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INTRODUCTION: surgical pain is managed with multi-modal anesthesia in total knee arthroplasty (TKA). It is dubious whether including local infiltrative anaesthesia (LIA) before wound closure provides adequate pain control and decreases morbidity. MATERIAL AND METHODS: this was a retrospective conducted to assess postoperative pain control, morbidity index, and opioid consumption in 116 patients who underwent TKA and were divided into two groups based on LIA (Modified Ranawat Regimen) or normal saline infiltration in the wound. RESULTS: the mean NRS score was significantly lower in LIA group (3.2) as compared to the control group (3.9) in the first 24 hours. Functional milestones were relatively achieved earlier in LIA group but the values were not significant. Tramadol consumption was remarkably higher in the control group as compared to LIA group on day 1 and 2. As per the morbidity index the mean score on day one was 16.18 and 23.40 which decreased to 6.37 and 9.21 by day three in LIA and control group respectively indicating morbidity has decreased but more so in LIA group. CONCLUSION: our study concludes that use of modified cocktail regimen in the knee effectively decreased morbidity with excellent to good results, declining NRS score, minimal rescue analgesia requirement, early ambulation with better safety.

INTRODUCCIÓN: el dolor quirúrgico se trata con anestesia multimodal en la artroplastia total de rodilla (ATR). Es dudoso que incluir anestesia local infiltrativa (LIA) antes del cierre de la herida proporcione un control adecuado del dolor y disminuya la morbilidad. MATERIAL Y MÉTODOS: se realizó una retrospectiva para evaluar el control del dolor posoperatorio, el índice de morbilidad y el consumo de opioides en 116 pacientes sometidos a ATR y se dividieron en dos grupos según el LIA (régimen de Ranawat modificado) o la infiltración de solución salina normal en la herida. RESULTADOS: la puntuación media NRS fue significativamente menor en el grupo LIA (3.2) en comparación con el grupo control (3.9) en las primeras 24 horas. Los hitos funcionales se alcanzaron relativamente antes en el grupo LIA, pero los valores no fueron significativos. El consumo de tramadol fue notablemente mayor en el grupo de control en comparación con el grupo de LIA los días 1 y 2. Según el índice de morbilidad, la puntuación media el día uno fue 16.18 y 23.40, que disminuyó a 6.37 y 9.21 en el día tres en el grupo de LIA y control, respectivamente, lo que indica que la morbilidad ha disminuido, pero más en el grupo LIA. CONCLUSIÓN: nuestro estudio concluye que el uso de un régimen de cóctel modificado en la rodilla disminuyó efectivamente la morbilidad con resultados excelentes a buenos, una disminución de la puntuación NRS, un requisito mínimo de analgesia de rescate y una deambulación temprana con mayor seguridad.

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PURPOSE: surgery under local anaesthesia can be a stressful experience for patients. The aim of this study was to determine the influence of a non-pharmacological psychotropic measures (NPTM) on the anxiety and stress levels of individuals undergoing ophthalmic surgery. This is the first study to use a bilateral haptic NPTM for this purpose. METHODS: In this clinical interventional case-control study, we assessed objective and subjective stress parameters immediately pre- and postoperatively. We randomly assigned patients to one of two groups: an intervention group with NPTM (n = 70) and a control group (n = 68). RESULTS: When comparing objective parameters (heart rate, blood pressure, and sweat secretion), there were no significant differences between the two groups pre- and postoperatively (p ≥ 0.05). Subjectively, 79% of patients in the intervention group perceived a positive effect from the NPTM (p < 0.01). Patients undergoing eye surgery for the first time described a positive effect significantly more often (p = 0.027). CONCLUSIONS: Our study results show that subjectively perceived anxiety and stress during eye surgery is significantly improved by using a bimanual NPTM. The majority of the patients experienced a positive effect on their wellbeing, particularly those undergoing eye surgery for the first time, although there was also a positive effect for patients who had previously undergone eye surgery. While the haptic NPTM used in this study has a positive impact on patients' perception of ophthalmic surgery, all patients undergoing surgery under local anaesthesia may benefit from this approach.

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BACKGROUND/AIM: Hysterectomy is the most frequent gynecological surgery. Vaginal hysterectomy (VH) seems to be related to favorable perioperative outcomes compared to abdominal or laparoscopic approaches. As the population ages, anesthesia that is safer for the elderly, such as local anesthesia (LA) with conscious sedation, is gaining popularity and is related to favorable outcomes in patients' recovery compared to general or regional anesthesia. We aimed to evaluate the efficacy of dexmedetomidine versus propofol for women undergoing VH for uterine prolapse under LA and conscious sedation. PATIENTS AND METHODS: A prospective study on 40 women with uterine prolapse stage ≥3 who had VH under LA with conscious sedation under either dexmedetomidine (n=20) or propofol (n=20) was performed. A standardized surgical approach with continuous hemodynamic monitoring and sedation assessment using the Ramsay Sedation Scale (RSS) was conducted. The primary endpoint of the study was to determine the percentage of patients receiving intraoperative fentanyl. RESULTS: Analysis of outcomes demonstrated a significant reduction in the proportion of patients requiring intraoperative rescue fentanyl (35% vs. 5%, respectively, p=0.04) and in postoperative pain scores, with more patients achieving an optimal RSS score of 3 in the dexmedetomidine group. CONCLUSION: Based on the findings of the present study, dexmedetomidine offered superior analgesia and patient comfort compared to propofol, suggesting a favorable anesthetic profile for VH under LA.

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BACKGROUND: The pain sensation in a transperineal prostate biopsy was obvious. This study explored the clinical value of ultrasound-guided full-needle path anesthesia in transperineal prostate biopsy. METHODS: Two hundred patients who underwent ultrasound-guided transperineal prostate biopsy at our department were randomly divided into 2 groups. The control group received routine local infiltration anesthesia, and the experimental group received ultrasound-guided full-needle path anesthesia. Immediately after biopsy, visual analog scoring was used to evaluate pain during the biopsy process. Seven days postbiopsy, telephone follow-up revealed symptoms, such as hematuria and discomfort during urination. The measured data were expressed as x ±â€…s. The 2 groups were compared using the t test, and the differences were statistically significant (P < .05). RESULTS: There were no significant differences in age, prostate-specific antigen (PSA) level, or prostate volume between the 2 groups, and all patients underwent prostate biopsy. The pain score of visual analog score was (2.55 ±â€…0.88), urination discomfort was (1.86 ±â€…0.67) days and hematuria time was (2.87 ±â€…0.91) days in the experimental group after biopsy. In the control group, the pain score of visual analog scale was (4.32 ±â€…0.94), the urination discomfort was (2.3 ±â€…0.77) days, and the hematuria time was (2.85 ±â€…0.83) days. Pain scores and urination discomfort were compared between the 2 groups (P < .01). Pain and urination discomfort associated with prostate biopsy in the experimental group were significantly lower than those in the control group. CONCLUSION: Ultrasound-guided full needle path anesthesia can alleviate pain sensation in patients undergoing transperineal prostate biopsy and has high clinical value.

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BACKGROUND: Local infiltration analgesia is commonly used for postoperative pain control after several surgical procedures including intra- and peri-articular as well as wound infiltration. Even though, various adjuvants injected with the local anesthetic have been studied in pairwise comparison or compared to peripheral nerve blocks, the question which adjuvant or combination of adjuvants is the most effective in prolonging the duration of different types of local infiltration analgesia (LIA) has not been answered conclusively. OBJECTIVE: The objective of this network meta-analysis was to determine the analgesic effectiveness and safety of adjuvants in local infiltration analgesia. DESIGN: Systematic review of randomized controlled trials with network meta-analyses. DATA SOURCES: A comprehensive literature search in Embase, CENTRAL, MEDLINE and Web of Science was performed up to March 2023. RESULTS: The best interventions to prolong the duration of analgesia were dexamethasone (Ratio of Means (ROM) 3.33) followed by the combinations of clonidine + morphine (ROM 3.35) and morphine + magnesium sulfate (ROM 2.92), fentanyl (ROM 2.27), ketorolac (ROM 2.26), buprenorphine (ROM 2.04), morphine (ROM 1.93), magnesium sulfate (ROM 1.91), clonidine (ROM 1.89), dexmedetomidine (ROM 1.74) and tramadol (ROM 1.58). Serious adverse events were not reported with either investigated adjuvant. CONCLUSION: There is moderate evidence that dexamethasone is the most effective adjuvant to prolong the duration of analgesia in LIA. The evidence for the alpha-2 agonists dexmedetomidine and clonidine is also moderate, but their effectivity to prolong analgesia stays behind dexamethasone. Clonidine and dexmedetomidine had a small detectable effect on pain scores, yet below clinical relevance, but the largest effect on MEQ consumption. The effects of different opioids were homogenous for all endpoints. The prespecified subgroup analysis of LIA of the knee did not show significantly different results than the pooled analysis. STUDY REGISTRATION: PROSPERO 2020 CRD42020176154 (28.04.2020).

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PURPOSE OF THE STUDY: The purpose of this study was to assess the patient experience of trapeziectomy under WALANT for trapeziometacarpal joint (TMJ) osteoarthritis (OA) in a prospective study with 2-year follow-up. MATERIAL AND METHODS: The study included 23 patients with TMJ OA undergoing trapeziectomy with WALANT. All patients were seen by a hand therapist preoperatively and at 3, 12, and 24 months postoperatively. At each visit, VAS pain scores, thumb range of motion, grip strength, and Disabilities of the Arm, Shoulder and Hand (DASH) score were assessed. The Picker Patient Experience (PPE-15) questionnaire was administered within 2 weeks of surgery. RESULTS: All 23 patients completed the PPE-15 questionnaire. Their mean age was 64 years. The 21 patients who remained at the 24-month follow-up all said they would choose the same anaesthesia method again. At this follow-up, VAS pain scores, thumb range of motion, key pinch grip and DASH scores had improved significantly, while thumb opposition and hand grip strength remained largely unchanged. The majority of patients felt well informed before and during the procedure, and all patients rated pain relief as good or satisfactory. Nearly 40% of patients reported receiving inadequate information about the postoperative medications. DISCUSSION: Patients have a positive attitude to trapeziectomy with WALANT, and seem to prefer WALANT over other methods of anaesthesia. Trapeziectomy with WALANT for TMJ OA is a safe procedure and appears to give a functional outcome similar to trapeziectomy under general anaesthesia. CONCLUSIONS: Trapeziectomy with WALANT for TMJ OA is safe, preferred by patients and has similar clinical outcome as trapeziectomy in general anesthesia. KEY WORDS: trapeziectomy, osteoarthritis, WALANT.

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BACKGROUND: Both precooling the site and injecting a warm anesthetic solution have proven to be efficient in reducing pain individually. However, there is insufficient data on evaluating the efficiency of precooling the site of injection along with the simultaneous administration of a warm local anesthetic solution on the same site in a single patient. AIM: The aim of this study was to evaluate and compare the efficacy, pain perception, hemodynamic changes, and adverse effects of a warm local anesthetic solution injected on precooled injection sites using 2% lignocaine with the conventional local anesthetic technique during inferior alveolar nerve block in 7-9-year-old children. METHODS: A split-mouth, double-blinded, randomized clinical trial was conducted on 70 children who received 2% lignocaine with either technique A or B during the first or second appointment of the treatment procedure. The pain perception, anesthetic efficacy, pulse rate, oxygen saturation levels, and adverse events were evaluated. RESULTS: Pain during injection and treatment after administration of the warm local anesthesia (LA) technique was less as compared to the conventional block technique. Anesthetic success was observed with a faster onset of action (212.57 ± 32.51 s) and shorter duration of LA (165.16 ± 33.09 min) in the warm local technique as compared to the conventional technique. No significant differences were found with regard to heart rate and oxygen saturation levels between the two techniques. Administrating warm LA solutions at precooled injection sites revealed fewer adverse events. CONCLUSION: Injecting warm LA solution on precooled injection sites causes less discomfort and anxiety in children, which makes it more suitable for the child as well as the pediatric dentist.

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Objectives: To assess the knowledge and awareness of dental house officers regarding calculation of local anaesthesia dosage, and to evaluate differences in practices at various tertiary care facilities. METHODS: The cross-sectional study was conducted at three dental hospitals affiliated with Dow University of Health Sciences, Karachi from July to December 2022, and comprised house officers of either gender currently enrolled at the participating centres. Data was collected using a self-administered questionnaire to assess knowledge and awareness of local anaesthesia dosage calculation, administration methods, and common complications. Data was analysed using SPSS 26. RESULTS: Of the 200 subjects approached, 136(68%) responded, and 89(65.4%) of them were females. Knowledge regarding the meaning of 2% lidocaine solution was low 45(33%), and 68(50%) subjects were knowledgeable about the maximum dosage of lidocaine with epinephrine. In terms of practice, lidocaine was the most commonly administered local anaesthetic 115(85%), followed by bupivacaine 15(11%). The majority of subjects administered local anaesthesia with vasoconstrictor 127(94%), but only 36(27%) performed aspiration during administration. Syncope 71(52%) was the most commonly reported complication, followed by lip/cheek/tongue biting by 35(26%). CONCLUSIONS: House officers' knowledge level of local anaesthesia administration indicated the need for adequate training.

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ABSTRACT: Nearly half of all pregnancies worldwide are unintended. Intrauterine devices are an effective, long-acting form of pregnancy prevention that require minimal maintenance, and also can be used in patients with menorrhagia. However, they are underused because of pain associated with their insertion. Topical and local anesthesia are good options for reducing procedural pain in select patients. IUD placement falls within the scope of practice for physician associates/assistants (PAs) practicing in family medicine, internal medicine, and women's health. PAs should be aware of these additional analgesia options available to patients in order to increase use of effective contraception.

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Deep brain stimulation (DBS) stands as the preferred treatment for Parkinson's disease (PD) patients manifesting refractory motor symptoms or when medication side effects outweigh the benefits. Though traditionally administered under local anesthesia coupled with sedation (LA + S), recent evidence hints at comparable outcomes under general anesthesia (GA). This systematic review and meta-analysis aimed to scrutinize post-surgical outcomes in randomized PD patients undergoing DBS surgery while GA versus LA + S. We searched PubMed, Cochrane, and Embase databases following PRISMA guidelines. We included randomized studies directly comparing DBS surgery under GA versus LA + S, delineating clinical outcomes. Safety outcomes assessed disparities in infection and hemorrhage risk. Mean differences (MD) and Risk Differences (RD) with 95% Confidence Intervals (CI) were utilized to evaluate outcomes, under a random-effects model. Heterogeneity was evaluated through I² statistics, and in studies exhibiting high heterogeneity, exclusion analysis was performed. Evaluated outcomes encompassed motor improvement, complications, behavioral and mood effects gauged by the Unified Parkinson's Disease Rating Scale (UPDRS), Parkinson's Disease Questionnaire 39 (PDQ39), and daily levodopa equivalent dose (LEDD). A total of 3 studies, encompassing 203 patients, were reviewed. At a 6-month follow-up, in patients undergoing GA during surgery, there was no statistically significant difference compared to the LA + S group in terms of UPDRS III ON (MD 0.19; 95% CI -2.21 to 2.59; p = 0.88; I²=0%), UPDRS III OFF (MD 0.58; 95% CI -4.30 to 5.45; p = 0.21; I²=0%), UPDRS IV ON ( (MD 0.98; 95% CI -0.95 to 2.92; p = 0.32; I²=23%), PDQ39 (MD -1.27; 95% CI -6.31 to 3.77; p = 0.62; I²=0%), and LEDD (MD -1.99; 95% CI -77.88 to 73.90; p = 0.96; I²=32%). There was no statistically significant difference between groups in terms of infection (RD 0.02; 95% CI -0.02 to 0.05; p = 0.377; I²=0%) or hemorrhage (RD 0.04; 95% CI -0.03 to 0.11; p = 0.215; I²=0%). Our findings suggest, based on short-term follow-up, that GA is not inferior to LA + S in terms of benefits for the selected outcomes. However, further studies are needed to determine whether there are significant long-term clinical differences between these groups.

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PURPOSE: To investigate the effects of different cortical bone thickness and jaw bone density at implant sites on intraoperative pain during implant surgery. METHODS: One hundred and eighty-seven patients(263 implant sites) who underwent implant placement surgery at the Fourth Affiliated Hospital of Nanchang University from August 2021 to August 2022 were selected to investigate the effects of different cortical bone thickness and jaw bone density HU values at implant sites on the anesthetic effect under local infiltration anesthesia with epinephrine in articaine. SPSS 26.0 software package was used for data analysis. RESULTS: The mean cortical bone thickness at the painful sites[(3.90±1.36) mm] was significantly greater than that at the non-painful sites [(2.24±0.66) mm], and the difference was statistically significant(P＜0.05). The differences in cortical bone thickness in the mandibular anterior, premolar, and molar regions were statistically significant in the comparison of pain and non-pain sites. The mean HU value of bone density was (764.46±239.75) for the painful sites and (612.23±235.31) for the non-painful sites, with significant difference(P＜0.05). The difference was not significant(P＞0.05) when comparing the HU values of painful sites with non-painful sites in the mandibular anterior teeth and anterior molar region, while the difference was significant(P＜0.05) when comparing the HU values of painful sites with non-painful sites in the mandibular molar region. CONCLUSIONS: Sites with large cortical bone thickness have a greater effect on blocking infiltrative anesthetic penetration and are more prone to intraoperative pain during implantation. In the mandibular anterior and premolar regions, the HU value of the implant sites had less effect on infiltrative anesthetic penetration, and the effect was greater in the mandibular molar region, and the implant sites with high HU values in the mandibular molar region were more likely to have intraoperative pain. When the cortical bone thickness in the planned implant site is greater than 3.9 mm and the mean bone density in the mandibular molar region is greater than 665 HU. If there is sufficient safe distance for hole operation, it is recommended to apply mandibular nerve block anesthesia combined with articaine infiltration anesthesia to avoid intraoperative pain and bad surgical experience for the patients.

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Depot-type drug delivery systems are designed to deliver drugs at an effective rate over an extended period. Minimizing initial "burst" can also be important, especially with drugs causing systemic toxicity. Both goals are challenging with small hydrophilic molecules. The delivery of molecules such as the ultrapotent local anesthetic tetrodotoxin (TTX) exemplifies both challenges. Toxicity can be mitigated by conjugating TTX to polymers with ester bonds, but the slow ester hydrolysis can result in subtherapeutic TTX release. Here, we developed a prodrug strategy, based on dynamic covalent chemistry utilizing a reversible reaction between the diol TTX and phenylboronic acids. These polymeric prodrugs exhibited TTX encapsulation efficiencies exceeding 90 % and the resulting polymeric nanoparticles showed a range of TTX release rates. In vivo injection of the TTX polymeric prodrugs at the sciatic nerve reduced TTX systemic toxicity and produced nerve block lasting 9.7±2.0 h, in comparison to 1.6±0.6 h from free TTX. This approach could also be used to co-deliver the diol dexamethasone, which prolonged nerve block to 21.8±5.1 h. This work emphasized the usefulness of dynamic covalent chemistry for depot-type drug delivery systems with slow and effective drug release kinetics.

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While mechanical vibration lessens discomfort associated with injection site pain (ISP), many local anesthetic injectors (LAIs) do not use vibratory anesthetic devices (VADs). Injector preference of vibration device is influenced by functional concerns, but qualitatively there is an element of adoption that is driven by visual feedback. We sought to capture operator preferences of vibration device design elements to further understand why injectors do not use these devices. We conducted a survey of image preferences among nurses and medical assistants employed at 8 dermatological clinics to investigate barriers to VAD use. Images were electronically modified with features distinct from the original device (a VAD commonly used in clinical practice). Participants rated their likelihood and comfort of use of each VAD represented in the images. Two-sample t-tests were used to compare the rating of the unmodified VAD to each modified VAD within participants. A response rate of 100% was achieved with 35 participants (average age, 38.5 years; 6 (17.1%) male, 29 (82.9%) female). Despite 28 (80%) participants knowing that mechanical vibration reduces ISP, only 16 (45.7%) endorsed ever using mechanical vibration as topical anesthetic. Images modified by pattern, color, and sterility covering were rated significantly lower than the original, unmodified VAD image (plain white VAD), confirming that visual feedback does impact adoption. Through independent comment categorization, aesthetics were found to be important to LAIs. Aesthetic preferences opposing functional concerns may factor into the lack of VAD use. Defining these visual preference barriers to adoption may help promote VAD use during dermatologic procedures.

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BACKGROUND: One of the main goals for pediatric dentists is to offer a painless anesthesia experience. Laser photobiomodulation is among the suggested strategies to decrease injection pain. So, this study aimed to assess the impact of laser photobiomodulation on local anesthesia (LA) injection pain in children and its effect on the efficacy of LA during pulpotomy and SSC procedures. METHODS: The research was carried out as a randomized controlled clinical trial with two parallel group design. It involved 64 cooperative healthy children, age range from 5 to 7 years, each having at least one maxillary molar indicated for pulpotomy. Children were randomly allocated to one of the two groups based on the pre-anesthetic tissue management technique used: test group received laser photobiomodulation, while control group received topical anesthetic gel. Pain during injection, pulpotomy, and SSC procedures was assessed using physiological measures (Heart Rate (HR)), subjective evaluation (modified Face-Pain-Scale (FPS), and objective analysis (Sound-Eye-Motor scale (SEM)). RESULTS: A total of 64 children with mean age 6.23 ± 0.78 participated in this research. The mean HR scores were significantly lower in the laser PBM group during buccal and palatal infiltration injections. The SEM mean scores were significantly lower in the laser PBM group during both injections. For the FPS scale, the number of children who recorded satisfaction during injection was significantly higher in laser PBM group. There was no statistically significant difference in mean HR as well as in SEM and FPS scores between the two groups during pulpotomy and SSC procedures. Comparisons between the two study groups were performed using independent samples t- and Mann-Whitney U tests. Significance was set at p value < 0.05. CONCLUSION: Laser photobiomodulation is a promising non-pharmacological pre-anesthetic tissue management technique in children that offered less painful injection compared to topical anesthetic gel without compromising the effectiveness of LA. TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT05861154. Registered on 16/5/2023.

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INTRODUCTION: There has been an increase in the popularity of the wide-awake local anesthesia no-tourniquet (WALANT) procedure for various upper limb surgeries. The present study aims to conduct a comprehensive analysis of the satisfaction levels of 106 patients, considering factors such as age, gender, comorbidities, and the specific procedures they underwent. METHOD: The present study was a retrospective cohort study conducted to analyze the overall satisfaction of a cohort of 106 patients who underwent various surgical procedures of the hand between 2018 and 2023. The satisfaction was assessed with a questionnaire comprising 13 questions/statements adjusted to a standard Swiss grading system (from 1 = I strongly agree to 6 = I strongly disagree). RESULTS: Overall satisfaction with WALANT was high, with most patients expressing positive experiences. Patients with hypertension reported similar satisfaction levels compared to those without, while diabetic patients experienced significantly higher anxiety levels during the procedure (p > 0.05). CONCLUSION: WALANT exhibits versatility as an anesthesia choice, demonstrating efficacy in both routine and complex hand surgeries. Our survey-based study reveals a high satisfaction level across diverse procedures. When assessing the correlation between WALANT satisfaction and patient comorbidities, hypertension displayed no significant impact, while diabetic patients reported heightened anxiety. Importantly, patient satisfaction remained consistently high even within the subgroup with comorbidities. Our results underscore WALANT's reliability in upper limb surgery, showcasing its usefulness and positive outcomes across a broad range of patients and surgical procedures.

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BACKGROUND: This meta-analysis aimed to perform a head-to-head comparison of the role of general anesthesia (GA) and local anesthesia (LA) in the management of patients with nasal bone fractures (NBFs). METHODS: PubMed, Embase, and Web of Science were comprehensively searched. Studies investigating the clinical outcomes of GA and LA in the management of NBFs were included. Pooled odds ratios (OR) with the respective 95% confidence intervals (CIs) were calculated. Heterogeneity between the included studies was evaluated. The risk of bias in the included studies was assessed. RESULTS: Eight studies were included in this meta-analysis. The pooled ORs for cosmetic results, residual septal deformity, the need for further surgery, patients' satisfaction with the anesthesia procedure, and patients' satisfaction with the surgery results were 0.70 (95% CI 0.18, 2.64; z = - 0.53, p = 0.5957), 1.11 (95% CI 0.37, 3.30; z = 0.18, p = 0.8558), 1.19 (95% CI 0.65, 2.20; z = 0.56, p = 0.5760), 1.57 (95% CI 0.92, 2.69; z = 1.65, p = 0.0982), and 1.00 (95% CI 0.55, 1.80; z = - 0.00, p = 0.9974). CONCLUSIONS: Insignificant difference on clinical outcomes was observed between GA and LA in the manipulation of patients with NBFs, and the choice of anesthetic approach should be based on the tolerability of the methods and the severity of nasal fractures.

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