A comparison between epidural anaesthesia using alkalinized solution and spinal (combined spinallepidural) anaesthesia for elective caesarean section

Smith, A. F.; Fernando, Roshan

doi:10.1016/s0959-289x(97)80018-0

Cited by 3 publications

(5 citation statements)

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“…However, the order in which the substances are mixed may play a role, with precipitation occurring if sodium bicarbonate is added directly to bupivacaine. Moreover, they add that these substances should not be mixed ahead of use as the chemical stability is unknown 24. Concerns about chemical stability are further aggravated by our finding that grade five crystallization develops within 1 hour after addition of sodium bicarbonate 8.4% to lidocaine 2%, invoking doubts about the chemical safety of preparing mixtures for later use.…”

Section: Discussionmentioning

confidence: 96%

Crystallization of short-acting and intermediate-acting local anesthetics when mixed with adjuvants: a semiquantitative light microscopy analysis

Hoerner

Stundner

Fiegl

et al. 2023

Reg Anesth Pain Med

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IntroductionThe addition of adjuvants to short-acting local anesthetics (LA) is common practice in clinical routine to speed up block onset and decrease pain on injection. In a previous study, we observed the development of microscopic crystal precipitations after bupivacaine or ropivacaine were mixed with adjuvants; this follow-up study is intended to clarify whether crystallization (A) also occurs in short-acting or intermediate-acting LA-adjuvant mixtures, (B) changes over time, and (C) is associated with the solutions’ pH.MethodsLidocaine 2%, prilocaine 2%, mepivacaine 2%, procaine 2% and chloroprocaine 2% were individually mixed with clonidine, dexamethasone, dexmedetomidine, epinephrine, fentanyl, morphine or sodium bicarbonate 8.4% in clinically established ratios. For each mixture, we measured initial pH and recorded crystallization patterns at 0, 15, 30 and 60 min using a standardized, semiquantitative light microscopy approach.ResultsLidocaine 2% and mepivacaine 2% plus sodium bicarbonate 8.4%, and mepivacaine 2% plus dexamethasone developed delayed grade 5 crystallization over 1 hour. Prilocaine-based, procaine-based and chloroprocaine-based mixtures showed much less pronounced crystallization, with a maximum of grade 2. Initial pH and grade of crystallization showed weak monotonic relationships at time points t0, t15and t30(ρ=−0.17, 0.31 and 0.32, (all p>0.05)) and a moderate relationship time point t60(ρ=0.57 (p=0.0003))ConclusionsOur study revealed high grades of crystallization in lidocaine/mepivacaine-bicarbonate and mepivacaine-dexamethasone mixtures, although these were previously considered safe for local, perineural or neuraxial use. Our findings cast particular doubt on the safety of preparing these formulations for later use.

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Section: Discussionmentioning

confidence: 96%

Crystallization of short-acting and intermediate-acting local anesthetics when mixed with adjuvants: a semiquantitative light microscopy analysis

Hoerner

Stundner

Fiegl

et al. 2023

Reg Anesth Pain Med

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“…In a pilot study, Lucas et al [11] found no differences in time to achieve a T4 sensory block when All results are expressed as mean (SD). However, because of the time and potential error involved in mixing such solutions, especially in an emergency situation, many anaesthetists prepare the drugs in advance [7]. There were no significant differences in percentage pH change between the groups (p 0.28).…”

Section: Discussionmentioning

confidence: 96%

“…It is also not uncommon for anaesthetists wishing to reduce the potential for error and the time involved in preparing these solutions, to premix the drugs in a syringe that is stored at room temperature for later use [7]. It is also not uncommon for anaesthetists wishing to reduce the potential for error and the time involved in preparing these solutions, to premix the drugs in a syringe that is stored at room temperature for later use [7].…”

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confidence: 99%

Chemical Stability Of Bupivacaine, Lidocaine And Epinephrine In pH Adjusted Solutions

Robinson¹,

Wai²,

Fernando³

1999

Anesthesiology

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Epinephrine and sodium bicarbonate may be added to local anaesthetic solutions in order to reduce the onset time and enhance the quality of epidural anaesthesia for Caesarean section. Such mixtures are sometimes prepared several hours in advance for subsequent use in emergency Caesarean section through a pre-existing epidural catheter. To evaluate this practice, we studied the chemical stability in solution over 24 h of nine epidural mixtures consisting of different combinations of bupivacaine, lidocaine, epinephrine and sodium bicarbonate. In mixtures alkalinised with sodium bicarbonate, epinephrine concentrations decreased significantly over 24 h (p , 0.0001), whereas those in nonalkalinised mixtures did not change with time. Bupivacaine and lidocaine concentrations in all mixtures did not decrease over time regardless of alkalinisation. We do not recommend adding epinephrine to alkalinised epidural solutions that are to be stored for a prolonged period before clinical use.

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“…Regardless of which epidural solution is used, adjuvants such as epinephrine and sodium bicarbonate remain popular to improve efficacy. However, because of the time and potential error involved in mixing such solutions, especially in an emergency situation, many anaesthetists prepare the drugs in advance [7]. These solutions are then stored for up to 24 h before being used.…”

Section: Discussionmentioning

confidence: 99%

“…Today several epidural mixtures, containing one or more of these drugs, are used to extend an epidural block for emergency Caesarean section. It is also not uncommon for anaesthetists wishing to reduce the potential for error and the time involved in preparing these solutions, to premix the drugs in a syringe that is stored at room temperature for later use [7].…”

mentioning

confidence: 99%

Chemical stability of bupivacaine, lidocaine and epinephrine in pH‐adjusted solutions

Robinson¹,

Fernando²,

Wai

et al. 2000

Anaesthesia

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SummaryEpinephrine and sodium bicarbonate may be added to local anaesthetic solutions in order to reduce the onset time and enhance the quality of epidural anaesthesia for Caesarean section. Such mixtures are sometimes prepared several hours in advance for subsequent use in emergency Caesarean section through a pre-existing epidural catheter. To evaluate this practice, we studied the chemical stability in solution over 24 h of nine epidural mixtures consisting of different combinations of bupivacaine, lidocaine, epinephrine and sodium bicarbonate. In mixtures alkalinised with sodium bicarbonate, epinephrine concentrations decreased significantly over 24 h (p , 0.0001), whereas those in nonalkalinised mixtures did not change with time. Bupivacaine and lidocaine concentrations in all mixtures did not decrease over time regardless of alkalinisation. We do not recommend adding epinephrine to alkalinised epidural solutions that are to be stored for a prolonged period before clinical use.

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A comparison between epidural anaesthesia using alkalinized solution and spinal (combined spinallepidural) anaesthesia for elective caesarean section

Cited by 3 publications

References 2 publications

Crystallization of short-acting and intermediate-acting local anesthetics when mixed with adjuvants: a semiquantitative light microscopy analysis

Crystallization of short-acting and intermediate-acting local anesthetics when mixed with adjuvants: a semiquantitative light microscopy analysis

Chemical Stability Of Bupivacaine, Lidocaine And Epinephrine In pH Adjusted Solutions

Chemical stability of bupivacaine, lidocaine and epinephrine in pH‐adjusted solutions

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