Administration Of Bupivacaine Research Articles

Persisting Neurological Symptoms After Uncomplicated Intrathecal Bupivacaine

In Response: Röhm and Boldt (1) remind us that (a) intrathecal bupivacaine may cause dose-dependent disabling neurological impairment; (b) clinical and laboratory studies suggest that the concentration at nerve roots may be an important factor for this toxicity; and (c) fortunately, this adverse event is rare. Röhm and Boldt provide adequate references in this respect. To emphasize their point, they report 15-day neurological impairment after intrathecal bupivacaine administration. Because an impairment lasting this long meets the definition of transient neurological syndrome, it was outside of our article's scope (2). Our message was that long-lasting disabling neurological impairment may also occur after a single uneventful intrathecal administration of bupivacaine, given in the absence of any predisposing factors that might result in maldistribution of local anesthetic. In our patient, the sensory levels were bilateral and symmetric, caudal to the expected level, and the neurological impairment persisted for 2 yr (2). Thouraya Chabbouh, MD Claude Lentschener, MD Department of Anesthesia Faculté de Médecine Université Paris-Descartes Assistance Publique Hôpitaux de Paris, Hôpital Cochin, Paris, France [email protected]

Skin Temperature during Sympathetic Block: A Clinical Comparison of Bupivacaine 0.5% and Ropivacaine 0.5% or 0.75%

Measurement of skin temperature can be used as an indicator of sympathetic blockade induced by neuraxial anaesthesia. The aim of the study was to test the skin temperature response to epidural administration of bupivacaine and different concentrations of ropivacaine. Forty-eight ASA class I-II patients undergoing herniorraphy were enrolled into a prospective, randomized, double-blind clinical trial. Patients were randomly allocated to receive epidural anaesthesia with a single dose of 18 ml of bupivacaine 0.5% (n=16); ropivacaine 0.5% (n=16), or ropivacaine 0.75% (n=16). A temperature probe was positioned on the skin of the thigh and skin temperature registered before epidural anaesthesia, every 10 minutes for the first hour after the epidural injection and every hour for the following four hours. Sensory blockade was assessed by pinprick and motor blockade using the Bromage scale. No significant difference was observed in sensory or motor blockade. A skin temperature rise of 1 to 1.8 degrees C compared with basal values was observed in all patients within the first hour. Temperature returned to basal values within four hours in the ropivacaine 0.5% group, within five hours in the ropivacaine 0.75% group, and remained 1 degrees C higher after five hours in the bupivacaine 0.5% group (P<0.01). The duration of sympathetic block is significantly shorter with ropivacaine than with bupivacaine.

P5-111: Induction of torsades de pointes in association with epidural administration of bupivacaine

We report two cases of torsades de pointes (TdP) in association with epidural analgesia with bupivacaine (BUP). The first patient was a 36-year-old man who underwent surgical repair of an incarcerated hiatal hernia and gastric perforation, complicated by hepatic and renal impairment and mild electrolyte imbalance which was promptly corrected. During the postoperative course, shortly after administration of epidural BUP, he developed QRS widening and QT prolongation with recurrent episodes of polymorphic ventricular tachycardia and TdP.

Hemodynamic Effects of Interpleural Lidocaine and Bupivacaine Combination in Anesthetized Dogs with and Without an Open Pericardium

To identify dysrhythmias and hemodynamic changes after lidocaine and bupivacaine infusion into the interpleural space with an open pericardium. Experimental study. Six adult dogs. Systemic arterial pressure and electrocardiogram were recorded. A 7.5 Fr Swan-Ganz catheter was advanced to the level of the main pulmonary artery to record pulmonary arterial pressure. Cardiac output was measured by a thermodilution technique. A pericardial window (PW) was performed in 3 dogs using thoracoscopy. Hemodynamic variables were recorded before and 15 minutes after injection of lidocaine (1.5 mg/kg) and bupivacaine (1.5 mg/kg) into the pleural space in the control group and in the pericardial space for the PW group. A randomized-block ANOVA for repeated measures was used to evaluate the effect of local anesthetic administration on hemodynamic and electrophysiologic variables in dogs with a pericardectomy. Each dog maintained sinus rhythm. Infusion of local anesthetic induced a significant increase in right ventricular diastolic pressure (P = .002) and a significant decrease in stroke volume (P = .047) in both groups; however, the effects were not significantly different between groups. Infusion of lidocaine and bupivacaine, either intrapleural or in the pericardial space, had a mild detrimental effect on cardiac output. Intrapleural administration of lidocaine and bupivacaine at a therapeutic dose can be used safely in healthy dogs with a pericardectomy.

The Effects of Local Anesthetics on Bile Flow, Potassium Equilibrium and Oxygen Consumption in the Perfused Rat Liver

Amide local anesthetics mainly undergo hepatic metabolism. Specific applications, such as catheter application for long-term pain therapy, may result in large plasma concentrations. As it is unknown whether local anesthetics influence liver function, we examined the influence of lidocaine, bupivacaine, and ropivacaine in concentrations of 1 and 10 microg/mL on the metabolic activity of the perfused rat liver. At the large concentrations, all three local anesthetics caused an immediate increase of oxygen consumption. Bupivacaine and ropivacaine also transiently reduced potassium release. All drugs increased bile flow; this choleretic effect was also significant for bupivacaine and lidocaine in smaller concentrations. In the smaller concentration, only lidocaine significantly increased oxygen consumption. No significant changes in hepatic venous pH were observed. The results show that acute administration of all three local anesthetics results in significant changes of functional variables of the liver. The observed effects appear to result from mitochondrial uncoupling, uptake of the drugs, biliary secretion of their metabolites, and from inhibition of potassium channels. The data provide no evidence that these acute changes may result in enduring postoperative disturbances of liver function, such as cholestasis or jaundice.

Acute response to intracisternal bupivacaine in patients with refractory pain of the head and neck

Continuous intracisternal infusion of bupivacaine for the management of intractable pain of the head and neck is effective in controlling pain in this patient group. With the catheter tip being located at the height of the C1 vertebral body, autonomic regulatory information may also be influenced by the infusion of bupivacaine. By combining direct sampling of cerebrospinal fluid (CSF), via a percutaneously placed catheter in the cisterna magna, with a noradrenaline and adrenaline isotope dilution method for examining sympathetic and adrenal medullary activity, we were able to quantify the release of brain neurotransmitters and examine efferent sympathetic nervous outflow in patients following intracisternal administration of bupivacaine. Despite severe pain, sympathetic and adrenal medullary activities were well within normal range (4.2 +/- 0.6 and 0.7 +/- 0.2 nmol min(-1), respectively, mean +/-S.E.M.). Intracisternal bupivacaine administration caused an almost instantaneous elevation in mean arterial blood pressure, increasing by 17 +/- 7 mmHg after 10 min (P < 0.01). Heart rate increased in parallel (17 +/- 5 beats min(-1)), and these changes coincided with an increase in sympathetic nervous activity, peaking with an approximately 50% increase over resting level 10 min after injection (P < 0.01). CSF levels of GABA were reduced following bupivacaine (P < 0.05). CSF catecholamines and serotonin, and EEG, remained unaffected. These results show that acutely administered bupivacaine in the cisterna magna of chronic pain sufferers leads to an activation of the sympathetic nervous system. The results suggest that the haemodynamic consequences occur as a result of interference with the neuronal circuitry in the brainstem. Although these effects are transient, they warrant caution at the induction of intracisternal local anaesthesia.

Hypothermie après rachianesthésie : rôle de la morphine ?

Spinal anaesthesia is the gold standard for elective caesarean section. This technique presents several adverse effects. We report a severe case of hypothermia (33.3 °C) after spinal administration of bupivacaine (10 mg) and morphine (100 μg) for elective caesarean section. After excluding other causes of hypothermia, this one could be explained by both the own effects of local anaesthesia (i.e. peripheral vasodilatation) and by the central effect of intrathecal morphine. Because hypothermia is not predictable after spinal injection of morphine both monitoring of central temperature and active warming of the patients could be proposed. Naloxone has been proposed in a case of hypothermia related to spinal injection of morphine.

The efficacy of caudal morphine or bupivacaine combined with general anesthesia on postoperative pain and neuroendocrine stress response in children

The aim of this study was to compare the effectiveness of caudal morphine and bupivacaine usage on surgical stress response in children undergoing abdominal and genitourinary surgery while keeping anesthesia depth constant utilizing the bispectral index analysis (BIS). Following the approval of Institutional Review Board and informed parental consent, 28 children with ages ranging between 4 and 16 years with ASA physical status I and II , undergoing elective lower abdominal and genitourinary surgery were included in this study. Patients were randomized and separated into two subgroups. Before induction of anesthesia, patients were monitored for BIS. Epidural injection of 30 microg.kg(-1) morphine in 1 ml.kg(-1) saline for the first group (group M) and the same volume of (0.25%) bupivacaine for second group (group B) were administered via the sacral hiatus. We analyzed serum cortisol and glucose concentrations for evaluation of the stress response in the patients. Blood samples for cortisol and glucose were withdrawn at the beginning of induction (first samples), 40 min after surgical incision (second samples), and 40 min after end of the surgery (third samples). BIS scores of the patients were kept between 40 and 60 during the surgical procedure. Group B had significantly lower levels of cortisol than group M in the second samples. There was a significant increase in serum glucose level in group M compared with group B during the intraoperative and postoperative periods. We conclude that, caudal administration of bupivacaine is more effective than morphine for attenuating intraoperative and postoperative stress response to surgery in children.

The pre‐emptive analgesic effect of intra‐articular bupivacaine in arthroscopic knee surgery*

The purpose of this study was to determine whether intra-articular injection of bupivacaine prior to surgery provided better pain control after arthroscopic meniscectomy as compared with post-operative administration of bupivacaine. Forty patients of American Society of Anesthesiologists (ASA) class I or II undergoing arthroscopic meniscectomy were assigned in a randomized, double-blinded manner into two groups: Group I received 20 ml of 2.5 mg/ml bupivacaine without epinephrine 30 min before skin incision and 20 ml of saline immediately after skin closure. Group II received identical injections in reverse order. All patients received total intravenous anesthesia. Post-operative pain scores were evaluated at 1, 2, 4, 6, 8, 12 and 24 h at rest and movement of the knee, using a 10-cm visual analog scale (VAS). The time to first analgesic use and 24-h analgesic consumption were recorded. Pain scores were lower in Group I compared with Group II at 1, 2, 4 and 6 h at rest and on movement (P < 0.05). The time to first analgesic use was longer in Group I, but there was no statistically significant difference in 24-h analgesic consumption. Intra-articular bupivacaine administered before surgery provided a statistically significant reduction in post-operative pain scores compared with post-operative bupivacaine administration.

Preemptive analgesia installation during gynecologic laparoscopy: A randomized trial

Study objective To evaluate the efficacy of intraoperative infusion of bupivacaine solution for the relief of pain after operative gynecologic laparoscopy. Design Prospective, double-blind, randomized, controlled trial (Canadian Task Force classification I4). Setting Tertiary teaching hospital. Patients Ninety-one women aged 16 to 69 years who underwent gynecologic laparoscopic surgery from November 2002 through November 2003. Interventions Group A (n = 30): intraperitoneal infusion of a mixture of 10 mL of 0.5% bupivacaine (50 mg) with epinephrine (1:500) in 40 mL of Ringer’s lactate solution postoperatively. Group B (n = 30): the same mixture solution infusion preoperatively and postoperatively (total 100 mg bupivacaine). Group C (n = 31): placebo. Measurements and main results Shoulder tip pain (STP), abdominal parietal pain (APP), and abdominal visceral pain (AVP) were recorded on a visual analog scale at 2, 4, 8, 16, and 24 hours postoperatively. A total of 79 patients fulfilled the study criteria. The overall incidence of STP was 60.8%. Abdominal visceral pain in group B was significantly less than in group C at 2 and 4 hours postoperatively (p = .011 and p = .010, respectively). No statistically significant difference was found in length of hospital stay, postoperative meperidine consumption, or side effects. Conclusion Intraperitoneal bupivacaine administration both immediately after placement of trocars and at the end of surgery was found to be effective in reducing the intensity of AVP but not in reducing STP, APP, or postoperative analgesia consumption after nonadvanced gynecologic laparoscopic procedures. The duration of the analgesic effect of bupivacaine instilled into the peritoneal cavity did not exceed 8 hours and probably was not dose related.

Sensitive bioassay of bupivacaine in human plasma by liquid-chromatography-ion trap mass spectrometry

A sensitive high-performance liquid chromatography–tandem mass spectrometric (HPLC–MS–MS) method, using an ion trap spectrometer, was developed for quantitation of bupivacaine in human plasma. Bupivacaine and an internal standard (ropivacaine) were extracted in a single step from 100 μL of alkalinized plasma with diethyl-ether. The mobile phase consisted of acetonitrile with 0.1% formic acid (50:50, v/v), and was delivered at a flow rate of 0.3 mL/min. The effluent was detected by MS–MS in positive ion mode. Ionisation was performed, using an electrospray ion source, operating at 200 °C. The selected reaction monitoring transitions m/ z 289 → m/ z 140 and m/ z 275 → m/ z 126 were chosen for bupivacaine and ropivacaine, respectively. Calibration curves were linear over the concentration range of 3.90–500 μg/L with determination coefficients >0.996. The method is accurate (bias <10%) and reproducible (intra-assay and inter-assay precision <15%), with a quantitation limit of 3.90 μg/L, using only 100 μL of plasma. The high specificity and sensitivity, achieved by this fast method (total run-time <3 min), allowed the determination of bupivacaine plasma levels in pediatric patients, following epidural administration of bupivacaine.

Recurrent Persistent Hiccups After Epidural Steroid Injection and Analgesia with Bupivacaine

This case report presents a patient who developed persistent hiccups after epidural administration of dilute bupivacaine on several different occasions. Substitution of saline for the dilute bupivacaine during epidural steroid injection did not result in hiccups; however, subsequent postoperative epidural analgesia with bupivacaine caused a recurrence of the hiccups.

Medetomidine with Ketamine and Bupivacaine for Epidural Analgesia in Buffaloes

The efficacy of ketamine and bupivacaine in enhancing the epidural analgesia induced by medetomidine was evaluated in 10 buffalo calves utilized repeatedly after a gap of 10 days so that each drug combination was tested in 4 randomly selected animals. In group A, medetomidine (15 microg/kg), in group B ketamine (2.0 mg/kg), in group C bupivacaine (0.125 mg/kg), in group D medetomidine and ketamine (15 microg/kg and 2.0 mg/kg), and in group E medetomidine and bupivacaine (15 microg/kg and 0.125 mg/kg) was administered epidurally. Onset of analgesia was significantly earlier in animals of groups B and D compared to the animals of groups A, C and E. Medetomidine alone or in combination with ketamine/bupivacaine produced complete analgesia of the tail, perineum, inguinal region and upper parts of hind limbs. Ketamine produced a very short duration of complete analgesia at the tail and perineum. Bupivacaine alone produced only mild to moderate analgesia. Both ketamine and bupivacaine prolonged the duration of analgesia. Motor incoordination was mild to moderate in animals of all the groups, but animals remained standing throughout the period of observation. Animals of groups A, D and E showed mild to moderate sedation during the observation period. Ruminal movements decreased nonsignificantly in animals of groups A and E. Mild salivation was observed in animals of all the groups except group C. Significant decrease in heart rate (HR) was recorded after epidural administration of medetomidine or bupivacaine; however, ketamine caused short duration of tachycardia. The administration of ketamine with medetomidine caused lesser decrease in HR compared to medetomidine alone or in combination with bupivacaine. Significant fall in respiratory rate (RR) was recorded after epidural administration of medetomidine or bupivacaine alone, but an increase in RR was recorded after ketamine administration. The fall in RR was less pronounced in animals in which medetomidine was used with ketamine compared to the animals in which medetomidine was used alone or in combination with bupivacaine. Mean arterial pressure (MAP) decreased and central venous pressure (CVP) increased significantly after epidural administration of medetomidine in combination with ketamine or bupivacaine. The ECG changes included tall T wave, QS pattern, RS pattern and ST elevation and heart blocks at different intervals, which were more frequent and pronounced in animals given bupivacaine with medetomidine. It can be concluded that epidural administration of medetomidine can produce complete analgesia of the tail, perineum, inguinal region and upper hind limbs in buffaloes. However, significant depression of cardiovascular parameters was recorded. Administration of ketamine along with medetomidine resulted in significantly early onset and slightly longer duration of analgesia with lesser cardiopulmonary side-effects compared to medetomidine alone or medetomidine with bupivacaine. Addition of ketamine to medetomidine thus seems to be useful for producing epidural analgesia; however, addition of bupivacaine failed to provide any advantage over medetomidine alone.

Management of post‐operative bladder spasm

Pain management following bladder surgery in children is often complicated by bladder spasm. The overall severity of spasm can be reduced with opioids, anticholinergic medication and sedatives, although breakthrough spasms often occur. At the Royal Children's Hospital, Melbourne, intravesical bupivacaine has been used to manage postoperative bladder spasm to good effect. The administration of intravesical bupivacaine is analysed in this prospective audit of locally applied intravesical anaesthetic and compared with other methods. From February to August 2003, histories of 58 patients who had intravesical bupivacaine were studied and compared with six other methods of management of postoperative bladder spasm. Data showed that epidural anaesthesia was the most effective treatment of pain, with a pain score reduction of 6.6, compared with a reduction of 6.1 with intravesical bupivacaine, and 4.5 using intravenous morphine. However, intravesical bupivacaine was the most effective method for the relief of bladder spasm.

Effect of Intraarticular Bupivacaine Administration on Postoperative Pain Relief after Arthrotomic or Arthroscopic Management of Cranial Cruciate Ligament Rupture in Dogs

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Interscalene brachial plexus anesthesia with ropivacaine 5 mg/mL and bupivacaine 5 mg/mL: Effects on electrocardiogram

Cardiotoxicity is the most severe complication of long-acting local anesthetics. The aim of this trial is to compare early signs of depression of cardiac conduction linked with the administration of either ropivacaine or bupivacaine for interscalene block. Thirty-two patients (American Society of Anesthesiologists I/II) scheduled for elective shoulder arthroscopy were prospectively enrolled to receive, in a randomized and double-blind fashion, either 40 mL of ropivacaine 5 mg/mL or 40 mL of bupivacaine 5 mg/mL for interscalene block. Holter monitoring was started the night before surgery and continued until the end of the study. Peripheral blood sampling was performed before administration of local anesthetics (= baseline) and 15, 20, 25, 30, 35, 40, 45, 60, and 360 minutes after completion of the interscalene block for measurement of total and unbound concentration of the 2 local anesthetics. Alpha-1-acid-glycoprotein was measured at baseline, t(30), and t(360). All anesthetic blocks in both groups were successful and comparable. Electrocardiographic recordings for QRS, QT, and QTC intervals did not change and were similar in both groups. In the bupivacaine group, significant prolongation of the PQ interval was noted 15 minutes after drug application and remained significantly prolonged until t(60). Total and unbound plasma local-anesthetic concentrations were comparable between both groups at all times. In both groups, local-anesthetic plasma mean levels reached a peak between 30 and 45 minutes after the bolus application. The highest mean plasma levels were 0.103 (+/-0.05) mg/L for unbound ropivacaine and 0.084 (+/-0.03) mg/L for unbound bupivacaine, which occurred in both groups at t(30). Electrocardiographic recordings were similar in both groups, except for a significant prolongation of the PQ interval in the bupivacaine group at plasma levels below threshold for cardiotoxicity.

A comparative, double-blind, randomized, placebo-controlled, trial of intraperitoneal administration of bupivacaine and lidocaine for pain control after diagnostic laparoscopy

A comparative, double-blind, randomized, placebo-controlled, trial of intraperitoneal administration of bupivacaine and lidocaine for pain control after diagnostic laparoscopy

Effect of topical bupivacaine on postoperative pain after laparoscopic tubal sterilization with Filshie clips

Objective The purpose of this study was to evaluate postoperative pain after the administration of topical bupivacaine during laparoscopic sterilization with Filshie clips. Study Design Sixty-three women who underwent laparoscopic tubal sterilization with Filshie clips were assigned randomly to receive topical bupivacaine or placebo. Presence of pain, pain intensity, nausea, vomiting, timing of request for pain medication, and pain medication requirements were assessed postoperatively. Results Patient demographics were similar between the 2 groups. Topical bupivacaine decreased the incidence ( P = .005) and intensity ( P = .028) of postoperative pain at 30 minutes. No differences in incidence or severity of pain were seen at hospital discharge or on postoperative day 1. Conclusion Topical bupivacaine that is applied to the fallopian tubes at the time of laparoscopic tubal sterilization with the Filshie clip decreases immediate postoperative pain.

Spinal analgesia: Efficacy of continuous epidural versus single-dose caudal analgesia using bupivacaine in children undergoing intravesical ureteroneocystostomy

The purpose of this RCT, with children undergoing intravesical ureteroneocystostomy, was to compare the effects of caudal injection and continuous epidural infusion of bupivacaine, on postoperative pain intensity, supplemental opioid analgesic requirements, and adverse effects. Children, ages 6 to 18 years, were randomized to receive either caudal injection of bupivacaine (0.25%, 1 ml/kg, maximum of 20 ml; n=16) or epidural catheter placement followed by bupivacaine administration (0.25%, 0.75 mg/kg, maximum of 20 ml; n=18), prior to surgical incision. Epidural infusion of 0.125% bupivacaine was initiated after surgery at 0.4ml/kg/hr for 48 hours. Intraoperative anesthetics were standardized and opioids were not given. Morphine PCA initiated in PACU included: 0.02 mg/kg/dose, 7 minute lockout, and 0.4 mg/kg 4-hour limit. IV ketorolac and oxybutynin were given postoperatively. Pain intensity was measured using a 0 to 10 numeric rating scale. Mean pain intensity scores were low (< 2/10) for children in both groups. In the PACU, 56% of patients in the caudal group required morphine versus 11% in the epidural group (p=0.009). Total PCA demands and doses delivered were significantly higher in the caudal group on day of surgery (p=0.032 and p=0.049, respectively) and on the first postoperative day (p=0.018 and p=0.018, respectively). Children in the epidural group tolerated a regular diet sooner than children in the caudal group (p=0.012). There were no group differences in opioid-related side effects. The epidural group had significantly more lower extremity numbness and motor block for the first 2 days after surgery. Both continuous epidural and single-dose caudal administration of bupivacaine, in conjunction with IV morphine PCA and ketorolac, provide adequate pain control following intravesical ureteroneocystostomy in children. Continuous epidural analgesia reduced the need for supplemental IV morphine and allowed earlier return to regular diet, but produced significant lower extremity sensory-motor block.

Intraoperative Intravenous Ketamine in Combination with Epidural Analgesia: Postoperative Analgesia After Renal Surgery

We designed this double-blinded, randomized, controlled study to evaluate the effect of small-dose ketamine IV in combination with epidural morphine and bupivacaine on postoperative pain after renal surgery. An epidural catheter was inserted, and the administration of morphine and bupivacaine was started before surgery. Forty patients were assigned to one of two groups (ketamine or control). The ketamine group was administered a ketamine bolus and infusion during surgery. The median visual analog pain scale (VAS) scores at rest were significantly lower in the ketamine group during the first 6 h (P < 0.01). VAS pain scores on coughing were also significantly lower in the ketamine group (P < 0.01). Cumulative postoperative total analgesic consumption was less in the ketamine group on Days 1 and 2 (P < 0.001). The first analgesic demand time was shorter in the control group (9.2 +/- 11.5 min) than in the ketamine group (22.3 +/- 17.1 min) (P < 0.0001). The incidence of nausea and pruritus was more frequent in the control group (P < 0.05). In conclusion, postoperative analgesia was more effective when spinal cord and brain sensitization were blocked by a combination of epidural morphine/bupivacaine and IV ketamine. Renal nociception conducted multisegmentally by both the spinal nerves (T10 to L1) and the vagus nerve cannot be blocked by epidural analgesia alone. We demonstrated that IV ketamine had an improved analgesic or opioid-sparing effect when it was combined with epidural bupivacaine and morphine after renal surgery.