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Matsota P, Karalis V, Saranteas T, Kiospe F, Markantonis SL. Ropivacaine pharmacokinetics in the arterial and venous pools after ultrasound-guided continuous thoracic paravertebral nerve block. J Anaesthesiol Clin Pharmacol 2024; 40:283-292. [PMID: 38919447 PMCID: PMC11196052 DOI: 10.4103/joacp.joacp_353_22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2022] [Revised: 10/18/2022] [Accepted: 10/19/2022] [Indexed: 06/27/2024] Open
Abstract
Background and Aims Although thoracic paravertebral blockade (TPVB) is employed in thoracic surgery to ensure satisfactory postoperative analgesia, large doses of anesthetics are required and manifestations of local anesthetic systemic toxicity (LAST) may appear. Currently, there are limited data on the pharmacokinetics of ropivacaine after continuous TPVB. The aim of this prospective study was to investigate ropivacaine kinetics, in the arterial and venous pools, after continuous TPVB and assess the risk of LAST. Material and Methods Immediately after induction of general anesthesia, an ultrasound-guided continuous TPVB at T5 or T6 or T7 thoracic level was performed in 18 adult patients subjected to open thoracotomy. A 25-ml single bolus injection of ropivacaine 0.5% was administered through thoracic paravertebral catheter, followed by a 14 ml/h continuous infusion of ropivacaine 0.2% starting at the end of surgery. Quantification of total ropivacaine concentrations was performed using a validated high-performance liquid chromatography method. Population pharmacokinetic models were developed separately for arterial and venous ropivacaine data. Results The best model was one-compartment disposition with an additional pre-absorption compartment corresponding to thoracic paravertebral space. Gender had a significant effect on clearance, with females displaying lower elimination than males. Some patients had ropivacaine concentrations above the toxic threshold, but none displayed evidence of LAST. Continuous thoracic paravertebral nerve blocks provided adequate postoperative analgesia. Conclusion Ropivacaine doses at the upper end of clinical use (800 mg/d) did not inflict the manifestations of LAST and provided adequate postoperative pain control. Pharmacokinetic models were developed, and the effect of gender was identified.
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Affiliation(s)
- Paraskevi Matsota
- 2 Department of Anesthesiology, School of Medicine, National and Kapodistrian University of Athens, “Attikon” University Hospital, Athens, Greece
| | - Vangelis Karalis
- Department of Pharmacy, School of Health Sciences, National and Kapodistrian University of Athens, Athens, Greece
| | - Theodosios Saranteas
- 2 Department of Anesthesiology, School of Medicine, National and Kapodistrian University of Athens, “Attikon” University Hospital, Athens, Greece
| | - Fay Kiospe
- Department of Pharmacy, School of Health Sciences, National and Kapodistrian University of Athens, Athens, Greece
| | - Sophia Liberty Markantonis
- Department of Pharmacy, School of Health Sciences, National and Kapodistrian University of Athens, Athens, Greece
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Bungart B, Joudeh L, Fettiplace M. Local anesthetic dosing and toxicity of adult truncal catheters: a narrative review of published practice. Reg Anesth Pain Med 2024; 49:209-222. [PMID: 37451826 PMCID: PMC10787820 DOI: 10.1136/rapm-2023-104667] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2023] [Accepted: 06/30/2023] [Indexed: 07/18/2023]
Abstract
BACKGROUND/IMPORTANCE Anesthesiologists frequently use truncal catheters for postoperative pain control but with limited characterization of dosing and toxicity. OBJECTIVE We reviewed the published literature to characterize local anesthetic dosing and toxicity of paravertebral and transversus abdominis plane catheters in adults. EVIDENCE REVIEW We searched the literature for bupivacaine or ropivacaine infusions in the paravertebral or transversus abdominis space in humans dosed for 24 hours. We evaluated bolus dosing, infusion dosing and cumulative 24-hour dosing in adults. We also identified cases of local anesthetic systemic toxicity and toxic blood levels. FINDINGS Following screening, we extracted data from 121 and 108 papers for ropivacaine and bupivacaine respectively with a total of 6802 patients. For ropivacaine and bupivacaine, respectively, bolus dose was 1.4 mg/kg (95% CI 0.4 to 3.0, n=2978) and 1.0 mg/kg (95% CI 0.18 to 2.1, n=2724); infusion dose was 0.26 mg/kg/hour (95% CI 0.06 to 0.63, n=3579) and 0.2 mg/kg/hour (95% CI 0.06 to 0.5, n=3199); 24-hour dose was 7.75 mg/kg (95% CI 2.1 to 15.7, n=3579) and 6.0 mg/kg (95% CI 2.1 to 13.6, n=3223). Twenty-four hour doses exceeded the package insert recommended upper limit in 28% (range: 17%-40% based on maximum and minimum patient weights) of ropivacaine infusions and 51% (range: 45%-71%) of bupivacaine infusions. Toxicity occurred in 30 patients and was associated with high 24-hour dose, bilateral catheters, cardiac surgery, cytochrome P-450 inhibitors and hypoalbuminemia. CONCLUSION Practitioners frequently administer ropivacaine and bupivacaine above the package insert limits, at doses associated with toxicity. Patient safety would benefit from more specific recommendations to limit excessive dose and risk of toxicity.
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Affiliation(s)
- Brittani Bungart
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
- Department of Anaesthesia, Harvard Medical School, Boston, Massachusetts, USA
| | - Lana Joudeh
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
- Department of Anaesthesia, Harvard Medical School, Boston, Massachusetts, USA
| | - Michael Fettiplace
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
- Department of Anaesthesia, Harvard Medical School, Boston, Massachusetts, USA
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Yeung J, Middleton L, Tryposkiadis K, Kerr A, Daniels J, Naidu B, Melody T, Goebel A, Wilson M, Kumar S, Szentgyorgyi L, Flanagan S, Shah R, Worrall A, Gao F. Randomised controlled trial to investigate the effectiveness of thoracic epidural and paravertebral blockade in reducing chronic post-thoracotomy pain (TOPIC): a pilot study to assess feasibility of a large multicentre trial. BMJ Open 2019; 9:e023679. [PMID: 31292172 PMCID: PMC6624049 DOI: 10.1136/bmjopen-2018-023679] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
OBJECTIVES Thoracotomy is considered one of the most painful surgical procedures. The incidence of chronic post-thoracotomy pain (CPTP) is up to 50%. Paravertebral blockade (PVB) may be superior to thoracic epidural blockade (TEB) in preventing CPTP. The specific objective of this pilot study was to assess the feasibility of conducting a larger trial to determine whether PVB at thoracotomy is more effective in reducing CPTP compared with TEB. DESIGN A randomised, parallel, external pilot study was conducted to assess whether a large randomised trial of TEB and PVB with CPTP as the primary outcome is feasible. SETTING Two adult thoracic centres in the UK. PARTICIPANTS All adult patients admitted for elective open thoracotomy. Participants were excluded if they were American Society of Anesthesiologists physical status IV or V; or if there is contraindication to local anaesthetics; infection near the proposed puncture site; coagulation/thoracic spine disorders; required chest wall resection or emergency thoracic surgery or had a previous thoracotomy. RESULTS All patients presenting for thoracotomy were screened over a 12-month period with 194 found to be eligible. Of these, 69 (36%) were randomised (95% CI 29% to 42%). Discounting five participants who died, 54 of 64 participants (84%) returned questionnaire booklets at 6 months. The number of participants indicating at least a moderate level of chest pain at 6 months was lower with PVB but with high levels of uncertainty (RR: 0.7; 95% CI 0.3 to 1.7 for worst pain; RR: 0.3; 95% CI 0.0 to 2.8 for average pain). There were no safety concerns. CONCLUSIONS A large, multicentre randomised controlled trial of PVB versus TEB is feasible as it is possible to randomise and follow up participants with high fidelity. Pain scores were lower on average with PVB compared with TEB but a much larger trial is required to confirm this reliably. TRIAL REGISTRATION NUMBER ISRCTN45041624.
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Affiliation(s)
- Joyce Yeung
- Warwick Medical School, University of Warwick, Coventry, UK
- Academic Department of Anaesthesia, Critical Care, Pain and Resuscitation, Birmingham Heartlands Hospital, University Hospital Birmingham NHS Foundation Trust, Birmingham, UK
| | - Lee Middleton
- School of Health and Population Sciences, University of Birmingham, Birmingham, UK
| | | | - Amy Kerr
- Department of Thoracic Surgery, Birmingham Heartlands Hospital, University Hospital Birmingham NHS Foundation Trust, Birmingham, UK
| | - Jane Daniels
- Nottingham Clinical Trials Unit, University of Nottingham, Nottingham, UK
| | - Babu Naidu
- Department of Thoracic Surgery, Birmingham Heartlands Hospital, University Hospital Birmingham NHS Foundation Trust, Birmingham, UK
- Institute of Inflammation and Ageing, College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK
| | - Teresa Melody
- Academic Department of Anaesthesia, Critical Care, Pain and Resuscitation, Birmingham Heartlands Hospital, University Hospital Birmingham NHS Foundation Trust, Birmingham, UK
| | - Andreas Goebel
- University of Liverpool, Institute of Translational Medicine, Liverpool, UK
| | - Matthew Wilson
- Health Services Research, University of Sheffield, Sheffield, UK
| | - Sajith Kumar
- Academic Department of Anaesthesia, Critical Care, Pain and Resuscitation, Birmingham Heartlands Hospital, University Hospital Birmingham NHS Foundation Trust, Birmingham, UK
| | - Lajos Szentgyorgyi
- Department of Anaesthesia, University Hospital of South Manchester NHS Foundation Trust, Manchester, UK
| | - Sarah Flanagan
- Institute of Applied Health Research, University of Birmingham, Birmingham, UK
| | - Rajesh Shah
- Department of Thoracic Surgery, University Hospital of South Manchester NHS Foundation Trust, Manchester, UK
| | - Antony Worrall
- Academic Department of Anaesthesia, Critical Care, Pain and Resuscitation, Birmingham Heartlands Hospital, University Hospital Birmingham NHS Foundation Trust, Birmingham, UK
| | - Fang Gao
- Academic Department of Anaesthesia, Critical Care, Pain and Resuscitation, Birmingham Heartlands Hospital, University Hospital Birmingham NHS Foundation Trust, Birmingham, UK
- Institute of Inflammation and Ageing, College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK
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Wojtyś ME, Wąsikowski J, Wójcik N, Wójcik J, Wasilewski P, Lisowski P, Grodzki T. Assessment of postoperative pain management and comparison of effectiveness of pain relief treatment involving paravertebral block and thoracic epidural analgesia in patients undergoing posterolateral thoracotomy. J Cardiothorac Surg 2019; 14:78. [PMID: 30992044 PMCID: PMC6469058 DOI: 10.1186/s13019-019-0901-3] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2018] [Accepted: 04/01/2019] [Indexed: 11/23/2022] Open
Abstract
Background TEA (thoracic epidural analgesia) is considered a basic method of analgesia used in thoracic surgeries. PVB (paravertebral block) is an alternative method. The thesis compares effectiveness of both methods in postoperative analgesia with particular focus on assessment of the postoperative pain management quality. Methods The study involved 2 groups of patients, each consisting of 30 patients undergoing posterolateral thoracotomy. The study group involved patients anesthetized applying PVB method, while the control group involved patients anesthetized with TEA. Hemodynamic and respiratory parameters as well as severity of pain assessed using NRS (numeric rating scale) during the first 3 days after the surgery, number of days of hospitalization, and the need to use additional pain relievers were taken into account in both groups. Evaluation of postoperative pain management quality was performed applying Clinical Quality Indicators in Postoperative Pain Management. Results No statistical significance was demonstrated between the groups in respect of hemodynamic and respiratory parameters values, the need to use additional pain relievers and the number of days of hospitalization. There was no statistically significant difference between the groups in respect of general assessment of pain management quality, except for the assessment of the lowest level of pain within the last 24 h of measurement. This result in TEA group was statistically significantly lower than the one in PVB group (p = 0.019). Conclusions In the assessment of postoperative pain management quality both analyzed methods are statistically significantly different only in the category of “lowest level of pain within the last 24 hours of measurement”, to the benefit of TEA group. No statistically significant difference has been observed between the two study groups with respect to the remaining parameters. Trial registration KB-0012/71/15. Date of registration 22 June 2015.
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Affiliation(s)
- Małgorzata Edyta Wojtyś
- Department of Thoracic Surgery and Transplantation, Pomeranian Medical University, Szczecin, Poland.
| | - Józef Wąsikowski
- The Department of Anesthesiology and Intensive Therapy, Prof. A. Sokołowski Specialist Hospital, Szczecin, Poland
| | - Norbert Wójcik
- Department of Thoracic Surgery and Transplantation, Pomeranian Medical University, Szczecin, Poland
| | - Janusz Wójcik
- Department of Thoracic Surgery and Transplantation, Pomeranian Medical University, Szczecin, Poland
| | - Piotr Wasilewski
- The Department of Anesthesiology and Intensive Therapy, Prof. A. Sokołowski Specialist Hospital, Szczecin, Poland
| | - Piotr Lisowski
- Students' Scientific Circle of the Department of Thoracic Surgery and Transplantation, Pomeranian Medical University, Szczecin, Poland
| | - Tomasz Grodzki
- Department of Thoracic Surgery and Transplantation, Pomeranian Medical University, Szczecin, Poland
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van den Berg JW, Tabrett K, Cheong E. Paravertebral catheter analgesia for minimally invasive Ivor Lewis oesophagectomy. J Thorac Dis 2019; 11:S786-S793. [PMID: 31080659 DOI: 10.21037/jtd.2019.03.47] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
Background Oesophagectomy is a major complex operation associated with significant morbidity and mortality. Epidural analgesia has long been the gold standard postoperative analgesia but is associated with side-effects like hypotension, epidural haematoma and infection. In an attempt to lower morbidity and enhance recovery postoperatively, we have adopted the use of paravertebral catheter analgesia (PVCA) for patients undergoing totally minimal invasive oesophagectomy (TMIO). Methods Our objective was to review the current literature about the use of both PVCA and epidural analgesia. In addition, we evaluated the effect of PVCA in a large group of patients undergoing TMIO for cancer. We reviewed the records of 100 consecutive patients who had a TMIO with PVCA, spinal morphine, and PCA. Prospective independent scoring of postoperative pain, length of stay, high-dependency unit (HDU) stay, PVCA failure, the use of patient-controlled analgesia (PCA), and the use of vasoconstrictor medication postoperatively was analysed. Results One hundred consecutive patients received PVCA with PCA after the TMIO. Catheter related failures occurred in 4 cases. The median pain score over each of the 5 days were 0. The average pain score was highest in the first 24 hours and decreased over the next 4 days postoperatively. The use of PCA was highest in the first 2 days and reduced daily over the subsequent 3 days. Seven patients required rescue analgesia in the form of intercostal nerve (ICN) block. Spinal morphine was successful in 94% of cases. Vasoconstrictors were required in 19% on day 1 and 3% on day 2, postoperatively. Conclusions Intraoperative placement of PVCA results in good postoperative pain control after a TMIO. This technique is simple, safe, reproducible and with very low failure rates. Therefore, it should be used instead of epidural catheter analgesia.
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Affiliation(s)
- Jan Willem van den Berg
- Norfolk and Norwich Oesophago-gastric Cancer Centre, Norfolk and Norwich University Hospital, Colney Lane, Norwich, UK
| | - Kate Tabrett
- Norfolk and Norwich Oesophago-gastric Cancer Centre, Norfolk and Norwich University Hospital, Colney Lane, Norwich, UK
| | - Edward Cheong
- Norfolk and Norwich Oesophago-gastric Cancer Centre, Norfolk and Norwich University Hospital, Colney Lane, Norwich, UK
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Shen C, Li J, Li P, Che G. [Evaluation Index of Enhanced Recovery After Surgery: Status and Progress of Patient Report Outcomes in Thoracic Surgery]. ZHONGGUO FEI AI ZA ZHI = CHINESE JOURNAL OF LUNG CANCER 2019; 22:161-166. [PMID: 30909996 PMCID: PMC6441120 DOI: 10.3779/j.issn.1009-3419.2019.03.08] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
加速康复外科临床应用的良好效果体现在降低围手术期并发症的发生率并缩短住院时间,但对围术期的患者症状管理及术后患者生活质量的关注不够高。从患者报告的资料角度评估临床疗效越来越受到重视。结合目前国内外关于病人报告结局的研究成果,本文系统论述了病人报告结局的概念内涵、研究意义及在胸外科的临床应用现状,提出借鉴国外病人报告的临床结局研究模式,开展有中国特色的结合学科特点的相关研究,并对已有的文献报告进行总结及分析。
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Affiliation(s)
- Cheng Shen
- Department of Thoracic Surgery, West China Hospital, Sichuan University, Chengdu 610041, China
| | - Jue Li
- Department of Thoracic Surgery, West China Hospital, Sichuan University, Chengdu 610041, China
| | - Pengfei Li
- Department of Thoracic Surgery, West China Hospital, Sichuan University, Chengdu 610041, China
| | - Guowei Che
- Department of Thoracic Surgery, West China Hospital, Sichuan University, Chengdu 610041, China
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D’Ercole F, Arora H, Kumar PA. Paravertebral Block for Thoracic Surgery. J Cardiothorac Vasc Anesth 2018; 32:915-927. [DOI: 10.1053/j.jvca.2017.10.003] [Citation(s) in RCA: 89] [Impact Index Per Article: 14.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/26/2017] [Indexed: 01/23/2023]
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Giménez-Milà M, Martinez G, George S. Enhanced recovery programmes in thoracic surgery: how does the future look? J R Soc Med 2018; 112:272-277. [PMID: 29355447 DOI: 10.1177/0141076817753625] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Affiliation(s)
- Marc Giménez-Milà
- Papworth Hospital NHS Foundation Trust, Papworth Everard, Cambridge CB23 3RE, UK
| | - Guillermo Martinez
- Papworth Hospital NHS Foundation Trust, Papworth Everard, Cambridge CB23 3RE, UK
| | - Shane George
- Papworth Hospital NHS Foundation Trust, Papworth Everard, Cambridge CB23 3RE, UK
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Anesthesia for Lung Resection. Anesthesiology 2018. [DOI: 10.1007/978-3-319-74766-8_10] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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