Local Anesthesia In Patients Research Articles

Evaluating the Safety of Transcarotid Artery Revascularization under Local Anesthesia Prior to Coronary Artery Bypass Grafting Surgery

Controversy exists regarding the timing of intervention for patients with critical coronary artery disease awaiting coronary artery bypass and severe carotid artery stenosis. Transcarotid artery revascularization (TCAR) is a minimally invasive revascularization alternative through direct transcervical carotid access that minimizes the chance of arch manipulation and consequent antegrade embolic stroke rate. While the TCAR procedure can be performed under local anesthesia (monitored anesthesia care, MAC) vs general anesthesia, the hemodynamic benefits of local anesthesia in patients with severe CAD are significant. Patients receiving staged TCAR-CABG have high-risk cardiovascular disease and require accurate perioperative neurological and hemodynamic evaluation that can be safely provided with local anesthesia. In this retrospective single-center study, 14 patients were systematically identified to have undergone staged TCAR prior to CABG surgery from December 2018 to October 2021. All patients underwent TCAR with local anesthesia and minimal sedation. Relevant patient demographics, medical and surgical history, preoperative covariates, and type of anesthesia administered were obtained from patients' charts. Carotid artery disease was confirmed by either carotid duplex imaging or computed tomography angiography (CTA) of the head/neck. Staged TCAR-CABG interventions were performed on 14 patients (64% male; mean age 65.0 years). No major adverse cardiac events were reported including transient ischemic attack (TIA), stroke, myocardial infarction, or TCAR-related death in the interval between their TCAR and CABG as well as in a 12-month follow-up period. One patient required to return to the operating room (OR) for evacuation of a neck hematoma. This study demonstrated high success rate of TCAR under local anesthesia prior to CABG (100%) with no incidence of perioperative stroke, myocardial infarction (MI), or death at 1-month, 6-month, and 12-month follow-up intervals. The authors support the use of staged TCAR-CABG with local anesthesia as a safe and promising treatment option for patients with high-grade cardiac disease, high risk of stroke, or multiple comorbidities that preclude a CEA.

Different effects of intravenous and local anesthesia in patients undergoing ultrasound-guided radiofrequency ablation of thyroid nodules: a prospective cohort study

Purpose To compare the efficacy and safety of intravenous anesthesia (IV) with local anesthesia (LA) in patients undergoing ultrasound (US)-guided radiofrequency ablation (RFA) of thyroid nodules. Methods 50 patients with American Society of Anesthesiologists classification grades I–II undergoing US-guided thyroid RFA were enrolled and randomly (1:1) divided into IV (conscious sedation with Ramsay Sedation Scale [RSS] scores of 2–3 with an anesthesiologist) and LA (subcutaneous anesthesia with lidocaine without an anesthesiologist) groups. Pre-, intra- and post-procedural blood pressure (BP) (SBP0/DBP0, SBP1/DBP1, and SBP2/DBP2), intra- and post-procedural pain (NRS1 and NRS2), ablated area volume, treatment time and adverse events were analyzed and compared. Results Age, sex, weight, number, nature, volume of nodules, and SBP0/DBP0 showed no difference between both groups. 11 and 0 patients’ SBP1/DBP1 were elevated in the LA and IV groups. NRS1 differed between both groups. 6 patients in the LA group had moderate or severe pain, but none in the IV group. No between-group difference in SBP2/DBP2, NRS2, ablation completion rate and ablated volume was noted. The median procedure duration differed from 1109 (176) s in IV group and 723 (227) s in LA groups. There was no increased incidence of adverse events in IV group. Conclusions IV with RSS scores of 2–3 maintained intra-procedural BP and relieved intra-procedural pain better, without affecting the ablation efficacy and increasing complications. Despite increased treatment time, IV is a potential option for patients undergoing US-guided RFA of thyroid nodules.

Transvenous lead extraction: safety and efficacy of local anesthesia

Abstract Funding Acknowledgements Type of funding sources: None. Introduction Patients undergoing transvenous lead extraction (TLE) usually receive general anesthesia, although in our experience local anesthesia is a frequent alternative. Purpose We sought to verify safety and effectiveness of local anesthesia in patients undergoing tranvenous lead extraction (TLE). Methods A retrospective analysis of patients who underwent to TLE in our center was performed. 1293 patients were divided in three groups depending on EROS class and comparisons were made in each group depending on type of anesthesia. Lead extraction was performed by manual traction or mechanical dilatation and use of transjugular approach was evaluated on case-by-case. Results In the EROS 1 group (726 pts.) 559 (77%) receive local anesthesia, in the EROS 2 (367 pts.) 252 (69%) and in the EROS 3 (200 pts.) 73 (36%). There was no differences in total complications (EROS 1 3.76% vs 2.99%, p=0.814, EROS 2 4.76% vs 5.21%, p=0.851, EROS 3 5.48% vs 11.81%, p=0.210) and clinical success (EROS 1 98.75% vs 99.40%, p=0.689, EROS 2 98.41% vs 94.78%, p=0.077, EROS 3 80.82% vs 85.04%, p=0.439) between local and general anesthesia throughout the groups; use of internal jugular approach was significantly higher in EROS 2 patients undergoing general anesthesia (4.76% vs 11.30%, p=0.021), while in EROS 1 and 3 patients this difference was not statistically significant (EROS 1 5.01% vs 8.38%, p= 0.101, EROS 3 8,22% vs 18,11%, p=0.056). Conclusion These results suggest that local anesthesia in patients undergoing transvenous lead extraction does not affect procedural outcomes and safety. Complex procedures with the need for internal jugular approach may drive this choice with preference for general anesthesia.

The role of biodegradable spacer implantation under local anesthesia for patients with massive rotator cuff tears and significant medical comorbidities

Massive rotator cuff tears are common, and the incidence increases with age. They are a challenging problem to deal with as many are irreparable. While there are a host of surgical options available, these can be prolonged procedures requiring general anesthesia and thus not suitable for elderly patients or those with significant medical comorbidities. In this study, we evaluate the role of a biodegradable balloon inserted under local anesthetic for a series of patients with massive cuff tears and significant medical comorbidities. A prospective pilot study was performed on a series of patients between June 2018 and April 2019. Demographic data, as well as preoperative and postoperative clinical data including Subjective Shoulder Value and Oxford Shoulder Scores, were obtained. Four patients with magnetic resonance imaging-proven massive rotator cuff tears involving the supraspinatus were treated with an InSpace balloon under local anesthesia. All were of American Society of Anesthesiologists grade 4 and had exhausted nonoperative treatment. The mean Oxford Shoulder Score improved from a preoperative baseline of 17.25 (range 6-25) to a peak of 25.75 (range 15-34) at the 6-week postoperative mark before declining to 13.67 (range 6-23) at the final follow-up of 6 months. Subjective Shoulder Values also improved initially from a mean of 31.25 (range of 20-40) to a peak of 58.75 (range of 50-70) before reducing to 36.67 (range of 30-50) at the final follow-up of 6 months. We have described the safety and early benefit from the use of a biodegradable balloon spacer inserted under local anesthetic as a management option for patients with massive rotator cuff tears, who may be unfit for other extensive reconstruction options, particularly for short-term pain relief as significant long-term gains were not demonstrated.

Is Prostate Urethral Lift Effective in Patients with Multiple Comorbidities?

A prostatic urethral lift (PUL) can be performed under local anesthesia in patients normally at high risk for general anesthesia due to multiple comorbidities. However, the clinical efficacy of PULs in patients with multiple comorbidities remains unknown. Therefore, in this this study, we aimed to evaluate the clinical efficacy of the PUL in patients with a high number of comorbidities by comparing its clinical efficacy in these patients with that in healthy individuals. We performed a retrospective observational cohort study, in which patients who underwent a PUL between December 2016 and January 2019 at a single tertiary care center were categorized into two groups: healthy individuals who wanted to preserve sexual function (Group 1) and patients with a high number of comorbidities who were at high risk for general anesthesia, based on an American Society of Anesthesiologists (ASA) score of ≥3 (Group 2). The International Prostate Symptom Score (IPSS), maximum urinary flow rate (Qmax), and post-void residual urine (PVR) were obtained preoperatively and compared throughout the 2-year follow-up. A total of 66 patients were enrolled, of whom 36 patients were included in Group 1 and 30 in Group 2. In Group 1, IPSS, IPSS quality of life (QoL), and Qmax significantly improved and were then maintained during follow-up, whereas, in Group 2, improvements in these parameters were not maintained during follow-up, except for IPSS QoL. Eleven patients (36%) in Group 2 required additional treatment for the recurrence of lower urinary tract symptoms. In conclusion, patients with a high number of comorbidities had a low therapeutic effect after PUL, suggesting a high rate of treatment failure. Therefore, comorbidity status should be considered when evaluating the potential benefits of the PUL procedure during preoperative counseling.

Antegrade placement of JJ catheter in the treatment of malignant ureteral obstruction: Retrospective analysis of a single centre

Objective: The aim of the present study was to examine the results of antegrade JJ stent placement in upper urinary tract obstruction in patients where retrograde placement was not possible. Methods: In this retrospective study, patients who underwent antegrade JJ stent placement for malignant ureteral obstruction in the urology clinic of a university hospital between January 1, 2018 and December 31, 2020 were included in the study. JJ stent was placed under local or general anaesthesia guided by ultrasonography and fluoroscopy. Age, gender, kidney function values, pathologies causing obstruction, and complications of the patients were examined. Results: In this study, 40 patients (16 men, 24 women) who underwent antegrade JJ stent placement were included. The mean ages of the women and men included were 51 (31-91) years and 62.5 (26-81) years, respectively. In all, antegrade JJ stenting was performed in 61 renal units of these patients. Of these, 21 were bilateral, 11 in the right collecting system and 8 in the left collecting systems. Clinical and technical success was achieved in 59 of the 61 procedures (96.6%). Arteriovenous fistula developed in only one patient, whereas no serious complications such as massive bleeding, resistant hematuria or pseudoaneurysm occurred in the remaining patients. The procedure was completed in a mean time of 15-30 minutes. Conclusions: Antegrade JJ stent placement is a procedure with a high success rate and low risk of complications that can be used in patients with severe ureteral obstruction owing to malignant or benign aetiologies. This method should be applied in centres experienced in malignant ureteral obstruction and on patients where retrograde placement was not possible. Furthermore, it should be considered as an alternative treatment option to open surgery as it can be performed under local anaesthesia in patients at a high risk of anaesthesia.

Outcome of Percutaneous Peritoneal Drainage in High Risk Perforated Peritonitis

Study Design: Prospective study Place and Duration: The study is conducted at Surgical A ward Mardan Medical Complex, Mardan and Surgery department of Ahmed Hospital, Bagh Azad Kashmir during the period from June to November 2021. Methods: There were 85 patients of both genders with ages 22-80 years included. Patients were included into the study after obtaining written permission from all participants. All the patients had high perforation peritonitis treated with percutaneous peritoneal drainage with local anesthesia. Post-operative success rate, mortality and complications among all cases were recorded. SPSS 22.0 version was used to analyze complete data. Results: Among 85 cases, 54 (63.5%) were males and 31 (36.5%) patients were females with mean age 51.7±8.71 years. COPD was mostly found among 29 (34.1%) cases, followed by ischaemic heart disease in 20 (23.5%) cases, congestive heart failure in 14 (16.5%) cases, cerebrovascular stroke 12 (14.1%) and 10 (11.8%) patients had comorbidity of steroid use. After drainage, improvement observed in urine output and in blood pressure. Post-operative effectiveness was found among 70 (82.4%) cases and 15 (17.55) patients died. In Post-operative, we found that the surgical site infection (SSI) was the most common symptom followed by chest infection. Conclusion: According to our findings and experience, the use of percutaneous peritoneal drainage under local anaesthesia in patients who have been reported late or are critically ill improves their general condition and allows them to be better prepared to undergo further surgery, which could ultimately save their lives. Keywords: Percutaneous Peritoneal Drainage, Perforated Peritonitis, Mortality, Complications

Епідуральна інфільтрація глюкокортикоїдів та місцевих анестетиків при лікуванні неспецифічного болю в спині

Актуальність. Неспецифічний біль у спині — найчастіша скарга після невеликих травм і гострих респіраторних захворювань та провідна причина обмеження фізичної активності пацієнтів молодше 45 років. Це захворювання продовжує залишатися соціально значущою медичною проблемою внаслідок як тривалої непрацездатності цієї групи пацієнтів, так і високої вартості лікування. Мета: оцінити ефективність епідуральної інфільтрації місцевими анестетиками і глюкокортикостероїдами при неспецифічному болі в спині, пов’язаному з дегенеративно-дистрофічним ураженням різних відділів хребта, та визначити її вплив на покращання якості життя таких хворих. Матеріали та методи. Проаналізовані результати лікування 71 пацієнта віком від 36 до 74 років, які перебували в Центрі лікування болю та неврологічному відділенні КЗОЗ «Харківська обласна клінічна лікарня — Центр екстреної медичної допомоги та медицини катастроф» із 2016 по 2017 рік із приводу хронічного неспецифічного болю в спині. Пацієнти були розподілені на 2 групи: основну — 38 осіб, яким як монотерапію епідурально вводили розчин глюкокортикостероїду та місцевого анестетика, та контрольну — 33 пацієнти, яким проводили стандартне консервативне лікування. Результати. У результаті проведеної терапії пацієнти відчували зменшення болю в спині, покращання загального самопочуття та якості життя. Однак через 6 тижнів після лікування рівень болю в групі пацієнтів, які отримувала епідуральні ін’єкції, був нижчим у 1,7 раза порівняно зі стандартною терапією. Покращання життєдіяльності та загального функціонування в два рази порівняно з результатами до лікування спостерігалось в основній групі через 3 тижні після початку терапії, у той час як пацієнти контрольної групи не досягли такого результату навіть через 6 місяців після лікування. Висновки. Проведене дослідження показало доцільність використання епідуральних ін’єкцій розчину глюкокортикоїду та місцевого анестетика в пацієнтів із хронічним неспецифічним болем у спині в моделюванні больового синдрому.

RADIOFREQUENCY DENERVATION OF THE FACET JOINTS AND LOCAL PERIARTICULAR ADMINISTRATION OF ANAESTHETICS IN FACET SYNDROME TREATMENT.

The aim: To determine the effectiveness of radiofrequency denervation of the facet joints in combination with periarticular administration of local anaesthetics in patients with facet syndrome. Materials and methods: The early and long-term results of treatment patients with facet syndrome were analysed. The Visual Analogue Scale of pain and the Oswestry Disability Index were used. The 47 patients underwent radiofrequency denervation of the facet joints in combination with periarticular administration of local anaesthetics (the main group). The 136 patients underwent only radiofrequency denervation of the facet joints (control group). Results: Immediately after the treatment as well as in 3 months and in 1 year after it, a reliable results of treatment of facet syndrome in both the main and the control groups was attained. At the same time, there were significant differences between the main group and the control group immediately after treatment. But in 3 months and in 1 year after it there were no such differences that proved a significantly higher efficiency of high radiofrequency denervation of facet joints in combination with periarticular administration of local anaesthetics in the early postoperative period. Conclusions: The radiofrequency denervation of the facet joints has proved to be an effective method of treatment of patients with spondyloarthritis both in the short and long term outcomes. Periarticular administration of local anaesthetics enhances the effectiveness of radiofrequency denervation of the facet joints only for the short term outcomes.

Surgical decompression via the unilateral intervertebral foraminal approach with local anesthesia for treating elderly patients with lumbar central canal stenosis.

Surgical decompression via a posterior interlaminar approach is widely used for treating lumbar central canal stenosis (LCCS). However, this surgical approach poses a challenge for elderly patients with comorbidities. Thus, the authors tried a new surgical decompression via the unilateral intervertebral foraminal approach with local anesthesia to treat such patients. The aim of this study was to evaluate the safety and effectiveness of surgical decompression via the unilateral intervertebral foraminal approach with local anesthesia for patients with LCCS. Patients with LCCS who underwent surgical decompression, performed by a single surgeon, between January 2016 and March 2019 were retrospectively analyzed. All patients received decompression via the unilateral intervertebral foraminal approach with local anesthesia. Visual analog scale (VAS) scores, Oswestry Disability Index (ODI) scores, modified Macnab criteria, walking distance, and Schizas classification were used as outcome predictors. Additionally, a decompression evaluation method was designed for use after spinal endoscopic surgery. Overall, 23 patients with a mean age of 69 years were included in this study, with a mean follow-up of 28 months. Low-back and leg pain were significantly improved after decompression surgery. Postoperative ODI scores and walking distances were statistically significantly better than before surgery. Postoperatively, the Schizas classification for all patients was improved by at least 1 grade compared with the preoperative grade. No complications occurred during the follow-up period. According to the novel decompression evaluation method, all patients had at least achieved decompression in part 123+B. Surgical decompression via the unilateral intervertebral foraminal approach with local anesthesia showed promising outcomes in the treatment of elderly patients with LCCS. Additionally, a proposed postoperative decompression evaluation method can help guide surgical decompression.

ODONTECTOMY MANAGEMENT WITH LOCAL ANESTHESIA IN PATIENT WITH OPEN-ANGLE GLAUCOMA

Background: Glaucoma is characterized by optic neuropathy with increased intraocular pressure. The high prevalence of impaction causes some glaucoma patients to require odontectomy. There are no contraindications to odontectomy in glaucoma patients, but special preparation is needed to prevent recurrence during the procedure. Glaucoma recurrence is precipitated by increased intraocular pressure which correlates with elevated systemic blood pressure with increased intraocular pressure and corticosteroid use. Therefore, dentists must be vigilant in choosing an atraumatic odontectomy procedure, anesthetic dose and techniques, as well as administering the type and dose of analgesics. Objective: This paper reports a case of mandibular third molar odontectomy with local anesthesia in a patient with open-angle glaucoma, which is a rare case and in this case there is a high risk of complications. Case: A 26-year-old male patient complained of pain in the left back gum when chewing. Orthopantomographic radiographic examination showed impacted 38. The patient has been diagnosed with open-angle glaucoma for 5 years. An odontectomy was performed under local anesthesia. Durante surgery, bleeding is minimal and does not cause recurrence of glaucoma. Postoperative evaluation gave good results, minimal complications, and no recurrence of glaucoma.Conclusion: Odontontectomy with local anesthesia in glaucoma patients requires special preparation in the form of atraumatic surgical procedures and perioperative pharmacotherapy management in the form of pre-emptive analgesia, selection of a maximum of two ampoules of lidocaine and epinephrine 1:80,000 with the mandibular block anesthetic technique, and using multimodal analgesia in combination with NSAIDs without corticosteroids. Keywords: Complications, Glaucoma, Odontectomy

Postoperative analgesic effect of parecoxib sodium local anesthesia in patients with breast cancer through systematic review and meta-analysis.

Postoperative pain can seriously affect a patient's recovery, and parecoxib sodium has a good analgesic effect. However, there is a lack of clinically systematic analyses of the effects of parecoxib sodium on postoperative pain in breast cancer patients. The aim of the present study was to systematically evaluate the efficacy and safety of parecoxib sodium local anesthesia in the treatment of postoperative pain in breast cancer patients. Literature published from January 2010 to December 2020 was searched in the China National Knowledge Infrastructure database, Wanfang database, PubMed, and Cochrane Library. Literature on randomized controlled trials of parecoxib sodium local anesthesia in patients with breast cancer was collected. Method of treatment was extracted and literature quality was assessed. Meta-analyses of included literature were performed using RevMan 5.3. A total of 17 randomized controlled trials were included, with a total of 1,032 breast cancer surgery patients. The experimental group was treated with parecoxib sodium anesthesia, and the control group was treated with other anesthesia methods. The meta-analysis results showed that there were obvious differences among visual analogue scale (VAS) score of the experimental group and control group 2 h after surgery [mean difference (MD): -0.79; 95% confidence interval (CI): -1.29 to -0.29; P=0.002], 4 h (MD =-0.77; 95% CI: =-1.51 to -0.03; P=0.04), 6 h (MD: -1.10; 95% CI: -1.41 to -0.80; P<0.00001), 8 h (MD: -0.66; 95% CI: -1.00 to -0.33; P=0.0001), 12 h (MD: -0.92; 95% CI: -1.24 to -0.60; P<0.00001), 24 h (MD: -0.86; 95% CI: -1.15 to -0.58; P<0.00001), and 48 h (MD: -0.90; 95% CI: -1.47 to -0.33; P=0.002). Moreover, visual analog scale score and the postoperative controlled analgesia frequency of patients in the experimental group (MD: -2.08; 95% CI: -2.88 to -1.27; P<0.00001) and the incidence of adverse reactions (odds ratio: 0.52; 95% CI: 0.34-0.80; P=0.002) were significantly reduced. Parecoxib sodium local anesthesia for breast cancer patients has good postoperative analgesia and treatment safety.

ASO Author Reflection: Pain Control Can Be Optimized with Surgeon-Administered Local Anesthesia in Patients Undergoing Lumpectomy and Sentinel Lymph Node Biopsy with Multimodal Analgesia.

ASO Author Reflection: Pain Control Can Be Optimized with Surgeon-Administered Local Anesthesia in Patients Undergoing Lumpectomy and Sentinel Lymph Node Biopsy with Multimodal Analgesia.

Suspected local anaesthetic systemic toxicity (LAST) after several bupivacaine injections through an epidural catheter in a cat

AbstractA 9‐year‐old male neutered domestic short hair cat was referred to our practice after a road traffic accident. On presentation, the cat was obtunded, with bilateral hindlimb fractures. The fractures were surgically repaired, and an epidural catheter was placed for perioperative pain management. Postoperative analgesia consisted of bupivacaine administered intermittently through the epidural catheter. In the days after surgery, the cat became duller and more obtunded, and marked bilateral mydriasis with absence of a pupillary reflex was noted. After ruling out different causes for mydriasis and weaning the cat from systemic opioids, local anaesthetic systemic toxicity (LAST) emerged the primary differential diagnosis. Bupivacaine plasma concentrations were measured and found a fourfold increase in concentration over that reported after a perineural block. Mydriasis and absent pupillary light reflex, among other clinical signs, could be early indicators of LAST secondary to accumulation of the local anaesthetic in patients with an epidural catheter.

Efficacy and Safety of Pectoral Nerve Block (Pecs) Compared With Control, Paravertebral Block, Erector Spinae Plane Block, and Local Anesthesia in Patients Undergoing Breast Cancer Surgeries: A Systematic Review and Meta-analysis.

We aimed to compare the safety and efficacy of pectoral nerve block (Pecs) I and II with control or other techniques used during breast cancer surgeries such as local anesthesia, paravertebral block, and erector spinae plane block (ESPB). We searched 4 search engines (PubMed, Cochrane Library, Scopus, and Web of Science) for relevant trials, then extracted the data and combined them under random-effect model using Review Manager Software. We found 47 studies, 37 of them were included in our meta-analysis. Regarding intraoperative opioid consumption, compared with control, a significant reduction was detected in Pecs II (standardized mean difference [SMD]=-1.75, 95% confidence interval [CI] [-2.66, -0.85], P=0.0001) and Pecs I combined with serratus plane block (SMD=-0.90, 95% CI [-1.37, -0.44], P=0.0002). Postoperative opioid consumption was significantly lowered in Pecs II (SMD=-2.28, 95% CI [-3.10, -1.46], P<0.00001) compared with control and Pecs II compared with ESPB (SMD=-1.75, 95% CI [-2.53, -0.98], P<0.00001). Furthermore, addition of dexmedetomidine to Pecs II significantly reduced postoperative opioid consumption compared with Pecs II alone (SMD=-1.33, 95% CI [-2.28, -0.38], P=0.006). Pecs block is a safe and effective analgesic procedure during breast cancer surgeries. It shows lower intra and postoperative opioid consumption than ESPB, and reduces pain compared with control, paravertebral block, and local anesthesia, with better effect when combined with dexmedetomidine.

Effects of intrathecal opioids on cesarean section: a systematic review and Bayesian network meta-analysis of randomized controlled trials.

We aimed to compare the beneficial and harmful effects of opioids used as adjuncts to local anesthetics in patients undergoing cesarean section under spinal anesthesia. We searched electronic databases and ClinicalTrials.gov from their inception until March, 2021 without language restrictions. The primary outcome was the complete analgesia duration (Time to VAS > 0). Data were synthesized using the Bayesian random-effects model. Evidence confidence was evaluated using the Confidence In Network Meta-Analysis. We identified 66 placebo-controlled randomized controlled trials (RCTs) comprising 4400 patients undergoing elective cesarean section. Compared with the placebo, intrathecal opioids (fentanyl, sufentanil, and morphine) significantly prolonged the analgesia duration by 96, 96, and 190min, respectively (mean difference). Despite morphine ranking first, opioid efficacy was similar; the results were inconsistent with respect to other analgesic outcomes. Except for diamorphine, all opioids were associated with significant increases in the pruritus incidence. Sufentanil and morphine were associated with increases in the respiratory depression incidence. We confirmed that intrathecal opioids benefit postoperative analgesia. Although morphine seems to be the most appropriate agent, some results were inconsistent, and the evidence confidence was often moderate or low, especially for adverse outcomes. Well-designed RCTs with an evidence-based approach are imperative for determining the most appropriate opioid for cesarean sections.

Local anesthetics for the Nephrologist.

Several specialists in medicine use local anesthetics. In patients with kidney disease, these agents are used during catheter insertions for hemodialysis and peritoneal dialysis, arteriovenous fistula and graft procedures, kidney transplantation, parathyroidectomy, kidney biopsies, and dental and skin procedures. Patients on chronic hemodialysis use a topical application prior to use of needles for arteriovenous fistula cannulation before starting dialysis. They are also used to manage acute and chronic pain conditions, in regional nerve blockade and in multi-modal enhanced recovery protocols. Despite their frequent use by both physicians and patients, data on the use of local anesthetics in patients with kidney impairment are not well reported. This review will summarize the use of local anesthetics in chronic kidney disease, describe their pharmacology and the impact of lower estimated glomerular filtration rate on their pharmacokinetics, and suggest dose regulation in those with kidney dysfunction.

A comparison of two different management plans for patients requiring both carotid endarterectomy and coronary artery bypass grafting.

Carotid endarterectomy (CEA) is a prophylactic operation that is used to mitigate the risk of stroke caused by embolism of atherosclerotic plaques in the carotid bifurcation. Previously, the large, multicentre, randomised, controlled GALA study found no significant differences in clinical outcomes between patients treated using general or local anaesthesia. While this study provided important insights into disease outcomes based on treatment modalities, it did not answer questions regarding the safety of CEA under local anaesthesia in patients at high risk for cardiovascular complications. Here, we examined the use of two different management plans in patients requiring both carotid endarterectomy and coronary artery bypass grafting (CABG), in terms of their effects on hospital mortality. Thirty-four patients consecutively operated on in our cardiovascular department were included in this analysis. The patients were divided into two groups based on the anaesthetic management plan. The first group consisted of patients who underwent CEA and CABG under general anaesthesia in the same session (GA group); the second group consisted of patients who initially underwent CEA under cervical block anaesthesia followed by CABG under general anaesthesia in a separate session (CB-GA group). These two groups were compared in terms of postoperative complications and hospital mortality. The incidence of postoperative myocardial infarction was higher in the CB-GA group, with four patients experiencing postoperative myocardial infarction, compared to no patients in the GA group. For patients requiring CEA and CABG, performing both operations under general anaesthesia in the same session was safer than initially performing CEA under cervical block anaesthesia followed by CABG under general anaesthesia.

The study and analysis of the prognosis criteria for a safe local anesthesia in patients with arterial hypertension

Relevance. To develop the algorithm for a safe and effective local anesthesia in dental outpatients with arterial hypertension.Materials and methods. The study was conducted in the laboratory of functional and clinical studies of Moscow State University of Medicine and Dentistry. Electric pulp testing (µA) was performed and pulp microcirculation (PU) was assessed in the intact teeth of patients with hypertension before and 5, 10, 15, 30 and 60 minutes after the administration of local anesthesia. We used 4% articaine solutions without a vasoconstrictor and with its minimal concentration 1:200 000 and 1:400 000, and 3% mepivacaine solution. The safety of the administered local anesthetic was assessed by the continuous hemodynamic monitoring.Results. 4% articaine solution without epinephrine had a shallow anesthetic effect in the maxilla and anterior mandible. 1:400 000 and 1:200 000 vasoconstrictor concentrations in 4% articaine solution increase the depth and duration of the anesthesia from 20 to 30 minutes respectively. Changes in the pulp sensibility but not in blood microcirculation were demonstrated by the functional parameters of the intact dental pulp in patients with hypertension after the administration of 3% mepivacaine solution at the mandibular foramen. The continuous hemodynamic monitoring data showed no changes in arterial blood pressure, heart rate, oxygen saturation on administration of either of the studied local anesthetic solutions or techniques.Conclusion. The analysis of the prognosis criteria for a safe local anesthesia allowed us to ground the choice of anesthetic in dental outpatients with arterial hypertension.

COMPARISON OF SUBCOSTAL TRANSVERSUS ABDOMINIS PLANE BLOCK WITH PORT SITE INFILTRATION OF LOCAL ANAESTHESIA IN LAPAROSCOPIC CHOLECYSTECTOMY

Objective: To compare the efficacy of ultrasound guided subcostaltransversus abdominis plane block and port site infiltration of local anaesthesia in patients undergoing laparoscopic cholecystectomy.&#x0D; Study Design: Comparative cross sectional study.&#x0D; Place and Duration of Study: Anesthesiology department, Pak Emirates Military Hospital, Rawalpindi, from Jan to Jun 2019.&#x0D; Methodology: A sample size of 62 patients calculated by World Health Organization calculator were randomized in a doubleblind study to undergo Sub costal transversus abdominis plane block or port site infiltration by non-probability, consecutive sampling into two equal groups. Group A received sub costal transversus abdominis plane block and group B local anaesthetic. Postoperative pain perception was measured using visual analogue scale.&#x0D; Results: The mean age of patients in group A was 33.39 ± 8.91 years and in group B was 33.77 ± 8.45 years. Out of 62 patients 38 (61.29%) were males and 24 (38.71%) were females. Mean pain score in group A (ultrasound guided sub costal transversus abdominis plane block) was 1.61 ± 0.91 while in group B (port site infiltration of local anaesthetic) was 3.61 ± 1.05 (p-value 0.0001).&#x0D; Conclusion: The mean pain score was less following use of ultrasound guided sub costal transversus abdominis plane block in patients undergoing laparoscopic cholecystectomy as compared to port site infiltration of local anaesthesia.