Factors associated with transient bradycardia during local anesthesia administration to the oral cavity under intravenous sedation: A retrospective cohort study.

Background/purpose: The possibility of triggering the trigeminocardiac reflex (TCR) during oral surgery is considerably lower than that during other surgeries. A reduced heart rate (HR) of ≥20% from baseline is usually considered a diagnostical criterion for the TCR. Our automated anesthesia charting system often revealed cases of slight transient HR decrease during sedation. We aimed to explore its incidence and associated factors during local anesthesia administration under intravenous sedation. Materials and methods: This study analyzed the data of 2636 cases that received infiltration anesthesia under intravenous sedation from 2008 to 2010 and had vital signs recorded using an automated anesthesia charting system. Especially, data concerning the average HR before anesthesia and the minimum HR between the initiation and end of anesthesia from anesthetic records were extracted. Moreover, data regarding patients' medical history and unusual reactions during dental treatment were collected. Multivariate logistic regression analysis was performed to identify factors associated with transient bradycardia (TB). Results: TB occurred in 472 patients (17.9%); no patient developed hypotension or any associated symptoms, suggesting that intravenous sedation was effective in stabilizing vital signs. The factors associated with TB were younger age, gag reflex, and allergy to local anesthetics. There were no differences in sex, patient history, or dose of sedatives between patients with TB and those without TB. Conclusion: The incidence of TB during infiltration anesthesia under sedation was found to be higher than that previously reported. Additionally, young age and gag reflex were identified as factors associated with bradycardia development.

Spinal Anaesthesia Using Hypobaric Drugs: A Review of Current Evidence.

Spinal anesthesia is one of the most widely used techniques in modern anesthesia practice. It involves the injection of local anesthetic drugs into the cerebrospinal fluid (CSF) within the subarachnoid space. The choice of drug, its concentration, and baricity play a crucial role in determining the characteristics of the spinal block and has evolved over the years with continuous advancements in drug formulations and administration methods. Spinal anesthesia with hypobaric drugs represents a valuable technique in the armamentarium of anesthesiologists, offering distinct advantages in terms of targeted action, reduced systemic toxicity, and enhanced hemodynamic stability. This review aims to scan the characteristics of hypobaric drugs, factors influencing their spread within the spinal canal, challenges associated with their use, clinical applications in various surgical scenarios, and potential implications for patient outcomes and healthcare practice. PubMed and Google Scholar databases were searched for relevant articles and a total of 23 relevant articles were selected for the review based on inclusion and exclusion criteria. Hypobaric drugs have many advantages in high-risk morbidly ill patients for some select surgical procedures and daycare surgeries. The concentration and volume of hypobaric drugs need to be selected according to the extensiveness of the surgery and the desired block can be achieved by giving spinal injection in specific positions. The dynamic field of anesthesiology encompasses the integration of emerging technologies and evidence-based practices, which will contribute to further refining the safety and efficacy of spinal anesthesia with hypobaric drugs.

Maternal and neonatal effects of epidural levobupivacaine combined with fentanyl or sufentanil for elective cesarean-section in brachycephalic breeds.

The aim of this study was to compare the safety and clinical efficacy of epidural levobupivacaine combined with fentanyl or sufentanil for bitches undergoing elective cesarean-section and the impact of these anesthetic protocols on neonatal viability. The anesthetic protocol consisted of intramuscular morphine (0.2 mg/kg), followed by an intravenous bolus of propofol, in a dose sufficient to allowed the puncture of the lumbosacral space. The dogs were randomly allocated to receive 0.5% levobupivacaine plus fentanyl (2.5 µg/kg; LF: n = 9) or sufentanil (1 µg/kg; LS; n = 11). Maternal cardiorespiratory parameters were monitored at specific time points during surgery. Intraoperative propofol supplementation was based on the presence of head and/or thoracic limb movements. Neonatal reflex responses and the Apgar score (range 0-10 points) were assessed at 5 and 60 minutes after birth. Puppy mortality rate was recorded until 24 hours after birth. Data were analyzed using two-way ANOVA, Tukey's test, Wilcoxon signed rank test, and Fisher's exact test (P < 0.05). Intraoperatively, maternal cardiorespiratory variables and propofol requirements were similar between groups, with no detection of anesthetic complications. The puppy reflex responses did not differ between groups at any time point. The medians (range) of Apgar scores were lower (P = 0.016) in the LF [5 (1-9)] at 5 minutes in comparison with LS [6 (2-9)], while no intergroup differences were recorded at 60 minutes [LF = 8 (2-10); LS = 9 (6-10]. The total mortality rate was 4.1%. In the LS group, no puppies died, while in the LF 8% of the puppies died in the first 24 hours after birth (P = 0.11). Epidural levobupivacaine combined with fentanyl or sufentanil provided minimal maternal and neonatal adverse effects, but neither protocol enabled the performance of a C-section in 100% of the French and English bulldogs, without propofol supplementation.

Association of anesthetic modality and other variables on 1-year functional patency of cephalic-based arteriovenous fistulae.

OBJECTIVES: Some studies suggest that regional (RA) provides better patency for arteriovenous fistula (AVF) for hemodialysis (HD) access as compared to Local (LA) and General Anesthesia (GA). This study evaluates the impact of anesthetic modality on long term fistula function at 12 months. METHODS: A retrospective review of patients undergoing cephalic vein-based HD access in consecutive cases between 2014 and 2019 was conducted from five safety net hospitals. The primary endpoint was functional patency at 12 months. Subset analysis individually evaluated cephalic based lower forearm and wrist versus upper arm AVFs. Bivariate and multivariate logistic regression models evaluated the relationship between anesthetic modality and fistula function at 12 months. RESULTS: There were 818 cephalic based fistulas created during the study period. The overall 12-month functional patency rate was 78.7%, including an 81.3% patency for upper arm AVF and 73.3% for wrist AVF (p=0.009). There was no statistically significant difference among patients with functional and nonfunctional AVFs at 12 months with respect to anesthetic modality when comparing regional, local, and general anesthesia (p=0.343). Multivariate regression analysis identified that history of AVF/AVG (OR 0.24, p=0.007), receiving intraoperative systemic anticoagulation (OR 2.49, p<0.001), and vein diameter (OR 1.85, p=0.039) as independently associated with AVF functional patency at 12 months. CONCLUSION: There was no association between anesthetic modality and functional patency of cephalic based-AVF at 12 months. Further studies are needed to better define which patients may benefit from regional anesthesia.

Endoscopic Posterior Cervical Foraminotomy under Lateral Decubitus Position with Local Anesthesia.

Endoscopic posterior cervical foraminotomy is gaining popularity among endoscopic spine surgeons for the treatment of radiculopathy caused by foraminal stenosis. This study describes a technique utilizing lateral decubitus position for an endoscopic posterior cervical foraminotomy under Monitored Anesthesia Care (MAC) and local anesthesia only. 10 patients with contraindications to general anesthesia underwent the procedure, resulting in an improvement in cervical radicular pain with no perioperative complications. The findings suggest that this approach is a viable alternative for high-risk patients for general anesthesia care, expanding the surgical options for the treatment of radiculopathy.

Clinical experience in intracranial stenting of Wingspan stent system under local anesthesia.

Objective: The use of endovascular treatments for symptomatic intracranial atherosclerosis disease (ICAD) remains contentious due to high periprocedural complications. Many centers resort to general anesthesia for airway protection and optimal periprocedural conditions; however, this approach lacks real-time monitoring of patients' neurological status during procedures. In this study, we employed intracranial stenting with the Wingspan system under local anesthesia to address this challenge. Methods: We conducted a retrospective study of 45 consecutive ICAD patients who underwent intracranial stenting with the Wingspan system at our hospital from August 2013 to May 2021. These stenting procedures were performed under local anesthesia in a hybrid operation room. Neurological assessments were conducted during the procedure. The patients with periprocedural complications were analyzed for the risk factors. Results: The study included 45 ICAD patients (median age 62 years; 35 male and 10 female individuals). Among them, 30 patients had anterior circulation ICAD, and 15 had posterior circulation ICAD. The periprocedural complication rate was 8.9% (4/45), with an overall mortality rate of 2.2% (1/45). Notably, no procedure-related perforation complications were found, and all ischemic complications occurred in the perforating bearing artery, specifically in patients with stents placed in the middle cerebral artery or basilar artery, while no complications were observed in the non-perforating bearing artery of the internal carotid artery and vertebral artery (p = 0.04). Conclusion: Our study demonstrates the safety and efficacy of the Wingspan stent system when performed on selected patients under local anesthesia. This approach seems to reduce procedural-related morbidity and be a safe intervention. In addition, it is crucial for surgeons to be aware that patients with perforator-bearing artery stenosis may be at a higher risk of complications.

Comparative Evaluation of Two Different Topical Anesthetic Agents against Pain Associated with Intraoral Injections in Pediatric Dental Patients.

Aim: This study aimed to examine the effectiveness of two topical anesthetics in minimizing the discomfort related to intraoral injections. Material and Method: For the study, 40 healthy kids between the ages of 6 and 10 were chosen. To the injection site, two topical anesthetic products were applied: lignocaine hydrochloride gel and benzocaine 20% gel. The effectiveness of the topical agents was evaluated using a four-point scale, which was previously used by Topçuoglu and colleagues to evaluate pain. Result: A significant difference between the lignocaine group (2.1 ± 0.5) and the benzocaine group (1.2 ± 0.6) was found on a four-point scale (P < 0.05). Conclusion: Benzocaine demonstrates a higher degree of efficacy in comparison with lignocaine. However, additional research is necessary to ascertain the result of this study.

Absorption and pharmacokinetics of bupivacaine after bilateral topical administration in tonsillar fossae for posttonsillectomy pain relief.

No previous studies have investigated the systemic absorption of bupivacaine when used topically for posttonsillectomy pain. The present study was undertaken to investigate the pharmacokinetics of bupivacaine after administration by a swab in the tonsillar fossae over 4 min after tonsillectomy. Eleven adult patients undergoing elective tonsillectomy were recruited. After removal of both tonsils, each of the two tonsillar fossae was covered with a swab moistened with 2 mL of bupivacaine 5 mg/mL, that is, a total of 20 mg bupivacaine. Blood samples were drawn after 0, 5, 10, 20, 30, 45, and 60 min. Bupivacaine was analyzed with an ultra-high-performance liquid chromatography-tandem mass spectrometry method. The highest single measured bupivacaine serum concentration was 23.2 ng/mL and took place 10 min after drug administration. Mean (±SD) Cmax was 11.4 ± 6.0 ng/mL and mean tmax was 11.3 ± 4.7 min. Mean t1/2 was 31.6 ± 9.3 min. As the toxic concentration threshold has been reported to be in the interval 1500-4500 ng/mL, the concentrations measured were well below 2% of the lowest cited toxic threshold. In conclusion, this study shows that applying 4 mL of bupivacaine 5 mg/mL by a swab in the tonsillar fossae posttonsillectomy yields very low plasma concentrations, suggesting its safe application without any risk of systemic toxic effects.

Local anesthesia with sedation and general anesthesia for the treatment of chronic subdural hematoma: a systematic review and meta-analysis.

BACKGROUND: Surgery is the primary treatment for chronic subdural hematoma, and anesthesia significantly impacts the surgery's outcomes. A previous systematic review compared general anesthesia to local anesthesia in 319 patients. Our study builds upon this research, analyzing 4,367 cases to provide updated and rigorous evidence. METHODS: We systematically searched five electronic databases: PubMed, Cochrane Library, Scopus, Ovid Medline, and Web of Science, to identify eligible comparative studies. All studies published until September 2023 were included in our analysis. We compared six primary outcomes between the two groups using Review Manager Software. RESULTS: Eighteen studies involving a total of 4,367 participants were included in the meta-analysis. The analysis revealed no significant difference between the two techniques in terms of 'recurrence rate' (OR = 0.95, 95% CI [0.78 to 1.15], P = 0.59), 'mortality rate' (OR = 1.02, 95% CI [0.55 to 1.88], P = 0.96), and 'reoperation rate' (OR = 0.95, 95% CI [0.5 to 1.79], P = 0.87). Local anesthesia demonstrated superiority with a lower 'complications rate' than general anesthesia, as the latter had almost 2.4 times higher odds of experiencing complications (OR = 2.4, 95% CI [1.81 to 3.17], P < 0.00001). Additionally, local anesthesia was associated with a shorter 'length of hospital stay' (SMD = 1.19, 95% CI [1.06 to 1.32], P < 0.00001) and a reduced 'duration of surgery' (SMD = 0.94, 95% CI [0.67 to 1.2], P < 0.00001). CONCLUSION: Surgery for chronic subdural hematoma under local anesthesia results in fewer complications, a shorter length of hospital stay, and a shorter duration of the operation.

Pain perception in 4-6-year-old children following intraoral dental injection with 26 and 31-gauge needles: a randomized controlled trial.

Background: Administering anesthesia in dentistry can be distressing for patients, especially those with dental fear and anxiety. Needle pain during local anesthesia is a common concern in intraoral procedures. This study aimed to compare pain perception in 4-6-year-old children following intraoral dental injections with 26- and 31-gauge needles. Methods: Fifty healthy children were divided according to age into Group I (N = 25; 4-5 years) and Group II (N = 25; 5-6 years). Each group was further subdivided according to the needle gauge as follows: Group IA (26 gauge), Group IB (31 gauge), Group IIA (26 gauge), and Group IIB (31 gauge). Using a lottery method, the gauge of the needle to be used at the first visit for local anesthesia administration was selected. Children's reactions to pain were evaluated using a Modified Behavioral Pain Scale. Immediately after administration of local anesthesia, pain perception was evaluated using the Faces pain rating scale. In the subsequent visit, another needle gauge was used to administer local anesthesia, and the previously described evaluations were performed. At the third appointment, the child was shown both syringes and asked to choose one of the syringes they preferred, and the choice was noted. Results: When local anesthesia was administered using a 31-gauge needle, pain perception was similar between the two groups. In group II, the children demonstrated significantly higher arm and leg movements (P = 0.001). However, the difference was significant in group I alone (P < 0.001). Conclusion: Irrespective of age, anesthesia with a 31-gauge needle resulted in significantly lower pain perception than anesthesia with a 26-gauge needle.

Thoracoscopic Direct Suture Closure for a Large Bulla With Severe Adhesion Under Local Anesthesia: A Case Report.

Although the usefulness of thoracoscopic surgery under local anesthesia for pneumothorax has been reported, there are some cases of failure. Therefore, it is important to share the various techniques and potential challenges associated with procedures performed under local anesthesia. A 79-year-old male, under monitoring for a left chronic pneumothorax, was newly diagnosed with a right pneumothorax. Chest computed tomography taken after thoracic drainage showed a poorly expanded right lung with severe adhesions and multiple bullae in the right lung, in addition to identifying a left pneumothorax. Although significant air leakage persisted, general anesthesia was deemed unsuitable, necessitating thoracoscopic surgery under local anesthesia. A fistula of approximately 1 × 1 cm was identified on the bulla wall, which was closed with 4-0 Prolene®sutures (Johnson&Johnson, New Jersey, United States), each reinforced with pledgets and covered with a polyglycolic acid sheet and fibrin glue. The patient was discharged on postoperative day six and no recurrence of pneumothorax was noted after discharge. Direct suture closure of the bulla wall under local anesthesia can be an alternative technique for the treatment of pneumothorax caused by large bulla collapse in patients at high risk for general anesthesia.

Comparative Evaluation of the Anesthetic Efficacy of Needle-Free Anesthesia and Conventional Anesthesia in Patients With Symptomatic Irreversible Pulpitis: A Randomized Clinical Trial.

Introduction Pain is the primary reason for which most of the patients seek endodontic treatment. Local anesthesia is considered to be the most important step in the procedure to reduce the pain. However, the majority of the patients do not cooperate due to the fear of syringe anesthesia. The aim of this clinical trial was to compare the anesthetic efficacy of needle-free anesthesia and conventional anesthesia in patients with symptomatic irreversible pulpitis undergoing root canal therapy. Materials and methods A total of 54 patients were enrolled in the study, and the treatment was administered by a single operator. The initial assessment of vitality included cold testing, heat testing, and electric pulp testing. Preoperative pain was assessed using the Visual Analog Scale (VAS) before the administration of anesthesia. Local anesthesia was administered according to the group assigned: Group 1 (conventional anesthesia) and Group 2 (needle-free anesthesia). The pain was assessed during the administration of anesthesia. Following the administration of anesthesia, the vitality of the tooth was evaluated using cold testing, heat testing, and electric pulp testing. Subsequently, the tooth was isolated with a rubber dam, and the access cavity was prepared. The pain was assessed during access cavity preparation and during the first file insertion. Working length was determined using an apex locator (Root ZX Mini, J Morita, Saitama, Japan) and was confirmed using intraoral periapical radiographs. Later on, further treatment was carried out. Results A total of 54 participants were included in this clinical trial. There was no significant difference in mean age distribution between the two groups (p=0.852). Considering the frequency distribution of gender, there was no significant difference; however, Group 1 had more female participants (59.3%) compared to Group 2 (33.3%). There was a significant reduction in the mean pain score in Group 2 compared to Group 1 during the delivery of anesthetic agents (p=0.000). Conclusion Needle-free anesthesia proves to be equally effective as the conventional syringe system in patients experiencing symptomatic irreversible pulpitis undergoing root canal treatment. However, it is noteworthy that patients exhibited greater comfort levels with needle-free anesthesia systems specifically during the administration of the anesthetic solution.

A Review of 1228 In-Office Hand Surgery Procedures With Wide Awake Local Anesthesia No Tourniquet (WALANT) at a Single Private Practice.

BACKGROUND: This study examined the complication rate of Wide Awake Local Anesthesia No Tourniquet (WALANT) technique in the clinic setting with field sterility at a single private practice. We hypothesized that WALANT is safe and effective with a low complication rate. METHODS: This retrospective chart review included 1228 patients who underwent in-office WALANT hand procedures at a single private practice between 2015 and 2022. Patients were divided into groups based on type of procedure: carpal tunnel release, A1 pulley release, first dorsal compartment release, extensor tendon repair, mass excision, foreign body removal, and needle aponeurotomy. Patient demographics and complications were recorded; statistical comparisons of cohort demographics and risk factors for complications were completed, and P < .05 was considered significant for all statistical comparisons. RESULTS: The overall complication rate for all procedures was 2.77% for 1228 patients including A1 pulley release (n = 962, 2.7%), mass excision (n = 137, 3.7%), extensor tendon repair (n = 23, 4.3%), and first dorsal compartment release (n = 22, 8.3%). Carpal tunnel release, foreign body removal, and needle aponeurotomy groups experienced no complications. No adverse events (e.g. vasovagal reactions, digital ischemia, local anesthetic toxicity, inadequate vasoconstriction) were observed in any group. Patients with known autoimmune disorders and those who were currently smoking had a statistically significant higher complication rate. CONCLUSIONS: Office-based WALANT procedures with field sterility are safe and effective for treating common hand maladies and have a similar complication profile when compared to historical controls from the standard operating room in an ambulatory center or hospital.

Optimizing Perioperative Experience in Upper Blepharoplasty: The Impact of Premedication on Anxiety, Pain, and Patient Satisfaction.

Background The periorbital area undergoes transformative changes with age, influencing both aesthetic appearance and functional aspects of the eyelids. Age-related alterations involve volume loss, shifts in eyelid crease position, drooping eyebrows, reduced skin elasticity, and the presence of dermatochalasis. Dermatochalasis, characterized by redundant upper eyelid skin folds, poses aesthetic and functional challenges, impacting visual acuity and eyelid elevation efficiency. Upper blepharoplasty addresses these age-related changes. Despite the elective nature of upper blepharoplasty, the procedure can evoke preoperative anxiety and discomfort. Various premedication strategies, including benzodiazepines, aim to alleviate anxiety and enhance the overall patient experience. However, ongoing debates persist regarding the optimal strategy for implementation. The study aims to contribute insights into the effectiveness of different premedication approaches in optimizing patient comfort during and after upper blepharoplasty. Methods The research design involves 182 patients divided into three groups: control group (CG) (n = 45) receiving no premedication, Group 1 (n = 98) receiving oral midazolam (a benzodiazepine), and Group 2 (n = 39) receiving a combination of midazolam, eutectic mixture of local anesthetics (EMLA) eyelid ointment, and oral paracetamol with codeine phosphate hemihydrate. The study assesses anxiety levels, pain perception during local anesthetic injection, surgery, and postoperatively, as well as the use of painkillers and adverse effects. Ethical approval was obtained for the study. Results Significant differences were noted among the groups during local anesthetic injection (p < 0.0001), surgery (p < 0.0001), and post surgery (p < 0.0197). CG patients experienced higher pain levels during local anesthetic injection and surgery compared to Groups 1 and 2. Group 1 reported more pain during surgery than Group 2. Substantial differences were observed in preoperative (p < 0.0001), during-surgery (p < 0.0001), and after-surgery (p < 0.0001) anxiety levels. The CG exhibited higher preoperative anxiety compared to Group 1, while Group 1 had lower anxiety during surgery compared to the CG. Group 1 also reported lower anxiety after surgery than both the CG and Group 2. A significant difference was found in post-surgery painkiller usage among the groups (p = 0.0003). Group 2 showed significantly lower usage compared to Group 1 (p = 0.0004) and the CG (p = 0.0006). A significant difference was observed in the duration of painkiller use after surgery (p < 0.0014). The CG had a longer duration than Group 1 (p = 0.0049) and Group 2 (p = 0.0495). Conclusions Midazolam alone as premedication effectively reduced anxiety before, during, and after surgery. EMLA administration for injection pain did not produce superior results, likely due to its delayed onset. Paracetamol with codeine phosphate hemihydrate effectively reduced surgical pain and postoperative pain duration and decreased the need for painkillers.

Intraoperative Takotsubo Cardiomyopathy: A Case Report.

Takotsubo cardiomyopathy (TTC) is a rare condition associated with transient akinesia of apical segments and hyperkinesia of basal segments of the heart. Although several mechanisms have been proposed to cause direct and indirect myocardial damage owing to catecholamine excess, the underlying pathophysiology remains unknown. An 18-year-old female was referred to our otorhinolaryngology outpatient clinic for a septorhinoplasty. Apart from the fear of surgery, the patient had no other health issues. After the administration of local anesthesia (lidocaine and epinephrine mix), tachycardia storms occurred and soon ended with cardiac collapse. Further evaluation revealed TTC. TTC should be considered, especially in cases of treatment-resistant hemodynamic problems after cardiac resuscitation, and nurses can play a crucial role during the preanesthetic period in helping the patient cope with the stress factors related to the upcoming surgery.

The effect of augmented reality book on the proficiency of local anesthesia administration of the inferior alveolar nerve.

BACKGROUND/OBJECTIVE: Advancements in augmented reality (AR) technology enable developers to create augmented reality books (AR Books). AR Books can show interactive 3D objects and multimedia content to the user. The purpose of this study was to investigate the effect of a developed AR Book on the theoretical and practical abilities in the administration of local anesthesia of the inferior alveolar nerve block. METHODS: An exclusive AR Book was developed based on Chapter 14, Handbook of Local Anesthesia, seventh edition, Stanley F. Malamed, which enabled students to use their book (printed or electronic) as an AR Book. Forty dental students were randomly divided into control and study groups. In the control group, students were asked to use regular books, while in the study group, students were instructed to use interactive AR Books. All students took the written exam, scoring 0 to 10. Also, the administration of mandibular local anesthesia was evaluated in students. The level of concentration during the study, the written exam score, the practical score, the success rate of local anesthesia, and the needed time for injection were compared between the two groups. RESULTS: There was a significant difference in the level of concentration during the study (p < 0.001), practical skill score (p = 0.037), and needed time for injection (p = 0.040) between the two groups. Conversely, the success rate of local anesthesia was almost similar (p = 0.705). Although the written exam score was higher in the study group than in the control group, the difference was not significant (p = 0.414). CONCLUSION: Using AR Books can engage students and help them to remain focused during the study. AR Books may be beneficial in enhancing the practical abilities of dental students.

Caesarean Delivery: A Narrative Review on the Choice of Neuraxially Administered Opioid and Its Implications for the Multimodal Peripartum Pain Concept.

Nowadays, obstetrical anesthesia-related mortality is a very rare complication in industrialized countries. The recommended choice of intrathecal opioid for spinal anesthesia in the context of a multimodal peripartum pain management concept is discussed in this narrative review. Nowadays, there is a consensus that a perioperative multimodal pain concept should be used for caesarean delivery. This pain concept should include neuraxial opioids for spinal anesthesia, acetaminophen, NSAIDs, intravenous dexamethasone, and postoperative local or regional anesthetic procedures. Long-acting lipophobic opioids (diamorphine and morphine) have a significant analgesic advantage over short-acting lipophilic opioids (sufentanil and fentanyl). The risk of clinically relevant respiratory depression after neuraxial long-acting opioids is nowadays considered negligible, even if the data situation is weak in this regard. The question remains as to whether a pain concept that is ideally adapted to a neuraxial short-acting opioid shows benefit to a pain concept that is optimally adapted to neuraxial morphine. If long-acting opioids are used, the timing of each additional component of the multimodal analgesia strategy could ideally be adjusted to this longer duration of action.

Pre-incisional local infiltration with levobupivacaine in laparoscopic cholecystectomy: a randomized and clinical trial.

OBJECTIVE: Laparoscopic cholecystectomy (LC), despite its minimally invasive nature, requires effective control of post-operative pain. The use of local anesthetics (LA) has been studied, but the level of evidence is low, and there is little information on important parameters such as health-related quality of life (HRQoL) or return to work. The objective of the study was to evaluate the efficacy of 0.50% levobupivacaine infiltration of incisional sites in reducing POP after LC. METHODS: This was a prospective, randomized, double-blind study. Patients undergoing elective LC were randomized into two groups: no infiltration (control group) and port infiltration (intervention group). POP intensity (numerical rating scale, NRS), need for rescue with opioid drugs, PONV incidence, HRQoL, and return to work data, among others, were studied. RESULTS: Two hundred and twelve patients were randomized and analyzed: 105 (control group) and 107 (intervention group). A significant difference was observed in the NRS values (control group mean NRS score: 3.41 ± 1.82 vs. 2.56 ± 1.96) (p < 0.05) and in the incidence of PONV (31.4% vs. 19.6%) (p = 0.049). CONCLUSIONS: Levobupivacaine infiltration is safe and effective in reducing POP, although this does not lead to a shorter hospital stay and does not influence HRQoL, return to work, or overall patient satisfaction.

OBJETIVO: la colecistectomía laparoscópica (CL), a pesar de su carácter mínimamente invasivo, requiere un control efectivo del dolor postoperatorio (POP). El uso de anestésicos locales (AL) ha sido estudiado pero el nivel de evidencia es bajo y existe poca información acerca de parámetros relevantes como la calidad de vida relacionada con la salud (CVRS) o la reincorporación laboral. El objetivo de este estudio es analizar la eficacia de la infiltración de los sitios incisionales con levobupivacaína 0,50% en la reducción del dolor postoperatorio tras la CL. MATERIAL Y MÉTODOS: estudio prospectivo, aleatorizado y doble ciego. Pacientes sometidos a CL programada fueron aleatorizados en dos grupos: sin infiltración (grupo control) y con infiltración preincisional (grupo intervención). La intensidad del dolor (escala de puntuación numérica, NRS), la necesidad de rescates con opioides, la incidencia de náuseas o vómitos postoperatorios (NVPO) y datos de CVRS o reincorporación laboral, entre otros, fueron recogidos. RESULTADOS: 212 pacientes fueron aleatorizados y analizados: 105 en el grupo control y 107 en el grupo de intervención. Se observó una diferencia estadísticamente significativa en la intensidad del dolor (puntuación media NRS: 3.41 ± 1.82 vs. 2.56 ± 1.96) (p < 0.05) y en la incidencia de NVPO (31.4% vs. 19.6%) (p = 0.049). CONCLUSIONES: La infiltración con levobupivacaína es segura y efectiva en la reducción del dolor postoperatorio, aunque esto no conlleva una menor estancia hospitalaria y no influye en los resultados de CVRS, reincorporación laboral o satisfacción del paciente.

Systemic Corticosteroid Uses in Endodontics- Part 2: Enhancing the Success of Local Anesthesia.

INTRODUCTION: Chronic inflammation in irreversible pulpitis leads to heightened sensitivity of nociceptive receptors, resulting in persistent hyperalgesia. This poses significant challenges in achieving effective anesthesia for patients with irreversible pulpitis. Various anesthetic techniques and pharmacological approaches have been employed to enhance the success of local anesthesia. Recently, the preemptive use of anti-inflammatory agents, specifically corticosteroids, has gained attention and shown promising results in randomized controlled trials. This systemic review and meta-analysis aimed to evaluate the impact of systemically administered corticosteroids on enhancing anesthetic success in patients undergoing endodontic treatment. METHODS: A comprehensive search was conducted across multiple databases including PubMed, Cochrane Library, Embase, Scopus, Dentistry & Oral Science, and ProQuest. Additionally, the references of primary studies and related systematic reviews were manually searched for additional relevant publications. The primary outcome assessed was the success of anesthesia, and the effect measure was Risk Ratio (RR) using the random-effects inverse variance method. Statistical significance was set at p < .05. The certainty of the evidence was evaluated using the GRADE approach. RESULTS: Twelve studies involving 917 participants were analyzed to determine the frequency of successful anesthesia. The corticosteroid group demonstrated a significantly higher number of patients achieving successful anesthesia (RR = 1.66; 95% CI, 1.34 to 2.06;p< .00001). However, heterogeneity within the pooled data analysis was observed (I2= 57%,p=0.007). CONCLUSIONS: Moderate certainty evidence indicates that preemptive use of systemic corticosteroids enhances the success of local anesthesia, specifically inferior alveolar nerve block (IANB), in cases of irreversible pulpitis.

Stereotactic biopsy for brain lesions: Doing more with less.

Objectives: Stereotactic biopsy (STB) is a potential diagnostic tool considering its minimal invasiveness, high diagnostic yield, and minimal associated complications. Over the years, various frame-based instrument systems and frameless stereotactic biopsy systems have emerged to be employed in clinical use. With this study, we intend to get more by doing less in the form of STB for the patients of doubtful intracranial lesions treated over the past 5 years. We also want to highlight the technique of performing the procedure under scalp block, which can be used as a versatile tool in many clinical scenarios. Stereotactic biopsies may be planned even in rural district-level health facilities. One-time investment to procure instruments and avail existing imaging can lead to establishing definitive diagnoses in many doubtful cases. This will result in lesser cost and early establishment of treatment. Independent risk factors determining the outcome, such as deep-seated lesions, associated edema, and intraoperative hypertension, were studied. Establishing the diagnosis helped in prognosticating the disease, explaining the natural progression of symptoms, and starting adjuvant therapy. This tissue biopsy would also help secure samples for research and molecular analysis. Materials and Methods: Twenty patients underwent STBs at our institution between January 2018 and December 2022. We retrospectively analyzed patient characteristics, tumor pathology, surgical procedures, and outcomes, including the diagnostic value and surgery-related complications. These patients were followed up, and their progression-free and overall survival were analyzed. The need for adjuvant treatment was noted and analyzed. All procedures were performed using Cosman Roberts Wells® stereotactic frame. Pre-procedure magnetic resonance scans were performed at the time of admission. Contrast-enhanced computerized tomography (CT) scan after frame application was performed to identify targets and calculate the coordinates. A post-procedure CT scan was done to confirm the accessibility of the targeted lesion. Results: The most common location of the tumor was a deep-seated thalamic lesion. A definitive diagnosis was established in 19 patients (95%) at the first STB. The diagnoses were glioma in 55% of cases, primary central nervous system lymphoma, tuberculosis, and demyelinating disorders in 10% of each, and a metastatic brain tumor in 1 (5%). The post-operative complications were all transient except in one patient with deterioration of motor weakness. The follow-up was noted, and modes of adjuvant treatment needed in these patients were recorded. Conclusion: Stereotactic biopsy is a useful and effective method for achieving a definitive diagnosis and aiding in treating multifocal or small deep-seated lesions in or around eloquent regions.