Anxiety and pain related to mandibular block injections: comparison of self-reported measures and physiological response.

OBJECTIVE: The aim of this study was to determine whether patients with a pain score ≥7 (high pain group) after a mandibular block injection had a higher physiologic response compared with patients with scores <7 (low pain group). STUDY DESIGN: Before oral surgery, patients (n = 66) filled out questionnaires to measure anxiety and expected pain. The questionnaires also assessed patients' experiences with dental injections and dental anxiety, as well as their emotional state and intensity of anxiety. Before, during, and after the injection, physiologic responses were measured by using Nexus-10. Patients were then asked about the pain and anxiety they had experienced. RESULTS: The mean score for pain experienced was 3.45 (standard deviation 2.17) on an 11-point rating scale. Eight patients (12.1%) experienced high injection pain. There was a significant increase in mean sweat secretion and a significant decrease in mean respiration between the relaxing phase and the injection phase. There was a significant positive relationship between experienced anxiety and mean heart rate during the injection phase. No significant difference in physiologic response was found between patients who experienced high pain and those who experienced low pain. CONCLUSIONS: Reported pain was not associated with the physiologic response of patients receiving mandibular block injections.

Pediatric post-traumatic headaches and peripheral nerve blocks of the scalp: a case series and patient satisfaction survey.

OBJECTIVE: This study's objective is to characterize the therapeutic effect of peripheral nerve blocks of the scalp for children and adolescents with post-traumatic headaches. BACKGROUND: Headaches are the most frequently reported persistent symptoms following a pediatric mild traumatic brain injury, may be challenging to treat, and can transform into debilitating chronic headaches. The beneficial use of peripheral nerve blocks of the scalp has been reported for adults with post-traumatic headaches. METHODS: Retrospective case series on all patients <18 years of age treated between January 2012 and June 2013 in the mild traumatic brain injury clinic with a nerve block. The main outcome measure was the proportion of patients with a good therapeutic effect, defined by the duration of the block being >24 hours and/or repeat blocks requested. A data extractor blinded to main outcome measures performed the chart review. A patient satisfaction survey was also sent to all patients to assess the recalled experience with the interventions received. RESULTS: A total of 62 nerve blocks were performed on 28 patients for 30 injuries that led to post-traumatic headaches. The mean (standard deviation) age was 14.6 (1.7) years. The first nerve blocks were performed a mean (standard deviation) of 70 (54.2) days post-injury. The therapeutic effect was good in 93% of patients with 71% reporting immediate complete relief of their headaches; the mean percent headache reduction was 94%. Most (91%) would recommend a nerve block for post-traumatic headaches. CONCLUSION: The ease with which peripheral nerve blocks of the scalp can be performed combined with the immediate relief experienced by patients makes them a potential addition to the armamentarium of headache management strategies for children and adolescent with post-traumatic headaches.

Assessment of general pre and postoperative anxiety in patients undergoing tooth extraction: a prospective study.

Our aim was to analyse the amount of anxiety and fear felt before, immediately after, and one week after, dental extraction. We studied 70 patients (35 men and 35 women (mean (SD) age 43 (±10) years), who were listed for dental extraction under local anaesthesia in a private clinic that specialised in oral surgery. Patients were evaluated on 3 consecutive occasions: immediately preoperatively, immediately postoperatively, and 7 days later. Each patient's anxiety was measured using Spielberger's State-Trait Anxiety Inventory (Spanish version), the Modified Corah Dental Anxiety Scale (MDAS) and the Dental Fear Survey. There were significant differences in the STAI-Trait scale between before and 7 days after extraction (p=0.04), and in the MDAS between before and immediately after extraction (p=0.02), and between immediately after and 7 days after extraction (p=<0.001). The DFS also differed between before and immediately after extraction (p=0.002), and between immediately and 7 days after extraction (p<0.001). Dental anxiety immediately after tooth extraction may be influenced by operative techniques (type of anaesthesia, duration of operation, or position of tooth extracted), but anxiety at 7 days after extraction is not.

Are patients satisfied after peripheral nerve blockade? Results from an International Registry of Regional Anesthesia.

INTRODUCTION: Peripheral nerve blockade (PNB) is associated with superior outcomes compared with opioids; however, little is known regarding patients' perceptions of the care they have received. Patient satisfaction is emerging as an important indicator of quality of health care, and identifying deficiencies in discrete aspects of satisfaction may allow targeted interventions to improve quality. In this study, we analyze data relevant to patient satisfaction from the International Registry of Regional Anesthesia. The primary objective of this analysis was to report the results of a patient-satisfaction questionnaire and to determine predictors associated with unwillingness to have PNB repeated in the case of future surgery. METHODS: The questionnaire used in this study was derived from this registry's results and from previously validated questionnaires and addressed 3 domains of importance, namely, provision of information, pain, and interaction with the anesthesiologist. The 11-item written, multidimensional questionnaire was given to patients within 2 days postoperatively. The primary outcome was willingness to have PNB repeated in the event of future similar surgery. RESULTS: Data related to 9969 surgical procedures were collected between July 1, 2011, and March 31, 2013. The survey response rate was 61.6%. Most respondents-94.6% (95% confidence interval, 94.0%-95.1%)--stated that they were willing to have a repeat PNB. Ninety percent of respondents were satisfied or completely satisfied with the information provided about the nerve block, as well as the anesthesiologist-patient interaction. Patients who were dissatisfied with either of these domains (ie, information provision or professional interaction) were less willing to undergo repeat PNB, as were patients who reported significant pain during the nerve block procedure. CONCLUSIONS: A high proportion of survey respondents were willing to undergo repeat PNB in case of future surgery and were satisfied with their anesthetic care. Targeted interventions to improve quality of PNB should be aimed at improving comfort, information provision, and physician-patient interaction.

A qualitative analysis of parturients' perspectives on neuraxial labor analgesia.

BACKGROUND: The decision to use, or not use, neuraxial analgesia is complex and likely multi-factorial. The objectives of this study were to understand parturients' concerns about neuraxial analgesia, and the reasons for not anticipating the use of neuraxial analgesia using qualitative methodology. METHODS: English-speaking, term parturients, who had not requested or received labor analgesia, were recruited for this mixed-methods study. In addition to a quantitative survey, the results of which have been published elsewhere, women were asked open-ended questions regarding concerns about neuraxial analgesia and reasons for not anticipating its use. Answers were recorded verbatim and analyzed using qualitative methodology. RESULTS: Interviews were conducted with 509 women. Thirty-nine percent of patients expressed some concern about neuraxial analgesia. These concerns were thematically represented by misunderstandings about neuraxial analgesia, general fears about the procedure, and lack of trust in providers. Many of the concerns were misunderstandings that were not supported by the medical literature. Of the 129 patients who did not anticipate using neuraxial analgesia, 23% stated that this was because they desired a natural childbirth and/or control over their labor experience, whereas 46% cited concerns about the procedure and its complications as the basis for their decision. CONCLUSION: Many women who anticipate not using neuraxial analgesia may be basing their decision on an inaccurate understanding of the risks of the procedure. Improved patient education and counseling that target specific areas of concern may address these misunderstandings.

Pain related to mandibular block injections and its relationship with anxiety and previous experiences with dental anesthetics.

OBJECTIVE: Anesthetic injections should reassure patients with the prospect of painless treatment, but for some patients it is the main source of their fear. We investigated pain resulting from mandibular block injections in relation to anxiety and previous experience with receiving injections. STUDY DESIGN: Patients (n = 230) filled out questionnaires before oral surgery. They were then asked to raise their hand when they felt pain as a result of the injection. The injection was administered, and pain intensity (11-point numeric rating scale) and pain duration (in seconds) was measured. RESULTS: In general, patients expected (mean 4.2, SD 2.7) significantly more pain than they experienced (2.4 ± 2.2). About 8.3% of patients reported a score in the range of 7 to 10. On average, pain lasted for 6.2 seconds (range 1-24.5 s), ≈ 36% of patients raised their hand for ≤ 2 seconds, and 14.6% raised their hand for ≥ 10 seconds. Pain was significantly positively associated with anxiety and the way previous injections were experienced. CONCLUSIONS: Mandibular block injections can be considered to be mildly painful, with pain lasting only a few seconds. The pain experience of a mandibular block seems only partly dependent on experienced anxiety and previous experiences with receiving injections.

Continuous at-home postoperative analgesia using a catheter in the case of hand surgery: preliminary study about 40 cases.

In hand surgery, ever since continuous at-home postoperative analgesia (CPA) was implemented, procedures which cause pain for more than 24h can now be performed in ambulatory surgery. The aim of our work was to study the feasibility of CPA. Our series comprised 40 patients with a mean age of 50 years. Twenty-four patients had an ASA score of 1 and 16 patients had an ASA score of 2. Indications were osteoarthritis and rheumatoid diseases. Three steps were involved: preoperative (patient screening and information), peroperative (placement of a peripheral nerve catheter through an axillary approach using an elastomeric device) and postoperative (at-home patient care provided by visiting nurses). Evaluation was rated using a CPA score (0 to 10) based on analgesia quality and network organization data. The global CPA score was 1.85. The quality of analgesia (2.6) scored less than the quality of organization (1.1). In the case of analgesia, sleep obtained the lowest score, followed by pain, and lastly, unwanted events. As far as organization was concerned, the network obtained the lowest score, followed by patient satisfaction, and lastly, patient information. Problems were encountered due to insufficient nurse training, analgesia failures, as well as unwanted events related to the oral antalgic treatment. However, technical success was almost always achieved. Our results show that the indications for ambulatory surgery could be extended and hospital-private practice networks be further developed. CPA appears to be a promising technique for analgesia and ambulatory surgery.

[External dacryocystorhinostomy under local anesthesia and sedation]. / Les dacryocystorhinostomies par voie externe sous anesthésie locale et sédation.

INTRODUCTION: External dacryocystorhinostomy (DCR) surgery is highly advantageous in that it can be performed under local anesthesia associated with sedation. We aimed at verifying the efficiency of the anesthesia, studying the general behavior of the patient and the quality of the surgery. PATIENTS AND METHODS: A prospective study of a local anesthetic protocol associated with sedation was conducted in our Oculoplastic Department on 34 patients (71.5+/-8.3 years of age) between may 2007 and march 2008. The anesthetic protocol consisted of blocking four nerves based on the analysis of the anatomy of facial innervation. The including criteria were patient antecedents such as arterial hypertension, cardiac or lung problems, diabetes, and no contraindications for local anesthesia. The hemodynamic constants, variability of the Ramsay score, and complications such as bleeding or pain were studied. The progress of the surgery was simultaneously evaluated by the patients, anesthesiologists, and surgeons. RESULTS: Both the hemodynamic constants and the Ramsay score remained stable intra- and postoperatively. In addition, the visual analog scale (VAS) scores remained low. Both surgeon and patient satisfaction was excellent (88.4 % of the patients declared that they were ready to choose the same anesthetic protocol if new surgery were to be performed). The surgery's success rate was 79.3 % (no watering at 3 months) versus 82 % for the patients operated under general anesthesia. CONCLUSION: The protocol of local anesthesia associated with sedation for external DCR is therefore safe and efficient.

Comparison of methods of local anaesthesia used for cataract extraction.

This paper will discuss the various techniques used for the instillation of local anaesthetics (LA) during intraocular (10) cataract extraction. It will be limited to a comparison of peribulbar block, sub-Tenons block and topical plus intracameral anaesthesia alone, as these are those most frequently used at the author's place of work. It will focus on both the surgeons' preferences and the patients' perceptions and comfort pre-, peri- and postoperatively. A description of each technique and the drugs available will be followed with a discussion of the patients' perceptions and pain levels. Included will be a summary of the patients' anxiety levels and the benefits of any sedation. Throughout, general and specific complications will be debated. All will be supported by current, relevant literature.

Randomized comparison of the single-injection volar subcutaneous block and the two-injection dorsal block for digital anesthesia.

BACKGROUND: Two commonly used methods of digital nerve block with local anesthetic are the two-injection dorsal technique and the single-injection volar subcutaneous technique. The authors compared these two digital block techniques with respect to local anesthetic injection pain and recipient preference of anesthetic technique. METHODS: Twenty-seven volunteers had the long finger of each hand injected with 2% lidocaine with 1:100,000 epinephrine. The two-injection dorsal method was used on one long finger and the other long finger received the volar single-injection technique. Volunteers completed a pain scale for each block and were then asked which technique they would prefer. The area of anesthetic skin was assessed in each finger by pinprick testing, and photographs were taken. RESULTS: Although there was a lower pain score for the volar single-injection block, the difference in pain scores between the two techniques was not statistically significant. However, 22 of the 27 subjects indicated that they would select the volar over the dorsal block if a future block was required, and this preference for the volar block was statistically significant. CONCLUSIONS: Although the difference in pain scores between the two techniques was not statistically significant, volunteers who received both blocks would prefer the volar single-injection subcutaneous block if given a choice. Therefore, the single-injection volar subcutaneous block is recommended as the technique of choice for anesthesia of the digit, except in patients for whom anesthesia over the dorsum of the proximal phalanx is required. These patients may prefer a supplementary dorsal nerve block or a traditional two-injection block.

Assessment of a palatal approach-anterior superior alveolar (P-ASA) nerve block with the Wand in paediatric dental patients.

OBJECTIVES: The purposes of the study were to compare the reaction of children while receiving local anaesthesia for anaesthetizing maxillary incisors with a computerized device Wand: a periodontal ligament injection (PDLi) and a palatal approach-anterior superior alveolar (P-ASA) nerve block compared with a conventional buccal infiltration (CBi), and to assess the efficacy of the anaesthesia and children's reaction after treatment. METHODS: One hundred and thirty-eight children aged 24-48 months participated in this study. RESULTS: More children reacted negatively during injection while receiving the CBi and positively during the injection with the Wand. After treatment, significantly more children scratched the upper lip and/or the nose or complained of numbness of the region after the CBi (P = 0.000). CONCLUSIONS: Same effectiveness was achieved with the Wand and the CBi. Children displayed better behaviour during injection when they received local anaesthesia with the WanD than they did when the CBi was used. They did not scratch the upper lip/nose and/or cried after treatment when they received the PDLi and the P-ASA, whereas they did when receiving a CBi.

Bradycardia and hypertension in anticipation of, and exacerbated by, peribulbar block: a prospective audit.

BACKGROUND: Changes in heart rate (HR), systolic arterial pressure (SAP) and diastolic arterial pressure (DAP) occur in anticipation of, and following, injection of a peribulbar local analgesic agent. We examined these changes in two groups of awake patients given a pre-medication of either hydroxyzine 1.0 mg/kg alone (control) or hydroxyzine 1.0 mg/kg with morphine 0.05 mg/kg. METHODS: HR, SAP and DAP of 100 patients per group were monitored the day before surgery (baseline), every 5 min in the anesthesia holding room before peribulbar injection, every minute for the first 5 min after peribulbar injection and then every 5 min until transfer to the operating room. Within and between pre-medication group values of HR, SAP and DAP before and after peribulbar injection were compared with baseline. RESULTS: The two groups of patients were similar. Before peribulbar injection, HR was unchanged in the hydroxyzine group, but 6% slower in those given morphine (P<0.01). After injection, HR slowed in both groups, by 5% and 7% (P<0.01, both comparisons), respectively. In anticipation of injection, SAP increased in both groups to 20% and 16% above baseline, respectively, and increased further after injection to 26% and 24% above baseline, respectively (P<0.001, all comparisons). In both groups, maximum SAP following injection exceeded maximum SAP before injection (P<0.02, both comparisons). DAP increased by 4% (P<0.05) in the hydroxyzine group before injection, and by 5% and 4%, respectively (P<0.005 and P<0.05, respectively) after peribulbar injection. CONCLUSION: The audit reveals pronounced increases in SAP accompanied by lesser increases in DAP and a tendency to slowing of HR in awake patients in anticipation of peribulbar injections. Peribulbar injections cause further increases in blood pressure and mild bradycardia. These changes occur similarly in patients pre-medicated with hydroxyzine or hydroxyzine plus morphine. A mix of neuro-humoral influences (anxiety/catecholamine/baroreceptor/trigemino-vagal) are postulated as etiological.

Danish dentists' knowledge, attitudes and management of procedural dental pain in children: association with demographic characteristics, structural factors, perceived stress during the administration of local analgesia and their tolerance towards pain.

OBJECTIVE: The aim of the present study was to describe Danish dentists' knowledge of, attitudes towards and management of procedural pain during paediatric dental care, and to assess the importance of demographic characteristics, structural factors, perceived stress during administration of local analgesia and the dentists' own tolerance towards procedural dental pain. DESIGN: A cross-sectional questionnaire study was conducted in Denmark in May 2001. SUBJECTS AND METHODS: The subjects were a random sample of 30% of Danish dentists treating children. Usable information was obtained from 327 (80.3%) of the dentists in the sample. RESULTS: One-quarter of the respondents answered that a 3-5-year-old child could report pain only with uncertainty. More than 80% of the dentists stated that they never compromised on painlessness. Very few agreed to the statement that children forget pain faster than adults. One-third agreed to, or were neutral to, the statement that all restorative care in primary teeth could be performed painlessly using N2O-O2 sedation alone. The majority of the respondents reported using three or more methods to assess the effect of their pain control methods. Almost 90% reported using local analgesia for restorative work 'always' or 'often'. A similar proportion reported using topical analgesia before injection 'always' or 'often'. Administering a mandibular block to preschool children was the procedure perceived as the most stressful (33.6%) pain control method. Demographic factors (gender), structural factors (always working alone and treating 3-5-year-old children daily), perceived stress during the administration of a mandibular block in preschool children and the dentists' own willingness to accept potentially painful dental treatment without local analgesia were associated with knowledge of, attitudes towards and management of procedural dental pain in children. CONCLUSIONS: Danish dentists treating children demonstrate concern about procedural dental pain in children. Factors amenable to change via training and reorganization into larger clinical units seem to determine their knowledge of, attitudes towards and management of procedural dental pain in children.

Analgesia and effectiveness of levobupivacaine compared with ropivacaine in patients undergoing an axillary brachial plexus block.

A common anesthetic technique for the upper extremity is local brachial plexus anesthesia using levobupivacaine and ropivacaine. To our knowledge, no study has been performed measuring differences in analgesic efficacy and latency when these local anesthetics are used for brachial plexus anesthesia. We enrolled 54 adults, assessed as ASA class I or II, into this double-blind, prospective investigation to receive 40 mL of 0.5% ropivacaine or levobupivacaine with 1:200,000 epinephrine. Pain was assessed using a 0 to 10 verbal numeric rating scale (VNRS). Motor blockade was determined using a modified Bromage scale. Variables included analgesic duration, latency, and overall patient satisfaction. The ropivacaine group had significantly higher VNRS scores at the 8th (P= .001) and 10th (P = .003) postoperative hours. The duration of sensory analgesia was significantly longer in the levobupivacaine group (831 minutes) than in the ropivacaine group (642 minutes, P = .013). Return of motor activity was significantly faster in the ropivacaine group (778 minutes) than in the levobupivacaine group (1,047 minutes; P = .001). No other significant differences were noted between the groups. When considering levobupivacaine and ropivacaine for brachial plexus anesthesia, levobupivacaine should be considered when postoperative analgesia is a concern but not when an early return of motor activity is required.

The addition of clonidine to bupivacaine in combined femoral-sciatic nerve block for anterior cruciate ligament reconstruction.

Clonidine has been shown to prolong sensory analgesia when given as an adjunct to peripheral nerve blocks but has not been evaluated when given in conjunction with a femoral-sciatic nerve block. The purpose of this investigation was to determine whether the addition of clonidine to a femoral-sciatic nerve block would prolong the duration of sensory analgesia in groups of patients undergoing anterior cruciate ligament (ACL) reconstruction. This prospective, randomized, double-blind investigation was performed on 64 subjects undergoing ACL reconstruction. Patients were assigned randomly to receive a femoral-sciatic nerve block using 30 mL of 0.5% bupivacaine with 1:200,000 epinephrine (control group) or 30 mL of 0.5% bupivacaine with 1:200,000 epinephrine and 1 microg/kg of clonidine (experimental group). Variables measured included demographics, timed pain intensity measurements, postoperative analgesic consumption, duration of analgesia, and patient satisfaction. No significant differences were noted between groups for pain intensity scores, duration of sensory analgesia, postoperative analgesic requirements, or overall patient satisfaction. Both groups reported minimal amounts of postoperative pain and high analgesic satisfaction scores. Based on our results, we do not recommend the addition of clonidine to a femoral-sciatic nerve block when given to facilitate postoperative analgesia in patients undergoing ACL reconstruction.

Therapeutic selective nerve root block in the nonsurgical treatment of traumatically induced cervical spondylotic radicular pain.

OBJECTIVE: To investigate the outcomes resulting from the use of fluoroscopically guided therapeutic selective nerve root block in the nonsurgical treatment of traumatically induced cervical spondylotic radicular pain. DESIGN: Retrospective study with independent clinical review. A total of 15 patients who met specific physical examination or electrodiagnostic criteria and failed to improve clinically after at least 4 wks of physical therapy were included. Each patient demonstrated a positive response to a fluoroscopically guided cervical selective nerve root block. Therapeutic selective nerve root blocks were administered in conjunction with physical therapy. Outcome measures included visual analog scale pain scores, employment status, medication usage, and patient satisfaction. RESULTS: Patients' symptom duration before diagnostic injection averaged 13.0 mos. An average of 3.7 therapeutic injections were administered. Follow-up data collection transpired at an average of 20.7 mos after discharge from treatment. An overall good or excellent outcome was observed in three patients (20.0%). Among those treated without surgery, a significant reduction (P = 0.0313) in pain score was observed at the time of follow-up. Six patients (40.0%) proceeded to surgery. CONCLUSIONS: These initial and preliminary findings do not support the use of therapeutic selective nerve root block in the treatment of this challenging patient population with traumatically induced spondylotic radicular pain.

Patients' experiences with multiple stimulation axillary block for fast-track ambulatory hand surgery.

BACKGROUND: Ambulatory axillary block by multiple nerve stimulation (MNS) is effective and time efficient, but may be rejected by patients because of block pain. This prospective study assessed patients' anxiety and acceptance of this block, identified which of the components of blocking procedure is most painful (i.v. line insertion, repeated needle passes, local anesthetic injection, or electrical stimulation) and recorded patients' anesthetic preferences for the future hand surgery. METHODS: Upon arrival at the day unit, 100 unpremedicated adult patients without previous experience of peripheral nerve stimulation indicated on the visual analog scale (VAS; 0-100) their anxiety about the block. The blocking procedure was then explained step-by-step. After inserting the i.v. line and freezing the skin in axilla, four terminal nerves (musculocutaneous, median, ulnar, radial) were electrolocated using an initial current of 2 mA and a target current of 0.1-0.5 mA. Pain caused by the individual components of blocking procedure was assessed on VAS before the start of surgery. On the day after the operation, the patients reassessed their anxiety for the next axillary block and indicated which anesthetic method (block alone, block plus sedation, or general anesthesia) they would prefer for the future hand surgery. RESULTS: Before the block, 59 patients admitted being anxious about regional block (median anxiety VAS=27), compared with 42 patients (anxiety VAS=10) postoperatively: P<0.01. Median intensity of electrical stimulation pain was significantly higher (VAS=16) than pain of local anesthetic injections (VAS=8), i.v. line insertion (VAS=6) and multiple needle passes (VAS=5). However, only 53 patients categorized electrolocation as painful. Twenty-seven reported discomfort but not pain, and 20 patients described the sensation as 'funny' or 'strange'. None of the patients had surgical pain during operation. Mean duration of surgery was 77 min, and of hospital stay 166 min. Ninety-eight patients would choose the same block for the future hand surgery, 13 of which would like sedation before the block, and two patients did not wish to be awake during any surgery. Ninety-five patients were satisfied with fast-tracking. CONCLUSIONS: Fear of block pain is diminished after experiencing the blocking procedure. Electrical stimuli was perceived as painful by 53% of patients, and this pain was more intense than with other block components. The majority of our patients would choose axillary block without sedation for future hand surgery and are satisfied with fast-tracking.