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Carvalho LIMD, Azi LMTDA, Leal PDC, Lorentz MN, Diego LADS, Schmidt AP. Anesthesia and perioperative care management in patients with Dengue Fever: considerations and challenges. BRAZILIAN JOURNAL OF ANESTHESIOLOGY (ELSEVIER) 2024; 74:844511. [PMID: 38723714 DOI: 10.1016/j.bjane.2024.844511] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/18/2024]
Affiliation(s)
| | - Liana Maria Tôrres de Araújo Azi
- Hospital Universitário Professor Edgard Santos, Departamento de Anestesiologia, Salvador, BA, Brazil; Universidade Federal da Bahia (UFBA), Salvador, BA, Brazil
| | - Plinio da Cunha Leal
- Hospital São Domingos, Departamento de Anestesiologia, São Luís, MA, Brazil; Universidade Federal do Maranhão (UFMA), São Luís, MA, Brazil
| | | | | | - André P Schmidt
- Hospital de Clínicas de Porto Alegre (HCPA), Serviço de Anestesia e Medicina Perioperatória, Porto Alegre, RS, Brazil; Universidade Federal de Ciências da Saúde de Porto Alegre (UFCSPA), Santa Casa de Porto Alegre, Serviço de Anestesia, Porto Alegre, RS, Brazil; Hospital Nossa Senhora da Conceição, Serviço de Anestesia, Porto Alegre, RS, Brazil; Universidade Federal do Rio Grande do Sul (UFRGS), Programa de Pós-graduação em Ciências Pneumológicas, Porto Alegre, RS, Brazil; Universidade Federal do Rio Grande do Sul (UFRGS), Programa de Pós-graduação em Ciências Cirúrgicas, Porto Alegre, RS, Brazil; Faculdade de Medicina da Universidade de São Paulo (FMUSP), Programa de Pós-Graduação em Anestesiologia, Ciências Cirúrgicas e Medicina Perioperatória, São Paulo, SP, Brazil
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Matsota P, Karalis V, Saranteas T, Kiospe F, Markantonis SL. Ropivacaine pharmacokinetics in the arterial and venous pools after ultrasound-guided continuous thoracic paravertebral nerve block. J Anaesthesiol Clin Pharmacol 2024; 40:283-292. [PMID: 38919447 PMCID: PMC11196052 DOI: 10.4103/joacp.joacp_353_22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2022] [Revised: 10/18/2022] [Accepted: 10/19/2022] [Indexed: 06/27/2024] Open
Abstract
Background and Aims Although thoracic paravertebral blockade (TPVB) is employed in thoracic surgery to ensure satisfactory postoperative analgesia, large doses of anesthetics are required and manifestations of local anesthetic systemic toxicity (LAST) may appear. Currently, there are limited data on the pharmacokinetics of ropivacaine after continuous TPVB. The aim of this prospective study was to investigate ropivacaine kinetics, in the arterial and venous pools, after continuous TPVB and assess the risk of LAST. Material and Methods Immediately after induction of general anesthesia, an ultrasound-guided continuous TPVB at T5 or T6 or T7 thoracic level was performed in 18 adult patients subjected to open thoracotomy. A 25-ml single bolus injection of ropivacaine 0.5% was administered through thoracic paravertebral catheter, followed by a 14 ml/h continuous infusion of ropivacaine 0.2% starting at the end of surgery. Quantification of total ropivacaine concentrations was performed using a validated high-performance liquid chromatography method. Population pharmacokinetic models were developed separately for arterial and venous ropivacaine data. Results The best model was one-compartment disposition with an additional pre-absorption compartment corresponding to thoracic paravertebral space. Gender had a significant effect on clearance, with females displaying lower elimination than males. Some patients had ropivacaine concentrations above the toxic threshold, but none displayed evidence of LAST. Continuous thoracic paravertebral nerve blocks provided adequate postoperative analgesia. Conclusion Ropivacaine doses at the upper end of clinical use (800 mg/d) did not inflict the manifestations of LAST and provided adequate postoperative pain control. Pharmacokinetic models were developed, and the effect of gender was identified.
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Affiliation(s)
- Paraskevi Matsota
- 2 Department of Anesthesiology, School of Medicine, National and Kapodistrian University of Athens, “Attikon” University Hospital, Athens, Greece
| | - Vangelis Karalis
- Department of Pharmacy, School of Health Sciences, National and Kapodistrian University of Athens, Athens, Greece
| | - Theodosios Saranteas
- 2 Department of Anesthesiology, School of Medicine, National and Kapodistrian University of Athens, “Attikon” University Hospital, Athens, Greece
| | - Fay Kiospe
- Department of Pharmacy, School of Health Sciences, National and Kapodistrian University of Athens, Athens, Greece
| | - Sophia Liberty Markantonis
- Department of Pharmacy, School of Health Sciences, National and Kapodistrian University of Athens, Athens, Greece
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Bungart B, Joudeh L, Fettiplace M. Local anesthetic dosing and toxicity of adult truncal catheters: a narrative review of published practice. Reg Anesth Pain Med 2024; 49:209-222. [PMID: 37451826 PMCID: PMC10787820 DOI: 10.1136/rapm-2023-104667] [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: 05/10/2023] [Accepted: 06/30/2023] [Indexed: 07/18/2023]
Abstract
BACKGROUND/IMPORTANCE Anesthesiologists frequently use truncal catheters for postoperative pain control but with limited characterization of dosing and toxicity. OBJECTIVE We reviewed the published literature to characterize local anesthetic dosing and toxicity of paravertebral and transversus abdominis plane catheters in adults. EVIDENCE REVIEW We searched the literature for bupivacaine or ropivacaine infusions in the paravertebral or transversus abdominis space in humans dosed for 24 hours. We evaluated bolus dosing, infusion dosing and cumulative 24-hour dosing in adults. We also identified cases of local anesthetic systemic toxicity and toxic blood levels. FINDINGS Following screening, we extracted data from 121 and 108 papers for ropivacaine and bupivacaine respectively with a total of 6802 patients. For ropivacaine and bupivacaine, respectively, bolus dose was 1.4 mg/kg (95% CI 0.4 to 3.0, n=2978) and 1.0 mg/kg (95% CI 0.18 to 2.1, n=2724); infusion dose was 0.26 mg/kg/hour (95% CI 0.06 to 0.63, n=3579) and 0.2 mg/kg/hour (95% CI 0.06 to 0.5, n=3199); 24-hour dose was 7.75 mg/kg (95% CI 2.1 to 15.7, n=3579) and 6.0 mg/kg (95% CI 2.1 to 13.6, n=3223). Twenty-four hour doses exceeded the package insert recommended upper limit in 28% (range: 17%-40% based on maximum and minimum patient weights) of ropivacaine infusions and 51% (range: 45%-71%) of bupivacaine infusions. Toxicity occurred in 30 patients and was associated with high 24-hour dose, bilateral catheters, cardiac surgery, cytochrome P-450 inhibitors and hypoalbuminemia. CONCLUSION Practitioners frequently administer ropivacaine and bupivacaine above the package insert limits, at doses associated with toxicity. Patient safety would benefit from more specific recommendations to limit excessive dose and risk of toxicity.
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Affiliation(s)
- Brittani Bungart
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
- Department of Anaesthesia, Harvard Medical School, Boston, Massachusetts, USA
| | - Lana Joudeh
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
- Department of Anaesthesia, Harvard Medical School, Boston, Massachusetts, USA
| | - Michael Fettiplace
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
- Department of Anaesthesia, Harvard Medical School, Boston, Massachusetts, USA
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Zaballos M, Fernández I, Rodríguez L, García S, Varela O, Quintela O, Anadón MJ, Almendral J. Effects of intravenous lipid emulsions on the reversal of pacing-induced ventricular arrhythmias and electrophysiological alterations in an animal model of ropivacaine toxicity. Clin Toxicol (Phila) 2022; 60:902-911. [PMID: 35658706 DOI: 10.1080/15563650.2022.2080075] [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: 11/03/2022]
Abstract
INTRODUCTION Ropivacaine is considered to have a wider margin of cardiovascular safety. However, several reports of ventricular arrhythmias (VA) due to ropivacaine toxicity have been documented. Intravenous lipid emulsions (ILEs) have recently been used successfully in the treatment of local anesthetic intoxication. The main objective of the present study was to evaluate the efficacy of the ILEs in the prevention of pacing-induced-VA and electrophysiological alterations in an animal model of ropivacaine toxicity. METHODS Nineteen pigs were anesthetized and instrumentalized. A baseline programmed electrical ventricular stimulation protocol (PEVSP) to induce VA was performed. Ropivacaine (5 mg·kg-1 + 100 μg·kg-1·min-1) followed by normal saline infusion (control group n = 8) or intralipid 20% (1.5 mL·kg-1 + 0.25 mL·kg-1·min-1) for the ILE group (n = 8), were administered three minutes after the ropivacaine bolus. PEVSP was repeated 25 min after the onset of ropivacaine infusion. Pacing-induced VA and electrophysiological abnormalities were assessed in both groups. A sham-control group (n = 3) without ropivacaine infusion was included. RESULTS Most of the electrophysiological parameters evaluated were affected by ropivacaine: PR interval by 28% (p = 0.001), AV interval by 40% (p = 0.001), sinus QRS by 101% (p = 0.001), paced QRS at a rate of 150 bpm by 258% (p = 0.001), and at 120 bpm by 241% (p = 0.001). Seven animals (87.5%) in the control group and eight animals (100%) in the ILE group developed sustained-VA (p = 0.30). Successful resuscitation occurred in 100% of animals in the ILE group vs. 57% of animals in the control group, p = 0.038. Pacing-induced-VA terminated at the first defibrillation attempt in 75% of the animals in the ILE group vs. 0% in the control group, p = 0.01. CONCLUSION Ropivacaine strongly altered the parameters of ventricular conduction, thus facilitating the induction of VA. ILEs did not prevent pacing-induced VA. However, facilitated resuscitation and termination of VA were delivered at the first defibrillation attempt compared to the control group.
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Affiliation(s)
- Matilde Zaballos
- Department of Forensic Medicine, Psychiatry and Pathology, Department of Anaesthesiology, Faculty of Medicine, Complutense University, Hospital Universitario Gregorio Marañón, Madrid, Spain
| | - Ignacio Fernández
- Department of Anesthesiology, Hospital Universitario Gregorio Marañón, Madrid, Spain
| | - Lucia Rodríguez
- Department of Anesthesiology, Hospital Universitario Gregorio Marañón, Madrid, Spain
| | - Sergio García
- Department of Anesthesiology, Hospital Universitario Gregorio Marañón, Madrid, Spain
| | - Olalla Varela
- Department of Anesthesiology, Hospital Universitario Gregorio Marañón, Madrid, Spain
| | - Oscar Quintela
- Department of Forensic Medicine, Psychiatry and Pathology, Faculty of Medicine, Complutense University, Madrid, Spain
| | - María-José Anadón
- Head Department of Forensic Medicine, Psychiatry and Pathology, Faculty of Medicine, National Institute of Toxicology and Forensic Science, Complutense University, Madrid, Spain
| | - Jesús Almendral
- Electrophysiology Arrhythmia Unit, Hospital Monteprincipe Grupo HM Hospitales, University CEU-San Pablo, Madrid, Spain
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Local Anesthetic Plasma Concentrations as a Valuable Tool to Confirm the Diagnosis of Local Anesthetic Systemic Toxicity? A Report of 10 Years of Experience. Pharmaceutics 2022; 14:pharmaceutics14040708. [PMID: 35456542 PMCID: PMC9025106 DOI: 10.3390/pharmaceutics14040708] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2022] [Revised: 03/22/2022] [Accepted: 03/24/2022] [Indexed: 01/27/2023] Open
Abstract
Background: Local anesthetic systemic toxicity (LAST) has been reported as a serious complication of local anesthetic (LA) peripheral injection. The signs and symptoms of LAST are highly variable, and the challenge remains to confirm its diagnosis. In this context, the determination of LA plasma concentration appears as a valuable tool to confirm LAST diagnosis. The aims of this study were to describe observed LA concentrations in patients suspected with LAST and their contribution to diagnostic confirmation. Methods: We retrospectively reported suspected LAST in patients for which at least one plasma LA concentration was determined to confirm diagnosis of LAST. Data collection came from our pharmacological laboratory’s database. Clinical signs and symptoms of toxicity, their onset time and observed LA concentrations were used to confirm LAST diagnosis. Results: 33 patients who presented with suspected LAST after ropivacaine and/or lidocaine administration were included. Prodromal symptoms were observed in 13 patients. Isolated central nervous system (CNS) toxicity occurred in 11 patients, and combined CNS and cardiovascular toxicity occurred in 12. One, two or three venous plasma samples were performed in 11, 3 and 19 patients, respectively. Toxic plasma LA concentrations were observed in three patients, receiving peripheral LA injection using lidocaine (16.1 µg/mL) and ropivacaine (4.2 and 4.8 µg/mL). Conclusion: This study presents an important biological and clinical dataset of patients who presented with suspected LAST. Plasma LA concentrations could bring valuable information in the diagnosis of LAST but requires rigorous sample protocols.
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Abstract
Abstract
Editor’s Perspective
What We Already Know about This Topic
What This Article Tells Us That Is New
Background
Thoracic paravertebral block is the preferred regional anesthetic technique for breast cancer surgery, but concerns over its invasiveness and risks have prompted search for alternatives. Pectoralis-II block is a promising analgesic technique and potential alternative to paravertebral block, but evidence of its absolute and relative effectiveness versus systemic analgesia (Control) and paravertebral block, respectively, is conflicting. This meta-analysis evaluates the analgesic effectiveness of Pectoralis-II versus Control and paravertebral block for breast cancer surgery.
Methods
Databases were searched for breast cancer surgery trials comparing Pectoralis-II with Control or paravertebral block. Postoperative oral morphine consumption and difference in area under curve for pooled rest pain scores more than 24 h were designated as coprimary outcomes. Opioid-related side effects, effects on long-term outcomes, such as chronic pain and opioid dependence, were also examined. Results were pooled using random-effects modeling.
Results
Fourteen randomized trials (887 patients) were analyzed. Compared with Control, Pectoralis-II provided clinically important reductions in 24-h morphine consumption (at least 30.0 mg), by a weighted mean difference [95% CI] of −30.5 mg [−42.2, −18.8] (P < 0.00001), and in rest pain area under the curve more than 24 h, by −4.7cm · h [−5.1, −4.2] or −1.2cm [−1.3, −1.1] per measurement. Compared with paravertebral block, Pectoralis-II was not statistically worse (not different) for 24-h morphine consumption, and not clinically worse for rest pain area under curve more than 24 h. No differences were observed in opioid-related side effects or any other outcomes.
Conclusions
We found that Pectoralis-II reduces pain intensity and morphine consumption during the first 24 h postoperatively when compared with systemic analgesia alone; and it also offers analgesic benefits noninferior to those of paravertebral block after breast cancer surgery. Evidence supports incorporating Pectoralis-II into multimodal analgesia and also using it as a paravertebral block alternative in this population.
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Sondekoppam RV, Uppal V, Brookes J, Ganapathy S. Bilateral Thoracic Paravertebral Blocks Compared to Thoracic Epidural Analgesia After Midline Laparotomy: A Pragmatic Noninferiority Clinical Trial. Anesth Analg 2019; 129:855-863. [PMID: 31425230 DOI: 10.1213/ane.0000000000004219] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
BACKGROUND Bilateral paravertebral block (PVB) is a suitable alternative to thoracic epidural analgesia (TEA) for abdominal surgeries. This randomized clinical trial aims to determine if PVB is noninferior to TEA in terms of analgesia after midline laparotomy. METHODS Seventy American Society of Anesthesiologists (ASA) class I-III patients undergoing a laparotomy through a midline incision were randomized to receive either TEA (TEA group) or continuous bilateral PVB (PVB group) as a part of a multimodal analgesia regimen in an open-label design. Noninferiority was to be concluded if the mean between-group difference in pain on movement at the 24 postoperative hours was within a margin of 2 points on a 0-10 numerical rating scale (NRS). Pain score at rest and on movement, analgesic consumption, hemodynamics, and adverse events during the first 72 postoperative hours were the secondary outcome measures assessed for superiority. Postblock and steady-state plasma concentrations of ropivacaine and pattern of dye spread were also recorded in the PVB group. RESULTS The primary outcome of pain scores on movement at 24 postoperative hours was noninferior in PVB group in comparison to TEA group (mean difference [95% confidence interval {CI}], 0.43 [-0.72-1.58]). The pain scores at rest and on movement at other time points of assessment were within clinically acceptable limits in both groups with no significant differences between the groups over time. Arterial plasma ropivacaine levels were within safe limits, while steady-state venous level was higher than an acceptable threshold in 9 of 34 cases. CONCLUSIONS As a component of multimodal analgesia, bilateral PVB provides noninferior analgesia compared to TEA for midline laparotomy.
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Affiliation(s)
- Rakesh V Sondekoppam
- From the Department of Anesthesia and Pain Medicine, University of Alberta, Edmonton, Alberta, Canada
| | - Vishal Uppal
- Department of Anesthesia, Pain Management & Perioperative Medicine, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Jonathan Brookes
- Department of Anesthesia and Perioperative Medicine, Western University, London, Ontario, Canada
| | - Sugantha Ganapathy
- Department of Anesthesia and Perioperative Medicine, Western University, London, Ontario, Canada
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Plasma Ropivacaine Concentrations Following Local Infiltration Analgesia in Total Knee Arthroplasty. Reg Anesth Pain Med 2018; 43:347-351. [DOI: 10.1097/aap.0000000000000727] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
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Khairnar P, Agarwal M, Verma UC, Kumar R. Comparative efficacy of ropivacaine and levobupivacaine in combined femoral and lateral femoral cutaneous nerve block with adjuvant magnesium for post-operative analgesia. Indian J Anaesth 2016; 60:584-9. [PMID: 27601742 PMCID: PMC4989810 DOI: 10.4103/0019-5049.187794] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
Background and Aims: Patients with burns may require multiple surgeries, but poor general condition and underlying protein energy malnutrition make them unsuitable candidates for general or spinal anaesthesia. This study evaluated the role of magnesium sulphate as an adjuvant with levobupivacaine and ropivacaine used in combined femoral and lateral femoral cutaneous nerve (LFCN) blocks in burn patients with relative sparing of thigh portion. Methods: This prospective, randomised, double-blind study included 54 adult patients of 18–65 years age, undergoing split-thickness skin graft harvest from the thigh, allotted to three equal groups of 18 each. Group L patients received femoral nerve (FN) block with 15 mL of 0.5% levobupivacaine and 8 mL for LFCN block; Group LM patients received 14 mL of 0.5% levobupivacaine along with 1.0 mL of 15% magnesium sulphate for FN block, 7.5 mL of 0.5% levobupivacaine with 0.5 mL of 15% of magnesium sulphate to LFCN block and Group R patients received 15 mL of 0.5% ropivacaine for FN block and 8 mL of 0.5% ropivacaine for LFCN block. Time to block onset and complete surgical block, duration of analgesia, total analgesic dose and the overall analgesia satisfaction score were measured in the first 24 h post-operatively. Quantitative data were analysed with ANOVA and qualitative data subjected to Chi-square tests. Intergroup comparison was performed with independent t-test. Results: The duration of post-operative analgesia did not differ with the addition of magnesium (P = 0.610). Time to onset of the block was significantly decreased with the addition of magnesium (P = 0.0341), but time to complete surgical block onset was similar across the groups. Conclusion: Both ropivacaine and levobupivacaine have good perioperative analgesic efficacy. Magnesium as an analgesia adjuvant with levobupivacaine does not prolong the duration of post-operative analgesia.
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Affiliation(s)
- Prakash Khairnar
- Department of Critical Care, Asian Institute of Medical Sciences, Faridabad, Haryana, India
| | - Munisha Agarwal
- Department of Anesthesia and Critical Care, Maulana Azad Medical College, New Delhi, India
| | - Uttam Chandra Verma
- Department of Anesthesia and Critical Care, Maulana Azad Medical College, New Delhi, India
| | - Rakesh Kumar
- Department of Anesthesia and Critical Care, Maulana Azad Medical College, New Delhi, India
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A Review of Local Anesthetic Systemic Toxicity Cases Since Publication of the American Society of Regional Anesthesia Recommendations. Reg Anesth Pain Med 2015; 40:698-705. [DOI: 10.1097/aap.0000000000000320] [Citation(s) in RCA: 57] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
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