Comparison of plasma levobupivacaine concentrations with and without epinephrine following erector spinae plane block for breast cancer surgery: a randomized controlled trial

Abstract

Background The erector spinae plane (ESP) block requires a large volume of local anesthetic to provide effective analgesia, which has the potential to cause local anesthetic systemic toxicity (LAST). Adjunctive epinephrine slows the entry of local anesthetic into the plasma and decreases its toxic effect on vulnerable tissues. We compared plasma levobupivacaine concentrations with and without epinephrine after ESP blocks for breast cancer surgery. Methods In this prospective, double-blinded, randomized controlled trial, 35 patients who underwent elective unilateral partial mastectomy with sentinel lymph node biopsy were enrolled. The patients were randomized to group L (ESP block with 2 mg/kg levobupivacaine) or LE (ESP block with 2 mg/kg levobupivacaine and 5 μg/mL epinephrine). Blood samples were obtained at 2.5, 5, 7.5, 10, 12.5, 15, 30, 60, and 120 min after the ESP block, and plasma concentrations of levobupivacaine were compared. Results Twenty-nine patients were included in the analysis. The maximum plasma concentration (Cmax) and the time to maximum concentration (Tmax) were, respectively, 1.24 μg/mL and 6.0 min in group L and 0.62 μg/mL and 7.2 min in group LE. The two groups showed no significant differences in the numerical rating scale scores immediately after extubation and 5 and 9 h after the ESP block, or in the interval from the ESP block to the first rescue analgesia. No patient developed symptoms suggestive of LAST. Conclusions A single bolus of 2 mg/kg levobupivacaine in the ESP block resulted in a short Tmax with high Cmax. Adding epinephrine to levobupivacaine decreased the Cmax and delayed the Tmax after ESP blocks but had no effect on postoperative analgesia. Trial registration UMIN Clinical Trials Registry, UMIN000034479. The trial was retrospectively registered on October 13, 2018.

Population pharmacokinetic and safety analysis of ropivacaine used for erector spinae plane blocks

“…Third, while sampling began within 5 min after the initial bolus dose, it is possible that the T max for some patients could have been earlier than measured. A previous study of levobupivacaine in ESP blocks found that T max occurred at 6 min 9. Practical anesthesia and surgical concerns made more frequent sampling difficult.…”

“…Accordingly, an initial bolus dose of ropivacaine 150 mg (40 mL of 0.375%) followed by intermittent boluses every 6 hours became our institutional practice in 2020. Previous pharmacokinetic studies of ESP blocks have focused on lidocaine8 or levobupivacaine9 10 or have only studied single-shot ESP blocks using ropivacaine in children 11. Studies evaluating ropivacaine concentrations with ESP catheters are absent.…”

Analgesia efficacy of erector spinae plane block in laparoscopic abdominal surgeries: a systemic review and meta-analysis

“…To mitigate this, Shigeta et al . 48 recommended the use of adjunctive epinephrine with local anaesthetics in patients with increased risk of LAST as epinephrine reduces the rate at which local anaesthetic agents diffuse into the plasma, delays systemic uptake, and decreases the toxic effect on vulnerable tissues, such as the myocardium and central nervous system (CNS). Yawata et al .…”