This article reviews historical background, essential practice principles, and the new emerging area of wide awake hand surgery. It outlines the reasons that wide awake, local anaesthesia, no ...tourniquet surgery has emerged so quickly in the last 10 years over the world. I explain the origin of the concepts and some of the challenges of getting the technique accepted; in particular, the debunking of the myth of epinephrine danger in the finger. I review the most recent developments in several operations in this rapidly changing field of the tourniquet-free approach. Finally, this review includes speculations on the future of this technique.
Objective
To determine the effect of concurrent versus delayed treatment with corticosteroid on equine articular tissues also treated with local anesthetic in vitro in the presence of inflammatory ...mediators.
Study design
Controlled laboratory study.
Animals
Five geldings, one mare (aged 3–18 years).
Methods
From each horse, 24 synovial and 12 osteochondral explants were cultured in a 12‐well plate (2 wells/group, 2 synovial and 1 osteochondral explant/well, total 216 explants in the study). Explants were stimulated in culture medium with 10 μg/ml recombinant equine interleukin‐1β and 10 μg/ml tumor necrosis factor‐α for 48 hours, then randomly assigned to six treatments: unstimulated control, stimulated control, triamcinolone acetonide (TA, 10−6 M), mepivacaine hydrochloride (MH, 4.4 mg/ml), MH + TA (concurrent) and MH + TA (delayed). The delayed group was treated with MH and, 6 days later, treated with TA. Every 3 days for 9 days total, medium levels of lactate dehydrogenase (LDH), prostaglandin E2 (PGE2), matrix metalloproteinase 13 (MMP‐13) and glycosaminoglycan (GAG) were quantified via ELISA. Data were analyzed with mixed‐effects models with Tukey's multiple comparisons.
Results
Stimulation increased medium PGE2 and MMP‐13 and had no effect on LDH or GAG. Treatment with MH increased LDH and decreased PGE2 and MMP‐13. Treatment with TA decreased PGE2 and MMP‐13.
Conclusion
There were no differences in cytotoxicity, inflammation or matrix degradation for delayed or concurrent MH and TA treatment groups up to 9 days in culture.
Clinical significance
The lack of an effect of concurrent versus delayed treatment might indicate that concurrent therapy is acceptable.
The choice of local anesthetics in regional anesthesia depends on desired onset, intensity, and duration of block, as well as possible adverse effects. This review highlights recent advances in ...day-case spinal anesthesia; considerations in selecting local anesthetic volume, concentration, and mass in peripheral nerve blockade; and the pharmacokinetics of ropivacaine.
Spinal anesthesia using 2-chloroprocaine offers fast onset and rapid recovery, whereas mepivacaine and lidocaine are suitable for longer procedures. Intrathecal lidocaine in the lithotomy position carries a significant risk of transient neurologic symptoms and should be avoided. Dosing studies of local anesthetics in peripheral nerve blockade suggest that mass of drug, not volume or concentration, primarily determines block onset, success, and duration. Commonly used doses of ropivacaine for Transversus Abdominis Plane blocks can result in high plasma concentrations and local anesthetic systemic toxicity.
There are effective alternatives to bupivacaine in day-case spinal anesthesia but more safety and outcome data are required, particularly for 2-chloroprocaine. The trend toward smaller doses of local anesthetics in ultrasound-guided regional anesthesia improves safety but should be weighed against possible reductions in speed of onset and analgesic duration. Strategies to reduce the risk of local anesthetic systemic toxicity should be employed when performing large-volume fascial plane blocks with ropivacaine.
We compare the efficacy and safety of intravenous lidocaine with that of hydromorphone for the treatment of acute abdominal pain in the emergency department (ED).
This was a randomized, double-blind, ...clinical trial conducted in 2 EDs in the Bronx, NY. Adults weighing 60 to 120 kg were randomized to receive 120 mg of intravenous lidocaine or 1 mg of intravenous hydromorphone. Thirty minutes after administration of the first dose of the study drug, participants were asked whether they needed a second dose of the investigational medication to which they were randomized. Patients were also stratified according to clinical suspicion of nephrolithiasis. The primary outcome was improvement in pain scores of 0 to 10 between baseline and 90 minutes. An important secondary outcome was need for “off-protocol” parenteral analgesics, including opioids and nonsteroidal anti-inflammatory drugs.
We enrolled 154 patients, of whom 77 received lidocaine and 77 received hydromorphone. By 90 minutes, patients randomized to lidocaine improved by a mean of 3.8 points on the 0-to-10 scale, whereas those randomized to hydromorphone improved by a mean of 5.0 points (mean difference 1.2; 95% confidence interval 0.3 to 2.2). Need for off-protocol “rescue” analgesics occurred for 39 of 77 lidocaine patients (51%) and 20 of 77 hydromorphone patients (26%) (difference 25%; 95% confidence interval 10% to 40%). Adverse events were comparable between groups. Among the subset of 22 patients with nephrolithiasis, lidocaine patients reported a mean improvement of 3.4 points on the pain scale, whereas hydromorphone patients reported a mean improvement of 6.4 points (mean difference 3.0; 95% confidence interval 0.5 to 5.5).
Intravenous hydromorphone was superior to intravenous lidocaine both for general abdominal pain and a subset of patients with nephrolithiasis. A majority of patients randomly allocated to lidocaine required additional analgesics.
Objective—To compare the anesthetic efficacy and adverse effects associated with peribulbar injection of ropivacaine (1% solution) performed with and without ultrasound guidance (UG) in dogs. ...Animals—15 dogs without ophthalmologic abnormalities. Procedures—Each dog was sedated and anesthetized. A peribulbar injection of ropivacaine (1% solution; 0.3 mL/kg) was performed with UG in 1 eye and without UG in the contralateral eye (control). For each eye, the intraocular pressure (IOP) immediately after eye centralization and number of punctures were recorded; ophthalmic complications, postinjection corneal sensitivity (determined by Cochet-Bonnet esthesiometry), durations of the sensory and motor blockades (the latter determined as the interval to restoration of the vestibuloocular reflex, pupillary light reflex, and conjugate eye movement), and blockade quality were assessed in both eyes following anesthetic recovery. Results—Needle placement was fully visualized in 8 of the 15 eyes injected with UG. For eyes injected with or without UG, there was no difference with regard to the number of punctures, postinjection corneal sensitivity, and sensory or motor blockade duration and quality; however, restoration of conjugate eye movement occurred later in control eyes. For eyes injected with UG, mean IOP was 18.6 mm Hg, compared with 23.3 mm Hg for control eyes. Incidence of subconjunctival hemorrhage was higher for control eyes; severity of chemosis and hyperemia varied over time within both groups of eyes. Conclusion and Clinical Relevance—In dogs, peribulbar injection of ropivacaine with UG is feasible in dogs and provides effective sensory and motor blockades similar to those achieved with conventional techniques.
Iontophoresis is a method of non‐invasive transdermal drug delivery based on the transfer of charged molecules using a low‐intensity electric current. Both local and systemic administration are ...possible; however, the skin pharmacokinetics of iontophoretically delivered drugs is complex and difficult to anticipate. The unquestionable theoretical advantages of the technique make it attractive in several potential applications. After a brief review of the factors influencing iontophoresis, we detail the current applications of iontophoresis in therapeutics and the main potential applications under investigation, including systemic and topical drugs and focusing on the treatment of scleroderma‐related ulcerations. Finally, we address the issue of safety, which could be a limitation to the routine clinical use of iontophoresis.
Purpose of Review. Since the original publication on the quadratus lumborum (QL) block, the technique has evolved significantly during the last decade. This review highlights recent advances in ...various approaches for administering the QL block and proposes directions for future research. Recent Findings. The QL block findings continue to become clearer. We now understand that the QL block has several approach methods (anterior, lateral, posterior, and intramuscular) and the spread of local anesthetic varies with each approach. In particular, dye injected using the anterior QL block approach spread to the L1, L2, and L3 nerve roots and within psoas major and QL muscles. Summary. The QL block is an effective analgesic tool for abdominal surgery. However, the best approach is yet to be determined. Therefore, the anesthetic spread of the several QL blocks must be made clear.
Epidural analgesia is an important means of pain control during labor throughout the world. Over its historic development, it has been implicated in several undesirable outcomes, including ...prolongation of labor and increased need for operative delivery. These effects have emerged in some retrospective and observational studies, but such methods of investigation are highly prone to bias and are particularly ill-suited for the study of labor analgesia. In high-quality studies, including Cochrane reviews and meta-analyses, epidural analgesia has been suggested to extend the first stage of labor by 30 minutes and the second stage by 15 minutes, when compared with alternative forms of analgesia. Although this may be a reproducible effect, it may be argued that it is clinically negligible.
With respect to mode of delivery, similar high-quality studies have consistently shown no increased risk of cesarean delivery associated with epidural analgesia. Some forms of epidural analgesia were associated with higher risk of assisted vaginal delivery, but the use of newer modalities has been shown to abolish this effect. Specific advancements have centered on reducing total anesthetic consumption, given that local anesthetic-induced motor block is theorized to interfere with maternal expulsive efforts in the second stage of labor. These measures include the use of low-concentration local anesthetic solutions equivalent to ≤0.1% bupivacaine, shown in meta-analyses to lead to no higher risk of assisted vaginal delivery relative to nonepidural analgesia. Additional advancements in the maintenance of analgesia include programmed intermittent epidural bolus and patient-controlled epidural analgesia, the combination of which has been shown to reduce the risk of assisted vaginal delivery, also likely mediated by reduction in local anesthetic dose. These techniques have gained popularity in the past two decades, such that studies published since 2005 show no higher risk of assisted vaginal delivery with epidural than with opioid analgesia (as reported in a Cochrane review).
Labor epidural analgesia has implications for maternal and fetal health perinatally. It is known to result in transient maternal hypotension (particularly with initiation), which may progress to the level of necessitating fluid or vasopressor therapy. This is not clearly associated with any adverse outcomes. There is also a consistently higher incidence of fever in parturients receiving neuraxial anesthesia, likely of noninfectious origin, which has similarly not been associated with adverse neonatal outcomes. Finally, neonates of parturients who receive epidural analgesia have been shown to have no worse Apgar scores and more favorable acid-base status than their counterparts. These observations should serve to reassure providers that modern labor analgesia, as currently understood, is not consistently associated with any significant adverse outcomes for the parturient or fetus.
In this review, we describe variations of modern labor epidural analgesia, conduct an in-depth review of current literature on its use, and explore the most up-to-date evidence on its implications for the progression and outcomes of labor, including the pertinent maternal and fetal side effects.
PDF
