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Saganuwan SA. Chirality of Central Nervous System (CNS) Acting Drugs: A Formidable Therapeutic Hurdle Against CNS Diseases. Cent Nerv Syst Agents Med Chem 2020; 19:171-179. [PMID: 31232237 DOI: 10.2174/1871524919666190624150214] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2018] [Revised: 05/31/2019] [Accepted: 06/10/2019] [Indexed: 11/22/2022]
Abstract
BACKGROUND Over fifty percent of drugs being used clinically are chiral and 90% of them are racemates. Unfortunately, they have both adverse and beneficial effects on body systems. METHODS Because of the erratic effects of chiral compounds on body functional systems, literature search was carried out with a view to identify CNS chiral drugs, their clinical advantages and disadvantages, unique physicochemical properties and structural modifications into safer drugs. RESULTS Findings have shown that majority of CNS and non-CNS acting drugs have chiral functional groups that may occur as either dextrorotatory (clockwise) or levorotatory (anticlockwise) or racemates which are inert. Sometimes, the enantiomers (optical isomers) could undergo keto-enol tautomerism, appearing in either acidic or basic or inert form. Chiral CNS acting drugs have agonistic and antagonistic effects, clinical advantages, disadvantages, and special clinical applications, possible modifications for better therapeutic effects and possible synthesis of more potent drugs from racemates. Clockwise chirality may be more effective and safer than the drugs with anticlockwise chirality. When chiral drugs are in racemate state they become inert and may be safer than when they are single. Also, diastereoisomers may be more dangerous than stereoisomers. CONCLUSION Therefore, chiral compounds should be adequately studied in lab rodents and primates, and their mechanisms of actions should be comprehensively understood before being used in clinical setting. Since many of them are toxic, their use should be based on principle of individualized medicine. Their molecular weights, functional groups, metabolites, polymers and stereoisomers could be valuable tools for their modifications.
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Affiliation(s)
- Saganuwan Alhaji Saganuwan
- Department of Veterinary Physiology, Pharmacology and Biochemistry, College of Veterinary Medicine, Federal University of Agriculture, P.M.B. 2373, Makurdi, Benue State, Nigeria
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Kang HY, Kim JE, Kim YJ, Park SW, Kim Y. An Unusual Delayed Onset of Systemic Toxicity After Fluoroscopy-Guided Cervical Epidural Steroid Injection With Levobupivacaine: A Case Report. Pain Pract 2019; 19:762-766. [PMID: 31165535 DOI: 10.1111/papr.12802] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2019] [Revised: 05/15/2019] [Accepted: 05/31/2019] [Indexed: 11/30/2022]
Abstract
BACKGROUND Cervical epidural steroid injection (CESI) with local anesthetics is commonly used to treat neck pain and radicular pain of the upper extremity. Local anesthetic systemic toxicity (LAST) occurs shortly after injection as a complication; however, delayed onset is a very rare event, especially in central nervous system (CNS) block. CASE REPORT We present a case in which delayed onset of LAST occurred in a patient who received CESI for cervical and arm radiating pain due to a cervical disc protrusion. We performed the interlaminar approach for CESI using fluoroscopic guidance. After confirming the location of the epidural space using the loss of resistance technique and spreading of contrast agent (Telebrix® 30), a mixture of 0.25% levobupivacaine 12.5 mg (5 mL in volume), hyaluronidase 1,500 IU (1 mL), dexamethasone 5 mg (1 mL), and normal saline 3 mL was administrated. After 50 minutes of injection, the patient showed CNS toxicity (unconsciousness, seizure) with normal blood pressure and tachycardia; therefore, she was immediately sedated with intravenous midazolam (3 mg), and 15 L/min of oxygen was administered. The patient fully recovered after 30 minutes of sedation without any sequelae. CONCLUSION Delayed onset of LAST is a rare complication of a common procedure in CESI, so it is important to be aware of this complication and the presentation of toxicity.
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Affiliation(s)
- Hee Yong Kang
- Department of Anesthesiology and Pain Medicine, Kyung Hee University Hospital, Seoul, Korea
| | - Jeong Eun Kim
- Department of Anesthesiology and Pain Medicine, Kyung Hee University Hospital, Seoul, Korea
| | - Yun Jong Kim
- Department of Anesthesiology and Pain Medicine, Kyung Hee University Hospital, Seoul, Korea
| | - Sung Wook Park
- Department of Anesthesiology and Pain Medicine, Kyung Hee University Hospital, Seoul, Korea
| | - Youngsoon Kim
- Department of Anesthesiology and Pain Medicine, Kyung Hee University Hospital, Seoul, Korea
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Pişkin Ö, Aydın BG. Effects of insulin+glucose pretreatment on bupivacaine cardiotoxicity in rats. Hum Exp Toxicol 2017; 37:451-457. [PMID: 28565972 DOI: 10.1177/0960327117712384] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
A mistaken overdose of bupivacaine into systemic circulation may cause severe cardiovascular side effects. The aim of this study was to assess the effects of pretreatment with combined intra venous lipid emulsion (ILE) and high-dose insulin therapy against cardiotoxicity caused by bupivacaine intoxication. The rats were divided into the following three groups: Group B received a saline pretreatment plus a bupivacaine, group L received ILE pretreatment plus a bupivacaine, and in group I, insulin with glucose was infused intravenously, plus ILE pretreatment plus a bupivacaine. The electrocardiogram tracing, invasive arterial pressure, and heart rate (HR) of rats were monitored continuously. Arterial blood gas analysis was performed in all groups. Arterial blood gas analysis revealed that the baseline pH, PaO2, and PaCO2 values were similar between groups ( p > 0.05). Widening of Q, R, and S wave complex was found 46.8 ± 16.7, 92.0 ± 5.80, and 106.5 ± 17.9 s after initiation of bupivacaine infusion in groups B, L, and I, respectively. Time elapsed until 25% reduction of HR 127.3 ± 17.7, 248.4 ± 34.1, and 260.1 ± 51.3 s for groups B, L, and I, and 25% reduction of mean arterial pressure 107.6 ± 14.1, 253.2 ± 36.3, and 292 ± 57.7 s for groups B, L, and I, respectively. Arrhythmia was observed after 142.2 ± 27.5, 180.7 ± 17.8, and 190.7 ± 19.2 s for groups B, L, and I, respectively. Finally, asystole occurred after 560.1 ± 76.4, 782.4 ± 63.0, and 882.5 ± 105.1 s for groups B, L, and I, respectively. This finding indicates that the survival time of rats administered pretreatment with ILE plus insulin+glucose and those given ILE was observed to be longer.
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Affiliation(s)
- Ö Pişkin
- Department of Anesthesiology and Reanimation, School of Medicine, Bulent Ecevit University, Zonguldak, Turkey
| | - B G Aydın
- Department of Anesthesiology and Reanimation, School of Medicine, Bulent Ecevit University, Zonguldak, Turkey
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Sato M, Iida T, Kikuchi C, Sasakawa T, Kunisawa T. Comparison of caudal ropivacaine-morphine and paravertebral catheter for major upper abdominal surgery in infants. Paediatr Anaesth 2017; 27:524-530. [PMID: 28181346 DOI: 10.1111/pan.13104] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 12/18/2016] [Indexed: 11/27/2022]
Abstract
BACKGROUND The caudal epidural block is one of the most commonly used regional anesthetic techniques in children. Administration of morphine via caudal injection enables analgesia, even for upper abdominal surgery. The thoracic paravertebral block has also been successfully used to treat perioperative pain during upper abdominal procedures in pediatric patients. AIM In the current study, we compared the two regional techniques for upper abdominal surgery in infants to determine whether one of them was preferable to the other. METHODS Consecutive patients under 12 months of age who underwent upper abdominal surgery were retrospectively divided according to the chosen postoperative analgesia: Group C, caudal ropivacaine-morphine; Group P, paravertebral catheter. We analyzed the following outcomes: requirement for additional analgesics, pain scores, need for mechanical ventilation and oxygen dosage, postoperative blood pressure and heart rate, time to pass first stool, time until first full meal, and complications. RESULTS Twenty-one consecutive patients were included: 10 in Group C and 11 in Group P. Median age at surgery was 80 (47.5-270.0) and 84.5 (34.3-287.5) days, respectively. No difference was found between the two groups in requirement for additional analgesics at 24 h after surgery (median 1 in Group C vs 1 in Group P, P = 0.288, 95% CI: -2 to 1). BOPS pain scores were only lower in Group P when compared to Group C at 24 h after surgery (median 1 vs 2, P = 0.041, 95% CI: -2 to 0). None of the patients had perioperative complications. CONCLUSIONS In this small series, there was no significant difference between caudal ropivacaine-morphine and paravertebral catheter for postoperative care in infants undergoing upper abdominal surgery. Further prospective studies are needed to compare the efficacy and incidence of complications of caudal block and paravertebral catheter for postoperative analgesia.
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Affiliation(s)
- Makoto Sato
- Department of Anesthesiology and Critical Care Medicine, Asahikawa Medical University, Asahikawa, Hokkaido, Japan
| | - Takafumi Iida
- Department of Anesthesiology and Critical Care Medicine, Asahikawa Medical University, Asahikawa, Hokkaido, Japan
| | - Chika Kikuchi
- Department of Anesthesiology and Critical Care Medicine, Asahikawa Medical University, Asahikawa, Hokkaido, Japan
| | - Tomoki Sasakawa
- Department of Anesthesiology and Critical Care Medicine, Asahikawa Medical University, Asahikawa, Hokkaido, Japan
| | - Takayuki Kunisawa
- Department of Anesthesiology and Critical Care Medicine, Asahikawa Medical University, Asahikawa, Hokkaido, Japan
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Rahiri J, Tuhoe J, Svirskis D, Lightfoot N, Lirk P, Hill A. Systematic review of the systemic concentrations of local anaesthetic after transversus abdominis plane block and rectus sheath block. Br J Anaesth 2017; 118:517-526. [DOI: 10.1093/bja/aex005] [Citation(s) in RCA: 44] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023] Open
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Local anesthetic systemic toxicity: Continuing Professional Development. Can J Anaesth 2016; 63:330-49. [DOI: 10.1007/s12630-015-0564-z] [Citation(s) in RCA: 42] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2015] [Revised: 09/17/2015] [Accepted: 12/07/2015] [Indexed: 10/22/2022] Open
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Wu G, Sun B, Liu LI, Zhou J, Mo L, Ren C, Ou C. Lipid emulsion mitigates local anesthesia-induced central nervous system toxicity in rats. Exp Ther Med 2015; 10:1133-1138. [PMID: 26622452 DOI: 10.3892/etm.2015.2594] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2014] [Accepted: 05/06/2015] [Indexed: 11/06/2022] Open
Abstract
The aim of the present study was to investigate the effect of intravenously administered lipid emulsion on local anesthetic (LA)-induced central nervous system (CNS) toxicity. A total of 100 male Sprague Dawley rats were allocated at random into the following groups: Sham (A), lidocaine (B), levobupivacaine (C) and ropivacaine (D). Groups B-D were each subdivided into three subgroups: Toxic, post-conditioning and pre-conditioning. Intracerebroventricular injections of 0.9% normal saline (sham group) or LA were administered via microsyringe; in addition, a 20% lipid emulsion was injected into tail vein prior to the LA injection (pre-conditioning subgroups) or following rat respiratory arrest (post-conditioning subgroups). The heart rate, blood pressure, neurological behavior scores, neuronal density and time from LA injection to respiratory arrest, apnea and start of arrhythmia were measured. Rats in the toxic groups died due to respiratory arrest following the injection of LA into the lateral ventricle. Rats in the post-conditioning subgroups were resuscitated from the LA-induced respiratory arrest, while the pre-conditioning subgroup rats exhibited no respiratory arrest. No significant differences in heart rate were observed between the toxic and post-conditioning subgroups in the levobupivacaine and ropivacaine groups (P>0.05); however, a significant difference was observed between these treatment groups and the rats treated with lidocaine (P<0.01). A significant difference was also observed in the time from the LA injection to the onset of arrhythmia among the rats in groups B, C and D (P<0.01). No significant differences in the neurological behavior scores and neuronal density were observed in the hippocampal CA1 zone among group C and D rats in the post- and pre-conditioning subgroups at various time-points following treatment. Beyond that, the same phenomena regarding neurological behavior scores was observed in post- and pre-conditioning subgroups of group B at 12 and 24 h treatment, contrasting with the statistically significant difference between post- and pre-conditioning subgroups at 6 h treatment (P<0.01). The results of the present study therefore indicate that pre- and post-conditioning with lipid emulsion effectively mitigates LA-induced CNS toxicity in rats.
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Affiliation(s)
- Gangming Wu
- Department of Anesthesiology and Pain, Affiliated Hospital of Luzhou Medical College, Luzhou, Sichuan 646000, P.R. China
| | - Bin Sun
- Department of Anesthesiology and Pain, Affiliated Hospital of Luzhou Medical College, Luzhou, Sichuan 646000, P.R. China
| | - L I Liu
- Department of Anesthesiology and Pain, Affiliated Hospital of Luzhou Medical College, Luzhou, Sichuan 646000, P.R. China
| | - Jun Zhou
- Department of Anesthesiology and Pain, Affiliated Hospital of Luzhou Medical College, Luzhou, Sichuan 646000, P.R. China
| | - Liqun Mo
- Department of Anesthesiology and Pain, Affiliated Hospital of Luzhou Medical College, Luzhou, Sichuan 646000, P.R. China
| | - Changhe Ren
- Department of Anesthesiology and Pain, Affiliated Hospital of Luzhou Medical College, Luzhou, Sichuan 646000, P.R. China
| | - Cehua Ou
- Department of Anesthesiology and Pain, Affiliated Hospital of Luzhou Medical College, Luzhou, Sichuan 646000, P.R. China
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Takeda A, Ferraro LHC, Rezende AH, Sadatsune EJ, Falcão LFDR, Tardelli MA. Concentração mínima efetiva de bupivacaína para o bloqueio do plexo braquial via axilar guiado por ultrassom. Braz J Anesthesiol 2015; 65:163-9. [DOI: 10.1016/j.bjan.2013.11.007] [Citation(s) in RCA: 46] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2013] [Accepted: 11/26/2013] [Indexed: 11/24/2022] Open
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Takeda A, Ferraro LHC, Rezende AH, Sadatsune EJ, Falcão LFDR, Tardelli MA. Minimum effective concentration of bupivacaine for axillary brachial plexus block guided by ultrasound. Braz J Anesthesiol 2015; 65:163-9. [PMID: 25925026 DOI: 10.1016/j.bjane.2013.11.007] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2013] [Revised: 11/05/2013] [Accepted: 11/26/2013] [Indexed: 10/24/2022] Open
Abstract
INTRODUCTION The use of ultrasound in regional anesthesia allows reducing the dose of local anesthetic used for peripheral nerve block. The present study was performed to determine the minimum effective concentration (MEC90) of bupivacaine for axillary brachial plexus block. METHODS Patients undergoing hand surgery were recruited. To estimate the MEC90, a sequential up-down biased coin method of allocation was used. The bupivacaine dose was 5 mL for each nerve (radial, ulnar, median, and musculocutaneous). The initial concentration was 0.35%. This concentration was changed by 0.05% depending on the previous block; a blockade failure resulted in increased concentration for the next patient; in case of success, the next patient could receive or reduction (0.1 probability) or the same concentration (0.9 probability). Surgical anesthesia was defined as driving force ≤ 2 according to the modified Bromage scale, lack of thermal sensitivity and response to pinprick. Postoperative analgesia was assessed in the recovery room with numeric pain scale and the amount of drugs used within 4h after the blockade. RESULTS MEC90 was 0.241% [R(2): 0.978, confidence interval: 0.20-0.34%]. No patient, with successful block, reported pain after 4h. CONCLUSION This study demonstrated that ultrasound guided axillary brachial plexus block can be performed with the use of low concentration of local anesthetics, increasing the safety of the procedure. Further studies should be conducted to assess blockade duration at low concentrations.
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Affiliation(s)
- Alexandre Takeda
- Department of Anesthesiology, Pain and Intensive Care, Escola Paulista de Medicina, Universidade Federal de São Paulo (UNIFESP), São Paulo, SP, Brazil
| | - Leonardo Henrique Cunha Ferraro
- Department of Anesthesiology, Pain and Intensive Care, Escola Paulista de Medicina, Universidade Federal de São Paulo (UNIFESP), São Paulo, SP, Brazil.
| | - André Hosoi Rezende
- Department of Anesthesiology, Pain and Intensive Care, Escola Paulista de Medicina, Universidade Federal de São Paulo (UNIFESP), São Paulo, SP, Brazil
| | - Eduardo Jun Sadatsune
- Department of Anesthesiology, Pain and Intensive Care, Escola Paulista de Medicina, Universidade Federal de São Paulo (UNIFESP), São Paulo, SP, Brazil
| | - Luiz Fernando dos Reis Falcão
- Department of Anesthesiology, Pain and Intensive Care, Escola Paulista de Medicina, Universidade Federal de São Paulo (UNIFESP), São Paulo, SP, Brazil
| | - Maria Angela Tardelli
- Department of Anesthesiology, Pain and Intensive Care, Escola Paulista de Medicina, Universidade Federal de São Paulo (UNIFESP), São Paulo, SP, Brazil
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Casoni D, Rohrbach H, Spadavecchia C. Total spinal anaesthesia following spinal lumbosacral injection of bupivacaine 0.5 per cent in a cat. VETERINARY RECORD CASE REPORTS 2014. [DOI: 10.1136/vetreccr-2014-000117] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Affiliation(s)
- Daniela Casoni
- Vetsuisse FacultyAnaesthesia and Pain Theray Division3012 CHBerneSwitzerland
| | - Helene Rohrbach
- Vetsuisse FacultyAnaesthesia and Pain Theray Division3012 CHBerneSwitzerland
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Ok SH, Park CS, Kim HJ, Lee SH, Choi BH, Eun SY, Kim KN, Yang SM, Shin IW, Choi MJ, Sohn JT. Effect of two lipid emulsions on reversing high-dose levobupivacaine-induced reduced vasoconstriction in the rat aortas. Cardiovasc Toxicol 2014; 13:370-80. [PMID: 23877627 DOI: 10.1007/s12012-013-9218-y] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
The goals of this study were to determine which lipid emulsion (Intralipid(®) and Lipofundin MCT/LCT(®)) is more effective in reversing high-dose levobupivacaine-induced reduced vasoconstriction in isolated rat aortas and to examine the associated cellular mechanisms with a particular focus on the endothelium. Two lipid emulsion concentration-response curves were generated using high-dose levobupivacaine-induced reduced vasoconstriction and vasodilation of isolated aortas pretreated with or without 60 mM KCl. Endothelial nitric oxide synthase (eNOS) and caveolin-1 phosphorylation were measured in rat aortic tissue treated with levobupivacaine in the presence or absence of lipid emulsion. Dichlorofluorescein oxidation, a measure of reactive oxygen species production, was measured in lipid emulsion-treated human umbilical vein endothelial cells. In levobupivacaine (0.3 mM)-induced reduced vasoconstriction of isolated aorta, the magnitude of the Intralipid(®)- and Lipofundin MCT/LCT(®)-mediated reversal was not significantly different. Lipid emulsion reversal of levobupivacaine-induced reduced vasoconstriction was greater in endothelium-intact aortas than in endothelium-denuded aortas. The two lipid emulsions similarly inhibited levobupivacaine-induced eNOS phosphorylation in aortic tissue. Pretreatment with both lipid emulsions increased dichlorofluorescein oxidation. Both Intralipid(®) and Lipofundin MCT/LCT(®) are equally effective for vascular tone recovery from high-dose levobupivacaine-induced reduced vasoconstriction. This reversal is mediated partially by decreasing nitric oxide bioavailability.
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Affiliation(s)
- Seong-Ho Ok
- Department of Anesthesiology and Pain Medicine, Gyeongsang National University Hospital, Jinju, 660-702, Republic of Korea
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Zhai Y, Zhao L, Wang Z, Zhai G. RETRACTED ARTICLE: Preparation and characterization of novel lipid nanocapsules of ropivacaine for transdermal delivery. Drug Deliv 2014; 23:619-28. [PMID: 25005584 DOI: 10.3109/10717544.2014.930761] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Ropivacaine, a novel long-acting local anesthetic, has been proved to own superior advantage. However, the application form used in clinic, ropivacaine hydrochloride (Naropin Injection), which should be administed intravenously, is causing poor patient convenience. The purpose of this study was to formulate ropivacaine (RPV) in lipid nanocapsules (LNCs) and character the potential of LNCs in delivering RPV transdermally to exploit novel external preparation. The RPV-LNCs were successfully prepared by phase inversion technique and the formulation was characterized in terms of size, zeta potential, ex vivo permeation study, and pharmacodynamics. The prepared RPV-LNCs displayed a typical core-shell structure with a narrow size distribution of 62.1 ± 1.7 nm and drug loading of 1.35 ± 0.20%. The results of differential scanning calorimetry (DSC) analysis and X-ray diffraction showed that RPV was in amorphous crystalline state when encapsulated into LNCs. Furthermore, the results of ex vivo permeation study displayed that RPV-LNCs had an improved permeability (349.0 ± 11.5 μg cm(-2) versus 161.0 ± 1.3 μg cm(-2)) compared with free RPV. The results of histopathology study showed that interaction between LNCs and skin could break the close conjugation of corneocyte layers. In the mice writhing test, RPV-LNCs exhibited obvious analgesic effect by both prolonging pain latency and reducing the writhing response with an inhibition rate of 91.3% compared to the control group. In conclusion, RPV-LNCs could be a promising delivery system to encapsulate RPV and deliver RPV for transdermal administration.
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Affiliation(s)
- Yingjie Zhai
- a Department of Pharmaceutics, College of Pharmacy , Shandong University , Jinan , China , and
| | - Lili Zhao
- a Department of Pharmaceutics, College of Pharmacy , Shandong University , Jinan , China , and
| | - Zimin Wang
- b Department of Orthopedics , Changhai Hospital, Second Military Medical University , Shanghai , China
| | - Guangxi Zhai
- a Department of Pharmaceutics, College of Pharmacy , Shandong University , Jinan , China , and
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Bicer C, Eskıtascıoglu T, Aksu R, Ulgey A, Yildiz K, Madenoglu H. Comparison of preincisional infiltrated levobupivacaine and ropivacaine for acute postoperative pain relief after septorhinoplasty. Curr Ther Res Clin Exp 2014; 72:13-22. [PMID: 24648572 DOI: 10.1016/j.curtheres.2011.02.003] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/16/2011] [Indexed: 12/01/2022] Open
Abstract
BACKGROUND To maintain a high standard of patient care, it is essential to provide adequate pain management in patients who undergo nasal surgery. Levobupivacaine and ropivacaine are relatively new long-acting local anesthetics. OBJECTIVE The aim of this study was to compare the analgesic effect and blood loss of preincisional levobupivacaine HCl 0.25% and ropivacaine HCl 0.375% in patients undergoing septorhinoplasty. METHODS Sixty American Society of Anesthesiologists (ASA) I and II patients (18-55 years old) who were scheduled for elective open technique septorhinoplasty under general anesthesia were recruited for this study. The anesthetic technique was standardized for both groups. Preoperative and postoperative hemoglobin levels were recorded for all patients. Patients were assigned randomly to 1 of 2 study groups, and preincisional surgical field infiltration with 5 mL of 0.5% levobupivacaine plus 5 mL of 0.9% saline (group L; n = 30) or 5 mL of 0.75% ropivacaine plus 5 mL of 0.9% saline (group R; n = 30) was performed by the same surgeon. The degree of pain was measured by visual analogue scale (VAS) for pain and recorded at multiple time points in all patients after surgery. RESULTS The analgesic effect at 2 hours in the postanesthesia care unit (PACU) and at 24 hours postoperatively did not differ significantly between the 2 local anesthetics (P > 0.05). Pain scores of patients decreased after the 24 hours in levobupivacaine group and ropivacaine group when compared with 0-minute VAS values, and this was statistically significant (P < 0.05). No significant difference was observed between groups with respect to the preoperative and postoperative hemoglobin (P = 0.767 and 0.824, respectively) values. CONCLUSIONS Local tissue infiltration with 0.25% levobupivacaine or 0.375% ropivacaine is similarly effective in reducing the postoperative pain associated with septorhinoplasty.
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Affiliation(s)
- Cihangir Bicer
- Department of Anaesthesiology, Erciyes University, Gevher Nesibe Hospital, Kayseri, Turkey
| | - Teoman Eskıtascıoglu
- Department of Plastic and Reconstructive Surgery, Erciyes University, Gevher Nesibe Hospital, Kayseri, Turkey
| | - Recep Aksu
- Department of Anaesthesiology, Erciyes University, Gevher Nesibe Hospital, Kayseri, Turkey
| | - Ayse Ulgey
- Department of Anaesthesiology, Erciyes University, Gevher Nesibe Hospital, Kayseri, Turkey
| | - Karamehmet Yildiz
- Department of Anaesthesiology, Erciyes University, Gevher Nesibe Hospital, Kayseri, Turkey ; Department of Biochemistry, Erciyes University, Gevher Nesibe Hospital, Kayseri, Turkey
| | - Halit Madenoglu
- Department of Anaesthesiology, Erciyes University, Gevher Nesibe Hospital, Kayseri, Turkey
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YILMAZ M, CELEBI H, AKCALI D, GUREL N. Pre-treatment of bupivacaine-induced cardiovascular depression using different lipid formulations of propofol. Acta Anaesthesiol Scand 2014; 58:298-302. [PMID: 24438483 DOI: 10.1111/aas.12263] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/13/2013] [Indexed: 11/27/2022]
Abstract
BACKGROUND Pre-treatment with lipid emulsions has been shown to increase lethal doses of bupivacaine, and the lipid content of propofol may alleviate bupivacaine-induced cardiotoxicity. The aim of this study is to investigate the effects of propofol in intralipid or medialipid emulsions on bupivacaine-induced cardiotoxicity. METHODS Rats were anaesthetised with ketamine and were given 0.5 mg/kg/min propofol in intralipid (Group P), propofol in medialipid (Group L), or saline (Group C) over 20 min. Thereafter, 2 mg/kg/min bupivacaine 0.5% was infused. We recorded time to first dysrhythmia occurrence, respective times to 25% and 50% reduction of the heart rate (HR) and mean arterial pressure, and time to asystole and total amount of bupivacaine consumption. Blood and tissue samples were collected following asystole. RESULTS The time to first dysrhythmia occurrence, time to 25% and 50% reductions in HR, and time to asystole were longer in Group P than the other groups. The cumulative bupivacaine dose given at those time points was higher in Group P. Plasma bupivacaine levels were significantly lower in Group P than in Group C. Bupivacaine levels in the brain and heart were significantly lower in Group P and Group L than in Group C. CONCLUSION We conclude that pre-treatment with propofol in intralipid, compared with propofol in medialipid or saline, delayed the onset of bupivacaine-induced cardiotoxic effects as well as reduced plasma bupivacaine levels. Further studies are needed to explore tissue bupivacaine levels of propofol in medialipid and adapt these results to clinical practice.
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Affiliation(s)
- M. YILMAZ
- Department of Anesthesiology and Reanimation; Gazi University Faculty of Medicine; Ankara Turkey
| | - H. CELEBI
- Department of Anesthesiology and Reanimation; Gazi University Faculty of Medicine; Ankara Turkey
| | - D. AKCALI
- Department of Anesthesiology and Reanimation; Gazi University Faculty of Medicine; Ankara Turkey
| | - N. GUREL
- The Scientific and Technological Research Council of Turkey (ATAL); Ankara Turkey
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Ferraro LHC, Takeda A, Falcão LFDR, Rezende AH, Sadatsune EJ, Tardelli MA. Determinação do volume mínimo efetivo de bupivacaína 0,5% para bloqueio do plexo braquial por via axilar guiado por ultrassom. Braz J Anesthesiol 2014. [DOI: 10.1016/j.bjan.2013.03.014] [Citation(s) in RCA: 59] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
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Ferraro LHC, Takeda A, dos Reis Falcão LF, Rezende AH, Sadatsune EJ, Tardelli MA. Determination of the minimum effective volume of 0.5% bupivacaine for ultrasound-guided axillary brachial plexus block. Braz J Anesthesiol 2013; 64:49-53. [PMID: 24565388 DOI: 10.1016/j.bjane.2013.03.014] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2012] [Accepted: 03/20/2013] [Indexed: 11/25/2022] Open
Abstract
BACKGROUND AND OBJECTIVE The use of ultrasound for needle correct placement and local anesthetic spread monitoring helped to reduce the volume of local anesthetic required for peripheral nerve blocks. There are few studies of the minimum effective volume of local anesthetic for axillary brachial plexus block. The aim of this study was to determine the minimum effective volume (VE90) of 0.5% bupivacaine with epinephrine (1:200,000) for ultrasound guided ABPB. METHOD Massey and Dixon's up-and-down method was used to calculate the minimum effective volume. The initial dose was 5 mL per nerve (radial, median, ulnar, and musculocutaneous). In case of blockade failure, the volume was increased to 0.5 mL per nerve. A successful blockade resulted in decreased volume of 0.5 mL per nerve to the next patient. Successful blockade was defined as a motor block ≤2, according to the modified Bromage scale; lack of thermal sensitivity; and response to pinprick. The achievement of five cases of failure followed by success cases was defined as criterion to complete the study. RESULTS 19 patients were included in the study. The minimum effective volume (VE90) of 0.5% bupivacaine with 1:200,000 epinephrine was 1.56 mL (95% CI, 0.99-3.5) per nerve. CONCLUSION This study is in agreement with some other studies, which show that it is possible to achieve surgical anesthesia with low volumes of local anesthetic for ultrasound-guided peripheral nerve blocks.
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Affiliation(s)
- Leonardo Henrique Cunha Ferraro
- Disciplina de Anestesiologia, Dor e Terapia Intensiva, Escola Paulista de Medicina, Universidade Federal de São Paulo, São Paulo, SP, Brazil.
| | - Alexandre Takeda
- Disciplina de Anestesiologia, Dor e Terapia Intensiva, Escola Paulista de Medicina, Universidade Federal de São Paulo, São Paulo, SP, Brazil
| | - Luiz Fernando dos Reis Falcão
- Disciplina de Anestesiologia, Dor e Terapia Intensiva, Escola Paulista de Medicina, Universidade Federal de São Paulo, São Paulo, SP, Brazil
| | - André Hosoi Rezende
- Disciplina de Anestesiologia, Dor e Terapia Intensiva, Escola Paulista de Medicina, Universidade Federal de São Paulo, São Paulo, SP, Brazil
| | - Eduardo Jun Sadatsune
- Disciplina de Anestesiologia, Dor e Terapia Intensiva, Escola Paulista de Medicina, Universidade Federal de São Paulo, São Paulo, SP, Brazil
| | - Maria Angela Tardelli
- Disciplina de Anestesiologia, Dor e Terapia Intensiva, Escola Paulista de Medicina, Universidade Federal de São Paulo, São Paulo, SP, Brazil
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Lee SH, Sung HJ, Ok SH, Yu J, Choi MJ, Lim JS, Sohn JT. Lipid emulsions enhance the norepinephrine-mediated reversal of local anesthetic-induced vasodilation at toxic doses. Yonsei Med J 2013; 54:1524-32. [PMID: 24142661 PMCID: PMC3809849 DOI: 10.3349/ymj.2013.54.6.1524] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
PURPOSE Intravenous lipid emulsions have been used to treat the systemic toxicity of local anesthetics. The goal of this in vitro study was to examine the effects of lipid emulsions on the norepinephrine-mediated reversal of vasodilation induced by high doses of levobupivacaine, ropivacaine, and mepivacaine in isolated endothelium-denuded rat aorta, and to determine whether such effects are associated with the lipid solubility of local anesthetics. MATERIALS AND METHODS The effects of lipid emulsions (0.30, 0.49, 1.40, and 2.61%) on norepinephrine concentration-responses in high-dose local anesthetic (6×10(-4) M levobupivacaine, 2×10(-3) M ropivacaine, and 7×10(-3) M mepivacaine)-induced vasodilation of isolated aorta precontracted with 60 mM KCl were assessed. The effects of lipid emulsions on local anesthetic- and diltiazem-induced vasodilation in isolated aorta precontracted with phenylephrine were also assessed. RESULTS Lipid emulsions (0.30%) enhanced norepinephrine-induced contraction in levobupivacaine-induced vasodilation, whereas 1.40 and 2.61% lipid emulsions enhanced norepinephrine-induced contraction in both ropivacaine- and mepivacaine-induced vasodilation, respectively. Lipid emulsions (0.20, 0.49 and 1.40%) inhibited vasodilation induced by levobupivacaine and ropivacaine, whereas 1.40 and 2.61% lipid emulsions slightly attenuated mepivacaine (3×10(-3) M)-induced vasodilation. In addition, lipid emulsions attenuated diltiazem-induced vasodilation. Lipid emulsions enhanced norepinephrine-induced contraction in endothelium-denuded aorta without pretreatment with local anesthetics. CONCLUSION Taken together, these results suggest that lipid emulsions enhance the norepinephrine-mediated reversal of local anesthetic-induced vasodilation at toxic anesthetic doses and inhibit local anesthetic-induced vasodilation in a manner correlated with the lipid solubility of a particular local anesthetic.
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Affiliation(s)
- Soo Hee Lee
- Department of Anesthesiology and Pain Medicine, Gyeongsang National University Hospital, 79 Gangnam-ro, Jinju 660-702, Korea.
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The inhibitory effects of bupivacaine, levobupivacaine, and ropivacaine on K2P (two-pore domain potassium) channel TREK-1. J Anesth 2013; 28:81-6. [DOI: 10.1007/s00540-013-1661-1] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2012] [Accepted: 06/13/2013] [Indexed: 12/18/2022]
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Griffiths J, Le N, Grant S, Bjorksten A, Hebbard P, Royse C. Symptomatic local anaesthetic toxicity and plasma ropivacaine concentrations after transversus abdominis plane block for Caesarean section. Br J Anaesth 2013; 110:996-1000. [DOI: 10.1093/bja/aet015] [Citation(s) in RCA: 111] [Impact Index Per Article: 10.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
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Udelsmann A, Dreyer E, Melo MDS, Bonfim MR, Borsoi LFA, Oliveira TGD. Lipídeos nas intoxicações por anestésicos locais. ABCD-ARQUIVOS BRASILEIROS DE CIRURGIA DIGESTIVA 2012; 25:169-72. [DOI: 10.1590/s0102-67202012000300007] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/13/2011] [Accepted: 03/20/2012] [Indexed: 11/22/2022]
Abstract
INTRODUÇÃO: Com o advento dos anestésicos locais de longa duração, a anestesia locorregional ganhou grande impulso sendo cada vez mais utilizada. Novas técnicas de bloqueios foram descritas e a técnica é frequentemente associada à anestesia geral com o objetivo de proporcionar analgesia pós-operatória. A contra-partida é a necessidade da utilização de grandes doses com risco de acidentes por injeção intravascular inadvertida; trata-se de complicação grave sem tratamento específico até há alguns anos. Em 1998 foi proposta a utilização de emulsões lipídicas em animais e a partir de 2006 vários trabalhos demonstraram o interesse dessas soluções nos casos de intoxicações por anestésicos locais com diminuição da morbi-mortalidade. O objetivo desta revisão foi fazer um levantamento da metodologia, revisando os mecanismos, interesses, limites e as condutas preconizadas atualmente. MÉTODO: Foram revistas algumas referências históricas sobre anestésicos locais, artigos publicados nos últimos 30 anos em revistas indexadas no Medline e em dois livros-texto. Foram selecionados os artigos que tratavam da intoxicação por anestésicos locais, da terapia com emulsões lipídicas, os de revisão sobre o assunto e as condutas adotadas em diversos serviços e países, sendo realizada uma síntese. CONCLUSÕES: A eficiência e interesse da terapia com emulsões lipídicas nas intoxicações por anestésicos locais não é mais a demonstrar; várias sociedades da especialidade já publicaram suas diretrizes e aconselham que se disponha desses produtos nos locais onde se pratica a anestesia locorregional.
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Intrathecally administered ropivacaine is less neurotoxic than procaine, bupivacaine, and levobupivacaine in a rat spinal model. Can J Anaesth 2012; 59:456-65. [PMID: 22383086 DOI: 10.1007/s12630-012-9685-9] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2010] [Accepted: 02/15/2012] [Indexed: 10/28/2022] Open
Abstract
PURPOSE The aim of this study was to compare the neurotoxicity of intrathecal procaine, bupivacaine, levobupivacaine, and ropivacaine in an animal model. METHODS The study comprised two experiments. In the concentration experiment, rats (n = 78) were administered 0.12 μL·g(-1) body weight (BW) of 2% or 20% procaine, 0.5% or 5% bupivacaine, 0.5% or 5% levobupivacaine, or 0.5% or 5% ropivacaine. Based on the findings, the doses were increased by volume in the subsequent volume experiment using 0.12, 0.24, or 0.48 μL·g(-1) BW of 6% procaine, 6% levobupivacaine, or 6% ropivacaine (n = 79). Walking behaviour and sensory threshold were analyzed, and a histological examination of the spinal cord, posterior and anterior roots, and cauda equina was performed. RESULTS The concentration experiment showed abnormalities only in the 5% bupivacaine group, and these abnormal findings were in the posterior root (PR) and posterior column (PC). The volume experiment revealed that procaine 0.24 μL·g(-1) was neurotoxic, mainly affecting the PR. At 0.48 μL·g(-1), severe injury was observed in the PR and PC in all six procaine rats and four of six levobupivacaine rats, while milder injury was limited to the PR in one of six ropivacaine rats, which differed significantly from the former two groups (P = 0.006 and P = 0.014, respectively). Electron microscopy showed axonal degeneration. CONCLUSION All four local anesthetics seemed to cause identical neurotoxic lesions commencing in the PR and extending to the PC by axonal degeneration. Bupivacaine appeared to be the most neurotoxic of the four drugs, and the neurotoxicity at higher doses increased by volume with procaine > levobupivacaine > ropivacaine.
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Suckow MA, Wolter WR, Fecteau C, Labadie-Suckow SM, Johnson C. Bupivacaine-enhanced small intestinal submucosa biomaterial as a hernia repair device. J Biomater Appl 2011; 27:231-7. [PMID: 21680611 DOI: 10.1177/0885328211406298] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Management of post-surgical pain following herniorrhaphy remains a clinical challenge and novel methods to deliver analgesic compounds could be of great benefit. Because there is great interest in the use of natural biomaterials for hernia repair, we investigated the biocompatibility of a natural biomaterial, porcine small intestinal submucosa (SIS), which was impregnated with bupivacaine (SIS-B) via immersion in a solution of poly(lactic-co-glycolic acid) (PLGA). Groups of Sprague Dawley rats underwent surgical creation of a ventral abdominal wall defect with subsequent repair using either SIS or SIS-B. Analysis of serial blood samples showed peak bupivacaine levels (83 ng/mL) were achieved 16 h after implantation of SIS-B. One month after surgery, the rats were euthanized and implant sites harvested for mechanical strength testing and histological analysis. At the time of necropsy, adhesion extent and tenacity was greater in SIS-B rats, with 90% of SIS-B rats have adhesion to the implant site compared to only 75% of SIS rats. Microscopically, SIS implant sites were characterized by small amounts of residual SIS surrounded by mild-to-moderate chronic inflammation. In contrast, rats treated with SIS-B, residual SIS-B was surrounded by a ring of acute inflammatory cells and an outer ring of chronic inflammatory cells, possibly due to bupivacaine or residual PLGA. Mechanical strength testing of the harvested implant sites showed no significant (p ≤ 0.05) difference between SIS and SIS-B implants. In summary, bupivacaine is readily elaborated from SIS-B; and impregnation of SIS with bupivacaine does not substantially alter the biocompatibility of the biomaterial or its mechanical strength following implantation.
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Affiliation(s)
- Mark A Suckow
- Freimann Life Science Center, University of Notre Dame, Notre Dame, IN 46556, USA.
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Consilvio C, Kuschner WG, Lighthall GK. The pharmacology of airway management in critical care. J Intensive Care Med 2011; 27:298-305. [PMID: 21436166 DOI: 10.1177/0885066611402154] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
This review provides an update on the pharmacology of airway management, emphasizing medications and management strategies widely used in an intensive care unit setting. Induction agents, muscle relaxants, opioids, sedative-hypnotics, and adjunctive agents are reviewed in the context of emergent airway management. Throughout this review, we emphasize the utility of considering a broad set of pharmacologic agents and approaches for airway management of the critically ill patient.
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Affiliation(s)
- Christian Consilvio
- Department of Anesthesia, Stanford University School of Medicine and Anesthesia Service, U.S. Department of Veterans Affairs Palo Alto Health Care System, Palo Alto, CA 94304, USA
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Culp WC, Culp WC. Practical Application of Local Anesthetics. J Vasc Interv Radiol 2011; 22:111-8; quiz 119. [DOI: 10.1016/j.jvir.2010.10.005] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2009] [Revised: 09/24/2010] [Accepted: 10/11/2010] [Indexed: 11/29/2022] Open
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Comparison of bupivacaine, ropivacaine, and levobupivacaine in an equal dose and concentration for sympathetic block in dogs. Reg Anesth Pain Med 2011; 35:409-11. [PMID: 20814280 DOI: 10.1097/aap.0b013e3181e6acf1] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND AND OBJECTIVES The aim of this study was to compare the potency of bupivacaine, ropivacaine, and levobupivacaine in an equal dose and concentration for sympathetic block. METHODS We measured mean arterial pressure, heart rate (HR), and right and left brachial artery blood flow (BABF) before and after cervicothoracic sympathetic block in 24 dogs. The experimental protocol was designed as follows: (1) left cervicothoracic sympathetic block with 1.0 mL of 0.25% bupivacaine (n = 8), (2) left cervicothoracic sympathetic block with 1.0 mL of 0.25% ropivacaine (n = 8), and (3) left cervicothoracic sympathetic block with 1.0 mL of 0.25% levobupivacaine (n = 8). RESULTS Mean arterial pressure and heart rate did not change significantly throughout the study in either group. Left cervicothoracic sympathetic block with 0.25% bupivacaine increased left BABF significantly from 5 to 100 mins after the block (baseline, 100%; peak at 20 mins after the block, 218% +/- 48%; P < 0.01). Left cervicothoracic sympathetic block with 0.25% ropivacaine increased left BABF significantly from 5 to 100 mins after the block (baseline, 100%; peak at 10 mins after the block, 254 +/- 38%; P < 0.01). Left cervicothoracic sympathetic block with 0.25% levobupivacaine increased left BABF significantly from 5 to 80 mins after the block (baseline, 100%; peak at 20 mins after the block, 183% +/- 38%; P < 0.01). CONCLUSIONS Ropivacaine may induce a greater increase in vasodilation than bupivacaine and levobupivacaine at the same dose and concentration for sympathetic block in dogs.
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Abstract
IMPORTANCE OF THE FIELD Systemic toxicity, usually from overdose or intravascular dose, is feared because it mainly affects the heart and brain, and may be acutely life-threatening. AREAS COVERED IN THIS REVIEW Pharmacological studies of local anesthetic toxicity have largely been reviewed primarily relating to the evaluation of ropivacaine and levobupivacaine during the past decade. This review/opinion focuses more on the principles and concepts underlying the main models used, from chemical pharmacological and pharmacokinetic perspectives. WHAT THE READER WILL GAIN Research models required to produce pivotal toxicity data are discussed. The potencies for neural blockade and systemic toxicity are associated across virtually all models, with some deviations through molecular stereochemistry. These models show that all local anesthetics can produce direct cardiovascular system toxicity and CNS excitotoxicity that may further affect the cardiovascular system response. Whereas the longer-acting local anesthetics are more likely to cause cardiac death by malignant arrhythmias, the shorter-acting agents are more likely to cause cardiac contraction failure. In most models, equi-anesthetic doses of ropivacaine and levobupivacaine are less likely to produce serious toxicity than bupivacaine. TAKE HOME MESSAGE Of the various models, this reviewer favors a whole-body large animal preparation because of the comprehensive data collection possible. The conscious sheep preparation has contributed more than any other, and may be regarded as the de facto 'standard' experimental model for concurrent study of local anesthetic toxicity ± pharmacokinetics, using experimental designs that can reproduce the toxicity seen in clinical accidents.
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Affiliation(s)
- Laurence E Mather
- The University of Sydney, Royal North Shore Hospital, Department of Anaesthesia & Pain Management, St Leonards, Sydney 2065, Australia.
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Lipid Rescue in Resuscitation of Local Anesthetic–Induced Cardiac Arrest in Aesthetic Surgery. Plast Reconstr Surg 2010; 125:257e-259e. [DOI: 10.1097/prs.0b013e3181cb671b] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Epidural Analgesia With Low-concentration Levobupivacaine Combined With Fentanyl Provides Satisfactory Postoperative Analgesia for Colorectal Surgery Patients. ACTA ACUST UNITED AC 2010; 48:68-74. [DOI: 10.1016/s1875-4597(10)60016-1] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2009] [Revised: 01/29/2010] [Accepted: 02/03/2010] [Indexed: 11/20/2022]
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Dillane D, Finucane BT. Local anesthetic systemic toxicity. Can J Anaesth 2010; 57:368-80. [DOI: 10.1007/s12630-010-9275-7] [Citation(s) in RCA: 92] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2009] [Accepted: 01/14/2010] [Indexed: 11/30/2022] Open
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MacMahon PJ, Eustace SJ, Kavanagh EC. Injectable corticosteroid and local anesthetic preparations: a review for radiologists. Radiology 2009; 252:647-61. [PMID: 19717750 DOI: 10.1148/radiol.2523081929] [Citation(s) in RCA: 146] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Corticosteroids and local anesthetics are some of the most commonly administered medications in radiology departments. These medications have marked variability in their formulations, which may increase their adverse event profile for specific procedures. In particular, certain corticosteroid preparations are associated with adverse central nervous system (CNS) sequelae. This is most likely due to distal embolization by particulate formulations. Nonparticulate steroid formulations are not associated with such events. Local anesthetics have severe CNS and cardiac adverse effects if injected intravascularly and have recently been associated with intraarticular chondrolysis if used in large doses. This review discusses these medications with particular emphasis on their established and postulated adverse effects. The administering radiologist should be aware of these potential effects and how best to reduce their occurrence.
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Affiliation(s)
- Peter J MacMahon
- Department of Radiology, Mater Misericordiae University Hospital, Eccles Street, Dublin 7, Ireland.
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Comparison of Hemodynamic Changes in Acute Intoxication with Intravenous Bupivacaine and Ropivacaine in Swine. Braz J Anesthesiol 2009; 59:592-601. [DOI: 10.1016/s0034-7094(09)70084-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2008] [Accepted: 05/19/2009] [Indexed: 11/16/2022] Open
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Udelsmann A, Silva WA, Moraes ACD, Dreyer E. Hemodynamic effects of ropivacaine and levobupivacaine intravenous injection in swines. Acta Cir Bras 2009; 24:296-302. [DOI: 10.1590/s0102-86502009000400009] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2009] [Accepted: 04/18/2009] [Indexed: 11/22/2022] Open
Abstract
PURPOSE: To compare the hemodynamic effects following a toxic dose of either agent after intravenous injection in swines, as might accidentally occur during regional anesthesia in humans. METHODS: Large White pigs were anesthetized with thiopental, tracheal intubation was performed and mechanical ventilation was instituted. Hemodynamic variables were recorded with invasive pressure monitoring and pulmonary artery catheterization. After a 30-minute resting period, the animals were randomly divided into two groups in a double-blinded fashion and received a bolus intravenous injection of 4 mg.kg-1 of either agent. Hemodynamic results were evaluated at rest and 1, 5, 10, 15, 20 and 30 minutes after intoxication. RESULTS: Hemodynamic repressions of acute intoxication with levobupivacaine were more important and more prolonged than those of ropivacaína. CONCLUSION: In pigs, levobupivacaine was shown to be more toxic than ropivacaine when the same large doses are injected intravenously.
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Mendola C, Ferrante D, Oldani E, Cammarota G, Cecci G, Vaschetto R, Della Corte F. Thoracic epidural analgesia in post-thoracotomy patients: comparison of three different concentrations of levobupivacaine and sufentanil. Br J Anaesth 2009; 102:418-23. [PMID: 19189982 DOI: 10.1093/bja/aep004] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Relative effects of dosage, volume and concentration of local anaesthetics used for postoperative thoracic epidural analgesia are still under debate. In this randomized, prospective, double-blinded study, we evaluated the incidence of side-effects such as changes in arterial pressure, postoperative nausea, vomiting, and pruritus in patients admitted for thoracic surgery during continuous thoracic epidural infusion using levobupivacaine and sufentanil mixture in three different volumes. METHODS We studied 150 patients who underwent thoracotomy with a thoracic epidural catheter placed between T4 and T7. The patients were randomized into three groups which received 10 mg h(-1) of levobupivacaine at three different concentrations (0.5%, 0.25%, and 0.15%), in combination with sufentanil at 2.6 microg h(-1). Haemodynamic effects, pruritus, nausea, vomiting, sensory and motor block, pain score, additional analgesic requirement, sedation, and patient satisfaction were registered immediately after the surgical operation and on the first, second, and third postoperative days. RESULTS We did not detect any differences in the incidence of side-effects such as changes in arterial pressure, and also postoperative nausea, vomiting, and pruritus. The three groups were also similar with regard to patient characteristics, sensory and motor block, pain score, analgesic rescue dose, sedation, and patient satisfaction. CONCLUSIONS The same dose of a mixture of levobupivacaine and sufentanil administered in three different volumes and concentrations during continuous thoracic epidural infusion for thoracotomy provided an equal incidence of adverse haemodynamic effects, nausea, vomiting, or pruritus.
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Affiliation(s)
- C Mendola
- Department of Clinical and Experimental Medicine, SCDU Anaesthesia and Intensive Care 1, Maggiore della Carità Hospital, University of Eastern Piedmont A. Avogadro, Corso Mazzini 18, 28100 Novara, Italy
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David JS, Ferreti C, Amour J, Vivien B, Eve O, Petit P, Riou B, Gueugniaud PY. Effects of bupivacaine, levobupivacaine and ropivacaine on myocardial relaxation. Can J Anaesth 2007; 54:208-17. [PMID: 17331933 DOI: 10.1007/bf03022642] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022] Open
Abstract
PURPOSE Ropivacaine and levobupivacaine were developed to reduce the risk of occasional toxicity reported with bupivacaine. While the effects of long-acting local anesthetics (LAAs) on myocardial contractility (inotropy) are well described, their effects on relaxation (lusitropy) remain largely unknown. The present study aimed to compare the effects of LAAs on rat myocardium. METHODS Left ventricular papillary muscles of male Wistar rats were used to compare the inotropic and lusitropic responses of increasing concentrations of LAAs (10(-8) to 10(-3) M) under isometric and isotonic conditions. Data are mean % (SD) of baseline value. RESULTS Long-acting local anesthetics induced a significant impairment of relaxation in isotonic and isometric conditions. As compared to ropivacaine, bupivacaine and levobupivacaine induced greater negative lusitropic effects in isotony [at 10(-3) M, maximum unloaded shortening velocity ((max)Vr) = 27 +/- 11 vs 13 +/- 6 and 8 +/- 5%] and isometry (at 10(-3) M, time-to-half-relaxation: 106 +/- 10 vs 127 +/- 17 and 133 +/- 17%). When the comparison was made with equipotent concentrations, the negative lusitropic effects induced with levobupivacaine were significantly greater than those of bupivacaine and ropivacaine in isometric and isotonic conditions (at 10(-3) M, (max)Vr = 7 +/- 4 vs 13 +/- 6 and 17 +/- 4 %). As previously described, LAAs also induced concentration-dependent negative inotropic effects that were greater for levobupivacaine compared to equivalent or equipotent concentrations of bupivacaine and ropivacaine. CONCLUSIONS Long-acting local anesthetics induce marked negative inotropic and lusitropic effects. Among LAAs, levobupivacaine exerts the greater depressant effects. Impairment of calcium handling and sarcoplasmic reticulum could explain the differential responses to local anesthetics.
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Affiliation(s)
- Jean-Stéphane David
- Laboratoire d'Anesthésiologie, Université Claude Bernard et Département d'Anesthésie-Réanimation, Hôpital Edouard Herriot et Centre Hospitalier Lyon-Sud, Hospices Civils de Lyon, Lyon, France.
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Renehan EM, Enneking KF, Varshney M, Partch R, Dennis DM, Morey TE. Scavenging Nanoparticles. Reg Anesth Pain Med 2005. [DOI: 10.1097/00115550-200507000-00010] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Casati A, Putzu M. Bupivacaine, levobupivacaine and ropivacaine: are they clinically different? Best Pract Res Clin Anaesthesiol 2005; 19:247-68. [PMID: 15966496 DOI: 10.1016/j.bpa.2004.12.003] [Citation(s) in RCA: 128] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Two new, long-acting local anaesthetics have been developed after the evidence of bupivacaine-related severe toxicity: levobupivacaine and ropivacaine. Both these agents are pure left-isomers and, based on their three-dimensional structure, they have less toxic potential both on the central nervous system and on the heart. Several clinical studies have evaluated their toxicology and clinical profiles: theoretically and experimentally, some differences can be seen, but the reflections of these characteristics into clinical practice have not been evident. Evaluating randomised, controlled trials that have compared these three local anaesthetics, this chapter supports the evidence that both levobupivacaine and ropivacaine have a clinical profile similar to that of racemic bupivacaine, and that the minimal differences observed between the three agents are mainly related to the slightly different anaesthetic potency, with racemic bupivacaine>levobupivacaine>ropivacaine. However, the reduced toxic potential of the two pure left-isomers supports their use in those clinical situations in which the risk of systemic toxicity related to either overdosing or unwanted intravascular injection is high, such as during epidural or peripheral nerve blocks.
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Affiliation(s)
- Andrea Casati
- Department of Anaesthesiology, University of Parma, Italy.
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Tsen LC. What’s new and novel in obstetric anesthesia? Contributions from the 2003 scientific literature. Int J Obstet Anesth 2005; 14:126-46. [PMID: 15795148 DOI: 10.1016/j.ijoa.2004.12.007] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/06/2004] [Accepted: 12/24/2004] [Indexed: 10/25/2022]
Abstract
THE PREGNANT PATIENT: Age; maternal disease; prophylactic antibiotics; gastroesophageal reflux; obesity; starvation; genotyping; coagulopathy; infection; substance abuse; altered drug responses in pregnancy; physiological changes of pregnancy. THE FETUS: Fetal monitoring; intrauterine surgery. THE NEWBORN: Breastfeeding; maternal infection, fever, and neonatal sepsis evaluation. OBSTETRIC COMPLICATIONS: Embolic phenomena; hemorrhage; preeclampsia; preterm delivery. OBSTETRIC MANAGEMENT: External cephalic version and cervical cerclage; elective cesarean delivery; fetal malpresentation; vaginal birth after cesarean delivery; termination of pregnancy. OBSTETRIC ANESTHESIA: Analgesia for labor and delivery; anesthesia for cesarean delivery; anesthesia for short obstetric operations; complications of anesthesia. MISCELLANEOUS: Consent; ethics; history; labor support; websites/books/leaflets/journal announcements.
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Affiliation(s)
- L C Tsen
- Department of Anesthesiology, Perioperative and Pain Medicine, Brigham & Women's Hospital, Harvard Medical School, Boston MA 02115, USA.
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McDonald SB, Jacobsohn E, Kopacz DJ, Desphande S, Helman JD, Salinas F, Hall RA. Parasternal Block and Local Anesthetic Infiltration with Levobupivacaine After Cardiac Surgery with Desflurane: The Effect on Postoperative Pain, Pulmonary Function, and Tracheal Extubation Times. Anesth Analg 2005; 100:25-32. [PMID: 15616047 DOI: 10.1213/01.ane.0000139652.84897.bd] [Citation(s) in RCA: 90] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Abstract
Early tracheal extubation has become common after cardiac surgery. Anesthetic techniques designed to achieve this goal can make immediate postoperative analgesia challenging. We conducted this randomized, placebo-controlled, double-blind study to investigate the effect of a parasternal block on postoperative analgesia, respiratory function, and extubation times. We enrolled 20 patients having cardiac surgery via median sternotomy; 17 patients completed the study. A de-sflurane-based, small-dose opioid anesthetic was used. Before sternal wire placement, the surgeons performed the parasternal block and local anesthetic infiltration of sternotomy and tube sites with either 54 mL of saline placebo or 54 mL of 0.25% levobupivacaine with 1:400,000 epinephrine. Effects on pain and respiratory function were studied over 24 h. Patients in the levobupivacaine group used significantly less morphine in the first 4 h after surgery (20.8 +/- 6.2 mg versus 33.2 +/- 10.9 mg in the placebo group; P=0.013); they also had better oxygenation at the time of extubation. Four of nine in the placebo group needed rescue pain medication, versus none of eight in the levobupivacaine group (P=0.08). Peak serum levobupivacaine concentrations were below potentially toxic levels in all patients (0.64 +/- 0.43 microg/mL; range, 0.24-1.64 microg/mL). Parasternal block and local anesthetic infiltration of the sternotomy wound and mediastinal tube sites with levobupivacaine can be a useful analgesic adjunct for patients who are expected to undergo early tracheal extubation after cardiac surgery.
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Affiliation(s)
- Susan B McDonald
- *Department of Anesthesiology, Virginia Mason Medical Center, Seattle, Washington; †Departments of Cardiothoracic Anesthesiology and Cardiothoracic Surgery, Washington University School of Medicine, St. Louis, Missouri; and ‡Department of Cardiac Surgery, Virginia Mason Medical Center, Seattle, Washington
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Abstract
Interest in the use of regional anaesthesia, particularly peripheral nerve blocks (PNBs) and continuous PNBs, has increased in recent years. Accompanying this resurgence in interest has been the development of new local anaesthetics and additives designed to enhance block duration and quality. This manuscript provides a literature-based review on accepted uses of local anaesthetics and adjuncts for a variety of regional anaesthesia techniques. A brief review of local anaesthetic pharmacodynamics describes the action of these drugs in preventing nerve depolarisation, thus blocking nerve impulses. Toxic adverse effects of local anaesthetics, specifically CNS and cardiac manifestations of excessive local anaesthetic blood concentrations and the direct neurotoxic properties of local anaesthetics, are discussed generally and specifically for many commonly used local anaesthetics. Clinically useful ester and amide local anaesthetics are evaluated individually in terms of their physical properties and toxic potential. How these properties impact on the clinical uses of each local anaesthetic is explored. Particular emphasis is placed on the long-acting local anaesthetic toxic potential of racemic bupivacaine compared with levobupivacaine and ropivacaine, which are both levorotatory stereoisomers. Guidelines for using ropivacaine and mepivacaine, based on the authors' experience using advanced regional anaesthesia in a busy practice, is provided. Finally, epinephrine (adrenaline), clonidine and other local anaesthetic additives and their rationale for use is covered along with other future possibilities.
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Abstract
PURPOSE OF REVIEW Local anaesthetic agents are administered every day in clinical practice. These agents are relatively safe when administered in proper dosages at appropiate anatomical sites. However, when excessive dosages are administered or the incorrect site of administration is used there is a potential for toxic reactions. Ropivacaine, a pure S-enantiomer, and levobupivacaine, a single isomer of bupivacaine, have been introduced as new long-acting local anaesthetic agents with a potentially reduced toxicity compared with bupivacaine. The present review deals with recent knowledge about systemically induced local anaesthetic toxicity and localized toxicity. RECENT FINDINGS Studies have compared cardiotoxicity directly between ropivacaine and levobupivacaine in intracoronary injection in sheep and pigs, in small mammals, and arrhythmias and resuscitation in dogs. Direct left coronary arterial infusions of local anaesthetics in a conscious sheep model precludes central nervous system actions. Intracoronary studies showed similar toxicity for levobupivacaine and ropivacaine. When comparing and interpreting in-vivo animal studies of local anaesthetic toxicity, species variations, differences in the mode and site of local anaesthetic administration, and whether the animal is under the influence of anaesthesia must all be considered. Stereoselectivity may play a role in the lengthening of the atrioventricular conduction time for bupivacaine. In-vitro studies have revealed that intracellular calcium concentrations may contribute to myotoxicity. SUMMARY Current evidence suggests that ropivacaine is slightly less toxic than levobupivacaine; however, the difference in potency between the two agents is greater. The new local anaesthetic agents can be regarded as 'safer', but must not be regarded as safe.
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Affiliation(s)
- Bernadette T Veering
- Department of Anesthesiology, Leiden University Medical Center, Leiden, the Netherlands.
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