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Local Anesthetics (local + anesthetic)
Terms modified by Local Anesthetics Selected AbstractsSafety and Acceptability of Implantation of Internal Cardioverter-Defibrillators Under Local Anesthetic and Conscious SedationPACING AND CLINICAL ELECTROPHYSIOLOGY, Issue 8 2007DAVID J. FOX B.M.Sc., M.B.Ch.B., M.R.C.P. Background: Implantation and testing of implantable defibrillators (ICDs) using local anesthetic and conscious sedation is widely practiced; however, some centers still use general anesthesia. We assessed safety and patient acceptability for implantation of defibrillators using local anesthetic and conscious sedation. Methods: The records of 500 consecutive device implants from two UK cardiac centers implanted under local anesthetic and conscious sedation from January 1996 to December 2004 were reviewed. Procedure time, left ventricular ejection fraction (LVEF) sedative dosage (midazolam), analgesic dosage (fentanyl or diamorphine), requirement for drug reversal, and respiratory support were recorded. Patient acceptability of the procedure was also assessed. Results: Of 500 implants examined, 387 were ICDs, 88 were biventricular ICDs, and 25 were generator changes. Patients with biventricular-ICDs had significantly longer (mean ± SD) procedure times 129.7 ± 7.6 minutes versus 63.3 ± 32.3 minutes; P < 0.0001 and lower LVEF 24.4 ± 8.4% versus 35.7 ± 15.4%; P < 0.0001. There were no differences in the doses (mean ± SD) of midazolam 8.9 ± 3.5 mg versus 8.0 ± 3.1 mg; P = NS, diamorphine 4.3 ± 2.0 mg versus 3.8 ± 1.7 mg; P = NS or fentanyl 94.4 ± 53.7 mcg versus 92.2 ± 48.6 mcg; P = NS, between the two groups. There were no deaths or tracheal intubations in either group. Acceptability was available for 373 of 500 (75%) patients, 41 of 373 (11%) described "discomfort," but from these 41 patients only 14 of 373 (3.8%) declined a second procedure under the same conditions. Conclusions: Implantation of defibrillators under local anesthetic and sedation is safe and acceptable to patients. General anesthesia is no longer routinely required for implantation of defibrillators. [source] Temporary Neurologic Deficit After Cervical Transforaminal Injection of Local AnestheticPAIN MEDICINE, Issue 2 2004Michael Karasek MD ABSTRACT Objective To describe the effects of spinal cord block after injection of local anesthetic into a cervical radicular artery. Design Case report. Setting Neurology practice specializing in spinal pain. Interventions A patient underwent a C6,7 transforaminal injection. Contrast medium indicated correct and safe placement of the needle. Results After the injection of local anesthetic, the patient developed quadriplegia. The injection was terminated. The neurologic impairment resolved after 20 minutes observation. Conclusion Despite correct placement of the needle for a cervical transforaminal injection, injectate may nevertheless enter a cervical radicular artery. Whereas local anesthetic, so injected, appears to have only a temporary effect on spinal cord function, particulate steroids may act as an embolus and cause permanent impairment. [source] Dextrose 5% in water: fluid medium for maintaining electrical stimulation of peripheral nerves during stimulating catheter placementACTA ANAESTHESIOLOGICA SCANDINAVICA, Issue 10 2005B. C. H. Tsui It is well documented that a higher electrical current is required to elicit a motor response following a normal saline (NS) injection during the placement of stimulating catheters for peripheral nerve block. We present three cases of continuous brachial plexus catheter placement in which Dextrose 5% in water (D5W) was used to dilate the perineural space instead of NS. Three brachial plexus blocks (two interscalene and one axillary) were performed in three different patients for pain relief. In each case, an insulated needle was advanced towards the brachial plexus. A corresponding motor response was elicited with a current less than 0.5 mA after needle repositioning. A stimulating catheter was advanced with ease after 3,5 ml of D5W was injected to dilate the perineural space. A corresponding motor response was maintained when the current applied to the stimulating catheter was less than 0.5 mA. Local anesthetic was then injected and the motor response immediately ceased. All blocks were successful and provided excellent pain relief with the continuous infusion of local anesthetics. [source] Liposomes for entrapping local anesthetics: A liposome electrokinetic chromatographic studyELECTROPHORESIS, Issue 9 2010Jana Lokajová Abstract Bupivacaine is a lipophilic, long-acting, amide class local anesthetic commonly used in clinical practice to provide local anesthesia during surgical procedures. Several cases of accidental overdose with cardiac arrest and death have been reported since bupivacaine was introduced to human use. Recent case reports have suggested that Intralipid (Fresenius Kabi) is an effective therapy for cardiac toxicity from high systemic concentrations of, e.g. bupivacaine, even though the mechanism behind the interaction is not fully clear yet. Our long-term aim is to develop a sensitive, efficient, and non-harmful lipid-based formulation to specifically trap harmful substances in vivo. In this study, the in vitro interaction of local anesthetics (bupivacaine, prilocaine, and lidocaine) with Intralipid or lipid vesicles containing phosphatidylglycerol, phosphatidylcholine, cardiolipin, cholesterol, and N -palmitoyl- D - erythro -sphingosine (ceramide) was determined by liposome electrokinetic chromatography. The interactions were evaluated by calculating the retention factors and distribution constants. Atomic force microscopy measurements were carried out to confirm that the interaction mechanism was solely due to interactions between the analytes and the moving pseudostationary phase and not by interactions with a stationary lipid phase adsorbed to the fused-silica wall. The heterogeneity of the liposomes was also studied by atomic force microscopy. The liposome electrokinetic chromatography results demonstrate that there is higher interaction between the drugs and negatively charged liposome dispersion than with the commercial Intralipid dispersion. [source] The role of peripheral Na+ channels in triggering the central excitatory effects of intravenous cocaineEUROPEAN JOURNAL OF NEUROSCIENCE, Issue 4 2006P. Leon Brown Abstract While alterations in dopamine (DA) uptake appear to be a critical mechanism underlying locomotor and reinforcing effects of cocaine (COC), many centrally mediated physiological and affective effects of this drug are resistant to DA receptor blockade and are expressed more quickly following an intravenous (i.v.) injection than expected based on the dynamics of drug concentration in the brain. Because COC is also a potent local anesthetic, its rapid action on Na+ channels may be responsible for triggering these effects. We monitored temperatures in the nucleus accumbens, temporal muscle and skin together with conventional locomotion during a single i.v. injection of COC (1 mg/kg), procaine (PRO, 5 mg/kg; equipotential anesthetic dose), a short-acting local anesthetic drug that, like COC, interacts with Na+ channels, and cocaine methiodide (COC-MET, 1.31 mg/kg, equimolar dose), a quaternary COC derivative that is unable to cross the blood,brain barrier. In this way, we explored not only the importance of Na+ channels in general, but also the importance of central vs. peripheral Na+ channels specifically. COC induced locomotor activation, temperature increase in the brain and muscle, and a biphasic temperature fluctuation in skin. Though PRO did not induce locomotor activation, it mimicked, to a greater degree, the temperature effects of COC. Therefore, Na+ channels appear to be a key substrate for COC-induced temperature fluctuations in the brain and periphery. Similar to PRO, COC-MET had minimal effects on locomotion, but mimicked COC in its ability to increase brain and muscle temperature, and induce transient skin hypothermia. It appears therefore that COC's interaction with peripherally located Na+ channels triggers its central excitatory effects manifested by brain temperature increase, thereby playing a major role in drug sensing and possibly contributing to COC reinforcement. [source] Is nerve stimulation needed during an ultrasound-guided lateral sagittal infraclavicular block?ACTA ANAESTHESIOLOGICA SCANDINAVICA, Issue 4 2010Y. GÜRKAN Background: The objective of the study was to evaluate the influence of ultrasound (US) guidance alone vs. neurostimulation (NS) and US (NSUS) guidance techniques on block performance time and block success rate for the lateral sagittal infraclavicular block (LSIB). Methods: In a randomized and prospective manner, 110 adult patients scheduled for distal upper limb surgery were allocated to the US or the NSUS groups. In the US group, a local anesthetic (LA) was administered only with US guidance to produce a ,U'-shaped distribution around the axillary artery. In the NSUS group, LA was administered under US guidance only after electrolocation of one of the median, ulnar or radial nerve-type responses. A total of 30 ml of LA (10 ml of levobupivacaine 5 mg/ml and 20 ml of lidocaine 20 mg/ml) was administered in both groups. Sensory block was tested at 10 min intervals for 30 min. Successful block was defined as analgesia or anesthesia of all five nerves distal to the elbow. Results: Block success rate was 94.5% in both groups. Block performance time was significantly shorter in the US than the NSUS group (157 ± 50 vs. 230 ± 104 s) (P=0.000). Block onset time was similar in both groups (12.5 ± 4.8 in the US vs. 12.8 ± 5.4 min in the NSUS groups). There were two arterial punctures in the NSUS group. Conclusions: During LSIB performance US guidance alone produces block success rate identical to both US and NS guidance yet with a shorter block performance time. [source] Single stimulation of the posterior cord is superior to dual nerve stimulation in a coracoid blockACTA ANAESTHESIOLOGICA SCANDINAVICA, Issue 2 2010J. RODRÍGUEZ Background: Both multiple injection and single posterior cord injection techniques are associated with extensive anesthesia of the upper limb after an infraclavicular coracoid block (ICB). The main objective of this study was to directly compare the efficacy of both techniques in terms of the rates of completely anesthetizing cutaneous nerves below the elbow. Methods: Seventy patients undergoing surgery at or below the elbow were randomly assigned to receive an ICB after the elicitation of either a single radial nerve-type response (Radial group) or of two different main nerve-type responses of the upper limb, except for the radial nerve (Dual group). Forty milliliters of 1.5% mepivacaine was given in a single or a dual dose, according to group assignment. The sensory block was assessed in each of the cutaneous nerves at 10, 20 and 30 min. Block performance times and the rates of complete anesthesia below the elbow were also noted. Results: Higher rates of sensory block of the radial nerve were found in the Radial group at 10, 20 and 30 min (P<0.05). The rates of sensory block of the ulnar nerve at 30 min were 97% and 75% in the Radial and in the Dual groups, respectively (P<0.05). The rate of complete anesthesia below the elbow was also higher in the Radial group at 30 min (P<0.05). Conclusions: Injection of a local anesthetic after a single stimulation of the radial nerve fibers produced more extensive anesthesia than using a dual stimulation technique under the conditions of our study. [source] Single vs. double stimulation during a lateral sagittal infraclavicular blockACTA ANAESTHESIOLOGICA SCANDINAVICA, Issue 10 2009E. AKY Background: The objective of this study was to evaluate the influence of single vs. dual control during an ultrasound-guided lateral sagittal infraclavicular block on the efficacy of sensory block and the time of block onset. Methods: In a prospective manner, 60 adult patients scheduled for distal upper limb surgery were randomly allocated to single (Group S) or double stimulation (Group D) groups. A local anesthetic (LA) mixture of 20 ml of levobupivacaine 5 mg/ml and 20 ml of lidocaine 20 mg/ml with 5 ,g/ml epinephrine (total 40 ml) was administered in both groups. In the Group S following a median, an ulnar or a radial nerve response, the entire LA was administered at a single site. In Group D 10 ml of LA was administered following the electrolocation of the musculocutaneous nerve and 30 ml LA was injected following median, ulnar or radial nerves. A successful block was defined as analgesia or anesthesia of all five nerves distal to the elbow. Sensory and motor blocks were tested at 5-min intervals for 30 min. Results: The block was successful in 27 patients in Group S and 28 patients in Group D. The time from starting the block until satisfactory anesthesia was significantly shorter in Group D than in Group S (19.3 vs. 23.2 min) (P<0.05). Total sensory scores were significantly higher in the double stimulation group at 20 and 30 min after the block performance (P<0.05). Conclusions: Although the block performance time was longer in the double stimulation group, block onset time and extent of anesthesia were more favorable in the double stimulation group. [source] Ultrasound-guided technique allowed early detection of intravascular injection during an infraclavicular brachial plexus blockACTA ANAESTHESIOLOGICA SCANDINAVICA, Issue 7 2009Á. MARTÍNEZ NAVAS The reported incidence of complications after peripheral nerve blocks is generally low and varies from 0% to 5%. The injuries related to brachial plexus block are perhaps more commonly reported, than after peripheral blocks of the lower extremity nerves. Recent reports suggest that expert ultrasound guidance may reduce but not completely eliminate complications as intraneural or intravascular injection. We report a case of accidental intravascular injection of local anesthetic during infraclavicular brachial plexus block, in spite of the use of ultrasound guidance technique, and negative aspiration for blood. [source] Back to Basics: The evidence for reducing the pain of administration of local anesthesia and cosmetic injectablesJOURNAL OF COSMETIC DERMATOLOGY, Issue 3 2010Kajal Babamiri MD Summary Administration of injections, whether local anesthetic or cosmetic injectable, can result in significant distress and discomfort to patients. This review explores factors that can alleviate anxiety and pain associated with injections including cosmetic injectables. We highlight that many techniques used to reduce pain have only been reported based on anecdotal evidence and small series. The techniques that have been reported to reduce pain, by randomized controlled trials, include pretreatment with topical local anesthetic agents and combined cosmetic injectables with local anesthetics. [source] CRANIAL TIBIAL ARTERY CATHETER FOR MONITORING PRESSURES AND SAMPLINGJOURNAL OF VETERINARY EMERGENCY AND CRITICAL CARE, Issue S1 2004DT Crowe A technique for placement of a long-term arterial catheter that the author developed was used in 20 canine patients. The catheter was used for pressure monitoring and arterial blood sampling. The technique involved the following steps post-sedation and placement of a local anesthetic: 1Clipping and prepping of the medial aspect of the distal tibia and proximal metatarsal region; 2Incision over the medial tibial malleolus just caudal to the cranial tibial muscle-tendon; 3Blunt dissection of the space just caudal to the cranial tibialis tendon; 4Isolation of the cranial tibial artery and loop placement proximally and distally; 5Placement of a 3 Fr. polyurethane 4,8 cm catheter using a Seldinger wire technique; 6Placement of a suture in the periosteium of the distal tibia and anchoring of the catheter with this suture; 7Closure of the skin incision with sutures or staples; 8Bandage application to hold the catheter in place. The entire surgical procedure was done using sterile technique. The catheter was able to be kept in place and working for up to 9 days (averaged 4 days). This compared favorably retrospectively over dorsalis pedis catheters that lasted only a maximum of 4 days. (average 1.5 days). Because of the size of the catheter (3 Fr.) it provided improved waveforms over that observed with the dorsalis pedis catheter (22 g) and its occlusion rate was very low (2 in 20). The cranial tibial artery catheter was found to be particularly effective because the catheter was able to be inserted several cm up the artery and the catheter was able to be anchored well. No major complications were observed with this technique. Because of its effectiveness it is recommended to be used routinely over femoral artery and dorsal pedis artery catheters. [source] Use of intravenous lidocaine to prevent reperfusion injury and subsequent multiple organ dysfunction syndromeJOURNAL OF VETERINARY EMERGENCY AND CRITICAL CARE, Issue 3 2003Benjamin H. Cassutto DVM Abstract Objective: The objective of this article is to review the human and veterinary literature and provide evidence for the potential beneficial effects of intravenous (IV) lidocaine hydrochloride in preventing post-ischemic,reperfusion injury, the systemic inflammatory response syndrome (SIRS), and subsequent multiple organ dysfunction syndrome (MODS). Human data synthesis: Lidocaine is a local anesthetic and antiarrhythmic agent that has been used for years in human and veterinary medicine for the treatment of ventricular dysrhythmias associated with blunt cardiac trauma, myocardial ischemia, and cardiac surgery. More recently, the drug has been touted as a scavenger of reactive oxygen species (ROS), and has been used to prevent reperfusion dysrhythmias after treatment of myocardial infarction, cross-clamping of the aorta, and in trauma medicine. Veterinary data synthesis: Although no clinical experiments with prophylactic intravenous lidocaine exist in veterinary medicine, there is a large body of evidence from experimental animals that support the use of lidocaine as a Na+/Ca2+ channel blocker, superoxide and hydroxyl radical scavenger, inflammatory modulator, and potent inhibitor of granulocyte functions. Lidocaine is being used in some clinical situations in an attempt to prevent the SIRS in veterinary trauma patients.a,b Conclusions: A large body of experimental evidence exists supporting the use of lidocaine as an anti-oxidant and inflammatory modulator useful in preventing reperfusion injury. With the lack of cost-effective and safe treatments for reperfusion injury in veterinary and human trauma medicine, the use of IV lidocaine to prevent the ensuing inflammatory response and MODS makes it an attractive addition to existing treatments. Therefore, it is essential that prospective clinical trials involving lidocaine as a treatment for prevention of reperfusion injury be performed in companion animals to demonstrate its safety and efficacy. [source] Postoperative epidural hematoma or cerebrovascular accident?ACTA ANAESTHESIOLOGICA SCANDINAVICA, Issue 2 2002A dilemma in differential diagnosis An elderly lady developed an epidural hematoma following combined spinal-epidural anesthesia with a local anesthetic,opioid mixture for a vaginal hysterectomy. This occurred in association with the use of prophylactic subcutaneously administered unfractionated heparin. She had diabetes, hypertension and had previously undergone coronary artery bypass surgery and right carotid endarterectomy. Warfarin and aspirin were discontinued 2 weeks before the surgery. Postoperatively, an atypical presentation of backache, bilateral sensory loss and left lower limb monoplegia ensued. The initial clinical impression was of a cerebrovascular accident. Magnetic resonance imaging, however, revealed an extensive epidural hematoma that necessitated decompression laminectomy. Progression to paraparesis occurred but the patient gradually regained much of her functionality over the next 2 years. [source] Safety and Acceptability of Implantation of Internal Cardioverter-Defibrillators Under Local Anesthetic and Conscious SedationPACING AND CLINICAL ELECTROPHYSIOLOGY, Issue 8 2007DAVID J. FOX B.M.Sc., M.B.Ch.B., M.R.C.P. Background: Implantation and testing of implantable defibrillators (ICDs) using local anesthetic and conscious sedation is widely practiced; however, some centers still use general anesthesia. We assessed safety and patient acceptability for implantation of defibrillators using local anesthetic and conscious sedation. Methods: The records of 500 consecutive device implants from two UK cardiac centers implanted under local anesthetic and conscious sedation from January 1996 to December 2004 were reviewed. Procedure time, left ventricular ejection fraction (LVEF) sedative dosage (midazolam), analgesic dosage (fentanyl or diamorphine), requirement for drug reversal, and respiratory support were recorded. Patient acceptability of the procedure was also assessed. Results: Of 500 implants examined, 387 were ICDs, 88 were biventricular ICDs, and 25 were generator changes. Patients with biventricular-ICDs had significantly longer (mean ± SD) procedure times 129.7 ± 7.6 minutes versus 63.3 ± 32.3 minutes; P < 0.0001 and lower LVEF 24.4 ± 8.4% versus 35.7 ± 15.4%; P < 0.0001. There were no differences in the doses (mean ± SD) of midazolam 8.9 ± 3.5 mg versus 8.0 ± 3.1 mg; P = NS, diamorphine 4.3 ± 2.0 mg versus 3.8 ± 1.7 mg; P = NS or fentanyl 94.4 ± 53.7 mcg versus 92.2 ± 48.6 mcg; P = NS, between the two groups. There were no deaths or tracheal intubations in either group. Acceptability was available for 373 of 500 (75%) patients, 41 of 373 (11%) described "discomfort," but from these 41 patients only 14 of 373 (3.8%) declined a second procedure under the same conditions. Conclusions: Implantation of defibrillators under local anesthetic and sedation is safe and acceptable to patients. General anesthesia is no longer routinely required for implantation of defibrillators. [source] Assessment of Celiac Plexus Block and Neurolysis Outcomes and Technique in the Management of Refractory Visceral Cancer PainPAIN MEDICINE, Issue 1 2010Michael A. Erdek MD ABSTRACT Objective., To assess demographic and clinical factors associated with celiac plexus neurolysis outcomes. Design., Retrospective clinical data analysis. Setting., A tertiary care, academic medical center. Patients., Forty-four patients with terminal visceral (mostly pancreatic) cancer who failed conservative measures. Interventions., Fifty celiac plexus alcohol neurolytic procedures done for pain control after a positive diagnostic block. Outcome Measures., A successful treatment was predefined as >50% pain relief sustained for ,1 month. The following variables were analyzed for their association with treatment outcome: age, gender, duration of pain, origin of tumor, opioid dose, type of radiological guidance used, single- vs double-needle approach, type of block (e.g., antero- vs retrocrural), immediate vs delayed neurolysis, volume of local anesthetic employed for both diagnostic and neurolytic blocks, and use of sedation. Results., Those variables correlated with a positive outcome included lower opioid dose and the absence of sedation. Strong trends for a positive association with outcome were found for the use of computed tomography (vs fluoroscopy), and using <20 mL of local anesthetic for the diagnostic block. Conclusions., Celiac plexus neurolysis may provide intermediate pain relief to a significant percentage of cancer sufferers. Both careful selection of candidates based on clinical variables, and technical factors aimed at enhancing the specificity of blocks may lead to improved outcomes. [source] Temporary Neurologic Deficit After Cervical Transforaminal Injection of Local AnestheticPAIN MEDICINE, Issue 2 2004Michael Karasek MD ABSTRACT Objective To describe the effects of spinal cord block after injection of local anesthetic into a cervical radicular artery. Design Case report. Setting Neurology practice specializing in spinal pain. Interventions A patient underwent a C6,7 transforaminal injection. Contrast medium indicated correct and safe placement of the needle. Results After the injection of local anesthetic, the patient developed quadriplegia. The injection was terminated. The neurologic impairment resolved after 20 minutes observation. Conclusion Despite correct placement of the needle for a cervical transforaminal injection, injectate may nevertheless enter a cervical radicular artery. Whereas local anesthetic, so injected, appears to have only a temporary effect on spinal cord function, particulate steroids may act as an embolus and cause permanent impairment. [source] EPIDUROGRAPHY: CHARACTERISTICS OF EPIDURALGRAMS PERFORMED DURING LESIPAIN MEDICINE, Issue 2 2002Article first published online: 4 JUL 200 David C. Miller MD, DABPM Woodland Pain Center, Michigan City, IN Fluoroscopically guided, contrast enhanced lumbar epidural steroid injections are commonly performed for persistent or sever lumbar radicular pain. An epiduralgram is a real-time fluoroscopic image of contrast injected into the epidural space prior to the injection of local anesthetic and steroid. This report details the results of one hundred consecutive epiduralgrams. The epidural needle was placed under continuous multiplainer fluoroscopic guidance using ISIS protocol. Three ml. of Omnipaque 300 were injected after initial insertion to obtain the epiduralgram. This was followed by injection of 3 ml. of Celestone diluted with 4 ml. of preservative-free 1% lidocaine to obtain the epiduralgram. The epidural needle was placed at the predetermined spinal level and appropriate side 100% of the time. Needles were successfully placed into the epidural space on the first attempt in 95%. One needle was subarachnoid, one was intra vascular, three were in tissue plains superficial to the epidural space and were apparent only with contrast injection. Three ml. of contrast flowed unilaterally in 74% of lumbar epidural injections. The contrast flowed cephalad only in 20%, caudad only in 28%, and bidirectional in 52%. Contrast spread less than three spinal levels 64% of the time. The desired nerve root was visualized in 62%. Contrast was seen in the ventral epidural space on lateral views 88% of the time. Ventral spread was always fewer levels than the dorsal spread. Epidurography provides essential information for the accurate performance of lumbar epidural steroid injections. One out of every twenty presumed epidural injections were inaccurately placed even by an experienced operator. One out of every fifty was dangerously positioned and identified only by performance of an epiduralgram. [source] (635) The Advantages and Adverse Effects of Long-Term Intrathecal Delivery of Opioid and Clonidine HCL AdmixturePAIN MEDICINE, Issue 2 2000Article first published online: 25 DEC 200 Introduction: Intrathecal clonidine may be effective in neuropathic pain situations where large doses of opioids and local anesthetics or baclofen result in side effects and inadequate pain control. Addition of clonidine activates K (ATP) channels via a-2 receptors. Clonidine administered intrathecally provides fourfold better pain control with lower side effects than systemic clonidine. Because clonidine does not interact with opioid receptors, it fails to cause opioid-like side effects. Clonidine and opioids may have a synergistic efficacy. Materials & Methods: We performed a retrospective analysis of 23 patients, 10 male and 13 female, with a mean age of 55.4 years. Seventeen patients had neuropathic pain and 6 patients had mixed (neuropathic-nociceptive) nonmalignant pain. They had failed to achieve satisfactory analgesia despite preclinical infusion of high dose morphine sulfate, hydromorphone HCL, or combinations of bupivacaine HCL/opioid or baclofen. The range of initiating daily dose of clonidine was 25 ,g to 50 ,g, to a maximum of 900 ,g/day. The clonidine doses were titrated upwards to the end point of either efficacy or adverse effects. Clinical parameters studied were patient vital signs, pain intensity, pain relief, quality of sleep, drug intake, and side effects. Results: The preclonidine VAPS scores were on average 7.67 and the postclonidine VAPS scores were 5.82. Sleep improved for 50% of patients having poor to fair sleep. Length of therapy ranges from 1 month to 35 months with an average of 14.7 months of therapy. Of the 23 patients studied, 8 patients have been satisfied, coping with any side effects, and are still receiving mixed clonidine/opioid therapy. The side effects noted were nausea (9), sleepiness (8), dry mouth (7), dizziness (7), orthostatic hypotension (2), short term memory loss (2), headache (2), edema (2), depression (2), tinnitus (1), lethargy (1), nausea with vomiting (1), decreased energy (1), decreased libido (1), impotence (1), fine tremor (1), and anxiety (1). Conclusions: Intraspinal infusion of clonidine plus opioid may provide safer and better synergistic control of intractable neuropathic or mixed nonmalignant pain than pure intraspinal infusions of u-opioid with local anesthetic. [source] Herpes zoster in older adults. (Duke University Medical Center, Durham, NC) Clinical Infectious Diseases.PAIN PRACTICE, Issue 4 20011486., 2001;32:148 Herpes zoster (HZ) strikes millions of older adults annually worldwide and disables a substantial number of them via postherpetic neuralgia (PHN). Key aged-related clinical, epidemiological, and treatment features of zoster and PHN are reviewed in this article. HZ is caused by renewed replication and spread of the varicella-zoster virus (VZV) in sensory ganglia and afferent peripheral nerves in the setting of age-related, disease-related, and drug-related decline in cellular immunity to VZV. VZV-induced neuronal destruction and inflammation causes the principal problems of pain, interference with activities in daily living, and reduced quality of life in elderly patients. Recently, attempts to reduce or eliminate HZ pain have been bolstered by the findings of clinical trials that antiviral agents and corticosteroids are effective treatment for HZ and that tricyclic antidepressants, topical lidocaine, gabapentin, and opiates are effective treatment for PHN. Although these advances have helped, PHN remains a difficult condition to prevent and treat in many elderly patients. Comment by Miles Day, M.D. This article reviews the epidemiology clinical features diagnosis and treatment of acute herpes zoster. It also describes the treatment of postherpetic neuralgia. While this is a good review for the primary care physician, the discussion for the treatment for both acute herpes zoster and postherpetic neuralgia do not mention invasive therapy. It is well documented in pain literature that sympathetic blocks with local anesthetic and steroid as well as subcutaneous infiltration of active zoster lesions not only facilitate the healing of acute herpes zoster but also prevents or helps decrease the incidence of postherpetic neuralgia. All patients who present to the primary care physician with acute herpes zoster should have an immediate referral to a pain management physician for invasive therapy. The treatment of postherpetic neuralgia is a challenging experience both for the patient and the physician. While the treatments that have been discussed in this article are important, other treatments are also available. Regional nerve blocks including intercostal nerve blocks, root sleeve injections, and sympathetic blocks have been used in the past to treat postherpetic neuralgia. If these blocks are helpful, one can proceed with doing crynourlysis of the affected nerves or also radio-frequency lesioning. Spinal cord stimulation has also been used for those patients who are refractory to noninvasive and invasive therapy. While intrathecal methylprednisolone was shown to be effective in the study quoted in this article one must be cautious not to do multiple intrathecal steroid injections in these patients. Multilple intrathecal steroid injections can lead to archnoiditis secondary to the accumulation of the steroid on the nerve roots and in turn causing worsening pain. [source] Study to assess the laryngeal and pharyngeal spread of topical local anesthetic administered orally during general anesthesia in childrenPEDIATRIC ANESTHESIA, Issue 8 2010FRCA, RICHARD BERINGER BMedSci Summary Background:, Topical local anesthesia of the airway of anaesthetized children has many potential benefits. In our institution, lignocaine is topically instilled blindly into the back of the mouth with the expectation that it will come into contact with the larynx. The volume and method of application varies between clinicians. There is no published evidence to support the plausibility of this technique. Aim:, To determine whether this technique of instillation results in the local anesthetic coming into contact with key laryngeal structures and whether this is influenced by volume or additional physical maneuvers. Methods/Materials:, Sixty-three healthy anaesthetized children between 6 months and 16 years old had lignocaine stained with methylene blue poured into the back of their mouths. The volume and subsequent physical maneuver were determined by randomization. A blinded observer assessed staining of the vocal cords, epiglottis, vallecula and piriform fossae by direct laryngoscopy. Airway complications were recorded. Results:, Fifty-three of the 63 children had complete staining of all four areas. Four children had one area unstained, and all others had at least partial staining of all four structures. Nine children coughed following induction of anesthesia. Coughing was more likely in children with incomplete staining (P = 0.03), low volume lignocaine (P = 0.003) and following a head lift (P = 0.02). Conclusion:, Oral administration of lignocaine without use of a laryngoscope frequently results in widespread coverage of key laryngeal structures and may reduce the risk of coughing. [source] Continuous incisional infusion of local anesthetic in pediatric patients following open heart surgeryPEDIATRIC ANESTHESIA, Issue 6 2009CHRISTOPHER F. TIROTTA MD MBA Summary Aim:, To determine the efficacy and safety of a continuous subcutaneous local anesthetic (LA) infusion in pediatric patients following open heart surgery. Background:, The use of a continuous LA infusion has been shown to be beneficial following adult cardiac surgery. To date there are no studies in the pediatric population. Methods/Materials:, Using a prospective, randomized, and double blind design, we compared LA, either 0.25% levobupivacaine or bupivacaine (Treatment Group) to saline (Placebo Group) delivered subcutaneously via a continuous infusion for 72 h after open heart surgery in 72 patients. Requirements for postoperative analgesics and pain scores were recorded for 72 h and plasma levels of local anesthetic were measured. Secondary outcomes measures included time to first oral intake, time to first bowel movement, time to urinary catheter removal, length of stay, requirements for antiemetics and additional sedation. Results:, Total morphine requirements over the first 24 h were less in the Treatment Group than the Placebo Group (0.05 mg·kg,1 vs 0.2 mg·kg,1, P = 0.007); this was true for all patient groups except those patients weighing less than 6.3 kg. The number of patients requiring no morphine was greater in the Treatment Group (7/35 vs 1/37, P = 0.02). The Treatment Group also received less midazolam, lorazepam, and ketorolac than the Placebo Group over 72 h due to the reduced clinical need for these agents in patients weighing less than 31 kg. There were no differences in secondary outcomes. Conclusions:, A continuous incisional infusion of LA reduced postoperative analgesic requirement and sedative use in pediatric patients undergoing a median sternotomy incision. Dosed at a maximum rate of 0.4 mg·kg,1·h,1, a continuous incisional infusion of LA is effective and safe for up to 72 h, with plasma levels of local anesthetic well below the toxic threshold. [source] Pterygopalatine Fossa Infiltration Through the Greater Palatine Foramen: Where to Bend the NeedleTHE LARYNGOSCOPE, Issue 7 2006FRACP, FRACS, Richard Douglas MD Abstract Objective: In the literature, there has been controversy regarding the length of the greater palatine canal. If the pterygopalatine fossa is infiltrated in an attempt to reduce bleeding during sinus surgery, this information is important to be able to place local anesthetic with maximal effect and the least likelihood of complications. Study Design: The authors conducted a prospective cadaver-based study using high-definition computed tomography (CT) scans. Methods: Twenty-two cadaver heads were CT scanned and the greater palatine canal length, pterygopalatine fossa height, and thickness of the soft tissue in the roof of the mouth were measured on parasagittal images using the CT scanner workstation. Results: The mean length of the greater palatine canal was 18.5 mm (95% confidence interval [CI] = 17.9,19.1) and the mean height of the pterygopalatine fossa was 21.6 mm (95% CI = 20.7,22.5). The mean thickness of the soft tissue in the roof of the mouth overlying the foramen of the greater palatine canal was 6.9 mm (95% CI = 6.2,7.6). Conclusion: To perform an effective infiltration of the pterygopalatine fossa, the needle should be bent at 25 mm from the tip at an angle of 45°. [source] 2167: Tear film biomarkers as prognostic indicators for recurrent pterygiumACTA OPHTHALMOLOGICA, Issue 2010N ZAKARIA Purpose The aim of this project is to establish the use of IL-6, IL-8 and VEGF as biomarkers in the tear film for early detection of recurrent pterygium. Methods Cytometric Bead Array (CBA) kits will be used to perform multicytokine assays in the tear samples of eyes having pterygium before and after surgical resection of the pterygia. This technique utilizes flow cytometry to determine the concentrations of multiple analytes namely IL-6, IL-8 and VEGF (proposed biomarkers) present in small volumes of tear fluid.Patients with pterygia showing corneal encroachment and requiring surgical excision will be recruited in this study along with a second population of control subjects consisting of individuals with no history of eye diseases or contact lens wear. After instilling a local anesthetic, 3 drops of normal saline will be applied and the at least 50µl of the diluted epithelial secretions collected and stored at -80°C for CBA analysis. From the results we can determine the baseline levels of IL-6, IL-8 and VEGF present in normal epithelial secretions and correlate it with potentially higher levels in the eyes of patients with pterygia. By collecting post op epithelial secretions at different time points along with regular ocular surface photographs and grading of any recurrent pterygia we will be able to ascertain the role of these cytokines and growth factors as biomarkers for recurrent pterygia. Conclusion By establishing higher tear film levels of IL-6, IL-8 and VEGF in eyes with pterygia compared to normal eyes and the return to baseline levels post excision we can begin to ascertain the role of these key players in the pathogenesis of pterygia. [source] Patterns of Use of Topical Skin Adhesives in the Emergency DepartmentACADEMIC EMERGENCY MEDICINE, Issue 6 2010Adam J. Singer MD Abstract Objectives:, The objective was to determine patterns of use of topical skin adhesives (TSA) for laceration repair. The authors hypothesized that TSA use would be more common in children and facial lacerations. Methods:, This was a structured retrospective chart review. The setting was a suburban, university-based emergency department (ED) with an emergency medicine (EM) residency; the annual census is 85,000 visits. Charts from consecutive patients presenting with lacerations in the summer of 2008 (June 2008 through August 2008) were reviewed. Demographic, clinical, and wound characteristics were extracted from electronic medical records by trained investigators using structured data collection forms. Characteristics of lacerations repaired with TSA or other closure devices were compared with bivariate and multivariate analyses using odds ratios (ORs) and 95% confidence intervals (CIs). Results:, A total of 755 patients presented to the ED with lacerations over the study period, of whom primary closure was used in 667; nine were excluded because the method of closure was unknown. The most common methods of laceration closure were sutures (485), adhesives (88), and staples (86). Adhesives were used to close 27% of facial lacerations, compared to 4% of all other body locations (difference = 23%, 95% CI = 18% to 29%), and in 20% of pediatric versus 8% of adult lacerations (difference = 13%, 95% CI = 7% to 18%). Adjustment for other potential patient and wound characteristics showed that adhesives were more likely to be used to close facial lacerations (OR = 10.0 CI, 95% CI = 5.5 to 18.0) and lacerations in children (OR = 1.8, 95% CI = 1.1 to 3.0) and less likely to be used as laceration length increased (OR = 0.6, 95% CI = 0.4 to 0.8). Adhesive use was not statistically associated with patient sex or race, laceration edges or shape, or the need for deep sutures. Forty-three percent of adhesive wounds were closed with no anesthetic, and a topical agent was used in another 48%. In contrast, a local anesthetic agent was injected in 87% of sutured wounds (p < 0.001) and 73% of stapled wounds (p < 0.001). Conclusions:, Topical skin adhesives are used more often for children, facial lacerations, and short lacerations. Use of adhesives may improve patient comfort as need for injecting a local anesthetic is reduced. ACADEMIC EMERGENCY MEDICINE 2010; 17:670,672 © 2010 by the Society for Academic Emergency Medicine [source] Viability of Preadipocytes In Vitro: The Influence of Local Anesthetics and pHDERMATOLOGIC SURGERY, Issue 8 2009MAIKE KECK MD BACKGROUND Autogenous fat transfer with lipoinjection for soft tissue augmentation is a commonly used surgical technique. Abundant donor tissue availability and relative ease of harvesting have made autologous fat an attractive soft tissue filler. The overall reliability of this technique is often disputed, and different authors describe different results after autologous fat transplantation despite using similar techniques. In this study, we examined the influence of different local anesthetics commonly used in fat harvest and the pH of the anesthetic solution on the viability of harvested preadipocytes. METHODS AND MATERIALS Preadipocytes were incubated with 1% lidocaine, 1% articaine plus epinephrine 1:200,000, 0.75% ropivacaine, and 1% prilocaine or our standardized tumescent solution (1 L of 0.9% sodium chloride solution plus 25 mL of 1% articaine plus epinephrine 1:200,000 plus 25 mL of bicarbonate) for 30 minutes. Additionally, we incubated cells with the local anesthetics as described above but diluted 1:2 with phosphate buffered saline (pH 7.4). Viability was measured using trypan blue dying as well as propidium iodine staining and fluorescence-activated cell sorting analysis. RESULTS There are significant differences in the viability of preadipocytes under the influence of various local anesthetics. DISCUSSION Our data could partially explain the varying results after autogenous fat transfer. [source] Liposomes for entrapping local anesthetics: A liposome electrokinetic chromatographic studyELECTROPHORESIS, Issue 9 2010Jana Lokajová Abstract Bupivacaine is a lipophilic, long-acting, amide class local anesthetic commonly used in clinical practice to provide local anesthesia during surgical procedures. Several cases of accidental overdose with cardiac arrest and death have been reported since bupivacaine was introduced to human use. Recent case reports have suggested that Intralipid (Fresenius Kabi) is an effective therapy for cardiac toxicity from high systemic concentrations of, e.g. bupivacaine, even though the mechanism behind the interaction is not fully clear yet. Our long-term aim is to develop a sensitive, efficient, and non-harmful lipid-based formulation to specifically trap harmful substances in vivo. In this study, the in vitro interaction of local anesthetics (bupivacaine, prilocaine, and lidocaine) with Intralipid or lipid vesicles containing phosphatidylglycerol, phosphatidylcholine, cardiolipin, cholesterol, and N -palmitoyl- D - erythro -sphingosine (ceramide) was determined by liposome electrokinetic chromatography. The interactions were evaluated by calculating the retention factors and distribution constants. Atomic force microscopy measurements were carried out to confirm that the interaction mechanism was solely due to interactions between the analytes and the moving pseudostationary phase and not by interactions with a stationary lipid phase adsorbed to the fused-silica wall. The heterogeneity of the liposomes was also studied by atomic force microscopy. The liposome electrokinetic chromatography results demonstrate that there is higher interaction between the drugs and negatively charged liposome dispersion than with the commercial Intralipid dispersion. [source] Theoretical studies on water,tetracaine interactionINTERNATIONAL JOURNAL OF QUANTUM CHEMISTRY, Issue 5 2006R. C. Bernardi Abstract The action of local anesthetics (LA) is controversial. There is experimental evidence that the unprotonated form of LA penetrates the axon, while the charged form acts in the intracellular phase. To obtain some insight on the structure of the local anesthetics tetracaine and its pharmacological action, we made calculations using the density functional theory (DFT) method. After those calculations, we performed molecular dynamics (MD) simulations in a p, N, T ensemble, in an aqueous environment, on both unprotonated and protonated forms of the molecule. The radial distribution function was used to study water solvent effects, through the characterization of the affinity of tetracaine to water. The results indicate that the molecule has regions with different degree of hydrophobicity, and the N-terminal of the anesthetic was primarily affected by changes in the protonation state of the anesthetic. The pH-dependent activity of TTC should then be analyzed in view of local changes in different regions of the molecule, rather than in terms of general effects on the hydrophobicity of the molecule as a whole. © 2005 Wiley Periodicals, Inc. Int J Quantum Chem, 2006 [source] Femoral nerve block with ropivacaine or bupivacaine in day case anterior crucial ligament reconstructionACTA ANAESTHESIOLOGICA SCANDINAVICA, Issue 4 2010H. WULF Background/Objective: Our aim was to evaluate analgesia, motor block and pharmacokinetics of ropivacaine 0.2% and 0.75% in a femoral nerve block (FNB) in day case patients for anterior crucial ligament (ACL)-reconstruction compared with bupivacaine 0.25% and placebo. Methods: Following ethics committee approval and informed consent, 280 patients were randomly allocated to four groups for single-shot FNB [30 ml ropivacaine 0.2% (group RO2.0), 0.75% (RO7.5), bupivacaine 0.25% (BU2.5) and NaCl 0.9% (NaCl)]. Analgesia (pain scores, primary outcome) and motor block were assessed at 4 h (dismissal) and up to 24 h. Plasma concentration was determined up to 240 min thereafter. Results: Pain scores at 4 h were significantly higher for NaCl 4 (0,8) (median, range) (vs.) BU2.5 2 (0,8), RO2.0 3 (0,9) and RO7.5 2 (0,8) (NS within the LA groups). Patients of the NaCl group needed analgesics significantly more often (93%) within 4 h after surgery vs. 16% of group RO2.0, 19% of group RO7.5 and 19% of group BU2.5. Motor block was significantly increased with all local anesthetics without a significant difference within the LA groups 3 (0,5) in RO2.0, 3 (0,5) in RO7.5 and 3 (0,4) in BU2.5 vs. 0 (0,3) in group NaCl (median (range); scale from 0=full strength to 5=complete paralysis). Peak plasma concentrations differed significantly: RO7.5: 1.4 ± 0.4 (0.73,2.6) [,g/ml, mean ± SD (range)] after 33 ± 14 (10,40) min, RO2.0: 0.6 ± 0.3 (0.13,1.0) after 22+17 (10,60) and BU2.5: 0.3 ± 0.16 (0.05,0.62) at 31 ± 17 (10,60), respectively. Conclusion: FNB for ACL reconstruction with ropivacaine or bupivacaine provided better post-operative analgesia than placebo without reaching toxic plasma concentrations. Significant motor block was observed after 4 h in all groups including the lowest concentration of ropivacaine but occurred even with placebo. [source] Back to Basics: The evidence for reducing the pain of administration of local anesthesia and cosmetic injectablesJOURNAL OF COSMETIC DERMATOLOGY, Issue 3 2010Kajal Babamiri MD Summary Administration of injections, whether local anesthetic or cosmetic injectable, can result in significant distress and discomfort to patients. This review explores factors that can alleviate anxiety and pain associated with injections including cosmetic injectables. We highlight that many techniques used to reduce pain have only been reported based on anecdotal evidence and small series. The techniques that have been reported to reduce pain, by randomized controlled trials, include pretreatment with topical local anesthetic agents and combined cosmetic injectables with local anesthetics. [source] Feasibility of infusion pumps for continuous spinal administration of local anesthetics in post-operative pain therapyACTA ANAESTHESIOLOGICA SCANDINAVICA, Issue 5 2009M. WENK Background and Objectives: For completion of perioperative care and for general ethical considerations, any intraoperatively used catheter technique should be utilizable for post-operative pain therapy. Continuous spinal anesthesia (CSA) is an established form of local anesthetic application. However, for its use in post-operative therapy, infusion pumps are required that are technically able to deliver low rates and are distinctive in design to avoid possible pump or medication swaps. Because of a lack of devices specifically designed for CSA, we investigated the potential deployability of infusion pumps for post-operative pain therapy via CSA microcatheters, which were originally designed and approved for different applications. Methods: The accuracy of infusion rates of three different pumps was measured in a liquor model environment. Furthermore, we investigated safety and user-friendliness by interviewing 30 anesthesiologists and 15 pain nurses. Results: Except for the first hour of infusion, all pumps provided comparable and adequate flow profiles. However, interviews revealed significant risk factors for all pumps in terms of swapping devices, lines or medications and misprogramming the units. Discussion: All pumps tested were technically able to deliver accurate flow rates; however, because the non-CSA-specific design involves the risk of medication overdosage and syringe swaps, none of the systems tested can be recommended for routine use in post-operative CSA, irrespective of the fact that it was an off-label application anyway. Therefore, to ensure patient safety, continuous spinal administration of local anesthetics via microcatheters is a questionable method of post-operative pain therapy as long as non-specific pumps are used. [source] | ||||||||||||||||||||||||||||||||||