In recent years levobupivacaine, the pure S (−)-enantiomer of bupivacaine, emerged as a safer alternative for regional anesthesia than its racemic parent. It demonstrated less affinity and strength of depressant effects onto myocardial and central nervous vital centers in pharmacodynamic studies, and a superior pharmacokinetic profile. Clinically, levobupivacaine is well tolerated in a variety of regional anesthesia techniques both after bolus administration and continuous postoperative infusion. Reports of toxicity with levobupivacaine are scarce and occasional toxic symptoms are usually reversible with minimal treatment with no fatal outcome. Yet, levobupivacaine has not entirely replaced bupivacaine in clinical practice. In anesthesia and analgesia practice, levobupivacaine and bupivacaine produce comparable surgical sensory block with similar adverse side effects, and equal labor pain control with comparable maternal and fetal outcome. The equipotency of the two drugs has been recently questioned, prompting clinicians to increase the dose of levobupivacaine in an attempt to ensure adequate anesthesia and analgesia and offsetting, therefore, the advantages of less motor block with levobupivacaine. In this review we aim to discuss the pharmacological essentials of the safer profile of levobupivacaine, and analyze the evidence regarding the current clinical indications.
SummaryThe addition of fentanyl or clonidine to levobupivacaine was evaluated in patients undergoing breast surgery under general anaesthesia with intra-and postoperative paravertebral analgesia. Patients were randomly allocated to four groups: Group L received 19 ml bolus levobupivacaine 0.25% plus 1 ml saline followed by an infusion of levobupivacaine 0.1%; Group LF received 19 ml bolus levobupivacaine 0.25% plus fentanyl 50 lg followed by an infusion of levobupivacaine 0.05% with fentanyl 4 lg.ml )1 ; Group LC received 19 ml bolus levobupivacaine 0.25% plus clonidine 150 lg followed by an infusion of levobupivacaine 0.05% with clonidine 3 lg.ml
A patient undergoing left mastectomy and immediate latissimus dorsi breast reconstruction under combined paravertebral block and general anaesthesia developed transient, well-demarcated, right-sided hemifacial erythema and sweating, and left-sided Horner syndrome postoperatively. This "harlequin" appearance occurs because of a normal or excessive vasodilatory, thermoregulatory response to heat or emotion mediated by an intact sympathetic pathway on the erythematous side, together with relative pallor of the pharmacologically blocked side.
Postoperative nausea and vomiting is common after cardiac surgery and may contribute to significant morbidity. Gastric decompression during anesthesia has been used for postoperative nausea and vomiting prophylaxis in shorter duration noncardiac surgery with conflicting results. We tested the hypothesis that gastric decompression during elective coronary revascularization surgery with cardiopulmonary bypass and continued afterwards until tracheal extubation would reduce the incidence of vomiting or retching and nausea. In a prospective, randomized, cohort study, 104 patients with at least 2 Apfel's risk factors for postoperative nausea and vomiting were allocated to receive a gastric tube on free gravity drainage after induction of anesthesia (n = 52) or to a control group (n = 52). The gastric tube was removed simultaneously with tracheal extubation postoperatively. The primary outcome measure was the incidence of vomiting or retching. Secondary outcomes included the incidence and severity of nausea measured on a visual analog scale. The incidence of vomiting or retching was 13.4% in patients with gastric decompression, compared with 11.5% in the control group (P = 0.7). Similarly, there was no statistically significant difference between the two groups in the incidence of nausea (32.7% versus 25.0%, P = 0.6), median severity of nausea on a visual analog scale at 12 h (25; range, 0-55 mm versus 30; range, 0-60 mm, P = 0.4), or antiemetics administration (38.5% versus 28.8%, P = 0.3). Continuous gastric decompression during coronary revascularization surgery and afterwards until tracheal extubation did not reduce the incidence of vomiting or retching or the incidence and severity of nausea in these patients.
Summary The purpose of this prospective randomised double‐blind study was to determine the effective dose of propofol required for the successful first attempt insertion of the laryngeal tube compared with the laryngeal mask airway in patients co‐induced using alfentanil 5 μg.kg–1, undergoing short elective gynaecological procedures. The first patient in each group received propofol 2.5 mg.kg−1 for induction. In accordance with Dixon's up‐and‐down method, the dose of propofol for consecutive patients in each group was varied with increments or decrements of 0.5 mg.kg−1 based on the previous patient ‘all‐or‐none’ purposeful movement response to first attempt of insertion of the randomised device. The ED50 (SD) of propofol was 2.66 (0.86) mg.kg−1 and 2.33 (0.37) mg.kg−1 for the laryngeal tube and laryngeal mask patients, respectively, which did not reach statistical significance (p = 0.40). We conclude therefore that the insertion of the two airway devices requires similar bolus doses of propofol when alfentanil is used as the co‐induction drug.
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