Patient Comfort with Various Local Infiltration Anesthetics for Minor Oculoplastic Surgery: A Systematic Review and Network Meta-Analysis

BACKGROUND

Although local anesthetics have been extensively studied, limited evidence is available regarding the optimal solution for maximizing patient comfort in minor oculoplastic procedures.

OBJECTIVES

To determine the optimal anesthetic solution for local infiltration in minor oculoplastic surgeries to maximize patient comfort.

METHODS

This systematic review with network meta-analysis of prospective studies was conducted to understand the efficacy of different local anesthetics in combination to maximize patient comfort. The study was designed according to the Cochrane Handbook for Systematic Reviews of Interventions. The population comprised patients receiving local infiltration anesthesia in minor oculoplastic surgeries. Various anesthetics with adjuvants were compared with respect to injection pain, operative bleeding, and complications. Random-effects model was performed. The primary outcome of injection pain was measured using the visual analog scale (VAS) or a preference question (which intervention was the least painful). Other outcomes were operative bleeding and complications, which were evaluated with a similar preference question.

RESULTS

Eleven randomized controlled trials (RCTs) of 521 patients (917 eyes) were included. The network meta-analysis revealed that "bicarbonate-buffered lidocaine with epinephrine" led to a significant decrease in injection pain (preference question) compared to "prilocaine with felypressin" and "lidocaine with epinephrine," whereas no significant differences were detected in the analysis of injection pain measured using the VAS.

CONCLUSIONS

"Bicarbonate-buffered lidocaine with epinephrine" may be the optimal anesthetic solution for local infiltration in minor oculoplastic surgeries due to reduced injection pain, operative bleeding, and postoperative swelling. However, this should be interpreted cautiously as the confidence in the evidence was very low.

THE CLINICAL TRIAL REGISTRATION NUMBER

CRD42021260332 (PROSPERO).

Comparison of two vasoconstrictors on glycemic levels in diabetic patients

OBJECTIVES

The aim of this study was to evaluate glycemic levels in diabetic patients before, during, and after extractions using 2% lidocaine with 1:100,000 epinephrine (Lido/Epi) and 3% prilocaine with 0.03 IU/mL felypressin (Prilo/Fely).

MATERIALS AND METHODS

A double-blind, randomized clinical trial was conducted to evaluate changes in body parameters and glycemic levels in diabetic patients undergoing two anesthetic protocols during dental extractions. During surgery, we evaluated blood pressure (BP), heart rate (HR), saturation (SpO2), and capillary glycemic levels (Gly). These parameters were measured at the following surgical moments: basal, 30 min after medication, incision, tooth removal, suture, and 30 and 60 min after anesthesia.

RESULTS

Data analysis showed no differences between the groups considering age, weight, and time spent in surgery. Increased systolic BP and decreased diastolic BP were observed in the lido/epi group. No difference was observed in the prilo/fely group among the surgical moments or between the groups regarding BP. No difference was observed in HR and SpO2 between the groups at any surgical moment. However, differences were found when compared the differences in glycemic and basal levels in both groups with greater decreases in blood glucose values for the lido/epi group. In anxiety level evaluation, there was no difference between the different surgical moments.

CONCLUSION

Thus, both lido/epi and prilo/fely (maximum 3.6 mL) can be safely used in controlled diabetic patients CLINICAL RELEVANCE: The use of lidocaine associated with epinephrine did not increase glycemic levels but leads to decrease over time when associated with an anxiety reduction protocol, offering some advantage over prilocaine plus felypressin for diabetic patients.

Intraoperative local anaesthesia for reduction of postoperative pain following general anaesthesia for dental treatment in children and adolescents

BACKGROUND

Whilst carrying out dental procedures under general anaesthesia (GA), practitioners routinely give local anaesthetics (LA) intraoperatively to children. Local anaesthetics are used to help manage postoperative pain and reduce bleeding and the physiological response to procedures. Studies of effectiveness of intraoperative LA to date have reported contradictory results.

OBJECTIVES

To assess the effects of intraoperative local anaesthesia for reducing postoperative pain following general anaesthesia for dental treatment in children and young people aged 17 years or younger.

SEARCH METHODS

We searched the following electronic databases: the Cochrane Oral Health Group Trials Register; the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library, 2013, Issue 12), MEDLINE via OVID (1946 to 02 January 2014), EMBASE via OVID (1980 to 02 January 2014) and Web of Science Conference Proceedings (1990 to 02 January 2014). We searched for ongoing trials in the US National Institutes of Health Register, the metaRegister of Controlled Trials (mRCT) and the International Federation of Pharmaceutical Manufacturers & Associations (IFPMA) Clinical Trials Portal. We did not place any restrictions on the language or date of publication when searching the electronic databases.

SELECTION CRITERIA

Randomised controlled trials in which local anaesthetic was given intraoperatively under general anaesthesia for dental treatment of children and young people aged 17 years or younger.

DATA COLLECTION AND ANALYSIS

We used standard methodological procedures expected by The Cochrane Collaboration. We performed data extraction and assessment of risk of bias independently and in duplicate. We contacted authors to clarify omissions in trial reports. In the 'Summary of findings' tables, we elected to report the outcomes pain, distress, postoperative bleeding, and physiological parameters related to the general anaesthetic, as we considered these to be the outcomes of greatest importance to readers of the review.

MAIN RESULTS

We included 14 trials in this review, with 1152 randomised participants. The studies were published between 1990 and 2009 and were conducted in the United Kingdom, Egypt, Saudi Arabia, and the United States. The age of participants ranged from 2 to 40 years. Three studies were at an overall high risk of bias, seven studies were at an unclear risk of bias, and we judged four studies to be at low risk of bias. The clinical heterogeneity of the included studies precluded pooling of studies in terms of method of administration of LA (e.g., intraligamental injection, infiltration injection, or topical delivery) and variation in the use of supplementary analgesics and follow-up time.Of the seven studies where administration of LA was by infiltration injection, six studies (very low-quality body of evidence, 542 participants analysed, 1 study had overall high risk of bias, 4 studies had overall unclear risk of bias, 1 study had overall low risk of bias) measured postoperative pain. The results were equivocal. There was a decrease in bleeding and increase in soft tissue damage in the LA groups, but we did not judge this to be clinically significant.In the 2 studies where administration of LA was by intraligamental injection, there was no difference in mean pain scores, and they did not report any soft tissue damage (very low-quality body of evidence, 115 participants analysed, 1 study had overall high risk of bias, 1 study had overall unclear risk of bias).One 3-armed study (very low-quality body of evidence, 54 participants analysed, overall high risk of bias) compared the effects of intraligamental and infiltration LA injection with no treatment. There was no evidence of a mean difference in pain, distress, or postoperative anxiety among the three groups.Four studies (very low-quality body of evidence, 343 participants analysed, 2 studies had overall low risk of bias, 2 studies had overall unclear risk of bias) evaluated the effects of topical LA compared with no treatment or placebo. One study (overall unclear risk of bias) with a no-treatment comparator reported lower mean pain in the LA group; all other studies reported no difference in mean pain scores. Two studies reported on bleeding (overall unclear risk of bias): One study reported a clinically insignificant increase in bleeding with no treatment; the other reported no difference.None of the studies reported on participant or child satisfaction.

AUTHORS' CONCLUSIONS

In this review, it was difficult to reach firm conclusions as to the benefit of using local anaesthetic for dental treatment under general anaesthesia. The information reported in the included studies was comprehensive and applicable to the review question, but ultimately it was not sufficient to address the objective of the review. We were unable to pool the included studies in a meta-analysis because of substantial variation in outcome measures, interventions, and treatment types. The use of supplementary analgesia further obscured the effect of local anaesthetics.Based on the literature review and the results of this review, we recommend further randomised controlled trials that minimise bias through adequate allocation concealment and blinding of participants and assessors, and assess the effect of intraoperative local anaesthetic on the volume and type of anaesthetic used and on the cardiovascular system in participants receiving supplementary analgesics as well. Researchers should give consideration to the impact of any changes on the health and well-being of the participant and report baseline measures of pain or distress, or both, and preoperative anxiety.

Peribulbar anaesthesia: a double-blind comparison of three local anaesthetic solutions

A prospective, randomised, double-blinded study comparing three agents for peribulbar anaesthesia is reported. Sixty patients undergoing extracapsular cataract extraction under local anaesthesia were randomly allocated to receive peribulbar anaesthesia with lignocaine 2% with adrenaline; prilocaine 3% with felypressin 0.03 IU.ml-1 or 2% lignocaine and 0.5% bupivacaine in a ratio of 1:1, using a standardised two-injection technique. The pain of injection, time of onset of the block and the operating conditions at the start and finish of surgery were assessed. Peribulbar anaesthesia using lignocaine 2% was significantly more painful than the other solutions. The onset of anaesthesia adequate for surgery was similar in all three groups. Prilocaine 3% with felypressin was associated with the greatest number of blocks providing total akinesia of the eye. Inadequate duration of anaesthesia was seen in only one case; the solution used for this block was 2% lignocaine.

Salivary catecholamine assay for assessing anxiety in pediatric dental patients

For the behavioral management of pediatric dental patients, it is important to estimate the degree of anxiety during dental treatment. The purpose of this study was to investigate salivary catecholamine levels in children undergoing dental treatment and to assess the degree of anxiety at each dental procedure. The salivary norepinephrine (NE) level was not influenced by a subcutaneous injection of 50 micrograms of NE in 6 adult volunteers, suggesting a poor diffusive effect of plasma NE into the salivary gland. The salivary NE and epinephrine (E) were measured in 8 children between the ages of 3 and 7 years who underwent restorative dental procedures. Salivary NE significantly increased when the children lay on a dental chair and subsequently received infiltration anesthesia. The salivary E level did not show a significant change throughout the study. After the treatment, salivary NE returned to the pretreatment level. These findings suggest that the increase in salivary NE before infiltration anesthesia reflects enhanced peripheral NE release as a result of stress-induced sympathetic responses and that salivary NE assay is useful for the assessment of dental anxiety in children.

A comparative study of anesthetic techniques for mandibular dental extraction

PURPOSE

To compare the effectiveness of the intraligamentary technique of anesthetic administration (ILA) with the inferior alveolar nerve block (IANB) in extraction of mandibular teeth.

MATERIALS AND METHODS

ILA and IANB injections using Citanest with Octapressin were administered on 16 patients requiring bilateral mandibular dental extractions. Discomfort during needle placement, profoundness of anesthesia obtained, and patient preference were evaluated for both techniques.

RESULTS

A total of 45 teeth were extracted. Ten patients (62.5%) reported discomfort during needle placement with ILA injection compared to three patients (18.75%) with IANB (P = 0.031). Fifty percent (12/24) of teeth extracted with ILA injection were removed without discomfort to the patient compared to 85.7% (18/21) using IANB (P = 0.027). No difference in patient preference between the two techniques was noted.

Low cost, patient acceptable, local analgesia approach to gynaecological outpatient surgery. A review of 817 consecutive procedures

The objective of this study was to evaluate safety, cost effectiveness and patient acceptability, of performing a wide variety of gynaecological procedures, including endometrial resections, in a clinic using only local analgesia. Eight hundred and seventeen consecutive gynaecological procedures were performed under local analgesia only, with no sedation, including endometrial resections, cone biopsies, terminations of pregnancy, hysteroscopies, and local vaginal and plastic vulval procedures, as well as many combined procedures (figure 1) in a day-surgery ward annexe in the Department of Gynaecology, St John's District General Hospital, Chelmsford Essex. The main outcome measures were patient acceptability, safety and encountered side-effects of procedures performed under local analgesia as well as evaluation of cost-effectiveness and reduction in theatre waiting list times. A high degree of safety and patient acceptability was achieved, with other considerable benefits being short waiting times and much quicker recovery. The only complications were from the endometrial resection group, with only 8 (3.6%) of these requiring intravenous sedation intraoperatively, and 6 (2.7%) requiring overnight admission. No transfers to theatre during any procedure occurred. Savings per procedure, in cost and in patient's time, were very considerable.

CONCLUSION

The local analgesia approach for a wide variety of gynaecological procedures in a combined outpatient theatre is safe and is highly acceptable to patients. There are also considerable benefits in cost and patient convenience, with a reduction in operating list waiting time, which in the current economic climate are worth considering.

Transcervical resection of the endometrium using intracervical block only. A review of 278 procedures

The objective of this study was to assess the efficacy and safety aspects of performing transcervical endometrial resection (T.C.R.E.) on a selected group of 278 patients with menstrual disorders under local analgesia (intracervical block) only. Patient acceptance of the procedure was high, with only 3 cases not completed due to insufficient analgesia (1.07%), although a further 9 (3.2%) were completed with the help of intravenous sedation. Patient satisfaction at 4 months was 90%. There were 4 perforations (1.4%), but no laparotomy was required. Five cases (1.7%) of haemorrhage required a Foley catheter, with 1 needing a transfusion. There was no case of clinically evident glycine overload. Twelve patients required an overnight stay. Patient acceptance of T.C.R.E. under local analgesia, and the incidence of major complications, compared favourably with other published series, including a series of 330 cases performed concurrently by the same operators under general anaesthesia.

Periodontal ligament injection: alternative solutions

This study was undertaken to investigate whether plain lidocaine, 3% plain mepivacaine and 3% prilocaine with felypressin were suitable epinephrine-free local anesthetic solutions for use in periodontal ligament anesthesia as alternatives to lidocaine with 1:80,000 epinephrine. Two hundred and seven patients received one of the four test solutions via a periodontal ligament injection and the success rate of anesthesia was confirmed using an electric pulp stimulator. Although neither mepivacaine nor prilocaine were as effective as lidocaine with epinephrine, the success rates of these three solutions were not statistically different. A single periodontal ligament injection of any of the solutions tested resulted in a low incidence of anesthesia. The success rate of lidocaine without epinephrine was consistently poor.

A randomized trial of Citanest with Octapressin for relief of pain associated with laser vaporization of the cervix

Fifty women undergoing laser vaporization of the cervix for cervical intraepithelial neoplasia were randomly allocated to one of two groups. In one group the patients received no anaesthesia, in the other the ectocervix was infiltrated with 2 ml of Citanest with Octapressin (prilocaine 3% with 0.03 i.u./ml. of felypressin) immediately before the procedure. The pain experienced by each group was assessed immediately after treatment by visual analogue and verbal rating scales. The pain experienced by those women receiving local anaesthesia was significantly reduced as assessed by the visual analogue scale (P = 0.011) and this reduction was not quite significant by the verbal rating scale (P = 0.06). The Citanest group had less troublesome bleeding but the difference in bleeding between the two groups was not significant.

Plasma catecholamine concentrations. The effects of infiltration with local analgesics and vasoconstrictors during nasal operations

Plasma catecholamine concentrations were measured in 19 patients allocated randomly to receive submucous infiltration with 4 ml of either 0.5% lignocaine with adrenaline 1:200 000 or prilocaine 0.5% with octapressin 0.03 iu per ml. Venous blood samples were obtained before and at 2, 5, and 10 minutes following infiltration. Plasma adrenaline increased from 0.35 to 1.72 p mol/ml at 2 minutes infiltration with the former solution whilst there was little change in plasma noradrenaline concentration. No similar peak in adrenaline concentration occurred after infiltration with prilocaine/ octapressin solutions but with both solutions there was a small increase in plasma noradrenaline and adrenaline concentrations 10 minutes after infiltration, at the time of surgical stimulation.

A comparison of four commonly used local analgesics

In a double-blind, cross-over, clinical study with nine probands, the efficiency parameters of four commonly used local analgesics were evaluated: 2% Carbocain with adrenaline 1:200,000, 3% Citanest with Octapressin 0.03 iu/mul, 3% Carbocain Dental, and 2% Xylocain with adrenaline 1:80,000. It was found that 3% Carbocain Dental (no vasoconstrictor content) demonstrated significantly shorter duration of analgesia than the other solutions in the soft tissues as well as in the dental pulp. 3% Citanest with Octapressin exhibited the longest soft tissue duration, but as far as duration of tooth analgesia was concerned there was no significant difference between 3% Carbocain Dental and 2% Carbocain with adrenaline. The longest duration of tooth analgesia was shown with 2% Xylocain with adrenaline; this solution also possessed the highest frequency of analgesia and extent of analgesia. All probands personally preferred injections with 3% Carbocain Dental as injection with this solution resulted in the least discomfort.

Circular-dichroic spectra of vasopressin analogues and their cyclic fragments

The circular dichroic spectra of [Arg8]vasopressin, [Mpr1, Arg8]vasopressin, [Mpr1, D-Arg8]-vasopressin, pressinamide, deaminopressinamide, tocinamide, deaminotocinamide, [Leu4, D-Arg8]-vasotocin, [Mpr1, Leu4, D-Arg8]vasotocin and [Phe2, Lys8]vasopressin have been studied. All these substances showed a characteristic positive dichroic band at about 225 nm due to the presence of tyrosine in sequence position 2. The intensity of this band was affected by interactions between the tyrosine side-chain and other structural elements in the molecule, such as the Na-amino group, the side-chain of phenylalanine in position 3 and the linear C-terminal peptide. Analysis of the response of this band to structural modifications of the molecule and change in the solvent (particularly comparing neutral aqueous solutions with hexafluoroacetone solutions) allowed some conformational conclusions. The linear C-terminal tripeptide is probably situated over the cyclic portion of the molecule both in vasopressin and oxytocin substances. Its steric interaction with the tyrosine side-chain seems to be particularly efficient in molecules containing D-arginine in position 8. In the vasopressin series the stacking interaction of neighbouring aromatic amino acid residues furthermore limits the conformational freedom of the tyrosine side-chain and also probably distorts the dihedral angles of residues 1-3 in comparison with oxytocin. The interactions of phenylalanine and arginine with tyrosine relatively decrease the conformational effects of the primary amino group. Consequently the local conformation of vasopressin in the region of the tyrosine residue is more rigid and less sensitive to changes in medium than that of oxytocin. The circular dichroic spectra did not show any basic conformational differences in the backbone peptide chain of oxytocin and vasopressin substances. A weak negative disulphide band at about 290 nm could be observed in the spectra of both series of substances.

ON THE ANTIDIURETIC ACTIVITY OF PHE2-LYS8-VASOPRESSIN IN THE RAT

The antidiuretic activity of phe2-lys8-vasopressin and lysine vasopressin was compared in experiments on hydrated rats. Doses were expressed in pressor units according to the labelled potency of commercial preparations. With either of two techniques, 1) intravenous injection into rats under ethanol anaesthesia and 2) subcutaneous injection into conscious rats, phe2-lys8-vasopressin was the more potent. Using technique 2), the estimated relative potency was about 3. The discrepancy between this and previous results of other investigators who found phe2-lys8-vasopressin less active in antidiuretic tests, is probably due to the use of different strains of rats.