Efficacy of Eutectic Mixture of Local Anesthetics on Pain Control During Extracorporeal Shock Wave Lithotripsy: A Systematic Review and Meta-Analysis.

BACKGROUND The efficacy of a eutectic mixture of local anesthetics (EMLA) for pain control in extracorporeal shock wave lithotripsy is unclear. The aim of this study was to assess the effect of EMLA cream on pain control during extracorporeal shock wave lithotripsy. MATERIAL AND METHODS We searched Medline, EMBASE, and the Cochrane Central Register of Controlled Trials to identify relevant randomized controlled trials that compared the pain control efficacies of EMLA vs. placebo. Study eligibility criteria, participants, and interventions: Randomized controlled trials that compared the effect of EMLA with placebo cream for patients underwent extracorporeal shock wave lithotripsy. Study appraisal and synthesis methods: Two review authors extracted data independently using a designed data extraction form and risk of bias by Cochrane Collaboration's tool. RESULTS Nine studies, including 10 randomized controlled trials with 1167 patients, were eligible. The EMLA group experienced less pain (mean difference, -0.47; 95% confidence interval, -0.78 to -0.16; p=0.003) and shorter duration of lithotripsy (mean difference, -1.70, 95% confidence interval: -2.31 to -1.10, p<0.0001) than the placebo group. There were no significant differences in the number of patients who needed extra intravenous medication (p=0.610), number of patients with insufficient extracorporeal shock wave lithotripsy pain control (p=0.530), and number of patients with opioid adverse effects (p=0.320). Limitations: Long interval between the studies, different kinds of lithotripters. CONCLUSIONS EMLA can reduce pain during the ESWL procedure.

Investigation of the Effects of Spinal Dexamethasone Injection as a Premedication in Rabbit Anesthesia.

Anesthesia and analgesia are important in human and veterinary medicine, especially in surgical procedures. Rodents, avians, and exotic species are required to be anesthetized using an appropriate anesthetic regimen. This study aimed to suggest a new anesthetic drug and method in order to facilitate anesthesia as well as analgesia among rabbits, laboratory animals, and humans. Spinal injection of dexamethasone combined with intramuscular ketamine among rabbits can play the role of premedication agents. A total of 24 healthy white adult rabbits from New-Zealand were equally assigned into four groups. Groups 1, 2, 3, and 4 were subjected to spinal xylazine (5mg/kg) with ketamine (35mg/kg,IM), spinal dexamethasone (0.37mg/kg-four times diluted) with ketamine (35mg/kg,IM), dexamethasone (4mg/kg,IM) with ketamine (35mg/kg,IM), and spinal dexamethasone (0.37mg/kg-four times diluted), respectively. The results showed that there was a significant difference in terms of clinical reflexes recorded for group 2, compared to groups 1 and 3. A significant difference was also observed regarding clinical reflexes between group 2 and the other groups. Furthermore, no abnormality was observed in terms of histological sections within groups 2 and 4. Spinal dexamethasone can be used as a premedication combined with ketamine in rabbit anesthesia.

Analgesic effect of trigger point injection and EMLA for shoulder pain in patients undergoing total laparoscopic hysterectomy: A randomized controlled study.

BACKGROUD: The purpose of this study was to evaluate the effects of trigger point injection (TPI) and eutectic mixture local anesthetics (EMLA) cream on the postoperative shoulder pain in patients undergoing total laparoscopic hysterectomy. METHODS: In this randomized, single-blinded, and controlled study, total 75 patients were randomly allocated to TPI group (n = 25), EMLA group (n = 25), and control group (n = 25). TPI group received TPIs with 2 mL of 0.2% ropivacaine, and EMLA group received an occlusive dressing with EMLA cream 2 g on both shoulders. Overall, abdominal, and shoulder pains were evaluated at rest and in motion on postoperative day 3. RESULTS: The incidence of shoulder pain was significantly reduced in EMLA group (56%) compared to control (88%) or TPI (88%) groups (P = .025 in both); the severity of shoulder pain was mitigated in EMLA and TPI groups compared to control group (P < .001, each). Consequently, the overall pain decreased in EMLA group and TPI group (P = .023). The patients with exercise habit (n = 31) showed lower incidence of pain than patients without exercise habit (n = 26) (P = .002, P = .005, and P = .037 in overall, abdominal, and shoulder pain, respectively). TPI or EMLA treatments decreased shoulder pain irrespective of exercise habit (P = .001 and P < .001, respectively), but decreased overall pain only in patients without exercise habit (P = .019). Lastly, EMLA lowered overall pain score at the time of first analgesic request in ward compared to control group (P = .02). CONCLUSIONS: TPI and EMLA with occlusive dressing effectively reduced the shoulder pain after total laparoscopic hysterectomy.

Prospective evaluation of anesthetic protocols during pediatric ophthalmic surgery.

PURPOSE: To date, no protocol of anesthesia for pediatric ophthalmic surgery is unanimously recognized. The primary anesthetic risks are associated with strabismus surgery, including oculocardiac reflex, postoperative nausea and vomiting, and postoperative pain. METHODS: This was a prospective, monocentric, observational study conducted in a tertiary pediatric ophthalmic unit. Our anesthetic protocol for strabismus surgery included postoperative nausea and vomiting prevention using dexamethasone and ondansetron. No drug-based prevention of oculocardiac reflex or local/locoregional anesthesia was employed. RESULTS: A total of 106 pediatric ophthalmic surgeries completed between November 2015 and May 2016 were analyzed. The mean patient age was 4.4 (range: 0.2-7.3, standard deviation: 2.4) years. Ambulatory rate was 90%. Oculocardiac reflex incidence was 65% during strabismus surgery (34/52), 50% during congenital cataract surgery (4/8), 33% during intramuscular injection of botulinum toxin (1/3), and 0% during other procedures. No asystole occurred. Postoperative nausea and vomiting incidence was 9.6% after strabismus surgery (5/52) and 0% following the other procedures. One child was hospitalized for one night because of persistent postoperative nausea and vomiting. Postoperative pain generally occurred early on in the recovery room and was quickly controlled. Its incidence was higher in patients who underwent strabismus surgery (27%) than in those who underwent other procedures (9%). CONCLUSION: Morbidity associated with ophthalmic pediatric surgery is low and predominantly associated with strabismus surgery. The benefit-risk ratio and cost-effectiveness of oculocardiac reflex prevention should be questioned. Our postoperative nausea and vomiting rate is low, thanks to the use of a well-managed multimodal strategy. Early postoperative pain is usually well-treated but could probably be more effectively prevented.

Analgesic effect of perineural magnesium sulphate for sciatic nerve block for diabetic toe amputation: A randomized trial.

BACKGROUND AND OBJECTIVES: High concentrations of local anesthetics may be neurotoxic for diabetic patients. Additive perineural administration of magnesium was reported to decrease the consumption of local anesthetics for nerve block. It was hypothesized that MgSO4 added to dilute ropivacaine was equianalgesic to more concentrated ropivacaine for toe amputations in diabetic patients. METHODS: Seventy diabetic patients were allocated into 3 groups: 1) perineural 200 mg MgSO4 added to 0.25% ropivacaine, 2) 0.25% ropivacaine alone, and 3) 0.375% ropivacaine alone. All patients underwent popliteal sciatic nerve block that was guided by ultrasonography using the respective regimens. Time of onset, duration of motor and sensory block were recorded. Spontaneous and evoked pain score, worst pain score, additional analgesic consumption, satisfaction score and initial time of analgesic requirement of each patient were documented up to 48 hours postoperatively. RESULTS: In comparison with 0.25% ropivacaine alone, magnesium supplement prolonged the duration of sensory block (p = 0.001), as well as better evoked pain score at 6 hour postoperatively (p = 0.001). In comparison with evoked pain score (1.6/10) in group of 0.375% ropivacaine, magnesium plus 0.25% ropivacaine presented a little higher score (2.5/10) at 6 hour postoperatively (p = 0.001), while lower worst pain score (p = 0.001) and less postoperative total analgesic consumption (p = 0.002). CONCLUSIONS: The regimen of adding 200mg MgSO4 to 0.25% ropivacaine for sciatic nerve block yields equal analgesic effect in comparison with 0.375% ropivacaine. These findings have suggested that supplemental MgSO4 could not improve analgesic quality except reducing the total amount of local anesthetics requirement in diabetic toe amputations with sciatic nerve blocks.

[Evaluation of peripherally inserted central catheters in a pediatric population]. / Évaluation des cathéters centraux à insertion périphérique en population pédiatrique.

A peripherally inserted central catheter (PICC) is a central venous access mostly used in France in the adult population, whereas it is only rarely used in the pediatric population. The main objective of this study was to analyze a cohort of children treated with PICCs inserted under radiological guidance. We conducted a single-center study in the Radiology department of Nice University Hospital and the Lenval Foundation Children's Hospital. During a 43-month period between November 2008 and June 2012, a total of 67 catheter placement attempts were performed in 57 pediatric patients aged from 7 months to 18 years. We achieved 95.5% technical success with a median procedure duration of 17min. Only 6% of the PICC placements required light intravenous sedation; all the others were performed using a combination of local anesthesia, EMLA cream, and equimolar mixture of oxygen and nitrous oxide (EMONO). Subjective scale analysis of pain during catheter insertion showed a median score of 2.1. Catheter life ranged from 1 to 210 days (median, 38.3 days) with the treatment fully completed in 75% of the cases. The overall complication rate was 18.7% (4.9 per 1000 catheter-days), largely dominated by mechanical complications (9.4%) such as accidental removal (6.2%) or catheter obstruction (3.1%). Infectious complications occurred in 7.8% of the patients. The duration of catheterization and the use of tape to secure the catheter significantly affected the occurrence of complications. Peripheral insertion of central catheters was highly feasible in infants and children. It is a simple, safe, and effective alternative to intravenous central devices in the pediatric population. The occurrence of complications, typically mechanical, must be reduced and prevented by strict management of this type of central line by the nursing team.

Dosis efectiva de ropivacaína vía intradural en cesáreas de emergencia del Departamento de Obstetricia en el Hospital de Supe Laura Esther Rodriguez Dulanto, Mayo - Septiembre 2013 / Effective dose of ropivacaine via intradural in caesarean section of emergency in the Department of Obstetrics at the Hospital of Supe Laura Esther Rodriguez Dulanto, May - September 2013

La investigación tiene como objetivo determinar evaluar y comparar dos dosis bajas de Ropivacaína conjuntamente con fentanilo 25 mg por vía intradural en pacientes sometidas a cesárea de emergencia del departamento de obstetricia en el Hospital de Supe Laura Esther Rodríguez Dulanto 2013. La investigación tiene diseño es no experimental, prospectivo, es de tipo descriptivo, observacional, comparativo. La muestra estuvo construido por 50 pacientes ASA I/II programadas para cesárea electiva. Las pacientes fueron distribuidos en dos grupos: 25 pacientes del grupo ROP 0,75 por ciento: ropivacaína 0,75 por ciento 1 mL con fentanilo 25ug y 25 pacientes del grupo ROP 1 por ciento: ropivacaína 1 por ciento 1 mL con fentanilo 25ug. La edad media de los pacientes con ROP 1 por ciento es de 23.2 años mientras que la edad de los pacientes con ROP 0.75 por ciento la edad media es 25.4 años, no se encontró diferencia significativas P0,05. Se encontró diferencias significativas P<0.05 en la presión arterial media en los TO, TI, T2, observándose menor tiempo en los pacientes con ROP 1 por ciento. Existe una mayor incidencia de hipotensión (60 por ciento) en el grupo...

A randomized, placebo controlled study: EMLA in minor breast surgery.

AIM: Patients undergoing excision for breast lumps prefer general anesthesia or local anesthesia plus sedation, because of the fear of pain for local anesthesia alone. The aim of this study is to show the efficacy of an eutectic mixture of local anesthetic lignocaine and prilocaine (EMLA®) in these patients. METHODS: This study has been designed randomized, placebo-controlled. Forty five patients undergoing excision for breast lumps were divided into three groups. The first group was administered local EMLA cream preoperatively (Group I, N.=15), the second group (Group II, N.=15) had no preoperative preparation and the third group was placebo group (Group III, N.=15). All groups underwent the operation under local anesthesia. Pain during the local anesthesia and three hours after the operation were assessed using the visual analog scale. The amount of local anesthetic used during the operation and the anesthetic need of patients after the operation were assessed. RESULTS: When the three groups were compared, it was found that the intensity of pain in the group with EMLA was considerably lower during and after the operation (P<0.05). The amount of local anesthetic used during the operation was lower (P<0.05) and the need for post-operative analgesic was also less than the usual (P<0.05). CONCLUSION: Topical EMLA use decreases the pain, provides per-operative and postoperative patient and physician comfort, improved patient's compliance, and simplifies the surgical procedure. This is the first study demonstrating that a topical anesthetic provides a non-invasive analgesia during benign breast mass excision.

High doses of ketamine-xylazine anesthesia reduce cardiac ischemia-reperfusion injury in guinea pigs.

Choosing an appropriate anesthetic protocol that will have minimal effect on experimental design can be difficult. Guinea pigs have highly variable responses to a variety of injectable anesthetics, including ketamine-xylazine (KX). Because of this variability, supplemental doses often are required to obtain an adequate plane of anesthesia. Our group studies the isolated guinea pig heart, and we must anesthetize guinea pigs prior to harvesting this organ. In this study, we sought to determine whether a higher dose of KX protected isolated guinea pig hearts against myocardial ischemia-reperfusion injury. Male Hartley guinea pigs (Crl:HA; 275 to 300 g; n = 14) were anesthetized with either of 2 doses of KX (K: 85 mg/kg, X: 15 mg/kg; or K: 200 mg/kg, X: 60 mg/kg). After thoracotomy, hearts underwent 20 min of ischemia followed by 2 h of reperfusion. The high dose of KX significantly reduced myocardial infarct size as compared with the low dose (36% ± 3% and 51% ± 6%, respectively). Furthermore, the high dose of KX improved hemodynamic function over that associated with the low dose as measured by increases in both left ventricular developed pressure (49 ± 4 and 30 ± 8 mm Hg, respectively) and maximal rate of left ventricular relaxation (-876 ± 70 and -576 ± 120 mm Hg/s, respectively). However, the high dose of KX did not alter the maximal rate of left ventricular contraction or coronary flow. These results suggest that supplementation of KX to ensure an adequate anesthetic plane may introduce unwanted variability in ischemia-reperfusion studies.

Evaluation of the efficacy of magnesium sulphate as an adjuvant to lignocaine for intravenous regional anaesthesia for upper limb surgery.

Several additives have been combined with local anaesthetics for intravenous regional anaesthesia to improve block quality, analgesia and to decrease tourniquet pain. Magnesium sulphate is one potential additive. This prospective, randomised, double-blinded study was conducted in 30 ASA physical status I or II patients undergoing upper limb surgery under tourniquet. In group L, patients received intravenous regional anaesthesia with lignocaine alone (9 ml of 2% lignocaine diluted with normal saline to total volume of 36 ml). Patients in group M received intravenous regional anaesthesia with lignocaine plus magnesium sulphate (6 ml of 25% magnesium sulphate plus 9 ml of 2% lignocaine diluted with normal saline to total volume of 36 ml). Assessment was by observing the response to injection of drug; sensory and motor block and tourniquet pain. The mean time of onset of sensory block was 12.40 and 3.47 minutes in groups L and M respectively (P < 0.001). The average times of onset of motor block in groups L and M were 17 and six minutes respectively (P < 0.001). Of the patients in group M, 66.7% reported moderate to severe pain while the drug was being injected, compared to 20% in group L (P=0.011). There was a statistically significant difference in visual analogue scale for tourniquet pain at 10 and 30 minutes after tourniquet inflation (lower in group M). These findings indicate that magnesium sulphate added as an adjuvant to lignocaine hastens the onset of sensory and motor block and decreases tourniquet pain. However there is increased incidence of transient pain on injection if magnesium sulphate is added.

A retrospective cohort study exploring the relationship between antenatal reflexology and intranatal outcomes.

The integration of reflexology into midwifery care has become more common in recent years as a result of a developing interest in alternative and complementary therapies and also due to the integration of new skills into midwifery practice. The objective of this study was to investigate the association of antenatal reflexology with different outcomes in the intranatal period. The key variables of interest were onset of labour, duration of labour, analgesia used and mode of delivery. The findings showed there was no significant difference in the onset of labour or duration of labour between the two groups. The group who had four or more reflexology treatments had a reduced length of labour but this was not statistically significant. There was a significant difference in the use of Entonox between the two groups with the reflexology group having a lower uptake. Fewer women in the reflexology group had a normal labour with a higher percentage of women having a forceps delivery. In conclusion the only statistically significant difference between groups was less use of Entonox in the reflexology group. Further research requires standardized treatment and outcome measurement using prospective randomized designs with large samples.

Chest drain removal pain and its management: a literature review.

AIMS AND OBJECTIVES: The purpose of this review was to analyse critically the published research on chest drain removal pain and its management. The findings of descriptive and non-pharmacological intervention studies were summarized and studies of analgesic efficacy were critiqued in depth. BACKGROUND: The removal of a chest drain is a painful and frightening experience, particularly for children. However, there is limited research regarding the amount of pain experienced or effectiveness of analgesia for this procedure. RESULTS: Fourteen studies were reviewed, including five descriptive studies; three studies of non-pharmacological interventions; and six randomized controlled trials of morphine, local anaesthetics and Entonox. The search revealed only two paediatric studies. Many of the studies had design limitations or were poorly reported. The majority of studies indicated that patients experienced moderate to severe pain during chest drain removal, even when morphine or local anaesthetics were given. CONCLUSIONS: Morphine alone does not provide satisfactory analgesia for chest drain removal pain. Non-steroidal anti-inflammatory drugs, local anaesthetics and inhalation agents may have a role to play in providing more effective analgesia for this procedure. RELEVANCE TO CLINICAL PRACTICE: Analgesic protocols for the management of painful procedures such as chest drain removal are unsatisfactory and practice in this area should be revised. More research is needed to determine the efficacy of drugs other than morphine, particularly Entonox and to investigate multi-modal techniques of management further.

Intrathecal fentanyl added to hyperbaric ropivacaine for transurethral resection of the prostate.

BACKGROUND: Our purpose was to evaluate the effect of intrathecal fentanyl 25 microg added to 18 mg of 6 mg ml(-1) hyperbaric ropivacaine on the characteristics of subarachnoid block and postoperative pain relief in patients undergoing TURP surgery. METHODS: The patients were randomly assigned into two groups: Group S (saline group, n=16) received 3 ml of 18 mg hyperbaric ropivacaine + 0.5 ml saline--in total, a 3.5-ml volume intrathecally; and Group F (fentanyl group, n=15) received 3 ml of 18 mg hyperbaric ropivacaine + 0.5 ml of 25 microg fentanyl--in total, a 3.5-ml volume intrathecally. In both groups the onset and recovery times of the sensory block, degree and recovery times of the motor block and side-effects were recorded and statistically compared. RESULTS: There was no significant difference between the groups in achieving the highest level of sensory block, and in the times taken to reach the peak level. Regression to L1 was significantly prolonged in the fentanyl group compared with the saline group (P=0.004). Times to the first feeling of pain and the first analgesic requirement were significantly prolonged in the fentanyl group compared with the saline group (P=0.011 and P=0.016, respectively). The frequency of pruritus was significantly higher in the fentanyl group compared with the saline group (P=0.022). CONCLUSION: Addition of fentanyl 25 microg to hyperbaric ropivacaine 18 mg for spinal anesthesia in patients undergoing TURP may significantly improve the quality and prolong the duration of analgesia, without causing a substantial increase in the frequency of major side-effects.

Effect of intratesticular injection of xylazine/ketamine combination on canine castration.

This study was performed to compare the effect of intratesticular (IT) injection of xylazine/ketamine combination for canine castration with those of intramuscular (IM) or intravenous (IV) injection. Xylazine and ketamine was administered simultaneously via intratesticularly (IT group), intramuscularly (IM group) or intravenously (IV group) at doses of 2 and 10 mg/kg, respectively. Pain response at the time of injection, mean induction time, mean arousal time, mean walking time and cardiopulmonary function during anesthesia were monitored after the xylazine and ketamine administration. In IV and IM groups, heart rates were significantly decreased 30 and 45 min after xylazine and ketamine administration, respectively (p < 0.05). Respiratory rates were significantly decreased in the IV group (p < 0.05). In the IT group, there was no significant changes in heart and respiratory rates. The occurrence of cardiac arrhythmias was less severe in IT group compared with those in IM and IV groups. The route of administration did not affect rectal temperature. Mean induction time was significantly (p < 0.05) longer in IT group than in IM and IV groups. On the contrary, mean arousal time and mean walking time were shortened in IT group. Clinical signs related to pain response at the time of injection and vomiting were less observed in IT group than in IM group, and head shaking was less shown in IT group than in IM and IV groups during recovery period. These results indicated that intratesticular injection of xylazine/ketamine for castration has several advantages such as less inhibition of cardiopulmonary function and fast recovery from anesthesia without severe complications, and would be an effective anesthetic method for castration in small animal practice.

Peribulbar anaesthesia using a combination of lidocaine, bupivocaine and clonidine in vitreoretinal surgery.

PURPOSE: The efficacy and safety of peribulbar anaesthesia was assessed using a combination of lidocaine, bupivacaine and clonidine during eye surgery. METHODS: We prospectively studied 100 vitreo-retinal surgical procedures performed by several surgeons. The exclusion criteria included age below 30 years and, axial length of the orbit above 28 mm. Peribulbar was performed using Hamilton's technique. A mixed anaesthetic solution of equal quantity of lidocaine 2% and bupivacaine 0.5% with clonidine (1 mg/kg) was injected. Patients received a mean volume of 14.5 ml +/- 3.5 of the mixture. Akinesia and analgesia were assessed 15 minutes later by the surgeon. Whenever required, supplemental lidocaine 2% (3 ml) by sub-Tenon infiltration was added by the surgeon. Supplemental injections were given only to patients who failed to develop analgesia. RESULTS: The mean age of patients (male 52%, female 48%) was 66 years +/- 10 (mean +/- SD, range 44-90). The 100 surgical procedures were made up of vitrectomy +/- gas +/- silicone oil (22/100), vitrectomy and lensectomy (6/100), vitrectomy and epiretinal membrane +/- laser coagulation +/- gas +/- silicone oil (35/100), scleral buckling or encircling +/- gas (36/100), and cryosurgery +/- gas (1/100). Analgesia was adequate throughout surgery without any supplementation in 85% of cases and with a sub-Tenon infiltration in 99%. Akinesia was complete in 84%, mild in 12% and absent in 4% of cases. The sub-Tenon injection was performed in 15% of cases. Three patients (3%) were agitated during surgery. No neurologic or cardiac complication was seen. In one patient, the systolic blood pressure decreased from 170 to 110 mmHg, 30 minutes after the institution of the peribulbar block. CONCLUSION: Our results show that peribulbar anaesthesia in the proposed mixture offers excellent analgesia in 85% of patients, and in 99% of the patients when supplemented by a subtenon injection. The current mixture of lidocaine, bupivacaine and clonidine is an excellent alternative to the previously used mixture etidocaine, bupivacaine and hyaluronidase for vitreoretinal surgery. However, a randomized controlled clinical trial is needed to prove the efficacy and safety of these results.

Anestesia y analgesia en cirugía proctológica ambulatoria / Analgesia and anaesthesia in ambulatory proctologic surgery

Introducción: Los avances de la cirugía proctológica, como la cirugía del día, constituyen un desafío para el desarrollo de las técnicas anestésicas. La analgesia balanceada puede favorecer este propósito. Objetivo: Evaluar una técnica de analgesia balanceada multimodal de analgesia sistémica, anestesia espinal y anestesia local en cirugía proctológica ambulatoria. Material y método: Se evaluaron en forma prospectiva 45 pacientes sometidos a cirugía proctológica de diversa patología orificial, a quienes se le administró analgesia sistémica con ketorolac 30 mg, anestesia espinal con bupivacaína 0,5 por ciento hiperbárica y anestesia local transesfinteriana con bupivacaína 0,25 por ciento. Fueron estudiados el nivel de bloqueo sensitivo y el grado de bloqueo motor. En el postoperatorio se evaluaron la regresión del bloqueo sensitivo-motor, la incidencia de complicaciones inmediatas en forma horaria, el tiempo hasta la ambulación, diuresis y el alta institucional. Resultados: En 48 por ciento de los pacientes se obtuvo un nivel de bloqueo sensitivo en "silla de montar", a nivel D11 en el 44 por ciento y a nivel D10 en el 8 por ciento de los casos. No hubo cambios intraoperatorios destacables. El tiempo promedio de recuperación de la sensibilidad fue de 88', y el de la motilidad de 150'. La ambulación tuvo lugar, en promedio, a los 201', y la micción espontánea a los 187'. Seis pacientes presentaron dolor con EVA menor que 60, tratados con rescates de dextropropoxifeno-dipirona. Discusión: La analgesia balanceada multimodal sistémica, espinal y local, permite una rápida recuperación y una ambulación precoz, con una incidencia de dolor fácilmente controlable, sin que se observen complicaciones tales como retención vesical o readmisiones no esperadas.

Anestesia y analgesia en cirugía proctológica ambulatoria / Analgesia and anaesthesia in ambulatory proctologic surgery

Introducción: Los avances de la cirugía proctológica, como la cirugía del día, constituyen un desafío para el desarrollo de las técnicas anestésicas. La analgesia balanceada puede favorecer este propósito. Objetivo: Evaluar una técnica de analgesia balanceada multimodal de analgesia sistémica, anestesia espinal y anestesia local en cirugía proctológica ambulatoria. Material y método: Se evaluaron en forma prospectiva 45 pacientes sometidos a cirugía proctológica de diversa patología orificial, a quienes se le administró analgesia sistémica con ketorolac 30 mg, anestesia espinal con bupivacaína 0,5 por ciento hiperbárica y anestesia local transesfinteriana con bupivacaína 0,25 por ciento. Fueron estudiados el nivel de bloqueo sensitivo y el grado de bloqueo motor. En el postoperatorio se evaluaron la regresión del bloqueo sensitivo-motor, la incidencia de complicaciones inmediatas en forma horaria, el tiempo hasta la ambulación, diuresis y el alta institucional. Resultados: En 48 por ciento de los pacientes se obtuvo un nivel de bloqueo sensitivo en "silla de montar", a nivel D11 en el 44 por ciento y a nivel D10 en el 8 por ciento de los casos. No hubo cambios intraoperatorios destacables. El tiempo promedio de recuperación de la sensibilidad fue de 88, y el de la motilidad de 150. La ambulación tuvo lugar, en promedio, a los 201, y la micción espontánea a los 187. Seis pacientes presentaron dolor con EVA menor que 60, tratados con rescates de dextropropoxifeno-dipirona. Discusión: La analgesia balanceada multimodal sistémica, espinal y local, permite una rápida recuperación y una ambulación precoz, con una incidencia de dolor fácilmente controlable, sin que se observen complicaciones tales como retención vesical o readmisiones no esperadas. (AU)

Does the use of topical lidocaine, epinephrine, and tetracaine solution provide sufficient anesthesia for laceration repair?

OBJECTIVE: To determine: 1) the effectiveness of lidocaine, epinephrine, and tetracaine (LET) solution in eliminating or reducing the pain experienced in suturing superficial lacerations in adult patients; and 2) the effectiveness of LET in reducing the pain of local anesthetic injection. METHODS: A prospective, randomized, double-blind study in which 60 adult patients with superficial lacerations were entered was conducted in the ED of a community-based teaching hospital affiliated with the University of Toronto. Following application of the LET or placebo (sterile water) solution to the laceration, a visual analog pain scale was recorded by the patient upon needle probing of the wound margin. If probing was painless, the laceration was repaired using LET alone. If injection of local anesthetic was required, an additional pain scale was elicited to quantify the attenuation of the pain of injection by the prior application of LET. RESULTS: Pain scale values on needle probing were significantly reduced in the LET group vs the placebo group (medians of 4.0 vs 5.0 cm, respectively; p < 0.05). Only 13 of the 30 patients in the LET group required additional anesthetic, while all 30 patients in the placebo group requested local anesthetic. Pain scale values on injection of local anesthetic were not significantly different between the LET and placebo groups (medians of 3.5 vs 5.0 cm, respectively; p = 0.09), although there was a trend for lower pain scale values for those patients who received LET. No adverse effects were noted after the application of either LET or placebo solution. Follow-up was achieved for 54 of 60 patients with only 1 complication (a wound infection) reported in the LET group. CONCLUSIONS: Significantly fewer patients require an injectable anesthetic when LET is applied. Those who do require an injection may experience less discomfort. These advantages should be balanced against the 20 to 30 minutes necessary for the LET to take effect.

EMLA versus TAC for topical anesthesia of extremity wounds in children.

STUDY OBJECTIVE: To compare the anesthetic efficacy of EMLA (eutectic mixture of local anesthetics) cream with that of TAC (tetracaine, adrenaline, and cocaine) solution for suturing uncomplicated extremity wounds. METHODS: We conducted a prospective, single-blind, randomized trial in a convenience sample of 32 children, ages 5 to 18 years, who required repair of an extremity laceration. Eligible wounds were less than 5 cm long and less than 12 hours old. Lacerations involving digits, deep tissues, or musculature were excluded. Patients receiving medications that predisposed them to methemoglobinemia were also excluded. Lacerations were treated with TAC .1 mL/kg (maximum, 3.0 mL) or EMLA .15 g/kg (maximum, 5.0 g). Anesthesia was assessed every 10 minutes. TAC and EMLA were allowed to remain on the wounds for a maximum of 30 and 60 minutes, respectively. Anesthesia was deemed successful if no supplemental lidocaine was required, as judged by a suturing caregiver who was blinded to the anesthetic used. RESULTS: The two groups were similar with regard to age, sex, wound length and depth, and wound age. EMLA-treated wounds were repaired without supplemental anesthesia more often than TAC-treated wounds: 13 of 16 (85%) versus 7 of 16 (45%, P= .03). More time was required for EMLA to cause anesthesia (55 versus 29 minutes, P<.01). Dehiscence occurred in one wound in each group; no wound infections were observed. CONCLUSION: EMLA appears to be superior to TAC for anesthesia of simple extremity lacerations in that those wounds treated with EMLA required supplemental anesthesia less often. EMLA required approximately 1 hour to cause optimal anesthesia in open wounds. Protocols should be developed to allow efficient use of EMLA for anesthesia of extremity lacerations in the ED.