Randomised, masked study of local anaesthesia administered prior to external dacryocystorhinostomy under general anaesthesia

External dacryocystorhinostomy: A critical overview of the current evidence

PURPOSE

External dacryocystorhinostomy (ext-DCR) is still considered the gold standard in the treatment of distal lacrimal duct obstruction. Despite an overall high success rate, some patients do relapse after surgery and the ideal perioperative management has not been identified yet. The purpose of this study is to critically discuss the published evidence in the last five years on the medical and surgical management of external dacryocystorhinostomy. Furthermore, the drawbacks of the available literature and the perspectives in this field will be also highlighted.

METHODS

Systematic review of the literature in the last 5 years by using PubMed and Google Scholar.

RESULTS

A total of 64 articles were included. Many technical modifications and surgical refinements have been proposed but a formal comparison among the various techniques is hampered by methodological heterogeneity. The use of local anesthesia, and the perioperative adjunctive techniques to reduce the risk of restenosis are also gaining popularity but the level of evidence remains weak.

CONCLUSION

Ext-DCR offers satisfactory clinical outcomes even though there are many gray areas that need to be addressed in future high-quality studies.

Isolation, structural characterization and quantification of impurities in bupivacaine

Bupivacaine was found to be unstable during the accelerated storage condition(40 ℃ and 75% relative humidity), and two degradation impurities with the same protonated molecular ion were observed by high performance liquid chromatography-mass spectrometry (LC-MS). A semipreparative method was used to separate and purify the two impurities, and their structures were elucidated via comprehensive HR-MSMS and NMR spectroscopy analyses. Their stereo structures were characterized through single crystal X-ray diffraction. Meanwhile, an LC-MS method was developed and validated to quantify the two degradation impurities of bupivacaine. Chromatographic separation was performed on a C18 reversed-phase column (4.6 × 150 mm, 5 µm) using an equivalent elution with water and methanol. The limits of quantitation for the two degradation impurities (named RS1 and RS2) were 0.89 and 0.65 ng, respectively, and the average recoveries were in the range of 90∼108% and relative standard deviations were less than 5.0%. The proposed LC-MS method can be used to control the quality of bupivacaine and its formulations. DATA AVAILABILITY: Data will be made available on request.

Management of postoperative pain in ophthalmic plastic surgery: a major review

PURPOSE

Clinicians are becoming increasingly aware of the risks of opioid analgesics, and, consequently, are searching for alternatives to these agents. This review considers the existing literature regarding the management of pain after ophthalmic plastic surgery.

METHODS

A literature search was performed through the PubMed database. Articles were assessed for relevance, and the appropriate data was extracted from the medical literature regarding pain management strategies after oculoplastic procedures.

RESULTS

An emerging body of literature suggests the efficacy of a variety of non-narcotic agents in post-operative pain management. Many of these medications prevent the development of pain, and several have been studied in randomized trials. Specifically, pregabalin, ketorolac, acetaminophen, memantine, local anesthetics, and alternative therapies all have documented benefit in this setting.

CONCLUSIONS

Several medications may prevent and treat pain after ophthalmic plastic surgery. These agents are well-tolerated, and many decrease the requirement for opioid analgesics. Clinicians should be aware of these therapies when considering non-narcotic pain management.

Dexmedetomidine Compared to Remifentanil Infusion as Adjuvant to Sevoflurane Anesthesia during Laparoscopic Sleeve Gastrectomy

Objectives

Evaluation of postoperative (PO) analgesic effects of intraoperative (IO) Dexmedetomidine (DEX) compared to remifentanil (REMI) infusions during sevoflurane anesthesia for laparoscopic gastric sleeve surgery.

Patients and Methods

One hundred and thirty-two patients with body mass index >35 kg.m^-2 and ASA Grades II or III were randomly divided into group R received REMI infusion (6-18 μg.kg^-1.h^-1) and Group D received DEX infusion (0.2-0.5 μg.kg^-1.h^-1) after tracheal intubation till before stoppage of inhalational anesthetic. Heart rate and mean arterial pressure were noninvasively monitored during and after surgery. Emergence time, time until postanesthetic care unit transfer, and total operating room (OR) time was recorded. PO shoulder-tip pain and wound pain scores were recorded and rescue analgesia was provided as 50 mg pethidine intramuscular injection. Occurrence of PO nausea and vomiting (PONV) and frequency of the need for antiemetic therapy were recorded. Primary study outcome was the ability of the study infusions to reduce consumption of PO pethidine down to one dose during 24-hr PO.

Results

IO use of REMI or DEX infusion allowed hemodynamic control to surgical stresses with nonsignificant difference between both infusions. REMI infusion insured significantly rapid recovery and short OR times but required larger volume of sevoflurane during surgery and proper PO follow-up for pain and PONV. DEX infusion significantly improved control of PO pain with a larger number of patient requested rescue analgesia only once, reduced the dose of PO analgesia, reduced the frequency of PONV, and the need for antiemetic therapy.

Conclusion

REMI or DEX infusion as IO adjuvant to general anesthesia is appropriate option to achieve hemodynamic control of surgical stresses and to improve perioperative outcomes. REMI infusion may be preferred for its induced rapid recovery and short OR time, whereas DEX infusion may be chosen for its improved control of PO pain and reduction of PO analgesia and frequency of PONV.