Local anaesthetic systemic toxicity complicating intraoperative intercostal nerve blocks: What do clinicians need to know to prevent similar occurrence?

Local anaesthetic systemic toxicity is a life-threatening adverse event that may occur after administration of local anaesthetics through a variety of routes. Local anaesthetic systemic toxicity is always a potential complication and may occur with all local anaesthetics and in any route of administration. Local anaesthetic systemic toxicity primarily affects the central nervous system and the cardiovascular system and may be fatal. The following is a case of local anaesthetic systemic toxicity complicating surgeon-performed intraoperative intercostal nerve blocks at multiple levels, with a mixture of liposomal bupivacaine and bupivacaine hydrochloride in a patient who underwent video-assisted segmental lung resection for lung cancer under general anaesthesia. Local anaesthetic systemic toxicity presented with seizures and hypotension. The patient was successfully managed and fully recovered. This case illustrates the importance of awareness regarding the prevention, diagnosis and treatment of local anaesthetic systemic toxicity among medical professionals who administer local anaesthetics.

[Anterior cutaneous nerve entrapment syndrome: a frequently overlooked cause of chronic abdominal pain in children].

Anterior cutaneous nerve entrapment syndrome (ACNES) is often overlooked in the differential diagnosis of chronic abdominal pain (CAP). An 11-year-old boy with CAP previously studied in emergency and digestive services without detecting organic pa-thology, suggesting a psychosomatic origin. On examination, he showed pain in the abdominal wall located to the area of the terminal branch of the Th11 intercostal nerve, with a positive Carnett's sign and a favorable response to injection with local anesthetic at the trigger point. Somatosensory evoked potentials revealed right anterior rectus nerve neuropathy. He was diagnosed with ACNES. As treatment, an ultrasound-guided subfascial injection with lidocaine and dexame-thasone into the trigger point was administered. After four months, he remains asymptomatic. For the treatment of ACNES in pediatrics patients, a step-up strategy should be applied, starting with trigger point in-jections of lidocaine and dexamethasone and reserving anterior neurectomy for those cases with limited effect of these injections.

Transthoracic Arteriovenous Graft Repair With the Pectoralis (PECS) II Nerve Block for Primary Intraoperative Anesthesia and Postoperative Analgesia: A Case Report.

The PECS II nerve block is a relatively new regional anesthetic technique that targets the medial and lateral pectoral nerves, as well as the lateral cutaneous branches of the intercostal nerves. It has been described for surgical cases involving the breast, as an adjunct or alternative to neuraxial or paravertebral techniques. This case report describes the first successful use of the PECS II nerve block placed using ultrasound guidance as the primary anesthetic and postoperative analgesic in a non-breast-related chest wall surgery.

[Electroacupuncture at intercostal nerve for mammary gland hyperplasia in rats].

OBJECTIVE: To explore the correlation between efficacy of electroacupuncture (EA) on mammary gland hyperplasia (MGH) and the regulatory pathway of intercostal nerve. METHODS: Fifty female SD rats were randomly divided into a blank group (group A, 12 rats), a model group (group B, 12 rats), an EA group (group C, 13 rats) and an intercostal nerve transection group (group D, 13 rats). The rats in the group B, group C and group D were prepared into MGH model; after model was successfully prepared, the 7th intercostal nerve was cut off in the group D. EA was applied at back acupoints including bilateral "Tianzong" (SI 11), "Ganshu" (BL 18) and "Shenshu" (BL 23) as well as chest acupoints including bilateral "Wuyi" (ST 15), "Hegu" (LI 4) and "Danzhong" (CV 17) in the group C and D. The two groups of acupoints were selected alternately. EA was given for 20 min, once a day; 5-day treatment was taken as one course; there was an interval of 2 days between course; totally 20 treatments were given. After treatment, the height and diameter of papilla were observed; the contents of serum estradiol (E2) and progestin (P), the expression of estrogen receptor α (ERα) and progestrone receptor (PR) in mammary gland were measured. RESULTS: (1) The height and diameter of papilla: after treatment, the height and diameter of papilla in the group C were significantly smaller than those in the group B (both P<0.05); the height and diameter of left-side papilla in the group D were significantly bigger than those in the group C (both P<0.05). (2) Serum E2 and P: after treatment, compared with the group B, the contents of E2 and E2/P were reduced and the content of P was increased in the group C and group D (all P<0.05). Compared with the group C, the contents of E2 and E2/P were increased and the content of P was reduced in the group D (all P<0.05). (3) ERα and PR in mammary gland: compared with the group B, the content of ERαwas decreased and the content of PR was increased in the group C (both P<0.05). Compared with the group C, the content of ERαwas increased and the content of PR was decreased in the group D ((both P<0.05). CONCLUSION: The efficacy mechanism of EA for MGH is likely to be related with the pathway of intercostal nerve; the mechanism may be acupuncture regulating the contents of serum E2 and P as well as contents of ERα and PR in mammary gland.

Nonintubated Uniportal Video-Assisted Thoracoscopic Surgery: A Single-Center Experience

BACKGROUND: We report our surgical technique for nonintubated uniportal video-assisted thoracoscopic surgery (VATS) pulmonary resection and early postoperative outcomes at a single center. METHODS: Between January and July 2017, 40 consecutive patients underwent nonintubated uniportal VATS pulmonary resection. Multilevel intercostal nerve block was performed using local anesthesia in all patients, and an intrathoracic vagal blockade was performed in 35 patients (87.5%). RESULTS: Twenty-nine procedures (72.5%) were performed in patients with lung cancer (21 lobectomies, 6 segmentectomies, and 2 wedge resections), and 11 (27.5%) in patients with pulmonary metastases, benign lung disease, or pleural disease. The mean anesthesia time was 166.8 minutes, and the mean operative duration was 125.9 minutes. The mean postoperative chest tube duration was 3.2 days, and the mean hospital stay was 5.8 days. There were 3 conversions (7.5%) to intubation due to intraoperative hypoxemia and 1 conversion (2.5%) to multiportal VATS due to injury of the segmental artery. There were 7 complications (17.5%), including 3 cases of prolonged air leak, 2 cases of chylothorax, 1 case of pleural effusion, and 1 case of pneumonia. There was no in-hospital mortality. CONCLUSION: Nonintubated uniportal VATS appears to be a feasible and valid surgical option, depending on the surgeon’s experience, for appropriately selected patients.

A Novel Minimally Invasive Wireless Technology for Neuromodulation via Percutaneous Intercostal Nerve Stimulation for Post-Herpetic Neuralgia: A Case Report with Short-Term Follow-up.

BACKGROUND: Peripheral nerve stimulation of primary afferent neurons provides control of localized chronic pain. This technique applies permanent electrical stimulation at the target area via a minimally invasive, subcutaneous placement of an electrode. OBJECTIVE: To assess the analgesic effects of minimally invasive wireless neuromodulation in the treatment of chronic intractable pain secondary to post-herpetic neuralgia. CASE SUMMARY: A 78-year-old man presented with severe intractable post-herpetic neuralgic pain. He was known to have non-Hodgkin's lymphoma under remission following treatment with chemotherapy and stem cell transplantation, twice. He also developed steroid-induced diabetes mellitus during this treatment. In view of his compromised immune status, he was deemed a suitable candidate for our minimally invasive neuromodulation technology. Two subcutaneous electrodes were placed on the right-hand side of the trunk, 10 cm medial and parallel to the spinous process at the level of T7-T8 under fluoroscopic guidance along the T7 intercostal nerve. The external transmitter was worn with a belt over a single layer of clothing and used to transmit power to the stimulator. The entire procedure required only a small incision for the introduction of the electrode placement. RESULTS: After an uneventful procedure, the pain score decreased from 8 to 3, with a reduction in pain medication. The EuroQol Five Dimensions Questionnaire scores were 0.102 before the trial, 0.630 at 1 month, and 0.576 at 3 months. CONCLUSIONS: Subcutaneous placement of electrodes with our minimally invasive technique and wireless neuromodulation technology was safe and effective. Significant improvements in pain relief ensued, and no further adverse events had been reported at the end of 3 months' follow-up.

Axillary local anesthetic spread after the thoracic interfacial ultrasound block - a cadaveric and radiological evaluation / Dispersão axilar de anestésico local após bloqueio interfascial torácico guiado por ultrassom - estudo radiológico e em cadáver

Abstract Background Oral opioid analgesics have been used for management of peri- and postoperative analgesia in patients undergoing axillary dissection. The axillary region is a difficult zone to block and does not have a specific regional anesthesia technique published that offers its adequate blockade. Methods After institutional review board approval, anatomic and radiological studies were conducted to determine the deposition and spread of methylene blue and local anesthetic injected respectively into the axilla via the thoracic inter-fascial plane. Magnetic Resonance Imaging studies were then conducted in 15 of 34 patients scheduled for unilateral breast surgery that entailed any of the following: axillary clearance, sentinel node biopsy, axillary node biopsy, or supernumerary breasts, to ascertain the deposition and time course of spread of solution within the thoracic interfascial plane in vivo. Results Radiological and cadaveric studies showed that the injection of local anesthetic and methylene blue via the thoracic inter-fascial plane, using ultrasound guide technique, results in reliable deposition into the axilla. In patients, the injection of the local anesthetic produced a reliable axillary sensory block. This finding was supported by Magnetic Resonance Imaging studies that showed hyper-intense signals in the axillary region. Conclusions These findings define the anatomic characteristics of the thoracic interfascial plane nerve block in the axillary region, and underline the clinical potential of this novel nerve block.

Resumo Justificativa Os analgésicos orais à base de opioides têm sido usados para o manejo da analgesia nos períodos peri e pós-operatório de pacientes submetidos à linfadenectomia axilar. A região axilar é uma zona difícil de bloquear e não há registro de uma técnica de anestesia regional específica que ofereça o seu bloqueio adequado. Métodos Após a aprovação do Conselho de Ética institucional, estudos anatômicos e radiológicos foram feitos para determinar a deposição e disseminação de azul de metileno e anestésico local, respectivamente injetados na axila via plano interfascial torácico. Exames de ressonância magnética foram então feitos em 15 de 34 pacientes programados para cirurgia de mama unilateral que envolveria qualquer um dos seguintes procedimentos: esvaziamento axilar, biópsia de linfonodo sentinela, biópsia de linfonodo axilar ou mamas supranumerárias, para verificar a deposição e o tempo de propagação da solução dentro do plano interfascial torácico in vivo. Resultados Estudos radiológicos e em cadáveres mostraram que a injeção de anestésico local e azul de metileno via plano interfascial torácico com a técnica guiada por ultrassom resulta em deposição confiável na axila. Nos pacientes, a injeção de anestésico local produziu um bloqueio sensitivo axilar confiável. Esse achado foi corroborado por estudos de ressonância magnética que mostraram sinais hiperintensos na região axilar. Conclusões Esses achados definem as características anatômicas do bloqueio da região axilar e destacam o potencial clínico desses novos bloqueios.

Lateral Cutaneous Nerve Entrapment Syndrome (LACNES): A previously unrecognized cause of intractable flank pain.

BACKGROUND AND AIMS: Chronic abdominal pain may occasionally be due to terminal endings of intercostal nerves (ACNES, abdominal cutaneous nerve entrapment syndrome) that are entrapped in the abdominal wall. Spontaneous neuropathic flank pain may also be caused by involvement of branches of these intercostal nerves. Aim is to describe a series of patients with flank pain due to nerve entrapment and to increase awareness for an unknown condition coined Lateral Cutaneous Nerve Entrapment Syndrome (LACNES). METHODS: Patients possibly having LACNES (constant area of flank tenderness, small point of maximal pain with neuropathic characteristics, locoregional altered skin sensation) presenting between January 2007 and May 2016 received a diagnostic 5-10mL 1% lidocaine injection. Pain levels were recorded using a numerical rating scale (0, no pain to 10, worst possible). A >50% pain reduction was defined as success. Long term effect of injections and alternative therapies were determined using a satisfaction scale (1, very satisfied, no pain - 5, pain worse). RESULTS: 30 patients (21 women, median age 52, range 13-78) were diagnosed with LACNES. Pain following one injection dropped from 6.9±1.4 to 2.4±1.9 (mean, p<0.001) leading to an 83% immediate success rate. Repeated injection therapy was successful in 16 (pain free n=7, pain acceptable, n=9; median 42 months follow-up). The remaining 14 patients received (minimally invasive) surgery (n=5) or other treatments (medication, manual therapy or pulsed radiofrequency, n=9). Overall treatment satisfaction (scale 1 or 2) was attained in 79%. CONCLUSIONS AND IMPLICATIONS: LACNES should be considered in patients with chronic flank pain. Injection therapy is long term effective in more than half of the population.

[Axillary local anesthetic spread after the thoracic interfacial ultrasound block - a cadaveric and radiological evaluation]. / Dispersão axilar de anestésico local após bloqueio interfascial torácico guiado por ultrassom - estudo radiológico e em cadáver.

BACKGROUND: Oral opioid analgesics have been used for management of peri- and postoperative analgesia in patients undergoing axillary dissection. The axillary region is a difficult zone to block and does not have a specific regional anesthesia technique published that offers its adequate blockade. METHODS: After institutional review board approval, anatomic and radiological studies were conducted to determine the deposition and spread of methylene blue and local anesthetic injected respectively into the axilla via the thoracic inter-fascial plane. Magnetic Resonance Imaging studies were then conducted in 15 of 34 patients scheduled for unilateral breast surgery that entailed any of the following: axillary clearance, sentinel node biopsy, axillary node biopsy, or supernumerary breasts, to ascertain the deposition and time course of spread of solution within the thoracic interfascial plane in vivo. RESULTS: Radiological and cadaveric studies showed that the injection of local anesthetic and methylene blue via the thoracic inter-fascial plane, using ultrasound guide technique, results in reliable deposition into the axilla. In patients, the injection of the local anesthetic produced a reliable axillary sensory block. This finding was supported by Magnetic Resonance Imaging studies that showed hyper-intense signals in the axillary region. CONCLUSIONS: These findings define the anatomic characteristics of the thoracic interfascial plane nerve block in the axillary region, and underline the clinical potential of this novel nerve block.

Pulsed radiofrequency or anterior neurectomy for anterior cutaneous nerve entrapment syndrome (ACNES) (the PULSE trial): study protocol of a randomized controlled trial.

BACKGROUND: Some patients with chronic abdominal pain suffer from an anterior cutaneous nerve entrapment syndrome (ACNES). This somewhat illusive syndrome is thought to be caused by the entrapment of end branches of the intercostal nerves residing in the abdominal wall. If ACNES is suspected, a local injection of an anesthetic agent may offer relief. If pain is recurrent following multiple-injection therapy, an anterior neurectomy entailing removal of the entrapped nerve endings may be considered. After 1 year, a 70% success rate has been reported. Research on minimally invasive alternative treatments is scarce. Pulsed radiofrequency (PRF) treatment is a relatively new treatment for chronic pain syndromes. An electromagnetic field is applied around the nerve in the hope of leading to pain relief. This randomized controlled trial compares the effect of PRF treatment and neurectomy in patients with ACNES. METHODS: Adult ACNES patients having short-lived success following injections are randomized to PRF or neurectomy. At the 8-week follow-up visit, unsuccessful PRF patients are allowed to cross over to a neurectomy. Primary outcome is pain relief after either therapy. Secondary outcomes include patient satisfaction, quality of life, use of analgesics and unanticipated adverse events. The study is terminated 6 months after receiving the final procedure. DISCUSSION: Since academic literature on minimally invasive techniques is lacking, well-designed trials are needed to optimize results of treatment for ACNES. This is the first large, randomized controlled, proof-of-concept trial comparing two therapy techniques in ACNES patients. The first patient was included in October 2015. The expected trial deadline is December 2017. If effective, PRF may be incorporated into the ACNES treatment algorithm, thus minimizing the number of patients requiring surgery. TRIAL REGISTRATION: Nederlands Trial Register (Dutch Trial Register), NTR5131 ( http://www.trialregister.nl/trialreg/admin/rctview.asp?TC=5131 ). Registered on 15 April 2015.

[Clinical evaluation of in-plane ultrasound-guided thoracic paravertebral block using laterally intercostal approach].

OBJECTIVE: To evaluate the feasibility and success rate of in-plane ultrasound-guided paravertebral block using laterally intercostal approach. METHODS: In the study, 27 patients undergoing elective thoracic surgery were selected to do paravertebral block preoperatively. The fifth intercostal space was scanned by ultrasound probe which was placed along the long axis of the rib and 8 cm lateral to the midline of the spine. The needle was advanced in increments aiming at the space between the internal and innermost intercostal muscles. Once the space between the muscles was achieved, 20 mL of 0.5% (mass fraction) ropivacaine was injected and a catheter was inserted. Whether the tip of catheter was in right place was evaluated by ultrasound image. The block dermatomes of cold sensation were recorded 10, 20 and 30 min after the bolus drug was given. Then 0.2% ropivacaine was infused with 6 mL/h via the catheter by an analgesia pump postoperatively. The block dermatomes of cold sensation and pain score were recorded 1, 6, 24 and 48 h postoperatively. RESULTS: The first attempt success rate of catheteration was 81.48% (22/27); the tips of catheter were proved in right places after the second or third attempt in 5 patients. The median numbers of the block dermatomes 10, 20 and 30 min after the bolus drug was given were 2, 3, 4; the median numbers of block dermatomes were 5, 5, 5, 4, and of pain score were 1, 1, 2, 2 at 1, 6, 24, 48 h postoperatively; no case of bilateral block, pneumothorax or vessel puncture occurred. CONCLUSION: Thoracic paravertebral block using laterally intercostal approach is feasible, which has high success rate of block and low rate of complications.

Multi-Modal Treatment Approach to Painful Rib Syndrome: Case Series and Review of the Literature.

BACKGROUND: Mechanical chest wall pain is a common presenting complaint in the primary care office, emergency room, and specialty clinic. Diagnostic testing is often expensive due to similar presenting symptoms that may involve the heart or lungs. Since the chest wall biomechanics are poorly understood by many clinicians, few effective treatments are offered to patients with rib-related acute pain, which may lead to chronic pain. OBJECTIVE: This case series and literature review illustrates biomechanics involved in the pathogenesis of rib-related chest wall pain and suggests an effective multi-modal treatment plan using interventional techniques with emphasis on manual manipulative techniques. STUDY DESIGN: Case series and literature review. SETTING: Pain clinic in an academic medical center. RESULTS: This is a case series of 3 patients diagnosed with painful rib syndrome using osteopathic palpatory physical examination techniques. Ultrasound-guided intercostal nerve blocks were followed by manual manipulation of mechanically displaced ribs as a part of our multi-modal treatment plan. A review of the literature was undertaken to clarify nomenclature used in the description of rib-related pain, to describe the biomechanics involved in the pathogenesis of mechanical rib pain, and to illustrate the use of effective manual manipulation techniques. LIMITATION: This review is introductory and not a complete review of all manual or interventional pain management techniques applicable to the treatment of mechanical rib-related pain. CONCLUSIONS: Manual diagnostic and therapeutic skills can be learned by physicians to treat biomechanically complex rib-related chest wall pain in combination with interventional image-guided techniques. Pain physicians should learn certain basic manual manipulation skills both for diagnostic and therapeutic purposes.

Bloqueo fascial ecoguiado de las ramas cutáneas de los nervios intercostales: una buena alternativa analgésica para la cirugía abierta de vesícula biliar / Ultrasound-guided cutaneous intercostal branches nerves block: a good analgesic alternative for gallbladder open surgery

El abordaje laparoscópico es el tratamiento de elección para la cirugía de vesícula, sin embargo, algunos pacientes requieren una conversión de la técnica, lo que origina en ellos un dolor postoperatorio moderado-severo. Tradicionalmente los opioides han sido utilizados para tratar dicho dolor, pero sus efectos secundarios han llevado a la búsqueda de nuevas alternativas (administración de anestésicos locales en plexos, fascias, nervios o herida). Presentamos 4 casos clínicos a los que se realizó el bloqueo ecoguiado de las ramas cutáneas de los nervios intercostales en la línea axilar media de T6 a T12 con levobupivacaína como alternativa analgésica en cirugía abierta de vesícula, con unos buenos resultados (AU)

Laparoscopic cholecystectomy has become the standard treatment for gallbladder diseases. However, there are still some patients for whom conversion to open surgery is required. This surgery can produce significant post-operative pain. Opioids drugs have traditionally been used to treat this pain, but side effects have led to seeking alternatives (plexus, nerve or fascia blocks or wound). The cases are presented of 4 patients subjected to ultrasound-guided intercostal branches blocks in the mid-axillary line from T6 to T12 with levobupivacaine as an analgesic alternative in open surgery of gallbladder, with satisfactory results (AU)

Comparative study of phrenic and intercostal nerve transfers for elbow flexion after global brachial plexus injury.

BACKGROUND: Global brachial plexus injuries (BPIs) are devastating events frequently resulting in severe functional impairment. The widely used nerve transfer sources for elbow flexion in patients with global BPIs include intercostal and phrenic nerves. OBJECTIVE: The aim of this study was to compare phrenic and intercostal nerve transfers for elbow flexion after global BPI. METHODS: A retrospective review of 33 patients treated with phrenic and intercostal nerve transfer for elbow flexion in posttraumatic global root avulsion BPI was carried out. In the phrenic nerve transfer group, the phrenic nerve was transferred to the anterolateral bundle of the anterior division of the upper trunk (23 patients); in the intercostal nerve transfer group, three intercostal nerves were coapted to the anterolateral bundles of the musculocutaneous nerve. The British Medical Research Council (MRC) grading system, angle of elbow flexion, and electromyography (EMG) were used to evaluate the recovery of elbow flexion at least 3 years postoperatively. RESULTS: The efficiency of motor function in the phrenic nerve transfer group was 83%, while it was 70% in the intercostal nerve transfer group. The two groups were not statistically different in terms of the MRC grade (p=0.646) and EMG results (p=0.646). The outstanding rates of angle of elbow flexion were 48% and 40% in the phrenic and intercostal nerve transfer groups, respectively. There was no significant difference of outstanding rates in the angle of elbow flexion between the two groups. CONCLUSION: Phrenic nerve transfer had a higher proportion of good prognosis for elbow flexion than intercostal nerve transfer, but the effective and outstanding rate had no significant difference for biceps reinnervation between the two groups according to MRC grading, angle of elbow flexion, and EMG.

Comparison of postoperative pain relief by intercostal block between pre-rib harvest and post-rib harvest groups.

OBJECTIVE: To compare intercostal nerve block before and after rib harvest in terms of mean postoperative pain score and mean postoperative tramadol usage. STUDY DESIGN: Randomized controlled trial. PLACE AND DURATION OF STUDY: Department of Plastic Surgery, Mayo Hospital, KEMU, Lahore, from January 2011 to July 2012. METHODOLOGY: Patients (n = 120) of either gender with ASA class-I and II requiring autogenous costal cartilage graft were inducted. Patients having history of local anaesthetic hypersensitivity and age < 15 years or > 60 years were excluded. Subjects were randomly assigned to pre-rib harvest (group-1) and post-rib harvest (group-2). Local anaesthetic mixture was prepared by adding 10 milliliters 2% lidocaine to 10 milliliters 0.5% bupivacaine to obtain a total 20 ml solution. Group-1 received local anaesthetic infiltration along the proposed incision lines and intercostals block before the rib harvest. Group-2 received the infiltration and block after rib harvest. Postoperative consumption of tramadol and pain scores were measured at 6 and 12 hours postoperatively using VAS. RESULTS: Mean age was 31.43 ± 10.78 years. The mean pain scores at 6 hours postoperatively were 1.033 ± 0.609 and 2.4667 ± 0.812 in pre-rib harvest and post-rib harvest groups respectively (p < 0.0001). The mean pain scores at 12 hours postoperatively were 1.45 ± 0.565 and 3.65 ± 0.633 in pre-rib harvest and post-rib harvest groups respectively (p < 0.0001). The mean tramadol used postoperatively in first 24 hours was 169 ± 29.24 mg and 255 ± 17.70 mg in prerib harvest and post-rib harvest groups respectively (p < 0.0001). CONCLUSION: Intercostal block administered before rib harvest as preemptive strategy result in decreased postoperative pain scores and narcotic use.

Combined usage of intercostal nerve block and tumescent anaesthesia: an effective anaesthesia technique for breast augmentation.

Patients are occasionally unhappy with the size, shape, and positioning of breast implants. An option to improve their satisfaction with breast augmentation includes directly involving them in the process with awake surgery done under nerve block and tumescence. This study describes the resultsof using such an awake anaesthesia technique in 35 patients. After the intercostal nerves dominating the Th3 to Th6 regions were anaesthetized using 0.5% bupivacaine, a tumescent solution consisting of lidocaine, epinephrine, and saline was injected around the mammary gland, and breast augmentation was conducted using silicon implants. The majority of patients (31/35) reported no pain during the procedure and all patients were able to choose and confirm their final implant size and positioning. In all cases, blood loss was less than 10 ml. No patient experienced pneumothorax or toxicity of local anaesthetics. Combined usage of the intercostal nerve block and tumescent anaesthesia effectively reduces pain during breast augmentation. Keeping patient conscious enables meeting their requests during operation, contributing to increased satisfaction. For these advantages, combined usage of the intercostal nerve block and tumescent anaesthesia is recommended as a useful anaesthetic technique for breast augmentation.

Randomized clinical trial of trigger point infiltration with lidocaine to diagnose anterior cutaneous nerve entrapment syndrome.

BACKGROUND: Anterior cutaneous nerve entrapment syndrome (ACNES) is hardly considered in the differential diagnosis of chronic abdominal pain. Some even doubt the existence of such a syndrome and attribute reported successful treatment results to a placebo effect. The objective was to clarify the role of local anaesthetic injection in diagnosing ACNES. The hypothesis was that pain attenuation following lidocaine injection would be greater than that after saline injection. METHODS: Patients aged over 18 years with suspected ACNES were randomized to receive an injection of 10 ml 1 per cent lidocaine or saline into the point of maximal abdominal wall pain just beneath the anterior fascia of the rectus abdominis muscle. Pain was recorded using a visual analogue scale (VAS; 1-100 mm) and a verbal rating scale (VRS; 0, no pain; 4, severe pain) during physical examination just before and 15-20 min after injection. A reduction of at least 50 per cent on the VAS and/or 2 points on the VRS was considered a successful response. RESULTS: Between August 2008 and December 2010, 48 patients were randomized equally (7 men and 41 women, median age 47 years). Four patients in the saline group reported a successful response compared with 13 in the lidocaine group (P = 0·007). CONCLUSION: Entrapped branches of intercostal nerves may contribute to the clinical picture in some patients with chronic abdominal pain. Pain reduction following local infiltration in these patients was based on an anaesthetic mechanism and not on a placebo or a mechanical (volume) effect. REGISTRATION NUMBER: NTR2016 (Nederlands Trial Register; http://www.trialregister.nl).

Breast augmentation and augmentation-mastopexy with local anesthesia and intravenous sedation.

BACKGROUND: Administration of intravenous sedation and intercostal nerve blocks has resulted in reduced postoperative nausea and faster recovery as compared to general anesthesia. OBJECTIVES: The authors present their experience with intercostal nerve blocks and intravenous sedation in breast augmentation, with and without simultaneous mastopexy. Their protocol does not include propofol and thus can be administered by the surgeon and circulating nurse. METHODS: The initial dose of intravenous sedation was administered by the surgeon, starting with midazolam, fentanyl, and ketamine; additional doses (as needed) were given by the circulating nurse. Local anesthesia blocks were injected into Intercostal Spaces 3-7 at the midaxillary line. The anesthetic solution was injected at the lateral sternal boarder in varying amounts. A retrospective review was performed of 171 patients who underwent bilateral breast augmentation or augmentation-mastopexy with this protocol. The two groups were analyzed for age, body mass index, operating time, total amount of sedation/anesthesia, recovery room time, postoperative nausea, and complications. RESULTS: Of the 171 patients, 132 underwent augmentation and 39 had augmentation-mastopexy. All recovered well from anesthesia. The mean recovery room time was 49.9 minutes for the augmentation group and 52.9 minutes for the augmentation-mastopexy group. Postoperative nausea occurred in 14 (10.6%) patients who received augmentation alone and in five (12.8%) who underwent augmentation-mastopexy. There were no serious complications or hospital admissions. CONCLUSIONS: Breast augmentation with or without mastopexy can be performed safely, with minimal discomfort and complications, by employing local anesthesia with intravenous sedation. Although augmentation-mastopexy requires more operating time than augmentation alone, the recovery times are comparable.

Extract of grains of paradise and its active principle 6-paradol trigger thermogenesis of brown adipose tissue in rats.

Grains of paradise (GP) is a species of the ginger family, Zingiberaceae, extracts of which have a pungent, peppery taste due to an aromatic ketone, 6-paradol. The aim of this study was to explore the thermogenic effects of GP extracts and of 6-paradol. Efferent discharges from sympathetic nerves entering the interscapular brown adipose tissue were recorded. Intragastric injection of a GP extract or 6-paradol enhanced the efferent discharges of the sympathetic nerves in a dose-dependent manner. The enhanced nerve discharges were sustained for as long as 3h. The rats did not become desensitized to the stimulatory effects these compounds on sympathetic nerve activity. The tissue temperature of brown adipose tissue showed significant increase in rats injected with 6-paradol. These results demonstrate that GP extracts and 6-paradol activate thermogenesis in brown adipose tissue, and may open up new avenues for the regulation of weight loss and weight maintenance.