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Equine practitioners frequently inject local anaesthetics (LA) intra‐articularly in both diagnosis of lameness and for pain management intra‐ or post‐operatively with synovial endoscopy. Recent reviews of the human and veterinary literature support the concept that chondrotoxicity of LA on joint tissues depends on the type of drug, dose administered, and duration of exposure. The purpose of this review is to summarise the current literature describing intra‐articular local anaesthetic use, including both in vitro and in vivo studies, and to draw some comparisons to literature from other species where potential toxicity and duration of effect have been evaluated with the goal of advancing the field's understanding of intra‐articular local anaesthetic use in horses, and indicating future directions for the field. The aggregate data available from all species, while generally sparse for horses, indicate that LA are rapidly cleared from the synovial fluid after injection, often within 30 min. In vitro data strongly suggest that lidocaine and bupivacaine are likely more chondrotoxic than other LA, although to what extent is still unknown, and cytotoxicity of LA may be mitigated through concurrent injection with HA, PRP, and drug combinations including nonsteroidal anti‐inflammatories and opioids. The current body of in vitro research is not reflective of the in vivo environment, and further in vitro work, if performed, should focus on mimicking the native joint environment, utilising PK data and joint/injection volumes to replicate the native environment more accurately within the joint and the expected exposures to LA. [ABSTRACT FROM AUTHOR]

Purpose: Inguinal hernia repair remains one of the most common elective general surgical procedures. Previous studies have suggested high rates of chronic pain afterwards. The aim of this study was to evaluate changes in quality of life after local anaesthetic (LA) inguinal hernia surgery performed in a primary care setting. Methods: Quality of life (QoL) was measured in all patients both pre-operatively and at 6-months post-operatively using the European Hernia Society Scoring tool. Data was analysed by tertile grouping according to initial symptom score. Results: 497 patients filled out pre-operative QoL forms between June 2020 and May 2022. Post-operative QoL scores were received from 179 patients (164 male (91.6%)). Median pre-operative score was 33 (IQR 20–48). Median post-operative score was 4 (IQR 1–11). Mean improvement in QoL score was 27.8. Nine patients had a worse score at 6-months compared to pre-op (5%). When the data was analysed by pre-op QoL group as expected the low symptom group (score 0–10) had minimal improvement in QoL (0.23) and 5 out of 13 patients (38%) had a worse score. The medium group (score 11–40) had a mean improvement in QoL of 17.25 with 3 out of 92 (3.2%) experiencing a worse score. The high symptom group (score 41–90) had a mean improvement in QoL of 45.4 with only 1 of 76 (1.3%) experiencing a worse score. Conclusions: LA Inguinal hernia repair improves QoL substantially 6-months after surgery. However, in those patients with low pre-operative scores (< 11) the gain is minimal and rates of chronic symptoms following surgery are very high. We recommend avoiding surgery in this group and instead adopting a surveillance approach. [ABSTRACT FROM AUTHOR]

Background: Local anaesthesia (LA) is frequently used in the Emergency Department (ED). Local anaesthetic systemic toxicity (LAST) is a potentially fatal complication associated with its use. It is assumed that all doctors administering LA are trained in all aspects of its use including the management of LAST. Methods: A prospective, multicentre cross-sectional study was conducted at three academic EDs in Gauteng. Doctors working in the ED completed an online questionnaire designed to assess knowledge, attitudes and practices regarding the use of LA as well as the recognition and management of LAST. Results: A total of 94 completed questionnaires were analysed. Of these, 44% of participants had graduated from medical school less than 5 years ago, and 72% had less than 5 years of experience working in the ED. The overall mean knowledge score percentage for the safe use of LA was 48.2%. The overall mean knowledge score percentage for recognition and management of LAST was 56.7%. A total of 78% of participants knew that intravenous intralipid emulsion (ILE) therapy is needed in managing LAST; however, only 25% of participants knew where to access ILE and only 33% knew how to use it. Conclusion: The overall level of knowledge on LA and the management of LAST among doctors working in the ED is low. There is also an apparent lack of awareness of the potential for toxicity despite frequent use of LA. Although the occurrence of LAST is rare, our findings highlight an obligation for continuous education on local anaesthesia and the management of LAST. Contribution: The result of this research indicates a gap in training regarding the potential for toxicity of local anaesthesia, recognition of systemic toxicity, and the management thereof. These findings suggest the possibility of misdiagnosis and under reporting of LAST.

Abstract Background Rezūm™ is a relatively new bladder outflow obstruction (BOO) procedure that uses thermal energy through water vapour to cause necrosis of prostatic tissue. The standard delivery of this treatment is in an operating theatre under a general or spinal anaesthetic, or under local anaesthetic with sedation that requires patient monitoring. Methods We propose an outpatient daycase method of delivering Rezūm™ under local anaesthetic without sedation, using a prostatic local anaesthetic block and cold local anaesthetic gel instillation into the urethra. Results Preliminary results of our first thirteen patients demonstrate the feasibility of this new technique, with a mean pain score of 2.1 out of 10 on a visual analogue scale, a successful trial without catheter in all 13 patients (one patient voided successfully on second trial), a reduction in mean International Prostate Symptom Score (IPSS) from 20.6 to 5.4, and improvement in maximum flow from 8.8 ml/s to 14.4 ml/s. The complications were minor (Clavien-Dindo less than III) and included a UTI, minor bleeding not requiring admission, and retrograde ejaculation. Conclusions We demonstrate that an outpatient local anaesthetic daycase service without sedation is feasible. This can be delivered in a clinic setting, reduce waiting times for BOO surgery, and increase availability of operating theatre for other general anaesthetic urological procedures.

Introduction: Apart from general anaesthesia, brachial plexus block by the axillary approach is one of the reliable sole anaesthetic techniques for patients undergoing upper limb surgeries. In this study, levobupivacaine was chosen due to fewer adverse effects compared to Bupivacaine, and fewer studies were available for the axillary approach to brachial plexus block. Adjuvants were added to hasten the onset and also to prolong their analgesic effect. Aim: To compare the effect of Dexmedetomidine (D) 0.5 mcg/kg and Fentanyl (F) 0.5 mcg/kg when added to 0.5% Levobupivacaine (L) as an adjuvant in brachial plexus block by the axillary approach for upper limb surgeries. Materials and Methods: A randomised double-blind controlled study was carried out at the Department of Anaesthesiology, Sree Balaji Medical College, BIHER, Chennai, Tamil Nadu, India from January 2020 to October 2021 on 60 American Society of Anaesthesiologists (ASA) I and II patients of either sex posted for various types of upper limb surgeries. Subjects were divided into two equal groups by computer-generated randomisation. Group A received 0.5% levobupivacaine and dexmedetomidine 0.5 mcg/kg, and Group B received 0.5% levobupivacaine and Fentanyl 0.5 mcg/kg. Both patients and the evaluator were unaware of the type of adjuvants added to the local anaesthetic. The onset time, duration of sensory and Motor blockade were recorded. Haemodynamic variables and duration of analgesia were recorded for 24 hours postoperatively. The Mann-Whitney U test demonstrated variations in the onset and duration of sensory and motor blocks. Adverse effects, including nausea, vomiting, and hypotension, exhibited significant differences according to Fisher’s-exact test. Results: Age and weight distributions were comparable between groups (mean age: Group A=45.20 years, Group B=44.80 years; mean weight: Group A=74.13 kg, Group B=74.43 kg). Group A exhibited faster sensory and motor block onset times (sensory: Group A=6.20 minutes, Group B=8.63 minutes; motor: Group A=8.27 minutes, Group B=10.00 minutes), longer block durations (sensory: Group A=11.63 hours, Group B=9.53 hours; motor: Group A=9.67 hours, Group B=8.20 hours), and required the first rescue analgesic (Group A=12.57 hours, Group B=10.27 hours) compared to Group B (p

Background: The most important problem in tonsillectomy is pain in the early postoperative period. Objective: We purposed to compare the effects of lidocaine, tetracaine, and articaine application to the peritonsillar bed on post-tonsillectomy pain in children. Methods: The prospective, placebo-controlled study included 80 patients, ages 3–14, who were scheduled for elective tonsillectomy. Patients were randomly divided into four groups. Group 1 received 0.9% NaCl; group 2 received 2% lidocaine; group 3 received 2% tetracaine; and group 4 received 4% articaine to the tonsillary bed for 5 min just after the operation. All patients were evaluated in terms of pain and pain-related adverse events in the postoperative 24 h. Results: All groups that used local anesthetics had significantly lower pain levels than the control group in the first eight hours (p <.001). Furthermore, the articaine group had a lower pain score than the tetracaine group at the eighth hour (p <.05). The articaine group had a lower pain score at the 16th hour than both the control and tetracaine groups (p <.05). There was no significant difference between the groups at the 24th hour (p >.05). Conclusion and significance: We recommend the immediate application of topical articaine to the tonsillar bed following the procedure to enhance postoperative pain management. [ABSTRACT FROM AUTHOR]

Introduction: Apart from general anaesthesia, brachial plexus block by the axillary approach is one of the reliable sole anaesthetic techniques for patients undergoing upper limb surgeries. In this study, levobupivacaine was chosen due to fewer adverse effects compared to Bupivacaine, and fewer studies were available for the axillary approach to brachial plexus block. Adjuvants were added to hasten the onset and also to prolong their analgesic effect. Aim: To compare the effect of Dexmedetomidine (D) 0.5 mcg/kg and Fentanyl (F) 0.5 mcg/kg when added to 0.5% Levobupivacaine (L) as an adjuvant in brachial plexus block by the axillary approach for upper limb surgeries. Materials and Methods: A randomised double-blind controlled study was carried out at the Department of Anaesthesiology, Sree Balaji Medical College, BIHER, Chennai, Tamil Nadu, India from January 2020 to October 2021 on 60 American Society of Anaesthesiologists (ASA) I and II patients of either sex posted for various types of upper limb surgeries. Subjects were divided into two equal groups by computer-generated randomisation. Group A received 0.5% levobupivacaine and dexmedetomidine 0.5 mcg/kg, and Group B received 0.5% levobupivacaine and Fentanyl 0.5 mcg/kg. Both patients and the evaluator were unaware of the type of adjuvants added to the local anaesthetic. The onset time, duration of sensory and Motor blockade were recorded. Haemodynamic variables and duration of analgesia were recorded for 24 hours postoperatively. The Mann-Whitney U test demonstrated variations in the onset and duration of sensory and motor blocks. Adverse effects, including nausea, vomiting, and hypotension, exhibited significant differences according to Fisher's-exact test. Results: Age and weight distributions were comparable between groups (mean age: Group A=45.20 years, Group B=44.80 years; mean weight: Group A=74.13 kg, Group B=74.43 kg). Group A exhibited faster sensory and motor block onset times (sensory: Group A=6.20 minutes, Group B=8.63 minutes; motor: Group A=8.27 minutes, Group B=10.00 minutes), longer block durations (sensory: Group A=11.63 hours, Group B=9.53 hours; motor: Group A=9.67 hours, Group B=8.20 hours), and required the first rescue analgesic (Group A=12.57 hours, Group B=10.27 hours) compared to Group B (p<0.05). Similarly, the mean time for the first rescue analgesia for patients among these two groups was also statistically significant (p<0.05). Conclusion: The addition of 0.5 mcg/kg dexmedetomidine to 0.5% levobupivacaine in axillary block was more effective in prolonging the duration of blockade and providing adequate intraoperative analgesia when compared to 0.5 mcg/kg fentanyl with 0.5% levobupivacaine, without producing any adverse events. [ABSTRACT FROM AUTHOR]

Objective: This review assessed the effectiveness of the nurse-led children's epistaxis clinic in streamlining patient care and avoiding unnecessary general anaesthesia. Methods: A retrospective case note review was conducted of children attending the nurse-led epistaxis clinic between 2019 and 2021. Results: A total of 718 children were seen over three years. Twelve (1.7 per cent) had a known coagulopathy. Of the children, 590 (82 per cent) had visible vessels and 29 (4 per cent) had mucosal crusting. Silver nitrate cautery was attempted under topical anaesthesia in 481 children, with 463 (96 per cent) successful cauterisations. Fifteen (3 per cent) were cauterised under general anaesthesia. Of the children, 706 (99 per cent) were prescribed nasal antiseptic preparations; this was the sole treatment for 58 (8 per cent). Blood investigations were requested for eight children (1 per cent) and haematology referral for three (0.4 per cent). Conclusion: This is the largest published series of children's nosebleeds. Given the short-lived benefit from cautery, it is suggested that general anaesthesia should not be offered routinely. However, improved haematology referral criteria are required to increase underlying diagnosis. [ABSTRACT FROM AUTHOR]

This document discusses the use of local anesthesia (LA) in reducing pain during rubber ring castration in lambs. The study found that administering LA 15 minutes before rubber ring application significantly reduced pain. However, on commercial sheep farms, it may not be practical to handle each lamb twice and wait 15 minutes between LA injection and ring application. Other studies showed that injecting LA immediately before or after ring application reduced pain behaviors in lambs over four weeks old. In lambs less than 8 days old, injecting LA at the time of ring placement significantly reduced painful behaviors and plasma cortisol levels. The document concludes that LA administered at the time of castration can effectively reduce pain in lambs. [Extracted from the article]

Background: The role of continuous wound infusion catheters as part of a multimodal analgesia strategy after Caesarean delivery is unclear. We introduced continuous wound infusion catheters to our multimodal analgesia regimen to evaluate the impact on analgesic outcomes after Caesarean delivery. Methods: After institutional review board (IRB) approval, a 4-month practice change was instituted as a quality improvement initiative. In addition to multimodal analgesia, continuous wound infusion catheters for up to 3 days were offered on alternate weeks for all women undergoing Caesarean deliveries. The primary outcome was postoperative in-hospital opioid consumption. Secondary outcomes were static and dynamic pain scores at 24 and 72 h, time until first analgesic request, opioid-related side-effects, length of stay, satisfaction (0–100%), and continuous wound infusion catheter-related complications. Results: All women scheduled for Caesarean delivery (n=139) in the 4-month period were included in the analysis, with 70 women receiving continuous wound infusion catheters, and 69 in the control group. Opioid consumption (continuous wound infusion catheter group 11.3 [7.5–61.9] mg morphine equivalents vs control group 30.0 [11.3–48.8] mg morphine equivalents), pain scores (except 24 h resting pain scores which were higher in the control group 2 [1–3] vs 1.5 [0–3] in the continous wound infusion catheters group; P=0.05), side-effects, length of stay, and complications were similar between groups. Satisfaction scores at 24 h were higher with continuous wound infusion catheters (100% [91–100%] vs 90% [86–100%]; P=0.003) with no differences at 72 h. One patient demonstrated symptoms of systemic local anaesthetic toxicity which resolved without significant harm. Conclusions: The addition of continuous wound infusion catheters to a multimodal analgesia regimen for post-Caesarean delivery pain management demonstrated minimal clinically significant analgesic benefits. Future studies are needed to explore the use of continuous wound infusion catheters in populations that may benefit most from this intervention.

The purpose of this scoping review was to identify possible chondrotoxic effects caused by drugs usually used for intra-articular injections. PubMed, Scopus, Web of Science and Cochrane were searched. Inclusion criteria required randomized controlled trials written in English that evaluate the toxic effect that damages the cartilage. The literature search resulted in 185 unique articles. 133 full-text articles were screened for inclusion, of which 65 were included. Corticosteroids, with the exception of triamcinolone, along with local anaesthetics, potentially excluding ropivacaine and liposomal bupivacaine, and nonsteroidal anti-inflammatory drugs, exhibited insufficient safety profiles to warrant casual use in clinical settings. Hyaluronic acid, on the other hand, appears to demonstrate safety while also mitigating risks associated with concurrent compounds, thereby facilitating therapeutic combinations. Additionally, there remains a paucity of data regarding platelet-rich plasma, necessitating further evaluation of its potential efficacy and safety. Overall, it seems that results are significantly influenced by the dosage and frequency of injections administered, observed in both human and animal studies.

PICO Question In lambs less than 7 days old undergoing castration with rubber rings does administration of local anaesthetic compared to no local anaesthetic result in a reduction of pain-related behaviours? Clinical bottom line Category of research Treatment. Number and type of study designs reviewed Six studies were appraised; all were controlled clinical or field trials. Strength of evidence Moderate. Outcomes reported Local anaesthetic administered to lambs castrated with rubber rings resulted in the demonstration of fewer pain related behaviours and also diminished the increases in plasma cortisol in the immediate post-castration period when compared to lambs castrated without local anaesthetic. Local anaesthetic administered at least 15 minutes before rubber ring castration may significantly reduce behavioural signs of pain and plasma cortisol changes. Conclusion In lambs less than 7 days old undergoing castration with rubber rings, local anaesthetic reduces markers of pain when compared to lambs castrated without local anaesthetic. How to apply this evidence in practice The application of evidence into practice should take into account multiple factors, not limited to: individual clinical expertise, patient’s circumstances and owners’ values, country, location or clinic where you work, the individual case in front of you, the availability of therapies and resources. Knowledge Summaries are a resource to help reinforce or inform decision making. They do not override the responsibility or judgement of the practitioner to do what is best for the animal in their care.

The prostate cancer pathway has evolved rapidly over the last decade responding to evidence‐based recommendations. These changes were accelerated further over the last 5 years due to the Covid‐19 pandemic and the antibiotic stewardship policies regarding nosocomial/iatrogenic infections. Local anaesthetic transperineal ultrasound‐guided biopsy is a relatively new technique that became gold‐standard practice for prostate cancer diagnosis due to decreased sepsis rates. However, data that justified its implementation was more focused on its efficacy and clinically significant cancer detection rates, lacking robust methodological complications data, including in some cases the utilization of validated tools to assess complications. In patients subjected to local anaesthetic transperineal ultrasound‐guided prostate biopsies, what are the most recent reported complications? This systematic literature review followed Bettany‐Saltikov and McSherry's Manual guidance for systematic literature reviews. Patient/target, Intervention, Comparison, Outcome (PICO) research method, and Preferred Reporting Items for Systematic Reviews and Meta‐Analysis (PRISMA) were used to structure the search strategy and report results. This review was conducted using PubMed/Medline, Excerpa Medica database (EMBASE), and Cumulative Index to Nursing and Allied Health Literature (CINAHL) databases. Inclusion criteria focused on recent studies which matched current national and international prostate cancer pathway guidelines (National Institute for Health and Care Excellence and European Association of Urology). Quality assessments were performed using Critical Appraisal Skills Programme checklists. Four cohort studies were included in this review. A total of 946 men were submitted to local anaesthetic transperineal prostate biopsy. Patient experience showed procedure was tolerated with the most painful part of the procedure being local anaesthetic infiltration with Visual Analogue Score variation [2–5]. Few complications were reported. Haematuria had broad definitions across studies, being difficult to interpret the results of this complication. Only one case reported gross haematuria leading to acute urinary retention. Historically, acute urinary retention was mentioned as one of the main adverse effects of transperineal biopsies. However, in this systematic literature review it had similar incidence as transrectal biopsies, particularly when local anaesthesia was utilized. Lower urinary tract symptoms and erectile dysfunction seemed to not be affected by prostate biopsy procedures, however, more data is required as only two studies addressed these issues. Six urinary tract infection patients were reported (0.63%), and one urosepsis case (0.10%). This seems to demonstrate few urinary infections occur and fewer sepsis cases, particularly when compared with transrectal biopsies data, concurring with previous research. Marginal difference was noted between infection rates with or without antibiotic prophylaxis. Local anaesthetic transperineal ultrasound‐guided prostate biopsies seem to remain a safe procedure from a complications rate point of view. It has been proven before to have fewer urinary tract infections and sepsis episodes. Low‐risk patients can have LATPUS biopsies without antibiotic prophylaxis. High‐risk patients need clinician assessment and judicious utilization of antibiotics. Other complications require further studies with standardized biopsy techniques, clear complication definitions, and use of validated tools to measure complications. [ABSTRACT FROM AUTHOR]

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Background: Rubber band ligation (RBL) is a widely accepted intervention for the treatment of haemorrhoids. However, post procedure pain is a common complaint. The aim of this study was to determine whether the addition of local anaesthetic (LA) to the haemorrhoid pedicle base, post RBL, aids in reducing early post-procedure pain. Additionally, to compare perceived perianal numbness, oral analgesia usage and total consumption, and adverse events. Methods: This study was a prospective, single-blinded randomised controlled trial. Patients were recruited from colorectal clinics in two Australian hospitals between 2018–2019. Patients randomised to the intervention (LA) group received 2mls bupivacaine 0.5% with adrenaline 1:200,000 to each haemorrhoid base. Patients in the control group were not administered LA. Pain scores were recorded over 48 h using visual analogue scales. Analgesia consumption was documented and other secondary objectives were recorded dichotomously (yes/no). Results: At 1 h post-procedure, patient reported pain scores were significantly lower in the LA group compared to the control group (p = 0.04). There were no significant differences in pain scores between the groups at 4, 24 or 48 h. Additionally, there were no significant differences between groups with respect to oral analgesia usage, perianal numbness or adverse events. Conclusions: LA to the haemorrhoid pedicle post RBL may significantly reduce early post procedure pain without any increased risk of adverse effects. [ABSTRACT FROM AUTHOR]

Background and Aims: Sciatic nerve block at the popliteal level for lower limb procedures provides unpredictable success rates even with ultrasonographic (USG) guidance. This study aimed to compare USG-guided single-point versus two-point injection techniques. Methods: Sixty patients posted for foot surgeries under USG-guided sciatic nerve block were randomised into Group Single Point, receiving a single injection of 20 mL of 1.5% lignocaine with adrenaline just proximal to the sciatic nerve bifurcation, and Group Double Point, receiving two injections of 10 mL of 1.5% lignocaine with adrenaline, one at the point similar to the first group and a second injection 6 cm above the first point. Sensory blockade onset, time to complete sensory blockade, time to complete motor blockade, length of the nerve exposed and analgesia duration were evaluated. Statistical analysis was performed with Statistical Package for the Social Sciences (SPSS) statistics version 20 software. Results: Double-point injection technique showed a significantly faster time to complete motor blockade [14.46 (9.93) min], increased length of nerve exposed to local anaesthetic [23.23 (7.209) cm] and extended duration of analgesia [420.40 (99.34) min] compared to the single-point injection technique [20.89 (12.62) min, 18.78 (5.95) cm and 344.28 (125.97) min, respectively]. The onset of sensory blockade and the time to complete sensory blockade were comparable between the two groups. Conclusion: USG-guided popliteal sciatic nerve block with a double-point injection technique does not significantly shorten the time to complete the sensory block. However, the time to complete motor nerve block and duration of analgesia are prolonged significantly, which may be clinically beneficial for postoperative analgesia. [ABSTRACT FROM AUTHOR]

Opioid and local anaesthetic receptors are abundantly concentrated in different layers of the skin. Therefore, simultaneous targeting of these receptors can produce more potent dermal anaesthesia. Herein, we developed lipid‐based nanovesicles for the co‐delivery of buprenorphine and bupivacaine to efficiently target skin‐concentrated pain receptors. Invasomes incorporating two drugs were prepared by ethanol injection method. Subsequently, the size, zeta potential, encapsulation efficiency, morphology, and in‐vitro drug release of vesicles were characterized. Ex‐vivo penetration features of vesicles were then investigated by the franz diffusion cell on the full‐thickness human skin. Wherein, it was demonstrated that invasomes penetrated the skin deeper and delivered bupivacaine more effectively than buprenorphine to the target site. The superiority of invasome penetration was further evidenced by the results of ex‐vivo fluorescent dye tracking. Estimation of in‐vivo pain responses by the tail‐flick test revealed that compared with the liposomal group, the group receiving invasomal formulation and drug‐free invasomal formulation (only containing menthol) displayed increased analgesia in the initial times of 5 and 10 min. Also, no signs of oedema or erythema were observed in the Daze test in any of the rats receiving the invasome formulation. Finally, ex‐vivo and in‐vivo assays demonstrated efficiency in delivering both drugs into deeper layers of skin and exposing them to the located pain receptors, which improves the time of onset and the analgesic effects. Hence, this formulation appears to be a promising candidate for tremendous development in the clinical setting. [ABSTRACT FROM AUTHOR]

This article discusses the use of a novel technique called transincisional quadratus lumborum block (QLB) in robotic and laparoscopic renal and adrenal surgery. The QLB is a regional anesthetic block that allows for effective pain management during surgery. The technique involves delivering local anesthetic through the lumbar interfacial triangle to the thoracolumbar fascia, which provides visceral analgesia. The article describes the steps of the procedure and highlights the potential advantages of this technique, including improved efficiency and reduced operating time. However, the article also acknowledges the limitations of the study and the need for further research to compare transincisional QLB with other approaches. [Extracted from the article]

Summary: The provision of anaesthesia for hip fracture surgery in elderly and frail patients can be challenging, with potentially significant risks associated with both general and neuraxial techniques. Here, we report the use of a sacral erector spinae plane block as an alternative to conventional anaesthetic approaches for a frail 89‐year‐old woman with significant cardiovascular and respiratory comorbidity who underwent intramedullary nailing for a proximal femoral fracture. A unilateral injection of local anaesthetic at the intermediate crest of the second sacral vertebra resulted in bilateral sensory block of the T12 to S2 dermatomes. The technique did not result in hypotension or motor block of the limbs, and the surgery was completed uneventfully. Sacral erector spinae plane block warrants further investigation as an alternative to spinal and general anaesthesia for hip and lower limb surgery. [ABSTRACT FROM AUTHOR]

Introduction: Local wound infiltration is an effective, simple, and practical method of postoperative analgesia. Time and resource consumption is minor; while being more acceptable. A low incidence of complications; and no major contraindications have been noted, other than patient refusal or local infection. Various systematic reviews outline the benefits of adjuvants such as opioids, non-steroidal anti-inflammatory drugs, steroids, alpha-2 agonists, ketamine, etc. in increasing the analgesic efficacy and opioidsparing effect when combined with local anaesthetic agents via wound infiltration; while also providing supportive evidence of the safety of these agents. Material and Method: The study was as a prospective double blind randomised controlled trial conducted between April 2022 to April 2023. The inclusion criteria were age 30 to 60 years, lumbar degenerative disc diseases needing posterior spinal fixation of one-or two-disc levels and of American Society of Anaesthesiologists (ASA) grade I/II. The criteria for exclusion were surgery of >2-disc levels (>3 vertebrae), surgery for non-degenerative spinal diseases, previous spinal surgery, osteoporosis and spondylolisthesis of grade III/IV, altered hepatic or renal parameters or ASA grade III/IV. Surgical decision was made according to the patient's history, flexion extension radiographs and MRI, with consultations with the patient. Patients were then randomly allocated randomly in 2 groups by a computer-generated randomization. Group N received inj nalbuphine 10mg, 0.5 % inj bupivacaine 9ml and 10ml normal saline while group B received inj butorphanol 1mg, inj bupivacaine 9ml and normal saline 10 ml. Results: At end of the recovery, patients in nalbuphine group had mild pain with mean NRS score 2.5±0.5. The pain remained mild in nature till 4 hours and then starts increasing slowly with NRS at 6 hours 3.8±0.7 and peaking between 6 and hours (table 2, figure 1). The hearts rate and MAP were also had similar trends with progressive increase from 4 hours and peaks at 8 hours. In the butorphanol group the mean NRS score at the end of recovery was 2.8±0.6 which was comparable to the that of nalbuphine group. It started to increase before 4 hours, with mean NRS score at 4 hours 3.8±0.7 and peaked between 4 and 6 hours. During intergroup comparison mean heart rates, MAP and NRS were comparable between the two groups at baseline, 0 hour and 2 hours. Significant difference in NRS score were observed among the two groups at 4 hours (p - 0.03), 6 hours (p-0.01) and 8 hours (p-0.006). After 8 hours the heart rate, MAP and NRS in both groups were comparable (p>0.05). Conclusion: In this study we have compared the benefits and safety of two different opioids as adjuvants to local infiltration in spine surgery. The study was done in similar group of patients of degenerative lumbar disease operated with similar surgery (lumbar spinal fixation and decompression) by a single surgeon. The results demonstrated that the NRS score remains low at both groups till 4 hours of recovery and the patients were haemodynamically stable with no tachycardia or increased blood pressure. In the butorphanol group the NRS score increase around 4 hours of recovery and the request for first rescue analgesia was between 4 and 6 hours, mean 289.7±46.8 minutes. But in nalbuphine group, NRS score remained low up to 8 hours and mean time for request of first rescue analgesia was 492.4±56.3 minutes. [ABSTRACT FROM AUTHOR]

Background: The incidences of systemic toxicity and other complications associated with existing local anaesthetics can occur at clinical concentration level and vary with the anaesthetic techniques, types of surgery and patient factors. This evidence suggests the need for therapeutic interventions in peripheral and regional anaesthesia. Buthus martensii Karsch (BmK) scorpion venom is a compound that contains mixtures of peptides that have analgesic properties. This study aimed to investigate the local anaesthetic activity of scorpion venom peptide, AGAP (analgesic-antitumor peptide) in mechanical hyperalgesia or acute inflammatory pain. Method: Formalin was injected into the left hind paw after 20 minutes of infiltration of drugs. The time of licking or flinching of the injected hind paw was recorded as indicative of nociceptive or acute inflammatory pain. Paw flinching or quick withdrawal was considered a positive response to pain in the partial sciatic nerve ligation. The paw-withdrawal threshold (PWT) was determined by consecutively increasing and decreasing the magnitude of the stimulus. Results: The results indicated that AGAP exhibited a 67.9% inhibition in licking or flinching time and an 88.1% inhibition in paw withdrawal in mechanical hyperalgesia. The addition of AGAP to lidocaine showed an 89.5% inhibition in paw withdrawal. Conclusion: The data presented in this study suggest that local infiltration of AGAP significantly reduced mechanical hyperalgesia and acute inflammatory pain. [ABSTRACT FROM AUTHOR]

Objectives Primary objectives: to determine whether local anaesthetic transperineal prostate (LATP) biopsy improves the detection of clinically significant prostate cancer (csPCa), defined as International Society of Urological Pathology (ISUP) Grade Group =2 disease (i.e., any Gleason pattern 4 disease), compared to transrectal ultrasound-guided (TRUS) prostate biopsy, in biopsy-naïve men undergoing biopsy based on suspicion of csPCa. Secondary objectives: to compare (i) infection rates, (ii) health-related quality of life, (iii) patient-reported procedure tolerability, (iv) patient-reported biopsy-related complications (including bleeding, bruising, pain, loss of erectile function), (v) number of subsequent prostate biopsy procedures required, (vi) cost-effectiveness, (vii) other histological parameters, and (viii) burden and rate of detection of clinically insignificant PCa (ISUP Grade Group 1 disease) in men undergoing these two types of prostate biopsy. Patients and Methods The TRANSLATE trial is a UK-wide, multicentre, randomised clinical trial that meets the criteria for level-one evidence in diagnostic test evaluation. TRANSLATE is investigating whether LATP biopsy leads to a higher rate of detection of csPCa compared to TRUS prostate biopsy. Both biopsies are being performed with an average of 12 systematic cores in six sectors (depending on prostate size), plus three to five target cores per multiparametric/bi-parametric magnetic resonance imaging lesion. LATP biopsy is performed using an ultrasound probe-mounted needle-guidance device (either the 'Precision-Point' or BK UA1232 system). TRUS biopsy is performed according to each hospital's standard practice. The study is 90% powered to detect a 10% difference (LATP biopsy hypothesised at 55% detection rate for csPCa vs 45% for TRUS biopsy). A total of 1042 biopsy-naïve men referred with suspected PCa need to be recruited. Conclusions This trial will provide robust prospective data to determine the diagnostic ability of LATP biopsy vs TRUS biopsy in the primary diagnostic setting. [ABSTRACT FROM AUTHOR]

Background and Aims: Sciatic nerve block at the popliteal level for lower limb procedures provides unpredictable success rates even with ultrasonographic (USG) guidance. This study aimed to compare USG-guided single-point versus two-point injection techniques. Methods: Sixty patients posted for foot surgeries under USG-guided sciatic nerve block were randomised into Group Single Point, receiving a single injection of 20 mL of 1.5% lignocaine with adrenaline just proximal to the sciatic nerve bifurcation, and Group Double Point, receiving two injections of 10 mL of 1.5% lignocaine with adrenaline, one at the point similar to the first group and a second injection 6 cm above the first point. Sensory blockade onset, time to complete sensory blockade, time to complete motor blockade, length of the nerve exposed and analgesia duration were evaluated. Statistical analysis was performed with Statistical Package for the Social Sciences (SPSS) statistics version 20 software. Results: Double-point injection technique showed a significantly faster time to complete motor blockade [14.46 (9.93) min], increased length of nerve exposed to local anaesthetic [23.23 (7.209) cm] and extended duration of analgesia [420.40 (99.34) min] compared to the single-point injection technique [20.89 (12.62) min, 18.78 (5.95) cm and 344.28 (125.97) min, respectively]. The onset of sensory blockade and the time to complete sensory blockade were comparable between the two groups. Conclusion: USG-guided popliteal sciatic nerve block with a double-point injection technique does not significantly shorten the time to complete the sensory block. However, the time to complete motor nerve block and duration of analgesia are prolonged significantly, which may be clinically beneficial for postoperative analgesia.

Cite this article: Bone Joint Res 2023;12(5):306–308.

Aims: To assess all available data and determine the success rates and tolerability of local anaesthetic myringoplasty in comparison with those undertaken under general anaesthetic myringoplasty. Materials and methods: The study was designed following a PRISMA-P protocol and registered with the PROSPERO database. MEDLINE, Cochrane Library (CDSR/Central), EMBASE and CINHAL—were directly searched for studies, which met the inclusion criteria. Objectives: Primary objective was to compare perforation closure rates between patients undergoing myringoplasty under local anaesthetic and those under general anaesthetic from all available published data. Secondary outcomes include complications, such as 'any minor complications', infection rates in the first 6 month post-op, facial nerve weakness, dysgeusia and patient satisfaction. Results: 27 studies were included in the final analysis and found that myringoplasty had an overall perforation closure rate of 89%. The pooled proportion of closures after myringoplasty under local anesthesia was 87% and for myringoplasties under general anesthesia was 91%. Analysis of myringoplasty under local anaesthesia focusing on 'in-office' performed procedures only, found a closure rate of 88%. Conclusions: There is no significant difference in the success rate of myringoplasty surgery when performed under local or general anaesthetic as measured by perforation closure rates. However, there are other factors, which can drive choosing local anaesthetic surgery, such as minimising anaesthetic risks, reducing costs and reducing environmental impact. [ABSTRACT FROM AUTHOR]

Objective: To conduct a systematic review of the literature to assess the diagnostic ability, complication rate, patient tolerability, and cost of local anaesthetic (LA) transperineal prostate biopsy. Methods: Two reviewers searched Medline, the Cochrane Library, and Embase for publications on LA transperineal prostate biopsy up to March 2021. Outcomes of interest included cancer detection rates, complication rates, pain assessments and cost. Results: A total of 35 publications with 113 944 men were included in this review. The cancer detection rate for LA transperineal prostate biopsy in patients undergoing primary biopsy was 52% (95% confidence interval [CI] 0.45–0.60; I2 = 97) and the clinically significant cancer detection rate (Gleason≥3 + 4) was 37% (95% CI 0.24–0.52; I2 = 99%). The rate of infection‐related complications in the included studies was 0.15% (95% CI 0.0000–0.0043; I2 = 86). The LA transperineal procedures had a low rate of procedural abandonment (26/6954, 0.37%), with the greatest pain scores measured during LA administration. No formal cost analyses on LA transperineal prostate biopsies were identified in the literature. The overall risk of bias in the included studies was high, with considerable study heterogeneity and publication bias. Conclusion: Transperineal prostate biopsy performed under LA is a viable option for centres interested in avoiding the risk of infection associated with transrectal biopsy, and the logistical burden of general anaesthesia. Further investigation into LA transperineal prostate biopsy with comparative studies is warranted for its consideration as the standard in prostate biopsy technique. [ABSTRACT FROM AUTHOR]

Background: The use of local anaesthetic (LA) agents has transformed medicine and enhanced the development of surgery. Local anaesthetic systemic toxicity (LAST) is a life-threatening incident that may occur following administration of LA agents. A sound knowledge of LAST and its treatment is important for patient safety. Surveys done at many hospitals demonstrated a lack of knowledge regarding LAST and the management thereof by non-anaesthetists. The aim of this study was to assess knowledge and awareness of LAST among registrars from various surgical disciplines at Tygerberg Academic Hospital (TBH). Methods: We performed a descriptive cross-sectional study. A web-based questionnaire was sent to 201 registrars from different surgical disciplines at TBH. The results were analysed using descriptive statistics. Results: We received 102 responses (response rate 51%). The mean knowledge score was 67.9%, standard deviation (SD) 15.2, with a range of 20-100%. Only 18.6% of the registrars had encountered a case of LAST in their practice. Approximately 50% of the registrars knew the maximum recommended dose of bupivacaine and 54% indicated that they had previous training in the management of LAST. Only 40.2% of the registrars knew the specific treatment of LAST. The knowledge score was higher for those who had previous training in the management of LAST with a mean (SD) of 73% (13.7). A statistical difference (p-value = 0.045) between the years of training and the knowledge about LAST was demonstrated. Conclusion: Registrars' knowledge and awareness of LAST and safe use of LA agents were concerning. This was shown to improve with years of registrar training as well as with previous training specifically about LAST. A lack of knowledge was found in identifying lipid emulsion as the specific treatment of LAST. These factors can be improved by training and awareness campaigns. [ABSTRACT FROM AUTHOR]

The Vector technique uses electromagnetic needle tracking under local anaesthetic for transperineal magnetic resonance imaging/ultrasound fusion prostate biopsy with a stable probe. This allows accurate and precise targeting while maintaining patient comfort. Detection rates for cancer are high and complication rates are low. Prostate magnetic resonance imaging (MRI) is now standard for assessment of suspected prostate cancer (PCa). A variety of approaches to MRI-based targeting has revolutionised prostate biopsies. To describe the procedure and show the accuracy and tolerability of a novel Vector MRI/ultrasound fusion transperineal (TP) biopsy technique that uses electromagnetic (EM) needle tracking under local anaesthesia (LA). Vector prostate biopsy using BiopSee fusion software, EM tracking technology, and transrectal ultrasound was performed in 69 patients meeting the biopsy criteria in two UK centres between September 2020 and August 2022. Stepper-mounted rectal ultrasound images were fused with MRI scans. LA was applied into two defined perineal tracks and a needle sheath with an EM sensor was inserted. The biopsy needle was directed precisely through the sheath to MRI targets under EM tracking. Biopsies were taken without antibiotic prophylaxis. Cancer detection (any PCa; grade group ≥2), side effects, and patient experience measures were recorded. Cancer detection in patients with Likert 4–5 lesions was 98% for any PCa and 83% for grade group ≥2. According to the 50 questionnaires returned, 42 patients (84%) reported no or minimal pain, while 40 (80%) reported no or minimal discomfort. No episodes of postoperative urinary retention occurred, and only one patient required treatment for infection. Limitations include the low patient number and incomplete responses to questionnaires. This novel Vector technique provides a feasible and tolerable procedure for MRI/ultrasound fusion TP biopsy under LA, with high cancer detection rates. This is achieved while maintaining patient comfort and with minimal rates of complications. We report a novel technique that uses electromagnetic needle tracking to perform highly accurate and comfortable prostate biopsies through the perineum under local anaesthetic. [ABSTRACT FROM AUTHOR]

Introduction ENTUK guidelines recommend that manipulation of nasal bones (MNB) should be performed within 14 days of injury. However, evidence suggests treatment under general anaesthetic remains effective up to 5 weeks after injury. With the SARS-CoV-2 pandemic leading to delays in referral and limited access to theatre, local practice changed to offer delayed MNB under local anaesthetic. This prospective study assesses the effectiveness of MNB delayed until 3 weeks or later from time of injury when performed mostly under local anaesthetic. Methods Data was prospectively collected between April and November 2020. All patients referred to ENT with a new nasal bone deformity presenting more than 21 days after injury were included. Demographic information, injury details and patient satisfaction was recorded for each patient. Results 11 patients were included. Average age was 32.6 years (Range 8-65 years). 10 procedures (91%) were performed under local anaesthetic, with 1 (9%) performed under general anaesthetic. 9 patients (82%) gained complete reduction of the deformity, and 1 patient (9%) gaining partial reduction. 10 patients (91%) patients were satisfied with the cosmetic outcome. Conclusion This study supports the small volume of recent literature showing that delayed manipulation of nasal bones is effective and additionally demonstrates that efficacy is maintained when performed under local anaesthetic. [ABSTRACT FROM AUTHOR]

Abstract A common and to some degree painful procedure in veterinary practice is to insert an intra-venous catheter. In both human and veterinary medicine, a topical mixture of lidocaine and prilocaine (EMLA cream) has shown to reduce the pain, however a period of 60 min between application and initiation of the procedure is recommended. This time lapse is not always suitable for clinical practise and a shorter time before anaesthetic effect is therefore desirable. Lidocaine has a shorter time lapse (1–3 min) when used on mucus membrane; however, the effect of lidocaine for desensitization of skin has shown variable results in humans. The aim of the study was to evaluate the effect of topical lidocaine spray 10% on the response to placement of venous catheters in dogs. Topical lidocaine spray 10% or NaCl 0.9% was administered prior to placing an intravenous catheter in the cephalic vein. A cross-over of treatment with 2 h wash out period was used before placing a catheter in the opposite cephalic vein. The procedure was video recorded and the dogs’ responses were later scored by three persons blinded to treatment using a visual analogue scale. The VAS scores were normalised and the mean difference between treatments were compared using Wilcox signed-rank test. This study could not find a statistical difference between the treatments (P = 0.1763) and could conclude that no significant difference in response to intravenous catheterisation was found between application of NaCl 0.9% or lidocaine 10% prior to the procedure.

Objectives: This randomised, prospective, masked clinical trial evaluated the postoperative analgesic efficacy of an ultrasound-guided transversus abdominis plane block (TAPB) with bupivacaine in cats undergoing ovariohysterectomy. Methods: Thirty-two healthy adult female cats undergoing elective ovariohysterectomy were randomised to undergo TAPB with bupivacaine (treatment group [TG], n = 16) vs placebo (control group [CG], n = 16) in addition to preoperative analgesia with buprenorphine (0.02 mg/kg IM). All patients received a general anaesthetic and, before surgical incision, a bilateral two-point (subcostal and lateral–longitudinal) TAPB was performed using 1 ml/kg bupivacaine 0.25% (0.25 ml/kg/point) or saline. Each cat was assessed by a blinded investigator before premedication (0 h) and at 1, 2, 3, 4, 8, 10 and 24 h postoperatively using the UNESP-Botucatu Feline Pain Scale – short form. Buprenorphine (0.02 mg/kg IV) and meloxicam (0.2 mg/kg SC) were administered when pain scores were ⩾4/12. Ten hours postoperatively, meloxicam was administered to cats that did not receive rescue analgesia. Statistical analysis included Student's t -tests, Wilcoxon tests and χ2 tests, and a linear mixed model with Bonferroni corrections (P <0.05). Results: Of the 32 cats enrolled, three in the CG were excluded from the analysis. The prevalence of rescue analgesia was significantly higher in the CG (n = 13/13) than in the TG (n = 3/16; P <0.001). Only one cat in the CG required rescue analgesia twice. Pain scores were significantly higher in the CG compared with the TG at 2, 4 and 8 h postoperatively. Mean ± SD pain scores were significantly higher in the CG, but not in the TG, at 2 (2.1 ± 1.9), 3 (1.9 ± 1.6), 4 (3.0 ± 1.4) and 8 h postoperatively (4.7 ± 0.6) than at 0 h (0.1 ± 0.3). Conclusions and relevance: A bilateral ultrasound-guided two-point TAPB with bupivacaine in combination with systemic buprenorphine provided superior postoperative analgesia than buprenorphine alone in cats undergoing ovariohysterectomy. [ABSTRACT FROM AUTHOR]

AIM: To identify current trends in anaesthesia technique for cataract surgery and make this information available to ophthalmologists. METHODS: An electronic survey was created and distributed to members of online ophthalmology forums; results were subsequently analysed in spreadsheet software. RESULTS: In total there were 71 completed surveys. The most preferred anaesthesia technique in cataract cases was topical anaesthesia with intracameral injection (n=34, 47.9%), and the least preferred techniques were retrobulbar (n=1, 1.4%) and peribulbar blocks (n=1, 1.4%). The most commonly preferred local anaesthetic was lidocaine 2% (n=41, 57.7%). CONCLUSION: Topical anaesthesia techniques with lidocaine 2% appear to be the most preferred method of anaesthesia in cataract surgery in our survey. Compared with previous literature our survey shows that topical anaesthesia is being increasingly used in cataract surgery, especially in conjunction with intracameral injection. The predominant reasons for this seem to be patient comfort and ease of technique.

Tramadol is an effective alternative local anaesthetic (LA) agent available in dentistry. This review aims to help guide practice by providing clinicians with relevant data regarding adverse effects (AE) associated with locally administered tramadol in the oral environment. A systematic search of three electronic databases was performed to identify relevant studies reporting AE associated with locally administered tramadol in the oral setting. Selected studies were reviewed and included based on inclusion and exclusion criteria. Data collected included: publication year, study design, participant numbers, adverse effects and follow-up duration. Fifteen articles were included comprising of 547 tramadol participants across eight exodontia and seven non-exodontia studies. Thirty-eight associated AE were reported. Nausea was the most commonly reported (4.6%), followed by dizziness (1.3%), vomiting (0.7%) and local erythema (0.4%). No other AE were reported. The prevalence of total AE was similar in ≥ 50 mg tramadol doses (7.2–7.3%); however the total affected number is not dose dependent. The prevalence of AE and affected participants was less when tramadol was used as a sole LA rather than as an adjunct (5.6% vs. 7.9% and 3.4–5.6% vs. 6.3%, respectively). Thus, tramadol is a safe LA agent with a low prevalence of AE when administered in the dental setting.

Aims: Single-shot adductor canal block (ACB) after total knee arthroplasty (TKA) for postoperative analgesia is a common modality. Patients can experience breakthrough pain when the effect of ACB wears off. Local anaesthetic infusion through an intra-articular catheter (IAC) can help manage breakthrough pain after TKA. We hypothesized that combined ACB with ropivacaine infusion through IAC is associated with better pain relief compared to ACB used alone. Methods: This study was a prospective double-blinded placebo-controlled randomized controlled trial to compare the efficacy of combined ACB+ IAC-ropivacaine infusion (study group, n = 68) versus single-shot ACB+ intra-articular normal saline placebo (control group, n = 66) after primary TKA. The primary outcome was assessment of pain, using the visual analogue scale (VAS) recorded at 6, 12, 24, and 48 hours after surgery. Secondary outcomes included active knee ROM 48 hours after surgery and additional requirement of analgesia for breakthrough pain. Results: The study group (mean visual analogue scale (VAS) pain score of 5.5 (SD 0.889)) experienced significant reduction in pain 12 hours after surgery compared to the control group (mean VAS 6.62 (SD 1.356); mean difference = 1.12, 95% confidence interval (CI) -1.46 to 0.67; p < 0.001), and pain scores on postoperative day (POD) 1 and POD-2 were lower in the study group compared to the control group (mean difference in VAS pain = 1.04 (-1.39 to -0.68, 95% CI, p < 0.001). Fewer patients in the study group (0 vs 3 in the control group) required additional analgesia for breakthrough pain, but this was not statistically significant. The study group had significantly increased active knee flexion (mean flexion 86.4° (SD 7.22°)), compared to the control group (mean 73.86° (SD 7.88°), mean difference = 12.54, 95% CI 9.97 to 15.1; p < 0.014). Conclusion: Combined ACB+ ropivacaine infusion via IAC is a safe, reproducible analgesic modality after primary TKA, with superior analgesia compared to ACB alone. Further large volume trials are warranted to generate evidence on clinical significance on analgesia after TKA. Cite this article: Bone Jt Open 2021;2(12):1082–1088.

Objective: To compare the frequency of pain and mean analgesia requirement after breast surgery under general anaesthesia when comparing pectoral nerve block with local anaesthesia infiltration. Study Design: Comparative prospective study. Place and Duration of Study: Combined Military Hospital, Rawalpindi from Mar 2018 to Sep 2019. Methodology: A total of 60 patients undergoing modified radical mastectomy were included in the study. Group A (n=30) received pectoral nerve blocks while Group B (n=30) received local anaesthetic infiltration. Outcome was assessed at 12 hours after injection of local anaesthetic. Results: Pain in 7 (23.33%) patients in Group A (Pectoral nerve blocks) and in 20 (66.67%) patients in Group B (Local anaesthetic infiltration), p-value of 0.001 which was considered statistically significant. Mean analgesic requirement was found to be 80 ± 33.73 mg in the Group A (pectoral nerve blocks) compared with 141.67 ± 47.50 mg in Group B (Local anaesthesia infiltration) patients with a p-value of

Lumbar erector spinae plane block (ESPB) is effective for spine surgeries but is deep and technically demanding. Sacral ESPB is a novel approach for sacrococcygeal procedures and can potentially cover lumbar dermatomes by the cranial drug spread. This is the first reported case series demonstrating the potential analgesic efficacy of sacral ESPB for lumbar spine surgeries. Five patients with radiculopathy at the lumbosacral area level were scheduled for transforaminal lumbar interbody fusion (TLIF). General anaesthesia was induced as per standard practice. All patients received sacral ESP in a prone position under ultrasound guidance with a needle inserted in-plane while targeting the fascial plane between the S2 median crest and overlying muscles. All the included patients had good analgesia in the postoperative period and required minimal opioid analgesic doses. Sacral ESPB is an easy, effective, and safe technique in the scheme of multimodal analgesia for TLIF surgeries as a component of pre-emptive analgesia, where the main goal is an opioid-sparing effect. [ABSTRACT FROM AUTHOR]

Summary: We present a case of inadvertent spread of local anaesthetic from combined pectoralis (PECS) 1 and 2 fascial plane blocks that resulted in an incomplete brachial plexus block. An otherwise healthy 42‐year‐old woman with a body mass index of 23.3 kg.m−2 presented for unilateral mastectomy with immediate prosthetic reconstruction for breast cancer. No axillary dissection was performed. Because of service requirements, the blocks were performed at the conclusion of surgery. This may have resulted in greater cranial spread of the local anaesthetic due to surgical dissection along musculature and placement of the breast implant. Following emergence from general anaesthesia, the patient experienced numbness over the ipsilateral medial forearm extending to the little finger. Further examination with a finger‐nose test revealed reduced coordination and joint proprioception of the ipsilateral arm. There was no detectable gross motor weakness. She was reviewed the following day (23 h after the blocks) by which time her symptoms had subsided entirely. We believe that this is the first documented brachial plexus block after injection of local anaesthetic into the pectoralis 1 and 2 fascial planes. [ABSTRACT FROM AUTHOR]

Introduction: Supraclavicular brachial plexus block is used for providing pain relief in upper limb surgeries and has many advantages over general anaesthesia. Alpha-2-adrenergic agonists are chosen with local anaesthetics for their sedative, analgesic and antihypertensive properties. Aim: To compare the efficacy of clonidine and dexmedetomidine when added to 0.5% ropivacaine in nerve stimulator guided supraclavicular block when performed for upper limb surgeries. Materials and Methods: This randomised clinical study was conducted in the Department of Anaesthesia Mata Chanan Devi Hospital, New Delhi, India (tertiary care center), from September 2015 to September 2016. Total 90 patients were randomly allocated into three groups. Group A {Inj. ropivacaine 0.5% (29 mL)+ normal saline 1 mL to make 30 mL}, group B {Inj. ropivacaine 0.5% (29 mL)+ clonidine 1 µg kg-1 to make 30 mL) and group C {Inj. ropivacaine 0.5% (29 mL)+ dexmedetomidine 1 µg kg-1 to make 30 mL}. Parameters observed included onset of sensory and motor block, total motor duration, postoperative analgesia as primary outcome; and intraoperative haemodynamic parameters and side effects as secondary outcome. results: All the three groups were found to be similar with demographic profile. Patients in dexmedetomidine group showed faster onset and longer duration of sensory and motor blocks (p-value<0.01). The mean onset of sensory block in minutes was 12.03±2.20, 8.20±1.40, 6.80±1.35 in groups A, B and C, respectively (p-value<0.001). The mean onset of motor block in minutes was 18.47±2.78, 13.37±2.86 and 11.30±2.04 in group A, group B and C, respectively (p-value<0.001). The mean duration of analgesia in group A, B and C was 555.17±65.36, 710.00±73.58 and 902.67±116.65 minutes, respectively (p-value<0.001). The mean duration of motor block in group A, group B and group C were 330.00±51.78, 418.17±38.29 and 516.83±50.33 minutes, respectively (p<0.0001). The duration of postoperative analgesia and total motor duration were significantly prolonged in dexmedetomidine group than group A and B. conclusion: It can be concluded that both clonidine and dexmedetomidine increases the total motor duration and postoperative analgesia when added to ropivacaine, but dexmedetomidine is a better choice when used in supraclavicular block, without any significant side-effects. [ABSTRACT FROM AUTHOR]

Introduction: Ropivacaine is an amide local anaesthetic agent. The lower limb surgeries involves the great somatic pain. By using these adjuvants such as buprenorphine and clonidine with local anaesthetic agent to know the effective intraoperative and postoperative analgesia. Aim: To compare the anaesthetic characteristics in terms of quality of blockade when intrathecal ropivacaine with buprenorphine and ropivacaine with clonidine as adjuvant. Materials and Methods: The present double-blinded randomised control trial was carried out at a tertiary care hospital, Ammapettai, Tamil Nadu, India, from December 2019 to June 2021. Total of 75 subjects were divided into three groups, with 25 per group-group R (Inj. ropivacaine 0.75% 3 mL with 0.2 mL sterile water), group RB (0.2 mL buprenorphine with Inj. ropivacaine 0.75% 3 mL), and group RC (0.2 mL Clonidine with Inj. Ropivacaine 0.75% 3 mL). Onset and duration of blocks were observed. Haemodynamic parameters and pain score were monitored intraoperatively and postoperatively. Data was entered in Microsoft excel sheet and analysed using Statistical Package for the Social Sciences (SPSS) software version 16.0. The p-value <0.05 were considered as statistically significant. Results: The onset time of sensory and motor blockade for group RC was significantly more in comparison to R and RB groups (sensory block-5 minutes 50 seconds vs 3 minutes 39 seconds vs 3 minutes 50 seconds); and (motor block-6 minutes 52 seconds vs 4 minutes 39 seconds vs 4 minutes 74 seconds). Group RC had significantly longer duration of sensory block than R and RB groups (327 minutes 88 seconds vs 166 minutes 60 seconds (167 minutes) vs 222 minutes 44 seconds). Conclusion: Ropivacaine with clonidine showed significantly more duration of sensory block, motor block and time for first rescue analgesia with haemodynamic stability than ropivacaine and ropivacaine with buprenorphine. [ABSTRACT FROM AUTHOR]

EEG studies have suggested that cattle perceive pain when bled without stunning. The present study on bleeding without stunning, compared cows that had received a local anaesthetic on the site of the bleeding cut (Lurocaine; Luro cows) one hour before bleeding with a 35 cm knife, with cows that had not (saline: Placebo cows). Various physiological indicators potentially related to pain or stress were evaluated. Increases in heart rate (P < 0.02) and cortisol levels (P < 0.001) during slaughter, compared to control levels are indicative of slaughter stress in both groups. GSH/GSSG ratio, plasma PGE2, TNFα, and NO levels and blood haematocrit levels at slaughter were not influenced by slaughter or treatment. At bleeding, excluding two out of the 15 cows with non-missing data, Placebo cows presented a longer delay between the loss of the corneal reflex and respiratory arrest. Post-mortem, Longissimus muscle of Placebo cows had a faster pH decline and remained warmer. Overall, results suggest greater stress levels in this group, probably due to pain. Plasma or brain β-endorphin contents in relevant brain structures did not increase following bleeding in either group, thus not supporting the hypothesis that stress or pain-induced release of endorphins reduces pain perceived following the cut. Furthermore, according to existing knowledge, plasma β-endorphins do not reduce pain perceived. Thus, both our study and previous research do not provide evidence that slaughter without stunning does not cause pain or other forms of stress in at least part of the animals., Competing Interests: Declaration of competing interest None., (Copyright © 2024 The Authors. Published by Elsevier Ltd.. All rights reserved.)

Following renal transplant, ureteral stents aim to minimise ureteroneocystostomy anastomotic complications. Although there is no specified timing for stent removal after transplantation, these are ideally removed at between 2 and 4 weeks. However, forgotten stents can adversely affect renal allograft function and contribute to obstructive uropathy. We present a 59-year-old man with a retained ureteral stent for more than 19 years with an absence of encrustations, fragmentation, migration and stone formation. To our knowledge, this is the longest retained ureteral stent in a renal transplant patient and the first forgotten stent removed via flexible cystoscopy under local anaesthetic.

Konstantinos Devetzis,1 Francesca Kum,1,2 Richard Popert2 1King’s College School of Medicine, London, UK; 2Department of Urology, 1st Floor Southwark Wing, Guy’s Hospital, London, SE1 9RT, UKCorrespondence: Richard PopertDepartment of Urology, 1 st Floor Southwark Wing, Guy’s Hospital, St Thomas’ St, London, SE1 9RT, UKTel +44 2071887188Email rick.popert@gstt.nhs.ukAbstract: Prostate biopsy is the definitive investigation to diagnose prostate cancer. The ideal procedure would be one that offers fast and efficient results safely as an outpatient procedure. Historically, transrectal ultrasound (TRUS) biopsy is considered the gold standard but transrectal biopsy can under-sample the anterior and apical regions of the prostate and is associated with a risk of prostate biopsy-related sepsis, which may require intensive care admission. Transperineal (TP) biopsy addresses the inefficient sampling of TRUS biopsy but historically has been done under general anaesthetic, which makes it difficult to incorporate into timed diagnostic pathways such as the National Health Service (NHS) 2-week cancer pathway. TRUS biopsy has remained the mainstay of clinical diagnosis because of its simplicity; however, the recent development of simpler local anaesthetic transperineal techniques has transformed outpatient biopsy practice. These techniques practically eliminate prostate biopsy-related sepsis, have a shallow learning curve and offer effective sampling of all areas of the prostate in an outpatient setting. The effectiveness of TP biopsy has been enhanced by the introduction of multiparametric MRI prior to biopsy, the use of PSA density for risk stratification in equivocal cases and combined with more efficient targeted and systematic biopsies techniques, such as the Ginsburg Protocol, has improved the tolerability and diagnostic yield of local anaesthetic TP biopsies, reducing the risk of complications from the oversampling associated with transperineal template mapping biopsies. Areas where the literature remains unclear is the optimum number of cores needed to detect clinically significant disease (CSD) in patients with a definable lesion on MRI, in particular, whether there is a need for systematic biopsy in the face of equivocal MRI findings to ensure no CSD is missed. The Covid-19 pandemic has had a profound impact on prostate cancer referrals and prostate biopsy techniques within the UK; prior to the pandemic 65% of all prostate biopsies were TRUS, since the pandemic the proportions have reversed such that now over 65% of all prostate biopsies in the NHS are transperineal.Keywords: transperineal, transrectal, local anaesthetic, prostate biopsies, Covid-19

Abstract Background Both wound infiltration (WI) with local anaesthetic and Erector Spinae Plane block (ESPB) have been described for post-operative analgesia after abdominal surgery. This study compared the efficacy of WI versus ESPB for post-operative analgesia after laparoscopic assisted colonic surgery. Methods Seventy-two patients between 18 and 85 years of age undergoing elective surgery were randomised to receive either WI or ESPB. In the WI group a 40 ml bolus of 0.5% Ropivacaine, infiltrated at the ports and minimally invasive wound at subcutaneous and fascia layers. In the ESPB group at T8 level, under ultrasound guidance, a 22-gauge nerve block needle was passed through the Erector Spinae muscle to reach its fascia. A dose up to 40 ml of 0.5% Ropivacaine, divided into two equal volumes, was injected at each side. Both groups had a multimodal analgesic regime, including regular Paracetamol, dexamethasone and patient-controlled analgesia (PCA) with Fentanyl. The primary end point was a post-operative pain score utilising a verbal Numerical Rating Score (NRS, 0–10) on rest and coughing in the post anaesthetic care unit (PACU) and in the first 24 h. Secondary outcomes measured were: opioid usage, length of stay and any clinical adverse events. Results There was no significant treatment difference in PACU NRS at rest and coughing (p-values 0. 382 and 0.595respectively). Similarly, there were no significant differences in first 24 h NRS at rest and coughing (p-values 0.285 and 0.431 respectively). There was no significant difference in Fentanyl use in PACU or in the first 24 h (p- values 0.900 and 0.783 respectively). Neither was there a significant difference found in mean total Fentanyl use between ESPB and WI groups (p-value 0.787). Conclusion Our observations found both interventions had an overall similar efficacy. Trial registration The study was registered with the Australian New Zealand Clinical Trial Registry (ACTRN: 12619000113156 ).

Abstract Background Corticosteroid injections are used in the treatment of hand and wrist conditions. The co-administration of a local anaesthetic and corticosteroid aims to reduce pain after the injection, although no studies have directly compared this with using corticosteroid alone. The aim is to determine whether pain experienced during the 24 h after a corticosteroid injection to the hand and wrist is no worse than (not inferior to) the pain experienced after a corticosteroid and local anaesthetic injection. Methods A single-site, patient- and assessor-blinded, non-inferiority randomised control trial recording pain visual analogue scale (VAS) scores in patients with a clinical diagnosis of trigger finger, de Quervains tenosynovitis or carpal tunnel syndrome, treated with a 1-ml triamcinolone (40 mg/1 ml) injection co-administered with or without 1 ml of 1% lidocaine. The primary aim is to investigate a difference in pain VAS scores at 1 h after the injection using a mean change score. A 95% power calculation was made using a minimally clinical important difference of 20 mm as the clinically admissible margin of non-inferiority and an assumed standard deviation of 25 mm, from previous studies. Including a 20% fall out rate, 100 patients are required. Discussion Patients with a clinical diagnosis of trigger finger, de Quervains and carpal tunnel syndrome, are over the age 18 years old and who are able to give written informed consent will be included. Patients will be excluded if they have had previous surgery or corticosteroid injection for the condition being treated at the site considered for injection. Patients will be electronically randomised and injections delivered during their clinic appointment. Pain is assessed using a 100-mm VAS score taken, before and at the time of injection and at 5 min, 1 h, 2 h, 3 h and 24 h after the injection. The secondary outcomes are to determine a difference in pain VAS score at the time of injection and during the 24 h after. Trial registration This study is registered on the IRAS (259336) on November 11, 2019, and EudraCT database on October 31, 2019 (2019-003742-32). REC/HRA approval was given in January 2020, and Clinical Trial Authorisation from the MHRA was given in December 2019. The study is registered on ClinicalTrials.gov ( NCT04253457 ) on February 5, 2020.

Introduction: Supraclavicular brachial plexus block is used for providing pain relief in upper limb surgeries and has many advantages over general anaesthesia. Alpha-2-adrenergic agonists are chosen with local anaesthetics for their sedative, analgesic and antihypertensive properties. Aim: To compare the efficacy of clonidine and dexmedetomidine when added to 0.5% ropivacaine in nerve stimulator guided supraclavicular block when performed for upper limb surgeries. Materials and Methods: This randomised clinical study was conducted in the Department of Anaesthesia Mata Chanan Devi Hospital, New Delhi, India (tertiary care center), from September 2015 to September 2016. Total 90 patients were randomly allocated into three groups. Group A {Inj. ropivacaine 0.5% (29 mL)+ normal saline 1 mL to make 30 mL}, group B {Inj. ropivacaine 0.5% (29 mL)+ clonidine 1 μg kg-1 to make 30 mL) and group C {Inj. ropivacaine 0.5% (29 mL)+ dexmedetomidine 1 μg kg-1 to make 30 mL}. Parameters observed included onset of sensory and motor block, total motor duration, postoperative analgesia as primary outcome; and intraoperative haemodynamic parameters and side effects as secondary outcome. Results: All the three groups were found to be similar with demographic profile. Patients in dexmedetomidine group showed faster onset and longer duration of sensory and motor blocks (p-value

Introduction: Ropivacaine is an amide local anaesthetic agent. The lower limb surgeries involves the great somatic pain. By using these adjuvants such as buprenorphine and clonidine with local anaesthetic agent to know the effective intraoperative and postoperative analgesia. Aim: To compare the anaesthetic characteristics in terms of quality of blockade when intrathecal ropivacaine with buprenorphine and ropivacaine with clonidine as adjuvant. Materials and Methods: The present double-blinded randomised control trial was carried out at a tertiary care hospital, Ammapettai, Tamil Nadu, India, from December 2019 to June 2021. Total of 75 subjects were divided into three groups, with 25 per group-group R (Inj. ropivacaine 0.75% 3 mL with 0.2 mL sterile water), group RB (0.2 mL buprenorphine with Inj. ropivacaine 0.75% 3 mL), and group RC (0.2 mL Clonidine with Inj. Ropivacaine 0.75% 3 mL). Onset and duration of blocks were observed. Haemodynamic parameters and pain score were monitored intraoperatively and postoperatively. Data was entered in Microsoft excel sheet and analysed using Statistical Package for the Social Sciences (SPSS) software version 16.0. The p-value