The aim of this study was to evaluate the patient's experience of transnasal flexible laryngo-oesophagoscopy under local anaesthetic in an out-patient setting. This was a clinical observational study using a patient questionnaire and visual analogue score. Subjects were 50 patients seen in the hospital's ENT outpatient clinic between March and August 2004 in whom transnasal flexible laryngo-oesophagoscopy was performed and who completed pain discomfort questionnaires. Any patient undergoing transnasal flexible laryngo-oesophagoscopy, for either diagnostic or therapeutic purposes, was included in the study. Patients in whom transnasal flexible laryngo-oesophagoscopy was not necessary as part of their investigation or treatment were excluded. Patients completed a questionnaire, providing a simple visual analogue score for discomfort during the procedure. Any operative complications were noted by the surgeon. All patients completed transnasal flexible laryngo-oesophagoscopy, and the upper aerodigestive tract was clearly visualized. The procedure is well tolerated, with mean score of <  1 out of 10 for all forms of discomfort. There was a complication rate of 2 per cent (one patient with epistaxis); no other complications occurred. Transnasal flexible laryngo-oesophagoscopy is a new diagnostic and therapeutic technique which is well tolerated by patients. It compares favourably with other flexible endoscopic techniques. This report documents for the first time a detailed description of patients' experience of this technique.

We have studied the apnoea time after induction with two successful drug intubating regimes, both containing remifentanil. Group 1 (n=20); propofol 2 mg kg−1 and remifentanil 2 μg kg−1 and group 2 (n=20); propofol 2 mg kg−1, remifentanil 1 μg kg−1 and lignocaine 1 mg kg−1. Intubation was possible in all 40 patients, and regarded as acceptable in 90% and 85% of patients, respectively. The median time to the return of spontaneous respiration was 487 s in group 1 and 270 s in group 2 (P < 0.05). Median end-tidal CO2 concentration at the time of the first spontaneous respiration was 7.37 kPa in group 1 and 6.3 kPa in group 2 (P < 0.05). Both groups had a decrease in heart rate after induction, but this failed to reach either clinical or statistical significance, and no patient required atropine. Similarly, there was a decrease in arterial pressure after induction in both groups (P < 0.05), but this was not deemed to be clinically significant. Only two patients in each group required ephedrine 6 mg before arterial pressure was restored to within 25% of the base-line. Intubating conditions were similar in both groups, but group 2 provided a significantly shorter apnoea time.

Lignocaine added to the anaesthetic preparation Diprivan® reduces propofol induced pain on injection. This effect is due to a drop in pH which decreases the content of propofol in the aqueous phase of the soya bean emulsion. This in turn changes the electrostatic forces in the emulsion and destabilization occurs. The effect of lignocaine on the anaesthetic potency of propofol was validated in a randomized blind study in the rat. The induction dose of 1% propofol mixed with 1% lignocaine (10+1) was significantly higher when compared with the induction dose of propofol 1% given after a separate injection of 1% lignocaine (9.4±5.5 vs. 5.6±5.2 mg; P<0.05). The duration of sleep was shorter in rats injected with propofol 1% mixed with lignocaine 1% (10+1) compared with those given 1% lignocaine and 1% propofol in separate injections (160±181 vs. 375±202 s; P<0.05). The anaesthetic potency of propofol was not significantly changed by the addition of either saline or hydrochloric acid. The anaesthesia inducing effect was not time-dependent. A similar lower potency was observed for a solution stored for 4 h compared with one freshly prepared, although sleeping time was longer (9.2±6.8 mg; 428±110 s) as compared with the 4 h mixture. The results indicate that lignocaine altered the propofol preparation. The reduced anaesthetic potency of propofol after addition of lignocaine is not due to the resultant drop in pH, which is known to occur.

Controversy persists over the efficacy of intercostal nerve block administered through a tunnelled extrapleural catheter. We have undertaken a randomized, prospective double-blind trial of two different local anaesthetic regimes to evaluate the effect of this technique on post-thoracotomy pain relief and pulmonary function. Sixty-eight patients were randomized to receive bupivacaine 0.25% (n=22), lignocaine 1% (n=21) or 0.9% NaCl (saline) (n=20) via an extrapleural catheter, inserted peroperatively. All patients underwent a standard posterolateral thoracotomy. Pain was assessed using a visual analogue pain score and by the requirement for opiate analgesia. Pulmonary function was measured using bedside spirometry. Pain scores were lower in the local anaesthetic groups at 24, 32 and 72 h compared with placebo (P< 0.05) and the total amount of opiate required was less than placebo for both lignocaine and bupivicaine (P< 0.05). Pulmonary function was better in the local anaesthetic groups throughout the post-operative period and was most pronounced at 24 h with a mean improvement of 30% for forced expiratory volume (FEV1), 24% for forced vital capacity (FVC) and 19% for peak expiratory flow rate (PEFR) compared with placebo. There was no significant difference between pain scores, opiate requirement or pulmonary function between lignocaine and bupivicaine. CT scanning demonstrated containment of the local anaesthetic in an extra-pleural tunnel. Extra-pleural infusion of local anaesthetics is a simple technique, with low risk of complications and provides effective pain relief as well as an improvement in post-operative pulmonary function. Lignocaine is equally as effective as bupivacaine and its use would result in some cost-saving.

Lignocaine is a suitable and safe agent for intravenous regional anaesthesia (IVRA) with rapid onset of good surgical anaesthesia. The onset time of the local anaesthetic action of lignocaine was 11.2±5.1 min. Satisfactory surgical conditions, evidenced by good sensory blockade were achieved within 20 min, and no additional analgesics were required. There was no trend towards a fixed sequence, radial, median and ulnar in the development of sensory blockade. No patient exhibited objective symptoms of toxicity, either local or systemic, after release of the tourniquet, nor were there any subjective complaints. No changes in blood pressure, heart rate or oxygen saturation were observed at any time during the procedure, or after deflation of the tourniquet. After releasing the tourniquet lignocaine is rapidly and biexponentially eliminated, with a t1/2a of 4.3±2.1 min and a t1/2β of 79.1±31.2 min. Total body clearance was 0.86 ± 0.39L min−1. Eight patients showed rapid release of lignocaine from the exsanguinated area. In two patients the systemic plasma concentration of lignocaine increased more slowly than in the remaining eight. This can be explained by a greater degree of lignocaine absorbtion in the tissues of the arm. Pharmacokinetic constants after rapid and slow absorption were calculated.

Topical anaesthesia of the trachea is used to avoid coughing during emergence from anaesthesia. This study was designed to compare the effects of an alkalinized lignocaine and plain lignocaine solution given intratracheally. After institutional approval and written informed consent, 30 patients were randomized into three groups and received in a double-blind fashion: lignocaine, alkalinized lignocaine and normal saline for control. After application of normal or alkalinized lignocaine the tolerance to the tube was significantly better during extubation (P = 0.001). Noradrenaline levels were significantly diminished in the lignocaine groups (P < 0.05). Plain and alkalinized lignocaine solutions for topical anaesthesia significantly improved tolerance to the tracheal tube during emergence from anaesthesia. Plain and alkalinized lignocaine given directly before intubation reduced the sympathomimetic stress response resulting in a lower noradrenaline concentration and a reduced heart rate.

The purpose of this study was to assess the value of lignocaine biotransformation into monoethylglycinexylidide (MEGX) and conventional liver function tests in the early post-operative period as an indicator of graft function and as a diagnostic tool for complications after hepatic transplantation. Monoethylglycinexylidide formation, plasma bilirubin, aspartate aminotransferase (ASAT), alanine amino- transferase (ALAT), factor V index (FVI) and prothrombin time index (PTI) were measured in 71 patients undergoing 80 liver transplantations respectively at 12 (T1), 24 (T2), 48 (T3) and 72 h (T4) after liver graft revascularization. Patients were divided into two group according to the post-operative outcome. Patients with favourable outcome (n = 59) had significantly higher monoethylglycinexylidide synthesis, higher factor V index and prothrombin time index plasma concentrations, lower bilirubin, ASAT and ALAT plasma concentration (P < 0.0001 at T2 and T3) than those with complicated time course (n = 21). Monoethylglycinexylidide synthesis was the best discriminant of a favourable outcome, whereas bilirubin and ALAT concentrations were associated with complications (bilirubin for primary non function [PNF], ALAT for acute rejection). Thus, the combination of parameters at T2 was a very efficient predictor of primary non function, acute rejection and an uncomplicated time course.

Ninety patients undergoing scheduled upper limb orthopaedic surgery were studied to determine the optimal anaesthetic dose using the ‘orthogonal two-needle technique’. The patients were randomly assigned to one of three groups to receive one of three different volumes (20, 30 and 40mL) (n = 30) of anaesthetic solution (a mixture of equal parts of 0.5% bupivacaine with adrenaline 1:200 000 and 2% lignocaine). A significant correlation was found between the volume injected and the anaesthetic spread for all tested areas. A better analgesic spread to all the major branches of the plexus was obtained when increased volumes of anaesthetic solution were injected. The comparisons between the 20 mL group and the other two groups are significant in all the tested areas, as well as the comparisons between 30 and 40 mL groups in the areas innervated by radial and musculo-cutaneous nerves. Only the area innervated by the axillary nerve showed a weaker volume-analgesia relation, confirming the elusiveness of this area to anaesthesia in the axillary approaches. The improved results observed using greater amounts of anaesthetic solution might result from a higher intrasheath pressure with disruption of sheath septa, or from a greater availability of drug for all the terminal branches of brachial plexus, or both.

A study was conducted on 100 middle-aged to elderly patients (n=52, healthy; n=48, suffering from either diabetes, hypertension, ischaemic heart disease or combination of these diseases) undergoing cataract extraction to assess the effects of laryngoscopy and tracheal intubation, anaesthesia and surgery, eye bandaging and tracheal extubation, saline (control), magnesium sulphate 40 mg kg−1, esmolol 4.0 mg kg−1, lignocaine 1.5 mg kg−1 and glyceryl trinitrate 7.5 μg kg−1 given i.v. at induction of anaesthesia on heart rate (HR), blood pressure (BP), rate-pressure product (RPP) and pressure-rate quotient (PRQ). Anaesthesia was standardized. Haemodynamic responses and requirements for atropine, ephedrine and labetalol to maintain HR and BP during surgery were similar inhealthy and diseased patients, and in the test drug groups. Differences produced by the test drugs were evident until 5 min following intubation. Esmolol prevented rises in HR and RPP. Glyceryl trinitrate prevented a rise in BP, but was associated with tachycardia and a fall in PRQ to < 1.0. Magnesium sulphate and lignocaine did not prevent responses to laryngoscopy and tracheal intubation, and were associated with rises in RPP. Application of the eye dressing and tracheal extubation at the end of surgery each caused significant increases in HR, BP and RPP in all groups.

In order to assess if a mixture of phenylephrine/lignocaine is as effective as cocaine for local analgesia and vasoconstriction during nasal fibreoptic intubation, 99 patients receiving topical nasal analgesia either with cocaine 10% or a mixture of phenylephrine 1% and lignocaine 4% were studied in a randomized double-blind investigation. After topical analgesia a flexible fibreoptic endoscope was advanced through a nostril. Larynx, glottis and trachea were endoscopically sprayed with lignocaine. Following induction of anaesthesia a nasotracheal tube was inserted fibreoptically. Pain intensity and amount of epistaxis during endoscopy were assessed.Blood pressure, heart rate and ECG-ST segment were determined before and after topical nasal analgesia, after induction of anaesthesia and after nasotracheal intubation. There were no significant differences in painintensity or epistaxis between groups during endoscopy, nor significant alterations in haemodynamic parameters or ST-segment. It is concluded that the mixture of phenylephrine and lignocaine is a useful alternative to cocaine for local analgesia and vasoconstriction during nasal fibreoptic intubation.

Idiopathic subjective tinnitus (1ST) is one of the most obscure otological pathologies. This paper presents the results of treating 1ST by intratympanic instillation of lignocaine (lidocaine) 2 per cent through a grommet, for five weekly courses. Fifty-two patients suffering from intractable tinnitus entered this therapeutic trial, but only nine finished all five courses. In one patient, the tinnitus was almost completely abolished, but in all the nine patients the decompensated tinnitus changed to a compensated one. We suggest this mode of treatment for patients that were previously treated by drugs, acupuncture and biofeedback, with disappointing results.Patients should be warned about the side effects of vertigo and vomiting, which subsides gradually with every new instillation, and that the tinnitus may not disappear but will be alleviated, enabling them to cope more easily with the disease and lead a more normal life.