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Alcantara R, Arenas EN, Azcona J, Pitarch M, Vall E, Vila-Trias E, Ejarque B, Maiques JM, Montes A. Local anaesthesia and pain management in image-guided breast interventions: Empathy in action. Eur J Radiol 2025; 189:112176. [PMID: 40424892 DOI: 10.1016/j.ejrad.2025.112176] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2025] [Revised: 05/07/2025] [Accepted: 05/13/2025] [Indexed: 05/29/2025]
Abstract
Effective pain management is critical in image-guided breast interventions, directly contributing to patient comfort and procedural success. This review provides breast radiologists with actionable insights into pain mechanisms, the optimisation of local anaesthetic delivery, and practical supplementary methods to minimise injection discomfort. Evidence-based techniques, including buffering, warming of solutions, and the addition of vasoconstrictors, are explored. Pharmacological properties, safety considerations, and innovative approaches, including patient-centred care and anxiety management strategies, are also discussed. Together, these considerations form a comprehensive framework to advance practices and elevate the standard of care in breast interventions.
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Affiliation(s)
- Rodrigo Alcantara
- Department of Medicine and Life Sciences (MELIS), Universitat Pompeu Fabra (UPF), Barcelona, Spain; Department of Radiology and Nuclear Medicine, Dibi - Hospital del Mar, Barcelona, Spain; Departament of Medicine, Universitat Autònoma de Barcelona (UAB), Barcelona, Spain.
| | - E Natalia Arenas
- Department of Radiology and Nuclear Medicine, Dibi - Hospital del Mar, Barcelona, Spain
| | - Javier Azcona
- Department of Medicine and Life Sciences (MELIS), Universitat Pompeu Fabra (UPF), Barcelona, Spain; Department of Radiology and Nuclear Medicine, Dibi - Hospital del Mar, Barcelona, Spain
| | - Mireia Pitarch
- Department of Radiology and Nuclear Medicine, Dibi - Hospital del Mar, Barcelona, Spain
| | - Elisenda Vall
- Department of Radiology and Nuclear Medicine, Dibi - Hospital del Mar, Barcelona, Spain
| | - Elisabet Vila-Trias
- Department of Radiology and Nuclear Medicine, Dibi - Hospital del Mar, Barcelona, Spain
| | - Belen Ejarque
- Department of Radiology and Nuclear Medicine, Dibi - Hospital del Mar, Barcelona, Spain
| | - José Maria Maiques
- Department of Medicine and Life Sciences (MELIS), Universitat Pompeu Fabra (UPF), Barcelona, Spain; Department of Radiology and Nuclear Medicine, Dibi - Hospital del Mar, Barcelona, Spain
| | - Antonio Montes
- Department of Medicine and Life Sciences (MELIS), Universitat Pompeu Fabra (UPF), Barcelona, Spain; Department of Anaesthesiology, Hospital del Mar, Barcelona, Spain
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2
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Bungart B, Joudeh L, Schwenk ES, Chiang C, Fettiplace MR. Comparative Methods to Predict Redosing of Bupivacaine and Ropivacaine in Truncal Catheters. Anesthesiology 2025; 142:885-895. [PMID: 39907706 PMCID: PMC11974616 DOI: 10.1097/aln.0000000000005406] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2024] [Accepted: 01/13/2025] [Indexed: 02/06/2025]
Abstract
BACKGROUND Despite the frequent use of ropivacaine and bupivacaine, there is limited guidance on redosing of these medications after an initial bolus. Intermittent redosing is a clinical practice in the setting of nerve catheters, often utilizing large doses. Comparatively, theoretical elimination rates are available from pharmacokinetic studies, providing estimates on total body content of these drugs. The authors hypothesized that published redosing of bupivacaine and ropivacaine in clinical literature comported with safe elimination of the drugs based on pharmacokinetic studies. METHODS Clinical redosing of bupivacaine and ropivacaine were identified from previously published articles that used intermittent bolus dosing into the transversus abdominis plane and paravertebral space. The dosing data were fit to an exponential curve using least squares regression and 1/Y 2 weighting with the equation: Y = Y M - (Y M - Y 0 ) * e -k * x , where YM is the maximal dose (175 mg for bupivacaine, 210 mg for ropivacaine), Y0 is the dose at time zero, k is the elimination constant, and x is time. Both minimal ( i.e. , slowest) and average pharmacokinetic elimination constants for ropivacaine and bupivacaine were identified in the published literature. Clinical redosing was compared with pharmacokinetic elimination. RESULTS The maximal pharmacokinetic half-lives of bupivacaine and ropivacaine were 603 min (range, 154 to 2,970 min; N = 49) and 528 min (range, 204 to 3,276 min; N = 39), respectively. Clinically reported redosing of bupivacaine fit to an exponential curve with k bupi(clinical) = 0.077 h -1 , representing the 53.5th percentile of extracted pharmacokinetic minimal elimination constants. Clinically reported redosing of ropivacaine fit to a curve with k ropi(clinical) = 0.083 h -1 consistent with the 52nd percentile of minimal pharmacokinetic elimination constants. CONCLUSIONS Clinically reported redosing of bupivacaine and ropivacaine in the published literature reflect the slowest pharmacokinetic elimination based on human studies. The combined data without evidence of toxicity permit the authors to make practical recommendations about safe redosing of these agents.
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Affiliation(s)
- Brittani Bungart
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, Massachusetts; and Department of Anaesthesia, Harvard Medical School, Boston, Massachusetts
| | - Lana Joudeh
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, Massachusetts; and Department of Anaesthesia, Harvard Medical School, Boston, Massachusetts
| | - Eric S. Schwenk
- Department of Anesthesiology and Perioperative Medicine, Sidney Kimmel Medical College at Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Christopher Chiang
- Department of Anesthesiology, University of Illinois at Chicago, Chicago, Illinois
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3
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Gitman M, Bezinover D, Pai SL. Current Practices and Recent Advances in Perioperative Pain Management for Liver Transplantation Living Donors and Recipients. Transplantation 2025; 109:774-783. [PMID: 39375901 DOI: 10.1097/tp.0000000000005239] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/09/2024]
Abstract
Analgesia in liver transplantation patients has been traditionally considered a secondary priority where perioperative management principally focused on survival rates in these critically ill patients. With recent advancements in both surgical and medical management, posttransplant survival rates have steadily improved. Outcome measurements are no longer limited to short-term mortality rates and hospital length of stay but are also measured by patient-centered outcomes, such as pain control and quality of life. As living donor liver transplantation has increased access to transplantation, it has also added a different patient population to manage in the perioperative period. For healthy patients undergoing living donor hepatectomies, it is important to reduce the impact of the surgery with proper perioperative pain management. We performed a literature search for articles related to perioperative pain management for liver transplantation living donors and recipients to identify current practices and recent advances. Neuraxial techniques, peripheral nerve blocks, and enteral and parenteral medications were all found to be feasible analgesia modalities for patients undergoing either liver transplant or donor hepatectomy. Patients may also benefit from nonpharmacological interventions and preoperative counseling. No particular perioperative analgesic modality was deemed superior to any other. For liver transplant living donors and recipients, perioperative pain management should emphasize the application of sustainable patient-centered pain control protocols.
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Affiliation(s)
- Marina Gitman
- Department of Anesthesiology, University of Miami, Jackson Memorial Hospital, Miami, FL
| | - Dmitri Bezinover
- Department of Anesthesiology and Critical Care, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Sher-Lu Pai
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Jacksonville, FL
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4
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Yoo S, Choi BM, Kim DJ, Kim JT. Plasma concentrations of total and unbound ropivacaine and its metabolite 2',6'-pipecoloxylidide after popliteal sciatic nerve block in chronic kidney disease patients not receiving haemodialysis: A population pharmacokinetic analysis. Eur J Anaesthesiol 2025:00003643-990000000-00294. [PMID: 40292526 DOI: 10.1097/eja.0000000000002194] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2025] [Accepted: 04/04/2025] [Indexed: 04/30/2025]
Affiliation(s)
- Seokha Yoo
- From the Department of Anaesthesiology and Pain Medicine, Seoul National University Hospital, Seoul National University College of Medicine (SY, J-TK), Department of Anaesthesiology and Pain Medicine, Asan Medical Centre, University of Ulsan College of Medicine (B-MC), Liver Research Institute and Seoul National University College of Medicine, Seoul, Republic of Korea (DJK)
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Chen X, Wan H, Huang Y, Chen A, Wu X, Guo Y, Wei J, Chen P, Jiang J, Zheng X. Repeated lidocaine exposure induces synaptic and cognitive impairment in aged mice by activating microglia and neurotoxic A1 astrocytes. iScience 2025; 28:112041. [PMID: 40092614 PMCID: PMC11910116 DOI: 10.1016/j.isci.2025.112041] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2023] [Revised: 06/28/2024] [Accepted: 02/13/2025] [Indexed: 03/19/2025] Open
Abstract
In the perioperative setting, the administration of intravenous lidocaine is widespread. This study investigates the effects of varying frequencies of intravenous lidocaine on cognitive function in mice of differing ages. Young adult and aged mice received systemic lidocaine either once or three times. Our findings indicated that repeated exposure to systemic lidocaine in aged mice resulted in cognitive impairment, accompanied by neuronal apoptosis and synaptic loss in the hippocampus. Additionally, repeated lidocaine exposure activated microglia and neurotoxic A1 astrocytes in aged mice. Notably, the adverse effects were significantly diminished when aged mice were treated with dehydroxymethylepoxyquinomicin (DHMEQ), a specific NF-κB inhibitor. Furthermore, depleting microglia with PLX5622 effectively prevented the activation of A1 astrocytes and synaptic loss following lidocaine exposure. This study provides evidence linking age and exposure frequency to cognitive impairment due to systemic lidocaine administration, correlating with the activation of microglia and neurotoxic A1 astrocytes.
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Affiliation(s)
- Xiaohui Chen
- Department of Anesthesiology, Shengli Clinical Medical College of Fujian Medical University, Fujian Provincial Hospital, Fuzhou University Affiliated Provincial Hospital, Fuzhou, China
| | - Haiyang Wan
- Department of Anesthesiology, First Affiliated Hospital of Yangtze University, First People's Hospital of Jingzhou, Jingzhou, China
| | - Yongxin Huang
- Department of Anesthesiology, Shengli Clinical Medical College of Fujian Medical University, Fujian Provincial Hospital, Fuzhou University Affiliated Provincial Hospital, Fuzhou, China
| | - Andi Chen
- Department of Anesthesiology, Shengli Clinical Medical College of Fujian Medical University, Fujian Provincial Hospital, Fuzhou University Affiliated Provincial Hospital, Fuzhou, China
| | - Xuyang Wu
- Department of Anesthesiology, Shengli Clinical Medical College of Fujian Medical University, Fujian Provincial Hospital, Fuzhou University Affiliated Provincial Hospital, Fuzhou, China
| | - Yanhua Guo
- Department of Anesthesiology, Shengli Clinical Medical College of Fujian Medical University, Fujian Provincial Hospital, Fuzhou University Affiliated Provincial Hospital, Fuzhou, China
| | - Jianjie Wei
- Department of Anesthesiology, Shengli Clinical Medical College of Fujian Medical University, Fujian Provincial Hospital, Fuzhou University Affiliated Provincial Hospital, Fuzhou, China
| | - Pinzhong Chen
- Department of Anesthesiology, Shengli Clinical Medical College of Fujian Medical University, Fujian Provincial Hospital, Fuzhou University Affiliated Provincial Hospital, Fuzhou, China
| | - Jiangdan Jiang
- Department of Anesthesiology, Shengli Clinical Medical College of Fujian Medical University, Fujian Provincial Hospital, Fuzhou University Affiliated Provincial Hospital, Fuzhou, China
| | - Xiaochun Zheng
- Department of Anesthesiology, Shengli Clinical Medical College of Fujian Medical University, Fujian Provincial Hospital, Fuzhou University Affiliated Provincial Hospital, Fuzhou, China
- Fujian Emergency Medical Center, Fujian Provincial Key Laboratory of Critical Care Medicine, Fujian Provincial Co-Constructed Laboratory of "Belt and Road", Fuzhou, China
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Chan D, Wood C, Rafizadeh A, Nagai M. Seizure following in-office lidocaine administration: a case report on local anesthetic systemic toxicity. Ther Adv Drug Saf 2025; 16:20420986251318843. [PMID: 40104514 PMCID: PMC11915292 DOI: 10.1177/20420986251318843] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2024] [Accepted: 01/21/2025] [Indexed: 03/20/2025] Open
Abstract
Local anesthetics have a broad application for minor and major surgeries, in outpatient and inpatient settings. Drug dosing, frequency, duration of action, and coadministration with other drugs, are some of many factors that must be considered for each patient, before drug administration. Like other medical treatments, the use of local anesthetics has potential complications, such as local anesthetic systemic toxicity (LAST). LAST primarily affects the cardiac and central nervous systems (CNS), seizures and cardiac arrest being some of the more time-sensitive symptoms requiring immediate treatment. Patients should be briefed on potential symptoms if LAST occurs and physicians should be aware of the warning signs, treatment, and prevention. In our case study, a 40-year-old, 51 kg woman was administered a lidocaine dosage of 760 mg in an outpatient setting. She presented to the emergency department with diffuse tremors, paresthesias of the mouth and face, spasticity, irritability, and a single generalized tonic-clonic seizure. The patient was successfully treated with Ativan along with lipid emulsion. We review this case and perform a literature review to identify key points in the use of local anesthetics. Healthcare providers should be trained in LAST treatment and prevention. Our case study therefore serves to reduce the frequency of LAST and other adverse outcomes associated with local anesthetic administration.
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Affiliation(s)
- Deana Chan
- Department of Plastic Surgery, Erie County Medical Center, Buffalo, NY, USA
| | - Christopher Wood
- Department of Plastic Surgery, Erie County Medical Center, 462 Grider Street, Buffalo, NY 14215, USA
| | - Andre Rafizadeh
- Department of Plastic Surgery, Erie County Medical Center, Buffalo, NY, USA
| | - Michael Nagai
- Department of Plastic Surgery, Erie County Medical Center, Buffalo, NY, USA
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Sohn JT. The Optimal Dose of Lidocaine for Bier Block. Pediatr Emerg Care 2025; 41:e1. [PMID: 38748414 DOI: 10.1097/pec.0000000000003222] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/01/2025]
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Butiulca M, Farczadi L, Vari CE, Imre S, Azamfirei L, Lazar A. The Study of Ropivacaine Pharmacokinetics in a Clinical Setting: A Critical Scoping Review from the Perspective of Analytical Methodologies. Int J Mol Sci 2024; 25:13487. [PMID: 39769250 PMCID: PMC11678900 DOI: 10.3390/ijms252413487] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2024] [Revised: 12/09/2024] [Accepted: 12/13/2024] [Indexed: 01/11/2025] Open
Abstract
Ropivacaine, a widely used regional anesthetic also used for pain management, has been increasingly used in recent years due to its increased efficacy and improved safety compared to similar anesthetics. Biomonitoring of ropivacaine and its metabolites during and after anesthesia is an essential process for ensuring therapeutic efficacy and safe usage for patients. The most useful biomonitoring tool in recent years has been liquid chromatography coupled with mass spectrometry (LC-MS/MS), which offers selectivity, sensitivity, as well as accuracy of measurements. The current manuscript summarizes and discusses the existing liquid chromatographic methods described in the literature, as well as the personal experience with developing bioanalytical and analytical methods for the quantification of ropivacaine in biological samples for clinical applications. It is focused on methodological aspects, recent advancements, challenges, and future perspectives, highlighting the importance of LC-MS/MS techniques in ropivacaine analysis.
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Affiliation(s)
- Mihaela Butiulca
- Department of Anesthesiology and Intensive Care Medicine, Faculty of General Medicine, George Emil Palade University of Medicine, Pharmacy, Science, and Technology of Targu Mures, 540142 Târgu Mureș, Romania; (M.B.); (L.A.); (A.L.)
- Department of Anesthesiology and Intensive Care Medicine, Emergency County Hospital, 540136 Târgu Mureș, Romania
| | - Lenard Farczadi
- Chromatography and Mass Spectrometry Laboratory, Center for Advanced Medical and Pharmaceutical Research, George Emil Palade University of Medicine, Pharmacy, Science, and Technology of Targu Mures, 540142 Târgu Mureș, Romania;
| | - Camil Eugen Vari
- Department of Pharmacology and Clinical Pharmacy, Faculty of Pharmacy, George Emil Palade University of Medicine, Pharmacy, Science, and Technology of Targu Mures, 540142 Târgu Mureș, Romania;
| | - Silvia Imre
- Chromatography and Mass Spectrometry Laboratory, Center for Advanced Medical and Pharmaceutical Research, George Emil Palade University of Medicine, Pharmacy, Science, and Technology of Targu Mures, 540142 Târgu Mureș, Romania;
- Department of Analytical Chemistry and Drug Analysis, Faculty of Pharmacy, George Emil Palade University of Medicine, Pharmacy, Science, and Technology of Targu Mures, 540142 Târgu Mureș, Romania
| | - Leonard Azamfirei
- Department of Anesthesiology and Intensive Care Medicine, Faculty of General Medicine, George Emil Palade University of Medicine, Pharmacy, Science, and Technology of Targu Mures, 540142 Târgu Mureș, Romania; (M.B.); (L.A.); (A.L.)
- Department of Anesthesiology and Intensive Care Medicine, Emergency County Hospital, 540136 Târgu Mureș, Romania
| | - Alexandra Lazar
- Department of Anesthesiology and Intensive Care Medicine, Faculty of General Medicine, George Emil Palade University of Medicine, Pharmacy, Science, and Technology of Targu Mures, 540142 Târgu Mureș, Romania; (M.B.); (L.A.); (A.L.)
- Department of Anesthesiology and Intensive Care Medicine, Emergency County Hospital, 540136 Târgu Mureș, Romania
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9
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Tsai YF, Lin YC, Hsieh PH, Liou JT, Chung YT, Shih BF, Yang MW, Liu FC, Lin HT. Incidence of local anesthetic systemic toxicity in patients receiving bupivacaine infiltration analgesia for total joint arthroplasty under general anesthesia: a retrospective single-center study. BMC Anesthesiol 2024; 24:422. [PMID: 39573988 PMCID: PMC11580633 DOI: 10.1186/s12871-024-02816-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2024] [Accepted: 11/15/2024] [Indexed: 11/25/2024] Open
Abstract
BACKGROUND Local infiltration analgesia (LIA) is a crucial component of multimodal analgesia that enhances recovery after total hip arthroplasty (THA) and knee arthroplasty (TKA). However, LIA can cause fatal local anesthetic systemic toxicity (LAST). The incidences of LIA-induced LAST in different surgeries and anesthetic agents have not been well investigated. METHODS This observational study enrolled 1,267 adult patients who received LIA with bupivacaine for primary THA or TKA under general anesthesia at a single medical center between January 2020 and October 2021. LAST incidence was graded by severity: severe (refractory seizure or arrhythmia requiring lipid rescue), major (seizure or arrhythmia requiring prompt medication), and minor (all other) events. Patient demographics, surgical and anesthesia details, recovery profiles, and LAST incidences were recorded and analyzed. RESULTS The incidence of severe LAST events was 2.41 per 1000 in unilateral THA, 0 in TKA, and 3.16 per 1000 in the entire cohort. The odds ratio of developing major LAST events was 4.35 in patients undergoing unilateral THA compared with those undergoing unilateral TKA in a matched comparison. Patients who underwent bilateral THA had the highest risk of developing LIA-induced LAST. Additionally, patients using propofol infusion for anesthesia maintenance had a lower risk of seizures and tremors than those using sevoflurane inhalation. The odds ratio of major LAST events was 0.47 in matched comparisons. CONCLUSIONS LIA was associated with a significantly higher risk of LAST in the THA group than in the TKA group. Propofol maintenance reduces the likelihood of seizures and tremors compared with sevoflurane inhalation. Exploring strategies to reduce the incidence of LIA-induced LAST is essential to improve perioperative patient safety.
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Affiliation(s)
- Yung-Fong Tsai
- Department of Anesthesiology, Chang Gung Memorial Hospital at Linkou, Taoyuan, 333, Taiwan
- College of Medicine, Chang Gung University, Taoyuan, 333, Taiwan
| | - Yen-Chu Lin
- Department of Anesthesiology, Chang Gung Memorial Hospital at Linkou, Taoyuan, 333, Taiwan
- College of Medicine, Chang Gung University, Taoyuan, 333, Taiwan
| | - Pang-Hsin Hsieh
- College of Medicine, Chang Gung University, Taoyuan, 333, Taiwan
- Department of Orthopaedic Surgery, Chang Gung Memorial Hospital at Linkou, Taoyuan, 333, Taiwan
- Bone and Joint Research Center, Chang Gung Memorial Hospital at Linkou, Taoyuan, Taiwan
| | - Jiin-Tarng Liou
- Department of Anesthesiology, Chang Gung Memorial Hospital at Linkou, Taoyuan, 333, Taiwan
- College of Medicine, Chang Gung University, Taoyuan, 333, Taiwan
| | - Yung-Tai Chung
- Department of Anesthesiology, Chang Gung Memorial Hospital at Linkou, Taoyuan, 333, Taiwan
- College of Medicine, Chang Gung University, Taoyuan, 333, Taiwan
| | - Bo-Fu Shih
- Department of Anesthesiology, Chang Gung Memorial Hospital at Linkou, Taoyuan, 333, Taiwan
- College of Medicine, Chang Gung University, Taoyuan, 333, Taiwan
| | - Min-Wen Yang
- Department of Anesthesiology, Chang Gung Memorial Hospital at Linkou, Taoyuan, 333, Taiwan
| | - Fu-Chao Liu
- Department of Anesthesiology, Chang Gung Memorial Hospital at Linkou, Taoyuan, 333, Taiwan
- College of Medicine, Chang Gung University, Taoyuan, 333, Taiwan
| | - Huan-Tang Lin
- Department of Anesthesiology, Chang Gung Memorial Hospital at Linkou, Taoyuan, 333, Taiwan.
- College of Medicine, Chang Gung University, Taoyuan, 333, Taiwan.
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10
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Wang C, Fan P, Wang Q. Evolving therapeutics and ensuing cardiotoxicities in triple-negative breast cancer. Cancer Treat Rev 2024; 130:102819. [PMID: 39216183 DOI: 10.1016/j.ctrv.2024.102819] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2024] [Revised: 07/18/2024] [Accepted: 08/16/2024] [Indexed: 09/04/2024]
Abstract
Defined as scarce expression of hormone receptors and human epidermal growth factor receptor 2, triple-negative breast cancer (TNBC) is labeled as the most heterogeneous subtype of breast cancer with poorest prognosis. Despite rapid advancements in precise subtyping and tailored therapeutics, the ensuing cancer therapy-related cardiovascular toxicity (CTR-CVT) could exert detrimental impacts to TNBC survivors. Nowadays, this interdisciplinary issue is incrementally concerned by cardiologists, oncologists and other pertinent experts, propelling cardio-oncology as a booming field focusing on the whole-course management of cancer patients with potential cardiovascular threats. Here in this review, we initially profile the evolving molecular subtyping and therapeutic landscape of TNBC. Further, we introduce various monitoring approaches of CTR-CVT. In the main body, we elaborate on typical cardiotoxicities ensuing anti-TNBC treatments in detail, ranging from chemotherapy (especially anthracyclines), surgery, anesthetics, radiotherapy to immunotherapy, with future perspectives on promising directions in the era of artificial intelligence and traditional Chinese medicine.
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Affiliation(s)
- Chongyu Wang
- Department of Medicine, Xinglin College, Nantong University, Nantong 226007, Jiangsu, China
| | - Pinchao Fan
- The First Clinical Medical College, Nanjing Medical University, Nanjing 211166, Jiangsu, China; Sir Run Run Hospital, Nanjing Medical University, Nanjing 211112, Jiangsu, China
| | - Qingqing Wang
- Department of Thyroid and Breast Surgery, Affiliated Hospital of Nantong University, Medical School of Nantong University, Nantong 226001, Jiangsu, China.
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11
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Kohan J, Cabanas C, Edalatpour A, Seitz A, Kuei MC, Gander BH. Upper Extremity Blocks for Hand Surgeons: A Literature Review of Regional Anaesthesia Techniques, Efficacy, and Safety. Plast Surg (Oakv) 2024; 32:667-676. [PMID: 39430260 PMCID: PMC11489971 DOI: 10.1177/22925503231184260] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2023] [Revised: 04/23/2023] [Accepted: 05/02/2023] [Indexed: 10/22/2024] Open
Abstract
Introduction: Regional anaesthesia (RA) techniques have increased in popularity due to evidence of reductions in acute pain, chronic pain, postoperative nausea and vomiting (PONV), and pulmonary complications. While upper extremity blocks (UEBs) have been the subject of several comprehensive reviews, no review to date has synthesised the information on their use in hand surgery. Methods: A search of PUBMED and Cochrane databases was performed to identify the evidence associated with upper extremity blocks. The results of this search and extant literature on UEBs were examined and the relevant information extracted. Results: Supraclavicular block is associated with transient complications such as Horner's syndrome and phrenic nerve palsy, affecting up to 54% and 50% of patients, respectively. The incidence of pneumothorax in supraclavicular blocks is up to 4%. Infraclavicular, interscalene and axillary blocks have a lower rate of all complications, however, each may require a supplementary block at a different anatomical site as each spares significant regions of the upper extremity. Epinephrine in concentrations of 1:100,000-200,000 is safe for use in digital blocks with no association digital gangrene. Current evidence suggests digital blocks are safe and efficacious when appropriately performed. Conclusion: UEBs are safe and may be administered by an anaesthesia provider or an appropriately trained surgeon. The choice of block is contingent on the anatomical location of the surgical procedure, procedure duration, patient preference, patient co-morbidieis, and the surgeon's experience. Most upper extremity surgeries can be performed using RA. Current evidence illustrates outcome benefits for patients, surgeons, and healthcare institutions utilising RA.
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Affiliation(s)
- Joshua Kohan
- The Larner College of Medicine at the University of Vermont, Burlington, Vermont, USA
| | - Cassandra Cabanas
- American University of Antigua College of Medicine, Coolidge, Antigua
| | - Armin Edalatpour
- Division of Plastic Surgery, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, USA
| | - Allison Seitz
- McGovern Medical School, University of Texas Health Science Center, Houston, Texas, USA
| | - Michelle C. Kuei
- Division of Anesthesiology, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, USA
| | - Brian H. Gander
- Division of Plastic Surgery, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, USA
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12
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Husain A. Effective regional anesthesia for pediatric surgical care. Semin Pediatr Surg 2024; 33:151457. [PMID: 39427367 DOI: 10.1016/j.sempedsurg.2024.151457] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2024]
Abstract
This review highlights the significant role of pediatric regional anesthesia in optimizing perioperative care and improving surgical outcomes. We examine common local anesthetics, adjuvant medications, and techniques. Safety, efficacy, adverse events, and controversies are addressed while spotlighting the broad utility of regional anesthesia to contribute to better outcomes and quality of life for pediatric surgical patients and their families.
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Affiliation(s)
- Ahmar Husain
- Anesthesia Section Vice Chief, Medical Director for Safety and Quality, Division of Anesthesiology, Medical Director Liver Transplant Anesthesiology, Clinical Assistant Professor, University of Arizona College of Medicine, Phoenix Children's, 1919 E Thomas Rd., Phoenix 85016, AZ, USA.
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13
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Douglas RN, Niesen AD, Johnson RL, Olsen DA, Taunton MJ, Portner ER, Acker CT, Hanson AC, Kopp SL. A single center descriptive study of local anesthetic dose in knee arthroplasty: Was there evidence of local anesthetic systemic toxicity? J Clin Anesth 2024; 97:111534. [PMID: 38943851 DOI: 10.1016/j.jclinane.2024.111534] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2023] [Revised: 03/01/2024] [Accepted: 06/13/2024] [Indexed: 07/01/2024]
Abstract
STUDY OBJECTIVE Describe dosing of local anesthetic when both a periarticular injection (PAI) and peripheral nerve block (PNB) are utilized for knee arthroplasty analgesia, and compare the dosing of local to suggested maximum dosing, and look for evidence of local anesthetic systemic toxicity (LAST). DESIGN A single center retrospective cohort study between May 2018 and November 2022. SETTING A major academic hospital. PATIENTS Patients who had both a PAI and PNB while undergoing primary, revision, total, partial, unilateral, or bilateral knee arthroplasty. INTERVENTIONS None. MEASUREMENTS Calculate the dose of local anesthetic given via PAI, PNB, and both routes combined as based on lean body weight and compare that to the suggested maximum dosing. Look for medications, clinical interventions, and critical event notes suggestive of a LAST event. MAIN RESULTS There were 4527 knee arthroplasties where both a PAI and PNB were performed during the study period. When combining PAI and PNB doses, >75% of patients received more than the suggested maximum dose of 3 mg/kg lean body weight. The median local anesthetic dosing over the study period, 4.4 mg/kg (IQR 3.5,5.9), was 147% of the suggested maximum dose (IQR 117,197). There was no conclusive evidence of LAST among any of the patients in the study. CONCLUSIONS Over the course of our study, we had 4527 knee arthroplasties with a median PAI and PNB local anesthetic dose that was 147% of the suggested maximum without any clear clinical evidence of a LAST event.
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Affiliation(s)
- Rachel N Douglas
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, MN, United States of America.
| | - Adam D Niesen
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, MN, United States of America.
| | - Rebecca L Johnson
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, MN, United States of America.
| | - David A Olsen
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, MN, United States of America.
| | - Michael J Taunton
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, MN, United States of America.
| | - Erica R Portner
- Department of Quantitative Health Sciences, Mayo Clinic, Rochester, MN, United States of America.
| | - Christopher T Acker
- Department of Quantitative Health Sciences, Mayo Clinic, Rochester, MN, United States of America.
| | - Andrew C Hanson
- Department of Quantitative Health Sciences, Mayo Clinic, Rochester, MN, United States of America.
| | - Sandra L Kopp
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, MN, United States of America.
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de la Cal C, Di Croce DE, Takara D. Changes in masseter muscle structure, membrane lipid peroxidation and Ca-ATPase activity as effects of different local anesthetics. ACTA ODONTOLOGICA LATINOAMERICANA : AOL 2024; 37:105-113. [PMID: 39479943 PMCID: PMC11590001 DOI: 10.54589/aol.37/2/105 36] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/01/2023] [Accepted: 06/01/2024] [Indexed: 11/02/2024]
Abstract
Local anesthetics (LA) can cause undesired effects such as sustained contraction of skeletal muscles as a result of structural and functional changes. Proper skeletal muscle function is controlled by intracellular Ca2+ concentration and efficient energy (ATP) production, which is closely related to cell ultrastructure. Aim: The aim of this study was to identify the structural and functional changes caused by LAs. Materials and Method: Male Wistar rats weighing 200 to 250g were used (n:49). They were divided into seven groups. One group was not anesthetized or treated (Control). The other six groups underwent intramuscular (IM) anesthesia with xylazine 2% (0.05 ml) and ketamine 50 mg/ml (0.1 ml/100g rat weight), and one of the following was applied to the masseter muscle (MM): no further treatment (Anesthetic Control group, CA); 0.1ml physiological saline solution (group SF); Carrageenin (group Carr) 1% as positive control group; prilocaine (group Pri), mepivacaine (group Mepi); or articaine (group Arti) 0.3M, IM. The animals were euthanized by cervical dislocation one hour after treatment. The effects of the different anesthetics on the MM were evaluated histologically and by electronic microscopy (EM). Ca-ATPase and membrane lipid peroxidation (LPX) were evaluated in muscle homogenates under the same conditions as those used to prepare the histological sections. Results: In general, structural damage and increased muscle contraction were observed in tissues treated with anesthetics. The most extreme values of Ca-ATPase activity and LPX were observed in the positive control group (carrageenin). Results were analyzed by one-way ANOVA for multiple comparisons and Tukey's test (p < 0.05). Conclusions: The results suggest that in the short term, local anesthetics affect the muscle function and are associated to structural changes.
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Affiliation(s)
- Carolina de la Cal
- Universidad de Buenos Aires. Facultad de Odontología, Cátedra de Biofísica y Bioestadística. Buenos Aires, ArgentinaBuenos AiresArgentina
| | - Daniel E Di Croce
- Universidad de Buenos Aires. Facultad de Odontología, Cátedra de Biofísica y Bioestadística. Buenos Aires, ArgentinaBuenos AiresArgentina
| | - Delia Takara
- Universidad de Buenos Aires. Facultad de Odontología, Cátedra de Biofísica y Bioestadística. Buenos Aires, ArgentinaBuenos AiresArgentina
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15
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De Valle MK, Adkison M, Maredia R, Stevenson C, Murugan S. Local Anesthetic Systemic Toxicity in Pregnancy: A Retrospective Cohort Analysis. Cureus 2024; 16:e69215. [PMID: 39398741 PMCID: PMC11469792 DOI: 10.7759/cureus.69215] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/04/2024] [Indexed: 10/15/2024] Open
Abstract
Introduction Local anesthetic systemic toxicity (LAST) is a rare complication of regional anesthesia. Pregnancy is a risk factor due to gestational physiologic changes. Labor and disorders of pregnancy can mask or delay symptoms of LAST, slowing appropriate intervention. This study examines LAST within a larger cohort and identifies features that help distinguish LAST in pregnant women from LAST in nonpregnant patients. Methods The TriNetX database was used to compare pregnant and nonpregnant patients with LAST from 2013 to 2023. Cohorts were matched on age, race, obesity status, diabetes, metabolic disorders, local anesthetic type, and cardiovascular, liver, kidney, and respiratory disease. Outcomes included prodromal symptoms of LAST and symptoms of cardiac and central nervous system excitation and depression. Results Matching occurred for 276 pregnant and 276 nonpregnant patients. Pregnant cohorts had a significantly higher risk of cardiac depression (risk ratio (RR)=1.96 (95% confidence interval (CI): 1.44-2.66), p<0.01) and significantly lower risk of cardiac excitation (RR=0.38 (95% CI: 0.22-0.63), p<0.01), prodromal symptoms (RR=0.17 (95% CI: 0.09-0.33), p<0.01), central nervous system excitation (RR=0.44 (95% CI: 0.21-0.90), p=0.02), and central nervous system depression (RR=0.24 (95% CI: 0.13-0.48), p<0.01) than nonpregnant cohorts. Conclusion Pregnant patients with LAST were more likely to exhibit cardiac depression and less likely to manifest prodromal symptoms, cardiac excitation, and central nervous system excitation and depression than nonpregnant patients. Physiological changes during pregnancy and prompt detection and treatment may explain these differences. These findings highlight the variable nature of LAST and how pregnancy may influence its clinical presentation.
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Affiliation(s)
- Micah K De Valle
- John Sealy School of Medicine, University of Texas Medical Branch, Galveston, USA
| | - Michael Adkison
- John Sealy School of Medicine, University of Texas Medical Branch, Galveston, USA
| | - Ruhi Maredia
- John Sealy School of Medicine, University of Texas Medical Branch, Galveston, USA
| | - Cooper Stevenson
- John Sealy School of Medicine, University of Texas Medical Branch, Galveston, USA
| | - Shobana Murugan
- Department of Anesthesiology, Baylor College of Medicine, Houston, USA
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Janes L, Sepehripour S, Lalonde D. Clinically Important Pharmacologic Considerations for Wide-Awake Local Anesthesia No Tourniquet Hand Surgery. Plast Reconstr Surg 2024; 154:391e-402e. [PMID: 37220403 DOI: 10.1097/prs.0000000000010706] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/25/2023]
Abstract
SUMMARY Understanding the clinically important pharmacokinetics (what the body does to the drug) and pharmacodynamics (what the drug does to the body) of medications used in surgery will help surgeons use them more safely and effectively. The goal of this article is to provide an overview of these considerations for the 2 medications used in wide-awake local anesthesia with no tourniquet upper extremity surgery (ie, lidocaine and epinephrine) to establish a better understanding of lidocaine and epinephrine in tumescent local anesthesia, as well as adverse reactions and how to manage them.
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Affiliation(s)
- Lindsay Janes
- From the Department of Orthopaedic Surgery, University of Pennsylvania
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17
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Jiang T, Ma C, Wang Z, Miao Y. A review of local anesthetic-induced heart toxicity using human induced pluripotent stem cell-derived cardiomyocytes. Mol Cell Probes 2024; 76:101965. [PMID: 38823509 DOI: 10.1016/j.mcp.2024.101965] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2024] [Revised: 05/11/2024] [Accepted: 05/29/2024] [Indexed: 06/03/2024]
Abstract
Local anesthetic (LA) cardiotoxicity is one of the main health problems in anesthesiology and pain management. This study reviewed the reported LA-induced cardiac toxicity types, risk factors, management, and mechanisms, with attention to the use of human induced pluripotent stem cell-derived cardiomyocytes (hiPSC-CMs) in heart toxicity research. Important scientific databases were searched to find relevant articles. We briefly assessed the reported cardiotoxic effects of different types of LA drugs, including ester- and amide-linked LA agents. Furthermore, cardiotoxic effects and clinical manifestations, strategies for preventing and managing LA-induced cardiotoxic effects, pharmacokinetics, pharmacodynamics, and sodium channel dynamics regarding individual variability and genetic influences were discussed in this review. The applications and importance of hiPSC-CMs cellular model for evaluating the cardiotoxic effects of LA drugs were discussed in detail. This review also explored hiPSC-CMs' potential in risk assessment, drug screening, and developing targeted therapies. The main mechanisms underlying LA-induced cardiotoxicity included perturbation in sodium channels, ROS production, and disorders in the immune system response due to the presence of LA drugs. Furthermore, drug-specific characteristics including pharmacokinetics and pharmacodynamics are important determinants after LA drug injection. In addition, individual patient factors such as age, comorbidities, and genetic variability emphasize the need for a personalized approach to mitigate risks and enhance patient safety. The strategies outlined for the prevention and management of LA cardiotoxicity underscore the importance of careful dosing, continuous monitoring, and the immediate availability of resuscitation equipment. This comprehensive review can be used to guide future investigations into better understanding LA cardiac toxicities and improving patient safety.
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Affiliation(s)
- Ting Jiang
- Department of Anesthesiology, Xi'an Children's Hospital, Xi'an, 710002, China
| | - Chao Ma
- Department of Anesthesiology, Xi'an Children's Hospital, Xi'an, 710002, China
| | - Zitong Wang
- Health Science Center, Lanzhou University, Lanzhou, 730000, China
| | - Yi Miao
- Department of Anesthesiology, Xi'an Children's Hospital, Xi'an, 710002, China.
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Santos GPDL, Kulcsar MAV, Capelli FDA, Steck JH, Fernandes KL, Mesa CO, da Motta-Leal-Filho JM, Scheffel RS, Vaisman F, Martins GLP, Szejnfeld D, Amoedo MK, de Menezes MR, Rahal A, Matos LL. Brazilian Consensus on the Application of Thermal Ablation for Treatment of Thyroid Nodules: A Task Force Statement by the Brazilian Society of Interventional Radiology and Endovascular Surgery (SOBRICE), Brazilian Society of Head and Neck Surgery (SBCCP), and Brazilian Society of Endocrinology and Metabolism (SBEM). ARCHIVES OF ENDOCRINOLOGY AND METABOLISM 2024; 68:e230263. [PMID: 39420896 PMCID: PMC11213574 DOI: 10.20945/2359-4292-2023-0263] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/04/2023] [Accepted: 02/07/2024] [Indexed: 10/19/2024]
Abstract
There is increasing interest in ultrasound-guided ablation treatments for thyroid diseases, including benign and malignant ones. Surgeons, radiologists, and endocrinologists carry out these treatments, and various organizations within these specialties have recently released multiple international consensus statements and clinical practice standards. The aim of the present consensus statement is to provide guidance, cohesion, and standardization of best practices for thermal ablation procedures of thyroid nodules. The statement includes the indications for these procedures, preprocedural evaluations, technical aspects of the procedures, posttreatment care, follow-up, complications, and training recommendations. This document was written by a panel of specialists from the Brazilian Society of Interventional Radiology and Endovascular Surgery (SOBRICE), the Brazilian Society of Head and Neck Surgery (SBCCP), and the Brazilian Society of Endocrinology and Metabolism (SBEM). The statement does not aim to provide criteria for assessing the capability of specialists to perform the procedure. Instead, it aims to promote the standardization of best practices to reduce potential adverse outcomes. Additionally, it strives to enhance the delivery of high-quality care and the widespread adoption of these technologies on a national level. The recommendations collectively serve as a guidebook for applying best practices in thyroid ablation.
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Affiliation(s)
- Gustavo Philippi de Los Santos
- Hospital Universitário Universidade Federal de Santa Catarina FlorianópolisSC Brasil Hospital Universitário da Universidade Federal de Santa Catarina, Florianópolis, SC, Brasil
| | - Marco Aurélio Vamondes Kulcsar
- Sociedade Brasileira de Cirurgia de Cabeça e Pescoço São PauloSP Brasil Sociedade Brasileira de Cirurgia de Cabeça e Pescoço, São Paulo, SP, Brasil
- Faculdade Israelita de Ciências da Saúde Albert Einstein São PauloSP Brasil Faculdade Israelita de Ciências da Saúde Albert Einstein,São Paulo, SP, Brasil
| | - Fabio de Aquino Capelli
- Hospital das Clínicas Faculdade de Medicina Universidade de São Paulo São PauloSP Brasil Serviço de Cirurgia de Cabeça e Pescoço, Instituto do Câncer do Estado de São Paulo, Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo, São Paulo, SP, Brasil
| | - Jose Higino Steck
- Hospital das Clínicas Faculdade de Medicina Universidade de São Paulo São PauloSP Brasil Instituto do Câncer do Estado de São Paulo, Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo, São Paulo, SP, Brasil
- Divisão de Otorrinolaringologia Universidade Estadual de Campinas CampinasSP Brasil Divisão de Otorrinolaringologia, Universidade Estadual de Campinas, Campinas, SP, Brasil
| | | | - Cleo Otaviano Mesa
- Universidade Federal da Paraíba João PessoaPB Brasil Universidade Federal da Paraíba, João Pessoa, PB, Brasil
- Serviço de Endocrinologia e Metabologia Hospital de Clínicas Universidade Federal do Paraná CuritibaPR Brasil Serviço de Endocrinologia e Metabologia, Hospital de Clínicas, Universidade Federal do Paraná, Curitiba, PR, Brasil
| | - Joaquim Mauricio da Motta-Leal-Filho
- Faculdade de Medicina Pontifícia Universidade Católica do Paraná CuritibaPR Brasil Faculdade de Medicina, Pontifícia Universidade Católica do Paraná, Curitiba, PR, Brasil
- Departamento de Radiologia Instituto do Câncer do Estado de São Paulo São PauloSP Brasil Departamento de Radiologia, Instituto do Câncer do Estado de São Paulo, São Paulo, SP, Brasil
| | - Rafael Selbach Scheffel
- Hospital das Clínicas Faculdade de Medicina Universidade de São Paulo São PauloSP Brasil Instituto do Coração, Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo, São Paulo, SP, Brasil
- Serviço de Tireoide Hospital de Clínicas de Porto Alegre Porto AlegreRS Brasil Serviço de Tireoide, Hospital de Clínicas de Porto Alegre, Porto Alegre, RS, Brasil
| | - Fernanda Vaisman
- Departamento de Farmacologia Universidade Federal do Rio Grande do Sul Porto AlegreRS Brasil Departamento de Farmacologia, Universidade Federal do Rio Grande do Sul, Porto Alegre, RS, Brasil
- Instituto Nacional do Câncer Rio de JaneiroRJ Brasil Instituto Nacional do Câncer (INCA), Rio de Janeiro, RJ, Brasil
| | - Guilherme Lopes Pinheiro Martins
- Hospital das Clínicas Faculdade de Medicina Universidade de São Paulo São PauloSP Brasil Serviço de Cirurgia de Cabeça e Pescoço, Instituto do Câncer do Estado de São Paulo, Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo, São Paulo, SP, Brasil
- Universidade Federal do Rio de Janeiro Rio de JaneiroRJ Brasil Universidade Federal do Rio de Janeiro, Rio de Janeiro, RJ, Brasil
- Hospital Sírio-Libanês São PauloSP Brasil Hospital Sírio-Libanês, São Paulo, SP, Brasil
| | - Denis Szejnfeld
- Hospital Samaritano São PauloSP Brasil Hospital Samaritano, São Paulo, SP, Brasil
| | - Mauricio Kauark Amoedo
- Departamento de Radiologia Intervencionista Universidade Federal de São Paulo São PauloSP Brasil Departamento de Radiologia Intervencionista, Universidade Federal de São Paulo, São Paulo, SP, Brasil
- Radioclínica SalvadorBA Brasil Radioclínica, Salvador, BA, Brasil
- Hospital Santa Izabel SalvadorBA Brasil Hospital Santa Izabel, Salvador, BA, Brasil
- Santa Casa da Bahia SalvadorBA Brasil Santa Casa da Bahia, Salvador, BA, Brasil
- Hospital da Bahia SalvadorBA Brasil Hospital da Bahia, Salvador, BA, Brasil
| | - Marcos Roberto de Menezes
- Departamento de Oncologia Sociedade Brasileira de Radiologia Intervencionista e Cirurgia Endovascular São PauloSP Brasil Departamento de Oncologia, Sociedade Brasileira de Radiologia Intervencionista e Cirurgia Endovascular, São Paulo, SP, Brasil
- Hospital das Clínicas Faculdade de Medicina Universidade de São Paulo São PauloSP Brasil Centro de Intervenção Guiada por Imagem, Instituto do Câncer do Estado de São Paulo, Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo, São Paulo, SP, Brasil
| | - Antonio Rahal
- Centro de Intervenção Guiada por Imagem Hospital Sírio-Libanês São PauloSP Brasil Centro de Intervenção Guiada por Imagem, Hospital Sírio-Libanês, São Paulo, SP, Brasil
- Área do Núcleo de Imagem e de Intervenção em Tireoide Hospital Israelita Albert Einstein São PauloSP Brasil Área do Núcleo de Imagem e de Intervenção em Tireoide, Hospital Israelita Albert Einstein, São Paulo, SP, Brasil
| | - Leandro Luongo Matos
- Faculdade Israelita de Ciências da Saúde Albert Einstein São PauloSP Brasil Faculdade Israelita de Ciências da Saúde Albert Einstein,São Paulo, SP, Brasil
- Hospital das Clínicas Faculdade de Medicina Universidade de São Paulo São PauloSP Brasil Serviço de Cirurgia de Cabeça e Pescoço, Instituto do Câncer do Estado de São Paulo, Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo, São Paulo, SP, Brasil
- Sociedade Paulista de Radiologia São PauloSP Brasil Radiologia Intervencionista, Sociedade Paulista de Radiologia, São Paulo, SP, Brasil
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19
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Arias-Vázquez PI. Intra-articular Injections for Treating Knee Osteoarthritis: A Classification According to Their Mechanism of Action. J Clin Rheumatol 2024; 30:168-174. [PMID: 38595298 DOI: 10.1097/rhu.0000000000002080] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/11/2024]
Affiliation(s)
- Pedro Iván Arias-Vázquez
- From the MD Rehabilitation Medicine, Sports Medicine, Department of Rehabilitation, Universidad Juárez Autónoma de Tabasco, Comalcalco, México
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Soliman Y, Hatfield AA, McAllister RK, Fettiplace MR, Hofkamp MP. Apparent local anesthetic systemic toxicity following activation of an epidural catheter for cesarean delivery: diagnosis and management of an uncommon obstetric anesthesia complication. Proc AMIA Symp 2024; 37:874-876. [PMID: 39165828 PMCID: PMC11332648 DOI: 10.1080/08998280.2024.2357522] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2024] [Revised: 05/15/2024] [Accepted: 05/16/2024] [Indexed: 08/22/2024] Open
Abstract
We present a 25-year-old, gravida 2, para 1 woman who developed apparent local anesthetic systemic toxicity (LAST) following activation of an epidural catheter for an urgent cesarean delivery. The patient had a height of 150 cm, weight of 92 kg, body mass index of 41 kg/m2, and calculated ideal body weight of 40 kg. A combined spinal epidural anesthetic was placed and the spinal component did not provide anesthesia to clamping of the abdomen. Subsequently, 300 mg of lidocaine was administered through the epidural catheter in three 5 mL doses over 8 minutes and surgery commenced. Approximately 30 minutes following the final 5 mL dose of epidural lidocaine, the patient had progressive loss of consciousness and was difficult to arouse. A presumptive diagnosis of LAST was made, and 60 mL of 20% intravenous lipid emulsion was administered. The patient's mental status improved to baseline within 5 minutes of lipid emulsion administration, and she made a complete recovery. Anesthesiologists should consider using ideal body weight when calculating the maximum dosage of local anesthetics, and LAST should be part of the differential diagnosis when patients have altered mental status in the setting of local anesthetic administration that exceeds recommended dosages.
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Affiliation(s)
- Youstina Soliman
- Department of Anesthesiology, Baylor Scott and White Medical Center, Temple, Texas, USA
| | - Angelica A. Hatfield
- Department of Anesthesiology, Baylor Scott and White Medical Center, Temple, Texas, USA
| | - Russell K. McAllister
- Department of Anesthesiology, Baylor Scott and White Medical Center, Temple, Texas, USA
| | - Michael R. Fettiplace
- Department of Anesthesiology, University of Illinois at Chicago, Chicago, Illinois, USA
| | - Michael P. Hofkamp
- Department of Anesthesiology, Baylor Scott and White Medical Center, Temple, Texas, USA
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Li Y, Li T. Enhancing patient comfort in varicose vein treatment through combined lidocaine and ropivacaine tumescent anesthesia. Front Surg 2024; 11:1359474. [PMID: 38783860 PMCID: PMC11111990 DOI: 10.3389/fsurg.2024.1359474] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2023] [Accepted: 04/24/2024] [Indexed: 05/25/2024] Open
Abstract
Objective To compare the analgesic effects of specific tumescent anesthetic solutions composed of lidocaine, ropivacaine, or a combination of lidocaine and ropivacaine during endovenous radiofrequency ablation for the treatment of great saphenous vein varicosities. Method This study included 149 patients with lower limb varicose veins who were admitted to our department between 2019 and 2023. The patients were randomly assigned to three groups: the lidocaine group (Group I), the ropivacaine group (Group II), and the lidocaine + ropivacaine group (Group III). Intraoperative vital signs, intraoperative and postoperative visual analog scale (VAS) pain scores, and long-term treatment outcomes were assessed using the venous clinical severity score (VCSS) based on clinical performance. Results There were no significant differences in age, body mass index, operative time, or blood loss among the three groups (P ≥ 0.05). The differences in the mean arterial pressure and heart rate during surgery in Group II were significantly greater than those in Groups I and III (P < 0.05). The intraoperative VAS scores in Group II were higher than those in Groups I and III (P < 0.05) and at 8 and 12 h postoperatively. There were no significant differences in VCSS among the groups (P ≥ 0.05). Conclusion The use of a tumescent anesthetic solution composed of lidocaine and ropivacaine significantly improved patient comfort during the perioperative period without affecting surgical outcomes. This formulation can be considered safe and reliable for preparing tumescent anesthesia solutions.
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Affiliation(s)
- Yubo Li
- Department of Plastic Surgery, Plastic Surgery Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Tan Li
- Department of Vascular Surgery, Beijing Chaoyang Hospital, Capital Medical University, Beijing, China
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Lee SH, Kim S, Sohn JT. Lipid emulsion treatment for local anesthetic systemic toxicity in pediatric patients: A systematic review. Medicine (Baltimore) 2024; 103:e37534. [PMID: 38489714 PMCID: PMC10939516 DOI: 10.1097/md.0000000000037534] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/08/2023] [Revised: 02/15/2024] [Accepted: 02/16/2024] [Indexed: 03/17/2024] Open
Abstract
BACKGROUND Local anesthetic systemic toxicity (LAST) is rare, but fatal; the current widely used treatment is lipid emulsion (LE). The goal of this study was to analyze and review case reports on LE treatment for LAST in pediatric patients. METHODS We performed a systematic review using case reports on LE treatment for LAST in pediatric patients, searching PubMed and Scopus databases to March 2023 using the following keywords: ("local anesthetic toxicity" OR "local anesthetic systemic toxicity" OR LAST") AND ("newborn" OR "infant" OR "child" OR "children" OR "adolescent" OR "pediatric") AND ("lipid emulsion" OR "Intralipid"). RESULTS Our search yielded 21 cases, revealing that nearly 43% patients with LAST were less than 1 year old, and most cases were caused by bupivacaine (approximately 67% cases). "Inadvertent intravascular injection" by anesthesiologists and "overdose of local anesthetics" mainly by surgeons were responsible for 52% and 24% cases of LAST, respectively. LAST occurred in the awake state (52%) and under general anesthesia (48%), mainly causing seizures and arrhythmia, respectively. Approximately 55% of patients received LE treatment in <10 minutes after LAST, mainly improving cardiovascular symptoms. A 20% LE (1.5 mL/kg) dose followed by 0.25 mL/kg/minutes dose was frequently used. LE and anticonvulsants were mainly used in the awake state, whereas LE with or without vasopressors was mainly used under general anesthesia. LE treatment led to full recovery from LAST in 20 cases; however, 1 patient died due to underlying disease. CONCLUSION Consequently, our findings reveal that LE is effective in treating pediatric LAST.
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Affiliation(s)
- Soo Hee Lee
- Department of Anesthesiology and Pain Medicine, Gyeongsang National University Changwon Hospital 11, Gyeongsangnam-do, Republic of Korea
- Department of Anesthesiology and Pain Medicine, Gyeongsang National University College of Medicine, Gyeongsangnam-do, Republic of Korea
- Institute of Medical Science, Gyeongsang National University, Jinju-si, Republic of Korea
| | - Sunmin Kim
- Department of Anesthesiology and Pain Medicine, Gyeongsang National University Hospital, Gyeongsangnam-do, Republic of Korea
| | - Ju-Tae Sohn
- Institute of Medical Science, Gyeongsang National University, Jinju-si, Republic of Korea
- Department of Anesthesiology and Pain Medicine, Gyeongsang National University College of Medicine, Gyeongsang National University Hospital, Gyeongsangnam-do, Republic of Korea
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Davidson VL, McGrath MC, Navarro S. Preventing Local Anesthetic Systemic Toxicity After Administration of Long-Acting Local Anesthetics. AORN J 2024; 119:164-168. [PMID: 38275262 DOI: 10.1002/aorn.14085] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2023] [Accepted: 09/13/2023] [Indexed: 01/27/2024]
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Azoury SC, Matros E. Top 25 Medications the Plastic and Reconstructive Surgery Trainee Should Know for an Emergency Medicine Department Consult. Plast Reconstr Surg 2024; 153:474e-489e. [PMID: 37141488 DOI: 10.1097/prs.0000000000010609] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/06/2023]
Abstract
SUMMARY Plastic surgery trainees are often called to render care in the emergency department (eg, for established patients, trauma, burns). Broad-based knowledge in pharmacotherapeutics during these encounters is critical. This includes an understanding of pain medications, anxiolytics, local anesthetics, antibiotics, anticoagulants, antidotes, and more to ensure optimal patient care. The purpose of this report is to describe 25 frequently used and other important medications that plastic surgery trainees should know for an adult emergency department encounter.
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Affiliation(s)
- Saïd C Azoury
- From the Division of Plastic Surgery, Department of Surgery, University of Pennsylvania
| | - Evan Matros
- Division of Plastic Surgery, Department of Surgery, Memorial Sloan Kettering Cancer Center
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Beaton AC, Solanki D, Salazar H, Folkerth S, Singla N, Minkowitz HS, Leiman D, Vaughn B, Skuban N, Niebler G. A randomized, double-blind, placebo-controlled study to evaluate the efficacy and safety of a bupivacaine hydrochloride implant in patients undergoing abdominoplasty. Reg Anesth Pain Med 2023; 48:601-607. [PMID: 37076252 PMCID: PMC10646917 DOI: 10.1136/rapm-2022-104110] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2022] [Accepted: 03/23/2023] [Indexed: 04/21/2023]
Abstract
INTRODUCTION Surgical site infiltration with bupivacaine hydrochloride (HCl) is a standard element of postoperative analgesia for soft tissue surgeries, but results in short-lived analgesia. A novel bupivacaine implant, XARACOLL (bupivacaine HCl), is Food and Drug Administration approved for treatment of acute postsurgical pain following adult inguinal herniorrhaphy. This study examined the efficacy and safety of the bupivacaine implant (300 mg) compared with placebo for postsurgical pain after abdominoplasty. METHODS In this double-blind, placebo-controlled study, patients undergoing abdominoplasty were randomized to three 100 mg bupivacaine implants or three placebo collagen implants, in a 1:1 ratio, implanted intraoperatively. No other analgesics were administered into the surgical site. Patients were allowed opioids and acetaminophen for postoperative pain. Patients were followed for up to 30 days after treatment. PRIMARY OUTCOME the analgesic effect of the bupivacaine implants through 24 hours postsurgery, measured by the sum of time-weighted pain intensity (SPI24). Prespecified key secondary outcomes included SPI48 and SPI72, percentage of opioid-free patients through 24, 48, and 72 hours, and adverse events, which were tested sequentially to control for multiplicity (ie, if the first variable failed to reach significance, no subsequent variables were declared statistically significant). RESULTS The bupivacaine implant patients (n=181) reported statistically significant lower SPI24 (mean (SD) SPI24=102 (43), 95% CI 95 to 109) compared with placebo patients (n=184; SPI24=117 (45), 95% CI 111 to 123, p=0.002). SPI48 was 190 (88, 95% CI 177 to 204) for INL-001 and 206 (96, 95% CI 192 to 219) for placebo, and not significantly different between groups. The subsequent secondary variables were therefore declared not statistically significant. SPI72 was 265 (131, 95% CI 244 to 285) for INL-001 and 281 (146, 95% CI 261 to 301) for placebo. The opioid-free percentage of patients at 24, 48, and 72 hours was 19%, 17%, and 17% for INL-001 and 6.5% for placebo patients (at all timepoints). The only adverse event occurring in ≥5% of patients and for which proportion INL-001 >placebo was back pain (7.7% vs 7.6%). CONCLUSION The study design was limited by not containing an active comparator. Compared with placebo, INL-001 provides postoperative analgesia that is temporally aligned with the period of maximal postsurgical pain in abdominoplasty and offers a favorable safety profile. TRIAL REGISTRATION NUMBER NCT04785625.
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Affiliation(s)
| | | | | | | | - Neil Singla
- Lotus Clinical Research, LLC, Pasadena, California, USA
| | | | - David Leiman
- HD Research/First Surgical Hospital, Bellaire, Texas, USA
| | | | - Nina Skuban
- Innocoll Pharmaceuticals Limited, Innocoll Biotherapeutics, Princeton, New Jersey, USA
| | - Gwendolyn Niebler
- Innocoll Pharmaceuticals Limited, Innocoll Biotherapeutics, Princeton, New Jersey, USA
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Capoglu R, Alemdar M, Bayhan Z, Gonullu E, Akın E, Altintoprak F, Harmantepe AT, Kucuk F, Demir H, Aka BU. Effects of cognitive status on outcomes of groin hernia repair using various anesthesia techniques. Hernia 2023; 27:1315-1323. [PMID: 36449177 DOI: 10.1007/s10029-022-02725-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2022] [Accepted: 11/20/2022] [Indexed: 12/03/2022]
Abstract
BACKGROUND AND AIM Because of increasing life expectancy, there is an increasing number of cognitively impaired older individuals undergoing surgeries such as groin hernia repair. Here, we evaluated the effects of cognitive status on postoperative complication rates in patients undergoing groin hernia repair using various anesthesia techniques. We also analyzed the rate of same-day hernia surgery in patients with cognitive decline. METHODS Patients who presented to our general surgery clinic for unilateral or bilateral inguinal or femoral hernia were prospectively classified into general (group 1), local (group 2), and spinal (group 3) anesthesia groups. The Mini-Mental State Examination (MMSE) was used for preoperative evaluation of each patient's cognitive status. The Visual Analog Scale (VAS) was used to evaluate postoperative pain. Groups were compared in terms of age, MMSE and VAS scores, cognitive decline and complication rates, and surgery duration. RESULTS In total, 33 (35.1%), 30 (31.9%), and 31 (33.0%) of 94 patients underwent surgery using general, local, and spinal anesthesia, respectively. The mean MMSE score did not differ among groups (p = 0.518). Cognitive decline was present in 18 (19.2%) patients, and the proportion did not significantly differ among groups. The complication rate did not differ between patients with and without cognitive decline. The mean surgery duration was similar among the three groups (p = 0.127). Group 2 had a lower mean postoperative VAS score, compared with the other groups (p < 0.001). Complications because of anesthesia and surgery were significantly more common in group 3 than in the other groups (p = 0.025). In the local anesthesia group, 7 patients had cognitive decline and 22 patients had normal cognition. There were no significant differences between patients with and without cognitive decline in terms of mean surgery duration (50.3 ± 15.4 min vs. 45.2 ± 10.7 min; p = 0.338) or mean VAS score (3.14 ± 0.90 vs. 3.13 ± 0.77; p = 0.985). Among the 22 and 7 patients without and with cognitive decline, 11 (50%) and 0 patients were discharged on the same day (p = 0.025). In the local anesthesia group, the respective median ages were 70, 52, and 59 years for patients with cognitive decline, patients with normal cognition discharged on the same day, and patients with normal cognition who were not discharged on the same day (p = 0.001). CONCLUSION Groin hernia repair was successfully performed under local anesthesia in all patients, including older patients with cognitive decline. Patients with cognitive decline were not discharged on the day of surgery, although the mean surgery duration and postoperative VAS score did not differ between patients with and without cognitive decline. Prolonged hospitalization in patients with cognitive decline may be related to their advanced age. Further studies are needed to determine the safety of same-day surgery in patients with cognitive decline.
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Affiliation(s)
- Recayi Capoglu
- Department of General Surgery, Sakarya University Training and Research Hospital, Sakarya, Turkey
| | - Murat Alemdar
- Department of Neurology, Sakarya University Faculty of Medicine, Sakarya, Turkey
| | - Zulfu Bayhan
- Department of General Surgery, Sakarya University Faculty of Medicine, Sakarya, Turkey.
| | - Emre Gonullu
- Department of General Surgery, Sakarya University Training and Research Hospital, Sakarya, Turkey
- Department of Neurology, Sakarya University Faculty of Medicine, Sakarya, Turkey
- Department of General Surgery, Sakarya University Faculty of Medicine, Sakarya, Turkey
- Department of Gastrointestinal Surgery, Sakarya University Faculty of Medicine, Sakarya, Turkey
| | - Emrah Akın
- Department of General Surgery, Sakarya University Faculty of Medicine, Sakarya, Turkey
| | - Fatih Altintoprak
- Department of General Surgery, Sakarya University Faculty of Medicine, Sakarya, Turkey
| | | | - Furkan Kucuk
- Department of General Surgery, Sakarya University Faculty of Medicine, Sakarya, Turkey
| | - Hakan Demir
- Department of General Surgery, Sakarya University Training and Research Hospital, Sakarya, Turkey
| | - Bahaeddin Umur Aka
- Department of General Surgery, Sakarya University Faculty of Medicine, Sakarya, Turkey
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Subramaniam J, Teh BL, Smith Q. Knowledge of local anaesthetic systemic toxicity and lipid emulsion therapy amongst healthcare providers in a stand-alone eye unit. Br J Anaesth 2023; 131:e123-e126. [PMID: 37541947 DOI: 10.1016/j.bja.2023.07.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2023] [Revised: 06/29/2023] [Accepted: 07/06/2023] [Indexed: 08/06/2023] Open
Affiliation(s)
- Jeevan Subramaniam
- Northern School of Anaesthesia & Intensive Care Medicine, Newcastle-upon-Tyne, UK.
| | - Boon Lin Teh
- Department of Ophthalmology, Sunderland Eye Infirmary, Sunderland, UK
| | - Quentin Smith
- Department of Anaesthesia, Sunderland Eye Infirmary, Sunderland, UK
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Mayich DJ. Wide-Awake Local Anesthetic No Tourniquet Surgery of the Foot and Ankle. Orthop Clin North Am 2023; 54:471-483. [PMID: 37718086 DOI: 10.1016/j.ocl.2023.05.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/19/2023]
Abstract
Wide awake local anesthetic no tourniquet (WALANT) surgery of the foot and ankle has the potential to offer safe and effective surgeon-based anesthesia for a significant number of surgeries about the foot and ankle. This has been documented with significant and growing body of literature. WALANT could offer significant advantages with respect to patient experience, per case cost of procedures as well as for improving access for patients to operative resources in a setting of scarcity or restricted access.
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Affiliation(s)
- D Joshua Mayich
- Stanton Territorial Hospital, 548 Byrne Road, Yellowknife, NT, Canada.
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Schwenk ES, Lam E, Abulfathi AA, Schmidt S, Gebhart A, Witzeling SD, Mohamod D, Sarna RR, Roy AB, Zhao JL, Kaushal G, Rochani A, Baratta JL, Viscusi ER. Population pharmacokinetic and safety analysis of ropivacaine used for erector spinae plane blocks. Reg Anesth Pain Med 2023; 48:454-461. [PMID: 37085287 DOI: 10.1136/rapm-2022-104252] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2022] [Accepted: 04/06/2023] [Indexed: 04/23/2023]
Abstract
INTRODUCTION Erector spinae plane blocks have become popular for thoracic surgery. Despite a theoretically favorable safety profile, intercostal spread occurs and systemic toxicity is possible. Pharmacokinetic data are needed to guide safe dosing. METHODS Fifteen patients undergoing thoracic surgery received continuous erector spinae plane blocks with ropivacaine 150 mg followed by subsequent boluses of 40 mg every 6 hours and infusion of 2 mg/hour. Arterial blood samples were obtained over 12 hours and analyzed using non-linear mixed effects modeling, which allowed for conducting simulations of clinically relevant dosing scenarios. The primary outcome was the Cmax of ropivacaine in erector spinae plane blocks. RESULTS The mean age was 66 years, mean weight was 77.5 kg, and mean ideal body weight was 60 kg. The mean Cmax was 2.5 ±1.1 mg/L, which occurred at a median time of 10 (7-47) min after initial injection. Five patients developed potentially toxic ropivacaine levels but did not experience neurological symptoms. Another patient reported transient neurological toxicity symptoms. Our data suggested that using a maximum ropivacaine dose of 2.5 mg/kg based on ideal body weight would have prevented all toxicity events. Simulation predicted that reducing the initial dose to 75 mg with the same subsequent intermittent bolus dosing would decrease the risk of toxic levels to <1%. CONCLUSION Local anesthetic systemic toxicity can occur with erector spinae plane blocks and administration of large, fixed doses of ropivacaine should be avoided, especially in patients with low ideal body weights. Weight-based ropivacaine dosing could reduce toxicity risk. TRIAL REGISTRATION NUMBER NCT04807504; clinicaltrials.gov.
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Affiliation(s)
- Eric S Schwenk
- Anesthesiology and Perioperative Medicine, Thomas Jefferson University Sidney Kimmel Medical College, Philadelphia, Pennsylvania, USA
| | - Edwin Lam
- Clinical Pharmacokinetics Research Lab, National Institutes of Health, Bethesda, Maryland, USA
| | - Ahmed A Abulfathi
- Pharmaceutics, University of Florida College of Medicine, Orlando, Florida, USA
- Clinical Pharmacology and Therapeutics, University of Maiduguri, Maiduguri, Borno, Nigeria
| | - Stephan Schmidt
- Pharmaceutics, University of Florida College of Medicine, Orlando, Florida, USA
| | - Anthony Gebhart
- Pharmaceutics, University of Florida College of Medicine, Orlando, Florida, USA
| | - Scott D Witzeling
- Anesthesiology and Perioperative Medicine, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - Dalmar Mohamod
- Anesthesiology and Perioperative Medicine, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - Rohan R Sarna
- Anesthesiology and Perioperative Medicine, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - Akshay B Roy
- Anesthesiology and Perioperative Medicine, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - Joy L Zhao
- Anesthesiology and Perioperative Medicine, Thomas Jefferson University Sidney Kimmel Medical College, Philadelphia, Pennsylvania, USA
| | - Gagan Kaushal
- Pharmaceutical Science, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Ankit Rochani
- Pharmaceutical Science, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
- Pharmaceutical Sciences, St John Fisher University Wegmans School of Pharmacy, Rochester, New York, USA
| | - Jaime L Baratta
- Anesthesiology and Perioperative Medicine, Thomas Jefferson University Sidney Kimmel Medical College, Philadelphia, Pennsylvania, USA
| | - Eugene R Viscusi
- Anesthesiology and Perioperative Medicine, Thomas Jefferson University Sidney Kimmel Medical College, Philadelphia, Pennsylvania, USA
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Schweitzer-Chaput A, Callot D, Bouazza N, Lesage F, Oualha M, Paret N, Boyer-Gervoise M, Treluyer JM, Chouchana L. Local anesthetics systemic toxicity in children: analysis of the French pharmacovigilance database. BMC Pediatr 2023; 23:321. [PMID: 37355586 PMCID: PMC10290397 DOI: 10.1186/s12887-023-04126-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/25/2023] [Accepted: 06/11/2023] [Indexed: 06/26/2023] Open
Abstract
PURPOSE To characterize clinical profile of pediatric local anesthetic (LA) systemic toxicity (LAST) and to identify determinants of life-threatening outcomes. METHODS Spontaneous reports notified to the French Pharmacovigilance Network were retrieved and followed by a case-by-case review, according to the following criteria: LA as suspected drug, age < 18 years, adverse drug reactions related to nervous system, cardiac, respiratory, psychiatric or general disorders. Multivariate logistic regression analysis was performed to identify factors leading to life-threatening reaction (i.e. continuous seizures or cardiorespiratory arrest). RESULTS Among 512 cases retrieved, 64 LAST cases were included (neonates 11%, infants 30%, children 36%, adolescents 23%) mainly involving lidocaine (47%), lidocaine + prilocaine (22%) and ropivacaine (14%). Toxicity profiles were neurological (58%), cardiac (11%) or mixed (20%) and 7 patients (11%) developed methemoglobinemia. LAST was life-threatening for 23 patients (36%) and 2 patients died. Doses were above recommendations in 26 patients (41%) and were not different between life-threatening and non-life-threatening cases. The context of use (general and orthopedic surgery, p = 0.006) and the type of LA agent (lidocaine, p = 0.016) were independently associated with a life-threatening outcome. CONCLUSION In this national retrospective analysis, LAST in children appear to be a rare event. Neurological and cardiac signs were the most frequently reported reactions. LAST in children can be life-threatening, even at therapeutic doses. Although a fatal outcome may anecdotally occur, the vast majority of patients recovered after appropriate medical care.
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Affiliation(s)
- Arnaud Schweitzer-Chaput
- Centre Régional de Pharmacovigilance, Service de Pharmacologie, Hôpital Cochin, AP-HP, Paris, France
| | - Delphine Callot
- Centre Régional de Pharmacovigilance, Service de Pharmacologie, Hôpital Cochin, AP-HP, Paris, France
| | - Naim Bouazza
- Pharmacologie Et Évaluation Des Thérapeutiques Chez L'enfant Et La Femme Enceinte (EA 7323), Université de Paris, Paris, France
- Unité de Recherche Clinique Paris Descartes Necker Cochin, AP-HP, Paris, France
| | - Fabrice Lesage
- Service de Réanimation Pédiatrique, Hôpital Necker, Paris, France
| | - Mehdi Oualha
- Pharmacologie Et Évaluation Des Thérapeutiques Chez L'enfant Et La Femme Enceinte (EA 7323), Université de Paris, Paris, France
- Service de Réanimation Pédiatrique, Hôpital Necker, Paris, France
| | - Nathalie Paret
- Centre Antipoison, Hospices Civils De Lyon, Lyon, France
| | - Marie Boyer-Gervoise
- Centre Régional de Pharmacovigilance, Service de Pharmacologie Clinique, Assistance Publique Hôpitaux de Marseille, Marseille, France
| | - Jean-Marc Treluyer
- Centre Régional de Pharmacovigilance, Service de Pharmacologie, Hôpital Cochin, AP-HP, Paris, France
- Pharmacologie Et Évaluation Des Thérapeutiques Chez L'enfant Et La Femme Enceinte (EA 7323), Université de Paris, Paris, France
- Unité de Recherche Clinique Paris Descartes Necker Cochin, AP-HP, Paris, France
| | - Laurent Chouchana
- Centre Régional de Pharmacovigilance, Service de Pharmacologie, Hôpital Cochin, AP-HP, Paris, France.
- Pharmacologie Et Évaluation Des Thérapeutiques Chez L'enfant Et La Femme Enceinte (EA 7323), Université de Paris, Paris, France.
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Kim SY, Jo HY, Na HS, Han SH, Do SH, Shin HJ. The Effect of Peripheral Nerve Block on Postoperative Delirium in Older Adults Undergoing Hip Surgery: A Systematic Review and Meta-Analysis of Randomized Controlled Trials. J Clin Med 2023; 12:jcm12072459. [PMID: 37048543 PMCID: PMC10095174 DOI: 10.3390/jcm12072459] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2023] [Revised: 03/20/2023] [Accepted: 03/20/2023] [Indexed: 04/14/2023] Open
Abstract
This meta-analysis aimed to determine whether peripheral nerve blocks (PNB) reduce postoperative delirium (POD) in elderly patients undergoing hip surgery. This study was registered in the International Prospective Register of Systematic Reviews (PROSPERO; CRD42022328320). The PubMed, EMBASE, Web of Science, and Cochrane Library databases were searched for randomized controlled trials (RCTs) on 26 April 2022. A total of 19 RCTs with 1977 participants were included. Perioperative PNB lowered the POD incidence on the third postoperative day (OR: 0.59, 95% CI [0.40 to 0.87], p = 0.007, I2 = 35%), in patients without underlying cognitive impairment (OR: 0.47, 95% CI [0.30 to 0.74], p = 0.001, I2 = 30%), and when a fascia iliaca compartment block (OR: 0.58, 95% CI [0.37 to 0.91], p = 0.02, I2 = 0%) or a femoral nerve block (OR: 0.33, 95% CI [0.11 to 0.99], p = 0.05, I2 = 66%) were performed. The pain score was also reduced (SMD: -0.83, 95% CI [-1.36 to -0.30], p = 0.002, I2 = 95%) after PNB. Perioperative PNB can lower the POD incidence and pain scores up to the third postoperative day. However, considering the wide variety of PNBs performed, more trials are needed to identify the effects of each PNB on POD.
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Affiliation(s)
- Su Yeon Kim
- Department of Anesthesiology and Pain Medicine, Seoul National University Bundang Hospital, Seongnam 13620, Republic of Korea
| | - Ha Young Jo
- Department of Anesthesiology and Pain Medicine, Seoul National University Bundang Hospital, Seongnam 13620, Republic of Korea
| | - Hyo-Seok Na
- Department of Anesthesiology and Pain Medicine, Seoul National University Bundang Hospital, Seongnam 13620, Republic of Korea
| | - Sung-Hee Han
- Department of Anesthesiology and Pain Medicine, Seoul National University Bundang Hospital, Seongnam 13620, Republic of Korea
| | - Sang-Hwan Do
- Department of Anesthesiology and Pain Medicine, Seoul National University Bundang Hospital, Seongnam 13620, Republic of Korea
| | - Hyun-Jung Shin
- Department of Anesthesiology and Pain Medicine, Seoul National University Bundang Hospital, Seongnam 13620, Republic of Korea
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Park M, Yu HK, Lee SH, Ok SH, Yoon S, Sohn JT. Lipid emulsion-induced recovery from unconsciousness caused by lidocaine toxicity: A case report. SAGE Open Med Case Rep 2023; 11:2050313X231153776. [PMID: 36776207 PMCID: PMC9909049 DOI: 10.1177/2050313x231153776] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2022] [Accepted: 01/11/2023] [Indexed: 02/09/2023] Open
Abstract
Lipid emulsion is used to treat systemic toxicity caused by local anesthetics. In addition, lipid emulsion was reported to be effective in ameliorating cardiovascular depression evoked by non-local anesthetic drug toxicity with high lipid solubility. A 47-year-old woman underwent local anesthetic infiltration with 40 mL of 2% lidocaine (20 and 20 mL) to remove a mass in the upper back. After operation, she experienced convulsions and loss of consciousness due to lidocaine toxicity. Midazolam followed by lipid emulsion was administered to treat central nervous system symptoms including unconsciousness and decreased Glasgow Coma Scale. The patient recovered from unconsciousness and presented improved Glasgow Coma Scale after lipid emulsion administration, and then fully recovered from local anesthetic systemic toxicity. This case suggests that early lipid emulsion treatment, before further progression of local anesthetic systemic toxicity, provides an enhanced recovery from unconsciousness and decreased Glasgow Coma Scale due to lidocaine toxicity.
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Affiliation(s)
- Miyeong Park
- Department of Anesthesiology and Pain Medicine, Gyeongsang National University Changwon Hospital, Changwon-si, Republic of Korea
| | - Ho Kyung Yu
- Department of Anesthesiology and Pain Medicine, Gyeongsang National University Changwon Hospital, Changwon-si, Republic of Korea
| | - Soo Hee Lee
- Department of Anesthesiology and Pain Medicine, Gyeongsang National University Changwon Hospital, Changwon-si, Republic of Korea,Department of Anesthesiology and Pain Medicine, Gyeongsang National University Hospital, Gyeongsang National University College of Medicine, Jinju-si, Republic of Korea,Institute of Health Sciences, Gyeongsang National University, Jinju-si, Republic of Korea
| | - Seong-Ho Ok
- Department of Anesthesiology and Pain Medicine, Gyeongsang National University Changwon Hospital, Changwon-si, Republic of Korea,Department of Anesthesiology and Pain Medicine, Gyeongsang National University Hospital, Gyeongsang National University College of Medicine, Jinju-si, Republic of Korea,Institute of Health Sciences, Gyeongsang National University, Jinju-si, Republic of Korea
| | - Sangcheol Yoon
- Department of Anesthesiology and Pain Medicine, Gyeongsang National University Hospital, Gyeongsang National University College of Medicine, Jinju-si, Republic of Korea
| | - Ju-Tae Sohn
- Department of Anesthesiology and Pain Medicine, Gyeongsang National University Hospital, Gyeongsang National University College of Medicine, Jinju-si, Republic of Korea,Institute of Health Sciences, Gyeongsang National University, Jinju-si, Republic of Korea,Ju-Tae Sohn, Department of Anesthesiology and Pain Medicine, Gyeongsang National University Hospital, Gyeongsang National University College of Medicine, 79 Gangnam-ro, Jinju-si 52727, Republic of Korea.
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Zaballos M, Fernández I, Melone A, Rodríguez L, Varela O, García S, Quintela O, Vazquez E, Anadón MJ, Almendral J. Sodium bicarbonate reverts electrophysiologic cardiotoxicity of ropivacaine faster than lipid emulsions in a porcine model. Basic Clin Pharmacol Toxicol 2023; 132:211-222. [PMID: 36479999 PMCID: PMC10107242 DOI: 10.1111/bcpt.13822] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2022] [Revised: 11/09/2022] [Accepted: 11/30/2022] [Indexed: 12/13/2022]
Abstract
Ropivacaine has been described as a safer local anaesthetic (LA); however, serious cardiotoxic accidents have been reported. Intravenous-lipid-emulsion (ILE) therapy during LA intoxication seems to act as an antidote. Sodium bicarbonate is the standard treatment for sodium channel blocker drug toxicity. We compared both antidotes on the reversion of electrophysiologic toxicity induced by ropivacaine. Ropivacaine 5 mg kg-1 was administered in 24 pigs, and 3 min later, the animals received ILE: 1.5 ml kg-1 + 0.25 ml kg-1 min-1 (ILE group); sodium bicarbonate: 2 mEq kg-1 + 1 mEq kg-1 h-1 (NaHCO3 group); saline solution (CTL group). Electrophysiological parameters were evaluated for 30 min. The area under the curve (AUC) for the first 5 or 30 min was compared between groups. Ropivacaine induced a lengthening of the PR interval by 17% (P = 0.0001), His-ventricle-interval by 58% (P = 0.001), sinus QRS complex by 56% (P = 0.0001), paced QRS at 150 bpm by 257% (P = 0.0001), and at 120 bpm by 143% (P = 0.0001) in all groups. At 5 min after treatment, sinus QRS in the NaHCO3 group was shorter than that in the CTL group (AUCQRS5 , P = 0.003) or ILE group (AUCQRS5 , P = 0.045). During the first minute, seven of the animals in the NaHCO3 group vs. two in the ILE or 0 in the CTL group recovered more than 30% of the sinus QRS previously lengthened by ropivacaine (P = 0.003). Sodium bicarbonate reversed the electrophysiological toxicity of ropivacaine faster than ILE and control groups.
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Affiliation(s)
- Matilde Zaballos
- Department of Toxicology, Faculty of Medicine, Complutense University, Madrid, Spain.,Department of Anaesthesiology, Hospital General Universitario Gregorio Marañón, Madrid, Spain
| | - Ignacio Fernández
- Department of Anaesthesiology, Hospital General Universitario Gregorio Marañón, Madrid, Spain
| | - Arturo Melone
- Department of Anaesthesiology, Hospital General Universitario Gregorio Marañón, Madrid, Spain
| | - Lucía Rodríguez
- Department of Anaesthesiology, Hospital General Universitario Gregorio Marañón, Madrid, Spain
| | - Olalla Varela
- Department of Anaesthesiology, Hospital General Universitario Gregorio Marañón, Madrid, Spain
| | - Sergio García
- Department of Anaesthesiology, Hospital General Universitario Gregorio Marañón, Madrid, Spain
| | - Oscar Quintela
- Department of Toxicology, Faculty of Medicine, Complutense University, Madrid, Spain.,National Institute of Toxicology and Forensic Science, Madrid, Spain
| | - Elena Vazquez
- Hospital General Universitario Gregorio Marañón, Madrid, Spain
| | | | - Jesús Almendral
- Director of the Electrophysiology Laboratory and Arrhythmia Unit, Hospital Monteprincipe, Grupo HM Hospitales, University CEU-San Pablo, Madrid, Spain
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Mantripragada K, Yerke Hansen P, Vazquez OA, Pires G, Becker H. Pain Reduction Using Ropivacaine in Tumescent Solution following Lipoaspiration. PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN 2023; 11:e4747. [PMID: 36776592 PMCID: PMC9911196 DOI: 10.1097/gox.0000000000004747] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2022] [Accepted: 11/11/2022] [Indexed: 06/18/2023]
Abstract
Tumescent solution utilizing dilute epinephrine and a local anesthetic agent injected into a fat compartment has been shown to effectively minimize blood loss and postoperative pain in liposuction. Ropivacaine has a longer duration of action compared to lidocaine and is a potential analgesic in tumescent solution. We sought to explore the effect of using ropivacaine in a tumescent technique with a focus on its efficacy for pain control postoperatively. The formula for the tumescent technique used combined 1 mL of epinephrine with 30 mL of ropivacaine into 500 mL of injectable saline. Tumescent solution was injected manually into fat donor sites of 10 consecutive patients followed by a 20-minute waiting period before beginning fat aspiration with liposuction cannula. Patients were seen immediately following their surgery and on postoperative day 1 and reported their pain using a numerical scale. Data gathered included the amount of ropivacaine used, average pain rating, and the average amount of fat removed. On average, participants reported little to no pain at the donor sites immediately following surgery and on postoperative day 1. Based on the low need for pain medication, we believe that ropivacaine may be successfully used in tumescent solution to reduce postoperative pain.
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Affiliation(s)
- Koushik Mantripragada
- From the Department of Surgery, University of Maryland Medical Center, Baltimore, Md
| | - Payton Yerke Hansen
- Charles E. Schmidt College of Medicine, Florida Atlantic University, Boca Raton, Fla
| | - Oscar Adrian Vazquez
- Charles E. Schmidt College of Medicine, Florida Atlantic University, Boca Raton, Fla
- Department of Surgery, Stanford University, Stanford, Calif
| | - Giovanna Pires
- Charles E. Schmidt College of Medicine, Florida Atlantic University, Boca Raton, Fla
| | - Hilton Becker
- Charles E. Schmidt College of Medicine, Florida Atlantic University, Boca Raton, Fla
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Yang CL, Jing JJ, Fu SY, Zhong YL, Su XZ, Shi ZM, Wu XZ, Yang F, Chen GZ. Ropivacaine-induced seizures evoked pain sensitization in rats: Participation of 5-HT/5-HT3R. Neurotoxicology 2022; 93:173-185. [DOI: 10.1016/j.neuro.2022.10.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2022] [Revised: 09/17/2022] [Accepted: 10/04/2022] [Indexed: 11/15/2022]
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Malik A, Thom S, Haber B, Sarani N, Ottenhoff J, Jackson B, Rance L, Ehrman R. Regional Anesthesia in the Emergency Department: an Overview of Common Nerve Block Techniques and Recent Literature. CURRENT EMERGENCY AND HOSPITAL MEDICINE REPORTS 2022. [DOI: 10.1007/s40138-022-00249-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
Abstract
Purpose of Review
This review seeks to discuss the use of RA in the ED including benefits of administration, types of RA by anatomic location, complications and management, teaching methods currently in practice, and future applications of RA in the ED.
Recent Findings
The early use of RA in pain management may reduce the transition of acute to chronic pain. Multiple plane blocks have emerged as feasible and efficacious for ED pain complaints and are now being safely utilized.
Summary
Adverse effects of opioids and their potential for abuse have necessitated the exploration of substitute therapies. Regional anesthesia (RA) is a safe and effective alternative to opioid treatment for pain in the emergency department (ED). RA can manage pain for a wide variety of injuries while avoiding the risks of opioid use and decreasing length of stay when compared to other forms of analgesia and anesthesia, without compromising patient satisfaction.
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Chen WC, Chen HY, Weng TI, Chen CK. Sudden quadriparesis after non-overdose local anesthesia. Int J Emerg Med 2022; 15:19. [PMID: 35581544 PMCID: PMC9112499 DOI: 10.1186/s12245-022-00423-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/01/2022] [Accepted: 04/29/2022] [Indexed: 11/19/2022] Open
Abstract
Background A well-known anesthetic, lidocaine is the most widely used local anesthetic. Local anesthetic systemic toxicity (LAST) is a life-threatening event with common and prominent presentations of central nervous system (CNS) toxicity and cardiovascular toxicity. The most frequent and prominent early warning signs and symptoms of LAST are central nervous system symptoms. While rare, cases quadriparesis after the administration of lidocaine has been reported. Case presentation In this paper, we report a very rare case of quadriparesis after local anesthesia administration for vocal cord cyst-removal surgery, which dramatically improved after treatment. LAST can occur during various routes of lidocaine administration, such as local spray. A possible mechanism of our case could be the local diffusion of lidocaine to the spinal cord, which caused the symptoms to mimic anterior cord syndrome. Conclusions Our case presented a favorable outcome following the administration of intravenous lipid emulsion (ILE) for non-over dose local anesthetic drug induced spinal cord inhibition symptoms. These findings highlight the need for further research on the use of ILE to reverse LAST and other adverse effects of local anesthetics.
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Affiliation(s)
- Wei-Chen Chen
- Department of Emergency Medicine, Chang Gung Memorial Hospital, Linkou, Taoyuan, Taiwan
| | - Hsien-Yi Chen
- Department of Emergency Medicine, Chang Gung Memorial Hospital, Linkou, Taoyuan, Taiwan.,College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Te-I Weng
- Department of Emergency Medicine, National Taiwan University College of Medicine and National Taiwan University Hospital, Taipei, Taiwan.,Forensic and Clinical Toxicology Center, College of Medicine, National Taiwan University Hospital, National. Taiwan University, Taipei, Taiwan.,Institute of Forensic Medicine, College of Medicine, National Taiwan University, Taipei, Taiwan
| | - Chun-Kuei Chen
- Department of Emergency Medicine, Chang Gung Memorial Hospital, Linkou, Taoyuan, Taiwan. .,College of Medicine, Chang Gung University, Taoyuan, Taiwan.
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Uppal NN, Jhaveri M, Hong S, Shore-Lesserson L, Jhaveri KD, Izzedine H. Local anesthetics for the Nephrologist. Clin Kidney J 2022; 15:186-193. [PMID: 35145634 PMCID: PMC8824772 DOI: 10.1093/ckj/sfab121] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2021] [Indexed: 12/03/2022] Open
Abstract
Several specialists in medicine use local anesthetics. In patients with kidney disease, these agents are used during catheter insertions for hemodialysis and peritoneal dialysis, arteriovenous fistula and graft procedures, kidney transplantation, parathyroidectomy, kidney biopsies, and dental and skin procedures. Patients on chronic hemodialysis use a topical application prior to use of needles for arteriovenous fistula cannulation before starting dialysis. They are also used to manage acute and chronic pain conditions, in regional nerve blockade and in multi-modal enhanced recovery protocols. Despite their frequent use by both physicians and patients, data on the use of local anesthetics in patients with kidney impairment are not well reported. This review will summarize the use of local anesthetics in chronic kidney disease, describe their pharmacology and the impact of lower estimated glomerular filtration rate on their pharmacokinetics, and suggest dose regulation in those with kidney dysfunction.
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Affiliation(s)
- Nupur N Uppal
- Division of Kidney Diseases and Hypertension, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Northwell Health, Great Neck, NY, USA
| | - Mital Jhaveri
- Department of Pharmacy, Queens Hospital Center, Jamaica, NY, USA
| | - Susana Hong
- Division of Kidney Diseases and Hypertension, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Northwell Health, Great Neck, NY, USA
| | - Linda Shore-Lesserson
- Department of Anesthesiology, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Northwell Health, Manhasset, NY, USA
| | - Kenar D Jhaveri
- Division of Kidney Diseases and Hypertension, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Northwell Health, Great Neck, NY, USA
| | - Hassan Izzedine
- Department of Nephrology, Peupliers Private Hospital, Ramsay Générale de Santé, Paris, France
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Kamel I, Ahmed MF, Sethi A. Regional anesthesia for orthopedic procedures: What orthopedic surgeons need to know. World J Orthop 2022; 13:11-35. [PMID: 35096534 PMCID: PMC8771411 DOI: 10.5312/wjo.v13.i1.11] [Citation(s) in RCA: 33] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/25/2021] [Revised: 07/20/2021] [Accepted: 01/10/2022] [Indexed: 02/06/2023] Open
Abstract
Regional anesthesia is an integral component of successful orthopedic surgery. Neuraxial anesthesia is commonly used for surgical anesthesia while peripheral nerve blocks are often used for postoperative analgesia. Patient evaluation for regional anesthesia should include neurological, pulmonary, cardiovascular, and hematological assessments. Neuraxial blocks include spinal, epidural, and combined spinal epidural. Upper extremity peripheral nerve blocks include interscalene, supraclavicular, infraclavicular, and axillary. Lower extremity peripheral nerve blocks include femoral nerve block, saphenous nerve block, sciatic nerve block, iPACK block, ankle block and lumbar plexus block. The choice of regional anesthesia is a unanimous decision made by the surgeon, the anesthesiologist, and the patient based on a risk-benefit assessment. The choice of the regional block depends on patient cooperation, patient positing, operative structures, operative manipulation, tourniquet use and the impact of post-operative motor blockade on initiation of physical therapy. Regional anesthesia is safe but has an inherent risk of failure and a relatively low incidence of complications such as local anesthetic systemic toxicity (LAST), nerve injury, falls, hematoma, infection and allergic reactions. Ultrasound should be used for regional anesthesia procedures to improve the efficacy and minimize complications. LAST treatment guidelines and rescue medications (intralipid) should be readily available during the regional anesthesia administration.
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Affiliation(s)
- Ihab Kamel
- Department of Anesthesiology, Lewis Katz School of Medicine at Temple University, Philadelphia, PA 19140, United States
| | - Muhammad F Ahmed
- Department of Anesthesiology, Lewis Katz School of Medicine at Temple University, Philadelphia, PA 19140, United States
| | - Anish Sethi
- Department of Anesthesiology, Lewis Katz School of Medicine at Temple University, Philadelphia, PA 19140, United States
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40
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Karamlou M, Asaria I, Barron J, Boutros P, Fisher V, Grandinetti R, Johnson J, Richard E, Susko D, Urrutia C, Woolsey B, Baumann R, Cottle J, Sweaney R, Wenzel M, Nusstein J, Hall D. Complications After Dental Sedation: A Myotonic Mystery Case Report. Anesth Prog 2022; 69:26-31. [PMID: 36534775 PMCID: PMC9773408 DOI: 10.2344/anpr-69-02-09] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2021] [Accepted: 03/18/2022] [Indexed: 12/23/2022] Open
Abstract
Myotonic dystrophy (dystrophia myotonica; DM) is an uncommon progressive hereditary muscle disorder that can present with variable severity at birth, in early childhood, or most commonly as an adult. Patients with DM, especially type 1 (DM1), are extremely sensitive to the respiratory depressant effects of sedative-hypnotics, anxiolytics, and opioid agonists. This case report describes a 37-year-old male patient with previously undiagnosed DM1 who received dental care under minimal sedation using intravenous midazolam. During the case, the patient experienced 2 brief episodes of hypoxemia, the second of which required emergency intubation after propofol and succinylcholine and resulted in extended hospital admission. A lipid emulsion (Liposyn II 20%) infusion was given approximately 2 hours after the last local anesthetic injection due to slight ST elevation and suspicion of local anesthetic toxicity (LAST). Months after treatment, the patient suffered a fall resulting in a fatal traumatic brain injury. Complications noted in this case report were primarily attributed to the unknown diagnosis of DM1, although additional precipitating factors were likely present. This report also provides a basic review of the literature and clinical guidelines for managing myotonic dystrophy patients for dental care with local anesthesia, sedation, or general anesthesia.
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Affiliation(s)
- Milad Karamlou
- Former Resident, The Ohio State University College of Dentistry General Practice Residency Program, Columbus, Ohio
| | - Iman Asaria
- Resident, The Ohio State University College of Dentistry General Practice Residency Program, Columbus, Ohio
| | - Jaime Barron
- Resident, The Ohio State University College of Dentistry General Practice Residency Program, Columbus, Ohio
| | - Petra Boutros
- Resident, The Ohio State University College of Dentistry General Practice Residency Program, Columbus, Ohio
| | - Vincent Fisher
- Resident, The Ohio State University College of Dentistry General Practice Residency Program, Columbus, Ohio
| | - Rachel Grandinetti
- Resident, The Ohio State University College of Dentistry General Practice Residency Program, Columbus, Ohio
| | - Julian Johnson
- Resident, The Ohio State University College of Dentistry General Practice Residency Program, Columbus, Ohio
| | - Emily Richard
- Resident, The Ohio State University College of Dentistry General Practice Residency Program, Columbus, Ohio
| | - David Susko
- Resident, The Ohio State University College of Dentistry General Practice Residency Program, Columbus, Ohio
| | - Cristobal Urrutia
- Resident, The Ohio State University College of Dentistry General Practice Residency Program, Columbus, Ohio
| | - Bryce Woolsey
- Chief Resident, The Ohio State University College of Dentistry General Practice Residency Program, Columbus, Ohio
| | - Ronald Baumann
- Former Assistant Professor and Attending, The Ohio State University College of Dentistry General Practice Residency Program, Columbus, Ohio
| | - James Cottle
- Assistant Professor and Attending, The Ohio State University College of Dentistry General Practice Residency Program, Columbus, Ohio
| | - Richard Sweaney
- Assistant Professor and Attending, The Ohio State University College of Dentistry General Practice Residency Program, Columbus, Ohio
| | - Mark Wenzel
- Program Director and Hospital Attending, The Ohio State University College of Dentistry General Practice Residency Program and Wexner Medical Center, Columbus, Ohio
| | - John Nusstein
- Professor and Chair Division of Endodontics, The Ohio State University College of Dentistry, Columbus, Ohio
| | - David Hall
- Associate Professor and Hospital Attending, The Ohio State University College of Dentistry General Practice Residency Program and Wexner Medical Center, Columbus, Ohio
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Orloff LA, Noel JE, Stack BC, Russell MD, Angelos P, Baek JH, Brumund KT, Chiang FY, Cunnane MB, Davies L, Frasoldati A, Feng AY, Hegedüs L, Iwata AJ, Kandil E, Kuo J, Lombardi C, Lupo M, Maia AL, McIver B, Na DG, Novizio R, Papini E, Patel KN, Rangel L, Russell JO, Shin J, Shindo M, Shonka DC, Karcioglu AS, Sinclair C, Singer M, Spiezia S, Steck JH, Steward D, Tae K, Tolley N, Valcavi R, Tufano RP, Tuttle RM, Volpi E, Wu CW, Abdelhamid Ahmed AH, Randolph GW. Radiofrequency ablation and related ultrasound-guided ablation technologies for treatment of benign and malignant thyroid disease: An international multidisciplinary consensus statement of the American Head and Neck Society Endocrine Surgery Section with the Asia Pacific Society of Thyroid Surgery, Associazione Medici Endocrinologi, British Association of Endocrine and Thyroid Surgeons, European Thyroid Association, Italian Society of Endocrine Surgery Units, Korean Society of Thyroid Radiology, Latin American Thyroid Society, and Thyroid Nodules Therapies Association. Head Neck 2021; 44:633-660. [PMID: 34939714 DOI: 10.1002/hed.26960] [Citation(s) in RCA: 126] [Impact Index Per Article: 31.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2021] [Accepted: 12/02/2021] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND The use of ultrasound-guided ablation procedures to treat both benign and malignant thyroid conditions is gaining increasing interest. This document has been developed as an international interdisciplinary evidence-based statement with a primary focus on radiofrequency ablation and is intended to serve as a manual for best practice application of ablation technologies. METHODS A comprehensive literature review was conducted to guide statement development and generation of best practice recommendations. Modified Delphi method was applied to assess whether statements met consensus among the entire author panel. RESULTS A review of the current state of ultrasound-guided ablation procedures for the treatment of benign and malignant thyroid conditions is presented. Eighteen best practice recommendations in topic areas of preprocedural evaluation, technique, postprocedural management, efficacy, potential complications, and implementation are provided. CONCLUSIONS As ultrasound-guided ablation procedures are increasingly utilized in benign and malignant thyroid disease, evidence-based and thoughtful application of best practices is warranted.
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Affiliation(s)
- Lisa A Orloff
- Department of Otolaryngology - Head & Neck Surgery, Stanford University School of Medicine, Stanford, California, USA
| | - Julia E Noel
- Department of Otolaryngology - Head & Neck Surgery, Stanford University School of Medicine, Stanford, California, USA
| | - Brendan C Stack
- Department of Otolaryngology - Head & Neck Surgery, Southern Illinois University School of Medicine, Springfield, Illinois, USA
| | - Marika D Russell
- Department of Otolaryngology - Head & Neck Surgery, San Francisco School of Medicine, University of California, San Francisco, California, USA
| | - Peter Angelos
- Department of Surgery, University of Chicago, Chicago, Illinois, USA
| | - Jung Hwan Baek
- Department of Radiology, Research Institute of Radiology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, South Korea
| | - Kevin T Brumund
- Division of Otolaryngology - Head and Neck Surgery, Department of Surgery, University of California, San Diego, San Diego, California, USA
| | - Feng-Yu Chiang
- Department of Otolaryngology - Head and Neck Surgery, E-Da Hospital, School of Medicine, College of Medicine, I-Shou University, Kaohsiung, Taiwan
| | - Mary Beth Cunnane
- Department of Radiology, Massachusetts Eye and Ear Infirmary, Harvard Medical School, Boston, Massachusetts, USA
| | - Louise Davies
- The Section of Otolaryngology, The Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine at Dartmouth, Hanover, New Hampshire, USA
| | - Andrea Frasoldati
- Department of Endocrinology and Metabolism, Arcispedale Santa Maria Nuova IRCCS-ASL, Reggio Emilia, Italy
| | - Anne Y Feng
- Department of Otolaryngology - Head and Neck Surgery, Brigham & Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Laszlo Hegedüs
- Department of Endocrinology and Metabolism, Odense University Hospital, Odense, Denmark
| | - Ayaka J Iwata
- Department of Otolaryngology - Head & Neck Surgery, Kaiser Permanente, Santa Clara, California, USA
| | - Emad Kandil
- Department of Surgery, Tulane University School of Medicine, New Orleans, Louisiana, USA
| | - Jennifer Kuo
- Department of Surgery, Columbia University Irving Medical Center, New York, New York, USA
| | - Celestino Lombardi
- Division of Endocrine and Metabolic Surgery, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Mark Lupo
- Thyroid & Endocrine Center of Florida, Sarasota, Florida, USA
| | - Ana Luiza Maia
- Unidade de Tireoide, Hospital de Clínicas de Porto Alegre, Faculdade de Medicina, Universidade Federal do Rio Grande do Sul, Porto Alegre, Brazil
| | - Bryan McIver
- Department of Head and Neck-Endocrine Oncology, H. Lee Moffitt Cancer Center, Research Institute, Tampa, Florida, USA
| | - Dong Gyu Na
- Department of Radiology, Gangneung Asan Hospital, University of Ulsan College of Medicine, Gangneung, South Korea
| | | | - Enrico Papini
- Department of Endocrinology and Metabolism, Regina Apostolorum Hospital, Rome, Italy
| | - Kepal N Patel
- Department of Surgery, New York University, New York, New York, USA
| | - Leonardo Rangel
- Division of Otorhinolaryngology - Head and Neck Surgery, State University of Rio de Janeiro, Rio de Janiero, Brazil
| | - Jonathon O Russell
- Department of Otolaryngology - Head and Neck Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Jennifer Shin
- Department of Otolaryngology - Head and Neck Surgery, Brigham & Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Maisie Shindo
- Department of Otolaryngology - Head and Neck Surgery, Oregon Health and Science University, Portland, Oregon, USA
| | - David C Shonka
- Department of Otolaryngology - Head and Neck Surgery, University of Virginia Health System, Charlottesville, Virginia, USA
| | - Amanda S Karcioglu
- Division of Otolaryngology - Head and Neck Surgery, Department of Surgery, NorthShore University Health System, Evanston, Illinois, USA.,Clinician Educator, Pritzker School of Medicine, Chicago, Illinois, USA
| | - Catherine Sinclair
- Department of Otolaryngology - Head and Neck Surgery, Mount Sinai West Hospital, New York, New York, USA
| | - Michael Singer
- Department of Otolaryngology - Head and Neck Surgery, Henry Ford Health System, Detroit, Michigan, USA
| | - Stefano Spiezia
- Endocrine Surgery, Ospedale del Mare, ASL NA1 Centro, Naples, Italy
| | - Jose Higino Steck
- Department of Otorhinolaryngology - Head and Neck Surgery, University of Campinas, Campinas, Brazil
| | - David Steward
- Department of Otolaryngology - Head and Neck Surgery, University of Cincinnati, Cincinnati, Ohio, USA
| | - Kyung Tae
- Department of Otolaryngology - Head and Neck Surgery, College of Medicine, Hanyang University, Seoul, South Korea
| | - Neil Tolley
- Hammersmith Hospital, Imperial College NHS Healthcare Trust, London, UK
| | | | - Ralph P Tufano
- Department of Otolaryngology - Head and Neck Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - R Michael Tuttle
- Endocrine Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Erivelto Volpi
- Oncology Center, Oswaldo Cruz German Hospital, Sao Paulo, Brazil
| | - Che Wei Wu
- Department of Otolaryngology - Head and Neck Surgery, Kaohsiung Medical University Hospital, Faculty of Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Amr H Abdelhamid Ahmed
- Department of Otolaryngology - Head and Neck Surgery, Division of Thyroid and Parathyroid Endocrine Surgery, Massachusetts Eye & Ear Infirmary, Harvard Medical School, Boston, Massachusetts, USA
| | - Gregory W Randolph
- Department of Otolaryngology - Head and Neck Surgery, Division of Thyroid and Parathyroid Endocrine Surgery, Massachusetts Eye & Ear Infirmary, Harvard Medical School, Boston, Massachusetts, USA
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Vingan NR, Teitelbaum S, Moorman R, Kenkel JM. Asystolic Cardiac Arrest Associated With Unstable Bradycardia During Augmentation Mammaplasty: A Case Report. Aesthet Surg J Open Forum 2021; 4:ojab047. [PMID: 35072070 PMCID: PMC8781763 DOI: 10.1093/asjof/ojab047] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Cardiac arrest is a rare but reported complication during breast augmentation surgery. It is even more rare in a reportedly healthy patient without preexisting cardiac disease. The authors present the case of a healthy 34-year-old female who underwent elective bilateral augmentation mammaplasty and experienced unanticipated asystolic cardiac arrest intraoperatively following general anesthesia supplemented by a regional pectoral (pec I) nerve block. The performing plastic surgeon provided cardiopulmonary resuscitation while the anesthesiologist initiated a rescue protocol per Advanced Cardiac Life Support (ACLS) guidelines. Fortunately, the patient was resuscitated in a timely manner and had a successful return of spontaneous circulation within 1 minute. This case report serves to briefly review the literature and recommendations on proper resuscitation of cardiac arrest per ACLS protocols as well as discuss unstable bradycardia in otherwise healthy patients undergoing breast augmentation surgery. Plastic surgeons and anesthesiologists who perform this procedure should be aware of the possible, rare but serious progression to asystole as well as the proper resuscitative measures to take should they be required. LEVEL OF EVIDENCE 5
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Affiliation(s)
- Nicole R Vingan
- University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Steven Teitelbaum
- associate clinical professor of plastic surgery, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
| | - Rita Moorman
- American Board of Anesthesiology in private practice in Santa Monica, CA, USA
| | - Jeffrey M Kenkel
- Corresponding Author: Dr Jeffrey M. Kenkel, Department of Plastic Surgery, University of Texas Southwestern Medical Center, 1801 Inwood Road, Dallas, TX 75390-9132, USA. E-mail:
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Liu Y, Zhang J, Yu P, Niu J, Yu S. Mechanisms and Efficacy of Intravenous Lipid Emulsion Treatment for Systemic Toxicity From Local Anesthetics. Front Med (Lausanne) 2021; 8:756866. [PMID: 34820396 PMCID: PMC8606423 DOI: 10.3389/fmed.2021.756866] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2021] [Accepted: 10/07/2021] [Indexed: 11/13/2022] Open
Abstract
Local anesthetics are widely used clinically for perioperative analgesia to achieve comfort in medical treatment. However, when the concentration of local anesthetics in the blood exceeds the tolerance of the body, local anesthetic systemic toxicity (LAST) will occur. With the development and popularization of positioning technology under direct ultrasound, the risks and cases of LAST associated with direct entry of the anesthetic into the blood vessel have been reduced. Clinical occurrence of LAST usually presents as a series of severe toxic reactions such as myocardial depression, which is life-threatening. In addition to basic life support (airway management, advanced cardiac life support, etc.), intravenous lipid emulsion (ILE) has been introduced as a treatment option in recent years and has gradually become the first-line treatment for LAST. This review introduces the mechanisms of LAST and identifies the clinical symptoms displayed by the central nervous system and cardiovascular system. The paper features the multimodal mechanism of LAST reversal by ILE, describes research progress in the field, and identifies other anesthetics involved in the resuscitation process of LAST. Finally, the review presents key issues in lipid therapy. Although ILE has achieved notable success in the treatment of LAST, adverse reactions and contraindications also exist; therefore, ILE requires a high degree of attention during use. More in-depth research on the treatment mechanism of ILE, the resuscitation dosage and method of ILE, and the combined use with other resuscitation measures is needed to improve the efficacy and safety of clinical resuscitation after LAST in the future.
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Affiliation(s)
- Yang Liu
- Department of Anesthesiology, The Second Affiliated Hospital of Nanchang University, Nanchang, China
- Key Laboratory of Anesthesiology of Jiangxi Province, Nanchang, China
| | - Jing Zhang
- Department of Anesthesiology, The Second Affiliated Hospital of Nanchang University, Nanchang, China
- Key Laboratory of Anesthesiology of Jiangxi Province, Nanchang, China
| | - Peng Yu
- Department of Endocrinology and Metabolism, The Second Affiliated Hospital of Nanchang University, Nanchang, China
| | - Jiangfeng Niu
- Department of Anesthesiology, The Second Affiliated Hospital of Nanchang University, Nanchang, China
- Key Laboratory of Anesthesiology of Jiangxi Province, Nanchang, China
| | - Shuchun Yu
- Department of Anesthesiology, The Second Affiliated Hospital of Nanchang University, Nanchang, China
- Key Laboratory of Anesthesiology of Jiangxi Province, Nanchang, China
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44
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Yin Q, Zhang W, Ke B, Liu J, Zhang W. Lido-OH, a Hydroxyl Derivative of Lidocaine, Produced a Similar Local Anesthesia Profile as Lidocaine With Reduced Systemic Toxicities. Front Pharmacol 2021; 12:678437. [PMID: 34603015 PMCID: PMC8481665 DOI: 10.3389/fphar.2021.678437] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2021] [Accepted: 07/15/2021] [Indexed: 02/05/2023] Open
Abstract
Background: lidocaine is one of the most commonly used local anesthetics for the treatment of pain and arrhythmia. However, it could cause systemic toxicities when plasma concentration is raised. To reduce lidocaine’s toxicity, we designed a hydroxyl derivative of lidocaine (lido-OH), and its local anesthesia effects and systemic toxicity in vivo were quantitively investigated. Method: the effectiveness for lido-OH was studied using mouse tail nerve block, rat dorsal subcutaneous infiltration, and rat sciatic nerve block models. The systemic toxicities for lido-OH were evaluated with altered state of consciousness (ASC), arrhythmia, and death in mice. Lidocaine and saline were used as positive and negative control, respectively. The dose-effect relationships were analyzed. Results: the half effective-concentration for lido-OH were 2.1 mg/ml with 95% confident interval (CI95) 1.6–3.1 (lidocaine: 3.1 mg/ml with CI95 2.6–4.3) in tail nerve block, 8.2 mg/ml with CI95 8.0–9.4 (lidocaine: 6.9 mg/ml, CI95 6.8–7.1) in sciatic nerve block, and 5.9 mg/ml with CI95 5.8–6.0 (lidocaine: 3.1 mg/ml, CI95 2.4–4.0) in dorsal subcutaneous anesthesia, respectively. The magnitude and duration of lido-OH were similar with lidocaine. The half effective doses (ED50) of lido-OH for ACS was 45.4 mg/kg with CI95 41.6–48.3 (lidocaine: 3.1 mg/kg, CI95 1.9–2.9), for arrhythmia was 16.0 mg/kg with CI95 15.4–16.8 (lidocaine: 3.0 mg/kg, CI95 2.7–3.3), and for death was 99.4 mg/kg with CI95 75.7–124.1 (lidocaine: 23.1 mg/kg, CI95 22.8–23.4). The therapeutic index for lido-OH and lidocaine were 35.5 and 5.6, respectively. Conclusion: compared with lidocaine, lido-OH produced local anesthesia at similar potency and efficacy, but with significantly reduced systemic toxicities.
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Affiliation(s)
- Qinqin Yin
- Department of Anesthesiology, West China Hospital, Sichuan University, Chengdu, China.,Laboratory of Anesthesia and Critical Care Medicine, Translational Neuroscience Centre and Sichuan Engineering Laboratory of Transformation Medicine of Anesthesiology, West China Hospital, Sichuan University, Chengdu, China.,Translational Neuroscience Centre, West China Hospital, Sichuan University, Chengdu, China
| | - Weiyi Zhang
- Department of Anesthesiology, West China Hospital, Sichuan University, Chengdu, China.,Laboratory of Anesthesia and Critical Care Medicine, Translational Neuroscience Centre and Sichuan Engineering Laboratory of Transformation Medicine of Anesthesiology, West China Hospital, Sichuan University, Chengdu, China
| | - Bowen Ke
- Translational Neuroscience Centre, West China Hospital, Sichuan University, Chengdu, China
| | - Jin Liu
- Department of Anesthesiology, West China Hospital, Sichuan University, Chengdu, China.,Laboratory of Anesthesia and Critical Care Medicine, Translational Neuroscience Centre and Sichuan Engineering Laboratory of Transformation Medicine of Anesthesiology, West China Hospital, Sichuan University, Chengdu, China.,Translational Neuroscience Centre, West China Hospital, Sichuan University, Chengdu, China
| | - Wensheng Zhang
- Translational Neuroscience Centre, West China Hospital, Sichuan University, Chengdu, China
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Lim VM, Barney T, Jayaraman AL. Multiple myeloma and malignant lesions: a potential risk factor for local anesthetic systemic toxicity. Reg Anesth Pain Med 2021; 46:1103-1106. [PMID: 34535547 DOI: 10.1136/rapm-2021-102845] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2021] [Accepted: 08/30/2021] [Indexed: 01/12/2023]
Abstract
BACKGROUND Multiple myeloma is a cancer of plasma cells that often leads to complications including osteolytic bone lesions, nephropathy and neuropathy. Multiple myeloma is only one etiology of many cancer pain conditions that may necessitate interventional pain treatment when refractory to multimodal medications. Notably, local anesthetic systemic toxicity is a rare but life-threatening complication of local anesthetic administered for these interventions. CASE PRESENTATION A 50-60-year-old woman presented with multiple myeloma complicated by chronic bone pain and in an acute pain crisis. A fluoroscopic-guided L4-5 epidural catheter was placed with clinical doses of bupivacaine for comfort to undergo MRI of the spine. Soon after, she became tachycardic, tachypneic and hypoxic requiring non-invasive positive pressure airway support. As this respiratory distress was attributed to a large pleural effusion, a pigtail catheter was inserted in the intensive care unit with submaximally dosed lidocaine infiltration. She then developed a left bundle branch block followed by cardiovascular collapse minimally responsive to high-dose inotrope and vasopressor support. Lipid emulsion was started with dramatic therapeutic response and recovery to baseline. A CT of the thoracolumbar spine showed worsening extensive lytic lesions throughout all vertebral bodies and ribs from diffuse myeloma. CONCLUSIONS Patients with oncologic lesions focal to the thoracolumbar spine may be at higher risk for local anesthetic systemic toxicity from palliative epidurals due to increased cancer-related angiogenesis. Likewise, local anesthetic infiltration for procedures near any malignant sites could have a similar risk and may require lower initial fractionated dosages with increased vigilance.
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Affiliation(s)
- Victoria M Lim
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic Arizona, Scottsdale, Arizona, USA
| | - Taylor Barney
- College of Osteopathic Medicine, Touro University Nevada, Henderson, Nevada, USA
| | - Arun L Jayaraman
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic Arizona, Scottsdale, Arizona, USA
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Barby KD, Keating N, Flynn Makic MB. Care of Critically Ill Patients with Epidural Pain Management. J Perianesth Nurs 2021; 36:428-430. [PMID: 34419220 DOI: 10.1016/j.jopan.2021.05.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2021] [Accepted: 05/17/2021] [Indexed: 10/20/2022]
Affiliation(s)
- Kristen D Barby
- Aeromedical Evacuation Civilian Institution Program, Air Force Institute of Technology, Wright-Patterson Air Force Base, OH
| | - Nicole Keating
- Aeromedical Evacuation Civilian Institution Program, Air Force Institute of Technology, Wright-Patterson Air Force Base, OH
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Liu W, Zhang G, Sun B, Wang S, Lu Y, Xie H. Activation of NLR family, domain of pyrin containing 3 inflammasome by nitrous oxide through thioredoxin-interacting protein to induce nerve cell injury. Bioengineered 2021; 12:4768-4779. [PMID: 34348577 PMCID: PMC8806838 DOI: 10.1080/21655979.2021.1954741] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
Nitrous Oxide (N2O) has been shown to be neurotoxic, but its specific mechanism is still unclear. The purpose of this work is to probe into the impact of N2O on nerve cell injury through regulating thioredoxin-interacting protein (TXNIP)/the NOD-like receptor domain of pyrin containing 3 (NLRP3) pathway. The results indicated that, N2O exposure elevated TXNIP/NLRP3 expression in vivo and in vitro, led to declined learning and memory capabilities in mice, reduced apoptosis rate in hippocampal neuron and Nissl bodies, elevated inflammatory factors TNF-α, IL-1β and IL-6 levels, as well as cleaved caspase-3 and Bax expressions, and reduced Bcl-2 expression. Overexpressing TXNIP or NLRP3 further aggravated these injuries, but knocking down TXNIP or NLRP3 improved them. CO-IP indicated that TXNIP and NLRP3 can be combined, with interaction relationship. All in all, the results manifested that N2O is available to promote nerve cell inflammation and apoptosis through activating the TXNIP/NLRP3 pathway that can be used as a potential target for N2O-induced nerve damage in the future.
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Affiliation(s)
- WenJuan Liu
- Department of Anesthesiology, The Second Affiliated Hospital of Soochow University, Suzhou City, Jiangsu Province, China.,Department of Anesthesiology, Tongren Hospital, Shanghai Jiaotong University School of Medicine, Shanghai City, China
| | - GuangMing Zhang
- Department of Anesthesiology, Tongren Hospital, Shanghai Jiaotong University School of Medicine, Shanghai City, China
| | - Bo Sun
- Department of Anesthesiology, The Second Affiliated Hospital of Soochow University, Suzhou City, Jiangsu Province, China
| | - ShuYan Wang
- Department of Anesthesiology, Tongren Hospital, Shanghai Jiaotong University School of Medicine, Shanghai City, China
| | - YinZhong Lu
- Department of Anesthesiology, Tongren Hospital, Shanghai Jiaotong University School of Medicine, Shanghai City, China
| | - Hong Xie
- Department of Anesthesiology, The Second Affiliated Hospital of Soochow University, Suzhou City, Jiangsu Province, China
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Minhaj FS, Leonard JB. A description of the clinical course of severe benzonatate poisonings reported in the literature and to NPDS: A systematic review supplemented with NPDS cases. Hum Exp Toxicol 2021; 40:S39-S48. [PMID: 34219543 DOI: 10.1177/09603271211030560] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Benzonatate is a commonly prescribed medication that can be lethal in acute overdose of a small number of capsules. OBJECTIVE This was a systematic review to describe the course of severe poisoning and deaths from benzonatate supplemented with the National Poison Data System (NPDS) fatalities module. METHODS The NPDS was queried from 2000 to 2018 for benzonatate fatalities. Pubmed, Cochrane, Embase, and Google Scholar were searched for combinations of benzonatate and "poisoning," "overdose," and "toxicity." References of relevant articles were searched for additional publications. Articles were included if they described the clinical course of at least one patient suffering from benzonatate poisoning and available in English. Dual independent review and extraction were performed. RESULTS Seventeen cases from NPDS and 19 published reports met the inclusion criteria resulting in 36 cases, mostly (28/36) self-harm ingestions. Most patients were young [17 (11-29), median (IQR)] and female (22). Onset of toxicity was rapid at <5 min (9). Most common symptoms included cardiac arrest (29), seizures (24), and dysrhythmias (24). Treatments included intubation (26), cardiopulmonary resuscitation (28), vasopressors (20) and others. Return of spontaneous circulation was achieved in 23/28 patients, but most had significant neurologic deficits or other end organ damage and 5 survived with a good neurologic outcome. CONCLUSION AND RELEVANCE Overdose ingestions of benzonatate can cause significant toxicity with a rapid onset. Interventions performed were generally supportive in nature. Duration of directly toxic effects is short, but dramatic with neurologic devastation and resuscitated patients often still have a poor outcome.
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Affiliation(s)
- F S Minhaj
- Maryland Poison Center, Department of Pharmacy Practice and Science, University of Maryland School of Pharmacy, Baltimore, MD, USA
| | - J B Leonard
- Maryland Poison Center, Department of Pharmacy Practice and Science, University of Maryland School of Pharmacy, Baltimore, MD, USA
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Mysore V, Kumaresan M, Garg A, Dua A, Venkatram A, Dua K, Singh M, Madura C, Chandran R, Rajput RS, Sattur S, Singh S. Hair Transplant Practice Guidelines. J Cutan Aesthet Surg 2021; 14:265-284. [PMID: 34908769 PMCID: PMC8611706 DOI: 10.4103/jcas.jcas_104_20] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
The field of hair transplant (HT) has grown exponentially in the past decade, especially after the introduction of follicular unit excision (FUE). There is much variation in criteria for case selection, the technique, pre- and post-procedure protocols, by different surgeons. Techniques continue to evolve and evidence in the form of controlled data is not available for all techniques and protocols being used; there is also a debate as to who can do what, what should be the training for staff, role of technicians. This has led to a situation wherein medico legal issues have cropped up as to what is minimum acceptable. An attempt is made to summarize standard protocols with the available evidence. It is emphasized that the objective of these guidelines is to recommend minimum standards for practice of hair transplantation. The principles outlined in these guidelines are of a general nature only, minimal in their level and are not meant to cover all situations. It should be understood that these recommendations are by no means binding and universal, represent minimum standards only and as in all surgical techniques, variations in techniques are possible. It is also further clarified that these are based on current literature, and as science evolves, these guidelines could also change in future. Where published evidence is not available, consensus expert opinion is presented. The task force emphasizes that each patient has to be treated on his/her own merit and that these guidelines do not limit the physician from making an appropriate choice or the necessary innovation for a given patient. The task force recognizes that the treating surgeon is best suited to decide what is needed for a given patient in a given situation. Innovations in medicine need flexibility in approach and these guidelines do not limit the surgeon from undertaking innovative research.
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Affiliation(s)
- Venkatram Mysore
- The Venkat Center for Skin and Plastic Surgery, Bengaluru, Karnataka, India
| | - Muthuvel Kumaresan
- Cutis Skin Clinic & Hair Transplant Center, Coimbatore, Tamil Nadu, India
| | - Anil Garg
- Rejuvenate Hair Transplant Center, Indore, Madhya Pradesh, India
| | - Aman Dua
- AK Clinics & Hair Transplant Center, Delhi, India
| | - Aniketh Venkatram
- Cutis Skin Clinic & Hair Transplant Center, Coimbatore, Tamil Nadu, India
| | - Kapil Dua
- AK Clinics & Hair Transplant Center, Delhi, India
| | | | - C Madura
- Cutis Academy of Cutaneous Sciences, Bangalore, India
| | - Ram Chandran
- Apollo Speciality Center, Chennai, Tamil Nadu, India
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Seventy-Fifth Anniversary of Plastic and Reconstructive Surgery: How Evidence-Based Medicine Has Transformed Plastic Surgery. Plast Reconstr Surg 2021; 147:1235-1241. [PMID: 33890912 DOI: 10.1097/prs.0000000000007913] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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