Application of nanotechnology in local anesthetic drug sustained release and light-responsive controlled release / 药学学报

Local anesthetic drugs are commonly used to block the conduction function of patient's nerves temporarily for anesthesia during surgery or to provide targeted analgesia after trauma. Compared with general anesthetics, local anesthetics makes less impact on the physiological status and alleviates pain complications in the presence of clear consciousness. However, its clinical application is still limited by its systemic toxicity, as well as toxicity to nerves and muscles, duration of action and lack of penetration. Nanotechnology can help it penetrate the physiological barrier, prolong the time of nerve block, and reduce toxic side effects. In addition, by building a light-responsive release system, local anesthetics can be released on demand, enhancing drug effectiveness and safety. However, in addition to the problems of poor consistency and high production costs, the system of light response release is still limited in application due to the limitation of the depth of penetration of the tissue. According to the current research progress, this paper briefly introduces and analyzes the main dosage forms, hoping to provide new ideas for the responsive release of local anesthetic drugs.

The therapeutic efficacy of compound lidocaine cream on psoriasis / 药学学报

Psoriasis is a non-infectious chronic inflammatory skin disease. It′s acknowledged that interleukin (IL)-17 signaling pathway dominantly drives the development of psoriasis. Recently, the role of neuro-immune axis in psoriasis has attracted widespread attention. Lidocaine, a local anesthetic, has ability to block the conduction of nerve impulses, while its therapeutic efficacy on psoriasis remains to be confirmed. Here, we evaluated the therapeutic efficacy of topical application of compound lidocaine cream (LIDO) on imiquimod (IMQ)-induced mouse psoriasis model. Animal welfare and experimental procedures follow the regulations of the Ethics Committee of China Pharmaceutical University. The psoriasis area and severity index (PASI) scoring was used to evaluate the severity of psoriasis-like symptoms. Hematoxylin-eosin staining was used to examine histopathological changes and epidermal thickness was measured. Ki67 immunofluorescence staining was used to evaluate the proliferation of keratinocytes. The relative mRNA expression of inflammatory cytokines (including Il17, Il22, Il23 and Il36) in skin was measured by real-time quantitative PCR. Results show that IMQ-induced increases in the PASI score, epidermal thickness, number of Ki67+ cells and the mRNA expression of inflammatory cytokines are significantly alleviated by topical application of LIDO, whose therapeutic efficacy is also better than that of the positive control drug calcipotriol. Our study suggests that LIDO could be used for psoriasis treatment.

Variations in Innervation Pattern to Dorsum of Foot by Medial Dorsal Cutaneous Nerve, Intermediate Dorsal Cutaneous Nerve, Lateral Dorsal Cutaneous Nerve with Surgical and Clinical Correlations: A Cadaveric Dissection Based Study

The complete reconstruction of any soft tissue defect includes even the sensory recovery which is very significant aspect pertaining to prognosis. Superficial nerves in the vicinity of the vascular axis can be considered as vascular relays and neuroskin grafts can be constructed on them. Variations in innervation to various part of the dorsum of the foot by this nerve should be kept in mind while making these grafts. Authors dissected 50 formalinized cadaveric feet and studied normal anatomy and variations in origin, course, branching pattern, communications, and any other variations in medial, intermediate and lateral dorsal cutaneous nerve. The intermediate dorsal cutaneous nerve was innervating larger area of the skin around 3rd and 4th web spaces in 60% of cadaveric feet. The 2nd web space was innervated by medial dorsal cutaneous nerve in 92% of cadaveric feet. In 52% of cadaveric feet communicating branches were found between intermediate dorsal cutaneous nerve and lateral dorsal cutaneous nerve. In 63% cadaveric feet communicating branches were found between medial dorsal cutaneous nerve and branch of deep peroneal nerve to 2nd web space. The mean distance between lateral malleolus and intermediate dorsal cutaneous nerve was 4.05cm. These all observations can provide anatomical basis at the time of preparing medial dorsal cutaneous nerve flaps and intermediate dorsal cutaneous nerve flaps and also can minimize morbidity at donor site.

Successful Spinal Block in Obstetric Patient with Past History of Scorpion Sting and Failed Spinal Anesthesia

Association between local anesthestic resistance and scorpion sting have been reported in literatures. Scorpion venom is known to affect the sodium channels in the nerve fibres and local anesthetics also acts on the same. But we report a case of successful spinal block in 23 years old second gravida posted for elective caesarean section with past history of failed spinal block and multiple scorpion sting 7 years and 2 years back. Last exposure was 4 months before previous caesarean section, thus failed spinal block may be due to recent exposure. Our conclusion is that, there is a direct relationship between duration of exposure to scorpion venom and susceptibility to local anesthetics.

The Clinical Efficacy of Minocycline Mouth Rinse on Recurrent Aphthous Stomatitis—A Randomized Controlled Trial

Introduction: Recurrent aphthous stomatitis (RAS) is one of the most common ulcerative diseases affecting the general population. The present study aimed to evaluate the clinical efficiency of 0.5% minocycline mouth rinse prescribed along with the topical anesthetic gel and vitamin supplement over the topical anesthetic gel and vitamin supplement prescribed alone for treating RAS. Materials and Methods: A total of 60 participants were randomly divided into two groups—experimental group: 0.5% minocycline mouth rinse prescribed along with vitamin supplement and topical anesthetic gel; and control group: vitamin supplement and topical anesthetic gel alone. The pain symptoms were evaluated using the VAS scores at baseline and first follow?up visits. The data were analyzed using Student’s t test. Results: A significant reduction in the pain scores was observed in participants using the 0.5% minocycline mouth rinse prescribed along with vitamin supplement and topical anesthetic gel on the first follow?up visit (P = < 0.001). Conclusion: The 0.5% minocycline mouth rinse prescribed along with vitamin supplement and topical anesthetic gel had shown more reduction in the pain symptoms when compared to topical anesthetic gel and vitamin supplement prescribed alone for the treatment of RAS.

Dispersão da lidocaína administrada por via epidural em cães posicionados em decúbito lateral ou esternal / [Dispersion of lidocaine epidurally administered to dogs positioned on lateral or external decubitus]

O objetivo do estudo foi verificar clinicamente a dispersão da lidocaína no espaço epidural de cães posicionados em diferentes decúbitos. Foram utilizados 16 cães, com peso médio de 17,5 quilogramas. Esses foram tranquilizados com acepromazina, anestesiados com propofol e alocados em dois grupos, conforme o decúbito de posicionamento: decúbito esternal (GE) e decúbito lateral direito (GLD). Ambos os grupos receberam lidocaína a 2%, no volume de 0,25mL/kg, e permaneceram no mesmo decúbito por 20 minutos. Em seguida, avaliou-se o bloqueio dos membros pélvicos e a extensão do bloqueio, a partir da sétima vértebra lombar, por meio de pinçamento interdigital e do panículo paravertebral. Foi, então, realizada cirurgia de orquiectomia. Após tal procedimento, avaliou-se o tempo total de bloqueio dos membros pélvicos. Todos os cães apresentaram bloqueio bilateral, sem diferenças quanto à extensão cranial entre os grupos, sendo a mediana de 7,5 (1-14) vértebras para GE e de 4 (1-14) para GLD. O tempo de bloqueio dos membros direito e esquerdo foi de 123 ± 26 e 130 ± 20 minutos, para GE, e de 120 ± 21 e 121 ± 20 minutos, para GLD, sem diferenças entre os grupos ou entre os membros. Conclui-se que o decúbito não interfere na distribuição da lidocaína administrada por via epidural.(AU)

The aim of this study was to clinically verify the dispersion of lidocaine in the epidural space of dogs placed in different positions. Sixteen dogs with an average weight of 17.5 kilograms were used. These were tranquilized with acepromazine, anesthetized with propofol and allocated to two groups: sternal decubitus (GE) and right lateral decubitus (GLD). Both groups received 2% of lidocaine in the volume of 0.25mL/kg and remained in the same position for 20 minutes. The blocking of the pelvic limbs and the extension of it from the seventh lumbar vertebra were evaluated by means of interdigital and paravertebral panniculus clamping. Orchiectomy surgery was then performed. Afterwards, the total blocking time of the pelvic limbs was evaluated. All dogs presented bilateral blocking, with no differences in cranial extension between groups, with a median of 7.5 (1-14) vertebrae for GE and 4 (1-14) for GLD. The blocking time of the right and left limbs were 123 ± 26 and 130 ± 20 minutes for GE, and 120 ± 21 and 121 ± 20 minutes for GLD with no difference between groups or between limbs. It is concluded that the decubitus does not interfere with the epidural lidocaine distribution.(AU)

Bloqueio motor e sensitivo da lidocaína ou da ropivacaína peridural em cães / [Motor and sensitive blockade provided by epidural lidocaine or ropivacaine in dogs]

Objetivou-se avaliar o bloqueio sensitivo e motor da administração peridural de 0,2mL/kg de duas concentrações de ropivacaína em comparação à lidocaína em cães. Utilizaram-se 24 cães, distribuídos em quatro grupos: NaCl a 0,9% (GS), lidocaína a 2% (GL), ropivacaína a 0,5% (GR5) e ropivacaína a 0,75% (GR7,5). Avaliaram-se a presença de movimentação espontânea, deambulação, sensibilidade superficial e profunda nos momentos cinco, 10, 15, 20, 25, 30, 45, 60, 90, 120, 180, 240 e 300 minutos após peridural. O retorno à movimentação espontânea foi semelhante entre GL (42,50 ± 6,12) e GR7,5 (69,2 ± 58,9). O tempo para deambulação foi mais prolongado em GR7,5 (107,5 ± 79,3) que em GS (9,2 ± 3,8) e em GR5 (32,5 ± 20,9). O retorno da sensibilidade profunda foi maior em GR 7,5 (152,5 ± 89,2) que em GS (5,8 ± 2,0), GR5 (46,7 ± 46,3) e GL (52,5 ± 20,7). O tempo de retorno da sensibilidade superficial foi maior em GR7,5 (205,0 ± 129,3) que em GS (7,5 ± 2,7), GL (72,5 ± 19,9) e GR5 (97,5 ± 55,1). Apesar do retorno precoce da movimentação, ropivacaína 0,75% está relacionada a tempo prolongado de recuperação da função muscular e bloqueio sensitivo mais prolongado que lidocaína e ropivacaína 0,5%.(AU)

The aim of the present study was to evaluate the sensory and motor blockade of epidural 0.5% and 0.75% Ropivacaine or Lidocaine in dogs. Twenty-four dogs were distributed in four groups: 0.9% NaCl (GS), 2% lidocaine (GL), 0.5% ropivacaine (GR5) and 0.75% ropivacaine (GR7.5). Spontaneous movement, ability to walk, superficial, and deep pain response were assessed 5, 10, 15, 20, 25, 30, 45, 60, 90, 120, 180, 240 and 300 minutes after epidural. Time to return to spontaneous movement was similar between GL (42.50 ± 6.12) and GR7.5 (69.2 ± 58.9). Time to return to ambulation was longer in GR7.5 (107.5 ± 79.3) than in GS (9.2 ± 3.8) and GR5 (32.5 ± 20.9). Time to recover deep sensitivity was longer in GR 7.5 (152.5 ± 89.2) than in GS (5.8 ± 2.0), GR5 (46.7 ± 46.3) and GL (52.5 ± 20.7). Time to return superficial sensitivity was longer in GR7.5 (205.0 ± 129.3) when compared to GS (7.5 ± 2.7), GL (72.5 ± 19.9) and GR5 (97.5 ± 55.1). Despite the early return of spontaneous movement, 0.75% ropivacaine is related to longer periods for muscle function recovery and longer sensory block than lidocaine and 0.5% ropivacaine.(AU)

Infusão de morfina e cetamina, associada ou não à lidocaína, em gatas submetidas à ovariossalpingo-histerectomia / Infusion of morphine and ketamine, with or without lidocaine, in cats undergoing ovariohysterectomy

O objetivo deste estudo foi avaliar os efeitos analgésicos transoperatórios da infusão contínua de morfina e cetamina, associada ou não à lidocaína, em gatas submetidas à OSH eletiva. Foram utilizadas 16 fêmeas adultas, hígidas, pré-medicadas com acepromazina (0,1mg/kg) e morfina (0,5mg/kg), ambas pela via intramuscular, induzidas com cetamina (1mg/kg) e propofol (4mg/kg), pela via intravenosa, e mantidas sob anestesia geral inalatória com isoflurano a 1,4 V%. Os animais foram alocados aleatoriamente em dois grupos: grupo morfina, lidocaína e cetamina (MLK, n=8), que recebeu bolus de lidocaína (1mg/kg), pela via IV, seguido de infusão de morfina, lidocaína e cetamina (0,26mg/kg/h, 3mg/kg/h e 0,6mg/kg/h, respectivamente); e grupo morfina e cetamina (MK, n=8), que recebeu bolus de solução salina, seguido de infusão de morfina e cetamina, nas mesmas doses do MLK. Os momentos avaliados foram: M0, basal, cinco minutos após a indução; M1, imediatamente após a aplicação do bolus de lidocaína ou solução salina; M2, M3, M4 e M5, a cada cinco minutos, até completar 20 minutos do início da infusão; M6, após a incisão da musculatura; M7, após pinçamento do primeiro pedículo ovariano; M8, após pinçamento do segundo pedículo ovariano; M9, após pinçamento da cérvix; M10, após sutura da musculatura; M11, ao final da cirurgia; e M12, M13 e M14, intervalos de cinco minutos, até completar uma hora de infusão. A FP no M0 foi maior no MLK quando comparado ao MK. Em ambos os grupos, a PAS foi maior no M7 e no M8 em relação ao M0, porém no MK, além da PAS, a FP foi maior do M7 ao M13, assim como a f. Os animais do MK necessitaram de um número maior de resgates transoperatorios, total de 23, do que o MLK, total de sete. Conclui-se que a adição de lidocaína incrementou a analgesia oferecida, reduzindo o número de resgates analgésicos transoperatórios, a dose total de fentanil, bem como a probabilidade de os animais necessitarem dese tipo de resgate.(AU)

The aim of this study was to evaluate the trans-operative analgesics, continuous infusion of morphine and ketamine, with or without lidocaine in cats undergoing elective OSH. Sixteen adult cats were used, otherwise healthy, pre-medicated with acepromazine (0.1mg/kg) and morphine (0.5mg/kg), both intramuscularly, induced with ketamine (1mg/kg) and propofol (4mg/kg), intravenous, maintained under general inhalation anesthesia with isoflurane 1.4 V%. The animals were randomly allocated into two groups: morphine, lidocaine and ketamine (MLK, n= 8), which received intravenous bolus of lidocaine (1mg/kg) followed by infusion of morphine, lidocaine and ketamine (0.26mg / kg/h, 3mg / kg/h and 0.6mg / kg/h, respectively); Morphine and ketamine (MK, n= 8), who received bolus of saline followed by infusion of morphine and ketamine at the same doses of MLK. The evaluated moments were: M0, basal, 5 minutes after induction; M1 immediately after the application of lidocaine bolus injection or saline; M2, M3, M4 and M5, every 5 minutes to complete 20 minutes after the start of infusion; M6, after the incision of the musculature; M7, after clamping of the first ovarian pedicle; M8, after clamping of the second ovarian pedicle; M9, after clamping of the cervix; M10, after suturing of the musculature; M11, at the end of surgery; And M12, M13 and M14, 5 minute intervals until completing one hour of infusion. The time to extubating and full recovery of animals, and the need for rescue analgesic fentanyl intraoperatively were also evaluated. HR in M0 was higher in MLK when compared to MK. In both groups the SBP was higher in M7 and M8 compared to M0, but the MK, addition of SAP, HR was greater M7 to M13, as well as f. MK animals required a greater number of trans-operative rescues than the MLK. It was concluded that the addition of lidocaine to the protocol using morphine and ketamine increased its analgesia.(AU)

Sensibilidad aumentada a lidocaína: estudio genético de un caso / Increased sensitivity to lidocaine: Genetic study of a case

Systemic toxicity by local anesthetics (LAs) is a severe and feared complication in anesthetic practice that generally results from the administration of an inappropriately high dose of LAs or an injection at an inappropriate place, either intravascular or a site with high absorption[1]. However, it is known that the susceptibility to these drugs may vary within the population, which may occur due to genetic changes in the LA binding site, located in the potential-dependent Na+ channels (Nav), thus increasing or decreasing its affinity and, therefore, its clinical consequences. We present a case of a 61 years-old female patient with a medical history of increased sensitivity to LAs. In this scenario, a genetic study was performed to exclude a Nav channel dysfunction.

La toxicidad sistémica por anestésicos locales (ALs) es una grave y temida complicación en la práctica anestésica que generalmente resulta de la administración de una dosis inapropiadamente alta de ALs o a una inyección en un lugar inadecuado, llámese intravascular o un sitio al alta absorción[1]. A pesar de lo anterior, es conocido que la susceptibilidad al efecto de estos fármacos puede variar dentro de la población, lo cual puede ocurrir debido a cambios genéticos en el sitio de unión de los AL, localizado en los canales de Na+ dependientes de potencial (Nav), incrementando o disminuyendo así su afinidad y, por ende, sus consecuencias clínicas. Presentamos el caso de una paciente de 61 años con historia de sensibilidad aumentada a Als. En este escenario, se le ofreció un estudio genético para excluir una disfunción específica a nivel de canal Nav

Difusión analgésica de lidocaína administrada a través de un catéter perilesional en hembras caninas sometidas a mastectomía: un reporte de caso / Analgesic diffusion of lidocaine administered through a wound soaker catheter in female canines undergoing mastectomy: a case report / Difusão analgésica de lidocaína administrada por um catéter perilesional em cadelas submetidas à mastectomía: um relato de caso

Resumen La mastectomía regional en caninos se considera un procedimiento quirúrgico con un grado de dolor intenso, por lo que exige una terapéutica analgésica posquirúrgica efectiva que actúe a favor del bienestar de los pacientes. El manejo farmacológico analgésico sistémico convencional en pacientes de carácter oncológico es deficiente y está fundamentado principalmente en antinflamatorios no esteroidales (AINEs) u opioides de baja potencia. El objetivo del presente reporte es describir el manejo analgésico posmastectomía en dos hembras caninas, mediante el uso de lidocaína como opción fármaco-terapéutica administrada a través de un catéter de difusión analgésica perilesional (MILA ®). Ambos pacientes fueron sometidos a mastectomía regional. Luego de retirar la masa mamaria para cada caso, se instauró un catéter perilesional y se administró lidocaína a 2 mg/kg/ hora de forma intralesional, mediante difusión constante por medio de un catéter y una jeringa perfusora. Se realizaron mediciones de variables fisiológicas y de dolor mediante la escala de la Universidad de Melbourne (UMPS) en ambos pacientes cada 2 horas (T0-T12) durante 24 horas. Ambos pacientes mostraron un descenso en el score de la UMPS durante el periodo de observación posquirúrgica y no hubo cambios significativos en las mediciones de las variables fisiológicas. La infusión intralesional de lidocaína aplicada en los dos pacientes sometidos a mastectomía del presente reporte logró un estado de analgesia posquirúrgico efectivo.

Abstract The regional mastectomy in canines is considered as an intense-pain degree surgical procedure in bitches, which requires an effective post-sur-gical analgesic therapy for the well-being of patients. The conventional systemic analgesic pharmacological management in oncological patients is deficient and is mainly based on non-steroidal anti-inflammatory drugs (NSAIDs) and/or low potency opioids. The present report aimed to describe post-mastectomy analgesic management in two bitches, using lidocaine as a drug-therapeutic option administered through a perilesional anal- gesic diffusion catheter (MILA®). Both patients were subjected to regional mastectomy. After removing the breast mass for each case, a perilesional catheter was placed and the lidocaine was administered at 2 mg/kg/hour intralesionally, by constant diffusion through a catheter and a perfusion syringe. Measurements of physiological and pain variables were collected using the University of Melbourne Scale (UMPS) in both patients every 2 hours (T0-T12) for 24 hours. Both patients showed a decrease in UMPS score during the post-surgical observation period and there were no sig- nificant changes in the measurements of the physiological variables. The intralesional infusion of lidocaine applied in the two patients subjected to mastectomy on this report achieved an effective post-surgical analgesia state.

Resumo A mastectomía regional em caninos é considerada um procedimento cirúrgico comgrau de dor intenso, que requer uma terapia analgésica pós-cirúrgica efetiva que atue em o bem-estar dos pacientes. A terapia farmacológica sistémica analgésico convencional nestes pacientes de características oncológicas é mau e baseada principalmente na antinflamatorios não esteroide (AINE) e/ou de opioides baixa potência. O objetivo deste trabalho é descrever a terapia analgésica pós-mastectomía dois cães fêmeas, através da utilização de lidocaína como opção terapêutico medicamentoso administrado o fármaco através de um cateter de difusão perilesional analgésico (MILA®). Duas cadelas foram submetidas a mastectomía regional. Após a remoção da massa mamária para cada caso, um cateter perilesional foi colocado e lidocaína foi administrada a 2 mg/kg/hora por via intralesional, por difusão constante através de cateter e seringa de perfusão. Medidas de variáveis fisiológicas e de dor foram feitas usando a escala da Universidade de Melbourne (UMPS) em ambos os pacientes a cada 2 horas (T0-T12) por 24 horas. Ambos pacientes mostraram uma diminuição no escore de dor de UMPS durante o período de observação pós-cirúrgica e não houve mudanças significativas nas medidas das variáveis fisiológicas. A infusão intralesional de lidocaína aplicada nas duas cadelas submetidos à mastectomía deste relato alcançou um estado analgésico pós-operatório eficaz.

Troubleshooting for epileptiform activity during percutaneous transvenous mitral commisurotomy

Percutaneous transvenous mitral commisurotomy (PTMC) is a frequently used minimally invasive procedure for patients with symptomatic mitral stenosis. However, it is not without complications. Few complications which are distinctive to the procedure are thromboembolism, left-to-right shunts, mitral regurgitation, cardiac tamponade and complete heart block. We present the case of a 32-year-old female patient scheduled for a PTMC, who had multiple complications during the procedure. She developed cardiac tamponade for which pericardiocentesis and autotransfusion was done. Subsequently she exhibited epileptiform activity for which there was a diagnostic dilemma due to the presence of multiple confounding factors. However, she had a complete recovery without any residual sequelae at the time of discharge.

Interscalene Brachial Plexus Block With and Without Dexamethasone: A comparative Study

Interscalene block is commonly used for anesthesia and analgesia in patients undergoing surgeries of shoulder and upper arm. Combination of lignocaine and bupivacaine is commonly used for this purpose. Addition of dexamethasone to local anesthetic drugs is reported to cause rapid onset and enhance the duration of anesthesia and analgesia. We conducted this study to compare the analgesic effect in interscalene block with local anesthetic versus local anesthetic and steroid. Methods: This was a prospective comparative study conducted in the department of anesthesiology of a tertiary care medical college situated in an urban area. In this study total 120 patients undergoing upper limb surgery under interscalene block were included on the basis of a predefined inclusion and exclusion criteria. Out of these 120 patients 60 patients received lignocaine, adrenaline, bupivacaine and dexamethasone (Group A) whereas remaining 60 patients were given lignocaine, adrenalin, bupivacaine and distilled water (Group B). The comparison of onset of analgesia, onset and duration of motor blockade as well as onset and duration of sensory blockade was compared in both the groups. For statistical analysis SSPE 21.0 software was used and P value less than 0.05 was taken as statistically significant. Results: Majority of the studied cases belonged to the age group of 21-30 years (24.17%) followed by 31-40 years (23.33%). The mean age of patients in both the group was found to be comparable with no statistically significant difference between mean age of both the groups (P>0.05). The mean time for onset of analgesia in Group A and Group B was found to be 7.43 +/- 1.65 and 6.01+/- 1.55. The difference was found to be statistically significant (P<0.0001). The duration of sensory and motor blockade was found to be 14.6+/-12.5 and 11.93+/- 1.48 in group A. where as in group B it was found to be 11.8+/-0.8614 and 8.85 +/- 1.15 respectively. Onset of sensory blockade was found to be 7.01 +/-2.12 and 9.09 +/- 3.08 in group A and group B respectively. The difference was found to be statistically significant for duration of sensory and motor blockade. Onset of motor blockade was found to be comparable in both the groups with no statistically significant difference (P>0.05). Conclusion: Addition of dexamethasone to local anesthetic agent for interscalene block is associated with rapid onset of analgesia and a prolonged duration of motor and sensory blockade.

Lipid emulsion therapy of local anesthetic systemic toxicity due to dental anesthesia

Local anesthetic systemic toxicity (LAST) refers to the complication affecting the central nervous system (CNS) and cardiovascular system (CVS) due to the overdose of local anesthesia. Its reported prevalence is 0.27/1000, and the representative symptoms range from dizziness to unconsciousness in the CNS and from arrhythmias to cardiac arrest in the CVS. Predisposing factors of LAST include extremes of age, pregnancy, renal disease, cardiac disease, hepatic dysfunction, and drug-associated factors. To prevent the LAST, it is necessary to recognize the risk factors for each patient, choose a safe drug and dose of local anesthesia, use vasoconstrictor , confirm aspiration and use incremental injection techniques. According to the treatment guidelines for LAST, immediate application of lipid emulsion plays an important role. Although lipid emulsion is commonly used for parenteral nutrition, it has recently been widely used as a non-specific antidote for various types of drug toxicity, such as LAST treatment. According to the recently published guidelines, 20% lipid emulsion is to be intravenously injected at 1.5 mL/kg. After bolus injection, 15 mL/kg/h of lipid emulsion is to be continuously injected for LAST. However, caution must be observed for >1000 mL of injection, which is the maximum dose. We reviewed the incidence, mechanism, prevention, and treatment guidelines, and a serious complication of LAST occurring due to dental anesthesia. Furthermore, we introduced lipid emulsion that has recently been in the spotlight as the therapeutic strategy for LAST.

The chondrotoxic and apoptotic effects of levobupivacaine and bupivacaine on the rabbit knee joint / Os efeitos condrotóxicos e apoptóticos de levobupivacaína e bupivacaína na articulação do joelho de coelhos

Abstract Background: A single dose injection or continuous infusion of local anesthetics into the joint space is considered to be a well-defined analgesia technique. The aim of this study was to investigate the chondrotoxic and apoptotic effects of single-dose intra-articular injection of levobupivacaine and bupivacaine on rabbit knee joint tissues. Materials and methods: The animals were allocated into two groups each containing 20 rabbits. 0.5% levobupivacaine (Group L) and 0.5% bupivacaine (Group B) were applied intra-articularly to the left posterior joints of rabbits. At the same time, normal saline was applied to the right posterior leg knee joints of rabbits in both groups and used as a control (Group S). At the end of the 7th and 28th days after the intraarticular injections, ten randomly chosen rabbits in each group were killed by applying intraperitoneal thiopental. Sections of cartilage tissue samples were stained for light microscopic examinations and the TUNEL method was used to investigate apoptotic cells. Results: As a result of immunofluorescence microscopic examination, the number of apoptotic cells in Group B at day 7 and day 28 were both significantly higher than Group L and S (p < 0.05). Also, the number of apoptotic cells in Group L at day 7 and day 28 were both significantly higher than Group S (p < 0.05). Conclusions: We found that bupivacaine is more chondrotoxic than other anesthetic agent and increases the number of apoptotic cells. These results indicated that bupivacaine caused high chondrotoxic damage and it led to more apoptotic activation than levobupivacaine.

Resumo Justificativa: Uma injeção em dose única ou infusão contínua de anestésicos locais no espaço articular é considerada uma técnica de analgesia bem definida. O objetivo deste estudo foi investigar os efeitos condrotóxicos e apoptóticos da injeção intra-articular com dose única de levobupivacaína e bupivacaína em tecidos articulares do joelho de coelho. Material e métodos: Os animais foram alocados em dois grupos, cada um contendo 20 coelhos. Levobupivacaína a 0,5% (Grupo L) e bupivacaína a 0,5% (Grupo B) foram aplicadas intra-articularmente nas articulações posteriores esquerdas de coelhos. Ao mesmo tempo, solução salina normal foi aplicada nas articulações do joelho da perna posterior direita de coelhos em ambos os grupos e usada como controle (Grupo S). Ao fim do 7° e 28° dias após as injeções intra-articulares, 10 coelhos escolhidos aleatoriamente em cada grupo foram mortos por aplicação de tiopental intraperitoneal. Seções de amostras de tecido cartilaginoso foram coradas para exames de microscopia de luz, e o método TUNEL foi usado para investigar células apoptóticas. Resultados: Como resultado do exame microscópico de imunofluorescência nos dias 7 e 28, o número de células apoptóticas no Grupo B foi significativamente maior que nos grupos L e S (p < 0,05). Além disso, o número de células apoptóticas nos dias 7 e 28 foi significativamente maior no Grupo L do que no Grupo S (p < 0,05). Conclusões: Demonstramos que a bupivacaína é mais condrotóxica do que o outro agente anestésico e aumenta o número de células apoptóticas. Esses resultados indicaram que a bupivacaína causou intensa lesão condrotóxica e levou a uma ativação apoptótica maior do que a levobupivacaína.

The efficacy of different modes of analgesia in postoperative pain management and early mobilization in postoperative cardiac surgical patients: A systematic review

Cardiac surgery induces severe postoperative pain and impairment of pulmonary function, increases the length of stay (LOS) in hospital, and increases mortality and morbidity; therefore, evaluation of the evidence is needed to assess the comparative benefits of different techniques of pain management, to guide clinical practice, and to identify areas of further research. A systematic search of the Cochrane Central Register of Controlled Trials, DARE database, Joanna Briggs Institute, Google scholar, PUBMED, MEDLINE, EMBASE, Academic OneFile, SCOPUS, and Academic search premier was conducted retrieving 1875 articles. This was for pain management postcardiac surgery in intensive care. Four hundred and seventy-one article titles and 266 abstracts screened, 52 full text articles retrieved for critical appraisal, and ten studies were included including 511 patients. Postoperative pain (patient reported), complications, and LOS in intensive care and the hospital were evaluated. Anesthetic infiltrations and intercostal or parasternal blocks are recommended the immediate postoperative period (4–6 h), and patient-controlled analgesia (PCA) and local subcutaneous anesthetic infusions are recommended immediate postoperative and 24–72 h postcardiac surgery. However, the use of mixed techniques, that is, PCA with opioids and local anesthetic subcutaneous infusions might be the way to go in pain management postcardiac surgery to avoid oversedation and severe nausea and vomiting from the narcotics. Adequate studies in the use of ketamine for pain management postcardiac surgery need to be done and it should be used cautiously.

Evaluation of Efficacy of Different Identification Tests to Distinguish Cerebrospinal Fluid from Local Anaesthetic Solution: A Comparative Study

Background: Local anaesthetics (LAs) are used clinically for anaesthesia and analgesia either following surgery or for management of other acute and chronic pain conditions; they only last a few hours. Various methods have been mentioned in the past literature for differentiating the CSF and the local anaesthetic solutions. Hence; we planned the present study to check and compare the efficacy of simple identifications tests to distinguish local anesthetic solutions from CSF. Materials & Methods: We planned the present study to compare the efficacy of simple identifications tests to distinguish local anesthetic solutions from CSF. We involved five experienced anesthetists for the present study. Both the anesthetics were asked to identify 0.1 ml sample of bupivacaine and mock CSF (tap water) by each of four physicochemical characteristics based on criteria: Temperature, pH, Presence of glucose, and Turbidity when mixed with thiopentone. The anesthetics involved in the present study were unaware of the results. All the results were recorded on excel sheet and were analyzed by SPSS software. Results: The two test solutions were identified conveniently together with the four physiochemical tests. However; the anesthetics were not able to identify and differentiate the solutions clearly with individual tests. Conclusion: Anesthetist should be accustomed with different physicochemical methods available for differentiating between CSF and local anaesthetic solution. However; no single test appears to have complete reliability. Therefore, combinations of tests must be used.

Comparison of anxiety and pain perceived with conventional and computerized local anesthesia delivery systems for different stages of anesthesia delivery in maxillary and mandibular nerve blocks

BACKGROUND: Fear of local anesthesia (LA) is a significant impediment to dental care as many patients delay or avoid treatment to avert pain. Computer-controlled local anesthetic delivery system (CCLAD), with constant and controlled rate of flow, present a painless alternative. The present study aimed to compare anxiety and pain perceived with conventional and computerized systems, for different stages of anesthesia delivery when administering various nerve blocks. METHODS: One hundred patients requiring bilateral LA participated in the study. One side was anesthetized using one system and the contralateral side was anesthetized using the other, in two separate appointments. Patients assigned anxiety scores on a 5-point scale and used the visual analogue scale (VAS) for pain determination at needle insertion, during delivery of anesthetic solution, immediately after injection, and at the end of the periodontal procedure. Each patient's preference for the delivery system of future injections was also recorded. RESULTS: Patients reported significantly lower anxiety levels with CCLAD compared to the syringe. Significantly lower mean VAS scores for anesthesia deposition, pain immediately after, and at the end of the periodontal procedure were also noted. However, pain at needle insertion was comparable between the two systems, with no statistical significance. Overall, 64.4% patients preferred CCLAD for future anesthesia. CONCLUSION: Lower pain perceived with CCLAD and higher preference for the system suggest that CCLAD should replace conventional syringes to allow pain-free dental treatment.

Hypersensitivity Reaction to Perioperative Drug Mistaken for Local Anesthetic Systemic Toxicity in a Patient under Brachial Plexus Block / 고신대학교의과대학학술지

Perioperative anaphylaxis, although rare, is a severe, life-threatening unexpected systemic hypersensitivity reaction. Simultaneous administration of various drugs during anesthesia, the difficulty of communicate with patients in sedation and anesthesia, and coverage of the patient with surgical drapes are considered to be factors that impede early recognition of anaphylactic reactions. It is very important to perform an intradermal skin test because antibiotics are the most common cause of perioperative anaphylaxis. We report a case of negative-intradermal skin test antibiotic anaphylaxis mistaken for local aesthetic systemic toxicity without increase of serum tryptase for confirmative diagnostic biomaker during surgery under brachial plexus block. It is not possible to exclude the danger of anaphylaxis completely, even if it is negative-intradermal skin test and normal tryptase level. Therefore, anesthesiologists should be closely monitored and treated early for antibiotics related hypersensitive reaction, like other medicines during anesthesia.

Sorption of Local Anesthetics by Fat Emulsion with Different Content of Lipid / 医药导报

Objective To research sorption of local anesthetic by fat emulsion with different content of lipid in vitro and then to discuss the mechanism of action of fat emulsion for treatment of local anesthetic toxicity. Methods 10%,20%,30% fat emulsion was added to the bupivacaine hydrochloride and ropivacaine hydrochloride.After the mixture was vortexed for 10 mins,it was vibrated in thermostatic water bath at 37 ℃ for 15 h,then centrifugated and got the aqueous phase to HPLC test.The chromatography was carried on a C18column(4.6 mm×250 mm,5 μm ),the mobile phase was composed of acetonitrile-natrium biphosphoricum(25:75),the flow rate was 1 mL·min-1,the column temperature was 30 ℃ and the detection wavelength was set at 210 nm. Results Under the condition of this test,the linear ranges and linear equations for bupivacaine hydrochloride and ropivacaine hydrochloride were 0.3-3.0 μg·mL-1,Y=0.093 6X-0.017 3(r=0.999 6),and 0.3-3.0 μg·mL-1,Y=0.086 6X-0.022 3(r=0.999 1) respectively.The lowest limit of quantitation were both 0.05 μg·mL-1(S/N>3),and the ingredients showed good relationships between the peak area and the concentration.Sample reproducibility was good because the test sample was stable in 5 h.The extraction rates of bupivacaine hydrochloride by 10%,20%,30% fat emulsion were 46.0%,70. 4%,89.2% respectively.The extraction rates of ropivacaine hydrochloride by 10%,20%,30% fat emulsion were 51.3%,71.6%, 90.7% respectively. Conclusion Electric potential and the pH value of the 10%,20%,30% fat emulsion are similar,while the particle size increase slightly.Free bupivacaine hydrochloride and ropivacaine hydrochloride can be absorbed and with the increase of fat content,the extraction of local anesthetic is increased.The mechanism of action of fat for the treatment of local anesthetic toxicity maybe related to that fat emulsions can provided lipid,so that the excessive local anesthetic or those which had already distributesd in tissue can re-dispersed in lipid,and then the plasma concentration of local anesthetic is reduced,the toxicity is also reduced.

Assessment of patient's anxiety and expectation associated with hemodynamic changes during surgical procedure under local anesthesia / Avaliação da ansiedade e da expectativa do paciente associadas às alterações hemodinâmicas durante procedimento cirúrgico sob anestesia local

Introduction: The dental patient's anxiety and expectation may significantly alter their vital signs. The use of local anesthetics associated with a vasoconstrictor may also alter the vital signs of these patients, promoting hemodynamic changes that may result in emergency situations. Objective: To evaluate the influence of anxiety of patients submitted to third molar extraction and the use of different anesthetic substances with adrenaline on their vital signs (oxygen saturation, heart rate, and systolic and diastolic blood pressure) in different moments. Material and method: Forty patients answered the questionnaire of the Dental Anxiety Scale (Corah's Scale) and fear (KleinKnecht's Scale) and were submitted to third molar extraction in two surgical times for the use of articaine or mepivacaine, both associated with adrenaline. The results were analyzed by ANOVA followed by Tukey post hoc test, Student's t test, and Pearson's correlation coefficients (α=0.05). Result: There was no significant differences in saturation or heart rate. The blood pressure showed significant variations during time for both anesthetics, however mepivacaine resulted in a longer postoperative time to restore blood pressure. Patients with high or moderate anxiety and high fear index were those who had positive correlations with the highest blood pressure values. Conclusion: Anxiety and fear positively influence the increase in blood pressure. Mepivacaine promoted a greater resistance to the return of normal vital signs, especially blood pressure levels.

Introdução: A ansiedade e a expectativa do paciente odontológico podem alterar de forma significativa seus sinais vitais. Da mesma forma, o uso de anestésico local associado a um vasoconstrictor também alteram os sinais vitais desses pacientes, promovendo alterações hemodinâmicas que podem resultar em situações de emergência. Objetivo: Avaliar a influência da ansiedade de pacientes submetidos à exodontia de terceiros molares e do uso de diferentes substâncias anestésicas com adrenalina sobre seus sinais vitais (saturação de oxigênio, pulsação e pressão arterial sistólica e diastólica) em diferentes momentos operatórios. Material e método: Quarenta pacientes responderam os questionários da Escala de Ansiedade Dentária (Escala de Corah) e de medo (Escala de Kleinknecht) e foram submetidos à exodontia dos terceiros molares em dois tempos cirúrgicos para utilização de articaína ou mepivacaína, ambos associados com adrenalina. Os resultados obtidos foram analisados por ANOVA seguido do teste post hoc de Tukey, t de Student e coeficientes de correlação de Pearson (α=0,05). Resultado: Não houve alteração significativa na saturação nem na frequência cardíaca. A pressão arterial apresentou variações significantes nos tempos aferidos para os dois anestésicos, entretanto a mepivacaína resultou em maior tempo de pós-operatório para o restabelecimento da pressão arterial. Os pacientes com muita ou moderada ansiedade e alto índice de medo foram os que tiveram correlações positivas com os maiores números pressóricos aferidos. Conclusão: A ansiedade e medo influenciam positivamente no aumento da pressão arterial. A mepivacaína promoveu uma maior resistência ao retorno da normalidade dos sinais vitais, especialmente dos níveis pressóricos.