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Heiderich S, Bastian B, Johannsen S, Klingler W, Rüffert H, Schuster F. [Trigger-free anesthesia : Indications and safe application]. DIE ANAESTHESIOLOGIE 2023:10.1007/s00101-023-01311-2. [PMID: 37382624 DOI: 10.1007/s00101-023-01311-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Accepted: 06/07/2023] [Indexed: 06/30/2023]
Abstract
The safe anesthesiological care of patients with neuromuscular diseases poses a particular challenge for anesthetists. Only a small group of muscle diseases and syndromes are associated with an increased risk of malignant hyperthermia and therefore require trigger-free anesthetic procedures avoiding volatile anesthetics and succinylcholine. These diseases are frequently associated with mutations in the RYR1, CACNA1S or STAC-3 genes. In other neuromuscular diseases, anesthetic-induced rhabdomyolysis can occur. Therefore, volatile anesthetics should be avoided in these patients in addition to the contraindication for succinylcholine. In other neuromuscular diseases the risk of a propofol infusion syndrome or myotonic crises can be elevated or the duration of the effect of non-depolarizing muscle relaxants can be changed in an incalculable way. In every case an individual anesthetic aproach including the avoidance of potential pharmacological or non-pharmacological triggers is essential for the safety of the patients.
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Affiliation(s)
- Sebastian Heiderich
- Klinik für Anästhesiologie und Intensivmedizin, Medizinische Hochschule Hannover, Carl-Neuberg-Straße 1, 30625, Hannover, Deutschland.
| | - Börge Bastian
- Klinik und Poliklinik für Anästhesiologie und Intensivtherapie, Universitätsklinikum Leipzig, Leipzig, Deutschland
| | - Stephan Johannsen
- Klinik und Poliklinik für Anästhesiologie, Intensivmedizin, Notfallmedizin und Schmerztherapie, Universitätsklinikum Würzburg, Würzburg, Deutschland
| | - Werner Klingler
- Fachabteilung für Anästhesie, Intensivmedizin und Schmerztherapie, SRH Kliniken Landkreis Sigmaringen, Sigmaringen, Deutschland
| | - Henrik Rüffert
- Klinik für Anästhesie, Intensivmedizin und Schmerztherapie, Helios Klinikum Schkeuditz, Schkeuditz, Deutschland
| | - Frank Schuster
- Institut für Anästhesiologie, Intensivmedizin und Notfallmedizin, Donau-Isar-Klinikum Deggendorf-Dingolfing-Landau, Deggendorf, Deutschland
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Otremba B, Dinges HC, Schubert AK, Zink W, Steinfeldt T, Wulf H, Wiesmann T. [Liposomal bupivacaine-No breakthrough in postoperative pain management]. Anaesthesist 2022; 71:556-564. [PMID: 35469071 DOI: 10.1007/s00101-022-01118-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/15/2022] [Indexed: 11/29/2022]
Abstract
One of the main limitations concerning the use of local anesthetics is due to their restricted duration of action. In recent years, liposomal formulations with prolonged release kinetics have been developed to extend the pharmacological duration of action of the 1‑stage peripheral regional anesthesia (single-shot procedure) and thus bring about a longer duration of action. The focus here is particularly on achieving postoperative freedom from pain for at least 24 h (or even better 48 h) and thus early mobilization of patients using on-demand medication causing (at most) minor local sensory blockade without causing motor impairments (at least that is the ideal). Therefore, methods of utilizing slow-release drugs as seen in liposomal carrier systems have experienced increasing scientific attention in the last few years. A common modern pharmacological example with a theoretically significantly longer duration of action is liposomal bupivacaine, an amide local anesthetic. Due to a multivesicular liposome structure, the retarded release of the active component bupivacaine HCl leads to a theoretical pharmacological effectiveness of up to 72 h. Previous studies consistently showed a safety profile comparable to conventional bupivacaine HCl. Liposomal bupivacaine has been approved by the U.S. Food and Drug Administration (FDA) under the trade name Exparel© (Pacira Pharmaceuticals, Parsippany, NJ, USA) since 2011; however, its use is currently limited to local wound infiltration, transverse abdominis plane (TAP) blocks, and interscalene nerve blocks of the brachial plexus. In 2020, the European Medicines Agency (EMA) also approved the use of liposomal bupivacaine for blockade of the brachial plexus or the femoral nerve and as a field block or for wound infiltration to treat postoperative pain. So far, studies on the clinical effectiveness of liposomal bupivacaine have been very heterogeneous and there have been no conclusive meta-analyses with sufficient rigor or significance. Recent systematic reviews and meta-analyses, combining the results of clinical studies regarding the analgesic efficiency of liposomal bupivacaine in different fields of application, consistently refuted any benefit of clinical relevance provided by the liposomal formulation. There is currently sufficient evidence to now end the ongoing debate around liposomal bupivacaine. The aim of this work is to give the reader a current, evidence-based overview of this substance.
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Affiliation(s)
- Berit Otremba
- Klinik für Anästhesie und Intensivtherapie Universitätsklinikum Marburg, Philipps-Universität Marburg, Baldingerstraße, 35033, Marburg, Deutschland.
| | - Hanns-Christian Dinges
- Klinik für Anästhesie und Intensivtherapie Universitätsklinikum Marburg, Philipps-Universität Marburg, Baldingerstraße, 35033, Marburg, Deutschland
| | - Ann-Kristin Schubert
- Klinik für Anästhesie und Intensivtherapie Universitätsklinikum Marburg, Philipps-Universität Marburg, Baldingerstraße, 35033, Marburg, Deutschland
| | - Wolfgang Zink
- Klinik für Anästhesiologie, Operative Intensiv- und Notfallmedizin, Klinikum der Stadt Ludwigshafen, Ludwigshafen, Deutschland
| | - Thorsten Steinfeldt
- Klinik für Anästhesie und Intensivtherapie Universitätsklinikum Marburg, Philipps-Universität Marburg, Baldingerstraße, 35033, Marburg, Deutschland.,Klinik für Anästhesie, Intensivmedizin und Schmerztherapie, Berufsgenossenschaftliche Unfallklinik, Frankfurt am Main, Deutschland
| | - Hinnerk Wulf
- Klinik für Anästhesie und Intensivtherapie Universitätsklinikum Marburg, Philipps-Universität Marburg, Baldingerstraße, 35033, Marburg, Deutschland
| | - Thomas Wiesmann
- Klinik für Anästhesie und Intensivtherapie Universitätsklinikum Marburg, Philipps-Universität Marburg, Baldingerstraße, 35033, Marburg, Deutschland.,Klinik für Anästhesiologie und operative Intensivmedizin, Diakoneo Diakonie-Klinikum Schwäbisch Hall, Schwäbisch Hall, Deutschland
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Abstract
For decades local anesthetics have proven to be safe and effective drugs in the clinical practice, crucially promoting the enormous achievements in regional anesthesia. Meanwhile, it is a well-known fact that local anesthetics are much more than just "simple" sodium channel blockers. They also interact with numerous other ion channels and subcellular structures, enhancing nerve blockade and resulting in systemic "alternative" effects, which can sometimes even be clinically used. By the simultaneous administration of various adjuvants (e.g., opioids, corticosteroids and α2-receptor agonists) attempts are made to prolong the time of action of local anesthetics after a single administration in order to achieve the best possible improvement in postoperative analgesia. In this context, ultralong-acting local anesthetics, such as liposomal bupivacaine, which at least theoretically can provide a sensory nerve block for several days, have been developed and clinically introduced. The coming years will show whether these approaches will develop into genuine alternatives to the personnel and cost-intensive continuous nerve blockades.Local anesthetic-induced systemic toxicity is meanwhile rare but still a potentially life-threatening event, frequently resulting from accidental intravascular injection or extensive systemic resorption. Consequently, slow and fractional application of these agents with intermittent aspiration helps to prevent toxic sequelae. If toxic symptoms occur, however, the intravenous infusion of 20% lipid solutions in addition to basic treatment measures can enhance the success of treatment.
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Affiliation(s)
- W Zink
- Klinik für Anästhesiologie, Operative Intensivmedizin und Notfallmedizin, Klinikum der Stadt Ludwigshafen am Rhein, Bremserstr 79, 67063, Ludwigshafen, Deutschland.
| | - T Steinfeldt
- Klinik für Anästhesiologie und operative Intensivmedizin, Diakonieklinikum Schwäbisch Hall, Schwäbisch Hall, Deutschland
| | - T Wiesmann
- Klinik für Anästhesie und Intensivtherapie, Philipps Universität Marburg, Marburg, Deutschland
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Stevic M, Vlajkovic A, Trifunovic B, Rakic I, Ristic N, Budic I, Marjanovic V, Jovanovski-Srceva M, Simic D. Topical anesthetics for pediatric laser treatment. J COSMET LASER THER 2019; 21:417-421. [PMID: 31698962 DOI: 10.1080/14764172.2019.1689273] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
Topical anesthetic agent causes transient insensibility to pain in a limited area of skin, and provides effective anesthesia in a short onset time, short duration, with seldom local or systemic side effects on intact skin and is simple to use. Topical formulations may offer significant benefits for prevention of procedural pain. Currently, they are considered to be the most effective anesthesia for laser treatments. Unfortunately, there is no standard anesthetic technique for this procedure. Lasers are being widely used in numerous dermatological and esthetics treatments in childhood. The advancement of new knowledge in laser technology have contributed to the development of new lasers that are commonly used in a pediatric population, such as Pulsed Dye, Carbon-dioxide and Nd:YAG laser. The most commonly used topical anesthetics in young patients for minimally or moderately painful laser cutaneous procedures are Lidocaine, Prilocaine, Tetracaine gel and combinations thereof.
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Affiliation(s)
- Marija Stevic
- Department of Anesthesia, Medical Faculty University of Belgrade, Serbia.,Department of Anesthesia, University Children's Hospital, Belgrade, Serbia
| | - Ana Vlajkovic
- Department of Anesthesia, University Children's Hospital, Belgrade, Serbia
| | | | - Ivan Rakic
- Department of Plastic Surgery, University Children's Hospital, Belgrade, Serbia
| | - Nina Ristic
- Department of Gastroenterology, University Children's Hospital, Belgrade, Serbia
| | - Ivana Budic
- Department of Anesthesia, Medical Faculty University of Nis, Serbia
| | - Vesna Marjanovic
- Department of Anesthesia, Medical Faculty University of Nis, Serbia
| | | | - Dusica Simic
- Department of Anesthesia, Medical Faculty University of Belgrade, Serbia.,Department of Anesthesia, University Children's Hospital, Belgrade, Serbia
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Löscher WN, Wanschitz J, Iglseder S, Vass A, Grinzinger S, Pöschl P, Grisold W, Ninkovic M, Antoniadis G, Pedro M, König R, Quasthoff S, Oder W, Finsterer J. Iatrogenic lesions of peripheral nerves. Acta Neurol Scand 2015; 132:291-303. [PMID: 25882317 DOI: 10.1111/ane.12407] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/20/2015] [Indexed: 11/28/2022]
Abstract
Iatrogenic nerve lesions (INLs) are an integral part of peripheral neurology and require dedicated neurologists to manage them. INLs of peripheral nerves are most frequently caused by surgery, immobilization, injections, radiation, or drugs. Early recognition and diagnosis is important not to delay appropriate therapeutic measures and to improve the outcome. Treatment can be causative or symptomatic, conservative, or surgical. Rehabilitative measures play a key role in the conservative treatment, but the point at which an INL requires surgical intervention should not be missed or delayed. This is why INLs require close multiprofessional monitoring and continuous re-evaluation of the therapeutic effect. With increasing number of surgical interventions and increasing number of drugs applied, it is quite likely that the prevalence of INLs will further increase. To provide an optimal management, more studies about the frequency of the various INLs and studies evaluating therapies need to be conducted. Management of INLs can be particularly improved if those confronted with INLs get state-of-the-art education and advanced training about INLs. Management and outcome of INLs can be further improved if the multiprofessional interplay is optimized and adapted to the needs of the patient, the healthcare system, and those responsible for sustaining medical infrastructure.
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Affiliation(s)
- W. N. Löscher
- Department of Neurology; Medical University Innsbruck; Innsbruck Austria
| | - J. Wanschitz
- Department of Neurology; Medical University Innsbruck; Innsbruck Austria
| | - S. Iglseder
- Department of Neurology; Barmherzige Brüder Linz; Linz Austria
| | - A. Vass
- Private Practice; Vienna Austria
| | - S. Grinzinger
- Department of Neurology; Paracelsus Private Medical University; Salzburg Austria
| | - P. Pöschl
- Barmherzige Brüder Regensburg; Regensburg Germany
| | - W. Grisold
- Department of Neurology; Kaiser-Franz-Josef Spital; Vienna Austria
| | - M. Ninkovic
- Department of Physical Medicine and Rehabilitation; Medical University Innsbruck; Innsbruck Austria
| | - G. Antoniadis
- Neurosurgical Clinic; University of Ulm and Province Hospital; Günzburg Germany
| | - M.T. Pedro
- Neurosurgical Clinic; University of Ulm and Province Hospital; Günzburg Germany
| | - R. König
- Neurosurgical Clinic; University of Ulm and Province Hospital; Günzburg Germany
| | - S. Quasthoff
- Department of Neurology; Graz Medical University; Graz Austria
| | - W. Oder
- AUVA Rehabilitation Center Wien Meidling; Vienna Austria
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