The effect of local injections of bupivacaine plus ketamine, bupivacaine alone, and placebo on reducing postoperative anal fistula pain: a randomized clinical trial

Postmastectomy analgesia with subcutaneous infiltration of ketamine with lidocaine in surgical wound

Background

Ketamine is an analgesic adjuvant useful in acute pain preventive treatment. However, there are few studies evaluating its efficacy in local administration for postoperative pain management.

Objective

To compare ketamine´s efficacy plus 2% lidocaine versus placebo plus 2% lidocaine infiltrated into surgical wound as postoperative analgesia in patients undergoing mastectomy.

Material and methods

An experimental, randomized, single-blind study was carried out in 18 patients older than 18 years scheduled for mastectomy under general anesthetic technique. The surgical wound was infiltrated before to its closure with 0.5 mg/kg of ketamine plus 10 mL of simple 2% lidocaine volumetric to 20 mL with saline solution (group 1) or 10 mL saline solution + 10 mL of simple 2% lidocaine (group 2). Each patient was randomly assigned to one of the two intervention groups by draw (from which a piece of paper was drawn indicating the group to which they would belong). The pain intensity was assessed by Analog Numerical Scale (ANS) at 2, 8 and 12 hours after surgery and the need for analgesic rescue doses.

Results

The scores on the ANS scale in both groups were similar at leaving (p 0.26) and 2 hours later (p 0.05). The ENA value was lower with 2% ketamine/lidocaine infiltration at 8 hours (ketamine 2.5 [2-3]; placebo 4 [3-7], p 0.01) and 12 hours (ketamine 3 [1-5]; placebo 5 [4-6], p < 0.001).

Conclusions

Ketamine infiltrated into the surgical wound provides superior analgesia and improves ENA scores in the post-surgical period.

Comparing the effects of dexmedetomidine and dexamethasone as perineural adjuvants on peripheral nerve block: A PRISMA-compliant systematic review and meta-analysis

BACKGROUND

Dexmedetomidine (Dexm), a selective alpha-2 adrenoceptor agonist, and dexamethasone (Dexa), a very potent and highly selective glucocorticoid, have both been proven effectively to prolong the duration of local anesthetics (LA) in regional anesthesia. However, data comparing the efficacy of Dexm and Dexa as perineural adjuvants are inconsistent. Therefore, this systematic review and meta-analysis of randomized and quasi-randomized controlled trials (RCTs) was conducted to compare the effects of Dexm and Dexa when used as LA adjuvants on peripheral nerve block (PNB).

METHODS

We systematically searched PubMed, Cochrane Library, EMBASE, Web of Science, and ScienceDirect databases up to October, 2020. The primary outcome was the duration of analgesia. Secondary outcomes included incidence of rescue analgesia, cumulative opioid consumption, time required for onset of sensory and motor blockades, duration of sensory and motor blockades, incidence of postoperative nausea and vomiting (PONV), and side effect-associated outcomes (e.g., bradycardia, sedation, hypotension, rates of infection, and neurological complications). The study was registered on PROSPERO, number CRD42020188796.

RESULTS

After screening of full-text relevant articles, 13 RCTs that met the inclusion criteria were retrieved for this systematic review. It was revealed that perineural Dexm provided equivalent analgesic duration to perineural Dexa. Besides, the intake of Dexm increased the incidence of rescue analgesia in limbs surgery, as well as the cumulative opioid consumption, and decreased the time required for onset of sensory and motor blockades for long-acting LA (all P < .05). Other analysis revealed insignificant difference between the 2 groups in terms of the incidence of PONV (P > .05). Additionally, 2 studies demonstrated that Dexm possesses more sedative properties than Dexa (P < .05).

CONCLUSIONS

This meta-analysis indicated that the analgesic duration of Dexm and Dexa as LA adjuvants in PNB is the same. Meanwhile, the effects of perineural Dexm and Dexa on some secondary outcomes, including the incidence of rescue analgesia, cumulative opioid consumption, and time required for onset of sensory and motor blockades, are associated with the surgical site and type of LA.

Chinese herbal fumigant and lotion for postoperative complication in surgical wound of anal fistula: A protocol for a systematic review and meta-analysis

BACKGROUND

Surgery is the most common and effective therapy for anal fistula, while the postoperative complication, such as pain, edema, pruritus, turgescence, and exudation in surgical wound, can have serious impact on wound healing and patients' quality of life. Chinese herbal fumigant and lotion have been commonly used in postoperative treatment and achieved satisfied effect in China. However, clinical evidence-based literature of Chinese herbal fumigant and lotion for postoperative anal fistula is not sufficient. This protocol is described for a systematic review to investigate the beneficial effects.

METHODS

A systematic search will be conducted in database involving PubMed, the Cochrane library, Embase, Web of Science, Google Scholar, SinoMed, China National Knowledge Infrastructure(CNKI), VIP, Wanfang Database, CiNii(National Institute of Informatics), and KISS(Koreanstudies Information Service System) from inceptions to December 31, 2019. We will include randomized controlled trials (RCT) regarding Chinese herbal fumigant and lotion in the treatment of complication in surgical wound of anal fistula. Quality of included RCTs will be assessed according to the Cochrane Handbook 5.1.0. GRADE will be used to assess the quality of evidence. The summary results will be pooled using the random-effects model or fixed-effects model according to the heterogeneity of included studies.

RESULTS

After peer-review, the study will be disseminated in scientific journals and conferences.

CONCLUSION

This systematic review will provide evidence for the efficacy of Chinese herbal fumigant and lotion for curing postoperative complication of anal fistula. In addition, it might provide suggestions for Chinese medicine clinical practice or guideline.

PROSPERO REGISTRATION

CRD42020164975.

Subcutaneous ketamine prolongs the analgesic effect of local infiltration of plain Bupivacaine in children undergoing inguinal herniotomy

Background

Inguinal herniotomy is one of the commonest paediatric surgical procedures at the University of Benin Teaching Hospital. Incisional infiltration with plain bupivacaine has been used to provide postoperative analgesia for this procedure but with a short duration of action, 4–6 hours.

Aims/Objectives

The aim of this study therefore was to evaluate the efficacy of subcutaneous ketamine on post-operative analgesia in children undergoing unilateral inguinal herniotomy

Methods

Forty-six (46) ASA I or II patients aged three to seven years scheduled for unilateral inguinal herniotomy were recruited. The patients were randomized to receive surgical wound site infiltration with plain bupivacaine plus subcutaneous injection of ketamine for group I or surgical wound site infiltration plain bupivacaine plus 2ml of saline subcutaneously for group II at the end of surgery. Data obtained were analyzed using SPSS version 20. Continuous data were compared using student t-test while categorical data were compared using Chi-square or Fisher's exact test. P-value <0.05 was considered statistically significant.

Results

In group, I, the mean time to first analgesic request was 667.7 minutes (11.12 hours) and in group II, it was 371.3 minutes (6.2 hours) with p<0.001. The pain scores were better and more favourable in group I from the 8th hour and above of the assessment period. The mean post-operative analgesic consumption in 24 hours was less in group I (19.35±5.4mg) than in group II (27.32±5.8 mg) with p-value <0.001.

Conclusion

The study showed that subcutaneous ketamine prolonged the analgesic effect of plain bupivacaine surgical wound site infiltration in children undergoing unilateral inguinal herniotomy.

Perianal block with ropivacaine as a supplement to anaesthesia in proctological surgery: double-blind randomized placebo-controlled trial (PERCEPT)

BACKGROUND

The benefit of a perianal block as an adjunct to general or regional anaesthesia is debated. This RCT aimed to compare pain at 24 h and up to 14 days after proctological surgery in patients with and without a perianal block.

METHODS

Between January 2018 and April 2019, patients were allocated to receive a perianal block with ropivacaine or placebo as an adjunct to anaesthesia. Patients, surgeons and assessors were blinded. The primary outcome was pain measured on a numerical rating scale (NRS) after 24 h. Secondary outcomes were need for rescue analgesia, and pain after 1, 2, 3, 6 and 12 h. The mean, rest and maximum NRS scores were measured for 14 days.

RESULTS

A total of 138 patients were included, of whom 46 and 44 received general anaesthesia with or without ropivacaine respectively, and 23 and 25 received spinal anaesthesia with or without ropivacaine respectively (P = 0·858). The mean NRS score differed significantly at 24 h (mean(s.d.) 1·1(0·1) versus 2·3(0·2); P < 0·001), but not at 1 h (1·4(0·2) versus 2·2(0·3); P = 0·051). The NRS score was lower with use of ropivacaine at 2 h (1·0(0·2) versus 1·6(0·2); P = 0·045), 3 h (0·9(0·2) versus 1·5(0·2); P = 0·022), 6 h (1·1(0·2) versus 1·8(0·2); P = 0·042) and 12 h (1·2(0·2) versus 1·8(0·2); P = 0·034). The use of oral morphine equivalents was 10·2(1·4) and 16·6(2·5) mg with and without ropivacaine respectively (P = 0·028). The mean and maximum NRS scores within 14 days were lower when ropivacaine was used (95 per cent c.i. for difference 0·14 to 0·49 (P = 0·002) and 0·39 to 0·63 (P < 0·001) respectively). There was no injection-associated morbidity.

CONCLUSION

Perianal block as an adjunct to general or regional anaesthesia should be recommended for proctological surgery. It yields a reduction in pain, a reduced need for opioids, and a faster recovery with minimal risk of adverse events. Registration number: NCT03405922 ( http://www.clinicaltrials.gov).

Laceration Management

BACKGROUND

Traumatic lacerations to the skin represent a fairly common reason for seeking emergency department care. Although the incidence of lacerations has decreased over the past decades, traumatic cutaneous lacerations remain a common reason for patients to seek emergency department care.

OBJECTIVE

Innovations in laceration management have the potential to improve patient experience with this common presentation.

DISCUSSION

Studies have confirmed that delays in wound closure rarely confer increased rates of infection, although comorbidities such as diabetes, chronic renal failure, obesity, human immunodeficiency virus, smoking, and cancer should be considered. Antibiotics should be reserved for high-risk wounds, such as those with comorbidities, gross contamination, involvement of deeper structures, stellate wounds, and selected bite wounds. Topical anesthetics, which are painless to apply, have a role in select populations. In most studies, absorbable sutures perform similarly to nonabsorbable sutures and do not require revisit for removal. Novel atraumatic closure devices and expanded use of tissue adhesives for wounds under tension further erode the primacy of regular sutures in wound closure. Maintaining a moist wound environment with occlusive dressings is more important than previously thought. Most topical wound agents are of limited benefit.

CONCLUSIONS

Recent innovations in wound closure are allowing emergency physicians to shift toward painless, atraumatic, and rapid closure of lacerations.

Perineural versus intravenous dexamethasone as an adjuvant in regional anesthesia: a systematic review and meta-analysis

Background

Dexamethasone is a common adjuvant for local anesthetics in regional anesthesia, but the optimal route of administration is controversial. Therefore, we did a systematic review and meta-analysis of randomized controlled trials to assess the effect of perineural versus intravenous dexamethasone on local anesthetic regional nerve-blockade outcomes.

Materials and methods

Medline (through PubMed), Embase, Cochrane, Web of Science, and Biosis Previews databases were systematically searched (published from inception of each database to January 1, 2017) to identify randomized controlled trials. The data of the selected trials were statistically analyzed to find any significant differences between the two modalities. The primary outcome was the duration of analgesia. Secondary outcomes included duration of motor block, postoperative nausea and vomiting, and postoperative analgesic dose at 24 hours. We conducted a planned subgroup analysis to compare the effects between adding epinephrine or not.

Results

Ten randomized controlled trials met the inclusion criteria of our analysis, with a total of 749 patients. Without the addition of epinephrine, the effects of perineural and intravenous dexamethasone were equivalent concerning the duration of analgesia (mean difference 0.03 hours, 95% CI –0.17 to 0.24). However, with the addition of epinephrine, the analgesic duration of perineural dexamethasone versus intravenous dexamethasone was prolonged (mean difference 3.96 hours, 95% CI 2.66–5.27). Likewise, the impact of epinephrine was the same on the duration of motor block. The two routes of administration did not show any significant differences in the incidence of postoperative nausea and vomiting, nor on postoperative analgesic consumption at 24 hours.

Conclusion

Our results show that perineural dexamethasone can prolong the effects of analgesic duration when compared to the intravenous route, only when epinephrine is coadministered. Without epinephrine, the two modalities show equivalent effect as adjuvants on regional anesthesia.

Tracking local anesthetic effects using a novel perceptual reference approach

Drug effects of loco-regional anesthetics are commonly measured by unidimensional pain rating scales. These scales require subjects to transform their perceptual correlates of stimulus intensities onto a visual, verbal, or numerical construct that uses a unitless cognitive reference frame. The conceptual understanding and execution of this magnitude estimation task may vary among individuals and populations. To circumvent inherent shortcomings of conventional experimental pain scales, this study used a novel perceptual reference approach to track subjective sensory perceptions during onset of an analgesic nerve block. In 34 male subjects, nociceptive electric stimuli of 1-ms duration were repetitively applied to left (target) and right (reference) mandibular canines every 5 s for 600 s, with a side latency of 1 ms. Stimulus strength to the target canine was programmed to evoke a tolerable pain intensity perception and remained constant at this level throughout the experiment. A dose of 0.6 ml of articaine 4% was submucosally injected at the left mental foramen. Subjects then reported drug effects by adjusting the stimulus strength (in milliamperes) to the reference tooth, so that the perceived intensity in the reference tooth was equi-intense to the target tooth. Pain and stimulus perception offsets were indicated by subjects. Thus, the current approach for matching the sensory experience in one anatomic location after regional anesthesia allows detailed tracking of evolving perceptual changes in another location. This novel perceptual reference approach facilitates direct and accurate quantification of analgesic effects with high temporal resolution. We propose using this method for future experimental investigations of analgesic/anesthetic drug efficacy.