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Versyck B, Vermeylen K, Willemse J, van Geffen GJ, Leunen I, Soetens F, Devos S, Roosens L. Serum concentrations of local anesthetics after unilateral interpectoral-pectoserratus plane block in breast cancer surgery: a pharmacokinetic study. Reg Anesth Pain Med 2023; 48:399-402. [PMID: 36787951 DOI: 10.1136/rapm-2022-104166] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2022] [Accepted: 01/30/2023] [Indexed: 02/16/2023]
Abstract
INTRODUCTION The ultrasound-guided interpectoral-pectoserratus plane block is a fascial plane block for superficial surgery of the anterolateral chest wall. This technique involves injecting a relatively large volume of local anesthetics (typically 30 mL of 0.25%-0.50%, ie, 75-150 mg ropivacaine) underneath the major and minor pectoral muscles of the anterior thoracic wall. There is a potential risk of toxic serum concentrations of local anesthetics due to systemic absorption. METHODS 22 patients scheduled for elective unilateral breast cancer surgery were included in this study. All surgery was performed with general anesthesia and an ultrasound-guided interpectoral-pectoserratus plane block with 2.5 mg/kg ropivacaine. Ten venous blood samples were collected at 0 (two samples) 10, 20, 30, 45, 60, 90 and 120 min and at 4 hours after performing the block. Free and total ropivacaine levels were measured at each time point. Albumin and alpha-1-acid-glycoprotein were measured to monitor shifts between the free and bound fraction of ropivacaine. RESULTS Samples of 20 patients were analyzed. The mean dose of ropivacaine was 172.8 (22.5) mg. In 50% of the patients, the potentially toxic threshold of 0.15 µg/mL free ropivacaine concentration was exceeded. Mean peak serum concentration occurred at 20 min postinjection. CONCLUSIONS This pharmacokinetic study demonstrated that a 2.5 mg/kg ropivacaine interpectoral-pectoserratus plane block may result in exceeding the threshold for local anesthetic systemic toxicity.
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Affiliation(s)
- Barbara Versyck
- Department of Anesthesia and Intensive Care, AZ Turnhout Campus Sint-Jozef, Turnhout, Antwerpen, Belgium
- Department of Anesthesiology, Catharina Hospital Eindhoven, Eindhoven, The Netherlands
| | - Kris Vermeylen
- Department of Anesthesia and Intensive Care, AZ Turnhout Campus Sint-Jozef, Turnhout, Antwerpen, Belgium
| | - Johan Willemse
- Department of Clinical Biology, AZ Turnhout Campus Sint Elisabeth, Turnhout, Antwerpen, Belgium
| | | | - Ine Leunen
- Department of Anesthesia and Intensive Care, AZ Turnhout Campus Sint-Jozef, Turnhout, Antwerpen, Belgium
| | - Filiep Soetens
- Department of Anesthesia and Intensive Care, AZ Turnhout Campus Sint-Jozef, Turnhout, Antwerpen, Belgium
| | - Sylvie Devos
- Department of Clinical Biology, University Hospital Antwerp, Edegem, Belgium
| | - Laurence Roosens
- Department of Clinical Biology, University Hospital Antwerp, Edegem, Belgium
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Alghanem H, Patoli D, Greenberg SB, Szokol JW, Silk VL. Electrocautery-Induced Complete Heart Block. J Cardiothorac Vasc Anesth 2020; 35:2230-2232. [PMID: 33268040 DOI: 10.1053/j.jvca.2020.11.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/23/2020] [Revised: 11/03/2020] [Accepted: 11/06/2020] [Indexed: 11/11/2022]
Affiliation(s)
- Husam Alghanem
- Department of Anesthesia and Critical Care, University of Chicago Medical Center, Chicago, IL.
| | - Daneel Patoli
- Department of Anesthesia and Critical Care, University of Chicago Medical Center, Chicago, IL
| | - Steven B Greenberg
- Department of Anesthesiology, Critical Care, and Pain Medicine, NorthShore University Health System, Evanston, IL
| | - Joseph W Szokol
- Department of Anesthesiology, Critical Care, and Pain Medicine, NorthShore University Health System, Evanston, IL
| | - Vicki L Silk
- Department of Anesthesiology, Critical Care, and Pain Medicine, NorthShore University Health System, Evanston, IL
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Lamy E, Fall F, Boigne L, Gromov K, Fabresse N, Grassin-Delyle S. Validation according to European and American regulatory agencies guidelines of an LC-MS/MS method for the quantification of free and total ropivacaine in human plasma. ACTA ACUST UNITED AC 2020; 58:701-708. [DOI: 10.1515/cclm-2018-1298] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2018] [Accepted: 03/05/2019] [Indexed: 11/15/2022]
Abstract
AbstractBackgroundRopivacaine is a widely used local anaesthetic drug, highly bound to plasma proteins with a free plasma fraction of about 5%. Therefore, the monitoring of free drug concentration is most relevant to perform pharmacokinetic studies and to understand the drug pharmacokinetic/pharmacodynamic (PK/PD) relationship.MethodsA high-sensitivity liquid chromatography-tandem mass spectrometry (LC-MS/MS) method using reverse-phase LC and electrospray ionisation mass spectrometry with multiple reaction monitoring (MRM) is described for the quantitation of both free and total ropivacaine in human plasma. Ropivacaine-d7 was used as an internal standard (IS).ResultsThe method was validated in the range 0.5–3000 ng/mL, with five levels of QC samples and according to the European Medicine Agency and Food and Drug Administration guidelines. The performance of the method was excellent with a precision in the range 6.2%–14.7%, an accuracy between 93.6% and 113.7% and a coefficient of variation (CV) of the IS-normalised matrix factor below 15%. This suitability of the method for the quantification of free and total ropivacaine in clinical samples was demonstrated with the analysis of samples from patients undergoing knee arthroplasty and receiving a local ropivacaine infiltration.ConclusionsA method was developed and validated for the quantification of free and total ropivacaine in human plasma and was shown suitable for the analysis of clinical samples.
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Affiliation(s)
- Elodie Lamy
- Plateforme de spectrométrie de masse MasSpecLab, INSERM UMR 1173, UFR Simone Veil – Santé, Université Versailles Saint Quentin, Université Paris Saclay, Montigny le Bretonneux, France
| | - Fanta Fall
- Plateforme de spectrométrie de masse MasSpecLab, INSERM UMR 1173, UFR Simone Veil – Santé, Université Versailles Saint Quentin, Université Paris Saclay, Montigny le Bretonneux, France
| | - Lisa Boigne
- Plateforme de spectrométrie de masse MasSpecLab, INSERM UMR 1173, UFR Simone Veil – Santé, Université Versailles Saint Quentin, Université Paris Saclay, Montigny le Bretonneux, France
| | - Kirill Gromov
- Department of Orthopaedic Surgery, Copenhagen University Hospital, Hvidovre, Denmark
| | - Nicolas Fabresse
- Plateforme de spectrométrie de masse MasSpecLab, INSERM UMR 1173, UFR Simone Veil – Santé, Université Versailles Saint Quentin, Université Paris Saclay, Montigny le Bretonneux, France
- Laboratoire de Toxicologie, Hôpital Raymond Poincaré, AP-HP, Garches, France
| | - Stanislas Grassin-Delyle
- Plateforme de spectrométrie de masse MasSpecLab, INSERM UMR 1173, UFR Simone Veil – Santé, Université Versailles Saint Quentin, Université Paris Saclay, Montigny le Bretonneux, France
- Département des maladies respiratoires, Hôpital Foch, Suresnes, France, Phone: +33.1.70.42.94.22
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Kuchálik J, Magnuson A, Lundin A, Gupta A. Local infiltration analgesia: a 2-year follow-up of patients undergoing total hip arthroplasty. J Anesth 2017; 31:837-845. [PMID: 28856511 PMCID: PMC5680378 DOI: 10.1007/s00540-017-2403-6] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2017] [Accepted: 08/11/2017] [Indexed: 11/29/2022]
Abstract
Purpose Local infiltration analgesia (LIA) is commonly used for postoperative pain management following total hip arthroplasty (THA). However, the long-term effects of the component drugs are unclear. The aim of our study was to investigate functional outcome, quality of life, chronic post-surgical pain, and adverse events in patients within 2 years of undergoing THA. Methods The study was a secondary analysis of data from a previous larger study. Eighty patients were randomized to receive either intrathecal morphine (Group ITM) or local infiltration analgesia (Group LIA) for pain management in a double-blind study. The parameters measured were patient-assessed functional outcome [using the Hip dysfunction and Osteo-arthritis Outcome Score (HOOS) questionnaire], health-related quality of life [using the European Quality of Life–5 dimensions (EQ-5D) questionnaire and the 36-Item Short Form Health Survey (SF-36) score], and pain using the numeric rating score (NRS), with persistent post-surgical pain having a NRS of > 3 or a HOOS pain sub-score of > 30. All complications and adverse events were investigated during the first 2 years after primary surgery. Results Pain intensity and rescue analgesic consumption were similar between the groups after hospital discharge. No differences were found in HOOS or SF-36 score between the groups up to 6 months after surgery. A significant group × time interaction was seen in the EQ 5D form in favor of the LIA group. No between-group difference in persistent post-surgical pain was found at 3 or 6 months, or in adverse events up to 2 years after surgery. Conclusion Analysis of functional outcome, quality of life, and post-discharge surgical pain did not reveal significant differences between patients receiving LIA and those receiving ITM. LIA was found to be a safe technique for THA during the long-term follow-up. However, it should be noted that these conclusions are based on a limited number of patients.
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Affiliation(s)
- Ján Kuchálik
- Department of Anaesthesiology and Intensive Care, Institution for Medicine and Health, Örebro University Hospital, Örebro, Sweden
| | - Anders Magnuson
- Clinical Epidemiology and Biostatistics Unit, Örebro University Hospital, Örebro, Sweden
| | - Anders Lundin
- Department of Orthopaedic Surgery, Institution for Medicine and Health, Örebro University Hospital, Örebro, Sweden
| | - Anil Gupta
- Department of Anaesthesiology and Intensive Care, Institution for Medicine and Health, Örebro University Hospital, Örebro, Sweden. .,Department of Anaesthesiology and Intensive Care, Karolinska University Hospital Solna-Karolinska Institutet, Stockholm, 17176, Sweden.
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Borges LA, Leal PDC, Moura ECR, Sakata RK. Randomized clinical study on the analgesic effect of local infiltration versus spinal block for hemorrhoidectomy. SAO PAULO MED J 2017; 135:247-252. [PMID: 28562733 PMCID: PMC10019844 DOI: 10.1590/1516-3180.2017.0001260117] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/16/2017] [Accepted: 01/26/2017] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND AND OBJECTIVES: Postoperative analgesia and early recovery are important for hospital discharge. The primary objective of this study was to compare the analgesic effectiveness of perianal infiltration and subarachnoid anesthesia for hemorrhoidectomy. The secondary objective was to compare time to discharge, adverse effects and complications. DESIGN AND SETTING: Randomized, prospective and comparative study at Dr. Mário Gatti Hospital. METHODS: Forty patients aged 18-60, in American Society of Anesthesiologists physical status category 1 or 2, were included. The local group (LG) received local infiltration (0.75% ropivacaine) under general anesthesia; the spinal group (SG) received subarachnoid block (2 ml of 0.5% bupivacaine). Analgesic supplementation consisted of fentanyl for LG and lidocaine for SG. Postoperative pain intensity, sphincter relaxation, lower-limb strength, time to discharge, analgesic dose over one week and adverse effects were assessed. RESULTS: Eleven LG patients (52.4%) required supplementation, but no SG patients. Pain intensity was higher for LG up to 120 min, but there were no differences at 150 or 180 min. There were no differences in the need for paracetamol or tramadol. Times to first analgesic supplementation and hospital discharge were longer for SG. The adverse effects were nausea, dizziness and urinary retention. CONCLUSIONS: Pain intensity was higher in LG than in SG over the first 2 h, but without differences after 150 and 180 min. Time to first supplementation was shorter in LG. There were no differences in doses of paracetamol and tramadol, or in adverse effects. REGISTRATION: ClinicalTrials.gov NCT02839538.
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Affiliation(s)
- Luis Antônio Borges
- MD. Anesthesiologist, Hospital Municipal Dr. Mário Gatti, Campinas (SP), Brazil.
| | - Plínio da Cunha Leal
- MD, PhD. Professor, Department of Medical Practice, Universidade Federal do Maranhão (UFMA), São Luiz (MA), Brazil.
| | - Ed Carlos Rey Moura
- MD, MSc. Professor, Department of Medical Practice, Universidade Federal do Maranhão (UFMA), São Luiz (MA), Brazil.
| | - Rioko Kimiko Sakata
- MD, PhD. Professor, Department of Anesthesia, Universidade Federal de São Paulo (Unifesp), São Paulo (SP), Brazil.
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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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Chiew A, Raos MP, Isbister GK. Sub-mammary injection of ropivacaine resulting in severe toxicity with seizures. Emerg Med Australas 2016; 28:246-7. [PMID: 26799698 DOI: 10.1111/1742-6723.12539] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2015] [Revised: 10/11/2015] [Accepted: 11/29/2015] [Indexed: 10/22/2022]
Affiliation(s)
- Angela Chiew
- Department of Clinical Toxicology, Prince of Wales Hospital, Sydne, New South Wales, Australia.,New South Wales Poison's Information Centre, The Children's Hospital at Westmead, Sydney, New South Wales, Australia
| | | | - Geoffrey K Isbister
- New South Wales Poison's Information Centre, The Children's Hospital at Westmead, Sydney, New South Wales, Australia.,Clinical Toxicology Research Group, University of Newcastle, Callaghan, New South Wales, Australia
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Abstract
PURPOSE OF REVIEW Pain following total knee arthroplasty is a challenging task for healthcare providers. Concurrently, fast recovery and early ambulation are required to regain function and to prevent postoperative complications. Ideal postoperative analgesia provides sufficient pain relief with minimal opioid consumption and preservation of motor strength. Regional analgesia techniques are broadly used to answer these expectations. Femoral nerve blocks are performed frequently but have suggested disadvantages, such as motor weakness. The use of lumbar epidurals is questioned because of the risk of epidural hematoma. Relatively new techniques, such as local infiltration analgesia or adductor canal blocks, are increasingly discussed. The present review discusses new findings and weight between known benefits and risks of all of these techniques for total knee arthroplasty. RECENT FINDINGS Femoral nerve blocks are the gold standard for total knee arthroplasty. The standard use of additional sciatic nerve blocks remains controversial. Lumbar epidurals possess an unfavourable risk/benefit ratio because of increased rate of epidural hematoma in orthopaedic patients and should be reserved for lower limb amputation; peripheral regional techniques provide comparable pain control, greater satisfaction and less risk than epidural analgesia. Although motor weakness might be greater with femoral nerve blocks compared with no regional analgesia, new data point towards a similar risk of falls after total knee arthroplasty with or without peripheral nerve blocks. Local infiltration analgesia and adductor canal blockade are promising recent techniques to gain adequate pain control with a minimum of undesired side-effects. SUMMARY Femoral nerve blocks are still the gold standard for an effective analgesia approach in knee arthroplasty and should be supplemented (if needed) by oral opioids. An additional sciatic nerve blockade is still controversial and should be an individual decision. Large-scale studies are needed to reinforce the promising results of newer regional techniques, such as local infiltration analgesia and adductor canal block.
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Brydone AS, Souvatzoglou R, Abbas M, Watson DG, McDonald DA, Gill AM. Ropivacaine plasma levels following high-dose local infiltration analgesia for total knee arthroplasty. Anaesthesia 2015; 70:784-90. [DOI: 10.1111/anae.13017] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/30/2014] [Indexed: 11/25/2022]
Affiliation(s)
- A. S. Brydone
- Department of Orthopaedic Surgery; Golden Jubilee National Hospital; Glasgow UK
| | - R. Souvatzoglou
- Department of Anaesthesia; Golden Jubilee National Hospital; Glasgow UK
| | - M. Abbas
- Institute of Pharmacy and Biomedical Sciences; Institute of Pharmacy and Biomedical Sciences; University of Strathclyde; Strathclyde UK
| | - D. G. Watson
- Institute of Pharmacy and Biomedical Sciences; Institute of Pharmacy and Biomedical Sciences; University of Strathclyde; Strathclyde UK
| | - D. A. McDonald
- Department of Anaesthesia; Golden Jubilee National Hospital; Glasgow UK
| | - A. M. Gill
- Department of Rehabilitation; Golden Jubilee National Hospital; Glasgow UK
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Wilkinson KM, Krige A, Brearley SG, Lane S, Scott M, Gordon AC, Carlson GL. Thoracic Epidural analgesia versus Rectus Sheath Catheters for open midline incisions in major abdominal surgery within an enhanced recovery programme (TERSC): study protocol for a randomised controlled trial. Trials 2014; 15:400. [PMID: 25336055 PMCID: PMC4223757 DOI: 10.1186/1745-6215-15-400] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2014] [Accepted: 10/03/2014] [Indexed: 01/10/2023] Open
Abstract
BACKGROUND Thoracic epidural analgesia (TEA) is recommended for post-operative pain relief in patients undergoing major abdominal surgery via a midline incision. However, the effectiveness of TEA is variable with high failure rates reported post-operatively. Common side effects such as low blood pressure and motor block can reduce mobility and hinder recovery, and a number of rare but serious complications can also occur following their use.Rectus sheath catheters (RSC) may provide a novel alternative approach to somatic analgesia without the associated adverse effects of TEA. The aim of this study is to compare the efficacy of both techniques in terms of pain relief, patient experience, post-operative functional recovery, safety and cost-effectiveness. METHODS/DESIGN This is a single-centre randomised controlled non-blinded trial, which also includes a nested qualitative study. Over a two-year period, 132 patients undergoing major abdominal surgery via a midline incision will be randomised to receive either TEA or RSC for post-operative analgesia. The primary outcome measures pain scores on moving from a supine to a sitting position at 24 hours post wound closure, and the patient experience between groups evaluated through in-depth interviews. Secondary outcomes include pain scores at rest and on movement at other time points, opiate consumption, functional recovery, morbidity and cost-effectiveness. DISCUSSION This will be the first randomised controlled trial comparing thoracic epidurals to ultrasound-guided rectus sheath catheters in adults undergoing elective midline laparotomy. The standardised care provided by an Enhanced Recovery Programme makes this a comparison between two complex pain packages and not simply two analgesic techniques, in order to ascertain if RSC is a viable alternative to TEA. TRIAL REGISTRATION Current Controlled Trials ISRCTN81223298 (16 January 2014).
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Affiliation(s)
- Kate M Wilkinson
- />Department of Anaesthesia and Critical Care, Royal Blackburn Hospital, Blackburn, BB2 3HH UK
| | - Anton Krige
- />Department of Anaesthesia and Critical Care, Royal Blackburn Hospital, Blackburn, BB2 3HH UK
| | - Sarah G Brearley
- />Faculty of Health and Medicine, Division of Health Research, Lancaster University, Lancaster, LA1 4YT UK
| | - Steven Lane
- />Department of Biostatistics, University of Liverpool, Duncan Building, Liverpool, L69 3GA UK
| | - Michael Scott
- />Department of Anaesthesia and Intensive Care, Royal Surrey County Hospital, University of Surrey, Guildford, GU2 7XX UK
| | - Anthony C Gordon
- />Section of Anaesthetics, Pain Medicine and Intensive Care, Department of Surgery and Cancer, Imperial College, London, SW7 2AZ UK
| | - Gordon L Carlson
- />Department of Surgery, Salford Royal NHS Foundation Trust, Stott Lane, Salford, M6 8HD UK
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