Prevention of persistent pain with lidocaine infusions in breast cancer surgery (PLAN): study protocol for a multicenter randomized controlled trial.

BACKGROUND: Persistent pain is a common yet debilitating complication after breast cancer surgery. Given the pervasive effects of this pain disorder on the patient and healthcare system, post-mastectomy pain syndrome (PMPS) is becoming a larger population health problem, especially as the prognosis and survivorship of breast cancer increases. Interventions that prevent persistent pain after breast surgery are needed to improve the quality of life of breast cancer survivors. An intraoperative intravenous lidocaine infusion has emerged as a potential intervention to decrease the incidence of PMPS. We aim to determine the definitive effects of this intervention in patients undergoing breast cancer surgery. METHODS: PLAN will be a multicenter, parallel-group, blinded, 1:1 randomized, placebo-controlled trial of 1,602 patients undergoing breast cancer surgery. Adult patients scheduled for a lumpectomy or mastectomy will be randomized to receive an intravenous 2% lidocaine bolus of 1.5 mg/kg with induction of anesthesia, followed by a 2.0 mg/kg/h infusion until the end of surgery, or placebo solution (normal saline) at the same volume. The primary outcome will be the incidence of persistent pain at 3 months. Secondary outcomes include the incidence of pain and opioid consumption at 1 h, 1-3 days, and 12 months after surgery, as well as emotional, physical, and functional parameters, and cost-effectiveness. DISCUSSION: This trial aims to provide definitive evidence on an intervention that could potentially prevent persistent pain after breast cancer surgery. If this trial is successful, lidocaine infusion would be integrated as standard of care in breast cancer management. This inexpensive, widely available, and easily administered intervention has the potential to reduce pain and suffering in an already afflicted patient population, decrease the substantial costs of chronic pain management, potentially decrease opioid use, and improve the quality of life in patients. TRIAL REGISTRATION: This trial has been registered on clinicaltrials.gov (NCT04874038, Dr. James Khan. Date of registration: May 5, 2021).

A preliminary study on the assessment of pain using figures among patients administered with dental local anesthesia for mandibular third molar extraction.

The aim of this study was to clarify or determine any possible association between pain reports with a visual analogue scale (VAS) and a figures based scale. This research was a preliminary study aimed at developing a new pain scale without any verbal description. Healthy Japanese patients aged 20 to 39 years who received anesthetic injections for mandibular third molar extraction at our department were enrolled. Regarding pain from dental local anesthetic injections, we recorded figures selected by participants (among options of a circle, triangle, square, bar, and cross), and VAS scores. Overall, 29 men and 31 women participated in the study. Pain caused by local dental anesthesia tended to remind both men and women of the triangle among the suggested figures. Furthermore, patients who chose a cross also reported higher VAS scores than those who chose other figures. Acute pain caused by local dental anesthesia was associated with triangles, and patients who selected a cross were associated with higher VAS scores. The results of this study provide clinicians with important information for dental practice, and could prove useful in developing new pain scales.

Assessment of Awareness of Local Anaesthetic Systemic Toxicity (LAST) among Postgraduate Trainees.

Introduction: Although uncommon, local anaesthetic systemic toxicity (LAST) may impose fatal risk to the patients. We investigated the awareness of LAST and knowledge on local anaesthetics among our postgraduate trainees. Materials and Methods: A total of 134 postgraduate trainees from the departments of general surgery (Surgical), orthopaedic surgery (Ortho), otorhinolaryngology (ENT), obstetrics and gynaecology (OBGYN), as well as anaesthesiology and intensive care (Anaesth) were recruited. A validated questionnaire was used to assess awareness and knowledge. All participants attended a medical-education session and completed the questionnaire as preassessment and postassessment. Data were analysed, and comparisons between disciplines were conducted. Results: The trainees' awareness of LAST was overall poor at preassessment which improved almost 6-folds at postassessment. Surprisingly, only 20 (45.5%) participants from the anaesthesiology group had awareness of LAST at preassessment, and none of the participants were from surgical, orthopaedic, and obstetrics and gynaecology departments. Preassessment scores were significantly higher in the anaesth group as compared to all other groups; with a difference in the average score for Anaesth vs Surgical of 3.46 (95%, CI:2.17, 4.74), Anaesth vs Ortho of 3.64 (95%, CI:2.64, 4.64), Anaesth vs ENT of 3.43 (95%, CI:2.20, 4.67), and Anaesth vs OBGYN of 6.93 (95%, CI:5.64, 8.21). However, there was no significant difference of awareness scores between all participants at postassessment scores. Conclusion: The overall level of awareness was poor. However, the implementation of an education session significantly improved the knowledge and awareness across all disciplines.

Avaliação dos padrões cardiovasculares e da concentração sérica de catecolaminas em pacientes submetidos à exodontias por via alveolar, sob anestesia local com epinefrina: um ensaio clínico controlado, cego e randomizado / Assessment of cardiovascular patterns and serum catecholamine concentration in patients undergoing alveolar extraction under local anesthesia with epinephrine: a controlled, blind and randomized clinical trial

Objetivos: Um ensaio clínico controlado, cego e randomizado foi desenvolvido para avaliar os efeitos cardiovasculares em pacientes saudáveis e com hipertensão submetidos à exodontia por via alveolar utilizando lidocaína com epinefrina 1:100.000. Materiais e métodos: Vinte pacientes foram divididos em grupos experimental (GE ­ pacientes hipertensos) e controle (GC ­ pacientes normotensos). As variáveis analisadas foram a frequência cardíaca (FC), saturação de oxigênio (SO2), pressão arterial sistólica e diastólica (PAsis e PAdias), concentração sérica de catecolaminas (dopamina, epinefrina e norepinefrina), extrassístoles ventriculares e supraventriculares (ESV e ESSV respectivamente) e depressão do segmento do ST. Os dados foram colhidos em três momentos distintos: inicial, transoperatório (trans) e final. Amostras de sangue foram coletadas para a mensuração das catecolaminas, e um aparelho de Holter foi utilizado para coleta de dados do eletrocardiograma incluindo um período de avaliação de 24 horas pós-operatório. Foram utilizados o teste de Mann-Whitney para identificar diferenças entre os grupos e o teste de Friedman com o pós-teste de Wilcoxon ajustado para a avaliação intragrupos das amostras repetidas. Resultados: O GE apresentou menor SO2 no momento inicial (p = 0,001) enquanto a PAsis apresentou diferença estatística para os três momentos de avaliação com o GE apresentando os maiores valores. As ESV foram maiores para o GE no período de avaliação pós-operatória de 24 horas (p = 0,041). As ESSV e as catecolaminas séricas foram similares nos dois grupos. A análise intragrupo revelou diferença significativa na avaliação da PAsis para o GE com o período trans operatório apresentando os maiores valores. Já avaliação das extrassístoles demonstrou que o período pós-operatório de 24 horas teve a maioria dos eventos sendo que apenas o GC não apresentou diferença significativa para a variável ESV durante esse período (p = 0,112). Não houve depressão do segmento ST para nenhum dos grupos, ou seja, a isquemia do miocárdio não foi observada durante o estudo. Conclusões: As exodontias por via alveolar, com o uso de ALVC com epinefrina podem ser realizadas de forma segura em pacientes hipertensos. A pressão arterial sistêmica deve ser monitorada durante todo o procedimento, sobretudo nos pacientes hipertensos, devido à tendência de aumento da pressão arterial nesses pacientes. Já o nível sérico de catecolaminas não sofre alteração nas condições estudadas assim como o uso de ALVC parecem não influenciar os padrões cardiovasculares nesse tipo de cirurgia (AU).

Objectives: A blind, randomized controlled clinical trial was developed to evaluate the cardiovascular effects of local anesthetics with vasoconstrictors (LAVC) containing epinephrine in healthy and hypertensive patients undergoing teeth extraction with lidocaine 2% with epinephrine 1:100.000. Materials and methods: 20 patients were divided into control (CG ­ normotensive patients) and experimental groups (EG ­ hypertensive patients). The variables analyzed were heart rate (HR), oxygen saturation (O2S), systolic and diastolic blood pressure (sysBP and diasBP), serum catecholamines concentration (dopamine, epinephrine, and norepinephrine), ventricular and supraventricular extrasystoles (VES and SVES respectively), and ST segment depression. Data was obtained in three different moments (initial, trans and final). Blood samples were taken to measure the catecholamines and a Holter device was used to measure data from the electrocardiogram including a 24-hour postoperative evaluation period. The Mann-Whitney test was used to identify differences between the two groups and the Friedman test with the adjusted Wilcoxon post-test were used for intragroup evaluation for repeated measures. Results: The EG presented a lower O2S in the initial period (p = 0,001) while the sysBP showed a statistical difference for the three evaluation periods with the EG presenting the highest values. The VES where higher for the EG during the 24-hour postoperative evaluation period (p = 0,041). The SVES and the serum catecholamines showed were similar between the groups. The intragroup analysis revealed significant statistical difference for the sysBP in the EG with the trans period presenting the highest measurements. The extrasystoles evaluation showed that the 24- hour postoperative period presented most events with only the CG not presenting statistical difference for the variable VES during this period (p = 0,112). No ST segment depression was noticed for both groups, ie, Myocardial ischemia was not observed. Conclusions: Teeth extraction with LAVC containing epinephrine can be safely executed in hypertensive patients. Blood pressure should be monitored during the entire procedure, especially in hypertensive patients due to a tendency to high blood pressure within these patients. Serum catecholamines concentration levels are not altered in the conditions seen in this study and the use of LAVC seem not to influence cardiovascular changes in this type of surgery (AU).

Study of Peri-Articular Anaesthetic for Replacement of the Knee (SPAARK): study protocol for a patient-blinded, randomised controlled superiority trial of liposomal bupivacaine.

BACKGROUND: Optimising the management of peri-operative pain and recovery following knee replacement has been identified as a patient priority. Current pain relief strategies use opiate-based analgesia; however, up to 50% of patients experience significant side effects. Local anaesthetic incisional infiltration is one alternative. The length of the duration of action is a major limiting factor of current local anaesthetic techniques. Liposomal bupivacaine has been reported to be effective for up to 72 h. This randomised controlled trial will evaluate the clinical and cost effectiveness of liposomal bupivacaine. METHODS: SPAARK is a patient-blinded, multi-centre, active comparator, superiority, two-arm, parallel-group randomised controlled trial. Five hundred patients undergoing knee replacement will be recruited and randomised to liposomal bupivacaine plus bupivacaine hydrochloride or bupivacaine hydrochloride alone. The co-primary outcomes are the Quality of Recovery 40 measured at 72 h post-surgery and also cumulative pain measured daily using a 0-10 visual analogue scale for the first 3 days following surgery. Secondary outcomes include cumulative opioid consumption, fitness for discharge, functional outcomes assessed using the Oxford Knee Score and American Knee Society Score, the EuroQol five dimensions instrument and complications. A cost utility analysis is also planned. DISCUSSION: The clinical effectiveness and cost effectiveness of liposomal bupivacaine have yet to be evaluated in the National Health Service, making this trial appropriate and timely. TRIAL REGISTRATION: ISRCTN registry, ISRCTN54191675. Registered on 14 November 2017.

The role of intraperitoneal ropivacaine in laparoscopic appendicectomy: a prospective, double-blinded randomized control Australian study.

BACKGROUND: Currently, intraoperative use of local anaesthetic is not routinely given in all laparoscopic appendicectomies. Although its use has been widely studied in laparoscopic hernia repairs, gynaecological laparoscopy and laparoscopic cholecystectomies, there are no published trials of the use of intraperitoneal local anaesthetic during laparoscopic appendicectomy in the Australasian setting. The aim of this study was to determine whether the use of intraperitoneal ropivacaine during laparoscopic appendicectomy will reduce the amount of post-operative opiate analgesia used, abdominal pain, post-operative nausea or vomiting, shoulder tip pain and length of hospital stay. METHODS: A randomized double-blinded placebo versus control trial was conducted with patients with clinically diagnosed appendicitis undergoing laparoscopic appendicectomy. Primary outcomes measured were the number of times the patient-controlled analgesia (PCA) button was pressed post-operatively and the average and total amount of fentanyl from PCA consumed during the post-operative period from 0 to 6 h and from 6 to 16 h. RESULTS: A total of 86 patients with 43 patients in the placebo normal saline group and 43 patients in the treatment ropivacaine group were included in the study. During the immediate post-operative period (0-6 h), there was a statistically significant reduction in the number of times the PCA button was pressed in the ropivacaine group compared to the normal saline group (16 versus 24 times, P = 0.02). CONCLUSION: Intraperitoneal ropivacaine has an analgesic effect for patients up to 6 h following emergency laparoscopic appendicectomy.

Liposomal bupivacaine mixture has similar pain relief and significantly fewer complications at less cost compared with indwelling interscalene catheter in total elbow arthroplasty.

BACKGROUND: Postoperative pain control, short-term and long-term narcotic consumption, complication rates, and costs of indwelling interscalene catheter (ISC) were compared with a liposomal bupivacaine (LBC) mixture in patients undergoing primary total elbow arthroplasty. METHODS: Forty-four consecutive patients were identified, the first 28 with an ISC and the later 16 with intraoperative LBC injection that also included ketorolac and 0.5% bupivacaine. Medical records were reviewed for visual analog scale scores for pain, oral morphine equivalent (OME) use, complications, and facility charges. RESULTS: Average visual analog scale scores at 24 hours, 2 weeks, 6 weeks, and 12 weeks were not significantly different. Mean OME use was significantly greater in the LBC group at 24 hours but less at 12 weeks, although this difference was not statistically significant. Twelve anesthetic-related complications occurred in the ISC group (1 major and 11 minor); 10 patients (36%) had at least 1 complication. The major complication was respiratory failure requiring emergent tracheostomy. Minor complications included leaking pump/catheters, catheters inadvertently pulled out early, global hand paresthesias, forearm paresthesias, and pain at the catheter site. There were no anesthetic-related complications in the LBC group. The average charge for the LBC mixture was $327.10; charges for ISC, including equipment and anesthesia fees, were $1472.42. CONCLUSIONS: An LBC mixture provides similar pain relief with fewer complications at a lower cost than indwelling ISC after total elbow arthroplasty. Although the OME use in the LBC group was almost double that of the ISC group at 24 hours, there was no difference at later time points.

[Topical anesthesia without the use of an anesthesiologist in adult outpatient cataract surgery: Assessment of selection criteria on consultation, report of 248 cases]. / L'anesthésie topique sans recours à un médecin anesthésiste dans la chirurgie de la cataracte ambulatoire de l'adulte : évaluation des critères de sélection en consultation, à propos de 248 cas.

INTRODUCTION: This work aims to evaluate selection criteria used during the cataract surgery scheduling visit, to choose whether or not there will be an anesthesiologist available during the surgery, depending upon the patient's comorbidities. MATERIALS AND METHODS: Retrospective study performed in 2016 in Angers university medical center. Two groups were established on the cataract surgery scheduling visit, based on patients' comorbidities and vital signs (blood pressure, heart rate). One group of patients were operated with topical anesthesia, with the anesthesia team, the other one only with blood pressure and heart rate monitoring, with, if needed, a written protocol of sedation or blood pressure control, which could be administrated by a circulating nurse. Those two groups were compared in terms of postoperative complications, intraoperative pain and postoperative visual acuity. RESULTS: 248 surgeries were performed on 185 individual patients, with 108 under stand-alone topical anesthesia, and 135 under anesthetist-monitored topical anesthesia. No significant difference was demonstrated between the two groups, in terms of complications, intraoperative pain or visual acuity outcomes. DISCUSSION: This study allows us to assess selection criteria used in our hospital to determine which patients can undergo cataract surgery under topical anesthesia without the anesthesia team. This procedure lowers organizational constraints while still insuring patient safety. Some patients still probably need an anesthesiologist present, such as those with an unstable disease or risk of agitation, in order to optimize the medications administered during surgery.

Outcomes and cost-effectiveness of ultrasound-guided injection of the trochanteric bursa.

We hypothesized that ultrasound (US) guidance improves outcomes of corticosteroid injection of trochanteric bursitis. 40 patients with greater trochanteric pain syndrome defined by pain to palpation over the trochanteric bursa were randomized to injection with 5 ml of 1% lidocaine and 80 mg of methylprednisolone using (1) conventional anatomic landmark palpation guidance or (2) US guidance. Procedural pain (Visual Analogue Pain Scale), pain at outcome (2 weeks and 6 months), therapeutic duration, time-to-next intervention, and costs were determined. There were no complications in either group. Ultrasonography demonstrated that at least a 2-in (50.8 mm) needle was required to consistently reach the trochanteric bursa. Pain scores were similar at 2 weeks: US: 1.3 ± 1.9 cm; landmark: 2.2 ± 2.5 cm, 95% CI of difference: - 0.7 < 0.9 < 2.5, p = 0.14. At 6 months, US was superior: US: 3.9 ± 2.0 cm; landmark: 5.5 ± 2.6 cm, 95% CI of difference: 0.8 < 1.6 < 2.4, p = 0.036. However, therapeutic duration (US 4.7 ± 1.4 months; landmark 4.1 ± 2.9 months, 95% CI of difference - 2.2 < - 0.6 < 1.0, p = 0.48), and time-to-next intervention (US 8.7 ± 2.9 months; landmark 8.3 ± 3.8 months, 95% CI of difference - 2.8 < - 0.4 < 2.0, p = 0.62) were similar. Costs/patient/year was 43% greater with US (US $297 ± 99, landmark $207 ± 95; p = 0.017). US-guided and anatomic landmark injection of the trochanteric bursa have similar 2-week and 6-month outcomes; however, US guidance is considerably more expensive and less cost-effective. Anatomic landmark-guided injection remains the method of choice, but should be routinely performed using a sufficiently long needle [at least a 2 in (50.8 mm)]. US guidance should be reserved for extreme obesity or injection failure.

Total spinal block after local anesthetic administration through the wrong access port of a spinal infusion pump. / Bloqueo espinal total tras administración de anestésico local por el puerto de acceso equivocado de una bomba de infusión intratecal.

We present a case reported on the SENSAR database. A patient with a spinal infusion pump was admitted for reservoir refill. On administration of 22ml of 0.75% bupivacaine the patient suffered a total spinal block with widespread loss strength and respiratory arrest. The patient required emergency orotracheal intubation, mechanical ventilation and admission to ICU, where extubation was achieved within two hours without incidences. At a later stage it was stated that the local anaesthetic had been administered via the access port for bolus or contrast administration instead of via the access to the reservoir. Analysis of the incident showed up latent factors related to absence lack of personnel training and internal protocols. The following measures were taken: pain unit meeting, alert sent to SENSAR bulletin and training request for members of the service.

Sensory Assessment and Regression Rate of Bilateral Oblique Subcostal Transversus Abdominis Plane Block in Volunteers.

BACKGROUND AND OBJECTIVES: The analgesic effect and duration of a transversus abdominis plane (TAP) block remain controversial. Transversus abdominis plane blocks are effective for somatic/incisional pain but do not provide analgesia for visceral pain from intra-abdominal procedures. The purpose of this study was to assess the area and extent of cutaneous sensory blockade and the regression of dermatomal anesthesia after bilateral oblique subcostal TAP block. METHODS: This observational, prospective clinical study consisted of 12 healthy volunteers. All volunteers received a bilateral oblique subcostal TAP block under real-time ultrasound guidance with 20 mL of 0.375% ropivacaine. The anterior abdominal cutaneous area was divided into 3 parts (midabdomen, left-lateral abdomen, right-lateral abdomen) using 2 lines drawn in a parasagittal fashion 5 cm lateral to the midline. The area of cutaneous sensory blockade involving the anterior abdomen was assessed 30 minutes after institution of the block using a cold stimulus. This was followed by repeated measurements using a cold stimulus applied along parasagittal lines drawn 3 cm lateral to the midline at 0.5, 6, 10, 14, 18, 22, and 26 hours after blockade. RESULTS: The area of cutaneous sensory blockade of the abdomen was 332 (SD, 73) cm; that of the midabdomen was 253 (SD, 29) cm, which represented an average of 90% of the area of the midabdomen; and that of the lateral abdominal wall (combination of left-lateral abdomen and right-lateral abdomen) was 79 (SD, 62) cm, which represented an average of 26% of total lateral abdominal area. Dermatomes T7-T12 of the midabdomen were successfully blocked in all volunteers after using the bilateral oblique subcostal technique. However, T6 and L1 were only variably blocked. The area of cutaneous sensory block of the anterior abdomen regressed over the ensuing 22 hours in the following manner: 90%, 87%, 73%, 50%, 22%, 3%, and 0% at 0.5, 6, 10, 14, 18, 22, and 26 hours, respectively. CONCLUSIONS: Bilateral oblique subcostal TAP block produces a widespread cutaneous sensory blockade with a consistent dermatomal distribution in the midabdomen for a considerable effective duration.

Facet joint injections for people with persistent non-specific low back pain (Facet Injection Study): a feasibility study for a randomised controlled trial.

BACKGROUND: The National Institute for Health and Care Excellence (NICE) 2009 guidelines for persistent low back pain (LBP) do not recommend the injection of therapeutic substances into the back as a treatment for LBP because of the absence of evidence for their effectiveness. This feasibility study aimed to provide a stable platform that could be used to evaluate a randomised controlled trial (RCT) on the clinical effectiveness and cost-effectiveness of intra-articular facet joint injections (FJIs) when added to normal care. OBJECTIVES: To explore the feasibility of running a RCT to test the hypothesis that, for people with suspected facet joint back pain, adding the option of intra-articular FJIs (local anaesthetic and corticosteroids) to best usual non-invasive care is clinically effective and cost-effective. DESIGN: The trial was a mixed design. The RCT pilot protocol development involved literature reviews and a consensus conference followed by a randomised pilot study with an embedded mixed-methods process evaluation. SETTING: Five NHS acute trusts in England. PARTICIPANTS: Participants were patients aged ≥ 18 years with moderately troublesome LBP present (> 6 months), who had failed previous conservative treatment and who had suspected facet joint pain. The study aimed to recruit 150 participants (approximately 30 per site). Participants were randomised sequentially by a remote service to FJIs combined with 'best usual care' (BUC) or BUC alone. INTERVENTIONS: All participants were to receive six sessions of a bespoke BUC rehabilitation package. Those randomised into the intervention arm were, in addition, given FJIs with local anaesthetic and steroids (at up to six injection sites). Randomisation occurred at the end of the first BUC session. MAIN OUTCOME MEASURES: Process and clinical outcomes. Clinical outcomes included a measurement of level of pain on a scale from 0 to 10, which was collected daily and then weekly via text messaging (or through a written diary). Questionnaire follow-up was at 3 months. RESULTS: Fifty-two stakeholders attended the consensus meeting. Agreement informed several statistical questions and three design considerations: diagnosis, the process of FJI and the BUC package and informing the design for the randomised pilot study. Recruitment started on 26 June 2015 and was terminated by the funder (as a result of poor recruitment) on 11 December 2015. In total, 26 participants were randomised. Process data illuminate some of the reasons for recruitment problems but also show that trial processes after enrolment ran smoothly. No between-group analysis was carried out. All pain-related outcomes show the expected improvement between baseline and follow-up. The mean total cost of the overall treatment package (injection £419.22 and BUC £264.00) was estimated at £683.22 per participant. This is similar to a NHS tariff cost for a course of FJIs of £686.84. LIMITATIONS: Poor recruitment was a limiting factor. CONCLUSIONS: This feasibility study achieved consensus on the main challenges in a trial of FJIs for people with persistent non-specific low back pain. FUTURE WORK: Further work is needed to test recruitment from alternative clinical situations. TRIAL REGISTRATION: EudraCT 2014-000682-50 and Current Controlled Trials ISRCTN93184143. FUNDING: This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 21, No. 30. See the NIHR Journals Library website for further project information.

Perineural Dexmedetomidine Is More Effective Than Clonidine When Added to Local Anesthetic for Supraclavicular Brachial Plexus Block: A Systematic Review and Meta-analysis.

BACKGROUND: Clonidine, an α-2 agonist, has long been used as a local anesthetic adjunct with proven efficacy to prolong peripheral nerve block duration. Dexmedetomidine, a newer α-2 agonist, has a more favorable pharmacodynamic and safety profile; however, data comparing its efficacy as an adjunct to that of clonidine are inconsistent. We sought to compare the clinical efficacy of these 2 α-2 agonists by examining their effects on peripheral nerve block characteristics for upper extremity surgery. METHODS: A preliminary search found that the overwhelming majority of randomized controlled trials comparing perineural dexmedetomidine to clonidine for upper extremity surgery were in the setting of supraclavicular brachial plexus block (SCB). Therefore, we performed a systematic review and meta-analysis of randomized controlled trials comparing dexmedetomidine with clonidine as perineural adjuncts to single-injection SCB. Sensory and motor block duration and onset, analgesic duration, α-2 agonist side effects, and block complications were analyzed. Sensory block duration was designated as a primary outcome. Data were combined using random-effects modeling, and ratio-of-means was used to analyze the results. RESULTS: A total of 868 patients from 14 clinical studies were included in the analysis. Compared with clonidine, dexmedetomidine prolonged the duration (ratio of means [95% confidence interval {CI}]) of sensory block by an estimate of 1.2 (1.2-1.3; P< .00001). It also prolonged the duration (ratio of means [99% CI]) of motor block by an estimate of 1.2 (1.1-1.3; P < .00001), and analgesia by an estimate of 1.2 (1.1-1.3; P < .00001). It also hastened the onset of sensory block by an estimate of 0.9 (0.8-1.0; P < .00001) and motor block by an estimate of 0.9 (0.9-1.0; P = .002). Dexmedetomidine was associated with an increased odds ratio (99% CI) of transient bradycardia by an estimate of 7.4 (1.3-40.8; P = .003) and postoperative sedation by an estimate of 11.8 (1.9-73.6; P = .0005). There were no differences in other α-2 agonist-related side effects or block-related complications. CONCLUSIONS: Compared with clonidine as a local anesthetic adjunct for single-injection SCB, perineural dexmedetomidine enhances sensory, motor, and analgesic block characteristics. These benefits should be weighed against the increased risk of transient bradycardia.

Lidocaine/prilocaine spray for premature ejaculation.

Although premature ejaculation is the most common ejaculation problem, it is poorly understood and currently has no standard definition.1 Typically, it involves reduced time to ejaculation, inability to control or delay ejaculation and associated distress.1-5 Treatments that have been assessed include psychosexual counselling, antidepressants (e.g. selective serotonin reuptake inhibitors), phosphodiesterase type-5 inhibitors, tramadol and topical anaesthetic agents (e.g. lidocaine/prilocaine cream). A new formulation (cutaneous spray) of lidocaine/prilocaine (Fortacin-Plethora Solutions Ltd.) was launched in the UK in November 2016 for the treatment of primary premature ejaculation.6,7 Here, we consider the evidence for lidocaine/prilocaine spray and whether it has a role in the treatment of premature ejaculation.

Wide Awake Hand Surgery.

Wide awake hand surgery employs local-only anesthesia with low-dose epinephrine to create a bloodless field without the use of an arm tourniquet. Despite traditional teaching, evidence-based medicine suggests epinephrine is safe for use in hand and digital anesthesia. Eliminating an arm tourniquet reduces the requirement for sedation and general anesthetic. This confers particular advantage in surgeries such as tendon repairs, tendon transfers, and soft tissue releases in which intraoperative active motion can used to optimize outcomes. The wide awake approach also confers significant benefit to patients, providers, and health care systems alike due to efficiencies and cost savings.

Epidural Local Anesthetics Versus Opioid-Based Analgesic Regimens for Postoperative Gastrointestinal Paralysis, Vomiting, and Pain After Abdominal Surgery: A Cochrane Review.

BACKGROUND: The aim of this review was to compare the effects of postoperative epidural analgesia with local anesthetics to postoperative systemic or epidural opioids in terms of return of gastrointestinal transit, postoperative pain control, postoperative vomiting, incidence of gastrointestinal anastomotic leak, hospital length of stay, and cost after abdominal surgery. METHODS: Trials were identified by computerized searches of the Cochrane Central Register of Controlled Trials (CENTRAL) (2014, Issue 12), Medical Literature Analysis and Retrieval System Online (MEDLINE) (from 1950 to December, 2014) and Excerpta Medica dataBASE (EMBASE) (from 1974 to December 2014) and by checking the reference lists of trials retained. We included parallel randomized controlled trials comparing the effects of postoperative epidural local anesthetic with regimens based on systemic or epidural opioids. The quality of the studies was rated according to the Cochrane tool. Two authors independently extracted data. We judged the quality of evidence according to the Grading of Recommendations, Assessment, Development and Evaluations (GRADE) working group scale. RESULTS: Based on 22 trials including 1138 participants, an epidural containing a local anesthetic will decrease the time required for return of gastrointestinal transit as measured by time required to observe the first flatus after an abdominal surgery standardized mean difference (SMD) -1.28 (95% confidence interval [CI], -1.71 to -0.86; high quality of evidence; equivalent to 17.5 hours). The effect is proportional to the concentration of local anesthetic used. Based on 28 trials including 1559 participants, we also found a decrease in time to first feces (stool): SMD -0.67 (95% CI, -0.86 to -0.47; low quality of evidence; equivalent to 22 hours). Based on 35 trials including 2731 participants, pain on movement at 24 hours after surgery is also reduced: SMD -0.89 (95% CI, -1.08 to -0.70; moderate quality of evidence; equivalent to 2.5 on a scale from 0 to 10). Based on 22 trials including 1154 participants, we did not find a difference in the incidence of vomiting within 24 hours: risk ratio 0.84 (95% CI, 0.57-1.23); low quality of evidence. Based on 17 trials including 848 participants we did not find a difference in the incidence of gastrointestinal anastomotic leak: risk ratio 0.74 (95% CI, 0.41-1.32; low quality of evidence). Based on 30 trials including 2598 participants, epidural analgesia reduces length of hospital stay for an open surgery: SMD -0.20 (95% CI, -0.35 to -0.04; very low quality of evidence; equivalent to 1 day). Data on cost were very limited. CONCLUSIONS: An epidural containing a local anesthetic, with or without the addition of an opioid, accelerates the return of the gastrointestinal transit (high quality of evidence). An epidural containing a local anesthetic with an opioid decreases pain after an abdominal surgery (moderate quality of evidence). An epidural containing a local anesthetic does not affect the incidence of vomiting or anastomotic leak (low quality of evidence). For an open surgery, an epidural containing a local anesthetic would reduce the length of hospital stay (very low quality of evidence).

An assessment of the awareness of local anesthetic systemic toxicity among multi-specialty postgraduate residents.

Local anesthetics (LAs) are extensively used in clinical practice by both anesthesiologists and non-anesthesiologists and are often associated with systemic toxicity. We hypothesize that this awareness is inadequate among medical specialists and entails a risk of misdiagnosis and underreporting of such events. We therefore conducted a cross-sectional questionnaire-based study to assess the level of understanding of LA use and effective management of systemic toxicity among 200 postgraduate residents of various specialties (with the exception of anesthesiology) in a tertiary care hospital in India from October to December 2013. Among those residents who had used LAs (193/200), 27 and 25 % of responders correctly identified the toxic doses of lidocaine and of lidocaine + adrenaline, respectively. Of the responders, 70 % always performed a negative aspiration of blood before injecting the drug, 27 % sometimes aspirated and the remaining 3 % never aspirated. The majority of the responders (93 %) were unaware of the toxic dose of bupivacaine. Only 70 % of responders believed that LAs could be toxic [95 % confidence interval (CI) 65.5-74.5 %], and 81 % of these correctly identified the signs and symptoms of cardiotoxicity. Only 2 % of responders knew that lipid emulsion is a part of its treatment (95 % CI 0.6-3.4 %). Based on these results, there is a definite need to increase the awareness of detection and treatment of local anesthetic toxicity among all medical practitioners who regularly use LAs.

[Spinal anesthesia versus general anesthesia in the surgical treatment of inguinal hernia. Cost-effectiveness analysis]. / Anestesia subaracnoidea y anestesia general en el tratamiento quirúrgico de la hernia inguinal en pacientes ambulatorios. Análisis comparativo de coste-efectividad.

OBJECTIVE: To compare the costs related to the clinical effectiveness of general anesthesia versus spinal anesthesia in inguinal hernioplasty ambulatory surgery. MATERIAL AND METHODS: An observational, retrospective cohort study measurement and analysis of cost-effectiveness, in the ambulatory surgery unit of a general hospital. All patients over 18 years of age diagnosed with primary inguinal hernia and scheduled for unilateral hernioplasty between January 2010 and December 2011 were included. Duration of anesthetic induction, length of stay in both the operating room, and in the post-anesthesia care unit, the anesthetic effectiveness (the incidence of adverse effects and the patient's comfort level), and variable economic costs associated with the use of drugs, as well as the use of human resources, were compared. RESULTS: The final analysis included 218 patients, 87.2% male, with a mean age of 53 years (range: 18-85 years). Of these, 139 (63.76%) received subarachnoid anesthesia and 79,(36.2%) general anesthesia. The length of time a patient remained in the post-anesthesia care unit was 337.6±160.2min in the subarachnoid anesthesia group, and 210.0±97.5min for the general anesthesia group (P<.001). Costs of drugs for general anesthesia were higher than that for subarachnoid anesthesia (86.2±8.3 vs. 18.7±7.2). The total cost difference between the 2 techniques was €115.8 more for subarachnoid anesthesia (P<.001). CONCLUSIONS: Both techniques showed similar effectiveness. The overall costs for subarachnoid anesthesia were greater than for the general. The cost-effectiveness of general anesthesia is better for outpatient inguinal hernia repair surgery.

Assessment of effects of physical or chemical factors on fat particle viability by glucose transport test.

BACKGROUND: It is important to protect fat viability during grafting. This study aimed to clarify whether physical or chemical factors damage fat viability. METHODS: Fat was harvested under high and low tumescence pressure, using syringes and a liposuction machine; this fat was injected through different gauge needles and cultured with lidocaine or epinephrine. Samples were subjected to glucose transport test and observed histologically. RESULT: The viability and microstructure of fat harvested under high and low tumescence pressure, and by syringe and liposuction machine, were similar (P > 0.05). The viability and intactness of fat cells injected through needles decreased with decreasing needle diameter (P < 0.05). Lidocaine (P < 0.05) and epinephrine (P < 0.05) weakened fat viability. CONCLUSIONS: Fat used for grafting can be harvested by tumescent techniques and a liposuction machine. Fat cell viability during injection increases with increasing needle diameter. Fat should be purified to remove drugs.