Sensitivity of a preanaesthesia screening and triage tool in identifying high-risk patients attending the preanaesthesia assessment clinic in a tertiary referral hospital in Sub-Saharan Africa: a diagnostic accuracy study.

OBJECTIVES: The use of preoperative triage questionnaires is an innovative way to mitigate the shortage of anaesthesiologists and to identify and refer high-risk patients early for evaluation. This study evaluates the diagnostic accuracy of one such questionnaire in identifying high-risk patients in a Sub-Saharan population. DESIGN: Diagnostic accuracy study SETTING: The study was conducted in a preanaesthesia assessment clinic in a tertiary referral hospital in Sub-Saharan Africa. PARTICIPANTS: The study had a sample size of 128, including all patients above the age of 18 scheduled for elective surgery under any modality of anaesthesia other than local anaesthesia presenting to the preanaesthesia clinic. Patients scheduled for cardiac and major non-cardiac surgery and those non-literate in English were excluded. OUTCOME MEASURES: The sensitivity of the preanaesthesia risk assessment tool (PRAT) was the primary outcome measure. Other outcome measures were specificity, positive predictive value and negative predictive value. RESULTS: Majority of patients were young and women with a mean age of 36 referred for obstetric and gynaecological procedures. The sensitivity of the PRAT in identifying high-risk patients was at 90.6% with 95% CI (76.9 to 98.2) in this current study while the specificity, negative predictive value (NPV) and positive predictive value (PPV) were 37.5% with 95% CI (24.0 to 43.7), 92.3% with 95% CI (77.7 to 97.0) and 32.6% with 95% CI (29.6 to 37.3) respectively. CONCLUSION: The PRAT has a high sensitivity and may be used as a screening tool in identifying high risk patients to refer to the anaesthesiologist early before surgery. Adjusting the high risk criteria to fit the anaesthesiologists' assessments may improve the specificity of the tool.

Local anaesthetic infiltration in rubber band ligation of rectal haemorrhoids: study protocol for a three-arm, double-blind randomised controlled trial (PLATIPUS trial).

INTRODUCTION: Rubber band ligation ('banding') is a common approach for the management of symptomatic haemorrhoids. However, up to 90% of patients experience postprocedural pain, and there is no consensus regarding the optimal analgesic strategy. In practice, patients may receive submucosal local anaesthetic, pudendal nerve block or routine periprocedural analgesia. The aim of this study is to compare the efficacy of submucosal local anaesthetic, pudendal nerve block and routine analgesia for postprocedural pain in patients undergoing haemorrhoid banding. METHODS AND ANALYSIS: This is a multicentre, prospective, three-arm, double-blind randomised controlled trial of adults booked for haemorrhoid banding. Participants will be randomised to one of three groups in a 1:1:1 ratio: (1)submucosal bupivacaine injection; (2) pudendal nerve ropivacaine injection and (3) no local anaesthetic. The primary outcome is patient reported postprocedural pain (scored 0-10) from 30 min to 2 weeks. Secondary outcomes include postprocedural analgesia use, time to discharge, patient satisfaction, time to return to work and complications. A sample size of 120 patients is required to achieve statistical significance. ETHICS AND DISSEMINATION: This study received Human Research Ethics Approval from the Austin Health Human Research Ethics Committee (March 2022). Trial results will be submitted to a peer-reviewed journal, and presented at academic meetings. A summary of the trial results will be made available to study participants on request. TRIAL REGISTRATION NUMBER: ACTRN12622000006741p.

Comparison of 270-degree percutaneous transforaminal endoscopic decompression under local anesthesia and minimally invasive transforaminal lumbar interbody fusion in the treatment of geriatric lateral recess stenosis associated with degenerative lumbar spondylolisthesis.

PURPOSE: Various lumbar decompression techniques have been used for the treatment of degenerative lumbar spondylolisthesis (DLS). Few studies have compared the clinical efficacy of percutaneous transforaminal endoscopic decompression (PTED) and minimally invasive transforaminal lumbar interbody fusion (MIS-TLIF) in the treatment of lateral recess stenosis associated with DLS (LRS-DLS) in geriatric patients. The objective of the study was to compare the safety and short-term clinical efficacy of 270-degree PTED under local anesthesia and MIS-TLIF in the treatment of LRS-DLS in Chinese geriatric patients over 60 years old. MATERIALS AND METHODS: From January 2017 to August 2019, the data of 90 consecutive geriatric patients with single-level L4-5 LRS-DLS were retrospectively reviewed, including those in the PTED group (n = 44) and MIS-TLIF group (n = 46). The patients were followed up for at least 1 year. Patient demographics and perioperative outcomes were reviewed before and after surgery. The Oswestry Disability Index (ODI), visual analog scale (VAS) for leg pain, and modified MacNab criteria were used to evaluate the clinical outcomes. X-ray examinations were performed 1 year after surgery to assess the progression of spondylolisthesis in the PTED group and bone fusion in the MIS-TLIF group. RESULTS: The mean patient ages in the PTED and MIS-TLIF groups were 70.3 years and 68.6 years, respectively. Both the PTED and MIS-TLIF groups demonstrated significant improvements in the VAS score for leg pain and ODI score, and no significant differences were found between the groups at any time point (P > 0.05). Although the good-to-excellent rate of the modified MacNab criteria in the PTED group was similar to that in the MIS-TLIF group (90.9% vs. 91.3%, P > 0.05), PTED was advantageous in terms of the operative time, estimated blood loss, incision length, drainage time, drainage volume, length of hospital stay, and complications. CONCLUSIONS: Both PTED and MIS-TLIF led to favorable outcomes in geriatric patients with LRS-DLS. In addition, PTED caused less severe trauma and fewer complications. In terms of perioperative quality-of-life and clinical outcomes, PTED could supplement MIS-TLIF in geriatric patients with LRS-DLS.

Topical Anesthetic Use in Cosmetic Dermatology.

In today's society, there is growing interest in outpatient cosmetic procedures. Topical anesthetics are commonly used as anesthesia for these procedures. They can be used alone or part of a multi-pronged anesthetic approach. Topical anesthetics have many benefits, but they also have some negatives including risk of toxicity. For this paper, we focused on the role of topical anesthetics in cosmetic dermatology. We surveyed cosmetic dermatologists on the use of topical anesthetics in their practices. We found that the most popular topical anesthetic was benzocaine 20% / lidocaine 6% / tetracaine 4%. When asked for which procedures topical anesthetics are used for anesthesia, the most frequent responses were fractionally ablative lasers and fractionally non-ablative lasers. Though the majority of surveyed dermatologists have not had issues with the topical anesthetic, a portion had experienced adverse events in their patients. Topical anesthetics play an important role in cosmetic dermatology, allowing cosmetic procedures to take place in ways that are both comfortable for patients and allow patients to avoid more involved types of anesthesia. This is a growing area of cosmetic dermatology that requires additional research. J Drugs Dermatol. 2023;22(3): doi:10.36849/JDD.6978.

Successful management of delayed hyaluronidase hypersensitivity after subtenon's anesthesia during the COVID-19 pandemic: A rare case report.

Subtenon's block is commonly used to achieve akinesia, analgesia, and anesthesia for ophthalmic surgeries. This case study detailed a rare hypersensitivity report in a 65-year-old female who had underwent manual small incision cataract surgery under subtenon's anesthesia (STA) in the left eye. On postoperative day 1, she presented with acute onset proptosis, periorbital edema, conjunctival chemosis, and restriction of extraocular movements. The pupillary reaction and dilated fundus examination were normal. A differential diagnosis of orbital cellulitis, Mucormycosis, and hyaluronidase hypersensitivity (HH) was considered. Since the patient was afebrile, and pupillary reactions, ENT, neurological, and fundus examination were normal, the diagnosis was narrowed down to delayed HH. The patient was managed with a 1 cc IV injection of dexamethasone once a day for 3 days, along with routine postoperative drugs. As per detailed literature review, this is probably a second case report of delayed HH post-STA.

Balloon Dilation Eustachian Tuboplasty Combined with Tympanotomy Tube Insertion for Treatment of Refractory Otitis Media with Effusion: A Randomized, Prospective, Controlled Trial Comparing Local Anesthesia Combined Sedation Versus General Anesthesia.

BACKGROUND Balloon dilation eustachian tuboplasty (BET) is used to treat eustachian dysfunction but its therapeutic effect and cost-effectiveness when combined with tympanotomy tube insertion (TBI) on refractory otitis media with effusion under local anesthesia with sedation compared to traditional general anesthesia are not well understood. MATERIAL AND METHODS Forty patients with refractory secretory otitis media who received BET+TBI were enrolled in this study and randomized into the local anesthesia with sedation group (n=20) and general anesthesia group (n=20). Tympanometry (TMM), 7-item eustachian tube dysfunction questionnaire (ETDQ-7) results, intraoperative anesthesia accidents, and operation costs were compared between the groups. RESULTS Patients in the local anesthesia with sedation group exhibited intraoperative awareness and pain. Differences in TMM, ETDQ-7 results, and postoperative VAS scores between the groups were comparable (P>0.05). Notably, operative time and treatment costs in the local anesthesia group were lower compared with general anesthesia group. CONCLUSIONS The treatment effects and safety of local anesthesia and general anesthesia under BET combined with TBI for treatment of refractory otitis media with effusion are comparable. However, further studies should aim at reducing pain and discomfort.

Surgical management of chronic rhinosinusitis with nasal polyps under local anaesthesia: indications and results.

Objective: Our objective was to specify the indications and duration of effectiveness of Awake Patient Polyp Surgery (APPS) in Chronic Rhinosinusitis with Nasal Polyps (CRSwNP). Secondary objectives were to evaluate complications and Patient-Reported Experience (PREMs) and Outcome Measures (PROMs). Methods: We collected information regarding sex, age, comorbidities and treatments. Duration of effectiveness was the duration of non-recurrence defined by the time between APPS and a new treatment. Nasal Polyp Score (NPS) and Visual Analogic Scales (VAS, from 0/10 to 10/10) for nasal obstruction and olfactory disorders were assessed preoperatively and one month after surgery. PREMs were evaluated using a new tool: the APPS score. Results: Seventy-five patients were enrolled (SR = 3.1, mean age = 60.9 ± 12.3 years). 60% of patients had a previous history of sinus surgery, 90% had stage 4 NPS and more than 60% had overuse of systemic corticosteroids. Mean time of non-recurrence was 31.3 ± 2.3 months. We found a significant improvement (all p < 0.001) for NPS (3.8 ± 0.4 vs 1.5 ± 0.6), VAS obstruction (9.5 ± 1.6 vs 0.9 ± 1.7) and VAS olfactory disorders (4.9 ± 0.2 vs 3.8 ± 1.7). Mean APPS score was 46.3 ± 5.5/50. Conclusions: APPS is a safe and efficient procedure in the management of CRSwNP.

Ensayo clínico aleatorizado. Efecto de dos tipos de ayuno en pacientes sometidos a procedimientos de intervencionismo percutáneo bajo anestesia local en un servicio de hemodinámica en Medellín, 2019 / Randomized clinical trial. Effect of two types of fasting in patients undergoing percutaneous intervention procedures under local anesthesia in a hemodynamic service in Medellín, 2019 / Ensaio clínico randomizado. Efeito de dois tipos de jejum em pacientes submetidos a procedimentos de intervenção percutânea sob anestesia local em um serviço de hemodinâmica em Medellín, 2019

Objetivo: determinar el efecto de dos tipos de ayuno sobre parámetros de satisfacción, náuseas, vómito, presión arterial y glucometría en pacientes sometidos a procedimientos de intervencionismo percutáneo bajo anestesia local en un servicio de hemodinámica en Medellín, 2019. Metodología: ensayo clínico aleatorizado abierto de dos brazos en pacientes sometidos a procedimientos de intervencionismo percutáneo bajo anestesia local durante tres meses. Cada brazo con 153 participantes; se asignó un ayuno de seis horas y al grupo de exposición un ayuno de dos horas para alimentos de fácil digestión; no hubo cega­miento, se realizó cálculo de muestra, y se hizo análisis univariado, bivariado y modelo de regresión logística con la variable satisfacción. Resultados: en el grupo de ayuno de seis horas el 2.6% presentó náuseas y en el grupo de exposición el 1.3%; se observó un caso de vómito. La presión arterial y glucometría mostraron diferencias estadísticas sin relevancia clínica. Se encontró significancia esta­dística para mareo, cefalea, hambre, sed y tipo de ayuno respecto con la satisfacción del paciente. Los pacientes con ayuno tuvieron un puntaje de satisfacción entre 60 y 100 y los de dieta ligera entre 82.5 y 100 puntos. Conclusiones: El ayuno de dos horas en dieta ligera mejora la satisfacción de los pa­cientes, disminuye la sensación de hambre, sed, presencia de cefalea y mareo, compa­rado con un ayuno de seis horas. Este estudio no encontró diferencias en las variables hemodinámicas ni en la frecuencia de náuseas y vómito.

Objective: to determine the effect of two types of fasting on parameters of satisfaction, nausea, vomiting, blood pressure and glucose measurement in patients undergoing percutaneous intervention procedures under local anesthesia in a hemodynamic service in Medellín, 2019. Methodology: Two-arm open-label randomized clinical trial in patients undergoing percutaneous interventional procedures under local anesthesia for three months, each arm with 153 participants, who were assigned a six-hour fast and the exposure group a two-hour fast for easily digestible foods. There was no blinding, sample calculation was performed, and univariate and bivariate analysis and logistic regression model were performed with the satisfaction variable. Results: in the six-hour fasting group, 2.6% presented nausea and in the exposure group, 1.3%; one case of vomiting was observed. Blood pressure and blood glucose showed statistical differences without clinical relevance. Statistical significance was found for dizziness, headache, hunger, thirst, and type of fasting with respect to patient satisfaction. Fasting patients had a satisfaction score between 60 and 100 and those on a light diet between 82.5 and 100 points. Conclusions: Fasting for two hours on a light diet improves patient satisfaction, decreases the sensation of hunger, thirst, headache and dizziness, compared to a six-hour fast. This study found no differences in the hemodynamic variables, nor in the frequency of nausea and vomiting.

Objetivo: determinaro efeito de dois tipos de jejum nos parâmetros de satisfação, náuseas, vômitos, pressão arterial e glicemia em pacientes submetidos a procedimentos de intervenção percutânea sob anestesia local em um serviço de hemodinâmica em Medellín, 2019. Metodologia: Ensaio clínico randomizado aberto de dois braços em pacientes submetidos a procedimentos intervencionistas percutâneos sob anestesia local por três meses. Cada braço com 153 participantes; um jejum de seis horas foi designado e o grupo de desafio um jejum de duas horas para alimentos facilmente digeríveis; não houve cegamento, foi realizado cálculo amostral, análise univariada, bivariada e modelo de regressão logística com a variável satisfação. Resultados: no grupo de jejum de seis horas, 2,6% apresentaram náuseas e no grupo de exposição, 1,3%; foi observado um caso de vômito. A pressão arterial e a glicemia apresentaram diferenças estatísticas sem relevância clínica. Foi encontrada significância estatística para tontura, dor de cabeça, fome, sede e tipo de jejum em relação à satisfação do paciente. Os pacientes em jejum tiveram um escore de satisfação entre 60 e 100 e os em dieta light entre 82,5 e 100 pontos. Conclusões: O jejum de duas horas com dieta leve melhora a satisfação do paciente, diminui a sensação de fome, sede, dor de cabeça e tontura, em comparação com o jejum de seis horas. Este estudo não encontrou diferenças nas variáveis hemodinâmicas ou na frequência de náuseas e vômitos.

Pro and Con: How Important Is the Exact Location of Adductor Canal and Femoral Triangle Blocks?

In this Pro-Con commentary article, we debate the importance of anterior thigh block locations for analgesia following total knee arthroplasty. The debate is based on the current literature, our understanding of the relevant anatomy, and a clinical perspective. We review the anatomy of the different fascial compartments, the course of different nerves with respect to the fascia, and the anatomy of the nerve supply to the knee joint. The Pro side of the debate supports the view that more distal block locations in the anterior thigh increase the risk of excluding the medial and intermediate cutaneous nerves of the thigh and the nerve to the vastus medialis, while increasing the risk of spread to the popliteal fossa, making distal femoral triangle block the preferred location. The Con side of the debate adopts the view that while the exact location of local anesthetic injection appears anatomically important, it has not been proven to be clinically relevant.

Comparison of the efficacy of 0.5% isobaric bupivacaine, 0.5% levobupivacaine, and 0.5% hyperbaric bupivacaine for spinal anesthesia in lower limb surgeries.

Various advantages of isobaric bupivacaine, levobupivacaine, and hyperbaric bupivacaine are described. There are no studies reliably determining the benefits of these forms of bupivacaine. The purpose of the study was to compare the efficacy of spinal anesthesia (SA) performed with 0.5% isobaric bupivacaine, 0.5% levobupivacaine, and 0.5% hyperbaric bupivacaine. The clinical study was approved by the ethics committee. The sample size was calculated for a confidence level of 99%. 111 patients were randomly allocated into 3 equal groups for spinal anesthesia in lower limb surgeries. In group 1 (1B) spinal anesthesia was performed with 3 ml of 0.5% isobaric bupivacaine (n = 37); in group 2 (2L)-3 ml of 0.5% levobupivacaine (n = 37), in group 3 (3H)-3 ml of 0.5% hyperbaric bupivacaine (n = 37). The criterion for assessing the effectiveness of anesthesia was the need to switch to another type of anesthesia (criterion-no anesthesia), or the need for additional use of narcotic analgesics or local anesthesia during surgery (criterion-reporting of painful feelings during the operation). In 1B anesthesia efficiency by the criterion of additional intraoperative analgesia was 100% (37 patients; 95% CI [0.88-1.0]); 2L-86.4%; (31 patients; 95% CI [0.68-0.92]); 3H-72.9% (27 patients; 95% CI [0.56-0.84]). There were significant differences between groups 1B and 2L: p < 0.05 (p = 0.0104). There were no significant differences between groups 2L and 3H (p = 0.2587). All patients in group 1B developed complete sensory block (++) within 4 (3; 5) min. In group 2L complete sensory block developed in 34 patients (89.4%) within 9 (5; 14) min, in group 3H sensory block developed in all patients within 3 (2.5; 4). The duration of analgesia period between 1B and 2L did not statistically differ (p = 0.73). In 3H the duration of analgesia was 170 (150; 200) min. The study found 83.7% efficacy of levobupivacaine and 72.9% efficacy of hyperbaric bupivacaine in comparison with isobaric bupivacaine (100%) when administered intrathecally in equal volumes and amounts (by the criterion of additional intraoperative analgesia).Trial registration: NCT05184465 (Initial Release: 12/01/2021; date of first publication-11/01/2022).

Pain-related complaints of paediatric patients after dental treatment under general anaesthesia.

AIM: To identify factors related to postoperative pain and to recognise strategies to reduce this pain after dental treatment under general anaesthesia. METHODS: Cross-sectional observational study. Children treated under general ansesthesia reported pain daily using the Wong Baker FACES® Pain Rating Scale. Their parents/caregivers filled in a related Yes/No questionnaire during hospitalisation and the first postoperative week. The duration and severity of pain were evaluated in relation to various factors. CONCLUSION: A well-established protocol is indicated to reduce operation time. Patients and their parents should be informed about the possibility of constantly subsiding postoperative pain that may last for a week. As additional local anaesthesia during general anaesthesia (GA) does not provide postoperative pain reduction in deciduous tooth extraction cases, its administration could be omitted.

Micro-Ultrasound Guided Transperineal Prostate Biopsy: A Clinic-Based Procedure.

Prostate cancer is the most common solid malignancy in men and requires a biopsy for diagnosis. This manuscript describes a freehand micro-ultrasound guided transperineal technique performed under local anesthesia, which maintains accuracy, keeps patients comfortable, has low adverse events, and minimizes the need for disposables. Prior micro-ultrasound-guided transperineal techniques required general or spinal anesthesia. The key steps described in the protocol include (1) the placement of the local anesthesia, (2) micro-ultrasound imaging, (3) and the visualization of the anesthetic/biopsy needle while uncoupled from the insonation plane. A retrospective review of 100 patients undergoing this technique demonstrated a 68% clinically significant cancer detection rate. Pain scores were prospectively collected in a subset of patients (N = 20) and showed a median procedural pain score of 2 out of 10. The 30 day Grade III adverse event rate was 3%; one of these events was probably related to the prostate biopsy. Overall, we present a simple, accurate, and safe technique for performing a micro-ultrasound-guided transperineal prostate biopsy.

Improving pain control during transarterial chemoembolization for hepatocellular carcinoma performed under local anesthesia with multimodal analgesia.

PURPOSE: The purpose of this study was to assess the performance of a reinforced analgesic protocol (RAP) on pain control in patients undergoing conventional trans-arterial chemoembolization (cTACE) for hepatocellular carcinoma (HCC). MATERIALS AND METHODS: Eighty-one consecutive patients (57 men, 24 women) with a mean age of 69 ± 10 (standard deviation) years (age range: 49-92 years) underwent 103 cTACEs. Standard antalgic protocol (50 mg hydroxyzine, 10 mg oxycodone, 8 mg ondansetron, and lidocaine for local anesthesia) was prospectively compared to a RAP (standard + 40 mg 2-h infusion nefopam and 50 mg tramadol). The individual pain risk was stratified based on age, the presence of cirrhosis and alcoholic liver disease, and patients were assigned to a low-risk group (standard protocol) or high-risk group (RAP). The primary endpoint was severe periprocedural abdominal pain (SAP), defined as a visual analog scale score ≥30/100. A predefined intermediate analysis was performed to monitor the benefit-risk of the RAP. Based on the intermediate analysis, all patients were treated with the RAP. RESULTS: The intermediate analysis performed after 52 cTACE showed that 2/17 (12%) high-risk patients (i.e., those receiving the RAP) experienced SAP compared to 15/35 (43%) low-risk patients (odds ratio [OR] = 0.18; 95% confidence interval [CI]: 0.02-0.98; P = 0.03). Analysis of all procedures showed that 12/67 (18%) patients in cTACE receiving the RAP experienced SAP compared to 15/36 (42%) patients who did not receive it (OR = 3.27; 95% CI: 1.32-8.14; P = 0.01). There were no statistical differences in adverse events, particularly for nausea, between groups. CONCLUSION: Reinforcing the analgesic protocol by combining non-opioid and opioid molecules reduces perioperative pain in patients undergoing cTACE for HCC.

Patients' satisfaction with local and general anaesthesia for video-assisted thoracoscopic surgery-results of the first randomized controlled trial PASSAT.

OBJECTIVES: The objective of this single-centre, open, randomized control trial was to compare the patients' satisfaction with local anaesthesia (LA) or general anaesthesia (GA) for video-assisted thoracoscopy. METHODS: Patients with indication for video-assisted thoracoscopy pleural management, mediastinal biopsies or lung wedge resections were randomized for LA or GA. LA was administered along with no or mild sedation and no airway devices maintaining spontaneous breathing, and GA was administered along with double-lumen tube and one-lung ventilation. The primary end point was anaesthesia-related satisfaction according to psychometrically validated questionnaires. Patients not willing to be randomized could attend based on their desired anaesthesia, forming the preference arm. RESULTS: Fifty patients were allocated to LA and 57 patients to GA. Age, smoking habits and lung function were similarly distributed in both groups. There was no significant difference between the 2 groups with regard to patient satisfaction with anaesthesiology care (median 2.75 vs 2.75, P = 0.74), general perioperative care (2.50 vs 2.50, P = 0.57), recovery after surgery (2.00 vs 2.00, P = 0.16, 3-point Likert scales). Surgeons and anaesthesiologists alike were less satisfied with feasibility (P < 0.01 each) with patients in the LA group. Operation time, postoperative pain scales, delirium and complication rate were similar in both groups. LA patients had a significantly shorter stay in hospital (mean 3.9 vs 6.0 days, P < 0.01). Of 18 patients in the preference arm, 17 chose LA, resulting in similar satisfaction. CONCLUSIONS: Patients were equally satisfied with both types of anaesthesia, regardless of whether the type of anaesthesia was randomized or deliberately chosen. LA is as safe as GA but correlated with shorter length of stay. Almost all patients of the preference arm chose LA. Considering the benefits of LA, it should be offered to patients as an equivalent alternative to GA whenever medically appropriate and feasible.

Ultrasound-guided carotid sheath block for carotid endarterectomy surgery in a high-risky patient and literature review.

Carotid endarterectomy (CEA) surgery is generally performed for patients who under the risk of ischemic cerebral stroke due to the critical obstruction of the carotid artery. Ischemic complications may occur during the surgery. So, the awakeness of the patient is very important during the surgery. Regional anesthesia techniques may be performed instead of general anesthesia for shunt placement during CEA surgery. Herein, we aimed to share our successful US-guided carotid sheath block experience for anesthesia management during CEA surgery.

Evaluation of the Local Anesthetic Activity, Acute Toxicity, and Structure-Toxicity Relationship in Series of Synthesized 1-Aryltetrahydroisoquinoline Alkaloid Derivatives In Vivo and In Silico.

Isoquinoline alkaloids constitute one of the most common classes of alkaloids that have shown a pronounced role in curing various diseases. Finding ways to reduce the toxicity of these molecules and to increase their therapeutic margin is an urgent matter. Here, a one-step method for the synthesis of a series of 1-aryl-6,7-dimethoxy-1,2,3,4-tetrahydroisoquinolines was performed in 85-98% yield by the Pictet-Spengler reaction. This was accomplished using the reaction between 3,4-dimethoxyphenylethylamine and substituted benzaldehydes boiling in trifluoroacetic acid. Furthermore, 1-(3'-amino-, 4'-aminophenyl)-6,7-dimethoxy-1,2,3,4-tetrahydroisoquinolines were obtained in 94% and 97% yield by reduction in 1-(3'-nitro-, 4'-nitrophenyl)-6,7-dimethoxy-1,2,3,4-tetrahydroisoquinolines with SnCl2 × 2H2O. The structures of the substances obtained were confirmed by infrared (IR) and nuclear magnetic resonance (1H and 13C NMR) spectra. ADMET/TOPKAT in silico study concluded that the synthesized compounds exhibited acceptable pharmacodynamic and pharmacokinetic properties without carcinogenic or mutagenic potential but with variable hepatotoxicity. The acute toxicity and structure-toxicity relationship (STR) in the series of 20 derivatives of 1-aryl-6,7-dimethoxy-1,2,3,4-tetrahydroisoquinolines (3a-r, 4a, b) was studied via determination of acute toxicity and resorptive action in white mice employing intragastric step-by-step administration. The first compound, 1-phenyl-6,7-dimethoxy-1,2,3,4-tetrahydroisoquinoline hydrochloride (3a), showed the highest toxicity with LD50 of 280 mg/kg in contrast to 1-(3'-bromo -4'-hydroxyphenyl)-6,7-methylenedioxy-1,2,3,4-tetrahydroisoquinoline hydrochloride (3e) which proved to be the safest of the compounds studied. Its toxicity was 13.75 times lower than that of the parent compound 3a. All compounds investigated showed high local anesthetic activity on rabbit eyes in the concentrations studied. Only 3r, 3n, and 4a caused eye irritation and redness. All investigated derivatives (except 4b) in 1% concentration were more active than lidocaine, providing longer duration of complete anesthesia. Therefore, based on the obtained results of in silico tests, local anesthesia, and acute toxicity, a conclusion can be drawn that the experimental compounds need further extensive future investigations and possible modifications so that they can act as promising drug candidates.

A Modified Approach to a Parasternal Block: A Case Report.

The parasternal block is an ultrasound-guided interfascial plane block that provides anesthesia of the medial quadrants of the breast. The original approach provided injections in the fascial plane between the pectoral major and external intercostal muscles. We observed that this technique might limit an adequate diffusion of the injectate due to the anatomical convexity of the ribs, which might hinder fascial hydrodissection. We suggest a modified approach by positioning the tip of the needle on the rib dome to reduce the local anesthetic volume and obtain a more homogeneous and longitudinal spread into the target fascial compartment.

Local anesthesia with SleeperOne S4 computerized device vs traditional syringe and perceived pain in pediatric patients: a randomized clinical trial.

Local anesthesia is performed in dentistry before clinical procedures to avoid pain. Children can show fear at the sight of the needle and pain at its insertion. To make local anesthesia more comfortable, the use of computer-controlled local anesthetic delivery (CCLAD) systems has been developed to control the flow rate of the anesthetic solution injected through the needle. The aim of the present research is to evaluate and compare the discomfort felt by patients using a traditional syringe and the CCLAD system SleeperOne®, by considering pain, size sensation, bitterness, and vomit. 30 patients were included in the study and randomly assigned to traditional anesthesia or CCLAD. After injection, patients were assessed for the abovementioned outcomes. A Visual Analogue Scale (VAS) from 0 to 10 scores was used. As far as pain is concerned, statistically lower mean values were found in the Trial group (p < 0.05). Instead, concerning size, bitterness and vomit perceptions, no statistically significant differences were found between the groups (p > 0.05). Linear regressions were calculated considering technique, quadrant, dental arch, tooth, dentition, sex, and age as independent variables. The technique has shown to have a significant influence on pain (p < 0.05), with lower values for SleeperOne® device. Pain resulted significantly influenced by the type of dentition (p < 0.05), with higher scores for deciduous one. Moreover, perceived pain decreased with the increase of the age of patients (p < 0.05). At last, bitterness perception scores resulted to be higher for primary first molars (p < 0.05). SleeperOne® device seems to be a valid support for the reduction of pain related to anesthetic injection, especially in children. Further studies should evaluate CCLADs' uses combined with lidocaine preanesthetic as well as with conscious sedation through nitrous oxide in order to determine possible synergistic effects between these procedures.

[Sterile puncture of large joints]. / Sterile Punktion großer Gelenke.

OBJECTIVE: Puncture of large joints is performed for diagnostic purposes on the one hand and for the treatment of joint pathologies on the other. Puncture can be used for rapid pain relief by relieving effusions or intra-articular hematomas. The obtained puncture specimen allows immediate visual assessment and subsequent microscopic-cytological and microbiological evaluation in the laboratory. INDICATIONS: The indication for puncture of a large joint is for diagnosis and/or therapy of inflammatory, traumatic or postoperative joint problems. Diagnostic punctures are used to obtain punctate, to differentiate the location of pain or (rarely) to apply contrast medium for magnetic resonance arthrography. Therapeutic punctures allow the injection of drugs or platelet-rich plasma (PRP) as well as the relief or drainage of effusions. CONTRAINDICATIONS: If there are inflammatory skin alterations-especially purulent inflammation-joint punctures through these lesions are absolutely contraindicated. Special attention is necessary if the patients are on anticoagulants. SURGICAL TECHNIQUE: Absolute sterile handling is mandatory. Unnecessary pain can be avoided by a sterile skin wheal of local anesthesia, safe puncture points, and careful handling of the cannulas. POSTOPERATIVE MANAGEMENT: Joint aspiration material has to be handled according to the local, intrahospital rules in a timely manner. Puncture sites are covered with sterile dressings, and if intra-articular medication is administered, the joints have to be passively moved through the range of motion to distribute the medication. Thereafter, compression therapy from distally to proximally while also covering the puncture site avoids recurrence of swelling or hematoma. FACTS: If sterile conditions are guaranteed, infections rarely occur (0.04-0.08%, 4-8/10,000 cases). The risk of false-positive detection of microorganisms is extremely low.