Local public administration plays a very important role for society. In theory, the contribution of local government activity, should help to create the welfare state through implemented social ...policies. In the scientific approach, we intend to explore in a comparative way the organization of local entities in Romania and Republic of Moldova. Along the same lines, we will analyse the legal provisions relating to the mayor as an executive authority. The importance of research is highlighted in the need to compare the legislation of Romania and Moldova, one as an European Union member state and another one as a state which want to join the big European family. After all, we will present a proposal to adapt certain articles of the law on local public entities in the Republic of Moldova, calling attention to the need to revise the legal framework in the spirit of European principles.
Caudal epidural blockade in children is one of the most widely administered techniques of regional anaesthesia. Recent clinical studies have answered major pharmacodynamic and pharmacokinetic ...questions, thus providing the scientific background for safe and effective blocks in daily clinical practice and demonstrating that patient selection can be expanded to range from extreme preterm births up to 50 kg of body weight. This narrative review discusses the main findings in the current literature with regard to patient selection (sub-umbilical vs mid-abdominal indications, contraindications, low-risk patients with spinal anomalies); anatomical considerations (access problems, age and body positioning, palpation for needle insertion); technical considerations (verification of needle position by ultrasound vs landmarks vs ‘whoosh’ or ‘swoosh’ testing); training and equipment requirements (learning curve, needle types, risk of tissue spreading); complications and safety (paediatric regional anaesthesia, caudal blocks); local anaesthetics (bupivacaine vs ropivacaine, risk of toxicity in children, management of toxic events); adjuvant drugs (clonidine, dexmedetomidine, opioids, ketamine); volume dosing (dermatomal reach, cranial rebound); caudally accessed lumbar or thoracic anaesthesia (contamination risk, verifying catheter placement); and postoperative pain. Caudal blocks are an efficient way to offer perioperative analgesia for painful sub-umbilical interventions. Performed on sedated children, they enable not only early ambulation, but also periprocedural haemodynamic stability and spontaneous breathing in patient groups at maximum risk of a difficult airway. These are important advantages over general anaesthesia, notably in preterm babies and in children with cardiopulmonary co-morbidities. Compared with other techniques of regional anaesthesia, a case for caudal blocks can still be made.
Postoperative pain has been poorly managed for decades. Recent surveys from USA and Europe do not show any major improvement. Persistent postoperative pain is common after most surgical procedures, ...and after thoracotomy and mastectomy, about 50% of patients may experience it. Opioids remain the mainstay of postoperative pain treatment in spite of strong evidence of their drawbacks. Multimodal analgesic techniques are widely used but new evidence is disappointing. Regional anaesthetic techniques are the most effective methods to treat postoperative pain. Current evidence suggests that epidural analgesia can no longer be considered the 'gold standard'. Perineural techniques are good alternatives for major orthopaedic surgery but remain underused. Infiltrative techniques with or without catheters are useful for almost all types of surgery. Simple surgeon-delivered local anaesthetic techniques such as wound infiltration, preperitoneal/intraperitoneal administration, transversus abdominis plane block and local infiltration analgesia can play a significant role in improvement of postoperative care, and the last of these has changed orthopaedic practice in many institutions. Current postoperative pain management guidelines are generally 'one size fits all'. It is well known that pain characteristics such as type, location, intensity and duration vary considerably after different surgical procedures. Procedure-specific postoperative pain management recommendations are evidence based, and also take into consideration the role of anaesthetic and surgical techniques, clinical routines and risk-benefit aspects. The role of acute pain services to improve pain management and outcome is well accepted but implementation seems challenging. The need for upgrading the role of surgical ward nurses and collaboration with surgeons to implement enhanced recovery after surgery protocols with regular audits to improve postoperative outcome cannot be overstated.
Purpose
To evaluate whether cooled anaesthetic eyedrops and antiseptics alleviate pain and minimise subconjunctival haemorrhage following intravitreal injection.
Methods
A prospective, double‐masked, ...randomised controlled trial of 100 participants receiving either cooled (n = 50) or room temperature (n = 50) topical anaesthetic eyedrops and antiseptics before receiving an injection of bevacizumab. Baseline tolerability was estimated using a self‐reported pain sensitivity questionnaire.
Results
Overall tolerability was comparable between the study group and the control group (0.75 ± 0.13 vs. 0.74 ± 0.14, respectively, p = 0.99). Subconjunctival haemorrhage incidence was similar in both groups (80% vs. 86%, respectively, p = 0.113), as was subconjunctival haemorrhage size (2.75 ± 5.51 mm2 vs. 5.53 ± 10.72 mm2, respectively, p = 0.11). Sub‐group analysis demonstrated that the participants taking daily ocular eyedrops who received cooled anaesthetic eyedrops and antiseptics reported less pain at 10 min and less burning sensation at 24 h compared with matched controls (0.67 ± 1.50 vs. 2.50 ± 3.03, respectively, p = 0.040 and 0.00 ± 0.00 vs. 1.44 ± 2.96, respectively, p = 0.045). Participants who received cooled eyedrops and did not use antithrombotic therapy had smaller‐sized subconjunctival haemorrhages compared with matched controls (1.55 ± 1.87 mm2 vs. 8.29 ± 14.61 mm2, respectively, p = 0.038). Participants with hypertension who received cooled eyedrops had smaller‐sized subconjunctival haemorrhage compared with matched controls (2.33 ± 4.99 mm2 vs. 6.89 ± 12.41 mm2, respectively, p = 0.045).
Conclusion
The benefit of using cooled anaesthetic eyedrops and antiseptics to alleviate pain and minimise subconjunctival haemorrhage following intravitreal injection was not proven in the general population. It may be beneficial in part for some patients, such as those who regularly use eyedrops, patients with hypertension or those not on antithrombotic therapy.
BACKGROUNDEffective postoperative analgesia after caesarean section is important because it enables early ambulation and facilitates breast-feeding. Several case reports have shown that local ...anaesthetic injection around the quadratus lumborum muscle is effective in providing pain relief after various abdominal operations and in patients with chronic pain. The quadratus lumborum block (QLB) is performed in close proximity to the surface and uses a fascial compartment path to extend the distribution of local anaesthesia into the posterior abdominal wall and paravertebral space. This central effect can be of vital importance when managing the visceral pain after caesarean section.
OBJECTIVEWe hypothesised that the QLB after caesarean section can provide adequate pain relief as part of a multimodal approach.
DESIGNDouble-blind, randomised and controlled clinical trial.
SETTINGA single centre between June 2014 and December 2014.
PATIENTSFifty patients who were American Society of Anesthesiologists physical status 1 or 2, with normal singleton pregnancies with a gestation of at least 37 weeks, and scheduled for elective caesarean section under spinal anaesthesia, were enrolled into the study. They were randomly assigned to receive a QLB (n = 25) with 0.125% bupivacaine 0.2 ml kg (Group 1) or a QLB (n = 25) with 0.9% Normal saline 0.2 ml kg (Group 2).
MAIN OUTCOME MEASURESThe primary outcome measure for the study was the morphine demands and doses delivered by a patient-controlled analgesia system at predetermined intervals (1, 2, 4, 6, 12, 24 and 48 h) after surgery. The secondary endpoints were visual analogue scale (VAS) for pain at rest and on movement (dynamic), heart rate, blood pressure, pruritus, itching, nausea, vomiting and sedation.
RESULTSThe patients who received local anaesthetic used significantly less morphine than the control group (P < 0.001) at 6 and 12 h, but not at 24 and 48 hours after caesarean section. The local anaesthetic group had significantly less morphine demand than the control group (P < 0.001) 6, 12, 24 and 48 h after caesarean section. The VAS was significantly lower in the local anaesthetic group than the control group, including VAS for pain at rest at all times except 24 h after caesarean section, and VAS for pain on movement (dynamic) at all times.
CONCLUSIONThe QLB after caesarean section was effective and provided satisfactory analgesia in combination with a typical postoperative analgesic regimen.
TRIAL REGISTRATIONClinicalTrials.gov identifierNCT02328378.
Summary
We systematically reviewed the safety and efficacy of perineural dexamethasone as an adjunct for peripheral nerve blockade in 29 controlled trials of 1695 participants. We grouped trials by ...the duration of local anaesthetic action (short‐ or medium‐ vs long‐term). Dexamethasone increased the mean (95% CI) duration of analgesia by 233 (172–295) min when injected with short‐ or medium‐term action local anaesthetics and by 488 (419–557) min when injected with long‐term action local anaesthetics, p < 0.00001 for both. However, these results should be interpreted with caution due to the extreme heterogeneity of results, with I2 exceeding 90% for both analyses. Meta‐regression did not show an interaction between dose of perineural dexamethasone (4–10 mg) and duration of analgesia (r2 = 0.02, p = 0.54). There were no differences between 4 and 8 mg dexamethasone on subgroup analysis.
Abdominal wall blocks rely on the spread of local anesthetic within musculofascial planes to anesthetize multiple small nerves or plexuses, rather than targeting specific nerve structures. ...Ultrasonography is primarily responsible for the widespread adoption of techniques including transversus abdominis plane and rectus sheath blocks, as well as the introduction of novel techniques such as quadratus lumborum and transversalis fascia blocks. These blocks are technically straightforward and relatively safe and reduce pain and opioid requirements in many clinical settings. The data supporting these outcomes, however, can be inconsistent because of heterogeneity of study design. The extent of sensory blockade is also somewhat variable, because it depends on the achieved spread of local anesthetic and the anatomical course of the nerves being targeted. The blocks mainly provide somatic analgesia and are best used as part of a multimodal analgesic regimen. This review summarizes the anatomical, sonographic, and technical aspects of the abdominal wall blocks in current use, examining the current evidence for the efficacy and safety of each.
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