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Although administration of local anaesthesia in dentistry is generally both safe and effective, problems do occur. This article summarizes the types of problem the dental practitioner may encounter, in the hope that increased awareness will decrease the incidence.
The underlying pathophysiology and technic of thoracotomy with local anaesthesia for the surgical treatment of pulmonary tuberculosis and other intra- and extrapulmonary diseases is described. The immediate as well as the long term results in 187 patients with 215 operations were favourable. In view of these results the described method of thoracotomy with local anaesthesia is to be preferred to an incorrectly administered general anaesthesia. However, it is beyond any doubt that in the presence of qualified anaesthetists and adequate equipment thoracotomy with general anaesthesia is preferable to local anaesthesia. However, wherever the conditions for expert application of general anaesthesia are lacking and surgical treatment of lung diseases is necessary, thoracotomy with local anaesthesia is an acceptable and reliable substitute.
BACKGROUND: The study was designed to compare local anaesthesia and conscious sedation for outpatient bipolar operative hysteroscopy in terms of pain control and patients' satisfaction. METHODS: A prospective multicentre randomized study was carried out in university hospitals and in a private endoscopy unit. A total of 166 women with surgically treatable lesions associated with infertility or abnormal uterine bleeding was considered eligible for the study. Patients were randomized, using a computer-generated randomization list, into two groups. Group A (82 patients) underwent operative hysteroscopy with local anaesthesia. Group B (84 patients) received conscious sedation. Operative hysteroscopy was performed with a bipolar electrosurgical device to cut, vaporize and coagulate. Main outcome measures were pain control during the procedure, the post-operative pain score at 15 and 60 min, and at 24 h after the procedure, and patients' satisfaction rate. RESULTS: All procedures were completed within 35 min, the amount of saline used varied from 400-1200 ml. There were no significant differences between local anaesthesia and conscious sedation in terms of pain control during the procedure and in postoperative pain at different intervals. Satisfaction rate was similar in the two groups. CONCLUSIONS: Both local anaesthesia and conscious sedation can be used for operative hysteroscopy using a bipolar electrosurgical system without significant differences in terms of pain control and patients' satisfaction.
This study was designed to evaluate the implantation of internal cardioverter/defibrillators under local anaesthesia by electrophysiologists and to compare this to our former experience of implants with general anaesthesia. Forty-seven internal cardioverter/defibrillators were implanted at our institution by electrophysiologists. Twenty-nine operations were performed under general anaesthesia (isoflurane 0.4-0.6%), and 18 under local anaesthesia (mepivacain 1%). The defibrillator leads were introduced by venotomy of the cephalic vein (n = 25), puncture of the subclavian vein (n = 17) or both (n = 5). All devices were implanted beneath the pectoral muscles. The mean operation time was 99 +/- 29 min. In the group with local anaesthesia the operation time was significantly shorter than with general anaesthesia (86 +/- 20 min vs 107 +/- 31 min; P = 0.027). The defibrillation threshold with biphasic shock application was below 24 J in all patients; thus, the implantation of an additional subcutaneous patch electrode was unnecessary. There were no major complications in either group. However, modifications were required in four patients: in one a set screw had to be re-tightened after delivery of an erroneous shock in the early postoperative phase; in another, device migration occurred several weeks after implantation, but no therapeutic intervention was required; in another, a rise in pacing threshold and partial sensing loss were noted ten days postoperatively; in the fourth, a minor pneumothorax occurred after subclavian puncture, but no further treatment was necessary. There was no intra-operative or postoperative mortality in either group. Implantation of internal cardioverter/defibrillators under local anaesthesia and mild sedation is feasible, and can be safely performed by electrophysiologists experienced in basic surgery. The newly developed smaller devices allow implantation in the subpectoral region, and with "active can' configuration and biphasic shock application, subcutaneous patch electrodes become unnecessary.
OBJECTIVE: To evaluate prospectively the safety and feasibility of the implantation of cardioverter/defibrillator systems under local anaesthesia. Conventionally, cardioverter/defibrillator systems are implanted under general anaesthesia. With the development of single-lead transvenous unipolar cardioverter/defibrillator systems for subpectoral implantation a pacemaker-like approach for device implantation appears applicable. METHODS: Implantation of a single-lead transvenous unipolar cardioverter/defibrillator under local anaesthesia with sedation for defibrillation threshold testing was performed in 37 consecutive patients. The presenting arrhythmia was ventricular fibrillation in 13 patients, and monomorphic ventricular tachycardia in 24 patients. A 1% lidocaine solution was used for local anaesthesia, and midazolam was applied for sedation to perform defibrillation threshold testing. Arterial blood pressure, arterial oxygen saturation and heart rate were monitored throughout the procedure. The patient's tolerance of the implantation procedure was evaluated with a standardized questionnaire. RESULTS: The unipolar transvenous cardioverter/defibrillator system was implanted successfully in all patients under local anaesthesia. During defibrillation threshold testing, sufficient sedation was achieved with 12.5 +/- 3.7 mg midazolam. For determination of the defibrillation threshold 5.9 +/- 1.4 episodes of ventricular fibrillation were induced. The mean defibrillation threshold was 13.1 +/- 5.5 J, and the mean duration of the implantation procedure was 68 +/- 30 min. Mean heart rate, mean arterial blood pressure and arterial oxygen saturation were not significantly different before and after defibrillation threshold testing. Twenty-six patients (70%) were symptom-free throughout the implantation procedure; most of the remaining patients reported minor symptoms. There were no complications, and patients were discharged 2.2 +/- 0.7 days after implantation. In 12 patients, post-implant testing of the implantable cardioverter/defibrillators was performed successfully, without sedation, 2.8 +/- 1.4 days after as an outpatient procedure. CONCLUSION: Single-lead unipolar transvenous implantable cardioverter/defibrillator systems can be safely implanted under local anaesthesia with mild sedation for defibrillation threshold testing. The procedure is well tolerated.
An ideal agent for local anaesthesia of the tympanic membrane has been missing so far. Recently, however, a eutectic mixture of lignocaine and prilocaine (EMLA, Astra, Södertälje, Sweden) has proved promising. We compared the anaesthetizing efficacy of EMLA, Bonain's solution (cocain, menthol, phenol ana partes) and Xylocain-spray (Astra, Södertälje, Sweden) in 42 voluntary subjects. EMLA was applied on one tympanic membrane and either one of the other two agents in the other ear of each subject. Small cotton pledgets were used for application. Sensitivity of the ear drum was tested under otomicroscope with a cotton tipped wire before and after each local anaesthesia. Full anaesthesia could be reached with EMLA very significantly (p less than 0.001) more often than with Xylocain and almost significantly (p = 0.057) more often than with Bonain's solution. Most of the test subjects preferred EMLA to Bonain's solution of Xylocain. Undesired side effects, including two tympanic membrane perforations, appeared in most of the ears anaesthetized with Bonain's solution. In the clinical part of the study, EMLA topical anaesthesia was used in 127 minor policlinical tympanic membrane procedures like myringotomy and tympanostomy tube assembling. Eighty-three of the procedures were assessed as painless, 36 unpleasant and 8 painful. A 30-min action time of EMLA was considered sufficient in most cases. No EMLA related side effects appeared. In conclusion, Bonain's solution is recommended to be replaced by EMLA or a corresponding agent for local anaesthesia of the tympanic membrane.
Midazolam is widely used as a sedative agent to produce amnesia in patients undergoing fibre-optic bronchoscopy. However, if a patient does not receive sufficient local anaesthesia, continuous severe cough and physical movement may interrupt the procedure and reduce its safety. We therefore examined whether codeine phosphate is a useful premedication for bronchoscopy. The study design was a randomized comparison between codeine phosphate and a placebo in patients undergoing light local anaesthesia and midazolam sedation. We used low dose local anaesthesia (5 ml of nebulized 2% xylocaine) on the assumption of insufficient local anaesthesia. Patients were allocated to receive codeine phosphate 0.4 mg kg-1 or a saline placebo 60 min before they were sedated with i.v. midazolam. If the patients exhibited severe cough during bronchoscopy, intrabronchial supplemental local anaesthesia (2% xylocaine solution in 1 ml increments) was instilled via a bronchoscope to the trachea and segmental bronchi to suppress the cough. The dose of supplemental xylocaine was assessed and the requirements were significantly lower in the codeine group compared to the placebo group: 36.4 +/- 10.2 mg vs. 95.1 +/- 24.6 mg, respectively. After bronchoscopy, patients were interviewed by a doctor to assess their willingness to undergo a repeat procedure if one was clinically indicated, but no significant difference was observed between the two groups. If local anaesthesia is insufficient, midazolam together with codeine phosphate premedication is useful for both the patient and the bronchoscopist.
OBJECTIVE: To investigate the relative importance of a range of explanatory variables concerning why child patients in Scotland enter pathways for tooth extractions under either Dental General Anaesthesia (DGA) or local anaesthesia (LA). BASIC RESEARCH DESIGN: A cross-sectional study was carried out involving DGA centres across Scotland. Data collected related to demographic characteristics of child DGA patients, reported anxiety and dental attendance levels of patients and parents, reasons given by referring practitioners for requesting DGA, number and type of teeth extracted and parental beliefs and attitudes to DGA. Similar data were collected relating to children having teeth extracted in primary care under LA. Multivariate analysis was performed to determine which factors were the best predictors of anaesthetic choice. RESULTS: 425 and 121 children having dental extractions under DGA and LA respectively participated. Ninety-six percent of DGA cases and 48% of LA patients had extractions for caries. For DGA cases, the mean age was 6.7 years, an average of 5.3 teeth were extracted and dental anxiety levels were higher than population norms. Multivariate analysis found the number of teeth extracted was the major predictor of anaesthetic type. On removing this variable, age became the most important factor, with 99% of children under 5.5 years receiving a DGA. Among DGA patients, 25% were reported to have had a previous DGA for tooth extraction. CONCLUSIONS: Future reductions in DGA numbers will be dependent on decreasing the number of young children presenting with advanced caries in multiple teeth. Consequently, guidelines are required concerning the prevention and appropriate management of caries in the primary dentition.
We performed 10 digital replantations under local anaesthesia. Nine were single digit replantations and one case had a digital replantation together with another digit revascularisation. Criteria for patient selection for the local anaesthetic procedure included healthy young individuals, solitary hand injury, ability to understand the procedure and a stable emotional makeup. A combination of 10 ml of lidocaine 1% and 10 ml of bupivacaine 0.5% was used for volar metacarpal block and a dorsal ring block to the base of the digit. The patient was simultaneously sedated with 10 mg diazepam intramuscularly. Standard intraoperative monitoring of blood pressure, continuous electrocardiogram and pulse oximeter were carried out. The average duration of surgery was 3 hours. There was complete pain relief intraoperatively and good postoperative sensory block for an additional 7 to 15 hours. The technical execution of microsurgery was not compromised. All replantations were successful with no complication encountered from the use of local anaesthesia.
Sixteen patients submitted to tonsillectomy under local anaesthesia in a sitting position were studied electrocardiographically. Continuous ECG monitoring was used to discover whether there were any electrocardiographic changes, especially ventricular extrasystolies, during the operation. During the entire registration time, which varied from 4.5-22.5 hours, ventricular extrasystolies were found in seven of the sixteen patients. During the operation only a single VES was seen, in one patient. We conclude that tonsillectomy done under local anaesthesia is safe from the cardiovascular point of view.
Cardiovascular hazards of laparoscopy performed under local anaesthesia and with room air pneumoperitoneum are not well known. Therefore we have recorded electrocardiogram, arterial blood pressure and central venous pressure in 63 consecutive liver patients undergoing this procedure. Electrocardiographic changes were found in 34 cases, and consisted in transistory tachycardia and bradycardia, ectopic supraventricular and ventricular beats, ST segment depression and flattening of T wave. Blood pressure did not change significantly, but five patients had transitory hypotension during the procedure. Central venous pressure did not vary immediately after inflation, but a significant increase was found during the performance of laparoscopy and it was still observed after deflation. Our findings show that cardiovascular changes during laparoscopy under local anaesthesia are minimal, and that they are probably due to neurogenic factors.
BACKGROUND: The use of local anaesthesia (LA) for vitreoretinal (VR) surgery is growing although surgeons in the UK traditionally use general anaesthesia. PURPOSE: To assess the use and attitudes towards local anaesthesia for VR surgery among the members of the British and Eire Association of Vitreo-retinal Surgeons (BEAVRS). METHODS: A questionnaire was sent to members of BEAVRS. Use of LA was assessed for the following procedures: macular hole; diabetic vitrectomy; vitrectomy; cryopexy and gas; buckling and re-buckling procedures. Attitudes of surgeons generally using LA for primary retinal detachment surgery (> 50% of cases) were compared with those generally using general anaesthesia (GA) (> 50% of cases). RESULTS: 33.6% of surgeons preferred LA for macular hole; 26.2% for diabetic vitrectomy; 23.3% for vitrectomy, cryopexy and gas; 21.4% for buckling procedures; and 9.35% for re-buckling procedures. When surgeons routinely using LA were compared with those regularly using GA they considered LA less stressful for patients and surgeon, patients tolerant to longer operations, and buckling or redo surgery no more difficult under LA. However, both groups considered surgery on young patients and teaching relatively more difficult under LA. CONCLUSION: The use of LA may convey benefits for VR surgery and faster rehabilitation for patients. However, we identified wide variations in the use of and attitudes to LA for VR surgery in British surgeons.
BACKGROUND: Thyroid surgery is usually performed under general anaesthesia. However, for a selected group of patients, local anaesthesia may be preferable. The aim of this study was to review the authors' experiences with local anaesthesia with regard to the safety and outcome of this approach. METHODS: A total of 65 consecutive patients who underwent primary thyroid surgery were accrued prospectively into this study from May to December 1999. A field block with 0.5% bupivacaine and adrenaline in 1:200 000 dilutions was given in all cases. In addition, light sedative and narcotics were given as necessary to achieve patient comfort and cooperation. The pain experienced during surgery was recorded using a visual analogue scoring system on a scale of 1-10. RESULTS: Unilateral thyroid resection was performed in 58 patients, isthmectomy in four patients and bilateral thyroid resection in three patients, two of which were in their second trimester of pregnancy diagnosed with papillary thyroid cancer. There were 55 women and 10 men with an average age of 38.2 years (range: 18-67 years). No conversion to general anaesthetic was needed, and the mean operating time was 80 min. The postoperative recovery was quick with this technique and, of interest, 22 (33.9%) patients were discharged within 6 h following the surgery. Overall 62 (95.4%) patients were discharged in the first 24 h and three (4.6%) patients after 24 h. There were no significant postoperative complications encountered except for wound infection in two (3.1%) patients. CONCLUSIONS: Thyroid surgery under local anaesthesia can be performed safely in a selected group of patients. It offers an effective alternative approach to general anaesthesia and is associated with low morbidity and high levels of patient satisfaction.
BACKGROUND: The purpose of the present study was to describe the possibility of surgical repair of anterior vaginal prolapse including amputation of the cervix using local anaesthesia. The description was made according to postoperative complication, recurrence rate, influence on urinary incontinence, and satisfaction of the patient. MATERIAL AND METHODS: Eighty-three women were consecutively operated in the anterior wall of the vagina using local anaesthesia and intravenously supplemented with propofol and fentanyl if needed, from January 1998 until September 2000 at a university clinic in Denmark. Operations executed by 16 different surgeons. Seventy patients were operated exclusively by anterior vaginal wall repair, 13 women were operated by other kinds of vaginal repair at the same time. All patients but one were interviewed by telephone. Ten patients reporting a sense of recurrence were called in for clinical examination. RESULTS: The median age was 64.5 years (range 37-85). The median follow-up period was 12.5 months (range 3-35). Median time of the operation was 25 min (range 10-60) including all patients, 20 min (range 10-60) for the patients solely operated in the anterior vaginal wall. The median time spent in hospital was 1 day (range 0-4). One patient was readmitted. Seven patients (8.4%) suffered from complications postoperatively including the patient readmitted, four of these patients were reoperated. By interview 10 women (12%) reported symptoms of prolapse again. By examination two women (2.4%) were diagnosed as recurrence, and were offered a new operation using local anaesthesia. The incontinence patterns before and after the operation are described. Seventy-nine women (95.2%) were totally satisfied with the type of anaesthesia, two women would not choose local anaesthesia for an eventually new operation, one patient did not know, and one patient was unsolved. CONCLUSIONS: The study illustrates an acceptable duration of the operation despite many different surgeons, a need of short time postoperative observation, low postoperative complication rate, low recurrence rate, and a high level of satisfaction reported by the patients. Surgical repair of anterior vaginal prolapse using local anaesthesia is described according to postoperative complication, recurrence rate, influence on urinary incontinence, and satisfaction of the patient. It is concluded that this way of handling anterior vaginal prolapse is suitable for all kinds of patients and in the out-patient clinic.
We previously demonstrated that anaesthetics affect leukocyte response by inhibiting lymphocyte capping and metabolism and the phagocytic activity of neutrophils in some experimental models. In the present study, we investigated the effects of the clinical use of three different types of anaesthesia on lymphocyte subset distribution and activity: inhalational anaesthesia (isoflurane), a neuroleptoanalgesia, or local anaesthesia was used in patients submitted to the same operation (hysterectomy). At time 0 (before administering the anaesthesia) and at 10 min and 48 h from the start of the operation, heparinized blood was obtained from each of the 30 patients studied; three lymphocyte subpopulations were isolated (CD4+, CD8+ and CD19+). Cell number was identified for each lymphocyte subset, and (as an indication of cellular function) the intracellular contents of ATP and cAMP were evaluated by luminescence methods. The relevant results for each of the 3 anaesthetic methods were as follows: i) treatment with isoflurane induced a significant reduction in the number and function of CD4+ cells at 10 min, which was reversed at 48 h; a functional but not reversible decrease of CD19+ cells was obtained, ii) treatment with neuroleptic drugs induced a significant progressive functional impairment of CD4+ and CD19+ cells, and iii) local anaesthesia caused a significant functional impairment of CD8+ cells at 48 h and a significant functional impairment of CD19+ cells at 10 min and 48 h.
Development of general anaesthesia has reduced the amount of operations performed by local anaesthesia considerably. Inevitably this will cause than junior traines in large hospitals will be less informed and instructed in local anaesthesia than his demand will be after he has left the hospital. New results of mechanism of action of local anaesthesia are given and compared with other similar drugs. Tetracain is less efficient than the drugs of the amidtype as far as surface anaesthesia activity is concerned and Procain is surpassed by amidtype anaesthesia drugs for infiltration and conductive anaesthesia use.
A technique for performing laparoscopic sterilisation under local anaesthesia and without systemic sedation is described. A mechanical tubalocclusion clip was employed. The procedure, and the technique of local anaesthesia are compared with other methods of sterilisation.
We have investigated the effect of pain without tissue injury on natural killer (NK) cell activity in peripheral blood in humans and the effect of local anaesthesia on the response. Ten subjects were investigated during two sessions. First, self-controlled painful electric stimulation was applied to abdominal skin for 30 min to an intensity of 8 on a visual analogue scale (0-10). Next, the electric intensity profile was reproduced during local anaesthesia (mepivacaine 10 mg ml-1 s.c. to a total dose of 2.5 mg kg-1). NK cell cytotoxicity was measured using a 4-h 51Cr-release assay against K562 target cells. NK cell activity increased from mean 22 (SEM 4)% (baseline) to 35 (6)% and 36 (5)% after 15 and 30 min of painful stimulation, respectively (P < 0.02). A simultaneous increase in the number of CD56+ cells in peripheral blood during pain was found. Stimulation after local anaesthesia did not change either NK cell activity or number. Parallel and significant increases in concentrations of plasma epinephrine and serum cortisol were observed. These changes were abolished by local anaesthesia. We conclude that acute severe pain without tissue injury markedly increased NK cell cytotoxicity. Local anaesthesia completely abolished this immunological and hormonal response.