Continuous, Intra-Articular Infusion of Bupivacaine After Total-Knee Arthroplasty May Lead to Potentially Toxic Serum Levels of Local Anesthetic

Hoeft, Mark A.; Rathmell, James P.; Dayton, Michael R.; Lee, Peter; Howe, James G.; Incavo, Stephen J.; Lawlis, John F.

doi:10.1097/00115550-200507000-00022

Cited by 11 publications

(6 citation statements)

References 4 publications

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“…Based on our search, we found one report of toxicity occurring at concentrations as low as 1.1 µg/ml 65. However, even the mildest toxic symptoms are unlikely to appear below plasma levels of 1.6 µg/ml 66,67 . Gupta et al used levobupivacaine in one trial and reported total and free medians of 2.2 and 0.04 µg/ml after 23 hours of infusion respectively, without any clinical toxicity 68 .…”

Section: Toxicitymentioning

confidence: 96%

Systemic Levels of Local Anaesthetic after Intra-Peritoneal Application – a Systematic Review

Kahokehr

Sammour

Vather

et al. 2010

Anaesth Intensive Care

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There is a lack of cohesive reports on the systemic levels of local anaesthetic after intraperitoneal application. A comprehensive systematic review with no language restriction was conducted. Eighteen suitable articles were identified. Data were compiled and presented according to local anaesthetic agent. Intraperitoneal local anaesthetic has been studied in many different procedures, including open and laparoscopic surgery. A total of 415 patients were included for analysis. There were no cases of clinical toxicity. There were 11 (2.7%) cases with a systemic level above or close to a safe threshold (as determined by the report authors) in three trials utilising intraperitoneal local anaesthetic after laparoscopic cholecystectomy. Intraperitoneal lignocaine doses varied from 100 to 1000 mg, mean Cmax ranged from 1.01 to 4.32 µg/ml and mean Tmax ranged from 15 to 40 minutes. Intraperitoneal bupivacaine doses varied from 50 to 150 mg (weight based doses also reported), mean Cmax ranged from 0.29 to 1.14 µg/ml and mean Tmax ranged from 15 to 60 minutes. Intraperitoneal ropivacaine doses varied from 100 to 300 mg, mean Cmax ranged from 0.66 to 3.76 µg/ml and mean Tmax ranged from 15 to 35 minutes. The addition of adrenaline to intraperitoneal local anaesthetic almost halves systemic levels and prolongs Tmax. Intraperitoneal local anaesthetic results in detectable systemic levels in the perioperative setting. Despite a lack of clinical toxicity, careful attention to dose is still required to prevent potential systemic toxic levels. Clinicians should also consider the addition of adrenaline to intraperitoneal local anaesthetic solutions to further add to the systemic safety profile.

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Section: Toxicitymentioning

confidence: 96%

Systemic Levels of Local Anaesthetic after Intra-Peritoneal Application – a Systematic Review

Kahokehr

Sammour

Vather

et al. 2010

Anaesth Intensive Care

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“…One study has been prematurely discontinued due to potentially toxic serum levels of bupivacaine (1.2 µg/mL); no bupivacaine-related side effects were observed. 22 No other major complications were mentioned. Reported side effects and complications are summarized in ►Table 5.…”

Section: Complicationsmentioning

confidence: 98%

“…The characteristics of the 11 included trials are summarized in ►Table 3. 6,10,[20][21][22][23][24][25][26][27][28] A total of 453 TKAs in 374 patients were included in this review.…”

Section: Included Studiesmentioning

confidence: 99%

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Continuous Local Infiltration Analgesia after TKA: A Meta-Analysis

Keijsers

Bekerom²,

Delft

et al. 2015

J Knee Surg

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The analgesic effect of local infiltration analgesia (LIA) after total knee arthroplasty (TKA) has been reported to be less than 24 hours. The concept of continuous LIA (CLIA) has been developed to achieve prolonged analgesia by bolus injections or by pump infusion of analgesics. The purpose of this meta-analysis is to assess the effect of CLIA versus single-shot injection LIA (SLIA) and placebo on pain after TKA.A systematic search was performed in most relevant databases to identify all randomized controlled trials (RCTs) comparing intra-articular CLIA with SLIA or placebo for TKA. Primary outcome measures were visual analogue scale (VAS)-scores after 24, 48, and 72 hours at rest and during activity. Data were extracted for meta-analysis and pooled using Cochrane software. The results of comparable studies were pooled using the fixed effects model or random effects model.A total of 11 RCTs were included. Five articles were eligible for meta-analysis comparing CLIA versus placebo, involving 227 TKAs. VAS scores at rest 24 hours after surgery were in favor of CLIA with a decrease of pain scores of 46%. On the second and third postoperative day, the decrease in VAS scores was no longer significant. During activity VAS scores were also in favor of CLIA after 24 and 48 hours.Two studies were eligible for meta-analysis comparing CLIA versus SLIA. VAS scores at rest, 48 hours after surgery, were in favor of CLIA. CLIA can possibly provide a reduced pain perception for 24 hours postoperative at rest after performing a TKA. This effect may persist until 48 hours postoperative during activity. Due to the high level of heterogeneity no firm further conclusions can be drawn.

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“…To date, the results were equivocal, with some studies finding lower pain scores, 86-95 opioid consumption, 87,89,[92][93][94] and/or length of hospital stay 89,91,[93][94][95][96] attributable to continuous wound infiltration, whereas others failed to find benefit on any of these outcome measures. [97][98][99][100][101][102][103] These variable results may be because of differences in the positioning of the catheter or dose of local anesthetic. There is a paucity of published data on costs of continuous local anesthetic infusion.…”

Section: Injectable Local Anesthetics and Their Place In Multimodal Amentioning

confidence: 99%

Evolving Role of Local Anesthetics in Managing Postsurgical Analgesia

Golembiewski

Dasta

2015

Clinical Therapeutics

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Continuous, Intra-Articular Infusion of Bupivacaine After Total-Knee Arthroplasty May Lead to Potentially Toxic Serum Levels of Local Anesthetic

Cited by 11 publications

References 4 publications

Systemic Levels of Local Anaesthetic after Intra-Peritoneal Application – a Systematic Review

Systemic Levels of Local Anaesthetic after Intra-Peritoneal Application – a Systematic Review

Continuous Local Infiltration Analgesia after TKA: A Meta-Analysis

Evolving Role of Local Anesthetics in Managing Postsurgical Analgesia

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