Preoperative interscalene block with levobupivacaine provides safe and effective analgesia for same-day elective shoulder surgery, but the benefit of this one-time intervention does not persist.

BackgroundTransversus abdominis plane (TAP) infiltration has been increasingly used for postsurgical analgesia in abdominal/pelvic procedures; however, duration/extent of analgesia with standard local anesthetics is limited. This pilot study assessed the preliminary efficacy and safety of two volumes of liposome bupivacaine administered via TAP infiltration in patients undergoing robotic laparoscopic prostatectomy.MethodsIn this single-center, open-label, prospective study, patients older than 18 years received TAP infiltration with liposome bupivacaine immediately after surgery. The first 12 patients received a total volume of 20 mL liposome bupivacaine (266 mg); the next 12 received 40 mL liposome bupivacaine (266 mg). The liposome bupivacaine was diluted with 0.9% normal saline. The primary efficacy measure was duration of analgesia, measured by time to first opioid administration. Secondary outcome measures included patient-assessed pain scores, opioid use, and opioid-related adverse events (AEs).ResultsTwenty-four patients received liposome bupivacaine (20 mL, n=12; 40 mL, n=12) and were included in the primary analysis. Three refused participation in a 10-day follow-up visit and did not complete the study. Median time to first opioid administration after surgery was 23 and 26 minutes for the 20 and 40 mL groups, respectively. Mean total amount of postsurgical opioids ranged from 25.4 to 27.3 mg; after hospital discharge to day 10, both groups required a mean of 0.7 oxycodone/acetaminophen tablets/day. Mean pain scores of 4.4 and 5.3 were reported at 1 hour and 3.1 and 3.9 at 2 hours postsurgery, with 20 and 40 mL doses, respectively. Neither group had mean scores higher than 3.0 at any further assessments. No opioid-related or treatment-related serious AEs were reported.ConclusionMedian time to first opioid administration did not differ between the two groups. No differences in secondary outcomes were observed on the basis of volume administered. These initial findings suggest further study of liposome bupivacaine administered via TAP infiltration as part of a multimodal analgesic regimen in laparoscopic robotic prostatectomy may be warranted.

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Swanson on procaine neurotoxicity, 1 and are interested in why they decided to use undiluted 10% procaine instead of 5% procaine prepared with 10% procaine and equal volumes of either 10% glucose or cerebral spinal fluid.When the first report of transient radicular irritation with spinal anesthesia using 5% lidocaine appeared, 2 our department decided to change to the routine use of 10% procaine for spinal anesthesia. We decided to use a 5% concentration as advocated by Winnie in his use of procaine for differential spinals in 1978.3 The statement that recent anesthesia texts do not recommend using a maximum concentration of 5% procaine is incorrect. Two anesthesia texts from our library either stated that spinal procaine should not be injected in concentrations exceeding 5%, 4 or that spinal procaine in a strength of 5% or less is not irritating to nervous tissue and meninges. 5 The recommendation to use 5% procaine is not referenced in these texts, but may have come from papers published in the 1930s that described neurotoxicity with 10% spinal procaine. 6,7 It is true that there are no current studies available describing the neurotoxicity of spinal procaine, 8 although it has been stated that "local anesthetics all have the potential to be neurotoxic particularly in concentrations and doses larger than those used clinically." 8 It appears that 10% spinal procaine may have that potential and should not be used for spinal anesthesia.We still feel that 5% spinal procaine remains a viable alternative to lidocaine, because there is no evidence at present that it is neurotoxic.