Bupivacaine 50mg/20ml (0.25%) / Adrenaline (base) 100micrograms/20ml (1 in 200,000) solution for injection ampoules

General anaesthesia (GA) as a pharmacological behaviour management strategy may be indicated for dental extractions in children unable to cooperate in the dental chair. Pain is the most common postoperative complication in children following dental GA. There is conflicting evidence available on the efficacy of local anaesthetic (LA) agents for postoperative pain management following dental extraction. Therefore, this review aimed to evaluate the efficacy of different pharmacological analgesic techniques on postoperative pain following dental extractions under GA in children. A search of PubMed, Embase, Scopus and CINAHL was conducted on 17/10/2023 to identify studies eligible for inclusion in this review. Two independent reviewers performed search screening, data extraction and critical appraisal. Results were narratively described due to heterogeneity of pain assessment tools and management strategies. The search yielded 8742 results, of which 15 studies were included. Methods of pain assessment varied greatly across included studies, with 14 different pain scales used across the 15 studies. Included studies suggest preoperative oral paracetamol and oral ibuprofen as well as postoperative topical bupivacaine lowered pain scores. This review underscores the challenges in reliably assessing pain in children and highlights the necessity for age-specific validated pain assessment tools.

Abstract licence: CC BY

Postoperative pain is a significant challenge that can delay early mobilization and prolong hospitalization after total knee arthroplasty (TKA). Effective pain management is critical to promote rehabilitation, reduce opioid consumption, and improve long-term patient outcomes. Bupivacaine and ropivacaine are widely utilized local anesthetics administered by way of peripheral nerve blocks, periarticular injections, and epidural anesthesia to help manage postoperative pain. This systematic review and meta-analysis aimed to compare postoperative pain levels after administering bupivacaine or ropivacaine via peripheral nerve blocks or periarticular injections. Secondary outcomes included length of stay (LOS), rescue analgesia, and motor blockade. Subgroup analysis was performed to differentiate between drug administration by way of peripheral nerve blocks and periarticular injections. A total of nine studies and 656 patients were included. There was no difference in pain levels at 6 hours (MD = 0.12, 95% CI, -0.41 to 0.65, P = 0.66), 12 hours (MD = - 0.01, 95% CI, -0.62 to 0.61, P = 0.98), and 24 hours postoperative (MD = 0.17; 95% CI, -0.27 to 0.61, P = 0.46) between peripheral nerve blocks and periarticular injections of bupivacaine and ropivacaine. At 72 hours postoperative, ropivacaine decreased pain levels when administered through peripheral nerve block only (MD = 0.82, 95% CI, 0.55 to 1.09, P = 0.002). There were no differences in LOS or rescue analgesia, but bupivacaine provided a greater degree of motor nerve blockade (MD = 0.18, 95% CI, 0.01 to 0.35, P = 0.04) assessed by the classical Bromage scale. The findings suggest that bupivacaine and ropivacaine provide comparable analgesic efficacy for postoperative pain control following TKA, indicating that the drug of choice may be due to secondary factors, including cost, availability, or provider preference.

Abstract licence: CC BY

ObjectiveTo evaluate the analgesic efficacy and safety of local anesthetic infiltration in the tonsillar fossa using ropivacaine compared to bupivacaine in pediatric patients undergoing tonsillectomy.Data sourcesCENTRAL, PubMed, Web of Science, Scopus, and Google Scholar.Review methodsEligible randomized controlled trials (RCTs) were evaluated for risk of bias using Cochrane's Risk of Bias Tool (RoB-2). The primary outcome was postoperative pain within the first 24 hours following tonsillectomy. Secondary outcomes included the time to first analgesic requirement and complication rates (ie, bleeding, airway obstruction, local anesthetic toxicity, and nausea). Data were synthesized using the standardized mean difference (SMD) for continuous outcomes and risk ratio (RR) for dichotomous outcomes, both reported with 95% confidence intervals (CI).ResultsSeven RCTs with a total of 375 patients were analyzed. Regarding posttonsillectomy pain scores, there was no significant difference between ropivacaine and bupivacaine at 1 hour (SMD = -0.01, 95% confidence interval [CI] [-0.36, 0.34]), 2 hours (SMD = 0.03, 95% CI [-0.45, 0.51]), 4 hours (SMD = -0.17, 95% CI [-0.39, 0.06]), 6-8 hours (SMD = 0.04, 95% CI [-0.38, 0.46]), and 12 hours (SMD = -0.23, 95% CI [-0.62, 0.15]). However, at 24 hours, ropivacaine demonstrated a superior effect compared to bupivacaine (SMD = -0.23, 95% CI [-0.43, -0.03]). There was no significant difference between ropivacaine and bupivacaine in terms of time to first analgesia and complication rates (P > .05).ConclusionThis meta-analysis demonstrated that ropivacaine and bupivacaine offer comparable clinical analgesic efficacy and safety profiles in pediatric patients undergoing tonsillectomy.

Abstract licence: CC BY

OBJECTIVES: Liposome bupivacaine is a long-acting anesthetic to prolong the duration of analgesia. However, the effectiveness of liposome bupivacaine for providing prolonged analgesia with transversus abdominis plane (TAP) blocks remains uncertain. Therefore, we performed a systematic review and meta-analysis to compare the analgesic efficacy of liposome bupivacaine to regular bupivacaine in TAP blocks. METHODS: PubMed, Embase, Web of Science, and the Cochrane Library were searched from inception to December 2024. Randomized controlled trials (RCTs) comparing liposome bupivacaine and regular bupivacaine in TAP blocks were included in this analysis. The primary outcomes were morphine milligram equivalents (MMEs) in the first 24 h and second 24 h after surgery. Secondary outcomes were pain scores at 24 h and 48 h postoperatively, length of hospital stay, and opioid-related side effects. RESULTS: 13 RCTs including 1195 patients were eligible for meta-analysis. The use of liposome bupivacaine in TAP blocks significantly decreased opioid requirement (WMD, -2.40; 95% CI, -4.47 to -0.34; I2 = 78.2%; P = 0.023) in the first 24 h after surgery. No difference was found in the opioid consumption in the second 24 h between the liposome bupivacaine and regular bupivacaine groups. Moreover, no significant difference in pain scores up to 48 h, length of hospital stay, and incidence of opioid-related side effects was found between the two groups. CONCLUSION: Liposomal bupivacaine for TAP blocks significantly reduced 24-hour opioid consumption (WMD = -2.40 MMEs) but provided no clinically meaningful benefits in pain control, prolonged analgesia, length of stay, or adverse events. Routine use cannot be justified given its higher cost.

Abstract licence: CC BY-NC-ND

BackgroundThe quality of recovery (QoR) is a multidimensional concept used to evaluate the restoration of physical and psychological functions after surgery. It is a key measure for assessing surgical efficacy, anesthetic modalities, and the effectiveness of perioperative interventions. Liposomal bupivacaine (LB), a long-acting local anesthetic recently introduced, is characterized by its sustained-release profile and prolonged analgesic effect. However, empirical findings regarding the impact of LB on the quality of postoperative recovery remain inconclusive.MethodsOn 5 March 2025, we conducted a systematic search of the PubMed, Embase, Web of Science, Cochrane Library, Scopus, CNKI, and VIP databases to identify randomized controlled trials (RCTs) assessing the efficacy of LB in postoperative recovery. Eligible studies compared postoperative recovery outcomes between patients receiving LB and those in control groups who did not receive LB. The primary outcome of interest was the QoR score measured 72 h after surgery. Secondary outcomes included QoR scores at 24 and 48 h after surgery; pain scores at rest at 24, 48, and 72 h after surgery; incidence of postoperative nausea and vomiting (PONV); cumulative morphine-equivalent opioid consumption within 72 h after surgery; and patient satisfaction.ResultsThis meta-analysis included 11 RCTs comprising a total of 1,357 patients. The findings indicate that the LB group showed a statistically significant improvement in overall QoR scores 72 h after surgery [standardized mean difference (SMD): 0.52; 95% confidence interval (CI): 0.20, 0.85; P = 0.00]. Furthermore, LB use was associated with significantly reduced pain scores at 24, 48, and 72 h after surgery. The LB group also exhibited lower cumulative morphine-equivalent opioid consumption within 72 h after surgery, a reduced incidence of PONV, and significantly higher patient satisfaction scores.ConclusionThe use of LB was associated with improved QoR scores within 72 h after surgery, a reduced incidence of PONV, and decreased opioid consumption. These findings suggest that LB not only improves overall postoperative recovery but also mitigates associated adverse effects, thereby contributing to improved patient satisfaction and a more streamlined recovery trajectory. Nevertheless, further research is needed to assess its long-term efficacy and broader clinical applicability.Systematic review registration[https://www.crd.york.ac.uk/prospero/], identifier [CRD420251003585].

Abstract licence: CC BY

IntroductionThis review systematically compares the efficacy and safety of bupivacaine and articaine in third molar surgery, with a focus on postoperative pain control, duration of analgesia, intraoperative outcomes, and hemodynamic stability.MethodsPubMed, Scopus, Web of Science, and CENTRAL were searched through December 24th, 2024, for randomized controlled trials (RCTs) comparing bupivacaine and articaine in third molar surgery. Primary outcomes included postoperative pain intensity (visual analog scale [VAS]), duration of postoperative analgesia, and need for rescue analgesia. Secondary outcomes included anesthesia onset time, intraoperative bleeding, operative time, and hemodynamic parameters. Meta-analysis was performed using a random--effects model.ResultsA total of 11 RCTs involving 749 patients (bupivacaine: 367, articaine: 382) were included. Bupivacaine significantly reduced postoperative pain scores at multiple time points, with the greatest effect observed at 4 h postoperatively (mean difference [MD] = -2.59; 95% confidence interval [CI]: -3.41, -1.77; I2 = 0%). The duration of postoperative analgesia was comparable between groups (MD = 91.22 min; 95% CI: -5.13, 187.57; I2 = 99.68%), with sensitivity analysis confirming this effect. Articaine exhibited a significantly faster onset of anesthesia (MD = 0.74 min; 95% CI: 0.36, 1.12; I2 = 81.05%), while intraoperative pain scores, surgical difficulty, and operative time were comparable between groups. No significant differences were found in hemodynamic parameters, suggesting similar safety profiles.ConclusionBupivacaine provides superior postoperative pain control and prolonged analgesia, making it advantageous for extended pain relief in third molar surgery. However, articaine's faster onset may enhance surgical efficiency. Both anesthetics demonstrated comparable intraoperative efficacy and safety.

Abstract licence: CC BY

Background/Objectives: Local anaesthetic systemic toxicity (LAST) is a rare but potentially fatal complication of dental and oral and maxillofacial surgical local anaesthesia (LA). Three amide agents are commonly used in the UK: lignocaine (lidocaine) 2% with adrenaline 1:80,000; articaine 4% with adrenaline 1:100,000 (2.2 mL cartridges); and bupivacaine 0.5%. Clinically significant discrepancies between guideline sources for maximum recommended dosages (MRDs) persist, and the additive toxicity of combined amide agents remains underappreciated. The objectives are: to provide clear, evidence-appraised MRD guidance for dental practitioners; to explain safe combination dosing using the fractional dose rule with acknowledgement of its pharmacokinetic limitations; and to outline recognition and management of LAST, including intravenous lipid emulsion (ILE) therapy, setting-stratified response, and differential diagnosis. Methods: These include the following: narrative review of MEDLINE (via PubMed), the Cochrane Library, and Embase (inception to May 2026), supplemented by key regulatory documents (British National Formulary (BNF) 91; US Food and Drug Administration (FDA) prescribing information; UK Summaries of Product Characteristics (SmPCs)); major guideline documents (American Society of Regional Anesthesia and Pain Medicine (ASRA) 2018; Association of Anaesthetists 2021; Resuscitation Council UK 2021); systematic reviews; and peer-reviewed literature, ranked by a jurisdiction-specific UK prescribing and regulatory source hierarchy. Results: BNF 91 and the FDA both support a 7 mg/kg (500 mg) MRD for lignocaine with adrenaline; in practice, the adrenaline ceiling limits administration to 6-7 cartridges (2.2 mL) regardless of the guideline followed. The principal reasons for caution when combining amide agents are; additive systemic toxicity, more complex dose calculation, absence of proven clinical benefit for concurrent mixing, unnecessary drug exposure, and incremental hypersensitivity risk-not metabolic pathway differences. The fractional dose rule is a pharmacologically justified safety heuristic with acknowledged pharmacokinetic limitations. ILE is a specific rescue therapy for severe or cardiovascular LAST; airway support and oxygenation remain the primary interventions. Patient-specific factors substantially lower the effective toxic threshold. Conclusions: Safe LA administration in oral surgery requires systematic MRD calculation, application of the fractional dose rule for combined-agent appointments, attention to patient-specific risk factors, setting-appropriate emergency preparedness, and structured differential diagnosis to distinguish LAST from more common dental emergencies.

Abstract licence: CC BY

Introduction Recent evidence has questioned the advantage of local anesthetic (LA) combinations. This study tested the hypothesis that mixing rapid-onset (lidocaine) and long-duration (bupivacaine) LA would provide faster onset of complete conduction blockade (CCB) compared with bupivacaine alone and longer duration of analgesia compared with lidocaine alone during low-volume (20 mL) ultrasound-guided (USG) supraclavicular brachial plexus block (SCBPB). Methods Sixty-three patients receiving USG-SCBPB were randomly allocated into: group L: 20 mL 2% lidocaine with epinephrine 1:200 000; group B: 20 mL 0.5% bupivacaine; group LB: 20 mL of equi-volume mixture of both drugs. Sensory and motor blockade was recorded on a three point sensory and motor assessment scale at 10 min intervals for up to 40 min and the total composite score (TCS) at each time point was determined. The duration of analgesia was also noted. Results The mean time to CCB of group LB (16±7 min) was comparable (p>0.05) with group L (14±6 min) and group B (21±8 min) in patients who were attained CCB. However, the proportion of patients attaining complete conduction block (TCS=16/16) was significantly lower (p=0.0001) in group B (48%) when compared with group L (95%) and group LB (95%) at the end of 40 min. The median (IQR) duration of postoperative analgesia was longest in group B; 12.2 (12–14.5) hours, followed by group LB 8.3 (7–11) hours and 4 (2.7–4.5) hours in group L. Conclusion At 20 mL LA volume, equal mixture of lidocaine and bupivacaine provided significantly faster onset of CCB compared with bupivacaine alone and longer duration of postoperative analgesia compared with lidocaine alone but shorter than bupivacaine alone during low-volume USG-SCBPB. Trial registration number CTRI/2020/11/029359.

Abstract licence: CC BY-NC 4.0