Continuous Epidural Infusion of Large Concentration/Small Volume Versus Small Concentration/Large Volume of Levobupivacaine for Postoperative Analgesia

Dernedde, Mira; Stadler, Michaela; Bardiau, Françoise; Boogaerts, Jean G.

doi:10.1213/01.ane.0000048977.66133.d5

Cited by 46 publications

(51 citation statements)

References 21 publications

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“…23 Several studies have subsequently demonstrated identical sensory and motor blockade when using local anesthetic solutions of widely different concentrations but of equal drug dose. [2][3][4][5][6][7][8][9][10][11][12]24,25 Some studies even demonstrated improved postoperative analgesia with concentrated epidural local anesthetic infusions 9 and more profound motor block 3,4 and hypotension 3,4 when using dilute solutions. Conversely, other studies have been published that support the superiority of dilute epidural local anesthetics for diffuse low intensity analgesia, particularly in labor analgesia.…”

Section: Discussionmentioning

confidence: 99%

Sympathectomy-mediated vasodilatation: a randomized concentration ranging study of epidural bupivacaine

Ginosar

Weiniger

Kurz

et al. 2009

Can J Anesth/J Can Anesth

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Purpose We tested the hypothesis that the development of sympathectomy-mediated vasodilatation is dependent on the concentration rather than the dose of epidural local anesthetic administered. Methods Sixty subjects receiving lumbar epidural bupivacaine were randomised to one of three groups: A: 10 ml 0.5% (50 mg); B: 10 ml 0.25% (25 mg); and C: 40 ml 0.0625% (25 mg). Groups A and B had equal volume but a twofold difference in drug dose, while groups B and C had equal drug dose, but a fourfold difference in drug volume. At baseline and 5, 10, and 20 min following epidural bupivacaine administration, we assessed the following indices of sympathectomy: pulse oximeter perfusion index in the toe and finger, skin temperature in the toe and finger, and mean arterial pressure. We also assessed sensory level (pinprick, cold, and light touch) and motor block. Results There was an increase in the pulse oximeter perfusion index by 20 min of 280%, 303%, and 59% in groups A, B, and, C, respectively. There was a significant sympathectomy-mediated vasodilatation in the toe for both groups A (P = 0.002) and B (P \ 0.001) but not C (P = 0.22). Vasoconstriction in the finger was observed in group A only (P = 0.015) but not in group B (P = 0.09) or group C (P = 0.20). There were similar blood pressure changes and similar sensory changes in all groups. The intensity of motor block increased with increasing drug concentration. Conclusions Our observations suggest that drug concentration is more important than drug dose in determining the degree of sympathectomy following lumbar epidural local anesthesia. RésuméObjectif Nous avons teste´l'hypothe`se selon laquelle l'apparition d'une vasodilatation me´die´e par sympathectomie e´tait lie´e à la concentration plutôt qu'a`la dose d'anesthe´sique local pe´ridural administre´. Méthode Soixante patients recevant de la bupivacaı¨ne pe´ridurale lombaire ont e´te´randomise´s en trois groupes : A : 10 ml 0,5 % (50 mg); B : 10 ml 0,25 % (25 mg); et C : 40 ml 0,0625 % (25 mg). Les groupes A et B ont reçu un volume e´quivalent mais la dose de me´dicament e´tait double´e pour le groupe A, alors que les groupes B et C ont reçu une dose e´gale, mais le volume de me´dicament a e´teq uadruple´pour le groupe C. Nous avons e´value´les indices de sympathectomie suivants aux niveaux de base ainsi qu'a5 , 10 et 20 minutes apre`s l'administration de la bupivacaı¨ne pe´ridurale : indice de perfusion de l'oxyme`tre de pouls a`l'orteil et au doigt, tempe´rature cutane´e à l'orteil et au doigt, et tension arte´rielle moyenne. Nous avons e´galement e´value´le niveau sensoriel (piquˆre a`l'aiguille, froid et toucher le´ger) et le bloc moteur. Résultats Sur la base de l'indice de perfusion de l'oxyme`tre de pouls, nous avons observe´une vasodilatation 123Can J Anesth/J Can Anesth (2009) 56:213-221 DOI 10.1007 me´die´e par sympathectomie significative dans l'orteil pour les groupes A (P = 0,002) et B (P \ 0,001) mais pas dans le groupe C (P = 0,22). La vasoconstriction au doigt a e´teó bserve´e uniquement ...

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Section: Discussionmentioning

confidence: 99%

Sympathectomy-mediated vasodilatation: a randomized concentration ranging study of epidural bupivacaine

Ginosar

Weiniger

Kurz

et al. 2009

Can J Anesth/J Can Anesth

View full text Add to dashboard Cite

show abstract

“…[6][7][8][9][10][11][12][13][14][15][16][17] Indeed, some studies reported an increased intensity of motor block, 7,8 increased hypotension, 7,8 and reduced analgesic effectiveness 16 when using dilute epidural local anesthetics as compared with concentrated drug regimes of equal dose. Dernedde and colleagues [7][8][9] reported an increased intensity of motor block and hypotension when using continuous infusions of bupivacaine administered in a low concentration, high volume (0.15%, 10 mL/h) compared with a high concentration, low volume (0.5%, 3 mL/h) solution. Murdoch et al 14 observed that 0.25% levobupivacaine as a continuous epidural infusion provided better postoperative analgesia without any significant increase in motor blockade compared with a 0.125% levobupivacaine infusion at twice the infusion rate.…”

Section: Discussionmentioning

confidence: 99%

“…2,5 Clinical studies of postoperative epidural analgesia provide conflicting evidence about the most important factor in determining the extent of a differential sensory block: absolute dose or volume of epidural local anesthetic. [6][7][8][9][10][11][12][13][14][15][16][17][18] A similar debate has recently re-emerged with labor analgesia. [16][17][18] In this prospective, randomized study in nulliparous women, patient-controlled epidural analgesia (PCEA) was used to administer epidural bupivacaine either as a concentrated (0.25%) or as a dilute (0.0625%) solution and analgesic requirement, maternal satisfaction, motor block and obstetric outcome were compared.…”

Section: Introductionmentioning

confidence: 99%

A randomized controlled trial using patient-controlled epidural analgesia with 0.25% versus 0.0625% bupivacaine in nulliparous labor: effect on analgesia requirement and maternal satisfaction

Ginosar

Davidson

Firman

et al. 2010

International Journal of Obstetric Anesthesia

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“…As regards the rate of epidural infusion (in the present case, 10 ml/h), comparative studies between two options -small volumes at high concentrations or large volumes at low concentrations -there is not much difference since the quality of analgesia depends on the total dose administered [16]. However, when post-operative perfusion continues for more than 72 hours we should pause to think whether such a rate is suitable given the high frequency of catheter migration described in.…”

Section: Discussionmentioning

confidence: 85%

Epidural catheter migration and extra-spinal drug delivery: a possible cause of inflammation and/or infection

Navarro¹,

Valverde²,

Carazo³

et al. 2013

J Anesthesiol Clin Sci

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Purpose: There is a strong possibility that many problems associated with local anaesthetics go undocumented. We describe an epidural catheter complication and its consequence. Clinical features: Female 56 year old patient operated 45 days previously for open gastric by-pass surgery and re-admitted to hospital because of pain and an infection related with the epidural technique. Lumbar Magnetic Resonance Imaging (MRI) revealed paravertebral inflammatory/infectious changes from L1 to L5, after lumbar epidural and post-operative epidural drug delivery for analgesia control. Intravenous antibiotic treatment and bed rest was continued for 21 days and a control MRI pointed to an improvement in the para-spinal alterations. There were never any signs of neurological deficit. We analyze, consider and discuss the clinical presentation of infectious complications of epidural anaesthesia, evaluating the various factors which might have led to this complication, as a silent migration of the catheter to a para-spinal region and the unintentional delivery of the drug involved, a foreign body reaction to the catheter tip or a result of the inflammatory process. Conclusions: An early diagnosis based on a combination of physical examination, imaging studies and appropriate follow up of those patients would avoid severe complications. In order to reduce the risk of serious infection following epidural anesthesia, the clinician must be knowledgeable in the pathogenesis of these infections, and use of meticulous aseptic technique and post operative regular assessment of the patient (as a routine) to look for effective analgesia, motor block, catheter migration etc. The right fixed-catheter manoeuvre and use of the correct pumps delivery system are clearly indicated. Treatment must be initiated as soon as there is any suspicion of an infection related with a spinal technique and that prevention is the best alternative.

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Continuous Epidural Infusion of Large Concentration/Small Volume Versus Small Concentration/Large Volume of Levobupivacaine for Postoperative Analgesia

Cited by 46 publications

References 21 publications

Sympathectomy-mediated vasodilatation: a randomized concentration ranging study of epidural bupivacaine

Sympathectomy-mediated vasodilatation: a randomized concentration ranging study of epidural bupivacaine

A randomized controlled trial using patient-controlled epidural analgesia with 0.25% versus 0.0625% bupivacaine in nulliparous labor: effect on analgesia requirement and maternal satisfaction

Epidural catheter migration and extra-spinal drug delivery: a possible cause of inflammation and/or infection

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