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91: Plasma levobupivacaine concentrations following epidural continuous infusion for postoperative analgesia: a preliminary study
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Posters
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Central Nerve Blocks
POSTERS
Central Nerve Blocks 149. Thoracic epidural anesthesia/ analgesia in cardiac surgical patients: can you do it on the same surgical day? C.E. Restrepo-Garces1,2, L.A. Marquez-Arabia3, F. Echeverry-Upegui3, H.D.J. Manrique2, G. Echavarria4 1Fellowship In Pain Medicine, Pain Clinic, Department of Anaesthesia,University of Toronto,Sunnybrook Health Science Centre, Toronto, Canada 2Department of Anaesthesia, Clinica Las Americas, Medellin, Colombia 3Department of Anaesthesia, Cardiothoracic Services, Clinica Las Americas, Medellin, Colombia 4Acute Pain Services, Clinica Las Americas, Medellin, Colombia Background: Thoracic epidural anesthesia/analgesia (TEA) appears to be attractive to cardiac surgical patients (CSP). TEA attenuates the surgical stress response, decrease supraventricular arrhythmias and pulmonary postoperative complications. Furthermore, decrease pain scores and permits early extubation. However applying TEA to CSP is not risk-free. Theoretical increased risk of Spinal Epidural Hematoma (SEH) formation in this scenario is the greatest concern. Many centers where TEA is used for CSP, performed the blockade 24-hours-in-advance, but it necessitates early admissions. We would like to describe our practice performing TEA as a same-day-procedure in CSP. Methods: During the years 2003⬃2006 CSP candidates to TEA were included. TEA was performed by the same group of anesthesiologist, using loss-of-resistance to air or saline, to find the epidural space at the level of T1-T4 trough the midline in the sitting position. After negative aspiration and a negative test-dose (2%lidocaine/ epinephrine-1:200:000) for intravascular or intrathecal spread, a continuous infusion of plain-bupivacaine1% plus Fentanyl-2gper-ml was started (3mls⬃10mls-hour). For all patients p.r.n opioids were available for breakthrough pain. The general anesthesia technique and the monitoring were performed at the discretion of each anesthesiologist. The minimal conditions and the anticoagulation regimen used, follow the ASRA recommendations on neuroaxial anesthesia and anticoagulation. Presences of SEH or regional neurological deficits were recorded. Results: 604 patients were identified during the period. Procedures included 4 surgical groups (CABG, valvular procedures, congenital and mixed). The epidural infusions were continued for a period of at least 48 hours. Post-operative VAS remained below 3/10 at rest and movement, after adjustment of the infusion rate. No SEH or new onsets of regional deficits were recorded during the study. Conclusions: TEA in CSP using a same-day-procedure approach did not result in any SEH in this clinical audit. Tight adhesion to anticoagulation guidelines should be encouraged when such interventions are planned.
91. Plasma levobupivacaine concentrations following epidural continuous infusion for postoperative analgesia: a preliminary study M. Allegri1, S. Bettinelli1, M. Parise1, C. Baldi1, M. Cusato2, M. Regazzi2, A. Braschi1 1Anestesia E Rianimazione I Fondazione IRCCS Policlinico San Matteo Pavia Italy, Pavia, Italy 2Unita` Operativa Di Farmacocinetica Clinica Fondazione IRCCS Policlinico San Matteo, Pavia, Italy Background and aims: In this study we studied the systemic absorption of Levobupivacaine in continuous epidural infusion for postoperative pain control. We compared our plasma concentrations with the maximum level before the onset of CNS symptoms (2,62 mcg/ml) published in the literature (Bradley). Methods: We enrolled 15 patients with epidural catheter for postoperative analgesia after major abdominal or urological surgery. The pharmacological protocol was as follow: first bolus 45 minutes before ending of surgery with 5 ml of Levobupivacaine 0,125% (second bolus after 20 minutes) ⫹ 10 mcg of Sufentanyl. At the end of surgery we start the infusion (48 hours) a infusion of Levobupivacaine 0.125% 5 ml/h with Sufentanyl 0,75 mcg/ml with a electronically device. During post-operative period we obtained arterial samples done before first local anaesthetic administration and at time ⫹3, ⫹6, ⫹12, ⫹24, ⫹48, ⫹54, ⫹60, and we studied the systemic absorption of local anaesthetic with HPLC-UV. All patients were monitored for eventual side effects. Results: The results are shown in the table. From preliminary results we can notice that plasma levels obtained in our patients at different time of evaluation are really inferior to the level of reference. Even at plasma peak the observed level is 36,08% of the toxic concentration. In all our patients the value of reference was not reached. Conclusions: In this study we underline that the continuous epidural infusion of Levobupivacaine at concentrations used are sure and safety even if we analysed the pharmacological kinetics.
TIME OF SAMPLE AL AL AL AL AL AL AL
⫹3 ⫹6 ⫹12 ⫹24 ⫹48 ⫹54 ⫹60
Mean plasma level of Levobupi vacaine
% of ref. level (2.62 mcg/ml)
Side effects
0.1296 0.1992 0.3095 0.5443 0.9454 0.7667 0.5379
4.94% 7.60% 11.81% 20.77% 36.08% 29.26% 20.53%
0 0 0 0 0 0 0
Posters
•
Central Nerve Blocks
POSTERS
Central Nerve Blocks 149. Thoracic epidural anesthesia/ analgesia in cardiac surgical patients: can you do it on the same surgical day? C.E. Restrepo-Garces1,2, L.A. Marquez-Arabia3, F. Echeverry-Upegui3, H.D.J. Manrique2, G. Echavarria4 1Fellowship In Pain Medicine, Pain Clinic, Department of Anaesthesia,University of Toronto,Sunnybrook Health Science Centre, Toronto, Canada 2Department of Anaesthesia, Clinica Las Americas, Medellin, Colombia 3Department of Anaesthesia, Cardiothoracic Services, Clinica Las Americas, Medellin, Colombia 4Acute Pain Services, Clinica Las Americas, Medellin, Colombia Background: Thoracic epidural anesthesia/analgesia (TEA) appears to be attractive to cardiac surgical patients (CSP). TEA attenuates the surgical stress response, decrease supraventricular arrhythmias and pulmonary postoperative complications. Furthermore, decrease pain scores and permits early extubation. However applying TEA to CSP is not risk-free. Theoretical increased risk of Spinal Epidural Hematoma (SEH) formation in this scenario is the greatest concern. Many centers where TEA is used for CSP, performed the blockade 24-hours-in-advance, but it necessitates early admissions. We would like to describe our practice performing TEA as a same-day-procedure in CSP. Methods: During the years 2003⬃2006 CSP candidates to TEA were included. TEA was performed by the same group of anesthesiologist, using loss-of-resistance to air or saline, to find the epidural space at the level of T1-T4 trough the midline in the sitting position. After negative aspiration and a negative test-dose (2%lidocaine/ epinephrine-1:200:000) for intravascular or intrathecal spread, a continuous infusion of plain-bupivacaine1% plus Fentanyl-2gper-ml was started (3mls⬃10mls-hour). For all patients p.r.n opioids were available for breakthrough pain. The general anesthesia technique and the monitoring were performed at the discretion of each anesthesiologist. The minimal conditions and the anticoagulation regimen used, follow the ASRA recommendations on neuroaxial anesthesia and anticoagulation. Presences of SEH or regional neurological deficits were recorded. Results: 604 patients were identified during the period. Procedures included 4 surgical groups (CABG, valvular procedures, congenital and mixed). The epidural infusions were continued for a period of at least 48 hours. Post-operative VAS remained below 3/10 at rest and movement, after adjustment of the infusion rate. No SEH or new onsets of regional deficits were recorded during the study. Conclusions: TEA in CSP using a same-day-procedure approach did not result in any SEH in this clinical audit. Tight adhesion to anticoagulation guidelines should be encouraged when such interventions are planned.
91. Plasma levobupivacaine concentrations following epidural continuous infusion for postoperative analgesia: a preliminary study M. Allegri1, S. Bettinelli1, M. Parise1, C. Baldi1, M. Cusato2, M. Regazzi2, A. Braschi1 1Anestesia E Rianimazione I Fondazione IRCCS Policlinico San Matteo Pavia Italy, Pavia, Italy 2Unita` Operativa Di Farmacocinetica Clinica Fondazione IRCCS Policlinico San Matteo, Pavia, Italy Background and aims: In this study we studied the systemic absorption of Levobupivacaine in continuous epidural infusion for postoperative pain control. We compared our plasma concentrations with the maximum level before the onset of CNS symptoms (2,62 mcg/ml) published in the literature (Bradley). Methods: We enrolled 15 patients with epidural catheter for postoperative analgesia after major abdominal or urological surgery. The pharmacological protocol was as follow: first bolus 45 minutes before ending of surgery with 5 ml of Levobupivacaine 0,125% (second bolus after 20 minutes) ⫹ 10 mcg of Sufentanyl. At the end of surgery we start the infusion (48 hours) a infusion of Levobupivacaine 0.125% 5 ml/h with Sufentanyl 0,75 mcg/ml with a electronically device. During post-operative period we obtained arterial samples done before first local anaesthetic administration and at time ⫹3, ⫹6, ⫹12, ⫹24, ⫹48, ⫹54, ⫹60, and we studied the systemic absorption of local anaesthetic with HPLC-UV. All patients were monitored for eventual side effects. Results: The results are shown in the table. From preliminary results we can notice that plasma levels obtained in our patients at different time of evaluation are really inferior to the level of reference. Even at plasma peak the observed level is 36,08% of the toxic concentration. In all our patients the value of reference was not reached. Conclusions: In this study we underline that the continuous epidural infusion of Levobupivacaine at concentrations used are sure and safety even if we analysed the pharmacological kinetics.
TIME OF SAMPLE AL AL AL AL AL AL AL
⫹3 ⫹6 ⫹12 ⫹24 ⫹48 ⫹54 ⫹60
Mean plasma level of Levobupi vacaine
% of ref. level (2.62 mcg/ml)
Side effects
0.1296 0.1992 0.3095 0.5443 0.9454 0.7667 0.5379
4.94% 7.60% 11.81% 20.77% 36.08% 29.26% 20.53%
0 0 0 0 0 0 0