Reduced painful facial infiltration with mixture of lignocaine–bupivacaine in comparison to individual agents

The anecdotal use of lignocaine and bupivacaine mixture as local anaesthetics (LA) in minor surgical operations is increasingly popular, despite a lack of evidence to support this practice. The infiltration of LA is frequently identified as the most unpleasant aspect of the whole surgical procedure. This study compared the level of infiltration associated pain when 1% lignocaine, 0.25% bupivacaine and their 1:1 (v:v) mixture were used in patients undergoing minor facial procedure. A prospective, randomised study was carried out on patients undergoing minor facial procedure at the day surgery unit. The Visual Analogue Score (VAS) at the time of infiltration, injected volume and number of injections were recorded and analysed between groups. A total of 94 patients were recruited. The average volume of LA injected was 2.5 ± 1.9 ml and the average number of injections was 2.3 ± 1.5. The lignocaine–bupivacaine mixture (VAS = 3.1 ± 0.4) was identified as the least painful agent (p < 0.05), when compared to 1% lignocaine (VAS = 4.6 ± 0.4) and 0.25% bupivacaine (VAS = 6.4 ± 0.5). In this cohort, female patients consistently reported a lower VAS score for all groups, but this observation was not statistically significant (p > 0.05) when compared to male patients. The mixture of lignocaine and bupivacaine was associated with less pain during skin infiltration when compared to individual agents. Thus, we recommend its use in facial surgical procedures involving LA as this practice allows us to improve patients comfort during their surgery.     

Cholestasis as a side effect of bupivacaine?

Background and Objectives. Cholestasis has been proposed as a side effect of interpleural bupivacaine. Therefore, the effects of various application techniques on liver enzymes were studied following ethics committee approval and informed patient consent. Methods. Patients following scheduled thoracotomy and laparoscopic cholecystectomy were prospectively studied and randomized to the following application techniques of bupivacaine: Thoracic surgery. T0: Control (systemic analgesia only: patient-controlled analgesia with opioids; n = 26); T1: Repetitive intercostal blocks (10–20 mL 0.5% bupivacaine, 2–4 times per day for 3–6 days; n = 17); T2: Interpleural injections via a catheter placed intraoperatively (20 mL 0.25%, 4–6 times per day for 3–6 days, right: n = 25 or left: n = 12). Laparoscopic cholecystectomy. Intraperitoneal application (single injection). L0: 50 mL saline (Control) (n = 21). L1: 50 mL 0.125% bupivacaine (n = 18); L2: 50 mL 0.25% (n = 20). The serum concentrations of bilirubin, γ-GT, alkaline phosphatase, leucine amino peptidase, glutamate oxalacetate transaminase, and glutamate pyruvate transaminase were measured preoperatively and on day 1, 3, and 7 postoperatively. Results. Neither application of plain bupivacaine was associated with significant changes in the postoperative concentration of hepatic enzymes. In particular, there was no difference between left- and right-sided interpleural application. Although increases in hepatic enzyme concentrations were observed in some patients postoperatively, this was similar in the bupivacaine and control groups. Conclusion. Perioperative interpleural, intercostal, and intraperitoneal administration of bupivacaine was not associated with findings indicative of cholestasis in the early postoperative course.     

Study of equivalence: spinal bupivacaine 15 mg versus bupivacaine 12 mg with fentanyl 15 μg for cesarean delivery

BackgroundA safe and effective intrathecal dose of bupivacaine alone for cesarean delivery has not yet been established. This study tested the hypothesis that an intrathecal dose of hyperbaric bupivacaine 15 mg would produce equivalent spinal anesthesia for cesarean delivery as the combination of hyperbaric bupivacaine 12 mg and fentanyl 15 μg.MethodsThis was a single center, double-blind, randomized clinical trial of equivalence. One hundred and thirty-eight healthy parturients scheduled for elective cesarean delivery were randomized to receive either intrathecal hyperbaric bupivacaine 15 mg (Group B) or hyperbaric bupivacaine 12 mg with fentanyl 15 μg (Group BF). Parturients where asked to describe their degree of sensation during surgery using a four-point scale 20 min after spinal injection. Secondary outcomes included the incidence of maternal side effects, maternal hemodynamics and the need for supplemental analgesia.ResultsThere was no difference in the quality of anesthesia between the two groups. Sixty-eight of 69 and 69/69 patients in Group B and Group BF, respectively had anesthesia classified as successful (RR = 1.01; 95% CI 0.85, 1.22). The only two secondary outcomes that were different between the groups were the largest change in mean arterial pressure (decrease of 40 mmHg and 34 mmHg for Group B and Group BF, respectively; P = 0.004) and the incidence of nausea (59% and 35% for Group B and Group BF, respectively; P = 0.006).ConclusionThere was no difference in the degree of sensation at 20 min between Group B and Group BF. The only significant differences between the two techniques were a higher incidence of nausea and decrease in maternal blood pressure in Group B.     

Surgically performed rectus sheath block – Effect of morphine added to bupivacaine versus bupivacaine only: A prospective randomized controlled double blinded trial

BackgroundExtended abdominal midline incision in laparotomies is associated with severe postoperative pain that is impacted badly on all body systems; proper management of this pain is essential for patient comfort and to minimize these bad impacts. Bilateral rectus sheath block (BRSB) is an option to achieve this.Methods50 Adult patients classified ASA1 and ASA2 submitted to extended abdominal midline incision were included. Bilateral rectus sheath catheters (BRSCs) were placed surgically during abdominal closure for BRSB. Patients were randomly assigned into 2 groups: in group 1(morphine group); a mixture of bupivacaine and morphine was used for BRSB, while in group 2 (bupivacaine group), only bupivacaine was used for BRSB.ResultsThere was a significant reduction in visual analogue scale (VAS) at rest and mobilization in the morphine group compared to bupivacaine group during 6th, 12th and 18th postoperative hours with P values: 0.001, 0.007, 0.04 and 0.003, 0.006, 0.036 during the same periods, respectively.ConclusionAddition of morphine to local bupivacaine for BRSB was effective and safe technique to achieve good quality of postoperative analgesia in patients submitted to extended midline abdominal incision.     

Does diazepam really reduce the cardiotoxic effects of intravenous bupivacaine?

The effect of diazepam on the cardiovascular toxicity of bupivacaine was investigated in a rat model. Under chloral hydrate (400 mg/kg intraperitoneal) anesthesia, unilateral femoral venous and bilateral femoral arterial cannulae were placed for administration of drugs, for blood sampling, and for continuous qualitative monitoring of arterial blood pressure. Lead II ECG was continuously recorded and a tracheostomy performed to increase FIO2 by use of a "T-piece." Four groups of 24 to 36 rats each were studied. All rats received IV bupivacaine 2 mg/kg, within 10 seconds. Group I, the control group, received only bupivacaine. Groups II and III received IV diazepam 0.2 mg/kg, or diazepam vehicle in an equivalent volume, respectively. Five minutes after this pretreatment, groups II and III received IV bupivacaine 2 mg/kg. Group IV was given diazepam, 0.2 mg/kg, 30 seconds after injection of 2 mg/kg bupivacaine. A marked respiratory and metabolic acidosis occurred in all rats but was significantly worse in groups II and III. No rat in the study became hypoxemic. Serious arrhythmias (ventricular or supraventricular tachycardia) were noted in all groups, but the incidence was significantly higher in the group of rats given diazepam pretreatment than in the other three groups. It is concluded that IV diazepam 0.2 mg/kg given 5 minutes before administration of IV bupivacaine 2 mg/kg increases the incidence of serious cardiac arrhythmias. Second, this increase is not solely due to increased acidosis, because the rats receiving the vehicle (group III) developed equivalent acidosis but did not develop increased arrhythmias.     

Does adrenaline improve epidural bupivacaine and fentanyl analgesia after abdominal surgery?

The alpha-adrenergic agonists have been demonstrated to have synergistic effects with opioids and local anesthetics in animal research. The present study was performed to determine whether the addition of adrenaline improves the analgesic effects of an epidural infusion of a combination of fentanyl and bupivacaine after abdominal surgery. We studied 90 ASA 1 or 2 patients scheduled for abdominal surgery under epidural anaesthesia, with or without general anaesthesia. Patients were randomly divided into two groups to receive a postoperative epidural infusion of fentanyl 5 micrograms/ml in bupivacaine 0.2%, with or without adrenaline 5 micrograms/ml, at a rate of 2 ml/h for more than 48 hours. Postoperative pain relief was assessed using visual analog scales (VAS), both at rest and during coughing, at 2, 24, and 48 hours after surgery. The number of rescue analgesics and side-effects such as nausea, vomiting, pruritus, respiratory depression, headache, muscle weakness, and hypotension were recorded. Patients who received adrenaline (n = 40) reported significantly lower mean VAS scores than those who received no adrenaline (n = 37), both at rest at 24 hours postoperatively and during coughing at 24 and 48 hours. The number of additional analgesics and incidence of side-effects did not differ between groups. In conclusion, the results of the present study demonstrate that the addition of adrenaline to a combination of fentanyl and bupivacaine improves the quality of epidural analgesia after abdominal surgery. Under the conditions of the study, we did not detect any disadvantage from the addition of adrenaline.     

Neostigmine added to bupivacaine in axillary plexus block: which benefit?

INTRODUCTION: Recent study showed that neostigmine (500 microg) by intra-articular produces postoperative analgesia without adverse effect. The author's goal was to determine whether 500 microg of neostigmine added to bupivacaine in axillary plexus block could prolonged postoperative analgesia without increasing the incidence of side effects. METHODS: Ninety patients scheduled for orthopedic or plastic surgery with axillary plexus block were randomly assigned to one of 3 groups : group 1 (TGr n = 30) received saline solution (1 ml) in the axillary plexus, group 2 (NAGr n = 30) received 500 microg (1 ml) neostigmine in the axillary plexus and group 3.500 microg neostigmine subcutaneously (NSGr n = 30). We evaluated visual analog pain scores (VAS), the consumption of the ketoprofene, nausea and vomiting incidence during the first 24 h. ANOVA, Kruskall Wallis and Fisher tests were used for statistical analysis. A p value of <0.05 was considered significant. RESULTS: The VAS score was lower in NAGr (21 +/- 18) vs NSGr (31 +/- 14) and control group TGr (45 +/- 2) (p < 0.05). The consumption of the ketoprofene is 127 +/- 65 mg in NAGr vs 150 +/- 53 mg in NSGr and 200 +/- 50 mg in group TGr (p = 0.02). Incidence of nausea and vomiting was 3.5% in NAGr vs 6.8% in NSGr and 0% for TGr. CONCLUSION: Neostigmine combined to a mixture of lidocaine and bupivacaine prolongs postoperative analgesia after axillary plexus block.     

Is there an advantage in using low-dose intrathecal bupivacaine for cesarean section?

Purpose  Spinal anesthesia for cesarean section is associated with a high incidence of maternal hypotension. The aim of this study was to assess the efficacy of low-dose bupivacaine with fentanyl to reduce the incidence of hypotension in spinal anesthesia for cesarean section. Methods  Forty pregnant women undergoing elective cesarean section were randomly allocated to two groups; those receiving 10 mg bupivacaine to group B (n = 20) and those receiving 4 mg bupivacaine plus 25 μg fentanyl to group BF (n = 20); the agents were given intrathecally with patients in the sitting position, with a combined spinal-epidural technique. Results  Sensory block was adequate for surgery in all patients. Hypotension occurred in all patients in group B (100%) and in 15 patients in group BF (75%). The incidence of hypotension, number of ephedrine treatments, and need for ephedrine were significantly greater in group B than group BF. Three patients in group BF required i.v. fentanyl supplementation after delivery. In 1 of these patients, i.v. fentanyl was not adequate, and epidural supplementation of 1% lidocaine was required. Conclusion  The development of hypotension after spinal block in subjects undergoing cesarean section was not prevented despite low-dose (4 mg) bupivacaine plus 25 μg fentanyl, but the severity of maternal hypotension, and the number of ephedrine treatments and the total dose of ephedrine were decreased.     

Cesarian section and local anaesthesia: insufficient spread of spinal anaesthesia with hyperbaric bupivacaine 0.5%/5% glucose compared to hyperbaric bupivacaine 0.5%/8% glucose?

In our hospital hyperbaric Carbostesin 0.5% (AstraZeneca) had been substituted by hyperbaric Bucain 0.5% (Curasan) and both drugs were believed to be identical in their actions.However, both local anaesthetics differ in the amount of glucose they contain. We report about three patients who underwent cesarian section under spinal anaesthesia. In two patients we observed an insufficient spread of spinal anaesthesia after administration of hyperbaric Bucain 0.5%.The third patient received the normally used combination of hyperbaric Carbostesin 0.5% and fentanyl and the subarachnoid block proceeded completely uneventfully. According to the literature the clinical efficacy of hyperbaric Carbostesin 0.5% and hyperbaric Bucain 0.5% should be identical and therefore a critical dilution of the Bucain should not have occurred because of the addition of fentanyl.