Prolonged Paralysis Following Emergent Cesarean Section with Succinylcholine Despite Normal Dibucaine Number.

Prolonged paralysis due to a quantitative or qualitative deficiency of pseudocholinesterase activity is an uncommon but known side effect of succinylcholine. We describe a patient who experienced prolonged paralysis following administration of succinylcholine for general anesthesia and endotracheal intubation for an emergent cesarean section despite laboratory evidence of normal enzyme function. The patient required mechanical ventilation in the intensive care unit for several hours following surgery. The patient was extubated following return of full muscle strength and had a good outcome. The enzyme responsible for the metabolism of succinylcholine, pseudocholinesterase, was determined to be low in quantity in this patient but was functionally normal. This low level, by itself, was unlikely to be solely responsible for the prolonged paralysis. The patient likely had an abnormal pseudocholinesterase enzyme variant that is undetectable by standard laboratory tests.

History of T-cain: a local anesthetic developed and manufactured in Japan.

In many anesthesia textbooks written in English, lidocaine, tetracaine, bupivacaine, ropivacaine, and chloroprocaine are listed as useful local anesthetics for spinal anesthesia. In contrast, T-cain is not included in these lists, even though it has been reported to be suitable for spinal anesthesia in Japan. T-cain was developed as a local anesthetic in the early 1940s by Teikoku Kagaku Sangyo Inc. in Itami, Japan, by replacing a methyl group on tetracaine (Pantocaine(®)) with an ethyl group. T-cain was clinically approved for topical use in Japan in November 1949, and a mixture of dibucaine and T-cain (Neo-Percamin S(®)) was approved for spinal use in May 1950. Simply because of a lack of foreign marketing strategy, T-cain has never attracted global attention as a local anesthetic. However, in Japan, T-cain has been used topically or intrathecally (as Neo-Percamin S(®)) for more than 60 years. Other than the side effects generally known for all local anesthetics, serious side effects have not been reported for T-cain. In fact, several articles have reported that T-cain decreases the neurotoxicity of dibucaine. In this historical review, the characteristics of T-cain and its rise to become a major spinal anesthetic in Japan are discussed.

Effectiveness of two flavored topical anesthetic agents in reducing injection pain in children: a comparative study.

UNLABELLED: Topical anesthesia is widely advocated in pediatric dentistry practice to reduce pain and anxiety produced by administration of local anesthesia. There are different combinations of topical anesthetic agents that are marketed worldwide. However, sparse literature reports exist regarding clinical efficacy of these agents. AIM: To compare the clinical effectiveness of two strawberry flavored topical anesthetics viz. Precaine (8% Lidocaine + 0.8% Dibucaine) and Precaine B (20% Benzocaine) in children before intra oral local anesthetic injections and for extraction of mobile primary teeth. STUDY DESIGN: This triple blind clinical study included sixty children divided equally under three techniques--palatal injections, inferior alveolar nerve block and extraction of mobile primary teeth. Both the products were used alternately using split mouth design in two visits and the child's pain response was assessed using VAS and SEM pain scale. The scores obtained were subjected to statistical analysis. RESULTS: Precaine has shown lower mean scores in all the techniques under both the pain scales, but were statistically insignificant. Gender wise comparison has also shown lower mean scores for Precaine for both males and females, however these were statistically insignificant. On visit wise comparison, Precaine B reported significant lower scores (p < 0.05) in visit 2 compared to visit 1 for inferior alveolar nerve block and extraction of mobile primary teeth under SEM pain scale. CONCLUSION: Precaine (8% Lidocaine + 0.8% Dibucaine) can be used as effectively as Precaine B (20% Benzocaine).

[Trigger point therapy for myofascial pain in cancer patients (second report) analysis results of special use-results surveillance by neovitacain® injection].

Our first report mentioned the analysis results of the safety and efficacy of trigger point (TP) therapy by Neovitacain® injection (NV) in the daily clinical treatment of myofascial pain in cancer patients. This time, we report additional considerations regarding the following points; (1) Injection sites: they were concentrated on both sides of the spine, indicating that TPs could be easily formed on the points and near them to support the body's weight when patients were supine. (2) Correlation between VAS and FS: VAS and FS were positively correlated in every measurement period. (3) Patient satisfaction: many patients made several comments expressing feelings of satisfaction from this treatment. The comments were considered to reflect the patients' candid feelings. Therefore, all comments were classified according to the degree of patients' feeling of satisfaction. It may be possible to obtain much higher patient satisfaction by hearing out the voice of the patients. Judging from this study, TP therapy by NV for myofascial pain in cancer patients relieved the total pain of cancer patients. TP therapy has potential for obtaining high patient satisfaction.

Lipschütz Ulcer: An Unusual Diagnosis that Should Not be Neglected.

The diagnosis of genital ulcers remains a challenge in clinical practice. Lipschütz ulcer is a non-sexually transmitted rare and, probably, underdiagnosed condition, characterized by the sudden onset of vulvar edema along with painful necrotic ulcerations. Despite its unknown incidence, this seems to be an uncommon entity, with sparse cases reported in the literature. We report the case of an 11-year-old girl who presented at the emergency department with vulvar ulcers. She denied any sexual intercourse. The investigation excluded sexually transmitted infections, so, knowledge of different etiologies of non-venereal ulcers became essential. The differential diagnoses are extensive and include inflammatory processes, drug reactions, trauma, and malignant tumors. Lipschütz ulcer is a diagnosis of exclusion. With the presentation of this case report, the authors aim to describe the etiology, clinical course, and outcomes of this rare disease, to allow differential diagnosis of genital ulceration.

PG-liposomes: novel lipid vesicles for skin delivery of drugs.

A novel type of lipid vesicles, propylene glycol-embodying liposomes or PG-liposomes, composed of phospholipid, propylene glycol and water, is introduced. The new lipid vesicles were developed and investigated as carriers for skin delivery of the model drug, cinchocaine base. PG-liposomes showed high entrapment efficiency and were stable for at least one month of storage at 5 +/- 1 degree C. Preliminary in-vivo skin deposition studies, carried out using albino rabbit dorsal skin, showed that PG-liposomes were superior to traditional liposomes, deformable liposomes and ethosomes, suggesting that PG-liposomes, introduced in the current work, are promising carriers for skin delivery of drugs.

In vitro release of hydrophilic and hydrophobic drugs from liposomal dispersions and gels.

A method for determining the rate of hydrophilic and hydrophobic drugs release from different types of liposomal dispersions and gels using a dialysis method is described. Dibucaine base and 5-fluorouracil were used as model drugs for a hydrophobic and a hydrophilic drug, respectively. A dialysis technique was employed. Release rates were affected by the rate of rotation of the paddles of the tablet dissolution tester, temperature, and the volume of release medium. The method was used to evaluate the in vitro drug release from hydrophilic and hydrophobic drugs from liposomal dispersions and gels. The in vitro release study of dibucaine base showed no burst effect, while the in vitro release study of 5-fluorouracil showed a clear burst effect with an initial fast release phase followed by a sustained release phase.

Lipschütz Ulcer: An Unusual Diagnosis that Should Not be Neglected

Abstract The diagnosis of genital ulcers remains a challenge in clinical practice. Lipschütz ulcer is a non-sexually transmitted rare and, probably, underdiagnosed condition, characterized by the sudden onset of vulvar edema along with painful necrotic ulcerations. Despite its unknown incidence, this seems to be an uncommon entity, with sparse cases reported in the literature. We report the case of an 11-year-old girl who presented at the emergency department with vulvar ulcers. She denied any sexual intercourse. The investigation excluded sexually transmitted infections, so, knowledge of different etiologies of non-venereal ulcers became essential. The differential diagnoses are extensive and include inflammatory processes, drug reactions, trauma, and malignant tumors. Lipschütz ulcer is a diagnosis of exclusion. With the presentation of this case report, the authors aim to describe the etiology, clinical course, and outcomes of this rare disease, to allow differential diagnosis of genital ulceration.

Effect of various formulation variables on the encapsulation and stability of dibucaine base in multilamellar vesicles.

Formulation of local anesthetics in liposomal topical drug delivery system could provide a sustained and localized anesthesia. The aim of this study was to develop a liposomal dibucaine base (DB) local anesthetic delivery system. DB-loaded multilamellar vesicles (MLVs) were prepared through varying lipid composition, induced charge and pH of the hydration medium. Liposomes were characterized for morphology, size, entrapment efficiency (EE), in vitro drug release and stability including leakage stability. The percentage of drug entrapped in liposomes was found to be hydration medium pH dependent and charge dependent and more pronounced for negatively charged liposomes prepared using hydration medium of pH 9. In vitro release studies of liposomes have shown a sustained release of entrapped dibucaine compared to control solution. Results revealed that adjusting the various formulation variables of dibucaine base MLVs could yield stable and effective topical liposomal local anesthetic formulations.

Pain relief of oral ulcer by dibucaine-film.

A water-soluble three-layered oral mucosa-adhesive film made from hydroxypropyl cellulose containing dibucaine (0.25 mg of drug/cm(2)) was designed for alleviation of severe pain due to oral ulcers, caused by chemotherapy and/or radiotherapy. We report two patients with constant severe pain ulcers treated with the dibucaine film. Patients were asked to record the time that pain was relieved while chewing following first application of the film. Pain relief lasted for 2-5 h after application of the dibucaine film.

Evaluation of two local anaesthetic sprays for the relief of post-episiotomy pain.

Aerosol formulations of lignocaine (5%) and cinchocaine (2%) were compared with a water-only placebo spray in a single-dose study in 76 primiparous patients complaining of moderate or severe post-episiotomy pain. In comparison with a water-only placebo, both local anaesthetic formulations gave significant relief when administered to the perineal wound but the lignocaine spray proved to be the more effective. The only side-effect reported was slight stinging occurring immediately after administration of the lignocaine spray in 2 cases. Serum concentrations of local anaesthetic post-administration were negligible. An interesting finding was that breast-feeding patients responded less well to this form of analgesia than patients in whom lactation had been suppressed with frusemide.

A comparison of alcoholic and aqueous formulations of local anaesthetic as a spray for the relief of post-episiotomy pain.

A comparison of pain relief after a single perineal application of alcoholic and aqueous formulations of lignocaine (5%) spray with an aqueous formulation of cinchocaine (2%) spray was made in 72 primiparous patients complaining of moderate or severe post-episiotomy pain. All three formulations were similar in efficacy, the aqueous lignocaine preparation appearing slightly more effective than the others.

Comparative efficacy and tolerability of two ointment and suppository preparations ('Uniroid' and 'Proctosedyl') in the treatment of second degree haemorrhoids in general practice.

A multi-centre general practice, open study was carried out in 89 patients with second degree haemorrhoids to compare the efficacy and tolerability of two antibiotic-corticosteroid combinations ('Uniroid' and 'Proctosedyl') in ointment and suppository formulations. Patients were allocated at random into 4 groups and received treatment with one of the trial preparations for 1, 2 or 3 weeks, as required, with weekly assessments of response. There were no significant differences between the various groups at the start of treatment. Significant improvement occurred in all groups during treatment. Both suppository and ointment formulations were broadly comparable and control of symptoms was achieved from Week 2 onwards, building up to levels in excess of 90% after 3 weeks of therapy. With regard to the symptoms of pain and itching, suppositories gave marginally greater relief in the early stages of treatment, while both ointment and suppositories were associated with similar reduction in bleeding from haemorrhoids. Whereas both suppository formulations were about equal in reducing anal discharge, 'Uniroid' ointment was clinically superior to 'Proctosedyl' ointment in controlling this symptom over the 3-week trial period. No unwanted effects were experienced attributable to treatment. No statistically significant differences between the two ointment and the two suppository formulations were identified in this study and all four preparations were found to be efficacious in the majority of patients studied.

Blood concentrations of tetracaine and its metabolite following spinal anesthesia.

Blood concentrations of tetracaine and its metabolite, p-butylaminobenzoic acid, were measured after spinal anesthesia with tetracaine which had been administered to patients under going orthopedic surgery. Tetracaine, an ester anesthetic, was given to 10 patients, the dose was 8-14mg, and blood samples were collected 1, 2 and 6h after the injection of tetracaine. We used gas chromatography/mass spectrometry for purposes of analysis. Tetracaine was not detected in any blood sample, but the metabolite was detected in each sample with the mean concentrations of 126.5, 97.9 and 43.3ng/ml at 1, 2 and 6h, respectively. This data will be useful in determination of the cause of death after spinal anesthesia with tetracaine.

Electrophysiologic studies of a combination of secobarbital and dibucaine for euthanasia of dogs.

A combination of secobarbital and dibucaine was compared with secobarbital and with dibucaine, given IV, for euthanasia of dogs. The secobarbital-dibucaine combination was the most effective, as determined by latency to electrical silence of the EEG and ECG, as well as by visual observation of the behavior of the animal. The combination product produced a quiet and rapid death, according to all electrophysiologic changes that were monitored, whereas the barbiturate resulted in prolonged myocardial activity. Dibucaine alone is not desirable for use for euthanasia.

Randomized, double-blind trial comparing topical nitroglycerine with xylocaine and Proctosedyl in idiopathic chronic anal fissure.

OBJECTIVE: To compare symptomatic relief, healing, and changes in maximal anal resting pressure with the use of topical formulations in patients with chronic anal fissure. METHODS: Sixty-four consecutive patients with chronic anal fissure were randomized into 4 groups that received, in a double-blind manner, a topical ointment that contained 0.2% nitroglycerine (GTN), 5% xylocaine, Proctosedyl (hydrocortisone acetate, heparin, framycetin sulfate, esculoside, ethoform, butoform) or petroleum jelly (Vaseline), to be applied twice daily. Patients were reviewed at 2-week intervals for 6 weeks. Anal manometry was done before, and 20 minutes after, the first application of the ointment. RESULTS: There was significant (p < 0.0001) reduction in mean anal resting pressure after application of GTN, but not any other ointment. Of 16 patients receiving GTN, complete pain relief occurred in 6 and 15 patients after 2 and 4 weeks of treatment, respectively; this was more frequent than in the other 3 groups. At 6 weeks also, complete pain relief occurred more often with GTN than with Vaseline or xylocaine. After 4 weeks of treatment, 3 patients on GTN had complete healing of fissure as compared to one each in the xylocaine and Proctosedyl groups and none in the Vaseline group. At 6 weeks, healing of fissure had occurred in 15 of 16 patients receiving GTN as compared to 4 receiving Vaseline, 11 receiving xylocaine, and 12 on Proctosedyl. CONCLUSIONS: Topical nitroglycerine produces 'chemical sphincterotomy' with reduction in mean anal resting pressure. Pain relief and healing of fissure occurred earlier with GTN than with other treatments. GTN should be considered as the treatment of choice for the non-surgical management of patients with chronic anal fissure.

Phonophoresis: an in vivo evaluation using three topical anaesthetic preparations.

An electrical sensory perception threshold technique has been developed for use with human volunteers. This technique has been used to reproducibly quantify the effects of three different commercially available topical anaesthetic preparations on superficial sensory cells (nociceptors) in the skin. Low intensities (0.25 W cm-2 SATA) of 1.1 MHz ultrasound had no detectable effects upon the rate of penetration of either one of the three anaesthetic preparations through human skin under conditions where temperature increases had been minimized.

Humane destruction of horses with a mixture of quinalbarbitone and cinchocaine.

One hundred and-two horses requiring to be euthanased for a variety of reasons were killed by the intravenous injection of a mixture of quinalbarbitone sodium (400 mg/ml) and cinchocaine hydrochloride (25 mg/ml). The dose rates used were 1 ml/10, 15, 20 and 30 kg bodyweight, and the time of injection was varied between 5 and 25 seconds. The average time to collapse from the start of the injection was 34 seconds and the average time to clinical death was 230 seconds. Slow injection (particularly of the low dose rates) and premedication with detomidine resulted in a longer time to collapse (median 46 seconds). Premedication with xylazine and low dose rates of the mixture resulted in an unacceptable degree of muscular activity and agonal gasping and death was delayed. Premedication with romifidine and butorphanol resulted in an apparent (but insignificant) reduction in the time to collapse and death but was also accompanied by significant agonal gasping. Without premedication quinalbarbitone and cinchocaine resulted in a smooth and quiet collapse with the cessation of cardiac and respiratory functions within three minutes in all cases, but the palpebral reflex of the horses was prolonged significantly beyond the time when all other reflex activity was lost. Occasional gasping and muscular tremors, particularly of the upper forelimb, occurred particularly when lower dose rates and either very slow or very fast rates of injection were used. One horse which was premedicated with xylazine and received a very low dose at a slow rate showed unacceptably violent muscular activity. At no other time was the procedure regarded as violent or unacceptable.(ABSTRACT TRUNCATED AT 250 WORDS)