Local Anesthetic Agents Research Articles

Block Quality Of Dexmedetomidine-Based Spinal Anaesthesia In Orthopaedic Surgeries: A Meta-Analysis Of Clinical Trials

Background: Dexmedetomidine is used as an adjuvant to local anesthetic agents in spinal anesthesia and is believed to increase quality of sensory and motor blocks. Our aim was to assess the effects of dexmedetomidine as an adjunct on block quality of spinal anesthesia in orthopedic procedures.
 Methodology: A systematic review of randomized control trials was conducted to assess the effect of intrathecal dexmedetomidine added to local anesthetic agents on the block quality of spinal anesthesia in orthopedic surgeries. PubMed, Google scholar, and Medline databases were searched for randomized controlled clinical trials. Studies met our inclusion criteria, if they used intrathecal 5 µg dexmedetomidine as an additive to 2.5−3 ml (12.5−15 mg) bupivacaine or ropivacaine, and these were included in our meta-analysis.
 Results: Eight trials comprising 510 patients matched our inclusion criteria. Time to one sensory segment block regression (mean difference 139.72 min; 95% confidence interval (CI) 35.18−244.26; P = 0.009), two sensory segments block regression (mean difference 54.8 min; 95% CI [31.36−78.24]; P < 0.001), and Bromage score of zero (mean difference 93.66 min; 95%CI [30.20−157.12]; P = 0.004 ) were significantly prolonged in dexmedetomidine group. There were no significant differences between dexmedetomidine group and control group in duration of surgery (P = 0.33) or time till block reaches T10 dermatomal level (P = 0.30). Finally, time to reach Bromage score of III following injection was significantly shorter in dexmedetomidine group (mean difference 2.62 min; 95%CI [−5.12−−0.13]; P = 0.04).
 Conclusion: Dexmedetomidine was found to achieve extended motor and sensory block when needed, bearing in mind higher cost and potential side effects.
 Key words: Dexmedetomidine, Spinal Anesthesia, Orthopedic surgery, Meta-analysis.
 Citation: Alhajahjeh AA, Suleiman A, Almustafa HM, Mesmar TM, Hamdan A, Almustafa MM. Neuraxial block quality of dexmedetomidine-containing regimens in orthopedic surgeries: a meta-analysis. Anaesth. pain intensive care 2022;27(1):43−52.
 DOI: 10.35975/apic.v27i1.1876
 Received: May 22, 2022; Reviewed: August 14, 2022; Accepted: December 28, 2022

Pharmacological Evaluation of the Anesthetic and Analgesic Potential of Injection Harsha 22: A Novel Polyherbal Local Anesthetic Formulation Intended for Parenteral Administration in Wistar Albino Rats.

Local anaesthetics are medications that cause numbness that can be reversed by applying them topically. Local anaesthetics are clinically used to control pain during minor surgeries or to treat other acute and chronic pain. The present investigation intended to investigate the anesthetic as well as analgesic potential of Injection Harsha 22, a novel polyherbal formulation in Wistar albino rats. The anesthetic potential of Injection Harsha 22 was evaluated by a heat tail-flick latency (TFL) test, whereas the analgesic effect was elevated by electrical stimulation testing. Here, lignocaine (2%) was used as the standard anesthetic drug. In TFL, Injection Harsha 22 showed anesthetic effects up to 90 minutes after application. Also, the duration of anesthesia in rats that were administered subcutaneously with Injection Harsha 22 was comparable to that of the rats treated with commercial lignocaine (2%). In an electrical stimulation test, single administration of Injection Harsha 22 to rats significantly prolonged analgesia compared with the normal control group. The median duration of analgesia in rats administered subcutaneously with Injection Harsha 22 and lignocaine solution was 40 minutes and 35 minutes, respectively. Furthermore, Injection Harsha 22 does not interfere with the hematopoietic system of the experiment animals. Thus, the present investigation established the in vivo anesthetic and analgesic potential of Injection Harsha 22 in experimental animals. Hence, it can be concluded that Injection Harsha 22 can become a prominent substitute for lignocaine as a local anaesthetic agent after establishing its efficacy through stringent clinical trials in humans.

Effect of the inferior alveolar nerve block injection versus maxillary infiltration with two local anesthetic agents on cardiovascular parameters: A randomized comparative double-blind clinical trial

Abstract This study aimed to assess the effect of inferior alveolar nerve (IAN) block of the mandible and infiltration anesthesia of the maxilla using lidocaine plus epinephrine or prilocaine with felypressin anesthetic agents on systolic and diastolic blood pressures, heart rate (HR) and peripheral oxygen saturation rate of patients. This randomized double-blind clinical trial evaluated 112 patients in four groups (n=28) based on the jaw (maxilla or mandible) and type of anesthetic agent (lidocaine with epinephrine or prilocaine with felypressin). Groups 1 and 2 received IAN block of the mandible or infiltration anesthesia of the maxilla, respectively, with 2% lidocaine plus 1:80.000 epinephrine. Groups 3 and 4 received IAN block of the mandible or infiltration anesthesia of the maxilla, respectively, using prilocaine with felypressin. Systolic and diastolic blood pressures and HR were measured by an automatic upper arm blood pressure monitor and the percentage of peripheral oxygen saturation rate was measured by a finger pulse oximeter 10 minutes before the injection, immediately after injection, 10 minutes after injection and 20 minutes after injection. The mean diastolic blood pressure showed a greater reduction following the administration of lidocaine with epinephrine, as compared with prilocaine with felypressin (p<0.001). The mean HR showed a significantly greater increase following the administration of lidocaine with epinephrine, as compared with prilocaine with felypressin (p<0.001). The effect of type of anesthetic agent on diastolic blood pressure depended on the type of injection (p=0.033). Administration of 2% lidocaine with 1:80.000 epinephrine, in comparison to prilocaine with felypressin, can cause changes in cardiovascular parameters such as heart rate and diastolic blood pressure in patients undergoing restoration of a maxillary or mandibular molar tooth. Type of injection has no significant effect on cardiovascular parameters.

CONTINUOUS SPINAL ANAESTHESIA: A PROMISING TECHNIQUE FOR PROLONGED LOWER LIMB ORTHOPAEDIC SURGERIES

Background: Continuous Spinal Anaesthesia (CSA) is an advancing technique for prolonged lower limb orthopaedic surgeries. It awards prompt anaesthesia and analgesia, controlled sensorimotor blockade along with better haemodynamic stability using titrated and lower doses of Local Anaesthetic (LA) agents. This mode of regional anaesthesia using intrathecal catheter thus demonstrated to be an efcient and safe technique providing lesser incidence of Local Anaesthetic Systemic Toxicity (LAST) and Post Dural Puncture Headache (PDPH). This study integrates our experience with CSA for prolonged lower limb orthopaedic surgeries. Methodology: Our study comprised six cases posted for lower limb orthopaedic surgery belonging to ASA grades I and II. A 20-gauge catheter was threaded in subarachnoid space. The catheter was inserted 3cm intrathecally through 18-Gauge Touhy's needle in L3-L4 interspace. 1ml of hyperbaric Ropivacaine 0.75% with 10µg Dexmedetomidine as an adjuvant was injected. In our case series, we considered aliquots of isobaric Ropivacaine with a concentration of 0.75% for maintenance of anaesthesia wherefore 0.375% for analgesia. All of our patients were Results: hemodynamically stable intraoperatively as well as in the postoperative period. The average duration of analgesia in the postop period was 14-16 hours on the rst top-up. Excellent patient and surgeon satisfaction was experienced. Our case series concludes that CSA is an Conclusion: effective and better option for Single-Shot and Epidural Anaesthesia in lower limb orthopaedic surgeries under skilled expertise

A comparative study of tumescent anaesthesia (0.1% lignocaine with adrenaline) versus 2% lignocaine for episiotomy

Introduction: Tumescent anaesthesia is a practice of giving a very dilute form of local anaesthesia drug combined with epinephrine to a tissue till the tissue becomes firm and tense (tumescent). Delivery is a physiological procedure associated with great pain, which is in turn added by the episiotomy procedure. Advantage of using tumescent anaesthesia as a local anaesthetic agent include that it reduces the blood loss by both epinephrine induced vasoconstriction and hydrostatic compression from the tumescent effect. Tumescent lignocaine absorbed slowly from subcutaneous tissue that produces lower & more delayed peek serum levels and also extended analgesic effect after procedure.Aim and Objectives: To compare the effects of tumescent anaesthesia over 2% lignocaine for episiotomy in patients delivering via labour natural in Rajah Muthiah Medical College and Hospital, Chidambaram. To study the effectiveness of tumescent anaesthesia in decreasing blood loss at episiotomy site. To study the effectiveness of tumescent anaesthesia in reducing pain and prolonging the analgesic effect. To study the effectiveness of tumescent anaesthesia aiding in demarcation of layers of episiotomy wound while repairing.Materials and Methods: To the patients who progress for vaginal delivery in stage two of labour before crowning of fetal head 10 ml of 2% lignocaine and 10 ml of tumescent anaesthesia [0.1% lignocaine with adrenaline) to be instilled into the perineal skin at the episiotomy site left mediolateral (By randomised selection of patients). When fetal head crowns episiotomy to be given and baby to be delivered. After removal of the placenta, episiotomy wound will be sutured in layers.Results: The mean Duration of analgesia in Group A was 93.467 ± 17.4529 & group B was 198.100 ± 12.0669 with P value less than 0.05, which was statistically significant. The mean time of suturing episiotomy n group A was 22.19 ± 1.642 and group B was 12.45 ± 1.947 with P value <0.05, which was statistically significant.Conclusion: The inference of the study shows that tumescent anaesthesia (0.1% lignocaine with adrenaline) has certain benefits when used as local anaesthesia for doing and repairing episiotomy when compared to 2% lignocaine in terms of prolonging duration of analgesia, reducing the time taken to suture episiotomy wound by demarcating the tissues which aids in easy suturing.

Continuous Erector Spinae Plane Block in Paediatric VATS: A Case Series.

Decortication and stripping of infected pleura by video-assisted thoracoscopic surgery or thoracotomy is the treatment of choice in cases of empyema. The stripping is associated with intense post-operative pain. Erector spinae block is an excellent and safe alternative to thoracic epidural block. The experience in paediatric erector spinae plane block is very limited. We present our experience of continuous erector spinae block and one single-shot erector spinae plane block in paediatric video-assisted thoracoscopic surgeries. We had 5 patients aged 2-8 years with right-sided empyema, who were taken up for video-assisted thoracoscopic surgery decortication, and 2 patients aged 1-4 years with congenital diaphragmatic hernia (CDH) for video-assisted thoracoscopic surgery CDH repair. After induction and intubation, using high-frequency straight ultrasound probe, an erector spinae plane catheter was inserted and the local anaesthetic agent was administered. The patients were monitored for signs of effective analgesia. Post-extubation continuous erector spinae plane block was continued for 48 hours using bupivacaine and fentanyl. All patients had excellent postoperative analgesia for more than 48 hours. There were no side effects like motor block, nausea, vomiting, or respiratory depression. Continuous erector spinae plane block provides excellent analgesia in paediatric patients undergoing video-assisted thoracoscopic surgery, causing minimal side effects. Further, a prospective randomized control trial is suggested to establish the efficacy of this block in paediatric video-assisted thoracoscopic surgeries.

Dexmedetomidine vs dexamethasone as adjuvants to levobupivacaine in ultrasound-guided erector spinae plane block for patients undergoing modified radical mastectomy: a randomized double-blind study

Background &amp; Objective: Erector Spinae Plane block (ESPB) is used in patients subjected to modified radical mastectomy (MRM) as a part of balanced anesthesia technique, and to offer prolonged postoperative analgesia. Local anesthetic agents are usually combined with various adjuvants to augment the effect. We compared dexmedetomidine (Dex) versus dexamethasone as adjuvants to ESPB in patients undergoing MRM.&#x0D; Methodology: This randomized controlled study involved 90 patients subjected to MRM under general anesthesia with preoperative ESPB using 30 ml levobupivacaine 0.25%. They were randomly assigned into three equal groups according to the adjuvants used. Dex Group (n = 30) received 1 µg/kg dexmedetomidine, Dexa Group (n = 30) received 10 mg dexamethasone, and ESPB Group (n = 30) received no adjuvants. Patients were monitored for pain using VAS scores and vital signs. The primary outcome measure was total morphine consumption. The secondary outcomes were intraoperative fentanyl consumption, pain intensity, and analgesia duration.&#x0D; Results: The postoperative analgesia duration was significantly longer in the Dex group compared with the ESPB group (P = 0.029) but not in the dexamethasone group. Intraoperative fentanyl and postoperative morphine consumption were significantly lower in the Dex group than in the ESPB group. VAS scores were significantly lower in the Dex group than in the ESPB group at rest and movement. VAS scores of the Dexamethasone group were similar to that of the ESPB group at rest and movement.&#x0D; Conclusion: As an adjuvant to levobupivacaine in erector spinae plane block, dexmedetomidine reduces pain at rest and with movement, reduces intraoperative fentanyl and postoperative morphine consumption, and prolongs the analgesia duration. It is superior to dexamethasone in pain reduction and duration of analgesia.&#x0D; Key words: Analgesia; Dexamethasone; Dexmedetomidine; Erector Spinae Plane Block; Radical Mastectomy; Postoperative Pain&#x0D; Citation: Ahmed HI, Ali AR, El Emam NH, Magdy M, Gamal RM. Dexmedetomidine vs dexamethasone as adjuvants to levobupivacaine in ultrasound-guided erector spinae plane block for patients undergoing modified radical mastectomy: a randomized double-blind study. Anaesth. pain intensive care 2022;27(1):65−72.&#x0D; DOI: 10.35975/apic.v27i1.2122&#x0D; Received: Oct 08, 2022; Reviewed: Nov 10, 2022; Accepted: Nov 22, 2022

EFFECT OF PREVIOUS SCORPION BITE ON THE EFFICACY OF INTRATHECALLY ADMINISTERED LEVOBUPIVACAINE IN SUBARACHNOID BLOCK

Objectives: Local anesthetics administered by spinal anesthesia acts through sodium channels. Mutations of sodium channels may be responsible for resistance to local anesthetic agents. The scorpion venom contains neurotoxins that block the sodium channels. In view of the high prevalence of scorpion stings in our region and observation of failure of spinal anesthesia in patients with a history of scorpion stings in routine practice, the present study is planned. Methods: Forty patients of the American Society of Anesthesiologists Grade I or II who were undergoing infraumbilical surgery were divided into two groups as S (patients with h/o scorpion bite) and C (patients with no such history). The subarachnoid block was given with 3.2 ml of injection Levobupivacaine 0.5% heavy using 26 gauzes Quincke spinal needle. A blind observer recorded a sensory block using a needle prick and a motor block using the Bromage scale. Onset of sensory and motorized block, time to peak of sensory, and motor block and its relation to number of scorpion bites were observed in both the groups. Results: The onset of sensory (2.61±1.68 mins) and motor blockade (2.91±1.80 mins) was significantly delayed in Group S (p=0.010 and 0.004, respectively). Time to peak of sensory and motor blockade was also prolonged in Group S (6.45±2.83 mins and 7.8±3.95 mins) compared to Group C (3.60±0.84 mins and 4.56±1.30 mins) which was statistically significant (p&lt;0.05). Patients who had previous scorpion bites (Group S) had a significant failure rate of spinal anesthesia compared to the control group. Conclusion: In this study, it was observed that the patients with scorpion bites had a significant failure rate of spinal anesthesia, suggesting probable resistance to the local anesthetic agents.

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

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

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

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

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

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

Pain Reduction Using Ropivacaine in Tumescent Solution following Lipoaspiration.

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

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

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

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

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

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

Objective: To compare the frequency of recurrence after surgical excision versus aspiration and injection of Steroids of wrist ganglion&#x0D; Study Design: Comparative cross-sectional study.&#x0D; Place and Duration of Study: Department of General Surgery at Combined Military Hospital, Kohat Pakistan, from Sep 2018 to Aug 2019.&#x0D; Methodology: Seventy patients reported to the Outpatient Department, Combined Military Hospital, Kohat Pakistan, with complaints of ganglion and wanted treatment. Patients were randomly allocated into two Study Groups 1 and 2, by lottery method. Group-1 was treated by aspiration of the cyst contents followed by Steroid injection, while Group-2 was by excisionof the ganglion surgically under a local anaesthetic agent. The patient was followed up after three months to look for recurrence in both groups.&#x0D; Results: The frequency of recurrence was 34.29% in Group-1 and 5.71% in Group-2, (p-value was less than 0.001).&#x0D; Conclusion: Surgical excision results in lesser recurrence when compared with simple aspiration and Steroid injection for ganglion of the wrist.

A Curious Case of Methaemoglobinemia

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

Malignant Hyperthermia in the Dental Setting: A Case Report

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

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

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

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

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

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

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