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Objective: To compare the early analgesic effects and the impact on knee joint function recovery after unicompartmental knee arthroplasty (UKA) between single adductor canal block (SACB) and continuous adductor canal block (CACB) combined with local infiltration anesthesia (LIA) using a prospective study., Methods: The patients with knee osteoarthritis admitted between April 2022 and December 2023 were enrolled as a subject. Among them, 60 patients met the selection criteria and were enrolled in the study. They were randomly assigned to the SACB group or CACB group in a ratio of 1:1 using a random number table method. There was no significant difference between the two groups ( P >0.05) in terms of age, gender, height, body mass, body mass index, affected side, and preoperative resting visual analogue scale (VAS) score and active VAS score, Oxford knee score (OKS), and American Hospital of Special Surgery (HSS) score. All patients received multimodal analgesia management using LIA combined with SACB or CACB. The operation time, pain related indicators (resting and activity VAS scores, number and timing of breakthrough pain, opioid consumption), joint function related indicators (quadriceps muscle strength, knee range of motion, OKS score, and HSS score), as well as postoperative block complications and adverse events were recorded and compared between the two groups., Results: There was no significant difference in the operation time between the two groups ( P <0.05). All patients in the two groups were followed up with a follow-up time of (9.70±4.93) months in the SACB group and (12.23±5.05) months in the CACB group, and the difference was not significant ( P >0.05). The CACB group had a significant lower resting VAS score at 24 hours after operation compared to the SACB group ( P <0.05). There was no significant difference in resting and active VAS scores between the two groups at other time points ( P >0.05). The CACB group had a significantly lower incidence of breakthrough pain compared to the SACB group [9 cases (30.00%) vs . 17 cases (56.67%); P <0.05). However, there was no significant difference in the timing of breakthrough pain occurrence and opioid consumption between the two groups ( P >0.05). Four cases in the SACB group and 7 cases in the CACB group experienced adverse events, with no significant difference in the incidence of adverse events between the two groups ( P >0.05). The CACB group had significantly better knee joint mobility than the SACB group at 1 and 2 days after operation ( P <0.05). There was no significant difference between the two groups in knee joint mobility on 0 day after operation and quadriceps muscle strength and OKS and HSS scores at different time points ( P >0.05)., Conclusion: In UKA, the analgesic effects and knee joint function recovery are similar when compared between LIA combined with SACB and LIA combined with CACB. However, SACB is simpler to perform and can avoid adverse events such as catheter displacement and dislocation. Therefore, SACB may be a better choice.

Since the introduction of Fascial Plane Blocks in 2007 there has been an enormous interest and application of Fascial Plane Blocks, evidenced by substantially more than 1000 PubMed items. Despite this gigantic number of publications, also including randomized controlled trials and meta-analyses in children, there is still no clear-cut insight into how much of the purported effect is in fact due to the blockade of nerve structures and how much is merely adding the well-known analgesic and anti-inflammatory effects of the plasma levels of local anesthetics that are achieved with these techniques. Furthermore, Fascial Plane Blocks appear useful only if compared to conventional multi-modal analgesia (no block or placebo) and Fascial Plane Blocks lack the potency to provide surgical anesthesia on their own and appear only to be of value when used for minor-moderate surgery. Despite the huge literature, there has so far not emerged any clinical situations where Fascial Plane Blocks have definitively been shown to be the block of choice, being decisively more effective than other established regional blocks. Lastly, Fascial Plane Blocks may appear as virtually free of complications, but case reports are emerging that point to a real risk for causing local anesthetic systemic toxicity when using Fascial Plane Blocks. This text aims to synthesize the current knowledge base regarding the Fascial Plane Blocks that are relevant to use in the pediatric context. In summary, there does currently not exist any convincing scientific evidence for the continued support for the use of Fascial Plane Blocks in children, except for the rectus sheath block and possibly also the transmuscular quadratus lumborum block., (© 2023 The Authors. Pediatric Anesthesia published by John Wiley & Sons Ltd.)

Background: While open hemorrhoidectomy under local anesthesia has been shown to be more cost-effective with shorter operation times and lower complication rates, local anesthesia is still not considered as a first-line technique in low-income countries like Uganda. The objective of this trial is to compare open hemorrhoidectomy using local anesthesia versus saddle block among patients with primary uncomplicated 3rd- or 4th-degree hemorrhoids in western Uganda., Methods: The protocol for a prospective equivalence randomized, double-blind controlled trial was conducted among patients with primary uncomplicated 3rd- or 4th-degree hemorrhoids. Recruitment was started in December 2021 and is expected to end in May 2022. Consenting participants who require open hemorrhoidectomy indicated at Kampala International Teaching Hospital, Uganda, will be randomized into two groups of 29 patients per arm., Discussion: The primary outcome of this study is to compare the occurrences of postoperative pain following open hemorrhoidectomy using the visual analog scale in an interval of 2, 4, and 6 h and 7 days postoperatively. Furthermore, the mean operative time from the induction of anesthesia to the end of the surgical procedure as well as the cost-effectiveness of the 2 techniques will be assessed in both groups. Open hemorrhoidectomy under local anesthesia has the potential to offer benefits to patients but most importantly expediting return to baseline and functional status, shorter hospital stay by meeting the faster discharge criteria, and reduction in costs associated with reduced length of stay and complications., Trial Registration: Pan African Clinical Trials Registry PACTR202110667430356. Registered on 8 October 2021., (© 2022. The Author(s).)

The pericapsular nerve group (PENG) block is a novel regional anaesthesia technique that aims to provide hip analgesia with preservation of motor function, although evidence is currently lacking. In this single-centre, observer-masked, randomised controlled trial, patients undergoing total hip arthroplasty received pericapsular nerve group block or no block (control group). Primary outcome measure was maximum pain scores (0-10 numeric rating scale) measured in the first 48 h after surgery. Secondary outcomes included postoperative opioid consumption; patient mobilisation assessments; and length of hospital stay. Sixty patients were randomly allocated equally between groups. The maximum pain score of patients receiving the pericapsular nerve group block was significantly lower than in the control group at all time-points, with a median (IQR [range]) of 2.5 (2.0-3.7 [0-7]) vs. 5.5 (5.0-7.0 [2-8]) at 12 h; 3 (2.0-4.0 [0-7]) vs. 6 (5.0-6.0 [2-8]) at 24 h; and 2.0 (2.0-4.0 [0-5]) vs. 3.0 (2.0-4.7 [0-6]) at 48 h; all p < 0.001. Moreover, the pericapsular nerve group showed a significant reduction in opioid consumption, better range of hip motion and shorter time to ambulation. Although no significant difference in hospital length of stay was detected, our results suggest improved postoperative functional recovery following total hip arthroplasty in patients who received pericapsular nerve group block., (© 2021 The Authors. Anaesthesia published by John Wiley & Sons Ltd on behalf of Association of Anaesthetists.)

Background: Diagnosis of sacroiliac region pain is supported by a positive response to sacroiliac region analgesia (SIRA). Varying techniques have been described for SIRA; with clinician preference often dictating method. Potential complications following SIRA include ataxia and recumbency. No study has specifically evaluated the prevalence of complications., Objectives: To describe the complication prevalence following SIRA in a referral clinic., Study Design: Retrospective cohort study., Methods: Review of records from horses presented to two of the authors at Rossdales, Newmarket, between January 2014 and December 2018, that underwent SIRA. Injection was performed using a blind midline approach with 20 mL mepivacaine (Intra-Epicaine 20mg/ml; Dechra) infiltrated through a straight 18 gauge 8.9cm spinal needle subdivided into four sub-locations per block., Results: 118 horses were included, with 167 individual blocks. One horse showed a mild hindlimb gait abnormality following SIRA, which resolved uneventfully over 3 hours; complication rate 1/118 horses (0.85%; 95% CI: 0,2.5%), 1/167 joints (0.60%; 95% CI: 0,1.8%). SIRA subjectively improved lameness/performance in 132/167 (79%) joints. 49/118 (42%) received bilateral SIRA with 53/118 (45%) evaluated ridden following SIRA., Main Limitations: Small population numbers with low complication prevalence rate., Conclusions: SIRA, using the described technique, has a low (0.85%) prevalence of complications., Competing Interests: The authors have declared that no competing interests exist.

Objectives: Simple prolapse operations can be performed using local anesthesia. However, this has not been the case for advanced pelvic organ prolapse operations. The aim of this study was to investigate the patient-reported feasibility and acceptability of local anesthesia and light sedation for sacrospinous fixation (SSF)., Methods: This is a prospective observational study on 105 women who underwent SSF in a public outpatient setting from April 2016 to October 2017. They received infiltration anesthesia with mepivacaine or lidocaine together with a pudendal nerve block with Marcaine. Local anesthesia was supplemented by intravenous light sedation and pain reliever. A Local Anesthetic Intraoperative Experience Questionnaire was used to evaluate patient experience., Results: One patient was converted to general anesthesia. Eighty-eight women answered the questionnaires. Ninety-nine percent defined themselves as satisfied or very satisfied with the anesthesia. Little or no pain during the operation was reported by 92% and 92% would choose the same type of anesthesia again. No adverse effect of the anesthetic procedure was observed. The median (range) admission time was 12 (4.5-48) hours, and 81% of the patients could be discharged on the day of surgery. At follow-up after 8 weeks and 6 months, no patients reported adverse events to the anesthesia., Conclusions: The SSF can be performed using local anesthesia and light sedation with high degree of patient satisfaction. These preliminary data indicate that the concept of ambulatory surgery might be implemented more widely if the use of local anesthesia is also applied to more advanced surgical procedures., Competing Interests: The authors have declared they have no conflicts of interest., (Copyright © 2019 Wolters Kluwer Health, Inc. All rights reserved.)

Facial nerve palsy is a rare but known complication of dental local anaesthesia and may be underreported. We describe a case of a transient facial nerve palsy following the administration of an inferior alveolar nerve block and discuss the immediate practical management. Knowing the likely transient nature of this complication means the patient can be reassured and unnecessary referral avoided. While the blink reflex is inhibited, steps are needed in order to protect the cornea and prevent secondary infection and scarring., Competing Interests: Competing interests: None declared., (© BMJ Publishing Group Limited 2020. No commercial re-use. See rights and permissions. Published by BMJ.)

Purpose of Review: The objective of this review is to identify the potential of peripheral nerve blocks established over the last years for perioperative pain management in breast surgery. These new blocks will be discussed with respect to their clinical effect and necessity., Recent Findings: After case reports and cadaver studies for the Pecs block and its variations sufficient clinical data from randomized controlled trial (RCT) and meta-analyses exist now. The modified Pecs block or Pecs II leads to a reduction of postoperative 24-h opioid consumption. The recently invented Erector spine block addresses the intercostal nerves. The benefits in analgesia of this approach were tested in few RCTs and showed superiority to the control group in terms of requested postoperative morphine. Most studies showed low intraoperative opioid doses and no study more than low to moderate postoperative pain scores., Summary: Taking the pain levels after breast surgery into account, the request of additional nerve blocks has to be pondered against the potential risks and resource requirement. To reduce or avoid intraoperative or postoperative opioids, an ultrasound-guided Pecs II block proves to be the best option for perioperative pain relief.

Objective: Some patients have been found to develop intraoperative amaurosis under sub-Tenon's anesthesia. We explored whether these patients have poor surgical outcomes during mid- to long-term postoperative follow-up., Methods: In this case series, 74 of 85 patients with macular diseases who underwent phacoemulsification combined with vitrectomy under sub-Tenon's anesthesia developed intraoperative amaurosis. The surgical outcomes at the 2- and 4-month follow-ups in these patients were investigated and compared with the outcomes in patients without amaurosis using best-corrected visual acuity (BCVA), optical coherence tomography (OCT), and pattern visual evoked potential (PVEP)., Results: Both BCVA and the OCT-based macular structure in patients with intraoperative amaurosis showed significant postoperative improvement comparable with that of patients without amaurosis. The presence of intraoperative amaurosis was not associated with either macular hole closure or macular edema regression. PVEP revealed no significant changes in the wave latency or amplitude before and after surgery., Conclusion: Intraoperative amaurosis following sub-Tenon's block is commonly seen but does not predict a poor surgical prognosis. When a patient develops amaurosis during surgery, the surgeon should increase patient comfort through verbal communication rather than perform an additional intervention to help relieve the patient's anxiety.

Purpose: To investigate the utilization of local anesthesia or peripheral nerve block with monitored anesthesia care (LPMAC) and its impact on the perioperative outcomes of hybrid lower extremity revascularization (LER) compared with general anesthesia (GA). Materials and Methods: A search of the ACS-NSQIP database between 2005 and 2017 identified 9430 patients who underwent hybrid LER for peripheral artery disease. Excluding 449 ineligible cases left 8981 hybrid LER patients for analysis. The patients were dichotomized based on the anesthetic technique: 8631 (96.1%) GA and 350 (3.9%) LPMAC. The GA patients were matched 3:1 based on propensity scores to patients in the LPMAC group based on gender, age, race, functional status, transfer status, chronic obstructive pulmonary disease (COPD), dialysis status, American Society of Anesthesiologists (ASA) class, emergent surgery, preoperative sepsis, indication, and type of open and endovascular procedure. Outcomes including complications, mortality, procedure time, and hospital length of stay were compared between the matched groups (801 GA vs 267 LPMAC). Results: Comparing the unmatched groups, those treated under LPMAC were older (72.7±9 vs 68±8.4 years, p<0.001) and had higher rates of COPD (24.3% vs 17%, p=0.001), dialysis dependence (8.1% vs 4.2%, p=0.002), preoperative sepsis (6.6% vs 4.2%, p=0.029), and ASA class ≥IV (29.1% vs 24.1%, p=0.036) than in the unmatched GA cohort. In the matched comparison, LPMAC was associated with lower overall morbidity (25.5% vs 32.3%, p=0.042) and shorter operating time (202.7±98 vs 217.7±102 minutes, p=0.034) compared with GA. The rate of myocardial infarction was lower (1.1% vs 2.4%) and ventilator use for >48 hours was less frequent (0.4% vs 2.6%) for LPMAC patients, though statistical significance was not reached. There was no difference in mortality or hospital length of stay. Conclusion: LPMAC is an infrequent anesthetic technique for hybrid LER and is primarily used for patients with a high burden of comorbidities. LPMAC is associated with reduced overall morbidity and operating time. Further studies are needed to identify which patients undergoing hybrid LER benefit most from LPMAC.

Objectives: To compare the efficacy, safety and cost of combinations of perineal pudendal nerve block + periprostatic nerve block and intrarectal local anesthesia + periprostatic nerve block with the standard technique (periprostatic nerve block)., Methods: The study was designed as a randomized prospective controlled trial. Patients with elevated serum prostate-specific antigen values (prostate-specific antigen ≥4 ng/mL) and/or abnormal digital rectal examination findings were included in the study. Patients with anorectal diseases, chronic prostatitis, previous history of prostate biopsy and anorectal surgery were excluded from the study. A total of 148 patients (group 1 [periprostatic nerve block], n = 48; group 2 [intrarectal local anesthesia + periprostatic nerve block], n = 51; group 3 [perineal pudendal nerve block + periprostatic nerve block], n = 49) were included in the final analysis. Pain during insertion and manipulation of the transrectal ultrasound probe was recorded as visual analog scale 1, pain during penetration of the biopsy needle into the prostate and sampling was recorded as visual analog scale 2, and pain during the entire procedure recorded as visual analog scale 3., Results: The mean visual analog scale 1 score was significantly lower in group 3, when compared with group 1 and group 2 (P < 0.001). There was no significant difference between the groups in terms of the mean visual analog scale 2 score. The mean visual analog scale 3 score was significantly lower in group 3 when compared with other groups (P < 0.001). The total cost for transrectal ultrasound-guided biopsy in the intrarectal local anesthesia + periprostatic nerve block group was significantly higher than the other two groups., Conclusions: The combination of perineal pudendal nerve block and periprostatic nerve block provides more effective pain control than intrarectal local anesthesia plus periprostatic nerve block and periprostatic nerve block alone, with similar complication rates and without increasing cost., (© 2019 The Japanese Urological Association.)

Background: The aim was to compare the effects on short-term and long-term pain and functional outcome of periarticular local anaesthetic infiltration (LIA) with LIA of the posterior knee capsule in combination with a femoral nerve block (FNB) catheter in patients undergoing total knee arthroplasty., Methods: Eighty patients were randomised to one of two groups: Subjects in group LIA received periarticular LIA with ropivacaine 0.2% for postoperative analgesia; subjects in group FNB received LIA of the posterior capsule and a FNB catheter. The primary outcome parameter was functional capacity of the knee 12 months after surgery. Secondary parameters included mobility as determined by accelerometer data, pain, satisfaction with the analgesic regimen, hospital length of stay, and use of pain medication 3 and 12 months after surgery., Results: There were no differences between groups in long-term functional capacity, patient satisfaction and hospital length of stay. In the first 2 days, subjects in group FNB had slightly lower pain scores and used less opioids, and subjects in group LIA had a higher level of accelerometer activity. Three and 12 months after surgery, subjects in group FNB had lower maximum pain scores and were less likely to use any pain medication 12 months after surgery., Conclusions: Both techniques were similar regarding long-term functional outcome. Subjects in group FNB had slightly lower pain scores and lower opioid consumption after operation, lower maximum pain scores at 3 and 12 months, and were less likely to use any pain medication at 12 months., Clinical Trial Registration: NCT01966263., (Copyright © 2018 British Journal of Anaesthesia. Published by Elsevier Ltd. All rights reserved.)

Ocular complications after an inferior alveolar nerve anesthesia are rare. These complications, although temporary and benign, can be distressing to both the patient and the clinician. A 37-year-old male patient was administered an inferior alveolar nerve block for the root canal treatment of tooth #30. Immediately after the administration of local anesthesia, the patient reported complete loss of vision. The patient recovered completely after 15 minutes. In particular, amaurosis is quite uncommon and usually heralds a more sinister pathology such as stroke. This case report presents an unusual case of ocular complication after an inferior alveolar nerve block. Adequate knowledge of the regional anatomy and physiology of the orbit and its nearby structures, the proposed causes of ocular complications, and prevention and management is necessary to manage such events., (Copyright © 2018 American Association of Endodontists. Published by Elsevier Inc. All rights reserved.)

Background: The relatively short duration of effect of local anesthetics has been addressed by encapsulation in drug delivery systems. Codelivery with a single compound that produces an adjuvant effect on nerve block but without intrinsic local anesthetic properties can further prolong the nerve block effect. Here, we investigated whether codelivery of more than 1 encapsulated adjuvant compound can further enhance nerve blockade., Methods: Liposomes loaded with bupivacaine (Bup), dexamethasone phosphate (DexP), or dexmedetomidine (DMED) were synthesized and its in vitro drug release profiles were determined. Animals (Sprague-Dawley rats) were injected with liposomal Bup (Lipo-Bup) and adjuvants at the sciatic nerve and underwent a modified hot plate test to assess the degree of nerve block. The duration of block was monitored and the tissue reaction was assessed., Results: Coinjection of Lipo-Bup with liposomal DexP (Lipo-DexP) and liposomal DMED (Lipo-DMED) prolonged the duration of sciatic nerve block 2.9-fold compared to Lipo-Bup alone (95% confidence interval, 1.9- to 3.9-fold). The duration of the block using this combination was significantly increased to 16.2 ± 3.5 hours compared to Lipo-Bup with a single liposomal adjuvant (8.7 ± 2.4 hours with Lipo-DMED, P = .006 and 9.9 ± 5.9 hours with Lipo-DexP, P = .008). The coinjection of Lipo-Bup with liposomal adjuvants decreased tissue inflammation (P = .014) but did not have a significant effect on myotoxicity when compared to Lipo-Bup alone. Coinjection of Lipo-Bup with unencapsulated adjuvants prolonged the duration of nerve block as well (25.0 ± 6.3 hours; P < .001) however was accompanied by systemic side effects., Conclusions: Codelivery of Lipo-DexP and Lipo-DMED enhanced the efficacy of Lipo-Bup. This benefit was also seen with codelivery of both adjuvant molecules in the unencapsulated state, but with marked systemic toxicity.

Local anesthetics have been used clinically for more than a century, but new insights into their mechanisms of action and their interaction with biological systems continue to surprise researchers and clinicians alike. Next to their classic action on voltage-gated sodium channels, local anesthetics interact with calcium, potassium, and hyperpolarization-gated ion channels, ligand-gated channels, and G protein-coupled receptors. They activate numerous downstream pathways in neurons, and affect the structure and function of many types of membranes. Local anesthetics must traverse several tissue barriers to reach their site of action on neuronal membranes. In particular, the perineurium is a major rate-limiting step. Allergy to local anesthetics is rare, while the variation in individual patient's response to local anesthetics is probably larger than previously assumed. Several adjuncts are available to prolong sensory block, but these typically also prolong motor block. The 2 main research avenues being followed to improve action of local anesthetics are to prolong duration of block, by slow-release formulations and on-demand release, and to develop compounds and combinations that elicit a nociception-selective blockade.

Purpose: To determine if patients treated with a single-shot femoral nerve block have strength and functional deficits at 9-month follow-up., Methods: Forty-three patients who underwent primary anterior cruciate ligament reconstructions were randomized to receive either a preoperative single-shot femoral nerve block or local infiltration anesthesia for primary pain control. All patients underwent a standardized comprehensive rehabilitation program postoperatively. Isokinetic strength and function was tested using a Biodex machine at 9 months or more postoperatively comparing the operative and nonoperative extremity., Results: No significant difference in strength was found at an average of 10.6 months postoperatively (range, 9-15 months) between the femoral nerve block and control groups. In comparing strength deficits, we found no difference in slow isokinetic extension strength (22.4% vs 27.8%, P = .51), fast isokinetic extension strength (18.5% vs 12.5%, P = .41), slow isokinetic flexion strength (11.0% vs 15.1%, P = .55), and fast isokinetic flexion strength (8.2% vs 4.9%, P = .56) in the femoral nerve block versus control groups, respectively. In terms of functional outcomes, there also was no difference in deficits for single-leg hop distance (P = .12), timed single-leg hop (P = .74), and single-leg triple hop distance (P = .94). Maximal strength noted to be within 15% of the contralateral limb was achieved in 40% of patients and maximal function in 63% of patients at an average of 10.6 months postoperatively. A 13% complication rate was found in patients who received a femoral nerve block (1 with prolonged quadriceps inhibition and 2 with prolonged sensory disturbances)., Conclusions: Our study found a 13% motor/sensory complication rate in patients who underwent femoral nerve block for pain control after anterior cruciate ligament reconstruction. Although these deficits may persist, they are not permanent and are not different when compared with controls at 9-month follow-up. However, maximal strength and function are not fully restored at normal return to play time and rehabilitation should continue long term to maximize recovery., Level of Evidence: Level I, prospective randomized trial., (Copyright © 2017 Arthroscopy Association of North America. Published by Elsevier Inc. All rights reserved.)

Dental health is one of the most important signs of life quality and depends on the level of health care organization. Recently the clinical odontology is intensively developing, including local anesthesia where constant searching of effective remedies and methods of suppression and treatment of pain is carried out. At the same time carrying out adequate local anesthesia has important practical value that is to some extent bound to massive visits of the patients to the clinics. One of the important factors in the solution of problems of effectiveness and safety of local anesthesia is knowledge of anatomy-topographical features of the structure of maxillofacial area as the irregular technique of local anesthesia which is carried out without features of the anatomical structure of jaws is the main reason for ineffective anesthesia. From the practical side, the special attention is paid to the patients having various accompanying diseases with negative treatment emotions that lead to the stress development, disorganization of work of functional systems of the organism, change of the mental state. However the basis of diagnostic process at dentist's consultation depends on the clinical thinking of the doctor which is bound to knowledge of medical psychology and psychoprophylaxis that needs to be applied in the daily practice. In particular clinical situations premedication methods are successfully used for carrying out adequate anesthesia for dental interventions. A wide range of ways and methods of the lower alveolar nerve blockade are used in dentistry, where the composite external and internal anatomy-topographical markers which are difficult to remember for the doctor are applied. It causes the need of carrying out further researches on the maximal simplification of technological and methodological features of mandibular anesthesia and its introduction into dental practice.

There has been a substantial increase in ambulatory day-case breast surgery in recent decades. This has been largely due to improvements in anesthetic procedures and pre-emptive analgesia. Thoracic paravertebral blockade (TPVB) is increasing in popularity, though concerns over iatrogenic injury remain, especially pneumothorax. The purpose of this study was to conduct a review of the incidence of pneumothorax following TPVB prior to breast surgery. Data from of a consecutive series of patients having TPVB prior to breast surgery between 2009 and 2014 were reviewed. TPVB were used prior to unilateral and bilateral procedures. Medical records were retrospectively assessed for any complication including pleural punctures, pneumothorax, hypotension, bradycardia as well as signs and symptoms of local anesthetic toxicity. 1152 patients underwent a total of 1322 TPVB injections (982 unilateral and 340 bilateral). Clinically significant hypotension and/or bradycardia occurred in 26 patients (2.2%). Two patients (0.17%) had a suspected toxicity from the local anesthetic. Incidence of pleural puncture was 0.6% (n=9) and pneumothorax 0.26% (n=3). All pneumothoraxes were managed conservatively. There was no statistical difference in complication rates in those that had unilateral vs bilateral TPVB or those that had ultrasound guidance (P=.09). Good pre-emptive analgesia is pertinent to prevent acute postoperative pain. TPVB have been shown to be successful in reducing rescue analgesia. This study shows TPVB is a well-tolerated procedure, with a low associated incidence of iatrogenic injury and complication., (© 2017 Wiley Periodicals, Inc.)

Aim: The aim of this study is to assess the efficacy of 4% articaine with 1:100,000 adrenaline given as buccal and lingual infiltration in adult patients undergoing erupted mandibular first and second molar teeth extraction versus inferior alveolar nerve block technique using 2% lignocaine with 1:80,000 adrenaline., Materials and Methods: A total of 100 patients undergoing extraction of mandibular posterior teeth were divided into two equally matched groups for the study, out of which 50 patients were given 4% articaine with 1:100,000 adrenaline as buccal and lingual infiltration and 50 patients were given 2% lignocaine with 1:80,000 adrenaline using classic direct inferior alveolar nerve block with lingual and buccal nerve block. Efficacy of anesthesia was determined using a numeric analog scale (NAS) ranging from 0 indicating no pain to 10 indicating the worst pain imaginable. The NAS was taken by a different operator to avoid bias., Results: The pain scores in both groups were analyzed using the Mann-Whitney U test, and a p value of 0.338 was obtained which is not statistically significant. Hence, no significant difference in the pain score was established between both groups. The adverse effects of both the local anesthetics if any were noted., Conclusion: From this study, we concluded that the use of 4% articaine with 1:100,000 adrenaline is as effective as inferior alveolar nerve block with lignocaine but without the risk of attendant adverse effects of inferior alveolar nerve block technique.

Context: The occurrence of amaurosis during ophthalmic anesthesia is well known. The reason for this manifestation has not been studied., Purpose: To investigate the effect of sub-tenon's anesthesia on visual conduction in rabbit eyes., Methods: Fifteen right eyes of 15 New Zealand albino rabbits were included. 2% lidocaine hydrochloride and 0.75% bupivacaine hydrochloride (1 ml, 1:1 mixture) was injected in the sub-tenon's space of 8 eyes while the control group (n = 7) was injected with 1 ml physiological saline. Flash visual evoked potentials (FVEP) were performed with Roland reti-scan system before and, 5 min, 15 min, and 5 days after injection. The natural pupillary diameter and minimal pupillary diameter with light reflex were recorded., Results: In the anesthesia group, N1 latency, P1 latency, and P1 amplitude were 17.13 ± 1.13 ms, 28.25 ± 1.83 ms, 13.45 ± 4.36 μv respectively before injection; 21.75 ± 3.06 ms, 29.63 ± 2.67 ms, 7.24 ± 4.64 μv at 5 min after injection; 22.25 ± 1.39 ms, 29.50 ± 2.51 ms, 7.54 ± 4.47 μv at 15 min after injection, and, 17.75 ± 0.71 ms, 28.13 ± 2.42 ms, 13.17 ± 4.08 μv 5 days after injection. When compared with baseline, N1 latency at 5 min and 15 min after injection showed prolongation (p = 0.019 and p = 0.001, respectively). Likewise, P1 amplitude decreased at 5 min and 15 min after injection (p < 0.001, p < 0.001, respectively). Both N1 latency and P1 amplitude recovered 5 days after the injection. Pupillary light reflex (PLR) constriction amplitude was 35.42% and 0.00% before and at 5 min after injection (p = 0.012). After 5 days it recovered to 33.33%. The FVEP and PLR constriction amplitude did not change significantly after injection in the control group., Discussion: Sub-tenon's anesthesia was associated with changes in the FVEP and pupullary light reflex in rabbit eyes in our study., Conclusions: The data from this study suggested that sub-tenon's anesthesia could reversibly block visual conduction in rabbit's eyes.

Competing Interests: Competing interests: None declared.

Purpose: We conducted a comparative study to evaluate analgesic efficacy between paravertebral block via the surgical field (PVB-sf), in which the catheter was inserted into the ventral side of the sympathetic trunk in the paravertebral space by a thoracic surgeon under thoracoscopic visualization, and epidural block (Epi) using ropivacaine for post-thoracotomy pain relief., Methods: Lung cancer patients scheduled for lobectomy via thoracotomy were randomly allocated to receive either PVB-sf or Epi (n = 36 per group). Before thoracotomy closure, 0.375% ropivacaine was administered as a bolus (PVB-sf, 20 mL; Epi, 5 mL), followed by a 300-mL continuous infusion of 0.2% ropivacaine at 5 mL/h. Postoperative pain was assessed using a visual analog scale (VAS) score at various time points, including the primary endpoint of 2 h after ropivacaine bolus injection. Sensory block area, vital signs, serum ropivacaine concentrations, and side effects were also evaluated., Results: The Epi group showed significantly lower VAS scores and blood pressure and a wider sensory block area than the PVB-sf group at all evaluation time points. While the mean serum ropivacaine concentration in the PVB-sf group was significantly higher than that in the Epi group until 1 h after injection of the ropivacaine bolus, there was no significant difference at any subsequent assessment point. The incidence of side effects was similar between the groups., Conclusion: The Epi was superior to PVB-sf for the management of post-thoracotomy pain in this patient cohort. The number of dermatomes anaesthetized by Epi was greater than that anaesthetized by PVB-sf. No difference in complication rates was observed between the two groups.

Autogenous fistulas and in particular radiocephalic fistulas are recommended as the first vascular access for hemodialysis. Unfortunately, the rates of early failure and non-maturation are very high. For more than a decade, brachial plexus block has been proposed as the anesthesia of choice for fistula creation due to its beneficial sympathectomy-like effect, causing vasodilation and attenuation of spasm. Until recently, there was not a single randomized clinical study supporting this proposition. Because performing regional anesthesia is time-consuming and requires expertise, many surgeons prefer local or general anesthesia for vascular access surgery. However, in August 2016 a randomized clinical trial was published showing that regional anesthesia significantly reduces early failure and improves primary and functional patency at 3 months compared to local anesthesia. The aging of the dialysis population, with their attendant morbidity and increased risk for general anesthesia, makes it clear that regional anesthesia is the recommended approach for fistula creation. The excess time required for this approach will decrease with increasing expertise along the learning curve, and will be compensated by a reduction in time that would otherwise be needed for new access construction due to failure of fistulas constructed under local anesthesia.

Purpose of Review: Needle-based and cannula-based eye blocks are 'blind' techniques prone to rare but serious complications. Ultrasound, an established adjunct for peripheral nerve block, may be beneficial for ophthalmic anesthesia application. The present review details the evolution of ultrasound-guided eye blocks, outlines safety issues, and reviews recent studies and editorial opinions., Recent Findings: Ultrasound-assisted ophthalmic regional anesthesia allows imaging of key structures such as the globe, orbit, and optic nerve. Recent findings reveal that needle path is not reliably predictable by clinical evaluation. Needle tips are frequently found to be intraconal, extraconal, or transfixed in the muscle cone independent of the intended type of block. In addition, contemporary human and animal studies confirm that real-time observation of local anesthetic spread inside of the muscle cone correlates directly with block success., Summary: Ultrasound-guided ophthalmic regional anesthesia is evolving beyond simple visualization of the anatomy. Recent research emphasizes the imprecision of needle tip location without ultrasound and the key role of imaging local anesthetic dispersion. There is ongoing debate in the literature regarding the utility of routine ultrasound for eye blocks.

Study Objectives: To determine the effectiveness of serratus plane block performed under direct vision on postoperative pain after mastectomy., Design: We performed a retrospective study of elective breast surgery patients undergoing mastectomy over 6 months. We collected data on the outcomes for the pain score and use of analgesia in recovery, the use of analgesia and antiemetics overnight, and the pain score and mobilization status of the patient 1 day after the operation., Setting: Breast cancer is the most common cancer in women, and mastectomy is commonly performed as part of the management. A mastectomy can cause significant acute pain which progresses to chronic pain in 25% to 60% of women. Recent studies have suggested that a serratus plane block is a viable alternative to regional anesthetic techniques without the side effect profile and that injection of local anesthetic into serratus anterior provided predictable and effective anesthesia to the chest wall. Serratus blocks target the thoracic nerves more selectively than pectoral blocks, and local blocks can reduce the use of opiates postoperatively thereby lessening opiate-related side effects., Patients: Our sample included 16 patients who had received a serratus block and 11 patients who only had wound infiltration with levobupivacaine with adrenaline and clonidine., Intervention: Serratus plane block was conducted by injecting 50% of the totally available levobupivacaine 0.375% with adrenaline and clonidine deep to serratus anterior under direct observation., Main Results: No patients receiving a serratus block suffered severe pain in recovery or day 1 postoperatively. Patients receiving wound infiltration alone had 2 patients suffering severe pain in recovery and 3 patients suffering severe pain day 1 postoperatively., Conclusion: Serratus block provides effective regional anesthesia, suitable for mastectomies, and currently appears to be superior to wound infiltration alone. However, further data will need to be collected to support this finding., (Copyright © 2016 Elsevier Inc. All rights reserved.)

Hemidiaphragmatic paralysis is the most common adverse effect associated with interscalene block. In most cases, it resolves with the resolution of nerve blockade with only an estimated incidence of 0.048% persisting for longer duration. Occasionally, interscalene block is also associated with recurrent laryngeal nerve block and seldom with cranial nerve paresis. We present a case of delayed onset and prolonged hemidiaphragmatic paralysis that was associated with 3 cranial nerve deficits after interscalene nerve block for shoulder surgery performed under general anesthesia in the beach chair position. Etiology is unclear, but most likely multifactorial., (Published by Elsevier Inc.)

Purpose: Pudendal nerve injection is used as a diagnostic procedure in the vulvar region and for therapeutic purposes, such as in vulvodynia. Here, we provide a new, easy-to-perform perineal injection technique., Patients and Methods: We analyzed 105 perineal injections into the pudendal nerve with a local anesthetic (LA), procaine in 20 patients. A 0.4 × 40 mm needle was handled using a stop-and-go technique while monitoring the patient's discomfort. The needle was placed 1-2 cm laterally to the dorsal introitus. After aspiration, a small amount of LA was applied. After subcutaneous anesthesia, the needle was further advanced step-by-step. Thus, 5 ml could be applied with little discomfort to the patient. Anesthesia in the pudendal target region was the primary endpoint of our analysis., Results: In 93 of 105 injections (88.6 %), complete perineal anesthesia was achieved with a single injection. 12 injections were repeated. These injections were excluded from the analysis. Severity of injection pain, on visual analog scale (VAS) from 0 to 100, was 26.8 (95 % CI 7.2-46.4). Age (β = 0.33, p < 0.01) and the number of previous injections (β = 0.35, p < 0.01) inversely correlated with injection pain. Injection pain and anesthesia were not affected by BMI, the number and the side of previous injections, or order of injection. A reversible vasovagal reaction was common, but no serious adverse effects occurred., Conclusion: Perineal pudendal injection is an effective and safe technique for anesthesia in diagnostic (vulva biopsy) and therapeutic indications (pudendal neuralgia), and regional anesthesia in perinatal settings.

Background: Local infiltration analgesia and peripheral nerve blocks are common methods for pain management in patients after THA but direct head-to-head, randomized controlled trials (RCTs) have not been performed. A network meta-analysis allows indirect comparison of individual treatments relative to a common comparator; in this case placebo (or no intervention), epidural analgesia, and intrathecal morphine, yielding an estimate of comparative efficacy., Questions/purposes: We asked, when compared with a placebo, (1) does use of local infiltration analgesia reduce patient pain scores and opioid consumption, (2) does use of peripheral nerve blocks reduce patient pain scores and opioid consumption, and (3) is local infiltration analgesia favored over peripheral nerve blocks for postoperative pain management after THA?, Methods: We searched six databases, from inception through June 30, 2014, to identify RCTs comparing local infiltration analgesia or peripheral nerve block use in patients after THA. A total of 35 RCTs at low risk of bias based on the recommended Cochrane Collaboration risk assessment tool were included in the network meta-analysis (2296 patients). Primary outcomes for this review were patient pain scores at rest and cumulative opioid consumption, both assessed at 24 hours after THA. Because of substantial heterogeneity (variation of outcomes between studies) across included trials, a random effect model for meta-analysis was used to estimate the weighted mean difference (WMD) and 95% CI. The gray literature was searched with the same inclusion criteria as published trials. Only one unpublished trial (published abstract) fulfilled our criteria and was included in this review. All other studies included in this systematic review were full published articles. Bayesian network meta-analysis included all RCTs that compared local infiltration analgesia or peripheral nerve blocks with placebo (or no intervention), epidural analgesia, and intrathecal morphine., Results: Compared with placebo, local infiltration analgesia reduced patient pain scores (WMD, -0.61; 95% CI, -0.97 to -0.24; p = 0.001) and opioid consumption (WMD, -7.16 mg; 95% CI, -11.98 to -2.35; p = 0.004). Peripheral nerve blocks did not result in lower pain scores or reduced opioid consumption compared with placebo (WMD, -0.43; 95% CI, -0.99 to 0.12; p = 0.12 and WMD, -3.14 mg, 95% CI, -11.30 to 5.02; p = 0.45). However, network meta-analysis comparing local infiltration analgesia with peripheral nerve blocks through common comparators showed no differences between postoperative pain scores (WMD, -0.36; 95% CI, -1.06 to 0.31) and opioid consumption (WMD, -4.59 mg; 95% CI, -9.35 to 0.17), although rank-order analysis found local infiltration analgesia to be ranked first in more simulations than peripheral nerve blocks, suggesting that it may be more effective., Conclusions: Using the novel statistical network meta-analysis approach, we found no differences between local infiltration analgesia and peripheral nerve blocks in terms of analgesia or opioid consumption 24 hours after THA; there was a suggestion of a slight advantage to peripheral nerve blocks based on rank-order analysis, but the effect size in question is likely not large. Given the slight difference between interventions, clinicians may choose to focus on other factors such as cost and intervention-related complications when debating which analgesic treatment to use after THA., Level of Evidence: Level I, therapeutic study.

The use of ultrasound (US) guidance in regional anaesthesia has evolved in the last then years and has even been considered the fatest and safest way to identify peripheral nerves and vascular structures thus eliminating the risk of injuring them. Prior to US guidance, peripheral nerve stimulation (PNS) was the gold standard procedure of the last twenty years, still being used in the present alone or alongside US guidance. However, sometimes -especially in vessel rich areas such as the axillary plexus- it is hard to avoid injuring vascular structures with blind techniques such as PNS. The study's hypothesis was that out-of-plane US guided peri-neural axillary plexus block has a better success rate, faster onset and less intravascular punctures than the PNS method.

Background: Local anaesthesia for cataract surgery can be provided by sub-Tenon's or topical anaesthesia. Both techniques offer possible advantages. This review, which originally was published in 2007 and was updated in 2014, was undertaken to compare these two anaesthetic techniques., Objectives: Our objectives were to compare the effectiveness of topical anaesthesia (with or without intracameral local anaesthetic) versus sub-Tenon's anaesthesia in providing pain relief during cataract surgery. We reviewed pain during administration of anaesthesia, postoperative pain, surgical satisfaction with operating conditions and patient satisfaction with pain relief provided, and we looked at associated complications., Search Methods: We searched the Cochrane Central Register of Controlled Trials, MEDLINE and EMBASE (last search in November 2014) and the reference lists of published articles. We looked for conferences abstracts and trials in progress and placed no constraints on language or publication status., Selection Criteria: We included all randomized studies that compared sub-Tenon's anaesthesia versus topical anaesthesia for cataract surgery., Data Collection and Analysis: We assessed trial quality and extracted data in the format allowing maximal data inclusion., Main Results: We included eight studies in this updated review but could retain in the analysis only seven studies on 742 operated eyes of 617 participants. Two cross-over trials included 125 participants, and five parallel trials included 492 participants. These studies were published between 1997 and 2005. The mean age of participants varied from 71.5 years to 83.5 years. The female proportion of participants varied from 54% to 76%. Compared with sub-Tenon's anaesthesia, topical anaesthesia (with or without intracameral injection) for cataract surgery increases intraoperative pain but decreases postoperative pain at 24 hours. The amplitude of the effect (equivalent to 1.1 on a score from 0 to 10 for intraoperative pain, and to 0.2 on the same scale for postoperative pain at 24 hours), although statistically significant, was probably too small to be of clinical relevance. The quality of the evidence was rated as high for intraoperative pain and moderate for pain at 24 hours. We did find differences in pain during administration of local anaesthetic (low level of evidence), and indications that surgeon satisfaction (low level of evidence) and participant satisfaction (moderate level of evidence) were less with topical anaesthesia. There was not enough evidence to say that one technique would result in a higher or lower incidence of intraoperative complications compared with the other., Authors' Conclusions: Both topical anaesthesia and sub-Tenon's anaesthesia are accepted and safe methods of providing anaesthesia for cataract surgery. An acceptable degree of intraoperative discomfort has to be expected with either of these techniques. Randomized controlled trials on the effects of various strategies to prevent intraoperative pain during cataract surgery could prove useful.

Background: Retrobulbar block is a local anesthetic technique widely used for intraocular surgery. Although retrobulbar anesthesia is considered to be relatively safe, a number of serious adverse events have been reported. To our knowledge, immediate onset of generalized seizures with contralateral hemiparesis after retrobulbar anesthesia has not been reported., Case Presentation: A 62-year-old Caucasian healthy male with a right eye retinal detachment was admitted for pars plana vitrectomy. During retrobulbar anesthesia with ropivacaine and before needle withdrawal, the patient developed twitching of the face which rapidly progressed to generalized tonic-clonic seizures. Arterial oxygen saturation decreased to 75 %. Chin lift was performed and 100 % oxygen was administrated via face mask, which increased saturation to 99 %. Midazolam 2 mg was administrated intravenously to control seizures. After cessation of seizures, left-sided hemiparesis was evident. Brain computed tomography and electroencephalogram were normal 3 h later. The patient underwent pars plana vitrectomy under general anesthesia 4 days later., Conclusion: Serious complications of local anesthesia for ophthalmic surgery are uncommon. We present a case in which generalized tonic-clonic seizures developed during retrobulbar anesthesia, followed by transient contralateral hemiparesis. The early onset of seizures indicated intra-arterial injection of the anesthetic. Our case suggested the need for close monitoring during the performance of retrobulbar anesthesia and the presence of well-trained personnel for early recognition and immediate management of the complications.

Background: Cataract is a major cause of blindness worldwide. Unless medically contraindicated, cataract surgery is usually performed under local (regional) anaesthesia. Local anaesthesia involves the blockage of a nerve subserving a given part of the body. It involves infiltration of the area around the nerve with local anaesthetic. The two main approaches in the eye are retrobulbar and peribulbar. There is debate over whether the peribulbar approach provides more effective, safer anaesthesia for cataract surgery than retrobulbar block., Objectives: The objective of this review was to assess the effects of peribulbar anaesthesia (PB) compared to retrobulbar anaesthesia (RB) on pain scores, ocular akinesia, patient acceptability and ocular and systemic complications., Search Methods: In the previous version of our review, we searched the databases until December 2007. In this updated version, we searched the Cochrane Central Register of Controlled Trials (CENTRAL) (March 2015); MEDLINE (1960 to March 2015); and EMBASE (1980 to March 2015)., Selection Criteria: We included randomized controlled clinical trials comparing peribulbar anaesthesia and retrobulbar anaesthesia for cataract surgery., Data Collection and Analysis: Two authors independently assessed trial quality and extracted data. We contacted trial authors for additional information, study methodology and missing data. We carried out a descriptive narrative of results as the included studies used varied methods for reporting the outcomes. We performed a subgroup analysis for globe akinesia., Main Results: We included six trials involving 1438 participants. Three of the six trials had adequate sequence generation while all the trials had unclear allocation concealment There was no evidence of any difference in pain perception during surgery with either retrobulbar or peribulbar anaesthesia. Both were largely effective. There was no evidence of any difference in complete akinesia or the need for further injections of local anaesthetic. Conjunctival chemosis was more common after peribulbar block (relative risk (RR) 2.11, 95% confidence interval (CI) 1.46 to 3.05) and lid haematoma was more common after retrobulbar block (RR 0.36, 95% CI 0.15 to 0.88). Retrobulbar haemorrhage was uncommon and occurred only once, in a patient who had a retrobulbar block., Authors' Conclusions: There is little to choose between peribulbar and retrobulbar block in terms of anaesthesia and akinesia during surgery measuring acceptability to patients, need for additional injections and development of severe complications. Severe local or systemic complications were rare for both types of block.

Purpose: Both paravertebral block (PVB) and thoracic epidural block (TEB) are recommended for postoperative pain relief after lung surgery. The addition of fentanyl to the anesthetic solution became popular for TEB because of the stronger effects; however, there have been few comparable trials about the addition of fentanyl to PVB. The purpose of this study was thus to compare postoperative analgesia, side effects, and complications between ultrasound-guided PVB (USG-PVB) and TEB with the addition of fentanyl to ropivacaine after lung surgery., Methods: We examined 90 consecutive patients (age 18-75 years) scheduled for video-assisted thoracic surgery (VATS). In both groups, all blocks (four blocks in USG-PVB and one block in TEB) and one catheter insertion were performed preoperatively. Continuous postoperative infusion (0.1% ropivacaine plus fentanyl at 0.4 mg/day) was undertaken for 36 h in both groups. The recorded data included the verbal rating scale (VRS) for pain, blood pressure, side effects, complications for 2 days, and overall satisfaction score., Results: There was no difference in the frequency of taking supplemental analgesics (twice or more frequently), or in VRS. Hypotension occurred significantly more frequently in TEB (n = 7/33) than in PVB (n = 1/36) (P = 0.02); on the other hand, the incidences of PONV and pruritus, as well as overall satisfaction score, were similar. There were no complications in both groups; however, the catheters migrated intrathoracically in four patients in PVB., Conclusion: USG-PVB achieved similar pain relief and lowered the incidence of hypotension compared with TEB. We conclude that both blocks with the same concentration of ropivacaine and fentanyl can provide adequate postoperative analgesia for VATS.

Nail procedures require an effective and reliable approach to anesthesia of the distal digit. Several techniques have been described in the literature. Herein, the relevant anatomy of the nail unit, pain pathways, anesthetic options, and several injection approaches to achieve complete anesthesia are reviewed. Also considered are the potential pitfalls and complications and their management. Ultimately, the physician's approach must be individualized to the patient, procedure, and setting., (Copyright © 2015 Elsevier Inc. All rights reserved.)

Local anesthetic intoxication is an uncommon complication of regional anesthesia. We report the case of a 4-month-old infant who presented with generalized tonic-clonic seizure complicated by cardiac arrest secondary to a severe intoxication to local anesthesia. These complications were observed after a bilateral dorsal penile nerve block with lidocaine for circumcision in a non-hospital setting. This report emphasizes the potential risk of local anesthetic systemic toxicity in such circumstances and describes its treatment., (Copyright © 2014 Elsevier Masson SAS. All rights reserved.)

A best evidence topic was constructed according to a structured protocol. The question addressed was: In children undergoing umbilical hernia repair is a rectus sheath block (RSB) better than local anaesthetic infiltration of the surgical site, at reducing post-operative pain? From a total of 34 papers, three studies provided the best available evidence on this topic. One randomised clinical trial showed RSB had a better analgesic effect in the immediate post-operative period. In another randomised trial opioid consumption in the peri-operative period was found to be significantly lower in patients administered RSB. These improvements in pain and analgesia consumption need to be balanced against the expertise, training, equipment required, time implications and complications of performing a RSB., (Copyright © 2014 Surgical Associates Ltd. Published by Elsevier Ltd. All rights reserved.)

Objective: To evaluate the effectiveness and safety of a computer-controlled periodontal ligament (PDL) injection system to the local soft tissues as the primary technique in endodontic access to mandibular posterior teeth in patients with irreversible pulpitis., Methods: A total of 162 Chinese patients who had been diagnosed with irreversible pulpitis in their mandibular posterior teeth without acute infection or inflammation in the periodontal tissues were enrolled in this clinical study. The patients were divided into 3 groups according to the position of the involved tooth: the premolar group (PM, n=38), first molar group (FM, n=66), and second molar group (SM, n=58). All the patients received computer-controlled PDL injection with 4% articaine and 1:100 000 epinephrine. Immediately after the injection, endodontic access was performed, and the degree of pain during the treatment was evaluated by the patients using Visual Analogue Scale for pain. The success rates were compared among the 3 groups. The responses of local soft tissues were evaluated 3-8 days and 3 weeks after the procedure., Results: The overall success rate was 76.5%. There was a significant difference in success rates among the PM, FM, and SM groups (92.1%, 53.0%, 93.1%, respectively; χ² = 34.3, P<0.01). Both the PM and SM groups showed higher success rates than that of the FM group (v=1, χ² = 16.73, P<0.01; v=1, χ² = 24.5, P<0.01). No irreversible adverse effects on the periodontal soft tissues at the injection sites were observed in the follow-up visits in any of the groups., Conclusion: The computer-controlled PDL injection system demonstrates both satisfactory anesthetic effects and safety in local soft tissues as primary anesthetic technique in endodontic access to the mandibular posterior teeth in patients with irreversible pulpitis.

Many intraoperative complications occurring during third molar surgery are described in the literature. Unilateral trochlear nerve palsy secondary to dental anaesthesia is a rare complication. We report the case of a 36-year-old healthy man, ASA I classification, requiring upper third molar extraction. Articaine 1:200,000 epinephrine for right posterior superior alveolar (PSA) nerve block was administered locally in the mucobuccal fold above the upper third molar. A few minutes after PSA nerve block the patient experienced double-vision. The patient was subsequently visited by an ophthalmologist and the condition was diagnosed as transient unilateral vertical diplopia due to temporary paralysis of the superior oblique muscle as a result of the anaesthetic solution involving the IV cranial nerve. The authors report this unusual case and discuss the possible anatomical pathways that might explain this rare phenomenon., (Copyright © 2013 International Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved.)

Background: Cervical dilatation and uterine intervention can be performed under sedation, local or general anaesthesia for obstetrics and gynaecological conditions. Many gynaecologists use paracervical local anaesthesia but its effectiveness is unclear. This review was originally published in 2009 and was updated in 2013., Objectives: The objectives of this review were to determine the effectiveness and safety of paracervical local anaesthesia for cervical dilatation and uterine intervention, versus no treatment, placebo, other methods of regional anaesthesia, sedation and systemic analgesia, and general anaesthesia., Search Methods: We reran our search to August 2013. We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2013, Issue 8), MEDLINE (1966 to August 2013), EMBASE (1980 to August 2013), and reference lists of articles. The original search was performed in January 2006., Selection Criteria: We included randomized or controlled clinical studies involving women who underwent cervical dilatation and uterine intervention for obstetrics and gynaecological conditions. We included studies which compared paracervical anaesthesia with no treatment, placebo, other methods of regional anaesthesia, systemic sedation and analgesia, or general anaesthesia., Data Collection and Analysis: Two authors independently evaluated the studies, extracted data, and checked and entered data into Review Manager., Main Results: This updated review includes nine new studies, in total 26 studies with 28 comparisons and involving 2790 participants. No study of local paracervical versus general anaesthesia met our criteria. Ten studies compared local anaesthetic versus placebo. Paracervical local anaesthetic (PLA) reduced pain on cervical dilatation with a standardized mean difference (SMD) of 0.37 (95% CI 0.17 to 0.58) and a relative risk (RR) of severe pain of 0.16 (95% CI 0.06 to 0.74). PLA also reduced abdominal pain during, but not after, uterine intervention (SMD 0.74, 95% CI 0.28 to 1.19); there was no evidence of any effect on postoperative back or shoulder pain. Comparisons against no treatment did not demonstrate any effect of PLA. Five studies compared paracervical block with uterosacral block, intracervical block, or intrauterine topical anaesthesia. Two of these studies showed no significant difference in pain during the procedure. Compared to intrauterine instillation, PLA slightly reduced severe pain (from 8.3 to 7.6 on a 10-point scale), which may be negligible. Six studies compared PLA with sedation. There were no statistically significant differences in pain during or after the procedure, postoperative analgesia requirement, adverse effects, patient satisfaction, and the operator's perception of analgesia. We performed risk of bias assessment using six domains and found that more than half of the included studies had low risk of bias., Authors' Conclusions: We found that no technique provided reliable pain control in the 26 included studies. Some studies reported that women experienced severe pain (mean scores of 7 to 9 out of 10) during uterine intervention, irrespective of the analgesic technique used. We concluded that the available evidence fails to show whether paracervical block is inferior, equivalent, or superior to alternative analgesic techniques in terms of efficacy and safety for women undergoing cervical dilatation and uterine interventions. We suggest that woman are likely to consider the rates and severity of pain during uterine interventions when performed awake to be unacceptable in the absence of neuraxial blockade, which are unaltered by paracervical block.

Background: An arteriovenous fistula is the optimal form of vascular access in patients with end-stage renal failure requiring haemodialysis. Unfortunately, approximately one-third of fistulae fail at an early stage. Different anaesthetic techniques can influence factors associated with fistula success, such as intraoperative blood flow and venous diameter. A regional anaesthetic brachial plexus block results in vasodilatation and improved short- and long-term fistula flow compared to the infiltration of local anaesthetic alone. This, however, has not yet been shown in a large trial to influence long-term fistula patency, the ultimate clinical measure of success.The aim of this study is to compare whether a regional anaesthetic block, compared to local anaesthetic infiltration, can improve long-term fistula patency., Methods: This study is an observer-blinded, randomised controlled trial. Patients scheduled to undergo creation of either brachial or radial arteriovenous fistulae will receive a study information sheet, and consent will be obtained in keeping with the Declaration of Helsinki. Patients will be randomised to receive either: (i) an ultrasound guided brachial plexus block using lignocaine with adrenaline and levobupivicaine, or (ii) local anaesthetic infiltration with lignocaine and levobupivicaine.A total of 126 patients will be recruited. The primary outcome is fistula primary patency at three months. Secondary outcomes include primary patency at 1 and 12 months, secondary patency and fistula flow at 1, 3 and 12 months, flow on first haemodialysis, procedural pain, patient satisfaction, change in cephalic vein diameter pre- and post-anaesthetic, change in radial or brachial artery flow pre- and post-anaesthetic, alteration of the surgical plan after anaesthesia as guided by vascular mapping with ultrasound, and fistula infection requiring antibiotics., Conclusions: No large randomised controlled trial has examined the influence of brachial plexus block compared with local anaesthetic infiltration on the long-term patency of arteriovenous fistulae. If the performance of brachial plexus block increases fistulae patency, this will have significant clinical and financial benefits as the number of patients able to commence haemodialysis when planned should increase, and the number of "redo" or revision procedures should be reduced., Trial Registration: This study has been approved by the West of Scotland Research Ethics Committee 5 (reference no. 12/WS/0199) and is registered with the ClinicalTrials.gov database (reference no. NCT01706354).

Background: While single shot femoral nerve blocks and indwelling femoral nerve catheters provide significant peri-operative analgesia, there are small but serious risks of neurovascular complications. We aimed to determine the incidence and characterise the nature of neural complications arising from femoral nerve blocks performed for knee surgery., Methods: One thousand eight hundred and two patients receiving a femoral nerve block for knee surgery during the study period were screened. Patients with possible neurological symptoms were evaluated with a detailed physical examination and self-report questionnaires. Also measures of depression, anxiety and tension/stress were collected., Results: In the patients screened, an incidence of 1.94% was found. Of the 24 patients available for testing, 4 had bilateral symptoms following bilateral nerve blocks. All had sensory abnormalities in the distribution of the femoral nerve. The incidence was significantly higher in females (females=2.5%, males=0.83% p=0.01) and in patients receiving a single shot block (single shot=2.66%, femoral catheter=0.93, p=0.01)., Conclusions: The incidence of neurological complication after FNB was higher in this series than typically reported and the symptoms significantly influenced the quality of life in the affected cases. The decision to include a femoral nerve block in the peri-operative analgesic regimen should be made on an individual basis considering the risks and benefits., (Copyright © 2012 Elsevier B.V. All rights reserved.)

Intra-operative, peri-articular injection of local anaesthesia is an increasingly popular way of controlling pain following total knee replacement. At the same time, the problems associated with allogenic blood transfusion have led to interest in alternative methods for managing blood loss after total knee replacement, including the use of auto-transfusion of fluid from the patient's surgical drain. It is safe to combine peri-articular infiltration with auto-transfusion from the drain. We performed a randomised clinical trial to compare the concentration of local anaesthetic in the blood and in the fluid collected in the knee drain in patients having either a peri-articular injection or a femoral nerve block. Clinically relevant concentrations of local anaesthetic were found in the fluid from the drains of patients having peri-articular injections (4.92 μg/ml (sd 3.151)). However, none of the patients having femoral nerve blockade had detectable levels. None of the patients in either group had clinically relevant concentrations of local anaesthetic in their blood after re-transfusion. The evidence from this study suggests that it is safe to use peri-articular injection in combination with auto-transfusion of blood from peri-articular drains during knee replacement surgery.

Our hypothesis was that the continuation of clopidogrel does not increase the risk of eye hemorrhage, compared to patients not treated with clopidogrel, when a peribulbar anesthesia is required. Our prospective case-control study enrolled two groups of 1,000 patients scheduled for intraocular eye surgery requiring a peribulbar block. Patients treated with clopidogrel were included in group A (1,000 patients). Patients who had never been treated with clopidogrel constituted the control group (group B, 1,000 patients). Hemorrhages were graded as follows: 1 = spot ecchymosis of eyelid and or subconjunctival hemorrhage; 2 = eyelid ecchymosis involving half the lid surface area; 3 = eyelid ecchymosis all around the eye, no increase in intraocular pressure; 4 = retrobulbar hemorrhage with increased intraocular pressure. Grade 1 hemorrhages were observed in 30 patients (3.0 %) in group A and in 20 patients (2.0 %) in group B. No grade 2, 3, or 4 hemorrhage was encountered. There was no significant difference in the grading of hemorrhage between the groups (p = 0.017). Clopidogrel was not associated with a significant increase in potentially sight-threatening local anesthetic complications.

Purpose: Assessment of the effectiveness of brachial plexus block (BPB) via axillary approach compared to regional anesthesia for arteriovenous fistula surgery in patients affected by end-stage renal disease., Methods: We compared forty patients randomly divided into two groups. Group A underwent BPB procedure with 15 mL ropivacaine 1% and 10 mL of saline (0.9% NaCl) via axillary approach. Group B received local anesthesia with lidocaine 2%. The forearm blood vessels were assessed by Doppler ultrasonography before and after the intervention., Results: BPB performed on Group A was associated with a considerable venous dilation and a significant decrease (48.7%, P<.05) in pulsatility index (PI) measured by Doppler ultrasound. In Group B, PI and venous dilation remained unaltered in the postoperative phase. No complications such as thrombosis or occlusion were encountered among patients who underwent BPB., Conclusions: The axillary-approached BPB was more advantageous than local anesthesia. Its effectiveness was because of venous dilation and the decrease in the PI, consequent to the reduction in peripheral resistances and the increase in local blood flow, thus offering an ideal background for fistula creation and short-term patency.