Regional anaesthesia for shoulder surgery remains challenging in patients with pre-existing respiratory comorbidities. Various alternative phrenic sparing techniques have been described in the literature, but to our knowledge, none have explored the benefits of using short-acting local anaesthetics in combination to achieve surgical anaesthesia for awake surgery. This case report describes the successful use of the superior trunk block catheter, a relative phrenic sparing shoulder nerve block, and 2% chloroprocaine, a short-acting local anaesthetic, to provide surgical anaesthesia for awake shoulder surgery in a patient with severe respiratory disease.

Lumbar erector spinae plane block (ESPB) is effective for spine surgeries but is deep and technically demanding. Sacral ESPB is a novel approach for sacrococcygeal procedures and can potentially cover lumbar dermatomes by the cranial drug spread. This is the first reported case series demonstrating the potential analgesic efficacy of sacral ESPB for lumbar spine surgeries. Five patients with radiculopathy at the lumbosacral area level were scheduled for transforaminal lumbar interbody fusion (TLIF). General anaesthesia was induced as per standard practice. All patients received sacral ESP in a prone position under ultrasound guidance with a needle inserted in-plane while targeting the fascial plane between the S2 median crest and overlying muscles. All the included patients had good analgesia in the postoperative period and required minimal opioid analgesic doses. Sacral ESPB is an easy, effective, and safe technique in the scheme of multimodal analgesia for TLIF surgeries as a component of pre-emptive analgesia, where the main goal is an opioid-sparing effect.

BACKGROUND: Pain is the main reason for staying overnight at hospital after an uncomplicated laparoscopic cholecystectomy.
OBJECTIVE: A randomised prospective study was planned to compare the efficacy of intraincisional and intraperitoneal use of 0.2% ropivacaine so that patients undergoing an uncomplicated laparoscopic cholecystectomy can be discharged as a day case in a cost-effective way.
METHODS: 191 patients were operated by elective four-port laparoscopic cholecystectomy. They were randomised into three groups after triple blinding according to location of 0.2% ropivacaine use. All patients were given ~23 mL of solution (drug or normal saline depending on the group), 20 mL of which was given at intraperitoneal location and ~1 mL/cm of incision intraincisionally. Pain scores (Visual Analogue Scale (VAS), Numeric Rating Scale (NRS) and Faces Pain Scale-Revised (FPS-R)) were evaluated at 4 and 8 hours postoperatively. Only those patients with a VAS ≤3, NRS ≤3 and FPS-R ≤2, no requirement of rescue analgesia, no shoulder pain, ambulated at least once, passed urine and taking oral sips were offered discharge as a day case.
RESULTS: 31% of patients in intraperitoneal group (n=62) could be discharged as a day case as compared with 48% in intraincisional group (n=68) (p>0.05) and 89% in combined group (n=61) (p<0.05, with respect to both other groups).
CONCLUSIONS: The combined use of intraincisional and intraperitoneal ropivacaine is a cost-effective way of discharging approximately 9 in 10 patients as a day case. This study is unique as this is the first study in which only a local anaesthetic has been used to predict discharges as a day case.

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BACKGROUND: An allergic reaction following a dental procedure is a rare event. A local anaesthetic (LA) may initially be suspected as a causative agent but allergy to dental LA solutions is extremely rare.
METHODS: This report concerns a 13 year old child who underwent dental treatment and was exposed to Lignospan Special(®) LA, mouthwash, latex gloves, ibuprofen medication, and a Magnum(®) (almond) ice cream all within 45 min. He subsequently developed acute symptoms of nasal rhinorrhoea, facial flushing, peri-orbital and lip angioedema, followed by throat tightness and wheeze (respiratory compromise). His acute reaction was treated by his medical practitioner with oral anti-histamines, steroid and nebulised salbutamol. The child was referred to a local allergist. The child underwent detailed allergic investigations including skin prick tests, blood tests, incremental local anaesthetic challenge and ibuprofen challenge. The patient was diagnosed with NSAID exacerbated respiratory disease (NERD), a hypersensitivity reaction to ibuprofen.
RESULTS: The patient was advised to avoid NSAIDs and to wear a medic-alert (allergy) bracelet. A detailed written report was sent to the patient\'s dentist and GP.
CONCLUSIONS: In the context of a suspected reaction post dental procedure, local anaesthetic should be considered a possible allergen but other important considerations include analgesics, antibiotics, and latex. All genuine allergic reactions need to be investigated. This report highlights NERD as a possible adverse outcome following dental treatment.

Local anaesthesia is used routinely throughout dentistry. Complications are, however, relatively uncommon. A unique case of superficial skin necrosis and neurological symptoms following administration of local anaesthesia for dental treatment is reported and the possible mechanisms behind this unusual presentation are discussed. Awareness of this possible complication and its mechanism helps clinicians diagnose and manage patients with similar problems appropriately.