Local anesthetic ‘in-situ’ toxicity during peripheral nerve blocks

We present a standardized method for using four-dimensional ultrasound (4D US) guidance for peripheral nerve blocks. 4D US allows for needle tracking in multiple planes simultaneously and accurate measurement of the local anesthetic volume surrounding the nerve following injection. Additionally, the morphology and proximity of local anesthetic spread around the target nerve is clearly seen with the described technique. This method provides additional spatial information in real time compared to standard two-dimensional ultrasound.

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Cardiac Arrest and Seizures Caused by Local Anesthetic Systemic Toxicity After Peripheral Nerve Blocks

Regional Anesthesia and Pain Medicine ◽

10.1097/aap.0000000000000329 ◽

2016 ◽

Vol 41 (1) ◽

pp. 5-21 ◽

Cited By ~ 28

Author(s):

Spencer S. Liu ◽

Sarah Ortolan ◽

Miguel Vizarreta Sandoval ◽

Jodie Curren ◽

Kara G. Fields ◽

...

Keyword(s):

Cardiac Arrest ◽

Peripheral Nerve ◽

Local Anesthetic ◽

Systemic Toxicity ◽

Nerve Blocks ◽

Peripheral Nerve Blocks ◽

Local Anesthetic Systemic Toxicity

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Adjuvant Drugs for Peripheral Nerve Blocks: The Role of NMDA Antagonists, Neostigmine, Epinephrine, and Sodium Bicarbonate

Anesthesiology and Pain Medicine ◽

10.5812/aapm.117146 ◽

2021 ◽

Vol 11 (3) ◽

Author(s):

Amber N. Edinoff ◽

Joseph S. Fitz-Gerald ◽

Krisha Andrea A. Holland ◽

Johnnie G. Reed ◽

Sarah E. Murnane ◽

...

Keyword(s):

Chronic Pain ◽

Peripheral Nerve ◽

Sodium Bicarbonate ◽

Local Anesthetic ◽

Synergistic Effects ◽

Small Sample ◽

Nerve Blocks ◽

Duration Of Action ◽

Peripheral Nerve Blocks

: The potential for misuse, overdose, and chronic use has led researchers to look for other methods to decrease opioid consumption in patients with acute and chronic pain states. The use of peripheral nerve blocks for surgery has gained increasing popularity as it minimizes peripheral pain signals from the nociceptors of local tissue sustaining trauma and inflammation from surgery. The individualization of peripheral nerve blocks using adjuvant drugs has the potential to improve patient outcomes and reduce chronic pain. The major limitations of peripheral nerve blocks are their limited duration of action and dose-dependent adverse effects. Adjuvant drugs for peripheral nerve blocks show increasing potential as a solution for postoperative and chronic pain with their synergistic effects to increase the duration of action and decrease the required dosage of local anesthetic. N-methyl-d-aspartate (NMDA) receptor antagonists are a viable option for patients with opioid resistance and neuropathic pain due to their affinity to the neurotransmitter glutamate, which is released when patients experience a noxious stimulus. Neostigmine is a cholinesterase inhibitor that exerts its effect by competitively binding at the active site of acetylcholinesterase, which prevents the hydrolysis of acetylcholine and subsequently retaining acetylcholine at the nerve terminal. Epinephrine, also known as adrenaline, can potentially be used as an adjuvant to accelerate and prolong analgesic effects in digital nerve blocks. The theorized role of sodium bicarbonate in local anesthetic preparations is to increase the pH of the anesthetic. The resulting alkaline solution enables the anesthetic to more readily exist in its un-ionized form, which more efficiently crosses lipid membranes of peripheral nerves. However, more research is needed to show the efficacy of these adjuvants for nerve block prolongation as studies have been either mixed or have small sample sizes.

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Curb your enthusiasm: local anesthetic adjuvants for peripheral nerve blocks

ASRA News ◽

10.52211/asra110120.071 ◽

2020 ◽

Vol 45 (4) ◽

Author(s):

Yatish Ranganath ◽

Melinda Seering ◽

Anil Marian

Keyword(s):

Peripheral Nerve ◽

Local Anesthetic ◽

Nerve Blocks ◽

Peripheral Nerve Blocks

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Variation in pediatric local anesthetic dosing for peripheral nerve blocks: an analysis from the Pediatric Regional Anesthesia Network (PRAN)

Regional Anesthesia and Pain Medicine ◽

10.1136/rapm-2020-101720 ◽

2020 ◽

Vol 45 (12) ◽

pp. 964-969 ◽

Cited By ~ 2

Author(s):

Andreas H Taenzer ◽

Michael Herrick ◽

Matthew Hoyt ◽

R J Ramamurthi ◽

Benjamin Walker ◽

...

Keyword(s):

Peripheral Nerve ◽

Regional Anesthesia ◽

Local Anesthetic ◽

Age Groups ◽

Geographic Location ◽

Average Weight ◽

Nerve Blocks ◽

Peripheral Nerve Blocks ◽

Increased Risk ◽

The Mean

BackgroundVariation of local anesthetic dosing has been reported for adult peripheral nerve blocks (PNBs) and infant caudal blocks. As higher doses of local anesthetics (LA) are potentially associated with increased risk of complications (eg, local anesthetic systemic toxicity), it is important to understand the source of LA dose variation. Using the Pediatric Regional Anesthesia Network (PRAN) database, we aimed to determine if variation in dosing exists in pediatric single-injection PNBs, and what factors influence that variation.The primary aim of this study was to determine the factors associated with dosing for the 10 most commonly performed PNBs, with the secondary aim of exploring possible factors for variation such as number of blocks performed versus geographic location.MethodsThe PRAN database was used to determine the 10 most common pediatric PNBs, excluding neuraxial regional anesthetics. The 10 most common pediatric PNBs in the PRAN database were analyzed for variation of LA dose and causes for variation.ResultsIn a cohort of 34 514 children receiving PNBs, the mean age was 10.38 (+/-5.23) years, average weight was 44.88 (+/-26.66) kg and 61.8% were men. The mean bupivacaine equivalent (BE) dose was 0.86 (+/-0.5) mg kg−1 and ropivacaine was used in 65.4% of blocks. Dose decreases with age (estimate −0.016 (−0.017, –0.015; p<0.001)). In all blocks for all age groups, the range of doses that make up the central 80% of all doses exceeds the mean BE dose for the block. Variation is not related to the number blocks performed at an institution (p=0.33 (CI −0.42 to 0.15)). The dose administered for a PNB is driven in order of impact by the institution where the block was performed (Cohen’s ƒ=0.45), then by weight (0.31), type of block (0.27), LA used (0.15) and age (0.03).ConclusionsConsiderable variation in dosing exists in all age groups and in all block types. The most impactful driver of local anesthetic dose is the institution where the block was performed, indicating the dosing of a potentially lethal drug is more based on local culture than on evidence.

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