ULTRASOUND-GUIDED GENICULAR NERVE BLOCK FOR KNEE OSTEOARTHRITIS: A CASE SERIES.

Objective: Knee genicular nerve blocks have been a topic of discussion among various types of treatment for knee osteoarthritis. This study aims to evaluate the pain and function of patients diagnosed with knee osteoarthritis after undergoing ultrasound-guided genicular nerve blockade using pharmacological agents. Methods: The study included 36 patients diagnosed with knee osteoarthritis, comprising 17 bilateral cases, totaling 53 knees undergoing UGNB using a mixture of triamcinolone, ropivacaine, and lidocaine under ultrasound guidance. Epidemiological data, pain outcomes measured by the Visual Analog Scale (VAS), and function assessed using the Western Ontario and McMaster Universities (WOMAC) score were evaluated before and after 12 weeks of the procedure. Results: The mean age was 75.5 years (standard deviation of 9.4 years), with a predominance of females and right-sided involvement. There was a mean reduction of 3.0 points in VAS (p < 0.001) and 15.4 points in WOMAC (p < 0.001). Two cases reported only minor and transient complications related to the procedure (skin anesthesia and edema). Conclusion: Ultrasound-guided genicular nerve blockade using pharmacological agents demonstrated pain reduction and improved function with a low complication rate after 12 weeks in patients with knee gonarthrosis. Level of Evidence IV, Case Series.

Objetivo: Os bloqueios geniculares do joelho têm sido tema de discussão entre os diversos tipos de tratamento da gonartrose. Este estudo tem por objetivo avaliar a dor e a função dos pacientes com diagnóstico de osteoartrose do joelho, após realização do procedimento de bloqueio farmacológico dos nervos geniculares (BFNG) guiado por ultrassom. Métodos: O estudo incluiu 36 pacientes com diagnóstico de gonartrose, sendo 17 casos bilaterais, totalizando 53 joelhos submetidos ao BFNG, com a mistura de triancinolona, ropivacaína e lidocaína guiado por ultrassom. Avaliou-se dados epidemiológicos, desfechos de dor pela Escala Visual Analógica (EVA) e função com escore Western Ontario and Mcmaster Universities (WOMAC) antes e após 12 semanas do procedimento. Resultados: A idade média encontrada foi de 75,5 anos (desvio padrão de 9,4 anos), com predominância do sexo feminino e do lado direito. Houve uma redução média na EVA de 3,0 pontos (p < 0,001) e no WOMAC de 15,4 (p < 0,001). Em dois casos, relataram apenas complicações menores e transitórias relacionadas ao procedimento (anestesia da pele e edema). Conclusão: O bloqueio farmacológico dos nervos geniculares guiado por ultrassom demonstrou redução da dor e melhora na função, com baixa taxa de complicação após 12 semanas nos pacientes com gonartrose. Nível de evidência IV, Série de Casos.

Ketamine in fibromyalgia: a systematic review.

OBJECTIVE: Fibromyalgia (FM) subjects are treated with antidepressant agents; in most cases, these drugs lose efficacy or have adverse effects. Ketamine is an anesthetic drug used in FM in some studies. This article aims to systematically review the safety and efficacy of ketamine in fibromyalgia (FM) patients. MATERIALS AND METHODS: We systematically searched articles on FM and ketamine published at Pubmed from 1966 to 2021. This study was registered at PROSPERO. RESULTS: There were only 6 articles published in this field, with a total of 115 patients. The female sex was predominant (88 to 100%). The age varied from 23 to 53 years old. Disease duration ranged from 1 month to 28 years. The dosage of ketamine changed from 0.1 mg/kg-0.3-0.5 mg/kg in intravenous infusion (4/5) and subcutaneous application (1/5). Regarding outcomes, the Visual analog scale (VAS) before ketamine was from 59 to 100 mm and after treatment from 2 to 95 mm. Most short-term studies had a good response. Only the study with 8 weeks of follow-up did not observe a good response. Side effects were common; all appeared during the infusion and disappeared after a few minutes of the ketamine injection. CONCLUSIONS: The present study demonstrates the effectiveness and safety of ketamine in FM patients in the short term. Although, more studies, including long-term follow-up studies, are still needed.

Manejo quirúrgico en el estado epiléptico superrefractario / Surgical management in Super-refractory epilepticus status

Resumen Introducción: El estado epiléptico refractario (EER) constituye una emergencia médica grave, donde la crisis no cede a pesar del tratamiento farmacológico convencional. Se describe como estado epiléptico superrefractario (EESR) la continua presencia de episodios con una duración de 24 horas o más. Este reporte de caso detalla la complejidad en el manejo y explora un enfoque multidisciplinario. Presentación del caso: Paciente masculino de 32 años con antecedente de epilepsia focal secundaria a traumatismo craneoencefálico en la niñez, quien ingresó en contexto de EESR, el cual recibió coma barbitúrico, plasmaféresis y dieta cetogénica. En los exámenes, la resonancia magnética reveló una lesión en la región frontotemporal insular derecha; en la tomografía por emisión de positrones se observaron zonas de hipermetabolismo y en el videoelectroencefalograma una continua actividad epileptiforme. Se optó por la cirugía paliativa, logrando la resolución exitosa del EESR y una clasificación Engels IA a los 14 meses. Discusión: El EESR es un evento neurológico crítico con pronóstico reservado y opciones terapéuticas desafiantes. Se describen opciones terapéuticas desde anticonvulsivantes, inmunoterapia y cirugía, donde el abordaje quirúrgico emerge como una opción eficaz, especialmente en casos con lesiones estructurales. La identificación temprana y la terapia adecuada son vitales para prevenir complicaciones. Conclusiones: El EESR representa un desafío crítico con alta carga de morbimortalidad, sin embargo, la cirugía de epilepsia muestra promisorios resultados en el contexto de causa cerebral estructural, responsable de la actividad epileptiforme. Se destaca la importancia de la identificación temprana y el manejo quirúrgico paliativo como opción viable, mejorando la calidad de vida de los pacientes.

Abstract Introduction: Refractory Status Epilepticus (RSE) is a serious medical emergency where the seizure does not subside despite conventional pharmacological treatment. The continuous presence of episodes lasting 24 hours or more is described as super-refractory status epilepticus (SRSE). This case report details the complex in teraphy management and explores a multidisciplinary approach. Case presentation: A 32-year-old male with a history of focal epilepsy secondary to head trauma in childhood. Enters emergency with a RSE episode. Barbiturate coma, plasmapheresis and ketogenic diet were administered. The Magnetic Resonance Imaging revealed a lesion in the right fronto-temporo-insular cortex, areas of hypermetabolism on Positron Emission Tomography and continuous epileptiform activity on video-electroencephalogram. Palliative surgery was chosen, achieving successful resolution of the SRSE and Engel Scale IA classification at 14 months of follow up. Discussion: The SRSE is a critical neurological event with a guarded prognosis and complex therapeutic options. Therapeutic options are described from anticonvulsants, immunotherapy and surgery. The surgical approach emerges as an effective option, especially in cases with structural injuries. Early identification and appropriate therapy are vital to prevent complications. Conclusions: SRSE represents a critical challenge with a high burden of morbidity and mortality. However, epilepsy surgery shows promising results in the context of the structural brain cause responsible for epileptiform activity. The importance of early identification and palliative surgical management as a viable option is highlighted, improving the quality of life of patients.

Influence of intravenous fentanyl or dexmedetomidine infusions, combined with lidocaine and ketamine, on cardiovascular response, sevoflurane requirement and postoperative pain in dogs anesthetized for unilateral mastectomy.

OBJECTIVE: To compare the effects of constant rate infusions (CRI) of fentanyl or dexmedetomidine, combined with lidocaine and ketamine, on cardiovascular response during surgery, sevoflurane requirement and postoperative pain in dogs undergoing mastectomy. STUDY DESIGN: Prospective, randomized, blinded, clinical trial. ANIMALS: A total of 29 female dogs with mammary tumors. METHODS: Premedication consisted of intramuscular acepromazine and morphine. General anesthesia was induced with intravenous propofol and maintained with sevoflurane. Dogs were randomized to be administered intravenous DLK [dexmedetomidine 1 µg kg-1 loading dose (LD) and 1 µg kg-1 hour-1; lidocaine 2 mg kg-1 LD and 3 mg kg-1 hour-1; ketamine 1 mg kg-1 LD and 0.6 mg kg-1 hour-1; n = 14] or FLK (fentanyl 5 µg kg-1 LD and 9 µg kg-1 hour-1; same doses of lidocaine and ketamine; n = 15) during anesthesia. Cardiorespiratory variables and end-tidal sevoflurane (Fe'Sevo) were recorded during surgery. The number of dogs administered ephedrine to treat arterial hypotension [mean arterial pressure (MAP) < 60 mmHg] was recorded. Meloxicam was administered to both groups. Postoperative pain and rescue analgesia requirement were assessed for 24 hours using the short form of the Glasgow Composite Measure Pain Scale. Data were compared using a mixed effects model or a Mann-Whitney test. RESULTS: More dogs required ephedrine in FLK than in DLK (67% versus 7%). Heart rate was not significantly different between groups, whereas lower values of MAP (p ≤ 0.01) and Fe'Sevo (p = 0.018) were observed in FLK than in DLK. Rescue analgesia was administered to 2/15 dogs in FLK and 0/14 dogs in DLK. CONCLUSIONS AND CLINICAL RELEVANCE: Based on the cardiovascular response during surgery, intraoperative infusions of FLK and DLK provided adequate antinociception. Infusion of DLK provided greater stability of blood pressure. Both protocols resulted in minimal need for additional analgesia within 24 hours postoperatively.

Periarticular Infiltration Compared to Single Femoral Nerve Block in Total Knee Arthroplasty: A Prospective Randomized Study.

Objective To compare patients undergoing total knee arthroplasty (TKA) under spinal anesthesia and single femoral nerve block (FNB) with subjects undergoing TKA under spinal anesthesia and periarticular infiltration (PAI). Materials and Methods A total of 100 patients undergoing primary TKA were randomized into two groups. Group 1 included patients undergoing surgery under FNB associated with spinal anesthesia, while group 2 included patients undergoing TKA under IPA and spinal anesthesia. The assessment of these subjects in the early postoperative period included pain, active flexion, active extension, elevation of the extended limb, and morphine use. Results There was no significant difference in the types of analgesia concerning pain, the elevation of the extended limb, and morphine use. Active flexion and extension were better in the PAI group ( p = 0.04 and p = 0.02 respectively). Conclusion We conclude that the techniques are similar regarding pain control, limb elevation, and morphine use. The use of IPA provided better active flexion and extension during the hospital stay compared to single FNB in patients undergoing TKA.

Transversus Abdominis Plane Block versus Epidural Anesthesia for Pain Management Post-Caesarean Delivery: A Pilot Study.

Background: Effective post-operative analgesia profoundly influences patient recovery and outcomes after caesarean delivery. The Transversus Abdominis Plane (TAP) block represents a potential alternative, potentially offering greater effectiveness than epidural analgesia while causing fewer adverse effects. Objective: To assess if the abdominal transverse block provides superior postoperative pain relief in patients undergoing caesarean delivery compared to epidural analgesia. Methods: Participants were divided into parallel groups: an experimental group receiving TAP block (n=25) and a control group receiving epidural analgesia (n=24). All patients received a 10 mg dose of hyoscine at the end of the surgery. Experimental Group received a total of 20 mL of 0.2% ropivacaine. In Epidural group received 0.2% ropivacaine at 4 mL/h for 24 hours. All participants were administered combined with neuroaxial block anesthesia. The patients selected for epidural analgesia received the mentioned dose, while the other group block had the epidural catheter removed after the cesarean section. The primary outcome was post-caesarean pain, evaluated using the Visual Analog Scale (VAS) at four intervals (0, 6, 12, and 24 hours). Also, surgical bleeding and residual motor were evaluated. VAS pain scores between the groups were compared using the Friedman test and Generalized Linear Model (GLM) for non-normally distributed data. The effect size was estimated with Eta Square ([Formula: see text]), considering values ≥0.38 as indicative of large effects. A two-tailed p-value < 0.05 was deemed statistically significant. Results: Statistically significant differences in pain scores were noted at 0 and 6 hours post-surgery (p<0.01). The TAP block group reported lower pain scores at 0 hours (mean=0.04) and 6 hours (mean=1.16) compared to the epidural group, reflecting a substantial effect size. Conclusion: The TAP block proves advantageous in mitigating postoperative pain for women post-caesarean delivery, particularly in the initial 6 postpartum hours. This relief promotes early mother-infant bonding and facilitates breastfeeding.

Comparison of Proparacaine, Tetracaine, and Oxybuprocaine in Corneal Sensitivity Measurement.

Purpose: This study aimed to determine the onset and duration of action of 3 commercially available topical anesthetic solutions in Brazil, using the Cochet-Bonnet esthesiometer (Luneau®, Paris, France) and to quantitatively assess patient-reported discomfort during application. Methods: A prospective, randomized, masked, and double-blind study was conducted, involving 40 eyes from 21 patients. Patients were administered each one of the topical anesthetics weekly, and corneal sensitivity was measured using the Cochet-Bonnet esthesiometer's corneal touch threshold (CTT). Patients rated the burning sensation using a visual analogue scale (VAS). Results: Among the 21 patients (42.9% male), with a mean age of 31.95 years (±standard deviation = 10.17, range = 22.0-58.0), corneal sensitivity significantly decreased 30 s after application, returning to baseline after 30 min for all groups (P < 0.0001). Significant differences in CTT were observed at 5 min, with proparacaine exhibiting a superior anesthetic effect (P = 0.0003), at 10 min, where tetracaine displayed the most substantial anesthetic effect (P = 0.0135), and at 20 min, where tetracaine demonstrated the highest anesthetic efficacy (P < 0.0001). VAS scores indicated the most intense burning sensation with tetracaine (P < 0.0001). Men reported experiencing more discomfort during instillation compared with women (P = 0.0168). Conclusions: Proparacaine exhibited the fastest onset of action among the 3 topical anesthetics and provided a more comfortable eye sensation during instillation. However, tetracaine demonstrated the longest duration of action despite causing more discomfort.

Uso de anestésicos tópicos para procedimientos timpánicos: revisión de la literatura / Use of topical anesthetics for tympanic procedures: a literature review

Los procedimientos intratimpánicos se realizan frecuentemente de manera ambulatoria en los policlínicos de otorrinolaringología. Dada la inervación de la membrana timpánica, estos procedimientos generan disconfort y dolor, por lo que la aplicación previa de anestésicos tópicos sobre la membrana timpánica y el conducto auditivo externo es habitual. Pese a su uso, no hay evidencia clara sobre la efectividad de estos y el correcto modo de aplicación. Se realizó una revisión de la literatura sobre la aplicación y uso de anestésicos tópicos previo a procedimientos intratimpánicos, donde pudimos concluir que actualmente no hay un estándar de oro para prevenir el dolor en los pacientes sometidos a procedimientos intratimpánicos, ya que en la mayoría de los estudios no se logró diferencia significativa entre el uso de anestésicos tópicos v/s placebo, al comparar dolor a los 5 y 45 minutos post procedimiento.

A literature review was performed to assess the use and efficacy of topical anesthetics in intratympanic procedures. The analysis led to the conclusion that a gold standard for pain prevention procedures is still lacking, as the majority of studies revised did not show statically significant differences between the use of topic anesthetics and placebo when compared pain at 5 and 45 minutes after procedures.

Exploring the effects of eugenol, menthol, and lidocaine as anesthetics on zebrafish glucose homeostasis.

Zebrafish (Danio rerio) are widely employed as an experimental model in various scientific fields. The investigation of glucose metabolism dysfunctions has gained recent significant prominence. Considering that certain anesthetics may impact glycemic levels, it is imperative to carefully select an anesthetic that does not induce such side effects, thereby mitigating potential adverse influences on research outcomes. In this sense, this study aimed to evaluate potential glucose alterations and induction and recovery times resulting from the use of eugenol, menthol and lidocaine as anesthetics in zebrafish. A total of 150 adult male and female zebrafish were divided into ten groups, comprising a control group euthanized by rapid chilling, and three groups anesthetized with low (40 mg/L eugenol, 60 mg/L menthol, 100 mg/L lidocaine), intermediate (60 mg/L eugenol, 90 mg/L menthol, 225 mg/L lidocaine), and high (80 mg/L eugenol, 120 mg/L menthol, 350 mg/L lidocaine) anesthetic concentrations. Glucose levels and induction and recovery times were assessed. The findings reveal that eugenol and menthol did not cause glucose level alterations at any of the investigated concentrations, while lidocaine caused a non-concentration-dependent hyperglycemia. Eugenol and menthol also exhibited similar recovery times at different concentrations, while lidocaine recovery times were concentration-dependent. This study, therefore, concludes that eugenol and menthol are safe and satisfactory anesthetics for use in zebrafish research involving glucose analyses, while lidocaine use can cause biases due to altered glucose levels and safety concerns. Researchers should, therefore, carefully consider anesthetic selection to ensure reliable results in zebrafish assessments.

Modulation of gene expression and influence of gene polymorphisms related to genotoxicity and redox status on occupational exposure to inhaled anesthetics.

The extensive use of inhalational anesthetics contributes to both indoor and outdoor (environmental) pollution. The influence of genetic susceptibility on DNA damage and oxidative stress and the possible modulation of gene expression have not yet been investigated upon occupational exposure to waste anesthetic gases (WAGs). This study assessed 8-oxoguanine DNA glycosylase 1 (OGG1) and superoxide dismutase 2 (SOD2) gene expression, which are related to oxidized DNA repair and antioxidant capacity, respectively, and the influence of their polymorphisms (OGG1 rs1052133 and SOD2 rs4880) in 100 professionals highly exposed to WAGs and 93 unexposed volunteers (control group). Additionally, X-ray repair cross complementing 1 (XRCC1 rs25487 and rs1799782) and ataxia telangiectasia mutated (ATM rs600931) gene polymorphisms as well as genetic instability (micronucleus-MN and nuclear bud-NBUD) and oxidative stress (malondialdehyde-MDA and ferric reducing antioxidant power-FRAP) biomarkers were assessed in the groups (control and exposed) and in the subgroups of the exposed group according to job occupation (anesthesiologists versus surgeons/technicians). Except for the ATM TT controls (associated with increased FRAP), there were no influences of OGG1, XRCC1, ATM, and SOD2 polymorphisms on MN, NBUD, MDA, and FRAP values in exposed or control subjects. No significant difference in the expression of either gene evaluated (OGG1 and SOD2) was found between the exposed and control groups. Increased OGG1 expression was observed among OGG1 -/Cys individuals only in the control group. Among the exposed group, anesthesiologists had a greater duration of WAG exposure (both h/week and years) than surgeons/technicians, which was associated with increased MDA and decreased antioxidant capacity (FRAP) and SOD2 expression (redox status). Higher expression of OGG1 was found in -/Cys surgeons/technicians than in anesthesiologists with the same genotype. Increased antioxidant capacity was noted in the surgeons/technicians carrying the ATM T allele and in those carrying XRCC1 -/Gln. Increased MN was influenced by OGG1 -/Cys in surgeons/technicians. Anesthesiologists with ATM CC exhibited increased MN, and those carrying the C allele (CC/CT genotype) exhibited increased NBUD. SOD2 polymorphism did not seem to be relevant for WAG exposure. These findings contribute to advancing the knowledge on genetic susceptibility/gene expression/genetic instability/oxidative stress, including differences in job occupation considering the workload, in response to occupational exposure to WAGs.

Periarticular Infiltration Compared to Single Femoral Nerve Block in Total Knee Arthroplasty: A Prospective Randomized Study / Infiltração periarticular comparada ao bloqueio do nervo femoral único na artroplastia total de joelho: Um estudo prospectivo randomizado

Abstract Objective To compare patients undergoing total knee arthroplasty (TKA) under spinal anesthesia and single femoral nerve block (FNB) with subjects undergoing TKA under spinal anesthesia and periarticular infiltration (PAI). Materials and Methods A total of 100 patients undergoing primary TKA were randomized into two groups. Group 1 included patients undergoing surgery under FNB associated with spinal anesthesia, while group 2 included patients undergoing TKA under IPA and spinal anesthesia. The assessment of these subjects in the early postoperative period included pain, active flexion, active extension, elevation of the extended limb, and morphine use. Results There was no significant difference in the types of analgesia concerning pain, the elevation of the extended limb, and morphine use. Active flexion and extension were better in the PAI group (p = 0.04 and p = 0.02 respectively). Conclusion We conclude that the techniques are similar regarding pain control, limb elevation, and morphine use. The use of IPA provided better active flexion and extension during the hospital stay compared to single FNB in patients undergoing TKA.

Resumo Objetivo Avaliar pacientes submetidos a artroplastia total do joelho (ATJ) sob raquianestesia e bloqueio do nervo femoral (BNF) único e comparar com pacientes que submetidos a ATJ sob raquianestesia e infiltração periarticular (IPA). Materiais e Métodos Um total de 100 pacientes submetidos a ATJ foram randomizados em dois grupos. O grupo 1 incluiu pacientes submetidos a ATJ sob BNF associado à raquianestesia, ao passo que o grupo 2 incluiu pacientes submetidos a ATJ sob IPA associada à raquianestesia. Os indivíduos foram avaliados no pós-operatório precoce quanto à dor, à flexão e extensão ativas, à elevação do membro estendido e ao uso de morfina. Resultados Não se observou diferença significativa associada ao tipo de analgesia em relação à dor, à elevação do membro em extensão e ao consumo de morfina. Houve melhor flexão e extensão ativas no grupo que recebeu IPA (p = 0,04 e p = 0,02, respectivamente). Conclusão Concluímos que as técnicas utilizadas são semelhantes quanto ao controle da dor, à elevação de membro e ao uso de morfina. O uso de IPA proporcionou uma melhor flexão e extensão ativas durante o período de internação hospitalar comparado ao uso de BNF único em pacientes submetidos a ATJ.

Modified thoracoabdominal nerves block through perichondrial approach for laparoscopic cholecystectomy

SUMMARY OBJECTIVE: A new block, namely, modified thoracoabdominal nerves block through perichondrial approach, is administered below the costal cartilage. We sought to compare the analgesic efficacy of the modified thoracoabdominal nerves block through perichondrial approach block with local anesthetic infiltration at the port sites in an adult population who underwent laparoscopic cholecystectomy. METHODS: Patients who will undergo laparoscopic cholecystectomy were randomized to receive bilateral ultrasound-guided modified thoracoabdominal nerves block through perichondrial approach blocks or local anesthetic infiltration at the port insertion sites. The primary outcome was the total amount of tramadol used in the first 12 h postoperatively. The secondary outcomes were total IV tramadol consumption for the first postoperative 24 h and visual analog scale scores. RESULTS: The modified thoracoabdominal nerves block through perichondrial approach group had significantly less tramadol use in the first 12 h postoperatively (p<0.001). The modified thoracoabdominal nerves block through perichondrial approach group's visual analog scale scores at rest (static) and with movement (dynamic) were significantly lower compared with the port infiltration group (p<0.05). CONCLUSION: Patients who received modified thoracoabdominal nerves block through perichondrial approach block had significantly less analgesic consumption and better pain scores than those who received port-site injections after laparoscopic cholecystectomy.

Usos y vías de administración de la lidocaína en oftalmología / Uses and Ways of Administering Lidocaine in Ophthalmology

La lidocaína es el anestésico local más utilizado a nivel mundial para la cirugía de catarata. También se usa de manera común en otras intervenciones quirúrgicas oftalmológicas del segmento anterior, la superficie del globo ocular, los párpados y vías lagrimales, así como en el segmento posterior del ojo. Esta revisión pretende brindar una actualización sobre las principales características, los efectos y vías de administración de la lidocaína usada en la oftalmología. Se realizó una búsqueda sistemática sobre el tema en publicaciones científicas indexadas en bases de datos, cuya información recopilada se resumió en este trabajo. La lidocaína se presenta en múltiples formas farmacéuticas, con variedad en concentración y formulación. Por lo general, para inyección se usan las concentraciones al 0,5 por ciento, 1 por ciento y 2 por ciento, para anestesia tópica en gel al 2 por ciento y en solución oftálmica al 4 por ciento. Su efecto como anestésico local es bien conocido, a nivel ocular se puede conseguir a través de inyecciones perioculares e intraoculares o mediante su aplicación tópica. Este efecto anestésico de la lidocaína ofrece cierta capacidad de dilatación pupilar, el cual se ha estudiado y aprovechado con frecuencia en los últimos años. Hoy día se encuentran en estudio otros efectos de la lidocaína a nivel local y sistémico. Los usos de la lidocaína en la oftalmología actual, están respaldados fundamentalmente por su eficacia y seguridad comprobadas en el tiempo(AU)

Lidocaine is the most widely used local anesthetic worldwide for cataract surgery. It is also commonly used in other ophthalmic surgical procedures of the anterior segment, surface of the eyeball, eyelids and lacrimal ducts, as well as in the posterior segment of the eye. This review aims to provide an update on the main characteristics, effects and ways of administering lidocaine used in ophthalmology. A systematic search on the subject was carried out in scientific publications indexed in databases, the information collected was summarized in this work. Lidocaine comes in multiple pharmaceutical forms, with a variety of concentrations and formulations. Generally, 0.5 percent, 1 percent and 2 percent concentrations are used for injection, 2 percent for topical anesthesia in gel and 4% in ophthalmic solution. Its effect as a local anesthetic is well known, at ocular level it can be achieved through periocular and intraocular injections or by topical application. This anesthetic effect of lidocaine offers some pupillary dilation capacity, which has been frequently studied and exploited in recent years. Other local and systemic effects of lidocaine are currently under study. The uses of lidocaine in ophthalmology today are supported primarily by its time-tested efficacy and safety(AU)

Ultrasound-guided genicular nerve block for knee osteoarthritis: a case series / Bloqueio do nervo genicular guiado por ultrassom para osteoartrose do joelho: uma série de casos

ABSTRACT Objective: Knee genicular nerve blocks have been a topic of discussion among various types of treatment for knee osteoarthritis. This study aims to evaluate the pain and function of patients diagnosed with knee osteoarthritis after undergoing ultrasound-guided genicular nerve blockade using pharmacological agents. Methods: The study included 36 patients diagnosed with knee osteoarthritis, comprising 17 bilateral cases, totaling 53 knees undergoing UGNB using a mixture of triamcinolone, ropivacaine, and lidocaine under ultrasound guidance. Epidemiological data, pain outcomes measured by the Visual Analog Scale (VAS), and function assessed using the Western Ontario and McMaster Universities (WOMAC) score were evaluated before and after 12 weeks of the procedure. Results: The mean age was 75.5 years (standard deviation of 9.4 years), with a predominance of females and right-sided involvement. There was a mean reduction of 3.0 points in VAS (p < 0.001) and 15.4 points in WOMAC (p < 0.001). Two cases reported only minor and transient complications related to the procedure (skin anesthesia and edema). Conclusion: Ultrasound-guided genicular nerve blockade using pharmacological agents demonstrated pain reduction and improved function with a low complication rate after 12 weeks in patients with knee gonarthrosis. Level of Evidence IV, Case Series.

RESUMO Objetivo: Os bloqueios geniculares do joelho têm sido tema de discussão entre os diversos tipos de tratamento da gonartrose. Este estudo tem por objetivo avaliar a dor e a função dos pacientes com diagnóstico de osteoartrose do joelho, após realização do procedimento de bloqueio farmacológico dos nervos geniculares (BFNG) guiado por ultrassom. Métodos: O estudo incluiu 36 pacientes com diagnóstico de gonartrose, sendo 17 casos bilaterais, totalizando 53 joelhos submetidos ao BFNG, com a mistura de triancinolona, ropivacaína e lidocaína guiado por ultrassom. Avaliou-se dados epidemiológicos, desfechos de dor pela Escala Visual Analógica (EVA) e função com escore Western Ontario and Mcmaster Universities (WOMAC) antes e após 12 semanas do procedimento. Resultados: A idade média encontrada foi de 75,5 anos (desvio padrão de 9,4 anos), com predominância do sexo feminino e do lado direito. Houve uma redução média na EVA de 3,0 pontos (p < 0,001) e no WOMAC de 15,4 (p < 0,001). Em dois casos, relataram apenas complicações menores e transitórias relacionadas ao procedimento (anestesia da pele e edema). Conclusão: O bloqueio farmacológico dos nervos geniculares guiado por ultrassom demonstrou redução da dor e melhora na função, com baixa taxa de complicação após 12 semanas nos pacientes com gonartrose. Nível de evidência IV, Série de Casos.

Eficácia de técnicas anestésicas para o manejo de molares inferiores com pulpite irreversível: uma revisão de literatura / Efficacy of anesthetic techniques for the management of mandibular molars with irreversible pulpitis: a literature review

Objetivo: A anestesia de molares mandibulares irreversivelmente inflamados está atrelada a taxas de falha que variam de 43% a 83% após o Bloqueio do Nervo Alveolar Inferior(BNAI). Portanto, o objetivo do presente trabalho foi revisar a literatura disponível sobre técnicas anestésicas primárias e complementares, para auxiliar o clínico a alcançar anestesia profunda durante o tratamento de urgência de molares mandibulares com pulpite irreversível. Materiais e métodos: Foram pesquisados, na base de dados PubMed, ensaios clínicos randomizados cuja população abrangeu pacientes com pulpite irreversível em molares mandibulares procurando atendimento de urgência. Foi avaliado o sucesso anestésico através do relato de dor durante a abertura coronária e/ou instrumentação dos canais radiculares utilizando a escala visual analógica. Dos 82estudosencontradossobre técnicas anestésicas primárias, 7foram incluídos, enquanto para as técnicas complementares, dos 21 estudos encontrados, foram incluídos 8.Revisão de literatura: A técnica Intraóssea (IO) chegou a apresentar 100%desucesso em dentes em que a BNAI havia falhado. Já, as técnicas Intraligamentar (IL)e Infiltração Mandibular (IM), aumentaram de 28,1% para 75% e 65,6% respectivamente, as taxas de sucesso anestésico. Discussão: Ouso de anestesia IO como técnica complementar ao BNAI, ou ainda, o uso deste, combinado com as anestesias IL e IM aumentam de forma significativa os percentuais de sucesso para alcançar anestesia pulpar. Conclusão: Embora a conquista da anestesia profunda de molares inferiores inflamados seja desafiadora, técnicas anestésicas podem ser combinadas para proporcionar ao paciente um conforto maior durante o tratamento.

Aim:Anesthesia of irreversibly inflamed mandibular molars is linked to failure rates ranging from 43% to 83% after Inferior Alveolar Nerve Block (IANB).Therefore, the objectiveof the present study was to review the available literature on primary and complementary anesthetic techniques to help the cliniciantoachieve deep anesthesia during the urgent treatment of mandibular molars with irreversible pulpitis. Materials and methods:randomizedclinical trialswhose population included patients with irreversible pulpitis in mandibular molars seeking emergency care were searched in the PubMed database. Anesthetic success was evaluated by reporting pain during coronary opening and/or instrumentation of root canals using the visual analog scale. 82 studieswerefoundedonprimary anesthetic techniques,and7 were included, while for the supplementary techniques, 21 studieswerefounded,and8 were included. Literature review:the Intraosseous (IO) technique was 100% successful when the BNAI had failed. Intraligamentary injection (IL) and Mandibular Infiltration (IM) techniques, increased from 28.1% to 75% and 65.6%, respectively, success rates. Discussion:the use of IO anesthesia as asupplementary technique to BNAI, or even its use, combined with IL and IM anesthesia significantly increasedthe percentages of success to achieve pulpal anesthesia. Conclusion:Although the achievement of deep anesthesia of inflamed lower molars is challenging, anesthetic techniques can be combinedto provide greater patient comfort during treatment.

Cardiac output and the pharmacology of general anesthetics: a narrative review

The relationship between cardiac output and anesthetic drugs is important to anesthesiologists, since cardiac output determines the speed with which a drug infused into the bloodstream reaches its target and the intensity of the drug's effect. But rather than focus on how anesthetic drugs affect cardiac output, this narrative review focuses on how changes in cardiac output affect the pharmacokinetics and pharmacodynamics of general anesthetics during the three phases of anesthesia. At induction, an increase in cardiac output shortens both the onset time of propofol for hypnosis and the neuromuscular blocking effect of rapid-acting neuromuscular blockers, favoring the conditions for rapid sequence intubation. During maintenance, changes in cardiac output are followed by opposite changes in the drug plasma concentration of anesthetic drugs. Thus, an increase in cardiac output followed by a decrease in the plasma concentration of the anesthetic could expose the patient to a real risk of intraoperative awakening, which can be avoided by increasing the dose of hypnotic drugs. At emergence, an increase in cardiac output secondary to an increase in pC02 allows for a more rapid recovery from anesthesia. The pC02 can be increased by adding CO2 to the respiratory circuit, lowering the ventilatory rate, or placing the patient on partial rebreathing. Finally, the reversal action of sugammadex for rocuronium-induced neuromuscular block can be shortened by increasing the cardiac output.

La relación entre el gasto cardíaco y los fármacos anestésicos es importante para los anestesiólogos puesto que el gasto cardíaco determina la velocidad con la cual un medicamento que se infunde al torrente sanguíneo llega a su diana y la intensidad del efecto del agente. Pero en lugar de concentrarnos en cómo los fármacos anestésicos afectan el gasto cardíaco, esta revisión narrativa se enfoca en cómo los cambios en el gasto cardíaco afectan la farmacocinética y la farmacodinámica de los agentes anestésicos generales durante las tres fases de la anestesia. En el momento de la inducción, un incremento en el gasto cardíaco acorta tanto el tiempo de inicio del efecto del propofol para la hipnosis como el efecto del bloqueo neuromuscular causado por los bloqueadores neuromusculares de acción rápida, favoreciendo las condiciones para la intubación de secuencia rápida. Durante la fase de mantenimiento, los cambios en el gasto cardíaco vienen seguidos de cambios opuestos en la concentración plasmática del medicamento de los agentes anestésicos. Por lo tanto, un aumento del gasto cardíaco, seguido de una reducción en la concentración plasmática del anestésico, podría exponer al paciente a un riesgo real de despertar intraoperatorio, lo cual puede evitarse aumentando la dosis de los fármacos hipnóticos. En la educción, un aumento en el gasto cardíaco secundario al incremento en el pCO2 permite una recuperación más rápida de la anestesia. El pCO2 puede aumentar agregando CO2 al circuito de la respiración, reduciendo la tasa ventilatoria, o colocando al paciente en re-inhalación parcial. Finalmente, la acción de reversión de sugammadex en caso de bloqueo neuromuscular inducido por rocuronio, puede acortarse aumentando el gasto cardíaco.

Safety and efficacy of target-controlled infusion versus intermittent bolus administration of propofol for sedation in colonoscopy: a randomized controlled trial

Abstract Background: Our objective was to compare the safety and efficacy of Target-Controlled Infusion (TCI) versus intermittent bolus of propofol for colonoscopy sedation. Methods: We conducted a randomized (1:1), single-blind, parallel-group superiority trial with fifty ASA I or II patients, both sexes, aged 18 to 65 years, Body Mass Index ≤ 30 kg.mr-2, undergoing colonoscopy, allocated to receive propofol by TCI (effect-site, 2 μg.mL-1 plus 0.5 μg.mL-1 until unconsciousness and as necessary for agitation) or intermittent bolus (1 mg.kg-1 plus 0.5 mg.kg-1 every 5 minutes or as above). The primary safety outcome was the need for airway maneuvers and the primary efficacy outcome was the need for interventions to adjust the level of sedation. Secondary outcomes included incidence of agitation, propofol dose, and time to recovery. Results: The median (IQR) number of airway maneuvers and interventions needed to adjust sedation was 0 (0-0) vs. 0 (0-0) (p = 0.239) and 1 (0-1) vs. 3 (1-4) (p < 0.001) in the TCI and control groups, respectively. Agitation was more common in the intermittent bolus group - 2 (0-2) vs. 1 (0-1), p < 0.001. The mean ± SD time to recovery was 4.9 ± 1.4 minutes in the TCI group vs. 2.3 ± 1.6 minutes in the control group (p < 0.001). The total propofol dose was higher in the TCI group (234 ± 46 μg.kg-1.min-1 vs. 195 ± 44 μg.kg-1.min-1 (p = 0.040)). Conclusions: During colonoscopy, TCI is as safe as intermittent bolus of propofol while reducing the incidence of agitation and the need for dose adjustments. However, intermittent bolus administration was associated with lower total propofol dose and earlier recovery.

Perineural low dexamethasone dose as adjuvant in supraclavicular brachial plexus block for arteriovenous fistula creation in end stage renal disease: a randomized controlled trial

Abstract Background and aims: Dexamethasone as adjunct to local anesthetic solution improves the quality of brachial plexus block (BPB). However, evidence for its efficacy at low doses (< 4 mg) is lacking. This study was designed to evaluate the duration of analgesia attained with low dose dexamethasone as adjuvant to local anesthetic for creation of arteriovenous fistula (AVF) under BPB. Methods: Sixty-six patients scheduled for AVF creation were randomly allocated to receive either saline (control) or 2 mg dexamethasone, together with 0.5% ropivacaine and 0.2% lignocaine. The primary outcome was duration of analgesia, defined as time from performing the block to the first analgesic request. The secondary outcomes were time from injection to complete sensory block, time from injection to complete motor block, duration of motor block, postoperative analgesic consumption, and fistula patency at three months. Results: All the blocks were effective. In the group that received dexamethasone, the time to first analgesic request was significantly delayed (432 ± 43.8 minutes vs. 386.4 ± 40.2 minutes; p < 0.01). The onset of sensory and motor blockade occurred faster in dexamethasone group and overall analgesic consumption was also reduced. However, dexamethasone addition did not prolong the duration of motor block. There was no statistically significant difference in the patency of fistulas between the two groups at three months. (p = 0.34). Conclusion: Addition of low-dose perineural dexamethasone to local anesthetic solution significantly prolonged the duration of analgesia. Further trials are warranted to compare the adverse effects between dexamethasone doses of 4 mg and lower.

Use of intravenous lidocaine in a patient with refractory chest pain secondary to Takayasu arteritis. Case report / Uso da lidocaína endovenosa em paciente com dor torácica refratária secundária à arterite de Takayasu. Relato de caso

ABSTRACT BACKGROUND AND OBJECTIVES: Takayasu's arteritis (TA) is a rare form of chronic inflammatory disease involving large vessels, with uncertain etiology, with chest pain as a common and challenging symptom, resulting from inflammation in the aortic root or arch, pulmonary artery or coronary arteries. The objective of this study was to describe the use of intravenous lidocaine to treat severe and refractory chest pain secondary to TA. CASE REPORT: A 33-year-old female patient diagnosed with TA, with severe chest pain that was difficult to manage, was admitted after consulting an emergency department. The pain was unresponsive to traditional treatment after a week of drug adjustments. As a therapeutic option, a Sympathetic Venous Blockade (SVB) with lidocaine was chosen, achieving a reduction in pain from 10 to 3 on the Visual Analog Scale. Infliximab was administered before discharge. The patient was re-evaluated at an outpatient appointment after 30 days. CONCLUSION: This strategy for the treatment of severe chest pain allowed for pain reduction and relief.

RESUMO JUSTIFICATIVA E OBJETIVOS: A arterite de Takayasu (AT) é uma forma rara de doença inflamatória crônica envolvendo grandes vasos, com etiologia incerta, tendo a dor torácica como um sintoma comum e desafiador, consequente à inflamação na raiz ou arco aórtico, artéria pulmonar ou coronárias. O objetivo deste estudo foi relatar a utilização da lidocaína por via endovenosa na abordagem da dor torácica intensa e refratária secundária à AT. RELATO DO CASO: Paciente do sexo feminino, 33 anos, com diagnóstico de AT, dor torácica intensa de difícil manejo, internada após consulta em serviço de emergência. Dor não responsiva ao tratamento tradicional após uma semana de ajustes em fármacos. Como opção terapêutica, foi escolhido o Bloqueio Simpático Venoso (BSV) com lidocaína, obtendo redução da dor de 10 para 3 na Escala Analógica Visual. Antes da alta hospitalar foi administrado infliximabe. Paciente foi reavaliada em consulta ambulatorial após 30 dias. CONCLUSÃO: Esta estratégia fora tratamento da dor torácica intensa permitiu redução e alívio da dor.

[Anafilaxia perioperatoria a sevoflurano, un caso muy raro].

Background: Perioperative anaphylaxis can be life-threatening. The global incidence is estimated to be 1 in 10,000-20,000 procedures. The most common agents are neuromuscular blockers, latex, and antibiotics. There are very few reports of allergies to inhaled anesthetics such as sevoflurane, which is considered relatively safe in patients with drug allergies. Case report: 12-year-old patient, admitted to oncology, diagnosed with acute lymphoblastic leukemia. History of two perioperative hypersensitivity reactions. In the first event, lidocaine and rupivacaine were administered, he presented urticaria, managed with an antihistamine. On the second occasion, he received only sevoflurane and presented anaphylaxis, treated with intramuscular adrenaline. Later during intrathecal therapy, he received sevoflurane, he presented rash and arterial hypotension, managed again with adrenaline, with total remission of symptoms. Retrospectively Brighton criteria level I of certainty, classified as serious by Brown. Hypersensitivity to sevoflurane was suspected, ruling out other anesthetics such as lidocaine and rupivacaine with negative intradermal skin tests. Molecular components for latex were requested with negative results for Hev b 1, Hev b 3, Hev b 6. Due to the above and associated with the characteristics of the drug, a basophil activation test for sevoflurane was performed with an activation percentage of 50% (positive). Perioperative anaphylaxis due to sevoflurane is confirmed. Conclusion: All drugs involved in perioperative hypersensitivity reactions should be considered to establish adequate and safe treatment alternatives for this small group of patients.

Antecedentes: La anafilaxia perioperatoria puede amenazar la vida del paciente. La incidencia global se estima 1 entre 10.000-20.000 procedimientos. Los agen- tes más frecuentes son bloqueadores neuromusculares, látex y antibióticos. Hay muy pocos reportes de alergia a anestésicos inhalados como el sevoflurano, el cual se considera relativamente seguro en pacientes con alergia a fármacos. Reporte de caso: Paciente de 12 años, ingresó en oncología, diagnóstico de leucemia linfoblástica aguda. Antecedente de dos reacciones de hipersensibilidad perioperatorias. En primer evento se administró lidocaína y rupivacaína, presentó urticaria, manejado con antihistamínico. Segunda ocasión recibió sólo sevo- fluorano y presentó anafilaxia, tratado con adrenalina intramuscular. Posteriormente durante terapia intratecal, recibió sevoflurano, presentó rash e hipotensión arterial, manejo nuevamente con adrenalina, con remisión total de síntomas. Retrospectivamente criterios de Brighton nivel I de certeza, clasificada grave por Brown. Se sospechó hipersensibilidad a sevoflurano, descartando otros anestésicos como lidocaína y rupivacaina con pruebas cutáneas intradérmicas negativas. Se solicitaron componentes moleculares para látex con resultados negativos para Hev b 1, Hev b 3, Hev b 6. Por lo anterior y asociado a las características del fármaco se realiza prueba de activación de basófilos para sevoflurano con un porcentaje de activación del 50% (positivo). Se confirma anafilaxia perioperatoria por sevoflurano. Conclusión: Deben considerarse todos los fármacos involucrados en las reacciones de hipersensibilidad perioperatoria, para establecer alternativas adecuadas y seguras de tratamiento de este pequeño grupo de pacientes.