Introduction. Methoxyflurane can cause hepatotoxicity and nephrotoxicity at anaesthetic doses but has excellent analgesic properties and no nephrotoxic effects in patients without preexisting disease. Approved for use in the UK and Ireland in 2015, it is currently being used in emergency departments for analgesia during fracture reduction. During the Covid emergency, with theatre access severely restricted and many patients unwilling to use inhaled Nitrous oxide, Penthrox had the potential to provide adequate pain relief to aid frame removals and minor procedures in the clinic. Materials and Methods. Patients presenting to the Limb Reconstruction Unit Elective clinic and requiring frame removal or minor procedures were included in the study. Patients with renal, cardiac or hepatic disease, history of sensitivity to fluorinated anaesthetic agents and those on any nephrotoxic or enzyme inducing drugs were excluded. Verbal consent was obtained, the risks and benefits explained and the procedure was done in a side room in the clinic. Besides patient and procedure details, the Visual Analog Score and Richmond Agitation Scale was noted and patient's satisfaction documented. The results were presented as numbers, means and averages. Results. A total of 39 patients were included in the study of which 17 had Ilizarov frames removed, 10 had Hexapod Removals, 9 had heel rings removed and 3 others had an ex fix removed. Eleven patients required/ requested extra pain relief in the form of oral analgesia. All patients were satisfied or very satisfied with the experience. One patient had a wire jam during removal and required a GA for removal. Conclusions. Patient satisfaction was very high (>95%) with good results and allowed frame removals and minor procedures to be done in the clinic during the Covid pandemic. It also cut expenses and has potential for regular future use

Conventional teaching advises against using adrenaline with local anaesthetic near end-arteries due to risks of irreversible vasospasm, however there are benefits of adjunctive adrenaline including enhanced anaesthetic effect, prolonged duration and temporary haemostasis. Retrospective analysis was undertaken for all elective finger and distal palmar surgery using digital nerve or field blocks performed by four orthopaedic hand surgeons, during a two-year period in a large teaching hospital. Data collected from theatre databases and clinical notes included procedure type, anaesthetic agent, adrenaline use, tourniquet use and evidence of post-operative digital ischaemia or wound complications. 230 procedures (mean age 59 years) were performed, including 158 cases with plain anaesthetic only (2%, 1% Lidocaine or 0.25% Bupivicaine in 150, 4 and 4 cases respectively) and 72 cases with 0.25% Bupivicaine and adrenaline (1:200,000.) Mean anaesthetic volume was 7.5ml (7.2ml vs 8.0ml without and with adrenaline respectively.) Tourniquet was used in all cases without adrenaline but was not used in 21 (29%) of cases with adrenaline. Mean tourniquet time in each group was 16 minutes. Two post-operative infections occurred in the group without adrenaline with none in the adrenaline group and there were no cases of digital necrosis in either group. In the elective setting, adjunctive adrenaline with local anaesthetic does not increase the risk of post-operative infections or digital ischaemia. For proximal finger surgery, where digital tourniquets are often restrictive, using adrenaline can prevent the need for painful arm tourniquets

It has been reported that some of the local anaesthetic agents possess antimicrobial activity against clinically-significant bacteria. Although bupivacaine exhibits a bacteriostatic effect at concentrations above 0.25% there are concerns that it might interact with some of the other antibiotics administered to patients. Whilst these interactions may be potentially benign, the risk is that they are antagonistic and that local bupivacaine might predispose the patient to a higher risk of infection. Bupivacaine is commonly administered as a local anaesthetic following knee arthroplasy; the purpose of this study was to assess its potential interactions with gentamicin eluting from the cement used to fix the device. A strain of Saphylococcus aureus (29213) with established susceptible Minimal Inhibition Concentration (MIC) and Minimal Bactericidal Concentration (MBC) for gentamicin was used. This organism was inoculated into four types of broth; Mueller-Hinton broth (MH), MH with different concentrations of gentamicin, MH with 0.25% and 0.125% bupivacaine and MH with various combinations of gentamicin and bupivacaine. The broths were incubated at 37C and at 0.5, 1, 2, 3, 6 and 24 hours post inoculation the number of bacteria remaining were counted. From these data kill-curves were generated describing the absolute and individual rates of killing seen with bupivacaine and gentamicin alone and when in combination. Bupivacaine showed a bacteriostatic effect only at concentrations of 0.25% and higher. All concentrations of gentamicin above or equal to the expected MBC showed bactericidal effect. However, in combination with both strengths of Bupivacaine (0.25 and 0.125%) the bacteriocidal effect of gentamicin was seen at a lower concentration and the rate of killing of bacteria was enhanced. Bupivacaine has bacteriostatic effect at concentrations above 0.25% in line with published data. In these experiments we have shown that the use of bupivacaine together with gentamicin does not reduce the bactericidal property of the antibiotic and that the bactericidal effect of gentamicin appears to be enhanced by bupivacaine. This would suggest that the local use of bupivacaine is unlikely to increase the risk of infection in patients undergoing knee arthroplasty and may actually be beneficial

Introduction. Many determinants of the length of stay (LOS) for primary total knee arthroplasty (TKA) have been described. Multimodal, pre-emptive analgesia, age, walking aid score and stair score are some of them. Single shot peripheral nerve block is a popular method to provide prolonged analgesia in immediate post operative period after TKA. Delayed recovery from the nerve block can delay the rehabilitation programme and subsequently lengthen the LOS when the multi disciplinary team discharge criteria are well defined and standardized. The aim of this study is to calculate the incidence of delayed recovery from the sciatic and femoral nerve block administered in cases of primary TKA and its influence on LOS. Methods. All the patients undergoing primary TKA and receiving forty milliliters of 0.375% of Bupivacaine for sciatic and femoral nerve block since April 2010 till January 2011 have been included in the study. Patients demographics, date and day of operation, time of nerve block, complete recovery from the nerve block post operatively and date of discharge were recorded prospectively. Results. Total 34 patients were included in the study. 24 patients recovered from the effect of peripheral nerve block on the post operative day one and 10 patients recovered on the post operative day two. Mean LOS of patients recovered on post operative day one is 4.8 days and mean LOS of those who recovered on post operative day 2 is 5.6 days. Conclusion. Almost one third of the patients receiving forty milliliters of 0.375% of Bupivacaine for sciatic and femoral nerve block recovered late. Delayed recovery from nerve block seems to increase the duration to achieve the discharge criteria after primary TKA. This information can be used favorably to influence the outcome by altering the concentration and amount of anaesthetic agent used