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Mohamed AA, Radwan TA, Mohamed MM, Mohamed HA, Mohamed Elemady MF, Osman SH, Safan TF, Khair TM, Ali NA, Fahmy RS, Belita MI, Abdalla SR, Seleem AA, Atta EM, Zaid OI, Ragab AS, Salem AE, AlKholy BM. Safety and efficacy of addition of hyaluronidase to a mixture of lidocaine and bupivacaine in scalp nerves block in elective craniotomy operations; comparative study. BMC Anesthesiol 2018; 18:129. [PMID: 30219027 PMCID: PMC6138934 DOI: 10.1186/s12871-018-0590-9] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2018] [Accepted: 08/28/2018] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Patients undergoing craniotomy operations are prone to various noxious stimuli, many strategies are commenced to provide state of analgesia, for better control of the stress response and to overcome its undesired effects on the haemodynamics and post-operative pain. Scalp nerves block are considered one of these strategies. This study was conceived to evaluate the effect of addition of hyaluronidase to the local anaesthetic mixture used in the scalp nerves block in patients undergoing elective craniotomy operations. METHODS 64 patients undergoing elective craniotomy operations were enrolled in this prospective randomized, double-blind comparative study. Patients were randomly assigned to two groups. Group LA, patients subjected to scalp nerves block with 15 ml bupivacaine 0.5%, 15 ml lidocaine 2%, in 1:400000 epinephrine. Group H as Group LA with15 IU /ml Hyaluronidase. RESULTS Patients in the H group showed lower VAS values for 8 h postoperative, compared to the LA group. The haemodynamic response showed lower values in the H group, compared to the LA group. Those effects were shown in the intraoperative period and for 6 h post-operative. No difference was detected regarding the incidence of complications nor the safety profile. CONCLUSION Our data supports the idea that addition of hyaluronidase to the local anesthetic mixture improves the success rates of the scalp nerves block and its efficacy especially during stressful intraoperative periods and in the early postoperative period. No evident undesirable effects in relation to the addition of hyaluronidase. TRIAL REGISTRATION Clinical Trial registry on ClinicalTrials.gov , NCT 03411330 , 25-1-2018.
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Affiliation(s)
- Ahmed Abdalla Mohamed
- Anaesthesia, Faculty of Medicine, Cairo University, 139 H,Kafra Gate,Hadayk AL Ahram, Giza, Egypt.
| | - Tarek Ahmed Radwan
- Anaesthesia, Faculty of Medicine, Cairo University, 52 Elthawra street, Heliopolis, Cairo, Egypt
| | - Mohamed Mahmoud Mohamed
- Anaesthesia, Faculty of Medicine, Cairo University, 10 Abdlhameed Kotb Street, Kozzika, Maadi, Cairo, Egypt
| | - Hatem Abdellatif Mohamed
- Anaesthesia, Faculty of Medicine, Cairo University, 6 Ahmed Angad Street, Faisal-Alharam-Giza, Egypt
| | | | - Safinaz Hassan Osman
- Anaesthesia, Faculty of Medicine, Cairo University, 4 Hussein El Ezaby Street, Misr Alexandria Road, Cairo, Egypt
| | - Tamer Fayez Safan
- Anaesthesia, Faculty of Medicine, Cairo University, 1 Alsaraya Street, Almanyal, 11559, Cairo, Egypt
| | - Tamer Mohamed Khair
- Anaesthesia, Faculty of Medicine, Cairo University, 290 Teraat el gabal Street, El Zayton, Cairo, Egypt
| | - Norhan Abdelaleem Ali
- Anaesthesia, Faculty of Medicine, Cairo University, 29 Mansoura street, Agouza, Giza, Egypt
| | - Rania Samir Fahmy
- Anaesthesia, Faculty of Medicine, Cairo University, 1 Alsaraya Street, Almanyal, 11559, Cairo, Egypt
| | - Mohamed Ibrahim Belita
- Anaesthesia, Faculty of Medicine, Cairo University, 1 Alsaraya Street, Almanyal, 11559, Cairo, Egypt
| | - Shady Rady Abdalla
- Anaesthesia, Faculty of Medicine, Cairo University, 1 Alsaraya Street, Almanyal, 11559, Cairo, Egypt
| | - Ahmed Abdelaziz Seleem
- Anaesthesia, Faculty of Medicine, Cairo University, 15 B, Misr Construction Buldings,Zahraa el Maadi, Cairo, Egypt
| | - Ehab Mohi Atta
- Anaesthesia, Faculty of Medicine, Cairo University, 1 Alsaraya Street, Almanyal, 11559, Cairo, Egypt
| | - Osama Ismail Zaid
- Anaesthesia, Faculty of Medicine, Cairo University, 1 Alsaraya Street, Almanyal, 11559, Cairo, Egypt
| | - Ahmed Shaker Ragab
- Anaesthesia, National Cancer Institute, Anaesthesiology Department, Cairo University, Kasr Alainy Street, Cairo, Egypt
| | - Ahmed Essam Salem
- Anaesthesia, Faculty of Medicine, Tanta University, 92 Ahmed Orabi Street, El Mohandsen, Cairo, Egypt
| | - Badawy Mohamed AlKholy
- Chemical Patholpgy, Faculty of Medicine, Cairo University, 10 B Youssef Algendy Street, Bab Allouk, Cairo, Egypt
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Rüschen H, Aravinth K, Bunce C, Bokre D. Use of hyaluronidase as an adjunct to local anaesthetic eye blocks to reduce intraoperative pain in adults. Cochrane Database Syst Rev 2018; 3:CD010368. [PMID: 29498413 PMCID: PMC6494176 DOI: 10.1002/14651858.cd010368.pub2] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
BACKGROUND Hyaluronidase has been used over many decades as an adjunct to local anaesthetic solution to improve the speed of onset of eye blocks and to provide better akinesia and analgesia. With the evolution of modern eye surgery techniques, fast onset and akinesia are not essential requirements anymore. The assumption that the addition of hyaluronidase to local anaesthetic injections confers better analgesia for the patient needs to be examined. There has been no recent systematic review to provide evidence that hyaluronidase actually improves analgesia. OBJECTIVES To ascertain if adding hyaluronidase to local anaesthetic solutions for use in ophthalmic anaesthesia in adults results in a reduction of perceived pain during the operation and to assess harms, participant and surgical satisfaction, and economic impact. SEARCH METHODS We carried out systematic searches in Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, Embase, and four other databases in June 2017. We searched the trial registers at www.ISRCTN.com, ClinicalTrials.gov and www.clinicaltrialsregister.eu for relevant trials. We imposed no language restrictions. SELECTION CRITERIA We included randomized controlled trials (RCTs) that evaluated the effect of hyaluronidase on pain experienced by adults during intraocular surgery using a rating scale. DATA COLLECTION AND ANALYSIS Two review authors (HR and KA) independently extracted data and assessed methodological quality using standard procedures as expected by Cochrane. MAIN RESULTS We included seven trials involving 500 participants that studied the effect of hyaluronidase on intraoperative pain. Four of the seven trials with 289 participants reported the primary outcome in a dichotomous manner, and we proceeded to meta-analyse the findings which showed a moderate heterogeneity that could not be explained (I2 = 41% ). The pooled risk ratio (RR) for these four trials was 0.83 with the 95% confidence interval ranging from 0.48 to 1.42. The reduction in intraoperative pain scores in the hyaluronidase group were not statistically significant. Among the three trials that reported the primary outcome in a continuous manner, the presence of missing data made it difficult to conduct a meta-analysis. To further explore the data, we imputed standard deviations for the other studies from another included RCT (Sedghipour 2012). However, this resulted in substantial heterogeneity between study estimates (I² = 76% ). The lack of reported relevant data in two of the three remaining trials made it difficult to assess the direction of effect in a clinical setting.Overall, there was no statistical difference regarding the intraoperative reduction of pain scores between the hyaluronidase and control group. All seven included trials had a low risk of bias.According to GRADE, we found the quality of evidence was low and downgraded the trials for serious risk of inconsistency and imprecision. Therefore, the results should be analysed with caution.Participant satisfaction scores were significantly higher in the hyaluronidase group in two high quality trials with 122 participants. Surgical satisfaction was also superior in two of three high quality trials involving 141 participants. According to GRADE, the quality of evidence was moderate for participant and surgical satisfaction as the trials were downgraded for imprecision due to the small sample sizes. The risk of bias in these trials was low.There was no reported harm due to the addition of hyaluronidase in any of the studies. No study reported on the cost of hyaluronidase in the context of eye surgery. AUTHORS' CONCLUSIONS The effects of adding hyaluronidase to local anaesthetic fluid on pain outcomes in people undergoing eye surgery are uncertain due to the low quality of evidence available. A well designed RCT is required to address inconsistency and imprecision among the studies and to determine the benefit of hyaluronidase to improve analgesia during eye surgery. Participant and surgical satisfaction is higher with hyaluronidase compared to the control groups, as demonstrated in moderate quality studies. There was no harm attributed to the use of hyaluronidase in any of the studies. Considering that harm was only rarely defined as an outcome measure, and the overall small number of participants, conclusions cannot be drawn about the incidence of harmful effects of hyaluronidase. None of the studies undertook cost calculations with regards to use of hyaluronidase in local anaesthetic eye blocks.
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Affiliation(s)
- Heinrich Rüschen
- Moorfields Eye Hospital NHS Foundation TrustDepartment of Anaesthesia162 City RoadLondonUKEC1V 2PD
| | - Kavitha Aravinth
- Moorfields Eye Hospital NHS Foundation TrustDepartment of Anaesthesia162 City RoadLondonUKEC1V 2PD
| | - Catey Bunce
- King's College LondonDepartment of Primary Care & Public Health Sciences4th Floor, Addison HouseGuy's CampusLondonUKSE1 1UL
| | - Desta Bokre
- Moorfields Eye Hospital & UCL Institute of OphthalmologyThe Joint Library of Ophthalmology11‐43 Bath StreetLondonUKEC1V 9EL
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