenous laser ablation of incompetent great saphenous veins with 1470-nm laser using bare tip and radial fibers results in similar short-term outcomes

ObjectiveThe common side effects of endovenous laser ablation (EVLA) are pain and discomfort in the treated leg. We compared the pain and outcomes after EVLA using a 1470-nm laser with bare tip or radial fibers in the treatment of incompetent great saphenous veins (GSVs). MethodsA total of 86 patients with primary varicose veins of the GSV were randomized to treatment using a 1470-nm laser and bare fiber (BF; n = 43) or radial fiber (RF; n = 43) during a 12-month period from January to December 2019. Patients were assessed clinically and using venous Doppler ultrasonography at 24 hours, 1 week, and 1 month. The periprocedural parameters and short-term outcomes of pain after the procedure, improvement in the Venous Clinical Severity Score (VCSS), and vein occlusion at 1 month were compared and analyzed. ResultsThe linear endovenous energy density (65.7 J/cm vs 65.2 J/cm), tumescent local anesthetic solution used (627.4 mL vs 661.4 mL), treated GSV length, and number of hook phlebectomies were similar in both groups. The pain score at 8 hours (2.77 vs 2.70) and 1 week (2.81 vs 2.74) were similar in the BF and RF groups, respectively. The improvement in the VCSS was significant in both groups and was slightly better in the BF group, although the difference was not statistically significant. Both fiber types had 100% efficacy in terms of closure of the treated vein at 1 month. ConclusionsEVLA using a 1470-nm laser with a BF had similar outcomes in the short term compared with a RF of the same wavelength. Both fibers were associated with significant improvement in the VCSS at 1 month.

Abstract 16068: Local Anesthesia Using the “Tumescent Technique” versus General Anesthesia for Subcutaneous-implantable Cardioverter Defibirllator Implantation: Description of a Novel Technique

Introduction: General anesthesia is routinely used during the implantation of S-ICD which dramatically prolongs total procedure time, patient recovery time and adds unnecessary potential complications. The tumescent local anesthesia (TLA) technique provides anesthesia of large areas of skin and subcutaneous tissue by means of the direct infiltration of large volumes of a dilute local anesthetic solution into subcutaneous fat. Hypothesis: TLA during S-ICD implantation is feasible and associated with a reduction in total procedure time. Methods: A retrospective analysis was conducted in two medical centers during 2019. Five patients underwent S-ICD with TLA due to baseline conditions that represented relative contraindications to general anesthesia (e.g, muscular dystrophy). A large volume of a local anesthesia solution (i.e., 1 liter of normal saline, 30 cc of 1% lidocaine, 30 cc of bupivacaine, 1 mg of epinephrine, 12.5 mEq of sodium bicarbonate) was used in each patient and injected 10 minutes prior to incisions. Five other patients who underwent S-ICD under general anesthesia served as controls. The skin-to-skin time, total length of procedure and post-procedural pain levels were compared between groups. Results: A total of 10 patients were included (male: 60%; mean age: 62 ± 16). All devices were implanted for primary prevention of sudden cardiac death. TLA was considered the best anesthetic approach in five patients who had medical conditions that represented a high risk of complications if general anesthesia was employed. In the group of TLA, an average of 260 ± 45 cc was administered. The skin-to-skin times were 44.8 ± 13.9 minutes in patients who underwent general anesthesia vs. 46.2 ± 14.3 minutes in TLA (p = 0.3). The total procedural time was 148 ± 28 min vs 64.2 ± 13.4 min (p &lt;0.001) for general anesthesia and TLA, respectively. There was a significant difference between groups in pain scale following the procedure being better pain control with TLA. Conclusions: S-ICD implantation using TLA appears to be a feasible and safe option in patients with contraindications to general anesthesia. This technique significantly decreases total procedure time with better post-procedural pain control.

Comparing the anaesthetic efficacy of 1.8 mL and 3.6 mL of anaesthetic solution for inferior alveolar nerve blocks for teeth with irreversible pulpitis: a systematic review and meta-analysis with trial sequential analysis.

The scientific literature is contradictory in relation to selecting the appropriate volume of local anaesthetic solution for inferior alveolar nerve blocks (IANB) when attempting to anaesthetize mandibular teeth with irreversible pulpitis. To compare the efficacy of 1.8 and 3.6mL of the same anaesthetic solution for IANBs when treating mandibular teeth with irreversible pulpitis. A literature search was performed in PubMed, Scopus and EBSCOhost databases until May 2020. Randomized clinical trials published in English, comparing 1.8 with 3.6mL of the same anaesthetic solution for IANBs in permanent mandibular teeth with irreversible pulpitis, were included. The risk of bias of the included trials was appraised using the revised Cochrane risk of bias tool. A meta-analysis was performed using the random-effects model. The effect of random errors on the results of the meta-analysis was evaluated by trial sequential analysis and the quality of evidence was appraised using the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) approach. Four clinical trials involving 280 teeth from patients with ages ranging from 18 to 65years were included. Among the four trials, three were categorized as having a 'low' risk of bias and one was categorized as having 'some concerns'. The primary meta-analysis revealed that 3.6mL of anaesthetic solution when administered for IANBs was associated with significantly greater success rates compared with 1.8mL (RR=1.94; 95% CI, 1.07, 3.52; I2 =77%). Similarly, the results of the sensitivity analysis (restricting trials only to those that used the Heft-Parker visual analogue pain scale) revealed that the use of 3.6mL significantly increased the success of IANBs compared with 1.8mL. The trial sequential analysis confirmed the evidence for the beneficial effect of 3.6mL to achieve success for IANBs was 'conclusive'. The quality of evidence was graded as 'high'. Increasing the volume of anaesthetic solution from 1.8 to 3.6mL improved the success rate for IANBs in mandibular molars with irreversible pulpitis. The quality of the evidence was 'high'. Future high-quality clinical trials are required with different types of anaesthetic solutions and other types of teeth.

Erector Spinae Plane Fascial Block in Multiple Rib Fractures (Case Report)

The aim of the study: to improve the efficacy of erector spinae plane (ESP) fascial block for pain management in patients with multiple rib fractures. Materials and methods. We observed 4 patients with multiple rib fractures who were treated with ESP fascial block with subsequent prolonged administration of local anesthetic for pain relief. To evaluate the efficacy of the ESP block, the visual analogue scale (VAS) for pain intensity, cough performance index and forced vital capacity (FVC), as well as a modified 3-item scale were used. The distribution of local anesthetic (10% lidocaine solution) and contrast (iohexol solution, 350 mg iodine/ml) media was analyzed by computed tomography and correlated with the data on reduced pain perception according to the thoracic vertebrae (Th) levels.Results. After the ESP block in patients with multiple rib fractures, we found a decrease in VAS pain intensity at rest by 3-4 points and on coughing by 3-6 points, an increase in cough performance by 1 point and in the modified 3-item scale by 1-3 points. The distribution of the local anesthetic solution was registered mainly in the cranial-caudal and anterior direction to the intertransversal space without significant leakage in lateral and medial directions. In all 4 cases the local anesthetic and contrast media spread from the catheter tip cranially several levels of thoracic vertebrae farther than in caudal direction.Conclusion. ESP block in patients with multiple rib fractures is a reasonably effective method of pain relief. Catheterization of the fascial plane of erector spinae muscle should be performed at the level of vertebra corresponding to the underlying fractured rib. The data obtained may serve as a basis for further studies with more patients included.

Buffered 2% articaine versus non-buffered 4% articaine in maxillary infiltration: randomized clinical trial.

This randomized, triple-blind, crossover clinical trial aimed to evaluate the efficacy, onset, length of pulp and soft tissue anesthesia, and pain during injection of 2% buffered articaine and 4% non-buffered articaine solutions. Each volunteer received two maxillary supraperiosteal anesthesia infiltrations in canine area. The infiltrations were performed at two different sessions using a different local anesthetic solution for each session, and the anesthetic injection speed was always 1 mL/min. The assessment of the onset and length of pulpal and soft tissue anesthesia was performed with the pulp electrical test "pulp tester" and the esthesiometer kit, respectively. Volunteers marked pain during injection on a visual analog scale (VAS). The anesthetics solutions pH was evaluated through the pH meter equipment. There was no difference between the two anesthetic solutions (onset of soft tissue anesthesia, p = 0.5386; length of soft tissue anesthesia, p = 0.718; onset of pulpal anesthesia, p = 0.747; length of pulpal anesthesia, p = 0.375), except for pain during the injection which was lower when buffered 2% articaine was used (p = 0.001) and the pH. The pH analysis revealed that the solutions differed from one another (p < 0.01). The 2% buffered articaine solution provided the same anesthetic properties then 4% unbuffered articaine with a great reduction in pain during injection. The possibility of use 2% buffered articaine solution instead of 4% articaine maintaining the same anesthetic properties with a great reduction in pain during injection and half of the anesthetic salt concentration.