The efficacy of long-acting local anesthetics for anesthesia during periodontal surgery and for analgesia during the immediate postoperative period was evaluated. The rationale for using long-acting local anesthetics such as etidocaine and bupivacaine is that they can provide surgical anesthesia and, because of their long duration, prevent discomfort that may occur for 4-6 hours postoperatively. Two clinical trials were performed. The first enrolled patients requiring bilateral periodontal surgery. Using a matched pair design and double-blind randomized study conditions, 2% lidocaine 1/100,000 epinephrine was compared with 1.5% etidocaine 1/200,000 epinephrine for periodontal surgery. The time until complete recovery and the time until pain onset were found to be longer for the etidocaine surgeries. Postoperative pain appeared more severe, and the need for oral analgesics was greater for the lidocaine surgeries. Surgeons' rating of surgical bleeding was significantly greater for the etidocaine procedures. When matched bilateral surgeries were not available, a second double-blind randomized parallel trial was performed that compared 1.5% etidocaine 1/200,000 epinephrine to 0.5% bupivacaine 1/200,000 epinephrine. No significant differences were seen in the quality of anesthesia, degree of bleeding, or postoperative pain between these two long-acting anesthetics.
In a three-phase trial, the anesthetic properties of lidocaine, bupivacaine and ropivicaine were compared in carpal tunnel release surgery. In phase I, two groups of 25 sequential patients were injected with either lidocaine plain 2% or lidocaine 2% with adrenaline 1:100,000 (E), as the local anesthetic for outpatient carpal tunnel release surgery. Subjective injection pain, postoperative pain at 2 h increments and the number of analgesic pills taken were recorded. During the first postoperative hours, outcome measures were superior in the lidocaine E group.
In phase II, a double-blind randomized design compared 42 patients injected with either lidocaine E or a combination of lidocaine E and bupivacaine. Postoperative pain scores and analgesic pills taken were compared using nonparametric statistical tests. During the first 4 h there was a slight benefit in the duration of the anesthetic and fewer pain pills were used in the bupivacaine group.
Phase III was a randomized double-blind comparison of ropivicaine and lidocaine E 2% in 72 patients. There was a slight decrease in pain scores and fewer analgesic pills required during the first 6 h in the ropivicaine group.
Lidocaine plain 2% provided significantly inferior analgesic and anesthetic properties compared with lidocaine E 2%, bupivacaine or ropivicaine. Sequential randomized comparisons between lidocaine E and bupivacaine and ropivicaine showed clinical equivalence. The present study showed lidocaine E 2% to be a satisfactory and comparatively cost-effective anesthetic for outpatient carpal tunnel surgery.
Carpal tunnel surgery; Local anesthesia
The purpose of this study is to evaluate, with the electric pulp tester, the anesthetic efficacy of the periodontal ligament injection using 2% lidocaine with 1:100,000 epinephrine and saline in human mandibular premolars. The periodontal ligament injection using 2% lidocaine with 1:100,000 epinephrine was found to be an effective technique for anesthetizing mandibular first premolars. However, the duration of profound pulpal anesthesia was approximately 10 minutes. The periodontal ligament injection using sterile saline was not an effective technique for anesthesia. Teeth mesial and distal to the injected tooth may also become anesthetized with this injection technique. The initial needle penetration and injection of the anesthetic solution in clinically healthy teeth were only mildly discomforting. No increase in tooth mobility was observed 45 minutes after the periodontal ligament injection. No clinically observable pulpal or periodontal damage was seen at 3 weeks after the injection.
A controlled, randomized, double-blind, within-patient, crossover study was made with 50 patients (28 women and 22 men) of mean age 47 years (range, 32-69 years) who were subjected to identical bilateral gingivectomies. On one occasion, lidocaine 2% was infiltrated as the local anesthetic. On the other occasion, lidocaine 2% with epinephrine 1:80,000 was given. Postoperative pain intensity was recorded by the patients on a 100-mm visual analogue scale every hour during an 11-hour observation period. The mean pain intensity was numerically higher after lidocaine 2% at 0 hours and 1 hour postoperatively. Then the mean pain intensity after lidocaine 2% was lower than that after lidocaine 2% with epinephrine 1:80,000 throughout the remaining observation period. The difference in pain intensity was statistically significant (P < .05) at 2, 4, 5, 6, and 7 hours after surgery. Mean sum (SEM) pain intensity over the 11-hour observation period was lower (P = .03) after lidocaine 2%, 66.5 (13.4) mm than after lidocaine 2% with epinephrine 1:80,000, 92.6 (15.4) mm. The study shows that high epinephrine concentration (1:80,000) increases the postoperative pain after dental soft tissue surgery with mild pain.
The purpose of this study was to compare the postoperative analgesic efficacy of the presurgical intravenous administration of a steroid (dexamethasone), a nonsteroidal anti-inflammatory drug (ketorolac), and a combination of the two medications. These drugs were administrated preoperatively, and their analgesic effects were assessed following the removal of four third molars using intravenous sedation (Fentany/Midazolam) and local anesthetic (2% lidocaine with 1:100,000 epinephrine). Thirty-four patients were randomly assigned to one of four groups: Group I (control), saline; Group II, 30 mg ketorolac; Group III, 8 mg dexamethasone; and Group IV, 30 mg ketorolac + 8 mg dexamethasone. Pain was assessed with the Heft-Parker graphic pain rating scale; the initial survey was completed preoperatively. The teeth were surgically removed by one of four oral and maxillofacial surgeons. Following surgery and initial recovery, the patients completed the second survey and were then admitted for overnight observation. The patients completed the remaining pain rating scales at 2-hr intervals for 12 hr. The last survey was completed at discharge (24 hr postoperatively). A postoperative narcotic analgesic was provided upon request (Tylenol 3). Pain data were assessed using one-way analysis of variance and the Duncan multiple range test (α = 0.05). At all postoperative intervals, the greatest pain scores were recorded in the control group. Statistically significant differences in pain scores were found at the 4-, 6-, 8-, and 10-hr postoperative intervals. At the 2-hr postoperative interval, pain had increased in all groups, but no differences were found among the groups. At the 4- and 6-hr interval, pain levels in Group I were significantly greater than those in Group II and Group IV, with Group III and IV not significantly different from Group II. At 10 hr, pain levels in the saline group were significantly greater than those in all the other groups. At all intervals, the only significant differences detected were found between the control group and the experimental groups; no significant differences were found at any point among any of the experimental groups. The relationship between the number of doses of narcotic medication taken postoperatively, and the preoperative intravenous regimen was assessed with a Kruskal-Wallis test. No significant difference was found among groups with respect to the need for postoperative pain medication (P > 0.05). Postoperative analgesia following third molar surgery was enhanced in the first 10 hr with the preoperative administration of ketorolac. The addition of dexamethasone did not improve the analgesic effect.
Analgesic efficacy; Pain control; Nonsteroidal anti-inflammatory drugs; Steroids
This study was undertaken to investigate whether plain lidocaine, 3% plain mepivacaine and 3% prilocaine with felypressin were suitable epinephrine-free local anesthetic solutions for use in periodontal ligament anesthesia as alternatives to lidocaine with 1:80,000 epinephrine. Two hundred and seven patients received one of the four test solutions via a periodontal ligament injection and the success rate of anesthesia was confirmed using an electric pulp stimulator. Although neither mepivacaine nor prilocaine were as effective as lidocaine with epinephrine, the success rates of these three solutions were not statistically different. A single periodontal ligament injection of any of the solutions tested resulted in a low incidence of anesthesia. The success rate of lidocaine without epinephrine was consistently poor.
This investigation evaluated the use and efficacy of prilocaine HCl (4% plain Citanest) for minimizing pain associated with the intraoral administration of local anesthesia. Clinical anecdotes support the hypothesis that prilocaine without a vasoconstrictor reduces pain during injection. To determine relative injection discomfort, use of 4% plain prilocaine was compared with use of 2% lidocaine with 1:100,000 epinephrine and 2% mepivacaine with 1:20,000 levonordefrin. Prior to routine endodontic procedures, 150 adult patients received 0.3 to 1.8 mL of local anesthetic via the same gauge needle without the use of a topical local anesthetic. Injection methods included buccal infiltration, labial infiltration, palatal infiltration, and inferior alveolar nerve block. Following each injection, patients were asked to describe the level of discomfort by scoring on a visual analog scale of 1 to 10, where 1 = painless and 10 = severe pain. Analyses via 2-way analysis of variance revealed no interaction between anesthetic and site of injection. However, there were statistically significant differences among the injection sites. Post hoc analysis revealed that prilocaine was associated with significantly less pain perception when compared to mepivacaine and lidocaine. These results suggest that differences in initial pain perception during transmucosal injection may be a function of the local anesthetic use, and prilocaine can produce less discomfort than the others tested.
The aim of the present clinical trial was to compare pain during injection of anterior middle superior alveolar (AMSA) technique with that of infiltration injection technique in the maxilla in periodontal flap surgeries of patients referring to the Department of Periodontics, Faculty of Dentistry, Tabriz University of Medical Sciences.
Twenty subjects with an age range of 20 to 40 years were selected for the present study. One side of the maxilla was randomly selected as the test side and the other as the control side using a flip of a coin. AMSA technique was used on the test side and infiltration technique was used on the control side for anesthesia. On both sides 2% lidocaine containing 1:80,000 epinephrine was used for anesthesia. The operator obtained the visual analogue scale for each patient immediately after the injection and immediately after surgery. Data was analyzed using descriptive statistical methods (frequency percentages, means and standard deviations) and Wilcoxon's test using SPSS ver. 13 (SPSS Inc.). Statistical significance was defined at P<0.05.
There were no statistically significant differences in pain during injection between the two techniques (P=0.856). There were statistically significant differences in postoperative pain between the two injection techniques (P=0.024).
Postoperative pain in AMSA injection technique was less than that in the infiltration technique. Therefore, the AMSA technique is preferable in the periodontal surgeries for the anesthesia of palatal tissues given the fact that it has other advantages, too.
Injections; Local anesthesia; Maxilla; Periodontium
The purpose of this study was to compare the analgesic efficacy of a single-dose of preoperative intravenous tramadol versus diclofenac in preventing pain after third molar surgery.
Materials and Methods
Fifty patients undergoing elective third molar surgery were randomly assigned into one of the two groups (25 in each group): Group 1 received diclofenac 75 mg, and Group 2 received tramadol 50 mg intravenously preoperatively before the surgery. After injection of the study drugs, the impacted third molars were removed under local anesthetic agent.
The difference in postoperative pain was assessed by four primary end-points: pain intensity as measured by a 100 mm visual analogue scale hourly for 12 h, median time to rescue analgesic, postoperative acetaminophen consumption, and patient’s global assessment. Throughout the 12 h investigation period, patients reported significantly lower pain intensity scores in the diclofenac versus tramadol group (P = 0.0001, Mann–Whitney U-test). Patients also reported significantly longer median time to rescue analgesic (10 vs. 8 h, P < 0.05, Student t test), lesser postoperative acetaminophen consumption (P < 0.05, Student t test) for the diclofenac versus tramadol group.
Preoperative intravenous diclofenac 75 mg is more effective than tramadol 50 mg in the prevention of postoperative dental pain.
Preemptive analgesia; Diclofenac; Tramadol
The need to relieve pain and inflammation after periodontal surgery and the side effects of systemic drugs and advantages of topical drugs, made us to evaluate the effect of Diclofenac mouthwash on periodontal postoperative pain.
In this double-blind, randomized clinical trial study 20 quadrants of 10 patients(n = 20) aged between 22-54 who also acted as their own controls, were treated using Modified Widman Flap procedure in two quadrants of the same jaw with one month interval between the operations.
After the operation in addition to ibuprofen 400 mg, one quadrant randomly received Diclofenac mouthwash (0/01%) for 30 seconds, 4 times a day (for a week) and for the contrary quadrant, ibuprofen and placebo mouthwash was given to be used in the same manner. The patients scored the number of ibuprofen consumption and their pain intensity based on VAS index in a questionnaire in days 1, 2, 3 and the first week after operation. The findings were analysed using two-way ANOVA, t-test and Wilcoxon. P-value less than 0.05 considered to be significant.
There was a significant difference between the mean values of pain intensity of two quadrants in four periods (P = 0.031). But, there was no significant difference between the average ibuprofen consumption in two groups (P = 0.51). Postoperative satisfaction was not significantly different in two quadrants (P = 0.059). 60% of patients preferred Diclofenac mouthwash.
Diclofenac mouthwash was effective in reducing postoperative periodontal pain but it seems that it isn’t enough to control postoperative pain on its own.
Diclofenac; Mouthwash; Pain; Pain measurement
The efficacy of a nonsteroidal anti-inflammatory agent, ketorolac tromethamine, was evaluated in pain control after periodontal surgery. This type of agent acts peripherally by inhibiting the release of prostaglandins and minimizing the local inflammatory response. Thus, there may be an advantage in pretreatment administration of ketorolac tromethamine, 10 mg, compared with placebo on operative pain during periodontal surgery.
Materials and Methods:
Two groups of 40 outpatients from the Department of Periodontology, Darshan Dental College and Hospital, Udaipur, were selected for this study. Patients who were to undergo periodontal surgery were randomly given either one group 10 mg ketorolac immediately before surgery or the other group placebo tablets at least 30 minutes before administration of local anesthesia (LA). All procedures were performed under LA, and the total volume of anesthetic used was recorded. The duration of surgery from the time of incision to the placement of the last suture was recorded. At the completion of the surgery, patients were supplied with printed record forms and were asked to rate their subjective operative pain intensity using a visual analog scale.
The data were analyzed using the student t test.
Results indicated that preoperative treatment with ketorolac significantly reduced initial pain intensity of operative pain as compared with placebo. No adverse reactions related to preoperative medication were observed.
The results of this study showed that 10-mg ketorolac administered immediately before periodontal surgery was effective for alleviating the operative painful sequelae.
Ketorolac; operative pain; pain/prevention and control; periodontal surgery
The purpose of this prospective, randomized, double-blind crossover study was to compare the anesthetic efficacy of 2% mepivacaine with 1 : 20,000 levonordefrin versus 2% lidocaine with 1 : 100,000 epinephrine in maxillary central incisors and first molars. Sixty subjects randomly received, in a double-blind manner, maxillary central incisor and first molar infiltrations of 1.8 mL of 2% mepivacaine with 1 : 20,000 levonordefrin and 1.8 mL of 2% lidocaine with 1 : 100,000 epinephrine at 2 separate appointments spaced at least 1 week apart. The teeth were electric pulp tested in 2-minute cycles for a total of 60 minutes. Anesthetic success (obtaining 2 consecutive 80 readings with the electric pulp tester within 10 minutes) was not significantly different between 2% mepivacaine with 1 : 20,000 levonordefrin and 2% lidocaine with 1 : 100,000 epinephrine for the central incisor and first molar. However, neither anesthetic agent provided an hour of pulpal anesthesia.
Lidocaine; Epinephrine; Mepivacaine; Levonordefrin; Infiltration; Maxillary
The purpose of this study was to investigate the effectiveness of a combination of bupivacaine and lidocaine and that of lidocaine alone for local dental anesthesia. First, on different days, healthy volunteers were given 2% lidocaine with 1/80,000 epinephrine or 2% lidocaine with 1/80,000 epinephrine + 0.5% bupivacaine, after which pain was produced with a pulp tester. No difference was found in the time until onset of anesthetic effect between the preparations. However, the duration of anesthetic effect was longer with both lidocaine and bupivacaine than with lidocaine alone. Next, patients undergoing dental surgery were given one of the anesthetic preparations, after which serum concentrations of the anesthetics and epinephrine were measured. The maximal serum concentration of lidocaine was higher and was reached sooner after injection in patients receiving lidocaine alone (1.74 microgram/ml after 5 min) than in patients receiving both anesthetics (0.85 microgram/ml after 3 min). The mean maximal serum concentration of lidocaine was higher in patients receiving lidocaine alone (1.77 +/- 0.03 microgram/ml) than in those receiving both anesthetics (0.99 +/- 0.45 microgram/ml). Furthermore, the mean plasma concentration of epinephrine 1 min after injection was significantly higher in patients receiving lidocaine alone (0.671 ng/ml) than in patients receiving both lidocaine and bupivacaine (0.323 ng/ml). The results of this study suggest that the combination of lidocaine with epinephrine and bupivacaine produces lower systemic levels of the anesthetic and epinephrine and a longer duration of activity than lidocaine with epinephrine alone for local dental anesthesia.
Expected blood levels of common local anesthetics have been reported for numerous types of injections. Comparative levels of mepivacaine and lidocaine after dental injection have been only partially evaluated. A study was designed to compare the circulating serum level of 36 mgs. of mepivacaine with 1:20,000 levonordefrin (M) and 36 mgs. of lidocaine with 1:100,000 epinephrine (L) in 1.8 cc dental cartridges after standardized's bilateral maxillary infiltrations. Each of five subjects received 1.8 cc of (L) to the left maxillary second bicuspid and 1.8 cc of (M) to the right maxillary second bicuspid at a rate of one cc per minute. The serum was sampled before the injections and at 5, 15, 30, 60, 90, 120 and 240 minute intervals after the injections and analyzed by gas liquid chromatography. The results indicated that the serum level of (M) peaked at 30 minutes, 0.37 μg/ml of serum and (L) had peaks at 15 and 30 minutes, 0.22 μg/ml of serum. This difference was statistically significant, (p <.01) at all times sampled with (M) always resulting in a higher serum level. Serum levels persisted throughout the four hour test period.
Postanesthetic pain is a relatively common complication after local anesthesia. This complication may be caused by the anesthetic technique or by the anesthetic solution used. Tissue reactions induced by the anesthetic solutions may be one of the factors resulting in pain after anesthesia. The objective of this study was to comparatively analyze tissue reactions induced by different anesthetic solutions in the subcutaneous tissue of rats. The following solutions were utilized: 2% lidocaine without vasoconstrictor; a 0.5% bupivacaine solution with 1:200,000 adrenaline; a 4% articaine solution and 2% mepivacaine, both with 1:100,000 adrenaline; and a 0.9% sodium chloride solution as a control. Sterilized absorbent paper cones packed inside polyethylene tubes were soaked in the solutions and implanted in the subcutaneous region. The sacrifice periods were 1, 2, 5, and 10 days after surgery. The specimens were prepared and stained with hematoxylin and eosin for histological analysis. The results showed that there is a difference in tissue irritability produced by the local anesthetic solutions. The results also showed that there is no relation between the concentration of the drug and the inflammatory intensity, that the mepivacaine and articaine solutions promoted less inflammatory reaction than the bupivacaine, and that the lidocaine solution produced the least intense inflammation.
The purpose of this prospective, randomized, double-blind study was to compare the pain of injection, heart rate increase, and postinjection pain of the intraligamentary injection of 4% articaine with 1:100,000 epinephrine and 2% lidocaine with 1:100,000 epinephrine administered with a computer-controlled local anesthetic delivery system. Using a crossover design, intraligamentary injections of 1.4 mL of 4% articaine with 1:100,000 epinephrine and 1.4 mL of 2% lidocaine with 1:100,000 epinephrine were randomly administered on the mesial and distal aspects of the mandibular first molar with a computer-controlled local anesthetic delivery system in a double-blind manner at 2 separate appointments to 51 subjects. The results demonstrated the incidence of moderate pain was 14%-27% with needle insertion, with 0%-4% reporting severe pain. For solution deposition, moderate pain was reported 8%-18% of the time, with no reports of severe pain. There were no significant differences between the articaine and lidocaine solutions. Regarding heart rate changes, neither anesthetic solution resulted in a significant increase in heart rate over baseline readings. On day 1 postinjection, there was a 31% incidence of moderate/severe pain with the articaine solution and 20% incidence of moderate/severe pain with the lidocaine solution. The moderate/severe pain ratings decreased over the next 2 days. There were no significant differences between the articaine and lidocaine solutions. We concluded that the intraligamentary injection of 4% articaine with 1:100,000 epinephrine was similar to 2% lidocaine with 1:100,000 epinephrine for injection pain and postinjection pain in the mandibular first molar when administered with a computer-controlled local anesthetic delivery system. For both anesthetic solutions, heart rate did not significantly increase with the intraligamentary injection using the computer-controlled local anesthetic system.
Perioperative lidocaine infusion improves postoperative outcomes, mostly after abdominal and urologic surgeries. Knowledge of the effect of lidocaine on peripheral surgeries is limited. Presently, we investigated whether intraoperative lidocaine infusion reduced anesthetic consumption, duration of ileus, pain intensity, analgesic consumption and hospital stay after breast plastic surgeries.
Sixty female patients, aged 20-60 years, enrolled in this prospective study were randomly and equally divided to two groups. One group (n = 30) received a 1.5 mg/kg bolus of lidocaine approximately 30 min before incision followed by continuous infusion of lidocaine (1.5 mg/kg/h) until skin closure (lidocaine group). The other group (n = 30) was untreated (control group). Balanced inhalation (sevoflurane) anesthesia and multimodal postoperative analgesia were standardized. End tidal sevoflurane concentration during surgery, time to the first flatus and defecation, visual analog pain scale (0-10), analgesic consumption and associated side effects at 24, 48, and 72 h after surgery, hospital stay, and patient's general satisfaction were assessed.
Compared to the control group, intraoperative lidocaine infusion reduced by 5% the amount of sevoflurane required at similar bispectral index (P = 0.014). However, there were no significant effects of lidocaine regarding the return of bowel function, postoperative pain intensity, analgesic sparing and side effects at all time points, hospital stay, and level of patient's satisfaction for pain control.
Low dose intraoperative lidocaine infusion offered no beneficial effects on return of bowel function, opioid sparing, pain intensity and hospital stay after various breast plastic surgeries.
Analgesic consumption; Anesthetic consumption; Bowel function; Hospital stay; Intravenous lidocaine; Pain score
The infiltration of local anesthetics can be painful, which is likely due, in part, to their acidity. In spite of a Cochrane study that recommended neutralizing lidocaine with bicarbonate to decrease the pain of injection, not many surgeons have adopted the practice, and there are many ‘recipes’ for how much bicarbonate one should add.
To determine the acidity of lidocaine and the correct ratio of bicarbonate that should be added to neutralize lidocaine to achieve body pH.
Fifty samples each of commonly used anesthetics (lidocaine 1% and 2%, with and without epinephrine 1:100,000) were obtained and tested for pH. Data were also analyzed according to whether the vials had been previously opened. Ten additional samples of lidocaine 1% with 1:100,000 epinephrine were titrated against sodium bicarbonate 8.4% and tested for pH and the presence of precipitate.
A solution of 1% lidocaine with 1:100,000 epinephrine had a mean (± SD) pH of 4.24±0.42, and 2% lidocaine with 1:100,000 epinephrine had a mean pH of 3.93±0.43. Plain 1% lidocaine had a pH of 6.09±0.16, and plain 2% lidocaine had a pH of 6.00±0.27. Epinephrine-containing solutions were more acidic when they had been previously opened. One per cent lidocaine with epinephrine required 8.4% sodium bicarbonate at a ratio of 1.1 mL:10 mL to 1.8 mL:10 mL to achieve the target tissue pH of 7.38 to 7.62.
Lidocaine with epinephrine was approximately 1000 times more acidic than subcutaneous tissue. The addition of bicarbonate to the local anesthetic solution is simple to perform and is inexpensive. The proper volume ratio of 8.4% sodium bicarbonate to 1% lidocaine with 1:100,000 epinephrine is approximately 1 mL:10 mL. Surgeons should be more aware of the simplicity and value of buffering with bicarbonate to decrease the pain of injection.
Anesthetics; Epinephrine; Lidocaine; Local; Pain of injection; pH
A double-blind method was used to compare anesthesia duration following intraligamental administration of 1.5% etidocaine with 1:200,000 epinephrine and 2% lidocaine with 1:100,000 epinephrine. Durations of anesthesia in pulpal and soft tissues were monitored following periodontal ligament injections adjacent to the maxillary canines of 20 individuals. Complete pulpal anesthesia was attained in 35% of the teeth injected with etidocaine and in 55% of those receiving lidocaine. Soft tissue anesthesia was consistently achieved. Both pulpal and soft tissue anesthesia were of longer duration following the use of lidocaine solution. These findings suggest that anesthetic duration following periodontal ligament injections is more related to the concentration of vasoconstrictor than to the anesthetic solution employed.
PURPOSE: Blepharoptosis repair by levator advancement is successful in most instances, but the postoperative eyelid level is not uniformly predictable. This study was undertaken to evaluate the possible effect of epinephrine (from local anesthetic) on eyelid position. METHODS: Seventeen adults with acquired unilateral ptosis as a result of levator aponeurosis dehiscence underwent levator aponeurosis advancement. The distance between the upper eyelid margin and the central corneal light reflex was measured preoperatively with the patient in both the upright and the supine position, 10 minutes after injection of 1.0 mL of anesthetic solution (2% lidocaine with 1:100,000 epinephrine and 12 U hyaluronidase per mL) in the supine position, intraoperatively after skin closure in the supine position, and 1 week or more postoperatively in the upright position. The ptotic lid was positioned intraoperatively in relation to the contralateral unoperated lid according to the change (presumably) induced by epinephrine stimulation of Müller's muscle. RESULTS: Eleven (65%) of the 17 patients had final postoperative lid positions within 1 mm between eyes. Two patients (12%) had undercorrection. Four patients (24%) had overcorrection by > 1 mm. The overcorrected lids were satisfactorily positioned, however, and none required further surgery; in 3 of these 4 patients, the unoperated lid had become ptotic, probably as a result of Hering's law. Differences between operated and unoperated lids and between the different times of measurement were analyzed. Significant changes in lid position occurred in the ptotic lids after injection (mean, +1.1 +/- 1.5 mm; median, +1.0 mm; P = .004) and in the final intraoperative difference between operated and unoperated lids (mean, +0.8 +/- 0.9 mm; median, +1.0 mm; P = .003). The change in the unoperated lid from preoperative upright to preoperative supine was significantly greater in the 6 failures (mean, -0.8 +/- 0.6 mm; median, -1.0 mm) than in the 11 successful outcomes (mean, +0.1 +/- 0.8 mm; median, 0.0 mm; P = .03). The change in unoperated lid position after injection of the ptotic lid was significantly greater in the failures (mean, +0.4 +/- 0.5 mm; median, +0.3 mm) than in the successful cases (mean, -0.2 +/- 0.4 mm; median, 0.0 mm; P = .02). CONCLUSION: Although it seems intuitively reasonable and clinically appropriate to account for the stimulatory effect of epinephrine during ptosis surgery, such intraoperative compensation alone did not yield a universally successful outcome in this study.
The effects of administering an epinephrine-containing local anesthetic on plasma catecholamine levels and cardiovascular parameters were evaluated. Significant elevations were observed following administration of 8 dental cartridges of 2% lidocaine with epinephrine 1:100,000 (144 μg) throughout the 20 minute observation period, while minimal changes were observed in the patients who received 6 cartridges of 3% mepivicaine. One minute after injection, the mean plasma epinephrine level in the group receiving epinephrine was 27.5 times higher than baseline. Concurrent elevations in systolic pressure (15%), heart rate (33%), and the rate-pressure product (52%) were also observed. These results indicate that significant amounts of epinephrine can be systemically absorbed following intraoral injection and the absorbed epinephrine can alter the cardiovascular status of the patient.
In a double-blind study conducted in 112 patients undergoing removal of four impacted third molar teeth, etidocaine hydrochloride 1.5% solution with epinephrine 1:200,000 and lidocaine hydrochloride 2.0% solution with epinephrine 1:100,000 were used, one on each side of the face, to produce inferior alveolar nerve block, infiltration anesthesia of the maxillary tooth and hemostasis of the mucoperiosteum around each tooth.
Surgically adequate anesthesia was rapidly produced by both agents but the duration of action of etidocaine was longer than that of lidocaine as reflected in more prolonged numbness of the lip and delayed onset of pain. Moreover, after etidocaine treatment fewer patients reported severe pain as the local anesthesia receded. No adverse local or systemic effects were observed in, or reported by, any of the patients.
Background and purpose
High-volume infiltration analgesia may be effective in postoperative pain management after hip arthroplasty but methodological problems prevent exact interpretation of previous studies.
In a randomized, double-blind placebo-controlled trial in 12 patients undergoing bilateral total hip arthroplasty (THA) in a fast-track setting, saline or high-volume (170 mL) ropivacaine (0.2%) with epinephrine (1:100,000) was administered to the wound intraoperatively along with supplementary postoperative injections via an intraarticular epidural catheter. Oral analgesia was instituted preoperatively with a multimodal regimen (gabapentin, celecoxib, and acetaminophen). Pain was assessed repeatedly for 48 hours postoperatively, at rest and with 45° hip flexion.
Pain scores were low and similar between ropivacaine and saline administration. Median hospital stay was 4 (range 2–7) days.
Intraoperative high-volume infiltration with 0.2% ropivacaine with repeated intraarticular injections postoperatively may not give a clinically relevant analgesic effect in THA when combined with a multimodal oral analgesic regimen with gabapentin, celecoxib, and acetaminophen.
The purpose of this study was to measure the degree of anesthesia obtained with 4% prilocaine with 1:200,000 epinephrine and 2% mepivacaine with 1:20,000 levonordefrin compared with 2% lidocaine with 1:100,000 epinephrine for inferior alveolar nerve block. Using a repeated measures design, 30 subjects randomly received an inferior alveolar injection using masked cartridges of each solution at three successive appointments. The first molar, first premolar, lateral incisor, and contralateral canine (control) were blindly tested with an Analytic Technology pulp tester at 3-min cycles for 50 min. Anesthetic success was defined as no subject response to the maximum output of the pulp tester (80 reading) within 16 min and maintenance of this reading for the remainder of the testing period.
Although subjects felt numb subjectively, anesthetic success as defined here occurred in 46% to 57% of the molars, in 50% to 57% of the premolars, and in 21% to 36% of the lateral incisors. No statistically significant differences in onset, success, failure, or incidence were found among the solutions. We conclude that the three preparations are equivalent for inferior alveolar nerve block of 50-min duration.
The effect of lidocaine and bupivacaine on postoperative pain were compared in a double blind crossover study. Diflunisal (500 mg) was used as an analgesic and given before commencement of the surgical procedure.
Bilateral impactions of lower third molars were removed on two occasions, four weeks apart, in a sample of 26 Chinese patients. One local anesthetic was used on one occasion and the alternate on the second. Pain intensity was indicated on a visual analogue scale hourly for eight hours, beginning one hour after the start of surgery.
Pain at each postoperative hour was lower after bupivacaine and more patients indicated little or no pain after bupivacaine than after lidocaine. This was not reflected in patients' preference: 12 preferring lidocaine, 11 bupivacaine, and 3 indicating no preference, an important reason being a shorter period of numbness with lidocaine.
Although diflunisal was given preoperatively, the postoperative course was not complicated by alveolitis in any case.
While bupivacaine plus diflunisal resulted in less postoperative pain than lidocaine plus diflunisal, some patients were willing to sustain some pain after oral surgery if sensation was regained sooner.