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Schubert AK, Seneviratne V, Stolz J, Wiesmann T, Wulf H, Eberhart L, Dinges HC. The effect of adjuvants added to local anaesthetics for single-injection upper extremity peripheral regional anaesthesia: A systematic review with network meta-analysis of randomised trials. Eur J Anaesthesiol 2023; 40:672-690. [PMID: 37337656 DOI: 10.1097/eja.0000000000001860] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/21/2023]
Abstract
BACKGROUND Peripheral regional anaesthesia is frequently used for upper extremity surgery. To prolong the duration of analgesia, adjuvants can be added to single-injection local anaesthetics. Despite attempts to compare several adjuvants in pairwise meta-analyses, a comprehensive comparison is still missing. OBJECTIVE The objective of this network meta-analysis was to determine the effectiveness of adjuvants in upper extremity peripheral nerve blocks. DESIGN A systematic review of randomised controlled trials with network meta-analyses. DATA SOURCES A literature search in Embase, CENTRAL, MEDLINE and Web of Science was performed up to March 2023. ELIGIBILITY CRITERIA Randomised trials comparing different adjuvants injected perineurally in peripheral upper extremity nerve blocks were eligible. Frequentist network meta-analysis was conducted using a random effects model with physiological saline as the comparator. The primary endpoint was the ratio of means (ROM) of the duration of analgesia. RESULTS The review included 242 randomised controlled trials with a total of 17 391 patients. Twenty-eight adjuvants were compared in the largest networks. Most network estimations consisted of a high proportion of direct evidence. Fourteen adjuvants increased the duration of analgesia significantly by the following factors, ROM [95% confidence interval (CI)]: dexamethasone 1.95 (1.79 to 2.13), buprenorphine 1.83 (1.51 to 2.24), butorphanol 1.84 (1.41 to 2.39), potassium chloride 1.89 (1.15 to 3.11), dexmedetomidine 1.70 (1.59 to 1.81), sufentanil 1.70 (1.27 to 2.29), ketorolac 1.68 (1.24 to 2.27), midazolam 1.55 (1.24 to 1.94), tramadol 1.52 (1.32 to 1.75), nalbuphine 1.50 (1.30 to 1.72), morphine 1.43 (1.09 to 1.88), magnesium sulfate 1.42 (1.20 to 1.67), clonidine 1.36 (1.24 to 1.50) and fentanyl 1.23 (1.08 to 1.40). Inconsistency in network meta-analysis was substantial. Overall side effect rates were low with all adjuvants. CONCLUSION The best interventions to prolong the duration of analgesia were dexamethasone, followed by dexmedetomidine, opioids, electrolytes, ketorolac and midazolam. There are general concerns about the quality of underlying studies and the risk of publication bias. TRIAL REGISTRATION PROSPERO 2018 CRD42018115722.
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Affiliation(s)
- Ann-Kristin Schubert
- From the Department of Anaesthesiology and Intensive Care Medicine, University Hospital Marburg, Philipps University of Marburg, Marburg (A-KS, VS, JS, TW, HW, LE, H-CD), and the Department of Anaesthesiology and Intensive Care Medicine, Diakoneo Diak Klinikum Schwäbisch-Hall, Schwäbisch-Hall, Germany (TW)
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Influence of Lidocaine including Buprenorphine for Postoperative Analgesia after the Extraction of Mandibular Third Molars: A Randomized Controlled, Double-Blind, Split-Mouth Study. ScientificWorldJournal 2021; 2021:7097948. [PMID: 34812251 PMCID: PMC8605912 DOI: 10.1155/2021/7097948] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2021] [Accepted: 10/12/2021] [Indexed: 11/17/2022] Open
Abstract
Background The presence of opioid receptors around the peripheral nerves offers the possibility of providing postoperative analgesia, thereby encouraging the study of the effect of opioids in combination with local anesthesia (LA). Studies have also reported the efficacy of peripherally administered opioids in achieving adequate analgesia in regions with inflammation. Applying the concept of peripheral opioid receptors, our study aimed to evaluate the effectiveness of opioid analgesia in managing postoperative pain. The split-mouth study was carried out to evaluate the efficacy of buprenorphine added to lidocaine 2% in providing postoperative analgesia after the surgical extraction of the impacted mandibular third molar. Materials and Methods We conducted a randomized, double-blinded, split-mouth trial among 21 patients with impacted mandibular third molars bilaterally. In all patients, bilateral impacted mandibular third molars were extracted at different periods. The primary outcomes assessed were postoperative analgesia by the VAS score and the number of rescue analgesics consumed by patients at 24, 48, and 72 hours of interval via a questionnaire. Results There was a statistical significant difference in postoperative analgesia duration at 24 (P = 0.012) and 48 hours (P = 0.024), respectively, between the test and control group. Even though the mean number of rescue analgesics consumed by the test group was less than that of the control group, no significant difference was seen. Conclusion Buprenorphine added to lidocaine 2% showed a minimal decrease in the pain score and duration of postoperative analgesia with no difference in the frequency of rescue analgesics consumed between the test and control.
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Miller EM, Rider D, Waterman BR. Editorial Commentary: The Evolution of Regional Anesthesia in Arthroscopic Rotator Cuff Repair: From Throbbing Shoulders to Paralyzed Diaphragms. Arthroscopy 2021; 37:3238-3240. [PMID: 34740403 DOI: 10.1016/j.arthro.2021.06.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/18/2021] [Accepted: 06/20/2021] [Indexed: 02/02/2023]
Abstract
Rotator cuff repair may result in significant postoperative pain. Although opioids were once the gold standard, addiction and other side effects are of significant concern. Nonsteroidal anti-inflammatory drugs reduce pain, sleep disturbance, and need for opioids, but they may impair soft tissue healing. The use of gabapentinoids is equivocal. Intralesional analgesia carries a risk of glenohumeral chondrolysis. Cryotherapy is beneficial, but it is often not covered by insurance companies. Suprascapular nerve block addresses innervation of only 70% versus interscalene block, but the latter has a higher incidence of unintended, temporary motor and sensory deficits of the upper extremity and hemidiaphragmatic paresis, despite similar pain scores. Although neurodeficits and diaphragmatic hemiparesis resolve by 3 weeks, temporary complications affect length of hospital stay, initiation of physical therapy, and patient satisfaction. These variables contribute to the challenge of postoperative pain control amid a growing wave of modalities aimed at improving the extent and duration of patient-focused analgesia, especially the application of continuous block infusions.
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Wu Z, Wang Y. Development of Guidance Techniques for Regional Anesthesia: Past, Present and Future. J Pain Res 2021; 14:1631-1641. [PMID: 34135627 PMCID: PMC8200162 DOI: 10.2147/jpr.s316743] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2021] [Accepted: 05/30/2021] [Indexed: 12/24/2022] Open
Abstract
Regional anesthesia has been widely used in clinical practice. Over the past 30 years, various guidance techniques have been developed for regional anesthesia ranging from paresthesia progressing to neurostimulation and currently ultrasound guidance. Especially, the use of point-of-care ultrasound greatly enhances the success rate of regional anesthesia. However, the poor imaging quality of ultrasound in patients with obesity, fat infiltration, etc., limits the use of ultrasound. The combined use of ultrasound with neurostimulator, electromyography, pressure monitoring, etc. is advocated in order to facilitate regional anesthesia in this cohort of patients. The accumulated evidence has shown that the ultrasound combined with other techniques (UCOT) can help to solve the difficulties of puncture location caused by obesity, anatomical variation, and other factors when using ultrasound guidance alone. In recent years, with the development of medical image fusion and medical image artificial intelligence identification technology, guidance techniques for regional anesthesia have advanced considerably. To understand the advantages and disadvantages of the various guidance techniques for regional anesthesia developed in recent years and to guide their rational clinical application, this paper reviews these techniques, describing the progression from the early use of paresthesia to the latest UCOT, as well as the latest research on UCOT, and the prospects for the development of new guidance techniques for regional anesthesia.
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Affiliation(s)
- Zehao Wu
- Department of Anesthesiology, Beijing Chaoyang Hospital, Capital Medical University, Beijing, 100020, People's Republic of China
| | - Yun Wang
- Department of Anesthesiology, Beijing Chaoyang Hospital, Capital Medical University, Beijing, 100020, People's Republic of China
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Dmytriiev D, Lisak Y, Zaletska O. Adjuvants in pain medicine. Selection of the drug depending on the desired effect – so which drug to choose? PAIN MEDICINE 2020. [DOI: 10.31636/pmjua.v5i2.1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
To date, much research has focused on finding the ideal adjuvant for local anesthetics. Each of them can have different effects. In anesthesiology and pain medicine, depending on the purpose, one or another effect may be desirable. For example, in some situations it is desirable to accelerate the onset of action or prolong the duration of the block, in others the desired effect may be a “response to intravascular administration”, it should also be borne in mind that not all adjuvants are allowed for intrathecal administration.
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Seering MS, Bayman EO, Wong CA, Ranganath YS, Marian AA. Comparison of the effect of three different adjuvants on the analgesic duration of single injection interscalene brachial plexus block: a prospective, randomized, triple blinded clinical trial. Reg Anesth Pain Med 2019; 44:rapm-2018-100201. [PMID: 31308262 DOI: 10.1136/rapm-2018-100201] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2018] [Revised: 06/12/2019] [Accepted: 06/17/2019] [Indexed: 11/03/2022]
Abstract
BACKGROUND AND OBJECTIVES Use of regional anesthesia can result in faster recovery and better patient satisfaction. Addition of perineural adjuncts to local anesthetics may improve the duration of analgesia, but there is a paucity of data comparing them in a single randomized trial. We compared the effects of three adjuncts clonidine, dexamethasone, and buprenorphine, on the duration of analgesia of interscalene brachial plexus block. METHODS 160 patients, undergoing elective shoulder surgery, were randomized to four groups to receive an interscalene block with one of the following solutions: ropivacaine alone, ropivacaine with clonidine 75 µg, ropivacaine with dexamethasone 8 mg, or ropivacaine with buprenorphine 300 µg. The primary outcome variable was the duration of analgesia; secondary outcome measures were time to onset of the block, and the duration of sensory and motor blocks. RESULTS There was no statistically significant difference in the total analgesia time among the four groups; p=0.11. The pairwise comparison in analgesic time and 99% CI were: control versus clonidine (-1.94 hours (-7.33 to 3.12)), control versus dexamethasone (-4.16 hours (-9.50 to 0.58)) and control versus buprenorphine (-1.1 hours (-5.34 to 3.23)). There was no differences in block set-up time, or total sensory and motor block duration among the groups. CONCLUSION There was no significant improvement in the duration of analgesia with addition of any of the three adjuncts to interscalene blocks. However, there was a larger than expected variability in patient response, hence the study may have been underpowered for the primary outcome.
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Affiliation(s)
- Melinda S Seering
- Department of Anesthesia, University of Iowa Carver College of Medicine, Iowa City, Iowa, USA
| | - Emine O Bayman
- Department of Anesthesia, University of Iowa Carver College of Medicine, Iowa City, Iowa, USA
| | - Cynthia A Wong
- Department of Anesthesia, University of Iowa Carver College of Medicine, Iowa City, Iowa, USA
| | | | - Anil A Marian
- Department of Anesthesia, University of Iowa Carver College of Medicine, Iowa City, Iowa, USA
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Nagpal V, Kaur T, Kapila S, Bhullar RS, Dhawan A, Kaur Y. Use of 0.5% bupivacaine with buprenorphine in minor oral surgical procedures. Natl J Maxillofac Surg 2018; 8:117-124. [PMID: 29386814 PMCID: PMC5773985 DOI: 10.4103/njms.njms_53_16] [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] [Indexed: 11/07/2022] Open
Abstract
Background: Minor oral surgical procedures are the most commonly performed procedures by oral and maxillofacial surgeons. Performance of painless surgical procedure is highly appreciated by the patients and is possible through the use of local anesthesia, conscious sedation or general anesthesia. Postoperative pain can also be controlled by the use of opioids, as opioid receptors exist in the peripheral nervous system and offers the possibility of providing postoperative analgesia in the surgical patient. The present study compares the efficacy of 0.5% bupivacaine versus 0.5% bupivacaine with 0.3 mg buprenorphine in minor oral surgical procedures. Patients and Methods: The present study was conducted in 50 patients who required minor oral surgical procedures under local anesthesia. Two types of local anesthetic solutions were used- 0.5% bupivacaine with 1:200000 epinephrine in group I and a mixture of 39 ml of 0.5% bupivacaine with epinephrine 1:200000 and 1 ml of 300 μg buprenorphine (3 μg/kg)in group II. Intraoperative and postoperative evaluation was carried out for both the anesthetic solutions. Results: The mean duration of postoperative analgesia in bupivacaine group (508.92 ± 63.30 minutes) was quite less than the buprenorphine combination group (1840.84 ± 819.51 minutes). The mean dose of postoperative analgesic medication in bupivacaine group (1.64 ± 0.99 tablets) was higher than buprenorphine combination group (0.80 ± 1.08 tablets). There was no significant difference between the two groups regarding the onset of action of the anesthetic effect and duration of anesthesia. Conclusion: Buprenorphine can be used in combination with bupivacaine for patients undergoing minor oral surgical procedures to provide postoperative analgesia for a longer duration.
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Affiliation(s)
- Varun Nagpal
- Department of Oral Surgery, Maharaja Ganga Singh Dental College, Sri Ganganagar, Rajasthan, India
| | - Tejinder Kaur
- Department of Oral Surgery, Sri Guru Ram Das Institute of Dental Sciences and Research, Amritsar, Punjab, India
| | - Sarika Kapila
- Department of Oral Surgery, Sri Guru Ram Das Institute of Dental Sciences and Research, Amritsar, Punjab, India
| | - Ramandeep Singh Bhullar
- Department of Oral Surgery, Sri Guru Ram Das Institute of Dental Sciences and Research, Amritsar, Punjab, India
| | - Amit Dhawan
- Department of Oral Surgery, Sri Guru Ram Das Institute of Dental Sciences and Research, Amritsar, Punjab, India
| | - Yashmeet Kaur
- Department of Oral Surgery, Sri Guru Ram Das Institute of Dental Sciences and Research, Amritsar, Punjab, India
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van Beek R, Zonneveldt HJ, van der Ploeg T, Steens J, Lirk P, Hollmann MW. In patients undergoing fast track total knee arthroplasty, addition of buprenorphine to a femoral nerve block has no clinical advantage: A prospective, double-blinded, randomized, placebo controlled trial. Medicine (Baltimore) 2017; 96:e7393. [PMID: 28682892 PMCID: PMC5502165 DOI: 10.1097/md.0000000000007393] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/30/2023] Open
Abstract
BACKGROUND Several adjuvants have been proposed to prolong the effect of peripheral nerve blocks, one of which is buprenorphine. In this randomized double blinded placebo controlled trial we studied whether the addition of buprenorphine to a femoral nerve block prolongs analgesia in patients undergoing total knee arthroplasty in a fast track surgery protocol. METHODS The treatment group (B) was given an ultrasound-guided femoral nerve block with ropivacaine 0.2% and 0.3mg buprenorphine. We choose to use 2 control groups. Group R was given a femoral nerve block with ropivacaine 0.2% only. Group S also received 0.3 mg buprenorphine subcutaneously. Only patients with a successful block were enrolled in the study. RESULTS We found no difference in our primary outcome parameter of time to first rescue analgesic. We found lower opioid use and better sleep quality the first postoperative night in patients receiving buprenorphine perineurally or subcutaneously. Buprenorphine did not lead to any significant change in pain or mobilization. We found a high overall incidence of nausea and vomiting. CONCLUSION In patients undergoing total knee arthroplasty, in the setting of a fast track surgery protocol, the addition of buprenorphine to a femoral nerve block did not prolong analgesia.
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Affiliation(s)
- Rienk van Beek
- Department of Anesthesiology, Westfriesgasthuis, Hoorn, The Netherlands
| | | | | | - Jeroen Steens
- Department of Orthopedic Surgery, Westfriesgasthuis, Hoorn, The Netherlands
| | - Phillip Lirk
- Department of Anesthesiology, Academic Medical Center, University of Amsterdam, The Netherlands
| | - Marcus W. Hollmann
- Department of Anesthesiology, Academic Medical Center, University of Amsterdam, The Netherlands
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Koyyalamudi V, Sen S, Patil S, Creel JB, Cornett EM, Fox CJ, Kaye AD. Adjuvant Agents in Regional Anesthesia in the Ambulatory Setting. Curr Pain Headache Rep 2017; 21:6. [PMID: 28210917 DOI: 10.1007/s11916-017-0604-1] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
PURPOSE OF REVIEW A majority of surgical practice has involved ambulatory centers with the number of outpatient operations in the USA doubling to 26.8 million per year. Local anesthesia delivery provides numerous benefits, including increased satisfaction, earlier discharge, and reduction in unplanned hospital admission. Further, with the epidemic of opioid mediated overdoses, local anesthesia can be a key tool in providing an opportunity to reduce the need for other analgesics postoperatively. RECENT FINDINGS Adjuvants such as epinephrine and clonidine enhance local anesthetic clinical utility. Further, dexmedetomidine prolongs regional blockade duration effects. There has also been a significant interest recently in the use of dexamethasone. Studies have demonstrated a significant prolongation in motor and sensory block with perineural dexamethasone. Findings are conflicting as to whether intravenous dexamethasone has similar beneficial effects. However, considering the possible neurotoxicity effects, which perineural dexamethasone may present, it would be prudent not to consider intravenously administered dexamethasone to prolong regional block duration. Many studies have also demonstrated neurotoxicity from intrathecally administered midazolam. Therefore, midazolam as an adjuvant is not recommended. Magnesium prolongs regional block duration but related to paucity of studies as of yet, cannot be recommended. Tramadol yields inconsistent results and ketamine is associated with psychotomimetic adverse effects. Buprenorphine consistently increases regional block duration and reduce opioid requirements by a significant amount. Future studies are warranted to define best practice strategies for these adjuvant agents. The present review focuses on the many roles of local anesthetics in current ambulatory practice.
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Affiliation(s)
| | - Sudipta Sen
- Department of Anesthesiology, LSUHSC-Shreveport, Shreveport, LA, USA
| | - Shilpadevi Patil
- Department of Anesthesiology, LSUHSC-Shreveport, Shreveport, LA, USA
| | - Justin B Creel
- Department of Anesthesiology, LSUHSC-Shreveport, Shreveport, LA, USA
| | - Elyse M Cornett
- Department of Anesthesiology, LSUHSC-Shreveport, Shreveport, LA, USA
| | - Charles J Fox
- Department of Anesthesiology, LSUHSC-Shreveport, Shreveport, LA, USA.
| | - Alan D Kaye
- Department of Anesthesiology, LSUHSC-NO, New Orleans, LA, USA
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Krishnan SH, Gilbert LA, Ghoddoussi F, Applefield DJ, Kassab SS, Ellis TA. Addition of buprenorphine to local anesthetic in adductor canal blocks after total knee arthroplasty improves postoperative pain relief: a randomized controlled trial. J Clin Anesth 2016; 33:432-7. [DOI: 10.1016/j.jclinane.2016.04.021] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2015] [Revised: 04/18/2016] [Accepted: 04/20/2016] [Indexed: 11/17/2022]
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Addition of Dexamethasone and Buprenorphine to Bupivacaine Sciatic Nerve Block: A Randomized Controlled Trial. Reg Anesth Pain Med 2016; 40:321-9. [PMID: 25974277 DOI: 10.1097/aap.0000000000000254] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
BACKGROUND AND OBJECTIVES Sciatic nerve block provides analgesia after foot and ankle surgery, but block duration may be insufficient. We hypothesized that perineural dexamethasone and buprenorphine would reduce pain scores at 24 hours. METHODS Ninety patients received ultrasound-guided sciatic (25 mL 0.25% bupivacaine) and adductor canal (10 mL 0.25% bupivacaine) blockade, with random assignment into 3 groups (30 patients per group): control blocks + intravenous (IV) dexamethasone (4 mg) (control); control blocks + IV buprenorphine (150 μg) + IV dexamethasone (IV buprenorphine); and nerve blocks containing buprenorphine + dexamethasone (perineural). Patients received mepivacaine neuraxial anesthesia and postoperative oxycodone/acetaminophen, meloxicam, pregabalin, and ondansetron. Patients and assessors were blinded to group assignment. The primary outcome was pain with movement at 24 hours. RESULTS There was no difference in pain with movement at 24 hours (median score, 0). However, the perineural group had longer block duration versus control (45.6 vs 30.0 hours). Perineural patients had lower scores for "worst pain" versus control (median, 0 vs 2). Both IV buprenorphine and perineural groups were less likely to use opioids on the day after surgery versus control (28.6%, 28.6%, and 60.7%, respectively). Nausea after IV buprenorphine (but not perineural buprenorphine) was severe, frequent, and bothersome. CONCLUSIONS Pain scores were very low at 24 hours after surgery in the context of multimodal analgesia and were not improved by additives. However, perineural buprenorphine and dexamethasone prolonged block duration, reduced the worst pain experienced, and reduced opioid use. Intravenous buprenorphine caused troubling nausea and vomiting. Future research is needed to confirm and extend these observations.
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Khurana S, Garg K, Grewal A, Kaul TK, Bose A. A comparative study on postoperative pain relief in laparoscopic cholecystectomy: Intraperitoneal bupivacaine versus combination of bupivacaine and buprenorphine. Anesth Essays Res 2016; 10:23-8. [PMID: 26957685 PMCID: PMC4767078 DOI: 10.4103/0259-1162.164731] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
CONTEXT To assess the analgesic efficacy of the combination of bupivacaine and buprenorphine in alleviating postoperative pain following laparoscopic cholecystectomy. AIMS Laparoscopic cholecystectomy is comparatively advantageous as it offers less pain in the postoperative period and requires a shorter hospital stay. There are only a few studies performed to evaluate the analgesic efficacy of intraperitoneal instillation of buprenorphine and bupivacaine during laparoscopic cholecystectomy. SETTINGS AND DESIGN The present research is a randomized, double-blind controlled study conducted in the Department of Anaesthesiology, Dayanand Medical College and Hospital Ludhiana, Punjab after formal ethical approval from Hospital's Ethics Committee. SUBJECTS AND METHODS This study analyzed 90 adults admitted for elective laparoscopic cholecystectomy. After the procedure, subjects were divided into three equal groups to conduct the study. Three Groups A, B, and C had intraperitoneal instillation of the 25 ml of physiological saline (0.9% normal saline), 0.25% of bupivacaine, 0.25% bupivacaine, and 0.3 mg buprenorphine, respectively. Necessary vitals were monitored and recorded. Visual analog scale (VAS) and verbal rating scale (VRS) scores were recorded and analyzed systematically. STATISTICAL ANALYSIS USED All observations were analyzed using analysis of variance and Student's t-test. RESULTS The mean pain scores were highest in Group A compared to Group B and Group C. Mean VAS and VRS scores were highest in Group C comparatively and lowest in Group A. CONCLUSION Combination of buprenorphine and bupivacaine intraperitoneally is comparatively more effective in relieving postoperative pain in comparison to intraperitoneal instillation of bupivacaine alone for postoperative pain management after laparoscopic cholecystectomy.
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Affiliation(s)
- Sandeep Khurana
- Department of Anaesthesia, Max Hospital, Mohali, Chandigarh, India
| | - Kamakshi Garg
- Department of Anaesthesia, Dayanand Medical College and Hospital, Ludhiana, Punjab, India
| | - Anju Grewal
- Department of Anaesthesia, Dayanand Medical College and Hospital, Ludhiana, Punjab, India
| | - Tej K Kaul
- Department of Anaesthesia, Dayanand Medical College and Hospital, Ludhiana, Punjab, India
| | - Abhishek Bose
- Department of Urology, Dayanand Medical College and Hospital, Ludhiana, Punjab, India
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YaDeau JT, Gordon MA, Goytizolo EA, Lin Y, Fields KG, Goon AK, Holck G, Miu TW, Gulotta LV, Dines DM, Craig EV. Buprenorphine, Clonidine, Dexamethasone, and Ropivacaine for Interscalene Nerve Blockade: A Prospective, Randomized, Blinded, Ropivacaine Dose-Response Study. PAIN MEDICINE 2015; 17:940-60. [PMID: 26814246 DOI: 10.1093/pm/pnv010] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/15/2015] [Accepted: 09/05/2015] [Indexed: 01/10/2023]
Abstract
OBJECTIVE This study investigated interscalene block for shoulder arthroplasty with various ropivacaine concentrations in the presence of clonidine, dexamethasone, and buprenorphine. The goal was prolonged analgesia with minimal motor blockade. DESIGN Prospective, double-blind, randomized controlled trial. SETTING University-affiliated orthopedic hospital. METHODS Patients (20/group) received acetaminophen, ketorolac, pregabalin, opioids, and "Control"; interscalene block, 0.375% ropivacaine, intravenous additives (buprenorphine, clonidine, dexamethasone); "High Dose"; 0.375% ropivacaine, perineural additives; "Medium Dose"; 0.2% ropivacaine, perineural additives; and "Low Dose"; 0.1% ropivacaine, perineural additives. RESULTS Pain with movement at 24 hours was 4.9 ± 2.5 (mean ± standard deviation [SD]) (Control), 4.5 ± 3.0 (High Dose), 3.4 ± 1.8 (Medium Dose), 4.2 ± 2.4 (Low Dose). The difference between Medium Dose and Control was -1.5 (95% CI: -2.9, -0.1) (P = 0.040). Median time until need for opioids was 16.1 hours (Control) vs 23.7 hours (High Dose); hazard ratio 0.37 [95% CI: 0.17, 0.79]. High Dose had less pain with movement the morning after surgery, vs Control; 2.9 ± 2.5 vs 4.9 ± 2.7; P = 0.027. Pain with movement in the Post-Anesthesia Care Unit was higher in Low Dose, vs Control; 0.9 ± 1.4 vs 0 ± 0, P = 0.009. Low Dose had superior hand strength in the Post-Anesthesia Care Unit (mean ± SD of pre-operative strength: 44.0 ± 20.3%) compared to Control (27.5 ± 24.5%) (P = 0.031). CONCLUSIONS For maximum pain reduction, combining perineural additives with ropivacaine 0.375% or 0.2% is suggested. To minimize motor blockade, perineural additives can be combined with ropivacaine, 0.1%.
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Affiliation(s)
- Jacques T YaDeau
- Departments of *Anesthesiology, and Orthopedic Surgery, Hospital for Special Surgery, Weill Cornell Medical College, New York, New York, USA;
| | - Michael A Gordon
- Departments of *Anesthesiology, and Orthopedic Surgery, Hospital for Special Surgery, Weill Cornell Medical College, New York, New York, USA
| | - Enrique A Goytizolo
- Departments of *Anesthesiology, and Orthopedic Surgery, Hospital for Special Surgery, Weill Cornell Medical College, New York, New York, USA
| | - Yi Lin
- Departments of *Anesthesiology, and Orthopedic Surgery, Hospital for Special Surgery, Weill Cornell Medical College, New York, New York, USA
| | - Kara G Fields
- Departments of *Anesthesiology, and Orthopedic Surgery, Hospital for Special Surgery, Weill Cornell Medical College, New York, New York, USA; Healthcare Research Institute, Hospital for Special Surgery, New York, New York, USA
| | - Amanda K Goon
- Departments of *Anesthesiology, and Orthopedic Surgery, Hospital for Special Surgery, Weill Cornell Medical College, New York, New York, USA
| | - Guilherme Holck
- Departments of *Anesthesiology, and Orthopedic Surgery, Hospital for Special Surgery, Weill Cornell Medical College, New York, New York, USA
| | - Timothy W Miu
- Departments of *Anesthesiology, and Orthopedic Surgery, Hospital for Special Surgery, Weill Cornell Medical College, New York, New York, USA
| | - Lawrence V Gulotta
- Departments of *Anesthesiology, and Orthopedic Surgery, Hospital for Special Surgery, Weill Cornell Medical College, New York, New York, USA
| | - David M Dines
- Departments of *Anesthesiology, and Orthopedic Surgery, Hospital for Special Surgery, Weill Cornell Medical College, New York, New York, USA
| | - Edward V Craig
- Departments of *Anesthesiology, and Orthopedic Surgery, Hospital for Special Surgery, Weill Cornell Medical College, New York, New York, USA; Healthcare Research Institute, Hospital for Special Surgery, New York, New York, USA
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15
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Kirksey MA, Haskins SC, Cheng J, Liu SS. Local Anesthetic Peripheral Nerve Block Adjuvants for Prolongation of Analgesia: A Systematic Qualitative Review. PLoS One 2015; 10:e0137312. [PMID: 26355598 PMCID: PMC4565585 DOI: 10.1371/journal.pone.0137312] [Citation(s) in RCA: 151] [Impact Index Per Article: 16.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2015] [Accepted: 08/14/2015] [Indexed: 12/13/2022] Open
Abstract
Background The use of peripheral nerve blocks for anesthesia and postoperative analgesia has increased significantly in recent years. Adjuvants are frequently added to local anesthetics to prolong analgesia following peripheral nerve blockade. Numerous randomized controlled trials and meta-analyses have examined the pros and cons of the use of various individual adjuvants. Objectives To systematically review adjuvant-related randomized controlled trials and meta-analyses and provide clinical recommendations for the use of adjuvants in peripheral nerve blocks. Methods Randomized controlled trials and meta-analyses that were published between 1990 and 2014 were included in the initial bibliographic search, which was conducted using Medline/PubMed, Cochrane Central Register of Controlled Trials, and EMBASE. Only studies that were published in English and listed block analgesic duration as an outcome were included. Trials that had already been published in the identified meta-analyses and included adjuvants not in widespread use and published without an Investigational New Drug application or equivalent status were excluded. Results Sixty one novel clinical trials and meta-analyses were identified and included in this review. The clinical trials reported analgesic duration data for the following adjuvants: buprenorphine (6), morphine (6), fentanyl (10), epinephrine (3), clonidine (7), dexmedetomidine (7), dexamethasone (7), tramadol (8), and magnesium (4). Studies of perineural buprenorphine, clonidine, dexamethasone, dexmedetomidine, and magnesium most consistently demonstrated prolongation of peripheral nerve blocks. Conclusions Buprenorphine, clonidine, dexamethasone, magnesium, and dexmedetomidine are promising agents for use in prolongation of local anesthetic peripheral nerve blocks, and further studies of safety and efficacy are merited. However, caution is recommended with use of any perineural adjuvant, as none have Food and Drug Administration approval, and concerns for side effects and potential toxicity persist.
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Affiliation(s)
- Meghan A Kirksey
- Department of Anesthesiology, Hospital for Special Surgery, New York, New York, United States of America; Department of Anesthesiology, Weill College of Medicine at Cornell University, New York, New York, United States of America
| | - Stephen C Haskins
- Department of Anesthesiology, Hospital for Special Surgery, New York, New York, United States of America; Department of Anesthesiology, Weill College of Medicine at Cornell University, New York, New York, United States of America
| | - Jennifer Cheng
- Department of Anesthesiology, Hospital for Special Surgery, New York, New York, United States of America
| | - Spencer S Liu
- Department of Anesthesiology, Hospital for Special Surgery, New York, New York, United States of America; Department of Anesthesiology, Weill College of Medicine at Cornell University, New York, New York, United States of America
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16
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Thakur D, Malde A. Buprenorphine for postoperative analgesia: Axillary brachial plexus block versus intramuscular administration in a placebo-controlled trial. J Anaesthesiol Clin Pharmacol 2015; 31:360-4. [PMID: 26330716 PMCID: PMC4541184 DOI: 10.4103/0970-9185.161673] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Abstract
Background and Aims: Peripheral administration of opioids has been suggested for prolongation of regional analgesia. This prospective, randomized, double-blind placebo-controlled study was undertaken to compare the effect of regional (axillary brachial plexus block [ABPB]) versus intramuscular (IM) buprenorphine (2 μg/kg) in adults. Material and Methods: Seventy-five adults undergoing upper limb surgery received ABPB with local anaesthetic (15 ml 0.5% bupivacaine, 15 ml 2% lignocaine with adrenaline 1:200,000, 9 ml normal saline [NS]). In addition, regional group RB (n = 25) received buprenorphine 2 μg/kg in ABPB and 1 ml NS IM. Systemic Group SB (n = 25) received 1 ml NS in ABPB and buprenorphine 2 μg/kg IM. Group C (n = 25) received 1 ml NS in ABPB and IM. Onset, duration of sensory and motor block, hemodynamic parameters, sedation score, pain scores using visual analog scale, duration of postoperative analgesia, rescue analgesic (RA) requirement, adverse events, and patient satisfaction were noted. Results: Demographics, onset and duration of sensory, motor block were similar. RB group had longest duration of analgesia (20.61 ± 1.33 h) compared to SB (10.91 ± 0.90 h) and control group (5.86 ± 0.57 h) (P < 0.05 RB vs. SB/C and SB vs. C). RA requirement was highest in the control group and least in RB group (P = 0.000 RB vs. SB/C and SB vs. C). SB group had a maximum number of side effects (P = 0.041, SB vs. RB/C). Patient satisfaction was highest with group RB (P < 0.05 RB vs. SB/C, and P = 0.06 SB vs. C). Conclusion: Buprenorphine 2 μg/kg in axillary plexus block provides significantly prolonged analgesia with less RA requirement and greater patient satisfaction compared to IM administration. This is highly suggestive of action on peripheral opioid receptors.
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Affiliation(s)
- Deepali Thakur
- Department of Anaesthesiology, LTMMC and LTMG Hospital, Sion, Mumbai, Maharashtra, India
| | - Anila Malde
- Department of Anaesthesiology, LTMMC and LTMG Hospital, Sion, Mumbai, Maharashtra, India
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17
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Vadhanan P, Tripaty DK, Adinarayanan S. Physiological and pharmacologic aspects of peripheral nerve blocks. J Anaesthesiol Clin Pharmacol 2015; 31:384-93. [PMID: 26330722 PMCID: PMC4541190 DOI: 10.4103/0970-9185.161679] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
A successful peripheral nerve block not only involves a proper technique, but also a thorough knowledge and understanding of the physiology of nerve conduction and pharmacology of local anesthetics (LAs). This article focuses on what happens after the block. Pharmacodynamics of LAs, underlying mechanisms of clinically observable phenomena such as differential blockade, tachyphylaxis, C fiber resistance, tonic and phasic blockade and effect of volume and concentration of LAs. Judicious use of additives along with LAs in peripheral nerve blocks can prolong analgesia. An entirely new group of drugs-neurotoxins has shown potential as local anesthetics. Various methods are available now to prolong the duration of peripheral nerve blocks.
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Affiliation(s)
- Prasanna Vadhanan
- Department of Anaesthesiology, Vinayaka Mission's Medical College and Hospital, Karaikal, Puducherry, India
| | | | - S Adinarayanan
- Department of Jawaharlal Nehru Institute of Postgraduate Medical Education and Research, Puducherry, India
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18
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Pearson LT, Lowry BP, Culp WC, Kitchings OE, Meyer TA, McAllister RK, Roberson CR, Burnett CJ. Effect of adding tetracaine to bupivacaine on duration of analgesia in supraclavicular brachial plexus nerve blocks for ambulatory shoulder surgery. Proc (Bayl Univ Med Cent) 2015; 28:307-11. [PMID: 26130874 DOI: 10.1080/08998280.2015.11929258] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022] Open
Abstract
The objective of this study was to determine if the addition of 1% tetracaine to 0.25% bupivacaine prolonged the duration of postoperative analgesia of supraclavicular brachial plexus nerve blockade for patients undergoing ambulatory shoulder surgery. We conducted a prospective, double-blinded, randomized controlled clinical study at an ambulatory surgery center utilizing ultrasound- and nerve stimulation-guided supraclavicular nerve blockade for postoperative analgesia. The control group received 30 mL of 0.25% bupivacaine plus 4 mL preservative-free saline. The study group received 30 mL of 0.25% bupivacaine plus 4 mL of 1% tetracaine. Patients documented their visual analog scale scores and intake of pain medications for 3 days. Primary outcomes included time of first postoperative pain, time of first postoperative pain pill, and time of return of motor and sensory function. Secondary outcomes included pain score and pain medication intake trends and adverse events secondary to the nerve block. A total of 84 patients completed the study, 42 patients in each group. The study group was statistically significantly older than the control group (mean age, 54 vs 48 years; P = 0.04). The mean duration of analgesia was 16.6 ± 8.3 h for the control group and 17.1 ± 7.3 h for the study group (P = 0.69). No outcomes were statistically different. In conclusion, there was no significant difference in duration of postoperative analgesia with the addition of 1% tetracaine to 0.25% bupivacaine in supraclavicular brachial plexus nerve blockade. No differences were identified in postoperative pain medications, pain scores, or complications.
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Affiliation(s)
- Linda T Pearson
- Department of Anesthesiology, Baylor Scott and White Health, and the Texas A&M University System Health Science Center College of Medicine, Temple, Texas
| | - Benjamin P Lowry
- Department of Anesthesiology, Baylor Scott and White Health, and the Texas A&M University System Health Science Center College of Medicine, Temple, Texas
| | - William C Culp
- Department of Anesthesiology, Baylor Scott and White Health, and the Texas A&M University System Health Science Center College of Medicine, Temple, Texas
| | - Olen E Kitchings
- Department of Anesthesiology, Baylor Scott and White Health, and the Texas A&M University System Health Science Center College of Medicine, Temple, Texas
| | - Tricia A Meyer
- Department of Anesthesiology, Baylor Scott and White Health, and the Texas A&M University System Health Science Center College of Medicine, Temple, Texas
| | - Russell K McAllister
- Department of Anesthesiology, Baylor Scott and White Health, and the Texas A&M University System Health Science Center College of Medicine, Temple, Texas
| | - Charles R Roberson
- Department of Anesthesiology, Baylor Scott and White Health, and the Texas A&M University System Health Science Center College of Medicine, Temple, Texas
| | - Christopher J Burnett
- Department of Anesthesiology, Baylor Scott and White Health, and the Texas A&M University System Health Science Center College of Medicine, Temple, Texas
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19
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Nirmala J, Kumar A, Devraj R, Vidyasagar S, Ramachandraiah G, Murthy PVLN. Role of buprenorphine in prolonging the duration of post-operative analgesia in percutaneous nephrolithotomy: Comparison between bupivacaine versus bupivacaine and buprenorphine combination. Indian J Urol 2015; 31:132-5. [PMID: 25878415 PMCID: PMC4397550 DOI: 10.4103/0970-1591.152815] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Introduction: Percutaneous nephrolithotomy (PCNL) is the treatment of choice for large renal calculi. Pain around the nephrostomy tube is a clinical problem and we have previously reported alleviation of pain by peritubal block with bupivacaine, which lasted for 14 hours. The present study aimed to investigate the role of buprenorphine and bupivacaine combination in prolonging the duration of analgesia in peritubal block. Materials and Methods: A prospective, randomized controlled study was undertaken in 40 American Society of Anesthesiologists (ASA) grade I and II patients who were scheduled for PCNL. Group I patients received 20 mL of 0.25% bupivacaine and group II patients received 20 mL of 0.25% bupivacaine with 100 μg of buprenorphine. Peritubal infiltration was given under fluoroscopic guidance along the nephrostomy tube from the renal capsule to the skin. Post-operative pain was assessed by Visual Analog Score (VAS), dynamic VAS (DVAS), sedation score, duration of analgesia and number of rescue analgesic demands. Rescue analgesia was inj tramadol 1 mg/kg IV if pain score exceeded 3. Results: Demographic data were comparable between the groups. Median duration of analgesia was 16 h in group I and 20 h in group II (P = 0.002). The maximum median VAS was 4 in group I and 2 in group II (P = 0.002). The median area under curve (AUC) for VAS was 7 and 5 in groups I and II, respectively (P = 0.047). The median maximum DVAS in group I was 6 and 4 in group II. The median AUC for DVAS in 24 h was 16 in group I and 15 in group II (P = 0.017). Conclusions: Peritubal infiltration of 0.25% bupivacaine with 100 μg buprenorphine around a nephrostomy tube increased the duration of analgesia following PCNL without any side-effects.
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Affiliation(s)
- Jonnavithula Nirmala
- Department of Anesthesiology and Intensive Care, Nizam's Institute of Medical Sciences, Punjagutta, Hyderabad, Andhra Pradesh, India
| | - Anil Kumar
- Department of Anesthesiology and Intensive Care, Nizam's Institute of Medical Sciences, Punjagutta, Hyderabad, Andhra Pradesh, India
| | - Rahul Devraj
- Department of Urology and Renal Transplantation, Nizam's Institute of Medical Sciences, Punjagutta, Hyderabad, Andhra Pradesh, India
| | - Sriramoju Vidyasagar
- Department of Urology and Renal Transplantation, Nizam's Institute of Medical Sciences, Punjagutta, Hyderabad, Andhra Pradesh, India
| | - Gunta Ramachandraiah
- Department of Urology and Renal Transplantation, Nizam's Institute of Medical Sciences, Punjagutta, Hyderabad, Andhra Pradesh, India
| | - Pisapati V L N Murthy
- Department of Urology and Renal Transplantation, Nizam's Institute of Medical Sciences, Punjagutta, Hyderabad, Andhra Pradesh, India
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20
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Behr A, Freo U, Ori C, Westermann B, Alemanno F. Buprenorphine added to levobupivacaine enhances postoperative analgesia of middle interscalene brachial plexus block. J Anesth 2012; 26:746-51. [PMID: 22644357 DOI: 10.1007/s00540-012-1416-4] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2011] [Accepted: 05/07/2012] [Indexed: 10/28/2022]
Abstract
PURPOSE The aim of this study was to assess whether addition of epineural buprenorphine prolonged postoperative analgesia of middle interscalene brachial plexus block (MIB) with levobupivacaine. METHODS One hundred and fifty consenting adult patients, scheduled for shoulder arthroscopic surgery for a rotator cuff tear under MIB with 29.5 ml of 0.75 % levobupivacaine, were randomized to receive additionally either saline or intramuscular buprenorphine 0.15 mg or epineural buprenorphine 0.15 mg. Onset of sensory and motor blocks, duration of postoperative analgesia, and consumption of postoperative analgesics were compared among the groups. RESULTS There were significant (P < 0.05) differences in the onset and the duration of the sensory block and in the duration of postoperative analgesia. Duration of both sensory block and postoperative analgesia was longer (P < 0.05) in patients who had received epineural buprenorphine (856.1 ± 215.2 and 1,049.7 ± 242.2 min) than in patients who had received intramuscular buprenorphine (693.6 ± 143.4 and 820.3 ± 335.3 min) or saline (488.3 ± 137.6 and 637.5 ± 72.1 min). Requirement of postoperative rescue analgesics was lower in the epineural buprenorphine group than in the other two groups. Few complications occurred from MIB (<1 %) and none from buprenorphine. CONCLUSIONS Epineural buprenorphine prolonged postoperative analgesia of MIB more effectively than intramuscular buprenorphine, which suggests that buprenorphine acts at a peripheral nervous system site of action.
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Affiliation(s)
- Astrid Behr
- Department of Pharmacology and Anesthesiology, University of Padova, Via C. Battisti 267, 35121, Padua (PD), Italy
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21
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Efficacy of buprenorphine added 2 % lignocaine 1:80000 in postoperative analgesia after minor oral surgery. J Maxillofac Oral Surg 2012; 12:30-4. [PMID: 24431810 DOI: 10.1007/s12663-012-0360-z] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2011] [Accepted: 03/01/2012] [Indexed: 10/28/2022] Open
Abstract
PURPOSE Recent studies have demonstrated that opioid analgesia cannot be exclusively attributed to effects within central nervous system. Peripheral opioid receptors exist that can be activated by locally applied opioid agonists which mediate analgesic effects that are particularly prominent in painful inflammatory conditions. Patients who present themselves with conditions requiring minor surgery in the maxillo-facial region usually have associated ongoing inflammatory process. The aim of our study was to apply the concept of peripheral opioid analgesia in minor oral surgery and evaluate its effectiveness in managing postoperative pain. The present study was designed to evaluate the efficacy of buprenorphine added lignocaine 2 % in providing postoperative analgesia after minor oral surgery. MATERIALS AND METHODS Hundred consenting adult patients who were scheduled to undergo various minor oral surgeries were enrolled in this double blinded study. Patients were randomly assigned into one of the two groups based on whether they received buprenorphine added 2 % lignocaine 1:80000 (Group I) or (Group II) lignocaine 2 % with adrenaline 1:80000 alone. Visual analog scale method was used for evaluation of the postoperative analgesia. RESULTS The duration of analgesia in Group I was found to be 36 ± 1.5 h and the average consumption of NSAIDs was found to be 1.86 as compared to Group II mean value of 4.4 (P < 0.0001). CONCLUSION Addition of small amounts of buprenorphine to 30 ml lignocaine with adrenaline 1:80000 for minor oral surgery results in significant improvement in postoperative analgesia up to 36 h and markedly reduces the need for excessive analgesic intake. Thus reducing the adverse effects associated with excessive use of NSAIDs.
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22
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White PF, White LM, Monk T, Jakobsson J, Raeder J, Mulroy MF, Bertini L, Torri G, Solca M, Pittoni G, Bettelli G. Perioperative care for the older outpatient undergoing ambulatory surgery. Anesth Analg 2012; 114:1190-215. [PMID: 22467899 DOI: 10.1213/ane.0b013e31824f19b8] [Citation(s) in RCA: 60] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
As the number of ambulatory surgery procedures continues to grow in an aging global society, the implementation of evidence-based perioperative care programs for the elderly will assume increased importance. Given the recent advances in anesthesia, surgery, and monitoring technology, the ambulatory setting offers potential advantages for elderly patients undergoing elective surgery. In this review article we summarize the physiologic and pharmacologic effects of aging and their influence on anesthetic drugs, the important considerations in the preoperative evaluation of elderly outpatients with coexisting diseases, the advantages and disadvantages of different anesthetic techniques on a procedural-specific basis, and offer recommendations regarding the management of common postoperative side effects (including delirium and cognitive dysfunction, fatigue, dizziness, pain, and gastrointestinal dysfunction) after ambulatory surgery. We conclude with a discussion of future challenges related to the growth of ambulatory surgery practice in this segment of our surgical population. When information specifically for the elderly population was not available in the peer-reviewed literature, we drew from relevant information in other ambulatory surgery populations.
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Affiliation(s)
- Paul F White
- Department of Anesthesia, Cedars-Sinai Medical Center, Los Angeles, California, USA.
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Neurotoxicity of adjuvants used in perineural anesthesia and analgesia in comparison with ropivacaine. Reg Anesth Pain Med 2012; 36:225-30. [PMID: 21519308 DOI: 10.1097/aap.0b013e3182176f70] [Citation(s) in RCA: 156] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
BACKGROUND AND OBJECTIVES Clonidine, buprenorphine, dexamethasone, and midazolam (C, B, D, M) have been used to prolong perineural local anesthesia in the absence of data on the influence of these adjuvants on local anesthetic-induced neurotoxicity. Therefore, the impact of these adjuvants on ropivacaine (R)-induced death of isolated sensory neurons was assessed. METHODS The trypan blue exclusion assay was used to assess death of sensory neurons isolated from adult male Sprague-Dawley rats. Drugs were applied, alone or in combination, for 2 or 24 hrs at 37°C. RESULTS Neuronal viability was halved by 24-hr exposure to R (2.5 mg/mL), far exceeding the neurotoxicity of C, B, D, or M (at 2-100 times estimated clinical concentrations). Plain M at twice the estimated clinical concentration produced a small but significant increase in neurotoxicity at 24 hrs. After 2-hr exposure, high concentrations of B, C, and M increased the neurotoxicity of R; the combination of R + M killed more than 90% of neurons. Estimated clinical concentrations of C + B (plus 66 μg/mL D) had no influence on (i) R-induced neurotoxicity, (ii) the increased neurotoxicity associated with the combination of R + M, or (iii) the neurotoxicity associated with estimated clinical concentrations of M. There was increased neurotoxicity with 133 μg/mL D combined with R + C + B. CONCLUSIONS Results with R reaffirm the need to identify ways to mitigate local anesthetic-induced neurotoxicity. While having no protective effect on R-induced neurotoxicity in vitro, future research with adjuvants should address if the C + B + D combination can enable reducing R concentrations needed to achieve equianalgesia (and/or provide equal or superior duration, in preclinical in vivo models).
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25
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Toward a potential paradigm shift for the clinical care of diabetic patients requiring perineural analgesia: strategies for using the diabetic rodent model. Reg Anesth Pain Med 2010; 35:329-32. [PMID: 20588148 DOI: 10.1097/aap.0b013e3181e82e0b] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
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Boezaart AP, Tighe P. New trends in regional anesthesia for shoulder surgery: Avoiding devastating complications. INTERNATIONAL JOURNAL OF SHOULDER SURGERY 2010; 4:1-7. [PMID: 20922086 PMCID: PMC2940165 DOI: 10.4103/0973-6042.68410] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Surgeons and patients are often reluctant to support regional anesthesia (RA) for shoulder and other orthopedic surgeries. This is because of the sometimes true but usually incorrectly perceived "slowing down" of operating room turnover time and the perceived potential for added morbidity. Recently, severe devastating and permanent nerve injury complications have surfaced, and this article attempts to clarify the modern place of RA for shoulder surgery and the prevention of these complications. A philosophical approach to anesthesiology and regional anesthesiology is offered, while a fresh appreciation for the well-described and often forgotten microanatomy of the brachial plexus is revisited to explain and avoid some of the devastating complications of RA for shoulder surgery.
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Affiliation(s)
- André P. Boezaart
- Department of Anesthesiology, University of Florida College of Medicine, Gainesville, FL, USA
- Department of Orthopaedic Surgery & Rehabilitation, University of Florida College of Medicine, Gainesville, FL, USA
| | - Patrick Tighe
- Department of Anesthesiology, University of Florida College of Medicine, Gainesville, FL, USA
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30
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Opioid and local anesthetic combination for brachial plexus block to provide postoperative analgesia. Reg Anesth Pain Med 2002. [DOI: 10.1097/00115550-200205000-00029] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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31
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Buprenorphine Added to the Local Anesthetic for Axillary Brachial Plexus Block Prolongs Postoperative Analgesia. Reg Anesth Pain Med 2002. [DOI: 10.1097/00115550-200203000-00009] [Citation(s) in RCA: 81] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Reply to Dr. De Co? rdoba et al. Reg Anesth Pain Med 2002. [DOI: 10.1097/00115550-200203000-00024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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