Intradermal injection of lidocaine with a microneedle device to provide rapid local anaesthesia for peripheral intravenous cannulation: A randomised open-label placebo-controlled clinical trial.

BACKGROUND: Peripheral venous cannulation is one of the most common procedures in medicine. It is associated with noticeable pain and apprehension, although in most cases it is performed without any anesthesia due to lack of a painless, cost-effective option, which would provide rapid local anesthesia with subsequent significant reduction in the experienced pain. We conducted an open-label placebo-controlled clinical trial to evaluate the efficacy and safety of a 2% lidocaine injection using the commercially available microneedle device MinronJet600 (NanoPass Technologies Ltd, Israel) to achieve rapid local anesthesia prior to peripheral venous cannulation. METHODS: One hundred and two subjects were randomly allocated into two groups. In the first group, 100µL of lidocaine hydrochloride (2%) was injected intradermally to subjects using the MicronJet600 device in the left arm (MJ-Lido) and 100µL of saline was injected intradermally using the device in the right arm (MJ-Saline). In the second group, 100µL of lidocaine hydrochloride (2%) was injected using the MicronJet600 device into the left arm (MJ-Lido), with no injection into the right arm of subjects (No pretreatment). In both groups the intradermal injection was performed at the cannulation site prior to insertion of a 18G cannula into a median cubital vein in both arms. As a primary variable, a score of cannulation-induced pain was indicated by subjects using a 100-point visual analog scale immediately after cannulation. As a secondary variable, subjects in Group 2 also indicated their preference to receive the anaesthetic injection with MicronJet600 in the future by using the 5-point Likert scale. Also, as a secondary variable, the duration of skin numbness after lidocaine injection was indicated by performing a superficial pin-prick with a 27G needle at 15, 30 and 45 minutes, at distances of 1, 2 and 3 centimeters from the injection site. RESULTS: A significant pain reduction (11.0-fold) was achieved due to the lidocaine injection compared to the cannulation without any pretreatment (p< 0.005). After the lidocaine injection the anesthesia was effective up to 2 centimeters from the injection site and remained for up to 30 minutes. Eighty percent of subjects from the second group preferred cannulation after the lidocaine injection over cannulation without any pretreatment. No significant side effects were identified. CONCLUSION: Intradermal injection of anaesthetic with Micronjet600 was found to be a safe and effective option for providing rapid local anesthesia for peripheral intravenous cannulation. TRIAL REGIATRATION: The clinical trial was registered, before the patient enrollment began, in the Research Registry publicly accessible database (registration identifier: researchregistry4662). Also, the trial was registered in ClinicalTrials.gov (registration identifier: NCT05108714) after its completion.

Development of a Low-Resource Operating Room and a Wide-Awake Orthopedic Surgery Program During the COVID-19 Pandemic.

Introduction. The COVID-19 pandemic resulted in significant medication, supply and equipment, and provider shortages, limiting the resources available for provision of surgical care. In response to mandates restricting surgery to high-acuity procedures during this period, our institution developed a multidisciplinary Low-Resource Operating Room (LROR) Taskforce in April 2020. This study describes our institutional experience developing an LROR to maintain access to urgent surgical procedures during the peak of the COVID-19 pandemic. Methods. A delineation of available resources and resource replacement strategies was conducted, and a final institution-wide plan for operationalizing the LROR was formed. Specialty-specific subgroups then convened to determine best practices and opportunities for LROR utilization. Orthopedic surgery performed in the LROR using wide-awake local anesthesia no tourniquet (WALANT) is presented as a use case. Results. Overall, 19 limited resources were identified, spanning across the domains of physical space, drugs, devices and equipment, and personnel. Based on the assessment, the decision to proceed with creation of an LROR was made. Sixteen urgent orthopedic surgeries were successfully performed using WALANT without conversion to general anesthesia. Conclusion. In response to the COVID-19 pandemic, a LROR was successfully designed and operationalized. The process for development of a LROR and recommended strategies for operating in a resource-constrained environment may serve as a model for other institutions and facilitate rapid implementation of this care model should the need arise in future pandemic or disaster situations.

Anesthesia using microcannula and sharp needle in upper blepharoplasty: A randomized, double-blind clinical trial evaluating pain, bruising, and ecchymoses.

INTRODUCTION: With the emergence of blunt-tipped microcannulas, there is a hypothesis that these could cause less damage and reduce pain as compared to conventional sharp needles in eyelid surgery. The purpose is to determine whether an 18G blunt-tipped cannula can be better than a 26G needle. METHODS: This prospective, observer-blinded, randomized clinical trial was conducted from June 2017 to December 2018. Sixty-eight patients were randomized to receive local anesthesia injections for upper blepharoplasty. Infiltration was performed by using a 26-gauge sharp needle on one side and on the other side, infiltration was performed by using an 18-gauge stainless-steel blunt-tipped microcannula. A numeric rating scale (NRS) from 0 to 10 was used to blindly assess pain in patients receiving anesthesia injections with both needle types. Photographs of the eyelids of each patient were taken in five different periods and used by three blinded observers to identify bruise or ecchymoses. RESULTS: A total of 136 eyelid operations were performed. There was no statistically significant difference when both groups were compared; however, the average score of pain was higher in patients taking the infiltration through the needle (2.85 versus 2.50). Regarding the evaluation of bruising and ecchymoses, the results showed that, in the five periods evaluated, there was no statistical difference in bruising and ecchymosis in the eyelids when taking the infiltration through a sharp needle when compared with that of the eyelids taking infiltration through a (blunt-tipped) microcannula. CONCLUSION: The evaluation of the blunt-tipped microcannula showed a lower pain score mean than that obtained for the sharp needle (2.5 versus 2.85) (p > 0.05). There was no statistically significant difference in the bruising and ecchymosis courses.

Efficacy of Higher Gauged Needles or Topical Pre-Cooling for Pain Reduction during Local Anesthesia Injection: A Split-Mouth Randomized Trial

ABSTRACT Objective: To evaluate the efficacy of pre-cooling and the use of higher gauged needles in reducing pain during local anesthetic infiltration. Material and Methods: We conducted a split-mouth randomized controlled trial among 70 patients who require bilateral maxillary local anesthetic (LA) injections for dental treatment. After applying the topical anesthetic, each participant received four local anesthetic injections, two on buccal and two palatal sides. At each visit, the participants received one buccal and one palatal infiltration based on the randomization. On the buccal aspect, participants received LA with a 26G needle injection on one side (control) and a 31G needle (test) on the contralateral side. On the Palatal aspect, participants either received LA with a 31G needle on one side (control). In contrast, the opposite side was preceded by topical ice application (iced cotton swab) before LA with a 31G needle (test). Both the visits were spaced with a gap of 7-10 days based on the participants' feasibility. Participants were asked to rate the pain on a visual analog scale independently for buccal and palatal LA injections. Results: On the Buccal aspect, the mean pain scores were 2.74 ± 1.26 and 2.11 ± 1.26 for control and test groups, respectively (p=0.002). On the Palatal aspect, the mean pain scores were 4.14 ± 1.49 and 4.3 ± 1.80 for control and test groups, respectively (p=0.295). Conclusion: Significant lower pain scores were reported with higher gauge needles (31G) when compared to traditional (26G) needles on the buccal aspect. No significant difference was seen with pre-cooling the injection site on the palatal aspect when used with higher gauged needles (31G).

Síndrome de la intersección distal. Una causa poco frecuente de dolor en el antebrazo / Distal intersection syndrome: an unusual cause of forearm pain

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Influence of information concerning a computerized anesthesia system on dental anxiety: a randomized controlled clinical trial

BACKGROUND: A single-blinded randomized controlled trial among patients requiring an upper third molar extraction was performed to evaluate the anxiety degree after receiving information or not about the functioning of The Wand system. Secondarily, perceived pain and the need of re-anesthesia were assessed. MATERIAL AND METHODS: Patients were randomly assigned to the experimental group (detailed explanation about The Wand) or control group (no specific information). Local anesthesia with The Wand consisted in a supraperiosteal infiltrative technique injection 1.6 mL at the buccal and 0.2 mL at the palatal side. Distinct questionnaires for assessing dental anxiety and 100-mm visual analog scales to assess pain were delivered. Demographic data, radiological parameters, operative time and type of intervention were also registered. A descriptive bivariate analysis by non-parametric tests to detect differences in anxiety, pain and re-anesthesia was performed by SPSS 22.0 (SPPS Inc. Chicago, USA). RESULTS: A total of 85 patients were assessed for eligibility but 17 participants were lost due to the cancellation of the visit for the surgical intervention. Finally, sixty-eight patients were included (34 participants in each group), 47 women (69.1%) and 21 men (30.9%), with an average age of 28.8 (± 9.3) years. CONCLUSIONS: Patients that received a detailed explanation of The Wand did not have a significant reduction of the anxiety degree and perceived pain during the anesthetic act compared to patients that received no information. The need of re-anesthesia was not related to the anxiety level but was significantly related to increasing operative time

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Infiltration Between Popliteal Artery and Capsule of the Knee Block to Augment Continuous Femoral Nerve Catheter for Adolescent Anterior Cruciate Ligament Reconstruction: A Case Series.

Infiltration between popliteal artery and capsule of the knee (IPACK) is a novel technique that can provide additional analgesic relief, although there are no studies to date in the adolescent population. In 3 adolescent patients undergoing anterior cruciate ligament surgery, IPACK block augmented continuous femoral nerve block by providing posterior knee analgesia with no or only minimal opioid needs in the post-anesthesia care unit and did not produce sciatic motor weakness.

Microneedles combined with a sticky and heatable hydrogel for local painless anesthesia.

In view of the inherent defects of traditional syringe anesthesia (pain, inaccurate anesthesia area, swelling after injection, slow recovery etc.), this article proposed a new anesthesia system based on microneedles and a hydrogel. After loading with AuNPs, a sticky PDA-PAM-AuNP hydrogel with near-infrared (NIR) light response properties was prepared here. After using microneedles (to open the skin of the target anesthesia area), a hydrogel patch embedded with a medical anesthetic soaked sponge was pasted to realize local painless anesthesia. The effects of anesthesia can also be modulated by external NIR. Compared to traditional syringe anesthesia, this hydrogel + microneedle method resulted in reduced pain, higher anesthetic accuracy and faster recovery, making it a promising local anesthesia alternative in clinical applications.

Effects of local anesthetics on wound healing / Efeitos dos anestésicos locais na cicatrização de feridas

Abstract Introduction Local anesthetic infiltration is used widely for post-operative analgesia in many situations. However the effects of local anesthetics on wound healing are not demonstrated clearly. This study planned to evaluate the effects of lidocaine, prilocaine, bupivacaine and levobupivacaine on wound healing, primarily on wound tensile strength and on collagen ultrastructure. Methods This study was conducted on male Sprague Dawley rats. On days 0, 8th, 15th, and 21st, all animals were weighed and received a preincisional subcutaneous infiltration of 3 mL of a solution according the group. Control saline (C), lidocaine (L) 7 mg.kg-1, prilocaine (P) 2 mg.kg-1, bupivacaine (B) 2 mg.kg-1 and levobupivacaine (LVB) 2.5 mg.kg-1. The infiltrations were done at the back region 1.5 cm where incision would be performed at the upper, middle and lower part along the midline, under general anesthesia. Wound tensile strengths were measured after 0.7 cm × 2 cm of cutaneous and subcutaneous tissue samples were obtained vertical to incision from infiltrated regions. Tissue samples were also obtained for electron microscopic examination. Evaluations were on the 8th, 15th and 21st days after infiltration. Results There was no difference between groups in the weights of the rats at the 0th, 8th, 15th and 21st days. The collagen maturation was no statistically different between groups at the 8th and 15th days. The maturation scores of the B and L groups at the 21st day was significantly lower than the Group C (1.40, 1.64 and 3.56; respectively). The wound tensile strength was no statistically different between groups at the 8th and 15th days but at the 21st day the Groups B and LVB had significantly lower value than Group C (5.42, 5.54 and 6.75; respectively). Conclusion Lidocaine and prilocaine do not affect wound healing and, bupivacaine and levobupivacaine affect negatively especially at the late period.

Resumo Introdução A infiltração de anestésico local é amplamente usada para analgesia pós-operatória em muitas situações. No entanto, os efeitos dos anestésicos locais na cicatrização de feridas não foram demonstrados claramente. Neste estudo planejamos avaliar os efeitos de lidocaína, prilocaína, bupivacaína e levobupivacaína sobre a cicatrização de feridas, principalmente sobre a força tênsil da ferida e a ultraestrutura do colágeno. Métodos Este estudo foi feito em ratos machos da linhagem Sprague Dawley. Nos dias 0, 8, 15 e 21, todos os animais foram pesados e receberam uma infiltração subcutânea pré-incisional de 3 mL de uma solução, de acordo com a designação dos grupos: Grupo C recebeu salina (controle); Grupo L recebeu lidocaína (7 mg.kg-1); Grupo P recebeu prilocaína (2 mg.kg-1); Grupo B recebeu bupivacaína (2 mg.kg-1); Grupo LVB recebeu levobupivacaína (2,5 mg.kg-1). As infiltrações foram feitas na região posterior a 1,5 cm de onde a incisão seria feita na parte superior, média e inferior ao longo da linha média, sob anestesia geral. A força tênsil da ferida foi medida após amostras de 0,7 × 2 cm de tecido cutâneo e subcutâneo serem obtidas das regiões infiltradas, verticalmente à incisão. Amostras de tecido também foram obtidas para exame microscópico eletrônico. As avaliações foram feitas nos dias 8, 15 e 21 após a infiltração. Resultados Não houve diferença entre os grupos em relação ao peso dos ratos nos dias 0, 8, 15 e 21. A maturação do colágeno não foi estatisticamente diferente entre os grupos nos dias 8 e 15. Os escores de maturação dos grupos B e L no dia 21 foram significativamente inferiores aos do Grupo C (1,40, 1,64 e 3,56, respectivamente). A força tênsil da ferida não foi estatisticamente diferente entre os grupos nos dias 8 e 15, mas no dia 21 os grupos B e LVB apresentaram valores significativamente menores que o Grupo C (5,42, 5,54 e 6,75, respectivamente). Conclusão Lidocaína e prilocaína não afetam a cicatrização de feridas, enquanto bupivacaína e levobupivacaína afetam negativamente, especialmente no período tardio.

Foot drop: an iatrogenic complication of spinal anesthesia / Pé caído: uma complicação iatrogênica da anestesia espinhal

Abstract Background and objectives Foot drop in postoperative period is very rare after spinal anesthesia. Early clinical assessment and diagnostic interventions is of prime importance to establish the etiology and to start appropriate management. Close follow-up is warranted in early postoperative period in cases when patient complain paresthesia or pain during needle insertion or drug injection. Case report A 22-year-old male was undergone lower limb orthopedic surgery in spinal anesthesia. During shifting from postoperative ward footdrop was suspected during routine assessment of regression of spinal level. Immediately the patient was referred to a neurologist and magnetic resonance imaging was done, which was inconclusive. Conservative management was started and nerve conduction study was done on the 4th postoperative day that confirmed pure motor neuropathy of right peroneal nerve. Patient was discharged with ankle splint and physiotherapy after slight improvement in motor power (2/5). Conclusions Foot drop is very rare after spinal anesthesia. Any suspected patient must undergo emergent neurological consultation and magnetic resonance imaging to exclude major finding and need for early surgical intervention.

Resumo Justificativa e objetivos Pé caído no período pós-operatório é muito raro após a anestesia espinhal. Avaliação clínica e intervenções diagnósticas precoces são de primordial importância para estabelecer a etiologia e iniciar o tratamento adequado. Um acompanhamento atento é justificado no pós-operatório imediato nos casos em que o paciente se queixa de parestesia ou dor durante a inserção da agulha ou da injeção de fármacos. Relato de caso Paciente do sexo masculino, 22 anos, submetido a cirurgia ortopédica de membros inferiores sob anestesia espinhal. Durante a transferência para a sala de recuperação pós-operatória, houve suspeita de pé caído durante a avaliação rotineira da regressão do nível espinhal. O paciente foi imediatamente enviado ao neurologista e uma ressonância magnética foi feita, mas não foi conclusiva. O manejo conservador foi iniciado e o estudo de condução nervosa foi feito no 4° dia de pós-operatório, o que confirmou a neuropatia motora pura do nervo fibular direito. O paciente foi dispensado com imobilizador de tornozelo e fisioterapia após ligeira melhoria da força motora (2/5). Conclusões Pé caído é muito raro após a anestesia espinhal. Qualquer paciente suspeito deve ser submetido à consulta neurológica de emergência e ressonância magnética para excluir o principal achado e a necessidade de intervenção cirúrgica precoce.

Entrapment of a laryngotracheal topical anesthesia kit during tracheobronchial foreign body removal: a case report.

BACKGROUND: In order to reduce the irritation of the airway during tracheobronchial foreign body (TFB) removal, tracheal surface anesthesia is usually performed using a laryngotracheal topical anesthesia (LTA) kit (LTA20, Highgreen Medical Technology Company, China), but difficulty in withdrawing the LTA kit is rarely reported. We present a case of a difficulty to withdraw the LTA kit due to its entrapment by the movement of a TFB. CASE PRESENTATION: A 1-year-old girl was undergoing TFB removal. After the surgeon completed the tracheal surface anesthesia, the girl suddenly suffered from bucking, leading to the dislodgment of the TFB to the subglottic region, complicating the withdrawal of the LTA applicator. At the same time, the girl's oxygen saturation (SpO2) decreased to 91% and her heart rate dropped from 150 to 100 bpm. Atropine and succinylcholine were administered intravenously immediately, then the surgeon tried to free the TFB by pushing it back into the trachea, after which the LTA applicator was easily withdrawn, and TFB was removed successfully. The girl was discharged from hospital without any complications 2 days later. CONCLUSION: This case report draws our attention to a significant anesthetic clinical consideration during the application of topical anesthesia on the trachea for TFB removal. The possibility of coughing or bucking can lead to migration of the TFB with subsequent airway obstruction, so the depth of anesthesia must be sufficient to prevent harmful reflexes. Also, strong teamwork and good communication are paramount to avoid serious complications.

Ketamine as an adjunct to bupivacaine in infra-orbital nerve block analgesia after cleft lip repair / Cetamina como adjuvante de bupivacaína em bloqueio do nervo infraorbitário para analgesia após correção de lábio leporino

Abstract Objectives: We conducted this study to investigate the safety and analgesic efficacy of the addition of Ketamine to Bupivacaine in bilateral extra-oral infra-orbital nerve block in children undergoing cleft lip surgeries. Methods: Sixty patients were randomly allocated into two groups (n = 30), Group B received infra-orbital nerve block with 2 mL of 0.25% Bupivacaine and Group BK received 0.5 mg.kg-1 Ketamine for each side added to 1 mL of 0.5% Bupivacaine solution diluted up to 2 mL solution to 0.25% Bupivacaine concentration. Assessment parameters included; hemodynamics, recovery time, time to first oral intake, postoperative Faces Legs Activity Cry Consolability (FLACC) scores, Four-point Agitation scores, analgesic consumption and adverse effects. Results: Patients in Group BK showed lower postoperative FLACC scores during all recorded time points (p < 0.0001). Two patients in Group BK versus 12 in Group B requested for postoperative rescue analgesia (p < 0.001). There were no differences between groups in time, minutes (min), to first request for rescue analgesia. Patients in Group BK reported lower analgesic consumption (366.67 ± 45.67 vs. 240.0 ± 0.0 mg, p < 0.04). The time to first oral intake was significantly reduced in Group BK (87.67 ± 15.41 vs. 27.33 ± 8.68 min, p < 0.001). Lower postoperative Agitation scores were recorded in Group BK patients that reached a statistical significance at 45 min (0.86 ± 0.11 vs. 0.46 ± 0.16, p < 0.04) and in the first hour (h) postoperatively (1.40 ± 0.17 vs. 0.67 ± 0.14, p < 0.003). Higher parent satisfaction scores were recorded in Group BK (p < 0.04) without significant adverse effects. Conclusions: The addition of Ketamine to Bupivacaine has accentuated the analgesic efficacy of infra-orbital nerve block in children undergoing cleft lip repair surgeries.

Resumo Objetivos: Realizamos este estudo para avaliar a segurança e eficácia da analgesia com a adição de cetamina à bupivacaína em bloqueio do nervo infraorbitário, bilateral e extraoral, em crianças submetidas à cirurgia de lábio leporino. Métodos: Foram randomicamente alocados 60 pacientes em dois grupos (n = 30): o Grupo B recebeu bloqueio do nervo infraorbitário com bupivacaína a 0,25% (2 mL) e o Grupo BC recebeu bloqueio com cetamina (0,5 mg.kg-1) em cada lado, mais a adição de 1 mL de solução de bupivacaína a 0,5% diluída até 2 mL da concentração a 0,25%. Os parâmetros de avaliação incluíram: hemodinâmica, tempo de recuperação, tempo até a primeira ingestão oral, escores da escala FLACC (que avalia a expressão facial [Face], os movimentos das pernas [Legs], a atividade [Activity], o choro [Cry] e a consolabilidade [Consolability]), escores de agitação em escala de quatro pontos, consumo de analgésicos e efeitos adversos no pós-operatório. Resultados: Os pacientes do Grupo BC apresentaram escores FLACC mais baixos em todos os momentos mensurados no pós-operatório (p < 0,0001). Dois pacientes do Grupo BC versus 12 do Grupo B solicitaram analgesia de resgate no pós-operatório (p < 0,001). Não houve diferenças entre os grupos em relação ao tempo até a primeira solicitação de analgesia de resgate. Os pacientes do Grupo BC relataram consumo menor de analgésicos (366,67 ± 45,67 vs. 240,0 ± 0,0 mg, p < 0,04). O tempo em minutos (min) até a primeira ingestão oral foi significativamente reduzido no Grupo BC (87,67 ± 15,41 vs. 27,33 ± 8,68 min, p < 0,001). Escores mais baixos de agitação no pós-operatório foram registrados para os pacientes do Grupo BC, com significância estatística no tempo de 45 min (0,86 ± 0,11 vs. 0,46 ± 0,16; p < 0,04) e na primeira hora de pós-operatório (1,40 ± 0,17 vs. 0,67 ± 0,14; p < 0,003). Índices mais altos de satisfação dos pais foram registrados no Grupo BC (p < 0,04), sem efeitos adversos significativos. Conclusões: A adição de cetamina à bupivacaína acentuou a eficácia analgésica do bloqueio do nervo infraorbitário em crianças submetidas à cirurgia de correção de lábio leporino.

Effects of a Training Needle on Dental Hygiene Student Anxiety.

Purpose: The purpose of this pilot study was to assess whether practicing with a cotton-tipped applicator as compared to a new training device had an effect on the anxiety levels of dental hygiene students prior to administering and receiving their first intraoral injection for local anesthesia.Methods: This pilot study used a convenience sample of senior dental hygiene students from an entry-level Bachelor degree dental hygiene program. Participants completed a pre-test survey after watching a video demonstrating the inferior alveolar nerve block (IANB) injection technique to determine anxiety levels regarding administering and receiving an intraoral injection. Test and control groups were randomly assigned; and participants either received a dental syringe with an attached training needle device (test) or a cotton tip applicator (control). Both groups completed a post-test survey following a 15 minute practice session. Descriptive statistics were performed and Chi-square tests were used to determine significance.Results: Pre-test results showed that 91% of the participants (n=23) reported having anxiety regarding administering or receiving an intraoral injection in one or multiple areas. Chi-square tests determined no statistical significance (p =0.125) between the test and control groups in the post-test surveys.Conclusion: Dental hygiene students demonstrated decreased anxiety levels regarding administering and receiving an intraoral injection regardless of the assigned practice device in this pilot study. While use of a training needle was not shown to be superior at reducing anxiety in novice student operators when compared to a cotton tipped applicator, it may be a useful device for teaching local anesthesia administration techniques.