Study of Peri-Articular Anaesthetic for Replacement of the Knee (SPAARK): study protocol for a patient-blinded, randomised controlled superiority trial of liposomal bupivacaine.

BACKGROUND: Optimising the management of peri-operative pain and recovery following knee replacement has been identified as a patient priority. Current pain relief strategies use opiate-based analgesia; however, up to 50% of patients experience significant side effects. Local anaesthetic incisional infiltration is one alternative. The length of the duration of action is a major limiting factor of current local anaesthetic techniques. Liposomal bupivacaine has been reported to be effective for up to 72 h. This randomised controlled trial will evaluate the clinical and cost effectiveness of liposomal bupivacaine. METHODS: SPAARK is a patient-blinded, multi-centre, active comparator, superiority, two-arm, parallel-group randomised controlled trial. Five hundred patients undergoing knee replacement will be recruited and randomised to liposomal bupivacaine plus bupivacaine hydrochloride or bupivacaine hydrochloride alone. The co-primary outcomes are the Quality of Recovery 40 measured at 72 h post-surgery and also cumulative pain measured daily using a 0-10 visual analogue scale for the first 3 days following surgery. Secondary outcomes include cumulative opioid consumption, fitness for discharge, functional outcomes assessed using the Oxford Knee Score and American Knee Society Score, the EuroQol five dimensions instrument and complications. A cost utility analysis is also planned. DISCUSSION: The clinical effectiveness and cost effectiveness of liposomal bupivacaine have yet to be evaluated in the National Health Service, making this trial appropriate and timely. TRIAL REGISTRATION: ISRCTN registry, ISRCTN54191675. Registered on 14 November 2017.

Liposomal bupivacaine mixture has similar pain relief and significantly fewer complications at less cost compared with indwelling interscalene catheter in total elbow arthroplasty.

BACKGROUND: Postoperative pain control, short-term and long-term narcotic consumption, complication rates, and costs of indwelling interscalene catheter (ISC) were compared with a liposomal bupivacaine (LBC) mixture in patients undergoing primary total elbow arthroplasty. METHODS: Forty-four consecutive patients were identified, the first 28 with an ISC and the later 16 with intraoperative LBC injection that also included ketorolac and 0.5% bupivacaine. Medical records were reviewed for visual analog scale scores for pain, oral morphine equivalent (OME) use, complications, and facility charges. RESULTS: Average visual analog scale scores at 24 hours, 2 weeks, 6 weeks, and 12 weeks were not significantly different. Mean OME use was significantly greater in the LBC group at 24 hours but less at 12 weeks, although this difference was not statistically significant. Twelve anesthetic-related complications occurred in the ISC group (1 major and 11 minor); 10 patients (36%) had at least 1 complication. The major complication was respiratory failure requiring emergent tracheostomy. Minor complications included leaking pump/catheters, catheters inadvertently pulled out early, global hand paresthesias, forearm paresthesias, and pain at the catheter site. There were no anesthetic-related complications in the LBC group. The average charge for the LBC mixture was $327.10; charges for ISC, including equipment and anesthesia fees, were $1472.42. CONCLUSIONS: An LBC mixture provides similar pain relief with fewer complications at a lower cost than indwelling ISC after total elbow arthroplasty. Although the OME use in the LBC group was almost double that of the ISC group at 24 hours, there was no difference at later time points.

Total spinal block after local anesthetic administration through the wrong access port of a spinal infusion pump. / Bloqueo espinal total tras administración de anestésico local por el puerto de acceso equivocado de una bomba de infusión intratecal.

We present a case reported on the SENSAR database. A patient with a spinal infusion pump was admitted for reservoir refill. On administration of 22ml of 0.75% bupivacaine the patient suffered a total spinal block with widespread loss strength and respiratory arrest. The patient required emergency orotracheal intubation, mechanical ventilation and admission to ICU, where extubation was achieved within two hours without incidences. At a later stage it was stated that the local anaesthetic had been administered via the access port for bolus or contrast administration instead of via the access to the reservoir. Analysis of the incident showed up latent factors related to absence lack of personnel training and internal protocols. The following measures were taken: pain unit meeting, alert sent to SENSAR bulletin and training request for members of the service.

[Use of 2 % hyperbaric prilocaine for spinal anesthesia : sensitivity analysis in outpatient surgery]. / Einsatz von 2 %igem hyperbarem Prilocain zur Spinalanästhesie : Sensitivitätsanalyse in der ambulanten Chirurgie.

BACKGROUND: Hyperbaric prilocaine 2 % has been available for spinal anesthesia in Germany for 2 years and is characterized by a short duration of action, a lack of postspinal urine retention and a reduction of transient neurological syndromes. However, desirable pharmacological properties are contrasted by higher pharmacological costs compared to hyperbaric bupivacaine 0.5 %. MATERIALS AND METHODS: This paper deals with a sensitivity analysis for the use of hyperbaric prilocaine 2 % versus hyperbaric bupivacaine 0.5 % in Germany and investigates the financial break-even point up to which time a shorter patient stay in the recovery area compensates for the higher costs for the use of prilocaine 2 % for ambulatory spinal aaesthesia. A sensitivity analysis is an instrument of investment appraisal. It is a model to reduce a complex system with numerous variables to a straightforward calculation by assuming a framework requirement and systematically changing only one or two variables. In this paper additional costs for spinal anesthesia have been neglected, only the time a nurse spends with the patient in the recovery area and the costs for each vial of drug have been taken into account. RESULTS: For the assumption of 75 min time until leaving the recovery area and being discharged after spinal anesthesia with hyperbaric prilocaine 2 % versus 150 min (recovery of motor competence) or 405 min (voiding) with hyperbaric bupivacaine 0.5 % the calculation shows a cost benefit for hyperbaric prilocaine 2 % of EUR 11.64 or EUR 64.76 compared to hyperbaric bupivacaine 0.5 % and EUR 13.32 or EUR 66.44 compared to isobaric bupivacaine 0.5 %. Under the assumption that all patients who have received spinal anesthesia with hyperbaric bupivacaine 0.5 % can be discharged from the recovery area after 150 min, the use of hyperbaric prilocaine 2 % remains more economical as long as the patient is discharged from the recovery area within 130 min. If 405 min recovery time is assumed for hyperbaric bupivacaine 0.5 % the costs compared with hyperbaric prilocaine 2 % will be compensated after 300 min. To be more economical compared to patients with hyperbaric prilocaine 2 % those who received hyperbaric bupivacaine 0.5 % must be discharged from the recovery area within at least 100 min. However, a time of less than 160 min for discharge from the recovery area is not published anywhere in the literature. In summary, the use of hyperbaric prilocaine 2 % for 60 min operation time is cheaper than the use of bupivacaine 0.5 % as long as patients do not stay in the recovery area for longer than 120 min and are discharged from the recovery area. CONCLUSIONS: For German framework conditions the use of hyperbaric prilocaine 2 % can provide an economical advantage compared to the use of hyperbaric bupivacaine 0.5 % if staff assignment can be flexible.

Subarachnoid bupivacaine and pethidine for caesarean section: assessment of quality of perioperative analgesia and side effects.

AIMS AND OBJECTIVES: This study determined the quality of perioperative analgesia and side effect profile of spinal bupivacaine plus pethidine for caesarean section. PATIENTS AND METHODS: Patients were randomised to receive 2.0mL of bupivacaine + pethidine 7.5mg or 2.0mL bupivacaine + saline of equal volume. Spinal anaesthesia was instituted at L2/3, L3/4 or L4/5 using a 25G pencil point spinal needle. Heart rate, blood pressure and oxygen saturation were monitored. Timelines such as time of injection of study medication, skin incision, delivery time, termination of surgery and time to first request for analgesia as well as complications were noted. Demographic characteristics were also recorded. RESULTS: 50 patients were studied in 2 groups and the demographic characteristics were similar. Addition of pethidine resulted in block height greater than T6 and longer duration of analgesia (256.9 ± 112.2 min.) compared with the saline group (160.5 ± 65.0 min; p = 0.0005). Maternal hypotension occurred more in the pethidine group (10/25 vs 2/25; p = 0.01). Peritoneal irritation and inadequate anaesthesia were more frequent in the saline group. Nausea and vomiting and drowsiness were mild and occurred only in the pethidine group. In the Post Anaesthetic Care Unit (PACU), more patients reported pain in the saline group (p = 0.002). CONCLUSION: Bupivacaine with pethidine 7.5mg resulted in better quality of anaesthesia, longer postoperative analgesia with acceptable side effect profile. This will be of value in the management of post-caesarean section pain particularly in the resource poor setting.

Spinal anesthesia in infant rats: development of a model and assessment of neurologic outcomes.

BACKGROUND: Previous studies in infant rats and case-control studies of human infants undergoing surgery have raised concerns about potential neurodevelopmental toxicities of general anesthesia. Spinal anesthesia is an alternative to general anesthesia for some infant surgeries. To test for potential toxicity, a spinal anesthesia model in infant rats was developed. METHODS: Rats of postnatal ages 7, 14, and 21 days were assigned to no treatment, 1% isoflurane for either 1 h or 6 h, or lumbar spinal injection of saline or bupivacaine at doses of 3.75 mg/kg (low dose) or 7.5 mg/kg (high dose). Subgroups of animals underwent neurobehavioral testing and blood gas analysis. Brain and lumbar spinal cord sections were examined for apoptosis using cleaved caspase-3 immunostaining. The lumbar spinal cord was examined histologically.Rats exposed to spinal or general anesthesia as infants underwent Rotarod testing of motor performance as adults. Data were analyzed using ANOVA with general linear models, Friedman tests, and Mann-Whitney U tests, as appropriate. RESULTS: Bupivacaine 3.75 mg/kg was effective for spinal anesthesia in all age groups. Impairments in sensory and motor function recovered in 40-60 min. Blood gases were similar among groups. Brain and spinal cord apoptosis increased in rats receiving 6 h of 1% isoflurane, but not among the other treatments. All groups showed intact motor performance at adulthood. CONCLUSIONS: Spinal anesthesia is technically feasible in infant rats and appears benign in terms of neuroapoptotic and neuromotor sequelae.

Focused review: ropivacaine versus bupivacaine for epidural labor analgesia.

Neuraxial analgesia is frequently administered to women in labor. For many years, bupivacaine has been used because of its long duration of action, lack of excessive motor block, and minimal fetal and neonatal effects. However, bupivacaine is one of the most cardiotoxic local anesthetics in current use and motor block is still a problem. Many local anesthetics such as bupivacaine exist in 2 forms, levorotatory and dextrorotatory. Ropivacaine, an amide local anesthetic produced in the pure levorotatory form addresses some of the concerns related to bupivacaine. In this article, we present the literature comparing ropivacaine and bupivacaine to determine whether there is an advantage to using one of these local anesthetics for labor analgesia. We found that there is no advantage to the routine use of ropivacaine for labor analgesia.

An economic evaluation of bupivacaine plus fentanyl versus ropivacaine alone for patient-controlled epidural analgesia after total-knee replacement procedure: a double-blinded randomized study.

BACKGROUND AND OBJECTIVES: Total-knee replacement (TKR) surgery is one of the most painful orthopedic procedures after surgery. Opioid has been commonly combined with a local anesthetic to improve the quality of pain relief, but the treatment has opioid-related side effects. This study compared the cost effectiveness of patient-controlled epidural analgesia (PCEA) with 0.0625% bupivacaine plus fentanyl (BF) 3 microg/mL versus 0.15% ropivacaine alone (R) during the first 48 hours after TKR procedure. METHODS: This prospective randomized double-blinded study was performed on 70 patients who underwent unilateral TKR procedure and received either BF or R after surgery. Visual analog scale (VAS) pain score at rest and upon movement, side effects, and cost of treatment were compared. RESULTS: Overall pain at rest and upon movement between groups was not significantly different (P = 0.58, 95% CI = 4.4 to -7.8 and P = 0.8, 95% CI = 6.4 to -8.2, respectively). Patients in the BF group experienced more pruritus and had more vomiting episodes than those in the R group (P = .015), whereas no difference occurred in other side effects. Nevertheless, patient satisfaction with pain management was higher in the BF group compared with that in the R group. In addition, pain treatment with bupivacaine and fentanyl was 18% less costly compared with ropivacaine alone. CONCLUSIONS: Considering the economic evaluation, we conclude that PCEA with 0.0625% bupivacaine plus fentanyl 3 microg/mL is more cost effective and provides more patient satisfaction than PCEA with ropivacaine alone. However, use of epidural ropivacaine alone causes fewer opioid-related side effects, particularly pruritus and vomiting.

Las lecciones derivadas del ASA Closed Claims Project (ASACCP). Proyecto de la ASA acerca de las razones que promovieron demandas contra anestesiólogos cuyos casos estuviesen ya archivados: 4a. parte. Anestesia Regional. Análisis de las demandas sobre casos/hechos asociados con la anestesia regional en la sala de operaciones / Lessons learned fron the ASA Closed Claims Project (ASACCP). Project about the reasons for which claims against anesthesiologists were renewed in cases that had already been closed: part. 4. Regional Anesthesia. Analysis of claims concerning regional anesthesia in the OR

Cuando se comparan las consecuencias de los accidentes anestésicos reclamados que constan en la base de datos del ASA CCP (Closed Claims Project), es significativo señalar que hubo un alto porcentaje de lesiones temporarias o no incapacitantes en los casos de anestesia regional (64 por ciento vs 46 por ciento p<0,05). Entre las lesiones incapacitantes permanentes derivadas de injurias del sistema nervioso periférico se hallan manifestaciones como la paraplejía y la cuadriplejía. Catorce de las reclamaciones legales asociadas con la paraplejía se debieron a síndromes de la anestesia espinal anterior. Los daños neurológicos permanentes fueron la causa más común de los daños incapacitantes, el más frecuente de los cuales (23 por ciento) fue asociado a bloqueos nerviosos para anestesia ocular (13 retrobulbares, 3 peribulbares) en los que hubo pérdida de la visión del ojo afectado. De todas maneras, se debe señalar que las complicaciones neurológicas como manifestaciones secundarias a la utilización de anestésicos locales para anestesia regional son muy poco frecuentes (0,02 y 0,07 por ciento de los casos), aunque es bastante común observar la aparición de manifestaciones neurológicas transitorias (entre 0,01 y 0,8 por ciento). La parestesia y el dolor durante la inyección son señales peligrosas ya que anuncian la posibilidad de la complicación. Se han descripto también abscesos peridurales y meningitis, en especial cuando se realizan bloqueos centrales con catéteres de pequeño diámetro a fin de alcanzar analgesia central para el dolor crónico. En la base de datos de la Mutual de Médicos Anestesiólogos de Buenos Aires están registradas las demandas realizadas contra anestesiólogos y los casos en los cuales los médicos, enfrentados a un incidente crítico, notifican la situación en previsión de una eventual demanda. Al igual que en el estudio de la ASACCP, desconocemos el número total de anestesia realizadas por los colegas adheridos. Hasta el 2004 hubo 339 notificaciones que incluyen 74 demandas, 24 causas penales y 50 causas civiles; 124 casos correspondieron a la anestesia regional, mientras que 215 formaron el grupo de pacientes que recibieron anestesia general. En 8 de los pacientes que presentaron radiculopatías se realizó una anestesia subaracnoidea con bupivacaína al 0,5 por ciento en solución hiperbara, habiéndose inyectado 15 mg (3 ml) de la solución anestésica...

Las lecciones derivadas del ASA Closed Claims Project (ASACCP). Proyecto de la ASA acerca de las razones que promovieron demandas contra anestesiólogos cuyos casos estaban ya archivados (2a parte): La paciente obstétrica. Una actualización / Lessons learned from the ASA Closed Claims Project (ASACCP). ASA Project about the reasons for wich claims against anesthesiologists were rewed in cases that had already been close (part 2): The obstetric patient. An update

El análisis de los últimos casos relacionados con el tema fue publicado en el año 1996 cuando en la base de la ASACCP constaban 3533 demandas terminadas. De éstas, 434 estuvieron relacionadas con la anestesia obstétrica. De las 434 demandas relacionadas con la anestesia obstétrica, 310 correspondieron a la operación cesárea y 124 al parto por vía vaginal con anestesia regional. Las muertes maternas (n=83) y el daño cerebral del recién nacido (n=82) continúan siendo las injurias más frecuentes en las pacientes obtétricas. La muerte materna estuvo más comúnmente relacionada con la anestesia general y con la operación cesárea. A pesar de que el número de muertes maternas consecutivas a la anestesia general se mantuvo estable a través de los años, el número de muertes asociadas a la anestesia regional declinó en forma marcada. Este decremento de muertes maternas bajo anestesia regional ocurrió sobre todo en los años 80, coincidiendo con la prohibición del uso de bupivacaína al 0,75 por ciento. Además, esta declinación se debe, sin duda, a la solución de los problemas creados por la vía aérea, la cual es más difícil de acceder en la mujer embarazada (1:270 en la paciente obstétrica, contra 1:2.230 de la no obstétrica). La necesidad de controlar la vía aérea es crucial para reducir los casos de muerte durante anestesia general. Lo mismo sucede con la anestesia regional cuando la altura del bloqueo es muy elevada o por cualquier otra razón que obligue a convertir una anestesia regional en una general. Siempre existe el temido problema de la aspiración de contenido gástrico, que sigue siendo la primera causa de muerte materna durante la anestesia y casi siempre asociada con una intubación dificultosa o fallida. El daño cerebral del recién nacido se produjo en el 19 por ciento de las demandas estudiadas por la ASACCP. En una Unidad de Cuidados Intensivo de recién nacidos en EE.UU se realizó un estudio retrospectivo, como los estudios de la ASACCP, para analizar el número de demandas relacionadas con los casos internados en dicha unidad. El estudio comprendió el período 1972-1992 durante el cual se produjeron 31 demandas por mala praxis sobre 9367 internaciones, con una incidencia de 0,33 por ciento. Según los autores, la frecuencia de juicios contra los anestesiólogos por problemas vinculados con el recién nacido se incrementó del 0,19 por ciento entre los años 1772-1974 al 0,39 entre 1980 y 1992...

New local anesthetics. Are they worth the cost?

Epidural analgesia that uses dilute concentrations of bupivacaine with fentanyl or sufentanil provides excellent analgesia, good sensory-motor discrimination, and minimal toxicity and is inexpensive. The new local anesthetic agents, ropivacaine and levobupivacaine, offer potential improvements in the risk of toxicity when administered in large doses but probably no important clinical difference when used in dilute concentrations for labor analgesia. After accounting for the potency difference, ropivacaine offers little or no motor-sparing advantage over bupivacaine. Currently, epidural anesthesia with concentrated bupivacaine is rarely used for cesarean section, so there is little indication for the newer anesthetic agents in this setting either. The authors believe that large difference in cost cannot be justified on the basis of currently available data.

[Use of ropivacaine for peridural postoperative analgesia]. / Utilisation de la ropivacaïne par voie péridurale pour l'analgésie postopératoire.

OBJECTIVES: To describe pharmacology and toxicology of ropivacaine. To assess the clinical efficacy of ropivacaine when used for postoperative epidural analgesia and to provide recommendations for clinical practice. DATA SOURCES: Search in the Medline data base of original articles in French and English published since 1995, using the following key words: ropivacaine, postoperative analgesia, epidural, caudal block. STUDY SELECTION: Prospective randomised studies in adults and children were selected. Letters to editors and editorials were excluded. DATA EXTRACTION: Articles have been analyzed: to determine the dose of ropivacaine required for postoperative epidural analgesia, to assess the benefits of combination of epidural ropivacaine and additives (opioids or other), to compare epidural ropivacaine and bupivacaine and to assess the use of ropivacaine via caudal route for paediatric postoperative analgesia. DATA SYNTHESIS: 20 mg h-1 of ropivacaine is required to provide effective analgesia. This dose produces a motor block in a significant number of patients. Combination with an opioid allows for a reduction in ropivacaine requirement and subsequently in the incidence of motor blockade. In adults, equipotency ratio of ropivacaine and bupivacaine varies between 1.5/1 and 1/1 depending upon the concentration used. At equipotent doses, early postoperative mobilisation is facilitated with ropivacaine. In case of paediatric caudal analgesia, this ratio is close to 1. CONCLUSIONS: Epidural ropivacaine combined with opioid provide good postoperative pain relief. Reduction in the incidence of motor blockade and safe toxicological profile make this local anaesthetic a suitable alternative of bupivacaine for postoperative epidural analgesia.

Uso comparativo de bupivacaína vs. ropivacaína peridural asociados a fentanilo en cesárea / Comparative study between epidural bupivacaine and ropivacaine with fentanyl in caesarean section

Introducción: La ropivacaína, un nuevo anestésico local, presenta menos toxicidad sistémica y bloqueo motor que la bupivacaína en dosis equipotente, con similar calidad anestésica y analgésica y sin aumentar la toxicidad con el embarazo. Esto lo convierte en un fármaco apropiado para la anestesia peridural en cesárea. Objetivo: los objetivos de este estudio comparativo con bupivacaína 5 mg/ml fueron evaluar eficacia, seguridad y tolerabilidad materna, fetal y neonatal, incluyendo farmacoeconomía cuando usamos ropivacaína 7,5 mg/ml asociados a fentanilo, para anestesia epidural en cesárea electiva. Lugar: Servicio de Anestesiología, Hospital Universitario de Córdoba, Córdoba, Argentina. Diseño: estudio prospectivo, abierto, a doble ciego y randomizado. Población: ciento veinte pacientes entre 15 y 45 años, ASA I-II, para cesárea electiva, divididos en dos grupos: sesenta en cada uno. Método: los pacientes recibieron 18 ml de bupivacaína (5 mg/ml) o ropivacaína (7,5 mg/ml), más 100 µg de fentanilo por vía epidural utilizando aguja metálica Tuohy n§ 18. Monitoreo: signos vitales maternos, monitoreo automático no invasivo de presión arterial, pulsioximetría, cardioscopía y latidos cardíacos fetales. Resultados: El tiempo de latencia fue menor con ropivacaína y la relajación muscular fue superior según la evaluación de los cirujanos. Los efectos adversos más frecuentes en ambos grupos fueron hipotensión, naúseas y escalofríos/temblores. Todos fueron de pequeña a moderada magnitud y respondieron al tratamiento etiológico correspondiente. En el grupo de ropivacaína fue mayor la incidencia de hipotensión arterial (18,3 por ciento), bradicardia (3,3 por ciento) y prurito (0,6 por ciento) siendo sólo estadísticamente significativo el primero (p<0,05). Es destacable la mejoría en la saturación de O2 postbloqueo en ambos grupos (p<0,05). No se observaron signos de toxicidad sistémica. Los anestésicos fueron bien tolerados por el feto y el neonato en ambos grupos, evaluados por los latidos cardíacos fetales, el test de Apgar y la clínica neonatológica, observándose una puntuación significativamente mayor en el test de Apgar en el grupo ropivacaína. Conclusiones: la ropivacaína es un anestésico local bien tolerado con una eficacia superior al de la bupivacaína cuando se la usa asociada a fentanilo. Por ende, puede ser una opción preferida debido al reducido potencial cardio y neurotóxico, por no aumentar su toxicidad en el embarazo..

Cardiac and CNS toxicity of levobupivacaine: strengths of evidence for advantage over bupivacaine.

Bupivacaine is currently the most widely used long-acting local anaesthetic. Its uses include surgery and obstetrics; however, it has been associated with potentially fatal cardiotoxicity, particularly when given intravascularly by accident. Levobupivacaine, a single enantiomer of bupivacaine, has recently been introduced as a new long-acting local anaesthetic with a potentially reduced toxicity compared with bupivacaine. Numerous preclinical and clinical studies have compared levobupivacaine with bupivacaine and in most but not all studies there is evidence that levobupivacaine is less toxic. Advantages for levobupivacaine are seen on cardiac sodium and potassium channels, on isolated animal hearts and in whole animals, anaesthetised or awake. In particular the intravascular dose of levobupivacaine required to cause lethality in animals is consistently higher compared with bupivacaine. In awake sheep, for example, almost 78% more levobupivacaine was required to cause death. In contrast, in anaesthetised dogs no differences were seen in the incidence of spontaneous or electrical stimulation- induced ventricular tachycardia and fibrillations among animals exposed to levobupivacaine or bupivacaine. The reversibility of levobupivacaine-induced cardiotoxicity has also been assessed. Some data point to an advantage of levobupivacaine over bupivacaine but this potential advantage was not confirmed in a recent study in anaesthetised dogs. Three clinical studies have been conducted using surrogate markers of both cardiac and CNS toxicity. In these studies levobupivacaine or bupivacaine were given by intravascular injection to healthy volunteers. Levobupivacaine was found to cause smaller changes in indices of cardiac contractility and the QTc interval of the electrocardiogram and also to have less depressant effect on the electroencephalogram. Assuming that levobupivacaine has the same local anaesthetic potency as bupivacaine, then, all things being equal, it is difficult to argue that levobupivacaine should not displace bupivacaine as the long-acting local anaesthetic of choice. It would appear, however, that levobupivacaine has not yet significantly displaced bupivacaine from the markets in which it is sold. This may be due to a lack of perceived safety benefit and/or consideration of the additional costs that are associated with switching to levobupivacaine, which is approximately 57% more expensive than bupivacaine. If the price of levobupivacaine were closer to bupivacaine then the argument to switch to levobupivacaine would undoubtedly be much stronger. With the continued clinical use of levobupivacaine the database available to make comparisons will increase and this may allow cost-benefit arguments to be made more forcefully for levobupivacaine in the future.

Intracameral anesthesia: a report by the American Academy of Ophthalmology.

OBJECTIVE: This document describes the technique of intracameral anesthesia and examines the available evidence to address questions about its effectiveness, possible corneal endothelial and retinal toxicity, and the optimal and maximal dose. METHODS: A literature search conducted for the years 1968 to 2000 retrieved over 180 citations that matched the search criteria. Panel members and a methodologist reviewed this information, and it was evaluated for the quality of the evidence presented. RESULTS: Some studies report effectiveness of intracameral anesthesia while others report no effect. In those studies showing an effect, levels of pain in the groups that were compared were low. Short-term studies seem to indicate that preservative (methylparaben)-free lidocaine 1% is well tolerated by the corneal endothelium but that higher concentrations of lidocaine are toxic. There is some evidence of electroretinogram changes after exposure to lidocaine or bupivacaine. CONCLUSIONS: The ideal timing and placement of intracameral anesthesia has not been determined. Because topical anesthesia alone is effective, surgeons may elect to use intracameral anesthesia for incremental pain control in patients who cannot be adequately managed with topical alone. Appropriate patient selection is important when using this method of anesthesia. While short-term studies seem to indicate safety, long-term effects are unknown. Patient preferences for anesthesia are not well studied.

Postoperative epidural analgesia with bupivacaine and fentanyl: hourly pain assessment in 348 paediatric cases.

BACKGROUND: The objective of this prospective study was the evaluation of the analgesia provided by an epidural infusion of bupivacaine and fentanyl after different types of surgery in children. METHODS: Data were collected from 348 epidural analgesia in 87 children below 2 years of age, in 80 children between 2 and 6 years and 181 above 6 years of age, for a median duration of 43 postoperative hours. Bupivacaine (mean concentration 0.185%) and fentanyl (5 microg.kg-1.day-1) were administered on the surgical ward. RESULTS: Pain control was considered excellent in 86% of the 11 072 pain hourly assessments. Analgesia was found to be better for children older than 2 years, and the overall quality of their night's sleep was better than that of older children. Higher pain scores were noted for Nissen fundoplication surgery and club foot repairs. Early discontinuation rarely occurred, and only because of technical problems with the epidural catheter (4%) or insufficient analgesia (6%). Complications were minor (nausea/vomiting 14%, pruritus 0.6%, urinary retention 17%) and easily reversed. CONCLUSIONS: This combination of bupivacaine-fentanyl provides safe analgesia after major surgery in children with frequent clinical monitoring. Regular pain assessments of intensity and duration are useful to improve the quality of postoperative analgesia.

Postoperative extradural infusions in children: preliminary data from a comparison of bupivacaine/diamorphine with plain ropivacaine.

To try to decrease the incidence of side-effects associated with postoperative extradural infusions of local anaesthetics in combination with opioids, we have used plain ropivacaine solutions in 200 children. The first 72 children received an infusion of bupivacaine 0.125% + diamorphine 20 microg x ml-1, then 200 children received plain ropivacaine solutions. The children who received ropivacaine were found to have lower incidences of nausea, pruritus, urinary retention, and were less sedated, despite comparable analgesia. The management of plain ropivacaine for extradural analgesia is discussed.