Plasma Ropivacaine Concentrations Following Local Infiltration Analgesia in Total Knee Arthroplasty

Miller, Reuben Jonathan; Cameron, A. F.; Dimech, J.; Orec, Robert J.; Lightfoot, Nicholas J

doi:10.1097/aap.0000000000000727

Cited by 14 publications

(14 citation statements)

References 23 publications

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“…The observed Cmax after LIA only in our study was nearly identical to the Cmax demonstrated in the study by Miller et al (0.53 vs 0.57 µg/mL), although our Tmax was shorter than what they reported (4 hours vs 12 hours) 9. It is not clear why there is such a difference in time to peak concentration between our study and that done by Miller et al .…”

Section: Discussionsupporting

confidence: 78%

Serum ropivacaine levels after local infiltration analgesia during total knee arthroplasty with and without adductor canal block

Koniuch

Buys

Campbell

et al. 2019

Reg Anesth Pain Med

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Background and objectivesA common analgesic technique for total knee arthroplasty (TKA) is to inject local anesthetic into the periarticular tissue during surgery, known as local infiltration analgesia (LIA). Since the solution used typically contains a large amount of local anesthetic, concerns arise about exceeding the maximum dosage when adding a peripheral nerve block. Little research exists that addresses serum ropivacaine concentrations following LIA combined with peripheral nerve block. We hypothesized that after combining LIA and adductor canal blockade (ACB), serum ropivacaine concentrations would remain below levels associated with local anesthetic toxicity.MethodsThis was a prospective observational study that included 14 subjects undergoing TKA with intraoperative LIA containing 270 mg ropivacaine with epinephrine. Patients weighing less than 80 kg were excluded due to standardized dosing by our pharmacy. Seven patients were assigned consecutively to receive LIA alone (Group LIA) and seven were assigned to receive LIA plus ACB with 100 mg ropivacaine with epinephrine (Group LIA+ACB). Venous serum ropivacaine concentrations were measured over 24 hours.ResultsPeak serum concentrations (Cmax) in Group LIA ranged from 0.23 to 0.75 µg/mL and occurred at times from 4 to 24 hours. Cmax in Group LIA+ACB ranged from 0.46 to 1.00 µg/mL and occurred at times from 4 to 8 hours. No participants demonstrated signs or symptoms of local anesthetic toxicity.ConclusionsTotal serum concentration of ropivacaine after LIA using 270 mg ropivacaine with and without an additional 100 mg perineural ropivacaine remained well below the toxicity threshold of 3.0 µg/mL at all time points. Additional studies are needed to ascertain the safety of combining LIA with peripheral nerve blockade.

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Section: Discussionsupporting

confidence: 78%

Serum ropivacaine levels after local infiltration analgesia during total knee arthroplasty with and without adductor canal block

Koniuch

Buys

Campbell

et al. 2019

Reg Anesth Pain Med

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“…Blood sampling for the analysis of total ropivacaine concentration was performed only in the QLB group through the right radial artery at 30, 45, 60 min, and 4 hours after the end of QLB 6 15 16. The study’s initial design included the measurement of ropivacaine concentrations at baseline (preblock).…”

Section: Methodsmentioning

confidence: 99%

Comparison of postoperative analgesic effects of posterior quadratus lumborum block and intrathecal morphine in laparoscopic donor hepatectomy: a prospective randomized non-inferiority clinical trial

Lee

Kang

Kim

et al. 2022

Reg Anesth Pain Med

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BackgroundPosterior quadratus lumborum block (QLB) and intrathecal morphine are accepted analgesic strategies in laparoscopic liver resection, but their effects have not been compared after laparoscopic donor hepatectomy. This study was planned to perform this comparison.MethodsFifty-six donors were randomized to receive bilateral posterior (QLB2, 20 mL of 0.375% ropivacaine on each side, 150 mg total) or preoperative injection of 0.4 mg morphine sulfate intrathecally. Primary outcome was resting pain score at 24 hour postsurgery. Secondary outcomes included cumulative opioid consumption and recovery parameters. Serial plasma ropivacaine concentrations were measured in QLB group. Only the outcome assessor was properly blinded.ResultsMean resting pain score at 24-hour postsurgery was 4.19±1.66 in QLB group (n=27) and 3.07±1.41 in intrathecal morphine group (n=27, p=0.04). Mean difference (QLB group-intrathecal morphine group) was 1.11 (95% CI 0.27 to 1.95), and the upper limit of CI was higher than prespecified non-inferiority margin (δ=1), indicating an inferior effect of QLB. Cumulative opioid consumption was significantly higher in QLB group at 24 hours and 48 hours postsurgery. QLB group exhibited lower incidence of postoperative pruritus at all time points, and there were no differences in other recovery outcomes. All measured ropivacaine concentrations were below the threshold for systemic toxicity (4.3 µg/mL).ConclusionsBilateral posterior QLB elicited higher resting pain scores at 24-hour after laparoscopic donor hepatectomy than intrathecal morphine and did not meet the definition of non-inferiority.Trial registration numberKCT0005360.

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“…Still, however, maximal serum anesthetic concentrations are at least transiently modified by renal function in addition to age and sex differences, and caution should be taken in patients with impaired kidney function. 43 Other studies have evaluated the efficacy of ACB alone versus ACB and PAI. Grosso et al 44 conducted a randomized control trial comparing patients who received ACB alone versus ACB with a PAI containing bupivacaine and adrenaline.…”

Section: Periarticular Injection and Peripheral Nerve Blockmentioning

confidence: 99%

Section: Periarticular Injection and Peripheral Nerve Blockmentioning

confidence: 99%

Periarticular Injection in Total Knee Arthroplasty

Schwartz

Cochrane

Jiranek

et al. 2023

J Am Acad Orthop Surg

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Optimal pain management after total knee arthroplasty (TKA) can expedite postoperative recovery, improve perioperative outcomes, and increase patient satisfaction. Periarticular injections (PAIs) have become increasingly used to improve pain management after TKA. Similar to peripheral nerve blocks, the use of intraoperative PAIs can lower pain scores and expedite discharge from the hospital. However, there is notable variability in the ingredients and administration techniques of PAIs. Currently, no standard of care exists for PAIs, especially in the setting of adjuvant peripheral nerve blocks. This study seeks to evaluate the ingredients, administration techniques, and outcomes of PAIs used during TKA. Pain control is an important component of recovery after total knee arthroplasty (TKA) and, when managed effectively, can expedite functional recovery and, ultimately, improve patient satisfaction. Evidence suggests that patients with poor pain control in the initial 48 hours postoperatively are limited in their ability to achieve long-term pain relief. 1 Efforts to improve pain control and avoid adverse effects of analgesic medications have led to the widespread use of multimodal analgesia to help facilitate rapid mobilization of TKA patients. Multimodal pain control modalities, including oral opioids, nonsteroidal anti-inflammatory medications, acetaminophen, and local or regional anesthetics including peripheral nerve blocks (PNBs) and periarticular injections (PAIs), have become the standard of care. 2 Still, notable variability exists with the use of local and regional anesthesia. Thus, this review will compare current pain management strategies after TKA and focus on the delivery and efficacy of PAIs. History of Periarticular InjectionsIn the past several decades, pain management after TKA has evolved markedly. During the 1980s, the cornerstone of pain management after TKA consisted of intramuscular injections of opioids. This slowly transitioned to patient-controlled analgesia in the 1990s, PNBs in the early 2000s, and finally, multimodal analgesia with the addition of PAIs in the late 2000s. The first prospective, randomized control trial on PAIs was published by Busch et al 3 in 2006. The authors randomized 64 patients undergoing TKA to receive a PAI containing ropivacaine, ketorolac, morphine, and adrenaline or to receive no

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Plasma Ropivacaine Concentrations Following Local Infiltration Analgesia in Total Knee Arthroplasty

Cited by 14 publications

References 23 publications

Serum ropivacaine levels after local infiltration analgesia during total knee arthroplasty with and without adductor canal block

Serum ropivacaine levels after local infiltration analgesia during total knee arthroplasty with and without adductor canal block

Comparison of postoperative analgesic effects of posterior quadratus lumborum block and intrathecal morphine in laparoscopic donor hepatectomy: a prospective randomized non-inferiority clinical trial

Periarticular Injection in Total Knee Arthroplasty

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