Pharmacokinetics and Cardiovascular Effects of Bupivacaine during Epidural Anesthesia in Children with Duchenne Muscular Dystrophy

Murat, I.; Esteve, Cristina; Montay, G.; Delleur, M. M.; Gaudiche, O; Saint-Maurice, C

doi:10.1097/00000542-198708000-00017

Cited by 11 publications

(3 citation statements)

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“…Depending on the type of surgical procedure and the neurocognitive level of the patient, options include general anesthesia, regional anesthesia or monitored anesthesia care. Although there is no evidence‐based medicine to demonstrate the advantage of one technique over another, one may postulate that the avoidance of general anesthesia and endotracheal intubation would be beneficial in decreasing the incidence of perioperative events especially respiratory complications . However, for major surgical procedures, general anesthesia and endotracheal intubation are necessary.…”

Section: Intraoperative Carementioning

confidence: 99%

Cardiac considerations in the operative management of the patient with Duchenne or Becker muscular dystrophy

Cripe

Tobias

2013

Pediatric Anesthesia

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Duchenne muscular dystrophy/Becker muscular dystrophy (DMD/BMD) is a progressive multisystem neuromuscular disorder. In addition to the skeletal muscle, the myocardium in the DMD/BMD patient is dystrophin deficient which results in a progressive cardiomyopathy. The myopathic myocardium poses significant risk of increased morbidity and mortality at the time of major surgical procedures. Careful attention must be given to the DMD/BMD patient during the intraoperative and postoperative period. Anesthesia selection is critical and anesthetics should be avoided which have been shown to be harmful in this patient population. Preanesthesia assessment should include cardiac consultation and detailed preoperative evaluation. Intraoperative management needs to insure that the weakened myocardium is not compromised by physiologic changes such as hypotension or major fluid shifts. Finally, attention to the cardiac status of the patient must continue into the postoperative period. The surgical care of the DMD/BMD patient requires a multispecialty approach to insure operative success.

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Section: Intraoperative Carementioning

confidence: 99%

Cardiac considerations in the operative management of the patient with Duchenne or Becker muscular dystrophy

Cripe

Tobias

2013

Pediatric Anesthesia

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“…First, except in neonates, the Vd ss , clearance and t 1 ⁄2 values for bupivacaine in infants and children are comparable to those seen in adults. [21,[23][24][25]54,77,93,96,97,[151][152][153][154][155][156][157][158][159][160][161][162][163][164][165][166][167][168] Second, in neonates and younger infants, although the clearance is still comparable to that in adults, the Vd ss , and thus the t 1 ⁄2 , are greater than the corresponding values in adults. [21,164] Third, in many of the studies looking at continuous infusions of bupivacaine, the maximum concentration of bupivacaine was seen either at or near the termination of the infusion or at the time of the last sample, suggesting that accumulation of bupivacaine was occurring during the infusion.…”

Section: Bupivacainementioning

confidence: 99%

“…While some early investigations of lumbar and thoracic epidural anesthesia in infants and children initially administered the epidural with 0.5% bupivacaine, [141,154] more recent reports are of initiation of thoracic or lumbar epidural anesthesia with 0.5 to 0.75 ml/kg of 0.25% bupivacaine. [23,25,54,56,153,156,157,179] Infusions of bupivacaine for postoperative analgesia have been reported with concentrations ranging from 0.125 to 0.25%; [23,25,54,153,156,157,172] even lower concentrations of bupivacaine can provide satisfactory postoperative analgesia when combined with epidural opioids.…”

Section: Bupivacainementioning

confidence: 99%

Benefit and Risks of Local Anesthetics in Infants and Children

Gunter

2002

Pediatric Drugs

157

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Regional anesthesia has become a routine part of the practice of anesthesiology in infants and children. Local anesthetic toxicity is extremely rare in infants and children; however, seizures, dysrhythmias, cardiovascular collapse, and transient neuropathic symptoms have been reported. Infants and children may be at increased risk from local anesthetics compared with adults. Larger volumes of local anesthetics are used for epidural anesthesia in infants and children than in adults. Metabolism and elimination of local anesthetics can be delayed in neonates, who also have decreased plasma concentrations of alpha(1)-acid glycoprotein, leading to increased concentrations of unbound bupivacaine. Most regional anesthetic procedures in infants and children are performed with the patient heavily sedated or anesthetized; because of this, and because a test dose is not a particularly sensitive marker of intravenous injection in the anesthetized patient, detection of intravascular local anesthetic injection is extremely difficult. The same local anesthetics used in adult anesthetic practice are also used in infants and children. Because of its extremely short duration of action, chloroprocaine has been used primarily for continuous epidural techniques in infants and children. The use of tetracaine has generally been limited to spinal and topical anesthesia. Lidocaine (lignocaine) has been used extensively in infants and children for topical, regional, plexus, epidural and spinal anesthesia. The association between prilocaine and methemoglobinemia has generally restricted prilocaine use in infants and children to the eutectic mixture of local anesthetics (EMLA). Because of its greater degree of motor block compared with other long-acting local anesthetics, etidocaine has generally been limited to plexus blocks in infants and children. Mepivacaine has been used for both plexus and epidural anesthesia in infants and children. Because postoperative analgesia is often the primary justification for regional anesthesia in infants and children, bupivacaine, a long-acting local anesthetic, is the most commonly reported local anesthetic for pediatric regional anesthesia. Given the lower toxic threshold of bupivacaine compared with other local anesthetics, the risk-benefit ratio of bupivacaine may be greater than that of other local anesthetics. Two new enantiomerically pure local anesthetics, ropivacaine and levobupivacaine, offer clinical profiles comparable to that of bupivacaine but without its lower toxic threshold. The extreme rarity of major toxicity from local anesthetics suggests that widespread replacement of bupivacaine with ropivacaine or levobupivacaine is probably not necessary. However, there are clinical situations, including prolonged local anesthetic infusions, use in neonates, impaired hepatic metabolic function, and anesthetic techniques requiring a large mass of local anesthetic, where replacement of bupivacaine with ropivacaine, levobupivacaine or (for continuous techniques) chloroprocaine appears prudent.

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