The Third American Society of Regional Anesthesia and Pain Medicine Practice Advisory on Local Anesthetic Systemic Toxicity: Executive Summary 2017

The feasibility and effectiveness of one-puncture of rectus sheath block combined with transverse abdominis plane block in patients undergoing thoracoscopic-laparoscopic radical esophagectomy: a prospective randomized controlled study

Background

This study aimed to assess the feasibility and effectiveness of ultrasound-guided one-puncture of rectus sheath block (RSB) combined with the transverse abdominis plane block (TAPB) for patients undergoing thoracoscopic-laparoscopic radical esophagectomy (TLE).

Methods

This prospective randomized controlled study enrolled 40 patients aged from 50 to 80 years who were eligible for TLE. The patients were randomly assigned into two groups: intervention group (one-puncture of RSB combined with TAPB) and control group (traditional RSB and TAPB). The primary outcome was the duration of the nerve block procedure, and the secondary endpoints in this study included the convenience of the nerve block operation, sufentanil consumption, visual analog scale (VAS) scores at 2, 4, 6, 12, 24 and 48 h after surgery, the Riker Sedation-Agitation Scale (SAS) score, postoperative nausea and vomiting (PONV), the first time of the need for rescue analgesic, time of first PCIA presses, the duration of the postoperative hospital stay, and the incidence of adverse reactions after surgery.

Results

The duration of the nerve block procedure in the intervention group was significantly shorter than that in the control group (182.7 ± 13.9 s vs. 199.4 ± 10.9 s, p = 0.0003), and the convenience of the nerve block operation in the intervention group was significantly higher than that in the control group (p < 0.001). There were no statistically significant differences between the groups in terms of the RSAS score, VAS scores, total analgesic consumption, additional analgesic use, and adverse effects (p > 0.05).

Conclusion

The one-puncture of RSB combined with TAPB could provide sufficient analgesia for patients undergoing TLE, and reduce the duration of the nerve block procedure and enhance the convenience of the nerve block operation compared to the traditional RSB and TAPB.

Evaluation of a multidisciplinary simulation training curriculum for local anesthetic systemic toxicity management: a quasi-experimental study using the Kirkpatrick model in India

BACKGROUND

Local anesthetic systemic toxicity (LAST) is a rare life-threatening complication of regional anesthesia. Simulation-based training offers an effective educational approach to improve the management of infrequent events. This quasi-experimental study assessed the impact of a multidisciplinary simulation-based educational intervention on managing LAST as a real peri-operative team.

METHODS

Twelve anesthesia trainees and eight nursing staff members participated in the study. The intervention included pre-course learning materials, cognitive aids, and immersive simulation scenarios. Simulation scenarios were conducted at baseline (O1), one week after a boot camp (O2), and six months later (O3). Participants' reactions to the training were evaluated using a 5-point Likert scale, while knowledge acquisition was measured through pre- and post-test questionnaires. Team-based skills acquisition and retention were assessed using a modified checklist from the simulation team assessment tool. Data were analyzed using paired t-tests, with P < 0.05 considered statistically significant.

RESULTS

All participants rated the LAST curriculum as satisfactory to very satisfactory. Significant improvements in both technical and non-technical skills were observed post-intervention (O2), with checklist scores increasing from an average of 39 (4.2) (95% confidence interval [CI], 34.88; 43.11) at O1 to 83.5 (5.7) (95% CI, 77.91; 89.08) at O2 (mean difference, 44.5; P < 0.001). At six months (O3), skill retention was indicated by an average score of 72 (7.8) (95% CI, 62.36; 77.64).

CONCLUSIONS

Multidisciplinary, simulation-based educational interventions remarkably improve knowledge and skills related to LAST management, with effective skill retention observed at six months when implemented by multiprofessional teams in real-world settings.

Repeated lidocaine exposure induces synaptic and cognitive impairment in aged mice by activating microglia and neurotoxic A1 astrocytes

In the perioperative setting, the administration of intravenous lidocaine is widespread. This study investigates the effects of varying frequencies of intravenous lidocaine on cognitive function in mice of differing ages. Young adult and aged mice received systemic lidocaine either once or three times. Our findings indicated that repeated exposure to systemic lidocaine in aged mice resulted in cognitive impairment, accompanied by neuronal apoptosis and synaptic loss in the hippocampus. Additionally, repeated lidocaine exposure activated microglia and neurotoxic A1 astrocytes in aged mice. Notably, the adverse effects were significantly diminished when aged mice were treated with dehydroxymethylepoxyquinomicin (DHMEQ), a specific NF-κB inhibitor. Furthermore, depleting microglia with PLX5622 effectively prevented the activation of A1 astrocytes and synaptic loss following lidocaine exposure. This study provides evidence linking age and exposure frequency to cognitive impairment due to systemic lidocaine administration, correlating with the activation of microglia and neurotoxic A1 astrocytes.

The Effect of Transversus Abdominis Plane Block on Pain-Related Outcomes in Kidney Transplantation: A Systematic Review with Meta-Analysis and Trial Sequential Analysis

Background/Objectives: Due to post-surgical discomfort in kidney transplant recipients and donors as well as opioids' multiple side effects, alternative analgesic methods are required in renal transplant surgeries. This study aimed to evaluate the analgesic effect of the transversus abdominis plane (TAP) block versus no-block controls in kidney transplantation patients. Methods: We conducted a meta-analysis with a trial sequential analysis (TSA) of randomized controlled trials (RCTs). We searched for relevant articles in PubMed, Scopus, and the Cochrane Library published before December 2023. Protocol registration: doi.org/10.17605/OSF.IO/PMZJ4. Results: A total of 11 RCTs were included in the meta-analysis. The TAP block group had lower pain intensity on postoperative day 1 (mean difference, MD = -0.65 [-0.88, -0.42]; p < 0.00001) than the control group. However, the heterogeneity among the included studies was considerable (I2 = 93%). Subgroup meta-analysis and TSA revealed a significant pain reduction at 24 h postoperatively in donors (MD = -0.70 [-1.16, -0.24]; p = 0.003); heterogeneity was substantial (I2 = 67%). The TAP block group also had lower overall morphine consumption within 24 h (MD = -4.82 [-7.87, -1.77]; p = 0.002) and cumulative 24 h morphine use (MD = -14.13 [-23.64, -4.63]; p = 0.004); however, heterogeneity was considerable (I2 = 98% in both cases). The time to first analgesia (hours) was significantly longer in the TAP block group (MD = 5.92 h [3.63, 8.22]; p < 0.00001, n = 3). There was no significant difference between the groups in postoperative nausea and vomiting (risk ratio, RR = 0.91 [0.49, 1.71]; p = 0.78). Conclusions: TAP block can lower pain intensity and reduce morphine consumption on the first postoperative day in patients undergoing renal transplantation. Pain reduction is especially notable in the subgroup of donors, but the benefits reported are minimum and certainly not clinically relevant. Larger, well-powered RCTs are warranted to confirm these results and evaluate the effect of TAP block in the subgroup of recipients.

Motor-sparing regional anaesthesia for total knee arthroplasty: a narrative and systematic literature review

Total knee arthroplasty is a life-changing surgical procedure that is associated with a high incidence of severe postoperative pain. Key to enhancing recovery after surgery is effective analgesia and early mobilisation. Innovations in motor-sparing regional anaesthesia techniques that have improved recovery include targeted surgical local infiltration analgesia, adductor canal blockade, genicular nerve blocks, and the infiltration between the popliteal artery and posterior capsule of the knee (iPACK) block. This narrative review discusses the current available motor-sparing regional anaesthetic techniques and assesses the evidence supporting each.

Local Anesthetic Systemic Toxicity in an Infant Following a Caudal Block: A Case Report and Review of Literature

Local anesthetic systemic toxicity (LAST) is a rare but serious complication of regional anesthesia, particularly in neonates and infants due to their immature hepatic metabolism, reduced protein-binding capacity, and increased vascular absorption. We report the case of a two-month-old ex-premature infant who developed ventricular fibrillation following a caudal block with bupivacaine during hernia repair and circumcision. Despite negative aspiration tests, systemic absorption of bupivacaine led to toxic plasma concentrations, resulting in sudden cardiovascular collapse without preceding neurological symptoms, a presentation typical in pediatric LAST. Immediate resuscitation, including cardiopulmonary resuscitation, epinephrine, and lipid emulsion therapy, successfully restored normal cardiac rhythm. This case underscores the importance of vigilance, strict adherence to weight-based dosing, and the availability of lipid emulsion therapy in pediatric anesthesia while emphasizing prevention through careful technique, monitoring, and the use of ultrasound guidance to minimize the risk of this life-threatening complication.

Costoclavicular block for distal radius open reduction and internal fixation

Interscalene and supraclavicular brachial plexus nerve blocks are routinely used for upper extremity surgeries, although they carry the risk of phrenic nerve involvement, which can lead to diaphragmatic paralysis. The costoclavicular block is a newer block that may mitigate the risk of this complication while providing similar coverage. Our case involves a patient who presented with a displaced distal radius fracture. He received a preoperative single-shot costoclavicular nerve block before undergoing a distal radius open reduction and internal fixation. The patient did not require any opioids or other pain medications intraoperatively or postoperatively in the post-anesthesia care unit. This case supports the utility of using a costoclavicular nerve block for upper extremity surgeries.

The Study of Ropivacaine Pharmacokinetics in a Clinical Setting: A Critical Scoping Review from the Perspective of Analytical Methodologies

Ropivacaine, a widely used regional anesthetic also used for pain management, has been increasingly used in recent years due to its increased efficacy and improved safety compared to similar anesthetics. Biomonitoring of ropivacaine and its metabolites during and after anesthesia is an essential process for ensuring therapeutic efficacy and safe usage for patients. The most useful biomonitoring tool in recent years has been liquid chromatography coupled with mass spectrometry (LC-MS/MS), which offers selectivity, sensitivity, as well as accuracy of measurements. The current manuscript summarizes and discusses the existing liquid chromatographic methods described in the literature, as well as the personal experience with developing bioanalytical and analytical methods for the quantification of ropivacaine in biological samples for clinical applications. It is focused on methodological aspects, recent advancements, challenges, and future perspectives, highlighting the importance of LC-MS/MS techniques in ropivacaine analysis.

Simulated bupivacaine pharmacokinetics after labor epidural analgesia followed by transversus abdominis plane block with liposomal bupivacaine for intrapartum cesarean delivery

STUDY OBJECTIVE

To simulate bupivacaine pharmacokinetics in scenarios of labor epidural analgesia (LEA) extended for intrapartum cesarean delivery (CD) with epidural or intrathecal boluses, followed by transversus abdominis plane (TAP) block with liposomal bupivacaine (LB) for postcesarean analgesia.

DESIGN

Bupivacaine plasma concentrations were simulated using a 2-compartment distribution model fit to previous study data.

SETTING

Virtual pharmacokinetic simulations.

PATIENTS

Virtual individuals (1000, each scenario) had uniform weight (80 kg) but varying absorption parameters.

INTERVENTIONS

The 6 scenarios varied in LEA infusion duration (6 or 24 h), local anesthetic used for bolus to extend LEA (epidural lidocaine or intrathecal bupivacaine), TAP block regimen, and time between bolus and TAP block.

MEASUREMENTS

Scenario outcomes included geometric mean (GM) peak bupivacaine plasma concentration (Cmax) with 95% prediction interval (PI), median (range) Cmax, and number of virtual individuals (per 1000) with Cmax reaching estimated toxicity thresholds (neurotoxicity: 2000 μg/L; cardiotoxicity: 4000 μg/L).

MAIN RESULTS

In simulated scenarios of LEA infusion for 24 h with an epidural bolus of lidocaine 400 mg for CD followed 1 h later by TAP block, the GM Cmax for the scenarios with TAP blocks including either LB 266 mg plus bupivacaine hydrochloride 52 mg or bupivacaine hydrochloride 104 mg was 1860 (95% PI, 1107-3124) and 1851 (95% PI, 1085-3157) μg/L, respectively. Among 1000 virtual individuals for each scenario, 404 and 401 had Cmax reaching 2000 μg/L, respectively; 1 and 0 had Cmax reaching 4000 μg/L, respectively. For other scenarios, GM Cmax remained <1000 μg/L.

CONCLUSIONS

Across 6 different simulations of TAP blocks for intrapartum CD analgesia, LEA with bupivacaine (with or without boluses for extension and including a conservative modeling of lidocaine without epinephrine), followed by TAP block with LB and/or bupivacaine hydrochloride 0, 1, or 2 h after CD, is unlikely to result in bupivacaine plasma concentrations reaching local anesthetic systemic toxicity thresholds in healthy patients.

Critical patient safeguards for ambulatory surgery centers

PURPOSE OF REVIEW

The role of ambulatory surgery centers in surgical care is evolving, as lower facility fees and improved patient experience increase the popularity of these venues. As care expands in ambulatory surgery center, so does the complexity of cases and patients cared for in these centers, which may pose a risk for patient safety. Anesthesiologists should lead multidisciplinary teams to screen for appropriate patients and procedures.

RECENT FINDINGS

Patient considerations go beyond physical status and include psychosocial factors. Ensuring patients understand preoperative instructions is crucial to decrease case cancellation rates and facilitate efficiency. Pediatric patients require special considerations including extra attention to preprocedure and postoperative care and instructions, PALS-certified staff, pediatric equipment and medications, as well as heightened awareness of respiratory complications.

SUMMARY

Procedural concerns start with the capabilities of the facility such as equipment, pharmacy, and staffing for each phase of care. However, nuances such as patient throughput in a given day, emergency preparedness, and after-hours staffing will affect both patient safety and staff morale. This article outlines the issues leaders need to consider to ensure patient safety in ambulatory surgery centers.

Incidence of local anesthetic systemic toxicity in patients receiving bupivacaine infiltration analgesia for total joint arthroplasty under general anesthesia: a retrospective single-center study

BACKGROUND

Local infiltration analgesia (LIA) is a crucial component of multimodal analgesia that enhances recovery after total hip arthroplasty (THA) and knee arthroplasty (TKA). However, LIA can cause fatal local anesthetic systemic toxicity (LAST). The incidences of LIA-induced LAST in different surgeries and anesthetic agents have not been well investigated.

METHODS

This observational study enrolled 1,267 adult patients who received LIA with bupivacaine for primary THA or TKA under general anesthesia at a single medical center between January 2020 and October 2021. LAST incidence was graded by severity: severe (refractory seizure or arrhythmia requiring lipid rescue), major (seizure or arrhythmia requiring prompt medication), and minor (all other) events. Patient demographics, surgical and anesthesia details, recovery profiles, and LAST incidences were recorded and analyzed.

RESULTS

The incidence of severe LAST events was 2.41 per 1000 in unilateral THA, 0 in TKA, and 3.16 per 1000 in the entire cohort. The odds ratio of developing major LAST events was 4.35 in patients undergoing unilateral THA compared with those undergoing unilateral TKA in a matched comparison. Patients who underwent bilateral THA had the highest risk of developing LIA-induced LAST. Additionally, patients using propofol infusion for anesthesia maintenance had a lower risk of seizures and tremors than those using sevoflurane inhalation. The odds ratio of major LAST events was 0.47 in matched comparisons.

CONCLUSIONS

LIA was associated with a significantly higher risk of LAST in the THA group than in the TKA group. Propofol maintenance reduces the likelihood of seizures and tremors compared with sevoflurane inhalation. Exploring strategies to reduce the incidence of LIA-induced LAST is essential to improve perioperative patient safety.

The use of lipid emulsion therapy in severe hydroxychloroquine overdose - a narrative review of case reports

INTRODUCTION

Hydroxychloroquine has cardiac and cerebral sodium channel- and human ether-à-go-go-related gene (HERG) potassium channel-blocking effects. This causes depolarization delays, resulting in cardiovascular toxicity with potentially fatal consequences. Despite several supportive care options, hydroxychloroquine poisoning remains difficult to treat. Its high lipid solubility suggests that lipid emulsion therapy might be beneficial; however, no clear evidence regarding its efficacy is available. The aim of this review is to assess the evidence, the outcomes, and adverse events regarding the use of intravascular lipid emulsion therapy as a treatment for hydroxychloroquine poisoning.

METHODS

We conducted a systematic search in PubMed, Embase.com, Cochrane Central Register of Controlled Trials (CENTRAL)/Wiley, Web of Science Core Collection/Clarivate Analytics, and Scopus/Scopus.com from inception until 1 November 2023. We adhered to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Inclusion criteria encompassed original observational or interventional studies, case series and case reports describing patients receiving lipid emulsion therapy for hydroxychloroquine toxicity. We extracted clinical data and performed a quality assessment of the included cases. We present the results as a narrative synthesis.

RESULTS

Of 157 identified articles, 16 case reports met the inclusion criteria, reporting on 18 patients. Lipid emulsion therapy was always associated with additional treatments, and detailed information on the circumstances regarding the administration of intravenous lipid emulsion and its presumed effect was often lacking. Fifteen of 18 patients survived to hospital discharge. Some reports described clear and almost immediate clinical improvement after intravenous lipid emulsion administration. No clear adverse effects were reported.

DISCUSSION

A limitation is the reliance on case reports, which varied in the degree of reported details. The administration of multiple therapeutic drugs in most cases made it difficult to attribute survival primarily to lipid emulsion. Publication bias may favour cases with successful outcomes.

CONCLUSION

Among published case reports, most patients who received lipid emulsion for treatment of hydroxychloroquine poisoning survived. The risk of bias, the small number of reports, and the lack of systematic reporting of both favourable and adverse effects limit any conclusions about the effectiveness of lipid emulsion for hydroxychloroquine poisoning.

The preventive efficacy of lipid emulsion on the occurrence of local anesthetic systemic toxicity in patients receiving local infiltration analgesia for total joint arthroplasty

BACKGROUND

Motor-sparing local infiltration analgesia (LIA) enhances recovery after total hip arthroplasty (THA) and total knee arthroplasty (TKA). However, LIA can induce local anesthetic systemic toxicity (LAST), sometimes necessitating rescue lipid emulsion therapy. Our institute initiated a pilot study to pretreat patients with lipid emulsion (SMOFlipid®) to test its efficacy in mitigating LIA-induced LAST events.

METHODS

This retrospective study enrolled 1,621 adult patients who received LIA with bupivacaine (2-3 mg/kg, maximum 300 mg) for unilateral primary THA or TKA under general anesthesia between January 2020 and April 2022. A total of 439 patients received lipid pretreatment, while 1,182 did not. Demographics, surgical and anesthesia profiles, along with LAST events affecting the neurological, cardiovascular, and respiratory systems, were compared after propensity score matching for age, sex, body mass index (BMI), and surgery type.

RESULTS

The incidence of severe LAST events requiring rescue lipid emulsion slightly decreased after lipid pretreatment (from 2.54 to 2.28 per 1000). Lipid pretreatment significantly reduced the incidence of bradycardia and new-onset arrhythmia (odds ratio: 0.13, adjusted p-value: 0.024) but increased postoperative opioid requirement (odds ratio: 1.71, adjusted p-value: 0.032) after Benjamini-Hochberg correction for multiplicity.

CONCLUSIONS

The efficacy of lipid pretreatment (SMOFlipid® 1.5 ml/kg, maximum 100 ml) in mitigating LIA-induced LAST remains controversial. While lipid pretreatment reduced the incidence of new-onset arrhythmia, it showed no clear benefits for neurologic and respiratory outcomes. Additionally, lipid pretreatment might hinder postoperative recovery by increasing the need for rescue opioid analgesia. Further prospective pharmacokinetic studies are required to assess plasma bupivacaine concentrations following LIA and lipid pretreatment, examine their relationship to LAST events, and establish the efficacy and safety of lipid pretreatment.

A single center descriptive study of local anesthetic dose in knee arthroplasty: Was there evidence of local anesthetic systemic toxicity?

STUDY OBJECTIVE

Describe dosing of local anesthetic when both a periarticular injection (PAI) and peripheral nerve block (PNB) are utilized for knee arthroplasty analgesia, and compare the dosing of local to suggested maximum dosing, and look for evidence of local anesthetic systemic toxicity (LAST).

DESIGN

A single center retrospective cohort study between May 2018 and November 2022.

SETTING

A major academic hospital.

PATIENTS

Patients who had both a PAI and PNB while undergoing primary, revision, total, partial, unilateral, or bilateral knee arthroplasty.

INTERVENTIONS

None.

MEASUREMENTS

Calculate the dose of local anesthetic given via PAI, PNB, and both routes combined as based on lean body weight and compare that to the suggested maximum dosing. Look for medications, clinical interventions, and critical event notes suggestive of a LAST event.

MAIN RESULTS

There were 4527 knee arthroplasties where both a PAI and PNB were performed during the study period. When combining PAI and PNB doses, >75% of patients received more than the suggested maximum dose of 3 mg/kg lean body weight. The median local anesthetic dosing over the study period, 4.4 mg/kg (IQR 3.5,5.9), was 147% of the suggested maximum dose (IQR 117,197). There was no conclusive evidence of LAST among any of the patients in the study.

CONCLUSIONS

Over the course of our study, we had 4527 knee arthroplasties with a median PAI and PNB local anesthetic dose that was 147% of the suggested maximum without any clear clinical evidence of a LAST event.

Adductor canal block combined with genicular nerve block versus local infiltration analgesia for total knee arthroplasty: a randomized noninferiority trial

OBJECTIVE

This randomized controlled and double-blind study aimed to investigate whether the analgesic effect of the adductor canal block (ACB) combined with the genicular nerve block (GNB) after total knee arthroplasty is noninferior to that of the adductor canal block combined with local infiltration analgesia (LIA).

METHODS

A total of 102 patients undergoing total knee arthroplasty under general anesthesia were included and randomly divided into: ACB + GNB and ACB + LIA groups; the ACB + LIA group received 80 mL of 0.2% ropivacaine with adrenaline 10 µg/mL for LIA, whereas the ACB + GNB group received 4 mL of 0.2% ropivacaine for the blockade of five peri-knee nerves. The primary outcome was the median difference in the visual analog scale scores at rest at 24 h between the two groups. Secondary outcomes involved the median differences in the pain scores at other time points. Other outcomes included the cumulative dosage of opioids calculated in morphine equivalents in the first 24 h and indicators related to knee joint functional recovery.

RESULTS

In total, 36 and 38 patients were included in the ACB + GNB and ACB + LIA groups, respectively. We found that the median difference (95% confidence internal) in postoperative rest pain at 24 h (noninferiority criteria, △ = 1) was - 0.5 (- 1 to 0, p = 0.002). The median difference in cumulative opioid consumption was 1 mg (- 1 to 3, p = 0.019), meeting the noninferiority criteria, △ = 7.7 mg.

CONCLUSIONS

ACB combined with GNB provides noninferior analgesia compared to ACB with LIA on the first day after total knee arthroplasty while significantly reducing local anesthetic use.

TRIAL REGISTRATION

Name of the Registry: Chinese Clinical Trial Registry; Trial Registration Number: ChiCTR2300074274; Date of Registration. August 2, 2023.

Local Anesthetic Systemic Toxicity in Pregnancy: A Retrospective Cohort Analysis

Introduction Local anesthetic systemic toxicity (LAST) is a rare complication of regional anesthesia. Pregnancy is a risk factor due to gestational physiologic changes. Labor and disorders of pregnancy can mask or delay symptoms of LAST, slowing appropriate intervention. This study examines LAST within a larger cohort and identifies features that help distinguish LAST in pregnant women from LAST in nonpregnant patients. Methods The TriNetX database was used to compare pregnant and nonpregnant patients with LAST from 2013 to 2023. Cohorts were matched on age, race, obesity status, diabetes, metabolic disorders, local anesthetic type, and cardiovascular, liver, kidney, and respiratory disease. Outcomes included prodromal symptoms of LAST and symptoms of cardiac and central nervous system excitation and depression. Results Matching occurred for 276 pregnant and 276 nonpregnant patients. Pregnant cohorts had a significantly higher risk of cardiac depression (risk ratio (RR)=1.96 (95% confidence interval (CI): 1.44-2.66), p<0.01) and significantly lower risk of cardiac excitation (RR=0.38 (95% CI: 0.22-0.63), p<0.01), prodromal symptoms (RR=0.17 (95% CI: 0.09-0.33), p<0.01), central nervous system excitation (RR=0.44 (95% CI: 0.21-0.90), p=0.02), and central nervous system depression (RR=0.24 (95% CI: 0.13-0.48), p<0.01) than nonpregnant cohorts. Conclusion Pregnant patients with LAST were more likely to exhibit cardiac depression and less likely to manifest prodromal symptoms, cardiac excitation, and central nervous system excitation and depression than nonpregnant patients. Physiological changes during pregnancy and prompt detection and treatment may explain these differences. These findings highlight the variable nature of LAST and how pregnancy may influence its clinical presentation.

Advancing pain management for extremity trauma: the evolution of ultrasound-guided nerve blocks for patients in the supine position in trauma centers

PURPOSE

Trauma, particularly extremity trauma, poses a considerable challenge in healthcare, especially among young adults. Given the severity of patient pain and the risks associated with excessive opioid use, managing acute pain in trauma centers is inherently complex. This study aims to investigate the application and benefits of ultrasound-guided nerve blocks for early pain management in patients with extremity trauma positioned supine.

METHODS

A comprehensive literature review was conducted to assess the effectiveness and advantages of ultrasound-guided peripheral nerve blocks in the acute pain management of extremity trauma patients in the supine position. Special emphasis was placed on evaluating the selection criteria, indications, contraindications, adverse reactions, and potential complications associated with these nerve block techniques.

RESULTS

Ultrasound-guided nerve blocks represent a safer and more precise option for managing pain in extremity trauma patients placed in the supine position. These techniques offer significant advantages in terms of reducing healthcare expenses, diminishing reliance on opioid medications, and mitigating opioid-related complications. Nonetheless, challenges may arise due to the necessity for patient cooperation during specific nerve block procedures.

CONCLUSION

Ultrasound-guided nerve blocks present a promising avenue for early pain management in extremity trauma patients positioned supinely. Their implementation can lead to improved patient outcomes by alleviating pain severity, reducing opioid consumption, and cutting down healthcare costs. Further research and clinical integration of these techniques is imperative to enhance pain management protocols in trauma centers.

Addressing human factors in the recognition and management of local anaesthetic systemic toxicity

In the perioperative environment, local anaesthetics are commonly administered to patients to provide analgesia and anaesthesia for a large range of surgical procedures. Although rare, their use can result in systemic toxicity, which is a life-threatening complication, underscoring the importance of early recognition and prompt management to mitigate patient risks. This article evaluates the impact of human factors and other aspects such as insufficient monitoring, errors in drug administration and poor adherence to safety protocols on the development and management of local anaesthetic systemic toxicity and provides practical considerations to minimise its occurrence.

Investigation of the Protective Effects of Magnesium on Bupivacaine-Induced Toxicity at the Level of Colon Cell Culture

The primary objective of this in vitro study was to prevent the risk of toxicity associated with bupivacaine, widely used in clinical practice, by using magnesium (Mg), a readily available and cost-effective element, as an adjuvant. We hypothesized that Mg might exhibit a protective effect against cytotoxicity in a colon cell culture model under conditions of bupivacaine-induced LAST. Our secondary aim was to investigate its effect on genotoxicity, apoptosis, and iROS. CCD-18Co cells were used in our study. Control group (group C), Bupivacaine group (group B), Magnesium group (group M), and Bupivacaine+Mg group (group BM) were created. The viability of CCD-18Co cells incubated for 24 h in group C was determined to be 100%. These cells were evenly divided, and bupivacaine was administered to group B at concentrations of 5 to 300 μM. In group M, doses of Mg at 0.625 to 320 mEq were added. It was determined that the maximum viability was observed at a Mg dose of 40 mEq (p < 0.05). In group BM, bupivacaine was administered at the same concentrations in combination with Mg (40 mEq), and cell viability was measured. DNA damage, apoptosis, and iROS were assessed at concentrations of bupivacaine by administering 40 mEq Mg. In group B, viability decreased dose-dependently in CCD-18Co (p < 0.05, p < 0.01, p < 0.001). In group BM, the viability decreased in cells at increasing concentrations compared to group C (p < 0.05, p < 0.01, p < 0.001), but the viability was affected positively compared to group B (p < 0.05). In group B, DNA damage increased (p < 0.05, p < 0.001). In group BM, DNA damage increased (p < 0.05, p < 0.001). However, in group BM, DNA damage levels were reduced compared to group B (p < 0.05, p < 0.01). In group B, apoptosis increased (p < 0.05, p < 0.001); in group BM, apoptosis increased (p < 0.001) compared to group C. However, in group BM, apoptosis decreased compared to group B (p< 0.05). iROS increased in group B (p < 0.05, p < 0.01, p < 0.01) and group BM (p < 0.05, p < 0.01, p < 0.001) compared to the group C. However, in group BM, iROS decreased in comparison to group B (p < 0.05). In conclusion, Mg exhibits a protective effect against bupivacaine-induced toxicity.

Brazilian Consensus on the Application of Thermal Ablation for Treatment of Thyroid Nodules: A Task Force Statement by the Brazilian Society of Interventional Radiology and Endovascular Surgery (SOBRICE), Brazilian Society of Head and Neck Surgery (SBCCP), and Brazilian Society of Endocrinology and Metabolism (SBEM)

There is increasing interest in ultrasound-guided ablation treatments for thyroid diseases, including benign and malignant ones. Surgeons, radiologists, and endocrinologists carry out these treatments, and various organizations within these specialties have recently released multiple international consensus statements and clinical practice standards. The aim of the present consensus statement is to provide guidance, cohesion, and standardization of best practices for thermal ablation procedures of thyroid nodules. The statement includes the indications for these procedures, preprocedural evaluations, technical aspects of the procedures, posttreatment care, follow-up, complications, and training recommendations. This document was written by a panel of specialists from the Brazilian Society of Interventional Radiology and Endovascular Surgery (SOBRICE), the Brazilian Society of Head and Neck Surgery (SBCCP), and the Brazilian Society of Endocrinology and Metabolism (SBEM). The statement does not aim to provide criteria for assessing the capability of specialists to perform the procedure. Instead, it aims to promote the standardization of best practices to reduce potential adverse outcomes. Additionally, it strives to enhance the delivery of high-quality care and the widespread adoption of these technologies on a national level. The recommendations collectively serve as a guidebook for applying best practices in thyroid ablation.

Awake Combined Spinal Caudal Anesthesia for Longer-Duration Urologic Surgery in Infants: A Case Series

Awake combined spinal caudal anesthesia has been used as an anesthetic technique for longer-duration infraumbilical surgeries in infants. Literature on the safety and feasibility of this technique is limited. We share our experience with 27 infants undergoing longer-duration urologic surgery using awake combined spinal and caudal anesthesia without the use of systemic sedatives or inhalational agents. We describe our technique, safety considerations, and details surrounding the optimal timing of caudal catheter activation for prolongation of surgical anesthesia.

Regional Anesthesia Complications and Contraindications

Regional anesthesia has a strong role in minimizing post-operative pain, decreasing narcotic use and PONV, and, therefore, speeding discharge times. However, as with any procedure, regional anesthesia has both benefits and risks. It is important to identify the complications and contraindications related to regional anesthesia, which patient populations are at highest risk, and how to mitigate those risks to the greatest extent possible. Overall, significant complications secondary to regional anesthesia remain low. While a variety of different regional anesthesia techniques exist, complications tend to fall within 4 broad categories: block failure, bleeding/hematoma, neurological injury, and local anesthetic toxicity.

Continuous Catheter Techniques

Continuous peripheral nerve block catheters are simple in concept: percutaneously inserting a catheter adjacent to a peripheral nerve. This procedure is followed by local anesthetic infusion via the catheter that can be titrated to effect for extended anesthesia or analgesia in the perioperative period. The reported benefits of peripheral nerve catheters used in the surgical population include improved pain scores, decreased narcotic use, decreased nausea/vomiting, decreased pruritus, decreased sedation, improved sleep, and improved patient satisfaction.

The possible therapeutic role of intravenous lipid emulsion in acute aluminium phosphide poisoning: a randomized controlled clinical trial

Introduction

Aluminum phosphide (ALP) is a highly toxic rodenticide and the mortality rates caused by it have been demonstrated up to 70-100% in various studies. Unfortunately, there is no specific antidote to manage its toxic effects. This study aimed to assess the biochemical and clinical efficacy and safety of intravenous lipid emulsion as an adjuvant therapy in acute aluminum phosphide poisoning.

Patients and methods

Sixty-four cases with acute ALP poisoning were stratified according to severity by the Poison Severity Score into severe and moderate groups (32 patients each). Patients were then randomly allocated into either receiving intravenous lipid emulsion in addition to the conventional treatment or receiving the conventional treatment only by using block randomization.

Results

Treatment by ILE resulted in a significant improvement in the survival time, the mean arterial blood pressure, arterial blood gases, and a significant reduction in serum lactate levels. The need for intubation and mechanical ventilation was insignificantly lower in the intervention groups compared to control groups. However, the reduction in mortality rate in the patients of intervention groups compared with control groups was found to be non-significant. Intravenous lipid emulsion use in acute ALP poisoning significantly prolonged the survival time, improved the metabolic acidosis, decreased the serum lactate levels and increased the mean arterial blood pressure and hospital stay in the intervention groups. And insignificantly decreased the mortality rate, need of intubation and mechanical ventilation, and the total dose of vasopressors.

Local Anesthetics, Local Anesthetic Systemic Toxicity (LAST), and Liposomal Bupivacaine

Local anesthetics have played a vital role in the multimodal analgesia approach to patient care by decreasing the use of perioperative opioids, enhancing patient satisfaction, decreasing the incidence of postoperative nausea and vomiting, decreasing the length of hospital stay, and reducing the risk of chronic postsurgical pain. The opioid-reduced anesthetic management for perioperative analgesia has been largely successful with the use of local anesthetics during procedures such as peripheral nerve blocks and neuraxial analgesia. It is important that practitioners who use local anesthetics are aware of the risk factors, presentation, and management of local anesthetic systemic toxicity (LAST).

An in vitro study to determine the impact of lipid emulsion on partitioning of a broad spectrum of drugs associated with overdose

Background

Intravenous lipid emulsion is recognised as a therapy for rescue in cases of local anaesthetic toxicity, but its use in reversing overdose or toxicity related to other drugs remains the subject of debate. This in vitro study sought to expand our understanding of the importance of partitioning in determining the impact of intravenous lipid emulsion on aqueous free drug concentrations.

Methods

Twenty-seven drugs and associated metabolites were screened for the ability of intravenous lipid emulsion to reduce the amount of free drug in the aqueous phase, using specialised cassettes designed for this purpose. The relative amount of drug equilibrating across the membrane from plasma to phosphate-buffered saline was measured, using liquid chromatography-mass spectrometry, at a 6 h timepoint in plasma samples treated with intravenous lipid emulsion and paired, untreated controls.

Results

The data obtained were plotted against measures of partition (LogP and cLogD7.4) and with log-transformed non-protein bound drug. There were significant inverse correlations between the capacity for intravenous lipid emulsion to reduce drug detected in the phosphate-buffered saline compartment and LogP and cLogD7.4, and a direct association with log [non-protein-bound drug]. However, a number of drugs showed substantial variance between different plasma samples.

Conclusions

Modulation of free drug in the aqueous compartment is broadly predictable by the partition coefficient, although ramipril was identified to be an outlier in this regard. Further mechanistic and clinical exploration is merited to establish a standardised protocol for lipid emulsion therapy.

Implementation of an Ultrasound-Guided Regional Anesthesia Program in the Emergency Department of a Community Teaching Hospital

STUDY OBJECTIVE

We sought to initiate an emergency department (ED)-based ultrasound-guided regional anesthesia (UGRA) program in our community teaching hospital system. Here, we present our development process and protocol. We also sought to assess the types, indications, and associated adverse event rates for the UGRA procedures in this study.

METHODS

We conducted a retrospective analysis of prospectively collected quality assurance data from a case series of patients who underwent an UGRA procedure in the ED. In August 2020, we developed an UGRA program for our community teaching hospital and its 2 affiliated freestanding EDs. For quality assurance purposes, we tracked all UGRA procedures performed in the ED, and we specifically assessed adverse events using structured follow-up. We subsequently obtained approval from our institutional review board to perform chart reviews of the patients in our dataset to abstract additional data and formally perform a research study. We determined the frequency with which different UGRA procedures were performed, and we calculated the adverse event rate.

RESULTS

Between August 24, 2020, and July 15, 2022, a total of 18 different sonographers performed and documented 229 UGRA procedures on 206 unique patients. This included 28 different types of procedures. Follow-up after disposition was successful in 82.0% of patients. In 2 cases, the patient reported no pain relief at all from the procedure, but no patients reported complications related to the procedure.

CONCLUSION

We successfully initiated a robust ED-based UGRA program in our community teaching hospital system. Among patients with successful follow-up, no adverse events were identified.

Apparent local anesthetic systemic toxicity following activation of an epidural catheter for cesarean delivery: diagnosis and management of an uncommon obstetric anesthesia complication

We present a 25-year-old, gravida 2, para 1 woman who developed apparent local anesthetic systemic toxicity (LAST) following activation of an epidural catheter for an urgent cesarean delivery. The patient had a height of 150 cm, weight of 92 kg, body mass index of 41 kg/m2, and calculated ideal body weight of 40 kg. A combined spinal epidural anesthetic was placed and the spinal component did not provide anesthesia to clamping of the abdomen. Subsequently, 300 mg of lidocaine was administered through the epidural catheter in three 5 mL doses over 8 minutes and surgery commenced. Approximately 30 minutes following the final 5 mL dose of epidural lidocaine, the patient had progressive loss of consciousness and was difficult to arouse. A presumptive diagnosis of LAST was made, and 60 mL of 20% intravenous lipid emulsion was administered. The patient's mental status improved to baseline within 5 minutes of lipid emulsion administration, and she made a complete recovery. Anesthesiologists should consider using ideal body weight when calculating the maximum dosage of local anesthetics, and LAST should be part of the differential diagnosis when patients have altered mental status in the setting of local anesthetic administration that exceeds recommended dosages.

Loco-Regional Anesthesia for Pain Management in Robotic Thoracic Surgery

Robotic thoracic surgery is a prominent minimally invasive approach for the treatment of various thoracic diseases. While this technique offers numerous benefits including reduced blood loss, shorter hospital stays, and less postoperative pain, effective pain management remains crucial to enhance recovery and minimize complications. This review focuses on the application of various loco-regional anesthesia techniques in robotic thoracic surgery, particularly emphasizing their role in pain management. Techniques such as local infiltration anesthesia (LIA), thoracic epidural anesthesia (TEA), paravertebral block (PVB), intercostal nerve block (INB), and erector spinae plane block (ESPB) are explored in detail regarding their methodologies, benefits, and potential limitations. The review also discusses the imperative of integrating these anesthesia methods with robotic surgery to optimize patient outcomes. The findings suggest that while each technique has unique advantages, the choice of anesthesia should be tailored to the patient's clinical status, the complexity of the surgery, and the specific requirements of robotic thoracic procedures. The review concludes that a multimodal analgesia strategy, potentially incorporating several of these techniques, may offer the most effective approach for managing perioperative pain in robotic thoracic surgery. Future directions include refining these techniques through technological advancements like ultrasound guidance and exploring the long-term impacts of loco-regional anesthesia on patient recovery and surgical outcomes in the context of robotic thoracic surgery.

Local Anesthetic Systemic Toxicity (LAST): More Common Than You Think

The number of anesthetic body procedures in the United States is rapidly increasing, with many being performed on an outpatient basis. These procedures are advertised as being safe, and many times the serious complications may not be discussed. Although local anesthetic systemic toxicity is a rare complication, it is associated with an increase in morbidity. The emergency department staff should be aware of the possibility of this rare complication, as well as the variety of resulting symptoms (from minor to severe), potential sequelae, and appropriate management for patients who have undergone an outpatient anesthetic body procedure. Multiple factors contribute to the development of local anesthetic systemic toxicity, resulting in life-threatening effects on the neurologic and cardiovascular systems. Also, the site of administration, along with the local anesthetic agent used, can impact the risk of the development of local anesthetic systemic toxicity. To minimize the risk and ensure the best possible outcome for these patients, emergency department staff must be highly aware of the mechanisms, risk factors, prevention, and management/treatment of local anesthetic systemic toxicity.

Emerging Insights into Brevetoxicosis in Sea Turtles

This review summarizes the current understanding of how brevetoxins, produced by Karenia brevis during harmful algal blooms, impact sea turtle health. Sea turtles may be exposed to brevetoxins through ingestion, inhalation, maternal transfer, and potentially absorption through the skin. Brevetoxins bind to voltage-gated sodium channels in the central nervous system, disrupting cellular function and inducing neurological symptoms in affected sea turtles. Moreover, the current evidence suggests a broader and longer-term impact on sea turtle health beyond what is seen during stranding events. Diagnosis relies on the detection of brevetoxins in tissues and plasma from stranded turtles. The current treatment of choice, intravenous lipid emulsion therapy, may rapidly reduce symptoms and brevetoxin concentrations, improving survival rates. Monitoring, prevention, and control strategies for harmful algal blooms are discussed. However, as the frequency and severity of blooms are expected to increase due to climate change and increased environmental pollution, continued research is needed to better understand the sublethal effects of brevetoxins on sea turtles and the impact on hatchlings, as well as the pharmacokinetic mechanisms underlying brevetoxicosis. Moreover, research into the optimization of treatments may help to protect endangered sea turtle populations in the face of this growing threat.

Lipid emulsion treatment for local anesthetic systemic toxicity in pediatric patients: A systematic review

BACKGROUND

Local anesthetic systemic toxicity (LAST) is rare, but fatal; the current widely used treatment is lipid emulsion (LE). The goal of this study was to analyze and review case reports on LE treatment for LAST in pediatric patients.

METHODS

We performed a systematic review using case reports on LE treatment for LAST in pediatric patients, searching PubMed and Scopus databases to March 2023 using the following keywords: ("local anesthetic toxicity" OR "local anesthetic systemic toxicity" OR LAST") AND ("newborn" OR "infant" OR "child" OR "children" OR "adolescent" OR "pediatric") AND ("lipid emulsion" OR "Intralipid").

RESULTS

Our search yielded 21 cases, revealing that nearly 43% patients with LAST were less than 1 year old, and most cases were caused by bupivacaine (approximately 67% cases). "Inadvertent intravascular injection" by anesthesiologists and "overdose of local anesthetics" mainly by surgeons were responsible for 52% and 24% cases of LAST, respectively. LAST occurred in the awake state (52%) and under general anesthesia (48%), mainly causing seizures and arrhythmia, respectively. Approximately 55% of patients received LE treatment in <10 minutes after LAST, mainly improving cardiovascular symptoms. A 20% LE (1.5 mL/kg) dose followed by 0.25 mL/kg/minutes dose was frequently used. LE and anticonvulsants were mainly used in the awake state, whereas LE with or without vasopressors was mainly used under general anesthesia. LE treatment led to full recovery from LAST in 20 cases; however, 1 patient died due to underlying disease.

CONCLUSION

Consequently, our findings reveal that LE is effective in treating pediatric LAST.

[Principles of the pharmacology of local anesthetics]

The development of local anesthetics revolutionized the performance of painful interventions. Local anesthetics have an effect on voltage-gated sodium channels in nerve fibers and modulate the conduction of impulses. With respect to the chemical structure, local anesthetics can be divided into amide and ester types. The structural differences of local anesthetics have an influence on the duration of action, the degradation pathways and specific side effects. Severe adverse events include cardiotoxicity and neurotoxicity. In addition to basic measures, such as the monitoring and securing of vital parameters, lipid infusion represents a treatment option in cases of intoxication. The recent developments of local anesthetics are particularly concerned with the reduction of toxicity and prolonging the duration of action.

Intravenous lipid emulsion for local anaesthetic systemic toxicity in pregnant women: a scoping review

BACKGROUND

Local anaesthetic systemic toxicity (LAST) is a rare but life-threatening complication that can occur after local anaesthetic administration. Various clinical guidelines recommend an intravenous lipid emulsion as a treatment for local anaesthetic-induced cardiac arrest. However, its therapeutic application in pregnant patients has not yet been established. This scoping review aims to systematically identify and map the evidence on the efficacy and safety of intravenous lipid emulsion for treating LAST during pregnancy.

METHOD

We searched electronic databases (Medline, Embase and Cochrane Central Register Controlled Trials) and a clinical registry (lipidrescue.org) from inception to Sep 30, 2022. No restriction was placed on the year of publication or the language. We included any study design containing primary data on obstetric patients with signs and symptoms of LAST.

RESULTS

After eliminating duplicates, we screened 8,370 titles and abstracts, retrieving 41 full-text articles. We identified 22 women who developed LAST during pregnancy and childbirth, all presented as case reports or series. The most frequent causes of LAST were drug overdose and intravascular migration of the epidural catheter followed by wrong-route drug errors (i.e. intravenous anaesthetic administration). Of the 15 women who received lipid emulsions, all survived and none sustained lasting neurological or cardiovascular damage related to LAST. No adverse events or side effects following intravenous lipid emulsion administration were reported in mothers or neonates. Five of the seven women who did not receive lipid emulsions survived; however, the other two died.

CONCLUSION

Studies on the efficacy and safety of lipids in pregnancy are scarce. Further studies with appropriate comparison groups are needed to provide more robust evidence. It will also be necessary to accumulate data-including adverse events-to enable clinicians to conduct risk-benefit analyses of lipids and to facilitate evidence-based decision-making for clinical practice.

Efficacy of erector spine plane block in two different approaches to lumbar spinal fusion surgery: a retrospective pilot study

Background

Erector spine plane block (ESPB) has been widely used in spinal surgery, although there are variable data about its efficacy.

Objectives

This study aimed to evaluate the efficacy of ESPB in elective lumbar spinal fusion surgery patients with two different surgical approaches.

Materials and methods

Retrospectively, 45 elective lumbar transpedicular fusion (TPF) surgery patients undergoing open surgery with different approaches [posterior transforaminal fusion approach (TLIF) or combined posterior and anterior approach (TLIF+ALIF)] were divided into 2 groups: general anesthesia (GA, n = 24) and general anesthesia combined with ESPB (GA + ESPB, n = 21). The primary outcome was to analyze the efficacy of ESPB in two different surgical approaches in terms of pain intensity in the first 48 h. Secondary: Fentanyl-free patients and opioid consumption in the first 24 h postoperatively. Comparative analysis was performed (SPSS® v. 28.0) (p < 0.05).

Results

Out of 45 patients (27 female), 21 received GA + ESPB and 24 received GA. The average age was 60.3 ± 14.3 years. Chronic back pain before the operation was registered in 56% of patients. ESPB was performed in 17 TLIF and in 4 TLIF+ALIF patients. ESPB significantly reduced pain intensity at rest in both surgical approaches 48 h after surgery (p < 0.05). The need for postoperative fentanyl infusion was significantly lower in the group treated with GA + ESPB in both surgical approaches than in those who only received GA (29% vs. 77% in TLIF and 0% vs. 80% in TLIF+ALIF); p = 0.01 and p = 0.004. Additionally, we observed that ESPB provides a good analgesic effect for up to 6.8 ± 3.2 h in the TLIF and 8.9 ± 7.6 h in the TLIF+ALIF approaches. Consequently, ESPB reduced the initiation of the fentanyl compared to GA alone, with a mean difference of 3.2 ± 4.2 h in the TLIF subgroup (p = 0.045) and 6.7 ± 5.3 h in TLIF +ALIF (p = 0.028). Only in the TLIF+ALIF approach, ESPB reduced the total fentanyl consumption compared to those with GA (1.43 ± 0.45 mg/24 h vs. 0.93 ± 0.68 mg/24 h; p = 0.015).

Conclusion

ESPB significantly reduced pain at rest after surgery, the number of patients requiring immediate postoperative fentanyl analgesia, and total fentanyl consumption in both surgical approaches, particularly in TLIF+ALIF. However, the application of ESPB does not always provide completely sufficient analgesia.

Anaesthetic considerations and challenges during awake craniotomy

ABSTRACT

This article summarises the key anaesthetic considerations and challenges surrounding the perioperative management of a patient undergoing awake craniotomy. The main goals include patient comfort, facilitation of patient cooperation during the critical awake phase and maintenance of optimal operating conditions. These are achieved through appropriate patient selection and preparation, familiarity with the complexity of each surgical phase and potential complications that may arise, as well as maintenance of close communication among all team members. Challenges such as loss of patient cooperation, loss of airway, intraoperative nausea and vomiting, seizures, cerebral oedema, hypertension, blood loss and use of intraoperative magnetic resonance imaging are discussed. The importance of teamwork, competence, vigilance and clear management strategies for potential complications to maximise patient outcomes is also highlighted.

Effects of Intravenous Lipid Emulsion Administration in Acute Tramadol Poisoning: A Randomized Controlled Trial

BACKGROUND

As the prevalence of tramadol toxicity is increasing, managing these patients with the aim of treatment and complete recovery has become a major challenge for health care professionals.

OBJECTIVE

This study evaluated the short-term effects of IV lipid emulsion (ILE) administration in cases of tramadol poisoning.

METHODS

In this double-blind, randomized controlled trial, 120 patients with pure tramadol poisoning and a Glasgow Coma (GCS) score ≤ 12 referred to a poisoning center in Tehran, Iran were selected and randomly assigned 1:1 to receive ILE 20% (intervention) or 0.9% saline (control) after admission and primary stabilization. The patient's vital signs, GCS score, hospitalization duration, and rate of seizure occurrence were recorded and compared between the two groups.

RESULTS

Mean (SD) age of participants was 25.3 (5.4) years and 84 (70%) were male. Mean (SD) ingested dose of tramadol was 3118 (244) mg, which was not different between the groups. Compared with controls, the ILE group had a higher level of consciousness after treatment (median [interquartile range] GCS score 12 [10-13] vs. 10 [8-12]; p = 0.03). In addition, length of hospitalization (median [interquartile range] (2 [1-3] days vs. 4 [4-6] days; p < 0.01) and rate of seizure occurrence were lower in the intervention group (16/60 vs. 30/60; p < 0.01).

CONCLUSIONS

In the setting of tramadol poisoning with a decreased level of consciousness and based on our study's findings, administration of ILE is suggested to help manage patients in hospital emergency departments. However, larger trials might be needed to confirm these findings before entering the guidelines.