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Objective: With respect to the high failure rate of conventional IANB technique and other associated disadvantages, in this study we focused on an alternative called Water on Tray technique and assessed the efficiency of this method compared to the conventional technique. Materials and methods: This single-blind, single center randomized controlled trial was carried out among 90 individuals referred to the dental clinic of the International Branch of Guilan University of Medical Sciences (IB-GUMS) from November to December of 2017. The patients were randomly assigned into two groups. Injection pain was assessed using Numeric Rating Scale (NRS) and patients were asked to report any tingling sensation on the lip and tongue on the side of injection. Electric pulp test (EPT) and the stick test were also performed. If no numbness was report within 15 min, the injection was deemed unsuccessful. SPSS software version 25 was used with the significance level of p < 0.05. Results: The WOT technique demonstrated a significantly higher success rate of achieving adequate anesthesia on the first attempt (p < 0.05). Additionally, the WOT technique exhibited other significant advantages, including no instances of positive aspiration, rapid onset of action coupled with lingual nerve block, and reduced pain during injection. Conclusion: The Water on Tray is a favorable technique to achieve inferior alveolar nerve block due to its ease and high success rate compared to the conventional technique. Clinical relevance: This technique allows dentists to achieve a higher success rate with inferior alveolar nerve blocks and reduce injection pain in patients. [ABSTRACT FROM AUTHOR]

Objectives: This study aimed to assess the effect of needle insertion angle on pain during labial infiltration anesthesia in the anterior maxillary region. Material and Methods: In this parallel‐design randomized clinical trial, participants were randomly assigned to four groups for labial infiltration anesthesia of the anterior maxilla. Local anesthesia was performed with needle orientation parallel to the longitudinal axis of the tooth using a conventional syringe (Syringe‐0), needle at α angle with a conventional syringe (Syringe‐α), computer‐controlled local anesthetic delivery (CCLAD) device parallel to the longitudinal axis of the tooth (CCLAD‐0), and CCLAD at α angle (CCLAD‐α). The heart rate (HR), blood pressure (BP), and respiratory rate (RR) of participants were measured before needle insertion, immediately after needle insertion, and immediately after the injection by a vital signs monitor. The level of pain experienced by participants was quantified using a numerical rating scale (NRS). Data were analyzed by repeated‐measures ANOVA and regression models (α = 0.05). Results: Thirty‐six participants aged from 21 to 60 years, with a mean age of 35.36 years were recruited. The mean pain scores were 7.44, 4.67, 2.89, and 0.67 in groups Syringe‐0, Syringe‐α, CCLAD‐0, and CCLAD‐α, respectively (p < 0.001). Age and sex had no significant effect on pain scores (p = 0.914 and p = 0.702, respectively). The four groups had no significant difference in vital signs (p > 0.05). Conclusions: Injection at an α angle and the application of CCLAD can be used in clinical practice to decrease the pain experienced by participants during labial infiltration anesthesia of the anterior maxilla. Trial Registration: Iranian Registry of Clinical Trials: IRCT20230719058849N1. [ABSTRACT FROM AUTHOR]

ABSTRACT Objectives This study aimed to assess the effect of needle insertion angle on pain during labial infiltration anesthesia in the anterior maxillary region. Material and Methods In this parallel‐design randomized clinical trial, participants were randomly assigned to four groups for labial infiltration anesthesia of the anterior maxilla. Local anesthesia was performed with needle orientation parallel to the longitudinal axis of the tooth using a conventional syringe (Syringe‐0), needle at α angle with a conventional syringe (Syringe‐α), computer‐controlled local anesthetic delivery (CCLAD) device parallel to the longitudinal axis of the tooth (CCLAD‐0), and CCLAD at α angle (CCLAD‐α). The heart rate (HR), blood pressure (BP), and respiratory rate (RR) of participants were measured before needle insertion, immediately after needle insertion, and immediately after the injection by a vital signs monitor. The level of pain experienced by participants was quantified using a numerical rating scale (NRS). Data were analyzed by repeated‐measures ANOVA and regression models (α = 0.05). Results Thirty‐six participants aged from 21 to 60 years, with a mean age of 35.36 years were recruited. The mean pain scores were 7.44, 4.67, 2.89, and 0.67 in groups Syringe‐0, Syringe‐α, CCLAD‐0, and CCLAD‐α, respectively (p 0.05). Conclusions Injection at an α angle and the application of CCLAD can be used in clinical practice to decrease the pain experienced by participants during labial infiltration anesthesia of the anterior maxilla. Trial Registration Iranian Registry of Clinical Trials: IRCT20230719058849N1.

Abstract Background This study aimed to determine the nature, frequency, and characteristics of medical emergencies occurring at the King Abdulaziz University Dental Hospital. Materials and methods The incident reports of medical emergencies recorded at the King Abdulaziz University Dental Hospital from January 2008 to December 2022 were retrospectively reviewed. The annual/overall incidence of medical emergency events was calculated per 100,000 patients. The following characteristics of the patients/events were evaluated: age, gender, operator, procedure, location, timing of treatment, administration of local anesthesia, past medical history, symptoms, diagnosis, outcome, and disposition. Multivariable logistic regression models were used to investigate the associations of these characteristics with two outcomes: syncope and transfer to the emergency room (ER). Results The incidence of emergency events was 17.4 per 100,000 patients. Syncope and hypoglycemia were the most common emergencies. Most incidents recovered, with only 13% requiring transfer to the ER. Undergoing no procedure and American Society of Anesthesiologists (ASA) class 2,3 were associated with syncope. Undergoing a general dental procedure, ASA class 2,3, and a diagnosis other than hypoglycemia and syncope were associated with transfer to the ER. Conclusions The incidence of medical emergencies was low. Dental practitioners need to remain aware of the contributing factors, such as past medical history and anxiety, but medical emergencies can occur in healthy individuals as well. Preparation of the dental office, training of the personnel, and proper recording of the events are essential components of a well-established medical emergency protocol in dental institutions.

Background: This study aimed to determine the nature, frequency, and characteristics of medical emergencies occurring at the King Abdulaziz University Dental Hospital. Materials and methods: The incident reports of medical emergencies recorded at the King Abdulaziz University Dental Hospital from January 2008 to December 2022 were retrospectively reviewed. The annual/overall incidence of medical emergency events was calculated per 100,000 patients. The following characteristics of the patients/events were evaluated: age, gender, operator, procedure, location, timing of treatment, administration of local anesthesia, past medical history, symptoms, diagnosis, outcome, and disposition. Multivariable logistic regression models were used to investigate the associations of these characteristics with two outcomes: syncope and transfer to the emergency room (ER). Results: The incidence of emergency events was 17.4 per 100,000 patients. Syncope and hypoglycemia were the most common emergencies. Most incidents recovered, with only 13% requiring transfer to the ER. Undergoing no procedure and American Society of Anesthesiologists (ASA) class 2,3 were associated with syncope. Undergoing a general dental procedure, ASA class 2,3, and a diagnosis other than hypoglycemia and syncope were associated with transfer to the ER. Conclusions: The incidence of medical emergencies was low. Dental practitioners need to remain aware of the contributing factors, such as past medical history and anxiety, but medical emergencies can occur in healthy individuals as well. Preparation of the dental office, training of the personnel, and proper recording of the events are essential components of a well-established medical emergency protocol in dental institutions. [ABSTRACT FROM AUTHOR]

Background: The pain caused by local anesthetic injection can lead to patient anxiety prior to surgery, potentially necessitating sedation or general anesthesia during the excision procedure. In this study, we aim to compare the pain relief efficacy and safety of using a digital automatic anesthetic injector for local anesthesia. Methods: Thirty-three patients undergoing excision of a benign soft tissue tumor under local anesthesia were prospectively enrolled from September 2021 to February 2022. A single-blind, randomized controlled study was conducted. Patients were divided into two groups by randomization: the experimental group with digital automatic anesthetic injector method (I-JECT group) and the control group with conventional injection method. Before surgery, the Amsterdam preoperative anxiety information scale was used to measure the patients’ anxiety. After local anesthetic was administered, the Numeric Pain Rating Scale was used to measure the pain. The amount of anesthetic used was divided by the surface area of the lesion was recorded. Results: Seventeen were assigned to the conventional group and 16 to the I-JECT group. The mean Numeric Pain Rating Scale was 1.75 in the I-JECT group and 3.82 in conventional group. The injection pain was lower in the I-JECT group (p< 0.01). The mean Amsterdam preoperative anxiety information scale was 11.00 in the I-JECT group and 9.65 in conventional group. Patient’s anxiety did not correlate to injection pain regardless of the method of injection (p= 0.47). The amount of local anesthetic used per 1 cm2 of tumor surface area was 0.74 mL/ cm2 in the I-JECT group and 2.31 mL/cm2 in the conventional group. The normalization amount of local anesthetic was less in the I-JECT group (p< 0.01). There was no difference in the incidence of complications. Conclusion: The use of a digital automatic anesthetic injector has shown to reduce pain and the amount of local anesthetics without complication. [ABSTRACT FROM AUTHOR]

Background Acetabular fracture surgery can cause severe postoperative pain. A combined lumbar erector spinae plane block and paraspinous sagittal shift quadratus lumborum block may augment analgesia. Methods Fifty two patients undergoing posterior column acetabular surgery were divided into: Group Single puncture combined lumbar Erector spinae and Quadratus lumborum block (SEQ): patients who received SEQ block before anesthesia; and Group morphine (MOR), those who received general anesthesia (GA) and morphine. Results Demographic characteristics were comparable. The heart rate and mean arterial blood pressure were significantly lower in the SEQ group than in the MOR group between 60 and 180 min intraoperatively (P < 0.001). Postoperative resting and dynamic visual analogue scale scores in the SEQ group were significantly lower than those in the MOR group at all studied periods (P = 0.022–0.001), except at 20 and 24 h postoperatively. Fentanyl was required in all MOR group patients at a mean dose of 110.0 ± 28.42 µg while 18 patients required fentanyl in SEQ group at a mean dose of 60.55 ± 25.54 µg. Postoperative morphine consumption was significantly less in SEQ group (6.33 ± 2.37 mg) than MOR group (17.0 ± 2.55 mg). Postoperative nausea and vomiting were recorded in eight and four patients in MOR and SEQ group, respectively. No complications associated with the block technique were observed. Conclusions The SEQ block reduces the postoperative opioid consumption and provides stable intra and postoperative hemodynamics without observed complications in posterior column acetabular surgery.

Abstract Objective The present study compares the analgesic efficacy of two techniques to perform non-surgical reduction: fracture hematoma block and radial nerve supracondylar block. Methods Forty patients with fractures of the distal third of the radius, who required reduction, were selected in a quasi-randomized clinical trial to receive one of the anesthetic techniques. All patients signed the informed consent form, except for those who did not wish to participate in the study, had neurological injury, had contraindication to the procedure in the emergency room, or with contraindication to the use of lidocaine. To measure analgesia, the numerical pain rate scale was used at four different moments: preblock, postblock, during reduction, and after reduction; then three differences were calculated: the first between before and after blocking; the second between during reduction and after blockade; and the third between before blocking and after reduction. Results The fracture hematoma and supracondylar block groups showed the following mean values, respectively: 3.90 (1–10) and 3.50 (-6–10) in difference 1; 4.35 (-5–10) and 5.00 (-3–10) in difference 2; and 4.65 (1–10) and 3.80 (-3–10) in difference 3. Conclusion Both techniques proved to be efficient for analgesia, with mild superiority of hematoma block, but without statistical significance.

Abstract Carpal tunnel syndrome (CTS) is the most common compressive neuropathy in the human body. Its symptoms result from compression of the median nerve in the carpus. The treatment can be conservative, with medications and/or infiltrations that alleviate the symptoms, or surgical, which is more effective, with decompression of the median nerve by surgical section of the flexor retinaculum of the carpus. The anesthetic technique varies according to the anesthesia method: sedation, venous locoregional anesthesia and, more recently, wide-awake local anesthesia no tourniquet (WALANT), which can be performed by the surgeons themselves. The WALANT technique uses local anesthesia with a vasoconstrictor, and does not require the use of a tourniquet on the upper limb nor sedation. The median nerve block in ultrasound-guided WALANT provides better accuracy to the technique, with greater patient safety; in the present article, its use in the performance of carpal tunnel decompression is described, and the literature is reviewed.

Abstract This crossover study aimed to compare the anesthetic effects of buffered 2% articaine with 1:200,000 epinephrine with that of non-buffered 4% articaine with 1:200,000 epinephrine. Forty-seven volunteers were administered two doses of anesthesia in the buccal region of the second mandibular molars in two sessions using 1.8 mL of different local anesthetic solutions. The onset time and duration of pulp anesthesia, soft tissue pressure pain threshold, and the score of pain on puncture and burning during injection were evaluated. The operator, volunteers, and statistician were blinded. There were no significant differences in the parameters: onset of soft tissue anesthesia (p = 0.80), duration of soft tissue anesthesia (p = 0.10), onset of pulpal anesthesia in the second (p = 0.28) and first molars (p = 0.45), duration of pulp anesthesia of the second (p = 0.60) and first molars (p = 0.30), pain during puncture (p = 0.82) and injection (p = 0.80). No significant adverse events were observed. Buffered 2% articaine with 1:200,000 epinephrine did not differ from non-buffered 4% articaine with 1:200,000 epinephrine considering anesthetic success, safety, onset, duration of anesthesia, and pain on injection.

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Introduction. Pain is the most common cause of complaints in hospitalized pediatric patients. Pain continues to be underestimated and undertreated in childhood. The European Society of Pediatric Anesthetists has published guidelines for pain management in children. Pain assessment. Pain assessment is very important in the treatment of pain in children. Basic pain management. Administration of basic analgesics is crucial for pain management. Paracetamol and non-steroidal anti-inflammatory drugs. Generally, basic or simple analgesia includes the use of paracetamol and non-steroidal anti-inflammatory drugs. Systemic opioids. Opioids are reserved for early postoperative and intraoperative use when adequate monitoring and specially trained personnel are available around the clock. Regional anesthesia and local anesthetics. Regional anesthesia in children has been increasingly used in recent decades, particularly against the background of multimodal analgesia. Conclusion. Basic analgesics are crucial, and opioids are added only when needed. Regional anesthesia and local anesthetics play a superior role in pain management compared to systemic analgesics in such cases in pediatric patients. [ABSTRACT FROM AUTHOR]

ABSTRACT Purpose: The primary objective of this study was to compare the WALANT (wide awake, local anesthesia, no tourniquet) technique with local anesthesia associated with sedation in relation to pain intensity for minor hand surgical procedures. The secondary objective was to evaluate the need for analgesic complementation. Methods: A prospective, randomized, comparative, and clinical study was carried out. The sample size in each group was determined after statistical evaluation of the results of a pilot project. The participants were allocated to one of two groups; those in group 1 were submitted to the WALANT technique, and those in group 2, to local anesthesia associated with sedation, for elective surgery. The surgical procedures were carpal tunnel syndrome, De Quervain’s tenosynovitis, synovial cyst, finger cyst, and trigger finger. Pain intensity, need for complementation and evolution to complex regional pain syndrome were evaluated. Results: There was no difference between groups in pain intensity after WALANT and need for intraoperative complementation. There was no significant difference in the amount of opioid applied postoperatively between the groups. There was no difference between groups regarding comfort during surgery. There was no difference in adverse effects and complications between the groups. Hematoma was the most frequent adverse event. No severe adverse events were observed. Conclusions: The WALANT technique promoted an analgesic effect similar to that of local anesthesia associated with sedation, without increasing adverse effects.

Objective To observe the effect of thoracic paravertebral block (TPVB) combined with erector spinae plane block (ESPB) on postoperative analgesia and quality of recovery in patients underwent video-assisted thoracic surgery. Methods Ninety patients underwent video-assisted thoracic surgery were selected and randomly divided into the E group, the T group and the TE group (preoperatively receiving ultrasound-guided ESPB, TPVB and TPVB+ESPB, respectively), with 30 patients in each group. In the three groups, 0.5% ropivacaine 25 mL was used as local anesthetic. In the TE group, TPVB combined with ESPB was executed, and 5 and 20 mL local anesthetics were used successively. Patient-controlled intravenous analgesia (PCIA) was used as a rescue analgesia postoperatively. Data of hypesthesia at lateral chest wall at 30 min after completion of block, intraoperative incidence of hypotension and dosage of anesthetics were recorded. Patients were followed up for Numeric Rating Scales (NRS) score, time to first rescue analgesia, number of rescue analgesia, quality of recovery-15 score, analgesia satisfaction score, postoperative nausea and vomiting (PONV) scores in the first 24 h postsurgery and incidence of postoperative chronic pain at 6 months. Results The incidence of preoperative hypesthesia was higher in the TE group and the T group than that in the E group (P＜0.05). The intraoperative use of remifentanil was lower in the T group than that of the E group and the TE group, but the utilization rate of vasoconstricting drugs was the highest (P＜0.05). NRS scores at rest and coughing were lower in the T group than those in the E and TE groups (P＜0.05). There were no significant differences in the time to first rescue analgesia and the number of rescue analgesia between the three groups (P＞0.05). Compared with the E group, the T group had a better postoperative QoR-15 scores (P＜0.05), and the group TE had lower incidence of postoperative chronic pain (P＜0.05). There were no statistical differences in analgesia satisfaction scores and PONV scores between the three groups (P＞0.05). Conclusion The effects of TPVB+ESPB on postoperative analgesia and quality of recovery in patients underwent thoracoscopic surgery are not better than those of ESPB and TPVB, but it has a faster onset time of sensory block than ESPB and reduces the occurrence of postoperative chronic pain. [ABSTRACT FROM AUTHOR]

Aim: To evaluate the effectiveness of a thermo mechanical stimulation device (Buzzy®) in relation to pain, fear and anxiety during local anesthesia in children. Materials and methods: Study carried out from May 2018 to July 2019, with children aged 7 to 11 years, without previous experience involving anesthesia in the last 2 years and who needed dental treatment (extraction, restoration or endodontic) under local anesthesia in deciduous molars. The sample was randomized into a control group, which received conventional anesthesia, and an intervention group, which received anesthesia with Buzzy®. The levels of anxiety, fear and pain perception of both groups were verified using: Come Modified Picture Test (VPTM); heart rate; Behavioral Scale Come; Faces Pain Scale – Revised (FPS-R) and Face, Legs, Activity, Cry, Consolability (FLACC). Results: Most children (55%) had low anxiety before and after treatment (P

Introduction: Botulinum neurotoxin injection is a valuable treatment method for patients with myofascial pain syndrome in the infraspinatus muscle. However, there is no botulinum neurotoxin injection guideline, and the most appropriate injection site based on topographical anatomic information for this injection to effectively treat myofascial pain syndrome in the infraspinatus muscle is unclear. The purpose of this study was to evaluate the intramuscular nerve terminal of the infraspinatus muscle and to suggest the most efficient botulinum neurotoxin injection sites.Methods: This study used 5 formalin-embalmed and 10 fresh frozen cadavers with a mean age of 78.9 years. Sihler's staining was applied to evaluate the intramuscular nerve terminal of the infraspinatus muscle. The ultrasound scanning of the infraspinatus muscle was performed based on the surface landmarks and internal structures near the scapular region.Results: The intramuscular nerve terminal was mostly observed in the medial third area of the infraspinatus muscle. The deltoid tubercle, inferior angle, and acromion of the scapula are useful as surface landmarks to scan the infraspinatus muscle.Discussion: The proposed injection sites based on the intramuscular nerve terminal and surface landmarks can be regarded as accurate locations to reach the cluster area of the intramuscular nerve terminal and each compartment of the infraspinatus muscle to manage the myofascial pain syndrome in the infraspinatus muscle. [ABSTRACT FROM AUTHOR]

Objective: To evaluate the feasibility of posterior maxillary teeth extraction buccal infiltration with or without the use of palatal injection. Material and Methods: A total of 70 patients underwent extraction of bilateral maxillary posterior teeth under 2% lignocaine hydrochloride with 1:2,00000 adrenaline infiltration in this single-centric split-mouth randomized trial. The test side was administered with a buccal infiltration of 2 mL of anesthetic alone. An extended waiting period of 10 minutes was given before the commencement of the procedure. A standard protocol was followed for the control side. A single operator performed all extractions. Results: A total of 140 posterior maxillary teeth were extracted. Patients marked pain perception on a visual analogue scale in three different instances. During the administration of injections for the test side, the pain score was less than that of the control side and was statistically significant. The overall pain during the extraction procedure was comparable and statistically insignificant. The overall success of the method was 90%. Conclusion: Extraction of posterior maxillary teeth was feasible with a single buccal infiltration without palatal injection in most cases using an extended waiting period. Dentists can attempt extraction without palatal injections with optimal success. However, the alternate technique could be used when there is a necessity for rescue palatal anesthesia.

Introduction: Caudal block is frequently performed to provide analgesia for hypospadias repair. Literature suggests that pudendal block provides prolonged postoperative analgesia as compared with caudal block in children between 2 and 5 years. We compared the efficacy of pudendal and caudal blocks in children less than 2 years.Methods: 60 children scheduled for hypospadias repair received standard general anesthesia along with either pudendal or caudal block (groups of 30 each). Variables collected were demographic data, block time, operating room time, intraoperative pain medication need, pain assessment score and medication need in the recovery room and pain assessment at home.Result: Groups were demographically similar. No differences were observed in the following recorded times (minutes): block procedure (caudal: 9.5±4.0, pudendal: 10.6±4.1, p=0.30), anesthesia (caudal: 17.3±5.3, pudendal: 17.7±4.3, p=0.75), total OR (caudal: 171±35, pudendal: 172±41; p=0.95) and postanesthesia care unit (PACU) stay (caudal: 88±37, pudendal: 86±42; p=0.80). Additionally, no differences were observed in rescue pain medication need in the operating room (caudal: 0, pudendal: 2 (p=0.49), in PACU (caudal: 4, pudendal: 4, p=0.99), pain assessed at home, time to pain level 2 (caudal: 13.93±8.9, pudendal: 15.17±8.7), average pain scores (p=0.67) and total pain free epochs (pain level of zero) (p=0.80) in the first 24 hours.Discussion: In children less than 2 years, both blocks provide comparable intraoperative and postoperative pain relief in the first 24 hours after hypospadias surgery.Trial Registration Number: NCT03145415. [ABSTRACT FROM AUTHOR]

Introduction: Injecting mixtures of local anesthetics with or without adjuvants is a common practise in regional and particularly obstetric anesthesia to decrease block onset time and/or augment epidural analgesia for cesarean section. While evidence on the efficacy of this practise is equivocal, little is known about its safety in terms of the pharmacologic compatibility of local anesthetics., Methods: We assessed the grade of crystallization in individual mixtures of seven local anesthetics (bupivacaine, ropivacaine, lidocaine, procaine, chloroprocaine, mepivacaine, prilocaine) with or without four adjuvants (sodium bicarbonate, dexamethasone, clonidine, fentanyl) using a semiquantitative light microscopy scale (ranging from 0 to 5), repeatedly for up to 60 min and performed correlation analysis between grade of crystallization and initial solution pH., Results: Of the 50 mixtures tested, 26 showed grades of crystallization ≥4 at admixture and 41 showed grades of crystallization ≥4 after 60 min. The addition of adjuvants to local anesthetic mixtures did not substantially change the grades of crystallization. Bupivacaine has a slightly lower precipitation tendency, compared with ropivacaine. A moderate relationship was found between initial pH and grade of crystallization after 15 min for the adjuvant mixtures (R=0.33, p=0.04), but not at other time points., Discussion: The preparation of local anesthetic (±adjuvant) mixtures leads to high grades of crystallization, which increase over 60 min and appear independent of solution pH. The risk of mixing medications with unknown physical or chemical compatibility profiles in regional anesthesia should be critically appraised and its clinical significance elucidated in future translational research., Competing Interests: Competing interests: None declared., (© American Society of Regional Anesthesia & Pain Medicine 2025. No commercial re-use. See rights and permissions. Published by BMJ Group.)

Background: Speech-language pathologists (SLPs) perform nasal laryngoscopy (LE) to assess voice and dysphagia-related disorders. The procedural aspects may include the use of topical nasal anaesthesia., Aims: To explore the practice patterns of American Speech-Language-Hearing Association (ASHA)-certified SLPs use of anaesthesia during laryngeal endoscopy procedures in the United States METHODS & PROCEDURES: Data were collected via a brief computerized survey. A mixed methodology was employed. National representation across the United States was achieved., Outcomes & Results: Limited pre-licensure training in LE with the majority of educational content embedded in a voice course (64.7%) and post-academic training via live continuing education (CE) (58.8-72.5%). Pharmacology training was notably lacking in pre- and post-licensure groups. A total of 50% of post-licensure training occurred via interprofessional (IP) mentorship with significant correlations (LE confidence and skills r = 0.64, < 0.001, anaesthesia r = 0.74, < 0.001). However, when looking at confidence of knowledge as compared with skills for the procedure, 83% of participants reported high levels of confidence in their knowledge, yet 31.25% reported high levels of confidence in the skills to perform LE. Conversely, when looking at confidence of anaesthesia knowledge (20.83%) as compared with skills, participants were less confident in their knowledge yet more confident in the skills (31.25%) to administer anaesthesia., Conclusions & Implications: Bandura's Social Cognitive Learning Theory of 1986 with standardized use of vicarious and self-regulatory capabilities based on prior experiences and the use of IP mentorship during pre- and post-licensure education for LE may be beneficial in training. Limitations and suggestions for future research are additionally reported., What This Paper Adds: What is already known on this subject Laryngeal endoscopy is an advanced competency procedure completed by SLPs used in the evaluation and treatment of voice and swallowing disorders. Standards for competency lack consistency. Simultaneously, topical nasal anaesthesia may be a component of some exams, yet training and, subsequently, competency is inconsistent. Education and training for use of anaesthesia and navigating potential complications is not a required element of graduate training for SLPs. While SLPs may be independent practitioners of the laryngeal endoscopy procedure, it is unclear if they, or others, are administering the anaesthesia within an IP practice model. What this study adds to the existing knowledge Laryngeal endoscopy is comparatively new within the field of SLP. There are no studies investigating the knowledge, skills, and practice patterns of SLPs related to the use of anaesthetic agents during such procedures. This study adds to the literature regarding the practices of a sample of SLPs in the United States regarding use of topical anaesthesia during flexible laryngeal endoscopy, their training in topical anaesthesia and use/barriers of IP teams during flexible laryngeal endoscopy. Initial insight relative to the variability of training and practice is documented with potential learning needs for SLPs related to pharmacology, patient safety and IP practice. What are the practical and clinical implications of this work? This study offers considerations for SLP graduate and postgraduate training in the areas of topical nasal anaesthesia use and laryngeal endoscopy procedures. The results show variability in training for completion of these exams which may contribute to patient safety and outcomes. Promoting an IP approach to care, specifically roles and responsibilities related to use of anaesthesia, may further benefit those we serve., (© 2024 Royal College of Speech and Language Therapists.)

Introduction: Whether a popliteal plexus block improves postoperative pain following total knee arthroplasty remains debated. This randomized trial tested if adding a popliteal plexus block to a continuous femoral nerve block decreases postoperative opioid requirement., Methods: We included 66 patients undergoing total knee arthroplasty. 32 received continuous femoral nerve block and popliteal plexus block (intervention), and 34 received continuous femoral nerve block alone (control). The primary endpoint was the 12-hour postoperative morphine-equivalent consumption (mg). Secondary outcomes included opioid consumption, Visual Analog Pain Score (0-10), and sensorimotor extension of the block in postanesthesia care unit, at 12 hours, 24 hours and 48 hours postoperatively., Results: 66 patients with a median body mass index of 28.7 (IQR 26.3-33.8) were included in the study. In an intention-to-treat analysis, the median 12-hour morphine-equivalent consumption was lower in the intervention group (6.1 mg (0.5-14.5) vs 10 mg (5.0-17.3); one-sided Wilcoxon test (p=0.04)). The average pain intensity experienced in postanesthesia care unit was lower in the intervention group (median: 3.0 (3.0-5.0) vs 2.0 (1.0-4.0), two-sided Wilcoxon p=0.01) and fewer patients reported lateroposterior pain of the knee (11 (34.4%) vs 21 (61.8%) p=0.03). These benefits disappeared after 24 hours. The median duration of the popliteal plexus block procedure was 5.0 min (2.0-5.0)., Conclusions: Adding a popliteal plexus block to a continuous femoral nerve block decreases 12-hour opioid utilization, but the effect size is small, calling into question its clinical relevance., Trial Registration Number: NCT04048889., Competing Interests: Competing interests: Authors declare that they have none., (© American Society of Regional Anesthesia & Pain Medicine 2024. Re-use permitted under CC BY-NC. No commercial re-use. Published by BMJ Group.)

Background and Objectives: The subcostal transversus abdominis plane block (scTAPB) provides analgesia to the anterior abdominal wall but analgesic spread following a single injection remains modest and variable. The oblique scTAPB, which is performed with a continuous injection during needle progression into the TAP along the oblique subcostal line, may extend the block to the whole anterior abdominal wall but needle progression by hydrodissection may be difficult, explaining why this block is not widely used. This study investigated if two sequential scTAPB injections (2scTAPI) may reach more nerves than a single scTAPB (1scTAPI)., Methods: After institutional approval and under ultrasound guidance, a single injection of 20 mL of blue dye was performed in 16 cadaveric subjects into the TAP along the costal margin and lateral to the semilunaris line (1scTAPI). On the opposite side, a 20 mL of green solution was split into two injections (2scTAPI), using one injection medial and one lateral to the semilunaris line. Dye spread was assessed via gross anatomical dissection using an indirect method to quantify the involvement of the anterior cutaneous branches of the intercostal nerves with each technique. A nerve was considered stained if the dye was observed in the TAP, reaching the costal margin aligned with the bony extremity of its corresponding rib., Results: According to the spread to the costal margin, the estimated median number of consecutive nerves reached by dye after 2scTAPI was 5 (IQR 5-6) vs 3 (IQR 3-4) for 1scTAPI (p=0.00001). Spread after 2scTAPI suggested coverage of nerves originating from T8 to T12 in 85% of the subjects, and from T7 to T12 in 5 out of 17 cases. Spread following the 1scTAPI suggested coverage of nerves from T9 to T11 in most cases., Conclusions: In a cadaveric model, a larger spread at the costal margin was obtained after 2scTAPI, suggesting a greater coverage of anterior branches of abdominal wall nerves compared with 1scTAPI. Clinical studies are needed to confirm these results., Competing Interests: Competing interests: None declared., (© American Society of Regional Anesthesia & Pain Medicine 2024. No commercial re-use. See rights and permissions. Published by BMJ.)

Introduction: We systematically describe the morphology and accessibility of interspinous spaces across age groups of patients. Our primary goal was to objectively estimate if the maneuver space for a virtual spinal needle changes with age. Our secondary goal was to estimate if the optimal site and angle for midline neuraxial puncture change with age., Methods: Measurements were performed in mid-sagittal CT images. The CT images were retrospectively collected from the database of the Department of Radiology of our hospital. Three age groups were studied: 21-30 years (n=36, abbreviated Y(oung)), 51-60 years (n=43, abbreviated M(iddle-aged)) and older than 80 years (n=46, abbreviated Old).A needle trajectory is defined by the chosen puncture point and by the angle at which the needle is directed to its target. We define a Spinal Accessibility Index (SAI) by numerically integrating for an interspace all possible combinations of puncture points and angles that lead to a successful virtual puncture. Successful in this context means that the needle tip reaches the spinal or epidural space without bone contact. Reproducible calculation of the SAI was performed with the help of custom-made software. The larger the value of the SAI, the more possible successful needle trajectories exist that the practitioner may choose from.The optimal puncture point and optimal angle in an age group at a certain level of the spine are defined by the combination of these two, which generates the highest success rate of the entire sample of this age group., Results: At all levels of the spine, the median SAI differed significantly between age groups (independent-samples Kruskal-Wallis test, p<0.001-0.047). The SAI consistently decreased with increasing age. Post-hoc analyses using pairwise comparisons showed a significantly higher SAI in group Y versus Old at all levels (p<0.001-0.006) except at level thoracic (Th)1-Th2 (p=0.138). The SAI was significantly higher in group M versus Old at all levels (p<0.001-0.028) except at level Th1-Th2 (p=0.061), Th4-Th5 (p=0.083), Th9-Th10 (p=1.00) and Th10-Th11 (p=1.00)., Conclusions: Needle maneuver space in midline neuraxial puncture significantly decreases with progressive age at all levels of the spine. Optimal puncture points and angles are similar between age groups., Competing Interests: Competing interests: None declared., (© American Society of Regional Anesthesia & Pain Medicine 2024. No commercial re-use. See rights and permissions. Published by BMJ.)

Background: Carpal tunnel release can be performed as open or endoscopic surgery. In WALANT (wide awake local anesthesia no tourniquet) a tourniquet is not used, ensuring less discomfort for the patient. In locoregional distal nerve block, on the other hand, a tourniquet is needed and can be painful. This raises the question as to which method of anesthesia is actually preferred for the patient and the surgeon. Patients undergoing staged bilateral carpal tunnel release present a unique opportunity to study this question., Methods: Fifteen patients were included in this prospective study. The primary endpoint was the preference for anesthesia type in patients and surgeons. Surgeon preference was based on the visibility and fluency of the procedure. Secondary endpoints for patients comprised pain scores for performing surgery and anesthesia and pain caused by the tourniquet., Results: Baseline demographic and clinical information was collected. There was no significant difference in pain for performing local anesthesia or surgery. Surgeons may find that performing endoscopic release under WALANT is more challenging, as visibility tends to be significantly poorer. The mean pain caused by the tourniquet used during the wrist block procedure was rated as 3.6. In both surgeries, 77% (10/13) of the patients preferred the WALANT anesthesia., Conclusion: In general, endoscopic carpal tunnel release was better tolerated under WALANT than locoregional distal nerve block. Although statistical analysis showed no significant difference in visibility and fluency for the surgeon between the two anesthesia techniques, we do not recommend endoscopic release under WALANT due to the consistent report of reduced visibility in the surgical field. This limitation, likely related to the presence of anesthetic fluid, may have failed to reach statistical significance due to small sample size, but is nevertheless a considerable challenge in practice., Level of Evidence: 1B., Competing Interests: Declaration of competing interest The authors have no conflicts of interest to declare., (Copyright © 2024 SFCM. Published by Elsevier Masson SAS. All rights reserved.)

Pain management remains among the most common and largely unmet clinical problems today. Local anesthetics play an indispensable role in pain management. The main limitation of traditional local anesthetics is the limited duration of a single injection. To address this problem, catheters are often placed or combined with other drugs in clinical practice to increase the time that local anesthetics act. However, this method does not meet the needs of clinical analgesics. Therefore, many researchers have worked to develop local anesthetic extended-release types that can be administered in a single dose. In recent years, drug extended-release systems have emerged dramatically due to their long duration and efficacy, providing more possibilities for the application of local anesthetics. This paper summarizes the types of local anesthetic drug delivery systems and their clinical applications, discusses them in the context of relevant studies on local anesthetics, and provides a summary and outlook on the development of local anesthetic extended-release agents.

Background and Objectives: The transversus abdominis plane (TAP) block is the most widely used abdominal field block in colorectal surgery with a postoperative enhanced recovery pathway. We aimed to determine whether the laparoscopic-assisted and ultrasound-guided TAP (US-TAP) blocks provide superior pain relief compared with placebo. We separately investigated whether the laparoscopic-assisted technique was non-inferior to the ultrasound-guided technique in providing pain relief, with a non-inferiority margin of 10 mg morphine dose equivalents., Methods: 340 patients undergoing elective minimally invasive colon surgery were randomly allocated to one of three groups: (1) US-TAP block, (2) laparoscopic-assisted TAP (L-TAP) block, or (3) placebo. Superiority and non-inferiority were tested for the primary outcome: 24-hour postoperative morphine equivalent consumption. Secondary outcomes, including patient-reported quality of recovery, were included in the superiority analysis., Results: 127 patients were included in each block group and 86 in the placebo group. The US-TAP block was no different from placebo at -1.4 mg morphine (97.5% CI -6.8 to 4.0 mg; p=0.55). The L-TAP block was superior to placebo at -5.9 mg morphine (97.5% CI -11.3 to -0.5 mg; p=0.01) and non-inferior to the US-TAP block at -4.5 mg morphine (98.75% CI -10.0 to 1.1 mg)., Conclusion: The L-TAP block was superior to placebo and non-inferior to the US-TAP block. However, neither met our predetermined estimate of the minimal clinically important difference of 10 mg morphine., Trial Registration Number: NCT04311099., Competing Interests: Competing interests: None declared., (© American Society of Regional Anesthesia & Pain Medicine 2024. Re-use permitted under CC BY-NC. No commercial re-use. Published by BMJ.)

Introduction: Postoperative pain after laparoscopic abdominal surgery remains complex. While lateral quadratus lumborum (QL) block and transversus abdominus plane (TAP) block are similar techniques, no studies have examined if one technique has greater dermatomal spread., Methods: Laparoscopic colorectal surgical patients were randomized to lateral QL or TAP blocks. Dermatomal anesthetic spread, as measured by loss of sensation to temperature in the postanesthesia care unit, was the primary outcome. If a clear level of dermatomal anesthesia could not be defined, the block was categorized as "indeterminate." Secondary outcomes included opioid consumption, pain scores, and opioid-related side effects., Results: 153 patients completed the study (75 QL and 78 TAP). Mean (95% CI) number of dermatomes with loss of sensation to ice was greater in subjects randomized to QL (4.2 (3.7 to 4.8)) versus TAP (2.7 (2.2 to 3.2); p=0.0001), and the QL group was more likely to have loss of sensation above T8 (p=0.01) and T10 (p=0.02). Indeterminate block was more often noted with TAP blocks (p<0.0001). Opioid consumption at 24 hours, pain scores, and opioid-related side effects did not differ., Discussion: Compared with TAP blocks, QL blocks had greater dermatomal anesthesia spread and lower rates of an indeterminate block. However, differences in pain and opioid consumption were not noted. The clinical importance of these findings should be investigated in future trials., Trial Registration Number: NCT03490357., Competing Interests: Competing interests: All the authors declare that they do not have any competing interests with the production of this paper., (© American Society of Regional Anesthesia & Pain Medicine 2024. No commercial re-use. See rights and permissions. Published by BMJ.)

Background: Surgery induces a temporal change in the immune system, which might be modified by regional anesthesia. Applying a bilateral preoperative anterior quadratus lumborum block has proven to be a safe and effective technique in pain management after abdominal and retroperitoneal surgery, but the effect on the immune response is not thoroughly investigated., Methods: This study is a substudy of a randomized, controlled, double-blinded trial of patients undergoing laparoscopic hemicolectomy due to colon cancer. Twenty-two patients were randomized to undergo either a bilateral anterior quadratus lumborum nerve block with a total of 60 mL ropivacaine 0.375% or placebo with corresponding isotonic saline injections. The main objective of this exploratory substudy was to investigate the systemic immune response in the first postoperative day by examining changes in blood transcript levels (n=750) and stimulated secretion of cytokines (n=17) on ex vivo activation with microbial ligands and anti-CD3/CD28., Results: Using unsupervised data analysis tools, we observed no effect of the bilateral anterior quadratus lumborum nerve block on gene expression in immune cells (permutational multivariate analysis of variance using distance matrices: F=0.52, p=0.96), abundances of major immune cell populations (Wilcoxon rank-sum test: p>0.05), and stimulated cytokine secretion (Wilcoxon rank-sum test: p>0.05)., Conclusions: Our study provides evidence that administration of bilateral anterior quadratus lumborum nerve block as a part of a multimodal analgesic regimen in an enhanced recovery after surgery for laparoscopic hemicolectomy in this cohort does not alter the systemic immune response. Trial registration number NCT03570541., Competing Interests: Competing interests: None declared., (© American Society of Regional Anesthesia & Pain Medicine 2024. No commercial re-use. See rights and permissions. Published by BMJ.)

Background: Inconsistent nomenclature and anatomical descriptions of regional anesthetic techniques hinder scientific communication and engender confusion; this in turn has implications for research, education and clinical implementation of regional anesthesia. Having produced standardized nomenclature for abdominal wall, paraspinal and chest wall regional anesthetic techniques, we aimed to similarly do so for upper and lower limb peripheral nerve blocks., Methods: We performed a three-round Delphi international consensus study to generate standardized names and anatomical descriptions of upper and lower limb regional anesthetic techniques. A long list of names and anatomical description of blocks of upper and lower extremities was produced by the members of the steering committee. Subsequently, two rounds of anonymized voting and commenting were followed by a third virtual round table to secure consensus for items that remained outstanding after the first and second rounds. As with previous methodology, strong consensus was defined as ≥75% agreement and weak consensus as 50%-74% agreement., Results: A total of 94, 91 and 65 collaborators participated in the first, second and third rounds, respectively. We achieved strong consensus for 38 names and 33 anatomical descriptions, and weak consensus for five anatomical descriptions. We agreed on a template for naming peripheral nerve blocks based on the name of the nerve and the anatomical location of the blockade and identified several areas for future research., Conclusions: We achieved consensus on nomenclature and anatomical descriptions of regional anesthetic techniques for upper and lower limb nerve blocks, and recommend using this framework in clinical and academic practice. This should improve research, teaching and learning of regional anesthesia to eventually improve patient care., Competing Interests: Competing interests: EA: grants from Swiss Academy for Anesthesia Research, Bbraun, Swiss National Science Foundation. Honoraria from Bbraun and Sintetica. JG: consulting fees from Pacira Biosciences and Pajunk Medical. AP: honoraria from FuijiFilm Sonosite. MW: advisory Board for Sintetica, Honoraria from Wisonic and Medovate. SA: Advisory Panel for DATAR innovations. JA: moderator of the Working Group Regional Anaesthesia Switzerland, Honoraria from Medtronic and Sintetica. AMRA: honoraria form AllerganSébastien Bloc—Consulting fees from BBraun—GE Medical Systems—Pajunk—Pfizer SAS. JB: Consulting fees from Intelligent Ultrasound. BC: jonoraria from Bbraun and Rivanna, Consulting from Stryker and Flat Medical, Research funding from Pacira, Share Options from Flat Medical. AC: speaking honoraria from GE Healthcare, royalties from textbook Oxford University Press. SC: consulting fees from MSD, Bbraun Medical, Wisonic, research grants from BARA (Belgian association of Regional anesthesia), ESRA and BeSARP (Belgian anesthesia society) HE-Consulting/Advisory Board Neuronoff, SPR, GateScience, NeuronoffBenjamin Fox—Speaking fees from Medovate and Sintetica. SG: consulting and speaking fees from MSD Switzerland. PH: royalties from Bestek Products. NH: Honoraria from Butterfly Network. RMGH- Honoraria from GE Healthcare. MH: consulting fees from Pacira Biosciences, Honoraria from Parcira Biosciences and Pajunk Medical. BMI: research funding to institution from SPR Therapeutics, Infutronix, Epimed International. AM: Consultant fees from Intelligent Ultrasound. CM: consultant fees from Masimo Corporation. SGM: Owner SGM Consulting, Partner Parvizi Surgical Innovations, Patent for Multicatheter infusion system. AN: Research support from SPR Therapeutics. SLO: Royalties from book Wolters-Kluwer. APawa: Honoraria from GE Healthcare, Consulting fees from Pacira Biosciences. PP: equipment support from Sonosiite Fujifilm Canada. MPS: Medovate speaking but no honoraria paid. SKS- Cofounder of Gate Science (developing a catheter for performing nerve blocks) JS: consulting fees from Sintetica. RT: Consulting fees from Clarius Mobile Health. VU: Associate Editor of the Canadian Journal of Anesthesia and Regional Anesthesia & Pain Medicine journals. TV: honoraria from CSL Behring, Pajunk., (© American Society of Regional Anesthesia & Pain Medicine 2024. No commercial re-use. See rights and permissions. Published by BMJ.)

Introduction: Local anaesthesia (LA) is fundamental to successful dental treatment. Graduating hygienists, therapist and dentists should be confident and proficient in delivering LA. There is one previously published article reviewing LA teaching in United Kingdom (UK) dental schools in 2016, and at this time 10 out of 14 schools allowed peer-to-peer administration. The method of teaching LA administration has become an area of debate in terms of legality and morality given the potential complications and issues with valid consent. The aim of the study was to explore current teaching practices and assessment of LA in UK dental schools., Materials and Methods: Two national surveys (2020 and 2023) were sent out via the ABAOMS Education Committee to all 16 dental schools in the United Kingdom with dental and/or hygiene and therapy programmes., Results: There was a 100% response rate from all schools. There has been a significant shift from peer-to-peer administration of local anaesthesia, with only 4 schools now allowing peer-to-peer administration. The majority of schools use simulation methods to deliver the teaching, including LA models, cadavers and 'cap-on' simulation with a peer. When comparing the timing of teaching between 2020 and 2023, BDS students now administer their first LA injection to a patient later in the programme, and there has been a reduction in intra-professional teaching., Conclusion: Due to the large shift away from practicing LA on peers, there is a need for further development of simulation methods given the drawbacks with current models and the limited development of haptic technology in relation to LA., (© 2024 The Author(s). European Journal of Dental Education published by John Wiley & Sons Ltd.)

Regulations that restrict the tasks that credentialed workers are allowed to perform may affect a firm's input choices, output, and which part of the market the firm serves. Using dental practice survey data from 1989 to 2014 and a stacked difference-in-differences design, this paper examines the effects of state-level scope of practice regulations on the behavior of dental practices. Results suggest that scope of practice deregulation in regards to dental hygienists' ability to administer nitrous oxide or local anesthesia is associated with fewer dentist visits per week in the short-term, lower patient wait times, and an increased likelihood of treating lower revenue generating publicly insured patients. There is weak evidence that scope of practice deregulation alters a practice's labor inputs., (© 2024 The Author(s). Health Economics published by John Wiley & Sons Ltd.)

Purpose: Wide awake local anesthesia no tourniquet (WALANT) is gaining popularity with flexor tendon repair. We hypothesized that results of zone II flexor tendon repair performed under WALANT would be superior to those performed under general anesthesia (GA)., Methods: A randomized controlled trial was conducted to compare results of repair of zone II flexor tendon lacerations under WALANT versus GA. Following sample size estimation, 86 digits were included and randomized into two groups. All surgeries were performed by a single surgeon using a six-stranded core stitch and running epitenon suture. All patients followed the same early active rehabilitation protocol. The primary outcome was recovery calculated using the Strickland and Glogovac criteria. Secondary outcomes included rupture rate, complication rate, and Disabilities of the Arm, Shoulder, and Hand (DASH) score. All outcomes were reported at the 6-month visit for all patients., Results: Of the 86 digits, three were lost to follow-up. Analysis was performed on 43 digits in the WALANT group and 40 in the GA group. Demographic characteristics including age and sex were comparable in both groups. Rupture of the repair occurred in two digits in each of the WALANT and GA groups. An excellent or good outcome was achieved in 49% and 56% of the digits in the WALANT and GA groups, respectively. This difference was not statistically significant. DASH scores averaged 12.9 and 8.4 for the WALANT and GA groups, respectively., Conclusions: WALANT may not be superior to GA in regards function, rates of rupture, and patient-reported outcomes in repair of zone II flexor tendon lacerations. Surgeons can be confident in choosing either technique if rigorous patient selection, sound surgical technique, and proper hand therapy are employed., Type of Study/level of Evidence: Therapeutic I., Competing Interests: Conflicts of Interest No benefits in any form have been received or will be received related directly to this article., (Copyright © 2024 American Society for Surgery of the Hand. Published by Elsevier Inc. All rights reserved.)

ABSTRACT Objective: assess pain and opioid consumption in patients undergoing anesthetic techniques of spinal erector plane block and local anesthetic block in video-assisted thoracic surgery in the immediate postoperative period. Methods: ninety-two patients undergoing video assisted thoracic surgery were randomized to receive ESPB or BAL before starting the surgical procedure. Using the numerical verbal scale, the primary outcome assessed was the patient’s pain in the immediate postoperative period (POI). The secondary outcome comprises the assessment of opioid consumption in the IPP by quantifying the medication used in an equianalgesic dose of morphine expressed in milligrams, in the immediate post-anesthetic recovery period, 6h, 12h, and 24h after surgery. Results: the EVN scores in the LBA and ESPB group in the POI had a mean of 0,8 (±1,89) vs 0,58 (±2,02) in the post-anesthesia care room (REPAI), 1,06 (±2,00) vs 1,30 (±2,30) in 6 hours of POI, 0,84 (±1,74) vs 1,19 (±2,01) within 12 hours of POI and 0,95 (±1,88) vs 1 ( ±1,66) within 24 hours of POI, all with p>0.05. Mean opioid consumption in the BAL and ESPB groups in the POI was 12.9 (± 10.4) mg vs 14.9 (±10.2) mg, respectively, with p = 0.416. Sixteen participants in the ESPB group and seventeen in the BAL group did not use opioids during the first 24 hours of the PO analyzed. Conclusion: local anesthesic block and ESP block techniques showed similar results in terms of low pain scores and opioid consumption during the period evaluated.

Introduction: Patients with refractory chronic migraine have poor quality of life. Intravenous infusions are indicated to rapidly 'break the cycle' of pain. Lidocaine infusions may be effective but evidence is limited.Methods: The records of 832 hospital admissions involving continuous multiday lidocaine infusions for migraine were reviewed. All patients met criteria for refractory chronic migraine. During hospitalization, patients received additional migraine medications including ketorolac, magnesium, dihydroergotamine, methylprednisolone, and neuroleptics. The primary outcome was change in headache pain from baseline to hospital discharge. Secondary outcomes measured at the post-discharge office visit (25-65 days after treatment) included headache pain and the number of headache days, and percentage of sustained responders. Percentage of acute responders, plasma lidocaine levels, and adverse drug effects were also determined.Results: In total, 609 patient admissions met criteria. The mean age was 46±14 years; 81.1% were female. Median pain rating decreased from baseline of 7.0 (5.0-8.0) to 1.0 (0.0-3.0) at end of hospitalization (p<0.001); 87.8% of patients were acute responders. Average pain (N=261) remained below baseline at office visit 1 (5.5 (4.0-7.0); p<0.001). Forty-three percent of patients were sustained responders at 1 month. Headache days (N=266) decreased from 26.8±3.9 at baseline to 22.5±8.3 at the post-discharge office visit (p<0.001). Nausea and vomiting were the most common adverse drug effects and all were mild.Conclusion: Lidocaine infusions may be associated with short-term and medium-term pain relief in refractory chronic migraine. Prospective studies should confirm these results. [ABSTRACT FROM AUTHOR]

Abstract Objective: To compare the use of 2 different local anesthetic solution (LAS) volumes of 1.5 mL and 3 mL in retrobulbar block in patients undergoing cataract surgery in terms of anesthesia, akinesia, and pain levels. Methods: 80 patients between 18-90 years old, ASA I-II-III, were included in the study. For retrobulbar anesthesia, 1.5 mL LAS was applied to one group (Group LV), and 3 mL LAS to the other group (Group HV). The patients' ocular and eyelid motion scores were evaluated and recorded in the first, third, fifth, and tenth minutes after the block, and at 30-minute intervals for 4 hours post-operatively. One day later, the first hour of analgesic need and the number of times they took analgesic agents were asked and recorded. In addition, side effects were questioned and recorded. Results: The 39 (48.75%) patients were male and 41 (51.25%) patients were female. The criteria determined in terms of ocular motor score after the retrobulbar block (ocular motor score≤4) were met in 92.5% of patients in Group LV in all patients in Group HV, and the time to fulfill the determined criteria in Group HV was found to be significantly lower compared to Group LV (p=0.004). The movements of the eye in all direction except the inward movement recovered in Group LV in a significantly shorter time than Group HV (p=0.004). There was no significant difference in pain levels and side effects between the groups (p=0.34). Conclusions: After 1.5 mL LAS administration in retrobulbar block, adequate akinesia was not achieved in about one tenth of patients, but no significant difference was found between 1.5 mL and 3 mL LAS volumes in analgesic efficacy and side effects.

Surgical management of carotid stenosis has evolved from open carotid endarterectomy (CEA) to include multiple alternative procedures including transfemoral carotid artery stenting (tfCAS) and transcarotid artery stenting. In recent years, Transcarotid Artery Revascularization (TCAR) has emerged as a third option, combining open cut down to the common carotid artery (CCA) with endovascular stenting and neuroprotection via reversal of cerebral blood flow. In this case series, a modified TCAR procedure using a prosthetic conduit was successfully performed exclusively under local anesthesia in a total of 10 patients with carotid artery stenosis, high cardiac risk, and anatomical contraindications to a traditional TCAR., Competing Interests: Declaration of conflicting interestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Introduction: Transdermal laser is an option for varicous veins treatment, yet it may be painful. In this study, we will present a technique for performing tumescent anesthesia associated to transdermal laser (TTL) to reduce pain during treatment., Objective: The study compares pain during treatment of telangiectasias in lower limb with and without tumescent anesthesia to offer a less painful procedure., Methods: 50 CEAP C1 patients with bilateral telangiectasias on thighs underwent transdermal laser treatment, using tumescent anesthesia on one side and standard technique on the other. Pain was assessed via the Visual Analogue Scale. The outcomes were compared with Student's t-test. Significance was set at p < .05., Results: Laser treatment without tumescent anesthesia resulted in a VAS pain score of 7.9, versus 0.0 with anesthesia, showing a significant statistical difference., Conclusion: Tumescent anesthesia and transdermal laser (TTL) is capable of reducing pain in laser treatment of telangiectasias and reticular veins., Competing Interests: Declaration of conflicting interestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Objective: To evaluate the level of pain experienced during infiltration anesthesia of the anterior maxilla following low-level laser therapy (LLLT) with 810-980 nm wavelengths. Material and Methods: In the current triple-blind clinical trial, 84 patients received a total of 168 infiltration anesthesia injections (1.8 mL of 2% lidocaine plus 1:100,000 epinephrine) in the anterior maxilla. Each patient received two injections into the buccal mucosa of the right and left central incisors with a two-week interval. One injection was performed after LLLT, while the other injection was administered conventionally without laser. The pain level was measured immediately after injection using a visual analog scale (VAS). Results: There was a significant difference in the pain level experienced with and without LLLT, such that the mean pain score following LLLT was significantly lower than that without LLLT (p

ABSTRACT BACKGROUND: There are several anesthetic techniques for surgical treatment of carpal tunnel syndrome (CTS). Results from this surgery using the “wide awake local anesthesia no tourniquet” (WALANT) technique have been described. However, there is no conclusive evidence regarding the effectiveness of the WALANT technique, compared with the usual techniques. OBJECTIVE: To evaluate the effectiveness of the WALANT technique, compared with intravenous regional anesthesia (IVRA; Bier’s block), for surgical treatment of CTS. DESIGN AND SETTING: Randomized clinical trial, conducted at Hospital Alvorada Moema and the Discipline of Hand Surgery, Universidade Federal de São Paulo (UNIFESP), São Paulo (SP), Brazil. METHODS: Seventy-eight patients were included. The primary outcome was measurement of perioperative pain through a visual analogue scale (VAS). The secondary outcomes were the Boston Questionnaire score, Hospital Anxiety and Depression Scale (HADS) score, need for use of analgesics, operating room times, remission of paresthesia, failures and complications. RESULTS: The WALANT technique (n = 40) proved to be superior to IVRA (n = 38), especially for controlling intraoperative pain (0.11 versus 3.7 cm; P < 0.001) and postoperative pain (0.6 versus 3.9 cm; P < 0.001). Patients spent more time in the operating room in the IVRA group (59.5 versus 46 minutes; P < 0.01) and needed to use more analgesics (10.8 versus 5.7 dipyrone tablets; P = 0.02). Five IVRA procedures failed (5 versus 0; P = 0.06). CONCLUSIONS: The WALANT technique is more effective than IVRA for CTS surgery.

Objective To compare the electrophysiological results of subthalamic nucleus deep brain stimulation (STN⁃DBS) for the treatment of Parkinson's disease (PD) under local or general anesthesia. Methods The data of 44 patients with PD who underwent STN⁃DBS surgery were retrospectively analyzed from January 2017 to October 2019. Among them, 22 cases were performed under general anesthesia with bispectral index (BIS), and the other 22 were implanted under local anesthesia. Microelectrode recording (MER) was used in 2 groups to locate the STN during operation and the electrophysiological signal length and the radial error of the electrode target after the MRI or CT reexaimined were analyzed and compared between 2 groups. Results Both general anesthesia group and local anesthesia group recorded typical discharges of the STN and located its sensorimotor function sub⁃regions. When the BIS value of patients in general anesthesia group was adjusted to 70 or above, their STN electrophysiological conditions were consistent with those under local anesthesia. There was no statistically significant difference in the electrophysiological length of bilateral STN between general anesthesia group and local anesthesia group [left (5.46 ± 0.98) mm vs. (5.30 ± 0.91) mm; t = 0.561, P = 0.578; right (5.21 ± 0.85) mm vs. (5.21 ± 1.21) mm; t = 0.000, P = 1.000]. There was no statistically significant difference in Unified Parkinson's Disease Rating Scale⁃Ⅲ (UPDRS⁃Ⅲ) score (16.37 ± 0.83 vs. 16.20 ± 0.98; t = 0.621, P = 0.538) and incidence of adverse reactions [68.18% (15/22) vs. 72.73% (16/22); χ2 = 0.109, P = 0.741] between 2 groups. After reexamination of MRI or CT and fusion with intraoperative MRI, there was no statistically significant difference in the radial error of the bilateral electrode targets between 2 groups [left (1.24 ± 0.56) mm vs. (1.18 ± 0.52) mm; t = 0.337, P = 0.738; right (1.10 ± 0.45) mm vs. (1.05 ± 0.53) mm, t = 0.368, P = 0.715]. Conclusions The typical discharge of STN could be recorded in both local and general anesthesia STN⁃DBS groups, and the sensory ⁃ motor area of STN could also be accurately indentified through its discharge. There is no significant difference in the length of STN electrophysiological signal and electrode error between 2 groups. The results showed that the precise implantation of intracranial electrodes in STN⁃DBS surgery could be performed under local or general anesthesia. DOI：10.3969/j.issn.1672⁃6731.2020.12.005

Objective To compare the efficacy of local anesthesia and general anesthesia of subthalamic nucleus deep brain stimulation (STN⁃DBS) for Parkinson's disease (PD). Methods Forty PD patients who underwent bilateral STN ⁃ DBS from January 2015 to January 2018 were retrospectively analyzed. Twenty⁃two patients underwent local anesthesia and 18 patients underwent general anesthesia. Pre⁃ and post⁃operative Unified Parkinson's Disease Rating Scale⁃Ⅲ (UPDRS⁃Ⅲ), Hoehn⁃Yahr, Activities of Daily Living (ADL), Wechsler Adult Intelligence Scale (WAIS), Wechsler Memory Scale (WMS), Hamilton Depression Rating Scale (HAMD)⁃17 and Hamilton Anxiety Rating Scale (HAMA)⁃14 were used to assess the motor symptoms, daily living function, cognitive function, memory, anxiety and depression. Results The target deviation of the second electrode in general anesthesia group was lower than that in local anesthesia group [(0.98 ± 0.39) mm vs. (1.21 ± 0.35) mm; t = ⁃ 2.041, P = 0.048], the target deviation of the first electrode was not statistically significant [(0.96 ± 0.29) mm vs. (1.01 ± 0.35) mm; t = ⁃ 0.496, P = 0.623]. At 6, 12, and 24 months after surgery, the "on" and "off" UPDRS⁃Ⅲ scores (P = 0.001, for all) and Hoehn⁃Yahr (P = 0.001, for all) in the general anesthesia group and the local anesthesia group were all significantly decreased compared with baseline, ADL score significanly increased (P = 0.001, for all). There were no significant differences in "on" and "off" UPDRS⁃Ⅲ, Hoehn⁃Yahr, ADL, WAIS and WMS scores between 2 groups (P > 0.05, for all). One day after surgery, the HAMA⁃14 in the local anesthesia group was higher than baseline (P = 0.027), in the general anesthesia group, HAMD⁃17 (P = 0.008) and HAMA⁃14 (P = 0.001) scores were lower than 1 d before surgery. The HAMD⁃17 (P = 0.001, for all) and HAMA ⁃ 14 (P = 0.001, for all) of 2 groups at 6, 12 and 24 months after surgery were all lower than baseline, 1 d before and 1 d after surgery. HAMD⁃17 score in the general anesthesia group was lower than the local anesthesia group (P = 0.048). Conclusions Both general anesthesia and local anesthesia STN⁃DBS can significantly improve PD motor symptoms and quality of life, as well as relieve the depression and anxiety symptoms, without affecting cognitive function and memory. Attention should be paid to mood fluctuations in using different anesthesia during the perioperative period. Choice of anesthesia method should be based on the patient's condition and indications. DOI：10.3969/j.issn.1672⁃6731.2020.12.006

Introduction: Different methods have been proposed for the reduction of the pain caused by the injection of local anesthetics. This study aimed to evaluate the effect of skin cooling on reduction of pain associated with local injection of lidocaine buffered with sodium bicarbonate. Methods: This randomized controlled trial included 108 adult patients with arm/forearm wounds who referred to the emergency departments. Participants were randomly allocated to two equal groups. Patients in both groups received subcutaneous injection of buffered lidocaine. In the intervention group, an ice cube measuring 2 × 2 × 2 cm (at 0 ° C) in sterile gloves were placed on the wound for 2 minutes before the injection of buffered lidocaine. The primary outcome was severity of pain during lidocaine injection using a visual analog scale (VAS). Results: One hundred and eight patients were enrolled in the study, 54 in each group. There was no statistically significant difference in age (p = 0.777), sex (p = 0.466), and length of laceration (p = 0.410) between the two groups. The pain scores during lidocaine injection were significantly lower in the intervention group compared to control group (2.39 ± 1.14 vs 4.26 ± 0.94, p < 0.001). Conclusions: Skin cooling prior to the injection of local anesthetics can significantly reduce the pain caused by local anesthetic infiltration

Introduction: Surgical procedures, even under local anesthesia, can induce significant stress and anxiety in patients. Innovative approaches to alleviate anxiety are crucial for improving patient outcomes. Sedatives and anxiolytics may alleviate this discomfort, but they can also subject patients to undesirable side effects, diminishing their overall effectiveness, and, finally, delaying discharge. We present the first case series of a patients underwent inguinal hernia surgical repair under local anesthesia using VRH (HypnoVR) to avoid use of sedatives and anxiolytics., Methods: 12 consecutive patients were enrolled to undergo elective monolateral inguinal hernia repair surgery via an open approach using HypnoVR, at Colorectal Surgery Unit of Fondazione Policlinico Universitario Campus Bio-Medico di Roma. Vital signs (heart rate, SpO2, blood pressure) were detected for all patients before surgery, during local anesthesia, during the whole intervention and after surgery., Results: No intraoperative or postoperative complications have been recorded and only one postoperative complication occurred (seroma), which not required invasive treatment but only drug administration. All patient's vital parameters were recorded during all operative and perioperative phasis. No use of intraoperative analgesic, sedative or anxiolytic were needed. All patients were discharged no later than 3 h after surgery., Conclusion: Virtual Reality Hypnosis is a promising tool for anxiety management in surgical settings. Our series highlights the positive impact of HypnoVR in reduction and management of surgical patient anxiety and discomfort, allowing to perform inguinal hernia repair using only local anesthesia, with good patients' satisfaction., (© 2024. The Author(s), under exclusive licence to Springer-Verlag GmbH Germany, part of Springer Nature.)

Postmortem histology and in vivo, animal-based ultra-high-definition microultrasound demonstrate a complex array of non-communicating adipose tissue compartments enclosed by fascia. Classic nerve block mechanisms and histology do not consider this tissue. Injected local anesthetic agents can occupy any of these adipose compartments, which may explain the significant differences in outcomes such as success rates, onset time, block density, duration of nerve block, and secondary continuous block failure. Furthermore, these adipose tissue compartments may influence injection pressures, making conclusions about needle tip location unreliable. This educational review will explain the neural anatomy associated with these fatty compartments in detail and suggest how they may affect block outcomes., Competing Interests: Competing interests: AB invented perineural catheters (StimuCath, TheraCath, and UltraCath) for which he received royalties from Arrow International and later, after 2007, from TeleFlex Medical for their sales for the duration of the patents, which have now expired. All other authors declare no conflict of interest., (© American Society of Regional Anesthesia & Pain Medicine 2024. No commercial re-use. See rights and permissions. Published by BMJ.)