Ml Of Anesthetic Solution Research Articles

Effect of Two Different Volumes of Ropivacaine and Lignocaine at Two Different Sites in Ultrasound-Guided Supraclavicular Brachial Plexus Block on Diaphragm Motility

Ultrasound (USG) guided supraclavicular brachial plexus block (BPB) helps in precise delivery of local anesthetic injection, reduced volume or dose of drug providing excellent surgical anesthesia with fewer complications. Objective of the study was to compare effect of two different volumes of Ropivacaine and Lignocaine at two different sites of USG-guided supraclavicular BPB on diaphragmatic motility, quality of block and tourniquet pain. A prospective randomized double-blinded comparative study was conducted among adult patient with below elbow elective surgery. In group A patients (n=17), 20ml of anesthetic solution was injected in the corner pocket and 10ml in the nerve cluster guided with USG. In group B patients (n=17), 15ml of the anesthetic solution was injected in the corner pocket and 5ml in the nerve cluster guided with USG. Hemodynamic parameters, diaphragmatic excursion, onset of anesthetic effects were measured at frequent intervals. The data were analyzed using Statistical Package for Social Sciences at P-value less than 0.05. Hemodynamic profile of the patients were similar in both groups (P-value>0.05). Statistically significant hemi-diaphragmatic dysfunction (partial and complete paralysis) after 15 and 30minutes of blockade was more common in group A than Group B (P<0.05). At 30 minutes after the injection of the anesthesia, all patient in both the groups had complete sensory and motor block in all nerve territory. Tourniquet time was lower in group A (80.35±9.59 minutes vs 84.12±7.75 minutes); however, it was statistically not significant (P-value>0.05). The present study showed that the patients who received lesser half of the required volume of local anesthetics had less incidence of hemidiaphragmatic dysfunction with similar successful rate of blockage (100%) and similar quality of the block as compared to the patients who received greater half of the required volume of local anesthetics.

Complications of classic double injection technique of peribulbar anaesthesia given in supine position before cataract surgery

Background: Peribulbar anaesthesia has almost totally replaced general anaesthesia and retrobulbar block for ocular procedures especially in adults. Peribulbar block involves injections above and below the orbit, with local anesthetic deposited within the orbit but does not enter the muscle cone. Relatively safe but it is still associated with complications which are detailed in this study.
 Aims and Objective: To study the complications of classic double injection technique of peribulbar anaesthesia given in supine position before cataract surgery and to find the percentage of patients achieving complete block with 7ml of anaesthetic solution given by peribulbar route.
 Materials and Methods: This prospective observational study was conducted on 500 patients who were admitted for undergoing cataract extraction surgery in the Department of Ophthalmology in GMC Jammu for a period of 8 months from December 2018 to July 2019.
 Results: It was observed that 103 patients out of 500 (20.6%) developed one or more of complications. Chemosis was the most common complication which occurred in 87 (17.4%) patients followed by subcunjunctival haemorrhage observed in 19 (3.8%) patients. Lid ecchymosis occurred in 16 (2.4%) patients. Retrobulbar haemorrhage occurred in 11 (2.2%) patients. 2 (0.4%) patients developed severe lid edema. In 2 (0.4%) patients wrong eye was given block. 1 (0.2%) patient developed CRAO. Complete akinesia was obtained in 415 (83%) patients with 7ml of block. Rest required supplementary injections. 14 (2.8%) patients did not attain full akinesia after 12ml of block.
 Conclusion: Peribulbar block is a relatively safe procedure for obtaining ocular analgesia and akinesia, but is still associated with complications ranging from minor lid edema and chemosis to grave events like RBH to CRAO.

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.

Stellate ganglion blockade for electrical storm: a case report

Introduction The Chronic Chagasic Cardiomyopathy is one important cause of arrhythmias in Brazil. The usual anti-arrhythmic treatment involves the use of medication, placement of implantable cardioverter defibrillator (ICD) and catheter ablation therapy. Some patients with ICD develop electrical storms (ES), 3 or more episodes of ventricular arrhythmia followed by electrical therapy in 24h. Under these circumstances is believed that the sympathetic tone is heightened. There has been a growing evidence showing that the modulation of neural activity with the Stellate Ganglion Blockade (SGB) can be an adjuvant treatment for patients with ES. Methods Case Report: A 50-year-old male patient with medical history of arrhythmogenic chagasic cardiomyopathy with previous ICD presented several episodes of chest pain, dizziness and Sustained Ventricular Tachycardia frequently leading him to the emergency room (ER). After cardioversion from the ICD and drug optimization he presented better control of the arrhythmia. A month later, a new episode of chest pain, dyspnea, abdominal pain, Sustained Ventricular Tachycardia with a heart rate of 130bpm - below the ICD trigger – brought him to the ER again. In addition to the pharmacological therapy, the stellate ganglion blockade was chosen (SGB). It was performed in sterile conditions and ultrasound-guided. From cricoid cartilage, the probe was moved caudad and laterally to visualize C7’s transverse process. We used a Quincke 22G needle to perform the SG . The tip of the needle was placed on the anterior fascia of the longus coli muscle. Through ultrasound imaging the dispersion of the 10ml of anesthetic solution with lidocaine 1% and bupivacaine 0,25% was seen throughout the stellate ganglion pathway. Results Procedure was performed without any complications.On the 24-hour follow up the patient presented a slow ventricular tachycardia, treated with ATP and sent to cardiac ablation, with satisfactory outcome. Discussion Conclusion: The SGB can be a bedside and efficient option as a treatment for ES, it improves cardiac autonomic modulation decreasing the occurrence of ES and can be used as a bridge for cardiac ablation.

Effect of magnesium sulphate added to lidocaine on inferior alveolar nerve block success in patients with symptoms of irreversible pulpitis: a prospective, randomized clinical trial.

To investigate the effect of magnesium sulphate used as an adjuvant to lidocaine with epinephrine local anaesthetic on the success of inferior alveolar nerve blocks (IANB) in patients with symptoms of irreversible pulpitis undergoing root canal treatment. In a double-blind clinical trial, following power calculation, 124 patients with symptoms of irreversible pulpitis in mandibular molar teeth were selected, and initial pain data were collected using a Heft-Parker (Pain, 19, 1984 and 153) visual analogue scale. The first group (control) received IANB with 1.8 mL of a local anaesthetic solution containing 1.8% lidocaine with 1:88000 epinephrine while the second group (test) received IANB with 1.8 mL of an anaesthetic solution containing 1% magnesium sulphate, and 1.8% lidocaine with 1:88000 epinephrine. Pain data were collected after access cavity and penetration of files in the canals using a Heft-Parker visual analogue scale. Two patients were not included in the study as they did not consent, and a further 54 patients were excluded as they did not report lip numbness within 15min after IANB administration; thus, the data presented in this study are related to 68 patients. The data were analysed using chi-square and t-test (α=0.05). The success of pulpal anaesthesia with IANB was 82% for the magnesium sulphate group and 53% for the control group. There was a significant difference in the effectiveness of the IANB between the two groups (P<0.001). There was no significant difference between the magnesium sulphate and control groups regarding gender (P=0.598) or age (P=0.208) or initial pain scores (P=0.431). The addition of 1% magnesium sulphate to 1.8% lidocaine with 1:88000 epinephrine resulted in a positive impact for the success of IANB in patients with a diagnosis of irreversible pulpitis related to mandibular molar teeth undergoing root canal treatment. Thus magnesium sulphate may be used as adjuvant for achieving profound pulpal anaesthesia in challenging cases. However, more studies with larger sample size and different concentration doses must be carried out to establish an appropriate conclusion before its routine clinical use.

Inferior Alveolar Nerve Block Using the Anterior Technique to Anesthetize Buccal Nerve and Improve Anesthesia Success Rates for Third Molar Extraction: A Randomized Controlled Trial and Magnetic Resonance Imaging Evaluation

The lack of anesthesia to the buccal nerve and an insufficient volume of anesthetic have been reported to be responsible for failed inferior alveolar nerve blocks (IANBs) using the Halsted approach (conventional IANB). We aimed to determine the extent of anesthesia in the buccal nerve innervation area and evaluate the anesthetic efficacy of injecting a larger volume of anesthetic during IANB using the anterior approach (anterior technique) in the clinical setting and with magnetic resonance imaging (MRI) analysis. The prospective randomized controlled trial included patients scheduled for removal of a mandibular third molar. The primary predictor variables were the approach for IANB (anterior technique vs conventional IANB) and anesthetic dose (1.8 vs 2.7mL). The primary outcome variables were the extent of anesthesia and the anesthesia success rate, defined as completion without additional anesthesia. The secondary outcome variable was the anesthetic drug distribution related to the pterygomandibular space measured on T2-weighted MRI scans. Statistical independence of the anesthesia success rate among the primary predictor variables was tested with statistical significance set at P≤.05. A total of 108 patients and 10 volunteers were enrolled in the clinical and MRI studies, respectively. Anesthesia of the buccal nerve was evident in patients receiving the anterior technique with 2.7mL of anesthetic. The success rate of the anterior technique with 2.7mL of anesthetic (96%) was greater than that with 1.8mL of anesthetic (67%; P=.0113), and increasing the dose had no effect on the efficacy of conventional IANB (78% vs 81%; P=1.000). The MRI study showed that the anesthetic was distributed over the anterior surface of the temporalis tendon and in the pterygomandibular space after the anterior technique. Anesthesia of the buccal nerve using the anterior technique with 2.7mL of anesthetic solution might contribute to increasing the success rate of anesthesia for removal of mandibular third molars.

Anesthetic efficacy of single buccal infiltration of 4% articaine and 2% lignocaine in extraction of maxillary 1st molar

Background:The extraction of tooth being the most common procedure in oral surgery should be pain free with limited dosage and limited needlepricks. Articaine being unique among amide local anesthetics contains a thiophene group, which increases its liposolubility, and an ester group which helps biotransformation in plasma. Because of the high diffusion properties, it can be used as a single buccal infiltration to extract a maxillary tooth.Aim and Objective:Objective of the study was to compare the efficacy of single buccal infiltration of 4% articaine with that of 2% lignocaine for maxillary first molar extraction.Methodology:A triple blind randomized controlled study was carried on 100 patients of age group 18-60 years who required maxillary first molar extraction, visiting the Department of Oral and Maxillofacial surgery. They were included in the study after obtaining informed consent. Buccal infiltration of 1.8 ml of anesthetic solution was given randomly to 100 patients with appropriate blinding of the cartridges. Objective signs were checked. If any additional injection was given, it was noted as type and number of rescue injection given. Postoperatively VAS score and surgeon's quality of anesthesia was noted. Duration of anesthesia was measured every 5 minutes for 50 minutes from infiltration.Results:Out of 50 patients in group A (Articaine), in 44 patients extraction was done without the need of additional injection whereas in group B(Lignocaine), 29 patients require additional infiltration on the palatal side. The VAS score values for group A were also significantly less in comparison with group B. The mean duration of anesthesia for Group A being (71.70 ± 17.82 min) in 44 patients who only received buccal infiltration.Interpretation and Conclusion:The efficacy of single buccal injection of articaine is comparable to buccal and palatal injection of lignocaine.

Computed tomographic diagnosis of incomplete palmar cortical (fatigue) fracture of the third metacarpal bone in two young adult endurance horses

SummaryTwo young adult endurance horses were presented for investigation of sudden‐onset forelimb lameness during competition. Clinical examination revealed a severe forelimb lameness and pain on palpation of the proximal palmar metacarpal area. Initial radiographic survey of the affected forelimb was unremarkable in both cases. A week of box rest resulted in only a mild improvement in the lameness. A second radiographic examination did not reveal any significant abnormalities. In both cases, scintigraphic examination was suggested, but was declined by the owner, and the lameness had significantly improved after local infiltration of 3 mL of anaesthetic solution in the proximal suspensory region. Radiographic and ultrasonographic examinations of the carpus and proximal suspensory region were unremarkable in Case 2. Case 1 had increased thickness of the medial lobe of the proximal aspect of the suspensory ligament. A computed tomographic examination was performed and an incomplete longitudinal (fatigue) fracture of the proximal third metacarpal bone was detected. After 8 months of box rest and rehabilitation, re‐examination revealed resolution of the lameness in both cases. Advanced diagnostic imaging should be considered in young endurance horses with severe lameness during competition or training, in which radiographic and ultrasonographic examinations are unremarkable or do not explain the severity of the lameness. Computed tomography imaging is considered a useful diagnostic imaging technique to detect incomplete longitudinal palmar metacarpal cortical (fatigue) fractures due to its ability to provide excellent bone detail.

Selective Low-Volume Nerve Block for the Open Surgical Fixation of a Midshaft Clavicle Fracture in a Conscious High-Risk Patient

We report a case of successful intraoperative management using only low-volume regional anesthesia for the open surgical fixation of a traumatic clavicle fracture in a conscious 69-year-old man with severe chronic obstructive pulmonary disease. To avoid general anesthesia, we provided low-volume C5 and C6 nerve root blocks along with a superficial cervical plexus block using only 9 mL of anesthetic solution to avoid the often encountered complications of higher volume injections. Throughout the procedure, the patient remained comfortable and cooperative with stable hemodynamics and respiration. The postoperative course was uncomplicated.

Anterior Middle Superior Alveolar Nerve Block Efficacy Utilizing different Anesthetic Solutions, Reduced Dosage and Conventional Syringe: A Breakthrough in Pain Control

ABSTRACT Introduction For over a decade of introducing the anterior middle superior alveolar (AMSA) injection, it has since majorly only been reported to show both pulpal and buccal mucosal effectiveness using a minimum of 0.9 ml of anesthetic solution. Aim The aim of this study was to demonstrate the AMSA nerve block efficacy using a reduced dosage and conventional syringe, while comparing the anesthetic effectiveness of lidocaine vs mepivacaine. A primary objective was to understand the behavioral difference between the two solutions, to better adapt their application into relevant clinical scenarios, where fewer injections are administered, pain control is better understood and implemented, and collateral anesthesia altering the natural lip line is eliminated. Materials and methods Twelve candidates (both sexes), of ages 18 to 24, were selected. All the participants received bilateral AMSA nerve block (split-mouth technique) using the conventional syringe, where 0.6 ml of lidocaine and mepivacaine 2% with epinephrine 1:100,000 were randomly administered to each side. Results Pulpal anesthesia on both premolar teeth showed 83.3% success within 15 minutes with lidocaine group (LG) and mepivacaine group (MG) alike. Buccal anesthesia at both premolar teeth showed 50% success within 15 minutes with LG and 54.2% with MG. There was no difference in anesthetic effectiveness between the two groups in pulpal anesthesia (p ≥0.05), and no significant difference in buccal mucosal anesthesia (p ≥0.05). Conclusion No statistically significant difference was observed between lidocaine and mepivacaine, while both expressed anesthetic effectiveness using a reduced dosage, as well as near painlessness using the conventional syringe. How to cite this article Tattan M, Kokovic V. Anterior Middle Superior Alveolar Nerve Block Efficacy Utilizing different Anesthetic Solutions, Reduced Dosage and Conventional Syringe: A Breakthrough in Pain Control. Int J Experiment Dent Sci 2015;4(2):80-86.

Effects of Mepivacaine 2% With Epinephrine in the Cardiovascular Activity of Patients Undergoing Third Molar Surgery

Cardiovascular effects of epinephrine, especially on blood pressure (BP) and heart rate (HR), have been well documented. When present in dental local anesthetic solutions, epinephrine concentration ranges from 5 to 20 µg/mL. Doses less than 200 µg are recommended to be clinically safe. This study investigated the effects of the anesthetic solution of mepivacaine (2%) with epinephrine (10 µg/mL) in cardiovascular activity (HR and BP). Twenty-six patients underwent outpatient surgery for the removal of 2 unilateral (group I, n = 15) or 4 (group II, n = 11) third molars in a single session, being injected 5.4 and 10.8 mL of anesthetic solution, equivalent to 54 and 108 µg of epinephrine, respectively. The cardiovascular activity was monitored by cardioscope during the experimental period of 2 hours. Heart rate and BP were measured at the intervals of 0, 5, 10, 15, 20, 30, 40, 60, 90, and 120 minutes after anesthetic injection. After application of 2-way analysis of variance test, comparison between groups was not statistically significant for HR (P = 0.1388), systolic BP (P = 0.0228), and diastolic BP (P = 0.9846). However, patients from group II presented significantly greater sway in HR (P < 0.0001), systolic BP (P = 0.0169), and diastolic BP (P < 0.0001) in the course of 2 hours. Blood pressure did not present significant alterations after a local injection of 54 or 108 µg of epinephrine during surgery to remove 2 or 4 third molars. Although without significance, HR was more elevated in the 108-µg dose of epinephrine during the removal of 4 third molars.

Ensayo clínico aleatorizado, controlado, doble ciego, para evaluar la analgesia posparto con morfina epidural: efectividad analgésica de dos dosis diferentes, comparadas con placebo

IntroductionPrior studies have shown that the conventional management of post-partum pain (acetaminophen, NSAIDS) is insufficient. In our setting, no advantage is taken of the epidural catheter placed as part of the analgesic management of pregnant women during labor. ObjectiveTo determine the efficacy of 2 and 3mg doses of epidural morphine used for analgesia during vaginal post-partum in patients receiving epidural analgesia for labor, compared to placebo. Patients and methodsDouble-blind randomized clinical trial with 114 patients, in which 38 patients received 10ml of anesthetic solution with 2mg of epidural morphine, 39 received 3mg of epidural morphine, and another 37 received 10ml of 0.9% epidural saline solution (control group), 1 hour after labor. The analgesic efficacy and the side effects occurring within the first 24 hours after administration were evaluated. ResultsThe dose of morphine was effective at controlling pain after delivery, making it possible to reduce the need for additional analgesia in the group receiving 2mg (NNT=4.56), as well as in the group receiving 3mg of morphine (NNT=3.66). The outcome was more marked in patients who needed perineorrhaphy (NNT =1.6) and in primiparity cases (NNT 2.4). In the experimental group, the analgesic effect extended over the 24-hour follow-up period.The incidence of side-effects in each of the treatment groups was as follows: pruritus, 30% and 36%; nausea, 18.4% and 15.4%; vomiting, 7.9% and 15.4%. ConclusionsThe use of epidural morphine during the immediate post-partum period is effective for managing pain ensuing after labor. Although there was evidence of adverse side effects at the doses used, they were tolerable and did not require treatment. The present management of post-partum analgesia is insufficient.

Randomized double-blind controlled clinical trial for the evaluation of post-partum analgesia using epidural morphine: analgesic effectiveness of different dose regimes compared with placebo

Introduction: Prior studies have shown that the conventional management of post-partum pain (acetaminophen, NSAIDS) is insufficient. In our setting, no advantage is taken of the epidural catheter placed as part of the analgesic management of pregnant women during labor. Objective: To determine the efficacy of 2 and 3 mg doses of epidural morphine used for analgesia during vaginal post-partum in patients receiving epidural analgesia for labor, compared to placebo. Patients and methods: Double-blind randomized clinical trial with 114 patients, in which 38 patients received 10 ml of anesthetic solution with 2 mg of epidural morphine, 39 received 3 mg of epidural morphine, and another 37 received 10 ml of 0.9% epidural saline solution (control group), 1 hour after labor. The analgesic efficacy and the side effects occurring within the first 24 hours after administration were evaluated. Results: The dose of morphine was effective at controlling pain after delivery, making it possible to reduce the need for additional analgesia in the group receiving 2 mg (NNT=4.56), as well as in the group receiving 3 mg of morphine (NNT=3.66). The outcome was more marked in patients who needed perineorrhaphy (NNT = 1.6) and in primiparity cases (NNT 2.4). In the experimental group, the analgesic effect extended over the 24-hour follow-up period. The incidence of side-effects in each of the treatment groups was as follows: pruritus, 30% and 36%; nausea, 18.4% and 15.4%; vomiting, 7.9% and 15.4%. Conclusions: The use of epidural morphine during the immediate post-partum period is effective for managing pain ensuing after labor. Although there was evidence of adverse side effects at the doses used, they were tolerable and did not require treatment. The present management of post-partum analgesia is insufficient.. © 2012 Sociedad Colombiana de Anestesiología y Reanimación. Published by Elsevier. All rights reserved. Introducción: Estudios previos han demostrado que el manejo convencional de dolor posparto (acetaminofén, AINE) es insuficiente. En nuestro medio se desaprovecha el uso del catéter epidural que es colocado como parte del manejo analgésico de las gestantes en el trabajo de parto. Objetivo: Determinar la eficacia de dosis de 2 mg y de 3 mg de morfina epidurales versus placebo, empleadas para analgesia durante el posparto vaginal en pacientes que recibieron analgesia epidural para su trabajo de parto. Pacientes y métodos: Ensayo clínico, doble ciego y aleatorizado realizado con 114 pacientes. 38 pacientes recibieron 10 ml de solución anestésica con 2 mg de morfina epidural, 39 pacientes recibieron 3 mg de morfina epidural, y 37 otras 10 ml de solución salina al 0,9% por vía epidural (grupo control), 1 hora después de la atención del trabajo de parto. Se evaluó la eficacia analgésica así como los efectos secundarios presentados durante las 24 horas posteriores a la administración. Resultados: La dosis de morfina fue efectiva para el control del dolor consecutivo al parto y se logró disminuir la necesidad de analgésico adicional tanto en el grupo de 2 mg (NNT 4,56) como en el de morfina 3 mg (NNT = 3,66). El resultado fue más marcado en el grupo de pacientes con necesidad de perineorrafia (NNT = 1,6) y en las madres primíparas (NNT 2,4). En el grupo experimental, el efecto analgésico se extendió a las 24 horas de seguimiento. En nuestro estudio, la incidencia de efectos secundarios fue la siguiente: prurito, 30% y 36%; náuseas, 18,4% y 15,4%; y vómito, 7,9% y 15,4% para cada uno de los grupos experimentales. Conclusiones: El uso de morfina epidural en el posparto inmediato es eficaz para el manejo del dolor que sobreviene al trabajo de parto. Si bien se evidenció una importante presencia de efectos adversos a las dosis usadas, estos fueron tolerables y no requirieron de tratamiento. El manejo actual de la analgesia posparto es insuficiente. © 2012 Sociedad Colombiana de Anestesiología y Reanimación. Publicado por Elsevier. Todos los derechos resevados.

Ropivacaine in Peribulbar Anesthesia – Vasoconstrictive Properties

Peribulbar anesthesia can reduce ocular blood flow (OBF) by increasing intraocular pressure (IOP) or due to the action of drugs. Ropivacaine has low toxicity and intrinsic vasoconstrictive properties, yet to be proven on the ocular vasculature. Measurements of ocular pulse amplitude (OPA) allow the indirect evaluation of the OBF. The objective of the present study was to evaluate through the OBF the vasoconstrictive properties of ropivacaine in peribulbar anesthesia. Forty eyes undergoing peribulbar anesthesia with 7 mL of anesthetic solution without vasoconstrictor were randomly divided into two groups: ropivacaine (n = 20) and bupivacaine (n = 20). The IOP, ocular perfusion pressure (OPP), OPA, hemodynamic parameters, and the degree of akinesia before and 5 and 10 minutes after the blockade were evaluated. A dynamic contour tonometer was used to evaluate ocular parameters. Sedation was similar in both groups. A significant variation in hemodynamic parameters and intensity of the motor blockade was not observed between groups. Differences in IOP, OPP, and OPA (p < 0.05) were observed between both groups at 5 and 10 minutes. The variation of IOP at 5 and 10 minutes was -0.88% and -4.54%, respectively with ropivacaine, and 17.61% and 16.56% with bupivacaine. The change in OPP after 5 and 10 minutes was 1.5% and 4.2% with ropivacaine, and -7% and -6% with bupivacaine. Ocular pulse amplitude varied -55.59% and -59.67% with ropivacaine at 5 and 10 minutes, and -34.71% and -28.82% with bupivacaine. Ropivacaine reduced more intensely the ocular pulse amplitude despite little changes in IOP and OPP. The reduction in ocular blood flow caused by ropivacaine can be attributed to its vasoconstrictive effect.

Labia Majora Hypertrophy

A case involving hypertrophy of the labia majora is described. A married 34-year-old mother of a 5-year-old daughter reported that from adolescence, her large labia majora and its protuberance have resembled male genitalia even when she is wearing a slip. For that reason, in the summer, she is ashamed of her appearance and thus has avoided swimming pools and beach areas.With the patient in supine position, the crural creases were marked. The marks were drawn 1 cm apart medially in to the medial part of the labia majora parallel to the natural vulvar crease. The estimated amount of skin and fat to be removed was marked. In this case, more skin and fat needed to be removed from the left side than from the right side. The surgery was performed using sedation and local anesthesia as with outpatient surgery. To avoid excessive bleeding of this area, profuse infiltration was performed using 200 ml of anesthetic solution. Resection of the skin and fat in the area was performed with two hooks holding the area up to avoid introducing the scalpel too deeply.Only the superficial fat was removed. After meticulous hemostasia, two layers of 3/0 absorbable running sutures were placed, one in the deep fat and another in the subdermis,until the wound edges were approached. A 5/0 mononylon running suture closed the skin. These sutures provided strong support to all this very mobile area,avoiding dead spaces and bleeding because postoperative compressive bandages are difficult to hold in this region.The patient was instructed to wash the area four times a day. The surgery was ambulatory, with the patient returning to her province the day after surgery, then coming back for a control visit on postoperative day 10. On postoperative day 1, a moderate edema was observed but no hematoma. The stitches were removed on day 10 after surgery. The postoperative evolution of the case was uneventful. The sensitivity of the labia majora's interior aspect was preserved. With legs open, the labia majora closed the entrance to the vagina without showing the labia minora. A moderate edema was observed 4 weeks after surgery, and 6 months after surgery, the patient's external genitalia had reached a normal appearance. At 4 months after surgery, the scars were barely noticeable.

Gow-Gates Technique: A Pilot Study for Extraction Procedures With Clinical Evaluation and Review

The aim of this study was to compare the effectiveness of 2 different volumes of anesthetic solution for a premolar-molar extraction, and to determine the onset of complete mandibular conduction anesthesia via a Gow-Gates mandibular block. One operator performed 32 blocks with a 27-gauge needle on patients who required a dental extraction: 16 blocks using 1.8 mL of anesthetic solution, and 16 blocks using 3.6 mL of anesthetic solution. The parameters evaluated were frequency of successful anesthesia and onset of complete anesthesia. Significant differences (P < .005) were observed in the evaluation of volume: the 3.6 mL group yielded a higher success rate (82.5%) than the 1.8 mL group (17.5%). The onset of complete conduction anesthesia was achieved in 8 minutes by 56% of the subjects (9 of 16) with 3.6 mL and only one subject in 16 (6%) with 1.8 mL. A larger volume of anesthetic solution (3.6 mL) is required to achieve a higher success rate and a faster onset of action for a dental extraction without the use of reinforcement anesthesia. The volume of anesthetic solution is indirectly proportional to the onset of complete anesthesia. A premolar-molar extraction can be done, with 3.6 mL of anesthetic solution, in more than 50% of the patients 8 minutes after injection.

High volume and low concentration of anaesthetic solution in the perivascular interscalene sheath determines qualityof block and incidence of complications

In the perivascular sheath of the brachial plexus, the volume of anaesthetic solution determines the quality of anaesthetic cover. Fibrous septa may divide the perivascular space into compartments, leading to inadequate diffusion of the anaesthetic solution. The aim of our study was to obtain good anaesthesia and less complications using high volume of low concentration anaesthetic solution, overcoming the obstacle of the septa with a double approach to the scalene sheath. Sixty patients scheduled for shoulder capsuloplasty received both Winnie interscalene brachial plexus block and Pippa proximal cranial needle approach. The patients were randomly assigned to two groups. A constant dose of local anaesthetic was administered to each group: Group I (30 patients) received high volume (60 mL of anaesthetic solution) and Group II (30 patients) received low volume of solution (30 mL of anaesthetic solution). Sensory and motor block in the upper limb and complications were evaluated. In all the patients the quality of anaesthesia obtained at the surgical site was excellent. In Group I also the areas supplied by the medial cutaneous nerves of the arm and forearm, ulnar, median and radial nerves were blocked (P < 0.002). Complications were only observed in Group II and consisted of bradycardia and hypotension (66% of the patients) and phrenic nerve paresis (27% of the patients). The lower concentration of the anaesthetic solution avoids complications while increased volume provides good analgesic cover. The combination of the Winnie interscalene plexus block and the Pippa proximal cranial needle approach should contribute to fill up the scalene sheath overcoming the septa obstacles.

Nerve Blocks at the Wrist for Carpal Tunnel Release Revisited: The Use of Sensory-Nerve and Motor-Nerve Stimulation Techniques

Because the median nerve at the wrist has mainly sensory endings, the aim of this study was to assess the response of the median nerve to nerve stimulation at the wrist and to evaluate the quality of median nerve block. A control group of patients who received blinded injections was analyzed and compared post hoc. One hundred and eleven patients scheduled for ambulatory endoscopic carpal-tunnel release performed under median and ulnar nerve blocks at the wrist were prospectively studied. The blocks were performed with a nerve stimulator. Nerve-stimulation techniques were explained to the patient before the block was performed. The patient was trained to inform the anesthetist of their perception of an electrical paresthesia that was synchronized to the nerve stimulator. The anesthetist recorded the first response of the patient to nerve stimulation: sensory (S), sensory-motor (SM), or motor response (M). When the minimal stimulating current was obtained, an equal volume of 4 mL of 1.5% mepivacaine was injected on median and ulnar nerves. If necessary, a lateral subcutaneous injection of 2 mL of 1.5% mepivacaine was administered at the wrist crease in the musculocutaneous nerve area. Thirty-five patients who received blinded local anesthetics injections were included post hoc. Quality of anesthesia was compared between groups. Responses included 89 S (80.2%), 18 SM (16.2%), and 4 M (3.71%). No differences occurred in time to perform the block, minimal current intensity, and efficacy. More punctures were necessary in the M group compared with the S group and the control group (P < .05). The onset time of sensory blocks increased significantly in control-group patients (P < .05), but the duration of the nerve-block procedure decreased in comparison with the M group. Respectively, 10% and 20% of patients experienced mild or severe pain in the nerve-stimulation group and control group. At 20 minutes, the block was complete for the median and ulnar nerves in 96.4% and 85% of the nerve-stimulation patients and control patients (P < .05). Two patients in the control group experienced painful mechanical paresthesia. Neither permanent nor transient nerve injuries were observed during or after the nerve block or surgery. This study describes how infrequently an initial motor response is identified when a nerve stimulator is used on the median nerve at the wrist. A very high success rate of median and ulnar nerve block at the wrist is obtained by use of sensory or sensory-motor-nerve stimulation and less than 10 mL of anesthetic solution.

Kinetic anaesthesia for laser surgery

Local anaesthetic is widely used in ophthalmic surgery and more recently in vitreoretinal surgery. Akinesia is a useful effect of local anaesthetic blocks, but there are situations where some residual globe movements are of benefit. We looked to see whether reducing the volume of anaesthetic solution used in a block could retain some kinesia while achieving good analgesia. We compared two groups of patients undergoing panretinal photocoagulation (PRP) with an indirect laser. The control group received 5 ml of anaesthetic solution in a single injection by a standard intraconal technique; a second group received a lower volume of solution by the same technique. We recorded the adequacy of anaesthesia and the amount of residual kinesia for the two groups. Differences between groups were analysed using the Student's t-test and chi(2) tests. The low-volume group received an average of 2.8 ml, compared to 5 ml in the control group. There was no significant difference in the adequacy of analgesia achieved, however 16/18 (89%: 95% confidence intervals (CI)=81.5-96.3%) of the low-volume group had good perioperative kinesia compared to just 3/21 (14%: 95% CI=6.6-21.9%) of the controls (P<0.001). We have shown that low-volume intraconal blocks retain some perioperative kinesia without compromising their analgesic effect.

A Double-Blind Comparison of Ropivacaine, Bupivacaine, and Mepivacaine During Sciatic and Femoral Nerve Blockade

A Double-Blind Comparison of Ropivacaine, Bupivacaine, and Mepivacaine During Sciatic and Femoral Nerve Blockade