A double-blind randomized controlled trial showing the analgesic and anesthetic properties of lidocaine E to be equivalent to those of ropivicaine and bupivacaine in carpal tunnel release surgery

In a three-phase trial, the anesthetic properties of lidocaine, bupivacaine and ropivicaine were compared in carpal tunnel release surgery. In phase I, two groups of 25 sequential patients were injected with either lidocaine plain 2% or lidocaine 2% with adrenaline 1:100,000 (E), as the local anesthetic for outpatient carpal tunnel release surgery. Subjective injection pain, postoperative pain at 2 h increments and the number of analgesic pills taken were recorded. During the first postoperative hours, outcome measures were superior in the lidocaine E group.In phase II, a double-blind randomized design compared 42 patients injected with either lidocaine E or a combination of lidocaine E and bupivacaine. Postoperative pain scores and analgesic pills taken were compared using nonparametric statistical tests. During the first 4 h there was a slight benefit in the duration of the anesthetic and fewer pain pills were used in the bupivacaine group.Phase III was a randomized double-blind comparison of ropivicaine and lidocaine E 2% in 72 patients. There was a slight decrease in pain scores and fewer analgesic pills required during the first 6 h in the ropivicaine group.Lidocaine plain 2% provided significantly inferior analgesic and anesthetic properties compared with lidocaine E 2%, bupivacaine or ropivicaine. Sequential randomized comparisons between lidocaine E and bupivacaine and ropivicaine showed clinical equivalence. The present study showed lidocaine E 2% to be a satisfactory and comparatively cost-effective anesthetic for outpatient carpal tunnel surgery.     

A comparison of local intraarticular anesthesia versus general anesthesia for ambulatory arthroscopic knee surgery

Various anesthetic techniques including local, regional, and general anesthesia have been utilized for ambulatory arthroscopic knee surgery. The choice of anesthetic technique for this surgical procedure can have a significant impact on postoperative recovery, side effects, and patient satisfaction. The objective of this randomized, prospective study is to evaluate the efficacy of utilizing either intraarticular (IA) local anesthesia or general anesthesia (GA) for patients undergoing outpatient arthroscopic knee surgery. Patients assigned to the local anesthesia group were administered an IA injection of 30 mL of bupivacaine 0.25% approximately 20-30 min before surgery. Intraoperative sedation was provided with the administration of propofol. Patients assigned to the GA group were administered propofol and fentanyl for induction and maintained with sevoflurane combined with nitrous oxide in oxygen by laryngeal mask airway. The surgeon injected 30 mL of bupivacaine 0.25% through the arthroscope at the completion of the surgical procedure. This study demonstrates that IA anesthesia provides for improved pain relief, decreased postoperative opioid use, postoperative nausea and vomiting (PONV), time spent in the recovery room, and improved patient satisfaction with similar operating conditions comparable to general anesthesia in patients undergoing outpatient arthroscopic knee surgery. Although both groups received a similar dose of IA bupivacaine, administering the local anesthetic prior to surgery resulted in more effective analgesia. We currently believe that intraarticular local anesthesia fulfills all the criteria for the optimal anesthetic technique for outpatient arthroscopic knee surgery.     

A randomized trial of local anesthesia with intravenous sedation vs general anesthesia for the vaginal correction of pelvic organ prolapse

The purpose of this study is to compare the feasibility of local anesthesia with IV sedation versus general anesthesia for vaginal correction of pelvic organ prolapse. Patients with pelvic organ prolapse who were scheduled for an anterior or posterior colporrhaphy, or an obliterative procedure, and who did not have a contraindication or preference to type of anesthesia were randomized to one of the two anesthesia groups. Nineteen patients were randomized to the general group and 21 patients were randomized to the local group. Mean operating room, anesthesia, and surgical time were similar in each group, and 10 patients in the local group bypassed the recovery room. Requests and doses of antiemetics, postoperative verbal numerical pain scores and length of hospital stay were similar between the two groups. Mean recovery room and total hospital costs were significantly lower in the local group. Local anesthesia with IV sedation is a feasible alternative for vaginal surgery to correct pelvic organ prolapse.     

Postoperative analgesia in herniorrhaphy with local anesthesia and monitored anesthesia care

Summary In this study the authors evaluated the grade of acceptance and the operating conditions of unilateral primary herniorrhaphy under local anesthesia and monitored anesthesia care (MAC). The amount of pain in the immediate postoperative period was assessed and the efficacy of treatment using a popular non-opiate analgesic, magnesic metamizol, by the oral route was studied. In a period of six months 63 consecutive patients were operated on by the same surgeon using the same technique of hernia repair (Shouldice technique) with local infiltration anesthesia supplemented by MAC in the form of conscious sedation. A mixture of 300 mg of plain mepivacaine and 50 mg of plain bupivacaine was used for infiltration. A standard dose of fentanyl 0.10 mg and midazolam 2 mg was used for conscious sedation. Propofol in continuous infusion was also employed. The average dose of propofol varied from 1–3 mg/kg/h. Conscious level was assessed using a five-point sedation score. A level-3 end point was persued (closed eyes, but answer verbal orders). Pain intensity in the postoperative period was measured by the visual analogue scale (VAS) and the verbal pain scale (VPS), based on the McGill pain questionnaire. The operating conditions were excellent in all cases except in three patients. In no case conversion to general anesthesia was necessary. In the postoperative period, 5 patients (8%) never felt pain and 58 (92%) felt pain on the average 4 hours 36 minutes after the local infiltration (VAS=2.5; VPS=1.45). Of the 58 patients 49 took the first dose of oral analgesic 6 hours 40 minutes after infiltration (VAS=4; VPS=1.97). All patients were satisfied with the anesthetic-surgical technique and were ready to repeat the experience. However, when the patients took the second dose of oral analgesic 28% of them had moderate pain and 9% severe pain. Our conclusions are that local infiltration with MAC is a valid and satisfying experience for both the patient and the surgeon. Nevertheless, further attempts should be made to better the postoperative pain relief when the oral route is elected.     

Preemptive analgesia and local anesthesia as a supplement to general anesthesia: a review

General anesthesia (GA) and local anesthesia (LA) evolved on separate tracks. Procedures that could not be performed under LA were typically conducted under GA. Decoding of afferent linkage of peripheral noxious stimuli has provided important understanding that may change the way we traditionally treat surgical pain. In the 1980s, animal studies suggested that preemptive peripheral blocking of painful (nociceptive) stimuli to the central nervous system with regional anesthesia or LA and nonsteroidal analgesics could be beneficial in attenuating postoperative pain. Clinical studies based on this knowledge suggest combining LA with GA, and perhaps non-steroidal analgesics with or without narcotics, to reduce the severity of postoperative pain. General anesthetics can be given in lower minimal alveolar concentration when combined with LA, and recovery characteristics are superior. Increasing evidence suggests that the combined use of GA and LA may reduce the afferent barrage of surgery, and that preemptive analgesia may reduce postoperative pain and should be used in patient care. This article reviews the evidence supporting the combined use of LA or analgesics with GA or sedation to provide improved pain management after surgery.     

Differences between men and women regarding attitudes toward dental local anesthesia among junior students at a United Kingdom dental school

The aim of this study was to assess the attitudes of junior dental students at a United Kingdom dental school regarding the administration and receipt of a local anesthetic injection. The effect of teaching on these attitudes was also evaluated. Data were collected by questionnaire. Previous experience with local anesthesia in a dental office did not affect students' attitudes toward administration and receipt of a local anesthetic injection from a classmate. Female students were more anxious about giving and receiving local anesthetic injections than male students. Didactic teaching decreased anxiety in relation to administration and receipt of a local anesthetic injection. The results showed that male and female students in a United Kingdom dental school differed in their attitudes toward local anesthesia.     

不同麻醉方式在腹股沟疝修补术后并发症及疼痛感受

目的探讨全身麻醉和局部麻醉对腹股沟疝修补术后的影响。 方法选取2017年1月至2018年11月，中国医科大学附属盛京医院进行腹股沟疝修补术的患者70例为研究对象。按照麻醉方法不同分为全麻组和局麻组，每组患者35例。观察2组患者的围手术期临床指标和并发症发生情况。 结果局麻组患者的手术、下床活动以及住院时间更短，但是疼痛程度更高；全麻组患者的感染、尿潴留、恶心及切口积液的发生率更低，差异均有统计学意义（P<0.05）。 结论局部麻醉患者的手术时间、下床活动时间和住院时间更短；并发症更少，全身麻醉术后减轻患者疼痛效果更好。     

中老年腹股沟疝局麻与硬膜外麻醉手术的比较

目的比较中老年人在局麻与硬膜外麻醉下行腹股沟疝修补术的疗效、住院时间、平均费用、恢复正常生活的时间及手术并发症等.方法采用随机对照方法,将223例病人分为局麻组(男,113人)和硬膜外阻滞麻组(男110人).结果局麻组病人平均手术时间(44min)、住院时间(2.1d)、恢复正常生活时间(5.4d)和手术并发症等均明显小于硬膜外阻滞组(P＜0.01～0.05).结论中老年人局麻下进行疝修补,可明显减少手术费用,术后并发症的发生率,是一安全而有效的方法,值得推广.     

An open-label comparison of local anesthesia with or without sedation for minor hand surgery

Background

The purpose of this study was to assess satisfaction and pain intensity in patients undergoing minor hand surgery under local anesthesia (LA) with or without sedation.

Methods

Seventy-three adult patients presenting to two hand surgeons were enrolled in this prospective observational study in 2012. They completed questionnaires prior to surgery (current pain intensity, Patient Health Questionnaire-2 (PHQ-2) to measure symptoms of depression, Pain Self-Efficacy Questionnaire (PSEQ) to assess the effective coping strategy of pain self-efficacy) and within 48 h after surgery (satisfaction with surgery, satisfaction with anesthesia, pain during the injection, and pain during the procedure). Thirty-seven patients had carpal tunnel release (bilateral in 3), 22 had release of one or more trigger digits, and 12 had excision of a benign tumor, gouty tophus (1 patient), or foreign body (1 patient). Forty-six patients chose LA and 27 chose LA with sedation.

Results

There was no difference in satisfaction with surgery or anesthesia by the type of anesthesia. Satisfaction with surgery was associated with older age alone. Satisfaction with anesthesia was associated with no prior surgery for the same condition. Pain during injection and during the procedure were significantly higher without sedation. Pain during injection was associated with younger age and LA. No factors were associated with pain during the procedure.

Conclusions

Patients that had local anesthesia immediately prior to incision with tourniquet use during surgery had more pain during the procedure but were equally satisfied on average with surgery and with anesthesia compared to patients that had sedation.     

A prospective comparison of wide-awake local anesthesia and general anesthesia for forefoot surgery

Background

A recent case series suggested that surgery with wide-awake local anesthesia is tolerated well by most foot and ankle patients. However, patients were assessed retrospectively and there was no comparison group to show the relative efficacy of this approach. The present study was conducted to address these concerns.

Dexmedetomedine vs midazolam sedation in middle ear surgery under local anesthesia: Effect on surgical field and patient satisfaction

BackgroundA relatively bloodless microscopic field is essential to facilitate surgical exposure in Simple Middle Ear Surgery (SMES). Our aim was to compare dexmedetomedine with midazolam in reducing bleeding in SMES performed under local anesthesia.MethodsIn this prospective, double-blind, comparative study, 54 patients undergoing SMES randomly received intravenous sedative infusion of either: Dexmedetomedine (Group D) or midazolam (Group M) titrated to a bispectral index reading of 70–80. Pain on local anesthesia injection was assessed by a verbal rating scale. Using a 3-grades score, the surgeon assessed the quality of surgical bleeding. Mean Arterial Pressure (MAP) and Heart Rate (HR) were assessed. Time parameters recorded include: time to reach adequate sedation, surgery duration, sedation recovery and postanesthesia care unit discharge. Patient satisfaction, visual analog scale for intraoperative pain, and number of patients required rescue fentanyl were recorded. Adverse effects were also recorded.ResultsSurgical field bleeding score was significantly better in group D compared to group M (Grade I: 18 vs 4, Grade II: 9 vs 19, Grade III: 0 vs 4, respectively) p < 0.001. Intraoperative MAP and HR in group D were lower than their baseline values and the corresponding values in group M. Group M patients were earlier to reach adequate sedation level than those of group D, but they felt more pain either on local anesthetic injection or during operation. Rescue fentanyl was needed only for group M patients. Patient satisfaction was higher in group D. Time of surgery was longer in group M. Both groups were similar in sedation recovery and ward discharge times, as well as, incidence of side effects.ConclusionCompared to midazolam sedation in SMES performed under local anesthesia, Dexmedetomedine was associated with a near bloodless microscopic surgical field, shorter surgery time, greater patient satisfaction, and lower pain scores with no adverse effects.     

Is main operating room sterility really necessary in carpal tunnel surgery? A multicenter prospective study of minor procedure room field sterility surgery

Background

Over 70% of Canadian carpal tunnel syndrome (CTS) operations are performed outside of the main operating room (OR) with field sterility and surgeon-administered pure local anesthesia [LeBlanc et al., Hand 2(4):173–8, 14]. Is main OR sterility necessary to avoid infection for this operation? This study evaluates the infection rate in carpal tunnel release (CTR) using minor procedure room field sterility.

Methods

This is a multicenter prospective study reporting the rate of infection in CTR performed in minor procedure room setting using field sterility. Field sterility means prepping of the hand with iodine or chlorhexidine, equivalent of a single drape, and a sterile tray with modest instruments. Sterile gloves and masks are used, but surgeons are not gowned. No prophylactic antibiotics are given.

Results

One thousand five hundred four consecutive CTS cases were collected from January 2008 to January 2010. Six superficial infections were reported and four of those patients received oral antibiotics. No deep postoperative wound infection was encountered, and no patient required admission to hospital, incision and drainage, or intravenous antibiotics.

Conclusions

A superficial infection rate of 0.4% and a deep infection rate of 0% following CTR using field sterility confirm the low incidence of postoperative wound infection using field sterility. This supports the safety and low incidence of postoperative wound infection in CTR using minor procedure field sterility without prophylactic antibiotics. The higher monetary and environmental costs of main OR sterility are not justified on the basis of infection for CTR cases.     

Local anesthesia in traditional and minimally invasive approach to the parathyroid

Summary Background: The advantage of minimally invasive parathyroidectomy and the cost saving associated with outpatient surgery has led to an increased interest in local or local/regional anesthesia. Methods: Local infiltration alone or local infiltration with cervical plexus block are the two commonly used techniques in parathyroid surgery. Results: Local anesthesia can be used for unilateral as well as for bilateral explorations. In combination with the support of a laryngeal mask and Sevofluorane it also allows videoassisted parathyroidectomy. Conclusions: Local/cervical block anaesthesia appears to provide significant advantages over general anaesthesia in outpatient parathyroid surgery.      

局部浸润麻醉与黏膜表面麻醉在经直肠超声引导前列腺穿刺活检中的应用比较

目的比较前列腺局部浸润麻醉与直肠黏膜表面麻醉在经直肠超声引导前列腺穿刺活检中应用的安全性和有效性。方法将2018年3月至8月中山大学附属第三医院拟行前列腺穿刺活检的疑似前列腺癌患者纳入本研究,前瞻性随机分成两组。实验组采用超声引导下利多卡因于前列腺基底部和精囊腺间交角周围的血管神经束进行局部浸润麻醉;对照组采用利多卡因凝胶直肠黏膜表面麻醉。收集患者穿刺前后基线特征及穿刺后VAS评分、穿刺前后膀胱残余尿、穿刺阳性率、Gleason评分及血尿等相关并发症进行比较。结果共66例患者纳入本研究。穿刺过程中实验组疼痛评分低于对照组。两组间穿刺阳性率、Gleason评分、残余尿、尿潴留、肉眼血尿、发热等没有组间差异。结论局部浸润麻醉比直肠黏膜表面麻醉更能明显缓解经直肠超声引导前列腺穿刺的疼痛,对穿刺阳性率无明显影响,是更安全有效的麻醉方法,但需要一定经验的超声医师引导。