Comparación entre dosis bajas de bupivacaína y prilocaína en cirugía perianal ambulatoria / Comparison between low doses of bupivacaine and prilocaine in ambulatory perianal surgery

La cirugía perianal ambulatoria se caracteriza por necesitar un plano anestésico profundo durante un periodo de tiempo corto. El bloqueo subaracnoideo en silla de montar consigue una anestesia sensitiva intensa sin apenas bloqueo motor asociado. Los anestésicos locales de larga duración, como la bupivacaína, permiten en dosis bajas la realización del procedimiento y el alta hospitalaria en un tiempo acorde con la dinámica de la unidad cirugía mayor ambulatoria (UCMA). La prilocaína es un anestésico local de vida media intermedia que se caracteriza por su bajo riesgo de síntomas neurológicos transitorios y que se puede usar a dosis de 10 mg en anestesia espinal en silla de montar para la realización de cirugía perianal de menos de 45 min de duración. La hipótesis planteada es que la prilocaína, al ser un anestésico de vida media más corta que la bupivacaína, proporciona un bloqueo suficiente para la realización de un procedimiento estándar de cirugía anorrectal, acortando la estancia en la UCMA. Este estudio prospectivo, a doble ciego de 100 pacientes ASA I-III, divididos en 2 grupos aleatorios: Grupo P (10 mg de prilocaína hiperbárica 20 % + 10 μg de fentanilo) y grupo B (2,5 mg bupivacaina hiperbárica 0,5 % + 10 μg de fentanilo), donde medimos como objetivo principal el tiempo desde la realización de la técnica anestésica hasta el alta hospitalaria. Y como secundarios: el éxito del bloqueo, el tiempo desde el final de la cirugía hasta el alta hospitalaria, el tiempo de regresión del bloqueo sensitivo/motor, el tiempo hasta deambulación, la retención de orina y los efectos adversos.(AU)

Ambulatory perianal surgery is characterized by the need for a deep anesthetic plane for a short period of time. The subarachnoid saddle block achieves intense sensory anesthesia with almost no associated motor blockade. Long-acting local anesthetics, such as bupivacaine, allow the procedure to be performed at low doses and discharge from the hospital in a time that is consistent with the dynamics of the major outpatient surgery unit (MOSU). Prilocaine is a local anesthetic with an intermediate half-life that is characterized by its low risk of transient neurological symptoms and can be used at a dose of 10 mg in saddle spinal anesthesia for perianal surgery of less than 45 min duration. The hypothesis put forward is that prilocaine, being a shorter half-life anesthetic than bupivacaine, provides sufficient blockade for the performance of a standard anorectal surgery procedure, shortening the stay in the AMCU. This prospective, double-blind study of 100 ASA I-III patients, divided into 2 randomized groups: group P (10 mg hyperbaric prilocaine 20 % + 10 μg of fentanyl) and group B (2.5 mg hyperbaric bupivacaine 0.5 % + 10 μg of fentanyl), where we measured as primary objective the time from the performance ofthe anesthetic technique to hospital discharge. And as secondary objectives: success of the block, time from the end of surgery to hospital discharge, time of regression of the sensory/motor block, time to ambulation, urine retention and adverse effects.(AU)

Effect of Perineural or Intravenous Betamethasone on Femoral Nerve Block Outcomes in Knee Arthroplasty: A Randomized, Controlled Study.

OBJECTIVES: Despite the use of multimodal analgesia, patients undergoing knee arthroplasty still encounter residual moderate pain. The addition of betamethasone to local anesthetic has been shown to improve postoperative pain. However, it remains uncertain whether the positive effects of perineural or intravenous administration of betamethasone on analgesia outcomes lead to better early mobility and postoperative recovery. METHODS: Between June 2022 and February 2023, a total of 159 patients who were undergoing knee arthroplasty were included in this study. These patients were allocated randomly into three groups: (i) the NS group, received ropivacaine 0.375% and intravenous 3mL 0.9% normal saline; (ii) the PNB group, received ropivacaine 0.375% plus perineural betamethasone (12mg) 3mL and intravenous 3mL 0.9% normal saline; and (iii) the IVB group, received ropivacaine 0.375% and intravenous betamethasone (12mg) 3mL. RESULTS: Both perineural and intravenous administration of betamethasone led to improved median (IQR) numeric rating scale (NRS) scores on the 6-meter walk test, with a score of 1.0 (1.0-2.0) for both groups, compared with 2.0 (1.0-2.0) for the NS group (p = 0.003). Compared to the NS group, both the PNB and IVB groups showed significant reductions in NRS scores at 24 and 36 h after surgery, along with a significant increase in ROM at 24, 36, and 48 h post-operation. Additionally, it exhibited lower levels of cytokine IL-1ß and TNF-α in fluid samples, as well as lower level of HS-CRP in blood samples in the PNB and IVB groups compared to the NS group. CONCLUSION: The administration of perineural and intravenous betamethasone demonstrated an enhanced analgesic effect following knee arthroplasty. Furthermore, it was associated with reduced levels of IL-1ß, TNF-α, and HS-CRP, as well as enhanced knee ROM, which is conducive to early ambulation and postoperative rehabilitation after knee arthroplasty.

Estudio in vitro de elución de anestésicos locales en cemento óseo de PMMA / In vitro elution of local anesthetics from PMMA bone cement

Antecedentes y objetivo:Actualmente, no disponemos de un gold standard para el manejo del dolor postoperatorio tras una artroplastia total de rodilla, dado que se pueden administrar analgésicos a través de diferentes vías y ninguna de estas está exenta de riesgos. El sistema ideal de administración de analgésicos debería proporcionar dosis terapéuticas, no tóxicas, en el sitio quirúrgico, especialmente durante las primeras 72h. El cemento óseo utilizado en las artroplastias se ha usado como un medio de liberación de fármacos, especialmente antibióticos, desde 1970. Basado en este principio, se desarrolló este estudio con el objetivo de conocer el perfil de elución de dos anestésicos locales (hidrocloruro de lidocaína e hidrocloruro de bupivacaína) desde el cemento óseo de polimetilmetacrilato (PMMA). Material y métodos: Se obtuvieron especímenes de cemento óseo Palacos® R+G e hidrocloruro de lidocaína o hidrocloruro de bupivacaína según el grupo de estudio. Estos especímenes se sumergieron en PBS (por sus siglas en inglés de phosphate buffered saline) y se retiraron de la solución en diferentes cortes temporales establecidos. Posteriormente, se analizó la concentración de anestésico local en el líquido mediante cromatografía líquida. Resultados: El porcentaje de lidocaína eludida del cemento óseo PMMA de este estudio ha sido del 9,74% del contenido total de lidocaína por espécimen a las 72h y del 18,73% a las 336h (14 días). En el caso de la bupivacaína, el porcentaje de elución ha sido del 2,71% del contenido total de bupivacaína por espécimen a las 72h y del 2,70% a las 336h (14 días). Conclusiones: Los anestésicos locales eluyen in vitro desde el cemento óseo, alcanzando a las 72h dosis cercanas a las dosis utilizadas en bloqueos anestésicos.(AU)

Background and aim: Currently, we do not have a gold standard for pain management after total knee arthroplasty. We may use one of more drug delivery systems, none of which are ideal. An ideal depot delivery system would provide therapeutic, nontoxic, doses of drug at the surgical side, especially during 72h postoperatively. The bone cement used in arthroplasties has been used as a drug delivery system, especially antibiotics, since 1970. Based on this principle, we developed this study with the aim to characterize the elution profile of two local anesthetics (lidocaine hydrochloride and bupivacaine hydrochloride) from PMMA (polymethilmethacrylate) bone cement. Material and methods: Palacos® R+G bone cement and lidocaine hydrochloride or bupivacaine hydrochloride specimens were obtained depending on the study group. These specimens were immersed in PBS (phosphate buffered saline) and removed from the solution at different set times. Subsequently, the concentration of local anesthetic in the liquid was analyzed by liquid chromatography. Results: The percentage of lidocaine eluted from PMMA bone cement in this study was 9.74% of the total lidocaine content per specimen at 72h and 18.73% at 336h (14 days). In case of bupivacaine, the elution percentage was 2.71% of the total bupivacaine content per specimen at 72h and 2.70% at 336h (14 days). Conclusions: Local anesthetics elute in vitro from PMMA bone cement, reaching doses at 72h close to the doses used in anesthetic blocks.(AU)

[Translated article] In vitro elution of local anaesthetics from PMMA bone cement / Estudio in vitro de elución de anestésicos locales en cemento óseo de PMMA

Antecedentes y objetivo:Actualmente, no disponemos de un gold standard para el manejo del dolor postoperatorio tras una artroplastia total de rodilla, dado que se pueden administrar analgésicos a través de diferentes vías y ninguna de estas está exenta de riesgos. El sistema ideal de administración de analgésicos debería proporcionar dosis terapéuticas, no tóxicas, en el sitio quirúrgico, especialmente durante las primeras 72h. El cemento óseo utilizado en las artroplastias se ha usado como un medio de liberación de fármacos, especialmente antibióticos, desde 1970. Basado en este principio, se desarrolló este estudio con el objetivo de conocer el perfil de elución de dos anestésicos locales (hidrocloruro de lidocaína e hidrocloruro de bupivacaína) desde el cemento óseo de polimetilmetacrilato (PMMA). Material y métodos: Se obtuvieron especímenes de cemento óseo Palacos® R+G e hidrocloruro de lidocaína o hidrocloruro de bupivacaína según el grupo de estudio. Estos especímenes se sumergieron en PBS (por sus siglas en inglés de phosphate buffered saline) y se retiraron de la solución en diferentes cortes temporales establecidos. Posteriormente, se analizó la concentración de anestésico local en el líquido mediante cromatografía líquida. Resultados: El porcentaje de lidocaína eludida del cemento óseo PMMA de este estudio ha sido del 9,74% del contenido total de lidocaína por espécimen a las 72h y del 18,73% a las 336h (14 días). En el caso de la bupivacaína, el porcentaje de elución ha sido del 2,71% del contenido total de bupivacaína por espécimen a las 72h y del 2,70% a las 336h (14 días). Conclusiones: Los anestésicos locales eluyen in vitro desde el cemento óseo, alcanzando a las 72h dosis cercanas a las dosis utilizadas en bloqueos anestésicos.(AU)

Background and aim: Currently, we do not have a gold standard for pain management after total knee arthroplasty. We may use one of more drug delivery systems, none of which are ideal. An ideal depot delivery system would provide therapeutic, nontoxic, doses of drug at the surgical side, especially during 72h postoperatively. The bone cement used in arthroplasties has been used as a drug delivery system, especially antibiotics, since 1970. Based on this principle, we developed this study with the aim to characterize the elution profile of two local anesthetics (lidocaine hydrochloride and bupivacaine hydrochloride) from PMMA (polymethilmethacrylate) bone cement. Material and methods: Palacos® R+G bone cement and lidocaine hydrochloride or bupivacaine hydrochloride specimens were obtained depending on the study group. These specimens were immersed in PBS (phosphate buffered saline) and removed from the solution at different set times. Subsequently, the concentration of local anesthetic in the liquid was analyzed by liquid chromatography. Results: The percentage of lidocaine eluted from PMMA bone cement in this study was 9.74% of the total lidocaine content per specimen at 72h and 18.73% at 336h (14 days). In case of bupivacaine, the elution percentage was 2.71% of the total bupivacaine content per specimen at 72h and 2.70% at 336h (14 days). Conclusions: Local anesthetics elute in vitro from PMMA bone cement, reaching doses at 72h close to the doses used in anesthetic blocks.(AU)

Effect of Acupressure on Pain during Inferior Alveolar Nerve Block Injection in Children Aged 5-10 Years Old - An Experimental Study.

Background: Acupressure, which is related to acupuncture, is a noninvasive therapy suitable for use in children. However, data examining acupressure's effects on the pain of local anesthetic injection in children are sparse. Objectives: The purpose of this study was to evaluate acupressure's effects on the pain of local anesthetic injection in children. Methods: This randomized, double-blind, parallel-group clinical study included 37 5- to 10-year-olds who had an inferior alveolar nerve block (IANB) for a mandibular extraction and were randomized to one of two groups: acupressure (study group) or non-acupressure (control group). The Wong-Baker FACES Pain Rating Scale (WBFPS) and the Sound, Eye, Motor (SEM) scale were utilized for subjective and objective pain assessment during injection. Results: The objective and subjective assessment of pain during injection significantly differed between the groups, with the acupressure group displaying lower scores. Conclusion: Acupressure at the extra one point (EX-HN1) reduced pain during IANB injection in 5- to 10-year-olds and can be used as an adjunct to conventional measures like topical anesthesia to reduce pain.

Qualitative Histologic Assessment vs. Geomorphometric Analysis of Nerve Fiber Shape after the Intraneural Application of Liposomal Bupivacaine / Evaluación Histológica Cualitativa Versus Análisis Geomorfométrico de la Forma de la Fibra Nerviosa Después de la Aplicación Intraneural de Bupivacaína Liposomal

SUMMARY: The preserved form of all components of the nerve fiber is a prerequisite for the proper conduction of the nerve impulse. various factors can change the shape of nerve fibers. In everyday practice, qualitative histological analysis is the gold standard for detecting changes in shape. Geometric morphometry is an innovative method that objectively enables the assessment of changes in nerve fibers' shape after local anesthetics action. A total of sixty sciatic nerves were used as material, which was intraneural injected with saline solution in the control group (n=30), and a solution of 1.33 % liposomal bupivacaine (n=30) in the test group. After the animals were sacrificed, nerve samples were taken and histological preparations were made. The preparations were first described and examined using a qualitative histological method, after which digital images were made. The images were entered into the MorphoJ program and processed using the method of geometric morphometry. Qualitative histological examination revealed no differences in nerve fibers after intraneurally applied physiological solution and liposomal bupivacaine. Using the method of geometric morphometry, a statistically significant change in the shape of axons was found after intraneurally applied saline solution and liposomal bupivacaine (p=0.0059). No significant differences in histological changes were found after the qualitative histological analysis of nerve fiber cross-section preparations. A statistically significant change in the shape of nerve fiber axons was observed after geometric morphometric analysis of digital images after intraneural application of saline and liposomal bupivacaine.

La forma conservada de todos los componentes de la fibra nerviosa es un requisito previo para la conducción correcta del impulso nervioso. Varios factores pueden cambiar la forma de las fibras nerviosas. En la práctica diaria, el análisis histológico cualitativo es el estándar de oro para detectar cambios de forma. La morfometría geométrica es un método innovador que permite evaluar objetivamente los cambios en la forma de las fibras nerviosas después de la acción de los anestésicos locales. Se utilizó como material un total de sesenta nervios ciáticos, que se inyectaron intraneuralmente con solución salina en el grupo control (n=30), y una solución de bupivacaína liposomal al 1,33 % (n=30) en el grupo de prueba. Después de sacrificados los animales, se tomaron muestras de nervios y se realizaron preparaciones histológicas. Primero se describieron y examinaron las preparaciones utilizando un método histológico cualitativo, después de lo cual se tomaron imágenes digitales. Las imágenes fueron ingresadas al programa MorphoJ y procesadas mediante el método de morfometría geométrica. El examen histológico cualitativo no reveló diferencias en las fibras nerviosas después de la aplicación intraneural de solución fisiológica y bupivacaína liposomal. Usando el método de morfometría geométrica, se encontró un cambio estadísticamente significativo en la forma de los axones después de la aplicación intraneural de solución salina y bupivacaína liposomal (p = 0,0059). No se encontraron diferencias significativas en los cambios histológicos después del análisis histológico cualitativo de las preparaciones de secciones transversales de fibras nerviosas. Se observó un cambio estadísticamente significativo en la forma de los axones de las fibras nerviosas después del análisis de morfometría geométrica de imágenes digitales después de la aplicación intraneural de solución salina y bupivacaína liposomal.

Enhancing Postoperative Pain Management and Decreasing Hospital Length of Stay on a Pediatric Orthopedic Unit: Implementation of an Ambulatory Continuous Peripheral Nerve Block Program.

PURPOSE: Pediatric Ambulatory Continuous Peripheral Nerve Block (ACPNB) programs are a safe and effective pain management modality that can reduce patient length of stay (LOS) while ensuring optimal, multimodal pain management at home after surgery. Our institution previously solely used electronic infusion pumps to deliver local anesthetic via peripheral nerve catheters, requiring postoperative inpatient admissions for pain management. We aimed to enhance postoperative pain management and decrease hospital LOS after orthopedic foot and ankle surgery through implementation of an ACPNB program. DESIGN: An ACPNB program was developed and implemented for pediatric patients undergoing foot and ankle reconstruction surgery. METHODS: We provide a detailed description of the multidepartment collaboration led by the acute pain service (APS) and orthopedics that resulted in the development and implementation of a pediatric ACPNB program using portable, elastomeric devices for patients undergoing reconstructive foot and ankle surgery. Implementation tools, including caregiver and nursing education resources, a data collection log, a process map, and staff surveys are shared. FINDINGS: Twenty-eight patients received elastomeric devices during the 12 months of data collection. All 28 patients who required a continuous peripheral nerve block (CPNB) for pain management following foot and ankle reconstruction surgery received their block via an elastomeric device rather than an electronic hospital infusion pump. All patients and caregivers expressed positive satisfaction with pain management after hospital discharge. No patient with an elastomeric device required scheduled opioids for pain management by the end of their hospital admission. LOS on the orthopedic inpatient unit for foot and ankle surgery decreased by 58%, representing an estimated 29 days and $27,557.88 saved. A majority (96.4%) of staff survey respondents reported feeling satisfied with their overall experience working with an elastomeric device. CONCLUSIONS: The successful implementation of a pediatric ACPNB program has led to positive patient outcomes, including a significant decrease in hospital LOS and health system cost savings for this patient population.

Adductor Canal Block Combined with General Analgesia for Patients with Recurrent Patellar Dislocation Undergoing "3-in-1" Procedure Surgery: A Prospective Randomized Controlled Trial.

OBJECTIVE: Patellar dislocation is a common injury in sports medicine. While surgical treatment is an important option, pain is severe after surgery. This study compared the analgesic effect and early rehabilitation quality between adductor canal block combined with general analgesia (ACB + GA) and single general analgesia (SGA) after recurrent patellar dislocation (RPD) for "3-in-1" procedure surgery. METHODS: From July 2018 to January 2020, a prospective randomized controlled trial was conducted in analgesia management after RPD for "3-in-1" procedure surgery. The 40 patients in the experimental group received ACB (0.3% ropivacaine 30 mL) + GA, while the 38 patients in the control group received SGA. Patients in both groups received "3-in-1" procedure surgery, standardized anesthesia, and analgesia during hospitalization. The outcomes included the visual analog scale (VAS), quadriceps strength, Inpatient Satisfaction Questionnaire (IPSQ), Lysholm scores, and Kujala scores. Total rescue analgesic consumption and adverse events were also recorded. One-way analysis of variance (ANOVA) was used to compare continuous variables between groups and chi-square or Fisher's exact tests were used to compare count data. Nonparametric Kruskal-Wallis H tests evaluated ranked data. RESULTS: No significant differences in resting VAS scores were observed at 8, 12, and 24 h postoperatively. However, the flexion and moving VAS scores of the ACB + GA group were significantly lower than those of the SGA group (p < 0.05). Meanwhile, the first triggering of rescue analgesics was advanced in the SGA group (p < 0.0001), and the dose of opioid analgesics was significantly higher (p < 0.0001). The quadriceps strength of the ACB + GA group was higher than that of the SGA group at 8 h postoperatively. The IPSQ of the ACB + GA group was significantly higher 24 h postoperatively. We observed no significant differences in Lysholm and Kujala scores between the two groups at 3 months after surgery. CONCLUSIONS: Early analgesia management of ACB + GA showed excellent analgesia effectiveness and a positive hospitalization experience for RPD patients undergoing "3-in-1" procedure surgery. Moreover, this management was good for early rehabilitation.

Postoperative effects and complications of intrathecal morphine compared to epidural analgesia in patients undergoing intracorporeal robot-assisted radical cystectomy: a retrospective study.

BACKGROUND: Analgesia after robot assisted radical cystectomy aims to reduce postoperative pain and opioid consumption, while facilitating early mobilization and enteral nutrition and minimizing complications. Epidural analgesia is currently recommended for an open radical cystectomy, but it is unclear if intrathecal morphine is a suiting, less-invasive alternative for a robot-assisted radical cystectomy. METHODS: The analgesic method of choice changed from epidural anesthesia to intrathecal anesthesia for patients undergoing a robot-assisted radical cystectomy. This single-center retrospective study aims to investigate if there is a difference between epidural and intrathecal analgesia in postoperative pain scores, opioid consumption, length of hospital stays and postoperative complications. An Propensity Matched Analysis was added to conventional analysis to consolidate the findings. RESULTS: The study population consisted of 153 patients of whom 114 received an epidural catheter with bupivacaine/sufentanil and 39 received a single shot of intrathecal bupivacaine/morphine. Mean pain scores on the first two postoperative days (POD) were slightly higher in the intrathecal analgesia group (epidural versus intrathecal analgesia, NRS POD0: 0(0-2)[0-8] versus 1(0-3)[0-5], p = 0.050; POD1: 2(1-3)[0-8] versus 3(1-4)[0-7], p = 0.058; POD2: 2(0-3)[0-8] versus 3(2-4)[0-7], p = 0.010). Total postoperative morphine consumption was similar over the first seven days: 15 mg (5-35)[0-148] in the epidural group versus 11 mg (0-35)[0-148] in the intrathecal morphine group, p = 0.167. Length of hospital stay and time until fit for discharge where slightly higher in the epidural group (respectively 7 days (5-9)[4-42] versus 6 days (5-7)[4-38], p = 0.006, and 5 days (4-8)[3-30]) versus 5 days (4-6)[3-34], p = 0.018). There was no further difference in postoperative course. CONCLUSIONS: This study showed that the effects of epidural analgesia and intrathecal morphine are comparable and that intrathecal morphine may be a suiting alternative for epidural analgesia.

Determination of the Optimal Volume of Programmed Intermittent Epidural Bolus When Combined With the Dural Puncture Epidural Technique for Labor Analgesia: A Random-Allocation Graded Dose-Response Study.

BACKGROUND: The dural puncture epidural (DPE) and the programmed intermittent epidural bolus (PIEB) techniques are recent innovations for labor analgesia. The optimal volume of PIEB during traditional epidural analgesia has been investigated previously but it is unknown whether these findings are applicable to DPE. This study aimed to determine the optimal volume of PIEB for effective labor analgesia after initiation of analgesia using DPE. METHODS: Parturients requesting labor analgesia received dural puncture with a 25-gauge Whitacre spinal needle and then had analgesia initiated with 15 mL of ropivacaine 0.1% with sufentanil 0.5 µg/mL. Analgesia was maintained using the same solution delivered by PIEB with boluses given at a fixed interval of 40 minutes starting 1 hour after the completion of the initial epidural dose. Parturients were randomized to 1 of 4 PIEB volume groups: 6, 8, 10, or 12 mL. Effective analgesia was defined as no requirement for a patient-controlled or manual epidural bolus for 6 hours after the completion of the initial epidural dose or until full cervical dilation. The PIEB volumes for effective analgesia in 50% of parturients (EV50) and 90% of parturients (EV90) were determined using probit regression. RESULTS: The proportions of parturients with effective labor analgesia were 32%, 64%, 76%, and 96% in the 6-, 8-, 10-, and 12-mL groups, respectively. The estimated values for EV50 and EV90 were 7.1 (95% confidence interval [CI], 5.9-7.9) mL and 11.3 (95% CI, 9.9-15.2) mL, respectively. There were no differences in side effects, including hypotension, nausea and vomiting, and fetal heart rate (FHR) abnormalities among groups. CONCLUSION: Under the conditions of the study, after initiation of analgesia using DPE, the EV90 of PIEB for effective labor analgesia using ropivacaine 0.1% with sufentanil 0.5 µg/mL was approximately 11.3 mL.

Conhecimento de acadêmicos de Odontologia sobre o uso de anestésicos locais / Conocimiento de los estudiantes de odontología sobre el uso de anestésicoslocales / Dentistry students' knowledge about the use of local anesthetics

O presente estudo teve como objetivo avaliar o conhecimento de estudantes de graduação do curso de Odontologia em relação à indicação e uso dos anestésicos locais nos procedimentos clínicos e cirúrgicos. Trata-se de um estudo prospectivo, observacional tendo como instrumento de coleta um questionário composto de perguntas abertas e fechadas sobre a temática. Após assinatura do termo de consentimento livre e esclarecido, 59 acadêmicos que obedeciam aos critérios de inclusão e exclusão participaram do estudo respondendo ao questionário. A amostra apresentou média de idade de 22,75 anos, 17 (29,31%) eram do sexo masculino e 41 (70,68%) do feminino, sendo que um participante não declarou o sexo. A média de tempo cursando Odontologia foi de 4 anos, sendo que 19 alunos (31%) cursavam o 6º período, 22 (37,9%) o 8º período e 18 (31%) o 10º período do curso. Situações relacionadas à toxicidade do anestésico foram corretamente identificadas por 20 participantes (57,2% dos 35 que responderam à pergunta), 56 (94,9%) realizaram anamnese direcionada e 55 (93,2%) fizeram a escolha do sal anestésico de acordo com a condição sistêmica do paciente. Porém, quando questionados sobre a dose anestésica máxima em determinada situação clínica, apenas 6 (10,2%) responderam corretamente. Considerando a disponibilidade de anestésicos para uma exodontia simples em paciente hipertenso ou diabético controlado, gestante, lactante e criança, pouco mais que a metade dos alunos (62,7% a 52,5%) souberam indicar corretamente solução anestésica,considerando a lidocaína com vasoconstritor o anestésico de escolha. Foram observadas diferenças estatisticamente significativas quando comparado o gênero dos acadêmicos em relação ao uso de anestésico tópico (p=0,018) e uso de anestesia local para o procedimento de raspagem periodontal subgengival (p = 0,008), sendo as duas indicações mais comuns na parcela feminina da amostra. Conclui-se que a maioria dos acadêmicos possui conhecimentos necessários para escolha do sal anestésico e sucesso quanto ao emprego da técnica, entretanto não realizaram de forma correta o cálculo da dose máxima recomendada diante de uma situação clínica hipotética, necessitando, neste e em outros parâmetros, de revisão de conceitos, procedimentos e condutas clínicas (AU).

El presente estudio tuvo como objetivo evaluar el conocimiento de estudiantes de graduación en odontologíasobre la indicación y uso de anestésicos locales en procedimientos clínicos y quirúrgicos. Se trata de un estudio observacional prospectivo que utiliza como instrumento de recogida de datos un cuestionario compuesto por preguntas abiertas y cerradas sobreel tema. Después de firmar el formulario de consentimiento libre e informado, 59 estudiantes que cumplieron con los criterios de inclusión y exclusión participaron en el estudio respondiendo el cuestionario. La muestra tenía una edad media de 22,75 años, 17 (29,31%) eran del sexo masculino y 41 (70,68%) del sexo femenino, y un participante no declaró el sexo. El tiempo promedio de estudio de Odontología fue de 4 años, con 19 alumnos (31%) cursando el 6° período, 22 (37,9%) el 8° período y 18 (31%) el 10° período de la carrera. Las situaciones relacionadas con la toxicidad del anestésico fueron identificadas correctamente por 20 participantes (57,2% de los 35 que respondieron la pregunta), 56 (94,9%) realizaron anamnesis dirigida y 55 (93,2%) eligieron la sal del anestésico según el estado sistémico del paciente. Sin embargo, cuando se les preguntó sobre la dosis máxima de anestésico en una situación clínica dada, solo 6 (10,2%) respondieron correctamente. Considerando la disponibilidad de anestésicos para una extracción dental simple en pacientes hipertensos o diabéticos controlados, gestantes, lactantes y niños, poco más de la mitad de los estudiantes (62,7% a 52,5%) sabían indicar correctamente la solución anestésica, considerando la lidocaína con vasoconstrictor el anestésico de elección. Se observaron diferencias estadísticamente significativas al comparar el sexo de los estudiantes en relación con el uso de anestésico tópico (p=0,018) y uso de anestesia local para el procedimiento de raspado periodontal subgingival (p=0,008), las dos indicaciones más comunes en la porción femenina de la muestra. Se concluye que la mayoría de los académicos tienen los conocimientos necesarios para elegir la sal anestésica y lograr el uso de la técnica, sin embargo, no calcularon correctamente la dosis máxima recomendada en una situación clínica hipotética, requiriendo, en este y otros parámetros, revisar conceptos, procedimientos y enfoques clínicos (AU).

The objective of the present study was to evaluate the knowledge of undergraduate dental students regarding the indication and use of local anesthetics in clinical and surgical procedures. This is a prospective, observational study, using a questionnaire with open and closed questions about the subject as a collection tool. After signing the ICF, 59 students who met the inclusion and exclusion criteria participated in the study by answering the questionnaire. The students included in the study had a mean age of 22.75 years, 29.31% (n=17) were male and 70.68% (n=41) were female, and one student did not declare. The average number of years in college was 4 years, with 19 students (31%) in 6th period, 22 (37.9%) in 8th period and 18 (31%) in 10th period. Fifty-seven percent identified situations related to anesthetic toxicity, 94.9% performed directed anamnesis, and 93.2% chose the anesthetic salt according to the general condition of the patient. However, when questioned about the maximum anesthetic dose in a given clinical situation, only 10.2% answered correctly. For anesthetic application procedures, 89.8% considered that controlling the volume of anesthetic solution injected was an important factor, and 72.9% informed that prior aspiration was done before starting the injection of the anesthetic. Regarding the success of the technique, 78% reported success. Considering the availabilityof anesthetics, the indication for patients with some systemic condition, 62.7% knew how to correctly indicate the anesthetic solution. Statistically significant differences were observed when comparing the gender of the students regarding the use of topical anesthetic (p = 0.018) and the use of local anesthesia for subgingival periodontal scaling (p = 0.008), both indications being more common in female students. It was concluded that most of the students had the necessary knowledge to choose the anesthetic salt and were successful in using the technique, however, they did not correctly calculate the maximum dose recommended for a clinical situation presented as an assumption, requiring, in this and other parameters, a review of concepts, procedures, and clinical conducts (AU).

Tumescent local anaesthesia for the surgical therapy of congenital nevi in the first year of life.

BACKGROUND: The indication for surgical treatment of congenital nevi must be made after individual consideration of the expected benefit and risk and requires careful information of the parents as well as interdisciplinary psychological support. In addition to suspected malignancy, a relevant indication is the risk of stigmatization depending on the size and localization of the nevus. Objective was to show which size reduction of the congenital nevus can be achieved by surgical therapy under tumescent local anaesthesia (TLA) in infancy and how often complications of anaesthesia or surgery occur. METHODS: All infants up to 12 months of age who underwent surgery for a congenital nevus under TLA at the University Dermatological Clinic Tuebingen between January 2015 and December 2021 were included; surgeries were performed using serial excisions (powerstretching technique), whereby the incisions were made inside the nevus and mobilization was strictly limited to the skin side without nevus. RESULTS: Overall, a cumulative total area of 38.65 cm2 could be removed on average within the first year of life (trunk: 67 cm2 , head: 21.2 cm2 , legs: 21.6 cm2 , arms: 13.2 cm2 ). A cumulative maximum area reduction of 406.9 cm2 could be achieved. We evaluated 363 surgical sites (123 children) on all body regions. The median age of the children at the first surgery was 3.5 months (0.46-10.7 months). Complications occurred in 2.3% (seven procedures). All these complications were reversible in the course of the operation and did not lead to a prolonged hospital stay. No anaesthesia-related complications occurred. CONCLUSION: We were able to show that a reduction of large areas of congenital nevi is possible in the first year of life with the combination of serial excisions using powerstretching technique, TLA, and intracutaneous butterfly sutures.

Comparative growth dynamics of bacterial and fungal contaminants in bupivacaine liposomal injectable suspension, bupivacaine 0.5%, and propofol.

OBJECTIVE: To determine whether bupivacaine liposomal injectable suspension (BLIS) supports microbial growth when artificially inoculated and to evaluate liposomal stability in the face of this extrinsic contamination as evidenced by changes in free bupivacaine concentrations. STUDY DESIGN: A randomized, prospective in vitro study in which three vials of each BLIS, bupivacaine 0.5%, and propofol were individually inoculated with known concentrations of Escherichia coli, Pseudomonas aeruginosa, Staphylococcus aureus, and Candida albicans (n = 36) to quantify bacterial and fungal growth was conducted. Over 120 hours, aliquots from contaminated vials were withdrawn, plated, and incubated to determine microbial concentrations. High-pressure liquid chromatography (HPLC) was used to evaluate free bupivacaine concentrations over time in BLIS. Data were analyzed using a mixed effects model with multiple comparisons. SAMPLE POPULATION: Twelve vials of each BLIS, bupivacaine 0.5%, and propofol. RESULTS: BLIS did not support significant growth of Staphylococcus aureus or Candida albicans at any time. BLIS supported significant growth of Escherichia coli and Pseudomonas aeruginosa beginning at the 24 hour time point. Bupivacaine 0.5% did not support significant growth of any organisms. Propofol supported significant growth of all organisms. Free bupivacaine concentrations changed minimally over time. CONCLUSION: Bacterial and fungal contaminant growth in artificially inoculated BLIS is organism dependent. BLIS supports significant growth of Escherichia coli and Pseudomonas aeruginosa. Extra-label handling of BLIS should only be undertaken with caution and with adherence to strict aseptic technique.

Does the Transversus Abdominis Plane Block Reduce Morbidity Following Iliac Crest Bone Harvest in Pediatric Patients With Alveolar Clefts?

OBJECTIVE: The purpose of this study is to determine whether a Transversus Abdominis Plane (TAP) block can reduce donor site morbidity among pediatric patients undergoing iliac crest bone grafting for repair of their alveolar cleft. DESIGN: This retrospective cohort study was carried out at the Division of Dentistry at the Montreal Children's Hospital. Medical charts of patients who underwent alveolar cleft bone grafting between January 2011 and January 2021 were reviewed and they were divided into two groups, intraoperative TAP block and intraoperative local anesthesia infiltration (control group). The outcomes measured were patients' post-operative pain at the donor site, in-hospital narcotics requirements and length of stay. RESULTS: A total of 66 patients were included. There were no significant differences in pain scale among the TAP group and control group [1.9 (SD 2.5) and 1.3 (SD 2.1), respectively (p = 0.23)]. The mean length of stay for both groups was 1 day. Interestingly, there was a significant higher proportion of patients who required in-hospital opioids (morphine) in the TAP block group when compared to the control group (p = 0.03). CONCLUSIONS: The results of our study suggest there may be no role for a TAP block in reducing pain and improving opioid stewardship.

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

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

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

Influence of height on ED95 of intrathecal 2-chloroprocaine for knee arthroscopy: A prospective dose-response clinical trial.

BACKGROUND: Plain 2-chloroprocaine , a rapid acting amino-ester-type local anaesthetic, is used in short ambulatory procedures under spinal anaesthesia. The ED 95 of 2-chloroprocaine for lower limb surgery has not yet been defined. Moreover, patients' body height could influence the effects of the administered dose. OBJECTIVES: The aim of this study was to determine the ED 95 of plain 2-chloroprocaine based on the height of patients undergoing ambulatory knee arthroscopy under spinal anaesthesia using the continual reassessment statistical method (CRM). DESIGN: Prospective, dose-response, double blind, controlled, bi-center, clinical trial. SETTING: One university teaching hospital in Brussels and one general teaching hospital, Braine l'Alleud, Belgium. Université libre de Bruxelles. PATIENTS: ASA I-III (120 patients) scheduled for day-case knee arthroscopy under spinal anaesthesia. INTERVENTIONS: Patients were divided into three groups of 40, each comprising 10 cohorts of 4 patients, according to their respective heights (Group 1: 150-165 cm, Group 2: 166-180 cm, Group 3: 181-195 cm). Each patient enrolled into one of the 3 groups received an intrathecal dose of plain 2-chloroprocaine determined by the CRM. The starting doses for the first cohorts of four were 40 mg in group 1, 45 mg in group 2 and 50 mg in group 3. The doses for subsequent cohorts were determined by CRM of outcomes in all patients in the previous competed cohorts. Anaesthesia was considered successful when there was a lack of pinprick or cold sensation up to T12, the visual analogue scale score for tourniquet pain was < 2 and no pain during surgery. MAIN OUTCOMES: The primary outcome was the success or failure of the block. Side effects were also recorded. RESULTS: ED 95 of 2-chloroprocaine is 40 mg in group 1, 35 mg in group 2, 45 mg in group 3. Groups were different in terms of height and gender ( P  < 0.05) and similar in terms of body mass index and age ( P  > 0.05). CONCLUSION: The ED95 of intrathecal 2-chloroprocaine for patients undergoing ambulatory knee arthroscopy is between 35 and 45 mg. Height could be a factor involved in the calculation, and patient sex could partly explain the nonlinear relation between height and dose. TRIAL REGISTRY NUMBER: Clinicaltrials.gov NCT03882489.

Hard polymeric porous microneedles on stretchable substrate for transdermal drug delivery.

Microneedles offer a convenient transdermal delivery route with potential for long term sustained release of drugs. However current microneedle technologies may not have the mechanical properties for reliable and stable penetration (e.g. hydrogel microneedles). Moreover, it is also challenging to realize microneedle arrays with large size and high flexibility. There is also an inherent upper limit to the amount and kind of drugs that can be loaded in the microneedles. In this paper, we present a new class of polymeric porous microneedles made from biocompatible and photo-curable resin that address these challenges. The microneedles are unique in their ability to load solid drug formulation in concentrated form. We demonstrate the loading and release of solid formulation of anesthetic and non-steroidal anti-inflammatory drugs, namely Lidocaine and Ibuprofen. Paper also demonstrates realization of large area (6 × 20 cm2) flexible and stretchable microneedle patches capable of drug delivery on any body part. Penetration studies were performed in an ex vivo porcine model supplemented through rigorous compression tests to ensure the robustness and rigidity of the microneedles. Detailed release profiles of the microneedle patches were shown in an in vitro skin model. Results show promise for large area transdermal delivery of solid drug formulations using these porous microneedles.

Lipid emulsions attenuate the inhibition of carnitine acylcarnitine translocase induced by toxic doses of local anesthetics in rat cardiomyoblasts.

The aim of this study was to examine the effects of lipid emulsions on carnitine palmitoyltransferase I (CPT-I), carnitine acylcarnitine translocase (CACT), carnitine palmitoyltransferase II (CPT-II), and the mitochondrial dysfunctions induced by toxic doses of local anesthetics in H9c2 rat cardiomyoblasts. The effects of local anesthetics and lipid emulsions on the activities of CPT-I, CACT, and CPT-II, and concentrations of local anesthetics were examined. The effects of lipid emulsions, N-acetyl-L-cysteine (NAC), and mitotempo on the bupivacaine-induced changes in cell viability, reactive oxygen species (ROS) levels, mitochondrial membrane potential (MMP), and intracellular calcium levels were examined. CACT, without significantly altering CPT-I and CPT-II, was inhibited by toxic concentration of local anesthetics. The levobupivacaine- and bupivacaine-induced inhibition of CACT was attenuated by all concentrations of lipid emulsion, whereas the ropivacaine-induced inhibition of CACT was attenuated by medium and high concentrations of lipid emulsion. The concentration of levobupivacaine was slightly attenuated by lipid emulsion. The bupivacaine-induced increase of ROS and calcium and the bupivacaine-induced decrease of MMP were attenuated by ROS scavengers NAC and mitotempo, and the lipid emulsion. Collectively, these results suggested that the lipid emulsion attenuated the levobupivacaine-induced inhibition of CACT, probably through the lipid emulsion-mediated sequestration of levobupivacaine.

Effect of topical local anaesthesia on injection pain associated with administration of sterile water injections - a randomized controlled trial.

BACKGROUND: Sterile water injections can provide effective pain relief during childbirth, particularly for low back pain related to childbirth. However, the pain associated administering the injections can negatively impact women's impressions of the procedure. It may discourage women from considering repeat doses despite the quality of analgesia experienced. Determining strategies to reduce the pain related to the administration of sterile water injections would improve the acceptability of the technique. Therefore, the aim of this study was to evaluate the effect of topical local anesthesia on the pain associated with administration of sterile water injections. METHODS: The study was designed as a multi-arm single-blind, randomized, controlled trial and 120 female healthy students were randomly divided according to one of four groups. The Intervention group received sterile water injections with topical local anesthesia. Control group 1 received sterile water injections without topical local anesthesia, control group 2 received injections of isotonic saline 0.9% with topical local anesthesia and control group 3 received injections of isotonic saline 0.9% without topical local anesthesia. Pain Immediately after the injections and subsidence in pain were recorded using a visual analogue scale. Sensations in the injection area were reported 15 min and the day after the injections. RESULTS: The main finding of this study was that local anesthesia with EMLA® reduces the pain associated with the administration of intracutaneous sterile water injections. There was a significant difference in the self-assessed pain score immediately following the injections between the control (73.3 mm) and intervention groups (50.0 mm), p = 0.001. No adverse side effects were reported. CONCLUSION: Local anesthesia with EMLA® reduces the pain associated with intracutaneous administration of sterile water injections. TRIAL REGISTRATION: The study was registered 08/07/2014 at ClinicalTrials.gov Identifier: NCT02213185 .

Effectiveness of Ultrasound-Guided Canal Adductor Blockade for Chronic Pain and Functioning in Knee Osteoarthritis: A Prospective Longitudinal Observational Study.

METHODS: Seventy-seven patients with chronic knee osteoarthritis pain received ultrasound-guided ACB with 14 ml 0.25% levobupivacaine and 100 mcg clonidine. At baseline and 1 month after the blockade, we assessed maximal and minimal pain intensity in the knee using a numeric rating scale (NRS) and the Knee Injury and Osteoarthritis Outcome Score (KOOS). The range of motion in extension and flexion (ROMext and ROMflex) and quadriceps muscle strength of both knees (QS), Timed Up and Go Test (TUG), and 30-Second Chair Stand Test (30CST) results were determined at baseline, 1 hour, 1 week, and 1 month after the blockade. RESULTS: ACB with levobupivacaine and clonidine appeared to decrease pain severity (NRSmax 8.13 to 4.2, p < 0.001 and NRSmin 3.32 to 1.40, p < 0.001). Similarly, knee ROMext decreased from 3.90 preintervention to 2.89 postintervention at 1 month, p < 0.001; ROMflex decreased from 5.70 to 3.29, p < 0.001; TUG time decreased from 3.22 to 2.93, <0.001; QS increased from 18.43 to 22.77, p < 0.001; CST increased from 8.23 to 10.74, p < 0.001. The KOOS for pain (36.40 to 58.34), symptoms (52.55 to 64.32), activities of daily living functions (ADLs, 36.36 to 60.77), and quality of life (QoL, 17.87 to 30.97) also increased, all p < 0.001. CONCLUSION: ACB appeared to decrease pain and increase ambulation. If our preliminary results are reproducible in a planned randomized controlled trial, ACB could be a useful adjunctive pain therapy in patients with disabling pain due to knee OA.