TXNIP knockdown protects rats against bupivacaine-induced spinal neurotoxicity via the inhibition of oxidative stress and apoptosis.

Bupivacaine (BUP) is an anesthetic commonly used in clinical practice that when used for spinal anesthesia, might exert neurotoxic effects. Thioredoxin-interacting protein (TXNIP) is a member of the α-arrestin protein superfamily that binds covalently to thioredoxin (TRX) to inhibit its function, leading to increased oxidative stress and activation of apoptosis. The role of TXNIP in BUP-induced oxidative stress and apoptosis remains to be elucidated. In this context, the present study aimed to explore the effects of TXNIP knockdown on BUP-induced oxidative stress and apoptosis in the spinal cord of rats and in PC12 cells through the transfection of adeno-associated virus-TXNIP short hairpin RNA (AAV-TXNIP shRNA) and siRNA-TXNIP, respectively. In vivo, a rat model of spinal neurotoxicity was established by intrathecally injecting rats with BUP. The BUP + TXNIP shRNA and the BUP + Control shRNA groups of rats were injected with an AAV carrying the TXNIP shRNA and the Control shRNA, respectively, into the subarachnoid space four weeks prior to BUP treatment. The Basso, Beattie & Bresnahan (BBB) locomotor rating score, % MPE of TFL, H&E staining, and Nissl staining analyses were conducted. In vitro, 0.8 mM BUP was determined by CCK-8 assay to establish a cytotoxicity model in PC12 cells. Transfection with siRNA-TXNIP was carried out to suppress TXNIP expression prior to exposing PC12 cells to BUP. The results revealed that BUP effectively induced neurological behavioral dysfunction and neuronal damage and death in the spinal cord of the rats. Similarly, BUP triggered cytotoxicity and apoptosis in PC12 cells. In addition, treated with BUP both in vitro and in vivo exhibited upregulated TXNIP expression and increased oxidative stress and apoptosis. Interestingly, TXNIP knockdown in the spinal cord of rats through transfection of AAV-TXNIP shRNA exerted a protective effect against BUP-induced spinal neurotoxicity by ameliorating behavioral and histological outcomes and promoting the survival of spinal cord neurons. Similarly, transfection with siRNA-TXNIP mitigated BUP-induced cytotoxicity in PC12 cells. In addition, TXNIP knockdown mitigated the upregulation of ROS, MDA, Bax, and cleaved caspase-3 and restored the downregulation of GSH, SOD, CAT, GPX4, and Bcl2 induced upon BUP exposure. These findings suggested that TXNIP knockdown protected against BUP-induced spinal neurotoxicity by suppressing oxidative stress and apoptosis. In summary, TXNIP could be a central signaling hub that positively regulates oxidative stress and apoptosis during neuronal damage, which renders TXNIP a promising target for treatment strategies against BUP-induced spinal neurotoxicity.

Local anesthetic dosing and toxicity of adult truncal catheters: a narrative review of published practice.

BACKGROUND/IMPORTANCE: Anesthesiologists frequently use truncal catheters for postoperative pain control but with limited characterization of dosing and toxicity. OBJECTIVE: We reviewed the published literature to characterize local anesthetic dosing and toxicity of paravertebral and transversus abdominis plane catheters in adults. EVIDENCE REVIEW: We searched the literature for bupivacaine or ropivacaine infusions in the paravertebral or transversus abdominis space in humans dosed for 24 hours. We evaluated bolus dosing, infusion dosing and cumulative 24-hour dosing in adults. We also identified cases of local anesthetic systemic toxicity and toxic blood levels. FINDINGS: Following screening, we extracted data from 121 and 108 papers for ropivacaine and bupivacaine respectively with a total of 6802 patients. For ropivacaine and bupivacaine, respectively, bolus dose was 1.4 mg/kg (95% CI 0.4 to 3.0, n=2978) and 1.0 mg/kg (95% CI 0.18 to 2.1, n=2724); infusion dose was 0.26 mg/kg/hour (95% CI 0.06 to 0.63, n=3579) and 0.2 mg/kg/hour (95% CI 0.06 to 0.5, n=3199); 24-hour dose was 7.75 mg/kg (95% CI 2.1 to 15.7, n=3579) and 6.0 mg/kg (95% CI 2.1 to 13.6, n=3223). Twenty-four hour doses exceeded the package insert recommended upper limit in 28% (range: 17%-40% based on maximum and minimum patient weights) of ropivacaine infusions and 51% (range: 45%-71%) of bupivacaine infusions. Toxicity occurred in 30 patients and was associated with high 24-hour dose, bilateral catheters, cardiac surgery, cytochrome P-450 inhibitors and hypoalbuminemia. CONCLUSION: Practitioners frequently administer ropivacaine and bupivacaine above the package insert limits, at doses associated with toxicity. Patient safety would benefit from more specific recommendations to limit excessive dose and risk of toxicity.

Local Anesthetic Systemic Toxicity During Transversus Abdominis Plane Block With Liposomal Bupivacaine.

Local anesthetic systemic toxicity (LAST) is a rare but potentially fatal outcome associated with local anesthetic administration. Liposomal bupivacaine (LB; EXPAREL®) is a widely used local anesthetic with extended-release and liposomal formulation that carries an improved cardiac and central nervous system safety profile. However, there is limited data regarding LAST associated with liposomal bupivacaine. Here is described a case of local anesthetic systemic toxicity in a 68-year-old male who presented with obstructing sigmoid adenocarcinoma and underwent open sigmoidectomy with end descending colostomy. The operation was complicated by LAST following transversus abdominis plane block injection with liposomal bupivacaine resulting in cardiac arrest. Return of spontaneous circulation was achieved following advanced cardiac life support and infusion of 20% I.V. fat emulsion. Given the widespread use of local anesthetics, providers must be aware of the pathophysiology, diagnosis, and immediate treatment of LAST.

Protocol for a randomized controlled trial of endoscopic ultrasound guided celiac plexus neurolysis (EUS-CPN) with vs without bupivacaine.

BACKGROUND: Pancreatic cancer is a devastating disease with less than 5% 5-year survival. Inoperable patients often present with pain. Randomized controlled trial have shown that endoscopic ultrasound-guided celiac plexus neurolysis (EUS-CPN) improves pain control. It is usually performed by injecting bupivacaine followed by absolute alcohol around the celiac axis. STUDY DESIGN: Single center, randomized, double blind controlled trial of EUS-CPN with and without bupivacaine in patients with inoperable malignancy (pancreatic or other) involving the celiac plexus. The study was approved by research ethics board with approval number of 2022-9969, 21.151 and registered on ClinicalTrials.gov (NCT04951804). DISCUSSION: We hypothesize that bupivacaine is superfluous and may actually reduce pain control by diluting the neurolytic effect of alcohol. Bupivacaine is also potentially dangerous in that it may produce serious adverse events such as arrythmias and cardiac arrest if inadvertently injected intravascularly. CONCLUSION: This randomized trial is designed to assess whether bupivacaine is of any value during EUS-CPN.

Local anaesthetic systemic toxicity complicating intraoperative intercostal nerve blocks: What do clinicians need to know to prevent similar occurrence?

Local anaesthetic systemic toxicity is a life-threatening adverse event that may occur after administration of local anaesthetics through a variety of routes. Local anaesthetic systemic toxicity is always a potential complication and may occur with all local anaesthetics and in any route of administration. Local anaesthetic systemic toxicity primarily affects the central nervous system and the cardiovascular system and may be fatal. The following is a case of local anaesthetic systemic toxicity complicating surgeon-performed intraoperative intercostal nerve blocks at multiple levels, with a mixture of liposomal bupivacaine and bupivacaine hydrochloride in a patient who underwent video-assisted segmental lung resection for lung cancer under general anaesthesia. Local anaesthetic systemic toxicity presented with seizures and hypotension. The patient was successfully managed and fully recovered. This case illustrates the importance of awareness regarding the prevention, diagnosis and treatment of local anaesthetic systemic toxicity among medical professionals who administer local anaesthetics.

Pericapsular nerve group block in hip arthroplasty: A prospective randomized trial.

OBJECTIVES: This study aimed to evaluate the analgesic effect of the ultrasound-guided pericapsular nerve group (PENG) block in hip arthroplasty (HA) surgery. DESIGN: A prospective double-blinded, randomized study. SETTING: Tertiary institutional clinical care. PARTICIPANTS: Fifty patients, more than 50 years old of both genders, were chosen according to the American Society of Anesthesiologists classification, with physical status I-III, and scheduled for unilateral HA surgeries. INTERVENTIONS: Patients were randomized to receive either a sham PENG block with 20 mL of normal saline (control group) or a PENG block with 20 mL of bupivacaine 0.25 percent (PENG group). MAIN OUTCOME MEASURES: From the onset of the first request for rescue opioid analgesia, preoperative pain scores before and after block (at rest and with a raised straight leg), the incidence of quadriceps weakness after the block, intraoperative fentanyl consumption, post-operative pain scores, and morphine consumption, besides the presence and frequency of adverse events, were recorded. RESULTS: The patients undergoing PENG block with bupivacaine had prolonged durations before the first analgesic request, lower perioperative pain scores, less intraoperative rescue fentanyl, and less post-operative morphine consumption than the control group, with nonsignificant motor weakness after the block and similar adverse events. CONCLUSIONS: The PENG block provided effective perioperative analgesia for HA with prolonged duration of analgesia, nonsignificant motor effects, reduced perioperative opioids consumption, and no major side effects.

Retrospective evaluation of the effects of traditional interscalene block alone versus combined with superior truncus block-associated diaphragm paralysis during arthroscopic shoulder surgery.

OBJECTIVES: The aim of this study was to investigate the effects of traditional interscalene block (ISB) alone and ISB combined with superior truncus block (STB)-associated diaphragm paralysis evaluated by ultrasound, duration of analgesia, and rate of complication in patients undergoing arthroscopic shoulder surgery. PATIENTS AND METHODS: Between January 2020 and December 2022, a total of 285 patients (158 males, 127 females; mean age: 48.0±15.1 years; range, 18 to 80 years) who underwent arthroscopic shoulder surgery under ISB, either alone or combined with STB, were retrospectively analyzed. The patients were operated under ISB alone using 30 mL 0.5% bupivacaine (n=140) or ISB using 10 mL (n=67) or 5 mL 0.5% bupivacaine (n=78) combined with STB using 20 mL 0.5% bupivacaine. Ultrasound reports of all patients' diaphragm function were also retrieved. Duration of analgesia, need for additional analgesics, and the type of analgesic drugs, and evaluations of patient and surgeon satisfactions were evaluated. Degree of diaphragm paralysis considered as complete (≥75%), partial (25.1 to 74.9%) and no paralysis (≤25%) were evaluated for comparison between the block types. RESULTS: The patients underwent operation due to rotator cuff rupture (n=218) or Bankart (n=67). Duration of analgesia, need for additional analgesia, and the type of analgesic drugs used were comparable between the block types. The most common complication was Horner syndrome (n=96, 33.68%) which was significantly lower in ISB (5 mL) +STB (20 mL) than the others (17.9% vs. 41.4% and 37.3%, p=0.002). The ISB (5 mL bupivacaine 0.5%) + STB (20 mL bupivacaine 0.5%) resulted in less complete diaphragm paralysis with adequate surgical anesthesia not requiring general anesthesia. CONCLUSION: The ISB using 5 mL of 0.5% bupivacaine + STB instead of traditional ISB alone can be preferred due to the low rate of complete hemi-diaphragm paralysis with adequate surgical anesthesia/analgesia and high patient and surgeon satisfaction.

Postoperative injectable opioid use and incidence of surgical site complications after use of liposomal bupivacaine in canine gastrointestinal foreign body surgery.

OBJECTIVE: To compare postoperative analgesic use and postoperative complications between dogs that received liposomal bupivacaine (LB) during surgical gastrointestinal foreign body (GIFB) removal and those that did not. STUDY DESIGN: Retrospective study. ANIMALS: Two hundred five dogs. METHODS: Medical records for all dogs with GIFB removal at the Purdue University Veterinary Hospital between May 2017 and August 2021 were searched. Incomplete records and dogs with less than 2 weeks' veterinary follow up were excluded. Data collected included: patient information, time until surgery, intraoperative findings, surgical data (including perforation at time of surgery, linear vs. solid, enterotomy vs. enterectomy), use of LB (including time and manner of administration), time to extubation after surgery, in-hospital postoperative analgesic use and duration, and postoperative complications. Fentanyl was noted as used/not used, quantified as mean hourly rate over 12 h intervals. All analyses were performed using commercial statistical software with p < .05 as the significance level. RESULTS: Dogs that received LB were heavier (n = 65, median 28.5 kg) than those that did not (n = 140, median 24.4 kg) (p = .005). Postoperative fentanyl use (p < .05 between 13 and 72 h) and hourly rates (p < .05 between 13 and 48 h) were less, and postoperative time in the intensive care unit (ICU) (p < .001) and hospital were shorter (p < .001) in dogs receiving LB. Postoperative wound complications were seen in 7/65 dogs (10.8%, 95% CI = 4.4-21.0%) with LB and 4/140 (2.9%, 95% CI = 0.8-7.2%) without LB (p = .039). CONCLUSION: Use of LB was associated with reduced postoperative analgesic use, and shortened ICU and hospital stay but also with wound complications. CLINICAL SIGNIFICANCE: Caution should be used when using LB in (clean) contaminated surgeries.

The use of liposomal bupivacaine in fracture surgery: a review.

Historically, opioids have played a major role in the treatment of postoperative pain in orthopedic surgery. A multitude of adverse events have been associated with opioid use and alternative approaches to pain relief are being investigated, with particular focus on multimodal pain management regimens. Liposomal bupivacaine (EXPAREL) is a component of some multimodal regimens. This formulation of bupivacaine encapsulates the local anesthetic into a multivesicular liposome to theoretically deliver a consistent amount of drug for up to 72 hours. Although the use of liposomal bupivacaine has been studied in many areas of orthopedics, there is little evidence evaluating its use in patients with fractures. This systematic review of the available data identified a total of eight studies evaluating the use of liposomal bupivacaine in patients with fractures. Overall, these studies demonstrated mixed results. Three studies found no difference in postoperative pain scores on postoperative days 1-4, while two studies found significantly lower pain scores on the day of surgery. Three of the studies evaluated the quantity of narcotic consumption postoperatively and failed to find a significant difference between control groups and groups treated with liposomal bupivacaine. Further, significant variability in comparison groups and study designs made interpretation of the available data difficult. Given this lack of clear evidence, there is a need for prospective, randomized clinical trials focused on fully evaluating the use of liposomal bupivacaine in fracture patients. At present, clinicians should maintain a healthy skepticism and rely on their own interpretation of the available data before widely implementing the use of liposomal bupivacaine.

Comparison of fentanyl and nalbuphine as adjuvants to intrathecal 0.5% bupivacaine in lower limb surgeries: A randomised double-blind prospective study.

INTRODUCTION: Local anaesthetics used in spinal anaesthesia have a limited duration of action. To prolong postoperative analgesia, adjuvants, mainly opioids, are used. As µ agonist drugs have side effects, other receptor agonists are considered. Nalbuphine is a safe and effective kappa agonist adjuvant. AIM: To compare the analgesic efficacy between fentanyl and nalbuphine adjuvants added to 3 mL of 0.5% intrathecal hyperbaric bupivacaine. MATERIALS AND METHODS: This prospective, double-blind, comparative study was conducted in 60 patients of either sex belonging to the American Society of Anesthesiologists classes I and II aged 18-65 years undergoing lower limb surgery with entropy monitoring, randomly allocated into two groups. Group F (n = 30) received 0.5% hyperbaric bupivacaine (3 mL) + 25 µg (0.5 mL) fentanyl. Group N (n = 30) received 0.5% hyperbaric bupivacaine (3 ml) + 0.8 mg (0.5 mL) nalbuphine intrathecally. Hemodynamics, entropy, motor and sensory block characteristics, and complications were noted. RESULTS: The nalbuphine group had a significantly longer two-segment regression time of sensory blockade and extended analgesia duration than the fentanyl group. Haemodynamics, entropy, time for onset of sensory and motor blockade and adverse effects were comparable in both groups. CONCLUSION: Nalbuphine prolongs sensory blockade and postoperative analgesia duration with minimal side effects and is a safe intrathecal adjuvant.

TRANSCARUNCULAR DOUBLE INJECTION TECHNIQUE FOR PERIBULBAR ANESTHESIA IN VITREORETINAL SURGERY.

PURPOSE: Local anesthesia is commonly adopted in vitreoretinal surgery to reach painless and akinesia surgical condition. Currently, peribulbar anesthesia (PBA) and subtenon injection (STN) are the most widely used methods. We propose a transcaruncular double injection peribulbar technique (TRS) and aim to compare it with both standard PBA and STN injections. METHODS: A total of 105 patients underwent TRS, PBA, or STN. A numerical rating scale was used to assess preoperative, postoperative, and intraoperative pain. Best akinesia score and onset and duration of akinesia were evaluated by two independent graders. The need for supplementary injection was also registered. RESULTS: TRS group was characterized by a lower intraoperative numerical rating scale variation and absolute numerical rating scale score both at the beginning of surgery ( P 0.046), after 30 minutes ( P 0.032), and at the end of surgery ( P 0.002) compared with the other groups. The TRS group also showed better akinesia score ( P 0.004), fastest onset ( P 0.002), and longer duration ( P 0.042) compared with both PBA and STN. No injection-related complications were reported in the three groups. CONCLUSION: The newly proposed transcaruncular PBA provided superior pain control and akinesia level with no additional adverse events.

Electroacupuncture alleviates multifidus muscle injury by modulating mitochondrial function and Ca2+ uptake.

Multifidus muscles maintain the stability of the lumbar spine and play a crucial role in the pathogenesis of nonspecific lower back pain. Previous studies have shown that electroacupuncture (EA) can relieve the symptoms of low back pain and reduce injury to the lumbar multifidus muscles. In this study, a rat model of lumbar multifidus muscle injury was established by 0.05% bupivacaine injection and subsequently treated with EA at bilateral "Weizhong" (BL40) acupoints. Disruption of the function and structure of multifidus muscles, increased cytosolic Ca2+ in multifidus myocytes, and reduced mitochondrial fission and ATP production were observed in the model group. Additionally, increased expression of the mitochondrial calcium uniporter (MCU) promoted mitochondrial reuptake of Ca2+ , reversing the excessive increase in cytoplasmic Ca2+ . However, the excessive increase in MCU not only aggravated the increased cytoplasmic Ca2+ but also decreased the expression of the mitochondrial division proteins dynamin-related protein 1 (Drp1) and mitochondrial fission factor (MFF). EA inhibited the overexpression of MCU, promoted mitochondrial reuptake of Ca2+ , and reversed cytosolic Ca2+ overload. Furthermore, EA regulated the expression of the mitochondrial fission proteins Drp1 and MFF and promoted the production of ATP, helping the recovery of mitochondrial function after multifidus injury. Therefore, EA can protect against bupivacaine-induced mitochondrial dysfunction, possibly by attenuating MCU overexpression in the inner mitochondrial membrane and reducing Ca2+ overloading in muscle cells, thereby protecting mitochondrial function and maintaining the normal energy demand of muscle cells.

Opioid-Sparing Effects of the Bupivacaine Pleural Catheter in Surgical Decompression of the Thoracic Outlet.

BACKGROUND: Rib resection in thoracic outlet decompression can result in significant postoperative pain requiring high levels of opioid medications. We evaluated the impact of a bupivacaine infusing pleural catheter on postoperative pain and opioid usage in patients undergoing rib resection for thoracic outlet syndrome. We hypothesized that delivery of local anesthetic via the pleural catheter would improve postoperative pain control compared to standard multimodal analgesia, and that the use of the catheter would decrease opioid use during the index hospitalization and prescriptions for opioid pain medications at discharge. METHODS: We conducted a single-center retrospective cohort study of 26 patients who underwent rib resection for thoracic outlet decompression. Primary outcome was opioid consumption during the index hospitalization, measured in morphine milligram equivalents (MME). Secondary outcomes were MME prescribed at discharge and pain scores during the index hospitalization before and after the pleural drain and pleural catheter were removed. RESULTS: Patients in the bupivacaine infusion pleural catheter group (n = 11) had significantly lower MME usage during the index hospitalization (22.5 [1.9, 65.6] vs. 119.8 [76.5, 167.4]), and significantly lower MME prescribed at discharge (0 [0, 37.5] vs. 225 [183, 315]), compared to standard multimodal analgesia in controls (n = 15). Only 3 patients in the bupivacaine pleural catheter group were discharged with any opioid prescriptions (27%), compared to 14 patients in the control group (93%). There was no difference in postoperative pain scores between groups before or after removal of the pleural drain, which was placed in all cases (P = 0.31 and P = 0.76, respectively). CONCLUSIONS: Intraoperative placement of a bupivacaine infusion pleural catheter significantly reduced opioid use during the index hospitalization and opioid prescribing at discharge. Anesthetic infusion pleural catheters should be the treatment modality of choice for postoperative pain management in patients undergoing thoracic outlet decompression.

The Effects of the Use of Diluted Bupivacaine in Sequential Combined Spinal and Epidural Anesthesia for Cesarean Delivery on Maternal Hypotension and Motor Block after Surgery: A Retrospective Observational Study.

BACKGROUND: Maternal hypotension is a common hemodynamic consequence of spinal anesthesia during cesarean delivery, but low-dose spinal anesthesia (<9 mg bupivacaine) ensures stable hemodynamics and reduces motor block. The purpose of this retrospective observational study was to examine the effects of baricity of intrathecal administration of diluted bupivacaine in combined spinal-epidural anesthesia (CSEA) for cesarean delivery on maternal hypotension and motor block after surgery. METHODS: The anesthesia and nursing records of 35 patients who had given birth by cesarean delivery under CSEA with intrathecal administration of plain or hyperbaric bupivacaine diluted in cerebrospinal fluid were reviewed. All patients were assigned to who received hyperbaric bupivacaine (hyperbaric group) or plain bupivacaine (plain group). Definition of feasibility of cesarean delivery by diluted low dose bupivacaine was set as no requirement of epidural administration of levobupivacaine during surgery. The incidences of hypotension (nadir blood pressure less than 80% of preanesthetic value) and motor block were reviewed. RESULTS: In 24 of the patients (68%), no additional epidural anesthesia was needed during surgery. One patient (3%) required additional epidural anesthesia before delivery. Feasibility of cesarean delivery was not different between hyperbaric group and plain group (p>0.99). Eighteen of the patients (51%) did not require vasopressors, while 17 (49%) developed hypotension. There was no difference in incidence of maternal hypotension between hyperbaric and plain group. Only 6 patients (17%) required more than 3 times of administration of vasopressors among all patients. Modified Bromage scale scores were recorded in 28 of the patients (80%); scores of 0 (no motor block) were recorded in seven of them, and 1 in eight of them. CONCLUSION: Low-dose either plain or hyperbaric bupivacaine diluted in cerebrospinal fluid to approximately twice the volume may provide sufficient analgesia, fast motor recovery. Incidence of maternal hypotension was similar in hyperbaric and plain group.

Local infiltration of HYR-PB21, a sustained-release formulation of bupivacaine, provides analgesia and reduces opioid requirement after haemorrhoidectomy: a randomised controlled trial.

BACKGROUND: HYR-PB21 is a new sustained-release formulation of bupivacaine indicated for controlling postoperative pain. The objectives of this study were to investigate the analgesic efficacy and safety profile of HYR-PB21 in patients after haemorrhoidectomy. METHODS: This was a multicentre, randomised, double-blind, positive-controlled trial. Patients were assigned randomly to receive a single dose of HYR-PB21 (150 mg or 300 mg) or bupivacaine HCl (75 mg) after surgery for prolapsing haemorrhoids. Postoperative pain was evaluated using a numeric rating scale at rest to calculate a cumulative pain score. Total rescue opioid usage and the proportion of subjects receiving rescue opioid were also assessed. RESULTS: We enrolled 72 patients with haemorrhoidectomy, and 71 patients completed the study. The average cumulative pain score through 72 h after surgery in the 300 mg HYR-PB21 group (87 scores) was lower than in the bupivacaine HCl group (166 scores) in an intention-to-treat analysis (P<0.001). There was a dose-response effect in reducing total opioid usage and the proportion of rescue opioid use between the 150 mg and 300 mg HYR-PB21 groups, with bupivacaine HCl as a reference group. The HYR-PB21 groups did not show more adverse effects than the bupivacaine HCl group. CONCLUSIONS: Local infiltration of a single dose of HYR-PB21 sustained-release bupivacaine had better efficacy in controlling postoperative pain, with similar adverse effects, compared with a single dose of bupivacaine HCl in patients after haemorrhoidectomy. CLINICAL TRIAL REGISTRATION: ChiCTR2000041318 (Chinese Clinical Trial Registry).

Troubleshooting obstetric spinal anaesthesia at district hospital level.

Obstetric spinal anaesthesia is routinely used in South African district hospitals for caesarean sections, providing better maternal and neonatal outcomes than general anaesthesia in appropriate patients. However, practitioners providing anaesthesia in this context are usually generalists who practise anaesthesia infrequently and may be unfamiliar with dealing with complications of spinal anaesthesia or with conversion from spinal to general anaesthesia. This is compounded by challenges with infrastructure, shortages of equipment and sundries and a lack of context-sensitive guidelines and support from specialised anaesthetic services for district hospitals. This continuous professional development (CPD) article aims to provide guidance with respect to several key areas related to obstetric spinal anaesthesia, and to address common concerns and queries. We stress that good clinical practice is essential to avoid predictable, common complications, and hence a thorough preoperative preparation is essential. We further discuss clinical indications for preoperative blood testing, spinal needle choice, the use of isobaric bupivacaine, spinal hypotension, failed or partial spinal block and pain during the caesarean section. Where possible, relevant local and international guidelines are referenced for further reading and guidance, and a link to a presentation of this topic is provided.

[Systemic toxicity secondary to local anesthetic infiltration]. / Toxicidad sistémica secundaria a infiltración con anestésico local.

INTRODUCTION: Local anaesthetics (LA) are drugs that are widely used in anaesthetic procedures because of their favourable risk/benefit profile compared to general anaesthetics. Yet, these drugs also have some adverse effects. CASE REPORT: We report the case of a 44-year-old man with no neurological history who presented systemic toxicity due to LA after instillation of intrathecal bupivacaine for hip arthroplasty surgery. CONCLUSIONS: Systemic toxicity caused by LA can give rise to neurological symptoms that may or may not be associated with haemodynamic instability. Neurological symptoms usually occur early on and should alert to the possible occurrence of further life-threatening haemodynamic events. Being aware of the existence of these toxicities and their clinical management is essential to improve the evolution and prognosis of this potentially fatal condition.

TITLE: Toxicidad sistémica secundaria a infiltración con anestésico local.Introducción. Los anestésicos locales (AL) son fármacos ampliamente utilizados para procedimientos anestésicos por su perfil riesgo/beneficio favorable respecto a los anestésicos generales. No obstante, estos fármacos no están exentos de efectos adversos. Caso clínico. Hombre de 44 años sin antecedentes neurológicos que presenta un cuadro de toxicidad sistémica por AL tras la instilación de bupivacaína intratecal para ser intervenido de artroplastia de cadera. Conclusiones. Los cuadros de toxicidad sistémica por AL pueden producir sintomatología neurológica asociada o no a inestabilidad hemodinámica. Habitualmente, los síntomas neurológicos ocurren de forma precoz y deben alertar sobre la posible ocurrencia de eventos hemodinámicos ulteriores que pueden comprometer la vida del paciente. Conocer la existencia y el manejo clínico de estos cuadros de toxicidad resulta fundamental para mejorar la evolución y el pronóstico de este cuadro potencialmente mortal.

Effects of general anesthesia with and without thoracic epidural block on length of stay after open spine surgery: a single-blinded randomized controlled trial.

BACKGROUND CONTEXT: Length of hospital stay (LOS) is an important concern in all types of surgery, and the enhanced recovery after surgery (ERAS) protocol has been developed to improve perioperative management and outcomes, which require multidisciplinary management. In terms of pain control, intraoperative regional anesthesia and postoperative opioid-sparing analgesia are recommended. For open spine surgery, we aimed to combine thoracic epidural analgesia to reduce pain and opioid-related side effects, thereby hastening recovery. PURPOSE: This study aimed to compare the length of hospital stay after open complete laminectomy with fusion between general anesthesia and combined general anesthesia involving a single thoracic epidural injection. DESIGN: A randomized single-blinded controlled study. PATIENT SAMPLE: Thirty-eight patients scheduled for elective open laminectomy with fusion between I and III levels were selected. OUTCOME MEASURES: LOS, postoperative pain, patient-controlled morphine consumption at 24 hours, patient satisfaction score, and other opioid-related side effects were recorded. METHODS: Patients were randomly selected to receive standard general anesthesia (GA) or GA combined with a single-shot thoracic epidural at T11-T12 or T12-L1, a block with 10 mL of 0.25% bupivacaine, and 4 mg of morphine. RESULTS: There were no significant differences in the demographic variables between groups. LOS was significantly lower in the combined epidural and/or GA than in the control group (3.78±0.81 [mean±standard deviation] and 4.79±1.51 days, respectively; p=.017). Numeric rating score (at rest) at the post-anesthesia care unit, 24 hours postoperative morphine consumption (mg), operating time, and blood loss were significantly lower in the epidural group. Patients who received combined epidural and/or GA were more likely to report higher patient satisfaction (p=.008). However, the incidence of intraoperative hypotension was significantly higher in the epidural group (72.2% vs. 21.1%, p=.003). The incidences of adverse events and surgical field rating scores did not differ between the 2 patient groups. CONCLUSIONS: Combined lower thoracic epidural and/or GA in patients undergoing elective lumbar spine surgery was associated with decreased LOS.

SABER-Bupivacaine Reduces Postoperative Pain and Opioid Consumption After Arthroscopic Subacromial Decompression: A Randomized, Placebo-Controlled Trial.

INTRODUCTION: Shoulder arthroscopy can result in substantial postoperative pain. Sucrose acetate isobutyrate extended-release bupivacaine (SABER-Bupivacaine; trade name Posimir) is a novel depot formulation of bupivacaine designed to provide analgesia at the surgical site for up to 72 hours. The objective of this study was to evaluate the effect of SABER-Bupivacaine on pain and opioid consumption after arthroscopic subacromial decompression and to assess short-term and long-term safety. METHODS: In this double-blind, placebo-controlled trial, 78 subjects were randomized in a 2:1 ratio to SABER-Bupivacaine 5 mL or SABER-placebo 5 mL injected into the subacromial space just before skin closure. Twenty-nine additional subjects were randomized on an exploratory basis to bupivacaine hydrochloride 20 mL, also injected subacromially. Subjects rated pain intensity on a 0 to 10 scale over the first 3 postoperative days and received intravenous or oral morphine for breakthrough pain. The coprimary efficacy end points were pain intensity on 90° shoulder flexion and cumulative morphine intake from 0 to 72 hours after surgery. The time to first use of opioid rescue analgesia was a secondary end point. RESULTS: The mean (SD) pain intensity was 5.16 (1.94) for SABER-Bupivacaine and 6.43 (1.77) for placebo (P = 0.012). The median consumption of intravenous morphine equivalents was 4.0 mg for SABER-Bupivacaine and 12.0 mg for placebo (P = 0.010). The median time to first use of morphine rescue was 12.4 hours for SABER-Bupivacaine and 1.2 hours for placebo (P = 0.014). The corresponding values for bupivacaine hydrochloride were 5.16 (2.38), 8.0 mg, and 1.4 hours. The incidence and severity of treatment-emergent adverse events were similar for all treatment groups, and no functional or radiographic differences were noted at the 6-month follow-up. DISCUSSION: Compared with placebo, SABER-Bupivacaine reduced pain and opioid analgesic consumption over 72 hours after arthroscopic subacromial decompression and prolonged the time to first use of opioid rescue analgesia. No safety signals were noted during the immediate postoperative period or at 6-month follow-up.

Dexmedetomidine versus tramadol as adjuvant to bupivacaine in intra-articular injection after knee arthroscopy: A prospective control randomized trial.

STUDY OBJECTIVE: Evaluating the time to the first request of rescue analgesic after adding either dexmedetomidine or tramadol to intraarticular bupivacaine. DESIGN: A prospective, randomized, control, double-blinded study. SETTING: Operating room at Tanta University Hospital. PATIENTS: Sixty adult patients were enrolled and scheduled for knee arthroscopic surgery. INTERVENTIONS: Post-operative intra-articular injection of dexmedetomidine 1 µg/kg or tramadol 100 mg compared with a control group receiving intra-articular bupivacaine alone. MAIN OUTCOME: The time to the first request of rescue analgesic, total consumption of analgesic, and post-operative numeric rating scale at 1, 3, 6, 9, 12, and 24 hours post-operatively. RESULTS: The time to the first request of analgesia was comparable between group D and group T with p value 0.84, but it was significantly shorter in group T and group D in comparison with group C, with p value 0.001 for both. Post-operative 24 hours morphine consumption was also comparable between group D and group T with p value 0.17, but it was significantly lower in group T and group D in comparison with group C, with p value 0.001 for both. There was also no significant difference in numeric rating scale between dexmedetomidine group and tramadol group over the 24 hours of the study, but numeric rating scale values were significantly higher in the control group. The incidence of nausea and vomiting was comparable among the three groups. All patients displayed a stable hemodynamic profile. CONCLUSIONS: Adding either dexmedetomidine or tramadol as a single dose to intra-articular bupivacaine resulted in the prolongation of the time to the first request of analgesic and reduced the incidence of post-operative pain and post-operative morphine requirement, when compared with the groups receiving intra-articular bupivacaine alone.