Intravenous ropivacaine bolus is a reliable marker of intravascular injection in premedicated healthy volunteers

McCartney, Colin J. L.; Murphy, Damian B.; Iagounova, Anna; Chan, Vincent

doi:10.1007/bf03019374

Cited by 23 publications

(8 citation statements)

References 13 publications

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“…Additionally, caution is advised in patients in whom toxicity is suspected and who have no convulsions, if premedication such as midazolam has been administered, because this medication may have a protective anticonvulsant effect [15,16].…”

Section: Discussionmentioning

confidence: 99%

Ropivacaine-induced toxicity with overdose suspected after axillary brachial plexus block

et al. 2007

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Ropivacaine has a high threshold for systemic toxicity. We report and highlight a rare case in which an overdose of ropivacaine was suspected of leading to a generalized convulsion following the injection of this agent for axillary brachial plexus block (ABPB). A 25-year-old woman (height, 153 cm; weight, 48 kg; American Society of Anesthesiologists physical status I) was scheduled for finger surgery with ABPB. The perivascular sheath was identified by fascial clicks. We administered 300 mg (6.25 mg x kg(-1)) ropivacaine, while confirming that no blood flow was observed in the injection line by repeated negative aspiration tests. Ten minutes after the injection, most sensory and motor nerves were blocked effectively. Thirteen minutes after the administration, the patient lost consciousness and convulsed suddenly. No severe symptoms of cardiovascular toxicity occurred. The concentration of ropivacaine in a venous blood sample taken 28 min after the ropivacaine injection was 3.65 microg x ml(-1). She recovered with no sequelae. Limited cases have indicated high efficacy and sufficient safety for the use of 300 mg ropivacaine for ABPB. However, the toxic threshold of ropivacaine remains unclear, and the dose should be calculated in relation to the weight of the patient to prevent severe toxic complications.

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Section: Discussionmentioning

confidence: 99%

Ropivacaine-induced toxicity with overdose suspected after axillary brachial plexus block

et al. 2007

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“…28 Ropivacaine at a dose of 60 mg (12 mL of a 0.5% solution) reliably produces symptoms even in premedicated volunteers. 29 Although useful for peripheral injections, all of these proposed local anesthetic test doses include volumes sufficient to produce extensive spinal anesthesia: if used in epidural techniques, a preliminary smaller test dose to exclude subarachnoid injection is required.…”

Section: Local Anestheticmentioning

confidence: 99%

Prevention of Local Anesthetic Systemic Toxicity

Mulroy

Hejtmanek

2010

Regional Anesthesia and Pain Medicine

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Although new drugs and techniques may improve outcomes when unintended high blood levels of local anesthetics occur, the primary focus of daily practice should remain the prevention of such events. Although adoption of no single "safety step" will reliably prevent systemic toxicity, the combination of several procedures seems to have reduced the frequency of systemic toxicity since 1981. These include the use of minimum effective doses, careful aspiration, and incremental injection, coupled with the use of intravascular markers when large doses are used. Epinephrine remains the most widely used and studied marker, but its reliability is impaired in the face of beta-blockade, anesthesia, advanced age, and active labor. As an alternative, the use of subtoxic doses of local anesthetics themselves can produce subjective symptoms in unpremedicated patients. Fentanyl has also been confirmed to produce sedation in pregnant women when used as an alternative. The use of ultrasound observation of needle placement and injection may be useful, but has also been reported as not completely reliable. Constant vigilance and suspicion are still needed along with a combination of as many of these safety steps as practical.

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“…The latter aspect is pertinent, given the conflicting views on the suitability of a discrete test dose to prevent intravenous administration of the main dose, particularly for ropivacaine and levobupivacaine, which are less likely than bupivacaine to provoke early CNS symptoms or signs. 43,44 Clearly, in this context, and especially in the CNSobtunded patient, there is a case to be made for using the response from an epinephrine-containing solution for the entire dose.…”

Section: Dose Dependence Of Local Anesthetic Intoxicationmentioning

confidence: 99%

Acute Toxicity of Local Anesthetics: Underlying Pharmacokinetic and Pharmacodynamic Concepts

Mather

Copeland

Ladd

2005

Regional Anesthesia and Pain Medicine

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The risk of accidental intravascular injection and consequent acute toxicity is ever-present with most neural blockade techniques. The severity of cardiovascular and central nervous system (respectively, CVS and CNS) toxicity is directly related to the local anesthetic potency, dose, and rate of administration. Nonetheless, although the anesthetic potency of ropivacaine and levobupivacaine is similar to that of bupivacaine, at usual clinical doses, ropivacaine and levobupivacaine are less likely than bupivacaine to cause convulsions or lethal dysrhythmias. Signs of CNS stimulation, ranging from tremors to convulsions and perhaps cardiac dysrhythmias, can be described in terms of a chaos-derived state change in which the local anesthetic appears to act as an initiator. Both CNS and CVS effects are rather poorly correlated with arterial drug concentrations but better correlated with concentrations in the respective regional venous drainage. Lung uptake reduces the maximum drug concentration by approximately 40%. Prolonging intravenous administration from 1 to 3 minutes results in a similar decrease in maximum concentration. This is an underlying tenet of dose fractionation, but the main advantage of dose fractionation is that the anesthesiologist is able to cease administration with less of the dose given if signs or symptoms of toxicity occur. Overall, it appears that the gains in safety from ropivacaine and levobupivacaine are due more to favorable pharmacodynamic enantioselectivity than to pharmacokinetic factors. This essay presents some pharmacokinetic aspects relevant to acute toxicity of local anesthetics, mainly using data from the authors' studies in a sheep model of simulated accidental intravenous administration.

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Intravenous ropivacaine bolus is a reliable marker of intravascular injection in premedicated healthy volunteers

Abstract: P Pu ur rp po os se e: : We designed the following volunteer study to determine if an intravascular bolus dose of ropivacaine could be found that would reliably produce mild symptoms of central nervous system (CNS) toxicity in sedated humans.

Cited by 23 publications

References 13 publications

Ropivacaine-induced toxicity with overdose suspected after axillary brachial plexus block

Ropivacaine-induced toxicity with overdose suspected after axillary brachial plexus block

Prevention of Local Anesthetic Systemic Toxicity

Acute Toxicity of Local Anesthetics: Underlying Pharmacokinetic and Pharmacodynamic Concepts

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