[Improving the effectiveness of local anesthesia in patients with arterial hypertension in the provision of emergency dental care]. / Povyshenie effektivnosti mestnogo obezbolivaniya u patsientov s arterial'noi gipertenziei pri okazanii neotlozhnoi stomatologicheskoi pomoshchi.

THE AIM OF THE STUDY: Was to evaluate the use of Ketorol Express as a preventive analgesia to increase the effectiveness of local anesthesia in providing emergency dental care to patients with arterial hypertension. MATERIALS AND METHODS: The study was conducted on the basis of the state autonomous healthcare institution of the Moscow region «Royal Dental Clinic¼ with the participation of 83 people. The patients were divided into two groups. In group 1, Ketorol Express was prescribed as a preventive analgesia in a dosage of 20 mg before local anesthesia. Patients of group 2 underwent dental interventions without the use of preventive analgesia. A 3% solution of mepivacaine was used as a local analgesic solution. For a subjective assessment of the effectiveness of anesthesia, use a visual analog scale. All patients had their blood pressure and heart rate measured before and after the interventions and hemodynamic parameters were continuously monitored during emergency dental care. RESULTS: In group 1, the effectiveness of combined anesthesia with the infiltration method of local anesthetic administration was 93±1.17%, according to the patient, 94±1.47%, according to the doctor, with the conductive method of anesthesia at the mandibular orifice - according to the patient it was 91±1.01%, according to the doctor 92± 1.36%. In group 2, when providing emergency dental care with the infiltration method of administration of 3% mepivacaine the anesthesia was effective in 80±1.97% of cases according to the patient and in 80±1.17% of cases according to the doctor, with the conductive method of anesthesia at the mandibular orifice, the effectiveness of anesthesia according to the patient was 82±1.11%, according to the doctor 85±1.23%. CONCLUSION: The results of the study demonstrated a statistically significant increase in the effectiveness of local anesthesia performed with a 3% solution of mepivacaine in patients with arterial hypertension due to the use of preventive analgesia with Ketorol Express at a dosage of 20 mg (2 tablets of 10 mg) in emergency dental care with registration and analysis of changes in hemodynamic parameters.

Spinal Versus General Anesthesia for Outpatient Total Hip and Knee Arthroplasty in the Ambulatory Surgery Center: A Matched-Cohort Study.

BACKGROUND: Spinal anesthesia is the predominant regimen in outpatient total joint arthroplasty (TJA), but induction often is unsuccessful, unobtainable, or against patient preference. We compared outcomes of same-day discharge (SDD) TJA with spinal versus general anesthesia in a free-standing ambulatory surgery center (ASC). METHODS: We took 105 general anesthesia TJA and one-to-one nearest-neighbor matched them to 105 spinal anesthesia TJA over 7 years at 1 ASC. The rate of successful SDD, minutes to discharge, postoperative pain and nausea, and 90-day complications were compared. Postanesthesia care unit outcomes were additionally stratified by spinal anesthetic (mepivacaine versus bupivacaine). RESULTS: All spinal anesthetic patients underwent SDD compared with 103 (98%) general anesthetic patients (P = .498). Mepivacaine spinal anesthesia patients spent the fewest minutes in postanesthesia care unit prior to discharge from the facility (206), followed by general anesthesia (227), and bupivacaine spinal anesthesia (291; P < .001). General anesthesia patients had the highest levels of pain at 1 hour (5.2 versus 1.5 versus 1.5) and 2 hours (3.2 versus 2.0 versus 1.3) postoperatively, and rates of nausea (48 versus 22 versus 28%) compared with mepivacaine and bupivacaine spinal anesthesia, respectively. The 90-day complications (6 versus 7), admissions (1 versus 3), and reoperations (5 versus 2) were similar among spinal and general anesthesia, respectively (P ≥ .445). CONCLUSIONS: Both spinal and general anesthesia led to reliable SDD with similar 90-day complication rates. General anesthesia facilitated faster discharge from the ASC compared with bupivacaine spinal anesthesia but led to higher levels of pain and incidence of nausea postoperatively. LEVEL OF EVIDENCE: Level 3, Retrospective Cohort Comparison.

Termografía en el efecto vasodilatador de anestésicos locales para el bloqueo troncular del primer dedo / Thermography of the vasodilator effect of local anaesthetics in ingrown toenail surgery

Objetivos: Los anestésicos locales de tipo amida empleados en cirugía podológica, como la lidocaína o mepivacaína, poseen cierto poder vasodilatador. Puesto que en algunas técnicas quirúrgicas puede haber sangrado postquirúrgico abundante, conocer si alguno de los dos anestésicos tiene mayor o menor efecto vasodilatador podría mejorar la respuesta postquirúrgica a estas técnicas. Así pues, el objetivo de este estudio fue comparar la respuesta térmica en el primer dedo tras la aplicación de los dos anestésicos al 2 %. Pacientes y métodos: Veintiséis participantes sanos se ofrecieron voluntarios para participar en este ensayo clínico aleatorizado con doble ciego. Los sujetos fueron divididos en dos grupos: lidocaína 2 % (n = 13) y mepivacaína 2 % (n = 13). Ambos grupos recibieron 1 cc del anestésico indicado. Se realizó una fotografía termográfica previa y tras 10 minutos al bloqueo troncular del hallux para cuantificar el aumento de temperatura. No se registraron complicaciones ni reacciones adversas. Resultados: Los dos grupos eran similares en cuanto a características antropométricas. No se observaron diferencias significativas entre grupos ni en la media de temperatura pre-anestésica (24.38 °C grupo lidocaína, 24.75 °C grupo mepivacaína, p = 0.918), ni en la media de temperatura postanestésica de los sujetos (31.3 °C para ambos grupos, p = 0.959). Los resultados de la diferencia pre-post anestésica fue de 6.91 °C para el grupo lidocaína y de 6.54 °C para el grupo mepivacaína, siendo esta diferencia estadísticamente no significativa (p = 0.7). Sin embargo, todos los sujetos (n = 26) mostraron un aumento de la temperatura tras la anestesia (p < 0.001). Conclusiones: Ambos fármacos mostraron una elevación de la temperatura en los sujetos y, por tanto, su poder vasoactivo. En cambio, no se evidenciaron diferencias significativas entre grupos...(AU)

Objectives: Local anaesthetics such as lidocaine or mepivacaine, commonly used in toenail surgery, have an associated vasodilator effect. Although is thought that lidocaine has a greater vasodilator effect than mepivacaine, there´s not strong in vivo evidence of this. So, the aim of this work was to assess the temperature increase experienced by the toes after be injected of 1 ml 2 % mepivacaine or lidocaine. Patients and methods: 26 participants were randomly divided into two groups and a pre-anæsthetic thermal image (Flir E60bx camera) was taken. Patients in group A (n = 13) received 1 ml of 2 % lidocaine, while those in group B (n = 13) received 1 ml of 2 % mepivacaine at four points of the hallux. After 10 minutes a second thermal image (post-anæsthetic image). Mean temperatures were assessed at the proximal phalanx and the pad of the hallux. Results: After application of the anæsthetic, the mean temperatures were 31.3 ± 3.07 °C at point 1 and 30.8 ± 3.08 °C at point 2 in the lidocaine group, and 31.3 ± 2.74 °C at point 1 and 29.5 ± 2.87 °C at point 2 in the mepivacaine group, with not statistically significant differences between them (p = 0.959 and p = 0.798). All the participants experienced temperature increases of between 5.13 °C and 6.91 °C, but there were no significant differences between groups (p = 0.7 and p = 0.0778). Conclusions: Even though most of the literature suggests that lidocaine has more potent vasodilator effect than mepivacaine, the present results do not reflect any real clinical impact distinguishing one drug from the other in the field block of the big toe, as measured with infrared thermal imaging.(AU)

Supraclavicular block with Mepivacaine vs Ropivacaine, their impact on postoperative pain: a prospective randomised study.

BACKGROUND: Supraclavicular block (SCB) with long-acting local anaesthetic is commonly used for surgical repair of distal radial fractures (DRF). Studies have shown a risk for rebound pain when the block fades. This randomised single-centre study aimed to compare pain and opioid consumption the first three days post-surgery between SCB-mepivacaine vs. SCB-ropivacaine, with general anaesthesia (GA) as control. METHODS: Patients (n = 90) with ASA physical status 1-3 were prospectively randomised to receive; SCB with mepivacine 1%, 25-30 ml (n = 30), SCB with ropivacaine 0.5%, 25-30 ml (n = 30) or GA (n = 30) with propofol/fentanyl/sevoflurane. Study objectives compared postoperative pain with Numeric Rating Scale (NRS) and sum postoperative Opioid Equivalent Consumption (OEC) during the first 3 days post-surgery between study-groups. RESULTS: The three groups showed significant differences in postoperative pain-profile. Mean NRS at 24 h was significantly lower for the SCB-mepivacaine group (p = 0.018). Further both median NRS and median OEC day 0 to 3 were significanly lower in the SCB-mepivacaine group as compared to the SCB-ropivacaine group during the first three days after surgery; pain NRS 1 (IQR 0.3-3.3) and 2.7 (IQR 1.3-4.2) (p = 0.017) and OEC 30 mg (IQR 10-80) and 85 mg (IQR 45-125) (p = 0.004), respectively. The GA-group was in between both in pain NRS and median sum OEC. Unplanned healthcare contacts were highest among SCB-ropivacaine patients (39.3%) vs. SCB-mepivacaine patients (0%) and GA-patients (3.4%). CONCLUSIONS: The potential benefit of longer duration of analgesia, associated to a long-acting local anaesthetic agent, during the early postoperative course must be put in perspective of potential worse pain progression following block resolution. TRIAL REGISTRATION: NCT03749174 (clinicaltrials.gov, Nov 21, 2018, retrospectively registered).

Implantation of a peritoneal dialysis catheter in patients with ESRD using local anesthesia and Remifentanil.

STUDY OBJECTIVE: The main objective of this study is to test the feasibility of the local anesthetic (LA) Mepivacaine 1% and sedation with Remifentanil as the primary anesthetic technique for the insertion of a peritoneal dialysis (PD) catheter, without the need to convert to general anesthesia. METHODS: We analyzed 27 consecutive end-stage renal disease (ESRD) patients who underwent the placement of a peritoneal catheter at our center between March 2015 and January 2019. The procedures were all performed by a general or vascular surgeon, and the postoperative care and follow-up were all conducted by the same peritoneal dialysis team. RESULTS: All of the 27 subjects successfully underwent the procedure without the need of conversion to general anesthesia. The catheter was deemed prone to usage in all patients and was found to be leak-proof in 100% of the patients. CONCLUSION: This study describes a safe and successful approach for insertion of a PD catheter by combined infiltration of the local anesthetic Mepivacaine 1% and sedation with Remifentanil. Hereby, ESRD patients can be treated without general anesthesia, while ensuring functionality of the PD catheter.

Complications following equine sacroiliac region analgesia are uncommon: A study in 118 horses.

BACKGROUND: Diagnosis of sacroiliac region pain is supported by a positive response to sacroiliac region analgesia (SIRA). Varying techniques have been described for SIRA; with clinician preference often dictating method. Potential complications following SIRA include ataxia and recumbency. No study has specifically evaluated the prevalence of complications. OBJECTIVES: To describe the complication prevalence following SIRA in a referral clinic. STUDY DESIGN: Retrospective cohort study. METHODS: Review of records from horses presented to two of the authors at Rossdales, Newmarket, between January 2014 and December 2018, that underwent SIRA. Injection was performed using a blind midline approach with 20 mL mepivacaine (Intra-Epicaine 20mg/ml; Dechra) infiltrated through a straight 18 gauge 8.9cm spinal needle subdivided into four sub-locations per block. RESULTS: 118 horses were included, with 167 individual blocks. One horse showed a mild hindlimb gait abnormality following SIRA, which resolved uneventfully over 3 hours; complication rate 1/118 horses (0.85%; 95% CI: 0,2.5%), 1/167 joints (0.60%; 95% CI: 0,1.8%). SIRA subjectively improved lameness/performance in 132/167 (79%) joints. 49/118 (42%) received bilateral SIRA with 53/118 (45%) evaluated ridden following SIRA. MAIN LIMITATIONS: Small population numbers with low complication prevalence rate. CONCLUSIONS: SIRA, using the described technique, has a low (0.85%) prevalence of complications.

Volume and effectiveness assessment of articain 4% versus mepivacaine 2% used in third molar surgery: randomized, double-blind, split-mouth controlled clinical trial

BACKGROUND: The different indications for extraction of the lower third molars, require resources to manage pain and discomfort, such as, for example, adequate anesthetic techniques, and the type of anesthetic used can influence the management of pain in tooth extractions. Few studies in the literature compare the anesthetics 4% articaine hydrochloride and 2% mepivacaine hydrochloride showing evidence that both allow for successful pain management. This study sought to compare the volume, efficacy and safety of these two anesthetic drugs, both associated with epinephrine at a ratio of 1:100,000, used in the extraction of lower third molars. MATERIAL AND METHODS: A controlled, clinical, split-mouth compared these both local anesthetics in a sample of 20 patients requiring bilateral extraction of teeth. Pain was the main parameter to be assessed by means of the visual analogue scale (VAS) applied during and immediately after the surgery. Hemodynamic parameters, adverse events, presence of paresthesia and satisfaction of patients and surgeon were also analysed. RESULTS: Pain management was more effective with mepivacaine up to two hours after surgery (p = 0.014), whereas the surgeon was more satisfied with the use of articaine during divulsion and suture (p < 0.05). However no statistically significant differences were found between both anesthetics regarding pain perception. CONCLUSIONS: It was observed that both anesthetics are efficient and safe in the management of pain for extraction of third molars, in which less amount of mepivacaine is needed. The satisfaction of patients and surgeon was the same for both anesthetics, with articaine being highlighted during divulsion and suture

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Mepivacaine versus Bupivacaine Spinal Anesthesia for Early Postoperative Ambulation.

BACKGROUND: Early ambulation after total hip arthroplasty predicts early discharge. Spinal anesthesia is preferred by many practices but can delay ambulation, especially with bupivacaine. Mepivacaine, an intermediate-acting local anesthetic, could enable earlier ambulation than bupivacaine. This study was designed to test the hypothesis that patients who received mepivacaine would ambulate earlier than those who received hyperbaric or isobaric bupivacaine for primary total hip arthroplasty. METHODS: This randomized controlled trial included American Society of Anesthesiologists Physical Status I to III patients undergoing primary total hip arthroplasty. The patients were randomized 1:1:1 to 52.5 mg of mepivacaine, 11.25 mg of hyperbaric bupivacaine, or 12.5 mg of isobaric bupivacaine for spinal anesthesia. The primary outcome was ambulation between 3 and 3.5 h. Secondary outcomes included return of motor and sensory function, postoperative pain, opioid consumption, transient neurologic symptoms, urinary retention, intraoperative hypotension, intraoperative muscle tension, same-day discharge, length of stay, and 30-day readmissions. RESULTS: Of 154 patients, 50 received mepivacaine, 53 received hyperbaric bupivacaine, and 51 received isobaric bupivacaine. Patient characteristics were similar among groups. For ambulation at 3 to 3.5 h, 35 of 50 (70.0%) of patients met this endpoint in the mepivacaine group, followed by 20 of 53 (37.7%) in the hyperbaric bupivacaine group, and 9 of 51 (17.6%) in the isobaric bupivacaine group (P < 0.001). Return of motor function occurred earlier with mepivacaine. Pain and opioid consumption were higher for mepivacaine patients in the early postoperative period only. For ambulatory status, 23 of 50 (46.0%) of mepivacaine, 13 of 53 (24.5%) of hyperbaric bupivacaine, and 11 of 51 (21.5%) of isobaric bupivacaine patients had same-day discharge (P = 0.014). Length of stay was shortest in mepivacaine patients. There were no differences in transient neurologic symptoms, urinary retention, hypotension, muscle tension, or dizziness. CONCLUSIONS: Mepivacaine patients ambulated earlier and were more likely to be discharged the same day than both hyperbaric bupivacaine and isobaric bupivacaine patients. Mepivacaine could be beneficial for outpatient total hip arthroplasty candidates if spinal is the preferred anesthesia type.

Axillary TAVR under locoregional anesthesia in a patient with peripheral artery disease.

Transcatheter aortic valve replacement (TAVR) is now a relatively commonly performed procedure and the number of eligible patients is growing exponentially.  In candidates with peripheral arterial disease, the axillary artery approach is an option worth considering. Usually TAVR performed using this approach is done under general anesthesia with tracheal intubation. At our center, however, we have developed a surgical approach to TAVR using the axillary artery under locoregional anesthesia.  This video tutorial demonstrates the technical details of our strategy. Because this procedure is extrathoracic, spares cerebral vessels, and is done under locoregional anesthesia, it is particularly suitable for fragile patients. This combination of both axillary access and locoregional anesthesia has the potential to become a primary main alternative for non-femoral TAVR patients and we hope it will be adopted also by other centers.

Safety of CT-guided cervical nerve root infiltrations using a dorsal approach.

Cervical nerve root infiltrations are frequently performed in patients with radiculopathy, and computed tomography (CT) is commonly used for image guidance. With the traditional anterolateral approach, catastrophic side events due to spinal ischemia have been reported. To minimize risk, a dorsal approach has been advised, but the safety of this dorsal approach has not been studied systematically. In a 5-year period, 137 cervical nerve root infiltrations using a dorsal approach were performed on 109 patients and retrospectively reviewed. In our series, no major complications like spinal ischemia, spondylodiscitis, large hematomas with the need for surgery or severe allergic reactions occurred. In conclusion, using a dorsal approach, CT-guided cervical nerve root infiltrations with an extraforaminal needle position seem to be a safe intervention.

Prospective randomized investigation of topical anesthesia during unilateral laparoscopic ovariectomy in horses.

OBJECTIVE: To compare pain-related responses in mares receiving topical or injected anesthesia of the ovarian pedicle prior to standing unilateral laparoscopic ovariectomy. STUDY DESIGN: Prospective randomized, blinded, placebo-controlled study. ANIMALS: Fifteen healthy research mares. METHODS: Mares were restrained in stocks and administered sedation. A right or left paralumbar ovariectomy was performed by using a laparoscopic portal and two instrument portals. Mares were divided into two treatment groups, and equal volumes of mepivacaine anesthesia were administered either topically (n = 8) or by injection into the ovarian pedicle (n = 7). Saline controls were simultaneously administered topically (n = 7) or by injection (n = 8), and surgeons were blinded to the treatment group. Ovarian removal was performed with traumatic forceps and a blunt tip vessel sealer and divider. Pain responses were measured by operative visual analog scale (VAS) scoring and perioperative serum cortisol response. Visual analog scale and serum cortisol were compared between groups by using Mann-Whitney testing. Serum cortisol concentrations were evaluated using repeated-measures one-way analysis of variance. RESULTS: Ovaries were removed in all mares by using the described technique without operative complications. Quantity of sedation required to complete the procedure, operative VAS scores, and perioperative cortisol concentrations did not differ between treatment groups. CONCLUSION: Application of topical mepivacaine to the ovary provided intraoperative analgesia similar to injection of the ovarian pedicle when performing unilateral standing laparoscopic ovariectomy in mares. CLINICAL SIGNIFICANCE: Topical anesthesia application to the ovary could provide an alternative to laparoscopic needle use, reducing the risk of inadvertent trauma to the pedicle or other visceral organs during laparoscopic ovariectomy.

Lidocaine-Epinephrine-Tetracaine Gel Is More Efficient than Eutectic Mixture of Local Anesthetics and Mepivacaine Injection for Pain Control during Skin Repair in Children: A Prospective, Propensity Score Matched Two-Center Study.

INTRODUCTION: Skin lacerations are common in children and their repair is a very unpleasant experience for a child. While pain management has been recognized as a key element of high-quality patient care, recent studies report that pain management in the pediatric emergency departments is still suboptimal. Lidocaine-epinephrine-tetracaine (LET) gel could potentially improve the traumatic experience caused by skin repair as it obviates the need for infiltration. Thus, the aim of the current study was to compare local eutectic mixture of local anesthetics (EMLA) plus mepivacaine infiltration with topical anesthetics (LET-gel). MATERIALS AND METHODS: Prospective, propensity score-matched multicenter study including all children between 3 and 16 years presented at two centers. After anesthetics (LET vs. EMLA and infiltration) standardized skin repair was performed. Pain assessment was performed using the faces pain rating scale or visual analogue scale. Follow-up, performed 2 weeks after initial presentation, assessed wound infection rates and overall satisfaction. RESULTS: Of 73 subjects 59 children (37 LET vs. 22 EMLA) were included after propensity score matching. Groups had similar baseline characteristics. Pretreatment was significantly less painful in LET versus local anesthetics group. Pain during skin repair was similar between groups (LET and EMLA with mepivacaine infiltration) and both groups demonstrated similar efficacy (procedure time, need for secondary infiltration, infection rate). Ultimately, pain levels during pretreatment and the surgical procedure were perceived significantly higher by the children than estimated by parents or surgeons. CONCLUSION: In conclusion, it appears that LET is superior to conventional anesthesia including mepivacaine infiltration in the pediatric emergency departments. Pretreatment with LET is significantly less painful but equally effective. Hence, we recommend LET as a topical anesthetic in the pediatric emergency department.

Needle fasciotomy for Dupuytren's contracture- a prospective cohort study of 58 fingers with a median follow-up of 6.5 years.

Needle fasciotomy (NF) is a minimally invasive treatment option for Dupuytren contractures, but long-term results have indicated a high recurrence rate. This prospective study was initiated to monitor the introduction of NF in a context where limited fasciectomy had been the only treatment option, and to investigate the long-term results. The inclusion criterion was a palpable cord with a Metacarpophalangeal (MCP) and/or Proximal interphalangeal (PIP) contracture in one or more fingers. Fifty-eight fingers in 42 patients (40 male and 2 female with a median age of 68 years) were treated by needle fasciotomy between November 2010 and March 2012, and were followed for a median of 6.5 years. The median total passive extension deficit (TPED) was 52° at baseline, but decreased significantly to 20° postoperatively. No severe adverse events such as nerve or tendon injuries were reported. At final-follow up of 48 fingers the median TPED was still significantly reduced to 23° for all fingers (p < 0.0001). Twenty-nine fingers retained full correction of the contracture, and in patients with recurrent contractures NF was preferred in 13 out of 17 patients. This study showed that needle fasciotomy is a safe procedure for Dupuytren's contracture, with excellent immediate reduction of the joint contracture and with a recurrence rate comparable to treatment by collagenase clostridium histolyticum (CCH).

Selective local anesthesia versus corticosteroid infiltration on low back pain: a randomized clinical trial. / Anestesia local selectiva frente a infiltración de corticosteroides en el dolor lumbar: ensayo clínico aleatorizado.

ANTECEDENTS AND OBJECTIVE: Local infiltrations are second line therapy in the treatment of chronic low back pain, although their use is controversial in the literature. Our objective was to compare the effectiveness of 2 types of infiltration at the paravertebral lumbar level in two groups of patients diagnosed with low back pain: corticosteroids, and selective local anaesthetic administered using segmental neural therapy (SNT). MATERIAL AND METHODS: Double-blind clinical trial in 55 patients diagnosed with low back pain in the neurosurgery department of the Hospital Central de la Defensa Gómez Ulla. Patients were randomised to 2 treatment groups to receive either paravertebral injections of corticosteroids or SNT. Outcomes were measured using a visual analogue scale, the Oswestry Disability Index, the Short Form-36, and patient satisfaction at the start of treatment (baseline) and at 3 and 12 months post intervention. RESULTS: The combined treatment group showed a statistically significant improvement in Oswestry Disability Index at 3 months. The SNT group showed a statistically significant improvement in baseline visual analogue scale vs. visual analogue scale at 3 (1.398cm, p=0.001) and 12 months (0.791cm, p=0.007). No differences were observed in the remaining variables measured. The percentage of patients that would repeat the treatment was 81% and 83%, respectively. CONCLUSIONS: Significant pain relief was achieved with SNT, and disability improved with the combined treatment. Although clinical improvement was limited, patients were satisfied. Local infiltrations should be considered as an alternative treatment for chronic low back pain. CLINICAL TRIAL REGISTRATION: This clinical trial was registered at the European Union Clinical Trials Register with EUDRA-CT number 2015-001146-29.

Tolerability of IM penicillin G benzathine diluted or not with local anesthetics, or different gauge needles for syphilis treatment: a randomized clinical trial.

BACKGROUND: Penicillin G Benzathine (PGB) is the cornerstone of syphilis treatment. However, its intramuscular (IM) administration is associated with pain at the site of injection. The dilution of PGB with local anesthetics is recommended in some guidelines, but the evidence that supports it, particularly in adults and in HIV infection, is scarce. Preliminary clinical experience also suggests that the IM administration of PGB through increased needle gauges might improve its tolerability. The aim of the study to identify less painful ways of administering IM PGB in the treatment of syphilis in adults. METHODS: Multicenter, randomized, double-blinded clinical trial in patients diagnosed with primary syphilis that required a single IM injection of PGB 2400,00 IU. Patients were randomized to receive PGB diluted with 0.5 mL mepivacaine 1% (MV) or PGB alone, and both groups either with a long 19G or short 21G IM needle. The primary objective was the effect on local pain immediately after the administration through a visual scale questionnaire on pain (0 to 10). RESULTS: One hundred eight patients were included, 27 in each group. Ninety-four (94.4%) were male, and 41.7% were also HIV-infected. Mean age 36.6 years (SD 11). Significant differences in immediate pain intensity were observed when comparing the long 19G group with anesthesia (mean pain intensity, [MPI] 2.92 [CI 95% 1.08-4.07]) vs long 19G without anesthesia (MPI 5.56 [CI 95% 4.39-6.73), p < 0.001; and also between short 21G group with anesthesia (MPI 3.36 [CI 95% 2.22-4.50]) vs short 21G without anesthesia (MPI 5.06 [CI 95% 3.93-6.19]), p = 0.015). No significant differences in immediate pain were observed between 19G and 21G in the presence or absence of anesthesia (p = 1.0 in both cases). No differences were found between study arms after 6 and 24 h. CONCLUSIONS: The IM administration of 1% mepivacaine-diluted PGB induces significantly less immediate local pain as compared to PGB alone. The needle gauge did not have any effect on the pain. Based on these results, we suggest anesthetic-diluted IM PGB as the standard treatment for primary syphilis. TRIAL REGISTRATION: EudraCT 2014-003969-24 (Date of registration 18/09/2014).

Ipsilateral transient amaurosis, mydriasis and light reflex absence after subconjunctival local anesthesia with mepivacaine in three patients with refractory glaucoma - a case report.

BACKGROUND: The subconjunctival anesthesia with local anesthetics is considered as a low-risk procedure allowing ocular surgery without serious complications typical for retro- or parabulbar anesthesia, especially in patients with preexisting Optic Nerve damage. We report development of ipsilateral transient amaurosis accompanied with mydriasis and both, direct and consensual light response absence. CASE PRESENTATION: Three patients with advanced refractory glaucoma undergoing laser cyclophotocoagulation (CPC) for intraocular pressure lowering experienced these adverse effects just few minutes after subconjunctival injection of mepivacaine 2% solution (Scandicaine® 2%, without vasoconstrictor supplementation). The vision was completely recovered to usual values in up to 20 h after mepivacaine application. Extensive ophthalmological examination, including cranial magnetic resonance imaging (MRI), revealed no further ocular abnormalities, especially no vascular constriction or thrombotic signs as well as no retinal detachment. The oculomotor function remained intact. The blockade of ipsilateral ciliary ganglion parasympathetic fibers by mepivacaine may be the responsible mechanism. Systemic pathways as drug-drug interactions seem to be unlikely involved. Importantly, all three patients tolerated the same procedure previously or at a later date without any complication. Overall, our thoroughly elaborated risk management could not determine the causative factor explaining the observed ocular complications just in the current occasion and not at other time points. CONCLUSIONS: Doctors should be aware and patients should be informed about such rare complications after subconjunctival local anesthetics administration. Adequate risk management should insure patients' safety.

Subcutaneous brompheniramine for cutaneous analgesia in rats.

Brompheniramine as an antihistamine blocked sodium channels, and local anesthetics by blocking sodium channels produced the local anesthetic effects. The authors aimed to assess local anesthetic quality and duration of brompheniramine when compared to the local anesthetic mepivacaine. After rats were shaved and injected subcutaneously on the dorsal skin, the panniculus reflex, induced via applying a noxious pinprick to the skin (injected area), was scored. The dose-response curve and nociceptive block duration of brompheniramine were constructed and compared with mepivacaine. The cutaneous analgesic effects in both brompheniramine and mepivacaine groups were concentration-dependent. On the basis of the amount required to produce a 50% block effect (ED50, 50% effective dose), the drug's potency was brompheniramine (0.89 [0.82-0.96] µmol) better than mepivacaine (2.45 [2.17-2.76] µmol) (P < 0.01). Full recovery time of brompheniramine was more prolonged than mepivacaine's (P < 0.01) on infiltrative cutaneous analgesia when comparing ED25s, ED50s and ED75s. Our preclinical data demonstrated that subcutaneous brompheniramine induces dose-relatedly analgesic effects, and brompheniramine induces prolonged analgesic duration when compared with mepivacaine. Brompheniramine also provokes better cutaneous analgesia than mepivacaine.

Comparison of analgesic techniques in MRI-guided in-bore prostate biopsy.

OBJECTIVES: To evaluate different analgesic techniques in MRI-guided in-bore prostate biopsy (IB-GB) regarding the influence on patient procedural experience of pain. METHODS: Two hundred fifty-two consecutive patients who had received an IB-GB either with intrarectal instillation of 2% lidocaine gel (n = 126, group A) or with periprostatic nerve block (PPNB) with 2% mepivacaine (n = 126, group B) were retrospectively included in this study. Pain scores were measured on a visual analog scale, the operating room time (ORT) was recorded for each biopsy and correlations between the parameters were analysed. RESULTS: Pain scores for IB-GB were slightly lower in group B compared with group A (2.0 ± 1.9; 2.4 ± 1.7; p = 0.02). In group A, significantly more targeted biopsy cores were acquired (group B: 5.2 ± 1.1; group A: 5.6 ± 0.8; p < 0.01). ORT was comparable and not significantly different in both groups. There was only a weak correlation between pain scores and ORT in group B (rS = 0.22; p = 0.01), but no correlation between pain scores and the number of biopsy cores or the prostate volume. CONCLUSIONS: Pain levels are generally low for MRI-guided in-bore biopsy using either PPNB or intrarectal instillation of lidocaine gel. A statistically significant, slightly lower pain score was documented for PPNB and might be preferred when the focus is analgesia. On the other hand, due to the minor difference and easier administration, intrarectal gel instillation seems to be a reasonable practice for standard analgesia for MRI-guided in-bore biopsy. KEY POINTS: • Pain levels were low for MRI-guided in-bore biopsy using either PPNB or intrarectal instillation of lidocaine gel as analgesic method. • PPNB prior to IB-GB resulted in a slightly lower pain score but required a higher effort. • Intrarectal gel anaesthesia seems to be a reasonable practice for standard analgesia for IB-GB in an outpatient setting.

Intrauterine mepivacaine instillation for pain relief during intrauterine device insertion in nulliparous women: a double-blind, randomized, controlled trial.

OBJECTIVE: To evaluate whether intrauterine mepivacaine instillation before intrauterine device (IUD) insertion decreases pain compared to placebo. STUDY DESIGN: We performed a double-blind, randomized, controlled trial comparing mepivacaine 1% 10 mL versus 0.9% NaCl intrauterine instillation using a hydrosonography catheter 5 min before IUD insertion in women 18 years of age or older. Participants completed a series of 10-cm visual analogue scales (VAS) to report pain during the procedure. The primary outcome was the difference in VAS scores with IUD insertion between intervention group and placebo. Secondary outcomes included VAS before and after insertion and analgesia method acceptability. RESULTS: We randomized 86 women in a 1:1 ratio; both groups had similar baseline characteristics. In the intention-to-treat analysis, the primary outcome, median VAS with IUD insertion, was 4.8 cm in the intervention group [n=41, interquartile range (IQR) =3.1-5.8] and 5.9 cm in the placebo group (n=40, IQR=3.3-7.5, p=.062). In the per-protocol analysis, the median VAS with IUD insertion was 4.8 cm (IQR=3.1-5.5) and 6.0 cm (IQR=3.4-7.6) for the intervention and placebo groups, respectively (p=.033). More women in the intervention group reported the procedure as easier than expected (n=26, 63.4% vs. n=15, 37.5%), and fewer reported it as worse than expected (n=3, 7.3% vs. n=14, 35%, p=.006). CONCLUSION: Intrauterine mepivacaine instillation before IUD insertion modestly reduces pain, but the effect size may be clinically significant. IMPLICATIONS STATEMENT: While the reduction in VAS pain scores did not meet our a priori difference of 1.3 points for clinical significance, participants' favorable subjective reaction suggests that this approach merits further study.

Retroclavicular vs supraclavicular brachial plexus block for distal upper limb surgery: a randomised, controlled, single-blinded trial.

BACKGROUND: Regional anaesthesia for upper limb surgery is routinely performed with brachial plexus blocks. A retroclavicular brachial plexus block has recently been described, but has not been adequately compared with another approach. This randomised controlled single-blinded trial tested the hypothesis that the retroclavicular approach, when compared with the supraclavicular approach, would increase the success rate. METHODS: One hundred and twenty ASA physical status 1-3 patients undergoing distal upper limb surgery were randomised to receive an ultrasound-guided retroclavicular or supraclavicular brachial plexus block with 30 mL of a 1:1 mixture of mepivacaine 1% and ropivacaine 0.5%, using a single-injection technique without needle tip repositioning. The primary outcome was block success rate 30 min after local anaesthetic injection, defined as a composite score of 14 of 16 points, inclusive of sensory and motor components. Secondary outcomes included needling time, time to first opioid request, oxycodone consumption, and pain scores (numeric rating scale, 0-10) at 24 h postoperatively. RESULTS: Success rates were 98.3% [95% confidence interval (CI): 90.8%, 99.9%] and 98.3% [95% CI: 90.9%, 99.9%] in the supraclavicular and retroclavicular groups, respectively (P=0.99). The mean needling time was reduced in the supraclavicular group [supraclavicular: 5.0 (95% CI: 4.7, 5.4) min; retroclavicular: 6.0 (95% CI: 5.4, 6.6) min; P=0.006]. The mean time to first opioid request was similar between groups [supraclavicular: 439 (95% CI: 399, 479) min; retroclavicular: 447 (95% CI: 397, 498) min; P=0.19] as were oxycodone consumption [supraclavicular: 10.0 (95% CI: 6.5, 13.5 mg; retroclavicular: 7.9 (95% CI: 4.8, 11.0) mg; P=0.80] and pain scores at 24 h postoperatively [supraclavicular: 1.2 (95% CI: 2.1, 2.7); retroclavicular: 1.5 (95% CI: 1.6, 2.4); P=0.09]. CONCLUSIONS: Ultrasound-guided retroclavicular and supraclavicular brachial plexus blocks share identical success rates, while providing similar pain relief. Reduced needling time in the supraclavicular approach is not clinically relevant. CLINICAL TRIAL REGISTRATION: NCT02641613.