Benefit and Harm of Adding Epinephrine to a Local Anesthetic for Neuraxial and Locoregional Anesthesia: A Meta-analysis of Randomized Controlled Trials With Trial Sequential Analyses

Tschopp, Chantal; Tramèr, Martin R.; Schneider, Alexis; Zaarour, Maroun; Elia, Nadia

doi:10.1213/ane.0000000000003417

Cited by 45 publications

(27 citation statements)

References 98 publications

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“…Epinephrine, dexamethasone, and opioids are commonly used because they are familiar to anesthesiologists and relatively safe. A recent meta-analysis reported that epinephrine prolongs anesthesia time without causing bradycardia, pruritus, or postoperative nausea and vomiting [ 7 ]. In the case reported here, epinephrine was used as an additive, resulting in the unusually prolonged spinal anesthesia.…”

Section: Clinical Discussionmentioning

confidence: 99%

“…In the case reported here, epinephrine was used as an additive, resulting in the unusually prolonged spinal anesthesia. It should be noted that when epinephrine is added to an anesthetic solution, it is recommended to observe level of dispersion approximately 3 min because intrathecal epinephrine increases the time to reach the highest sensory block [ 7 ].…”

Section: Clinical Discussionmentioning

confidence: 99%

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A case report of arthroscopic surgery under extended spinal anesthesia for 402 minutes, assisted by monitored anesthesia care

Park

Song

Kim

2021

Annals of Medicine &Amp; Surgery

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Introduction Surgical spinal anesthesia is usually maintained for approximately 3 h with bupivacaine, but it is difficult to accurately predict the duration of surgery for each case. When an operation continues for an extended duration, regression of spinal anesthesia often leads to general anesthesia. Here we present a case of extended spinal anesthesia assisted by monitored anesthesia care. Case presentation A 32-year-old male who suffered from persistent pain of the right knee was diagnosed with rupture of the right anterior cruciate ligament. Arthroscopic surgery of the right knee was conducted with spinal anesthesia. A local anesthetic mixture of 0.5% hyperbaric bupivacaine 12 mg with 50 μg of epinephrine was used. The surgery took longer than expected with a total anesthesia time of 402 minutes. In the final 30 minutes of surgery, spinal anesthesia regressed and the procedure was completed under monitored anesthesia care (MAC). Clinical discussion When spinal anesthesia is on regression during the final stage of surgery, the application of MAC safely secures additional operation time. By adopting MAC, the patient avoided general anesthesia and had minimal physiological distress and a rapid recovery. Another benefit of MAC is the reduced consumption of resources. Further, by avoiding endotracheal intubation and mechanical ventilation, the risk of transmission of infectious agents is minimized. Conclusion In situations where spinal anesthesia is regressing close to the end of a surgical procedure, the application of MAC has potential benefits over general anesthesia. These benefits are particularly relevant during the current COVID-19 pandemic.

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Section: Clinical Discussionmentioning

confidence: 99%

Section: Clinical Discussionmentioning

confidence: 99%

A case report of arthroscopic surgery under extended spinal anesthesia for 402 minutes, assisted by monitored anesthesia care

Park

Song

Kim

2021

Annals of Medicine &Amp; Surgery

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“…Preemptive analgesia—an antinociceptive treatment that prevents the establishment of altered processing of afferent input—has been widely implemented into clinical practice, aiming to inhibit the development of hypersensitivity and hyperalgesia and to control postsurgical pain with minimum side‐effects . Early reports focused on the pre‐incisional injection of local anesthetics as preventive analgesic modality after tonsillectomy in pediatric patients . Nowadays, peritonsillar infiltration of other drugs has been investigated as alternatives to local anesthetics in the context of preemptive analgesia.…”

Section: Discussionmentioning

confidence: 99%

Analgesic Efficacy and Safety of Local Infiltration of Tramadol in Pediatric Tonsillectomy Pain: A Systematic Review and Meta‐Analysis

et al. 2020

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Objectives The aim of this systematic review and meta‐analysis was to appraise clinical evidence of the impact of peritonsillar infiltration of tramadol, on postoperative pain control and the occurrence of adverse effects in children undergoing tonsillectomy. Methods A database search was conducted to identify randomized controlled trials (RCTs) pertinent to peritonsillar infiltration of tramadol compared to no treatment (placebo) or other analgesic regimens. The outcomes of interest were postoperative pain intensity, time to first analgesic demand, rescue analgesic consumption up to 24 hours after intervention, and the occurrence of adverse events. Results Twelve RCTs enrolling 972 pediatric patients were selected for qualitative analysis, among which eight were suitable for meta‐analysis. Tramadol infiltration induced a significant reduction of pain intensity up to 24 hours post‐tonsillectomy (mean difference [MD], −2.31; 95% confidence interval [CI], −3.49 to −1.12; P < 0.001; I2 = 97%) and time to first analgesic (MD 180.54; 95% CI, 56.91 to 304.18; P = 0.004; I2 = 99%), with no profound impact on postoperative nausea and vomiting (risk ratio [RR] 0.98; 95% CI, 0.73 to 1.32; P = 0.90; I2 = 0%) compared to the placebo group. The analgesic efficacy of tramadol infiltration was equivalent to the local or systematic use of ketamine or infiltration with local anesthetics. This effect was further enhanced when tramadol infiltration served as an adjunct to other analgesic interventions. No serious adverse events were reported. Conclusions In children undergoing tonsillectomy, peritonsillar infiltration of tramadol is associated with a postoperative analgesic benefit when compared to placebo, with negligible adverse events. Yet, no definite conclusion can be drawn due to the low quality, considerable heterogeneity, and paucity of the available data.

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“…It is commonly used in the dose range of 2.5-5 mcg/ml. However, due to the local vasoconstrictor effect, it is seen to prolong the duration of the block slightly [21]. The peak plasma level of local anaesthetic is reduced hence higher local anaesthetic recommended doses.…”

Section: Vasoactive Agentsmentioning

confidence: 99%

Adjuvants in Peripheral Nerve Blocks

2021

IJRA

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Benefit and Harm of Adding Epinephrine to a Local Anesthetic for Neuraxial and Locoregional Anesthesia: A Meta-analysis of Randomized Controlled Trials With Trial Sequential Analyses

Abstract: Adding epinephrine to intrathecal or locoregional local anesthetics prolongs analgesia and motor block by no more than 60 minutes. The impact of adding epinephrine to epidural local anesthetics or to a combined spinal-epidural remains uncertain.

Cited by 45 publications

References 98 publications

A case report of arthroscopic surgery under extended spinal anesthesia for 402 minutes, assisted by monitored anesthesia care

A case report of arthroscopic surgery under extended spinal anesthesia for 402 minutes, assisted by monitored anesthesia care

Analgesic Efficacy and Safety of Local Infiltration of Tramadol in Pediatric Tonsillectomy Pain: A Systematic Review and Meta‐Analysis

Adjuvants in Peripheral Nerve Blocks

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