Efficacy of local anaesthetic and steroid combination in prevention of post-herpetic neuralgia: A meta-analysis

Objective: The objective was to provide synthesized evidence on the efficacy of local anaesthetics and steroid injections for prevention and management of PHN, compared to the standard treatment using anti-viral and analgesic medications. The primary outcomes of interest were incidence of PHN and duration of neuralgic pain. Methods: Comprehensive searches were done systematically through PubMed, Scopus, Cochrane Central Register of Controlled Trials and Google scholar databases. Randomized controlled trials that compared the efficacy of local anaesthetics and steroid injections for preventing and managing PHN were included for this meta-analysis. A comprehensive search was done for papers published until 15th July 2021. Results: A total of 10 RCTs were included in the meta-analysis. In the overall pooled analyses, compared to standard care/placebo, those receiving a combination of local anaesthetic and steroid injection had 55% lower risk of PHN at 3 months from onset of rash (RR 0.45; 95% CI, 0.29; 0.70). Out of the different modes of intervention delivery i.e., intravenous, subcutaneous and nerve block, maximum beneficial effect in reducing the incidence of PHN was noted in nerve block (RR 0.55; 95% CI, 0.34, 0.89). Conclusions: The meta-analysis provides some evidence to support the use of combined local anaesthetic and steroids in reducing risk of post-herpetic neuralgia and duration of neuralgic pain in patients with herpes zoster rash. doi: https://doi.org/10.12669/pjms.38.3.5140 How to cite this:Zhang X, Wang Z, Xian Y. Efficacy of local anaesthetic and steroid combination in prevention of post-herpetic neuralgia: A meta-analysis. Pak J Med Sci. 2022;38(3):---------. doi: https://doi.org/10.12669/pjms.38.3.5140 This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

COMPARISON OF ULTRASOUND GUIDED MODIFIED PECTORAL NERVE BLOCK WITH LOCAL ANAESTHESTIC INFILTRATION FOR ANALGESIA IN BREAST CANCER SURGERY

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 <0.001 which was statistically significant. Conclusion: Pectoral nerve block significantly reduces early postoperative pain and analgesia requirement when compared with Local anaesthesia infiltration after breast surgery.

Manual extraction of a dislodged and migrated DES from radial artery puncture site

This is a rare case of manual retrieval of a dislodged stent from radial artery access site under local anaesthetic. The LAD PCI was complicated by stent distortion which occurred due to in adequate preparation of a calcified, tortuous lesion. The dislodged stent was unable to be retrieved percutaneously and had to be left in the distal radial artery which a few weeks later migrated from the radial artery and taken out manually from the puncture site.

Supraclavicular block with Mepivacaine vs Ropivacaine, their impact on postoperative pain: a prospective randomised study

Background Supraclavicular block (SCB) with long-acting local anaesthetic is commonly used for surgical repair of distal radial fractures (DRF). Studies have shown a risk for rebound pain when the block fades. This randomised single-centre study aimed to compare pain and opioid consumption the first three days post-surgery between SCB-mepivacaine vs. SCB-ropivacaine, with general anaesthesia (GA) as control. Methods Patients (n = 90) with ASA physical status 1–3 were prospectively randomised to receive; SCB with mepivacine 1%, 25–30 ml (n = 30), SCB with ropivacaine 0.5%, 25–30 ml (n = 30) or GA (n = 30) with propofol/fentanyl/sevoflurane. Study objectives compared postoperative pain with Numeric Rating Scale (NRS) and sum postoperative Opioid Equivalent Consumption (OEC) during the first 3 days post-surgery between study-groups. Results The three groups showed significant differences in postoperative pain-profile. Mean NRS at 24 h was significantly lower for the SCB-mepivacaine group (p = 0.018). Further both median NRS and median OEC day 0 to 3 were significanly lower in the SCB-mepivacaine group as compared to the SCB-ropivacaine group during the first three days after surgery; pain NRS 1 (IQR 0.3–3.3) and 2.7 (IQR 1.3–4.2) (p = 0.017) and OEC 30 mg (IQR 10–80) and 85 mg (IQR 45–125) (p = 0.004), respectively. The GA-group was in between both in pain NRS and median sum OEC. Unplanned healthcare contacts were highest among SCB-ropivacaine patients (39.3%) vs. SCB-mepivacaine patients (0%) and GA-patients (3.4%). Conclusions The potential benefit of longer duration of analgesia, associated to a long-acting local anaesthetic agent, during the early postoperative course must be put in perspective of potential worse pain progression following block resolution. Trial registration NCT03749174 (clinicaltrials.gov, Nov 21, 2018, retrospectively registered).

Anaesthetic emergencies

This chapter discusses anaesthetic emergencies. It begins with a description of adult basic life support (BLS) and advanced life support (ALS). It goes on to describe post resuscitation care; severe bradycardia; tachycardia; severe hypo- or hypertension; severe hypoxia; laryngospasm; air/ gas embolism; gastric aspiration; severe bronchospasm; pulmonary oedema; anaphylaxis; latex allergy; intra-arterial injection; incomplete reversal of neuromuscular blockade; local anaesthetic toxicity; failed intubation; the can’t-intubate-can’t-oxygenate (CICO) scenario and malignant hyperthermia (MH).

Regional anaesthesia

This chapter discusses the techniques of regional anaesthesia and analgesia. It begins with an overview of regional anaesthesia and goes on to describe safe practice, and local anaesthetic agents. Techniques of locating nerves are then discussed, including ultrasound, and needle design is explored. Nerve blocks of the neck; upper limb; trunk; lower limb, and the neuraxis (spine) are described. Coagulation disorders, nerve injury and the management of local anaesthetic toxicity are discussed. The chapter concludes with a dermatome map and tables of recommended nerve blocks for particular operations.