Systemic Levels of Local Anaesthetic after Intra-Peritoneal Application – a Systematic Review

Abstract

There is a lack of cohesive reports on the systemic levels of local anaesthetic after intraperitoneal application. A comprehensive systematic review with no language restriction was conducted. Eighteen suitable articles were identified. Data were compiled and presented according to local anaesthetic agent. Intraperitoneal local anaesthetic has been studied in many different procedures, including open and laparoscopic surgery. A total of 415 patients were included for analysis. There were no cases of clinical toxicity. There were 11 (2.7%) cases with a systemic level above or close to a safe threshold (as determined by the report authors) in three trials utilising intraperitoneal local anaesthetic after laparoscopic cholecystectomy. Intraperitoneal lignocaine doses varied from 100 to 1000 mg, mean Cmax ranged from 1.01 to 4.32 µg/ml and mean Tmax ranged from 15 to 40 minutes. Intraperitoneal bupivacaine doses varied from 50 to 150 mg (weight based doses also reported), mean Cmax ranged from 0.29 to 1.14 µg/ml and mean Tmax ranged from 15 to 60 minutes. Intraperitoneal ropivacaine doses varied from 100 to 300 mg, mean Cmax ranged from 0.66 to 3.76 µg/ml and mean Tmax ranged from 15 to 35 minutes. The addition of adrenaline to intraperitoneal local anaesthetic almost halves systemic levels and prolongs Tmax. Intraperitoneal local anaesthetic results in detectable systemic levels in the perioperative setting. Despite a lack of clinical toxicity, careful attention to dose is still required to prevent potential systemic toxic levels. Clinicians should also consider the addition of adrenaline to intraperitoneal local anaesthetic solutions to further add to the systemic safety profile.

Pharmacokinetics of bupivacaine after intraperitoneal administration to cats undergoing ovariohysterectomy

“…In humans, the mean maximum concentration after IP administration of bupivacaine is within the range of 0.29 to 1.14 µg/mL for doses of 1.5 to 2 mg/kg and when using bupivacaine concentrations between 0.15% and 0.75%. 3 Peak plasma concentrations in the present study were approximately onethird the concentration that has been reported to cause a convulsive electroencephalogram pattern in cats (3.6 ± 0.7 µg/mL) 26 and approximately oneseventh the concentration required to cause arrhythmias (7.5 to 10.9 µg/mL). 27 A convulsive electroencephalogram pattern and hypotension have been reported for cats at higher plasma concentrations (17 and 21 to 23 µg/mL, respectively).…”

“…In human medicine, serum concentrations of bupivacaine after IP administration were higher in individuals undergoing laparoscopic cholecystectomy, compared with concentrations in patients receiving a similar dose of bupivacaine and undergoing laparoscopic ovariohysterectomy. 3 This may have been attributable to the extent of dissection and tissue surface area that could have increased the absorption rate. 3 Studies are also warranted to assess the effects of epinephrine on systemic absorption of bupivacaine.…”

“…3 This may have been attributable to the extent of dissection and tissue surface area that could have increased the absorption rate. 3 Studies are also warranted to assess the effects of epinephrine on systemic absorption of bupivacaine. Maximum concentrations of bupivacaine were decreased by 50% without adverse effects when the drug was administered with epinephrine to human patients undergoing diagnostic laparoscopy 22 and laparoscopic cholecystectomy.…”

“…[3][4][5][6][7][8][9][10][11][12] According to meta-analyses and systematic reviews, IP administration of bupivacaine currently is recommended for laparoscopic surgery in humans as an adjuvant analgesic technique. 3,[13][14][15][16] Intraperitoneal administration of bupivacaine can reduce pain scores and blunt surgery-induced stress responses in dogs undergoing ovariohysterectomy. [17][18][19] The technique has been recommended by a panel of experts as an adjuvant technique for pain relief in dogs and cats undergoing abdominal surgery.…”

Cardiac Arrest from Local Anesthetic Toxicity After a Field Block and Transversus Abdominis Plane Block

“…After intraperitoneal administration of ropivacaine at doses varying from 100 to 300 mg, her mean Cmax ranged from 0.66 to 3.76 μg/mL and mean Tmax ranged from 15 to 35 minutes. 2 Using ropivacaine, Griffiths et al 3 reported a mean serum concentration of 2.54 mg/mL, 30 minutes after an injection of 3 mg/kg of ropivacaine during a bilateral TAP block. While our ropivacaine dose of 5.2 mg/ kg used for TAP block was higher, it was still within French guidelines which recommend a maximum dose…”