|Year : 2014 | Volume
| Issue : 3 | Page : 314-319
Comparative study between lidocaine/epinephrine, lidocaine/ketamine/epinephrine, and lidocaine/dexamethasone/epinephrine mixtures in rhinoplasty surgery
Hesham M El-Azzazi, Sahar M Talaat
Department of Anesthesiology, Intensive Care and Pain Management, Faculty of Medicine, Ain Shams University, Cairo, Egypt
|Date of Submission||12-Jun-2013|
|Date of Acceptance||23-Dec-2013|
|Date of Web Publication||27-Aug-2014|
Sahar M Talaat
Department Of Anesthesiology, Intensive Care and Pain Management, Faculty of Medicine, Ain Shams University, Cairo
Source of Support: None, Conflict of Interest: None
The aim of this study was to evaluate the prolongation of lidocaine epinephrine for local anesthesia (LA) of the nose for rhinoplasty by adding dexamethasone 8 mg or ketamine 100 mg.
Patients and methods
Fifty-nine ASA I female patients aged 20-45 years scheduled for rhinoplasty surgery under LA were included in this randomized prospective study. Patients were randomly assigned to have LA for the nose by injecting a volume of 32 ml of either lidocaine 1%+epinephrine (1 : 200 000) (group lidocaine, n = 20), lidocaine 1%+epinephrine (1 : 200 000) and 8 mg dexamethasone (group lidocaine dexamethasone, n = 20), or lidocaine 1%+epinephrine (1 : 200 000) and 100 mg ketamine (group lidocaine ketamine, n = 19). Heart rate and NIBP were measured and recorded before injection of the LA and every 5 min after that until the end of surgery. Any extra LA injection required by the patient was recorded. The duration of sensory block was recorded. Postoperative pain was measured by visual analog score and pain scores were obtained on arrival in the postanesthesia care unit (PACU) and 1 and 2 h postoperatively.
The duration of sensory block was significantly longer in the lidocaine ketamine group compared with the lidocaine group and the lidocaine dexamethasone group, and the duration was significantly longer in the lidocaine dexamethasone group than the lidocaine group. Only one (5.26%) patients in the lidocaine ketamine group required extra LA injection, whereas five (25%) patients in the lidocaine dexamethasone group and eight (40%) in lidocaine group required extra LA injection; thus, the need for extra LA injection was significantly lower in the lidocaine ketamine group. Visual analog score in PACU and 1, and 2 h postoperatively showed significant decrease in the lidocaine ketamine group in comparison with the lidocaine and lidocaine dexamethasone groups. Heart rate, systolic blood pressure, and diastolic blood pressure showed no significant difference among the three groups throughout the procedure.
Addition of ketamine to lidocaine epinephrine mixture significantly prolonged the duration of sensory block for rhinoplasty and significantly decreased pain in PACU and 1 and 2 h postoperatively compared with lidocaine epinephrine mixture and lidocaine epinephrine dexamethasone mixture. Thus, the addition of ketamine 100 mg to lidocaine epinephrine mixture is a useful adjuvant to lidocaine epinephrine admixture.
Keywords: lidocaine, lidocaine dexamethasone, lidocaine ketamine, local anesthesia, rhinoplasty surgery
|How to cite this article:|
El-Azzazi HM, Talaat SM. Comparative study between lidocaine/epinephrine, lidocaine/ketamine/epinephrine, and lidocaine/dexamethasone/epinephrine mixtures in rhinoplasty surgery. Ain-Shams J Anaesthesiol 2014;7:314-9
|How to cite this URL:|
El-Azzazi HM, Talaat SM. Comparative study between lidocaine/epinephrine, lidocaine/ketamine/epinephrine, and lidocaine/dexamethasone/epinephrine mixtures in rhinoplasty surgery. Ain-Shams J Anaesthesiol [serial online] 2014 [cited 2019 May 24];7:314-9. Available from: http://www.asja.eg.net/text.asp?2014/7/3/314/139556
| Introduction|| |
Rhinoplasty is a common surgery nowadays. Regional anesthesia is suitable for outpatient nasal surgery . Rhinoplasty is one of the surgeries particularly suitable for ambulatory, day-care surgery . Local anesthesia (LA) combined with sedation or dissociative anesthesia has been advocated by Niechajev and Haraldsson  for most routine rhinoplasties. Many patients ask LA for this type of surgery. Most of these surgeries last 2-3 h, but the use of LA usually lasts only around 2 h; therefore, many additives are tried to prolong the duration of LA besides the usually added epinephrine, which is used to prolong the duration of LA  and to act as a hemostatic because there is no possibility of hypotensive anesthesia in these awake patients. Although bupivacaine is a long-acting drug and lignocaine is a short-acting drug, the use of lignocaine is safer than bupivacaine especially in this highly vascular area of the face. A few studies have demonstrated the analgesic effect of corticosteroids [5,6] and ketamine  when added during peripheral nerve blockade. There are no studies assessing the analgesic effects and duration of analgesia of dexamethasone and ketamine when used as an adjunct to lidocaine anesthesia during LA of the nose. The aim of this study was to evaluate the prolongation of lidocaine for LA of the nose by dexamethasone or ketamine taking into consideration any side effects attributed to possible systemic absorption of ketamine, which are nausea, vomiting, dizziness, hallucination, and skin rash [8-11].
| Patients and methods|| |
This was a prospective, randomized, double-blinded study. After the University Review Board approval and informed consent were obtained, 60 ASA physical status I female patients aged 20-45 years scheduled for rhinoplasty surgery in Ain Shams University Hospitals were enrolled in the study. Patients with any contraindication to the drugs used or LA of the nose were excluded. The patients were randomized into three groups (20 patients in each group) after enrollment into the study by opening sealed opaque envelopes that had been sorted by computer-generated random allocation.
Midazolam (3 mg, intravenous) was given to all patients in the operating room for sedation. ECG, NIBP, and pulse oximeter monitoring were initiated. Baseline heart rate and blood pressure were measured and recorded every 5 min after LA until the end of surgery. LA of the nose was performed by injecting LA in the following areas around the nose: 6 ml to block the supraorbital and supratrochlear branches on each side, 5 ml to block the infraorbital nerve on both sides, 5 ml to block the superior labial nerve, and 5 ml in the tip of the nose [1, 2, 12]. Patients received a total injection volume of 32 ml with frequent aspirates during the injection. LA solution with its adjuvant is prepared by three methods according to each group:
Group 1: lidocaine 1% with epinephrine (1 : 200 000) and 2 ml of normal saline.
Group 2: lidocaine 1% with epinephrine (1 : 200 000) and 8 mg dexamethasone.
Group 3: lidocaine 1% with epinephrine (1 : 200 000) and 100 mg ketamine.
All LA solutions and adjuvant medications were prepared by an anesthesiologist not involved in the performance of the block or data collection. A 10 ml sterile syringe containing lidocaine epinephrine 1% was left for the surgeon to be used in case the effect of the LA subsided before finishing the surgery. After performance of the block, two pieces of gauze soaked with epinephrine solution 1 : 200 000 were inserted deeply in each nostril in all patients as a pack to prevent blood aspiration during surgery. These gauzes were removed at the end of surgery. Any extra LA injection required by the patient was recorded. The duration of sensory block was recorded. This duration was considered as the time elapsing from the establishment of the sensory block by pinprick until the first sensation of pain by the patient.
Postoperative pain was measured by visual analog score (VAS) (with 0 representing 'no pain' and 10 representing 'worst imaginable pain'). Pain scores were obtained on arrival in the postanesthesia care unit (PACU) and 1 and 2 h postoperatively.
Any side effects were recorded during the postoperative period - for example, nausea, vomiting, dizziness, hallucinations, and skin rash. The level of sedation of patients was evaluated using a sedation scale (0, awake; 1, drowsy but responsive to verbal orders; 2, drowsy but responsive to physical stimulus; and 3, sleepy but responsive to pain stimulus).
Statistical analysis was performed using SPSS (SPSS Inc., Chicago, Illinois, USA) software package. Demographic data, the duration of sensory block, and the need for additional LA injections were analyzed using one-way analysis of variance and post-hoc test with Tukey's method. The χ2 analysis was used to compare differences of sensory block duration. The Kruskal-Wallis test was used to compare VAS among the three groups. P-value less than 0.05 was considered to be significant. The minimal sample size for the study was 49 patients for all study groups, as the mean difference between patients and control (the lidocaine group) was 5.5, SD1 was 10.5, and SD2 was 5.4, with significance level α (type I error) of 0.05 and β (type II error) of 0.1 with power of test 90%.
| Results|| |
Data were collected from 59 female patients, aged 20-45 years. One case was cancelled from group 2 due to excessive patient irritability where general anesthesia was induced. There were no significant differences among the three groups with respect to age, ASA classification, and duration of surgery (P > 0.05) [Table 1].
Heart rate, systolic blood pressure, and diastolic blood pressure values measured at baseline were not significantly different among groups. Heart rate and systolic and diastolic blood pressure values measured 5 min after injection of the LA and every 5 min throughout the procedure showed no significant difference as well among the three groups, although they were slightly higher in the lidocaine ketamine group in comparison with the lidocaine and lidocaine dexamethasone groups (P > 0.05) ([Figure 1], [Figure 2], [Figure 3]).
|Figure 1: Heart rate (HR) measured during study period. Values are expressed as mean ± SD. dexa, dexamethasone; lido, lidocaine .|
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|Figure 2: Systolic blood pressure (SBP) measured during study period. Values are expressed as mean ± SD. dexa, dexamethasone; lido, lidocaine .|
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|Figure 3 Diastolic blood pressure (DBP) measured during study period. Values are expressed as mean ± SD. dexa, dexamethasone; lido, lidocain e.|
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With respect to the duration of sensory block, there was a highly significant difference between the three groups, and the duration of sensory block was highly significantly longer in the lidocaine ketamine group than in both the lidocaine and lidocaine dexamethasone groups, whereas the duration was significantly longer in the lidocaine dexamethasone group than in the lidocaine group [Table 2].
Regarding the need for extra LA injection, there was a significant difference among the number of patients who required extra LA injection in the three groups, where only one (5.26%) patient in the lidocaine ketamine group required extra LA injection, whereas five (25%) patient in the lidocaine dexamethasone group and eight (40%) in the lidocaine group required extra LA injection.
With respect to postoperative pain assessed by the VAS in PACU and 1 and 2 h postoperatively, VAS showed significant decrease in the lidocaine ketamine group in all times in comparison with the lidocaine and lidocaine dexamethasone groups [Table 3].
|Table 3 Visual analog score in postanesthesia care unit|
and 1 and 2 h postoperatively
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Regarding the adverse effects, there were no statistically significant differences among the three groups [Table 4].
Median sedation values showed no statistical difference between the three groups during the postoperative period.
| Discussion|| |
Rhinoplasty under LA  has become a widely accepted technique nowadays. However, the short duration of LA using the lidocaine epinephrine mixture alone remains a drawback that hinders applying this technique. In the current study, we investigated whether the addition of ketamine 100 mg or dexamethasone 8 mg to lidocaine 1% could prolong the duration of LA of the nose for performing rhinoplasty to overcome this problem.
Our study demonstrated that the addition of ketamine to lidocaine epinephrine mixture significantly prolonged the duration of sensory block during performing rhinoplasty. Addition of dexamethasone to lidocaine epinephrine mixture significantly prolonged the duration of sensory block as well but to a much lesser extent than the addition of ketamine. The addition of ketamine to lidocaine epinephrine mixture significantly reduced the need for extra LA injection in comparison with administering lidocaine epinephrine alone or adding dexamethasone to lidocaine epinephrine. Furthermore, addition of ketamine to lidocaine epinephrine significantly decreased postoperative pain in PACU and 1 and 2 h postoperatively as assessed by VAS in comparison with lidocaine epinephrine mixture and lidocaine epinephrine dexamethasone mixture.
Tverskoy et al.  showed that the use of ketamine in addition to bupivacaine for wound infiltration in patients undergoing inguinal herniorrhaphy enhanced both the LA and analgesic effects of bupivacaine and increased the wound pain threshold as well. Safavi et al.  demonstrated that the preincisional treatment with subcutaneous infiltration of ketamine (2 mg/kg) decreased postoperative pain scores in comparison with preincisional infiltration of normal saline solution in patients undergoing open cholecystectomy without significant side effects. Furthermore, their study confirmed that subcutaneous infiltration of ketamine delayed the first analgesic requirement and produced a significant meperidine-sparing effect during the first 24 h after open cholecystectomy. Honarmand et al.  showed that preincisional subcutaneous infiltration with ketamine (0.5 mg/kg) in patients undergoing appendectomy decreased postoperative pain scores, delayed the time to first rescue analgesia, and reduced postoperative analgesic requirements in comparison with the control group in which subcutaneous saline was injected. Sonbaty et al.  demonstrated that peritonsillar infiltration of a mixture of bupivacaine 10 mg and ketamine 0.5 mg/kg provided efficient postoperative analgesia after adenotonsillectomy compared with infiltration of each drug alone.
In contrast to the current study, Lee et al.  found that 30 mg ketamine added to ropivacaine in the interscalene brachial plexus block did not improve the duration of sensory block, which might be due to a lower dose of ketamine than our dose.
Vieira et al.  showed that dexamethasone 8 mg when added to bupivacaine clonidine mixture in ultrasound-guided interscalene brachial plexus blockade increased the duration of sensory block and decreased postoperative opioid requirements when compared with saline added to the previous mixture. In addition, Golwala et al.  demonstrated that adding dexamethasone at a dose of 8 mg to lidocaine bupivacaine epinephrine mixture in supraclavicular brachial plexus block significantly prolonged duration of analgesia, and moreover accelerated the onset of sensory and motor block. Movafegh et al.  found that dexamethasone when combined with lidocaine adrenaline mixture also prolonged the duration of analgesia and accelerated the onset of sensory and motor blockade for brachial plexus blockade. Several other studies [22-24] reported that steroids significantly prolonged the duration of analgesia in extremity nerve blocks. Furthermore, it has been shown that addition of dexamethasone to LAs increased the duration of analgesia after subcutaneous infiltration, intra-articular injection, intercostal blockade, and epidural administration [24-27].
Ketamine is a noncompetitive N-methyl-d-aspartate receptor antagonist. Neurotransmitters such as glutamate and aspartate are released in response to painful stimuli and bind to N-methyl-d-aspartate, AMPA, and glutamate-type M receptors, playing a significant role in the mechanism of central sensitization and wind-up phenomenon, which are involved in the perpetuation of pain .
LA properties of ketamine were described by Dowdy et al.  who found that the ketamine concentration-response curve for depression of the compound action potentials (frog sciatic nerve in vitro) was similar to that of procaine. The effect of ketamine on nerve conduction was also confirmed in in-vitro experiments by Weber et al. , who also found that the subcutaneous infiltration of 0.5% ketamine caused loss of thermal and pain sensations for 8-10 min. Durrani et al.  demonstrated in volunteers that 0.5 and 0.3% ketamine could provide an adequate intravenous regional anesthesia (restricted to the upper limb by a tourniquet).
Dexamethasone is a very potent and highly selective glucocorticoid. Basically, it is used as anti-inflammatory and immunosuppressant. Clinical uses of dexamethasone are for treatment of many inflammatory and autoimmune conditions, but glucocorticoids are also used to treat patients suffering from neuropathic pain and complex regional pain syndromes. Hence, steroids have anti-inflammatory as well as analgesic effects .
Adding small doses of dexamethasone to LAs increased duration of analgesia after several routes of administration [24-27]. Actual mechanism of dexamethasone in prolonging duration of analgesia is not well understood, but according to various studies it might be due to local action of dexamethasone on nerve as well as systemic anti-inflammatory effect after being observed from peripheral site to systemic circulation. There are other probabilities that are alteration in potassium channel of nerve cell thus having synergistic action with LAs or the action on corticosteroid receptor in the brain after being absorbed from periphery to systemic circulation [33-35].
It was observed that there was a slight increase in blood pressure values and heart rate values in the lidocaine ketamine group in comparison with the other two groups, but it was nonsignificant and had a little effect clinically in our study age group as all our patients were medically free. Although this type of surgery usually needs hypotensive anesthesia, the vasoconstrictive effect of the added epinephrine has helped to reduce blood loss. Side effects such as nausea, vomiting, dizziness, hallucination, and skin rash showed no statistical difference between the groups, which might encourage the use of ketamine as an adjuvant to LA in local rhinoplasty. Sedation as well showed no statistical difference.
In conclusion, the addition of ketamine to lidocaine epinephrine mixture significantly prolonged the duration of sensory block during performing rhinoplasty. Addition of dexamethasone to lidocaine epinephrine mixture also prolonged the duration of sensory block but to a lesser extent than the addition of ketamine. Addition of ketamine to lidocaine epinephrine significantly decreased postoperative pain in PACU and 1 and 2 h postoperatively in comparison with lidocaine epinephrine mixture and lidocaine epinephrine dexamethasone mixture. Thus, the addition of ketamine 100 mg to lidocaine epinephrine mixture is a useful adjuvant to lidocaine epinephrine admixture in performing rhinoplasty under LA.
| Acknowledgements|| |
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[Figure 1], [Figure 2], [Figure 3]
[Table 1], [Table 2], [Table 3], [Table 4]