Super-refractory status epilepticus, rhabdomyolysis, central hyperthermia and cardiomyopathy attributable to spinal anesthesia: a case report and review of literature.

BACKGROUND: There are only six past reports of super-refractory status epilepticus induced by spinal anesthesia. None of those patients have died. Only < 15 mg of bupivacaine was administered to all six of them and to our case. Pathophysiology ensuing such cases remains unclear. CASE PRESENTATION: A 27 year old gravida 2, para 1, mother at 37 weeks of gestation came to the operating theater for an elective cesarean section. She had no significant medical history other than controlled hypothyroidism and one episode of food allergy. Her current pregnancy was uneventful. Her American Society of Anesthesiologists (ASA) grade was 2. She underwent spinal anesthesia and adequate anesthesia was achieved. After 5-7 min she developed a progressive myoclonus. After delivery of a healthy baby, she developed generalized tonic clonic seizures that continued despite the induction of general anesthesia. She had rhabdomyolysis, one brief cardiac arrest and resuscitation, followed by stress cardiomyopathy and central hyperthermia. She died on day four. There were no significant macroscopic or histopathological changes in her brain that explain her super refractory status epilepticus. Heavy bupivacaine samples of the same batch used for this patient were analyzed by two specialized laboratories. National Medicines Quality Assurance Laboratory of Sri Lanka reported that samples failed to confirm United States Pharmacopeia (USP) dextrose specifications and passed other tests. Subsequently, Therapeutic Goods Administration of Australia reported that the drug passed all standard USP quality tests applied to it. Nonetheless, they have detected an unidentified impurity in the medicine. CONCLUSIONS: After reviewing relevant literature, we believe that direct neurotoxicity by bupivacaine is the most probable cause of super-refractory status epilepticus. Super-refractory status epilepticus would have led to her other complications and death. We discuss probable patient factors that would have made her susceptible to neurotoxicity. The impurity in the drug detected by one laboratory also would have contributed to her status epilepticus. We propose several possible mechanisms that would have led to status epilepticus and her death. We discuss the factors that shall guide investigators on future such cases. We suggest ways to minimize similar future incidents. This is an idiosyncratic reaction as well.

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.

Injectable and topical local anesthetics for acute dental pain: 2 systematic reviews.

BACKGROUND: Local anesthesia is essential for pain control in dentistry. The authors assessed the comparative effect of local anesthetics on acute dental pain after tooth extraction and in patients with symptomatic irreversible pulpitis. TYPES OF STUDIES REVIEWED: The authors searched MEDLINE, EMBASE, Cochrane Central Register of Controlled Trials, and the US Clinical Trials registry through November 21, 2020. The authors included randomized controlled trials (RCTs) comparing long- vs short-acting injectable anesthetics to reduce pain after tooth extraction (systematic review 1) and evaluated the effect of topical anesthetics in patients with symptomatic pulpitis (systematic review 2). Pairs of reviewers screened articles, abstracted data, and assessed risk of bias using a modified version of the Cochrane risk of bias 2.0 tool. The authors assessed the certainty of the evidence using the Grading of Recommendations Assessment, Development and Evaluation approach. RESULTS: Fourteen RCTs comparing long- vs short-acting local anesthetics suggest that bupivacaine may decrease the use of rescue analgesia and may not result in additional adverse effects (low certainty evidence). Bupivacaine probably reduces the amount of analgesic consumption compared with lidocaine with epinephrine (mean difference, -1.91 doses; 95% CI, -3.35 to -0.46; moderate certainty) and mepivacaine (mean difference, -1.58 doses; 95% CI, -2.21 to -0.95; moderate certainty). Five RCTs suggest that both benzocaine 10% and 20% may increase the number of people experiencing pain reduction compared with placebo when managing acute irreversible pulpitis (low certainty). PRACTICAL IMPLICATIONS: Bupivacaine may be superior to lidocaine with epinephrine and mepivacaine with regard to time to and amount of analgesic consumption. Benzocaine may be superior to placebo in reducing pain for 20 through 30 minutes after application.

Narcotic Utilization After Cleft Lip Repair: Does Local Anesthetic Choice Matter?

To analyze whether the choice of intraoperative local anesthetic for cleft lip repair is associated with the amount of perioperative narcotic utilization.Retrospective cohort study.Hospitals participating in the Pediatric Health Information System.Primary cleft lip repairs performed in the United States from 2010 to 2020.Local anesthesia injected-treatment with lidocaine alone, bupivacaine alone, or treatment with both agents.Perioperative narcotic administration.During the study interval, 8954 patients underwent primary cleft lip repair. Narcotic utilization for unilateral (P < .001) and bilateral (P = .004) cleft lip repair has decreased over the last 5 years. Overall, 21.8% (n = 1950) of infants were administered perioperative narcotics for cleft lip repair, such that 14.3% (n = 1282) required narcotics on POD 0, and 7.2% (n = 647) required narcotics on POD 1.In this study, 36.5% (n = 3269) patients received lidocaine, 22.0% (n = 1966) patients received bupivacaine, and 19.7% (n = 1762) patients received both local anesthetics. Administration of any perioperative narcotic was significantly lower in patients receiving both lidocaine and bupivacaine than those receiving only lidocaine (P = .001, 17.5% vs 21.7%) or only bupivacaine (P < .001, 17.5% vs 22.9%). Narcotic utilization on the day of surgery was significantly lower in patients receiving both lidocaine and bupivacaine than those receiving only lidocaine (P < .001, 11.5% vs 15.1%) or only bupivacaine (P = .004, 11.5% vs 14.6%). Narcotic utilization on the first postoperative day was significantly lower in patients receiving both lidocaine and bupivacaine than those receiving only bupivacaine (P = .009, 5.9% vs 8.1%). CONCLUSIONS: In children undergoing cleft lip repair, local anesthetic combination of lidocaine and bupivacaine is associated with decreased perioperative narcotic use compared to lidocaine or bupivacaine alone.

The Benefits of Local Anesthesia Used in Mastectomy Without Reconstruction.

BACKGROUND: The opioid epidemic has driven renewed interest in local anesthesia to reduce postoperative opioid use. Our objective was to determine if local anesthesia decreased hospital pain scores, oral morphine equivalents (OME), length of stay (LOS), and nausea/vomiting. METHODS: Single institution retrospective study of females who underwent mastectomy without reconstruction. RESULTS: Overall, 712 patients were included; 63 (8.8%) received bupivacaine (B), 512 (72%) liposomal bupivacaine (LB), and 137 (19%) no local. 95% were discharged on POD1. Liposomal bupivacaine use increased from 2014 to 2019. Additional factors associated with use of local regimen were surgeon and extent of axillary surgery. Fewer patients used postop opioids during their hospital stay if any local was used compared to none (76 vs 88%; 0.003). Compared to none, local had shorter mean PACU LOS (95 vs 87 min; P = .02), lower mean intraoperative-OME (96 vs 106; P < .001), and lower mean postoperative OME/hr (1.4 vs 1.8 P = .001). Multivariable analysis (MVA) showed lower OME/hr with LB compared to B and none (P = .002); this translates to 22 mg and 30 mg of oxycodone in a 24-hr period, respectively. MVA showed lower POD1 pain scores with LB relative to none (P = .049). Local did not impact nausea/emesis. CONCLUSION: Local anesthesia was superior to no local in several measures. However, a consistent benefit of a specific local anesthetic agent was not demonstrated (LB vs B). A prospective study is warranted to determine the optimal local regimen for this cohort and further inform clinical relevance.

Effectiveness Of Local Anaesthetic In Reducing Postoperative Pain At Port Site After Laparoscopic Cholecystectomy.

Background: Laparoscopy has become the highest quality level way to deal with cholecystectomy since its inception 30 years preceding, and is perhaps the most normally performed general surgeries. Pain being a significant issue after laparoscopic cholecystectomy bringing about extended admissions or readmissions. With significant varieties in pain relieving conventions an integrated approach is important to diminish pain. The aim of this study is to assess the effectiveness of Bupivacaine as local anesthetic agent at port sites after laparoscopic cholecystectomy. Method: Study population of 84 patients was divided into control group (receiving no local anesthetic) and study group (receiving Bupivacaine as local anesthetic). Visual analogue scale was used to quantify and compare pain perceived by each group; at fixed intervals of 6, 12 and 24 hours after shifting of the patients back to the ward. Results: Each group comprised 42 patients. At 6 hours post operative pain score in study group, 4.5±0.32 was significantly lower than in control group, 7.6±0.41 (p<0.05). Though pain assessments at 12 and 24 hours didn't reveal any significant differences among the two groups; postoperative requirement of Tramadol was significantly (p<0.05) lower in study group (92±0.064mg) in comparison to control group (158±0.21mg). Conclusion: Use of long-acting local anesthetic injections at port sites after laparoscopic cholecystectomy significantly lowers pain during first 6 hours post operatively and also lowers narcotic analgesics requirements during post operative period.

Comparative study to assess the effect of ropivacaine and a mixture of lidocaine and bupivacaine on intraocular pressure after peribulbar anesthesia for cataract surgery.

Purpose: To compare the efficacy of ropivacaine with a mixture of lidocaine and bupivacaine in peribulbar anesthesia for cataract surgery, in terms of post-block intraocular pressure (IOP). Methods: A one-year comparative study was done to compare two anesthetic solutions in peribulbar anesthesia for cataract surgery, from January 2020 to December 2020 at a tertiary health care hospital. Two hundred patients (40-70 years of age) planned for small-incision cataract surgery with posterior chamber intraocular lens (IOL) implantation under peribulbar anesthesia were included in the study. A single-site inferotemporal injection was given till a total eyelid drop was observed. The IOP was measured at four time-points: before block (control), 1-, 5-, and 15-minute post-block with a tonometer. Results: The 1-minute post-block mean IOP in both the groups was higher than the baseline levels. This reflected raised intraorbital pressure secondary to peribulbar injection of local anesthetic. However, the rise in 1-minute post-block IOP was significantly less in the ropivacaine group. The 5- and 15-min post-block mean IOP values in the ropivacaine group were significantly lower than the corresponding values of the lidocaine-bupivacaine group and baseline (control) ropivacaine values. Conclusion: The results of this study support that ropivacaine as a local anesthetic drug for peribulbar block for small-incision cataract surgery can be a suitable alternative to the lidocaine-bupivacaine combination. Studies involving a larger sample size are required to consider ropivacaine as a superior drug to the lidocaine-bupivacaine combination.

The Effect of Commonly Used Local Anesthetic on Bacterial Growth.

INTRODUCTION: Liposomal bupivacaine (LB) has emerged as a superior form of local anesthetic across numerous surgical subspecialties. The purpose of this study is to evaluate the ex-vivo antimicrobial effects of LB in comparison with traditional local anesthetics. METHODS: A standardized inoculum of bacteria commonly associated with surgical site infection was inoculated into a suspension of 1% lidocaine, 0.25% bupivacaine, Exparel (proprietary liposomally packaged 1.3% bupivacaine), and normal saline as a growth control. RESULTS: In all five bacteria tested, the medium inoculated with traditional local anesthetics reduced growth to a greater degree than LB-inoculated plates. Both conventional local anesthetics reduced the growth of all bacteria when compared with the control with the exception of methicillin-susceptible Staphylococcus aureus growth in bupivacaine. LB-inoculated plates had equivalent growth to the control in all plates with the exception of Escherichia coli plates which demonstrated superior growth. CONCLUSIONS: The results of this simple ex-vivo model suggest that the liposomal packaging of bupivacaine may decrease this local anesthetic's innate antibacterial properties.

The Effect of Perianal Tramadol Infiltration on Postoperative Pain Following Hemorrhoidectomy.

INTRODUCTION: The present study was attempted to evaluate the effect of perianal infiltration of tramadol on postoperative pain in patients undergoing hemorrhoidectomy. METHOD: This double-blind clinical trial study was carried out on 90 patients with grade 3 and 4 hemorrhoids undergoing hemorrhoidectomy. Patients were randomly assigned into 3 groups of control or bupivacaine or tramadol. Before the surgery, perianal infiltration of .25% bupivacaine or tramadol or normal saline was prescribed to each group, respectively. Data on pain severity (based on the visual analog scale (VAS), the duration of surgery, sedation score, pain at the first defecation, first request time for additional analgesia, nausea and vomiting, and analgesic intakes) were evaluated and analyzed. RESULTS: Duration of surgery was almost similar in all 3 groups (P = .974). The results showed a significant difference in pain score between 3 groups (P ≤.05) at all times after the surgery. In addition, the means of sedation scores (P = .03), pain score at the first defecation (P = .001), the time to first analgesic request (P = .001), and ketorolac administration times (P = .01) were significantly different between 3 groups. Finally, no complication was reported regarding postoperative nausea and vomiting. CONCLUSION: Given the notable efficacy of tramadol in reducing pain after hemorrhoidectomy and its minor side effects, this medication is suggested as an effective topical anesthetic to decrease pain after hemorrhoidectomy.

Bupivacaine liposome use reduces length of post-anesthesia care unit stay and postoperative narcotic use following robotic inguinal herniorrhaphy.

In the current opioid crisis, multimodal analgesic protocols should be considered to reduce or eliminate narcotic usage in the postoperative period. We assess the impact of bupivacaine liposome used along with a standard analgesia protocol following robotic inguinal hernia repair. A retrospective review of a prospectively maintained data including robotic inguinal hernia repairs (IHR) by two surgeons in the United States was performed. Within a multimodal analgesic protocol, local anesthetic was administered intraoperatively. One group received a mix of bupivacaine and bupivacaine liposome (BL), and one received standard bupivacaine (SB). Recovery room and home opiate doses were recorded. Primary outcomes included length of stay (LOS) and postoperative medication requirements. Statistical analysis was performed using Chi-square or Fisher's exact test and Mann-Whitney U test as appropriate. 122 robotic IHRs were included; 55 received BL and 67 received SB. Hospital LOS (hours) was reduced in the BL group (2.8 ± 1.1 vs 3.5 ± 1.2; p = 0.0003). There was no significant difference in recovery room parenteral MME requirements between the groups; however, BL group had less oral MME requirements (5.0 ± 6.5 MME vs. 8.1 ± 6.9 MME, p = 0.02). The BL group had a higher rate of zero opiate doses at home (44% vs 5%, p = 0.0005). Of those that did require opiates at home, there was a significant reduction in number of narcotic pills used by the BL compared to the SB group (median 1 vs 5, respectively; p < 0.0001). Intraoperative administration of BL as part of a pain management protocol may decrease length of hospital stay, and reduce or eliminate the need for narcotic analgesic use at home.

Evaluation of corneal anaesthesia after the application of topical 0.5% bupivacaine, 2% lidocaine and 0.4% oxybuprocaine in normal horses.

OBJECTIVE: To compare the corneal anaesthetic effect of 0.5% bupivacaine, 2% lidocaine and 0.4% oxybuprocaine on normal equine eyes. STUDY DESIGN: Prospective, blinded crossover study. ANIMALS: A group of 10 clinically healthy horses. METHODS: Corneal sensitivity was determined in each eye by measuring corneal touch threshold (CTT). The study had three phases. Each subject was randomly given one of the three treatments followed by a 72 hour washout period. Every horse received all treatments. Baseline CTT was recorded prior to anaesthetic instillation (T0) then CTT was measured 5 and 10 minutes after (T1 and T2, respectively), then 20 to 90 minutes (T3 to T10) at 10 minute intervals. CTT data were compared among treatments at each time point using the Friedman test p < 0.05. RESULTS: Median (range) baseline CTT was 51.3 (25.0-60.0) mm for bupivacaine, 50.0 (40.0-55.0) mm for oxybuprocaine and 55.0 (30.0-60.0) mm for lidocaine. All treatments caused a significant decrease in CTT at T1. The lowest CTT was observed at T3 with bupivacaine and oxybuprocaine treatments. Median CTTs at this time point were 18.7 (5.0-25.0) mm and 28.7 (25.0-40.0) mm, respectively. The lowest CTT with lidocaine treatment was 28.7 (20.0-50.0) mm at T6 (50 minutes). At T3, CTT was significantly lower with the bupivacaine treatment compared with oxybuprocaine and lidocaine treatments (p < 0.0074). There was no significant difference in CTT values between T1 and T6 for bupivacaine, between T1 and T7 for lidocaine, and between T1 and T8 for oxybuprocaine. Duration of the maximum effect was 45 minutes for the bupivacaine, 55 minutes for the lidocaine and 65 minutes for the oxybuprocaine treatment. CONCLUSIONS AND CLINICAL RELEVANCE: Administration of a 0.5% injectable solution of bupivacaine or a 2% lidocaine had similar anaesthetic effect to the commonly used oxybuprocaine. Therefore, they might be used as alternatives for corneal anaesthesia.

In vitro evaluation of loaded chitosan membranes for pain relief and infection prevention.

Wounds resulting from surgeries, implantation of medical devices, and musculoskeletal trauma result in pain and can also result in infection of damaged tissue. Up to 80% of these infections are due to biofilm formation either on the surface of implanted devices or on surrounding wounded tissue. Bacteria within a biofilm have intrinsic growth and development characteristics that allow them to withstand up to 1,000 times the minimum inhibitory concentration of antibiotics, demonstrating the need for new therapeutics to prevent and treat these infections. Cis-2-decenoic acid (C2DA) is known to disperse preformed biofilms and can prevent biofilm formation entirely for some strains of bacteria. Additionally, local anesthetics like bupivacaine have been shown to have antimicrobial effects against multiple bacterial strains. This study sought to evaluate hexanoic acid-treated electrospun chitosan membranes (HA-ESCM) as wound dressings that release C2DA and bupivacaine to simultaneously prevent infection and alleviate pain associated with musculoskeletal trauma. Release profiles of both therapeutics were evaluated, and membranes were tested in vitro against Methicillin-resistant Staphylococcus aureus (MRSA) to determine efficacy in preventing biofilm infection and bacterial growth. Results indicate that membranes release both therapeutics for 72 hr, and release profile can be tailored by loading concentration. Membranes were effective in preventing biofilm growth but were toxic to fibroblasts when loaded with 2.5 or 5 mg of bupivacaine.

Bupivacaine-eluting soy protein structures for controlled release and localized pain relief: An in vitro and in vivo study.

Burn pain is known to be excruciating, and while burn care has greatly advanced, treatment for burn-related pain is lacking. Current pain relief methods include systemic administration of analgesics, which does not provide high drug concentration at the wound site. In the present study, soy protein was used as the base material for bupivacaine-loaded hybrid wound dressings. The effect of the formulation on the drug release profile was studied using high performance liquid chromatography, and the cytotoxicity was tested on human fibroblasts. A second-degree burn model in rats was used to quantify the efficacy of the wound dressings in vivo, using the Rat Grimace Scale. All tested films exhibited high biocompatibility, and the drug release profiles showed rapid release during the initial 5 hr and a continuous slower release for another 24 hr. Significant pain relief was achieved in the animal trials, proving a decrease of 51-68% in pain levels during days 1-3 post-burn. Hence, the results indicate a safe and controlled bupivacaine release for a period of more than 24 hr, effectively treating pain caused by second-degree burns. The understanding of the formulation-properties effects, together with our in vivo study, enables to advance this field toward tailorable systems with high therapeutic potential.

Liposomal Bupivacaine Single-Injection Compared With Continuous Local Anesthetic Nerve Blocks for Painful Surgeries: A Meta-Analysis of Randomized Controlled Trials and Trial Sequential Analysis.

OBJECTIVE: This meta-analysis aimed to determine whether liposomal bupivacaine (LB) single-injection could achieve an analgesic effect similar to that of continuous local anesthetic nerve blocks (CNBs) after painful surgeries. METHODS: Embase, PubMed, and the Cochrane Library databases were comprehensively searched. Randomized controlled trials (RCTs) with a modified Jadad score ≥ 4 compared LB single-injection with CNBs in patients after painful surgeries were included. The primary outcomes were VAS pain score and opioid consumption. The secondary outcomes were complications and length of hospital stay. Review Manager 5.3 and trial sequential analysis (TSA) 0.9.5.10 were used to analyze the extracted data. RESULTS: Six RCTs of 625 patients were included for meta-analysis. Both groups in 5 RCTs described standard concomitant treatment with multimodal analgesia. There were no significant differences in mean VAS scores for postoperative day 0 (P = 0.12), day 1 (P = 0.18), and day 2 (P = 0.41); highest VAS scores for day 0 (P = 0.18), day 1 (P = 0.46), and day 2 (P = 0.18); total opioid consumption for day 0 (P = 0.05), day 1 (P = 0.28), and day 2 (P = 0.57); complications (P = 0.30); and length of hospital stay (P = 0.64) between the 2 groups. TSA of primary outcomes showed that all cumulative Z curves failed to cross the TSA boundary and did not reach the required information size. CONCLUSIONS: This meta-analysis showed that LB single-injection and CNBs have similar efficacy of pain relief and safety in patients after painful surgeries when concomitant with multimodal analgesia. However, the results of TSA indicate that further trials are still needed to confirm these findings.

Efficacy of ropivacaine versus bupivacaine in preventing peribulbar block failure: A meta-analysis.

PURPOSE: Peribulbar block is considered a standard of care in ophthalmological practice due to its easy execution and minor complications. There is a paucity of studies confirming efficacy between ropivacaine and bupivacaine for this specific technique. We evaluated the efficacy of ropivacaine or bupivacaine in preventing total or partial peribulbar block failure in ophthalmic surgeries. METHODS: Meta-analysis of randomized clinical trials, comparing patients submitted to ophthalmic surgeries under peribulbar anesthesia with ropivacaine and bupivacaine. We searched in different databases for articles published until March, 2018. Data on patients, anesthesia, procedures and akinesia were tabulated. After calculating the chi-square of heterogeneity, we adopted a random-effects model with DerSimonian-Laird test, as well as an odds ratio and a 95% confidence interval. RESULTS: From the 310 articles identified, 21 studies were selected. The use of ropivacaine was considered a protective factor for ocular akinesia failure in peribulbar block when compared to bupivacaine (OR = 0.53, 95% CI = 0.35-0.81 and p value = 0.003). CONCLUSIONS: In ophthalmic surgeries, ropivacaine in peribulbar anesthesia is associated with lower rate of block failure when compared to bupivacaine.

Determination of Anesthetic Efficacy of Lidocaine Versus Bupivacaine in Single Visit Root Canal Treatment.

Objective: To compare the anesthetic efficacy of 2% Lidocaine with 1:80,000 epinephrine and 0.5% Bupivacaine with 1:200,000 epinephrine in one-visit root canal treatment in patients with symptomatic irreversible pulpitis. Methods: A total of 60 patients presenting with symptomatic irreversible pulpitis with normal periapical tissues on periapical radiography of mandibular 1st and 2nd molars, reporting moderate to severe pain as assessed by visual analogue scale (VAS) for at least 24 hours were included in this study. All patients received local anesthesia via the inferior alveolar nerve block technique by the investigator. These patients were randomly allocated into two groups in which first group received 2% lidocaine with 1:80,000 epinephrine and the second group received 0.5% bupivacaine with 1:200,000 epinephrine. Patients were instructed to rate the intensity of pain during root canal treatment which was then noted on visual analogue scale (VAS). Results: The average age of the patients was 34.15±9.49 years, in which 32 (53.3%) were male and 28 (46.7%) were female. The anesthetic efficacy was significantly high in bupivacaine as compared to lidocaine local anesthesia group (76.7% versus 40%; P=0.004). Conclusion: The administration of bupivacaine anesthetic agent for inferior alveolar nerve block (IANB) injections can be a better and appropriate pain management aid as compared to lidocaine during root canal treatment of patient with symptomatic irreversible pulpitis.

Electroacupuncture pretreatment alleviates myocardial injury through regulating mitochondrial function.

BACKGROUND: Electroacupuncture is well known for its advantageous neuroanalgesic and therapeutic effects on myocardial ischemia-reperfusion injury. The purpose of the present research was to verify whether electroacupuncture can alleviate bupivacaine-induced myocardial injury. METHODS: Specific pathogen-free Wistar rats were used to establish the bupivacaine-induced myocardial injury model. Western blot, PCR, transmission electron microscope and enzyme-linked immunosorbent (ELISA) methods were used to evaluate bupivacaine-induced structure injury and dysfunction of the mitochondria as well as the alleviating effects of lipid emulsion, acupoint injection, and electroacupuncture pre-treatment of the oxidase stress response. RESULTS: Bupivacaine caused structural damage, degradation, and swelling of mitochondria. Furthermore, it reduced adenosine triphosphate (ATP) synthesis and impaired energy metabolism in the mitochondria. Structural and functional impairment of the mitochondria was alleviated via lipid emulsion injection, acupoint injection, and electroacupuncture pre-treatment. Electroacupuncture pre-treatment of PC6 yielded a greater alleviating effect than others approaches. Following electroacupuncture pre-treatment of PC6 point, the number of mitochondria increased; apoptosis was reduced, enzymatic activity of cytochrome C oxidase (COX) and superoxide dismutase and expression of uncoupling protein 2, voltage-dependent anion channel 1, and Bcl 2 were upregulated and SLC25A6, MDA levels were downregulated. Additionally, our findings indicated that electroacupuncture pre-treatment of PC6 point exerted an effect on the mitochondria via the mitochondrial-transcription-factor-A/nuclear-respiratory-factor-1/proliferator-activated-receptor-gamma-coactivator-1 pathway. CONCLUSION: The present study revealed that electroacupuncture pre-treatment of PC6 could effectively alleviate bupivacaine-induced myocardial mitochondrial damage, thereby providing a theoretical basis for clinical studies and applications of this treatment method.

Transient lower cranial nerve palsies following spinal anesthesia with bupivacaine-fentanyl combination for transurethral resection of the prostate.

Spinal anesthesia is a widely used regional anesthesia for many infra-umbilical surgical procedures with proven efficacy and safety. However, although rare, some neurologic complications can occur with potentially life threatening consequences. Among them, lower cranial nerve palsies have been rarely reported in the literature. We report such a case in a 75-year-old man with transient dysphagia, dysphonia and spinal accessory nerve palsy occurring four days after spinal anesthesia for transurethral resection of the prostate. His symptoms completely resolved spontaneously within 2 weeks. The possibility of lower cranial nerve palsies should be added to the potential complications during or following spinal anesthesia with bupivacaine-fentanyl combination. Although transitional, this complication may occur few days after the procedure and need to be promptly recognized, carefully evaluated and treated by conservative measures.

Dural sac cross-sectional area is a highly effective parameter for spinal anesthesia in geriatric patients undergoing transurethral resection of the prostate: a prospective, double blinded, randomized study.

BACKGROUND: Spinal anesthesia is optimal choice for transurethral resection of the prostate (TURP), but the sensory block should not cross the T10 level. With advancing age, the sensory blockade level increases after spinal injection in some patients with spinal canal stenosis. We optimize the dose of spinal anesthesia according to the decreased ratio of the dural sac cross-sectional area (DSCSA), the purpose of this study is to hypothesis that if DSCSA is an effective parameter to modify the dosage of spinal anesthetics to achieve a T10 blockade in geriatric patients undergoing TURP. METHODS: Sixty geriatric patients schedule for TURP surgery were enrolled in this study. All subjects were randomized divided into two groups, the ultrasound (group U) and the control (group C) groups, patient receive either a dose of 2 ml of 0.5% isobaric bupivacaine in group C, or a modified dose of 0.5% isobaric bupivacaine in group U. We measured the sagittal anteroposterior diameter (D) of the dural sac at the L3-4 level with ultrasound, and calculated the approximate DSCSA (A) according to the following formula: A = π(D/2)2, ( π = 3.14). The modified dosage of bupivacaine was adjusted according to the decreased ratio of the DSCSA. RESULTS: The cephalad spread of the sensory blockade level was significantly lower (P < 0.001) in group U (T10, range T7-T12) compared with group C (T3, range T2-T9). The dosage of bupivacaine was significantly decreased in group U compared with group C (P < 0.001). The regression times of the two segments were delay in group U compared with group C (P < 0.001). The maximal decrease in MAP was significantly higher in the group C than in group U after spinal injection (P < 0.001), without any modifications HR in either group. Eight patients in group C and two patients in group U required ephedrine (P = 0.038). CONCLUSIONS: The DSCSA is a highly effective parameter for spinal anesthesia in geriatric patients undergoing TURP, a modified dose of local anesthetic is a critical factor for controlling the sensory level. TRIAL REGISTRATION: This study was registered in the Chinese Clinical Trial Registry (Registration number: ChiCTR1800015566).on 8, April, 2018.