Cost-effectiveness of Transforaminal epidural steroid injections for patients with ACUTE sciatica: a randomized controlled trial.

BACKGROUND: Transforaminal epidural injections with steroids (TESI) are increasingly being used in patients sciatica. The STAR (steroids against radiculopathy)-trial aimed to evaluate the (cost-) effectiveness of TESI in patients with acute sciatica (< 8 weeks). This article contains the economic evaluation of the STAR-trial. METHODS: Participants were randomized to one of three study arms: Usual Care (UC), that is oral pain medication with or without physiotherapy, n = 45); intervention group 1: UC and transforaminal epidural steroid injection (TESI) 1 ml of 0.5% Levobupivacaine and 1 ml of 40 mg/ml Methylprednisolone and intervention group 2: UC and transforaminal epidural injection (TEI) with 1 ml of 0,5% Levobupivacaine and 1 ml of 0.9% NaCl (n = 50). The primary effect measure was health-related quality of life. Secondary outcomes were pain, functioning, and recovery. Costs were measured from a societal perspective, meaning that all costs were included, irrespective of who paid or benefited. Missing data were imputed using multiple imputation, and bootstrapping was used to estimate statistical uncertainty. RESULTS: None of the between-group differences in effects were statistically significant for any of the outcomes (QALY, back pain, leg pain, functioning, and global perceived effect) at the 26-weeks follow-up. The adjusted mean difference in total societal costs was €1718 (95% confidence interval [CI]: - 3020 to 6052) for comparison 1 (intervention group 1 versus usual care), €1640 (95%CI: - 3354 to 6106) for comparison 2 (intervention group 1 versus intervention group 2), and €770 (95%CI: - 3758 to 5702) for comparison 3 (intervention group 2 versus usual care). Except for the intervention costs, none of the aggregate and disaggregate cost differences were statistically significant. The maximum probability of all interventions being cost-effective compared to the control was low (< 0.7) for all effect measures. CONCLUSION: These results suggest that adding TESI (or TEI) to usual care is not cost-effective compared to usual care in patients with acute sciatica (< 8 weeks) from a societal perspective in a Dutch healthcare setting. TRIAL REGISTRATION: Dutch National trial register: NTR4457 (March, 6th, 2014).

Extrapleural infusion of levobupivacaine versus levobupivacaine-sufentanil-adrenaline after video-assisted thoracoscopic surgery (VATS): A randomised controlled trial.

BACKGROUND: Peripheral blocks are increasingly used for analgesia after video-assisted thoracic surgery (VATS). We hypothesised that addition of sufentanil and adrenaline to levobupivacaine would improve the analgesic effect of a continuous extrapleural block. METHODS: We randomised 60 patients undergoing VATS to a 5-mL h-1 extrapleural infusion of levobupivacaine at 2.7 mg mL-1 (LB group) or levobupivacaine at 1.25 mg mL-1 , sufentanil at 0.5 µg mL-1 , and adrenaline at 2 µg mL-1 (LBSA group). The primary outcome was the cumulative morphine dose administered as patient-controlled analgesia (PCA-morphine) at 48 and 72 h. The secondary outcomes were pain according to numerical rating scale (NRS) at rest and after two deep breaths twice daily, peak expiratory flow (PEF) daily, quality of recovery (QoR)-15 score at 1 day and 3 weeks postoperatively, serum levobupivacaine concentrations at 1 h after the start and at the end of the intervention, and adverse events. RESULTS: At 48 h, the median cumulative PCA-morphine dose for the LB group was 6 mg (IQR, 2-10 mg) and for the LBSA group 7 mg (IQR, 3-13.5 mg; p = .378). At 72 h, morphine doses were 10 mg (IQR, 3-22 mg) and 12.5 mg (IQR, 4-21 mg; p = .738), respectively. Median NRS score at rest and after two deep breaths was 3 or lower at all time points for both treatment groups. PEF did not differ between groups. Three weeks postoperatively, only the LB group returned to baseline QoR-15 score. The LB group had higher, but well below toxic, levobupivacaine concentrations at 48 and 72 h. The incidence of nausea, dizziness, pruritus and headache was equally low overall. CONCLUSION: For a continuous extrapleural block, and compared to plain levobupivacaine at 13.5 mg h-1 , levobupivacaine at 6.25 mg h-1 with addition of sufentanil and adrenaline did not decrease postoperative morphine consumption. The levobupivacaine serum concentrations after 48 and 72 h of infusion were well below toxic levels, therefore our findings support the use of the maximally recommended dose of levobupivacaine for a 2- to 3-day continuous extrapleural block.

Local Anesthetic Systemic Toxicity Following Inadvertent Intravenous Levobupivacaine Infusion in Infants: A Case Report.

Background and objectives: Local anesthetic systemic toxicity (LAST) in children is extremely rare, occurring at an estimated rate of 0.76 cases per 10,000 procedures. However, among reported cases of LAST in the pediatric population, infants and neonates represent approximately 54% of reported LAST cases. We aim to present and discuss the clinical case of LAST with full clinical recovery due to accidental levobupivacaine intravenous infusion in a healthy 1.5-month-old patient, resulting in cardiac arrest necessitating resuscitation. Case presentation: A 4-kilogram, 1.5-month-old female infant, ASA I, presented to the hospital for elective herniorrhaphy surgery. Combined anesthesia was planned, involving general endotracheal and caudal anesthesia. After anesthesia induction, cardiovascular collapse was noticed, resulting in bradycardia and later cardiac arrest with EMD (Electromechanical Dissociation). It was noticed that during induction, levobupivacaine was accidentally infused intravenously. A local anesthetic was prepared for caudal anesthesia. LET (lipid emulsion therapy) was started immediately. Cardiopulmonary resuscitation was carried out according to the EMD algorithm, which lasted 12 min until spontaneous circulation was confirmed and the patient was transferred to the ICU. In ICU, the girl was extubated the second day, and the third day she was transferred to the regular pediatric unit. Finally, the patient was discharged home after a total of five days of hospitalization with full clinical recovery. A four-week follow-up has revealed that the patient recovered without any neurological or cardiac sequelae. Conclusions: The clinical presentation of LAST in children usually begins with cardiovascular symptoms because pediatric patients are already under general anesthesia when anesthetics are being used, as was the case in our case. Treatment and management of LAST involve cessation of local anesthetic infusion, stabilization of the airway, breathing, and hemodynamics, as well as lipid emulsion therapy. Early recognition of LAST as well as immediate CPR if needed and targeted treatment for LAST can lead to good outcomes.

Effects of an Intrathecal Drug Delivery System Connected to a Subcutaneous Port on Pain, Mood and Quality of Life in End Stage Cancer Patients: An Observational Study.

BACKGROUND: In cancer patients with limited life expectancy, an implant of an intrathecal (IT) drug delivery system connected to a subcutaneous port (IDDS-SP) has been proposed as a successful strategy, but conflicting results are reported on quality of life (QoL). The aim of this prospective observational study is to report the effects on pain, mood and QoL of an IT combination therapy delivered by an IDDS-SP in malignant refractory pain. METHODS: Adult patients in which IT therapy was recommended were recruited. An IT therapy with morphine and levobupivacaine was started: VASPI score, depression and anxiety (evaluated by the Edmonton Symptom Assessment System -ESAS-), the Pittsburgh Sleep Quality Index (PSQI), the 5-level EuroQol 5D version (EQ-5D-5L) and the requirements of breakthrough cancer pain (BTcP) medications were registered, with adverse events rate and the satisfaction of patients scored as Patient Global Impression of Change (PGIC). RESULTS: Fifty patients, (16 F/34 M) were enrolled (age 69 ± 12). All had advanced cancer with metastasis. The median daily VASPI score was 75, the median depression score was 6, and the median anxiety score was 4, median PSQI was 16. At 28 days, a significant reduction in VASPI score was registered as well as in depression and anxiety item. Also, PSQI decreased significantly. The EQ-5D-5 L showed a significant improvement in all components at 14 and 28 days. Patient Global Impression of Change scores showed high level of satisfaction. A low incidence of adverse events and a reduction in BTCP episodes were also registered. CONCLUSION: Intrathecal combination therapy delivered by an IDDS-SP could ensure adequate control of cancer related symptoms, such as pain, depression, anxiety and sleep disturbances. These effects, with low rate of AEs and reduced BTcP episodes, could explain the improvement in QoL and the overall high levels of patients' satisfaction.

The Potential Effect of Lidocaine, Ropivacaine, Levobupivacaine and Morphine on Breast Cancer Pre-Clinical Models: A Systematic Review.

Breast cancer (BC) is one of the most common types of cancer and the second leading cause of death in women. Local anaesthetics (LAs) and opioids have been shown to influence cancer progression and metastasis formation in several pre-clinical studies. However, their effects do not seem to promote consensus. A systematic review was conducted using the databases Medline (via PubMed), Scopus, and Web of Science (2010 to December 2021). Search terms included "lidocaine", "ropivacaine", "levobupivacaine", "morphine", "methadone", "breast cancer", "breast carcinoma" and "breast neoplasms" in diverse combinations. The search yielded a total of 784 abstracts for initial review, 23 of which met the inclusion criteria. Here we summarise recent studies on the effect of analgesics and LAs on BC cell lines and animal models and in combination with other treatment regimens. The results suggest that local anaesthetics have anti-tumorigenic properties, hence their clinical application holds therapeutic potential. Regarding morphine, the findings are conflicting, but this opioid appears to be a tumour-promoting agent. Methadone-related results are scarce. Additional research is clearly required to further study the mechanisms underlying the controversial effects of each analgesic or LA to establish the implications upon the outcome and prognosis of BC patients' treatment.

Chronic post-surgical pain after colon surgery in patients included in an enhanced recovery program.

BACKGROUND: Enhanced recovery after surgery (ERAS) program improves immediate recovery. Beyond immediate benefits, long-term impact of ERAS implementation is not yet evident. This retrospective single-center cohort study investigates prevalence and characteristics of chronic post-surgical pain (CPSP) in patients who underwent colon surgery. METHODS: Two hundred and ninety-seven patients enrolled prospectively in our ERAS database were contacted by mail to question the presence of CPSP. In case of CPSP, intensity, location, and type of pain, impact of pain on quality of life and treatment taken were assessed. Post-operative pain experience during hospital stay, recall of pain, and discomfort duration when back home were assessed in all patients. Comparison between patients with and without CPSP was made to approach the risk factors of CPSP in this population. RESULTS: At 27 months after colon surgery, 25/198 patients reported CPSP (12.6%) and pain was severe in 5 patients (2.5%). CPSP had a deep abdominal component in 56% of patients and a parietal component in 20% of patients. Patients with CPSP+ differed from patients CPSP- for pre-operative pain presence (56% vs 24.8%, P = 0.004), recalled post-operative pain intensity (4 vs 3, P = 0.045), duration of discomfort after discharge (2 vs 1 weeks, P = 0.035). Pre-operative pain was found as a significant CPSP risk factor (odds ratio 1.34; 95% CI: 1.05-1.70). CONCLUSION: CPSP prevalence after laparoscopic colon surgery seems not much affected by ERAS context. Pre-operative presence of pain emerged as an important risk factor. These findings should be confirmed in a prospective multicenter study.

Analgesic Effect of Local Infiltration of the Surgical Wound Containing Levobupivacaine, Ibuprofen, and Epinephrine in Rats Undergoing Laparotomy.

BACKGROUND: Inappropriate use of drugs and their combinations for analgesics has made it difficult to determine the optimal drug combinations for pain mangement. AIM: To reduce postoperative pain effectively and safely. MATERIALS AND METHODS: Laparotomy was performed in an adult rat under isoflurane anesthesia. During surgery, the surgical wounds were infiltrated with 50 µL solution containing 0.3% w/v levobupivacaine, 2 mg/mL ibuprofen, and 8 mg/mL epinephrine (treatment group) over the sutured muscle wound before skin closing, and compared to infiltration of that of the normal saline (vehicle group). The 10-fold higher dose of the same combination of medications was injected systemically as a control. Postoperative pain assessed by rodent grimace scales scoring. One-way ANOVA following Dunnett multiple comparisons test was used at 95% of confidence level. RESULTS: There was decreased pain for the treatment group (p = 0.025, q = 4.527) and the control group (p = 0.031, q = 4.178) only 24 h after the end of the successful infiltration. The rodent GS scale scoring showed the fall in pain was started within three hours post-surgery in the treatment group. There was decreased pain in the treatment group (p = 0.048, q = 3.527) and the control group (p = 0.043, q = 3.891) only as compared to vehicle group 24 h after the end of the successful infiltration. CONCLUSION: The infiltration of the surgical wound with levobupivacaine, ibuprofen, and epinephrine combination was effective in the healing of wounds after laparotomy.

Disposition of levobupivacaine during intraoperative continuous caudal epidural analgesia in a preterm neonate.

BACKGROUND: Continuous caudal epidural analgesia used intraoperatively in children is an effective and safe technique. However, in preterm neonates, developmental factors may significantly affect levobupivacaine disposition, leading to variable pharmacokinetics, pharmacodynamics, and potential large-variable systemic toxicity of local anesthetics. OBJECTIVE: To our knowledge, this is the first case report describing the disposition of levobupivacaine used for intraoperative caudal epidural analgesia in a preterm neonate treated for the postoperative pain profile. METHOD: 4-days old neonate (postmenstrual age 35+5, weight 2140 g) with congenital anal atresia received continuous caudal epidural long-term analgesia (loading dose 1.694 mg/kg, initial infusion 0.34 mg/kg/hour) before correction surgery. The blood samples were obtained at 1.0, 1.5, 6.5, 12, and 36.5 h after the start of epidural infusion. The pharmacokinetic profile of levobupivacaine was determined by using the Stochastic Approximation Expectation Maximization algorithm. COMFORT and NIPS pain scores were used for the assessment of epidural analgesia. RESULTS: The levobupivacaine absorption rate constant, apparent volume of distribution, apparent clearance, and elimination half-life were 10.8 h-1, 0.9 L, 0.086 L/h, and 7.3 h, respectively. CONCLUSION: The results confirm our hypothesis of altered pharmacokinetics in the preterm neonate. Therefore, levobupivacaine therapy in these patients should be carefully monitored. Since therapeutic drug monitoring of levobupivacaine is not established in clinical routines, we suggest monitoring the intraoperative pain profile using validated scores. TRIAL REGISTRATION: EudraCT number: 2020-000595-37.

Effect of Transforaminal Epidural Corticosteroid Injections in Acute Sciatica: A Randomized Controlled Trial.

OBJECTIVE: Transforaminal epidural steroid injections (TESIs) are widely administered for sciatica. The aim of this trial was to evaluate the effectiveness of TESIs in patients with acute sciatica (<8 wk). METHODS: This study was conducted in 2 Dutch hospitals. Participants (n=141) were randomly assigned to (1) usual care and TESI of 1 ml of 40 mg/ml Methylprednisolone plus 1 ml of 0.5% Levobupivacaine (intervention 1); (2) usual care and transforaminal epidural injection with 1 ml of 0.5% Levobupivacaine and 1 ml NaCl 0.9% (intervention 2); (3) usual care consisting of oral pain medication with or without physiotherapy (control). Co-primary outcomes were back pain and leg pain intensity, physical functioning, and recovery measured during 6-month follow-up. RESULTS: There were no statistically significant mean differences in co-primary outcomes between groups during follow-up, except for leg pain when comparing intervention group 1 with control (-0.96 95%CI:-1.83 to -0.09). For secondary outcomes, some statistical significant between-group differences were found for treatment satisfaction and surgery, but only when comparing intervention group 2 to control. Post hoc analyses showed a statistically significant difference in response [50% improvement of leg pain (yes/no)] between intervention 1 and the control group at 3 months and that both intervention groups used less opioids. DISCUSSION: Except for a statistically significant effect of TESI on leg pain for patients with acute sciatica compared with usual care, there were no differences in co-primary outcomes. Nonetheless, transforaminal epidural injections seem to be associated with less opioid use, which warrants further exploration.

Sustained release of levobupivacaine from temperature-sensitive injectable hydrogel for long-term local anesthesia in postoperative pain management.

Postoperative pain is a major concern for most of the surgical patients, and an inadequate postoperative pain control may cause a series of complications. With an effective pain control and lesser side effects, local anesthetics are preferred for use in postoperative pain management. However, the action duration of current local anesthetics is too short to meet the requirements of postoperative analgesia. In this study, an injectable levobupivacaine (LB)-loaded thermo-sensitive hydrogel system based on biodegradable poly(D,L-lactide)-poly(ethylene glycol)-poly(D,L-lactide) (PLEL) was developed for long-acting local anesthetic, in which the soluble charged cation form of LB (LB HCl) was partly alkalified to the poorly soluble base form (LB base). This hybrid LB loaded PLEL system (hLB/PLEL) is a free flowable liquid at room temperature and changes into a semi-solid hydrogel once injection in response to the physiological temperature. Then, the dissolved LB HCl could release firstly from the hydrogel contributing to a quick work, and the insoluble LB base dissolved and released gradually as the decrease of the pH during the biodegradation of PLEL hydrogel, resulting in a long-term LB release in local. The drug release behavior, pharmacokinetic, and biocompatibility of the thermo-sensitive hLB/PLEL were studied in vitro and in vivo. The anesthetic effects of hLB/PLEL system were evaluated in the rat models of sciatic nerve block, subcutaneous infiltration anesthesia and postoperative pain as well. This hLB/PLEL system generated a significantly prolonged analgesic effect in rat models, which produced approximately 7 times longer duration than 0.75% LB HCl and effectively relieved the spontaneous pain for 3 days. In general, the presented hLB/PLEL system can not only achieve a fast-acting but also sustainably release LB to block the nerve and significantly extend the effect of local analgesia, which means a promising candidate for long-acting postoperative pain management.

Gonyautoxins 2/3 Local Periarticular Injection for Pain Management after Total Knee Arthroplasty: A Double-Blind, Randomized Study.

The purpose of this study was to compare the efficacy of periarticular infiltration of gonyautoxin 2/3 (GTX 2/3) and a mixture of levobupivacaine, ketorolac, and epinephrine for pain management after total knee arthroplasty (TKA). Forty-eight patients were randomly allocated to receive periarticular infiltration of 40 µg GTX 2/3 (n = 24) diluted in 30 mL of sodium chloride 0.9% (study group) or a combination of 300 mg of levobupivacaine, 1 mg of epinephrine, and 60 mg ketorolac (n = 24) diluted in 150 mL of sodium chloride 0.9% (control group). Intraoperative anesthetic and surgical techniques were identical for both groups. Postoperatively, all patients received patient-controlled analgesia (morphine bolus of 1 mg; lockout interval of 8 minutes), acetaminophen, and ketoprofen for 72 hours. A blinded investigator recorded morphine consumption, which was the primary outcome. Also, the range of motion (ROM) and static and dynamic pain were assessed at 6, 12, 36, and 60 hours after surgery. The incidence of adverse events, time to readiness for discharge, and length of hospital stay were also recorded. The median of total cumulative morphine consumption was 16 mg (range, 0-62 mg) in the GTX 2/3 group and 9 mg (range, 0-54 mg) in control group, which did not reach statistical difference (median test, p = 0.40). Furthermore, static and dynamic pain scores were similar at all time intervals. GTX 2/3 was inferior in range of motion at 6 and 12 hours; nevertheless, we noted no difference after 36 hours. No differences between groups were found in terms of complications, side effects, or length of hospital stay. No significant differences were found between groups in terms of breakthrough morphine requirement. However, local anesthetic use resulted in an increased ROM in the first 12 hours. This prospective randomized clinical trial shows that GTX 2/3 is a safe and efficient drug for pain control after TKA; nevertheless, more studies using GTX 2/3 with larger populations are needed to confirm the safety profile and efficiency. This is level 1 therapeutic study, randomized, double-blind clinical trial.

Drugs used in regional block analgesia for thyroidectomy: A network meta-analysis of randomized controlled trials.

BACKGROUND: Postoperative pain has become one of the major obstacles to postoperative recovery and can lead to increasing demand for opioids. So far, a wide variety of drugs is used for regional block anesthesia, but which one is the best remains unclear. Thus, this study aims to obtain the best drug for thyroid surgery regional block based on their efficacy and side effects through Bayesian network meta-analysis. METHODS: Systemically searched MEDLINE, CENTRAL, Embase, and web of science on July 3, 2021 to obtain randomized controlled trials (RCTs) focusing on adults who underwent open thyroidectomy and regional blocks, and took opioids requirement, and the postoperative pain level as outcomes. The "Gemtc" package of R-4.1.1 was used for Bayesian network meta-analysis based on extracted data. RESULTS: We retrieved 398 articles, and finally included 31 RCTs, which included a total of 2221 patients. Patients received levobupivacaine had the lowest requirement rate for opioids and lowest pain score at T6 and T12. Non-steroidal anti-inflammatory drugs show significant superiority neither in the opioids requirement nor the pain score. Clonidine has a better potential to act as a qualified anesthetic adjuvant compared to adrenaline. The ranking results of the subgroup analysis were consistent with the integrated analysis. CONCLUSION: Levobupivacaine has a relatively greater advantage in reducing opioids requirement and decreasing the pain score of patients, and bilateral superficial cervical plexus blockade and pre thyroidectomy intervention have more advantages than local wound infiltration and post thyroidectomy intervention in alleviating patients' pain.

Analgesic efficacy of local versus proximal nerve blocks after hallux valgus surgery: a systematic review.

BACKGROUND: Hallux valgus (HV) surgery is an orthopaedic procedure that commonly causes mild to moderate postoperative pain. Effective management of this pain has become an important element of modern hallux valgus surgical treatment. A local anaesthetic (LA) with an antinociceptive effect can control this pain. However, relatively few papers have evaluated this strategy in depth. The objective of the current systematic review was to address this demand by comparing the efficacy of proximal and local blocks in controlling postoperative pain following hallux valgus surgery. MAIN TEXT: Ovid-MEDLINE, Cochrane Central, PubMed, Web of Science (WOS), Scopus, and Embase were searched from their inceptions through December 29, 2021. Observational and clinical trial publications in peer-reviewed English-language journals with a sample size of at least 20 were included. The trials involved adults over 18 who could describe their discomfort and had a bunionectomy. The included studies were evaluated using the Cochrane risk of bias 2 method. Descriptive analysis synthesised the results. Among the 439 articles identified, five studies compromising 459 participants were included. Ankle blocks were superior to control in two studies (P = 0.001, P < 0.001) and superior to local blocks in one study (P < 0.001). Additionally, one study showed that popliteal and ankle blocks administered with lidocaine or levobupivacaine were equivalent (P = 0.123 and P = 0.055, respectively). However, one of these five included studies indicated that ankle blocks were not effective (P = 0.123) in reducing postoperative pain. CONCLUSIONS: The key findings presented herein suggest that regional blocks effectively reduce postoperative pain and that an ankle block has more supportive evidence for its effectiveness. However, an adequate assessment of the effectiveness of various administrative routes was challenging due to the lack of reliable evidence. This needs to be addressed in future studies. TRIAL REGISTRATION: PROSPERO registration: CRD42022307974.

Efficacy of Levobupivacaine Versus Levobupivacaine Plus Dexmedetomidine Infiltration for Post-Tonsillectomy Analgesia: A Randomized Controlled Trial.

Background: The study evaluated the analgesic effects of levobupivacaine infiltration in the tonsil bed, and a combination of levobupivacaine and dexmedetomidine in patients undergoing tonsillectomy. Methods: Ninety children (ages 3 to 7 years) who were scheduled for a tonsillectomy were allocated randomly into two groups. (L Group): peritonsillar infiltration with 0.25% levobupivacaine (2 ml + 0.5 ml saline 0.9% per tonsil). (LD Group): levobupivacaine 0.25% (2 ml) plus dexmedetomidine 1 µg/kg diluted in 1 ml saline 0.9% (0.5 ml in each tonsil), and administered by peritonsillar infiltration (2.5 ml per tonsil) following intubation 3-5 minutes before operation. To avoid bias, infiltrate a total volume of 2.5 ml in each tonsil. The first analgesic request time was the primary outcome, with postoperative pain score, total analgesic consumption, total oral intake, sedation, and side effects as secondary outcomes. Results: The first rescue analgesia time in the LD group was longer (644.31 ± 112.89 min) than in the L group (551.51 ± 146.16 min, P-value <0.001). The number of patients who required >1 analgesic dose in the L group (n = 13) was higher than in the LD group (n = 5). The LD group consumes a lower total dose of IV paracetamol in the first 24 hours postoperatively (321.89 ± 93.25 mg) than the L group (394.89 ± 183.71 mg, P < 0.00-value < 0.050). On the first day postoperatively, patients in the LD group had a higher total oral intake (P < 0.001). Except for a slight increase in laryngospasm in the L group, there were no side effects. Conclusions: The Children's peritonsillar infiltration of levobupivacaine and dexmedetomidine improved postoperative pain after adenotonsillectomy. The topically applied levobupivacaine and dexmedetomidine were concomitant with no systemic effects, greater total oral intake on the first day postoperative, and higher family satisfaction.

Magnesium Sulfate Combined with a Levobupivacaine Periarticular Cocktail for Analgesia in the Early Postoperative Period after Total Knee Arthroplasty.

This study aimed to evaluate the analgesic effect of magnesium sulfate combined with a levobupivacaine periarticular cocktail in the early postoperative period after total knee arthroplasty (TKA). A total of 60 patients who underwent primary unilateral TKA in our department from March 2018 to May 2019 were prospectively selected and randomly divided into the trial group (30 patients with 20 mL of magnesium sulfate 250 mg + levobupivacaine 50 mg + triamcinolone 25 mg + 0.9% normal saline) and the control group (30 patients with 20 mL of levobupivacaine 50 mg + triamcinolone 25 mg + 0.9% normal saline). Visual analog scale (VAS) scores at 6, 12, 24, 48, and 72 hours postoperatively during rest; VAS scores at 12, 24, 48, and 72 hours postoperatively during motion; the time required to reach 30 degrees straight leg elevation and 60 degrees active knee flexion; and the analgesia pump dosage at 6, 12, 24, and 48 hours postoperatively were recorded. Magnesium sulfate combined with levobupivacaine injection around the knee joint can significantly prolong the time of postoperative analgesia, significantly reduce the use of postoperative analgesics, and effectively alleviate early postoperative pain after TKA.

Comparison Between the Effects of Bupivacaine and Levobupivacaine for Spinal Anesthesia on QT Dispersion.

BACKGROUND: Bupivacaine and Levobupivacaine are frequently used local anesthetic drugs in spinal anesthesia practice. Both agents have arrhythmic effects on the heart. However, there is no clear information about which agent is more arrhythmogenic. OBJECTIVE: The aim of this article is to investigate the effects of bupivacaine and its S (-)-enantiomer, levobupivacaine, on cardiac arrhythmias in patients. METHODS: The study included 40 patients scheduled for inguinal hernia surgery. Patients were randomly divided into the following two groups using a sealed envelope method: Group I, the bupivacaine group (n = 20); and Group II, the levobupivacaine group (n = 20). The QT values were taken preoperatively and during the 10th of the spinal block, the 10th of the surgical incision, and the 10th postoperative minute. Additionally, systolic blood pressure (SBP), diastolic blood pressure (DBP), mean arterial pressure (MAP), oxygen saturation (SO2), and heart rate (HR) values, in addition to motor block (Bromage scale) levels and durations, were recorded for each patient. RESULTS: HR values measured at 10 min after spinal block were significantly higher than the baseline values in the levobupivacaine group (p < 0.05). The corrected QT interval (QTc) values increased significantly at 10 minutes after spinal block and at 10 min postoperatively in the bupivacaine group (p < 0.05). QTd and QTcd measurements were taken at the 10th minute of spinal anesthesia, the 10th minute of the incision, and the 10th minute postoperatively. When compared to the levobupivacaine group, a statistically significant increase was found in the bupivacaine group (p < 0.05). CONCLUSION: Levobupivacaine allows greater hemodynamic stability, while bupivacaine affects QTc and QTd measurement times more. As such, we believe that levobupivacaine may be a better alternative to bupivacaine during clinical practice, particularly in patients with cardiac problems.

Comparison of the onset time between 0.375% ropivacaine and 0.25% levobupivacaine for ultrasound-guided infraclavicular brachial plexus block: a randomized-controlled trial.

At centers with pressure on rapid operating room turnover, onset time is one of the important considerations for choosing a local anesthetic drug. To hasten the onset of the block, higher concentrations of local anesthetics are sometimes used. However, the use of diluted local anesthetics may be safer. Therefore, we aimed to compare the onset times of equipotential levobupivacaine and ropivacaine at low concentrations for infraclavicular brachial plexus block. Adult patients undergoing upper extremity surgery under ultrasound-guided infraclavicular brachial plexus block at our center were randomly allocated to the levobupivacaine and ropivacaine groups. Infraclavicular brachial plexus block was induced with 0.25% levobupivacaine or 0.375% ropivacaine depending on the assigned group. The degrees of sensory and motor blockade were assessed for 40 min after the administration of local anesthetics. A total of 46 patients were included in the analysis. Infraclavicular brachial plexus block with 0.25% levobupivacaine and 0.375% ropivacaine provided sufficient surgical anesthesia. The sensory onset time of 0.375% ropivacaine was shorter than that of 0.25% levobupivacaine (group R, 15 [15.0-22.5] min; group L, 30 [17.5-35.0] min, p = 0.001). There were no significant differences in other block characteristics and clinical outcomes between the two groups. Thus, when a quicker block onset is required, 0.375% ropivacaine is a better choice than 0.25% levobupivacaine.Trial registration ClinicalTrials.gov (NCT03679897).

Pain control after laparoscopic cholecystectomy. A prospective study.

AIM: The purpose of this study is to evaluate three different analgesic procedures after laparoscopic cholecystectomy for pain control. MATERIAL OF STUDY: The study involved 183 patients who underwent laparoscopic cholecystectomy with the same technique for the induction and maintenance of the general anesthesia. They were divided into three different postoperative pain treatment groups: continuous infusion of Tramadol and Ketorolac with elastomeric pump, intraperitoneal topical instillation of Levobupivacaine, and intraperitoneal aerosolization of Levobupivacaine. RESULTS: No differences were found in the demographics. shorter operating time was observed in group 1. Eight hours after surgery in groups 2 and 3, there was an increase in pain compared to patients in the first group. The request for postoperative analgesic assistance was lower in groups 1 and 2. DISCUSSION: Various topical and intravenous ways for analgesic actions have been used to improve the pain control after laparoscopic procedures, individually and in comparison between them. The main result of our research is that the use of levobupivacaine employed in the topical intraperitoneal application anesthesia by instillation and nebulization, do not improve the postoperative pain in the first 24 hours after LC, compared with intravenous analgesic elastomeric pump. CONCLUSIONS: Despite the positive data found in the literature, our observations have not shown a better pain control after laparoscopic cholecystectomy with the use of intraperitoneal analgesia compared to intravenous. KEY WORDS: Gallstone disease, Gallbladder bladder, Laparoscopic cholecystectomy, Postoperative pain, Stones.

[Analgesic efficacy of intraperitoneal, incisional, and intraperitoneal + incisional levobupivacaine in laparoscopic gynecological surgery]. / Laparoskopik jinekolojik cerrahide intraperitoneal, insizyonel, intraperitoneal+insizyonel levobupivakainin analjezik etkisi.

OBJECTIVES: We aimed to investigate the analgesic efficacy of intraperitoneal, incisional, and intraperitoneal + incisional levobupivacaine in laparoscopic gynecological surgery. METHODS: Group 1 received levobupivacaine 20 mL intraperitoneally, Group 2 received levobupivacaine 20 mL to the trocar wounds, Group 3 received levobupivacaine 20 mL intraperitoneally and levobupivacaine 20 mL to the trocar wounds. Postoperative abdominal pain at rest and during mobilization and shoulder pain were assessed at the 2nd, 4th,12th, and 24th postoperatively by VAS. If VAS was >3, the analgesia was assessed as inadequate, and diclofenac sodium was injected. In addition, time the first analgesic requirement, total analgesic consumption, analgesic effectiveness, and the satisfaction of patients about the analgesic method were recorded during the postoperative period. RESULTS: No significant difference was found between groups with respect to VAS (p>0.05). Patients in Group 2 had a higher postoperative analgesic consumption and lower timing of the first analgesic requirement than Groups 1 and 3, but these differences were not significant (p>0.05). The satisfaction of the patients about the analgesic technique was similar between the groups. CONCLUSION: The use of levobupivacaine intraperitoneally is an alternative method to reducing of postoperative shoulder and abdominal pain in gynecological laparoscopic surgery. Also, we observed a lower total analgesic consumption and more analgesic effectiveness in intraperitoneal groups than the other. Further studies are needed with different intraperitoneal local anesthetics.