Mixing short- and long-acting local anaesthetics in peripheral nerve blocks: Protocol for a systematic review and meta-analysis.

INTRODUCTION: This protocol describes a systematic review and meta-analysis to evaluate the clinical effects of mixing short- and long-acting local anaesthetics in peripheral nerve blocks. Clinicians often combine short- and long-acting local anaesthetics to achieve a briefer onset time. However, this may come with a prize, namely a shorter total duration of the block, which is of clinical importance. OBJECTIVE: This systematic review aims to strengthen the knowledge of the clinical effects associated with this practice. The primary outcome is the duration of block analgesia. Secondary outcomes are block onset time, sensory and motor block duration. Exploratory outcomes are postoperative pain scores, cumulative 24-h opioid consumption and the prevalence of serious adverse events. METHODS: We will conduct a meta-analysis of the extracted data, and the risk of bias for each study will be evaluated. We will perform a Trial Sequential Analysis, subgroup, and sensitivity analyses and assess the overall risk of publication bias. Finally, we will evaluate the review using the GRADE principles.

Feasibility of outpatient daycase local anaesthestic Rezum™ without sedation.

BACKGROUND: Rezum™ is a relatively new bladder outflow obstruction (BOO) procedure that uses thermal energy through water vapour to cause necrosis of prostatic tissue. The standard delivery of this treatment is in an operating theatre under a general or spinal anaesthetic, or under local anaesthetic with sedation that requires patient monitoring. METHODS: We propose an outpatient daycase method of delivering Rezum™ under local anaesthetic without sedation, using a prostatic local anaesthetic block and cold local anaesthetic gel instillation into the urethra. RESULTS: Preliminary results of our first thirteen patients demonstrate the feasibility of this new technique, with a mean pain score of 2.1 out of 10 on a visual analogue scale, a successful trial without catheter in all 13 patients (one patient voided successfully on second trial), a reduction in mean International Prostate Symptom Score (IPSS) from 20.6 to 5.4, and improvement in maximum flow from 8.8 ml/s to 14.4 ml/s. The complications were minor (Clavien-Dindo less than III) and included a UTI, minor bleeding not requiring admission, and retrograde ejaculation. CONCLUSIONS: We demonstrate that an outpatient local anaesthetic daycase service without sedation is feasible. This can be delivered in a clinic setting, reduce waiting times for BOO surgery, and increase availability of operating theatre for other general anaesthetic urological procedures.

Chondrotoxicity of Intra-Articular Injection Treatment: A Scoping Review.

The purpose of this scoping review was to identify possible chondrotoxic effects caused by drugs usually used for intra-articular injections. PubMed, Scopus, Web of Science and Cochrane were searched. Inclusion criteria required randomized controlled trials written in English that evaluate the toxic effect that damages the cartilage. The literature search resulted in 185 unique articles. 133 full-text articles were screened for inclusion, of which 65 were included. Corticosteroids, with the exception of triamcinolone, along with local anaesthetics, potentially excluding ropivacaine and liposomal bupivacaine, and nonsteroidal anti-inflammatory drugs, exhibited insufficient safety profiles to warrant casual use in clinical settings. Hyaluronic acid, on the other hand, appears to demonstrate safety while also mitigating risks associated with concurrent compounds, thereby facilitating therapeutic combinations. Additionally, there remains a paucity of data regarding platelet-rich plasma, necessitating further evaluation of its potential efficacy and safety. Overall, it seems that results are significantly influenced by the dosage and frequency of injections administered, observed in both human and animal studies.

Nano-invasomes for simultaneous topical delivery of buprenorphine and bupivacaine for dermal analgesia.

Opioid and local anaesthetic receptors are abundantly concentrated in different layers of the skin. Therefore, simultaneous targeting of these receptors can produce more potent dermal anaesthesia. Herein, we developed lipid-based nanovesicles for the co-delivery of buprenorphine and bupivacaine to efficiently target skin-concentrated pain receptors. Invasomes incorporating two drugs were prepared by ethanol injection method. Subsequently, the size, zeta potential, encapsulation efficiency, morphology, and in-vitro drug release of vesicles were characterized. Ex-vivo penetration features of vesicles were then investigated by the franz diffusion cell on the full-thickness human skin. Wherein, it was demonstrated that invasomes penetrated the skin deeper and delivered bupivacaine more effectively than buprenorphine to the target site. The superiority of invasome penetration was further evidenced by the results of ex-vivo fluorescent dye tracking. Estimation of in-vivo pain responses by the tail-flick test revealed that compared with the liposomal group, the group receiving invasomal formulation and drug-free invasomal formulation (only containing menthol) displayed increased analgesia in the initial times of 5 and 10 min. Also, no signs of oedema or erythema were observed in the Daze test in any of the rats receiving the invasome formulation. Finally, ex-vivo and in-vivo assays demonstrated efficiency in delivering both drugs into deeper layers of skin and exposing them to the located pain receptors, which improves the time of onset and the analgesic effects. Hence, this formulation appears to be a promising candidate for tremendous development in the clinical setting.

A systematic review on the outcomes of local anaesthetic transperineal prostate biopsy.

OBJECTIVE: To conduct a systematic review of the literature to assess the diagnostic ability, complication rate, patient tolerability, and cost of local anaesthetic (LA) transperineal prostate biopsy. METHODS: Two reviewers searched Medline, the Cochrane Library, and Embase for publications on LA transperineal prostate biopsy up to March 2021. Outcomes of interest included cancer detection rates, complication rates, pain assessments and cost. RESULTS: A total of 35 publications with 113 944 men were included in this review. The cancer detection rate for LA transperineal prostate biopsy in patients undergoing primary biopsy was 52% (95% confidence interval [CI] 0.45-0.60; I2 = 97) and the clinically significant cancer detection rate (Gleason≥3 + 4) was 37% (95% CI 0.24-0.52; I2 = 99%). The rate of infection-related complications in the included studies was 0.15% (95% CI 0.0000-0.0043; I2 = 86). The LA transperineal procedures had a low rate of procedural abandonment (26/6954, 0.37%), with the greatest pain scores measured during LA administration. No formal cost analyses on LA transperineal prostate biopsies were identified in the literature. The overall risk of bias in the included studies was high, with considerable study heterogeneity and publication bias. CONCLUSION: Transperineal prostate biopsy performed under LA is a viable option for centres interested in avoiding the risk of infection associated with transrectal biopsy, and the logistical burden of general anaesthesia. Further investigation into LA transperineal prostate biopsy with comparative studies is warranted for its consideration as the standard in prostate biopsy technique.

Protocol for the TRANSLATE prospective, multicentre, randomised clinical trial of prostate biopsy technique.

OBJECTIVES: Primary objectives: to determine whether local anaesthetic transperineal prostate (LATP) biopsy improves the detection of clinically significant prostate cancer (csPCa), defined as International Society of Urological Pathology (ISUP) Grade Group ≥2 disease (i.e., any Gleason pattern 4 disease), compared to transrectal ultrasound-guided (TRUS) prostate biopsy, in biopsy-naïve men undergoing biopsy based on suspicion of csPCa. SECONDARY OBJECTIVES: to compare (i) infection rates, (ii) health-related quality of life, (iii) patient-reported procedure tolerability, (iv) patient-reported biopsy-related complications (including bleeding, bruising, pain, loss of erectile function), (v) number of subsequent prostate biopsy procedures required, (vi) cost-effectiveness, (vii) other histological parameters, and (viii) burden and rate of detection of clinically insignificant PCa (ISUP Grade Group 1 disease) in men undergoing these two types of prostate biopsy. PATIENTS AND METHODS: The TRANSLATE trial is a UK-wide, multicentre, randomised clinical trial that meets the criteria for level-one evidence in diagnostic test evaluation. TRANSLATE is investigating whether LATP biopsy leads to a higher rate of detection of csPCa compared to TRUS prostate biopsy. Both biopsies are being performed with an average of 12 systematic cores in six sectors (depending on prostate size), plus three to five target cores per multiparametric/bi-parametric magnetic resonance imaging lesion. LATP biopsy is performed using an ultrasound probe-mounted needle-guidance device (either the 'Precision-Point' or BK UA1232 system). TRUS biopsy is performed according to each hospital's standard practice. The study is 90% powered to detect a 10% difference (LATP biopsy hypothesised at 55% detection rate for csPCa vs 45% for TRUS biopsy). A total of 1042 biopsy-naïve men referred with suspected PCa need to be recruited. CONCLUSIONS: This trial will provide robust prospective data to determine the diagnostic ability of LATP biopsy vs TRUS biopsy in the primary diagnostic setting.

A randomised controlled trial of intravenous dexmedetomidine added to dexamethasone for arthroscopic rotator cuff repair and duration of interscalene block.

Prolongation of peripheral nerve blockade by intravenous dexamethasone may be extended by intravenous dexmedetomidine. We randomly allocated 122 participants who had intravenous dexamethasone 0.15 mg.kg-1 before interscalene brachial plexus block for day-case arthroscopic rotator cuff repair to intravenous saline (62 participants) or intravenous dexmedetomidine 1 µg.kg-1 (60 participants). The primary outcome was time from block to first oral morphine intake during the first 48 postoperative hours. Fifty-nine participants reported taking oral morphine, 25/62 after placebo and 34/60 after dexmedetomidine, p = 0.10. The time to morphine intake was shorter after dexmedetomidine, hazard ratio (95%CI) 1.68 (1.00-2.82), p = 0.049. Median (IQR [range]) morphine doses were 0 (0-12.5 [0-50]) mg after control vs. 10 (0-30 [0-50]) after dexmedetomidine, a difference (95%CI) of 7 (0-10) mg, p = 0.056. There was no effect of dexmedetomidine on pain at rest or on movement. Intra-operative hypotension was recorded for 27/62 and 50/60 participants after placebo vs. dexmedetomidine, respectively, p < 0.001. Other outcomes were similar, including durations of sensory and motor block. In conclusion, dexmedetomidine shortened the time to oral morphine consumption after interscalene block combined with dexamethasone and caused intra-operative hypotension.

General anaesthetic vs local anaesthetic myringoplasties: a systematic review and meta-analysis.

AIMS: To assess all available data and determine the success rates and tolerability of local anaesthetic myringoplasty in comparison with those undertaken under general anaesthetic myringoplasty. MATERIALS AND METHODS: The study was designed following a PRISMA-P protocol and registered with the PROSPERO database. MEDLINE, Cochrane Library (CDSR/Central), EMBASE and CINHAL-were directly searched for studies, which met the inclusion criteria. OBJECTIVES: Primary objective was to compare perforation closure rates between patients undergoing myringoplasty under local anaesthetic and those under general anaesthetic from all available published data. Secondary outcomes include complications, such as 'any minor complications', infection rates in the first 6 month post-op, facial nerve weakness, dysgeusia and patient satisfaction. RESULTS: 27 studies were included in the final analysis and found that myringoplasty had an overall perforation closure rate of 89%. The pooled proportion of closures after myringoplasty under local anesthesia was 87% and for myringoplasties under general anesthesia was 91%. Analysis of myringoplasty under local anaesthesia focusing on 'in-office' performed procedures only, found a closure rate of 88%. CONCLUSIONS: There is no significant difference in the success rate of myringoplasty surgery when performed under local or general anaesthetic as measured by perforation closure rates. However, there are other factors, which can drive choosing local anaesthetic surgery, such as minimising anaesthetic risks, reducing costs and reducing environmental impact.

Local anaesthetic for pain post rubber band ligation of haemorrhoids: a prospective, single-blinded randomised controlled trial.

BACKGROUND: Rubber band ligation (RBL) is a widely accepted intervention for the treatment of haemorrhoids. However, post procedure pain is a common complaint. The aim of this study was to determine whether the addition of local anaesthetic (LA) to the haemorrhoid pedicle base, post RBL, aids in reducing early post-procedure pain. Additionally, to compare perceived perianal numbness, oral analgesia usage and total consumption, and adverse events. METHODS: This study was a prospective, single-blinded randomised controlled trial. Patients were recruited from colorectal clinics in two Australian hospitals between 2018-2019. Patients randomised to the intervention (LA) group received 2mls bupivacaine 0.5% with adrenaline 1:200,000 to each haemorrhoid base. Patients in the control group were not administered LA. Pain scores were recorded over 48 h using visual analogue scales. Analgesia consumption was documented and other secondary objectives were recorded dichotomously (yes/no). RESULTS: At 1 h post-procedure, patient reported pain scores were significantly lower in the LA group compared to the control group (p = 0.04). There were no significant differences in pain scores between the groups at 4, 24 or 48 h. Additionally, there were no significant differences between groups with respect to oral analgesia usage, perianal numbness or adverse events. CONCLUSIONS: LA to the haemorrhoid pedicle post RBL may significantly reduce early post procedure pain without any increased risk of adverse effects.

Comparison of ultra-low, low and high concentration local anaesthetic for labour epidural analgesia: a systematic review and network meta-analysis.

Lumbar epidural is the gold standard for labour analgesia. Low concentrations of local anaesthetic are recommended. This network meta-analysis investigated whether further reducing the concentration of local anaesthetic can improve maternal and neonatal outcomes without compromising analgesia. We conducted a systematic search of relevant databases for randomised controlled trials comparing high (>0.1%), low (>0.08% to ≤0.1%) or ultra-low (≤0.08%) concentration local anaesthetic (bupivacaine or equivalent) for labour epidural. Outcomes included mode of delivery, duration of labour and maternal/neonatal outcomes. Bayesian network meta-analysis with random-effects modelling was used to calculate odds ratios or weighted mean differences and 95% credible intervals. A total of 32 studies met inclusion criteria (3665 women). The total dose of local anaesthetic received increased as the concentration increased; ultra-low compared with low (weighted mean difference -14.96 mg, 95% credible interval [-28.38 to -1.00]) and low compared with high groups (weighted mean difference -14.99 [-28.79 to -2.04]), though there was no difference in the number of rescue top-ups administered between the groups. Compared with high concentration, ultra-low concentration local anaesthetic was associated with increased likelihood of spontaneous vaginal delivery (OR 1.46 [1.18 to 1.86]), reduced motor block (Bromage score >0; OR 0.32 [0.18 to 0.54]) and reduced duration of second stage of labour (weighted mean difference -13.02 min [-21.54 to -4.77]). Compared with low, ultra-low concentration local anaesthetic had similar estimates for duration of second stage of labour (weighted mean difference -1.92 min [-14.35 to 10.20]); spontaneous vaginal delivery (OR 1.07 [0.75 to 1.56]; assisted vaginal delivery (OR 1.35 [0.75 to 2.26]); caesarean section (OR 0.76 [0.49 to 1.22]); pain (scale 1-100, weighted mean difference -5.44 [-16.75 to 5.93]); and maternal satisfaction. Although a lower risk of an Apgar score < 7 at 1 min (OR 0.43 [0.15 to 0.79]) was reported for ultra-low compared with low concentration, this was not sustained at 5 min (OR 0.12 [0.00 to 2.10]). Ultra-low concentration local anaesthetic for labour epidural achieves similar or better maternal and neonatal outcomes as low and high concentration, but with reduced local anaesthetic consumption.

Knowledge, attitude and practice on usage and toxicity of local anaesthetic agents (LA) amongst health care professionals in obstetrics and gynaecology.

A sound knowledge of LA and their dosage is essential for effective anaesthesia and patient safety as LA toxicity could be potentially life-threatening and clinicians undertaking LA procedures must be competent in early recognition of toxicity and instigating remedial measures timely. This is a prospective national-level survey using self-administered questionnaires among health care professionals in Obstetrics and Gynaecology primarily based in Worcestershire Acute Hospital NHS Trust and further extended to other regions of the United Kingdom. The survey was focussed on evaluating the knowledge, attitude and practice (KAP) of the common local anaesthetic agents, their dosage, early recognition and management of LA systemic toxicity(LAST). We understood that all groups of health care professionals did not demonstrate adequate knowledge of safe and effective use of LA agents. We thereby propose an accredited knowledge-based learning module, laminated safety information cards for LA use and ensuring availability of Lipid-emulsion therapy in clinical areas.IMPACT STATEMENTWhat is already known on this subject? Health care professionals using LA should have sufficient knowledge of LA including the required and maximum dose allowance, pharmacokinetic properties, possible complications and management of systemic toxicity. The lack this can trigger potentially fatal and life-threatening complications if misused. Therefore, the key objectives of the use of LA in clinical settings are to optimise pain management while ensuring safe practice.What do the results of this study add? We understood that all groups of health care professionals did not demonstrate adequate knowledge of the safe and effective use of LA agents and appropriate management of its toxicity. This highlights the urgent need for extending awareness among the professionals on the safe administration of LA, early identification and prompt management of LAST. This will improve not only the safety but also the overall patient experience and quality of care.What are the implications of these findings for clinical practice and/or further research? We thereby propose that an accredited knowledge-based module on safe administration and safety concerns of LA must be made compulsory for all those administering LA. Laminated safety information cards on LA with explicit algorithms/guidelines should be made available in all clinical areas to avoid any delays in the management of toxicity. Moreover, all health-care institutions must ensure the availability of Lipid Emulsion Therapy.

Evaluation of efficacy of computer-controlled local anaesthetic delivery system vs traditional injection system for minor pediatric surgical procedures in children.

Background: One of the biggest barriers to successful delivery of quality dental care to paediatric patients is fear related to injection of local anaesthetic. This study aimed to evaluate the efficacy of a computer-controlled local anaesthetic delivery (CCLAD) system when compared with a traditional anaesthetic injection. The two systems were compared with respect to reducing pain-related fear and anxiety. Methods: Eighty children in the age group between 6 and 13 yrs requiring minor paediatric dental procedures on both sides of the dental arch were administered local anaesthesia using a CCLAD system and traditional injection system in two consecutive treatment sessions. The anxiety and fear related to the injection before and after the procedure was evaluated using Children's Fear Survey Schedule - Dental Subscale (CFSS-DS). The pain perception was evaluated using Wong-Bakers pain scale. Results: The percentage wise distribution of pain rating as filled out by the subjects after being administered the local anaesthesia using CCLAD system, and the conventional injection system showed that pain levels experienced by the subjects was lower with the CCLAD injection system than with the conventional injection system. The comparison of CCLAD and conventional groups pretest and post-test CFSS-DS scores showed significantly lower values for CCLAD group indicating lower anxiety levels. Conclusion: This study showed that the CCLAD system could be an useful alternative in administration of local anaesthesia. However, its effectiveness could be tested when used in highly anxious children. The disadvantages of CCLAD systems is that it requires a longer time during administration and cost.

Updates in our understanding of local anaesthetic systemic toxicity: a narrative review.

Despite advances in clinical practice, local anaesthetic systemic toxicity continues to occur with the therapeutic use of local anaesthesia. Patterns of presentation have evolved over recent years due in part to the increasing use of ultrasound which has been demonstrated to reduce risk. Onset of toxicity is increasingly delayed, a greater proportion of clinical reports are secondary to fascial plane blocks, and cases are increasing where non-anaesthetist providers are involved. The evolving clinical context presents a challenge for diagnosis and requires education of all physicians, nurses and allied health professionals about these changing patterns and risks. This review discusses: mechanisms; prevention; diagnosis; and treatment of local anaesthetic systemic toxicity. The local anaesthetic and dose used, site of injection and block conduct and technique are all important determinants of local anaesthetic systemic toxicity, as are various patient factors. Risk mitigation is discussed including the care of at-risk groups, such as: those at the extremes of age; patients with cardiac, hepatic and specific metabolic diseases; and those who are pregnant. Advances in the changing clinical landscape with novel applications and settings for the use of local anaesthesia are also described. Finally, we signpost future directions to potentially improve the management of local anaesthetic systemic toxicity. The utility of local anaesthetics remains unquestionable in clinical practice, and thus maximising the safe and appropriate use of these drugs should translate to improvements in patient care.

Local anaesthetic adjuncts for peripheral regional anaesthesia: a narrative review.

Moderate-to-severe postoperative pain persists for longer than the duration of single-shot peripheral nerve blocks and hence continues to be a problem even with the routine use of regional anaesthesia techniques. The administration of local anaesthetic adjuncts, defined as the concomitant intravenous or perineural injection of one or more pharmacological agents, is an attractive and technically simple strategy to potentially extend the benefits of peripheral nerve blockade beyond the conventional maximum of 8-14 hours. Historical local anaesthetic adjuncts include perineural adrenaline that has been demonstrated to increase the mean duration of analgesia by as little as just over 1 hour. Of the novel local anaesthetic adjuncts, dexmedetomidine and dexamethasone have best demonstrated the capacity to considerably improve the duration of blocks. Perineural dexmedetomidine and dexamethasone increase the mean duration of analgesia by up to 6 hour and 8 hour, respectively, when combined with long-acting local anaesthetics. The evidence for the safety of these local anaesthetic adjuncts continues to accumulate, although the findings of a neurotoxic effect with perineural dexmedetomidine during in-vitro studies are conflicting. Neither perineural dexmedetomidine nor dexamethasone fulfils all the criteria of the ideal local anaesthetic adjunct. Dexmedetomidine is limited by side-effects such as bradycardia, hypotension and sedation, and dexamethasone slightly increases glycaemia. In view of the concerns related to localised nerve and muscle injury and the lack of consistent evidence for the superiority of the perineural vs. systemic route of administration, we recommend the off-label use of systemic dexamethasone as a local anaesthetic adjunct in a dose of 0.1-0.2 mg.kg-1 for all patients undergoing surgery associated with significant postoperative pain.

Regional anaesthesia for labour, operative vaginal delivery and caesarean delivery: a narrative review.

This narrative review discusses recent evidence surrounding the use of regional anaesthesia in the obstetric setting, including intrapartum techniques for labour and operative vaginal delivery, and caesarean delivery. Pudendal nerve blockade, ideally administered by an obstetrician, should be considered for operative vaginal delivery if neuraxial analgesia is contraindicated. Regional techniques are increasingly utilised in clinical practice for caesarean delivery to minimise opioid consumption, reduce pain, improve postpartum recovery and facilitate earlier discharge as part of enhanced recovery protocols. The evidence surrounding transversus abdominis plane and quadratus lumborum blockade supports their use when: long-acting neuraxial opioids cannot be administered due to contraindications; if emergency delivery necessitates general anaesthesia; or as a postoperative rescue technique. Current data suggest quadratus lumborum blockade is no more effective than transversus abdominis plane blockade after caesarean delivery. Transversus abdominis plane blockade, wound catheter insertion and single shot wound infiltration are all effective techniques for reducing postoperative opioid consumption, with transversus abdominis plane blockade favoured, followed by wound catheters and then wound infiltration. Ilio-inguinal and iliohypogastric, erector spinae plane and rectus sheath blockade all require further studies to determine their efficacy for caesarean delivery in the presence or absence of long-acting neuraxial opioids. Future studies are needed to: compare approaches for individual techniques; determine which combinations of techniques and dosing regimens result in optimal analgesic and recovery outcomes following delivery; and elucidate the populations that benefit most from regional anaesthesia in the obstetric setting.

A comparison of ultrasound guided bilateral single injection shot Erector Spinae Plane blocks versus wound infiltration for post-operative analgesia in laparoscopic assisted colonic surgery- a prospective randomised study.

BACKGROUND: Both wound infiltration (WI) with local anaesthetic and Erector Spinae Plane block (ESPB) have been described for post-operative analgesia after abdominal surgery. This study compared the efficacy of WI versus ESPB for post-operative analgesia after laparoscopic assisted colonic surgery. METHODS: Seventy-two patients between 18 and 85 years of age undergoing elective surgery were randomised to receive either WI or ESPB. In the WI group a 40 ml bolus of 0.5% Ropivacaine, infiltrated at the ports and minimally invasive wound at subcutaneous and fascia layers. In the ESPB group at T8 level, under ultrasound guidance, a 22-gauge nerve block needle was passed through the Erector Spinae muscle to reach its fascia. A dose up to 40 ml of 0.5% Ropivacaine, divided into two equal volumes, was injected at each side. Both groups had a multimodal analgesic regime, including regular Paracetamol, dexamethasone and patient-controlled analgesia (PCA) with Fentanyl. The primary end point was a post-operative pain score utilising a verbal Numerical Rating Score (NRS, 0-10) on rest and coughing in the post anaesthetic care unit (PACU) and in the first 24 h. Secondary outcomes measured were: opioid usage, length of stay and any clinical adverse events. RESULTS: There was no significant treatment difference in PACU NRS at rest and coughing (p-values 0. 382 and 0.595respectively). Similarly, there were no significant differences in first 24 h NRS at rest and coughing (p-values 0.285 and 0.431 respectively). There was no significant difference in Fentanyl use in PACU or in the first 24 h (p- values 0.900 and 0.783 respectively). Neither was there a significant difference found in mean total Fentanyl use between ESPB and WI groups (p-value 0.787). CONCLUSION: Our observations found both interventions had an overall similar efficacy. TRIAL REGISTRATION: The study was registered with the Australian New Zealand Clinical Trial Registry (ACTRN: 12619000113156 ).

Use of topical local anaesthetics for paediatric facial lacerations.

BACKGROUND: Closure of facial lacerations in young children can be difficult under local anaesthetic in an emergency department setting. Sedation or general anaesthetic are often required to close lacerations safely and to a good surgical standard. Our hospital introduced the use of local anaesthetic gel (LAT) following an audit, to reduce the need for paediatric admissions. In light of the current COVID-19 pandemic, this can be a valuable tool to help avoid admissions. OBJECTIVES: To ascertain the usefulness of LAT gel in reducing paediatric admissions. METHODS: Data was collected prospectively of all children presenting to the paediatric emergency department for input by the oral and maxillofacial team after the introduction of LAT gel. Data collected included age, aetiology, length and position of laceration, associated injuries and management. Use of LAT gel and other anaesthetics was recorded. FINDINGS: Over a 12 month period, 536 children attended the paediatric ED. Paediatric lacerations accounted for 45% of the reasons for attendance. LAT gel was used in management of 33% of patients with facial lacerations. The use of the gel was successful in 76% of occasions. Ninety children (16.8% of all attendances) were admitted to hospital during this time, of which 49 were paediatric lacerations. CONCLUSION: LAT gel is an effective adjunct to management of laceration in the paediatric population.

The effect of local anaesthetic on delayed bleeding in a epigastric flap model of rats.

OBJECTIVE: Local anaesthetics are often used in plastic surgery practice. Through their mechanism of action, local anaesthetics produce a sympathetic blockage with a subsequent vasodilatation and a resulting local increase of perfusion. The effect of vasodilation of the local anaesthetics causes bleeding locally resulting in haematoma, bruising and/or pain. We present an experimental study of the effects of local anaesthetics on delayed bleeding. METHOD: In this animal study, 36 adult male Wistar rats were divided into four groups of nine animals: lidocaine; lidocaine and epinephrine; bupivacaine; and control. An epigastric flap model was harvested. Local anaesthetics that are frequently used in daily practice were administered in equal amounts to the harvested flap. RESULTS: After 24 hours, the rats were euthanised to collect and measure all coagula under the epigastric flap. No statistically significant differences in relation to the amount of coagulum were found between the groups. CONCLUSION: Our results suggest that proper haemostasis is achieved, there is no difference on the effect of delayed bleeding between the local anaesthetics which are often used.

Intraperitoneal Tramadol in Abdominal Surgery: A Systematic Review.

BACKGROUND: Multimodal analgesic regimes are required to treat pain. Intraperitoneal (IP) agents, such as local anesthetics (LAs), have been shown to reduce pain after abdominal surgery. Other IP analgesics have been tested in several randomized control trials (RCTs), but no reviews or guidelines have evaluated their use. Tramadol is an effective oral and intravenous analgesia with recent evidence supporting the use of IP tramadol (IPT). We aimed to review the efficacy of IPT as an adjunct to intraperitoneal local anesthetics (IPLAs) for pain relief after abdominal surgery. MATERIALS AND METHODS: Relevant articles were identified by two independent reviewers from MEDLINE, EMBASE and PubMed using Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines up to January 2019. Only RCT comparing IPT + IPLA with IPLA alone were included. Outcomes recorded were the postoperative analgesic requirement, pain scores at 4 h and 24 h and adverse events. Data were analyzed with Review Manager, version 5.3. RESULTS: A total of five RCTs (4× laparoscopic cholecystectomy and 1× abdominal hysterectomy) were included in this review from 419 studies screened. All doses were given as a single bolus. Pain relief requirements over the first 24 h weres less in the IPT + IPLA groups when compared with those in IPLA alone. Pain scores were less for IPT + IPLA groups at 4 h and 24 h. There were no significant differences in adverse events between groups. CONCLUSIONS: In summary, IPT, in combination with IPLA, is effective in the management of acute postoperative pain and reduces the total amount of pain relief consumed in the first 24 h after surgery. Studies reporting the use of IPT + IPLA reported no toxicity or systemic adverse events. Further research into standardizing the dosing of IPT to optimize its effectiveness and further reduce the additional analgesic requirement is indicated.

Intraperitoneal ropivacaine reduces time interval to initiation of chemotherapy after surgery for advanced ovarian cancer: randomised controlled double-blind pilot study.

BACKGROUND: Advanced-stage ovarian cancer has a poor prognosis; surgical resection with the intent to leave no residual tumour followed by adjuvant chemotherapy is the standard treatment. Local anaesthetics (LA) have anti-inflammatory and analgesic effects. We hypothesised that intraperitoneal LA (IPLA) would lead to improved postoperative recovery, better pain relief, and earlier start of chemotherapy. METHODS: This was a prospective, randomised, double-blind, placebo-controlled pilot study in 40 women undergoing open abdominal cytoreductive surgery. Patients were randomised to receive either intraperitoneal ropivacaine (Group IPLA) or saline (Group Placebo) perioperatively. Except for study drug, patients were treated similarly. Intraoperatively, ropivacaine 2 mg ml-1 or 0.9% saline was injected thrice intraperitoneally, and after operation via a catheter and analgesic pump into the peritoneal cavity for 72 h. Postoperative pain, time to recovery, home discharge, time to start of chemotherapy, and postoperative complications were recorded. RESULTS: No complications from LA administration were recorded. Pain intensity and rescue analgesic consumption were similar between groups. Time to initiation of chemotherapy was significantly shorter in Group IPLA (median 21 [inter-quartile range 21-29] vs 29 [inter-quartile range 21-40] days; P=0.021). Other parameters including time to home readiness, home discharge and incidence, and complexity of postoperative complications were similar between the groups. CONCLUSIONS: Intraperitoneal ropivacaine during and for 72 h after operation after cytoreductive surgery for ovarian cancer is safe and reduces the time interval to initiation of chemotherapy. Larger studies are warranted to confirm these initial findings. CLINICAL TRIAL REGISTRATION: NCT02256228.