Use of chloroprocaine in orthopedic day surgery: a brief report in a cohort of patients undergoing knee arthroscopy

OBJECTIVE

Spinal anesthesia with local anesthetics is a viable alternative to general anesthesia in orthopedic surgery, and it is currently considered the standard of care for knee arthroscopy. The use of chloroprocaine may offer several potential advantages over other local anesthetics, including, above all, its rapid onset and short duration of action. The aim of the present retrospective study is to evaluate the post-surgical outcomes of patients who underwent knee arthroscopy using spinal anesthesia with chloroprocaine in an outpatient orthopedic setting.

PATIENTS AND METHODS

Data from patients who underwent elective knee arthroscopy between January 2022 and December 2022 were collected for the present study. Spinal anesthesia with chloroprocaine 10 mg/mL was administered in the designated subarachnoid space (L3-L4 in the majority of patients). A dosage of 40 mg was used to obtain a satisfactory sensory and motor block.

RESULTS

A total number of 302 patients met the inclusion criteria. No complications were reported during surgery in the present series of patients. None of the patients required bladder catheterization. In 84% of cases, the PADSS (Post-Anesthetic Discharge Scoring System) score at discharge was 10, whereas in 16% of cases, the PADSS score was 9. The mean time from anesthesia induction to first urination was 75±9.4 minutes, while the mean time from the anesthesia induction to the discharge from the hospital was 152±18.5 minutes.

CONCLUSIONS

Spinal chloroprocaine for knee arthroscopy demonstrated a short motor block duration, resulting in a fast time to discharge. These limited data show that chloroprocaine may be safely and effectively applied in outpatient knee arthroscopy procedures. However, more studies, possibly with a randomized design, are required to confirm these findings.

Local anaesthetic procaine derivatives protect rat against diabetic nephropathy via inhibition of DPP-4, inflammation and oxidative stress

Diabetic nephropathy (DN) is a serious devastating disease. However, the current clinical options to treat DN are not adequate. Thus, in the present study, we intend to develop novel series of procaine-embedded thiazole-pyrazoles as protective agent against DN. The compounds were tested for inhibition of dipeptidyl peptidase (DPP)-4, -8, and - 9 enzyme subtypes, where they selectively and potently inhibit DPP-4 as compared to other subtypes. The top three ranked DPP-4 inhibitors (8i, 8e and 8k) were further screened for inhibitory activity against NF-ĸB transcription. Among these three, compound 8i was identified as the most potent NF-ĸB inhibitor. The pharmacological benefit of compound 8i was further established in streptozotocin-induced diabetic nephropathy in rats. Compound 8i showed marked improvements in blood glucose, ALP, ALT, total protein, serum lipid profile such as total cholesterol, triglyceride, HDL levels and renal functions such as urine volume, urinary protein excretion, serum creatinine, blood urea nitrogen and creatinine clearance as compared to nontreated diabetic control group. It also reduces oxidative stress (MDA, SOD and GPx) and inflammation (TNF-α, IL-1β and IL-6) in the rats as compared to disease control group rats. This study demonstrated the discovery of procaine-embedded thiazole-pyrazole compounds as a novel class of agent against diabetic nephropathy.

Del Nido versus HTK cardioplegia for myocardial protection during adult complex valve surgery: a retrospective study

BACKGROUND

Histidine-tryptophan-ketoglutarate (HTK) and del Nido (DN) cardioplegia are intracellular-type and extracellular-type solution respectively, both can provide a long period of myocardial protection with single-dose infusion, but studies comparing the two are rare for adult cardiac surgery. This study aims to evaluate whether DN is suitable for cardioplegia in complex and high-risk valve surgery with long-term cardiac ischemia when compared with HTK.

METHODS

The perioperative records of adult patients infused with DN/HTK as a cardioplegic solution who underwent complex valve surgery with an expected myocardial ischaemic duration longer than 90 min between Oct 2018 and Oct 2019 were analysed retrospectively.

RESULTS

Of the 160 patients who received DN/HTK and underwent complex valve surgery, we propensity matched 73 pairs. Both groups achieved satisfactory cardiac arrest effects, and no significant difference was found in their cTnI and CK-MB levels within 12 to 72 h postoperatively. The DN group had a higher rate of return to spontaneous rhythm (0.88 v 0.52, P < 0.001), a lower frequency of postoperative severe arrythmias (12% v 26%, P = 0.036), a higher postoperative stroke volume (65 v 59 ml, P = 0.011) and a higher cardiac output (6.0 v 4.9 L/min, P = 0.007) as evaluated by echocardiography, fewer transfusions and shorter ICU stays (both P < 0.05). The two groups had similar inotrope usage and similar incidences of low cardiac output, morbidities and mortality. Subgroup analysis showed that when the aortic clamping time was greater than 120 min, the advantages of DN were weakened.

CONCLUSIONS

DN can be safely applied to complex valve surgery, and it has a similar myocardial protection effect as HTK. Further prospective studies are required to verify these retrospective findings. Trial registration retrospectively registered.

Procaine-The Controversial Geroprotector Candidate: New Insights Regarding Its Molecular and Cellular Effects

Since its discovery in 1905 and its employment in everyday medical practice as a local anesthetic, to its highly controversial endorsement as an "anti-aging" molecule in the sixties and seventies, procaine is part of the history of medicine and gerontoprophylaxis. Procaine can be considered a "veteran" drug due to its long-time use in clinical practice, but is also a molecule which continues to incite interest, revealing new biological and pharmacological effects within novel experimental approaches. Therefore, this review is aimed at exploring and systematizing recent data on the biochemical, cellular, and molecular mechanisms involved in the antioxidant and potential geroprotective effects of procaine, focusing on the following aspects: (1) the research state-of-the-art, through an objective examination of scientific literature within the last 30 years, describing the positive, as well as the negative reports; (2) the experimental data supporting the beneficial effects of procaine in preventing or alleviating age-related pathology; and (3) the multifactorial pathways procaine impacts oxidative stress, inflammation, atherogenesis, cerebral age-related pathology, DNA damage, and methylation. According to reviewed data, procaine displayed antioxidant and cytoprotective actions in experimental models of myocardial ischemia/reperfusion injury, lipoprotein oxidation, endothelial-dependent vasorelaxation, inflammation, sepsis, intoxication, ionizing irradiation, cancer, and neurodegeneration. This analysis painted a complex pharmacological profile of procaine: a molecule that has not yet fully expressed its therapeutic potential in the treatment and prevention of aging-associated diseases. The numerous recent reports found demonstrate the rising interest in researching the multiple actions of procaine regulating key processes involved in cellular senescence. Its beneficial effects on cell/tissue functions and metabolism could designate procaine as a valuable candidate for the well-established Geroprotectors database.

Toxic epitheliopathy from a single application of preservative free oxybuprocaine (0.4%) in a patient with Sjogren's syndrome

Topical ocular anaesthetic agents are frequently used for ophthalmic diagnosis and surgery. While corneal complications following long-term use or misuse of local anaesthetic solutions have been described, toxic epitheliopathy after a single application of six drops of preservative free oxybuprocaine is rare. In order to increase the awareness of this ocular complication, we report such a case in a patient with Sjogren's syndrome who presented for elective cataract surgery. We outline the mechanisms proposed to explain the ocular toxic effects of oxybuprocaine and discuss the management principles in preventing this complication in the context of Sjogren's syndrome.

Sequential bilateral upper extremity intravenous regional anesthesia with chloroprocaine

PURPOSE

This case report describes the novel use of sequential bilateral upper extremity intravenous regional anesthesia with 2-chloroprocaine for bilateral endoscopic carpal tunnel decompression.

CLINICAL FEATURES

A 49-yr-old female, American Society of Anesthesiologists physical status I, presented for outpatient bilateral carpal tunnel release. Sequential bilateral intravenous regional anesthesia was performed with 0.5% 2-chloroprocaine 30 mL per arm using a double upper arm tourniquet. Intraoperative sedation consisted of midazolam and fentanyl. Tourniquet times for the right and left arms were 28 and 19 min, respectively. After deflation of each tourniquet, mild limb twitching occurred but resolved immediately after administration of intravenous midazolam. The patient made a rapid recovery, and she was discharged home uneventfully.

CONCLUSIONS

Bilateral sequential intravenous regional anesthesia with 2-chloroprocaine is effective for upper extremity surgery of short duration. Recommendations to minimize the risk of local anesthetic toxicity are reviewed.

Comparison of bupivacaine and 2-chloroprocaine for spinal anesthesia for outpatient surgery: a double-blind randomized trial

BACKGROUND

We have always been searching for the ideal local anesthetic for outpatient spinal anesthesia. Lidocaine has been associated with a high incidence of transient neurological symptoms, and bupivacaine produces sensory and motor blocks of long duration. Preservative-free 2-chloroprocaine (2-CP) seems to be a promising alternative, being a short-acting agent of increasing popularity in recent years. This study was designed to compare 2-CP with bupivacaine for spinal anesthesia in an elective ambulatory setting.

METHODS

A total of 106 patients were enrolled in this randomized double-blind study. Spinal anesthesia was achieved with 0.75% hyperbaric bupivacaine 7.5 mg (n = 53) or 2% preservative-free 2-CP 40 mg (n = 53). The primary endpoint for the study was the time until reaching eligibility for discharge. Secondary outcomes included the duration of the sensory and motor blocks, the length of stay in the postanesthesia care unit, the time until ambulation, and the time until micturition.

RESULTS

The average time to discharge readiness was 277 min in the 2-CP group and 353 min in the bupivacaine group, a difference of 76 min (95% confidence interval [CI]: 40 to 112 min; P < 0.001). The average time for complete regression of the sensory block was 146 min in the 2-CP group and 329 min in the bupivacaine group, a difference of 185 min (95% CI: 159 to 212 min; P < 0.001). Times to ambulation and micturition were also significantly lower in the 2-CP group.

CONCLUSION

Spinal 2-chloroprocaine provides adequate duration and depth of surgical anesthesia for short procedures with the advantages of faster block resolution and earlier hospital discharge compared with spinal bupivacaine. (ClinicalTrials.gov number, NCT00845962).

Clinical evaluation of De Marco formula as an adjunctive therapy for infected ischemic diabetic foot: a prospective randomized controlled trial

BACKGROUND

De Marco Formula (DMF) is a novel formulation of procaine and PVP.

OBJECTIVE

To assess the efficacy and safety of DMF as an adjunctive therapy for infected ischemic diabetic foot in a prospective randomized controlled clinical trial.

METHODS

Adult patients, 39 male/ 79 female, were randomly assigned (59 patients/treatment group) to the conventional therapy alone (A) or plus DMF (0, 15 ml/kg .day i.m.) during ten days and them twice a week until healing of the lesions or completion of 52 days (B).The response to the treatment was considered favorable when an amputation was not needed even though a decrease of the wound area or complete healing was not shown. It was considered unfavorable when a major amputation was necessary because of worsening of the lesion (wound spreading to any magnitude greater than the initial one) or the appearance of new wounds in the same leg.

RESULTS

Both groups were comparable with regard to age, sex, level of arterial occlusion, type of lesion, anatomic localization of lesions and previous surgical procedures. The cumulative percentage of unfavorable results was significantly lower after treatment B with respect to treatment A (25.4% vs. 45.8%; p= 0.02), for a reduction of 44.5%. Four slight adverse reactions were associated with DMF: vertigo and nausea at the 7th treatment administration (one patient), and headache and tachycardia at the 12th dose (another patient). Blood hemoglobin and leukocyte counts and serum alanine transaminase were not affected.

CONCLUSION

The treatment with DMF for 52 days as an adjuvant for the conventional therapy was associated with a lower need for major amputations. It was also well tolerated and safe.

Procaine treatments for cognition and dementia

BACKGROUND

Procaine is a controversial substance which has been used for "antiageing" effects including cognitive improvement for more than 50 years.Preparations which contain procaine as a component are claimed to prevent, reverse and interrupt dementia. Several products are widely promoted and can be purchased "over the counter" outside the US and via the Internet. Procaine preparations are said to be readily available in over 70 countries and to be used by more than 100 million people.

OBJECTIVES

To assess the efficacy and adverse effects of procaine (and preparations containing procaine as a component) on cognitive function in the treatment of people with dementia as well as healthy elderly people.

SEARCH STRATEGY

References regarding trials with people with dementia or cognitive impairment were identified from a search of the Specialized Register of the Cochrane Dementia and Cognitive Improvement Group on 8 September 2007 using the search terms: gerovital* or aslavital* or procain* or KH3 or novocain* or GH3 or trofibial or "Zell H3" or Vitacel* or GH7 or "Ultimate 9". The Cochrane Library, MEDLINE, EMBASE, PsycINFO, CINAHL and LILACS were searched on 18 September 2007 to find references to trials with healthy people.The CDCIG Specialized Register contains records from major health databases (including MEDLINE, EMBASE, CINAHL, PsycINFO, CENTRAL, LILACS) as well as many ongoing trial databases and grey literature sources.

SELECTION CRITERIA

All human, unconfounded, randomized double-blind trials in which treatment with procaine was administered for its effects on cognitive function and behavioural symptoms in demented or healthy elderly participants in parallel group comparison with placebo.

DATA COLLECTION AND ANALYSIS

The two review authors independently selected trials, assessed quality, extracted data, and performed the data analysis.

MAIN RESULTS

Pooling data from two studies showed a detrimental effect of procaine in terms of causing side effects (20/208 active versus 3/207 placebo, OR 7.30, 95% CI 2.13 to 25.02, P = 0.002). In patients with dementia, a single small study also suggested a detrimental effect. Two trials referring to healthy elderly persons suggested a positive effect of procaine preparation on cognitive function. Meta-analysis of beneficial outcomes was not appropriate due to the different preparations, durations and poor quality of trials. Most trials were performed before the 1990s and none reported any criteria for cognitive decline and dementia.

AUTHORS' CONCLUSIONS

This review suggests that the evidence for detrimental effects of procaine and its preparations is stronger than the evidence for benefit in preventing and/or treating dementia or cognitive impairment.There is some evidence from older studies that procaine preparations might improve memory in persons without cognitive impairment. However, the clear evidence of side effects suggests that the risks might outweigh the benefits. In the light of this, the strong marketing claims for procaine preparations should be withdrawn until trials of adequate size, duration and quality have been conducted.

[Action of novocain on cardiac and somatomotor autorhythmical functions in early postnatal ontogenesis in rats]

In conscious rat pups aged 2-3, 10-11, and 22-23 postnatal days, it has been shown that intraperitoneal administration of 0.5 % novocain at a dose of 25 mg/kg body mass leads to phasic changes of the level of spontaneous periodic motor activity--from increased at once after the administration to depression and subsequent restoration. They are accompanied by the cardiac rhythm fluctuations that change with age their direction on the background of an increased motor activity from brady--to tachycardia. All the changes are the most pronounced in newborns. At comparison of the results with the afferent impulsation level fluctuations recorded under the same conditions in the peripheral vagus segment, it is suggested that the revealed reactions are associated with changes of the interoceptive afferentation flow. The conclusion is made that at early stages of ontogenesis, interoception plays an important role in regulation of autorhythmical functions and that this role decreases with age.

Topical anesthesia-induced keratopathy after laser-assisted subepithelial keratectomy

A 42-year-old woman had uneventful bilateral laser-assisted subepithelial keratectomy (LASEK) to correct myopia. She experienced intense pain in the first postoperative week and obtained topical oxybuprocaine for pain relief. Subsequently, she developed bilateral persistent corneal epithelial defects, epithelial edema, and bullae that failed to heal with bandage contact lens and topical lubricants. Over the next 4 months, there was progressive corneal stromal thinning and descemetocele formation in 1 eye, requiring application of cyanoacrylate glue, and stromal edema and scarring in the other eye, which resulted in a visual acuity of counting fingers. Investigations did not reveal associated infection or an underlying immunological disorder; however, the patient admitted to excessive use of topical anesthetic eyedrops in the post-LASEK period. She subsequently had penetrating keratoplasty and lens extraction with IOL implantation in the right eye. The left eye healed with central corneal scarring. This case illustrates that serious sight-threatening complications may occur after LASEK due to abuse of topical anesthetic agents.

Spinal Anesthesia with Lidocaine or Preservative-Free 2-Chlorprocaine for Outpatient Knee Arthroscopy: A Prospective, Randomized, Double-Blind Comparison

BACKGROUND

In this prospective, randomized, double-blind study we tested the hypothesis that 50 mg of 1% preservative-free 2-chloroprocaine would provide a faster resolution of spinal block than the same dose of 1% plain lidocaine.

METHODS

After IV midazolam premedication (0.03 mg/kg), 30 ASA physical status I-II outpatients undergoing knee arthroscopy were randomly allocated to receive 50 mg of either 1% plain lidocaine (n = 15) or 1% preservative-free plain chloroprocaine (n = 15). A blinded observer recorded the evolution of sensory (loss of pinprick sensation) and motor (modified Bromage scale) block until complete regression, as well as times to unassisted ambulation and voiding. A telephone call follow-up was performed 24 h and 7 days after surgery.

RESULTS

Two chloroprocaine patients (13%) and one lidocaine patient (7%) required fentanyl supplementation (100 microg IV) (P = 0.99) intraoperatively, but no patient required general anesthesia to complete surgery. Median (range) times for recovery of sensory and motor function, and unassisted ambulation were faster with 2-chloroprocaine [95 (68-170) min; 60 (45-120) min; and 103 (70-191) min] than lidocaine [120 (80-175) min; 100 (60-140) min; and 152 (100-185) min] (P = 0.019, P = 0.0005, and P = 0.003, respectively). No differences in first voiding were reported between chloroprocaine [180 (100-354) min] and lidocaine patients [190 (148-340) min] (P = 0.191). Transient neurological symptoms were reported in five lidocaine patients (33%) but no chloroprocaine patients (0%) (P = 0.042).

CONCLUSION

Intrathecal injection of 50 mg of preservative-free 2-chloroprocaine 1% resulted in quicker recovery of sensory/motor function, and unassisted ambulation, and fewer incidences of transient neurologic symptoms than the same dose of 1% lidocaine.

Use of spinal anaesthesia in day surgery

PURPOSE OF REVIEW

An increasing number of day-case surgical patients is challenging the presently used methods of anaesthesia: reliable surgical anaesthesia should be fast, with rapid recovery and minimal side effects. To compete with modern ambulatory general anaesthesia a knowledge of special spinal anaesthesia techniques is essential. This review brings together important issues concerning the spinal technique, anaesthetic agents and benefits as well as the disadvantages of spinal anaesthesia in outpatients.

RECENT FINDINGS

For surgical procedures in one lower limb, a low dose of hyperbaric bupivacaine with standardized spinal anaesthesia technique produces a reliable block, with low incidence of side effects and home-readiness equal to spinal anaesthesia with lidocaine (50 mg) or general anaesthesia (desflurane), whereas ropivacaine has not shown benefits over spinal anaesthesia with bupivacaine. 'Walk-in, walk-out' spinals with an extremely low dose of lidocaine and opioids for gynaecological laparoscopy created the concept of selective spinal anaesthesia. Reintroduction of chloroprocaine may provide a solution for bilateral, short-acting spinal anaesthesia in the future.

SUMMARY

To produce reliable spinal anaesthesia with a reasonable recovery time it is essential to understand the factors affecting the spread of spinal block and to choose the optimal drug and adequate dose for specific surgical procedures.

Atrial fibrillation following subconjunctival injection of mydricaine number 02

Mydricaine is a mydriatic agent used as a subconjunctival injection to maintain perioperative mydriasis. The drug consists of a mixture of 1.3 mg atropine sulphate, 0.12 mg adrenaline and 8.4 mg procaine hydrochloride in a single vial of 0.4 mL. It is common practice to use mydricaine injections during vitreoretinal surgery in the Royal Adelaide Hospital. Even though the drug is used widely in many vitreoretinal centres, mydricaine is not listed in the British National Formulary nor Monthly Index of Medical Specialities. Therefore, case reports provide the main forum for reporting side-effects.

Current status and perspective of liver preservation solutions

BACKGROUND

A safe and effective preservation solution is a precondition for liver transplantation, which is accepted as the radical treatment for patients with end-stage liver disease. The increasing use of marginal donors and non-heart beating donors as well as the establishment of a national organ allocation network call for better preservation. New preservation solutions like histidine-tryptophan-ketoglutarate (HTK) solution and Celsior solution have been introduced to liver preservation, and protective gene intervention and other modifications have also been investigated. In this article, we review recent advances in liver preservation solutions.

DATA SOURCES

An English-language literature search was conducted using MEDLINE (1990-2005) on liver preservation solution, biliary complication, protective gene and other related subjects.

RESULTS

Although the high viscosity of the University of Wisconsin (UW) solution proved harmful to the hepatic microcirculation, three solutions showed equivalent preservation effects. When the cold ischemia time was short, there were no significant differences among the three solutions in the incidence of biliary complications. So far, modifications of preservation solutions have achieved great success. Several types of protective genes like A20, Bcl-2, Bcl-X(L) and HO-1 were reported to have definite liver protective effects. The addition of other substrates like TNF-alpha antibody, tacrolimus (FK506) and fructose-1,6-bisphosphate (FBP) can also improve the preservation effect. However, addition of insulin to UW solution is harmful to the graft.

CONCLUSIONS

In centers with highly-developed transplantation techniques, HTK and Celsior solutions are acceptable in liver preservation. Protective gene modification and addition of substrates like TNF-alpha antibody, FK506 and FBP are prominent approaches to improve liver preservation.

[Analysis on 27 autopsy cases died of anaphylactic shock induced by mainline]

27 autopsy cases died of anaphylactic shock induced by mainline during 1996-2005 were selected and analyzed. The results showed that most anaphylactic shock induced by mainline were rapid type and more easily happened in individual clinique and lawless clinique, and it could be arisen by either antibiotics or non-antibiotics. In some cases, there may be no pathologic findings by autopsy. So, all the materials must be taken into account for determination the anaphylactic shock, such as drugs, clinic symptom, autopsy findings, and so on.

Use of preservative-free lidocaine for cataract surgery in a patient allergic to “caines”

Although many patients have been labeled allergic to local anesthetics (LAs), true allergic reactions to LAs are rare. An 81-year-old woman with a history of procaine (Novocaine) allergy presented for cataract surgery. Skin testing showed sensitivity to amide and ester LAs. Further testing with preservative-free lidocaine was negative, suggesting the patient was allergic to ester LAs and preservatives found in amide anesthetic preparations. Cataract extraction was subsequently and uneventfully performed in both eyes with topical anesthesia using preservative-free lidocaine.

Tachycardia and myocardial ischaemia following subconjunctival injection of mydricaine (number 02) for vitrectomy procedure

Mydricaine is a mydriatic agent used routinely at the Royal Adelaide Hospital in subconjunctival injections that are given prior to all vitreoretinal surgery. The drug is manufactured by the hospital pharmacy and each vial of 0.4 mL mydricaine number 02 consists of a mixture of 1.3 mg atropine sulphate, 0.12 mg adrenaline and 8.4 mg procaine hydrochloride. Mydricaine is routinely used by many vitreoretinal units, even though the drug is not listed in the British National Formulary (BNF) or Monthly Index of Medical Specialities (MIMS). Therefore, published case reports provide the main forum for reporting side-effects. The case presented is of a patient with no previous ischaemic heart disease who developed transient myocardial ischaemia with tachycardia following the administration of subconjunctival mydricaine number 02. To the authors' knowledge this is the first case report documenting myocardial ischaemia in a patient with no previous ischaemic heart disease following mydricaine administration.

Supracubital perineurioma misdiagnosed as carpal tunnel syndrome: case report

Background

Perineuriomas have been defined as tumorous lesions of the peripheral nerves which derive from perineurial cell proliferation and may be associated with abnormalities on chromosome 22.

Case presentation

Three years after a painful cubital vein procaine injection, a 33 year-old man developed a median nerve lesion, initially diagnosed as carpal tunnel syndrome. Symptoms progressed despite appropriate surgery. Clinical and electrophysiological re-evaluation revealed a fusiform mass at the distal upper arm, confirmed by MRI. Immunohistochemical studies classified the tumor as a mixed perineurioma and neuroma.

Conclusions

Perineurioma mixed with neuroma may potentially caused by the previous trauma or cytotoxic effects of procaine.

Toxic keratopathy associated with abuse of low-dose anesthetic: a case report

OBJECTIVE

To describe the clinical course and treatment of toxic keratopathy associated with abuse of topical anesthetic at a very low concentration, 0.05%.

METHOD

Case report.

RESULT

A 47-year-old female systemic lupus erythematosus (SLE) patient with blurred vision and irritated right eye was referred to the ophthalmology department of our hospital. Under slit-lamp microscope, a 5.5 x 4.5 mm central corneal epithelial defect with underlying infiltrative and opaque stroma was noted in her right eye. Two weeks before, a corneal ulcer was diagnosed, and oxybuprocaine 0.05% (Lacrimin, Santen, Osaka, Japan) eye drops were prescribed 4 times daily but used every 5 to 10 minutes because the right eye was severely irritated. She was admitted immediately under the impression of toxic corneal ulcer. Preservative-free lubricants and prophylactic topical antibiotics 4 times daily were applied. Therapeutic soft contact lens was started after no infective agents were detected. Two weeks later, the stromal infiltration subsided, and the corneal epithelium was slowly healing, but superficial punctate epithelial defects at the lesion site persisted for another 6 months. The vision of her right eye improved from finger-counting at a 30-cm distance to 20/1200 with correction.

CONCLUSION

Toxic keratopathy may result from abuse of topically administered anesthetics even at a very low concentration, 0.05%. Because this SLE patient has tear problems, we suggest that topical anesthetics must be used very cautiously and never prescribed to patients with dry eyes where the integrity of ocular surface is altered.

Cross-reactivity among p-amino group compounds in sulfonamide fixed drug eruption: diagnostic value of patch testing

We studied 28 patients with fixed drug eruption (FDE) caused by sulfonamide antibiotics to investigate cross-reactivity between sulfonamide derivatives and p-amino compounds and to explore the usefulness of patch testing, as an alternative to controlled oral challenge testing (COCT), in diagnosis within this clinical area. COCT with sulfamethoxazole (SMX), sulfadiazine (SDZ), sulfamethizole (SMZ), furosemide (FU), procaine (PRO) and glipizide (GPZ) was performed. Patch testing (PT) with SMX and SDZ was carried out. In all patients, the diagnosis of FDE was confirmed by positive COCT and allergy to trimethoprim ruled out by COCT. 42.8 and 31.8% of the SMX-induced FDE patients reacted to SMZ and SDZ, respectively. All patients (n = 28) tolerated FU, PRO and GPZ. COCT performed with the 3 sulfonamide antibiotics in 12 patients was positive in 2 subjects with the 3 drugs, in 2 patients only with SMX and SMZ and in the remaining 8, SMX was the only causative drug. PT was positive in 5 of 25 patients positive on COCT. The probability of obtaining a positive PT was higher among patients who had a residual lesion than that among those who lacked this. Cross-reactivity between different sulfonamide antibiotics is thus variable, being most likely between SMX and SMZ. We have found no cross-reactivity between sulfonamide antibiotics and other sulfonamide derivatives or p-amino drugs in FDE. PT is a useful tool in the diagnosis of FDE, especially if there are residual lesions, because it avoided the need for COCT in 20% of patients.

0.5% Versus 1.0% 2-Chloroprocaine for Intravenous Regional Anesthesia: A Prospective, Randomized, Double-Blind Trial

In this randomized prospective double-blind study we tested the hypothesis that compared with 40 mL chloroprocaine 0.5%, 40 mL chloroprocaine 1% results in an earlier onset to analgesia duration and improves distal tourniquet tolerance in 150 patients undergoing forearm surgery under IV regional anesthesia using a double-cuff technique, switching from the proximal to the distal cuff was performed if pain scores increased above 4 of 10. Switching to the distal cuff resulted in pain scores below 4 in 69% of patients in the 0.5% group and in 88% of patients in the 1% group (P = 0.047). In addition, both groups differed in the sustained effect on distal tourniquet pain (P = 0.020). Time between injection and onset to analgesia duration was 13 +/- 1 min in the 0.5% group and 11 +/- 1 min in the 1% group (P = 0.0006). On release of the tourniquet, signs of systemic local anesthetic toxicity occurred in 6 patients of the 0.5% group and 28 of the 1% group (P < 0.0001). We conclude that chloroprocaine 1% resulted in an earlier onset of analgesia and improved distal tourniquet tolerance. However, these beneficial effects must be weighed against a fourfold increase in side effects.

IMPLICATIONS

Compared to a standard dose of 40 mL 0.5% chloroprocaine, 40 mL 1% chloroprocaine resulted in an earlier onset of analgesia duration and improved distal tourniquet tolerance during IV regional anesthesia. These beneficial effects must be weighed against a fourfold increase in signs of systemic local anesthetic toxicity.

Spinal 2-chloroprocaine: a dose-ranging study and the effect of added epinephrine

With the availability of preservative- and antioxidant-free 2-chloroprocaine (2-CP), there may be an acceptable short-acting alternative to lidocaine for spinal anesthesia. We examined the safety, dose-response characteristics, and effects of epinephrine with spinal 2-CP. Six volunteers per group were randomized to receive 30, 45, or 60 mg of spinal 2-CP with and without epinephrine. Intensity and duration of sensory and motor blockade were assessed. When 11 of the 18 volunteers complained of vague, nonspecific flu-like symptoms, breaking of the blind revealed that all spinal anesthetics associated with the flu-like symptoms contained epinephrine. There were no complaints of flu-like symptoms in the volunteers who received 2-CP without epinephrine. No further spinal anesthetics containing epinephrine were administered, resulting in 29 anesthetics (11 with epinephrine, 18 without epinephrine.) Plain 2-CP demonstrated a dose-dependent increase in peak block height and duration of effect at all variables except time to 2-segment regression and time to regression to T10. Time to complete sensory regression with plain 2-CP was 98 +/- 20, 116 +/- 15, and 132 +/- 23 min, respectively. 2-CP with epinephrine produced times to complete sensory regression of 153 +/- 25, 162 +/- 33, and 148 +/- 29 min, respectively. Preservative and antioxidant free 2-CP can be used effectively for spinal anesthesia in doses of 30-60 mg. Epinephrine is not recommended as an adjunct because of the frequent incidence of side effects.

IMPLICATIONS

Hyperbaric spinal 2-chloroprocaine is effective and has an anesthetic profile appropriate for use in the surgical outpatient over the dose range of 30-60 mg without signs of transient neurologic symptoms. The addition of epinephrine is not recommended because of the frequent incidence of side effects.

Spinal 2-Chloroprocaine: The Effect of Added Dextrose

Spinal 2-chloroprocaine is being investigated as an alternative short-acting spinal anesthetic to replace lidocaine for outpatient surgery. Adding dextrose increases the baricity of solutions and alters the characteristics of spinal anesthesia. In this study, we compared 2-chloroprocaine spinal anesthesia performed with or without the addition of dextrose (1.1%). Eight volunteers underwent 2 spinal anesthetics, receiving 40 mg 2-chloroprocaine (2 mL, 2%) with 0.25 mL saline with one and 0.25 mL 10% dextrose with the other in a double-blinded, randomized, balanced crossover manner. Pinprick anesthesia, tolerance to transcutaneous electrical stimulation, and tourniquet, motor strength measurements, and time to ambulation and void were assessed. Postvoid residual bladder volume was measured via ultrasound. Spinal anesthesia was successful in all subjects and regressed within 110 (80-110) min. There was no significant difference in peak height T4 (T7-C6), time to achieve peak block height (14 +/- 6 min), time for 2-segment regression (44 +/- 9 min), regression to L1 (66 +/- 12 min), tolerance of tourniquet (43 +/- 9 min), or return of motor function (81 +/- 14 min). Mean postvoid residual volume was larger with dextrose (74 +/- 67 mL versus 16 +/- 35 mL; P = 0.02). No subject reported signs of transient neurologic symptoms (TNS). In conclusion, spinal 2-chloroprocaine provides adequate potency with reliable regression, seemingly without TNS. Adding dextrose does not significantly alter spinal block characteristics but increases residual bladder dysfunction. Therefore, the addition of glucose to 2-chloroprocaine for spinal anesthesia is not necessary.

IMPLICATIONS

Spinal chloroprocaine provides adequate potency with reliable regression, seemingly without concerns of transient neurologic symptoms, and hence an appealing profile for outpatient surgery. The addition of dextrose does not alter peak block height or tolerance of thigh tourniquet, and increases the degree of residual bladder dysfunction.

Spinal 2-Chloroprocaine: The Effect of Added Fentanyl

Chloroprocaine is being investigated as a possible replacement for spinal lidocaine. Adding fentanyl to lidocaine increases the quality of spinal anesthesia without prolongation of block. We report the characteristics of 2-chloroprocaine (2-CP) spinal anesthesia with or without fentanyl in 8 volunteers receiving 40 mg 2-CP with saline or 20 micro g fentanyl in a double-blinded, randomized, crossover manner. Spinal anesthesia was successful for all subjects with complete block regression, ambulation, and void by 110 min. Itching occurred in all subjects receiving fentanyl, though medication was not required. No subject reported signs of transient neurological symptoms. Peak block with fentanyl averaged T5 (T3-7) and without fentanyl T9 (L1-T4) (P = 0.005). Regression to L1 was 78 +/- 7 min with fentanyl and 53 +/- 19 min without fentanyl (P = 0.02). Tourniquet was tolerated for 51 +/- 8 min with fentanyl and for 34 +/- 14 min without fentanyl (P = 0.02). Complete regression of block occurred at 104 +/- 7 min with fentanyl and by 95 +/- 9 min without fentanyl (P = 0.02). We conclude that 2-CP spinal anesthesia provides rapid onset and adequate potency, giving it a positive profile for ambulatory surgery. The addition of fentanyl lengthens regression to L1 and tourniquet tolerance while minimally lengthening block duration.

IMPLICATIONS

Spinal 2-chloroprocaine (40 mg) provides rapid onset and reliable blockade without signs of transient neurological symptoms, giving it a positive profile for ambulatory surgical settings. The addition of fentanyl appears to lengthen the regression to L1 dermatome and tourniquet time while minimally lengthening duration of block.

Spinal 2-chloroprocaine: a comparison with lidocaine in volunteers

Subarachnoid lidocaine has been the anesthetic of choice for outpatient spinal anesthesia. However, its use is associated with transient neurologic symptoms (TNS). Preservative-free formulations of 2-chloroprocaine are now available and may compare favorably with lidocaine for spinal anesthesia. In this double-blinded, randomized, crossover study, we compared spinal chloroprocaine and lidocaine in 8 volunteers, each receiving 2 spinal anesthetics: 1 with 40 mg 2% lidocaine and the other with 40 mg 2% preservative-free 2-chloroprocaine. Pinprick anesthesia, tolerance to transcutaneous electrical stimulation and thigh tourniquet, motor strength, and a simulated discharge pathway were assessed. Chloroprocaine produced anesthetic efficacy similar to lidocaine, including peak block height (T8 [T5-11] versus T8 [T6-12], P = 0.8183) and tourniquet tolerance (46 +/- 6 min versus 38 +/- 24 min, P = 0.4897). Chloroprocaine anesthesia resulted in faster resolution of sensory (103 +/- 13 min versus 126 +/- 16 min, P = 0.0045) and more rapid attainment of simulated discharge criteria (104 +/- 12 min versus 134 +/- 14 min, P = 0.0007). Lidocaine was associated with mild to moderate TNS in 7 of 8 subjects; no subject complained of TNS with chloroprocaine (P = 0.0004). We conclude that the anesthetic profile of chloroprocaine compares favorably with lidocaine. Reliable sensory and motor blockade with predictable duration and minimal side effects make chloroprocaine an attractive choice for outpatient spinal anesthesia.

IMPLICATIONS

The spinal anesthetic profile of chloroprocaine (40 mg) compares favorably with the same dose of spinal lidocaine. Reliable sensory and motor blockade with predictable duration and minimal side effects and without signs of transient neurological symptoms make chloroprocaine an attractive choice for outpatient spinal anesthesia.

Corneal thickness values before and after oxybuprocaine 0.4% eye drops

PURPOSE

To determine changes in corneal thickness after topical anesthesia.

METHODS

Corneal thickness was measured before and 3 minutes after administration of two drops of oxybuprocaine 0.4% to 26 patients (26 eyes). We analyzed the corneal thickness of a control group, which was made up of 26 patients (26 eyes) before and 3 minutes after administration of two drops of saline solution. Corneal thickness was measured with the Orbscan Topography System II (Bausch Lomb Surg., Barcelona).

RESULTS

Variations higher than +/- 10 microm were found following the instillation of 2 oxybuprocaine eye drops in eight eyes (30.76%) at the inferonasal cornea, in six eyes (23.08%) at the superotemporal, temporal and inferotemporal cornea, in five eyes (19.23%) at the nasal cornea, in three eyes (11.53%) at the central cornea, and in two eyes (7.69%) at the superonasal cornea. Nevertheless, no significant differences in the mean corneal thickness at each corneal location between the first and the second corneal thickness measurements were found in anesthetized eyes.

CONCLUSIONS

Some individuals can present important increases and decreases in corneal thickness values after anesthetic eye drops. This effect of anesthetic eye drops must be considered by refractive surgeons when carrying out preoperative laser in situ keratomileusis corneal thickness measurements.

[Relevant allergans by periorbital allergic contact dermatitis. Oxybuprocain, an underestimated allergen]

BACKGROUND

Periorbital allergic contact dermatitis is a rare disease and the main differential diagnoses are atopic and seborrhoeic dermatitis. The diagnosis is based on clinical appearance, patient history and patch testing. Current systematic overviews on contact allergens involved are lacking and with changes in medical preparations, new relevant antigens may emerge.

PATIENTS AND METHODS

Based on the systematic data of the information network of dermatological clinics (IVDK), patch test reactions in 48,969 patients tested between 1996 and 2000 were evaluated. A total of 763 patients suffered from periorbital dermatitis which was suspected to be due to the use of topical medication.

RESULTS

The most common epidermal sensitizations in the general population were observed against nickel and fragrances. In the periorbital dermatitis group, sensitization against local anaesthetics and antibiotics was more frequent than in the general population.

CONCLUSIONS

In three patients, oxybuprocain was identified as the causative agent, which has not yet been recognized as a common allergen.

[A rare complication of conduction anesthesia in the treatment of finger injury]

At the present time novocain still remains the anesthetic of choice in ambulatory surgery and traumatology. In practical work the 2% and 0.5% solutions are used. The 2% solution of novocain can in some cases (in patients prone to angiodystonic reactions) cause a persistent spasm of digital arteries that results in irreversible alterations in finger tissues down to the development of gangrene. This fact was confirmed in experiments with 2% solutions of novocain. It is proposed to follow the recommendations on using the 0.5% and 1% solutions of novocain for regional anesthesia in fingers. Such anesthetics as Lidocain and Trimecain should be used more widely since they possess more pronounced and continuous anesthetizing properties.

Toxicity of local anaesthetics

The complications of failure, neural injury and local anaesthetic toxicity are common to all regional anaesthetic techniques, and individual techniques are associated with specific complications. All potential candidates for regional anaesthesia should be thoroughly evaluated and informed of potential complications. Central neural blockades still account for more than 70% of regional anaesthesia procedures. Permanent neurological injury is 0.02-0.07%. Pain on injection and paraesthesias while performing regional anaesthesia are danger signals of potential injury and must not be ignored. The incidence of systemic toxicity to local anaesthetics has significantly decreased in the past 30 years, from 0.2 to 0.01%. Peripheral nerve blocks are associated with the highest incidence of systemic toxicity (7.5 per 10,000) and the lowest incidence of serious neural injury (1.9 per 10,000).

Preclinical in vitro evaluation of hematotoxicity of the cisplatin-procaine complex DPR

We evaluated in vitro the inhibitory effect of cis-diaminechloro-[2-(diethylamino) ethyl 4-amino-benzoate, N4]-chlorideplatinum(II) monohydrochloride monohydrate (DPR) on colony formation by granulocyte/macrophage (CFU-GM) peripheral blood progenitor cells, representing a method to quantitate the toxicity of drugs to the hematopoietic system, and human leukemic cell lines. The results were compared with those obtained exposing cells to cisplatin and carboplatin. Our data showed that while DPR had a significantly better cytotoxic activity than cisplatin and carboplatin against HL60 and K562, and than carboplatin against Molt 4 cells, it showed 12 and 43 times less inhibitory effect on CFU-GM than cisplatin and carboplatin, respectively. These results suggest that the myelosuppressive activity of DPR could be lower than that of cisplatin and carboplatin, and, furthermore, that leukemic cells represent a preferential target for its cytotoxic activity compared to normal committed hemopoietic progenitor cells. All our results speak in favor of a better therapeutic index for DPR than for the other platinum compounds considered here.

Pharmacological and toxicological aspects of combination of beta-lactam and aminoglycoside antibiotic, prednisolone and procaine hydrochloride on the example of Vetramycin

Vetramycin is an injectable veterinary compound for animal use only. In veterinary medicine, it has been used for a long time as a bactericidal beta-lactam and aminglycoside antibiotics combination, extending the bactericidal spectrum of these substances. This compound, in addition to bactericidal procaine penicillin and dihydrostreptomycin (DHS), contains also prednisolone acetate and procaine hydrochloride, two biologically active substances. Prednisolone, a glucocorticoide, has an antiinflammatory, antiallergic, antiitchical and analgesic effect. Procaine hydrochloride, in turn, has a local anaesthetic effect and attenuates pain caused by irritable properties of antibiotics at the injection sites. The average dosage of, respectively, procaine benzylpenicillin (I.U./kg(-1) b.w.), DHS (microg/kg(-1) b.w.), prednisolone acetate (microg/kg(-1) b.w.) and procaine hydrochloride (mg/kg(-1) b.w.) in horses, cattle, pigs is 6000-15000, 10-11, 0.24-0.6 and 1.2-3.0; s.i.d., in sheep, foals, calves, piglets is 20000-40000, 10, 0.8-1.6 and 4-8; s.i.d., in dogs and cats is 30000-200000, 10, 0.8-1.6 and 4-8; s.i.d.. Intramammary injection dose (Vetramycin antimastitis ointment in syringe) in cows is 1000000 I.U. of procaine benzylpenicillin + 1000000 I.U. of dihydrostreptycin sulphate per quarter of udder, s.i.d., during 3 successive days.

Chloroprocaine is less painful than lidocaine for skin infiltration anesthesia

Skin infiltration of local anesthetics causes pain. In a double-blinded protocol, 22 volunteers received random intradermal injections to the volar surface of the forearm with each of the following solutions: normal saline solution 0.9% (NSS), lidocaine 1% (L), lidocaine 1% and sodium bicarbonate 8.4% (L+BIC), 2-chloroprocaine 2% (CP), 2-chloroprocaine 2% and sodium bicarbonate 8.4% (CP+BIC), and NaCHO(3) 8.4% (BIC). Initially, each volunteer received an open-labeled injection of NSS. A 100-mm visual analog scale (VAS, 1-100) was used to assess pain with each injection. The pH of each solution was stable for the length of the study. Repeated measures of variance were used for analysis. The VAS scores (mean +/- SD) for open-label and blinded NSS injections were 15.5 +/- 15.9 and 14.0 +/- 18.1, respectively. The scores for the studied solutions were as follows: BIC, 47.2 +/- 25.5; L, 25.8 +/- 27.6; L+BIC, 16.0 +/- 14.2; CP, 8.6 +/- 7.4; and CP+BIC, 6.8 +/- 6.7. No significant difference was found between CP and alkalinized CP, but the injection of both solutions was significantly less painful than that of all other solutions (P < 0.05). The pH of the solutions was not related to the pain score. We found that chloroprocaine caused less pain at injection than the more commonly used lidocaine.

IMPLICATIONS

Using 2-chloroprocaine can diminish pain caused by the intradermal injection of lidocaine. pH variations of the solution did not relate to the pain profile of the local anesthetic.

Allergy to local anaesthetics in dentistry. Myth or reality?

BACKGROUND

Local anesthetics (LA) are frequently used in dentistry. Although these drugs are usually well-tolerated, they can sometimes provoke adverse reactions of various types and severity. The true incidence of LA allergic reactions is unknown. The objectives of this study were (i) to evaluate the incidence of immediate adverse events in subjects requiring local anesthetic injection in order to receive dental treatment; (ii) to assess the incidence of anaphylactic allergic reactions among those recorded as adverse events and (iii) to analyze the relationship between the atopic antecedents of these patients and documented allergic reactions.

MATERIALS AND METHODS

A prospective, open-label, non-comparative study including 5,018 subjects who received LA during dental treatment, despite their age, was carried out in 7 private or public odontological centers. All the possible reactions that could appear during the first hour of anesthetic administration were assessed.

RESULTS

Twenty-five adverse reactions were diagnosed, representing 0.5 % of the study population. None of these reactions was due to an allergic cause. Most (22/25) were mild, quickly reversible psychogenic or vasovagal reactions. One case was related to defects in the anesthetic technique. In two further cases, allergic etiology was ruled out after skin and dose provocative challenge tests with the anesthetic. In conclusion, allergic reactions to LA are very rare. Most adverse reactions are psychogenic or vasovagal. Physicians and dentists should be aware of these facts in order to minimize the frequent fears and myths concerning the use of LA in the dentist's office.

[Investigation on the mechanisms of leukocyte alteration in patients with intolerance to some drugs (with novocaine as a model)]

The mechanisms of novocain damaging action on blood cells in persons with increased sensitivity to this drug were studied in the leukocyte alteration test. The leading role of histamine liberated from basophils was established. The increased sensitivity to novocain was shown not to be passively transferred to the cells of healthy donors with patient serum with intolerance to the drug; moreover, the joint action of both cell-mediated and thermolabile humoral factors was found to be necessary for the realization of leukocyte alteration under the action of novocain. The comparison of the information content of a number of methods--skin testing, dosed provocation, leukocyte alteration test and chemiluminescence--for revealing increased sensitivity to novocain in 30 persons with adverse reactions to this preparation registered in their medical history. The two in vitro tests were shown to be comparable in their diagnostic significance with the method of dosed provocation.