Continuous flow local anesthetic wound infusion for post-operative analgesia following kidney transplantation.

BACKGROUND: Some patients with end stage renal disease are or will become narcotic-dependent. Chronic narcotic use is associated with increased graft loss and mortality following kidney transplantation. We aimed to compare the efficacy of continuous flow local anesthetic wound infusion pumps (CFLAP) with patient controlled analgesia pumps (PCA) in reducing inpatient narcotic consumption in patients undergoing kidney transplantation. MATERIALS AND METHODS: In this single-center, retrospective analysis of patients undergoing kidney transplantation, we collected demographic and operative data, peri-operative outcomes, complications, and inpatient oral morphine milligram equivalent (OME) consumption. RESULTS: Four hundred and ninety-eight patients underwent kidney transplantation from 2020 to 2022. 296 (59%) historical control patients received a PCA for postoperative pain control and the next 202 (41%) patients received a CFLAP. Median age [53.5 vs. 56.0 years, p = .08] and BMI [29.5 vs. 28.9 kg/m2, p = .17] were similar. Total OME requirement was lower in the CFLAP group [2.5 vs. 34 mg, p < .001]. Wound-related complications were higher in the CFLAP group [5.9% vs. 2.7%, p = .03]. Two (.9%) patients in the CFLAP group experienced cardiac arrhythmia due to local anesthetic toxicity and required lipid infusion. CONCLUSIONS: Compared to PCA, CFLAP provided a 93% reduction in OME consumption with a small increase in the wound-related complication rate. The utility of local anesthetic pumps may also be applicable to patients undergoing any unilateral abdominal or pelvic incision.

A review of local anesthetic-induced heart toxicity using human induced pluripotent stem cell-derived cardiomyocytes.

Local anesthetic (LA) cardiotoxicity is one of the main health problems in anesthesiology and pain management. This study reviewed the reported LA-induced cardiac toxicity types, risk factors, management, and mechanisms, with attention to the use of human induced pluripotent stem cell-derived cardiomyocytes (hiPSC-CMs) in heart toxicity research. Important scientific databases were searched to find relevant articles. We briefly assessed the reported cardiotoxic effects of different types of LA drugs, including ester- and amide-linked LA agents. Furthermore, cardiotoxic effects and clinical manifestations, strategies for preventing and managing LA-induced cardiotoxic effects, pharmacokinetics, pharmacodynamics, and sodium channel dynamics regarding individual variability and genetic influences were discussed in this review. The applications and importance of hiPSC-CMs cellular model for evaluating the cardiotoxic effects of LA drugs were discussed in detail. This review also explored hiPSC-CMs' potential in risk assessment, drug screening, and developing targeted therapies. The main mechanisms underlying LA-induced cardiotoxicity included perturbation in sodium channels, ROS production, and disorders in the immune system response due to the presence of LA drugs. Furthermore, drug-specific characteristics including pharmacokinetics and pharmacodynamics are important determinants after LA drug injection. In addition, individual patient factors such as age, comorbidities, and genetic variability emphasize the need for a personalized approach to mitigate risks and enhance patient safety. The strategies outlined for the prevention and management of LA cardiotoxicity underscore the importance of careful dosing, continuous monitoring, and the immediate availability of resuscitation equipment. This comprehensive review can be used to guide future investigations into better understanding LA cardiac toxicities and improving patient safety.

Comparison of diffusion ranges at different local anesthetic volumes during superior laryngeal nerve block.

OBJECTIVES: Ultrasound-guided superior laryngeal nerve (SLN) block is a practical and painless approach to avoid the hemodynamic stress response during endotracheal intubation and relieve sore throat after laryngeal surgery. The main purpose of this study was to establish an optimal dosage of local anesthetic when performing SLN block to help anesthetists balance analgesia and side effects. METHODS: Twenty fresh larynx specimens were obtained immediately after resection and then injected with 2-, 3-, 4-, or 5- mL of a lidocaine-blue dye mixture at bilateral SLN puncture sites. Superficial areas of deposited blue dye were measured. Dye leakage and surrounding dyed tissue were recorded. Another 40 patients were included in the ultrasound investigation. Distances between the internal branch of the SLN (iSLN) and adjacent structures were calculated. RESULTS: The dye spread area was greater with the administration of larger doses, especially to the visceral space. A 2- or 3-mL injection of local anesthetic was sufficient to infiltrate the SLN gap. A higher incidence of dye leaking out of the thyrohyoid membrane and anterior epiglottis space was observed; furthermore, there was substantially more dyed hyoid/thyroid cartilage with 4 and 5 mL of injected dye mixture than 2 mL. There was no significant difference between the specimen and ultrasound measurements of for length of iSLN-adjacent structures. CONCLUSIONS: In the Chinese population, 2- or 3- mL of local anesthetic is a safe dose during SLN block. A larger volume could overflow from the cavity to cause complications. The thyrohyoid membrane combined with the superior laryngeal artery is a reliable target for positioning the iSLN during ultrasound-guided regional anesthesia.

Serum Levels of Bupivacaine After Bilateral Ultrasound-Guided Deep Parasternal Intercostal Plane Block in Cardiac Surgery with Median Sternotomy.

OBJECTIVE: To evaluate systemic levels of bupivacaine after bilateral ultrasound-guided deep parasternal intercostal plan (PIP) block in cardiac surgical patients undergoing median sternotomy. DESIGN: Prospective, observational study SETTING: Single institution; academic university hospital PARTICIPANTS: Twenty-eight adult patients undergoing cardiac surgery with median sternotomy received a PIP block with 2.5 mg/kg bupivacaine with or without dexamethasone and dexmedetomidine. MEASUREMENTS: Arterial blood samples were analyzed for total serum bupivacaine concentration at 5, 15, 30, 45, 60, 90, 120, and 150 minutes after placement of PIP. Local anesthetic volume, local anesthetic adjuncts, time to extubation, postoperative pain scores, and opioid consumption were recorded. MAIN RESULTS: The mean peak bupivacaine concentration was 0.60 ± 0.62 µg/mL, and the mean time to maximum concentration (Tmax) was 16.92 ± 12.97 minutes. Two patients (7.1%) had a concentration >2.0 µg/mL within 15 minutes of block placement. The mean Tmax of bupivacaine was significantly greater in patients who did not receive additives compared to those patients who did (22.86 ± 14.77 minutes v 10.0 ± 5.22 minutes; p = .004). The times to extubation and postoperative pain were not improved with additives. CONCLUSIONS: Bilateral PIP placed at the end of cardiac surgery resulted in low systemic bupivacaine levels. The inclusion of additives shortened Tmax without improving outcome.

Assessing the safety and tolerability of rhinologic surgery under local anesthetic: an 8-year retrospective analysis.

PURPOSE: Office-based rhinologic procedures (OBRP) have become widely available in North America due to technological advances and appropriate patient selection. Nevertheless, the literature exploring the safety of these procedures remains limited. The objective of this study was to further evaluate the safety, tolerability and efficacy of these procedures with a more robust sample size to allow for capture of rare events. METHODS: A retrospective chart review of all patients who underwent OBRP from May 2015 to March 2023. Information regarding patient demographics, the indication for surgery, wait time, tolerability, intra- and postoperative complications, need for revisions, and type of revision (if applicable) was recorded. RESULTS: 1208 patients underwent OBRP during the study period. No patients were excluded. These included turbinoplasties (35%), endoscopic sinus surgeries (ESS) (26%), septoplasties (15%), nasal fracture reductions (7%), and a variety of other procedures. For ESS procedures, the anterior ethmoids and the maxillary sinuses were the most common sinuses treated. 1.1% of procedures were aborted prior to completion. The post-operative complication rate was 3.2%, with 2 major complications (significant bleeding and sepsis) encountered. The mean follow-up overall was 11 months and for ESS it was 15.8 months. CONCLUSION: Office-based rhinologic procedures are well tolerated and safe for the appropriate patient and associated with shorter wait-times as well as avoidance of general anesthesia. The complication rates are similar to or lower than previously reported rates for rhinologic surgeries done in the operating room. The low rates of revision surgery also demonstrate the efficacy of these procedures.

Ultrasound-guided sciatic nerve block injections in barred owl (Strix varia) cadavers.

OBJECTIVE: To describe an ultrasound-guided approach to the sciatic nerve and the distribution of nerve staining using two injectate volumes of dye in barred owls. STUDY DESIGN: Descriptive, randomized, assessor-blinded, cadaveric study. ANIMALS: Twelve barred owl cadavers. METHODS: The sciatic nerve was visualized with a 13-6 MHz linear ultrasound probe placed on the medial aspect of the proximal femur in barred owl cadavers. A needle was inserted at the proximal caudal thigh, and cranially advanced in-plane until the tip was immediately adjacent and ventral to the sciatic nerve. Eleven owls were injected bilaterally with a 1:1 solution of 1% methylene blue and 0.5% ropivacaine, with high-volume (HV; 0.4 mL kg-1) and low-volume (LV; 0.2 mL kg-1) treatments. Nerve staining ≥ 1 cm circumferentially was determined by dissection 15 minutes post-injection. The coelom was then opened to inspect for aberrant dye spread. In one barred owl cadaver, a 1:1 solution of 1% methylene blue and 74% ioversol contrast was injected, and computed tomography was performed immediately before and 15 minutes after injection for evaluation of injectate spread. RESULTS: The HV treatment (0.4 mL kg-1) resulted in successful nerve staining in 100% of injections, whereas the LV treatment (0.2 mL kg-1) resulted in successful nerve staining in 91% of injections. There was no leakage of injectate into undesired locations (e.g. coelomic cavity) in any cadaver. CONCLUSIONS AND CLINICAL RELEVANCE: In barred owls, the sciatic nerve can be visualized with ultrasound and injecting a ropivacaine/dye solution under ultrasound guidance successfully stained the sciatic nerve in the majority of cases. This technique holds potential for providing analgesia distal to the stifle joint; however, further investigations are necessary to evaluate its practical application in a clinical setting.

Local Anesthetic Systemic Toxicity (LAST): More Common Than You Think.

The number of anesthetic body procedures in the United States is rapidly increasing, with many being performed on an outpatient basis. These procedures are advertised as being safe, and many times the serious complications may not be discussed. Although local anesthetic systemic toxicity is a rare complication, it is associated with an increase in morbidity. The emergency department staff should be aware of the possibility of this rare complication, as well as the variety of resulting symptoms (from minor to severe), potential sequelae, and appropriate management for patients who have undergone an outpatient anesthetic body procedure. Multiple factors contribute to the development of local anesthetic systemic toxicity, resulting in life-threatening effects on the neurologic and cardiovascular systems. Also, the site of administration, along with the local anesthetic agent used, can impact the risk of the development of local anesthetic systemic toxicity. To minimize the risk and ensure the best possible outcome for these patients, emergency department staff must be highly aware of the mechanisms, risk factors, prevention, and management/treatment of local anesthetic systemic toxicity.

Local Anesthetic Systemic Toxicity: Ensuring Sustained Nursing Knowledge in a High-Volume Outpatient Surgery Center.

PURPOSE: Local anesthetic systemic toxicity (LAST) is a low-frequency, high-risk event that can occur within minutes of a patient receiving a local anesthetic. The goals of this project were to standardize LAST care management across an academic medical center and sustain an improvement in nurses' knowledge of how to recognize signs and symptoms of LAST and how to competently manage a LAST scenario. DESIGN: We used a quantitative design to accomplish the goals of the project. METHODS: Our interdisciplinary team developed a clinical practice guideline based on the LAST Checklist published by the American Society of Regional Anesthesia and Pain Medicine, and used a simulation scaffolded by multimodal education and system changes to ensure sustained knowledge. We measured improvement using a graded knowledge assessment as well as qualitative feedback. FINDINGS: Scores on the assessment increased from 4.76 to 6.34 (out of seven points) following the intervention and remained significantly higher than the baseline 9 months after the educational intervention (9-month score = 6.19, t = 2.99, P = .004). Nurses reported feeling more confident and knowledgeable following the intervention and requested to have regular sessions of the simulation. To sustain improvements, we developed a computer-based learning module. The module and simulation were integrated into nursing orientation and an annual competency. CONCLUSIONS: While standardizing LAST care in accordance with evidence-based guidance is critical to patient safety due to its infrequent occurrence, nurses should consider implementing simulation supplemented with multimodal education and system changes to ensure sustained knowledge.

Comparison of the clinical efficacy of ultrasound-guided GON blockade using low and high concentrations of bupivacaine in chronic migraine.

Background/aim: In this study, it was aimed to retrospectively compare the effect of greater occipital nerve (GON) block performed with ultrasonography using low (0.3%) and high (0.5%) concentrations of bupivacaine on pain scores and patient satisfaction in chronic migraine (CM). Materials and methods: The mean number of days with pain, the mean duration of pain in the attacks, and the highest numerical rating scale (NRS) scores recorded in the 1 month preblock and 1 and 3 months postblock of 80 patients (40 for Group 1, 0.3% bupivacaine; 40 for Group 2, 0.5% bupivacaine) who underwent ultrasonography-guided GON block were recorded from the patient file data. According to the protocol applied by our clinic, GON block was applied to each patient 6 times with the same procedures, in total. Results: While there was a statistically significant difference between the groups in terms of the number of days with pain and the maximum NRS score in the 1-month preblock evaluation (p = 0.01, p < 0.001), at 3 months postblock, no statistical difference was observed in terms of the number of days with pain, duration of pain, or NRS score (p = 0.961, p = 0.108, and p = 0.567). In the intragroup evaluations, at 3 months postblock, the number of days with pain decreased from 17.5 days to 7 days in Group 1 and from 24.0 days to 8.0 days in Group 2. The duration of pain and maximum NRS values were statistically significantly decreased in the intragroup evaluation in both groups pre and postblock. Conclusion: Complications arising from the procedure and the local anesthetic used are essential points to consider in applying GON block. In CM treatment using GON block application, a similar effect to the standard local anesthetic application (0.5%) can be achieved by administering local anesthetic at a lower dose (0.3%).

Peripheral nerve blocks for analgesia following cesarean delivery A narrative review.

Spinal and epidural blocks are commonly employed for pain relief during and following cesarean section. Intrathecal morphine (ITM) has been the gold standard for the same for many years. In recent times, many peripheral nerve blocks (PNBs) have been tried for postoperative analgesia following cesarean delivery (PACD). This article has reviewed the common PNBs used for PACD. The role of PNBs along with ITM has been studied and the current best strategy for PACD has also been explored. Currently, Ilio-inguinal nerve and anterior transversus abdominis plane block in conjunction with intrathecal morphine have been found to be the most effective strategy, providing lower rest pain at 6 hours as compared to ITM alone. In patients not receiving intrathecal morphine, recommended PNBs are lateral transversus abdominis plane block, single shot local anesthetic wound infiltration, or continuous wound infiltration with catheter below rectus fascia. PNBs are recommended for PACD. They have an opioid-sparing effect and are devoid of adverse effects associated with central neuraxial blocks such as hypotension, bradycardia, and urine retention. However, caution must be observed with PNBs for possible local anesthetic toxicity due to the large volumes of drug required.

Postmortem concentrations of ropivacaine, bupivacaine, and lidocaine in femoral venous blood after hip fracture surgery.

Pain relief in hip fracture patients may be sought by injecting local anesthetic such as ropivacaine, bupivacaine, and lidocaine to the femoral area. As femoral veins are a routine sampling site for postmortem blood, this short report aimed to describe the levels of local anesthetics in ipsilateral (i.e., side of surgery) and contralateral (i.e., opposite side) femoral blood in ten medico-legal autopsy cases that had undergone a hip fracture surgery within 7 days before death. Postmortem blood samples were systematically collected from the ipsilateral and contralateral femoral veins, and toxicological analysis was performed in an accredited laboratory. The sample comprised six female and four male decedents who died at the age of 71-96 years. Median postoperative survival was 0 days and median postmortem interval 11 days. Strikingly, ropivacaine concentration was a median of 24.0 (range 1.4-28.4) times higher on the ipsilateral than contralateral side. The median ipsilateral concentration of ropivacaine clearly exceeded the 97.5th reference percentile measured in this laboratory for ropivacaine in postmortem cases representing all causes of death. The remaining drugs did not show high concentrations or notable differences between the sides. Our data clearly advise against performing postmortem toxicology on femoral blood from the operated side; the contralateral side may constitute a better sampling site. Toxicology reports that are based on blood collected from the operated area should be interpreted with caution. Larger studies are needed to confirm the findings, with accurate records of the dosage and administration route of local anesthetics.

Bupivacaine/meloxicam ER: A New Dual-acting Extended-Release Local Anesthetic for Opioid-Sparing Postoperative Pain Management.

OBJECTIVE: To review data for bupivacaine/meloxicam extended-release (ER) solution for management of postoperative pain and opioid-sparing effects. DATA SOURCES: Literature search of PubMed (1946 to August 2021) and ProQuest (1946 to August 2021) was performed using the terms: Zynrelef, HTX-011, and "bupivacaine AND meloxicam." Additional information sources include ClinicalTrials.gov, prescribing information, Heron Therapeutics' Clinical and Economic Evidence Dossier, meeting abstracts, and references of identified articles. STUDY SELECTION AND DATA EXTRACTION: Clinical trials and articles evaluating bupivacaine/meloxicam ER for postoperative pain management. DATA SYNTHESIS: Bupivacaine is a short-acting local anesthetic. Its efficacy is negatively impacted by the acidic environment of surgical sites. Meloxicam, a nonsteroidal antiinflammatory, reduces inflammation at the surgical site and increases pH propagating bupivacaine movement into the neurons. In Phase 2 and Phase 3 clinical trials, bupivacaine/meloxicam ER was compared with bupivacaine HCl, bupivacaine ER, and meloxicam ER with and without scheduled nonopioid multimodal analgesia (MMA) in bunionectomies, herniorrhaphies, total knee arthroplasty and abdominoplasty. Postoperative pain was well controlled for 72 hours and consistently superior to placebo, with minimal or no opioid use. Wound healing was not impacted and adverse effects were similar to placebo (most commonly nausea, dizziness, constipation, and headaches). RELEVANCE TO PATIENT CARE AND CLINICAL PRACTICE: Bupivacaine/meloxicam ER is a viable, safe, nonopioid local anesthetic for sustained 72-hour postoperative pain management mitigating opioid consumption. CONCLUSION: Bupivacaine/meloxicam ER is the only dual-acting, extended-release local anesthetic available. It provides effective analgesia in the postoperative setting and successfully reduces or eliminates postoperative opioid consumption.

Interventions to improve tolerability of local anesthetic intradetrusor Botulinum toxin injections: A systematic review.

INTRODUCTION: Intradetrusor BotulinumtoxinA (BTA) injections are recommended for patients with overactive bladder (OAB) refractory to lifestyle changes and medical intervention. It is preferable to perform injections using a flexible cystoscope under local anesthetic (LA) rather than under spinal or general anesthetic owing to the associated anesthetic risks, increased costs, and need for repeated inpatient admission. Injections under LA can be difficult to tolerate for some patients. This review aims to assess interventions that may improve the tolerability of intradetrusor BTA injections under LA. METHODS: A systematic review was performed using Ovid of Embase + Embase classic and MEDLINE® ALL in November 2021. Articles were included if they reported objectively measured pain scores during LA intradetrusor BTA injections for refractory OAB. The risk of bias was assessed using Cochrane risk of bias tools. Meta-analysis was not performed owing to the heterogeneity of outcome measures. RESULTS: Ten studies were included in this review with a total of 429 participants. The review identified alkalinized lidocaine, electromotive drug administration (EMDA), opiate suppositories, lidocaine bladder instillations, number of injections, and dose of BTA as interventions aimed at improving tolerability. CONCLUSION: EMDA of intravesical alkalinized lidocaine, intravesical, alkalinized lidocaine without EMDA, and a reduction in the number of injection site were all associated with improvements in patient tolerability during LA BTA injections. Further research should address which subgroups of patients find the procedure most painful and would benefit most from these interventions.

Epidural lidocaine, butorphanol, and butorphanol - lidocaine combination in dromedary camels.

BACKGROUND: The use of general anesthesia in dromedary camels is constrained by risks related to decubitus. Caudal epidural analgesia is an alternative convenient technique providing loco-regional analgesia for numerous invasive and noninvasive painful conditions. Lidocaine is probably the most commonly used local anesthetic in clinical practice, but has a relatively short duration and may not provide significant long term analgesic benefits. Epidural administration of an opioid-local anesthetic mixture would improve the quality and length of analgesia and minimizes the adverse motor effects provoked by local anesthetics. Butorphanol (potent agonist-antagonist opioid) has been used to improve the duration of epidural analgesia in some animal species, but not in camels. Therefore, our purpose was to investigate the onset and duration of analgesia as well as the clinical and hemato-biochemical effects produced by the epidural administration of butorphanol (0.04 mg/kg), lidocaine (0.22 mg/ kg), and butorphanol-lidocaine (0.04 mg/kg-0.22 mg/ kg) mixture in nine adult dromedary camels in a crossover experimental study. RESULTS: The onset of analgesia was not statistically different between lidocaine (6.5 ± 2.3 min) and butorphanol-lidocaine (7.3 ± 1.5 min) combination. Delayed onset of analgesia was reported after butorphanol administration (14.7 ± 3.5 min). Butorphanol-lidocaine combination produced marked longer duration (175 ± 8.7 min) than lidocaine (55 ± 6.8 min) and butorphanol (158 ± 5.3 min). Mild ataxia was observed in the butorphanol-lidocaine and lidocaine treated animals and slight sedation was reported after butorphanol and butorphanol-lidocaine administration. A transient significant increase in the glucose levels was recorded after all treatments. CONCLUSIONS: Epidural administration of butorphanol augments the analgesic effects and duration of lidocaine with minimal adverse effects.

Long-lasting postoperative analgesia with local anesthetic-loaded hydrogels prevent tumor recurrence via enhancing CD8+T cell infiltration.

Postoperative pain (POP) can promote tumor recurrence and reduce the cancer patient's quality of life. However, POP management has always been separated from tumor treatment in clinical practice, and traditional postoperative analgesia using opioids is still unsatisfactory for patients, which is not conducive to tumor treatment. Here, ropivacaine, a popular amide-type LA, was introduced into a Pluronic F127 hydrogel. Postoperative analgesia with ropivacaine-loaded hydrogels reduced the incidence of high-dose ropivacaine-induced convulsions and prolonged pain relief for more than 16 h. More interestingly, ropivacaine-loaded hydrogel was found to upregulate major histocompatibility complex class I (MHC-I) in tumor cells by impairing autophagy. Therefore, a hydrogel co-dopped with ropivacaine and TLR7 agonist imiquimod (PFRM) was rationally synthesized. After postoperative analgesia with PFRM, imiquimod primes tumor-specific CD8+T cells through promoting DCs maturation, and ropivacaine facilitates tumor cells recognition by primed CD8+T cells through upregulating MHC-I. Consequently, postoperative analgesia with PFRM maximumly increases CD8+T cells infiltration into residual tumor tissue and prevents tumor recurrence. Overall, this study for the first time provides an LA-based approach for simultaneous long-lasting postoperative analgesia and prevention of tumor recurrence.

Ropivacaine-loaded hydrogels for prolonged relief of chemotherapy-induced peripheral neuropathic pain and potentiated chemotherapy.

Chemotherapy can cause severe pain for patients, but there are currently no satisfactory methods of pain relief. Enhancing the efficacy of chemotherapy to reduce the side effects of high-dose chemotherapeutic drugs remains a major challenge. Moreover, the treatment of chemotherapy-induced peripheral neuropathic pain (CIPNP) is separate from chemotherapy in the clinical setting, causing inconvenience to cancer patients. In view of the many obstacles mentioned above, we developed a strategy to incorporate local anesthetic (LA) into a cisplatin-loaded PF127 hydrogel for painless potentiated chemotherapy. We found that multiple administrations of cisplatin-loaded PF127 hydrogels (PFC) evoked severe CIPNP, which correlated with increased pERK-positive neurons in the dorsal root ganglion (DRG). However, incorporating ropivacaine into the PFC relieved PFC-induced CIPNP for more than ten hours and decreased the number of pERK-positive neurons in the DRG. Moreover, incorporating ropivacaine into the PFC for chemotherapy is found to upregulate major histocompatibility complex class I (MHC-I) expression in tumor cells and promote the infiltration of cytotoxic T lymphocytes (CD8+ T cells) in tumors, thereby potentiating chemotherapy efficacy. This study proposes that LA can be used as an immunemodulator to enhance the effectiveness of chemotherapy, providing new ideas for painless cancer treatment.

Comparison of analgesic efficacy of different local anesthetic volumes for erector spinae plane block in thoracotomy patients; a prospective randomized trial.

BACKGROUND: Erector spinae plane block (ESPB) is a thoracic wall block that has been used frequently in recent years. It was aimed to compare the analgesic efficacy of bupivacaine in different volumes for ESPB in patients undergoing thoracotomy. METHODS: Patients who were in the age range of 18 to 65 years, ASA I-III, had a body mass index (BMI) of 18-30 kg/m2 and were undergoing thoracotomy were included in the study. Patients were assigned to ESPB with 30 ml 0.25% bupivacaine (Group-1) or ESPB with 20 ml 0.25% bupivacaine (Group-2) groups according to the analgesia protocol. In the postoperative care unit, intravenous morphine was administered via a patient-controlled analgesia pump for 24 h. A paracetamol dose of 1 g every 8 h and a dexketoprofen dose of 50 mg twice daily were administered iv for multimodal analgesia. RESULTS: Visual analog scale (VAS) resting scores, the 1st (p = 0.001), 2nd (< 0.001), 4th (< 0.001), 8th (< 0.001), 16th (< 0.010), 24th (< 0.044), and 48th (< 0.005)-hour VAS resting results were found to be statistically significantly higher in the 20 ml group than the 30 ml group. VAS cough scores were statistically significantly higher in the 20 ml group at the 1st (< 0.003), 2nd (< 0.001), 4th (< 0.001), 8th (< 0.001), 16th (< 0.004), 24th (< 0.031), and 48th (< 0.009)-hour. Morphine consumption, and additional analgesic use were found to be statistically significantly higher in the 20 ml group than in the 30 ml group (p < 0.001, p = 0.001, respectively). There was no statistically significant difference between the groups in terms of side effects (p > 0.05). CONCLUSIONS: The results of ESPB applied with 20 ml and 30 ml of local anesthetic before the surgical incision in thoracotomy patients showed that the use of 30 ml of local anesthetic provided more effective analgesia. In addition, similar side-effect rates show that 30 ml of local anesthetic can be used safely.

How I Do It: Transperineal prostate biopsy using local anesthetic in an outpatient setting.

Transperineal prostate biopsy (TPPB) is proven to be an effective diagnostic tool for prostate cancer detection. It allows satisfactory sampling of apical and anterior areas which is not well achieved with the transrectal route, without the associated risks of urinary tract infection or sepsis. The main objective of this paper is to describe the technique utilized in our institution to perform transperineal prostate biopsy under local anesthetic in the outpatient clinic setting.

Safety of local anesthetics in cervical nerve root injections: a narrative review.

Severe neurological adverse events have been reported after fluoroscopically guided cervical nerve root injections. Particulate corticosteroids inadvertently injected intraarterially and iatrogenic vertebral artery trauma have been implicated in these outcomes. This has raised concern for the potential consequences of including local anesthetic with these injections. As a result, some providers have now discontinued the routine administration of local anesthetic with corticosteroid when performing cervical nerve root injections. At present, there is no consensus regarding whether the use of local anesthetic in this context is safe. Here, the current literature is synthesized into a narrative review aiming to clarify current perspectives of the safety of local anesthetics in cervical nerve root injections.

The Optimization of the Synthesis Process and the Identification of Levobupivacaine Hydrochloride.

In this study, we not only optimized and improved the synthesis process of levobupivacaine hydrochloride (21) but also conducted a comprehensive exploration of critical industrial-scale production details, and a novel high-performance liquid chromatography (HPLC) analysis method was developed. Starting with the readily available and cost-effective (R,S)-N-(2,6-dimethylphenyl)piperidine-2-carboxamide (28) as the initial material and utilizing l-(-)-dibenzoyl tartaric acid (29) for chiral separation, and then through substitution and a salting reaction, levobupivacaine hydrochloride (21) was obtained with high purity (chemical purity of 99.90% and enantiomeric excess (ee) values of 99.30%). The total yield of the three steps was 45%. Structures of intermediates and the final product were confirmed using nuclear magnetic resonance (NMR) (1H NMR, 13C NMR), mass spectrometry (MS), and elemental analysis. The crystal structure of the final product was determined through differential scanning calorimetry (DSC), thermogravimetric analysis (TGA), and X-ray diffraction (XRD). Furthermore, we evaluated the risk of the substitution reaction using a reaction calorimeter and accelerating rate calorimetry (ARC). This process offers the advantages of simple operation, greenness, safety, controllable quality, and cost-effectiveness. It provides reliable technical support for the industrial-scale production of levobupivacaine hydrochloride (21), which is of significant importance in meeting clinical demands. Pilot-scale production has already been successfully completed by China National Medicines Guorui Pharmaceutical Co., Ltd., with a production scale of 20 kg.