Levobupivacaine – dextran mixture for transversus abdominis plane block and rectus sheath block in patients undergoing laparoscopic colectomy: a randomised controlled trial

Abstract

SummaryWe performed a randomised controlled double-blinded study of patients having laparoscopic colectomy with bilateral transversus abdominis plane block plus rectus sheath block, comparing a control group receiving 80 ml levobupivacaine 0.2% in saline with a dextran group receiving 80 ml levobupivacaine 0.2% in 8% low-molecular weight dextran. Twenty-seven patients were studied in each group. The mean (SD) maximum plasma concentration of levobupivacaine in the control group (1410 (322) ng.ml À1) was higher than the dextran group (1141 (287) ng.ml À1 ; p = 0.004), and was reached more quickly (50.6 (30.2) min vs 73.2 (24.6) min; p = 0.006). The area under the plasma concentration-time curve from 0 min to 240 min in the control group (229,124 (87,254) ng.min.ml À1 ) was larger than in the dextran group (172,484 (50,502) ng.min.ml À1; p = 0.007). The median (IQR [range]) of the summated numerical pain rating score at rest during the first postoperative 24 h in the control group (16 (9-20 [3-31]) was higher than in the dextran group (8 (2-11 [0-18]); p = 0.0001). In this study, adding dextran to levobupivacaine decreased the risk of levobupivacaine toxicity while providing better analgesia.

American Society for Enhanced Recovery (ASER) and Perioperative Quality Initiative (POQI) joint consensus statement on optimal analgesia within an enhanced recovery pathway for colorectal surgery: part 1—from the preoperative period to PACU

“…TAP blocks provide comparable short-term analgesia to wound infiltration but provide superior analgesia in longer term and in the setting of a multimodal analgesic regimen (Yu et al 2014; Guo et al 2015a). Concerning the choice of local anesthetic, ropivacaine, bupivacaine, and liposomal bupivacaine have all been used in ERPs with good results (Hamada et al 2016; Cohen 2012). Liposomal bupivacaine shows some promise for longer-term postoperative analgesia either as infiltration or for TAP blocks (Hutchins et al 2015); however, there are no large-scale randomized controlled trials available in intra-abdominal surgery to guide practice or to definitively demonstrate the analgesic efficacy of this intervention (Cohen 2012; Candiotti et al 2014).…”

Adding dextran to local anesthetic enhances analgesia

“…Our previous studies showed that adding low-molecular weight dextran (LMWD) to LA and an adrenaline mixture reduced systemic adrenaline absorption, abrogating adverse hemodynamic effects [2]. Also, LMWD added to LA induced long-term profound analgesia with lower LA systemic toxicity by reducing systemic LA absorption [3]. These effects were demonstrated in infiltration nerve block (NB) [2], transversus abdominis plane block [3], rectus sheath block [3], quadratus lumborum block [4], and mandibular NB cases.…”

“…Also, LMWD added to LA induced long-term profound analgesia with lower LA systemic toxicity by reducing systemic LA absorption [3]. These effects were demonstrated in infiltration nerve block (NB) [2], transversus abdominis plane block [3], rectus sheath block [3], quadratus lumborum block [4], and mandibular NB cases. Formation of an LMWD and LA complex that remains at the NB site longer may be the associated mechanism [3,4].…”

In reply: Use of low-molecular weight dextran as an LA adjuvant to extend LA action

“…We did not describe the use of dextran as an LA adjuvant in this review, but it is interesting to extend the LA action using with low-molecular weight dextran. Hamada et al demonstrated that the absorption of levobupivacaine was suppress in 90 min notably adding the 8% lowmolecular weight dextran solution [2]. We hope for high quality postoperative pain management using long acting LA.…”