1
|
Alfirevic A, Almonacid-Cardenas F, Yalcin EK, Shah K, Kelava M, Sessler DI, Turan A. Blood bupivacaine concentrations after pecto-serratus and serratus anterior plane injections of plain and liposomal bupivacaine in robotically-assisted mitral valve surgery: Sub-study of a randomized trial. J Clin Anesth 2024; 95:111470. [PMID: 38604047 DOI: 10.1016/j.jclinane.2024.111470] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2024] [Revised: 03/06/2024] [Accepted: 04/07/2024] [Indexed: 04/13/2024]
Abstract
STUDY OBJECTIVE To investigate the timing of peak blood concentrations and potential toxicity when using a combination of plain and liposomal bupivacaine for thoracic fascial plane blocks. DESIGN Pharmacokinetic analysis. SETTING Operating room. PATIENTS Eighteen adult patients undergoing robotically-assisted mitral valve surgery. INTERVENTIONS Ultrasound-guided pecto-serratus and serratus anterior plane blocks using a mixture of 0.5% bupivacaine HCl up to 2.5 mg/kg and liposomal bupivacaine up to 266 mg. MEASUREMENTS Arterial plasma bupivacaine concentration. MAIN RESULTS Samples from 13 participants were analyzed. There was substantial inter-patient variability in plasma concentrations. A geometric mean maximum bupivacaine concentration was 1492 ng/ml (range 660 to 4650 ng/ml) at median time of 30 min after injection. In 4/13 (31%) patients, plasma bupivacaine concentrations exceeded our predefined 2000 ng/ml toxic threshold. A second much smaller peak was observed about 32 h after the injection. No obvious signs of local anesthetic toxicity were observed. CONCLUSIONS Combined injection of plain and liposomal bupivacaine for pecto-serratus/serratus anterior plane blocks produced a biphasic pattern, with the highest arterial plasma concentrations observed within 30 min. Maximum concentrations exceeded the potential toxic threshold in nearly a third of patients, but without clinical evidence of toxicity. Clinicians should not assume that routine combinations of plain and liposomal bupivacaine for thoracic fascial plane blocks are inherently safe.
Collapse
Affiliation(s)
- Andrej Alfirevic
- Division of Cardiothoracic Anesthesiology, Department of Anesthesiology, Cleveland Clinic, Cleveland, OH, USA.
| | | | - Esra Kutlu Yalcin
- Division of Multi-specialty Anesthesiology, Department of Anesthesiology, Cleveland Clinic, Cleveland, OH, USA
| | - Karan Shah
- Outcomes Research Consortium, Department of Anesthesiology, Cleveland Clinic, Cleveland, OH, USA
| | - Marta Kelava
- Division of Cardiothoracic Anesthesiology, Department of Anesthesiology, Cleveland Clinic, Cleveland, OH, USA
| | - Daniel I Sessler
- Outcomes Research Consortium, Department of Anesthesiology, Cleveland Clinic, Cleveland, OH, USA
| | - Alparslan Turan
- Outcomes Research Consortium, Department of Anesthesiology, Cleveland Clinic, Cleveland, OH, USA; Division of Multi-specialty Anesthesiology, Department of Anesthesiology, Cleveland Clinic, Cleveland, OH, USA
| |
Collapse
|
2
|
Hunter C, Kendall MC, Chen TH, Apruzzese P, Maslow A. Serum Levels of Bupivacaine After Bilateral Ultrasound-Guided Deep Parasternal Intercostal Plane Block in Cardiac Surgery with Median Sternotomy. J Cardiothorac Vasc Anesth 2024:S1053-0770(24)00378-1. [PMID: 38908936 DOI: 10.1053/j.jvca.2024.06.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/01/2024] [Accepted: 06/03/2024] [Indexed: 06/24/2024]
Abstract
OBJECTIVE To evaluate systemic levels of bupivacaine after bilateral ultrasound-guided deep parasternal intercostal plan (PIP) block in cardiac surgical patients undergoing median sternotomy. DESIGN Prospective, observational study SETTING: Single institution; academic university hospital PARTICIPANTS: Twenty-eight adult patients undergoing cardiac surgery with median sternotomy received a PIP block with 2.5 mg/kg bupivacaine with or without dexamethasone and dexmedetomidine. MEASUREMENTS Arterial blood samples were analyzed for total serum bupivacaine concentration at 5, 15, 30, 45, 60, 90, 120, and 150 minutes after placement of PIP. Local anesthetic volume, local anesthetic adjuncts, time to extubation, postoperative pain scores, and opioid consumption were recorded. MAIN RESULTS The mean peak bupivacaine concentration was 0.60 ± 0.62 µg/mL, and the mean time to maximum concentration (Tmax) was 16.92 ± 12.97 minutes. Two patients (7.1%) had a concentration >2.0 µg/mL within 15 minutes of block placement. The mean Tmax of bupivacaine was significantly greater in patients who did not receive additives compared to those patients who did (22.86 ± 14.77 minutes v 10.0 ± 5.22 minutes; p = .004). The times to extubation and postoperative pain were not improved with additives. CONCLUSIONS Bilateral PIP placed at the end of cardiac surgery resulted in low systemic bupivacaine levels. The inclusion of additives shortened Tmax without improving outcome.
Collapse
Affiliation(s)
- Caroline Hunter
- Department of Anesthesiology, The Warren Alpert Medical School of Brown University, Providence, RI
| | - Mark C Kendall
- Department of Anesthesiology, The Warren Alpert Medical School of Brown University, Providence, RI
| | - Tzong Huei Chen
- Department of Anesthesiology, The Warren Alpert Medical School of Brown University, Providence, RI
| | | | - Andrew Maslow
- Department of Anesthesiology, The Warren Alpert Medical School of Brown University, Providence, RI.
| |
Collapse
|
3
|
Cameron MJ, Long J, Kardash K, Yang SS. Superficial parasternal intercostal plane blocks in cardiac surgery: a systematic review and meta-analysis. Can J Anaesth 2024; 71:883-895. [PMID: 38443735 DOI: 10.1007/s12630-024-02726-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2023] [Revised: 01/11/2024] [Accepted: 01/20/2024] [Indexed: 03/07/2024] Open
Abstract
PURPOSE Traditional multimodal analgesic strategies have several contraindications in cardiac surgery patients, forcing clinicians to use alternative options. Superficial parasternal intercostal plane blocks, anesthetizing the anterior cutaneous branches of the thoracic intercostal nerves, are being explored as a straightforward method to treat pain after sternotomy. We sought to evaluate the literature on the effects of superficial parasternal blocks on pain control after cardiac surgery. METHODS We conducted a systematic review and meta-analysis of randomized controlled trials (RCTs). We searched MEDLINE, Embase, CENTRAL, and Web of Science databases for RCTs evaluating superficial parasternal intercostal plane blocks in adult patients undergoing cardiac surgery via midline sternotomy published from inception to 11 March 2022. The prespecified primary outcome was opioid consumption at 12 hr. The risk of bias was assessed with the Cochrane Collaboration Risk of Bias Tool, and the quality of evidence was evaluated using the grading of recommendations, assessments, development, and evaluations. Outcomes were analyzed with a random-effects model. All subgroups were prespecified. RESULTS We reviewed 1,275 citations. Eleven RCTs, comprising 756 patients, fulfilled the inclusion criteria. Only one study reported the prespecified primary outcome, precluding the possibility of meta-analysis. This study reported a reduction in opioid consumption (-11.2 mg iv morphine equivalents; 95% confidence interval [CI], -8.2 to -14.1) There was a reduction in opioid consumption at 24 hr (-7.2 mg iv morphine equivalents; 95% CI, -5.6 to -8.7; five trials; 436 participants; moderate certainty evidence). All five studies measuring complications reported that none were detected, which included a sample of 196 blocks. CONCLUSION The literature suggests a potential benefit of using superficial parasternal blocks to improve acute postoperative pain control after cardiac surgery via midline sternotomy. Future studies specifying dosing regimens and adjuncts are required. STUDY REGISTRATION PROSPERO (CRD42022306914); first submitted 22 March 2022.
Collapse
Affiliation(s)
- Matthew J Cameron
- Faculty of Medicine, McGill University, Montreal, QC, Canada.
- Department of Anesthesia, Jewish General Hospital, K1401-3755 Cote Sainte Catherine, Montreal, QC, H3T 1E2, Canada.
- Lady Davis Research Institute, Montreal, QC, Canada.
| | - Justin Long
- Faculty of Medicine, McGill University, Montreal, QC, Canada
| | - Kenneth Kardash
- Faculty of Medicine, McGill University, Montreal, QC, Canada
- Department of Anesthesia, Jewish General Hospital, Montreal, QC, Canada
| | - Stephen S Yang
- Faculty of Medicine, McGill University, Montreal, QC, Canada
- Department of Anesthesia, Jewish General Hospital, Montreal, QC, Canada
- Lady Davis Research Institute, Montreal, QC, Canada
| |
Collapse
|
4
|
Pawa A, White L. Pro: The erector spinae plane block is useful for thoracic surgery. J Clin Anesth 2024; 92:111300. [PMID: 37857169 DOI: 10.1016/j.jclinane.2023.111300] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2023] [Accepted: 10/13/2023] [Indexed: 10/21/2023]
Affiliation(s)
- Amit Pawa
- Department of Theatres, Anaesthesia and Perioperative Medicine, Guy's and St Thomas' NHS Foundation Trust, London, UK; Faculty of Life Sciences and Medicine, King's College London, London, UK
| | - Leigh White
- Department of Anaesthesia and Perioperative Medicine, Sunshine Coast University Hospital, Sunshine Coast, Australia; School of Medicine & Dentistry, Griffith University, Queensland, Australia.
| |
Collapse
|
5
|
Zhu X, Ye W, Chen J, Xiao J, Zhao W. Comparative retrospective review of perioperative analgesia using ultrasound-guided programmed intermittent erector spinae plane block for video-assisted thoracoscopic lobectomy. BMC Anesthesiol 2023; 23:370. [PMID: 37950148 PMCID: PMC10638794 DOI: 10.1186/s12871-023-02338-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2023] [Accepted: 11/05/2023] [Indexed: 11/12/2023] Open
Abstract
BACKGROUND The retrospective cohort study was conducted to estimate the opioid-sparing anesthesia and limited side-effects with ultrasound (US)-guided ESPB using programmed intermittent bolus (PIB) or continuous infusion (CI) and standard opioid-based anesthesia in patients undergoing video-assisted thoracoscopic lobectomy (VATS). METHODS Patients underwent VATS were stratified into either control group or one of the two ESPB groups in a 1:2:2 ratio depending on whether PIB was implemented or not. The primary endpoint was intra- and post-operative opioids consumption over the first 48 h following surgery. RESULTS A total of 180 cases were included in the analysis. Cumulative perioperative opioid administration was found to be significantly different between PIB, CI and control group (both p < 0.001), and between PIB and CI group (p = 0.028). More specifically, the mean was 305.30 ± 51.35 mg, 339.68 ± 56.07 mg and 468.91 ± 79.84 mg in PIB, CI and control group. NRS scores at rest across all postoperative times were comparable in two ESPB groups, while significantly lower than control group, however, scores during exercising at postoperative 3, 6, 12 h were significantly lower in PIB group as compared to CI group. A wider anesthetized dermatomes with PIB was observed at 6, 24 and 48 h as opposed to the CI. The mean of levobupivacaine plasma concentration was significantly lower for PIB at postoperative 0.5, 12, 24 and 48 h after initiation than CI. However, local anesthetic toxicity was not observed in any of the two ESPB groups. CONCLUSIONS When US-guided ESPB using PIB was performed preoperatively, it contributed to the minimization of intra- and post-operative opioid consumption due to better analgesia with a wider anesthetic dermatome opposed to conventional CI, whereas, it was also associated with lower risk of local anesthetic toxicity because of lower plasma concentration of levobupivacaine.
Collapse
Affiliation(s)
- Xuefang Zhu
- Department of Anesthesiology, The Fifth People's Hospital of Huan'an, No 1 Huaihe East Street, Huaiyin District, 223001, Huai'an City, Jiangsu Province, China
| | - Wei Ye
- Department of Anesthesiology, The Fifth People's Hospital of Huan'an, No 1 Huaihe East Street, Huaiyin District, 223001, Huai'an City, Jiangsu Province, China
| | - Jinhong Chen
- Department of Anesthesiology, The Fifth People's Hospital of Huan'an, No 1 Huaihe East Street, Huaiyin District, 223001, Huai'an City, Jiangsu Province, China
| | - Jiwen Xiao
- Department of Anesthesiology, The Fifth People's Hospital of Huan'an, No 1 Huaihe East Street, Huaiyin District, 223001, Huai'an City, Jiangsu Province, China
| | - Weibing Zhao
- Department of Anesthesiology, The Fifth People's Hospital of Huan'an, No 1 Huaihe East Street, Huaiyin District, 223001, Huai'an City, Jiangsu Province, China.
| |
Collapse
|
6
|
Pawa A, King C, Thang C, White L. Erector spinae plane block: the ultimate 'plan A' block? Br J Anaesth 2023; 130:497-502. [PMID: 36775671 DOI: 10.1016/j.bja.2023.01.012] [Citation(s) in RCA: 22] [Impact Index Per Article: 22.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2022] [Revised: 12/21/2022] [Accepted: 01/12/2023] [Indexed: 02/12/2023] Open
Abstract
The erector spinae plane block (ESPB) is one of seven 'Plan A' blocks proposed by Regional Anaesthesia UK, covering the key areas of commonly encountered surgeries and acute pain. Unlike the other six blocks, the ESPB can be performed at all levels of the spine and provides analgesia to most regions of the body, leading to the argument that the ESPB is the ultimate Plan A block. Current studies show a high level of evidence supporting use in thoracoabdominal surgery but a lack of benefit in upper and lower limb surgery compared with local infiltration and other Plan A blocks. Thus, there is insufficient evidence to support the claim that the erector spinae plane block is the ultimate Plan A block.
Collapse
Affiliation(s)
- Amit Pawa
- Department of Theatres, Anaesthesia and Perioperative Medicine, Guy's and St Thomas' NHS Foundation Trust, London, UK; Faculty of Life Sciences and Medicine, King's College London, London, UK
| | - Christopher King
- Department of Theatres, Anaesthesia and Perioperative Medicine, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Christopher Thang
- Department of Anaesthesia and Perioperative Medicine, Sunshine Coast University Hospital, Sunshine Coast, Australia; School of Medicine & Dentistry, Griffith University, Brisbane, QLD, Australia; Faculty of Medicine, University of Queensland, Brisbane, QLD, Australia
| | - Leigh White
- Department of Anaesthesia and Perioperative Medicine, Sunshine Coast University Hospital, Sunshine Coast, Australia; School of Medicine & Dentistry, Griffith University, Brisbane, QLD, Australia.
| |
Collapse
|
7
|
Abdella AMMR, Areda EEAEM, Megahed NA, Ghoneim HEDM, El-Amrawy WZ. Analgesic efficacy, immunomodulation and complications of Erector spinae plane block in breast cancer surgeries: A randomized controlled trial. EGYPTIAN JOURNAL OF ANAESTHESIA 2022. [DOI: 10.1080/11101849.2022.2094070] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022] Open
Affiliation(s)
| | - Emad Eldin Abd El Monem Areda
- Department of Anaesthesia and Surgical Intensive Care, Faculty of Medicine, University of Alexandria, Alexandria, Egypt
| | - Nagwa Ahmed Megahed
- Department of Anaesthesia and Pain Management, Medical Research Institute, University of Alexandria, Alexandria, Egypt
| | | | - Wessam Zakaria El-Amrawy
- Department of Anaesthesia and Pain Management, Medical Research Institute, University of Alexandria, Alexandria, Egypt
| |
Collapse
|
8
|
De Cassai A, Geraldini F, Costa F, Tulgar S. Local anesthetics and erector spinae plane blocks: a spotlight on pharmacokinetic considerations and toxicity risks. Expert Opin Drug Metab Toxicol 2022; 18:537-539. [PMID: 36084290 DOI: 10.1080/17425255.2022.2122811] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Affiliation(s)
- Alessandro De Cassai
- UOC Anesthesia and Intensive Care Unit, University Hospital of Padova, Padova, Italy
| | - Federico Geraldini
- UOC Anesthesia and Intensive Care Unit, University Hospital of Padova, Padova, Italy
| | - Fabio Costa
- Unit of Anaesthesia, Intensive Care and Pain Management, Department of Medicine, Università Campus Bio-Medico di Roma, Rome, Italy
| | - Serkan Tulgar
- Samsun University, Faculty of Medicine, Samsun Education and Research Hospital
| |
Collapse
|