Local wound infiltration with bupivacaine in lumbar laminectomy

BACKGROUND: Parenteral administration of narcotics has been the mainstay for postoperative pain relief in patients undergoing lumbar laminectomy. However, this may lead to respiratory depression and nausea, which may be hazardous in these patients. METHODS: We evaluated the efficacy of wound infiltration with bupivacaine in 45 consecutive patients undergoing elective single-level lumbar laminectomy for intervertebral disc prolapse in a prospective, double-blind, randomized controlled trial. Prior to wound closure, the muscle and subcutaneous tissues were infiltrated with bupivacaine 0.375% or sterile physiologic saline. Postoperatively, the patients were assessed hourly for pain and an analgesic administered if the patient had moderate or severe pain. RESULTS: All the 21 placebo recipients required analgesics in the first 9 hours postoperatively, compared to only 11 of 24 patients who received bupivacaine (p < 0.001). The mean (standard deviation) time before administration of the first dose of analgesic postoperatively in the bupivacaine and placebo recipients was 807.7 (567.6) minutes and 181.4 (110.1) minutes, respectively (p < 0.001). No adverse effects of local wound infiltration were noted. CONCLUSIONS: Local wound infiltration with bupivacaine is a safe and effective method for providing postoperative pain relief and reducing narcotic use in patients undergoing lumbar laminectomy.     

A case of acute pulmonary edema and bulbar paralysis after local epinephrine infiltration

A cataract developed in a 23-year-old man 4 months after a vitrectomy to repair a traumatic retinal detachment. An uneventful phacoemulsification was performed, using antibiotic-fortified infusion solution. Afterward, a large area of atrophic retina, consistent with gentamicin toxicity, was observed in the macula. The patient remains stable with 20/200 best-corrected acuity. The authors suggest that because the vitreous had been removed, gentamicin was able to settle over the macula during the entire cataract procedure. Therefore, gentamicin should be used intracamerally with caution, especially in eyes in which vitrectomy has been performed.     

Analgesia following day-case knee arthroscopy--the effect of piroxicam with or without bupivacaine infiltration

Sixty patients presenting for day-case arthroscopy of the knee under general anaesthesia were studied. Patients were randomly allocated to receive, in addition to intramuscular piroxicam 20 mg, either bupivacaine 0.25% 20 ml applied locally to the knee at the end of the procedure (n = 30) or no further intra-operative analgesia (n = 30). Visual analogue pain scores were significantly lower at 1, 2 and 4 h postoperatively in the bupivacaine group (p < 0.05). A higher proportion of patients in the piroxicam-only group required supplemental analgesia before discharge from hospital. The combination of piroxicam and bupivacaine provided superior analgesia to piroxicam alone.     

The effect of epinephrine on small-dose hyperbaric bupivacaine spinal anesthesia: clinical implications for ambulatory surgery

The effect of adding epinephrine to small doses of spinal bupivacaine on the duration of sensory motor block has not been carefully investigated. Twelve volunteers underwent hyperbaric bupivacaine spinal anesthesia (7.5 mg) with and without epinephrine (0.2 mg) in a randomized, double-blind, cross-over fashion. Sensory block was assessed with pinprick, transcutaneous electrical stimulation (TES) equivalent to surgical stimulation (at umbilicus, pubis, knee, and ankle), and tolerance of a pneumatic thigh tourniquet. Motor block was assessed with isometric force dynamometry. Discharge criteria were defined as return of pinprick sensation to dermatome S2, ability to ambulate, and ability to urinate. Extent of sensory block to pinprick over time was unaffected by the addition of epinephrine. However, epinephrine prolonged tolerance of TES at the pubis, knee, and ankle (33-48 min, P < 0.05) and of thigh tourniquet (30 min, P < 0.01). Motor block was prolonged by epinephrine at the quadriceps and gastrocnemius muscles (by 23 and 51 min, respectively, P < 0.002). Achievement of discharge criteria was prolonged by 48 min by the addition of epinephrine (P < 0.01). Thus, epinephrine may prolong surgical anesthesia for lower abdominal and lower extremity surgery and delay time until patients achieve discharge criteria. Implications: Using a cross-over study design, 12 volunteers underwent bupivacaine spinal anesthesia with and without epinephrine. This study suggests that adding epinephrine to bupivacaine may prolong surgical anesthesia and also delay patients' discharge.     

Influence of timing of administration on the analgesic effect of bupivacaine infiltration in carrageenin-injected rats

BACKGROUND: Recent evidence has suggested that the timing of administration of analgesic drugs could influence their efficacy by reducing the sensitization of the nervous system induced by the nociceptive inputs, but this concept of preemptive analgesia is still debated in both clinical and basic research. METHODS: The model of acute inflammatory pain induced by carrageenin was used to study the influence of timing of administration of bupivacaine (0.2 ml of a 0.5% solution with 0.005 mg/ml epinephrine) on the development of hyperalgesia, edema, and increase in temperature. The animals received bupivacaine 5 min before (BUPI PRE group, n = 20) or 60 min after (BUPI POST group, n = 20) carrageenin (1 ml/kg of 1% solution) was injected into the left hind paw. Two control groups (n = 15 in each) received saline 5 min before or 60 min after administration of carrageenin. Hyperalgesia of the injected paw was evaluated by the vocalization threshold to paw pressure, edema by measuring paw circumference with a thread, and plantar temperature with a thermocouple thermometer. All measurements were done before carrageenin injection then every 30 min thereafter for 240 min. Another series (n = 24), with the same four groups was also evaluated at 24 h. RESULTS: Local injection of bupivacaine 60 min after carrageenin partially reduced the edema and hyperalgesia. The injection of bupivacaine 5 min before carrageenin was more efficient than the delayed injection and reduced hyperalgesia, edema and the increase in temperature temporarily, but did not totally prevent their development. All groups were similar at 240 min and 24 h. CONCLUSIONS: These results show that a slight advantage of infiltration with bupivacaine before injury exists in this carrageenin model of acute inflammatory pain. However, this benefit is limited in time and bupivacaine did not have any preemptive analgesic effect.     

Local bupivacaine infusion following bone graft harvest from the iliac crest

A method of local analgesic delivery to the donor site after the harvest of autogenous corticocancellous bone from the iliac crest is described. The technique reduces the need for postoperative systemic analgesia and facilitates early patient mobilization.     

Local anaesthetic bupivacaine alters function of sarcoplasmic reticulum and sarcolemmal vesicles from rabbit masseter muscle

The effects of local anaesthetics, bupivacaine and lidocaine, on Ca2+ flux behaviour of sarcoplasmic reticulum and on sarcolemmal functions were studied in the rabbit masseter muscle. The experiments were performed on sarcoplasmic reticulum and sarcolemmal vesicles prepared at 1 to 10 days after injection of local anaesthetics or saline into masseter muscle as well as on sarcoplasmic reticulum vesicles prepared from non-treated rabbits (for assessment of the effect on in vitro incubation with local anaesthetics). Bupivacaine potently reduced the efficiency of active sarcoplasmic reticulum Ca2+ transport as evaluated by coupling ratio (Ca2+ transported/ATP hydrolyzed, in the presence of oxalate) at 3 days after the injection; there was only a slight degree of uncoupling of Ca2+ transport from ATP hydrolysis with lidocaine injection. Bupivacaine but not lidocaine, at 3 days after injection, decreased both the apparent permeability of sarcoplasmic reticulum vesicles to Ca2+, determined by measuring net efflux of Ca2+ after stopping pump-mediated fluxes, and the steady-state Ca2+ load in sarcoplasmic reticulum, but had no effect on overall turnover of the Ca2+ATPase. The effects of bupivacaine on apparent sarcoplasmic reticulum Ca2+ permeability and steady-state Ca2+ load were inhibited by a Ca2+ antagonist verapamil. The reduction of Ca2+ uptake of sarcoplasmic reticulum and the protective effect of verapamil were reproduced in unfractionated homogenates prepared at 3 days after bupivacaine injection. In vitro exposure of sarcoplasmic reticulum vesicles to bupivacaine (0.5 to 50 mM) reduced steady-state Ca2+ load in a dose-dependent manner. The observed effect elicited by bupivacaine (25 mM) was partially protected by procaine, an inhibitor of Ca2(+)-induced Ca2+ release from sarcoplasmic reticulum, or by specific closure of the sarcoplasmic reticulum Ca2+ release channel by ryanodine, suggesting the possibility that in vitro exposure of sarcoplasmic reticulum vesicles to bupivacaine may produce an increase in apparent permeability of sarcoplasmic reticulum to Ca2+. In sarcolemma, bupivacaine reduced Na+,K(+)-ATPase and Na(+)-Ca2+ exchange activities at 3 days after injection; the effects on sarcolemmal vesicles were prevented by verapamil. These results suggest that although the effects elicited by bupivacaine injection and the in vitro exposure to bupivacaine on steady-state Ca2+ load of sarcoplasmic reticulum vesicles were similar, the membrane properties of the vesicles from bupivacaine-treated masseter muscles and those from normal untreated muscles may not be the same, which indicates that pure bupivacaine effect is due partly by an effect on ryanodine- and procaine-sensitive Ca2+ channels.(ABSTRACT TRUNCATED AT 400 WORDS)     

Ketamine effects on bupivacaine local anaesthetic activity and pharmacokinetics of bupivacaine in mice

This study was designed to document possible changes in bupivacaine (B) local anaesthetic activity and pharmacokinetics in mice after a ketamine (K) injection. In the experiments, bupivacaine (8.25 mg.kg(-1)), was injected into the popliteal space of the right posterior limb: the local anaesthetic activity was assessed according to a sciatic nerve blockade method with three different doses (2, 10 and 40 mg/kg) of ketamine and the kinetics were studied after a 10 mg/kg dose. When ketamine was associated, the local anesthetic activity of bupivacaine was significantly enhanced as well as its elimination half-life. Significantly lower levels of the main metabolite, PPX, were observed, when ketamine was associated, suggesting a metabolic inhibition phenomenon. The ketamine-induced increase in the total anaesthetic effect of bupivacaine may thus be explained by kinetic modifications i.e. a possible inhibiting effect of ketamine on the metabolism of bupivacaine.     

Acute pharyngitis, tonsillitis and tonsillectomy

Respiratory infections are the most common group of diseases experienced in the community and treated by doctors. Tonsillitis and pharyngitis, sometimes referred to together as acute sore throat, are among the most common of the individual respiratory infections.     

The effect of tonsillectomy and adenoidectomy on neutrophil chemotaxis

Although tonsillectomy and adenoidectomy are common surgical procedures, the effects of these operations on the immune system have not been thoroughly determined. Our data on neutrophil chemotaxic functions in a group of 17 patients with chronic tonsillitis and adenoid hypertrophy show that chronic tonsillitis and adenoid hypertrophy impair neutrophil chemotaxic functions and that there is a subsequent normalization of these values following tonsillectomy and adenoidectomy.     

Peribulbar anesthesia. A prospective statistical analysis of the efficacy and predictability of bupivacaine and a lignocaine/bupivacaine mixture

Involvement of endogenous nitric oxide (NO) on glutamate receptor-mediated response was investigated in neuronal cells cultured from embryonic rat hippocampus. L-NG-Nitroarginine (NOARG), a NO synthase inhibitor, augmented NMDA- and kainate-induced increase in intracellular Ca2+ concentration ([Ca2+]i) measured by fura-2 fluorometry. However, quisqualate-induced response was not affected. The potentiating effect of NOARG was blocked by L-arginine, a substrate for NO synthase. NOARG was also effective when added after glutamate-induced response had reached a steady-state. Hemoglobin itself increased the basal level of [Ca2+]i at concentrations higher than 10 mM, and treatment of the cells with 1.0 mM hemoglobin had no effect on NMDA response. 8-Bromo-cyclic GMP was not effective on NMDA response. These results suggest that endogenous NO inhibits NMDA- and kainate-induced increase in [Ca2+]i as a negative feedback system independent of guanylate cyclase activation.     

Subcutaneous emphysema as a complication of tonsillectomy

Subcutaneous emphysema occurs when air is introduced into the tissues. This can happen as a complication during, or immediately after surgery. It has rarely been described after tonsillectomy. Definitive treatment will depend on the cause. We report two cases of subcutaneous emphysema following tonsillectomy.     

Long-term epinephrine therapy of ocular hypertension

Nineteen patients with symmetrical ocular hypertension and symmetrical cupping of the optic nerves were made asymmetric with respect to intraocular pressure for one to five years by unilateral topical treatment with epinephrine hydrochloride. Development of glaucomatous visual field defects was observed in 32% of the untreated eyes and in none of the treated eyes (P less than .05). Progressive cupping of the optic nerve was noted in 53% of the untreated eyes and in 11% of the treated eyes (P less than .025). Evidence of glaucomatous damage was observed more frequently in subjects maintained on this regimen for longer periods and in subjects with initial horizontal cup/disc ratios greater than 0.4 (P less than .05). None of the eyes, either treated or untreated, with mean intraocular pressures less than 24 mm Hg developed glaucomatous damage during the period of this study.     

Effects of epinephrine upon novelty preference and arousal.

To get evidence relevant to a choice between a theoretical interpretation asserting that it is an optimum of arousal that determines whether a person will approach or withdraw from a source of novel input, and another asserting that it is an optimum of incongruity which is crucial, a test of novelty preference was administered to human Ss before and after injections of epinephrine and of sterile Ringer's solution. To ascertain independently whether the injections of epinephrine increased arousal, measures of palmar sweating, heart rate, and pulse pressure were made before the injections, after the injections, and after the postinjection tests of novelty preference. As would be expected if incongruity rather than arousal determines the direction of response, the scores for novelty preference were no more altered by injections of epinephrine than by injections of Ringer's solution. The epinephrine failed also to increase palmar sweating. Although it did increase arousal as indicated by heart rate and pulse pressure, it is not these indices of arousal but rather that of palmar sweating which has been found associated with encountering incongruity. Thus, the failure of epinephrine to affect novelty preference has diminished relevance to the issue of whether the optimum determining direction of response to incongruous input is one of arousal or of incongruity. These is a by-product in the differential response of these various physiological indicators of arousal which with other findings calls into question the concept of generalized drive, and indicates that the differential response of these indicators to various kinds of input deserves thorough investigation. (35 ref.) (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

The effect of tonsillectomy on eustachian tube function

A two-part study was designed to investigate the effect of tonsillectomy on eustachian tube function and to identify if any change is related to postoperative pain. Middle ear pressure was measured by tympanometry and results were classified as type A (+50 daPa to -99 daPa), type B (flat) or type C (-100 daPa to -350 daPa). Thirty-one patients with type A tympanograms, undergoing tonsillectomy enrolled in study A. Patients had tympanometry the next day and filled in a questionnaire incorporating visual analogue pain scores. In study B, 30 patients underwent a similar protocol and were followed up at 1 week tympanometry and a questionnaire. A control group of 26 patients undergoing appendicectomy was recruited. Follow-up was available on 23 patients from study B. Combining A and B, on the first postoperative day 39% of patients developed type C tympanograms. No member of the control group developed any change in middle ear pressure. There was no significant relationship between pain scores for throat pain or otalgia and the development of negative middle ear pressure. By day 7 all patients had type A tympanograms. Otalgia was a delayed symptom significantly associated with increased throat pain. Transient negative middle ear pressure commonly occurs following tonsillectomy.     

A review of tonsillectomy for recurrent throat infection

Tonsillectomy is most frequently carried out for recurrent throat infection, but there is uncertainty about its effectiveness. This paper reviews the evidence of its effectiveness obtained from a search of the Cochrane database and MEDLINE for randomized controlled trials comparing tonsillectomy with non-surgical management of recurrent throat infection. The results show that the effectiveness of a procedure such as tonsillectomy, needs to be considered in the light of its adverse effects. Attempts should be made to inform patients about the uncertainty surrounding the procedure.