The impact of timing, type, and method of instillation of intraperitoneal local anaesthetic in laparoscopic abdominal surgery: a systematic review and network meta-analysis

BACKGROUND

Pain is common after laparoscopic abdominal surgery. Intraperitoneal local anaesthetic (IPLA) is effective in reducing pain and opioid use after laparoscopic surgery, although the optimum type, timing, and method of administration remains uncertain. We aimed to determine the optimal approach for delivering IPLA which minimises opioid consumption and pain after laparoscopic abdominal surgery.

METHODS

MEDLINE, Embase, Scopus, and Cochrane Central Register of Controlled Trials (CENTRAL) databases were systematically searched for randomised controlled trials comparing different combinations of the type (bupivacaine vs lidocaine vs levobupivacaine vs ropivacaine), timing (pre-vs post-pneumoperitoneum at the beginning or end of surgery), and method (aerosol vs liquid) of IPLA instillation in patients undergoing any laparoscopic abdominal surgery. A network meta-analysis was conducted to ascertain the optimum approach for delivering IPLA resulting in the least cumulative opioid consumption and pain (overall and localising to the shoulder) 24 h after surgery. Certainty of evidence was evaluated using Grading of Recommendations, Assessment, Development, and Evaluations (GRADE) assessments (PROSPERO ID: CRD42022307595).

RESULTS

Twenty-five RCTs were included, among which 15 different combinations of delivering IPLA were analysed across 2401 participants. Aerosolised bupivacaine instilled at the end of surgery, before deflation of the pneumoperitoneum, was associated with significantly less postoperative opioid consumption compared with all other approaches for delivering IPLA (98.7% of comparisons; moderate certainty), aside from liquid levobupivacaine instilled before surgery and during or after creation of the pneumoperitoneum (mean difference -11.6, 95% credible interval: -26.1 to 2.5 i.v. morphine equivalent doses). There were no significant differences between different IPLA approaches regarding overall pain scores and incidence of shoulder pain up to 24 h after surgery.

CONCLUSIONS

There are limited studies and low-quality evidence to conclude on the optimum method of delivering IPLA in laparoscopic abdominal surgery. While aerosolised bupivacaine instilled at the end of surgery but before deflation of the pneumoperitoneum minimises postoperative opioid consumption, pain scores up to 24 h did not differ between the different modalities of delivering IPLA. The generalisability of these results is limited by the lack of utilisation of non-opioid analgesics in most trials.

SYSTEMATIC REVIEW PROTOCOL REGISTRATION

PROSPERO CRD42022307595.

Safety of blood reinfusion drains after local infiltration analgesia in total joint replacement

BACKGROUND

Local infiltration analgesia (LIA) is frequently administered to patient undergoing joint replacement surgical procedures. The aim of the present research was to verify the safety of collected shed blood to be reinfused postoperatively, by measuring levobupivacaine levels in drainage blood in patients undergoing LIA during knee replacement surgery.

PATIENTS AND METHODS

24 patients who underwent total knee arthroplasty (TKA) and 12 scheduled for total hip arthroplasty (THA) who received intraoperative LIA were considered. Blood samples were collected from shed blood which was present in drainage 2 and 5 hours after surgery and serum was analysed by liquid chromatography-tandem mass spectrometry.

RESULTS

At 2 hours postoperatively, the median levobupivacaine serum concentration in the collected shed blood was 1.2 mg/L (SD: 4.2) for TKA and 17.13 mg/L (SD: 24.4) for THA. At 5 hours, levobupivacaine concentration was 1.84 mg/L (SD: 2.2) for TKA and 17.5 mg/L (SD: 25.2) for THA. Higher values of average serum levobupivacaine concentration were reported in drains collected from patients who had undergone THA compared to TKA (p<0.001). BMI significantly influenced levels of serum drug, that resulted to be higher in patients with BMI<25 (p= 0.01).

CONCLUSION

Levobupivacaine from collected shed blood that would have been returned to the patient, was below toxicity level at 2 and 5 hours after LIA during total joint replacement. The average serum levobupivacaine concentration was found to be higher in drains taken from THA patients than TKA patients. Patients with lower BMI demonstrated the highest levels of levobupivacaine in shed blood and a lower blood volume needed for central nervous system toxicity. Therefore, in patients with a lower BMI undergoing THA, anaesthetic dosage should be reduced or autotransfusion should be avoided to prevent potential risks of toxicity.

[Efficacy and safety analysis of bupivacaine liposome for pericapsular nerve group block for postoperative analgesia in elderly patients with hip replacement]

Objective: To investigate the efficacy and safety of bupivacaine liposome for pericapsular nerve group block (PENGB) for postoperative analgesia in elderly patients with total hip replacement. Methods: A total of 42 elderly patients underwent total hip replacement were selected in the Second Affiliated Hospital of Wenzhou Medical University from May to July in 2023, including 19 males and 23 females, aged (68.8±6.3) years, the American Society of Anesthesiologists (ASA) grade Ⅰ to Ⅲ. They were divided into bupivacaine liposome group (observation group) and levobupivacaine hydrochloride group (control group) according to random number table, with 21 cases in each group. All the patients were anesthetized by lumbar anesthesia combined with PENGB. During PENGB, the observation group was injected with 10 ml (133 mg) bupivacaine liposome+5 ml normal saline, and the control group was injected with 10 ml (75 mg) levobupivacaine hydrochloride+5 ml normal saline. The primary outcome measures included the rest and movement visual analogue scale (VAS) scores at 6, 12, 24, 36, 48, 60, and 72 h after operation, the sufentanil consumption in analgesic pump, the numbers of analgesic pump compressions, and the rates of additional parexib sodium use in ward. The secondary outcome measures were the changes in lower limb muscle strength, the length of hospital stay and the occurrence of adverse reactions. Results: There was no significant difference in the rest and movement VAS scores between the two groups at pre-operation and at 6 h after operation (P>0.05);but the rest and movement VAS scores at 12, 24, 36, 48, 60 and 72 h after operation in observation group were significantly lower than those in control group (P<0.05); the rest and movement VAS scores at 6, 12, 24, 36, 48, 60 and 72 h after operation were lower than those at pre-operation in two group (P<0.05). The consumption of sufentanil in analgesic pump and parexib sodium usage in observation group were lower than those in control group at 12, 24, 36 and 48 h after operation (P<0.05). The total number of analgesic pump compressions, the number of effective compressions and the number of ineffective compressions in 48 h in observation group were lower than those in control group (P<0.05). The muscle strength of the lower limbs of all patients were able to move against gravity at 12 h after operation. The incidence of nausea in 48 h after operation in observation group was 9.5% (2/21), which was lower than 42.9% (9/21) in control group (P=0.014). No postoperative vomiting occurred in all patients. The length of the hospital stay was (9.3±2.2) d in observation group and (8.9±1.9) d in control group, and there was no significant difference between the two groups (P=0.500). Conclusion: Compared with levobupivacaine hydrochloride, liposomal bupivacaine in PENGB provides analgesic effects for up to 72 h after total hip replacement in elderly patients, reduces postoperative opioid and other analgesics usage, decreases the incidence of postoperative nausea, and has a minor effect on lower limb movement without prolonging hospitalization.

Comparison of the effect of adding midazolam versus fentanyl to intrathecal levobupivacaine in patients undergoing cesarean section: double-blind, randomized clinical trial

BACKGROUND

Many adjuvants are added to prolong the effects of spinal analgesia. We investigated the postoperative analgesic efficacy of the addition of midazolam or fentanyl to intrathecal levobupivacaine in women undergoing cesarean delivery.

METHODS

Eighty patients were randomly assigned to two groups (n = 40). Group M received 10 mg of 0.5% levobupivacaine plus 2 mg of midazolam. Group F received 10 mg of 0.5% levobupivacaine plus 25 μg of fentanyl. Assessments included motor and sensory block, APGAR score, time to first request for analgesia, postoperative pain score, total consumption of rescue analgesics, and adverse effects.

RESULTS

Sensory blockade was prolonged in Group M compared with Group F (215.58 ± 27.94 vs. 199.43 ± 19.77 min; p = 0.004), with no differences in other characteristics of the spinal block in intraoperative hemodynamics or APGAR score. The mean time to first request for rescue analgesia was longer in Group M (351.45 ± 11.05 min) than in Group F (268.83 ± 10.35 min; p = 0.000). The median total consumption of rescue analgesics in the first 24 hours postoperatively was 30 mg in Group M vs. 60 mg in Group F (p = 0.003). The median Visual Analog Scale (VAS) scores were lower in Group Ethan in Group F from the 8th to the 12th hour postoperatively, with no differences between the groups at other time points. The incidence of adverse effects was higher in Group F than in Group M.

CONCLUSION

Intrathecal midazolam (2 mg) was superior to intrathecal fentanyl (25 μg) in increasing the duration of the sensory blockade and postoperative analgesia with lower postoperative pain scores and decreasing the incidence of adverse effects.

Pre-incisional local infiltration with levobupivacaine in laparoscopic cholecystectomy: a randomized and clinical trial

OBJECTIVE

Laparoscopic cholecystectomy (LC), despite its minimally invasive nature, requires effective control of post-operative pain. The use of local anesthetics (LA) has been studied, but the level of evidence is low, and there is little information on important parameters such as health-related quality of life (HRQoL) or return to work. The objective of the study was to evaluate the efficacy of 0.50% levobupivacaine infiltration of incisional sites in reducing POP after LC.

METHODS

This was a prospective, randomized, double-blind study. Patients undergoing elective LC were randomized into two groups: no infiltration (control group) and port infiltration (intervention group). POP intensity (numerical rating scale, NRS), need for rescue with opioid drugs, PONV incidence, HRQoL, and return to work data, among others, were studied.

RESULTS

Two hundred and twelve patients were randomized and analyzed: 105 (control group) and 107 (intervention group). A significant difference was observed in the NRS values (control group mean NRS score: 3.41 ± 1.82 vs. 2.56 ± 1.96) (p < 0.05) and in the incidence of PONV (31.4% vs. 19.6%) (p = 0.049).

CONCLUSIONS

Levobupivacaine infiltration is safe and effective in reducing POP, although this does not lead to a shorter hospital stay and does not influence HRQoL, return to work, or overall patient satisfaction.

Comparative retrospective review of perioperative analgesia using ultrasound-guided programmed intermittent erector spinae plane block for video-assisted thoracoscopic lobectomy

BACKGROUND

The retrospective cohort study was conducted to estimate the opioid-sparing anesthesia and limited side-effects with ultrasound (US)-guided ESPB using programmed intermittent bolus (PIB) or continuous infusion (CI) and standard opioid-based anesthesia in patients undergoing video-assisted thoracoscopic lobectomy (VATS).

METHODS

Patients underwent VATS were stratified into either control group or one of the two ESPB groups in a 1:2:2 ratio depending on whether PIB was implemented or not. The primary endpoint was intra- and post-operative opioids consumption over the first 48 h following surgery.

RESULTS

A total of 180 cases were included in the analysis. Cumulative perioperative opioid administration was found to be significantly different between PIB, CI and control group (both p < 0.001), and between PIB and CI group (p = 0.028). More specifically, the mean was 305.30 ± 51.35 mg, 339.68 ± 56.07 mg and 468.91 ± 79.84 mg in PIB, CI and control group. NRS scores at rest across all postoperative times were comparable in two ESPB groups, while significantly lower than control group, however, scores during exercising at postoperative 3, 6, 12 h were significantly lower in PIB group as compared to CI group. A wider anesthetized dermatomes with PIB was observed at 6, 24 and 48 h as opposed to the CI. The mean of levobupivacaine plasma concentration was significantly lower for PIB at postoperative 0.5, 12, 24 and 48 h after initiation than CI. However, local anesthetic toxicity was not observed in any of the two ESPB groups.

CONCLUSIONS

When US-guided ESPB using PIB was performed preoperatively, it contributed to the minimization of intra- and post-operative opioid consumption due to better analgesia with a wider anesthetic dermatome opposed to conventional CI, whereas, it was also associated with lower risk of local anesthetic toxicity because of lower plasma concentration of levobupivacaine.

A comparison of intra and postoperative analgesic effects of sacrococcygeal and lumbosacral epidural levobupivacaine in cats undergoing ovariohysterectomy

The aim of this study was to compare the intra and postoperative analgesic effects of sacrococcygeal epidural levobupivacaine with those of lumbosacral levobupivacaine in feline ovariohysterectomy. Thirty-six cats were premedicated with intramuscular acepromazine (0.05 mg/kg) and meperidine (6 mg/kg). Anesthesia was induced with intravenous propofol and maintained with isoflurane in oxygen. The cats were randomly assigned one of the three treatments receiving 0.33% levobupivacaine (0.3 mL/kg) into the sacrococcygeal (S-C group, n=12) or lumbosacral (L-S group, n=12) epidural space, or the same volume of 0.9% saline solution into one of the epidural approaches (Control group, n=12). Intraoperatively, cardiorespiratory variables, end-tidal isoflurane concentration (FE´ISO), and fentanyl requirements were recorded. Postoperative pain was assessed by the UNESP (Universidade Estadual Paulista)-Botucatu multidimensional composite pain scale and the Glasgow feline composite measure pain scale up to 8 hr post-extubation. Morphine was administered as rescue analgesia. Overall FE´ISO and fentanyl requirements were lower in the L-S and S-C compared to the Control (P=0.002-0.048, respectively). There was no significant difference in the cardiorespiratory variables during anesthesia, postoperative pain and rescue analgesia among groups. The time to standing after anesthesia was prolonged in the L-S and S-C groups than in the Control (P<0.001). Lumbosacral and sacrococcygeal epidural levobupivacaine resulted in similar decreases in isoflurane requirements and intraoperative fentanyl supplementation in the cats, with no postoperative benefits.

Efficacy of ultrasound-guided infiltration with levobupivacaine and triamcinolone for myofascial pain syndrome of the quadratus lumborum: a retrospective observational study

INTRODUCTION AND OBJECTIVES

Myofascial Pain Syndrome (MPS) of the Quadratus Lumborum muscle (QL) is a frequent cause of chronic low back pain. With this study, we aimed to assess the efficacy of ultrasound-guided infiltration with 0.25% levobupivacaine and 40.ßmg triamcinolone for MPS of the QL.

METHODS

Observational and retrospective study of participants submitted to ultrasound-guided infiltration of the QL muscle from January 1, 2015 to June 31, 2019. Pain intensity was assessed using the five-point pain Numeric Rating Scale (NRS): pre-intervention, at 72.ßhours, 1 month, 3 months and 6 months post-intervention. Additional data collected were demographic characteristics, opioid consumption, and adverse effects.

RESULTS

We assessed 90 participants with mean age of 55.2 years. Sixty-eight percent of participants were female. Compared to the pre-intervention assessment, there was an improvement in pain at 72.ßhours (Mean Difference [MD.ß=.ß3.085]; 95% CI: 2.200...3.970, p.ß<.ß0.05), at the 1st month (MD.ß=.ß2.644; 95% CI: 1.667...3.621, p.ß<.ß 0.05), at the 3rdmonth (MD.ß=.ß2.017; 95% CI: 0.202...2.729, p.ß<.ß0.05) and at the 6th month (MD.ß=.ß1.339; 95% CI 0.378...2.300, p.ß<.ß0.05), post-intervention. No statistically significant differences in opioid consumption were observed. No adverse effects associated with the technique were reported.

CONCLUSIONS

Ultrasound-guided infiltration of the QL muscle is a safe and effective procedure for the treatment of pain in the QL MPS within 6 months post-intervention.

Chronological changes in plasma levobupivacaine concentrations after bilateral modified thoracoabdominal nerve block through perichondrial approach

The local anesthetic (LA) systemic toxicity of trunk blocks is a major concern. Recently, modified thoracoabdominal nerve block through perichondrial approach (M-TAPA) has attracted attention; however, plasma LA level is unknown. We tested whether the peak plasma LA concentration following M-TAPA, using 25 mL of 0.25% levobupivacaine mixed with epinephrine on each side, would be below the toxic level (2.6 μg/mL). We recruited 10 patients undergoing abdominal surgery with planned M-TAPA between November 2021 and February 2022. In all patients, 25 mL of 0.25% levobupivacaine mixed with 1:200,000 epinephrine was administered on each side. Blood samples were obtained at 10, 20, 30, 45, 60, and 120 min after the block. The highest individual peak and the mean peak plasma LA concentrations were 1.03 and 0.73 μg/mL, respectively. We could not capture the peak in five patients; however, the highest concentrations in all patients were significantly lower than the toxic level. A negative correlation between the peak level and body weight was observed. Our results indicated that the plasma LA concentration following M-TAPA using total of 50 mL of 0.25% levobupivacaine with epinephrine remains below the toxic level. Further research is required due to the small sample size of this study.Trial registry number: UMIN000045406.

Automated mandatory bolus versus basal infusion for maintenance of epidural analgesia in labour

BACKGROUND

Epidural analgesia is often used for pain relief during labour and childbirth, and involves administration of local anaesthetics (LA) into the epidural space resulting in sensory blockade of the abdomen, pelvis, and perineum. Epidural opioids are often co-administered to improve analgesia. Administration of epidural medications can be accomplished by basal infusion (BI) or automated mandatory bolus (AMB). With BI, medications are administered continuously, while AMB involves injecting medications at set time intervals. Patient-controlled epidural analgesia (PCEA) on top of AMB or BI enables patients to initiate additional boluses of epidural medications.  The superior method of delivering epidural medications would result in lower incidence of pain requiring anaesthesiologist intervention (breakthrough pain). Also, it should be associated with lower incidence of epidural-related adverse effects including caesarean delivery, instrumental delivery (use of forceps or vacuum devices), prolonged duration of labour analgesia, and LA consumption. However, clear evidence of the superiority of one technique over the other is lacking. Also, differences in the initiation of epidural analgesia such as combined spinal-epidural (CSE) (medications given into the intrathecal space in addition to the epidural space) compared to epidural only, and medications used (types and doses of LA or opioids) may not have been accounted for in previous reviews.  Our prior systematic review suggested that AMB reduces the incidence of breakthrough pain compared to BI with no significant difference in the incidence of caesarean delivery or instrumental delivery, duration of labour analgesia, and LA consumption. However, several studies comparing AMB and BI have been performed since then, and inclusion of their data may improve the precision of our effect estimates.

OBJECTIVES

To assess the benefits and harms of AMB versus BI for maintaining labour epidural analgesia in women at term.

SEARCH METHODS

We searched CENTRAL, Wiley Cochrane Library), MEDLINE, (National Library of Medicine), Embase(Elseiver), Web of Science (Clarivate), the WHO-ICTRP (World Health Organization) and ClinicalTrials.gov (National Library of Medicine) on 31 December 2022. Additionally, we screened the reference lists of relevant trials and reviews for eligible citations, and we contacted authors of included studies to identify unpublished research and ongoing trials.

SELECTION CRITERIA

We included all randomised controlled studies that compared bolus dosing AMB with continuous BI during epidural analgesia. We excluded studies of women in preterm labour, with multiple pregnancies, with fetal malposition, intrathecal catheters, those that did not use automated delivery of medications, and those where AMB and BI were combined.

DATA COLLECTION AND ANALYSIS

We used standard methodology for systematic review and meta-analysis described by Cochrane. Primary outcomes included: incidence of breakthrough pain requiring anaesthesiologist intervention; incidence of caesarean delivery; and incidence of instrumental delivery. Secondly, we assessed the duration of labour; hourly LA consumption in bupivacaine equivalents, maternal satisfaction after fetal delivery, and neonatal Apgar scores.  The following subgroup analyses were chosen a priori: epidural alone versus CSE technique; regimens that used PCEA versus those that did not; and nulliparous versus combination of nulli- and multi-parous women. We used the GRADE system to assess the certainty of evidence associated with our outcome measures.

MAIN RESULTS

We included 18 studies of 4590 women, of which 13 enrolled healthy nulliparous women and five included healthy nulli- and multiparous women. All studies excluded women with preterm or complicated pregnancies. Techniques used to initiate epidural analgesia differed between the studies: seven used combined spinal epidural, 10 used epidural, and one used dural puncture epidural (DPE). There was also variation in analgesics used. Eight studies utilised ropivacaine with fentanyl, three used ropivacaine with sufentanil, two utilised levobupivacaine with sufentanil, one used levobupivacaine with fentanyl, and four utilised bupivacaine with fentanyl. Most of the studies were assessed to have low risk of randomisation, blinding, attrition, and reporting biases, except for allocation concealment where eight studies were assessed to have uncertain risk and three with high risk. Our results showed that AMB was associated with lower incidence of breakthrough pain compared to BI (risk ratio (RR) 0.71; 95% confidence interval (CI) 0.55 to 0.91; I2 = 57%) (16 studies, 1528 participants), and lower hourly LA consumption in bupivacaine equivalents (mean difference (MD) -0.84 mg/h; 95% CI -1.29 to -0.38, I2 = 87%) (16 studies, 1642 participants), both with moderate certainty. AMB was associated with an estimated reduction in breakthrough pain incidence of 29.1% (incidence 202 per 1000, 95% CI 157 to 259), and was therefore considered clinically significant. The incidence of caesarean delivery (RR 0.85; 95% CI 0.69 to 1.06; I2 = 0%) (16 studies, 1735 participants) and instrumental delivery (RR 0.85; 95% CI 0.71 to 1.01; I2 = 0%) (17 studies, 4550 participants) were not significantly, both with moderate certainty. There was no significant difference in duration of labour analgesia (MD -8.81 min; 95% CI -19.38 to 1.77; I2 = 50%) (17 studies, 4544 participants) with moderate certainty. Due to differences in the methods and timing of outcome measurements, we did not pool data for maternal satisfaction and Apgar scores. Results reported narratively suggest AMB may be associated with increased maternal satisfaction (eight studies reported increased satisfaction and six reported no difference), and all studies showed no difference in Apgar scores. WIth the exception of epidural alone versus CSE which found significant subgroup differences in LA consumption between AMB and BI, no significant differences were detected in the remaining subgroup analyses.

AUTHORS' CONCLUSIONS

Overall, AMB is associated with lower incidence of breakthrough pain, reduced LA consumption, and may improve maternal satisfaction. There were no significant differences between AMB and BI in the incidence of caesarean delivery, instrumental delivery, duration of labour analgesia, and Apgar scores. Larger studies assessing the incidence of caesarean and instrumental delivery are required.

Effect of a continuous perineural levobupivacaine infusion on pain after major lower limb amputation: a randomised double-blind placebo-controlled trial

OBJECTIVES

Randomised controlled trial of the effect of a perineural infusion of levobupivacaine on moderate/severe phantom limb pain 6 months after major lower limb amputation.

SETTING

Single-centre, UK university hospital.

PARTICIPANTS

Ninety patients undergoing above-knee and below-knee amputation for chronic limb threatening ischaemia under general anaesthesia. Exclusion criteria were patients having surgery under neuraxial anaesthesia; inability to operate a patient-controlled analgesia device or complete a Visual Analogue Scale; amputation for trauma or malignancy; or contraindication to levobupivacaine.

INTERVENTIONS

Either levobupivacaine 0.125% or saline 0.9% (10 mL bolus, infusion of 8 mL/hour for 96 hours) via a sciatic or posterior tibial nerve sheath catheter placed under direct vision during surgery.

PRIMARY AND SECONDARY OUTCOME MEASURES

The primary outcome measure was the presence of phantom limb pain, residual limb pain and phantom limb sensations up to 6 months after amputation. Secondary outcome measures included early postoperative pain and morphine requirements after surgery.

RESULTS

Data from 81 participants were analysed; 6-month follow-up data were available for 62 patients. Pain and morphine requirements varied widely before and after amputation in both groups. The incidences of moderate/severe phantom limb pain, residual limb pain and phantom limb sensations were low from 6 weeks with no significant differences between groups in phantom limb pain at rest (OR 0.56, 95% CI 0.14 to 2.14, p=0.394) or movement (OR 0.58, 95% CI 0.15 to 2.21, p=0.425) at 6 months. Early postoperative pain scores were low in both groups with no between-group differences in residual limb pain or phantom limb sensations (rest or movement) at any time point. High postoperative morphine consumption was associated with worsening phantom limb pain both at rest (-17.51, 95% CI -24.29 to -10.74; p<0.001) and on movement (-18.54, 95% CI -25.58 to -11.49; p<0.001). The incidence of adverse effects related to the study was low in both groups: postoperative nausea, vomiting and sedation scores were similar, and there were no features of local anaesthetic toxicity.

CONCLUSIONS

Long-term phantom limb pain, residual limb pain and phantom limb sensations were not reduced significantly by perineural infusion of levobupivacaine, although the study was underpowered to show significant differences in the primary outcome. The incidence of phantom limb pain was lower than previously reported, possibly attributable to frequent assessment and early intervention to identify and treat postoperative pain when it occurred. There were large variations in postoperative pain scores, high requirements for analgesics before and after surgery and some problems maintaining recruitment and long -term follow-up. Knowledge of these potential problems should inform future research in this group of patients. Further work should investigate the association between perioperative morphine requirements and late phantom limb pain.

TRIAL REGISTRATION NUMBERS

EudraCT 2007-000619-27; ISRCTN68691928.

Plasma concentrations of levobupivacaine in neonates during caudal epidural analgesia maintained over 48 hours

BACKGROUND

Differences in neonatal pharmacokinetics are known to cause systemic accumulation of levobupivacaine with adverse effects during epidural analgesia. Therefore, it is not recommended to surpass 48 hours of administration in neonates. Free and total levobupivacaine levels are considered as predictors of toxicity.

OBJECTIVE

The aim of the LEVON pilot study was to detect the accumulation of levobupivacaine during epidural analgesia exceeding 48 hours in neonates.

METHODS

Ten neonates received a loading dose of levobupivacaine (1.25 mg/kg) followed by a continuous infusion (0.2 mg/kg/hour) epidurally. Free and total levobupivacaine concentrations were measured 0.5, 1, 6, 12, 36, 72 and 144 hours after the start of infusion. Cumulative doses of levobupivacaine, pain scores and clinical signs of toxicity were used for assessing efficacy and safety.

RESULTS

The median concentrations of total levobupivacaine were 586.0, 563.0, 837.5, 957.0, 1930.0, 708.5 and 357.5 ng/ml. The median concentrations of free levobupivacaine were 4.0, 3.6, 5.5, 3.6, 5.5, 0.8 and 0.0 ng/ml. Three patients reached concerning concentrations of total levobupivacaine. Levels of free levobupivacaine remained low. No signs of toxicity were observed.

CONCLUSION

Caudal epidural analgesia with levobupivacaine lasting longer than 48 hours appears to be safe providing that free levobupivacaine levels are below the presumed threshold for toxicity (Tab. 1, Fig. 1, Ref. 29). Text in PDF www.elis.sk Keywords: free levobupivacaine, total levobupivacaine, neonate, caudal continuous epidural analgesia, postoperative pain.

Impact of Pectoralis Nerve Block (PECS) on postoperative pain in patients submitted to mastectomy with lymphadenectomy

OBJECTIVE

Breast cancer is the most common malignant neoplasm in women worldwide. Surgery has been traditional treatment and, generally, it´s mastectomy with lymphadenectomy, that can causes postoperative pain. Therefore, we seek to study regional anesthesic techniques that can minimize this effect, such as the interpectoral block (PECS).

METHODS

randomized controlled study with 82 patients with breast cancer who underwent mastectomy with lymphadenectomy from January 2020 to October 2021 in oncology hospital.

INTERVENTIONS

two randomized groups (control - exclusive general anesthesia and PECS group - received PECS block with levobupivacaine/ropivacaine and general anesthesia). We applied a questionnaire with Numeric Rating Scale for pain 24h after surgery. We used Shapiro-Wilk, Mann-Whitney and Chi-square tests, and analyzed the data in R version 4.0.0 (ReBEC).

RESULTS

in the PECS group, 50% were pain-free 24h after surgery and in the control group it was 42.86%. The majority who presented pain classified it as mild pain (VAS from 1 to 3) - (42.50%) PECS group and (40.48%) control group (p=0.28). Only 17.50% consumed opioids in the PECS group, similar to the control group with 21.43%. (p=0.65). There was a low rate of complications such as PONV in both groups. In the subgroup analysis, there was no statistical difference between the groups that used levobupivacaine or ropivacaine regarding postoperative pain and opioid consumption.

DISCUSSION

the studied group had a low rate of pain in the postoperative period and it influenced the statistical analysis. There wasn´t difference in postoperative pain in groups.

CONCLUSION

was not possible to demonstrate better results with the association of the PECS block with total intravenous analgesia. Need further studies to assess the efficacy of the nerve block.

Comparison of programmed intermittent epidural bolus injection and continuous epidural injection in controlling nighttime pain and improving sleep quality after thoracotomy

BACKGROUND

Postoperative pain after open thoracotomy is known to be very severe and affects sleep quality. This study aimed to investigate the effects of a programmed intermittent epidural bolus injection versus continuous epidural injection for controlling nighttime pain and improving sleep quality after thoracotomy.

METHODS

Seventy-six patients scheduled for open thoracotomy for lung cancer or other lung diseases were enrolled. The participants were divided into 2 groups. Group A was continuously injected with 0.2% levobupivacaine at 1.1 mL/h, and group B was injected intermittently with 3 mL 0.2% levobupivacaine at 3 hours intervals through a thoracic epidural catheter via a programmed infusion pump. Within 48 hours after surgery, the degree of pain control using visual analog scale and the patients' sleep conditions on postoperative day (POD) 0 and 1 were evaluated, and other adverse events were investigated.

RESULTS

On POD 1 night, the visual analog scale in group B showed lower than group A (P = .009). Comparison of time to fall asleep showed no differences between 2 groups. Total sleep time was no difference on POD 0 but was longer in group B than that in group A on POD 1 (P = .042). Awakening from sleep on POD 0 was lower in group B than that in group A (P = .033), and satisfaction with sleep quality on POD 0 was superior in group B compared to group A (P = .005). Postoperative nausea and vomiting occurred more frequently in group B than in group A (P = .018).

CONCLUSION

The programmed intermittent epidural bolus technique of patient-controlled epidural analgesia reduces postoperative nighttime pain and improves sleep quality in patients undergoing thoracotomy for lung cancer or other lung diseases.

Cauda equina syndrome following combined spinal-epidural anesthesia with levobupivacaine for cesarean section

Cauda equina syndrome (CES) is a rare but possible complication of neuroaxial anesthesia. Damage to the nerve roots may occur due to compression, inflammation, stretching, direct trauma, spinal ischemia or neurotoxicity, usually with lidocaine or bupivacaine. We describe a case of a 33-year-old patient that underwent an uneventful cesarean section with a combined spinal-epidural technique anesthesia, with levobupivacaine. 48 h after the procedure, she presented diminished muscular strength and abolished osteotendinous reflexes in the left lower limb, limited flexion of the right hallux, urinary retention and saddle anesthesia. Imaging exams excluded hematoma, thickening or compression of the cauda equina nerve roots. CES was suspected and treatment was initiated. 9-month follow up revealed diminished osteotendinous reflexes on the left lower limb and perianal hypoesthesia. Despite being unusual, neurological complications require prompt recognition and management to avoid permanent damage.

Effect of adding dexmedetomidine to intra-articular levobupivacaine on postoperative pain following arthroscopic meniscus surgery: A prospective, double-blind, randomized, placebo- controlled, clinical trial

OBJECTIVE

The aim of this study was to determine the effect of adding dexmedetomidine to intra-articular levobupivacaine on postoperative pain levels and analgesic requirements following arthroscopic meniscectomy.

METHODS

A total of 60 American Society of Anesthesiologist physical status I-II patients, aged 20 to 62 years, and scheduled for arthroscopic partial meniscectomy under general anesthesia were included in this study. All the patients were randomly assigned to one of four groups (15 patients in each group): Group 1 (8 male, 7 female; mean age = 46.70 ± 13.13 years; 0.9% isotonic 20 ml), group 2 (7 male, 8 female; mean age = 42.60 ± 12.18 years; levobupivacaine 0.5 mg/kg plus 0.9% isotonic), group 3 (8 male, 7 female; mean age = 43.80 ± 12.63 years; 1μg/kg dexmedetomidine plus 0.9% isotonic), and group 4 (7 female, 8 male; mean age = 40.40 ± 11.79 years; levobupivacaine 0.5 mg/kg plus 1μg/kg dexmedetomidine and 0.9% isotonic). All medications were administered at the end of arthroscopic surgery. Pain levels were measured using a Visual Analogous Scale (VAS) and Verbal Rating Scale (VRS) at postoperative 1, 2, 4, 6, 12, and 24 hours.

RESULTS

VAS scores at rest were significantly lower in Group 4 at postoperative 1th, 2nd, 4th, 6th,12th, and 24th hours than in other groups. The time to take the first analgesic was significantly higher in Group4 (964 ± 288 min), and total analgesic consumption was significantly lower in Group 4 compared to those of other groups.

CONCLUSION

Although administration of intra-articular dexmedetomidine alone may have a weaker effect than intra-articular levobupivacaine on postoperative pain relief after arthroscopic partial meniscectomy, adding dexmedetomidine to intra-articular levobupivacaine may increase the durationand quality of postoperative analgesia without any side effect.

LEVEL OF EVIDENCE

Level I, Therapeutic Study.

Posteromedial quadratus lumborum block versus wound infiltration after caesarean section: A randomised, double-blind, controlled study

BACKGROUND

Reducing pain and minimising the use of opioids after caesarean section are crucial to enhancing maternal recovery and promoting mother-newborn interaction. Various techniques have been implemented to improve analgesia. We compared the analgesic efficacy of posteromedial quadratus lumborum block with that of wound infiltration following elective caesarean section.

OBJECTIVE

We hypothesised that within a multimodal analgesia approach, posteromedial quadratus lumborum block would, due to its potential to relieve visceral pain, result in a 15% reduction in 24-h postoperative opioid consumption compared with wound infiltration.

DESIGN

A double-blind, randomised, placebo-controlled clinical study.

SETTING

A single-centre study between August 2019 and May 2020.

PATIENTS

One hundred and sixteen women were randomly allocated into two groups. In the quadratus lumborum group, 20 ml 0.9% saline was injected into the surgical wound followed by bilateral posteromedial quadratus lumborum block using 20 ml 0.25% levobupivacaine per side. In the wound infiltration group, 20 ml of 0.25% levobupivacaine was injected into the surgical wound followed by a bilateral posteromedial quadratus lumborum injection with 20 ml 0.9% saline per side.

MAIN OUTCOME MEASURES

The primary outcome was opioid (piritramide) consumption at 24 h. Secondary outcomes were piritramide consumption at 48 h, time-to-first analgesic request, pain scores at rest and with movement, surgery-to-first-ambulation time, surgery-to-breastfeeding time, sedation, pruritus and complications.

RESULTS

Piritramide consumption in 24 h was significantly lower with posteromedial quadratus lumborum block (1.5 ± 1.8 mg) than with wound infiltration (2.2 ± 1.7 mg) (P = 0.04), mean difference of -0.7 mg, (95% CI -1.3 to -0.03). In those who required piritramide, time-to-first analgesic request was significantly longer with posteromedial quadratus lumborum block 11 [7 to 14] h, than with wound infiltration 7 [5 to 11] h (P = 0.02). Pain scores were low, with no differences recorded at rest and with movement. There were no differences in time-to-ambulation and time-to-breastfeed between the groups.

CONCLUSION

As a component of multimodal post-caesarean section analgesia, posteromedial quadratus lumborum block was associated with lower 24-h opioid consumption compared with wound infiltration.

TRIAL REGISTRATION

ClinicalTrials.gov identifier: NCT04000308.

Efficiency of intracavitary levobupivacaine infusion for pain management during cystoscopic procedures: A randomised study

AIM

This study evaluated the effect of intracavitary levobupivacaine infusion diluted with locally applied isotonic solution for pain control in cystoscopy.

METHODS

Included in this study are 100 patients who had previously undergone transurethral tumour resection for bladder tumour and were followed up by cystoscopy. The patients were randomised into five groups (n = 20). In the first, second, third, and fourth groups, 4, 6, 8, and 10 mL of levobupivacaine HCl (5.0 mg/mL) were mixed with 26, 24, 22, and 20 mL of isotonic solution, respectively. Hence, the total mixture was 30 mL for each group. The fifth group was the control group. In this group, the standard method commonly used in most clinics was utilised. That is, a gel containing Cathejell-2% lidocaine (25 mg lidocaine) was applied for local analgesia. Cystoscopic interventions were performed with a 17.5 Fr rigid cystoscope and 0°, 30°, and 70° lens. During cystoscopy and 30 min later, the pain status of patients was assessed using the Visual Analogue Scale (VAS) and patient satisfaction was questioned.

RESULTS

The mean VAS score during and after the cystoscopy procedure was significantly lower in the levobupivacaine groups compared with the lidocaine group. In addition, patient satisfaction in the levobupivacaine groups was significantly higher than in the lidocaine group. No drug-related side-effects were observed in all groups.

CONCLUSION

Thus, levobupivacaine is a more effective drug than lidocaine alone to control pain during cystoscopy. The use of levobupivacaine is recommended to prevent possible complications of general anaesthesia by eliminating the need for the aforementioned as well as its cost-saving advantage.

Cardiac Arrest due to Failed Pacemaker Capture After Peripheral Nerve Blockade With Levobupivacaine: A Case Report

We describe a patient with a pacemaker who developed cardiac arrest shortly after ultrasound-guided rectus sheath block for postoperative analgesia. The cause of cardiac arrest was capture failure due to an increased pacing threshold, and the patient was promptly treated by increasing the pacing amplitude. Local anesthetics used for rectus sheath block might have affected the pacing threshold and caused pacing capture failure, since local anesthetics can block cardiac sodium channels. Anesthesiologists should recognize the risk of pacemaker capture failure when a large amount of local anesthetic is given to patients with a cardiac pacemaker.

Paravertebral block using levobupivacaine or dexmedetomidine-levobupivacaine for analgesia after cholecystectomy: a randomized double-blind trial

Background

Thoracic paravertebral block (TPVB) has emerged as an effective and feasible mode of providing analgesia in laparoscopic cholecystectomy. Though a variety of local anaesthetic combinations are used for providing TPVB, literature is sparse on use of dexmedetomidine in TPVB. We aimed to compare levobupivacaine and levobupivacaine-dexmedetomidine combination in ultrasound guided TPVB in patients undergoing laparoscopic cholecystectomy.

Methodology

70 ASA I/II patients, aged 18–60 years, scheduled to undergo laparoscopic cholecystectomy under general anaesthesia were enrolled and divided into two groups. Before anaesthesia induction, group A patients received unilateral right sided ultrasound guided TPVB with 15 ml 0.25% levobupivacaine plus 2 ml normal saline while group B patients received unilateral right sided ultrasound guided TPVB with 15 ml 0.25% levobupivacaine plus 2 ml solution containing dexmedetomidine 1 μg.kg^-1. Patients were monitored for pain using Numeric Rating Scale (NRS) at rest, on movement, coughing and comfort scores post surgery. Total analgesic consumption in first 48 hour postoperative period, time to first request analgesic and pain scores were recorded.

Results

Total amount of rescue analgesia (injection tramadol plus injection tramadol intravenous equivalent dose) consumed during 48 hours postoperatively in group A was 146.55 mg while in group B was 111.30 mg (p = 0.026). Mean time for demanding rescue analgesia was 273 minutes in group A while in group B was 340 minutes (p = 0.00).

Conclusion

TPVB using dexmedetomidine 1 μg.kg^-1 added to levobupivacaine 0.25% in patients undergoing laparoscopic cholecystectomy significantly reduced total analgesic consumption in first 48 hours and provided longer duration of analgesia postoperatively compared to levobupivacaine 0.25% alone.

Continuous Mandibular Nerve Block for Intractable Mandibular Pain Due to Antiresorptive Agent-Related Osteonecrosis of the Jaw: A Case Report

Antiresorptive agent-related osteonecrosis of the jaw (ARONJ) causes severe pain that cannot be controlled well by common analgesic drugs. This is a first case report of intractable mandibular pain due to ARONJ that was eliminated by a continuous mandibular nerve block. A 72-year-old woman with osteoporosis had been administered bisphosphonate. One year after extraction of her tooth, she was diagnosed as having ARONJ. Jaw pain was so severe that she was unable to open her mouth and eat. We performed a continuous mandibular nerve block through an indwelling catheter with levobupivacaine for pain management. After the procedure, her rest pain was markedly improved, and the pain induced by opening her mouth disappeared. We conclude that a continuous mandibular nerve block may be helpful in the management of ARONJ.

[Perineural dexamethasone in ultrasound-guided interscalene brachial plexus block with levobupivacaine for shoulder arthroscopic surgery in the outpatient setting: randomized controlled trial]

BACKGROUND AND OBJECTIVES

In shoulder arthroscopy, on an outpatient basis, the patient needs a good control of the postoperative pain that can be achieved through regional blocks. Perineural dexamethasone may prolong the effect of these blocks. The aim of this study was to evaluate the effect of perineural dexamethasone on the prolongation of the sensory block in the postoperative period for arthroscopic shoulder surgery in outpatient setting.

METHODS

After approval by the Research Ethics Committee and informed consent, patients undergoing arthroscopic shoulder surgery under general anesthesia and ultrasound-guided interscalene brachial plexus block were randomized into Group D - blockade performed with 30 mL of 0.5% levobupivacaine with vasoconstrictor and 6 mg (1.5 mL) of dexamethasone and Group C - 30 mL of 0.5% levobupivacaine with vasoconstrictor and 1.5 mL of 0.9% saline. The duration of the sensory block was evaluated in 4 postoperative moments (0, 4, 12 and 24 hours) as well as the need for rescue analgesia, nausea and vomiting incidence, and Visual Analog Pain Scale (VAS).

RESULTS

Seventy-four patients were recruited and 71 completed the study (Group C, n=37; Group D, n=34). Our findings showed a prolongation of the mean time of the sensitive blockade in Group D (1440±0 min vs. 1267±164 min, p<0.001). It was observed that Group C had a higher mean pain score according to VAS (2.08±1.72 vs. 0.02±0.17, p <0.001) and a greater number of patients (68.4% vs. 0%, p <0.001) required rescue analgesia in the first 24 hours. The incidence of postoperative nausea and vomiting was not statistically significant.

CONCLUSION

Perineural dexamethasone significantly prolonged the sensory blockade promoted by levobupivacaine in interscalene brachial plexus block, reduced pain intensity and rescue analgesia needs in the postoperative period.

Perineural dexamethasone in ultrasound-guided interscalene brachial plexus block with levobupivacaine for shoulder arthroscopic surgery in the outpatient setting: randomized controlled trial

Background and objectives

In shoulder arthroscopy, on an outpatient basis, the patient needs a good control of the postoperative pain that can be achieved through regional blocks. Perineural dexamethasone may prolong the effect of these blocks. The aim of this study was to evaluate the effect of perineural dexamethasone on the prolongation of the sensory block in the postoperative period for arthroscopic shoulder surgery in outpatient setting.

Methods

After approval by the Research Ethics Committee and informed consent, patients undergoing arthroscopic shoulder surgery under general anesthesia and ultrasound-guided interscalene brachial plexus block were randomized into Group D – blockade performed with 30 mL of 0.5% levobupivacaine with vasoconstrictor and 6 mg (1.5 mL) of dexamethasone and Group C – 30 mL of 0.5% levobupivacaine with vasoconstrictor and 1.5 mL of 0.9% saline. The duration of the sensory block was evaluated in 4 postoperative moments (0, 4, 12 and 24 hours) as well as the need for rescue analgesia, nausea and vomiting incidence, and Visual Analog Pain Scale (VAS).

Results

Seventy-four patients were recruited and 71 completed the study (Group C, n = 37; Group D, n = 34). Our findings showed a prolongation of the mean time of the sensitive blockade in Group D (1440 ± 0 min vs. 1267 ± 164 min, p < 0.001). It was observed that Group C had a higher mean pain score according to VAS (2.08 ± 1.72 vs. 0.02 ± 0.17, p < 0.001) and a greater number of patients (68.4% vs. 0%, p < 0.001) required rescue analgesia in the first 24 hours. The incidence of postoperative nausea and vomiting was not statistically significant.

Conclusion

Perineural dexamethasone significantly prolonged the sensory blockade promoted by levobupivacaine in interscalene brachial plexus block, reduced pain intensity and rescue analgesia needs in the postoperative period.

Comparing erector spinae plane block with serratus anterior plane block for minimally invasive thoracic surgery: a randomised clinical trial

BACKGROUND

Minimally invasive thoracic surgery causes significant postoperative pain. Erector spinae plane (ESP) block and serratus anterior plane (SAP) block promise effective thoracic analgesia compared with systemically administered opioids, but have never been compared in terms of terms of quality of recovery and overall morbidity after minimally invasive thoracic surgery.

METHODS

Sixty adult patients undergoing minimally invasive thoracic surgery were randomly assigned to receive either single-shot ESP or SAP block before surgery using levobupivacaine 0.25%, 30 ml. The primary outcome was quality of patient recovery at 24 h, using the Quality of Recovery-15 (QoR-15) scale. Secondary outcomes included area under the curve (AUC) of pain verbal rating scale (VRS) over time, time to first opioid analgesia, postoperative 24 h opioid consumption, in-hospital comprehensive complication index (CCI) score and hospital stay.

RESULTS

The QoR-15 score was higher among ESP patients compared with those in the SAP group, mean (standard deviation): 114 (16) vs 102 (22) (P=0.02). Time (min) to first i.v. opioid analgesia in recovery was 32.6 (20.6) in ESP vs 12.7 (9.5) in SAP (P=0.003). AUC at rest was 92 (31) mm h-1vs 112 (35) in ESP and SAP (P=0.03), respectively, whereas AUC on deep inspiration was 107 mm h-1 (32) vs 129 (32) in ESP and SAP (P=0.01), respectively. VRS pain on movement in ESP and SAP at 24 h was, median (25-75% range): 4 (2-4) vs 5 (3-6) (P=0.04), respectively. Opioid consumption at 24 h postoperatively was 29 (31) vs 39 (34) (P=0.37). Median (25-75%) CCI in ESP and SAP was 1 (0-2) vs 4 (0-26) (P=0.03), whereas hospital stay was 3 (2-6) vs 6 (3-9) days (P=0.17), respectively.

CONCLUSION

Compared with SAP, ESP provides superior quality of recovery at 24 h, lower morbidity, and better analgesia after minimally invasive thoracic surgery.

CLINICAL TRIAL REGISTRATION

NCT03862612.

Levobupivacaine versus Racemic Bupivacaine in Spinal Anaesthesia for Urological Surgery

Racemic bupivacaine is the most common local anaesthetic used intrathecally. This prospective, randomized, double-blind study compared the clinical efficacy and motor block of 0.5% levobupivacaine with 0.5% racemic bupivacaine in spinal anaesthesia for urological surgery. The surgery required an upper level of sensory block of at least the tenth thoracic dermatome. Fifty patients were recruited (levobupivacaine group n=24; bupivacaine group n=26). Spinal anaesthesia was achieved with 2.6 ml of study solution injected in the subarachnoid space at the lumbar 3/4 interspace. One patient from the levobupivacaine group was excluded due to technical failure. There were no significant differences between the two groups in the quality of sensory and motor block or in haemodynamic change. Anaesthesia was adequate and patient satisfaction good in all cases.

We conclude that 0.5% levobupivacaine can be used as an alternative to 0.5% racemic bupivacaine in spinal anaesthesia for surgery when a sensory block to at least T10 is required.

Supra-inguinal fascia iliaca block under ultrasound guidance for perioperative analgesia during bipolar hip arthroplasty in a patient with severe cardiovascular compromise: A case report

RATIONALE

The relief of selective hip pain may be difficult to attain. Therefore, a deep nerve block such as epidural anesthesia or lumbar plexus nerve block is required. However, deep nerve blocks may not be possible in patients with complications, including severe cardiovascular disease.

PATIENTS CONCERNS

The patient in our report had coronary stents inserted previously and required continuous anticoagulant therapy owing to severe heart failure.

DIAGNOSIS

Bipolar hip arthroplasty was required in our patient because of a fracture of the neck of femur on the left side.

INTERVENTIONS

We decided to perform the surgery using a fascia iliaca block (block of the femoral and the lateral femoral cutaneous nerves) by the suprainguinal approach. The fascia iliaca nerve block was performed under ultrasound guidance, using 20 mL of levobupivacaine.

OUTCOMES

The surgery was performed successfully with adequate sensory block around the hip region.

LESSONS

Ultrasound-guided fascia iliaca nerve block by the supra-inguinal approach may be an effective anesthetic technique for patients undergoing surgery for fracture of the neck of femur.

CONSORT-epidural dexmedetomidine improves gastrointestinal motility after laparoscopic colonic resection compared with morphine

BACKGROUND

We have previously shown that epidural dexmedetomidine, when used as an adjunct to levobupivacaine for control of postoperative pain after open colonic resection, improves recovery of gastrointestinal motility compared with morphine.

METHODS

Sixty patients undergoing laparoscopic colonic resection were enrolled and allocated randomly to treatment with dexmedetomidine (group D) or morphine (group M). Group D received an epidural loading dose of dexmedetomidine (5 mL, 0.5 μg/kg), followed by continuous epidural administration of dexmedetomidine (80 μg) in 0.125% levobupivacaine (240 mL) at a rate of 5 mL/h for 2 days. Group M received an epidural loading dose of morphine (5 mL, 0.03 mg/kg) followed by continuous epidural administration of morphine (4.5 mg) in 0.125% levobupivacaine (240 mL) at a rate of 5 mL/h for 2 days. Verbal rating score (VRS) of pain, postoperative analgesic requirements, side effects related to analgesia, and time to postoperative first flatus (FFL) and first feces (FFE) were recorded.

RESULTS

VRS and postoperative analgesic requirements were not significantly different between the treatment groups. In contrast, FFL and FFE were significant delayed in group M compared with group D (P < .05). Patients in group M also had a significantly higher incidence of nausea, vomiting, and pruritus (P < .05). No neurological deficits were observed in either group.

CONCLUSIONS

Compared with morphine, epidural dexmedetomidine is a better adjunct to levobupivacaine for control of postoperative pain after laparoscopic colonic resection.

Impedance cardiography as tool for continuous hemodynamic monitoring during cesarean section: randomized, prospective double blind study

BACKGROUND

Impedance Cardiography (ICG) is a non-invasive tool for continuous hemodynamic monitoring. Aims of our study were to assess the utility of ICG to evaluate the hemodynamic impact of 6 mg (GL6) vs 8 mg (GL8) levobupivacaine combined with fentanyl in healthy patients undergoing elective cesarean section; secondary, to compare the duration and quality of analgesia and anesthesia.

METHODS

Sixty-two women receiving combined spinal-epidural (CSE) for elective cesarean delivery were randomly allocated to GL6 or GL8 groups. Mean arterial pressure (MAP), cardiac index (CI), systemic vascular resistance index (SVRI), heart rate (HR), stroke volume index (SVI) were recorded from Tbaseline to 31 min after CSE by ICG. Sensory and motor blocks, patients and surgeons satisfaction, neonatal data were also recorded.

RESULTS

Fifteen of 32 patients in GL6 and 15 of 30 patients in GL8 experienced hypotension at T2 vs Tbaseline (P < .001) and SVRI reduction (P = .035 and P < .001 respectively). MAP, CI and SVRI were always slightly higher in GL6 vs GL8. HR and SVI remained stable until the end of surgery in all patients. Total ephedrine requirements was higher in GL8 (P = .010). The onset and offset time of sensory and motor block were similar in both groups, but the number of patients with motor block was lower in GL6 vs GL8 (P = .001). Patients and surgeon satisfaction scores, the number of patients needed systemic rescue doses, neonatal data were similar in both groups.

CONCLUSIONS

ICG is a useful noninvasive tool to monitor continuously hemodynamics during cesarean section. The hemodynamic stability, the satisfying sensory block and rapid mobilization provided by low levobupivacaine dose may be particularly advantageous in obstetric patients.

TRIAL REGISTRATION

ClinicalTrials.gov: NCT03170427 . Retrospectively Registered (Date of registration: May 2017).

A prospective, randomized, open label, controlled study investigating the efficiency and safety of 3 different methods of rectus sheath block analgesia following midline laparotomy

BACKGROUND

There is a controversy regarding the efficacy of rectus sheath block (RSB). The aim of the present study was to evaluate analgesic efficacy and safety of three different methods of RSB in postoperative pain management after midline laparotomy.

METHODS

A prospective, randomized, controlled, open-label clinical trial with 4 parallel groups was conducted in a tertiary care hospital in Finland. A total of 57 patients undergoing midline laparotomy were randomized to the control group (n = 12) or to 1 of the 3 active RSB analgesia groups: single-dose (n = 16), repeated-doses (n = 12), or continuous infusion (n = 17). Opioid consumption with iv-patient-controlled analgesia pump was recorded, and pain scores and patients' satisfaction were surveyed on an 11-point numeric rating scale for the first 48 postoperative h. Plasma concentrations of oxycodone and levobupivacaine were analyzed. All adverse events during the hospital stay were recorded.

RESULTS

Oxycodone consumption was less during the first 12 h in the repeated-doses and in the continuous infusion groups (P = .07) and in numerical values up to 48 h in the repeated-doses group. Plasma oxycodone concentrations were similar in all 4 groups. Pain scores were lower in the repeated-doses group when coughing during the first 4 h (P = .048 vs. control group), and at rest on the first postoperative morning (P = .034 vs. the other 3 groups) and at 24 h (P = .006 vs. the single-dose group). All plasma concentrations of levobupivacaine were safe. The patients' satisfaction was better in the repeated-doses group compared with the control group (P = .025). No serious or unexpected adverse events were reported.

CONCLUSIONS

RSB analgesia with repeated-doses seems to have opioid sparing efficacy, and it may enhance pain relief and patients' satisfaction after midline laparotomy.

Erector spinae plane block for radical mastectomy: A new indication?

The erector spinae plane block is a technique recently described by Forero et al. in September 2016. It has applications in the control of chronic pain with neuropathic component of the chest wall, and for pain control in thoracoscopic surgery. In this article, we describe the use of this technique as part of a multimodal analgesic approach in a 40-year-old woman, who underwent radical mastectomy due to breast cancer. By performing this block before anesthetic induction, we have achieved an opioid sparing effect, avoiding a possible immunomodulatory effect, although not yet proven in humans. During hospitalization, the patient reported no pain (0/10 in numeric scale), without resorting to rescue analgesia. The easy, fast and safe execution of erector spinae plane block makes it a promising technique in the context of surgical pain during radical mastectomy.

Ropivacaine versus levobupivacaine in peripheral nerve block: A PRISMA-compliant meta-analysis of randomized controlled trials

BACKGROUND

To determine which is more potent in peripheral nerve block between ropivacaine and levobupivacaine.

METHODS

A literature search was performed in the EMBASE, Medline, the Cochrane Library, and the Web of Science. The trials that were found were then evaluated for eligibility. The Cochrane Collaboration's Review Manager software was used to perform the meta-analyses.

RESULTS

Twelve studies including 556 patients were included for final analysis. No statistically significant difference was observed between the 2 drugs with respect to onset time of surgical anesthesia, onset time of sensory block, onset time of motor block, duration of motor block, and patients overall satisfaction. Levobupivacaine provided more long-term anesthesia (weighted mean difference [WMD], -2.94; 95% confidence interval [CI], -5.56 to -0.32; I = 93%) and significantly lower incidence of postoperative rescue analgesia (odds ratio [OR], 2.11; 95% CI 1.18-3.74; I = 21%) than ropivacaine. There was a trend toward greater duration of sensory block in the levobupivacaine group (WMD, -1.16; 95% CI, -1.89 to -0.43; I = 14%).

CONCLUSION

Levobupivacaine is more potent than ropivacaine in peripheral nerve block to some extent. Otherwise, more rigorous randomized control trials are required in the future.

Analgesic efficacy of ultrasound-guided subcostal transversus abdominis plane block

BACKGROUND

To evaluate the analgesic efficacy on defined areas of the abdomen and back after ultrasound-guided subcostal transversus abdominis plane (TAP) block using 0.25% levobupivacaine 0.5 mL/kg.

METHODS

Twenty patients undergoing elective laparoscopic cholecystectomy, between 20 and 60 years of age with operative time <1 hour, received subcostal TAP block using 0.25% levobupivacaine 0.5 mL/kg on the left side. Surgery started after 1 hour of observation. Sensory assessment was undertaken using pinprick and 75% ethyl alcohol at 10, 20, 30 minutes, 1, 3, and 12 hours after TAP block at 19 testing zones that were divided by anatomic landmark lines on the abdomen and the back. Efficacy of zone was defined as loss of cold temperature sensation or loss of pinprick pain sensation in more than 50% patients in that testing zone. Duration was determined by analgesia and loss of temperature sensation beginning within 30 minutes of TAP block placement lasting until time points of 1, 3, and 12 hours. All of the testing zones were divided as Group I effective at 20 minutes in less than 50% patients (0%-50%), Group II 50% to 70% patients, Group III 70% to 90% patients, and Group IV 90% to 100% patients.

RESULTS

Twenty patients meeting the study requirements were included. At each time point, the efficacies among 4 groups were significantly different. Subcostal TAP had good efficacy and stable duration in zones 1, 2, 3, 5, and 6.

CONCLUSION

Subcostal TAP block with 0.25% levobupivacaine 0.5 mL/kg dose provided effective analgesia in the anterior abdominal wall between medioventral line to anterior axillary line except the lateral upper abdominal region.

Postoperative analgesia comparing levobupivacaine and ropivacaine for brachial plexus block: A randomized prospective trial

BACKGROUND

On a pharmacologic basis, levobupivacaine is expected to last longer than ropivacaine. However, most reports of these anesthetics for brachial plexus block do not suggest a difference in analgesic effect. The aim of this study is to compare the postoperative analgesic effects of levobupivacaine and ropivacaine when used for treating ultrasound-guided brachial plexus block.

METHODS

A total of 62 patients undergoing orthopedic surgery procedures were prospectively enrolled and randomized to receive levobupivacaine (group L, N = 31) or ropivacaine (group R, N = 31). The duration of analgesia, offset time of motor block, need for rescue analgesics, and sleep disturbance on the night of surgery were recorded. Pain score was recorded on the day of surgery, and on postoperative days 1 and 2.

RESULTS

There was no difference in the time interval until the first request for pain medication comparing the two groups (group L: 15.6 [11.4, 16.8] hours; group R: 12.5 [9.4, 16.0] hours, P = 0.32). There was no difference in the duration of motor block (group L: 12.2 [7.6, 14.4] hours; group R: 9.4 [7.9, 13.2] hours, P = 0.44), pain score (P = 0.92), need for rescue analgesics (group L: 55%; group R: 65%, P = 0.6), or rate of sleep disturbance (group L: 61%, group R: 58%, P = 1.0) on comparing the two groups.

CONCLUSIONS

There was no difference in postoperative analgesia comparing levobupivacaine and ropivacaine when used for brachial plexus block.

The effects of intra-articular levobupivacain versus levobupivacain plus magnesium sulfate on postoperative analgesia in patients undergoing arthroscopic meniscectomy: A prospective randomized controlled study

Objective

The aim of this study was to compared the effectiveness of intraarticular levobupivacain with levobupivacain and magnesium sulfate.

Methods

In this prospective randomized double blinded study, 96 patients (67 male, 29 female; age range: 18–65 years) with ASA (American Society of Anesthesiologist) score I and II, who had undergone arthroscopic meniscectomy operation, were divided to 3 groups that had postoperative analgesia with intra-articular saline injection (control group), levobupivacain injection (L group) or levobupivacain and magnesium sulfate injection (LM group). Patients were compared with postoperative VAS (Visual Analog Score) score during rest and activity, opioid analgesic need, non-opioid analgesic need and other medication needs.

Results

Postoperative VAS scores during rest and activation at early postoperative period were significantly lower at LM group when compared with L group and lower than control group at all time periods. Opioid analgesic need, non-opioid analgesic need and other medication needs for non-pain symptoms were lower at LM group when compared with L and control groups at all time periods.

Conclusion

Intraarticular magnesium sulfate plus Levobupivacain injection is a safe and effective method for post operative pain management after arthroscopic meniscectomy.

Keywords: Intra-articular injection, Magnesium sulfate, Levobupivacain, Postoperative analgesia, Chondrocyte apoptosis, Pain management, Arthroscopic menisectomy

Level of Evidence

Level I, Therapeutic study

3D ultrasound estimation of the effective volume for popliteal block at the level of division

Local anaesthetic injection between the tibial and commmon peroneal nerves within connective tissue sheath results in a predictable diffusion and allows for a reduction in the volume needed to achieve a consistent sciatic popliteal block. Using 3D ultrasound volumetric acquisition, we quantified the visible volume in contact with the nerve along a 5cm segment.

METHODS

We included 20 consecutive patients scheduled for bunion surgery. Ultrasound guided popliteal block was performed using a posterior, out of plane approach at the level of división of the sciatic nerve. Thirty ml of mepivacaine 1.5% and levobupivacaine 0.5% were slowly injected while assessing the injection pressure and the diffusion of the local anaesthetic. Volumetric acquisition was performed before and after the block to quantify the the volume of the sciatic nerve and the volume of the surrounding hypoechoic halo contained inside the connective tissue in a 5cm segment.

RESULTS

All blocks were successful within 20min after the injection. The total estimated volume contained inside the common connective tissue sheath was 6.8±2.6cm³. Of this, the volume of the halo sorrounding the nerve was 4.4±1.7cm³ and the volume inside the sciatic nerve was 2.4±1.7cm³.

CONCLUSIONS

The volume of local anaesthetic in close contact with the sciatic nerve can be estimated by volumetric acquisition. Our results suggest that the effective volume of local anaesthetic needed for a successful sciatic popliteal block could be reduced to less than 7ml.

Effectiveness and safety of continuous ultrasound-guided femoral nerve block versus epidural analgesia after total knee arthroplasty

OBJECTIVES

Total knee arthroplasty is associated with severe postoperative pain. The aim of this study was to compare continuous ultrasound-guided femoral nerve block with continuous epidural analgesia, both with low concentrations of local anaesthetic after total knee arthroplasty.

MATERIAL AND METHODS

A prospective, randomised, unblinded study of 60 patients undergoing total knee replacement, randomised into two groups. A total of 30 patients received continuous epidural block, while the other 30 received continuous ultrasound-guided femoral nerve block, as well as using 0.125% levobupivacaine infusion in both groups. Differences in pain control, undesirable effects, and complications between the two techniques were assessed, as well as the need for opioid rescue and the level of satisfaction with the treatment received during the first 48hours after surgery.

RESULTS

No differences were found in demographic and surgical variables. The quality of analgesia was similar in both groups, although in the first six hours after surgery, patients in the epidural group had less pain both at rest and with movement (P=.007 and P=.011). This difference was not observed at 24hours (P=.084 and P=.942). Pain control at rest in the femoral block group was better at 48hours after surgery than in the epidural group (P=.009). The mean consumption of morphine and level of satisfaction were similar. Epidural analgesia showed the highest rate of side effects (P=.003).

CONCLUSIONS

Continuous ultrasound-guided femoral nerve block provides analgesia and morphine consumption similar to epidural analgesia, with the same level of satisfaction, but with a lower rate of side effects after total knee arthroplasty.

A Comparison of Three Different Volumes of Levobupivacaine for Caudal Block in Children Undergoing Orchidopexy and Inguinal Hernia Repair

OBJECTIVE

The aim of this study was to compare the efficacy of 3 different volumes of 0.25% levobupivacaine caudally administered on the effect of intra- and postoperative analgesia in children undergoing orchidopexy and inguinal hernia repair.

SUBJECTS AND METHODS

Forty children, aged 1-7 years, American Society of Anesthesiologists (ASA) physical status I and II, were randomized into 3 different groups according to the applied volumes of 0.25% levobupivacaine: group 1 (n = 13): 0.6 mL∙kg-1; group 2 (n = 10): 0.8 mL∙kg-1; and group 3 (n = 17): 1.0 mL∙kg-1. The age, weight, duration of anesthesia, onset time of intraoperative analgesic, dosage, and addition of intraoperative fentanyl were compared among the groups. The time to first use of the analgesic and the number of patients who required analgesic 24 h after surgery in the time intervals within 6 h, between 6 and 12 h, and between 12 and 24 h postoperatively were evaluated among the groups. Statistical analyses were performed with a Dunnett t test, ANOVA, or Kruskal-Wallis test and χ2 test. Logistic regression analysis was used in order to examine predictive factors on duration of postoperative analgesia.

RESULTS

Age, weight, duration of anesthesia, onset time of intraoperative analgesic, dosage, and addition of intraoperative fentanyl were similar among the groups. The time to first analgesic use did not differ among the groups, and logistic regression modelling showed that using the 3 different volumes of levobupivacaine had no predictive influence on duration of postoperative analgesia. The numbers of patients who required analgesics within 6 h (3/2/3), between 6 and 12 h (3/1/3), and between 12 and 24 h (1/0/2) after surgery were similar among the groups.

CONCLUSION

The 3 different volumes of 0.25% levobupivacaine provided the same quality of intra- and postoperative pain relief in pediatric patients undergoing orchidopexy and inguinal hernia repair.

Maintenance of the parturient in the left lateral position after spinal anesthesia with plain levobupivacaine for cesarean section reduces hypotension: a randomized study

PURPOSE OF INVESTIGATION

Hypotension during spinal anesthesia is a main concern in cesarean delivery. The authors hypothesized that keeping parturients in a prolonged left lateral position before turning them to a supine position with left lateral tilt would reduce the incidence of hypotension without jeopardizing the quality of anesthesia.

MATERIALS AND METHODS

Randomized comparative unblinded prospective study. This randomized comparative prospective study was conducted at Gaziantep University Hospital between June and December 2011. Sixty parturients undergoing cesarean section were included. Patients were randomized to two groups: turning to the supine position with left lateral tilt immediately or 15 minutes after subarachnoid injection of 2.5 ml 0.5% plain levobupivacaine in the left lateral position. Loss of pinprick sensation to T6 was accepted as adequate for cesarean section, and surgery proceeded. Characteristics of anesthesia; incidences of hypotension, bradycardia, and other adverse events, and ephedrine use were assessed.

RESULTS

Compared with the supine group, parturients kept in a lateral position for 15 minutes showed marked reductions in the incidence of hypotension (33.3% vs. 83.3%, p < 0.001) and adverse events related to hypotension, such as nausea and vomiting (16.7% vs. 57.3%, p <0.001). In addition, ephedrine consumption per hypotension case was significantly reduced in the lateral group (5.4 ± 4.7 vs. 8.9 ± 5.8 mg; p < 0.00 1).

CONCLUSIONS

Keeping parturients in the lateral position for 15 minutes before turning them to the supine position for cesarean section can provide reliable spinal anesthesia with a lower incidence and severity of hypotension and nausea/vomiting.

The effect of intra-articular levobupivacaine on shoulder cartilage at different doses-experimental study

BACKGROUND AND OBJECTIVES

In this study it was aimed to examine the histological and morphometric effects on cartilage structure of intra-articular application of levobupivacaine to the shoulder joint.

METHODS

In twenty New Zealand adult male rabbits, 35 shoulders were used for the study and prepared in 5 groups of 7. These groups were defined as Groups L1, L2, L3 and L4 which were right shoulders administered with 0.25% and 0.5% levobupivacaine, Group C which were left shoulders as the control group and Groups S1 and S2 which were left shoulders administered with 0.9% saline. On the 2nd and 15th days the animals were killed, the glenohumeral joints were evaluated macroscopically then cartilage samples were taken. These samples were evaluated with Mankin score, and histomorphometrically by measuring the thickness of the cartilage between the superficial cartilage layer and the tidemark and the thickness of calcified cartilage between the tidemark and the subchondral bone.

RESULTS

Macroscopically, on the 15th day the joint fluid was seen to have reduced in all the groups. After microscopic evaluation, the highest Mankin score (mean: 3.14±2.1/14) was in the L4 group (15th day 0.5% levobupivacaine) and was found to be statistically significant (p<0.05). No statistically significant difference was determined between the other groups.

CONCLUSIONS

Histologically, as the highest Mankin score was in the L4 group, this indicates that in a single intra-articular injection of levobupivacaine a low concentration should be selected.

LEVEL OF EVIDENCE

Level 5, animal study.

Comparison of intrathecal plain articaine and levobupivacaine with fentanyl for Caesarean section

PURPOSE

Articaine is used as a local anesthetic for outpatient surgery because it offers rapid onset of anesthesia and short duration motor block. Levobupivacaine is often preferred for Caesarean section. We evaluated the anesthetic characteristics of fentanyl-supplemented plain articaine and levobupivacaine for Caesarean section under combine spinal epidural anesthesia.

METHODS

Patients undergoing Caesarean section received in random order plain articaine 40 mg (Group A, n=50) or plain levobupivacaine 10 mg (Group L, n=50) mixed with fentanyl 20 µg intrathecally. The onset and duration of sensory and motor block, first analgesic request, and hemodynamic parameters were recorded.

RESULTS

Onset times of maximum motor block were longer in Group L than Group A (P=0,001). Time to two-segment regression of sensory block were 70 min for Group A and 90 min group L (P=0.001). Times to complete regression of motor blockade were significantly longer in group L than group A (P =0,001).

CONCLUSION

To have a faster onset and shorter duration of spinal anesthesia, we recommend the use of plain articaine for Caesarean section.

Postoperative pain relief and functional outcome following total knee arthroplasty - a prospective comparative audit of three analgesic regimes

Pain control plays a key role in joint-replacement -surgery. As a surgeon the challenge is to reduce pain to an acceptable level in the post-operative period. The aim of the study was to assess the efficacy of bolus -local anaesthesia, infusion in to the surgical site and nerve blocks with femoral nerve catheter and its functional outcome. A prospective audit of 114 patients undergoing total knee arthroplasty were carried out.The patients were divided in to three groups : Group 1 (n = 27) received a bolus injection of 20 ml 0.25% levobupivacaine + 10 ml 0.25%bupivacaine + adrenaline + 30 ml saline. Group 2 (n = 39) received a bolus injection as on group 1 with 240 ml 0.25% bupivacaine infusion and 5 ml/hour using a Pain Buster pump. Group 3 (n = 48) received 30 ml 0.125% levobupivacaine to femoral (3-in-1) block with 30 ml 0.25% levobupivacaine to -sciatic nerve and introduction of a femoral nerve catheter. All patients were prescribed paracetamol 1 g QDS, Oxycontin 20 mg BD and Ibuprofen post -operatively. Pain was assessed with a Visual Analog Scale (VAS). The incidence of PONV was measured by PONY intensity score. The mean post-op VAS score for Group 3 was 4. The demand of oxynorm and NSAID were minimal in Group 3. The mean in patient stay for Group 3 was 3.1 days. The PONV intensity score was > 50 for 9 (36%) in Group 1, 15 (40%) in Group 2 and 9 (20%) in Group 3. There was loss of 20-30 degrees of flexion movements in Group 3 in the first 4 to 6 days post-op. Our study demonstrated that Regime 3 with the use of nerve blocks and femoral nerve catheter has given the maximum pain relief and good functional outcome following total knee replacement.

The use of vitamin B1 as a perineural adjuvant to middle interscalene block for postoperative analgesia after shoulder surgery

BACKGROUND

Perineural administration of thiamine, via axonal flow, could strenghthen synthesis of ACh in the dorsal horn inhibitory interneurons, thus potentiating analgesia. The purpose of the present retrospective analysis is therefore to investigate whether adding perineurally 2 mg/Kg of thiamine to 0.75% levobupivacaine in patients undergoing middle interscalene block may prolong the duration of analgesia.

METHOD

The hospital records of all ASA status 1-2 patients, undergoing a single-shot interscalene block for arthroscopic rotator cuff repair from January 2011 to May 2012 were retrospectively reviewed. All blocks were performed with 0.75% levobupivacaine or a solution of thiamine hydrochloride and 0.75% levobupivacaine. The local anesthetic solution, postoperative visual analogue score for pain at rest and rescue medication were registered. We calculated the time interval elapsing between block anesthetic mixture injection and the patient's first analgesic requirement, ie time to end of analgesia. Eventual postoperative side effects were also reported.

RESULTS

59 patients received 0.4 ml/Kg of 0.75% levobupivacaine (Group L) and 51 patients received a mixture of 2 mg/Kg of thiamine hydrocloride (maximum dose 200 mg) with 0.4 ml/Kg of 0.75% levobupivacaine (Group B1). Tea was 11.4 ± 3.0 hours in Group L versus 17.6 ± 3.0 hours in Group B1 (p < 0.001). The scores for pain in the two Groups at the time of the first analgesic rescue were comparable.

CONCLUSION

The present retrospective analysis suggests that thiamine helps to prolong postoperative analgesia when added to the local anesthetic solution. Further prospective studies are necessary to confirm these preliminary results.Word count: 250.

Unintentional epidural placement of a thoracic paravertebral catheter inserted using an ultrasound-guided technique: a case report

This is the first case report describing the epidural misplacement of an infusion catheter, which was intended to be located in the thoracic paravertebral space using an ultrasound-guided technique. The patient was a 57-year-old female undergoing a laparoscopy-assisted left partial nephrectomy. Before surgery, a Tuohy needle was inserted into the paravertebral space at the left ninth intercostal space using an in-plane transverse ultrasound-guided approach in the lateral-to-medial direction. A catheter was then threaded into the paravertebral space through the needle. Subsequently, the catheter position was secured, although ultrasound-guided confirmation of air injected through the catheter into the paravertebral space was not obtained. Twenty milliliters of 0.5 % levobupivacaine was administered through the catheter at both the initiation and conclusion of surgery. A neurologic examination following surgery revealed paraplegia, along with sensory deficits in the bilateral T3-S5 dermatome. The motor dysfunction in the lower extremities lasted 7 h, and the sensory block lasted 13.5 h. Postoperative radiologic confirmation of the catheter position concomitant with the spread of radiopaque dye revealed that the tip of the catheter was lying in the epidural space. Unless precise attention is paid to detection of the catheter tip location, a thoracic paravertebral catheter can enter into the epidural space even under ultrasound guidance.

[A Case of Cardiac Arrest following Intra-articular Administration of Levobupivacaine during Total Knee Arthroplasty]

A 73-year-old woman with normal cardiac function underwent an elective total knee arthroplasty. After skin closure, levobupivacaine 225 mg was injected into the knee and 25 mg was injected subcutaneously. The patient recovered from general anesthesia 5 min after the surgery. Thirty five min after surgery, while in general radiology department her carotid arterial pulses were not palpable. Cardiopulmonary resuscitation (CPR) was initiated with intravenous (i.v.) administration of adrenaline 1 mg. Circulation was rapidly restored. Coronary angiography demonstrated no coronary stenosis; however, left ventriculography demonstrated takotsubo cardiomyopathy. The patient regained consciousness, but pulmonary edema and renal failure became worse. On postoperative day 2, continuous hemodialysis was instituted. Weaning from ventilatory support was completed on postoperative day 3; hemodialysis was stopped on day 14; and the patient left the intensive care unit on day 15. We believe cardiac arrest may have been precipitated by local anesthetic systemic toxicity (LAST), and administration of i. v. adrenaline 1 mg may have resulted in pulmonary edema. Patients should be carefully observed following local anesthetic with attention given to the side-effects of i. v. adrenaline.

Postarthroscopy analgesia using intraarticular levobupivacaine and intravenous dexketoprofen trometamol

PURPOSE

The aim of this prospective study was to determine the efficacy of intraarticular levobupivacaine with and without intravenous dexketoprofen trometamol for postarthroscopy analgesia.

METHODS

Sixty patients who underwent arthroscopic knee surgery were randomly assigned to three treatment groups. When the surgical procedure was completed, patients received the following treatments: group I (n = 20) patients received 20 mL intraarticular normal saline and 2 mL intravenous dexketoprofen trometamol (50 mg); group II (n = 20) patients received 20 mL intraarticular 0.5 % levobupivacaine (100 mg) and 2 mL intravenous normal saline; and group III (n = 20) patients received 20 mL intraarticular 0.5 % levobupivacaine (100 mg) and 2 mL intravenous dexketoprofen trometamol (50 mg). The visual analogue scale (VAS) was used, and the total analgesic consumption was assessed at 1, 2, 4, 6, 12, and 24 h post-operatively.

RESULTS

The VAS scores at 1, 2, 4, 6, 12, and 24 h post-operatively were significantly increased in group I and group II compared with group III (p < 0.05). The average VAS score during the first 24 h post-operatively was significantly lower in group III than in group I and group II (p < 0.001). Total meperidine consumption was significantly lower in group III than in groups I and II (p < 0.001).

CONCLUSION

Intraarticular levobupivacaine with adjuvant intravenous dexketoprofen trometamol administration provided better pain relief and less analgesic requirement after arthroscopic knee surgery during the first 24 h than that induced by dexketoprofen alone or levobupivacaine intraarticular alone.

LEVEL OF EVIDENCE

II.

Application of Ropivacaine and Levobupivacaine in Epidural Anesthesia for Gynecological Surgery

OBJECTIVE

To explore the application of ropivacaine and levobupivacaine in epidural anesthesia for gynecological surgery.

STUDY DESIGN

A total of 80 patients who were to undergo gynecological surgeries in our hospital were selected from May 2010 to May 2012 and divided into a control group treated with ropivacaine (40 cases) and an observation group treated with levobupivacaine (40 cases). For each surgery the following were observed: the onset time of anesthesia (T0), fully working time of anesthesia (T1), duration of anesthesia (T2), time to recovery of both lower extremities (T3), and the total amount of dosage.

RESULTS

There were significant differences in T0, T2, T3, and Bromage score between the 2 groups (p < 0.05), while there were no remarkable differences in T1 and the total amount of dosage (p > 0.05).

CONCLUSION

Levobupivacaine has excellent anesthetic effect in epidural anesthesia for gynecology and it is suitable for clinical use.

Continuous epidural analgesia, a new prospect in analgesia of newborns

The popularity of continuous caudal epidural block in post-operative analgesia in very young children has been growing. This method of analgesia is used in major abdominal and urological surgeries. A local anaesthetic, usually levobupivacaine, is administered through an epidural catheter introduced via hiatus canalis sacralis. The usual type of the catheter is Arrow G20 armed with a metal spiral, which can be used for children of up to approximately 2000 g of body weight. We want to introduce a modification of the method which uses the thin silicone catheter Premicath G28. This catheter allows for the administration of caudal epidural analgesia even in premature children of approximately 500 g of body weight. This solution eliminates adverse effects of systemic opioid analgesia, accelerates surgical wound healing and disconnection from ventilation system, and improves the potential of enteral nutrition. Depth and quality of analgesia in very young children are monitored using a complex scheme called Comfort Neo Scale (Tab. 1, Fig. 2, Ref. 7).