A comparison of plasma levobupivacaine concentrations following transversus abdominis plane block and rectus sheath block

Yasumura, Rie; Kobayashi, Yoshiro; Ochiai, Ryoichi

doi:10.1111/anae.13414

“…The C max after bilateral rectal sheath block with a total of 1.0 mg/kg 0.25 % bupivacaine is approximately 0.6 µg/ ml and the t max is 45 min in children aged between 2 and 16 years [20], similar to those reported in adults [21].…”

Section: Pharmacokinetics After Other Routes Of Administrationsupporting

confidence: 74%

Pharmacokinetics and systemic toxicity of local anesthetics in children

Oda

¹

2016

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toxicity is 2-3 µg/ml of total (protein bound and unbound) and 0.1-0.2 µg/ml of unbound bupivacaine, levobupivacaine and ropivacaine [1,2]. Notably, the intra-arterial concentration of unbound bupivacaine for inducing CNS toxicity is approximately 50 % of unbound ropivacaine, both of which are three-and four-fold higher, respectively, than the intravenous concentration [1]. Cumulative case reports and animal experiments have also shown that the systemic toxicity of levobupivacaine and ropivacaine is less than bupivacaine [3,4]. Infants are prone to develop CNS toxicity by bupivacaine at total and unbound concentrations lower than these values [5]. Although the threshold plasma concentration for cardiac toxicity is higher than for CNS, symptoms such as dysrhythmia and QRS widening due to decreased intraventricular conduction by long-acting local anesthetics may appear prior to any neurological manifestations in infants [6]. As neonates and infants have a higher heart rate than adults, the intensity of the block is also higher (use-dependent block) and they are more prone to the toxic effects of bupivacaine, levobupivacaine and ropivacaine than adults. Hypoxia, acidosis, hypothermia and electrolyte disorders increase cardiac toxicity [3]. Protein binding and dispositionAmide local anesthetics are predominantly bound to plasma alpha 1 -acid glycoprotein (AAG), and to a minor extent to albumin. The plasma concentration of AAG at birth is approximately 20-50 % of that in adults. During the first 6-9 months of life, it progressively increases to reach adult levels by the end of the first year [7] (Fig. 1a). Although the levels of albumin in neonates are also lower than in adults, its affinity to local anesthetics is approximately 5,000-10,000 times lower than AAG, suggesting that albumin

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“…Higher doses of intrathecal morphine prolong analgesia and improve postoperative satisfaction but increase rates of maternal itching and vomiting after caesarean section . It is possible that other doses and volumes of rectus sheath injectate might have had different effects . We did not use postoperative patient‐controlled analgesia, which would have provided objective individual measures of morphine consumption.…”

Section: Discussionmentioning

confidence: 99%

A randomised, controlled trial of rectus sheath bupivacaine and intrathecal bupivacaine, without or with intrathecal morphine, vs. intrathecal bupivacaine and morphine after caesarean section

Lui

¹

,

Li

²

,

Lui

³

et al. 2017

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We recruited 144 women of whom 131 underwent scheduled caesarean section and were allocated to intrathecal bupivacaine without (46) or with (47) morphine and postoperative rectus sheath bupivacaine; or intrathecal bupivacaine with morphine and postoperative rectus sheath saline (38). We measured postoperative pain with a 10-point numeric rating scale. The mean (SD) areas under the curve for pain on movement during 48 postoperative hours were 273.5 (63.6), 223.8 (80.7) and 223.8 (80.7), respectively, p = 0.008. There was no difference between women who had intrathecal morphine with or without rectus sheath bupivacaine, p = 1. The equivalent values for pain at rest were 160.8 (64.7), 85.8 (79.4) and 82.8 (74.3), respectively, p < 0.001. There was no difference between women who had intrathecal morphine with or without rectus sheath bupivacaine, p = 0.98.

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“…The safe range of the plasma levobupivacaine concentration during continuous peripheral nerve blocks has not been established 23. At an arterial concentration of 2.5124 or 1.99 µg/mL25 or less, no central nervous or cardiovascular toxicity was reported.…”

Section: Discussionmentioning

confidence: 99%

Effects of programmed intermittent thoracic paravertebral bolus of levobupivacaine on the spread of sensory block: a randomized, controlled, double-blind study

Hida

¹

,

Murata

²

,

Ichinomiya

³

et al. 2019

Regional Anesthesia &Amp; Pain Medicine

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Background and objectives This randomized, controlled, double-blind trial compared the effectiveness of levobupivacaine delivery of a programmed intermittent paravertebral bolus with a continuous paravertebral infusion. Methods Thirty-two consecutively enrolled patients who underwent unilateral video-assisted thoracic surgery were randomized to receive either a programmed intermittent paravertebral bolus of 10 mL of 0.2% levobupivacaine every 2 hours (Bolus group, n=16) or a continuous paravertebral infusion of 0.2% levobupivacaine at 5 mL/hour (Infusion group, n=16) after the operation. Postoperatively, after injection of 20 mL of 0.25% levobupivacaine through the paravertebral catheter, a mechanical infusion pump was set depending on the assigned group. The primary efficacy outcome was the number of anesthetized dermatomes 24 hours after the initial bolus of levobupivacaine. The secondary efficacy outcomes included the number of anesthetized dermatomes at other time points, pain at rest and coughing, additional analgesic use and patient acceptance of the analgesic technique. Arterial levobupivacaine concentration was measured to ensure safety. P<0.05 was considered statistically significant. Results The mean (95% CI) number of anesthetized dermatomes 24 hours after the initial bolus of levobupivacaine was significantly larger among subjects receiving programmed intermittent bolus (n=16) compared with those receiving continuous infusion (n=16; 6.8 (5.7–7.9) vs 3.1 (2.0–4.2); p<0.001). The arterial levobupivacaine concentration did not reach a toxic level. Conclusions The programmed intermittent paravertebral bolus of levobupivacaine provided a wider dermatomal spread of sensory block than continuous paravertebral infusion with an identical hourly dose of levobupivacaine. Trial registration number NCT000022532.

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A comparison of plasma levobupivacaine concentrations following transversus abdominis plane block and rectus sheath block

Cited by 32 publications

References 15 publications

Pharmacokinetics and systemic toxicity of local anesthetics in children

Pharmacokinetics and systemic toxicity of local anesthetics in children

A randomised, controlled trial of rectus sheath bupivacaine and intrathecal bupivacaine, without or with intrathecal morphine, vs. intrathecal bupivacaine and morphine after caesarean section

Effects of programmed intermittent thoracic paravertebral bolus of levobupivacaine on the spread of sensory block: a randomized, controlled, double-blind study

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