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Zaballos M, Fernández I, Melone A, Rodríguez L, Varela O, García S, Quintela O, Vazquez E, Anadón MJ, Almendral J. Sodium bicarbonate reverts electrophysiologic cardiotoxicity of ropivacaine faster than lipid emulsions in a porcine model. Basic Clin Pharmacol Toxicol 2023; 132:211-222. [PMID: 36479999 PMCID: PMC10107242 DOI: 10.1111/bcpt.13822] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2022] [Revised: 11/09/2022] [Accepted: 11/30/2022] [Indexed: 12/13/2022]
Abstract
Ropivacaine has been described as a safer local anaesthetic (LA); however, serious cardiotoxic accidents have been reported. Intravenous-lipid-emulsion (ILE) therapy during LA intoxication seems to act as an antidote. Sodium bicarbonate is the standard treatment for sodium channel blocker drug toxicity. We compared both antidotes on the reversion of electrophysiologic toxicity induced by ropivacaine. Ropivacaine 5 mg kg-1 was administered in 24 pigs, and 3 min later, the animals received ILE: 1.5 ml kg-1 + 0.25 ml kg-1 min-1 (ILE group); sodium bicarbonate: 2 mEq kg-1 + 1 mEq kg-1 h-1 (NaHCO3 group); saline solution (CTL group). Electrophysiological parameters were evaluated for 30 min. The area under the curve (AUC) for the first 5 or 30 min was compared between groups. Ropivacaine induced a lengthening of the PR interval by 17% (P = 0.0001), His-ventricle-interval by 58% (P = 0.001), sinus QRS complex by 56% (P = 0.0001), paced QRS at 150 bpm by 257% (P = 0.0001), and at 120 bpm by 143% (P = 0.0001) in all groups. At 5 min after treatment, sinus QRS in the NaHCO3 group was shorter than that in the CTL group (AUCQRS5 , P = 0.003) or ILE group (AUCQRS5 , P = 0.045). During the first minute, seven of the animals in the NaHCO3 group vs. two in the ILE or 0 in the CTL group recovered more than 30% of the sinus QRS previously lengthened by ropivacaine (P = 0.003). Sodium bicarbonate reversed the electrophysiological toxicity of ropivacaine faster than ILE and control groups.
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Affiliation(s)
- Matilde Zaballos
- Department of Toxicology, Faculty of Medicine, Complutense University, Madrid, Spain.,Department of Anaesthesiology, Hospital General Universitario Gregorio Marañón, Madrid, Spain
| | - Ignacio Fernández
- Department of Anaesthesiology, Hospital General Universitario Gregorio Marañón, Madrid, Spain
| | - Arturo Melone
- Department of Anaesthesiology, Hospital General Universitario Gregorio Marañón, Madrid, Spain
| | - Lucía Rodríguez
- Department of Anaesthesiology, Hospital General Universitario Gregorio Marañón, Madrid, Spain
| | - Olalla Varela
- Department of Anaesthesiology, Hospital General Universitario Gregorio Marañón, Madrid, Spain
| | - Sergio García
- Department of Anaesthesiology, Hospital General Universitario Gregorio Marañón, Madrid, Spain
| | - Oscar Quintela
- Department of Toxicology, Faculty of Medicine, Complutense University, Madrid, Spain.,National Institute of Toxicology and Forensic Science, Madrid, Spain
| | - Elena Vazquez
- Hospital General Universitario Gregorio Marañón, Madrid, Spain
| | | | - Jesús Almendral
- Director of the Electrophysiology Laboratory and Arrhythmia Unit, Hospital Monteprincipe, Grupo HM Hospitales, University CEU-San Pablo, Madrid, Spain
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Zaballos M, Varela O, Fernández I, Rodríguez L, García S, Quintela O, Vázquez E, Anadón MJ, Almendral J. Assessment of cardiotoxicity and plasma ropivacaine concentrations after serratus intercostal fascial plane block in an experimental model. Sci Rep 2023; 13:47. [PMID: 36593251 PMCID: PMC9807569 DOI: 10.1038/s41598-022-26557-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2022] [Accepted: 12/16/2022] [Indexed: 01/03/2023] Open
Abstract
Serratus intercostal fascial plane block (SIFPB) has emerged as an alternative to paravertebral block in breast surgery. It involves the administration of high volumes and doses of local anesthetics (LA) that can potentially reach toxic levels. Ropivacaine is widely used in thoraco-fascial blocks; however, there is no information on the plasma concentrations attained after SIPFB and whether they are associated with cardiotoxicity. Plasma concentrations of ropivacaine and its electrophysiological effects were evaluated in eight pigs after bilateral SIFPB with ropivacaine in doses of 3 mg/kg. Plasma concentrations, electrophysiological and hemodynamic parameters were measured sequentially for the following 180 min until the end of the study. The area under the curve, the maximum plasma concentration (Cmax) and the time to reach Cmax (tmax) were calculated. The median arterial ropivacaine concentration Cmax was, 2.34 [1.40 to 3.74] µg/ml. The time to reach the highest concentration was 15 [10 to 20] min. Twenty-five percent of the animals had arterial concentrations above the lower limit concentration of ropivacaine for LA systemic toxicity (3.4 µg/ml). No alterations were observed in the electrophysiological or electrocardiographic parameters except for a prolongation of the QTc interval, from 489 ± 30 to 544 ± 44 ms (Δ11.38 ± 6%), P = 0.01. Hemodynamic parameters remained in the physiological range throughout the study. SIFPB with ropivacaine in doses of 3 mg/kg has reached potentially toxic levels, however, it has not been associated with adverse electrophysiological or hemodynamic effects.
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Affiliation(s)
- Matilde Zaballos
- grid.4795.f0000 0001 2157 7667Department of Forensic Medicine, Psychiatry and Pathology, Complutense University, Madrid, Spain ,grid.410526.40000 0001 0277 7938Department of Anesthesiology, Hospital General Universitario Gregorio Marañón, C/ Dr Esquerdo nº46, 28007 Madrid, Spain
| | - Olalla Varela
- grid.410526.40000 0001 0277 7938Department of Anesthesiology, Hospital General Universitario Gregorio Marañón, C/ Dr Esquerdo nº46, 28007 Madrid, Spain
| | - Ignacio Fernández
- grid.410526.40000 0001 0277 7938Department of Anesthesiology, Hospital General Universitario Gregorio Marañón, C/ Dr Esquerdo nº46, 28007 Madrid, Spain
| | - Lucía Rodríguez
- grid.410526.40000 0001 0277 7938Department of Anesthesiology, Hospital General Universitario Gregorio Marañón, C/ Dr Esquerdo nº46, 28007 Madrid, Spain
| | - Sergio García
- grid.410526.40000 0001 0277 7938Department of Anesthesiology, Hospital General Universitario Gregorio Marañón, C/ Dr Esquerdo nº46, 28007 Madrid, Spain
| | - Oscar Quintela
- grid.4795.f0000 0001 2157 7667Department of Forensic Medicine, Psychiatry and Pathology, Complutense University, Madrid, Spain
| | - Elena Vázquez
- grid.410526.40000 0001 0277 7938Hospital General Universitario Gregorio Marañón, Madrid, Spain
| | - María-José Anadón
- grid.4795.f0000 0001 2157 7667Department of Forensic Medicine, Psychiatry and Pathology, Complutense University, Madrid, Spain
| | - Jesús Almendral
- grid.8461.b0000 0001 2159 0415Hospital Monteprincipe, Grupo HM Hospitales, University CEU-San Pablo, Madrid, Spain
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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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Zaballos M, Callejo D, Sevilla R, Quintela O, López-Menchaca R, Melone A, Varela O, Anadón Baselga MJ, Almendral J. Comparative Effects of Sodium Bicarbonate and Intravenous Lipid Emulsions on Reversing Bupivacaine-Induced Electrophysiological Toxicity in a Porcine Experimental Model. Anesth Analg 2019; 129:63-72. [DOI: 10.1213/ane.0000000000003875] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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De Diego C, Zaballos M, Quintela O, Sevilla R, Callejo D, González-Panizo J, Anadón MJ, Almendral J. Bupivacaine Toxicity Increases Transmural Dispersion of Repolarization, Developing of a Brugada-like Pattern and Ventricular Arrhythmias, Which is Reversed by Lipid Emulsion Administration. Study in an Experimental Porcine Model. Cardiovasc Toxicol 2019; 19:432-440. [DOI: 10.1007/s12012-019-09515-y] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Gosselin S, Hoegberg LCG, Hoffman RS, Graudins A, Stork CM, Thomas SHL, Stellpflug SJ, Hayes BD, Levine M, Morris M, Nesbitt-Miller A, Turgeon AF, Bailey B, Calello DP, Chuang R, Bania TC, Mégarbane B, Bhalla A, Lavergne V. Evidence-based recommendations on the use of intravenous lipid emulsion therapy in poisoning. Clin Toxicol (Phila) 2016; 54:899-923. [DOI: 10.1080/15563650.2016.1214275] [Citation(s) in RCA: 66] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Affiliation(s)
- Sophie Gosselin
- Department of Emergency Medicine, McGill University Health Centre, Montréal, Québec, Canada
- Centre Antipoison du Québec, Montréal, Québec, Canada
- Province of Alberta Drug Information Services, Calgary, Alberta, Canada
| | - Lotte C. G. Hoegberg
- Danish Poisons Information Centre, Anaesthesiology, Copenhagen University Hospital Bispebjerg, Copenhagen, Denmark
| | - Robert. S. Hoffman
- Division of Medical Toxicology, Ronald O. Perelman Department of Emergency Medicine, New York University School of Medicine, New York, NY, USA
| | - Andis Graudins
- Monash Clinical Toxicology Service, Program of Emergency Medicine, Monash Health and School of Clinical Sciences at Monash Health, Faculty of Medicine, Nursing and Health Sciences, Monash University, Clayton, Victoria, Australia
| | - Christine M. Stork
- Upstate NY Poison Center, Syracuse, NY, USA
- Department of Emergency Medicine, Upstate Medical University, Syracuse, New York, USA
| | - Simon H. L. Thomas
- National Poisons Information Service (Newcastle) and Medical Toxicology Centre, Institute of Cellular Medicine, Newcastle University, Newcastle, UK
| | | | - Bryan D. Hayes
- Department of Pharmacy, University of Maryland Medical Center, Baltimore, MD, USA
- Department of Emergency Medicine, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Michael Levine
- Department of Emergency Medicine, Section of Medical Toxicology, University of Southern California, Los Angeles, CA, USA
| | - Martin Morris
- Schulich Library of Science and Engineering, McGill University, Montréal, Québec, Canada
| | - Andrea Nesbitt-Miller
- Schulich Library of Science and Engineering, McGill University, Montréal, Québec, Canada
| | - Alexis F. Turgeon
- Division of Critical Care Medicine, Department of Anesthesiology and Critical Care Medicine, and CHU de Québec, Université Laval Research Center, Population Health and Optimal Health Practices Unit, Université Laval, Québec City, Québec, Canada
| | - Benoit Bailey
- Division of Emergency Medicine, Department of Pediatrics, CHU Sainte-Justine, Montréal, Québec, Canada
- Centre Antipoison du Québec, Quebec, Canada
| | - Diane P. Calello
- Medical Toxicology, Department of Emergency Medicine, Morristown Medical Center, Emergency Medical Associates, Morristown, NJ, USA
| | - Ryan Chuang
- Department of Emergency Medicine, Division of Clinical Pharmacology and Toxicology, University of Calgary, Poison and Drug Information Service, Calgary, Alberta, Canada
| | | | - Bruno Mégarbane
- Department of Medical and Toxicological Intensive Care, Lariboisière Hospital, Paris-Diderot University, INSERM UMRS1144, Paris, France
| | - Ashish Bhalla
- Department of Internal Medicine, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Valéry Lavergne
- Department of Medical Biology, Sacré-Coeur Hospital, University of Montréal, Montréal, Québec, Canada
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