Octogenarians fare better under local anesthesia for elective endovascular aortic aneurysm repair

OBJECTIVE

With an aging patient population, an increasing number of octogenarians are undergoing elective endovascular abdominal aortic aneurysm repair (EVAR) in the United States. Multiple studies have shown that, for the general population, use of local anesthetic (LA) for EVAR is associated with improved short-term and long-term outcomes as compared with performing these operations under general anesthesia (GA). Therefore, this study aimed to study the association of LA for elective EVARs with perioperative outcomes, among octogenarians.

METHODS

The Vascular Quality Initiative database (2003-2021) was used to conduct this study. Octogenarians (Aged ≥80 years) were selected and sorted into two study groups: LA (Group I) and GA (Group II). Our primary outcomes were length of stay and mortality. Secondary outcomes included operative time, estimated blood loss, return to operating room, cardiopulmonary complications, and discharge location.

RESULTS

Of the 16,398 selected patients, 1197 patients (7.3%) were included in Group I, and 15,201 patients (92.7%) were in Group II. Procedural time was significantly shorter for the LA group (114.6 vs 134.6; P < .001), as was estimated blood loss (152 vs 222 cc; P < .001). Length of stay was significantly shorter (1.8 vs 2.6 days; P < .001), and patients were more likely to be discharged home (LA 88.8% vs GA 86.9%; P = .036) in the LA group. Group I also experienced fewer pulmonary complications; only 0.17% experienced pneumonia and 0.42% required ventilator support compared with 0.64% and 1.02% in Group II, respectively. This finding corresponded to fewer days in the intensive care unit for Group I (0.41 vs 0.69 days; P < .001). No significant difference was seen in 30-day mortality cardiac, renal, or access site-related complications. Return to operating room was also equivocal between the two groups. Multivariate regression analysis confirmed GA was associated with a significantly longer length of stay and significantly higher rates of non-home discharge (adjusted odds ratio [AOR], 1.59; P < .001 and AOR, 1.40; P = .025, respectively). When stratified by the New York Heart Association classification system, classes I, II, III, and IV (1.55; P < .001; 1.26; P = .029; 2.03; P < .001; 4.07; P < .001, respectively) were associated with significantly longer hospital stays.

CONCLUSIONS

The use of LA for EVARs in octogenarians is associated with shorter lengths of stay, fewer respiratory complications, and home discharge. These patients also experienced shorter procedure times and less blood loss. There was no statistically significant difference in 30-day mortality, return to operating room, or access-related complications. LA for octogenarians undergoing EVAR should be considered more frequently to shorten hospital stays and decrease complication rates.

Local Anesthesia for Endovascular Repair of Abdominal Aortic Aneurysm Allows for Accurate Graft Deployment with Durable Results

BACKGROUND

Local anesthesia (LA) is sparsely used in endovascular aneurysm repair (EVAR) despite short-term benefit, likely secondary to concerns over patient movement preventing accurate endograft deployment. The objective of this study is to examine the association between anesthesia type and endoleak, sac regression, reintervention, and mortality.

METHODS

The Vascular Quality Initiative database was queried for all EVAR cases from 2014 to 2022. Patients were included if they underwent percutaneous elective EVAR with anatomical criteria within instructions for use of commercially approved endografts. Multivariable logistic regression with propensity score weighting was used to determine the association between anesthesia type on the risk of any endoleak noted by intraoperative completion angiogram and sac regression. Multivariable survival analysis with propensity score weighting was used to determine the association between anesthesia type and endoleak at 1 year, long-term reintervention, and mortality.

RESULTS

Thirteen thousand nine hundred thirty two EVARs met inclusion criteria: 1,075 (8%) LA and 12,857 (92%) general anesthesia (GA). On completion angiogram, LA was associated with fewer rates of any endoleaks overall (16% vs. 24%, P < 0.001). On multivariable analysis with propensity score weighting, LA was associated with similar adjusted odds of any endoleak on intraoperative completion angiogram (odds ratio [OR] 0.56, 95% confidence interval [CI] 0.47-0.68) as well as combined type 1a and type 1b endoleaks (OR 0.72, 95% CI 0.47-1.09). Follow-up computed tomography imaging at 1 year was available for 4,892 patients, 377 (8%) LA and 4,515 (92%) GA. At 1 year, LA was associated with similar rate of freedom from any endoleaks compared to GA (0.66 [95% CI 0.63-0.69] vs. 0.71 [95% CI 0.70-0.72], P = 0.663) and increased rates of sac regression (50% vs. 45%, P = 0.040). On multivariable analysis with propensity score weighting, LA and GA were associated with similar adjusted odds of sac regression (OR 1.22, 95% CI 0.97-1.55). LA and GA had similar rates of endoleak at 1 year (hazard ratio [HR] 0.14, 95% CI 0.63-1.07); however, LA was associated with decreased hazards of combined type 1a and 1b endoleaks at 1 year (HR 0.87, 95% CI 0.80-0.96). LA and GA had similar adjusted long-term reintervention rate (HR 0.77, 95% CI 0.44-1.38) and long-term mortality (HR 1.100, 95% CI 079-1.25).

CONCLUSIONS

LA is not associated with increased adjusted rates of any endoleak on completion angiogram or at 1-year follow-up compared to GA. LA is associated with decreased adjusted rates of type 1a and type 1b endoleak at 1 year, but similar rates of sac regression, long-term reintervention, and mortality. Concerns for accurate graft deployment should not preclude use of LA and LA should be increasingly considered when deciding on anesthetic type for standard elective EVAR.

Complications and side effects of Wide-Awake Local Anaesthesia No Tourniquet (WALANT) in upper limb surgery: a systematic review and meta-analysis

PURPOSE

Wide-Awake Local Anaesthesia No Tourniquet (WALANT), a groundbreaking anaesthetic technique resurging in practice, warrants a comprehensive safety analysis for informed adoption. Our study aimed to identify complications/side effects of WALANT upper limb procedures through a systematic review and meta-analysis.

METHODS

This PROSPERO-registered study was performed with strict adherence to PRISMA guidelines. Embase, OVIDMedline, Cochrane, Web of Science, and Scopus databases were searched until February 2023. Inclusion criteria involved English articles, reporting complications/side effects in primary WALANT upper limb surgeries. Outcomes included all complications and side effects, data on the anaesthetic mixture, publication year/location, study type, and procedures performed. The meta-analysis employed the Freeman-Tukey Double Arcsine Transformation, computed I2 statistics, and utilized common or random effects models for pooled analysis.

RESULTS

2002 studies were identified; 79 studies met the inclusion criteria representing 15,595 WALANT patients. A total of 301 patients had complications, and the meta-analysis using a random effects model provided a complication rate of 1.7% (95% CI: 0.93-2.7%). The most reported complications were superficial infection (41%, n = 123/300), other/specified (12%, n = 37/300), and recurrent disease (6.7%, n = 20/300). A decade-by-decade analysis revealed no statistically significant difference in complication rates spanning the last three decades (p = 0.42). Adding sodium bicarbonate to the anaesthetic solution significantly reduced postoperative complications (p = 0.025).

CONCLUSION

WALANT has a low overall complication rate of 1.7%, with no significant temporal variation and a significant reduction in complications when sodium bicarbonate is added to the anaesthetic solution. Our findings support the safety of WALANT in upper limb procedures.

REGISTRATION

PROSPERO: CRD42023404018.

[A prospective comparative study on effectiveness of single versus continuous adductor canal block combined with local infiltration anesthesia in unicompartmental knee arthroplasty]

Objective

To compare the early analgesic effects and the impact on knee joint function recovery after unicompartmental knee arthroplasty (UKA) between single adductor canal block (SACB) and continuous adductor canal block (CACB) combined with local infiltration anesthesia (LIA) using a prospective study.

Methods

The patients with knee osteoarthritis admitted between April 2022 and December 2023 were enrolled as a subject. Among them, 60 patients met the selection criteria and were enrolled in the study. They were randomly assigned to the SACB group or CACB group in a ratio of 1:1 using a random number table method. There was no significant difference between the two groups ( P>0.05) in terms of age, gender, height, body mass, body mass index, affected side, and preoperative resting visual analogue scale (VAS) score and active VAS score, Oxford knee score (OKS), and American Hospital of Special Surgery (HSS) score. All patients received multimodal analgesia management using LIA combined with SACB or CACB. The operation time, pain related indicators (resting and activity VAS scores, number and timing of breakthrough pain, opioid consumption), joint function related indicators (quadriceps muscle strength, knee range of motion, OKS score, and HSS score), as well as postoperative block complications and adverse events were recorded and compared between the two groups.

Results

There was no significant difference in the operation time between the two groups ( P<0.05). All patients in the two groups were followed up with a follow-up time of (9.70±4.93) months in the SACB group and (12.23±5.05) months in the CACB group, and the difference was not significant ( P>0.05). The CACB group had a significant lower resting VAS score at 24 hours after operation compared to the SACB group ( P<0.05). There was no significant difference in resting and active VAS scores between the two groups at other time points ( P>0.05). The CACB group had a significantly lower incidence of breakthrough pain compared to the SACB group [9 cases (30.00%) vs. 17 cases (56.67%); P<0.05). However, there was no significant difference in the timing of breakthrough pain occurrence and opioid consumption between the two groups ( P>0.05). Four cases in the SACB group and 7 cases in the CACB group experienced adverse events, with no significant difference in the incidence of adverse events between the two groups ( P>0.05). The CACB group had significantly better knee joint mobility than the SACB group at 1 and 2 days after operation ( P<0.05). There was no significant difference between the two groups in knee joint mobility on 0 day after operation and quadriceps muscle strength and OKS and HSS scores at different time points ( P>0.05).

Conclusion

In UKA, the analgesic effects and knee joint function recovery are similar when compared between LIA combined with SACB and LIA combined with CACB. However, SACB is simpler to perform and can avoid adverse events such as catheter displacement and dislocation. Therefore, SACB may be a better choice.

Retinal artery occlusion after ophthalmic surgery under regional anaesthesia: A narrative review

Two recent cases of central retinal artery occlusion under otherwise uncomplicated sub-Tenon's block that resulted in significant visual loss after cataract surgery prompted us to undertake a literature review of such cases. We identified 97 cases of retinal artery occlusion after ophthalmic surgery under regional anaesthesia that had no immediate signs of block-related complications. These occurred after various intraocular (87%) and extraocular (13%) operations, across a wide range of ages (19-89 years) on patients with (59%) or without (39%) known risk factors. The anaesthetic techniques included 40 retrobulbar blocks, 36 peribulbar blocks, 19 sub-Tenon's blocks, one topical anaesthetic and one unspecified local anaesthetic. Different strengths of lidocaine, bupivacaine, mepivacaine and ropivacaine, either alone or in various combinations, were used. The details of the anaesthetic techniques were often incomplete in the reports, which made comparison and analysis difficult. Only nine cases had their cause (optic nerve sheath injury) identified, while the mechanism of injury was unclear in the remaining patients. Various mechanisms were postulated; however, the cause was likely to be multifactorial due to patient, surgical and anaesthetic risk factors, especially in those with compromised retinal circulation. As there were no definite risk factors identified, no specific recommendations could be made to avoid this devastating outcome. We have provided rationales for some general considerations, which may reduce this risk, and propose anaesthetic options for ophthalmic surgery on the fellow eye if required, based both on our literature review and our personal experience.

Effect of General Anesthesia Versus Conscious Sedation/Local Anesthesia on the Outcome of Patients with Minor Stroke and Isolated M2 Occlusion Undergoing Immediate Thrombectomy: A Retrospective Multicenter Matched Analysis

BACKGROUND

This study investigates the impact of general anesthesia (GA) versus conscious sedation/local anesthesia (CS/LA) on the outcome of patients with minor stroke and isolated M2 occlusion undergoing immediate mechanical thrombectomy (iMT).

METHODS

The databases of 16 comprehensive stroke centers were retrospectively screened for consecutive patients with isolated M2 occlusion and a baseline National Institutes of Health Stroke Scale score ≤5 who received iMT. Propensity score matching was used to estimate the effect of GA versus CS/LA on clinical outcomes and procedure-related adverse events. The primary outcome measure was a 90-day modified Rankin Scale (mRS) score of 0-1. Secondary outcome measures were a 90-day mRS score of 0-2 and all-cause mortality, successful reperfusion, procedural-related symptomatic subarachnoid hemorrhage, intraprocedural dissections, and new territory embolism.

RESULTS

Of the 172 patients who were selected, 55 received GA and 117 CS/LA. After propensity score matching, 47 pairs of patients were available for analysis. We found no significant differences in clinical outcome, rates of efficient reperfusion, and procedural-related complications between patients receiving GA or LA/CS (mRS score 0-1, P = 0.815; mRS score 0-2, P = 0.401; all-cause mortality, P = 0.408; modified Treatment in Cerebral Infarction score 2b-3, P = 0.374; symptomatic subarachnoid hemorrhage, P = 0.082; intraprocedural dissection, P = 0.408; new territory embolism, P = 0.462).

CONCLUSIONS

In patients with minor stroke and isolated M2 occlusion undergoing iMT, the type of anesthesia does not affect clinical outcome or the rate of procedural-related complications. Our results agree with recent data showing no benefit of one specific anesthesiologic procedure over the other and confirm their generalizability also to patients with minor baseline symptoms.

The Comparison of Efficacy and Safety Between General and Topical Anesthesia on Micro-Plasma Radiofrequency Treatment for Hypertrophic Scar: A Retrospective Cohort Study

BACKGROUND

While micro-plasma radiofrequency (MPR) treatment has a significant impact on hypertrophic scars, patients often require anesthesia to alleviate substantial discomfort. Currently, patients with similar degrees of scarring may choose surface anesthesia or general anesthesia based on their personal preferences. Nevertheless, the effectiveness and safety of different anesthesia modalities remain uncertain.

OBJECTIVE

To assess the effectiveness and safety of both general and surface anesthesia in MPR treatment for hypertrophic scars.

METHODS

We conducted a retrospective cohort study involving 101 patients diagnosed with hypertrophic scars who underwent MPR with different anesthesia methods. The primary measures of efficacy included the Vancouver Scar Scale (VSS) scores assessed before the first treatment and six months after the final treatment. Pain relief was evaluated using Visual Analog Scale (VAS) scores. Safety was assessed by comparing the incidence of adverse reactions between the two groups.

RESULTS

Patients in the general anesthesia group showed a significant difference in scar pigmentation 6 months after the treatment and lower pain level than those in the surface anesthesia group in the treatment of MPR. The difference in safety was not statistically significant. After adjusting for confounding factors and propensity score matching, the outcome of VSS and VAS scores was stable.

CONCLUSION

General anesthesia, as opposed to surface anesthesia, appears to enhance both the effectiveness and safety of MPR while reducing postoperative pain in the treatment of hypertrophic scars. For patients with heightened pain sensitivity, general anesthesia may be the preferred treatment option.

LEVEL OF EVIDENCE II

This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors http://www.springer.com/00266 .

Fascial plane blocks in children-Scientifically supported or not?

Since the introduction of Fascial Plane Blocks in 2007 there has been an enormous interest and application of Fascial Plane Blocks, evidenced by substantially more than 1000 PubMed items. Despite this gigantic number of publications, also including randomized controlled trials and meta-analyses in children, there is still no clear-cut insight into how much of the purported effect is in fact due to the blockade of nerve structures and how much is merely adding the well-known analgesic and anti-inflammatory effects of the plasma levels of local anesthetics that are achieved with these techniques. Furthermore, Fascial Plane Blocks appear useful only if compared to conventional multi-modal analgesia (no block or placebo) and Fascial Plane Blocks lack the potency to provide surgical anesthesia on their own and appear only to be of value when used for minor-moderate surgery. Despite the huge literature, there has so far not emerged any clinical situations where Fascial Plane Blocks have definitively been shown to be the block of choice, being decisively more effective than other established regional blocks. Lastly, Fascial Plane Blocks may appear as virtually free of complications, but case reports are emerging that point to a real risk for causing local anesthetic systemic toxicity when using Fascial Plane Blocks. This text aims to synthesize the current knowledge base regarding the Fascial Plane Blocks that are relevant to use in the pediatric context. In summary, there does currently not exist any convincing scientific evidence for the continued support for the use of Fascial Plane Blocks in children, except for the rectus sheath block and possibly also the transmuscular quadratus lumborum block.

Functional neurologic disorder as a rare complication of dental local anaesthetics: two contrasting cases

Adverse reactions to dental local anaesthetics are fortunately rare. However, when they occur, they can be severe and debilitating to the patient. Adverse reactions may be either prolonged anaesthesia, with or without dysaesthesia, or systemic reactions. Although these systemic reactions are commonly thought to be allergies, this is rarely the case. Much more commonly, these adverse systemic reactions are either cardiovascular or from the central nervous system. This paper describes two contrasting cases of functional neurologic disorder which illustrates the consequences and appropriate management. The responsibilities of the dentist who injected the local anaesthetic are outlined.

General anesthesia vs. conscious sedation and local anesthesia for endovascular treatment in patients with posterior circulation acute ischemic stroke: An updated systematic review and meta-analysis

INTRODUCTION

The best anesthetic choice for patients with acute posterior circulation stroke during endovascular treatment (EVT) remains uncertain.

METHOD

We searched five databases to identify studies that met the inclusion criteria. Our primary outcome measure was functional independence (FI). Secondary outcomes were 3-month mortality, any intracranial hemorrhage (ICH), symptomatic ICH (sICH), successful reperfusion, and procedure- and ventilator-associated complications.

RESULTS

A total of 10 studies were included in our meta-analysis. No significant differences were detected between the general anesthesia (GA) and conscious sedation and local anesthesia (CS/LA) groups in 3-month FI (nine studies; OR=0.69; 95% CI 0.45-1.06; P=0.083; I2=66%;), 3-month mortality (nine studies; OR=1.41; 95% CI 0.94-2.11; P=0.096; I2=61.2%;), any ICH (three studies; OR=0.75; 95% CI 0.44-1.25; P=0.269; I2=0%;), or sICH (six studies; OR=0.64; 95% CI 0.40-1.04; P=0.073; I2=0%;). No significant differences were observed for successful reperfusion (10 studies; OR=1.17; 95% CI 0.91-1.49; P=0.219; I2=0%;), procedure-related complications (four studies; OR=1.14; 95% CI 0.70-1.87; P=0.603; I2=7.9%;), or respiratory complications (four studies; OR=1.19; 95% CI 0.61-2.32; P=0.616; I2=64.9%;) between the two groups.

CONCLUSIONS

Our study showed no differences in 3-month FI, 3-month mortality, and successful reperfusion between patients treated with GA and those treated with CS/LA. Additionally, no increased risk of hemorrhagic transformation or pulmonary infection was observed in the CS/LA group. These results indicate that CS/LA may be an EVT option for acute posterior circulation stroke patients.

[Extensive transfixing skin necrosis after breast biopsy under local anesthesia: About four cases]

INTRODUCTION

Local anesthetics with adrenaline are widely used in routine practice and have long proven their benefits and safety. The rare complications due to their use mainly concern immuno-allergic and vascular mechanisms.

DESCRIPTION

In this article, we present four similar cases of early transfixing skin necrosis occurring after radioguided breast biopsy under local anesthesia using epinephrine local anesthetics in the context of a diagnostic approach to breast cancer.

DISCUSSION

Although the literature is comforting about the use of local anesthetics, even on the extremities, severe skin complications continue to be reported sporadically. The analysis and understanding of these phenomena would allow, in the long run, to avoid them and to reduce their importance.

CONCLUSION

The occurrence of skin necrosis after breast biopsy under radiographic control is rare and seems to be related to the local anesthetic procedure. Although similar cases have been reported in the literature, it does not seem possible today to conclude on the exact physiopathology of these complications. A better knowledge of the pathophysiology of these complications would help to avoid their occurrence in the future.

Combined laryngeal framework surgery and cricopharyngeal muscle-origin transection: a novel effective surgery for dysphagia with pharyngolaryngeal palsy and cricopharyngeal dysfunction under local anesthesia

BACKGROUND

Cricopharyngeal myotomy and laryngeal framework surgery can improve swallowing function in patients with severe dysphagia. We developed a novel surgical technique for severe dysphagia associated with pharyngolaryngeal paralysis and cricopharyngeal dysfunction, performed under local anesthesia, and investigated its effectiveness.

METHODS

We included nine patients who underwent cricopharyngeal muscle-origin transection with laryngeal framework surgery through a horizontal skin incision under local anesthesia.

CONCLUSIONS

All patients demonstrated significant improvement in the Food Intake LEVEL Scale without complications. Thus, this surgical technique may serve as a useful and less invasive treatment option for patients with severe dysphagia.

Royal College of Ophthalmologists' National Ophthalmology Database study of cataract surgery: report 11, techniques and complications of local anesthesia for cataract surgery in the United Kingdom

PURPOSE

To describe variation in local anesthesia techniques and complications over a 10-year period for cataract surgery in the United Kingdom.

SETTING

Reporting centers to the Royal College of Ophthalmologists (RCOphth) National Ophthalmology Database (NOD).

DESIGN

Retrospective cross-sectional register-based study.

METHODS

Data from the RCOphth NOD were used. Eligible for analysis were 1 195 882 cataract operations performed using local anesthesia between April 1, 2010, and March 31, 2020, in 80 centers.

RESULTS

Overall, topical anesthesia alone was used in 152 321 operations (12.7%), combined topical and intracameral in 522 849 (43.7%), sub-Tenon in 461 175 (38.6%), and peribulbar/retrobulbar in 59 537 (5.0%). In National Health Service (NHS) institutions, 48.3% of operations were topical with/without intracameral vs 88.7% in independent sector treatment centers (ISTCs). 45.9% were sub-Tenon in NHS vs 9.6% in ISTCs. 5.8% were peribulbar/retrobulbar in NHS vs 1.7% in ISTCs. Anesthetic complication rates decreased from 2.7% in the 2010 NHS year to 1.5% in the 2019 NHS year (overall, 2.1% for NHS; 0.2% for ISTCs). Overall anesthetic complication rates were 0.3%, 0.3%, 3.5%, and 3.1% for topical alone, combined topical/intracameral, sub-Tenon, and peribulbar/retrobulbar, respectively. Complication rates were higher for sharp-needle anesthesia (peribulbar/retrobulbar) in patients taking warfarin rather than direct oral anticoagulants (4.8% vs 3.1%; P = .024). Considerable variation was observed between centers on anesthetic choices and anesthetic complication rates.

CONCLUSIONS

Combined topical and intracameral is the most common choice of anesthesia for cataract surgery in the United Kingdom and is associated with lower anesthetic-related complication rates than sub-Tenon and peribulbar/retrobulbar anesthesia. Variation in the anesthetic choice exists between centers and between NHS and ISTC sectors.

A Prospective, Randomized Controlled, Single-Blinded Study to Assess the Effect of a 33-Gauge Needle Versus a 34-Gauge Needle on Pain Experienced During Injection of Local Anesthetic on the Face

BACKGROUND

Most pain experienced by patients during Mohs micrographic surgery is associated with the initial injection. Previous studies have shown that a smaller gauge needle (33-gauge vs 30-gauge) is associated with less patient-reported pain.

OBJECTIVES

To evaluate patient-reported pain levels following injection with a 33-gauge versus a 34-gauge needle.  Methods: During this prospective, randomized, controlled, single-blinded study, 480 patients were randomized into a 33-gauge versus a 34-gauge needle group. Pain levels following needle insertion were recorded using the validated numerical rating scale (VNRS)-11 scale.  Results: Injection of local anesthetic with a 34-gauge needle is associated with significantly less pain compared to a 33-gauge needle across all subgroups (P=0.007, average pain level 0.49 [34-gauge group] vs 0.79 [33-gauge group] rated on a 0-10 pain scale). Females, first-time Mohs patients, patients under age 65, patients with basal cell carcinoma, and those with tumor locations on the nose experienced the most pain reduction with the use of a 34-gauge needle.  Limitations: This was a single-blinded study; thus, the injector was able to see which needle was being used. This knowledge could have subconsciously affected the angle, speed, or force used to insert the needle.

CONCLUSIONS

Injections with a 33-gauge and a 34-gauge needle are both tolerated well and associated with minimal pain. While the pain reduction associated with using a 34-gauge needle is statistically significant, the use of a 34-gauge needle may be most clinically relevant for certain patient subgroups. J Drugs Dermatol. 2023;22(11): doi:10.36849/JDD.7689.

Local anesthetic with monitored anesthesia care in cephalomedullary nailing of proximal femur fractures

INTRODUCTION

Proximal femur fractures have high rates of morbidity, mortality, and perioperative complications. Limiting anesthesia, especially in the elderly population, is a priority from a medical perspective. The goal of the current study is to present a technique of using local anesthetic with monitored anesthesia care (MAC) for the fixation of intertrochanteric (IT) femur fractures with cephalomedullary nailing (CMN), provide early clinical results in a small series of patients, and evaluate the safety, efficiency, and anesthetic efficacy of our technique.

HYPOTHESIS

The use of only local anesthetic with MAC for the fixation of IT fractures is safe and leads to decreased operative times when compared to spinal and general anesthesia.

MATERIALS AND METHODS

Patients undergoing cephalomedullary nailing (CMN) with a long nail for IT femur fractures by a single surgeon from January 2020 to June 2021 were identified retrospectively from a prospectively-collected patient registry. Patient demographics, operative time, length of hospital stay, perioperative medication use, and complications were collected. Analysis of variance, Chi2, linear regression, and two-sampled T-tests were performed to analyze potential differences between the local anesthesia group and the general or spinal anesthesia group.

RESULTS

Thirty-seven patients were identified. Eleven patients underwent CMN using local anesthesia with MAC, 11 using spinal anesthesia, and 15 using general anesthesia. The local anesthesia group demonstrated significantly lower operating room times and anesthesia induction to incision time compared to other anesthesia techniques. The local anesthesia group also trended towards less need for vasopressors during surgery and less postoperative delirium. No differences were identified in intraoperative narcotic use, complications, patient mortality, or hospital readmissions.

CONCLUSIONS

Local anesthesia with MAC for the treatment of IT fractures with CMN was associated with decreased operating room times and had similar complication rates including blood transfusions, readmissions, and mortalities, when compared to spinal and general anesthesia.

LEVEL OF EVIDENCE

III, therapeutic.

Association of biopsy core number and location with pain in patients undergoing a transperineal prostate biopsy under local anaesthesia: a secondary analysis of the APROPOS trial

BACKGROUND

APROPOS was a multicentre, randomized, blinded trial focus on investigating the perineal nerve block versus the periprostatic block in pain control for men undergoing a transperineal prostate biopsy. In the analysis reported here, the authors aimed to evaluate the association of biopsy core count and location with pain outcomes in patients undergoing a transperineal prostate biopsy under local anesthesia.

METHODS

APROPOS was performed at six medical centers in China. Patients with suspected prostate cancer were randomized to receive either a perineal nerve block or a periprostatic block (1:1), followed by a transperineal prostate biopsy. The secondary analysis outcomes were the worst pain experienced during the prostate biopsy and postbiopsy pain at 1,6, and 24 h.

RESULTS

Between 12 August 2020 and 20 July 2022, a total of 192 patients were randomized in the original trial, and 188 were involved in this analysis, with 94 patients per group. Participants had a median (IQR) age of 68 (63-72) and a median (IQR) prostate volume of 42.51 (30.04-62.84). The patient population had a median (IQR) number of biopsy cores of 15 (12-17.50), and 26.06% of patients had a biopsy cores count of more than 15. After adjusting the baseline characteristics, the number of biopsy cores was associated with the worst pain during the biopsy procedure in both the perineal nerve block group ( β 0.19, 95% CI: 0.12-0.26, P <0.001) and the periprostatic block group ( β 0.16, 95% CI: 0.07-0.24, P <0.001). A similar association was also evident for the postbiopsy pain at 1, 6, and 24 h. A lesser degree of pain in both groups at any time (r range -0.57 to -0.01 for both groups) was associated with biopsy cores from the peripheral zone of the middle gland, while other locations were associated with a higher degree of pain. In addition, the location of the biopsy core had less of an effect on pain during the biopsy (r range -0.01-0.25 for both groups) than it did on postbiopsy pain (r range -0.57-0.60 for both groups).

CONCLUSIONS

In this secondary analysis of a randomized trial, biopsy core count and location were associated with pain in patients undergoing a transperineal prostate biopsy under local anesthesia. These results may be helpful for making clinical decisions about the anesthetic approach for scheduled transperineal prostate biopsies.

Transperineal vs. transrectal prostate biopsies under local anesthesia: A prospective cohort study on patient tolerability and complication rates

OBJECTIVES

An increasing number of urologists is switching from transrectal (TR) to transperineal (TP) biopsy procedures for the diagnosis of prostate cancer. Local anesthesia (LA) might be advantageous in terms of patient management, risks and costs. We aimed to evaluate the tolerability and complication rates of TP prostate biopsy performed under LA.

METHODS

This is a monocentric, prospective, comparative, observational cohort study. Between July 2020 and July 2021 we included 128 consecutive patients (TR, n = 61; TP, n = 67), with a suspicion of prostate cancer. Transrectal vs. transperineal prostate biopsies were both performed under LA. To evaluate the tolerability we administered a validated visual analog pain score (VAS) during the different steps of the biopsy procedure as well as at 12-, 24- and 48-hours post procedure. The International Prostate Symptom Score (IPSS) questionnaire was administered before the procedure and at the same time intervals. The presence of hematuria, hematospermia, rectal blood loss, acute retention and febrile urinary tract infection (UTI) were also monitored.

RESULTS

There were no significant differences in pain or IPSS between groups, except for a significantly higher pain score during the LA of the prostate in the TP group. In general, complication rates were similar, only the prevalence of hematuria at 24 hours was significantly higher in the TP group, as was rectal blood loss at 12 hours postprocedure in the TR group.

CONCLUSIONS

In conclusion, our study showed that transperineal prostate biopsy under local anesthesia could be performed with similar pain scores and complication rates, compared to the transrectal procedure.

Application of a topical anesthetic reduces pain-associated parameters during spermatic cord transection in piglet castration using a minimal anesthesia model

OBJECTIVE

This study assessed the use of a topical anesthetic as a feasible approach to reduce pain during piglet castration using a minimal anesthesia protocol.

ANIMALS

18 male piglets, aged 3-6 days, were included in this study.

METHODS

A minimal anesthetic state was induced with isoflurane administered by facemask, with anesthetic depth individually adjusted based on responses to interdigital pinch. To desensitize the scrotal skin, a vapocoolant was applied 3 times. Scrotal incisions were made subsequently and Tri-Solfen (TS) or Placebo (P) was administered in both incisional gaps. After 30 seconds, the spermatic cords were severed followed by a further application of TS/P to both incision edges. Nociception-related variables, such as mean arterial blood pressure (MAP), heart rate (HR), and nocifensive movements, were assessed.

RESULTS

Significant differences in MAP changes were assessed between the TS (14 ± 4 mmHg) and the P group (36 ± 8 mmHg) for cutting the spermatic cords. Furthermore, significantly fewer nocifensive movement score points appeared in the TS than in the P group (0; IQR = 0 vs 5; IQR = 6).

CLINICAL RELEVANCE

In this anesthesia model, the application of TS after skin incision significantly reduced MAP responses and nocifensive movements with spermatic cord transection compared with the application of P. However, the waiting period between TS-application and spermatic cord transection might limit the benefit of the method in conscious piglets, as pain during castration is reduced but additional stress is caused by the prolonged handling. Furthermore, using a vapocoolant did not provide anesthesia for skin incisions.

Anatomical proposal of local anesthesia injection for median nerve block in treating hyperhidrosis with botulinum neurotoxin

INTRODUCTION

Hyperhidrosis, causing excessive sweat, can be treated with Botulinum neurotoxin injection. Botulinum toxin, an effective and safe treatment for hyperhidrosis, unfortunately involves significant pain due to multiple injections. This study aims to propose a more efficient and less painful approach to nerve blocks for relief, by identifying optimal injection points to block the median nerve, thereby enhancing palmar hyperhidrosis treatment.

METHODS

This study, involving 52 Korean cadaver arms (mean age 73.5 years), measured the location of the median nerve relative to the transverse line at the pisiform level to establish better nerve block injection sites.

RESULTS

In between the extensor carpi radialis and palmaris longus, the median nerve was located at an average distance of 47.39 ± 6.43 mm and 29.39 ± 6.43 mm from the transverse line at the pisiform level.

DISCUSSION

To minimize discomfort preceding the botulinum neurotoxin injection, we recommend the optimal injection site for local anesthesia to be located 4 cm distal to the transverse line of the pisiform, within the tendons of the palmaris longus and flexor carpi radialis muscles.

To evaluate the efficacy and safety of dezocine combined with lidocaine in local anesthesia for percutaneous testicular sperm aspiration

A total of 130 patients who underwent percutaneous testicular sperm aspiration from March 2021 to February 2023 were randomly divided into a Dezocine group and a control group. The Dezocine group received a muscle injection of 0.05mg/kg Dezocine 30 minutes before surgery, while the control group received a muscle injection of 0.01ml/kg normal saline. Both groups received 3ml of 2% lidocaine for spermatic cord block anesthesia. The anesthesia onset time, anesthesia duration, numeric rating scale (NRS) score, anesthesia satisfaction rate and incidence of adverse reactions were recorded and compared between the two groups. The statistical results showed that there were significant differences between the two groups in terms of anesthesia onset time, anesthesia duration, anesthesia satisfaction rate, non-steroidal anti-inflammatory drug (NSAID) use within 24 hours after surgery and NRS scores at 15 minutes, 1 hour and 2 hours after surgery. The incidence of adverse reactions in the Dezocine group was lower than that in the control group, but the difference was not statistically significant. The combination of Dezocine and lidocaine for spermatic cord block anesthesia during percutaneous testicular sperm aspiration is safe, effective and associated with fewer adverse reactions. It is suitable for clinical application and promotion in reproductive medicine outpatient surgery.

Mental and Lingual Nerve Paresthesia Following Infiltration Anesthesia for Dental Implant Placement in a Patient With Guillain-Barré Syndrome

Guillain-Barré syndrome (GBS) is a rare rapid onset autoimmune peripheral polyneuropathy, most commonly characterized by inflammatory demyelination of peripheral nerves. Patients with GBS are considered higher risk for anesthetic-induced neurotoxicity caused by demyelination. In the present report, a case is described of a 56-year-old man with GBS who experienced mental and lingual nerve paresthesia following infiltration anesthesia for dental implant placement in the posterior mandible. The pareshesia lasted 5 months postoperatively and subsided spontaneously without any intervention. The patient was successfully restored with fixed partial dental prosthesis without any other complication. This is considered the first report of such complication in patient with GBS after local anesthesia in the oral and maxillofacial region. Possible pathogenic mechanism of the complication and clinical implications are discussed.

Clinical application of 3DSlicer and Sina in minimally invasive puncture drainage of elderly patients with spontaneous intracerebral hemorrhage under local anesthesia

BACKGROUND

Decreased organ function and poor physical compensatory capacity in elderly patients diagnosed with spontaneous intracerebral hemorrhage (ICH) can make surgical treatment procedures challenging and risky. Minimally invasive puncture drainage (MIPD) combined with urokinase infusion therapy is a safe and feasible method of treating ICH. This study aimed to compare the treatment efficacy of MIPD conducted under local anesthesia using either 3DSlicer + Sina application or computer tomography (CT)-guided stereotactic localization of hematomas in elderly patients diagnosed with ICH.

METHODS

The study sample included 78 elderly patients (≥ 65 years of age) diagnosed with ICH for the first time. All patients exhibited stable vital signs and underwent surgical treatment. The study sample was randomly divided into two groups, either receiving 3DSlicer+Sina or CT-guided stereotactic assistance. The preoperative preparation time; hematoma localization accuracy rate; satisfactory hematoma puncture rate; hematoma clearance rate; postoperative rebleeding rate; Glasgow Coma Scale (GCS) score after 7 days; and modified Rankin scale (mRS) score 6 months after surgery were compared between the two groups.

RESULTS

No significant differences in gender, age, preoperative GCS score, preoperative hematoma volume (HV), and surgical duration were observed between the two groups (all p-values > 0.05). However, the preoperative preparation time was shorter in the group receiving 3DSlicer + Sina assistance compared to that receiving CT-guided stereotactic assistance (p-value < 0.001). Both groups exhibited significant improvement in GCS scores and reduction in HV after surgery (all p-values < 0.001). The accuracy of hematoma localization and puncture was 100% in both groups. There were no significant differences in surgical duration, postoperative hematoma clearance rate, rebleeding rate, postoperative GCS and mRS scores between the two groups (all p-values > 0.05).

CONCLUSIONS

A combination of 3DSlicer and Sina is effective in accurately identifying hematomas in elderly patients with ICH exhibiting stable vital signs, thus simplifying MIPD surgeries conducted under local anesthesia. This procedure may also be preferred over CT-guided stereotactic localization in clinical practice due to its ease of use and accuracy in hematoma localization.

Insulin syringe for anesthesia in ptosis surgery: a randomized, fellow eye-controlled clinical study

PURPOSE

Unlike ordinary 30-gauge needles, insulin syringe needles are thinner and shorter and have a comparatively blunt tip. Therefore, insulin syringes may reduce injection discomfort, bleeding, and edema by minimizing tissue damage and vascular penetration. This study aimed to evaluate the potential benefits of using insulin syringes for local anesthesia in ptosis surgery.

METHODS

This randomized, fellow eye-controlled study included 60 patients (120 eyelids), conducted at a university-based hospital. An insulin syringe was used on one eyelid, and a conventional 30-gauge needle was used on the other. Patients were instructed to score pain in both eyelids using a visual analog scale (VAS) ranging from 0 (no pain) to 10 (unbearable pain). Ten minutes after the injection, two observers scored degrees of hemorrhage and edema in both eyelids on five- and four-pointing grading scales (0-4 and 0-3) for each value, and the average score between the two observers was calculated and compared.

RESULTS

The VAS score was 5.17 in the insulin syringe group and 5.35 in the 30-gauge needle group (p = 0.282). Ten minutes after the anesthesia, the median hemorrhage scores were 1.00 and 1.75 (p = 0.010), and the median eyelid edema scores were 1.25 and 2.00 (p = 0.007) in the insulin syringe and 30-gauge needle groups, respectively (Fig. 1).

CONCLUSION

Injecting local anesthesia using an insulin syringe significantly reduces hemorrhage and eyelid edema, but not injection pain, before skin incision. Insulin syringes are useful in patients at high risk of bleeding because they can reduce the penetrative tissue damage caused by needle insertion.

Evaluating the Safety of Transcarotid Artery Revascularization under Local Anesthesia Prior to Coronary Artery Bypass Grafting Surgery

BACKGROUND

Controversy exists regarding the timing of intervention for patients with critical coronary artery disease (CAD) awaiting coronary artery bypass and severe carotid artery stenosis (CAS). Transcarotid artery revascularization (TCAR) is a minimally invasive revascularization alternative through direct transcervical carotid access that minimizes the chance of arch manipulation and consequent antegrade embolic stroke rate. While the TCAR procedure can be performed under local anesthesia (monitored anesthesia care [MAC]) versus general anesthesia, the hemodynamic benefits of local anesthesia in patients with severe CAD are significant. Patients receiving staged TCAR-coronary artery bypass grafting (CABG) have high-risk cardiovascular disease and require accurate perioperative neurological and hemodynamic evaluation that can be safely provided with local anesthesia.

METHODS

In this retrospective single-center study, 14 patients were systematically identified to have undergone staged TCAR prior to CABG surgery from December 2018 to October 2021. All patients underwent TCAR with local anesthesia and minimal sedation. Relevant patient demographics, medical and surgical history, preoperative covariates, and type of anesthesia administered were obtained from patients' charts. CAD was confirmed by either carotid duplex imaging or computed tomography angiography (CTA) of the head/neck.

RESULTS

Staged TCAR-CABG interventions were performed on 14 patients (64% male; mean age 65.0 years). No major adverse cardiac events were reported including transient ischemic attack (TIA), stroke, myocardial infarction (MI), or TCAR-related death in the interval between their TCAR and CABG as well as in a 12-month follow-up period. One patient required to return to the operating room (OR) for evacuation of a neck hematoma.

CONCLUSIONS

This study demonstrated high success rate of TCAR under local anesthesia prior to CABG (100%) with no incidence of perioperative stroke, MI, or death at 1-month, 6-month, and 12-month follow-up intervals. The authors support the use of staged TCAR-CABG with local anesthesia as a safe and promising treatment option for patients with high-grade cardiac disease, high risk of stroke, or multiple comorbidities that preclude a carotid endarterectomy (CEA).

Topical Anesthetic Use in Cosmetic Dermatology

In today's society, there is growing interest in outpatient cosmetic procedures. Topical anesthetics are commonly used as anesthesia for these procedures. They can be used alone or part of a multi-pronged anesthetic approach. Topical anesthetics have many benefits, but they also have some negatives including risk of toxicity. For this paper, we focused on the role of topical anesthetics in cosmetic dermatology. We surveyed cosmetic dermatologists on the use of topical anesthetics in their practices. We found that the most popular topical anesthetic was benzocaine 20% / lidocaine 6% / tetracaine 4%. When asked for which procedures topical anesthetics are used for anesthesia, the most frequent responses were fractionally ablative lasers and fractionally non-ablative lasers. Though the majority of surveyed dermatologists have not had issues with the topical anesthetic, a portion had experienced adverse events in their patients. Topical anesthetics play an important role in cosmetic dermatology, allowing cosmetic procedures to take place in ways that are both comfortable for patients and allow patients to avoid more involved types of anesthesia. This is a growing area of cosmetic dermatology that requires additional research. J Drugs Dermatol. 2023;22(3): doi:10.36849/JDD.6978.

Locoregional Anaesthesia and Intra-Operative Angiography in Carotid Endarterectomy: 16 Year Results of a Consecutive Single Centre Series

OBJECTIVE

The benefit of local (LA) over general (GA) anaesthesia and the rationale of intra-operative imaging strategies during carotid endarterectomy (CEA) is debated. This study analysed the associations between patient characteristics, LA, and intra-operative imaging strategies and the in hospital stroke and death rates in elective CEA over a 16 year period.

METHODS

All consecutive patients treated by elective CEA between January 2004 and December 2019 (n = 1 872; median age 71 years, 70% male, 37% symptomatic) were included. All patients were assessed neurologically before and within 48 hours after CEA. The primary outcome event was the combined rate of any in hospital stroke or death. Secondary outcome events were the combined rates of any in hospital major stroke (modified Rankin scale [mRS] 3 - 5) or death, stroke, minor stroke (mRS 0 - 2), major stroke, and death alone. To detect changes over time, four quartiles (2004 - 2007, 2008 - 2011, 2012 - 2015, and 2016 - 2019) of this cohort were analysed. Statistical analysis comprised trend tests, and uni- and multivariable logistic regression.

RESULTS

Median patient age increased from 68 to 73 years (p < .001). Over time, LA (from 28% to 91%) and intra-operative imaging (angiography 2.8 - 98.1%, duplex ultrasound 0 - 78.2%) was applied more frequently. Surgical techniques did not change. The in hospital stroke or death and major stroke or death rates decreased from 3.7% to 1.5% (p = .041) and from 2.8% to 0.9% (p = .014), respectively, corresponding to a relative risk of decline of 7% and 12% annually. Multivariable analysis revealed that LA (odds ratio [OR] 0.25, 95% confidence interval [CI] 0.1 - 0.62) and intra-operative angiography (OR 0.09, 95% CI 0.10 - 0.81) were associated with lower in hospital major stroke and death rates.

CONCLUSION

These data demonstrate a decline in the combined rates of any in hospital major stroke or death after non-emergency CEA over time. Locoregional anaesthesia and intra-operative quality control were associated with these improvements and might be worthwhile in elective CEA.

Anesthesia techniques and the risk of complications as reflected in the European Registry of Quality Outcomes for Cataract and Refractive Surgery

PURPOSE

To determine the trends in anesthesia techniques for cataract surgery over the past decade and their relationship to surgical complications.

SETTING

Clinics affiliated with the European Registry of Quality Outcomes for Cataract and Refractive Surgery (EUREQUO).

DESIGN

Retrospective cross-sectional register-based study.

METHODS

Variables include patient demographics, visual acuity, ocular comorbidities, surgery characteristics, intraoperative complications, and postoperative complications for the study period from January 2008, to December 2018. The anesthesia methods registered in the EUREQUO and included in the study are topical, combined topical and intracameral, sub-Tenon, regional, and general anesthesia. Multivariate logistic regression models for each complication were constructed to estimate the adjusted odds ratio (OR) and 95% CIs.

RESULTS

Complete data were available of 1 354 036 cataract surgeries. Topical anesthesia increased significantly over time (from 30% to 76%, P < .001). Sub-Tenon and regional anesthesia decreased (from 27% and 38% to 16% and 6%, respectively, P < .001), and general and combined topical and intracameral anesthesia remained stable (around 2%). Sub-Tenon (OR, 0.80; 95% CI, 0.71-0.91, P < .001), regional (0.74; 95% CI, 0.71-0.78, P < .001), general (0.53; 95% CI, 0.50-0.56, P < .001), and intracameral anesthesia (0.76; 95% CI, 0.64-0.90, P = .001) carried a significantly decreased risk of posterior capsule rupture (PCR), with and without dropped nucleus, compared with topical anesthesia. The risk of endophthalmitis was significantly lower with regional anesthesia compared with topical anesthesia (OR, 0.60; 95% CI, 0.44-0.82, P = .001).

CONCLUSIONS

The use of topical anesthesia for cataract surgery increased over time. Topical anesthesia is associated with an increased risk of PCR with and without dropped nucleus, and endophthalmitis.

Are Prophylactic Systemic Antibiotics Required in Patients with Cataract Surgery at Local Anesthesia?

The reduced use of antimicrobial drugs has been recommended worldwide, according to the global action for antimicrobial resistance published in 2015 by the World Health Organization. In this study, we retrospectively reviewed the incidence of surgical site infection in consecutive patients with cataract surgeries at a single hospital in the 6-year process when prophylactic systemic antibiotics were reduced in a step-by-step manner. The entire study period from 2016 to 2022 was divided into five stages, based on the use of systemic antibiotics. In stage 1 with 649 cataract surgeries, an intravenous drip infusion of cefazolin 1 g was given at surgery, followed by oral cefdinir 100 mg in the evening on surgery day and three times for two postoperative days. In stage 2 with 541 cataract surgeries, oral cefdinir 100 mg was given in the late morning before surgery, in the evening, and three times (300 mg in total) for two postoperative days. In stage 3 with 103 cataract surgeries, oral levofloxacin 500 mg was given in the late morning before surgery and once in the morning for two postoperative days. In stage 4 with 545 cataract surgeries, oral levofloxacin 500 mg was given only in the late morning before surgery. In stage 5 with 311 cataract surgeries, no systemic antibiotics were given. As common procedures in all stages, moxifloxacin eye drops were given four times daily as topical antibiotics in the 3 days before surgery and about 2 weeks after surgery. At surgery, the ocular surface was frequently irrigated with saline-diluted povidone iodine at 0.5% working concentration. No postoperative infection was recorded in any stage. This study showed neither harm nor risk in reduced use and, consequently, no use of prophylactic systemic antibiotics in cataract surgery as far as local precautionary measures were secured.

Evaluation of the effect of nutritive versus non-nutritive pacifiers as adjuncts to local anaesthesia in male neonatal circumcision using the plastibell technique - A prospective randomised controlled study

BACKGROUND

Male circumcision is the most common surgical procedure worldwide and is often carried out for religious, cultural, medical and public health reasons. It is commonly performed during the neonatal period. Many studies have now shown that pain is a common intra- and post-operative complication. To ensure proper analgesia during the procedure, many surgeons opt for the use of pacifiers as an adjunct to anaesthesia during neonatal circumcision. The aim of this study is to compare nutritive pacifiers (NPs) versus non-NPs (NNPs) as adjuncts to local anaesthesia in male neonatal circumcision using the Plastibell technique.

METHODS

A prospective randomised controlled study was carried out between October 2019 and March 2020. A total of 100 neonates were circumcised using the Plastibell technique and randomised into NP (Group A, n = 33), NNP (Group B, n = 33) and controls (Group C, n = 34), respectively. The differences in pain scores using the Neonatal Infant Pain Scale, total crying time and heart rate during circumcision were recorded and assessed.

RESULTS

The age of participants ranged from 5 to 28 days and the weight ranged from 2.5 to 5.0 kg. The overall mean age, birth weight and current weight of the participants were 15.5 ± 6.1 days, 3.4 ± 0.4 kg and 3.5 ± 0.6 kg, respectively. The control group had the highest average pain score of 5.5 (4.5-5.8) compared to the intervention groups with median pain score (NP: 3.3 [1.3-4.3] and (NNP: 4.3 [3.1-5.1], respectively). NPs had significantly lower pain scores (P = 0.023) and reduced total crying time (P = 0.019) at all stages of the circumcision compared to those given NNPs and controls.

CONCLUSION

This study showed that NPs were superior to NNPs in providing additional pain control during male neonatal circumcision.

Carpal tunnel release under wide awake local anesthesia with no tourniquet in hemodialysis patients with arteriovenous shunt

INTRODUCTION

Long-term hemodialysis patients experience many hand diseases caused by dialysis-related amyloidosis (DRA), with carpal tunnel syndrome (CTS) being the most common. For the patients with arteriovenous (AV) shunt, surgical decompression remains challenging because of the contraindications of a tourniquet. A technique called wide-awake local anesthesia with no tourniquet (WALANT), in which epinephrine provides hemostasis instead of the tourniquet, can be a good option for hemodialysis patients. The purpose of this study was to assess the prevalence of CTS and related factors in hemodialysis patients, and to establish the efficacy and safety of WALANT on hemodialysis patients with AV shunt.

MATERIALS AND METHODS

This prospective study included 275 hemodialysis patients between March 2013 and July 2019. 43 patients were diagnosed with CTS, involving surgical treatment on 70 wrists. We performed mini-open carpal tunnel release using WALANT on the AV shunt arm (defined as the WALANT group), while using lidocaine and a tourniquet on the arm without an AV shunt (defined as the tourniquet group). The operative time, surgical field bleeding (blood loss and hemostasis score), surgical pain (injection pain and tourniquet pain), outcomes, complications, and satisfaction were compared between the two groups.

RESULTS

The incidence of CTS in hemodialysis patients was 15.6%. Longer dialysis durations were related to higher proportions of patients with CTS. There was no significant difference in blood loss (p=0.184) and hemostasis score (p=0.165) between the two groups. Clinical symptoms improved in all patients, and there were no severe complications. The WALANT group had a significantly longer preparation time of approximately 20minutes, but they had low injection pain and no tourniquet pain. There was also no significant difference in terms of satisfaction levels (p=0.212).

DISCUSSION

CTS is a very common disease among hemodialysis patients. WALANT provided sufficient hemostasis without a tourniquet, despite the patients' high bleeding tendency. The technique also had the advantages of low injection pain, no tourniquet pain, and no major complications. In this respect, WALANT can be a good choice for hemodialysis patients with AV shunt.

LEVEL OF EVIDENCE

II.

Iatrogenic central retinal artery occlusion following retrobulbar anesthesia with adrenaline for vitreoretinal surgery: a case report

BACKGROUND

We describe a patient presenting with central retinal artery occlusion (CRAO) of the right eye after retrobulbar anesthesia with adrenaline for macular pucker surgery.

CASE PRESENTATION

The patient, a 67-year-old Caucasian man, developed a CRAO postoperatively by the next-day control likely due to the retrobulbar injection of a combination of Xylocaine and Bupivacaine with adrenaline as anesthetic.

CONCLUSIONS

The addition of adrenaline to the standard anesthetic solution could be a risk factor for serious complications, such as CRAO.

Prompt Detection and Management of Globe Perforation due to Retrobulbar Anaesthesia

Null.

Ten-year follow-up of a randomized controlled trial comparing saphenofemoral ligation and stripping of the great saphenous vein with endovenous laser ablation (980 nm) using local tumescent anesthesia

OBJECTIVE

The long-term results of saphenofemoral ligation and stripping (SFL/S) were compared with 980-nm bare fiber endovenous laser ablation (EVLA) for the treatment of great saphenous vein (GSV) incompetence.

METHODS

This was a single-center, randomized, controlled trial with a follow-up time of 10 years. Patients with GSV incompetence were randomized to undergo SFL/S or EVLA under tumescent anesthesia. The primary outcome was recurrence of groin-related varicose veins seen on duplex ultrasound imaging and clinical examination. The secondary outcomes were (changes or improvement in) CEAP clinical class, venous symptoms, cosmetic results, quality of life, reinterventions, and complications.

RESULTS

Between June 2007 and December 2008, 122 patients (130 limbs) were included; of these, 68 limbs were treated with SFL/S and 62 limbs with EVLA. The 10-year estimated freedom from groin recurrence as seen on duplex ultrasound imaging was higher in the SFL/S group (73% vs 44% in the EVLA group; P = .002), and the same trend was seen for clinically evident recurrence (77% vs 58%, respectively; P = .034). Nine reinterventions (17%) were deemed necessary in the SFL/S group vs 18 (36%) in the EVLA group (P = .059). All reinterventions in the SFL/S group consisted of foam sclerotherapy. Reinterventions in the EVLA group included foam sclerotherapy (n = 5), crossectomy (n = 2), and endovenous procedures (n = 11). There was no significant differences in quality of life and relief of venous symptoms. Cosmetic appearance improved, with a better cosmetic rating in the SFL/S group compared with the EVLA group (P = .026). One patient in the SFL/S group had a persisting neurosensory deficit remaining at 10 years.

CONCLUSIONS

This study showed no clear long-term advantage of EVLA with a 980-nm wavelength and bare-tip fiber over high ligation and stripping of the GSV under local tumescent anesthesia.

[Coaxial system with permanent infiltration anesthesia for ct-assisted transthoracic trepanobiopsy of lung tumors]

OBJECTIVE

To assess irradiation time, pain syndrome and safety of the proposed device and technique compared to conventional CT-assisted transthoracic biopsy.

MATERIAL AND METHODS

CT-guided transthoracic trepanobiopsy of thoracic tumors was carried out in 296 patients between January 2017 and January 2020. There were 189 (63.8%) men and 107 (36.2%) women. Mean age of patients was 64.1±9.6 years (range 35-83). All patients were randomized into 2 groups by 148 people: group 1 - morphological verification via conventional CT-guided transthoracic trepanobiopsy, group 2 - morphological verification using a coaxial system and a specially developed CT-guided transthoracic trepanobiopsy.

RESULTS

Coaxial system with permanent anesthesia in CT-guided transthoracic manipulations reduces post-manipulation complications by 4-5%, get more qualitative morphological material (by 4%), reduces the time of procedure by 2 times and irradiation of patients by 27%, excludes irradiation of physicians and significantly reduces pain syndrome.

Accelerated Idioventricular Rhythm Following Intraoral Local Anesthetic Injection During General Anesthesia

Some anesthetic agents or adjunct medications administered during general anesthesia can cause an accelerated idioventricular rhythm (AIVR), which is associated with higher vagal tone and lower sympathetic activity. We encountered AIVR induced by vagal response to injection-related pain following local anesthetic infiltration into the oral mucosa during general anesthesia. A 48-year-old woman underwent extraction of a residual tooth root from the left maxillary sinus under general anesthesia. Routine preoperative electrocardiogram (ECG) was otherwise normal. Eight milliliters of 1% lidocaine (80 mg) with 1:100,000 epinephrine (80 μg) was infiltrated around the left maxillary molars over 20 seconds using a 23-gauge needle and firm pressure. Widened QRS complexes consistent with AIVR were observed for ∼60 seconds, followed by an atrioventricular junctional rhythm and the return of normal sinus rhythm. A cardiology consultation and 12-lead ECG in the operating room produced no additional concerns, so the operation continued with no complications. AIVR was presumably caused by activation of the trigeminocardiac reflex triggered by intense pain following rapid local anesthetic infiltration with a large gauge needle and firm pressure. Administration of local anesthetic should be performed cautiously when using a large gauge needle and avoid excessive pressure.

Local Anesthetic Systemic Toxicity during Labor, Birth, and Immediate Postpartum: Clinical Review

ABSTRACT

Local anesthetic systemic toxicity (LAST) is a life-threatening event caused by elevated local anesthetic plasma concentration. It is often unrecognized or misdiagnosed. Peripartum women are at increased risk for toxicity due to pregnancy-related physiological changes. Rising serum drug levels can cause cellular level impairment of mitochondria and voltage-gated ion channels leading to a cascade of symptoms that can end in cardiac arrest. Local anesthetic systemic toxicity can mimic other maternal pathologies but may be considered if local anesthetics have been used. Published treatment guidelines for this event include lipid emulsion which is approved for use in pregnant women. We review LAST in the maternity care setting, published treatment protocols, management of maternity patients with toxicity, and recommendations to increase awareness among maternity care clinicians for this medical emergency.

Impact of the pericapsular nerve group (PENG) block on postoperative analgesia and functional recovery following total hip arthroplasty: a randomised, observer-masked, controlled trial

The pericapsular nerve group (PENG) block is a novel regional anaesthesia technique that aims to provide hip analgesia with preservation of motor function, although evidence is currently lacking. In this single-centre, observer-masked, randomised controlled trial, patients undergoing total hip arthroplasty received pericapsular nerve group block or no block (control group). Primary outcome measure was maximum pain scores (0-10 numeric rating scale) measured in the first 48 h after surgery. Secondary outcomes included postoperative opioid consumption; patient mobilisation assessments; and length of hospital stay. Sixty patients were randomly allocated equally between groups. The maximum pain score of patients receiving the pericapsular nerve group block was significantly lower than in the control group at all time-points, with a median (IQR [range]) of 2.5 (2.0-3.7 [0-7]) vs. 5.5 (5.0-7.0 [2-8]) at 12 h; 3 (2.0-4.0 [0-7]) vs. 6 (5.0-6.0 [2-8]) at 24 h; and 2.0 (2.0-4.0 [0-5]) vs. 3.0 (2.0-4.7 [0-6]) at 48 h; all p < 0.001. Moreover, the pericapsular nerve group showed a significant reduction in opioid consumption, better range of hip motion and shorter time to ambulation. Although no significant difference in hospital length of stay was detected, our results suggest improved postoperative functional recovery following total hip arthroplasty in patients who received pericapsular nerve group block.

Local versus general anaesthesia for carotid endarterectomy

BACKGROUND

Carotid endarterectomy may significantly reduce the risk of stroke in people with recently symptomatic, severe carotid artery stenosis. However, there are significant perioperative risks that may be minimised by performing the operation under local rather than general anaesthetics. This is an update of a Cochrane Review first published in 1996, and previously updated in 2004, 2008, and 2013.

OBJECTIVES

To determine whether carotid endarterectomy under local anaesthetic: 1) reduces the risk of perioperative stroke and death compared with general anaesthetic; 2) reduces the complication rate (other than stroke) following carotid endarterectomy; and 3) is acceptable to individuals and surgeons.

SEARCH METHODS

We searched CENTRAL, MEDLINE, Embase, and two trials registers (to February 2021). We also reviewed reference lists of articles identified.

SELECTION CRITERIA

Randomised controlled trials (RCTs) comparing the use of local anaesthetics to general anaesthetics for people having carotid endarterectomy were eligible.

DATA COLLECTION AND ANALYSIS

Three review authors independently extracted data, assessed risk of bias, and evaluated quality of evidence using the Grading of Recommendations, Assessment, Development, and Evaluations (GRADE) tool. We calculated a pooled Peto odds ratio (OR) and corresponding 95% confidence interval (CI) for the following outcomes that occurred within 30 days of surgery: stroke, death, ipsilateral stroke, stroke or death, myocardial infarction, local haemorrhage, and arteries shunted.

MAIN RESULTS

We included 16 RCTs involving 4839 participants, of which 3526 were obtained from the single largest trial (GALA). The main findings from our meta-analysis showed that, within 30 days of operation, neither incidence of stroke nor death were significantly different between local and general anaesthesia. Of these, the incidence of stroke in the local and general anaesthesia groups was 3.2% and 3.5%, respectively (Peto odds ratio (OR) 0.91, 95% confidence interval (CI) 0.66 to 1.26; P = 0.58; 13 studies, 4663 participants; low-quality evidence). The rate of ipsilateral stroke under both types of anaesthesia was 3.1% (Peto OR 1.03, 95% CI 0.71 to 1.48; P = 0.89; 2 studies, 3733 participants; low-quality evidence). The incidence of stroke or death in the local anaesthesia group was 3.5%, while stroke or death incidence was 4.1% in the general anaesthesia group (Peto OR 0.85, 95% CI 0.62 to 1.16; P = 0.31; 11 studies, 4391 participants; low-quality evidence). A lower rate of death was observed in the local anaesthetic group but evidence was of low quality (Peto OR 0.61, 95% CI 0.35 to 1.06; P = 0.08; 12 studies, 4421 participants).

AUTHORS' CONCLUSIONS

The incidence of stroke and death were not convincingly different between local and general anaesthesia for people undergoing carotid endarterectomy. The current evidence supports the choice of either approach. Further high-quality studies are still needed as the evidence is of limited reliability.

Trans-cricoid thyroid injection of local anaesthesia: a serious complication

Transcricothyroid membrane (CTM) injection of local anaesthesia is widely used during bronchoscopic procedures. It is an effective way of delivering topical anaesthesia, and has been shown to reduce patient discomfort, improve clinician satisfaction and reduce overall sedation requirements. Risks from this procedure are uncommon and usually minor. Localisation of the CTM is usually performed clinically by palpation of anatomical landmarks and can vary depending on clinician skillset and experience. Clinical identification may be less accurate compared with ultrasound guidance in identifying puncture site, however, ultrasound is not always readily available and seldom used for this purpose. This case describes a rare complication following attempted local anaesthetic infiltration into the cricothyroid space, after clinical identification of puncture site. An obstructive fluid-filled mass formed around the site of injection on the right vocal cord; resulting in airway compromise, abandonment of procedure and subsequent intubation.

Lidocaine: A Local Anesthetic, Its Adverse Effects and Management

The most widely used medications in dentistry are local anesthetics (LA), especially lidocaine, and the number of recorded adverse allergic responses, particularly of hazardous responses, is quite low. However, allergic reactions can range from moderate to life-threatening, requiring rapid diagnosis and treatment. This article serves as a review to provide information on LA, their adverse reactions, causes, and management.

High Volume Liposuction in Tumescence Anesthesia in Lipedema Patients: A Retrospective Analysis

BACKGROUND

Lipedema is a chronic, progressive disease that occurs almost exclusively in women and leads to pathological, painful fat growths at the extremities. Only symptomatic therapy can be offered since the etiology of the disease has not yet been clarified. Liposuction in tumescent anesthesia has established itself as a surgical treatment method of choice. The complication rate associated with the procedure and the pharmacological course and safety of treatment in patients with lipedema has not yet been sufficiently studied. The aim of the study was to broaden the evidence on the safety of ambulatory high-volume liposuction in tumescent anesthesia in lipedema patients. Influencing factors of patients (weight, fat content, comorbidities) or the process technique (drug administration, volume of aspirates) should be investigated on the safety and risks of tumescent anesthesia. This was a retrospective data analysis in which data from 27 patients (40 liposuction procedures) treated at the Sandhofer and Barsch lipedema center between 2016 and 2018 were evaluated. The liposuctions were carried out in tumescent anesthesia and using a Power-Assisted Liposuction system. Clinical examinations and regular blood samples were carried out before the procedure, intra- and postoperatively. The procedures lasted an average of 118 minutes and an average of 6111 ml of aspirate was removed. For tumescent anesthesia, patients were given an average lidocaine dose of 34.23 mg/kg body weight and an epinephrine dose of 0.11 mg/kg body weight. No relevant complications associated with drug side effects, hypovolemia or hypervolemia or blood loss were detected. Liposuction under high volume tumescent anesthesia for the treatment of lipedema patients is, even for major intervention, a safe procedure. J Drugs Dermatol. 2021;20(3):326-334. doi:10.36849/JDD.5828.

Using local rather than general anesthesia for inguinal hernia repair is associated with shorter operative time and enhanced postoperative recovery

BACKGROUND

Inguinal hernia repair is the most common general surgery procedure and can be performed under local or general anesthesia. We hypothesized that using local rather than general anesthesia would improve outcomes, especially for older adults.

METHODS

This is a retrospective review of 97,437 patients in the Veterans Affairs Surgical Quality Improvement Program who had open inguinal hernia surgery under local or general anesthesia. Outcomes included 30-day postoperative complications, operative time, and recovery time.

RESULTS

Our cohort included 22,333 (23%) Veterans who received local and 75,104 (77%) who received general anesthesia. Mean age was 62 years. Local anesthesia was associated with a 37% decrease in the odds of postoperative complications (95% CI 0.54-0.73), a 13% decrease in operative time (95% CI 17.5-7.5), and a 27% shorter recovery room stay (95% CI 27.5-25.5), regardless of age.

CONCLUSIONS

Using local rather than general anesthesia is associated with a profound decrease in complications (equivalent to "de-aging" patients by 30 years) and could significantly reduce costs for this common procedure.

Anesthetic choice during transcarotid artery revascularization and carotid endarterectomy affects the risk of myocardial infarction

OBJECTIVE

Previous studies have shown no differences in the outcomes of transcarotid artery revascularization (TCAR) performed with general anesthesia (GA) vs local or regional anesthesia (LRA). To date, no study has specifically compared the outcomes of TCAR to those of carotid endarterectomy (CEA) stratified by anesthetic type. The aim of the present study was to identify the effect of the anesthetic type on the outcomes of TCAR vs CEA.

METHODS

Patients undergoing CEA and TCAR for carotid artery stenosis from 2016 to 2019 in the Vascular Quality Initiative were included. We excluded patients who had undergone concomitant procedures, patients with more than two stented lesions, and patients who had undergone the procedure for a nonatherosclerotic indication. Propensity score matching was performed between the two procedures stratified by the anesthetic type for age, sex, race, presenting symptoms, major comorbidities (ie, hypertension, diabetes, coronary artery disease, congestive heart failure, chronic obstructive pulmonary disease, chronic kidney disease), previous coronary artery bypass grafting or percutaneous transluminal coronary intervention, previous CEA or carotid artery stenting, degree of ipsilateral stenosis, the presence of contralateral occlusion, and preoperative medications. Intergroup differences between the treatment groups and differences in the perioperative outcomes were tested using the McNemar test for categorical variables and the paired t test or Wilcoxon matched pairs signed rank test for continuous variables, as appropriate. The relative risk (RR) and 95% confidence intervals (CIs) were estimated as the ratio of the probability of the outcome event for the patients treated within each treatment group.

RESULTS

A total of 65,337 patients were included. Of the 65,337 patients, 59,664 had undergone carotid revascularization under GA (91%). When performed with LRA, TCAR and CEA had similar rates of stroke, death, and MI. However, when performed with GA, patients undergoing TCAR had a 50% decreased risk of MI compared with those undergoing CEA under GA (0.5% vs 1.0%; RR, 0.50; 95% CI, 0.32-0.80; P < .01). When stratified by symptomatic status, patients undergoing TCAR with GA for symptomatic carotid disease had a 67% decreased risk of MI compared with those undergoing CEA with GA for symptomatic disease (0.4% vs 1.2%; RR, 0.33; 95% CI, 0.15-0.75; P < .01). In contrast, no difference was found in the risk of MI between patients undergoing CEA vs TCAR for asymptomatic carotid disease (0.6% vs 0.9%; RR, 0.64; 95% CI, 0.37-1.14; P = .13).

CONCLUSIONS

The results from the present study have confirmed previous studies suggesting that TCAR confers a lower risk of MI compared with CEA. However, our findings demonstrated no differences in the MI rates between TCAR and CEA when performed with LRA. Patients undergoing TCAR under GA had lower rates of MI compared with patients undergoing CEA under GA. When stratified by symptomatic status, the benefit of TCAR persisted only for the symptomatic patients.