Plain Lidocaine Research Articles

Prospective evaluation of pain and follow-up results when pre-cooling skin versus buffering lidocaine for upper blepharoplasty

Objectives: To find out whether there is a difference in the incidence of injection pain and other complications using pre-cooling versus the buffered equivalent in upper blepharoplasty. Methods: A prospective, randomized study in patients scheduled for primary upper blepharoplasty was performed. Each subject was his/her own control by performing pre-cooling for 2 min before plain lidocaine injection in one eyelid, while the buffered solution injection was used in the other eyelid. Data were collected regarding injection pain, postoperative pain, bleeding, bruising, swelling and scar appearance. Results: Sixty patients participated in this study. Injection pain, checked immediately, revealed a mean operative pain rating of 2.20 ± 0.32 in the eye with pre-cooling versus 2.30 ± 0.35 in the buffered lidocaine (p = 0.074). A statistical difference was observed in postoperative pain after 2–4 h, with the pre-cooling group having a score of 4.00 ± 0.14 versus 4.40 ± 0.30 in the buffered lidocaine group (p = 0.021). The postoperative pain after 24 h was 2.00 ± 0.56 in the pre-cooling group versus 2.30 ± 0.23 in the buffered lidocaine group (p = 0.006). There were no statistical differences between the buffered and unbuffered lidocaine eyes after 2 days or 1 week in regard to postoperative pain, bleeding, swelling, bruising and scar appearance. Conclusions: Pre-cooling could induce similar injection pain relief to that of buffered lidocaine while maintaining longer postoperative anesthetic results than buffered lidocaine.

Adrenaline with lidocaine for digital nerve blocks.

Surgery on fingers is a common procedure in emergency and day care surgery. Adrenaline combined with lidocaine can prolong digital nerve block and provide a bloodless operating field. Extended postoperative pain relief can reduce the need for analgesics and can facilitate hand rehabilitation. Conventionally, adrenaline is avoided at anatomical sites with end arteries such as digits, penis and pinna because of concerns about arterial spasm, ischaemia and gangrene distal to the site of drug infiltration. To assess the safety and efficacy of use of adrenaline (any dilution) combined with lidocaine (any dilution) for digital nerve blocks (fingers and toes). We searched the Cochrane Central Register of Controlled Trials (CENTRAL, Issue 11, 2014), MEDLINE via Ovid SP (1966 to 18 November 2014) and EMBASE via Ovid SP (1980 to 18 November 2014). We also searched specific websites, such as www.indmed.nic.in; www.cochrane-sadcct.org; and www.Clinicaltrials.gov. We included randomized controlled trials (RCTs) that compared the use of adrenaline with lidocaine and plain lidocaine in patients undergoing surgery on digits (fingers and toes). Our primary outcomes were duration of anaesthesia, adverse outcomes such as ischaemia distal to the injection site and cost analysis. Our secondary outcomes were duration of postoperative pain relief and reduced bleeding during surgery. We used standard methodological procedures expected by The Cochrane Collaboration. Two review authors independently extracted details of trial methodology and outcome data from reports of all trials considered eligible for inclusion. We performed all analyses on an intention-to-treat basis. We used a fixed-effect model when no evidence of significant heterogeneity between studies was found and a random-effects model when heterogeneity was likely. We included four RCTs with 167 participants. Risk of bias of the included studies was high, as none of them reported method of randomization, allocation concealment or blinding. Only one trial mentioned our primary outcome of duration of anaesthesia. The mean difference in duration of anaesthesia with use of adrenaline with lidocaine was 3.20 hours (95% confidence interval (CI) 2.48 to 3.92 hours; one RCT, 20 participants; low-quality evidence). No trial reported adverse events such as ischaemia distal to the injection site, and no trial reported cost analysis. One trial mentioned the secondary outcome of duration of postoperative pain relief, but available data were insufficient for analysis of the findings. Two trials reported the secondary outcome of reduced bleeding during surgery.Bleeding during surgery was observed in nine out of 52 participants as compared with 25 out of 51 participants in the adrenaline with lidocaine and plain lidocaine groups, respectively. The risk ratio for bleeding in the adrenaline with lidocaine group was 0.35 (95% CI 0.19 to 0.65; two RCTs, 103 participants; low-quality evidence). From the limited data available, evidence is insufficient to recommend use or avoidance of adrenaline in digital nerve blocks. The evidence provided in this review indicates that addition of adrenaline to lidocaine may prolong the duration of anaesthesia and reduce the risk of bleeding during surgery, although the quality of the evidence is low. We have identified the need for researchers to conduct large trials that focus on other important outcomes such as adverse events, cost analysis and duration of postoperative pain relief.

The Effect of Lidocaine with/without Epinephrine on Healing of Cutaneous Incised Wounds in Donkeys: An Experimental Study

Objective: To study the effect of lidocaine with / without epinephrine on the wound healing. Study Design: An experimental study. Animals: 18 clinically healthy donkeys of both sexes. Methods: Animals were divided into 3 equal main groups, lidocaine group in which plain lidocaine 2% was used for local infiltration, epinephrine group in which lidocaine 2% with epinephrine 0.00227% was used and the control group, in which wounds were induced under effect of intravenous (IV) thiopental aesthesia 10% (6 mg/kg) without any local infiltration. Wound samples were taken for histopathological examination on the 7th and the 14th days post wound induction. Results: There was no distinct difference in bleeding after wound inductions between the experimental groups. Grossly, lidocaine group had delayed healing process on the 7th day post wound induction, manifested by dehiscence between wound edges especially in the mid-way of the wounds. Lidocaine with epinephrine group had good healing process with complete closure between wound edges within the same period. Rate of infection was of high incidence in lidocaine group. In histopathological examination, skin sections of lidocaine group showed extensive hemorrhage on the 7th day post wound induction and there was incomplete epithelization in the epidermis by the 14th day post wound induction. Lidocaine with epinephrine group showed partial epithelization of the epidermis on the 7th day while on the 14th day post wound induction; skin section had completed epithelization in the epidermis with presence of mature collagen bundles at the dermis. Conclusions: The present study showed that addition of epinephrine to lidocaine enhances and accelerates the healing process more bitter than plain lidocaine.

Comparative Effects of Clonidine and Adrenaline with Lignocaine during Maxillary Infiltration Anaesthesia for Dental Extraction.

Lignocaine is a commonly used local anaesthetic in dental practice. Many practitioners use adrenaline (epinephrine) as additive with lignocaine, and some have used clonidine, instead of adrenaline. Both having benefits and limitations. Hence a study was undertaken in our department to evaluate the advantages and disadvantages of using (plain lidocaine local anaesthetic) versus (lidocaine with adrenaline as additive) versus (lidocaine with clonidine as additive). Randomised, prospective, double blind study. Seventy five patients requiring extraction of maxillary molar teeth who fall under ASA I category were included and randomly divided into group - I (n=25) (Lignocaine), group - II (n=25) (Lignocaine ± Adrenaline) and group - III (n=25) (Lignocaine ± Clonidine). The observations recorded were, time of onset of anaesthesia, hemodynamic parameters, blood loss during procedure and duration of post operative analgesia. The statistical analysis was carried out using SPSS 16 software. A statistically significant difference was seen in blood loss, being higher in group I and duration of anaesthesia, being shortest in group I. There was no statistical difference between the three groups amongst other parameters. Adrenaline at 10 μg/ml and clonidine at 15 μg/ml can be safely used as additives with lignocaine, in maxillary infiltration anaesthesia for dental extraction; with addition of either of these two drugs, having an equal advantage over use of plain lignocaine; in terms of lower blood loss and longer duration of anaesthesia; but, with no difference in the onset of anaesthesia and with no significant hemodynamic changes.

Evaluating the success of Nd: YAG laser ablation in the treatment of recalcitrant verruca plantaris and a cautionary note about local anaesthesia on the plantar aspect of the foot.

There are various methods advocated for the treatment of verruca plantaris. However, many verrucas do not respond to simple treatment. This study presents our results using Nd: YAG laser ablation therapy for such recalcitrant cases. We performed a retrospective audit by sending a questionnaire to all patients with recalcitrant verrucas who had been treated with Nd:YAG laser ablation over the previous 12months. The questionnaire asked whether treatment had been successful, successful but new lesions had emerged, partially successful with improvement or unsuccessful. A Fontana Nd:YAG laser was used at the following specifications; long pulsed mode with pulse width 25ms, frequency 1.0Hz; fluence 240J/cm(2) and spot size 2mm. Some patients requested local anaesthesia and had direct infiltration with 0.5% plain lidocaine. Fifty-three of the original 87 patients responded (60.9% response rate) with a male to female ratio of 24:29, mean age of 47years and an age range between 22-72. Thirty-seven patients reported complete success post treatment (69.8%) and a further five reported improvement. The remaining 11 felt their treatment was unsuccessful. The cure rate was 81.8% in unilateral single cases, 68.1% in unilateral multiple cases and 65% in bilateral cases. Ten patients requested sublesional lidocaine injections of which 4 had skin breakdown after Nd: YAG ablation. Nd:YAG laser ablation is effective in the treatment of recalcitrant verruca plantaris. However, we caution against the use of direct local anaesthesia infiltration before laser treatment.

Reducing Pain Associated with Arterial Punctures for Blood Gas Analysis

Arterial punctures for arterial blood gases (ABGs) analysis are described as the most painful laboratory procedure and are performed without the benefit of pain management. This study originated from one nurse's concern about the level of pain her hospitalized patients endured when she drew their ABGs. A review of the literature found that ABG pain relief has not been studied in hospitalized patients. Therefore, this study explored the question “Can the pain of arterial blood gas draws be reduced through the use of infiltration with a local anesthetic agent?” This study compared the pain scores of 40 hospitalized patients who received either no intervention or one of three analgesic interventions (infiltration of 0.7 ml 1% lidocaine, 0.7 ml buffered 1% lidocaine, or 0.7 ml of bacteriostatic saline at the arterial puncture site). Results showed that, although lidocaine and buffered lidocaine are effective in reducing the pain associated with the arterial puncture, plain lidocaine was the only intervention in which the pain rating score for the overall experience was significantly diminished. This study is limited by partial randomization, small sample size, and patient duress; however, it provides a foundation for further nursing research that explores methods to reduce the pain associated with this very painful procedure. Future studies should be directed at larger, diverse populations, multiple operators, and comparison of interventions to topical analgesics and nonpharmacological measures.

Comparison of Tolerance and Cost‐Effectiveness of Two Nasal Anesthesia Techniques for Transnasal Flexible Laryngoscopy

(1) Compare tolerance of aerosolized spray versus syringe administration of topical anesthesia for transnasal flexible laryngoscopy (TFL), (2) analyze cost-effectiveness of both techniques. Prospective, blinded, randomized trial. Tertiary academic laryngology practice. One hundred and eight patients underwent TFL over 3 months. Patients were randomized to receive equivalent dose 1:1 neosynephrine/4% plain lidocaine mixture via aerosolized spray ("spray") or application with 1-cc syringe ("syringe"). Patients and physicians independently rated comfort of TFL on 5-point scale (1 = not at all comfortable to 5 = very comfortable). Data were collected on patient and endoscopist experience with TFL and reasons for poor tolerance of laryngoscopy. Cost analyses of disposable spray tips and syringes were calculated. Both patients and physicians reported very high tolerance of TFL. Patient tolerance appears to be similar between spray- versus syringe-administered anesthesia, although study limitations preclude definitive analysis. Poor tolerance of laryngoscopy was reported in 6.5% with comparable distribution between anesthetic delivery methods. There was no impact of patient prior experience with TFL, and there was no difference between anesthetic methods for TFL performed by resident, fellow, or attending. The difference between costs of the disposable spray tip versus syringe was $1.32 per unit. Use of a 1-cc syringe is an effective method to provide topical nasal anesthesia for TFL and saves $1.32 per unit compared to disposable spray tips. In our practice, transition to syringe-administered nasal anesthesia is projected to save $1300 per 1000 patients, or an anticipated $1000 per year per physician, with excellent patient tolerance of TFL.

Effects of adding epinephrine on the early systemic absorption kinetics of local anesthetics in abdominal truncal blocks

We evaluated the pharmacokinetics of ropivacaine following rectus sheath block (RSB) and transversus abdominis plane (TAP) block with or without epinephrine. A total of 26 adult patients undergoing lower abdominal surgery with RSB (=RSB trial) and another 26 adult patients undergoing open prostatectomy with TAP block (=TAP trial) were enrolled. Patients were randomly assigned to receive either a mixture of 0.75 % ropivacaine 13.2 mL with 1 % plain lidocaine 6.8 mL (TAP-E(-) and RSB-E(-) groups) or a mixture of 0.75 % ropivacaine 13.2 mL and 1 % lidocaine containing adrenaline (1:100,000) 6.8 mL (TAP-E(+) and RSB-E(+) groups) under general anesthesia. The serum concentrations of ropivacaine were measured using gas chromatography with mass spectrometry. The peak concentration was significantly lower and time to peak concentration was significantly longer in the TAP-E(+) group than in the TAP-E(-) group (P < 0.05 and <0.01, respectively), while there were no significant differences in these parameters between the RSB-E(+) and RSB-E(-) groups. These results indicate that epinephrine attenuates the early phase of local anesthetic absorption from the injected site in TAP blocks, but not RSB.

Can the addition of a paracervical block to systemic or local analgesics improve the pain perceived by the patient during hysterosalpingography?

The aim of the present study was to investigate whether the addition of a paracervical block to local intrauterine anaesthesia or the use of an intramuscular non-steroidal anti-inflammatory drug was effective for pain control during and at 30 min after hysterosalpingography (HSG). A total of 120 patients undergoing hysterosalpingography were randomised into four groups. Patients received intramuscular dexketoprofen trometamol with or without a paracervical block or intracavitary lidocaine instillation with or without paracervical block. The primary outcome was the overall pain score from the four stages of the procedure. The lowest pain scores were observed in the patients receiving dexketoprofen trometamol with a paracervical block, whereas the highest pain scores were observed in patients with intracavitary lidocaine instillation without a paracervical block (p = 0.021). No beneficial effect was found when a paracervical block (PCB) was added to either systemic or local analgesics. The combination of intramuscular dexketoprofen and a paracervical block with plain lidocaine produced the best pain relief during the three specified steps and at up to 30 min after the HSG procedure.

Comparison of Tolerance and Cost‐Effectiveness of Two Nasal Anesthesia Techniques for Trans‐nasal Flexible Laryngoscopy (TFL)

Objectives: 1) Compare tolerance of aerosolized spray vs. syringe administration of topical anesthesia for TFL. 2) Analyze cost-effectiveness of both techniques. Methods: Prospective, blinded, randomized trial. 108 patients underwent TFL over a 3-month period. Patients were randomized to receive equivalent dose of 1:1 neosynephrine/4% plain lidocaine mixture via either aerosolized spray (“spray”) or application with 1-cc syringe (“syringe”). Patients and physicians independently rated comfort of TFL on a 5-point scale (1=not at all comfortable to 5=very comfortable). Data was collected on patient and endoscopist experience with TFL as well as reasons for poor tolerance of laryngoscopy. Cost analyses of disposable spray tips and syringes were calculated. Results: Both patients and physicians reported very high tolerance of TFL. There was no difference in patient tolerance between spray- vs. syringe-administered anesthesia ( P = 0.89). Poor tolerance of laryngoscopy was reported in 6.5% with comparable distribution between anesthetic methods ( P = 0.93). There was no impact of patient prior experience with TFL ( P = 0.280), and there was no difference between anesthetic methods for TFL performed by the resident, fellow, or attending. The difference between costs of the disposable spray tip vs. syringe was $1.30 per unit. Conclusions: Use of a 1-cc syringe is an effective method to provide topical nasal anesthesia for TFL and saves $1.30 per unit compared to disposable spray tips. In our practice, transition to syringe-administered nasal anesthesia is projected to save $1,300 per 1,000 patients, or an anticipated $3,000 per year, with continued excellent patient tolerance of TFL.

Optimal Time Delay between Epinephrine Injection and Incision to Minimize Bleeding

The time until maximal cutaneous vasoconstriction after injection of lidocaine with epinephrine is often given in textbooks and multiple choice examinations as 7 to 10 minutes. However, in our experience, there is significantly less cutaneous bleeding if one waits considerably longer than 7 to 10 minutes after injection of local anesthesia with epinephrine for most procedures on human skin. This was a prospective, randomized, triple-blind study where 12 volunteers were injected simultaneously in each arm with either 1% lidocaine with epinephrine (study group) or 1% plain lidocaine (control group), after which the relative hemoglobin concentration of the underlying skin and soft tissues was measured over time using spectroscopy. In the epinephrine group, the mean time at which the lowest cutaneous hemoglobin level was obtained was 25.9 minutes (95 percent CI, 25.9 ± 5.1 minutes). This was significantly longer than the historical literature values of 7 to 10 minutes for maximum vasoconstriction after injection. Mean hemoglobin index values at every time measurement after postinjection minute 1 were significantly different between the study group and the control group, with use of a two-tailed paired t test (p < 0.01). If optimal visualization is desired, the ideal time for the surgeon to begin the incision should be 25 minutes after injection of local anesthetic with epinephrine. It takes considerably longer than 7 to 10 minutes for a new local equilibrium to be obtained in relation to hemoglobin quantity.

Local anaesthetic systemic toxicity treated with intravenous lipid emulsion: ineffective treatment or selection of an inadequate lipid rescue dose?

We thank Aveline et al.1 for their detailed account of central nervous system (CNS) toxicity following ultrasound-guided sciatic and saphenous nerve block using lidocaine and ropivacaine in a patient scheduled for hallux valgus surgery. They reported clinical signs compatible with systemic absorption of local anaesthetics and initiated treatment with 20% intralipid as 100 ml bolus doses 2 min apart. Unfortunately, this intervention was unsuccessful and general anaesthesia was required. The authors concluded that intralipid had been ineffective and suggested an interaction between local anaesthetic agents, intralipid, and carbamazepine treatment the patient was taking for trigeminal neuralgia, may have been a contributory factor. We agree that the patient exhibited local anaesthetic systemic toxicity (LAST) and wish to suggest possible explanations for the apparent failure of intralipid in this case. In their calculations of the local anaesthetic dose administered, the authors appear to have omitted the saphenous nerve component of their technique of 100 mg lidocaine, which, if included means the patient received a total dose of 400 mg or 7.02 mg kg−1 of plain lidocaine. The plasma lidocaine concentration of 2.3 μg ml−1, recorded 25 min after the block, is consistent with levels previously reported with injection of the same dose of lidocaine in the subcutaneous tissue of the abdominal wall.2 This would support the notion that LAST most likely represents systemic absorption from correctly placed peripheral nerve blocks rather than primarily from an intravascular injection. If the additive effect of the ropivacaine element of the block is taken into consideration in overall dose calculations,3 this may explain why CNS signs of LAST became apparent. Given the absence of significant cardiovascular, metabolic or electrolyte disturbance, all of which may have contributed to the severity of LAST, we agree that drug interaction may have been relevant in this case.4 All three drugs rely on protein binding of 75% or more for transport within the blood and all three are lipid soluble to varying degrees, with log P values for carbamazepine, lidocaine and ropivacaine of 2.73, 2.36 and 3.11, respectively. It is possible that competition for protein-binding sites between drugs resulted in a greater proportion of unbound local anaesthetics manifesting as systemic toxicity. Thus, for the lipid sink sequestration activity of intralipid to be fully effective, we consider this may have required administration of a proportionately larger volume of intralipid than usual. Previously intravenous lipid emulsion (ILE) has been reported to reverse LAST completely after presumed intravascular injection. We are aware of two published reports in which recovery from LAST occurred by early bolus administration of 20% intralipid followed by an infusion to a total volume of 500 ml.5,6 Although the time taken to restore a full level of consciousness did vary, in these cases the ILE reversed the LAST rapidly enough to avoid tracheal intubation. We advocate the early use of ILE but not as an alternative to safe local anaesthetic dosing and other appropriate resuscitation measures. Guidance for treatment of LAST has been posted on the Lipid Rescue website (http://www.LipidRescue.com) and elsewhere.7 For adults, these recommendations generally advocate an initial bolus dose of 100 ml (approximately 1.5 ml kg−1) 20% intralipid, followed by a rapid infusion of 400 ml over 20 min. Two further 100 ml boluses may be given and an infusion continued until signs of LAST have been reversed, if necessary continuing until a total volume of 12 ml kg−1 has been administered. We are curious as to why intravenous lipid treatment was suspended when only 200 ml had been given. Although we can only speculate at what might have happened had the volume of intralipid administered been bigger, this case is of value because it seems to confirm that the effects of ILE in the clinical setting are dose-dependent and perhaps the dose administered in this case was inadequate.

Do Not Use Epinephrine in Digital Blocks: Myth or Truth? Part II. A Retrospective Review of 1111 Cases

Epinephrine in digital blocks has been condemned by traditional medical theory. The authors provide a retrospective review of 1111 cases involving digital block anesthesia with epinephrine in conjunction with an extensive literature review. The authors conducted a retrospective review of 1111 cases involving digital and hand surgery. Observations were made concerning the location of and indication for surgery, age, sex, type of block used, type and dose of anesthetic, use of epinephrine and concentration, use of a tourniquet, follow-up, and complications. Dorsal and transthecal techniques were used exclusively. Patients with vascular compromise did not receive epinephrine and were excluded from the study. One thousand one hundred eleven cases were reviewed, distributed among 692 male patients and 419 female patients. Sites of surgery ranged throughout the hand and all fingers for a variety of indications. Five hundred patients received injections of 1% plain lidocaine with a dosage range of 2 to 10 cc and an average of 5.7 cc. Six hundred eleven patients received injections of 1% lidocaine with epinephrine (1:100,000) in a dose range of 0.5 to 10 cc and an average dose of 4.33 cc. Nine hundred eighty-six patients (88.75 percent) followed up in the clinic. No patients suffered from digital gangrene in the epinephrine group. After reviewing 1111 cases, there were no complications associated with the use of epinephrine in digital blocks. The authors suggest that correct application of epinephrine in digital blocks is appropriate, and defend its use.

Vapocoolant spray vs subcutaneous lidocaine injection for reducing the pain of intravenous cannulation: a randomized, controlled, clinical trial

BackgroundWe compared the efficacy, acceptability, and safety of a topical vapocoolant alkane spray and 1% plain s.c. lidocaine in reducing pain from i.v. cannulation. MethodsThis was a non-blinded, randomized, controlled trial, in a large emergency department. Adult patients requiring i.v. cannulation were enrolled. The vapocoolant was administered from a pressure pack, at a distance of 12 cm for 2 s, and cannulation was undertaken within 15 s. Alternatively, 1% plain lidocaine 0.2 ml was administered s.c. using a 27 G needle, and cannulation was undertaken after a minimum of 30 s. The primary outcomes were anaesthetic administration and cannulation pain (0–100 mm visual analogue scale). Convenience of anaesthetic use and patient satisfaction were measured using a five-point Likert scale. ResultsOne hundred and ten patients were enrolled in each group. The groups did not differ in age, gender, cannulation anxiety, cannulator experience, cannulation indication or site, or cannula size. Median anaesthetic administration pain scores were 0 and 11 mm in the vapocoolant and lidocaine groups, respectively (P<0.001). Median cannulation pain scores were 9 and 0 mm, respectively (P<0.001). Vapocoolant was associated with greater cannulation success (83.6% vs 67.3%, P=0.005), less time to administer (median 9.0 vs 84.5 s, P<0.001), and more staff convenience (median 5 vs 4, P<0.001). Median patient satisfaction was 4 in both groups. Unexpected events were rare and minor. ConclusionsAlthough vapocoolant reduces cannulation pain less than lidocaine, it has a number of important advantages. Vapocoolant offers a useful alternative in the emergency department setting.

Digital Block With and Without Epinephrine During Chemical Matricectomy with Phenol

Digital block with epinephrine is safe in selected patients. Chemical matricectomy with phenol is a successful, cheap, and easy method for the treatment of ingrown nails. To determine the effect of digital block with epinephrine in chemical matricectomy with phenol. Forty-four patients with ingrown toenail were randomly divided into two groups. The plain lidocaine group (n=22) underwent digital anesthesia using 2% plain lidocaine, and the lidocaine with epinephrine group (n=22) underwent digital anesthesia with 2% lidocaine with 1:100,000 epinephrine. In the postoperative period, the patients were evaluated for pain, drainage, and peripheral tissue destruction and were followed for up to 18 months for recurrence. The mean anesthetic volume used in the epinephrine group (2.2 ± 0.4 mL) was significantly lower than the plain lidocaine group (3.1 ± 0.6 mL). There was no statistically significant difference in postoperative pain and recurrence rates, but duration of drainage was significantly shorter in the epinephrine group (11.1 ± 2.5 days) than in the plain lidocaine group (19.0 ± 3.8 days). CONCLUSION Digital block with epinephrine is safe in selected patients, and epinephrine helps to shorten the postoperative drainage period. The authors have indicated no significant interest with commercial supporters.

No-Needle Local Anesthesia for Adult Male Circumcision

We used a local anesthetic jet injection technique for adult male circumcision. This method eliminates needle use and may decrease the fear of local anesthetic injection used for male circumcision. We recruited 60 men seeking voluntary adult male circumcision into the study from June to September 2009. We used a MadaJet Medical Injector to deliver a high pressure spray of 0.1 ml 2% plain lidocaine solution directly through the penile skin circumferentially around the proximal third of the penis. All men underwent circumcision using the Shang Ring and were evaluated for anesthetic safety, efficacy and acceptability. Pain was measured on a visual analog scale. The average volume of 2% lidocaine anesthetic solution delivered by jet injection was 0.1 ml with a mean total of 0.9 ml per circumcision procedure. More than 85% of men did not require supplemental anesthesia. Anesthetic onset required approximately 45 seconds from the time that injections were completed. Mean pain scores for immediate postoperative, 24-hour postoperative, ring removal and post-ring removal events were 0.1, 6.8, 2.2 and 0.9, respectively. In 4 patients (6.67%) mild urethral bleeding resolved with pressure, resulting in technique modification. No-needle jet injection is safe and effective for adult MC. The technique efficiently delivers local anesthesia with rapid onset in men undergoing circumcision. This needle-free approach may enhance the popularity of adult male circumcision.

Parathyroid gland preservation and selective autotransplantation utilizing topical lidocaine in total thyroidectomy

To review a new technique during total thyroidectomy that facilitates parathyroid gland preservation and selective autotransplantation utilizing topical 2% plain lidocaine as a spasmolytic/vasodilator agent. Retrospective case series review at a university hospital. The study population comprised 100 consecutive patients (84 women and 16 men; mean age, 52 years) undergoing total thyroidectomy from January 2007 to December 2008. Interventions were: parathyroid glands (PGs) with signs of devascularization treated with a topical solution of 2% plain lidocaine in an attempt to restore blood flow before committing to autotransplantation. The main outcome measure was the incidence of hypoparathyroidism. A total of 40 parathyroid glands were autotransplanted. None of the 100 patients developed permanent hypoparathyroidism. There were no adverse effects utilizing this technique. In our experience, the use of lidocaine spasmolysis is a useful technique in thyroid surgery for salvaging devascularized PGs. Its utility as a selection method for PG autotransplantation incurs minimal risk or cost and might further reduce the incidence of permanent hypoparathyroidism. Further study is warranted.

Lidocaine with epinephrine infiltration does not impair wound healing

Background: Local anaesthetic agents are frequently used to infiltrate wounds to delay nociceptive input in postoperative pain management. Aim: This study investigates the comparative effects of wound infiltration with lidocaine plain and lidocaine with epinephrine for postoperative pain relief at normal clinical doses. Methods: This is a prospective randomized double-blind study of a convenience sample of paediatric patients with postoperative wound healing characteristics after herniotomies. Patients were randomly allocated into two groups after written informed consent had been obtained from their legal guardians. Each patient received general anaesthesia. At the end of surgery, wounds were infiltrated using the assigned local anaesthetic agent. The healing characteristics and other outcomes were studied. Results: Forty-eight patients were enrolled into the study, 42 (87.5%) participated until discharge from the surgical clinic. A total of 9 (21.4%) females and 33 (78.6%) males were studied. The mean age in the lidocaine plain (Lid P) was 11.0 ± 4.7 months while lidocaine with epinephrine (Lid E) was 10.3 ± 4.4 months (p=0.3). The mean body weight in the Lid P and Lid E were 9.9 ± 2.6 kg and 9.4 ± 2.3 kg respectively (p=0.3). The mean lengths of surgical incision were 39.1 ± 0.5mm and 39.6 ± 0.4 mm for Lid P and Lid E respectively (p=0.4). The mean duration of analgesia in Lid P was 68.9 ± 11.8 mins and 89.0 ± 17.4 mins for Lid E (p=0.01). Wounds healed by primary intention by the 7th postoperative day in both groups. Conclusion: Wound infiltration with lidocaine with epinephrine did not impair wound healing in humans. Keywords: Lidocaine plain, Lidocaine with epinephrine, Infiltration, Wound healing

Prospective Randomized Evaluation of Short-Term Complications When Using Buffered or Unbuffered Lidocaine 1% With Epinephrine for Blepharoplasty Surgery

To determine whether there is a difference in the incidence of short-term complications using plain lidocaine with epinephrine versus the buffered equivalent in eyelid surgery. The authors performed a prospective, double-masked, randomized study in patients scheduled for combined upper eyelid blepharoplasty and levator advancement ptosis repair surgery with local anesthesia. Exclusion criteria included: documented allergies to lidocaine and/or epinephrine; known pregnancy; profound cognitive impairment; inability to understand the visual analog scale or the informed consent; and previous eyelid surgery. Each subject was his/her own control by using the unbuffered local anesthetic in one eye, while the buffered solution was used in the other eye. The surgeon completed a specific standardized data collection form for quantifying both intraoperative and postoperative complications, such as bleeding, bruising, and edema. Data regarding pain on injection and postoperative pain were collected from patients using a visual analog pain scale. Thirty-nine patients were included in this study, of which 18 experienced less pain during the injection on the side where buffered lidocaine was used, 11 reported no difference, and 10 reported less pain in the eye injected with unbuffered lidocaine. Injection pain revealed a mean operative pain rating of 4.01 +/- 2.45 in the eye with buffered lidocaine versus 4.49 +/- 2.58 in the control (p = 0.06). There were no significant differences between the buffered and unbuffered lidocaine eyes as regards postoperative bleeding, swelling, or pain, and there was a trend toward less pain on injection with the buffered solution. There were no significant differences in postoperative pain, swelling, or bleeding with the use of plain versus buffered lidocaine in eyelid surgery. There was a trend for the buffered anesthetic to cause less pain on injection.

Complex of branched cyclodextrin and lidocaine prolonged the duration of peripheral nerve block

Although laboratories have tried to synthesize new local anesthetics, currently available local anesthetics rarely provide prolonged regional blockade. New models of sustained-release preparations of local anesthetics with liposomes and microspheres have been studied to prolong the duration of the effects of the local anesthetics. In the present study, we examined whether a complex of a branched cyclodextrin (CD), 6-O-alpha-D-maltosyl-beta-cyclodextrin (G2-beta-CD) and lidocaine could prolong local nerve block when compared with plain lidocaine. The sciatic nerve in male Sprague-Dawley rats was blocked with plain lidocaine (n = 10), the complex of G2-beta-CD + lidocaine (n = 10), or plain G2-beta-CD (n = 4). Sensory block was assessed with a hotplate set at 56 degrees C. The median duration of the block was longer in the complex group than in the plain lidocaine group (110 min; range, 70-150 min vs 55 min; range, 40-80 min; P < 0.05), thus demonstrating that the complex with CyD significantly prolonged the nerve block effect of lidocaine. In conclusion, the present study showed that this encapsulating technique with CyD is useful to expand local anesthetic effect in peripheral nerve blockade.