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Chen Y, Xu J, Li P, Shi L, Zhang S, Guo Q, Yang Y. Advances in the use of local anesthetic extended-release systems in pain management. Drug Deliv 2024; 31:2296349. [PMID: 38130151 PMCID: PMC10763865 DOI: 10.1080/10717544.2023.2296349] [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: 07/13/2023] [Accepted: 11/15/2023] [Indexed: 12/23/2023] Open
Abstract
Pain management remains among the most common and largely unmet clinical problems today. Local anesthetics play an indispensable role in pain management. The main limitation of traditional local anesthetics is the limited duration of a single injection. To address this problem, catheters are often placed or combined with other drugs in clinical practice to increase the time that local anesthetics act. However, this method does not meet the needs of clinical analgesics. Therefore, many researchers have worked to develop local anesthetic extended-release types that can be administered in a single dose. In recent years, drug extended-release systems have emerged dramatically due to their long duration and efficacy, providing more possibilities for the application of local anesthetics. This paper summarizes the types of local anesthetic drug delivery systems and their clinical applications, discusses them in the context of relevant studies on local anesthetics, and provides a summary and outlook on the development of local anesthetic extended-release agents.
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Affiliation(s)
- Yulu Chen
- Department of Anesthesiology, Xiangya Hospital, Central South University, Changsha, China
| | - Jingmei Xu
- Department of Anesthesiology, Xiangya Hospital, Central South University, Changsha, China
| | - Ping Li
- National Clinical Research Center for Geriatric Disorders, Xiangya Hospital, Central South University, Changsha, China
- Department of Obstetrics, Xiangya Hospital, Central South University, Changsha, China
| | - Liyang Shi
- College of Biology, Hunan University, Changsha, China
| | - Sha Zhang
- Department of Anesthesiology, Xiangya Hospital, Central South University, Changsha, China
| | - Qulian Guo
- Department of Anesthesiology, Xiangya Hospital, Central South University, Changsha, China
- National Clinical Research Center for Geriatric Disorders, Xiangya Hospital, Central South University, Changsha, China
| | - Yong Yang
- Department of Anesthesiology, Xiangya Hospital, Central South University, Changsha, China
- National Clinical Research Center for Geriatric Disorders, Xiangya Hospital, Central South University, Changsha, China
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Xu HT, Zimmerman J, Bertoch T, Chen L, Chen PJ, Onel E. CPL-01, an investigational long-acting ropivacaine, demonstrates safety and efficacy in open inguinal hernia repair. Hernia 2024; 28:1345-1354. [PMID: 38713429 PMCID: PMC11297089 DOI: 10.1007/s10029-024-03047-3] [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: 02/20/2024] [Accepted: 04/13/2024] [Indexed: 05/08/2024]
Abstract
BACKGROUND There is an unmet medical need for effective nonopioid analgesics that can decrease pain while reducing systemic opioid use. CPL-01, an extended-release injectable formulation of ropivacaine, is designed to safely provide analgesia and reduce or eliminate opioid use in the postoperative period. METHODS Subjects undergoing open inguinal hernia with mesh were prospectively randomized to 1 of 3 doses of CPL-01 (10, 20, or 30 ml of 2% CPL-01, n = 14, 12, and 14, respectively), Naropin (150 mg, n = 40), or saline placebo (n = 13) infiltrated into the surgical site prior to closure. Pain and rescue medication usage was assessed, and Numeric Rating Scale (NRS) pain scores were adjusted for opioid usage using windowed worst observation carried forward (wWOCF) imputation. The primary efficacy endpoint was the mean area under the curve (AUC) of the NRS pain intensity scores with activity. RESULTS Ninety-three subjects were treated, and 91 subjects completed 72 h of post-operative monitoring. Subjects who received the highest dose of CPL-01 in Cohort 3 showed a clinically meaningful reduction in postoperative pain intensity scores, which was the lowest value for any treatment in all cohorts, showing a trend towards statistical significance as compared to the pooled placebo group (p = 0.08), and numerically better than the 40 subjects who received Naropin. Opioid use through 72 h in subjects who received CPL-01 in Cohort 3 was approximately half of that shown in the placebo and Naropin groups; approximately 2/3 of the CPL-01 subjects (9/14) required no opioids at all through the first 72 h after the operation. More CPL-01 subjects avoided severe pain and were ready for discharge earlier than other groups. CPL-01 was safe and well-tolerated, with no clinically meaningful safety signals, and showed predictable and consistent extended-release pharmacokinetics. CONCLUSION Results suggest that CPL-01 may be the first long-acting ropivacaine to address postoperative pain while reducing the need for opioids.
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Affiliation(s)
- H T Xu
- Cali (SZ) Biosciences Co., Ltd. Shanghai Branch, Building 7, 690 Bibo Road, Shanghai, R715S, China.
| | - J Zimmerman
- Trovare Clinical Research, 3838 San Dimas St Ste A280, Bakersfield, CA, 93301, USA
| | - T Bertoch
- CeneExel JBR, 650 East 4500 South, Suite 100, Salt Lake City, UT, 84107, USA
| | - L Chen
- Cali Biosciences US, LLC, 9675 Businesspark Avenue, San Diego, CA, 92131, USA
| | - P J Chen
- Cali (SZ) Biosciences Co., Ltd. Shanghai Branch, Building 7, 690 Bibo Road, Shanghai, R715S, China
- Cali Biosciences US, LLC, 9675 Businesspark Avenue, San Diego, CA, 92131, USA
| | - E Onel
- Cali Biosciences US, LLC, 9675 Businesspark Avenue, San Diego, CA, 92131, USA
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On'Gele MO, Weintraub S, Qi V, Kim J. Local Anesthetics, Local Anesthetic Systemic Toxicity (LAST), and Liposomal Bupivacaine. Anesthesiol Clin 2024; 42:303-315. [PMID: 38705678 DOI: 10.1016/j.anclin.2023.11.011] [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] [Indexed: 05/07/2024]
Abstract
Local anesthetics have played a vital role in the multimodal analgesia approach to patient care by decreasing the use of perioperative opioids, enhancing patient satisfaction, decreasing the incidence of postoperative nausea and vomiting, decreasing the length of hospital stay, and reducing the risk of chronic postsurgical pain. The opioid-reduced anesthetic management for perioperative analgesia has been largely successful with the use of local anesthetics during procedures such as peripheral nerve blocks and neuraxial analgesia. It is important that practitioners who use local anesthetics are aware of the risk factors, presentation, and management of local anesthetic systemic toxicity (LAST).
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Affiliation(s)
- Michael O On'Gele
- Department of Anesthesiology and Critical Care, Hospital of the University of Pennsylvania, 3400 Spruce Street, Suite 680 Dulles, Philadelphia, PA 19104, USA
| | - Sara Weintraub
- Department of Anesthesiology and Critical Care, Hospital of the University of Pennsylvania, 3400 Spruce Street, Suite 680 Dulles, Philadelphia, PA 19104, USA
| | - Victor Qi
- Department of Anesthesiology and Critical Care, Hospital of the University of Pennsylvania, 3400 Spruce Street, Suite 680 Dulles, Philadelphia, PA 19104, USA
| | - James Kim
- Department of Anesthesiology and Critical Care, Hospital of the University of Pennsylvania, 3400 Spruce Street, Suite 680 Dulles, Philadelphia, PA 19104, USA.
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Chelly JE, Goel SK, Kearns J, Kopac O, Sadhasivam S. Nanotechnology for Pain Management. J Clin Med 2024; 13:2611. [PMID: 38731140 PMCID: PMC11084313 DOI: 10.3390/jcm13092611] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2024] [Revised: 04/17/2024] [Accepted: 04/21/2024] [Indexed: 05/13/2024] Open
Abstract
Introduction: In the context of the current opioid crisis, non-pharmacologic approaches to pain management have been considered important alternatives to the use of opioids or analgesics. Advancements in nano and quantum technology have led to the development of several nanotransporters, including nanoparticles, micelles, quantum dots, liposomes, nanofibers, and nano-scaffolds. These modes of nanotransporters have led to the development of new drug formulations. In pain medicine, new liposome formulations led to the development of DepoFoam™ introduced by Pacira Pharmaceutical, Inc. (Parsippany, NJ, USA). This formulation is the base of DepoDur™, which comprises a combination of liposomes and extended-release morphine, and Exparel™, which comprises a combination of liposomes and extended-release bupivacaine. In 2021, Heron Therapeutics (San Diego, CA, USA) created Zynrelef™, a mixture of bupivacaine and meloxicam. Advancements in nanotechnology have led to the development of devices/patches containing millions of nanocapacitors. Data suggest that these nanotechnology-based devices/patches reduce acute and chronic pain. Methods: Google and PubMed searches were conducted to identify studies, case reports, and reviews of medical nanotechnology applications with a special focus on acute and chronic pain. This search was based on the use of keywords like nanotechnology, nano and quantum technology, nanoparticles, micelles, quantum dots, liposomes, nanofibers, nano-scaffolds, acute and chronic pain, and analgesics. This review focuses on the role of nanotechnology in acute and chronic pain. Results: (1) Nanotechnology-based transporters. DepoDur™, administered epidurally in 15, 20, or 25 mg single doses, has been demonstrated to produce significant analgesia lasting up to 48 h. Exparel™ is infiltrated at the surgical site at the recommended dose of 106 mg for bunionectomy, 266 mg for hemorrhoidectomy, 133 mg for shoulder surgery, and 266 mg for total knee arthroplasty (TKA). Exparel™ is also approved for peripheral nerve blocks, including interscalene, sciatic at the popliteal fossa, and adductor canal blocks. The injection of Exparel™ is usually preceded by an injection of plain bupivacaine to initiate analgesia before bupivacaine is released in enough quantity from the depofoarm to be pharmacodynamically effective. Finally, Zynrelef™ is applied at the surgical site during closure. It was initially approved for open inguinal hernia, abdominal surgery requiring a small-to-medium incision, foot surgery, and TKA. (2) Nanotechnology-based devices/patches. Two studies support the use of nanocapacitor-based devices/patches for the management of acute and chronic pain. A randomized study conducted on patients undergoing unilateral primary total knee (TKA) and total hip arthroplasty (THA) provided insight into the potential value of nanocapacitor-based technology for the control of postoperative acute pain. The results were based on 2 studies, one observational and one randomized. The observational study was conducted in 128 patients experiencing chronic pain for at least one year. This study suggested that compared to baseline, the application of a nanocapacitor-based Kailo™ pain relief patch on the pain site for 30 days led to a time-dependent decrease in pain and analgesic use and an increase in well-being. The randomized study compared the effects of standard of care treatment to those of the same standard of care approach plus the use of two nanocapacitor-based device/patches (NeuroCuple™ device) placed in the recovery room and kept in place for three days. The study demonstrated that the use of the two NeuroCuple™ devices was associated with a 41% reduction in pain at rest and a 52% decrease in the number of opioid refills requested by patients over the first 30 days after discharge from the hospital. Discussion: For the management of pain, the use of nano-based technology has led to the development of nano transporters, especially focus on the use of liposome and nanocapacitors. The use of liposome led to the development of DepoDur™, bupivacaine Exparel™ and a mixture of bupivacaine and meloxicam (Zynrelef™) and more recently lidocaine liposome formulation. In these cases, the technology is used to prolong the duration of action of drugs included in the preparation. Another indication of nanotechnology is the development of nanocapacitor device or patches. Although, data obtained with the use of nanocapacitors are still limited, evidence suggests that the use of nanocapacitors devices/patches may be interesting for the treatment of both acute and chronic pain, since the studies conducted with the NeuroCuple™ device and the based Kailo™ pain relief patch were not placebo-controlled, it is clear that additional placebo studies are required to confirm these preliminary results. Therefore, the development of a placebo devices/patches is necessary. Conclusions: Increasing evidence supports the concept that nanotechnology may represent a valuable tool as a drug transporter including liposomes and as a nanocapacitor-based device/patch to reduce or even eliminate the use of opioids in surgical patients. However, more studies are required to confirm this concept, especially with the use of nanotechnology incorporated in devices/patches.
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Affiliation(s)
- Jacques E. Chelly
- Department of Anesthesiology and Perioperative Medicine, University of Pittsburgh Medical Center, Pittsburgh, PA 15219, USA; (S.K.G.); (J.K.); (O.K.); (S.S.)
- Department of Orthopaedic Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA 15219, USA
| | - Shiv K. Goel
- Department of Anesthesiology and Perioperative Medicine, University of Pittsburgh Medical Center, Pittsburgh, PA 15219, USA; (S.K.G.); (J.K.); (O.K.); (S.S.)
| | - Jeremy Kearns
- Department of Anesthesiology and Perioperative Medicine, University of Pittsburgh Medical Center, Pittsburgh, PA 15219, USA; (S.K.G.); (J.K.); (O.K.); (S.S.)
| | - Orkun Kopac
- Department of Anesthesiology and Perioperative Medicine, University of Pittsburgh Medical Center, Pittsburgh, PA 15219, USA; (S.K.G.); (J.K.); (O.K.); (S.S.)
| | - Senthilkumar Sadhasivam
- Department of Anesthesiology and Perioperative Medicine, University of Pittsburgh Medical Center, Pittsburgh, PA 15219, USA; (S.K.G.); (J.K.); (O.K.); (S.S.)
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Zheng LX, Yu Q, Li Q, Zheng CD. Targeted local anesthesia: a novel slow-release Fe 3O 4-lidocaine-PLGA microsphere endowed with a magnetic targeting function. J Anesth 2024; 38:232-243. [PMID: 38310577 DOI: 10.1007/s00540-023-03305-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2023] [Accepted: 12/25/2023] [Indexed: 02/06/2024]
Abstract
PURPOSE Lidocaine microspheres can prolong the analgesic time to 24-48 h, which still cannot meet the need of postoperative analgesia lasting more than 3 days. Therefore, we added Fe3O4 to the lidocaine microspheres and used an applied magnetic field to attract Fe3O4 to fix the microspheres around the target nerves, reducing the diffusion of magnetic lidocaine microspheres to the surrounding tissues and prolonging the analgesic time. METHODS Fe3O4-lidocaine-PLGA microspheres were prepared by the complex-emulsion volatilization method to characterize and study the release properties in vitro. The neural anchoring properties and in vivo morphology of the drug were obtained by magnetic resonance imaging. The nerve blocking effect and analgesic effect of magnetic lidocaine microspheres were evaluated by animal experiments. RESULTS The mean diameter of magnetically responsive lidocaine microspheres: 9.04 ± 3.23 μm. The encapsulation and drug loading of the microspheres were 46.18 ± 3.26% and 6.02 ± 1.87%, respectively. Magnetic resonance imaging showed good imaging of Fe3O4-Lidocain-PLGA microspheres, a drug-carrying model that slowed down the diffusion of the microspheres in the presence of an applied magnetic field. Animal experiments demonstrated that this preparation had a significantly prolonged nerve block, analgesic effect, and a nerve anchoring function. CONCLUSION Magnetically responsive lidocaine microspheres can prolong analgesia by slowly releasing lidocaine, which can be immobilized around the nerve by a magnetic field on the body surface, avoiding premature diffusion of the microspheres to surrounding tissues and improving drug targeting.
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Affiliation(s)
- Ling-Xi Zheng
- Institute of Biomedical Engineering, College of Medicine, Southwest Jiaotong University, Chengdu, 610031, Sichuan, China
| | - Qian Yu
- Institute of Biomedical Engineering, College of Medicine, Southwest Jiaotong University, Chengdu, 610031, Sichuan, China
| | - Qiang Li
- Department of Anesthesiology, The Third People's Hospital of Chengdu, Affiliated Hospital of Southwest Jiaotong University, 19 Yangshi Street, Qingyang District, Chengdu, 610031, Sichuan, China
| | - Chuan-Dong Zheng
- Institute of Biomedical Engineering, College of Medicine, Southwest Jiaotong University, Chengdu, 610031, Sichuan, China.
- Department of Anesthesiology, The Third People's Hospital of Chengdu, Affiliated Hospital of Southwest Jiaotong University, 19 Yangshi Street, Qingyang District, Chengdu, 610031, Sichuan, China.
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Matthews E, Ragatha P, Smart N, Bethune R. Single-shot liposomal bupivacaine in place of rectus sheath catheters to provide non-opiate analgesia after laparotomy: a quality improvement project to reduce the need for ongoing nursing input. BMJ Open Qual 2024; 13:e002313. [PMID: 38413091 PMCID: PMC10900319 DOI: 10.1136/bmjoq-2023-002313] [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: 02/19/2023] [Accepted: 01/25/2024] [Indexed: 02/29/2024] Open
Abstract
Opioid-sparing pain management is an integral component of enhanced recovery after colonic and rectal surgery. In our hospital, rectus sheath catheters (RSCs) are routinely placed during emergency laparotomy for colorectal procedures to allow a postoperative compartmental block of the surgical site with repeated doses of bupivacaine. However, RSCs require a significant amount of clinical nursing time to maintain and 'top-up'. We present a quality improvement project in which we administered single-shot liposomal bupivacaine (LB) intraoperatively as an alternative to bolus doses of conventional bupivacaine delivered through RSCs. Having thereby reduced the demands placed on nursing time through a reduction in the use of RSCs, we sought to establish whether there was any associated change in analgesic efficacy. Patient pain scores, use of patient-controlled analgesia (PCA) and length of stay following surgery were analysed before and after the introduction of LB. No disruption in these outcomes was identified using statistical process control analysis. A direct comparison of results for patients who received LB versus those who received bolus dosing of bupivacaine via RSCs found no significant differences, with a median total PCA dose of 270 mg oral morphine equivalents (OME) for patients who received LB versus 396 mg OME for patients who had RSCs (p=0.54). The median length of stay for patients who received LB was 15.5 days versus 16 days for those who had RSCs (p=0.87). We conclude that LB represents a viable alternative to boluses of conventional bupivacaine via RSCs in promoting enhanced recovery after emergency laparotomy and look to extend its use locally.
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Affiliation(s)
| | | | - Neil Smart
- Royal Devon and Exeter Hospital, Exeter, UK
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Nijs K, Ruette J, Van de Velde M, Stessel B. Regional anaesthesia for ambulatory surgery. Best Pract Res Clin Anaesthesiol 2023; 37:397-408. [PMID: 37938085 DOI: 10.1016/j.bpa.2022.12.001] [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: 10/25/2022] [Revised: 12/05/2022] [Accepted: 12/12/2022] [Indexed: 12/23/2022]
Abstract
Regional anaesthesia (RA) has an important and ever-expanding role in ambulatory surgery. Specific practices vary depending on the preferences and resources of the anaesthesia team and hospital setting. It is used for various purposes, including as primary anaesthetic technique for surgery but also as postoperative analgesic modality. The limited duration of action of currently available local anaesthetics limits their application in postoperative pain control and enhanced recovery. The search for the holy grail of regional anaesthetics continues. Current evidence suggests that a peripheral nerve block performed with long-acting local anaesthetics in combination with intravenous or perineural dexamethasone gives the longest and most optimal sensory block. In this review, we outline some possible blocks for ambulatory surgery and additives to perform RA. Moreover, we give an update on local anaesthesia drugs and adjuvants, paediatric RA in ambulatory care and discuss the impact of RA by COVID-19.
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Affiliation(s)
- Kristof Nijs
- Department of Anaesthesiology and Pain Medicine, Jessa Hospital, Hasselt, Belgium; UHasselt, Faculty of Medicine and Life Sciences, Diepenbeek, Belgium; KULeuven, Department of Cardiovascular Sciences, Leuven, Belgium; Department of Anaesthesiology and Pain Medicine, University Hospitals Leuven, Leuven, Belgium.
| | - Joke Ruette
- Department of Anaesthesiology and Pain Medicine, Jessa Hospital, Hasselt, Belgium; Department of Anaesthesiology and Pain Medicine, University Hospitals Leuven, Leuven, Belgium
| | - Marc Van de Velde
- KULeuven, Department of Cardiovascular Sciences, Leuven, Belgium; Department of Anaesthesiology and Pain Medicine, University Hospitals Leuven, Leuven, Belgium
| | - Björn Stessel
- Department of Anaesthesiology and Pain Medicine, Jessa Hospital, Hasselt, Belgium; UHasselt, Faculty of Medicine and Life Sciences, Diepenbeek, Belgium
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Peripheral Regional Anesthesia Using Local Anesthetics: Old Wine in New Bottles? J Clin Med 2023; 12:jcm12041541. [PMID: 36836081 PMCID: PMC9962037 DOI: 10.3390/jcm12041541] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2023] [Revised: 02/08/2023] [Accepted: 02/13/2023] [Indexed: 02/18/2023] Open
Abstract
During the past decade, numerous efforts were undertaken aiming at prolonging the analgesic effect of regional anesthesia. With the development of extended-release formulations and enhanced selectivity for nociceptive sensory neurons, a very promising contribution to the development of pain medications has been achieved. At present, liposomal bupivacaine is the most popular, non-opioid, controlled drug delivery system, but its duration of action, which is still controversially discussed, and its expensiveness have decreased initial enthusiasm. Continuous techniques can be seen as an elegant alternative for providing a prolonged duration of analgesia, but for logistic or anatomical reasons, they are not always the best choice. Therefore, focus has been directed towards the perineural and/or intravenous addition of old and established substances. As for perineural application, most of these so-called 'adjuvants' are used outside their indication, and their pharmacological efficacy is often not or only poorly understood. This review aims to summarize the recent developments for prolonging the duration of regional anesthesia. It will also discuss the potential harmful interactions and side effects of frequently used analgesic mixtures.
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Schubert AK, Wiesmann T, Dinges HC. Measures to prolong duration of sensory block after regional anaesthesia. Curr Opin Anaesthesiol 2023; 36:103-108. [PMID: 36326074 DOI: 10.1097/aco.0000000000001204] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
PURPOSE OF REVIEW The duration of single-injection regional anaesthesia is limited due to the inherent pharmacological properties of local anaesthetics. The ideal duration of a regional anaesthesia block lasting for the first 24 h postoperatively can be stated, while a residual analgesic effect thereafter is desirable.The aim of this review is to present current options to prolong the duration of action of single-injection peripheral regional anaesthesia in the ambulatory setting. Secondly, this review outlines and discusses the latest evidence regarding the clinical use of adjuvants and sustained-release local anaesthetics. RECENT FINDINGS Extended-release formulations of local anaesthetics such as liposomal bupivacaine have been developed to prolong regional anaesthesia up to 96 h. Recent studies, however, show that the actual effects remain far behind expectations and that the efficacy is only marginally better than bupivacaine hydrochloride.Adjuvants to local anaesthetics have been studied extensively with heterogenous results. Dexamethasone and alpha-2 agonists range among the most effective measures to prolong single-injection nerve blocks.Continuous nerve blocks and catheter techniques may prolong regional anaesthesia very effectively, but are less cost-effective regarding block procedure, postoperative care and handling logistical issues especially in ambulatory surgery. SUMMARY In conclusion, adjuvants are the recommended measure to prolong regional anaesthesia where needed. With good evidence supporting it, dexamethasone is the most effective adjuvant, followed by dexmedetomidine. Both have few side effects and a favourable safety profile. However, a preferable duration of analgesia lasting for the first 24 h postoperatively is still not reliably achievable.
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Affiliation(s)
- Ann-Kristin Schubert
- University Hospital Marburg, Department of Anesthesia and Intensive Care, University Hospital Marburg, Baldingerstraße, Marburg
| | - Thomas Wiesmann
- University Hospital Marburg, Department of Anesthesia and Intensive Care, University Hospital Marburg, Baldingerstraße, Marburg
- Department of Anesthesiology and Intensive Care Medicine, Diakoneo Diak Klinikum Schwäbisch-Hall, Schwäbisch-Hall, Germany
| | - Hanns-Christian Dinges
- University Hospital Marburg, Department of Anesthesia and Intensive Care, University Hospital Marburg, Baldingerstraße, Marburg
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On'Gele MO, Weintraub S, Qi V, Kim J. Local Anesthetics, Local Anesthetic Systemic Toxicity (LAST), and Liposomal Bupivacaine. Clin Sports Med 2022; 41:303-315. [PMID: 35300842 DOI: 10.1016/j.csm.2021.12.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Local anesthetics have played a vital role in the multimodal analgesia approach to patient care by decreasing the use of perioperative opioids, enhancing patient satisfaction, decreasing the incidence of postoperative nausea and vomiting, decreasing the length of hospital stay, and reducing the risk of chronic postsurgical pain. The opioid-reduced anesthetic management for perioperative analgesia has been largely successful with the use of local anesthetics during procedures such as peripheral nerve blocks and neuraxial analgesia. It is important that practitioners who use local anesthetics are aware of the risk factors, presentation, and management of local anesthetic systemic toxicity (LAST).
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Affiliation(s)
- Michael O On'Gele
- Department of Anesthesiology and Critical Care, Hospital of the University of Pennsylvania, 3400 Spruce Street, Suite 680 Dulles, Philadelphia, PA 19104, USA
| | - Sara Weintraub
- Department of Anesthesiology and Critical Care, Hospital of the University of Pennsylvania, 3400 Spruce Street, Suite 680 Dulles, Philadelphia, PA 19104, USA
| | - Victor Qi
- Department of Anesthesiology and Critical Care, Hospital of the University of Pennsylvania, 3400 Spruce Street, Suite 680 Dulles, Philadelphia, PA 19104, USA
| | - James Kim
- Department of Anesthesiology and Critical Care, Hospital of the University of Pennsylvania, 3400 Spruce Street, Suite 680 Dulles, Philadelphia, PA 19104, USA.
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Kaye AD, Edinoff AN, Yan JY, Kaye AJ, Alvarado MA, Pham AD, Chami AA, Shah RJ, Dixon BM, Shafeinia A, Cornett EM, Fox C. Novel Local Anesthetics in Clinical Practice: Pharmacologic Considerations and Potential Roles for the Future. Anesth Pain Med 2022; 12:e123112. [PMID: 35433373 PMCID: PMC8995776 DOI: 10.5812/aapm.123112] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2022] [Accepted: 02/08/2022] [Indexed: 12/14/2022] Open
Abstract
The treatment of pain, both acute and chronic, has been a focus of medicine for generations. Physicians have tried to develop novel ways to effectively manage pain in surgical and post-surgical settings. One intervention demonstrating efficacy is nerve blocks. Single-injection peripheral nerve blocks (PNBs) are usually preferred over continuous PNBs, since they are not associated with longer lengths of stay. The challenge of single injection PNBs is their length of duration, which at present is a major limitation. Novel preparations of local anesthetics have also been studied, and these new preparations could allow for extended duration of action of anesthetics. An emerging preparation of bupivacaine, exparel, uses a multivesicular liposomal delivery system which releases medication in a steady, controlled manner. Another extended-release local anesthetic, HTX-011, consists of a combination of bupivacaine and low-dose meloxicam. Tetrodotoxin, a naturally occurring reversible site 1 sodium channel toxin derived from pufferfish and shellfish, has shown the potential to block conduction of isolated nerves. Neosaxitoxin is a more potent reversible site 1 sodium channel toxin also found in shellfish that can also block nerve conduction. These novel formulations show great promise in terms of the ability to prolong the duration of single injection PNBs. This field is still currently in development, and more researchers will need to be done to ensure the efficacy and safety of these novel formulations. These formulations could be the future of pain management if ongoing research continues to prove positive effects and low side effect profiles.
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Affiliation(s)
- Alan D. Kaye
- Department of Anesthesiology, Louisiana State University Health Science Center, Shreveport, Los Angeles, USA
| | - Amber N. Edinoff
- Department of Psychiatry and Behavioral Medicine, Louisiana State University Health Science Center, Shreveport, Los Angeles, USA
- Corresponding Author: Department of Psychiatry and Behavioral Medicine, Louisiana State University Health Science Center, Shreveport, Los Angeles, USA.
| | - Justin Y. Yan
- Department of Anesthesiology, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Aaron J. Kaye
- Louisiana State University Health Sciences Center, New Orleans, Los Angeles, USA
| | - Michael A. Alvarado
- Department of Anesthesiology, Louisiana State University Health Science Center, Shreveport, Los Angeles, USA
| | - Alex D. Pham
- Department of Anesthesiology, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Azem A. Chami
- Department of Anesthesiology, Louisiana State University Health Science Center, Shreveport, Los Angeles, USA
| | - Rutvij J. Shah
- Department of Anesthesiology, Louisiana State University Health Science Center, Shreveport, Los Angeles, USA
| | - Bruce M. Dixon
- Department of Anesthesiology, Louisiana State University Health Science Center, Shreveport, Los Angeles, USA
| | - Amineh Shafeinia
- Pain Research Center, Department of Anesthesiology and Pain Medicine, Iran University of Medical Sciences, Tehran, Iran
- Corresponding Author: Pain Research Center, Department of Anesthesiology and Pain Medicine, Akbar Abadi Hospital, Iran University of Medical Sciences, Tehran, Iran.
| | - Elyse M. Cornett
- Department of Anesthesiology, Louisiana State University Health Science Center, Shreveport, Los Angeles, USA
| | - Charles Fox
- Department of Anesthesiology, Louisiana State University Health Science Center, Shreveport, Los Angeles, USA
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Rodriguez-Patarroyo FA, Cuello N, Molloy R, Krebs V, Turan A, Piuzzi NS. A guide to regional analgesia for Total Knee Arthroplasty. EFORT Open Rev 2021; 6:1181-1192. [PMID: 35839095 PMCID: PMC8693230 DOI: 10.1302/2058-5241.6.210045] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Regional analgesia has been introduced successfully into the postoperative pain management after total knee arthroplasty, reducing pain scores, opioid use and adverse effects. Combination of regional analgesia techniques is associated with better pain management and lower side effects than single regional techniques. Adductor canal block provides good analgesia and considerably lower detrimental effect in muscular strength than femoral nerve block, enhancing surgical recovery. Infiltration techniques may have equivalent analgesic effect than epidural analgesia and peripheral nerve blocks, however there should be awareness of dose dependent toxicity. Novel long-acting local anesthetics role for regional analgesia is still to be determined, and will require larger randomized trials to support its advantage over traditional local anesthetics.
Cite this article: EFORT Open Rev 2021;6:1181-1192. DOI: 10.1302/2058-5241.6.210045
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Affiliation(s)
| | - Nadin Cuello
- Department of Orthopaedic and Trauma Surgery, Hospital Interzonal General de Agudos Eva Perón, San Martín, Buenos Aires, Argentina
| | - Robert Molloy
- Department of Orthopaedic Surgery, Cleveland Clinic, Cleveland, Ohio, USA
| | - Viktor Krebs
- Department of Orthopaedic Surgery, Cleveland Clinic, Cleveland, Ohio, USA
| | - Alparslan Turan
- Outcomes Research Department, Anesthesiology Institute, Cleveland Clinic Ohio, USA
- Department of Anesthesiology, Cleveland Clinic, Cleveland, Ohio, USA
| | - Nicolas S. Piuzzi
- Department of Orthopaedic Surgery, Cleveland Clinic, Cleveland, Ohio, USA
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13
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Quan C. Local is “lekker”. SOUTHERN AFRICAN JOURNAL OF ANAESTHESIA AND ANALGESIA 2020. [DOI: 10.36303/sajaa.2020.26.6.s3.2560] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Local anaesthetics agents (LAA) are used ubiquitously in the medical field and in a wide variety of ways: tissue infiltration, perineural, intra-articular and intravenous. The purpose of this review is to explore the pharmacology of LAAs and to examine the clinical applications for LAAs.
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Affiliation(s)
- C Quan
- University of the Witwatersrand
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Fiala T. Commentary on: Analgesic Efficacy of Nerve Blocks After Abdominoplasty: A Systematic Review. Aesthet Surg J 2020; 40:1216-1218. [PMID: 32027736 DOI: 10.1093/asj/sjz349] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023] Open
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Kaye AD, Armstead-Williams C, Hyatali F, Cox KS, Kaye RJ, Eng LK, Farooq Anwar MA, Patel PV, Patil S, Cornett EM. Exparel for Postoperative Pain Management: a Comprehensive Review. Curr Pain Headache Rep 2020; 24:73. [DOI: 10.1007/s11916-020-00905-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/17/2020] [Indexed: 01/16/2023]
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16
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Marciniak DA, Alfirevic A, Hijazi RM, Ramos DJ, Duncan AE, Gillinov AM, Ahmad U, Murthy SC, Raymond DP. Intercostal Blocks with Liposomal Bupivacaine in Thoracic Surgery: A Retrospective Cohort Study. J Cardiothorac Vasc Anesth 2020; 35:1404-1409. [PMID: 33067088 DOI: 10.1053/j.jvca.2020.09.116] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/04/2020] [Revised: 09/17/2020] [Accepted: 09/18/2020] [Indexed: 11/11/2022]
Abstract
OBJECTIVE Assess the efficacy of adding liposomal bupivacaine (LB) to bupivacaine-containing intercostal nerve blocks (ICNBs) to improve analgesia and decrease opioid consumption and hospital length of stay compared with bupivacaine-only ICNBs. DESIGN This retrospective, observational investigation compared pain intensity scores and cumulative opioid consumption within the first 72 postoperative hours in patients who received ICNBs with bupivacaine plus LB (LB group) versus bupivacaine only (control group) after minimally invasive anatomic pulmonary resection. LB was tested for noninferiority on pain scores and opioid consumption. If LB was noninferior, superiority of LB was tested on both outcomes. SETTING Academic tertiary care medical center. PARTICIPANTS Adult patients undergoing minimally invasive anatomic pulmonary resection. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS For the secondary analysis, hospital length of stay was compared through the Cox regression model. Of 396 patients, 178 (45%) received LB and 218 (55%) did not. The mean (standard deviation) pain score was three (one) in the LB group and three (one) in the control group, with a difference of -0.10 (97.5% confidence interval [-0.39 to 0.18]; p = 0.41). The mean (standard deviation) cumulative opioid consumption (intravenous morphine equivalents) was 198 (208) mg in the LB group and 195 (162) mg in the control group. Treatment effect in opioid consumption was estimated at a ratio of geometric mean of 0.94 (97.5% confidence interval [0.74-1.20]; p = 0.56). Pain control and opioid consumption were noninferior with LB but not superior. Hospital discharge was not different between groups. CONCLUSIONS LB with bupivacaine in ICNBs did not demonstrate superior postoperative analgesia or affect the rate of hospital discharge.
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Affiliation(s)
- Donn A Marciniak
- Department of Cardiothoracic Anesthesia, Cleveland Clinic, Cleveland, OH.
| | - Andrej Alfirevic
- Department of Cardiothoracic Anesthesia, Cleveland Clinic, Cleveland, OH
| | - Ryan M Hijazi
- Department of General Anesthesia, Cleveland Clinic, Cleveland, OH
| | - Daniel J Ramos
- Department of General Anesthesia, Cleveland Clinic, Cleveland, OH
| | - Andra E Duncan
- Department of Cardiothoracic Anesthesia, Cleveland Clinic, Cleveland, OH
| | - A Marc Gillinov
- Department of Cardiothoracic Surgery, Cleveland Clinic, Cleveland, OH
| | - Usman Ahmad
- Department of Cardiothoracic Surgery, Cleveland Clinic, Cleveland, OH
| | - Sudish C Murthy
- Department of Cardiothoracic Surgery, Cleveland Clinic, Cleveland, OH
| | - Daniel P Raymond
- Department of Cardiothoracic Surgery, Cleveland Clinic, Cleveland, OH
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Yamak Altinpulluk E, Turan A. Future in regional anesthesia: new techniques and technological advancements. Minerva Anestesiol 2020; 87:85-100. [PMID: 32959636 DOI: 10.23736/s0375-9393.20.14791-6] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Regional anesthesia has a very interesting long history, initially preferred over general anesthesia because of safety concerns, then for a period general anesthesia became safer and was preferred. The use of innovative technologies such as ultrasound technology has made the blocks safer and successful by directly visualizing targeted nerves and the location of local anesthetics. With the wide use of ultrasound in the regional anesthesia field success rate of peripheral nerve blocks increased and novel blocks techniques developed. Moreover, new extended-release local anesthetic agents have begun to be promising time-efficient and longer duration of analgesia with a single injection. In this article, we attempt to summarize some of the novel block techniques, pharmacological agents, and new technologies in the field of regional anesthesia.
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Affiliation(s)
- Ece Yamak Altinpulluk
- Department of Outcomes Research, Anesthesiology Institute, Cleveland Clinic, Cleveland, OH, USA.,Department of Anesthesiology and Reanimation, Faculty of Medicine, Istanbul University Cerrahpaşa, Instambul, Turkey
| | - Alparslan Turan
- Department of Outcomes Research, Anesthesiology Institute, Cleveland Clinic, Cleveland, OH, USA - .,Department of General Anesthesiology, Anesthesiology Institute, Cleveland Clinic OH, USA
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