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Objectives As the population ages and implantation criteria are relaxed, more patients with complex comorbidities are becoming eligible for cochlear implantation (CI). These patients have higher risks associated with general anesthesia. This systematic review assesses outcomes and complications following CI under local anesthetic to examine utility for patients deemed not suitable or at high risk for general anesthesia. Methods A systematic review and meta‐analysis performed according to the 2020 PRISMA guidelines. Databases searched were MEDLINE, PubMed, EMBASE, CINAHL, Web of Science Core Collection, Cochrane Database of Systematic Reviews, and Cochrane Central Register of Controlled Trials and ClinicalTrials.gov. There were no limitations on year of publication or language. Results Then, 132 unique were identified. After screening abstracts and full texts for eligibility criteria a total of 18 articles were included. In the nine studies where audiological data were reported, all patients demonstrated improvement in audiological outcomes following implantation under local anesthetic (LA). Only minor complications of transient vertigo, wound infection, facial nerve paralysis, confusion, and tinnitus were reported but all were transient. Meta‐analysis showed surgical time was significantly shorter under LA. Conclusions CI under LA is safe for patients with comorbidities which preclude them from general anesthesia, with minimal complications and an improved cost‐effectiveness profile. However, larger scale, robust trials are required to assess this further.

Background The management of pain resulting from anesthesia injection, tooth extraction and in the period after extraction is of great importance in pediatric dentistry. Objective The aim of this study was to compare the efficacy of the preemptive administration of ibuprofen or acetaminophen with placebo in reducing the pain during injection, extraction and postoperatively in children undergoing primary tooth extraction. Material and methods A randomized, placebo‐controlled, triple‐blinded clinical trial of cooperative children who needed primary molar extraction by local anesthesia. Sixty‐six children aged between 6 and 8 years were randomly assigned to one of three groups: (a) Acetaminophen syrup (320 mg/10 ml); (b) placebo solution; and (c) ibuprofen syrup (200 mg/10 ml). Each of the three solutions was given 30 min before administration of the local anesthetic agent. The Pain level was assessed using the Wong–Baker faces® pain rating scale after injection, extraction, and postoperatively. The Kruskal–Wallis and Mann–Whitney U test were used to evaluate the pain scores between groups at confidence level of 95%. Results The use of preemptive analgesics showed lower pain scores compared to placebo. Additionally, only ibuprofen significantly reduced pain scores compared to placebo at the points immediately after injection (p = 0.001), immediately after extraction (p = 0.0001) and 5 h after extraction (p = 0.002). Conclusion Preemptive usage of ibuprofen reduces injection pain and relieves both extraction and postoperative pain in children undergoing primary tooth extraction. What this paper or case report adds It adds the knowledge regarding pain relief of injection and extraction in children. Preemptive analgesic medications have a beneficial effect on alleviating postoperative pain following tooth extraction in children. Ibuprofen is an effective analgesic for postoperative pain relief in children undergoing primary tooth extraction. Why this paper or case report is important to pediatric dentists Pediatric dentists may consider preemptive ibuprofen in children before injection and extractions. Identifies that Ibuprofen is an effective method of reducing postoperative pain.

Pain assessment is challenging in neonates. Behavioral and physiological pain scales do not assess neocortical nociception, essential to pain encoding and central pain pathway development. Functional near-infrared spectroscopy (fNIRS) can assess neocortical activation to noxious stimuli from changes in oxy-(HbO) and total-hemoglobin concentrations (HbT). This study aims to assess fNIRS nociceptive functional activation in the prefrontal cortex of neonates undergoing circumcision through changes in HbO and HbT, and the correlation between changes in fNIRS and Neonatal Infant Pain Scale (NIPS), a behavioral pain assessment scale.In healthy term neonates, HbO, HbT, and NIPS were recorded during sequential circumcision events 1-Prep before local anesthetic injection; 2-Local anesthetic injection; 3-Prep before incision; 4-Oral sucrose; 5-Incision; 6-Gomco (hemostatic device) attached; 7-Gomco twisted on; and 8-Gomco removed. fNIRS and NIPS changes after each event were assessed with Wilcoxon signed-rank test and summarized as median and interquartile range (IQR). Changes in fNIRS vs. NIPS were correlated with Spearman coefficient.In 31 neonates fNIRS increased (median [IQR] µmol/L) with noxious events: Local injection (HbO: 1.1 [0.5, 3.1], p .001; HbT: 2.3 [0.2, 7.6], p .001), Gomco attached (HbO: 0.7 [0.1, 1.7], p = .002; HbT: 0.7 [-0.2, 2.9], p = .02), and Gomco twisted on (HbO: 0.5 [-0.2, 1.7], p = .03; HbT: 0.8 [-0.1, 3.3], p = .02). fNIRS decreased with non-noxious event: Prep before incision (HbO: -0.6 [-1.2, -0.2] p .001; HbT: -1 [-1.8, -0.4], p .001). Local anesthetic attenuated fNIRS increases to subsequent sharp stimuli. NIPS increased with subsequent sharp stimuli despite local anesthetic. Although fNIRS and NIPS changed in the same direction, there was not a strong correlation between them.During neonatal circumcision, changes in fNIRS differed between different types of painful stimuli, which was not the case for NIPS, suggesting that fNIRS may complement NIPS to assess the quality of pain.

Complex regional pain syndrome type I (CRPS I) is a multifactorial condition that is related to neural damage, and leads to chronic neuropathic pain. Due to its multifactorial nature, there are many methods that have been recruited for its management. Most of them limit the symptoms to some degree, but the most effective of them so far seems to be blockade of the sympathetic innervation of the region. We present the case of a 71-year-old woman, with an upper limb fracture which was treated conservatively, and later on developed CRPS type I. Analgesic medications and pregabalin were ineffective in controlling her symptoms. Blockade of the stellate ganglion was performed with local anesthetic and dexamethasone. After the stellate ganglion blockade was marked as successful in relieving her symptoms, cryoneurolysis was performed which was very effective. There are not many cases that have been treated with cryoneurolysis, and this is what makes this case interesting.

Background Dry pleural dissemination (DPD) and minimal (, Local anesthetic thoracoscopy using a single‐puncture technique with a flex‐rigid pleuroscope might be a useful tool for accurate pleural staging in cases wherein dry pleural dissemination and minimal pleural effusion were suspected radiologically.

Background Ultrasound (US)-guided hip joint injections are commonly performed for patients with suspected or known intra-articular hip pain. Lidocaine is a well-established local anesthetic used prior to hip joint injections, but it is often associated with discomfort during infiltration. Bacteriostatic saline is an alternative local anesthetic that has been shown to be less painful during infiltration for superficial injections. Objective To compare infiltrative pain and anesthetic efficacy of bacteriostatic saline (0.9% benzyl alcohol) with a standard local anesthetic (buffered 1% lidocaine) used for local anesthesia prior to US-guided intra-articular hip corticosteroid injections. Design Double-blinded, randomized controlled trial. Setting Tertiary care medical center. Participants Sixty eight patients age 18-80 (mean 54.8) years referred for US-guided intra-articular hip corticosteroid injections. Intervention Patients were randomized to receive a US-guided hip joint corticosteroid injection using either bacteriostatic saline or buffered 1% lidocaine for preinjection local anesthesia. Main outcome measures Visual Analog Scale (VAS) for pain (0-100) during local anesthetic infiltration as well as during the intra-articular injection. Adverse events were also recorded. Results There were no significant differences between bacteriostatic saline and buffered lidocaine with respect to pain during local anesthetic infiltration or during the subsequent intra-articular injection. Pain VAS during local anesthetic infiltration was 13.2 (95% confidence interval [CI] 7.8, 18.5) in the bacteriostatic saline group and 14.0 (95% CI 9.4, 18.5) in the buffered 1% lidocaine group (P = .82). Furthermore, pain VAS during the intra-articular injection was 20.7 (95% CI 14.1, 27.3) in the bacteriostatic saline group and 15.7 (95% CI 10.9, 20.3) in the buffered 1% lidocaine group (P = .57). No adverse events occurred. Conclusions Bacteriostatic saline is a safe and comparably effective alternative to buffered 1% lidocaine for local anesthesia before US-guided hip joint injections and may be considered for subcutaneous/periarticular anesthesia during similar musculoskeletal procedures.

Objectives Abdominal electromyogram or visceromotor response (VMR) elicited by bladder distension is a validated as a measure of bladder nociception in mice, however it is not without its limitations. The aim of this study is to address some of these limitations and validate voiding evoked VMR as a measure of bladder nociception mice. Methods Using both male and female C57BL/6 mice we assessed the VMR response to cytometry- induced voiding before and after instillation of 0.5% acetic acid into the bladder. We then delivered intravesical lidocaine to confirm the VMR response as nociceptive. VMR and correlative cystometric bladder pressures were analyzed. Results We found that the VMR can be evoked by continuous fluid infusion into the bladder of both male and female mice. This response is potentiated after bladder injury and can be attenuated by administration of a local anesthetic, providing strong evidence that this method can be used to evaluate bladder nociception. Further, evaluation of cystometric pressure traces obtained during VMR recording revealed that intercontraction intervals were not altered after bladder injury in either male or female mice. However, we did observe a decrease in peak threshold pressures after bladder injury in female mice, which could be rescued by lidocaine administration. Conclusions In conclusion, this technique can measure the VMR and bladder nociception associated with voiding in both female and male mice. Although confounds still exist with the use of anesthesia, further exploration of non-anesthetized voiding-evoked VMR is warranted.

Background α2 adrenoceptor agonists have been proposed as adjuncts to prolong analgesia in pediatric caudal block. The aim of this meta-analysis was to compare the analgesic efficacy of caudal vs intravenous α2 adrenoceptor agonists during pediatric caudal block. Methods A systematic search, data extraction, bias risk assessment, and pooled data analysis were performed following the PRISMA guidelines. All randomized controlled trials comparing caudal with intravenous α2 adrenoceptor agonists in pediatric caudal block were included. Relative risk and weighted mean differences (the corresponding 95% confidence intervals) were calculated for dichotomous and continuous data, respectively. Trial sequential analyses were performed to evaluate the credibility of the meta-analysis. Results A total of 244 patients in five trials were identified. Compared with the intravenous group (9.56 ± 4.23 hours), the time to the first rescue analgesia was prolonged in the caudal α2 adrenoceptor agonists group (12.72 ± 5.99 hours) by a weighted mean difference of 2.98 hours [95% confidence interval: 0.59-5.36 hours; P = .01]. The number of children requiring rescue analgesia in the caudal group (64, 66.67%) was lower than that in the intravenous group (80, 81.63%) [relative risk = 0.82; 95% confidence interval: 0.69-0.97; P = .02]. These findings were also verified by trial sequential analysis. There were no significant differences in the side effects. Conclusion Caudal α2 adrenoceptor agonists as adjuncts to local anesthetic during pediatric caudal block are more effective than intravenous injection. However, the results were affected by small sample size and significant heterogeneity.

Background and objectives The ultrasound-guided proximal infraclavicular costoclavicular block (PICB) appears popular but its results are inconsistent. We sought an accurate demonstration of septae formed between the brachial plexus cords. Methods We performed in-plane, lateral-to-medial PICBs on 120 patients and recorded images. Once the most superficial lateral cord component was entered, a 0.4 to 0.6 mA current was applied to confirm needle placement; 5 mL of local anesthetic solution was then injected and its spread was observed and recorded. As the needle was advanced, the presence or absence of a hyperechoic linear structure was noted before the deeper compartment was reached, specifically looking for the possible displacement of such a septum. Results Upon initial scanning, a septum was observed in 67 of the 120 patients (46.2%). However, there was clear displacement of a linear septum between the lateral cord compartment and the medial and posterior cord compartments that prevented spread between the compartments in 94.16% of patients. Piercing the septum evoked motor responses from the medial or posterior cord. The same anatomical regions were studied microanatomically by analyzing cross-sections obtained with the same approach angle as the ultrasound probe. Conclusions Intraplexus fascial septae that bundled the medial and posterior cords into one compartment and separated them from the lateral cord were demonstrated and confirmed microanatomically. This suggests the need for two separate injections (or two separate catheter placements for continuous peripheral nerve blockade) into the superficial and deep compartments to ensure local anesthetic spread around all three cords of the brachial plexus at this level.

Background Caudal epidural anesthesia is a frequently performed regional anesthesia block in infants and young children. Traditional landmark-based blind needle insertion remains the norm with no immediate, objective method to determine the presence of local anesthetic in the epidural space. Increasingly, ultrasound-imaging is used in pediatric regional anesthesia with demonstrated improvements in block efficacy and efficiency. The value of ultrasound-imaging in confirming success rate of traditional caudal placement is not well defined. Aim To assess the success rate of conventional landmark-based caudal technique using ultrasound-imaging. Methods Prospective observational study of 30 children ages 1 month to 7 years undergoing surgical procedures with consent for caudal blockade. Provider success rate of caudal blockade placed by landmark technique was measured using ultrasound-imaging of needle tip and local anesthetic flow in the epidural space. Results Ultrasound-imaging demonstrated 80% success to correct positioning of the needle tip and local anesthetic in the epidural space. Failure was associated with decreasing experience and presence of anatomic variances. All improperly positioned needles were subsequently successfully positioned using real-time ultrasound-imaging. Mean time for confirmatory ultrasound-imaging (SD; range) was 1 minute (0.3; 1-3). Conclusion The use of ultrasound-imaging can be used to identify proper needle placement in the sacral epidural canal and facilitate subsequent corrected placement.

Introduction Adequate management of post-tonsillectomy pain is an important consideration in postoperative management after tonsillectomy. A 2008 meta-analysis showed that the use of local anaesthetic either by infiltration or topical application reduced postoperative pain. Objectives To review the current evidence for the use of local anaesthetic as a means of reducing post-tonsillectomy pain and compare current evidence to the previous meta-analysis 10 years ago. Method Systematic literature searches of MEDLINE [*"ANESTHETICS, LOCAL"/ AND *TONSILLECTOMY/], EMBASE [*"LOCAL ANESTHETIC AGENT"/ AND *TONSILLECTOMY/] and PubMed [(Tonsillectomy).ti,ab AND (Local Anaesthetic).ti,ab OR (Local Anesthetic).ti,ab]. A meta-analysis of randomised control trials assessing the use of local anaesthetic agents for post-tonsillectomy pain. Results Twenty-three studies were included in the meta-analysis. Overall, local anaesthetic, applied topically or infiltrated, significantly reduces pain scores compared with controls at 4-6 hours [-0.65 (95% CI: -0.77; -0.53)]; 24 hours [-0.50 (95% CI: -0.66, -0.35)]; and 5-7 days [-0.78 (95% CI: -0.90, -0.65)] (standardised mean differences). Conclusion Current studies suggest that use of peri-operative local anaesthetic during tonsillectomy does improve postoperative pain outcomes. The limitations of the analysis are as follows: all studies are small, and a multi-centred larger trial is recommended to guarantee statistical reliability. There was no description of significant adverse side effects from local anaesthetic use.

BACKGROUND Local anesthetic is one of the major ways to obtain satisfactory anesthesia in majority of plastic surgical procedures. OBJECTIVES To compare the effect on pain while injecting buffered vs nonbuffered local anesthetic. MATERIALS AND METHODS The single-blind, split-scalp study was conducted in 25 patients undergoing first hair transplant surgery after informed consent and ethics committee approval using two solutions. Solution A was composed of normal saline (200 mL), 2% lidocaine (40 mL), 1 mL of epinephrine 1:1000, and triamcinolone acetate (40 mg). Solution B was composed of normal saline (200 mL), 2% lidocaine (40 mL), 1 mL of epinephrine 1:1000, triamcinolone acetate (40 mg), and 8.4% soda bicarbonate (5 mL). A 3-mL syringe with 30-G needle was used. On one side of the scalp, solution A was used and solution B on the other side. The pain response was recorded using Wong-Baker Faces Pain Scale corresponding to 0-10 scale. The data were analyzed statistically. No preoperative analgesic was used in any patient. The injections were administered by the 2nd author. RESULTS A total of 25 patients were included in the study. The mean age of the patients was 33.4 years (range; 28 to 41 years). The average pain score was 4.96 (range, 3-7) with solution A whereas 3.28 (range, 2-6) using the solution B (P < .05). Eleven of the patients (44%) were smokers. The average pain score in smokers was 5.82 with solution A and 3.73 with solution B. The pain score in nonsmokers was 4.29 with solution A and 2.93 with solution B (P < .05).

Background Pain control is a mandatory aspect in pediatric dentistry office through local anesthesia. Aim To assess the safety and efficacy of 4% articaine local anesthetic in young children below four years old. Design An equivalent randomized control trial with two parallel arms included 184 young children (92 per group) aged from 36 to 47 months seeking pulpotomy of mandibular primary molars which performed after buccal infiltration injection. The control group received lidocaine hydrochloride 2% with epinephrine 1:100 000. The intervention was articaine hydrochloride 4% with epinephrine 1:100 000. Children's behavior during injection and treatment have assessed using Faces, Legs, Activity, Cry, and Consolability (FLACC) and child's behavior using Frankl Behavior Rating Scale (FBRS). In addition, post-operative complications have been addressed. Results Both anesthetic agents were equivalent during the injection phase. During the treatment phase, the absolute risk difference (ARR) between the two groups was 0.120 (95% CI: -0.003; 0.243). The maximum limit of 95% CI surpassed the margin of equivalence, indicating that less pain has been expressed during pulpotomy among children delivered articaine when compared to their counterparts in the lidocaine group. Concerning post-operative complications, no statistically significant difference was detected between the two anesthetic drugs. Conclusion The findings supported the efficient and secure use of articaine hydrochloride 4% with epinephrine 1:100 000 to treat children between the ages of 3 and below 4 years old.

Background Anterocollis posture is a relatively rare finding among patients with cervical dystonia and often the cause of treatment failure. The dystonic posture can be complex to analyze, and the deep flexor muscles of the neck, longus capiti, and longus coli can be challenging to access. Methods We present a modification of a previously described endoscopic technique that allows straightforward access to the longus capiti muscles in an outpatient setting under local anesthetic. Results We describe the technique based on our experience on 6 patients during a 2-year period with a total of 22 injections, and we review the literature. Conclusion The injection is well tolerated and has led to significant improvement in the majority of patients.

Made available in DSpace on 2020-12-12T01:58:10Z (GMT). No. of bitstreams: 0 Previous issue date: 2020-07-01 Magnesium may be used as an adjunctive analgesic for perioperative pain management because of its antinociceptive properties. This study investigated the analgesic efficacy of intraperitoneal ropivacaine combined with magnesium sulfate in canine ovariohysterectomy. Forty-five dogs sedated with acepromazine/meperidine and anesthetized with propofol/isoflurane were randomly distributed into three treatments, administered intraperitoneally (n = 15 per group): saline solution (group S), 0.25% ropivacaine (3 mg/kg) alone (group R), or in combination with magnesium sulfate (20 mg/kg, group R-Mg). Intravenous fentanyl was given to control cardiovascular responses to surgical stimulation. Postoperative pain was assessed using an Interactive Visual Analog Scale (IVAS), the short form of the Glasgow Composite Pain Scale, and mechanical nociceptive thresholds. Morphine/meloxicam was administered as rescue analgesia. Intraoperatively, the R-Mg group required less fentanyl (p =.02) and exhibited higher incidence of hypotension (systolic arterial pressure

Objectives: As the population ages and implantation criteria are relaxed, more patients with complex comorbidities are becoming eligible for cochlear implantation (CI). These patients have higher risks associated with general anesthesia. This systematic review assesses outcomes and complications following CI under local anesthetic to examine utility for patients deemed not suitable or at high risk for general anesthesia. Methods: A systematic review and meta-analysis performed according to the 2020 PRISMA guidelines. Databases searched were MEDLINE, PubMed, EMBASE, CINAHL, Web of Science Core Collection, Cochrane Database of Systematic Reviews, and Cochrane Central Register of Controlled Trials and ClinicalTrials.gov. There were no limitations on year of publication or language. Results: Then, 132 unique were identified. After screening abstracts and full texts for eligibility criteria a total of 18 articles were included. In the nine studies where audiological data were reported, all patients demonstrated improvement in audiological outcomes following implantation under local anesthetic (LA). Only minor complications of transient vertigo, wound infection, facial nerve paralysis, confusion, and tinnitus were reported but all were transient. Meta-analysis showed surgical time was significantly shorter under LA. Conclusions: CI under LA is safe for patients with comorbidities which preclude them from general anesthesia, with minimal complications and an improved cost-effectiveness profile. However, larger scale, robust trials are required to assess this further.

Background Lumbar radicular pain (LRP) results from inflammation and irritation of lumbar spinal nerves and the dorsal root ganglion (DRG). Methods Our study is a prospective, triple-blind, randomized, activecontrol trial (CTRI/2016/02/006666) comparing transforaminal epidural local anesthetic (LA) injection and pulsed radiofrequency treatment of DRG in patients with chronic LRP. Patients with LRP after failed conservative management for >3 months received selective diagnostic nerve root block with 1 mL 2% lidocaine. Fifty patients showing positive responses were divided into groups of 25 each. The LA group received transforaminal epidural injection of 1 mL 0.5% bupivacaine. The lumbar pulsed radiofrequency (LPRF) group received transforaminal epidural injection of 1 mL 0.5% bupivacaine with 3 cycles of pulsed radiofrequency of the DRG for 180 seconds RESULTS: Both groups were compared by observing pain intensity on a 0- to 100-point VAS and improvement in functional status by the Oswestry Disability Index (ODI version 2.0) at 2 weeks and 1, 2, 3, and 6 months. All baseline variables were comparable between the 2 groups. Statistically significant reduction in both outcomes was seen in the LPRF group compared to the LA group from 2 weeks to 6 months. One hundred percent of patients in the LPRF group had a ≥20- point decrease in VAS and significant percentage reduction in ODI at all time intervals up to 6 months, whereas it was seen in 80% and 28% of patients in the LA group at 3 and 6 months, respectively. No complications were seen in any patients CONCLUSION: Pulsed radiofrequency of the DRG applied for longer duration results in long-term pain relief and improvement in the functional quality of life in patients with chronic LRP.

Advances in anesthesia techniques and guidance imaging have made regional anesthetics effective both for pain management and as a primary anesthesia modality for patients undergoing operative and other invasive procedures. Patients can receive regional anesthesia in most areas of the body, including the upper and lower extremities and torso. It is critical that perioperative nurses are familiar with regional anesthetic options and understand them well enough to support their patients in the preoperative, intraoperative, and postoperative phases of surgical care. They also should be familiar with the signs and symptoms of local anesthetic systemic toxicity and be prepared to help treat this condition as soon as indicated. Nurses play a pivotal role in ensuring patients are properly educated about regional anesthetics and remain safe throughout all phases of perioperative care.

BACKGROUND Post-operative pain after an above-knee amputation is often severe, and in the elderly patients the adverse effects of post-operative opioids are evident. We hypothesized that continuous perineural local anesthetic infusion (CPI) combined to a wound infusion will reduce acute pain and opioid consumption compared to placebo after above knee amputation. METHODS Ninety-three patients going through an above knee amputation were recruited for this randomized, controlled trial. Two catheters were placed, one to the sciatic nerve sheath and one under the fasciae during the amputation. After two 10 mL boluses of ropivacaine 0.75% a post-operative infusion of ropivacaine 0.2% or placebo (NaCl 0.9%) at 2 mL/h was administered for 72 hours to both catheters. The primary outcome was average stump pain during the first 5 days. RESULTS The mean intensity of stump pain during the first five post-operative days was 1.4 (0.8) in the CPI group and 1.9 (0.9) in the placebo group on VRS, mean (SD), P = .006. The opioid consumption on first five post-operative days did not differ between the groups. CONCLUSION A combination of continuous perineural and wound local anesthetic infusion seems to diminish the intensity of stump pain after above knee amputation.

Background Cervical epidural steroid injection (CESI) with local anesthetics is commonly used to treat neck pain and radicular pain of the upper extremity. Local anesthetic systemic toxicity (LAST) occurs shortly after injection as a complication; however, delayed onset is a very rare event, especially in central nervous system (CNS) block. Case report We present a case in which delayed onset of LAST occurred in a patient who received CESI for cervical and arm radiating pain due to a cervical disc protrusion. We performed the interlaminar approach for CESI using fluoroscopic guidance. After confirming the location of the epidural space using the loss of resistance technique and spreading of contrast agent (Telebrix® 30), a mixture of 0.25% levobupivacaine 12.5 mg (5 mL in volume), hyaluronidase 1,500 IU (1 mL), dexamethasone 5 mg (1 mL), and normal saline 3 mL was administrated. After 50 minutes of injection, the patient showed CNS toxicity (unconsciousness, seizure) with normal blood pressure and tachycardia; therefore, she was immediately sedated with intravenous midazolam (3 mg), and 15 L/min of oxygen was administered. The patient fully recovered after 30 minutes of sedation without any sequelae. Conclusion Delayed onset of LAST is a rare complication of a common procedure in CESI, so it is important to be aware of this complication and the presentation of toxicity.

The aim of this study was to describe a perineural ultrasound-guided infiltration technique for management of radial tunnel syndrome and to report its preliminary results in 54 patients. A mixture of a saline solution, a local anesthetic, and a corticosteroid solution was infiltrated in the perineural region at the arcade of Frohse. Pain was reported in 100% of patients before the procedure versus 1.9% after the procedure. Scratch collapse and Cozen test results were positive in 98.1% and 66.7% of patients before infiltration, respectively, versus 5.6% and 9.2% after infiltration. All variables had statistically significant differences between preprocedure and postprocedure evaluations (P < .01).

BACKGROUND High volume injection (HVI) shows promising results in the treatment of chronic midportion Achilles tendinopathy (AT). HVI consists of a large volume of saline with a small amount of corticosteroid and local anesthetic. OBJECTIVE To determine the effect of corticosteroid in HVI in AT. METHODS A total of 28 men (18-59 years) with chronic (>3 months) AT were included in a double-blinded RCT and followed for 24 weeks. All performed eccentric training and randomized to either (a) HVI injection with corticosteroid or (b) HVI injection without corticosteroid. Outcomes included self-reported function (VISA-A score) and pain (VAS score) and ultrasound imaging (tendon thickness, Doppler flow). RESULTS VISA-A and VAS score improved in both groups at all time-points (P

Objective To review the current literature on the effects of intraarticular local anesthetics on human knee articular cartilage. Literature survey PubMed; MEDLINE; SCOPUS; PEDro; CINAHL databases (1/1990-06/1/2018) were searched for local anesthetic effects on human knee articular cartilage. Methodology Sixteen studies met the inclusion criteria, with outcome measures assessing chondrocyte viability, morphology, and histology. A systematic review was performed using PRISMA guidelines. Synthesis Seven studies were identified evaluating lidocaine, with five of them demonstrating statistically significant chondrotoxic effects. Fourteen studies examined bupivacaine, with all but one study demonstrating a chondrotoxic effect. Eight studies examined ropivacaine and found a dose-dependent chondrotoxicity starting at 0.75%. Two studies evaluated levobupivacaine showing chondrotoxicity, with one study showing it to be more chondrotoxic than bupivacaine. One study looked at mepivacaine and showed it to have more chondrotoxicity than ropivacaine. When studied the chondrotoxicity was found to be both dose and time dependent. Also, the addition of corticosteroids appeared to worsen the chondrotoxic effects. Conclusions Lidocaine, bupivacaine, ropivacaine, levobupivacaine, and mepivacaine were reported to have dose- and time-dependent deleterious effects on chondrocytes that appeared to be made worse by the coadministration of corticosteroids. Ropivacaine at concentrations of 0.5% or less was found to be the least chondrotoxic anesthetic. Level of evidence I.

Objectives Multiple topical anesthesia techniques exist for office-based laryngeal surgery. Our objective was to assess patient and surgeon satisfaction for three different techniques. Study design Cohort study. Methods All consecutive patients presenting to an outpatient laryngology office for awake surgical procedures were enrolled. Patients were anesthetized with local anesthesia (2 cubic centimeters of 4% lidocaine) in one of three ways: 1) nebulizer, 2) flexible cannula through a channeled laryngoscope, or 3) transtracheal instillation. Demographics, procedure times, and surgeon satisfaction were recorded. A validated 11-item patient satisfaction questionnaire (Iowa Satisfaction with Anesthesia Survey) was administered after the procedure to calculate an overall satisfaction score (-3[worst] to 3[best]). Descriptive and correlative statistics were performed. Results One hundred consecutive patients were included (37 females, 73 males), with relatively equal numbers between groups (32 nebulizer, 35 cannula, 33 transtracheal). Seven procedures were aborted (4 nebulizer, 2 cannula, 1 transtracheal) due to movement, anxiety, or technical issues. Three patients did not adequately complete the survey. Of the 90 remaining patients, patient satisfaction was highest with the transtracheal technique (2.04) versus cannula (1.46) or nebulizer (1.45), and this was statistically significant (P = 0.0167). This difference was driven by decreased pain and nausea scores in the transtracheal group. Surgeon satisfaction was lower with nebulizer and higher with transtracheal injection (P = 0.0081). There was a correlation between surgeon satisfaction and patient satisfaction (P Conclusion Transtracheal instillation was favored by both patients and the surgeon. Choice of local anesthetic techniques may impact patient preferences and surgical success. This may serve as a basis for optimizing anesthetic care in office-based laryngeal surgery. Level of evidence 4 Laryngoscope, 130:166-170, 2020.

Adequate postoperative analgesia after hallux valgus (HV) correction surgery improves early mobilization and decreases hospital stay. Peripheral nerve block and peri-incisional local anesthetic (LA) infiltration are both widely used for pain management in orthopedic surgeries. The aim of this study was to compare the analgesic effects between the ankle block and peri-incisional infiltration technique in patients undergoing HV correction surgery. Ninety patients scheduled for hallux valgus correction surgery were randomly allocated into three groups. In group N, patients were pretreated with tibial and peroneal nerve blocks with 8-10 mL of 0.25% bupivacaine before surgery. In group P, patients received the same LA for peri-incisional infiltration preoperatively. In group C, patients underwent surgery without regional analgesic pretreatment. All patients had intravenous fentanyl patient control analgesia as part of multimodal postoperative pain management. Fentanyl consumption, rest and moving pain scale, and adverse effects were evaluated at postoperative 6 h (Poh6), Poh12, Poh 24, and Poh36, respectively. Patients receiving bilateral feet surgeries were excluded in this study. Seventy-five patients were enrolled into final analysis. The patients in group N expressed lower resting and moving pain scores at Poh6, but the pain scores turned similarly among the three groups following Poh12 and then. The total fentanyl consumption was significantly less in group N than in group P. The postoperative activities and mood disturbance were not significantly different between groups after Poh12 and then. We conclude that ankle block is better than peri-incisional LA infiltration in HV correction surgery in pain relief and fentanyl consumption.

Background Surgical wound infiltration with local anesthetics is common as part of multimodal analgesia and enhanced recovery pathways in pediatric surgical patients. Liposomal bupivacaine can provide up to 92 hours of pain relief, and was approved by the U.S Food and Drug Administration for local infiltration in adults. It is also commonly used by pediatric surgeons, but its safety profile in this age group has not been described. Aims The aim of this study was to describe the incidence of local anesthetic systemic toxicity syndrome in pediatric surgical patients receiving liposomal bupivacaine compared to plain bupivacaine for surgical wound infiltration. Methods We conducted a retrospective, single center, assessor blinded cohort study of pediatric surgical inpatients having open or laparoscopic surgery in the Cleveland Clinic between 2013 and 2017 and receiving wound infiltration with local anesthetics. We compared the incidence of local anesthetic systemic toxicity among those who received any dose of liposomal bupivacaine and those who received plain bupivacaine. Groups were matched 1:2 according to procedure type, age, and physical status score. Local anesthetic systemic toxicity was primarily defined as at least two signs or symptoms possibly related to anesthetic toxicity, as judged by two independent adjudicators blinded to the type of local anesthetic. A sensitivity analysis compared the incidence of a single sign/symptom possibly related to anesthetic toxicity. Results A total of 924 surgical cases were included in the final analysis (356 liposomal bupivacaine and 568 plain bupivacaine cases). The primary outcome did not occur in any patient. The sensitivity analysis found three cases in the liposomal bupivacaine group and two cases in the plain bupivacaine group having a single sign/symptom possibly related to local anesthetic administration (relative risk 2.4, 95% CI 0.4-14.0, P = 0.38). Conclusion In a cohort of pediatric surgical patients receiving wound infiltration with either plain or liposomal bupivacaine, we identified no cases of local anesthetic systemic toxicity syndrome, and only few patients with any sign or symptom that could potentially be related to local anesthetic toxicity.

AimTo investigate total serum levobupivacaine concentrations after a caudal‐epidural loading dose followed by a maintenance infusion in infants aged 3‐6 months over 48 hours.BackgroundThe local anaesthetic, levobupivacaine, is the safer enantiomer of racemic bupivacaine. Present protocols for levobupivacaine are based on studies and pharmacokinetic modelling with racemic bupivacaine. This study will inform clinical practice in this age group and validate the pharmacokinetic model for levobupivacaine infusions in infants, aged 3‐6months.MethodsThe clinical trial was conducted in 8 infants aged 3‐6 months, undergoing bladder exstrophy repair. Pharmacokinetic modelling allowed optimisation of clinical sampling to measure total levobupivacaine and α1‐acid glycoprotein and prediction of the effect of α1‐acid glycoprotein on levobupivacaine plasma protein binding.ResultsThe observed median total levobupivacaine serum concentration was 0.30 mg.L−1 (range: 0.20‐0.70 mg.L−1) at 1 hour after the loading dose of 2 mg.kg−1. The median total levobupivacaine concentration after 47 hours of infusion, at 0.2 mg.h−1.kg−1, was 1.21 mg.L−1 (0.07‐1.85 mg.L−1). Concentrations of α1‐acid glycoprotein were found to rise throughout the study period. Pharmacokinetic modelling suggested that unbound levobupivacaine quickly reached steady state at a concentration of approximately 0.03 mg.L−1.ConclusionThis study examines the pharmacokinetics of levobupivacaine after a loading dose (given over 5 minutes) followed by a maintenance infusion in infants 3‐6 months. The study allows the development of a pharmacokinetic model, combining levobupivacaine and α1‐acid glycoprotein data. Modelling indicates that unbound levobupivacaine quickly reaches steady state once the infusion is started. Simulations suggest that it may be possible to continue the infusion beyond 48 hours.

We report a case of temporary right vocal cord paralysis manifesting as hoarseness after hemodialysis, beginning several hours after placement of a non-cuffed hemodialysis catheter into the right internal jugular vein using prilocaine local anesthesia. Diagnosis of right vocal cord paralysis was confirmed by laryngoscopy. Hoarseness completely resolved that same day, and subsequent laryngoscopy showed normal vocal cord movement, suggesting that the most likely cause of the initial vocal cord paralysis was diffusion of the local anesthetic agent injected during catheter insertion.

BACKGROUND Surgical sperm retrieval, requiring local anesthetic injection, is the most frequent surgical procedure in male infertility. However, needle phobia is common and may contribute to negative experiences or refusal of procedures employing needle injection. OBJECTIVES The aim of this study was to compare the acceptability, safety, and efficacy of needle-free jet anesthetic technique (MadaJet) with conventional needle injection for surgical sperm retrievals in patients with azoospermia. MATERIALS AND METHODS This single-blind randomized controlled trial (RCT) was included of 59 participants who underwent surgical sperm retrievals. Patients were randomly assigned to the needle-free jet (n = 29) or needle injection (n = 30) groups prior to undergoing the surgery. The primary endpoint was the pain score. RESULTS Baseline characteristics were comparable between the two groups. The safety and adverse outcomes were also not statistically significant difference (p > 0.05). The pain score in patients using needle-free jet was significantly lower than that in patients using needle injection (p

BACKGROUND Dexmedetomidine can prolong the duration of action of a local anesthetic agent, but the route of administration that is the most beneficial remains unclear. The purpose of this study was to compare the clinical effectiveness of caudal or intravenous dexmedetomidine administration on postoperative analgesia in children undergoing inguinal hernia repair given caudal levobupivacaine. METHODS This was a prospective, randomized, double-blinded, placebo-controlled trial. Ninety ASA I subjects, aged 2-5 year, undergoing unilateral inguinal hernia repair were enrolled. The children were randomized in a double-blind fashion to three groups. The L-Dcau group received 1 mL/kg of caudal 0.25% levobupivacaine plus 1 μg/kg dexmedetomidine and IV 20 mL saline. The L-Div group received 1 mL/kg of caudal 0.25% levobupivacaine and IV 1 μg/kg dexmedetomidine in 20 mL saline. The L group received 1 mL/kg of caudal 0.25% levobupivacaine and IV 20 mL saline. The primary outcome was the duration of analgesia, which was defined as the time from the caudal block to a Postoperative Pain Scale (CHIPPS) score ≥4. Secondary outcomes were the number of patients requiring rescue analgesia, pain intensity, the incidence of emergence agitation, intraoperative hemodynamic variations, residual motor block, and adverse effects. RESULTS The median duration of analgesia in the L-Dcau group was 14.2 hour compared to 6 hour in the L group with a median difference of 8.5 hour [95% CI (6.5, 10.5), P

Recent anatomical discoveries indicate the importance of identifying membranes and compartments surrounding peripheral nerves into which local anesthetic agents can be injected and continuous nerve block catheters placed during regional anesthetic procedures. However, current markers used in anatomical studies have multiple drawbacks, specifically extravasation into noninjected locations, which can result in inadequate treatment. We studied a readily-available new marker, heparinized blood solution (HBS), which is easy to identify by microscopy and can remain in the nerve compartment into which it is deposited without distorting the tissue. We collected blood from 22 patients and prepared it as HBS. This was then injected into four fresh cadavers as in routine clinical practice for ultrasound-guided nerve blocks to form a so-called "doughnut" by "hydro-dissecting" at 32 sites. All samples, including nerves and neighboring tissues, were then prepared and examined by light microscopy. Although no deliberate intraneural injection was attempted, the marker was identified inside all the nerve compartments except the fascicles. Apart from leaking through the needle entry site in some instances, there was no extravasation of the HBS into neighboring nerve compartments in either direction. The tissues were not distorted and the erythrocytes did not form a thrombus. Nerve membranes and compartments could be clearly identified with routine staining. This technique enabled us to study the longitudinal and circumferential spread in all nerve compartments and to collect data for better interpretation of factors influencing an anesthetic nerve block and situations in which complications could possibly arise. HBS seemed superior to other markers because it did not leave the compartments into which it had been injected, did not distort the tissue, and was easily visible under the light microscope. Clin. Anat., 31:1050-1057, 2018. © 2018 Wiley Periodicals, Inc.

Introduction Pericatheter bleeding (PB) following tunneled hemodialysis catheter (THC) placement is a common phenomenon. In addition to complicating securement of the THC, the PB may loosen the adhesive catheter dressing and delay wound healing. The primary aim of this study was to determine whether epinephrine-containing local anesthetics rather than plain ones reduce superficial PB after THC placement. Methods The study was based on the retrospective analysis of the prospectively gathered data. Forty-six patients receiving local analgesia during THC placement were randomly assigned in a double-blind manner to two groups according to local anesthetic mixtures used (n =22 to prilocaine group [group 1]; n =24 to epinephrine-containing lidocaine group [group 2]). Presence or absence of PB after the THC placement was evaluated. Differences between groups with and without controlling other variables were statistically analyzed. Findings Epinephrine-containing lidocaine (group 2) significantly reduced PB in comparison with prilocaine, P = 0.003. Use of epinephrine-containing lidocaine (group 2) was associated with a reduction in the likelihood of PB (Odds ratio = 0.017). Meanwhile, use of prilocaine (group 1) had 59.7 times higher odds in the likelihood of PB after THC placement. Lower rate of systolic blood pressure (SBP) in group 2 patients after 5 minutes of injections was also noted, P = 0.008. Epinephrine-containing lidocaine was well tolerated and caused no significant cardiovascular disturbance. Discussion Local infiltration of epinephrine-containing lidocaine instead of plain local anesthetics during THC insertion may reduce superficial PB and improve patient comfort.

Difficulty in identifying the susprascapular nerve (SSN) limits the success of US-guided regional anesthetic injections. A proximal SSN block could be an effective and reliable approach. The primary objective was to validate the feasibility of the US-guided proximal SSN block. The secondary objective was to quantify the spread of the colored local anesthetic to the phrenic nerve (PN). Fourteen brachial plexuses from seven cadavers were included. Characterization of the proximal SSN was performed using US to determine the diameter and depth of the origin of the SSN (orSSN). Ten mL of methylene blue-infused ropivacaine 0.2% were then injected to the proximal portion of the SSN. After dissection, the distances between the tip of the needle and the orSSN and the PN were anatomically determined. The PN was also judged to be colored or not by the methylene blue. The mean diameter and depth of the orSSN were 0.2 cm (range, 0.1-0.3 cm) and 1.5 cm (range, 0.6-2 cm) respectively. The orSSN was successfully targeted in 14 of 14 specimens with US; the tip of the needle was a mean of 1.6 cm (range, 0.2-2.5 cm) and 5.1 cm (range, 4-6.5 cm) from the orSSN and PN respectively. The orSSN and PN were marked in 14 and 3 cases respectively. US-guided proximal SSN block is effective and reliable. The origin of the SSN is an easily identifiable landmark. This regional anesthesia could also reduce the risk of phrenic nerve palsy following interscalene brachial plexus block. Clin. Anat. 31:824-829, 2018. © 2018 Wiley Periodicals, Inc.

Objective To determine the influence of epidural detomidine and morphine on serum corticosteroid concentrations and pain-related behavioral responses in mares during and after ovariectomy via colpotomy. Study design Blinded prospective study. Animals Nine university-owned mares. Methods Five of 9 horses received caudal epidural detomidine hydrochloride (0.01 mg/kg) and morphine sulfate (0.1 mg/kg) prior to surgery. All horses received local anesthetic around the ovarian pedicle, 0.02 mg/kg butorphanol IV at the start of the procedure and after first ovary removal, were sedated as required throughout the procedure, and were monitored for leg lifting, grunting, and abdominal tensing. Horses were monitored hourly for pain postoperatively. Heart rate was recorded every 4 hours, and photographs were taken to assess pain according to the horse grimace scale (HGS). Control group horses (n = 4) were treated with butorphanol (0.02 mg/kg IV) every 4 hours for 24 hours postoperatively. All horses received oral phenylbutazone 18 hours postoperatively. Serum cortisol was measured prior to the procedure, after first and second ovary removal, and 8 and 24 hours postoperatively. Results No differences were detected between horses receiving caudal epidural detomidine and morphine and those that received systemic opioids. A decrease in HGS score occurred after phenylbutazone administration. Conclusion Administration of caudal epidural detomidine and morphine resulted in similar pain-related behavior and corticosteroid concentrations as did administration of systemic butorphanol every 4 hours for 24 hours postoperatively. Clinical significance Caudal epidural detomidine and morphine may mitigate the requirement for frequent systemic opioid administration after a potentially painful procedure.

OBJECTIVES The purpose of this study was to perform an updated analysis of complications associated with upper and lower extremity peripheral nerve blocks (PNBs) performed with ultrasound (US) guidance versus the landmark approach. METHODS We conducted a single-center retrospective cohort analysis to compare the incidence of PNB complications between the techniques. The primary outcome was local anesthetic systemic toxicity (LAST), whereas the secondary outcomes included short- and long-term nerve injuries. The current query included cases performed between 2012 and 2015. A combined analysis included data extending to 2006. The Statistical examination relied on the χ2 test. RESULTS During this 4-year period, we performed 7789 US-guided and 498 landmark-guided blocks with no statistically significant difference in the incidence of nerve injury or LAST between the groups. Our 10-year analysis, however, revealed a significant increase (P

Background and objective Local anesthetic cream (LAC) has been used for analgesia in various procedures. However, the analgesic effect of LAC in cryotherapy for warts is unclear. We aimed to evaluate the effects of LAC in cryotherapy for warts. Material and methods We conducted a systematic review and meta-analysis of randomized controlled trials (RCTs) on the effects of LAC in cryotherapy for warts. We searched MEDLINE, CENTRAL, and EMBASE on 31 March 2017 for relevant RCTs. Two authors independently selected trials, assessed risk of bias, and extracted data. Disagreement was resolved by discussion with a third author. Results We included three RCTs with 228 participants. Two included RCTs had a high risk of reporting bias, with one having a high risk of other bias as well. Use of LAC decreased the pain associated with cryotherapy for warts on the hardened skin of children (visual analogue scale, mean difference -20.80, 95 % confidence interval -40.71 to -0.89), but not in adults or on the nonhardened skin of either adults or children. Conclusions The available evidence does not support the routine use of LAC applied for ≤ 60 min in cryotherapy for warts.

Objectives Labor epidural analgesia failure may relate to nonmidline placement of epidural catheters. We hypothesized that greater deviations of the epidural catheter insertion point from the ultrasound (US)-determined midline would be associated with less effective labor analgesia. Methods A prospective ethically approved cohort study was conducted. Fifty-two healthy average-sized women receiving labor epidural analgesia, inserted by the landmark technique, were approached after delivery. Immediately after removing the epidural catheter, we determined the epidural space midline using US and compared it to the epidural catheter insertion point and to the patient-identified midline (assessed by a pinprick in 1-mm increments). Correlations between the US midline-to-catheter insertion point distance and additional epidural local anesthetic requirements (primary outcome), pain verbal numeric rating scale scores (0-10) 1 hour after epidural insertion, and maternal satisfaction with analgesia were determined. The differences in distances were assessed by a Bland-Altman analysis. Results There were no significant correlations between the US midline-to-epidural catheter insertion point distance and additional epidural local anesthetic requirements (R2 = 0.138; P = .33), pain verbal numeric rating scale scores 1 hour after the epidural (R2 = 0.121; P = .40) or maternal satisfaction (R2 = 0.085; P = .57). The Bland-Altman analysis revealed that the mean ± SD US midline-to-epidural catheter insertion point distance and patient-identified midline distances were 0.38 ± 0.31 and 0.35 ± 0.46 cm, respectively. Conclusions In our laboring population, the hypothesis that nonmidline epidural insertion is associated with less-effective labor analgesia was not confirmed in this study cohort. We found minimal differences in distances between the US midline to epidural catheter insertion point and US midline to patient-identified midline.

Key Clinical Message Conventional treatment of Bulimia Nervosa is long term, expensive, and often ineffective. Neural therapy holds promise for treating Bulimia Nervosa in a shorter term, lower cost, and more effective manner. Much of neural therapy involves the superficial injection of local anesthetic injections. Implementation into current practice would be feasible.

Key Clinical Message Donor site pain associated with skin graft procedures is frequently intense and difficult to treat. Liposomal bupivacaine, a prolonged‐release local anesthetic indicated for single‐dose administration to produce postsurgical analgesia, may be a viable option in managing donor site pain.

Background and aim Trigger thumb is a common hand disability in children and is primarily treated with open surgery. A conscious median nerve block can usually meet the requirements for trigger thumb-releasing surgery in adults; however, its effectiveness in children requires further clarification. The present study aims to demonstrate whether ultrasound-guided lower forearm median nerve blockade is a viable option for children undergoing open surgery for trigger thumb. Methods A prospective randomized study was designed to compare median nerve blocks guided by ultrasonography with those guided by anatomic landmarks. Following induction of general anesthesia, the children received a median nerve block performed either by ultrasound-guided block of the lower forearm (group U) or landmark-based blocking at the proximal wrist crease level (group T) with a 0.2% ropivacaine injection. The success rates were compared between groups as the primary endpoint; additional sufentanil and propofol administration, anesthesia recovery time, and other secondary endpoints were also compared. Results A total of 100 children (age 1-3 years) with ASA status I who were scheduled for open surgery for trigger thumb were included in this study (n = 50 per group). Thirty-seven children in group T and 50 children in group U underwent successful blocks. The rate of unsuccessful blockade was significantly lower in group U than group T (0% and 26%, respectively), and rate of additional sufentanil and propofol administration was also lower in group U than in group T. Conclusion Ultrasound-guided lower forearm median nerve block can provide more effective analgesia, a higher success rate, and lower general and local anesthetic dosages than the anatomic landmark-based blocking method in children undergoing open surgery for trigger thumb.

Introduction Implantable loop recorder (ILR) insertion has historically been performed in a surgical environment such as the electrophysiology (EP) lab. The newest generation loop recorder (Medtronic Reveal LINQ™, Minneapolis, MN, USA) is injectable with potential for implantation in a non-EP lab setting by advanced practice providers (APPs) facilitating improved workflow and resource utilization. We report the safety and efficacy of injectable ILR placement in the ambulatory care setting by APPs. Methods A retrospective review was performed including all patients referred for injectable ILR placement from March 2014 to November 2015. All device placement procedures were performed in an ambulatory care setting using the standard manufacturer deployment kit with sterile technique and local anesthetic following a single dose of intravenous antibiotics. Acute procedural success and complication rates following injectable ILR placement in the ambulatory setting were reviewed. Results During the study period, 125 injectable ILRs were implanted. Acute procedural success with adequate sensing (R-waves ≥ 0.2 mV) occurred in 100% of patients. There were no acute procedural complications. Subacute complications occurred in two patients (1.6% of implantations), including one possible infection treated with oral antibiotics and one device removal due to pain at the implant site. Conclusion In this retrospective single-center study, implantation of injectable ILR in an ambulatory care setting by APPs following a single dose of intravenous antibiotics and standard manufacturer technique yielded a low complication rate with high acute procedural success. Use of this implantation strategy may improve EP lab workflow while providing a safe and effective technique for device placement.

Background Surgery/anesthetic technique-stimulated immunosuppression may be associated with outcome for cancer patients. Here, the immune responses of patients undergoing day surgery versus hospitalization surgery for breast cancer were compared in a prospective study. Methods Between February 2012 and August 2014, 21 breast cancer patients underwent day surgery and 16 breast cancer patients underwent hospitalization surgery. The former group received lidocaine/propofol/pethidine, while propofol/systemic opioid- and sevoflurane/propofol/systemic opioid-based anesthesia were administered to the latter group. Surgical stress response was evaluated based on time of operation and amount of bleeding during operation. Immune function was assessed based on natural killer (NK) cell activity, CD4/8 T cell ratio, and cytokine levels of IL-6 and IL-10 that were detected before surgery, after surgery, and on the first postoperative day. Results Operation time did not differ between the two groups. Blood loss was significantly less for the hospitalization surgery group. No change in NK cell activity was observed for either group, although the CD4/8 T cell ratio increased transiently following day surgery. Levels of IL-6 increased significantly in both groups following surgery, and these levels tended to be higher in the hospitalization surgery group. One patient who underwent hospitalization surgery had higher levels of IL-10. Conclusions There were few differences in immune response between the two groups, potentially since a majority of the hospitalization surgery patients received propofol-based anesthesia. We hypothesize that the use of volatile anesthetic/opioid analgesia in hospitalization surgery has a greater influence on immune function in breast cancer patients than local anesthetic/propofol-based anesthesia in day surgery.

Objective The aim of the present study was to assess the level of access site pain in patients undergoing transradial coronary catheterization by using topical application of an anesthetic ointment (lidocaine/prilocaine—AO) compared to standard local anesthesia (LA) by means of injectable lidocaine. Methods We prospectively studied 444 patients undergoing elective trans-radial coronary angiography. The quality of analgesia was assessed using a visual analogue scale (VAS) immediately after the puncture and 30 min after the removal of the sheath. The number and duration of attempts before successful sheath insertion, as well as artery spasm, were compared between the two groups. Results Pain levels measured by VAS were found to be similar between the two groups during sheath insertion (VAS: AO: 4.84 ± 1.0 vs 4.82 ± 1.2, P = NS), as well as 30 min after sheath removal (VAS: AO: 0.07 ± 0.5 vs LA: 0.15 ± 0.6, P = NS). The time to obtain radial access was also not affected by the use of anesthetic ointment (AO: 62.24 ± 25.7 s vs LA: 64.04 ± 18.78 sec, P = NS). The rate of clinical or angiographic radial artery spasm was similar (8-10%) between the groups (P = NS) Conclusion Use of a local anesthetic ointment, versus injectable lidocaine, in trans-radial cardiac catheterization as means of local anesthesia, was found to be equally effective in terms of pain, artery spasm, or artery cannulation speed.