Bupivacaine for Intercostal Nerve Blocks in Children

Rothstein, Peter; Arthur, G. R.; Feldman, Hal S.; Kopf, Gary S.; Covino, Benjamín G.

doi:10.1213/00000539-198606000-00011

Cited by 48 publications

(12 citation statements)

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“…First, except in neonates, the Vd ss , clearance and t 1 ⁄2 values for bupivacaine in infants and children are comparable to those seen in adults. [21,[23][24][25]54,77,93,96,97,[151][152][153][154][155][156][157][158][159][160][161][162][163][164][165][166][167][168] Second, in neonates and younger infants, although the clearance is still comparable to that in adults, the Vd ss , and thus the t 1 ⁄2 , are greater than the corresponding values in adults. [21,164] Third, in many of the studies looking at continuous infusions of bupivacaine, the maximum concentration of bupivacaine was seen either at or near the termination of the infusion or at the time of the last sample, suggesting that accumulation of bupivacaine was occurring during the infusion.…”

Section: Bupivacainementioning

confidence: 99%

Benefit and Risks of Local Anesthetics in Infants and Children

Gunter

2002

Pediatric Drugs

157

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Regional anesthesia has become a routine part of the practice of anesthesiology in infants and children. Local anesthetic toxicity is extremely rare in infants and children; however, seizures, dysrhythmias, cardiovascular collapse, and transient neuropathic symptoms have been reported. Infants and children may be at increased risk from local anesthetics compared with adults. Larger volumes of local anesthetics are used for epidural anesthesia in infants and children than in adults. Metabolism and elimination of local anesthetics can be delayed in neonates, who also have decreased plasma concentrations of alpha(1)-acid glycoprotein, leading to increased concentrations of unbound bupivacaine. Most regional anesthetic procedures in infants and children are performed with the patient heavily sedated or anesthetized; because of this, and because a test dose is not a particularly sensitive marker of intravenous injection in the anesthetized patient, detection of intravascular local anesthetic injection is extremely difficult. The same local anesthetics used in adult anesthetic practice are also used in infants and children. Because of its extremely short duration of action, chloroprocaine has been used primarily for continuous epidural techniques in infants and children. The use of tetracaine has generally been limited to spinal and topical anesthesia. Lidocaine (lignocaine) has been used extensively in infants and children for topical, regional, plexus, epidural and spinal anesthesia. The association between prilocaine and methemoglobinemia has generally restricted prilocaine use in infants and children to the eutectic mixture of local anesthetics (EMLA). Because of its greater degree of motor block compared with other long-acting local anesthetics, etidocaine has generally been limited to plexus blocks in infants and children. Mepivacaine has been used for both plexus and epidural anesthesia in infants and children. Because postoperative analgesia is often the primary justification for regional anesthesia in infants and children, bupivacaine, a long-acting local anesthetic, is the most commonly reported local anesthetic for pediatric regional anesthesia. Given the lower toxic threshold of bupivacaine compared with other local anesthetics, the risk-benefit ratio of bupivacaine may be greater than that of other local anesthetics. Two new enantiomerically pure local anesthetics, ropivacaine and levobupivacaine, offer clinical profiles comparable to that of bupivacaine but without its lower toxic threshold. The extreme rarity of major toxicity from local anesthetics suggests that widespread replacement of bupivacaine with ropivacaine or levobupivacaine is probably not necessary. However, there are clinical situations, including prolonged local anesthetic infusions, use in neonates, impaired hepatic metabolic function, and anesthetic techniques requiring a large mass of local anesthetic, where replacement of bupivacaine with ropivacaine, levobupivacaine or (for continuous techniques) chloroprocaine appears prudent.

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Section: Bupivacainementioning

confidence: 99%

Benefit and Risks of Local Anesthetics in Infants and Children

Gunter

2002

Pediatric Drugs

157

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“…PVB requires relatively high doses of LA 42. Systemic absorption of a LA is the fastest when injected intercostally, compared to other modes of regional administration 43,44. Predisposing factors for potential LAs’ toxic effects are aging, small patient size, liver insufficiency, decreased hepatic blood flow (influenced by disease and/or drugs), hypovolemia, drug–drug interactions, renal impairment, hypoalbuminemia, hypocalcemia,45 extensive surgical disruption of tissue (pleurae) administered with LA, and inappropriate LA administration 46.…”

Section: Discussionmentioning

confidence: 99%

“…BP and heart rate remained within recommended ranges during her stay in the hospice. The patient had hypoproteinemia, hypoalbuminemia, and hypocalcemia (Table 2); thus, after the decision of performing PVB with bupivacaine, which is eliminated unchanged in the urine in ±1%43,49 and its hepatic extraction ratio value is 0.3150 (the lowest of the amide-type local anesthetics), the LA’s dosage in the patient was still carefully chosen and reconsidered.…”

Section: Discussionmentioning

confidence: 99%

Lumbar paravertebral blockade as intractable pain management method in palliative care

Zaporowska-Stachowiak¹,

Kotlińska-Lemieszek²,

Kowalski³

et al. 2013

OTT

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Optimal symptoms control in advanced cancer disease, with refractory to conventional pain treatment, needs an interventional procedure. This paper presents coadministration of local anesthetic (LA) via paravertebral blockade (PVB) as the alternative to an unsuccessful subcutaneous fentanyl pain control in a 71-year old cancer patient with pathological fracture of femoral neck, bone metastases, and contraindications to morphine. Bupivacaine in continuous infusion (0.25%, 5 mL · hour−1) or in boluses (10 mL of 0.125%–0.5% solution), used for lumbar PVB, resulted in pain relief, decreased demand for opioids, and led to better social interactions. The factors contributing to an increased risk of systemic toxicity from LA in the patient were: renal impairment; heart failure; hypoalbuminemia; hypocalcemia; and a complex therapy with possible drug-drug interactions. These factors were taken into consideration during treatment. Bupivacaine’s side effects were absent. Coadministered drugs could mask LA’s toxicity. Elevated plasma α1-acid glycoprotein levels were a protective factor. To evaluate the benefit-risk ratio of the PVB treatment in boluses and in constant infusion, bupivacaine serum levels were determined and the drug plasma half-lives were calculated. Bupivacaine’s elimination was slower when administered in constant infusion than in boluses (t½ = 7.80 hours versus 2.64 hours). Total drug serum concentrations remained within the safe ranges during the whole treatment course (22.9–927.4 ng mL−1). In the case presented, lumbar PVB with bupivacaine in boluses (≤ 137.5 mg · 24 hours−1) was an easy to perform, safe, effective method for pain control. Bupivacaine in continuous infusion (≤150 mg · 12 hours−1) had an acceptable risk-benefits ratio, but was ineffective.

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“…Intercostal neural blockade in children has only been described as a single percutaneous injection (Shelly & Park 1987). The pharmacokinetics of intercostal bupivacaine show that the absorption of the local anaesthetic from the intercostal space appears to be more rapid in children than in adults and also that the volume of distribution and clearance is greater in children (Rothstein et al 1986).…”

Section: Discussionmentioning

confidence: 99%

Intra‐operative placement of intercostal catheter for post‐thoracotomy pain relief in a child

Cooper

Seaton

1992

Pediatric Anesthesia

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Summa yIntra-operative placement of a catheter in the posterior intercostal space at thoracotomy is technically easier than other forms of regional analgesia such as thoracic epidural. Intermittent bolus dosing of bupivacaine with adrenaline allows subpleural spread to other intercostal interspaces. This spread is volume dependent and may be even greater due to smaller distances between these spaces in children. This technique has advantages over interpleural analgesia which may not be completely effective for post-thoracotomy pain. Analgesia can occur for up to 10 h with each dose, and markedly decrease opioid requirements. This technique is described in a 7-year-old child undergoing anterior thoracic spine fusion.

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Bupivacaine for Intercostal Nerve Blocks in Children

Cited by 48 publications

References 0 publications

Benefit and Risks of Local Anesthetics in Infants and Children

Benefit and Risks of Local Anesthetics in Infants and Children

Lumbar paravertebral blockade as intractable pain management method in palliative care

Intra‐operative placement of intercostal catheter for post‐thoracotomy pain relief in a child

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