Systemic Toxicity Following the Use of 1% Ropivacaine for Pediatric Penile Nerve Block

Najafi, Nadia; Veyckemans, Francis; Maine, Christine Du; Velde, A. Van de; Backer, Antoine De; Vanderlinden, Kim; Poelaert, Jan

doi:10.1097/aap.0000000000000415

Cited by 8 publications

(6 citation statements)

References 5 publications

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“…Ropivacaine at a concentration of 0.75% has been associated with mild central neurotoxicity even when injected correctly in 10-ml unilateral doses for RSB in adult patients [ 4 ]. Overdose of ropivacaine for children has been reported [ 5 , 6 ]. Therefore, in pediatric patients, it is important to perform the RSB at the lowest effective dose to avoid toxicity.…”

Section: Discussionmentioning

confidence: 99%

The Ropivacaine Concentration Required for Ultrasound-Guided Rectus Sheath Block in Pediatric Patients Undergoing Single-Incision Laparoscopic Hernia Repair: A Sequential Allocation Dose-Finding Study

Tachi¹,

Inomata²,

Tanaka³

2023

Cureus

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Background: The local anesthetic concentration required for ultrasound-guided rectus sheath block (RSB) in children remains unknown. Knowledge of appropriate ropivacaine concentration can help clinicians reduce local anesthetic toxicity risk when performing ultrasound-guided RSB in children. This study aimed to determine the appropriate ropivacaine concentration for ultrasound-guided RSB in children undergoing laparoscopic inguinal hernia repair. Methods: In this single-arm prospective study with an up-down sequential allocation design of binary response variables, 18 consecutive children aged 11 months to 7 years undergoing single-incision laparoscopic percutaneous extraperitoneal closure were assessed. Orotracheal intubation was performed without intravenous anesthesia or a neuromuscular relaxant. After intubation, ultrasound-guided RSB was performed with a ropivacaine dose of 0.30 ml/kg (0.15 ml/kg per side). Dixon's up-and-down method was used to determine the concentration, starting from 0.25% in 0.05% increments. Surgery commenced ≥15 min following RSB. Body movement or a 20% increase in heart rate or systolic blood pressure within 1 min of surgery initiation determined an unsuccessful RSB. The 95% effective concentration of ropivacaine needed for successful RSB was calculated using the probit test. Results: The 95% effective concentration of ropivacaine needed for successful ultrasound-guided RSB was 0.31% (95% confidence interval, 0.25-7.29). The highest concentration of ropivacaine required for successful ultrasound-guided RSB in the group of patients in this study was 0.3%. Conclusion: The 95% effective concentration of ropivacaine (0.30 ml/kg total, 0.15 ml/kg per side) for ultrasound-guided RSB was 0.31% in children undergoing single-incision laparoscopic surgery under general anesthesia.

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Section: Discussionmentioning

confidence: 99%

The Ropivacaine Concentration Required for Ultrasound-Guided Rectus Sheath Block in Pediatric Patients Undergoing Single-Incision Laparoscopic Hernia Repair: A Sequential Allocation Dose-Finding Study

Tachi¹,

Inomata²,

Tanaka³

2023

Cureus

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“…9,25,28 In 1 of these 3 cases, the patient was under general anesthesia when CV signs were noticed; therefore, the presence or absence of CNS toxicity is uncertain. 25 Prodromal features occurred in 8 patients-4 in isolation (metallic taste in mouth, dysgeusia) and 4 that proceeded to more serious CNS features (3 with seizures and 1 with agitation and other features). 6,11,13,17,21,31,37,39 Five had continuous infusions of local anesthetic, and 2 had tissue infiltration with excessive local anesthetic dosage (bupivacaine, 400 mg; 11 lidocaine, 1000mg 17 ).…”

Section: Vascular Markersmentioning

confidence: 99%

“…All LAST events (seizures) occurred in patients where either landmark or nerve stimulator techniques were used for PNB. In a follow-up study, Orebaugh et al 42 (25,336 PNBs from 20,021 patients) from the Australian and New Zealand Registry of Regional Anaesthesia (AURORA). There were 22 cases of LAST (13 minor, 8 major, and 1 cardiac arrest), with an overall incidence of LAST of 0.87 per 1000 PNBs.…”

Section: Clinical Registries/observational and Administrative Datamentioning

confidence: 99%

“…Analysis of this data set using logistic regression and propensity scoring demonstrated that ultrasound guidance was significantly associated with a reduced risk (60%-65% compared with the reference population) of LAST. 45 25,336 PNBs; therefore, it was not possible to determine the potential risks associated with this drug. During the time period of the AURORA registry (2007-2012), epinephrine use was not uniformly captured to the database; therefore, this could not be entered as a covariate in logistic regression.…”

Section: Clinical Registries/observational and Administrative Datamentioning

confidence: 99%

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Local Anesthetic Systemic Toxicity

Gitman

Barrington

2018

Regional Anesthesia and Pain Medicine

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This review summarizes presenting features, management, and outcomes of local anesthetic systemic toxicity (LAST) from published cases and those submitted to online registries capturing use of intravenous lipid emulsion (ILE) therapy. The results of single-center and multicenter registries and epidemiologic studies complement this information. Between March 2014 and November 2016, 47 separate cases of LAST were described in 35 peer-reviewed articles. Local anesthetic systemic toxicity events occurred as a result of penile blocks (23%), local infiltration (17%), and upper/lower extremity, torso, and neuraxial blockade. Twenty-two patients (47%) were treated with ILE, and 2 patients (4.3%) died. During the same time period, 11 cases submitted to lipidrescue.org were treated with ILE and survived. The incidence of LAST reported in registries is 0.03% or 0.27 (95% confidence interval, 0.21-0.35) per 1000 peripheral nerve blocks (denominator of 251,325). Seizure (53% and 61% from case reports and registries, respectively) was the most common presenting feature.

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“…We used a local anesthetic with a rapid onset such as mepivacaine 1%, to allow surgery to begin immediately after the block was performed, associated with levobupivacaine 0.25%, to achieve a prolonged analgesic effect after the end of the procedure, minimizing the anesthetic concentration and reducing possible risks of toxicity ( 14 , 15 ).…”

Section: Discussionmentioning

confidence: 99%

Pediatric ultrasound-guided dorsal penile nerve block and sedation in spontaneous breathing: a prospective observational study

Dottore,

Meroi,

Tomasino

et al. 2023

Front. Med.

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BackgroundWorldwide, one of the most common surgical procedures in the pediatric population is circumcision. There is no consent on the best anesthesiologic approach. This study aimed to investigate ultrasound-guided dorsal penile nerve block (DPNB) plus sedation in spontaneous breathing as a time-saving, safe, effective, and opioid-sparing technique.AimsThe primary outcome was the assessment of the time from the end of surgery and the discharge to the post-anesthesia care unit. Secondary outcomes were to evaluate the cumulative dosages of opioids, differences in pain levels between the two groups, and complications at the awakening, 4 h and 72 h after surgery, respectively.MethodsThis was a prospective study with a retrospective control group, approved by the Friuli–Venezia Giulia Ethics Committee. Children in the intervention group received an ultrasound-guided DPNB under sedation and spontaneous breathing. With the probe positioned transversally at the base of the penis using an in-plane approach with a modified technique, local anesthetic was injected under the deep fascia of the penis.ResultsWe recruited 70 children who underwent circumcision at the University Hospital of Udine, Italy, from 1 January 2016 to 1 October 2021: 35 children in the ultrasound-guided DPNB group and 35 children in the control group. Children who received ultrasound-guided DPNB had a statistically significant lower time to discharge from the operating room, did not require mechanical ventilation, maintained spontaneous breathing at all times, received fewer opioids, had lower mean intraoperative arterial pressures, and lower pain levels immediately after surgery.ConclusionUltrasound-guided DPNB associated with sedation and spontaneous breathing is a time-saving, opioid-sparing, safe, and effective strategy for the management of intraoperative and postoperative pain in children undergoing circumcision.Clinical trial registration:ClinicalTrial.gov (NCT04475458, 17 July 2020).

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Systemic Toxicity Following the Use of 1% Ropivacaine for Pediatric Penile Nerve Block

Cited by 8 publications

References 5 publications

The Ropivacaine Concentration Required for Ultrasound-Guided Rectus Sheath Block in Pediatric Patients Undergoing Single-Incision Laparoscopic Hernia Repair: A Sequential Allocation Dose-Finding Study

The Ropivacaine Concentration Required for Ultrasound-Guided Rectus Sheath Block in Pediatric Patients Undergoing Single-Incision Laparoscopic Hernia Repair: A Sequential Allocation Dose-Finding Study

Local Anesthetic Systemic Toxicity

Pediatric ultrasound-guided dorsal penile nerve block and sedation in spontaneous breathing: a prospective observational study

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