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Bungart B, Joudeh L, Fettiplace M. Local anesthetic dosing and toxicity of adult truncal catheters: a narrative review of published practice. Reg Anesth Pain Med 2024; 49:209-222. [PMID: 37451826 PMCID: PMC10787820 DOI: 10.1136/rapm-2023-104667] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2023] [Accepted: 06/30/2023] [Indexed: 07/18/2023]
Abstract
BACKGROUND/IMPORTANCE Anesthesiologists frequently use truncal catheters for postoperative pain control but with limited characterization of dosing and toxicity. OBJECTIVE We reviewed the published literature to characterize local anesthetic dosing and toxicity of paravertebral and transversus abdominis plane catheters in adults. EVIDENCE REVIEW We searched the literature for bupivacaine or ropivacaine infusions in the paravertebral or transversus abdominis space in humans dosed for 24 hours. We evaluated bolus dosing, infusion dosing and cumulative 24-hour dosing in adults. We also identified cases of local anesthetic systemic toxicity and toxic blood levels. FINDINGS Following screening, we extracted data from 121 and 108 papers for ropivacaine and bupivacaine respectively with a total of 6802 patients. For ropivacaine and bupivacaine, respectively, bolus dose was 1.4 mg/kg (95% CI 0.4 to 3.0, n=2978) and 1.0 mg/kg (95% CI 0.18 to 2.1, n=2724); infusion dose was 0.26 mg/kg/hour (95% CI 0.06 to 0.63, n=3579) and 0.2 mg/kg/hour (95% CI 0.06 to 0.5, n=3199); 24-hour dose was 7.75 mg/kg (95% CI 2.1 to 15.7, n=3579) and 6.0 mg/kg (95% CI 2.1 to 13.6, n=3223). Twenty-four hour doses exceeded the package insert recommended upper limit in 28% (range: 17%-40% based on maximum and minimum patient weights) of ropivacaine infusions and 51% (range: 45%-71%) of bupivacaine infusions. Toxicity occurred in 30 patients and was associated with high 24-hour dose, bilateral catheters, cardiac surgery, cytochrome P-450 inhibitors and hypoalbuminemia. CONCLUSION Practitioners frequently administer ropivacaine and bupivacaine above the package insert limits, at doses associated with toxicity. Patient safety would benefit from more specific recommendations to limit excessive dose and risk of toxicity.
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Affiliation(s)
- Brittani Bungart
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
- Department of Anaesthesia, Harvard Medical School, Boston, Massachusetts, USA
| | - Lana Joudeh
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
- Department of Anaesthesia, Harvard Medical School, Boston, Massachusetts, USA
| | - Michael Fettiplace
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
- Department of Anaesthesia, Harvard Medical School, Boston, Massachusetts, USA
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Eloy A, Tinoco J, Regufe R, Cortez J, Cordeiro L. Epidural Catheter Migration: A Case Report of a CT Scan Examination. Cureus 2022; 14:e30831. [DOI: 10.7759/cureus.30831] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/29/2022] [Indexed: 11/05/2022] Open
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Liu R, Clark L, Bautista A. Unilateral Bilevel Erector Spinae Plane Catheters for Flail Chest: A Case Report. A A Pract 2020; 14:e01211. [DOI: 10.1213/xaa.0000000000001211] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Damjanovska M, Stopar Pintaric T, Cvetko E, Vlassakov K. The ultrasound-guided retrolaminar block: volume-dependent injectate distribution. J Pain Res 2018; 11:293-299. [PMID: 29445296 PMCID: PMC5808708 DOI: 10.2147/jpr.s153660] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Purpose The ultrasound-guided retrolaminar block is one of the newer and simpler alternatives to the traditional, often technically challenging, paravertebral (PV) block. Its feasibility, safety, and efficacy have already been clinically demonstrated in patients with multiple rib fractures using higher volumes of local anesthetic, when compared with the traditional approach. The primary aim of this observational anatomical study was to assess the spread of local anesthetic from the retrolaminar injection point to the PV space and its volume dependence. Second, we assessed the incidence of epidural and contralateral PV spread in the both groups. Methods Ten fresh porcine cadavers were randomized into 2 groups (n=5 each) to receive ultrasound-guided retrolaminar injections at Th4-Th5 level with either 10 mL (low-volume group) or 30 mL (high-volume group) of 2% lidocaine and methylene blue mixture. After the procedure, the cadavers were dissected and frozen. Cross-section cuts (~1 cm thick) were performed to evaluate the injectate spread. Results In the high-volume group, injectate spread from the retrolaminar to the PV space was observed in all specimens (5 out of 5; 100%), while in the low-volume group, no apparent spread to the PV space was found (0 out of 5; 0%). No epidural or contralateral PV spread was observed in any of the specimens. Conclusion Following ultrasound-guided retrolaminar injections in fresh porcine cadavers, injectate spread from the retrolaminar tissue plane to the PV space is strongly volume dependent, suggesting that, clinically, high local anesthetic volumes maybe critical for achieving regional anesthesia and analgesia consistent with traditional PV blockade.
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Affiliation(s)
- Marija Damjanovska
- Clinical Department of Anesthesiology and Intensive Therapy, University Medical Centre Ljubljana, Ljubljana, Slovenia
| | - Tatjana Stopar Pintaric
- Clinical Department of Anesthesiology and Intensive Therapy, University Medical Centre Ljubljana, Ljubljana, Slovenia.,Institute of Anatomy, Faculty of Medicine, University of Ljubljana, Ljubljana, Slovenia
| | - Erika Cvetko
- Institute of Anatomy, Faculty of Medicine, University of Ljubljana, Ljubljana, Slovenia
| | - Kamen Vlassakov
- Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
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Sun JX, Bai KY, Liu YF, Du G, Fu ZH, Zhang H, Yang JH, Wang B, Wang XY, Jin B. Effect of local wound infiltration with ropivacaine on postoperative pain relief and stress response reduction after open hepatectomy. World J Gastroenterol 2017; 23:6733-6740. [PMID: 29085218 PMCID: PMC5643294 DOI: 10.3748/wjg.v23.i36.6733] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/16/2017] [Revised: 08/17/2017] [Accepted: 08/25/2017] [Indexed: 02/06/2023] Open
Abstract
AIM To prospectively evaluate the effect of local wound infiltration with ropivacaine on postoperative pain relief and stress response reduction after open hepatectomy.
METHODS A total of 56 patients undergoing open hepatectomy were randomly divided into two groups: a ropivacaine group (wound infiltration with ropivacaine solution) and a control group (infiltration with isotonic saline solution). A visual analog scale (VAS) at rest and on movement was used to measure postoperative pain for the first 48 h after surgery. Mean arterial pressure (MAP), heart rate (HR), time to bowel recovery, length of hospitalization after surgery, cumulative sufentanil consumption, and incidence of nausea and vomiting were compared between the two groups. Surgical stress hormones (epinephrine, norepinephrine, and cortisol) were detected using enzyme-linked immunosorbent assay, and the results were compared.
RESULTS VAS scores both at rest and on movement at 24 h and 48 h were similar between the two groups. Significantly lower VAS scores were detected at 0, 6, and 12 h in the ropivacaine group compared with the control group (P < 0.05 for all). MAP was significantly lower at 6, 12, and 24 h (P < 0.05 for all); HR was significantly lower at 0, 6, 12, and 24 h (P < 0.05 for all); time to bowel recovery and length of hospitalization after surgery (P < 0.05 for both) were significantly shortened; and cumulative sufentanil consumption was significantly lower at 6, 12, 24, and 36 h (P < 0.05 for all) in the ropivacaine group than in the control group, although the incidence of nausea and vomiting showed no significant difference between the two groups. The levels of epinephrine, norepinephrine, and cortisol were significantly lower in the ropivacaine group than in the control group at 24 and 48 h (P < 0.01 for all).
CONCLUSION Local wound infiltration with ropivacaine after open hepatectomy can improve postoperative pain relief, reduce surgical stress response, and accelerate postoperative recovery.
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Affiliation(s)
- Jing-Xian Sun
- Department of Anorectal Surgery, Affiliated Hospital of Shandong University of Traditional Chinese Medicine, Jinan 250011, Shandong Province, China
| | - Ke-Yun Bai
- Department of Anorectal Surgery, Affiliated Hospital of Shandong University of Traditional Chinese Medicine, Jinan 250011, Shandong Province, China
| | - Yan-Feng Liu
- Department of Hepatobiliary Surgery, Qilu Hospital of Shandong University, Jinan 250012, Shandong Province, China
| | - Gang Du
- Department of Hepatobiliary Surgery, Qilu Hospital of Shandong University, Jinan 250012, Shandong Province, China
| | - Zhi-Hao Fu
- Department of Hepatobiliary Surgery, Qilu Hospital of Shandong University, Jinan 250012, Shandong Province, China
| | - Hao Zhang
- Department of Hepatobiliary Surgery, Qilu Hospital of Shandong University, Jinan 250012, Shandong Province, China
| | - Jin-Huan Yang
- Department of Hepatobiliary Surgery, Qilu Hospital of Shandong University, Jinan 250012, Shandong Province, China
| | - Ben Wang
- Department of Hepatobiliary Surgery, Qilu Hospital of Shandong University, Jinan 250012, Shandong Province, China
| | - Xiu-Yu Wang
- Department of Anesthesiology, Qilu Hospital of Shandong University, Jinan 250012, Shandong Province, China
| | - Bin Jin
- Department of Hepatobiliary Surgery, Qilu Hospital of Shandong University, Jinan 250012, Shandong Province, China
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Yoshida T, Shimizu H, Furutani K, Baba H. Unintentional epidural placement of a thoracic paravertebral catheter inserted using an ultrasound-guided technique: a case report. J Anesth 2016; 30:727-30. [PMID: 27040105 DOI: 10.1007/s00540-016-2170-9] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2016] [Accepted: 03/27/2016] [Indexed: 11/26/2022]
Abstract
This is the first case report describing the epidural misplacement of an infusion catheter, which was intended to be located in the thoracic paravertebral space using an ultrasound-guided technique. The patient was a 57-year-old female undergoing a laparoscopy-assisted left partial nephrectomy. Before surgery, a Tuohy needle was inserted into the paravertebral space at the left ninth intercostal space using an in-plane transverse ultrasound-guided approach in the lateral-to-medial direction. A catheter was then threaded into the paravertebral space through the needle. Subsequently, the catheter position was secured, although ultrasound-guided confirmation of air injected through the catheter into the paravertebral space was not obtained. Twenty milliliters of 0.5 % levobupivacaine was administered through the catheter at both the initiation and conclusion of surgery. A neurologic examination following surgery revealed paraplegia, along with sensory deficits in the bilateral T3-S5 dermatome. The motor dysfunction in the lower extremities lasted 7 h, and the sensory block lasted 13.5 h. Postoperative radiologic confirmation of the catheter position concomitant with the spread of radiopaque dye revealed that the tip of the catheter was lying in the epidural space. Unless precise attention is paid to detection of the catheter tip location, a thoracic paravertebral catheter can enter into the epidural space even under ultrasound guidance.
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Affiliation(s)
- Takayuki Yoshida
- Department of Anesthesiology, Niigata University Medical and Dental Hospital, Niigata, Japan.
- Division of Anesthesiology, Niigata University Graduate School of Medical and Dental Sciences, 1-757 Asahimachi-Dori, Niigata, Niigata, 951-8510, Japan.
| | - Hiroki Shimizu
- Department of Anesthesiology, Niigata University Medical and Dental Hospital, Niigata, Japan
| | - Kenta Furutani
- Division of Anesthesiology, Niigata University Graduate School of Medical and Dental Sciences, 1-757 Asahimachi-Dori, Niigata, Niigata, 951-8510, Japan
| | - Hiroshi Baba
- Division of Anesthesiology, Niigata University Graduate School of Medical and Dental Sciences, 1-757 Asahimachi-Dori, Niigata, Niigata, 951-8510, Japan
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Zheng X, Feng X, Cai XJ. Effectiveness and safety of continuous wound infiltration for postoperative pain management after open gastrectomy. World J Gastroenterol 2016; 22:1902-1910. [PMID: 26855550 PMCID: PMC4724622 DOI: 10.3748/wjg.v22.i5.1902] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/13/2015] [Revised: 10/28/2015] [Accepted: 11/19/2015] [Indexed: 02/06/2023] Open
Abstract
AIM: To prospectively evaluate the effectiveness and safety of continuous wound infiltration (CWI) for pain management after open gastrectomy.
METHODS: Seventy-five adult patients with American Society of Anesthesiologists (ASA) Physical Status Classification System (ASA) grade 1-3 undergoing open gastrectomy were randomized to three groups. Group 1 patients received CWI with 0.3% ropivacaine (group CWI). Group 2 patients received 0.5 mg/mL morphine intravenously by a patient-controlled analgesia pump (PCIA) (group PCIA). Group 3 patients received epidural analgesia (EA) with 0.12% ropivacaine and 20 µg/mL morphine with an infusion at 6-8 mL/h for 48 h (group EA). A standard general anesthetic technique was used for all three groups. Rescue analgesia (2 mg bolus of morphine, intravenous) was given when the visual analogue scale (VAS) score was ≥ 4. The outcomes measured over 48 h after the operation were VAS scores both at rest and during mobilization, total morphine consumption, relative side effects, and basic vital signs. Further results including time to extubation, recovery of bowel function, surgical wound healing, mean length of hospitalization after surgery, and the patient’s satisfaction were also recorded.
RESULTS: All three groups had similar VAS scores during the first 48 h after surgery. Group CWI and group EA, compared with group PCIA, had lower morphine consumption (P < 0.001), less postoperative nausea and vomiting (1.20 ± 0.41 vs 1.96 ± 0.67, 1.32 ± 0.56 vs 1.96 ± 0.67, respectively, P < 0.001), earlier extubation (16.56 ± 5.24 min vs 19.76 ± 5.75 min, P < 0.05, 15.48 ± 4.59 min vs 19.76 ± 5.75 min, P < 0.01), and earlier recovery of bowel function (2.96 ± 1.17 d vs 3.60 ± 1.04 d, 2.80 ± 1.38 d vs 3.60 ± 1.04 d, respectively, P < 0.05). The mean length of hospitalization after surgery was reduced in groups CWI (8.20 ± 2.58 d vs 10.08 ± 3.15 d, P < 0.05) and EA (7.96 ± 2.30 d vs 10.08 ± 3.15 d, P < 0.01) compared with group PCIA. All three groups had similar patient satisfaction and wound healing, but group PCIA was prone to higher sedation scores when compared with groups CWI and EA, especially during the first 12 h after surgery. Group EA had a lower mean arterial pressure within the first postoperative 12 h compared with the other two groups.
CONCLUSION: CWI with ropivacaine yields a satisfactory analgesic effect within the first 48 h after open gastrectomy, with lower morphine consumption and accelerated recovery.
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Abstract
PURPOSE OF REVIEW Pain management in the trauma patient can be challenging, especially outside the operating room setting. Traditional analgesics such as opioids and NSAIDs are also problematic in trauma care. In this review, the use of regional anesthetic techniques outside the operating theatre is discussed. RECENT FINDINGS Regional anesthesia is an increasing but still underutilized clinical tool for the trauma patient outside the operating room. Regional anesthesia provides well tolerated and effective analgesia and anesthesia for many indications in the trauma setting including hip fracture, reduction of joint dislocation, wound debridement, laceration repair, and multiple rib fractures. Its use can increase safety and resource allocation in emergency departments. Performance of peripheral nerve blocks, especially with ultrasound, is amenable in various medical environments with minimal training. SUMMARY Pain is often poorly managed in the trauma patient. In addition to quality analgesia, regional anesthesia provides a variety of benefits in the trauma setting outside the traditional operating room setting. While further utilization requires increased training and structural changes, existing tools such as ultrasound are removing barriers to the widespread use of peripheral nerve block techniques across multiple disciplines.
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Toxic plasma concentration of ropivacaine after a paravertebral block in a patient suffering from severe hypoalbuminemia. J Clin Anesth 2014; 26:149-51. [DOI: 10.1016/j.jclinane.2013.11.008] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2013] [Revised: 11/04/2013] [Accepted: 11/08/2013] [Indexed: 11/18/2022]
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Paravertebral block: the first procedure with "no contraindications" … really? Gen Thorac Cardiovasc Surg 2014; 62:266-7. [PMID: 24519351 DOI: 10.1007/s11748-014-0370-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2013] [Accepted: 12/27/2013] [Indexed: 10/25/2022]
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