Bupivacaine postoperative

After thoracotomy and lobectomy, a 67-year-old male who had been administered a paravertebral catheter with continuous infusion plus multiple bolus doses of 20 mL 0.1% bupivacaine postoperatively developed tonic-clonic seizures and subsequent pulmonary aspiration. He was initially treated with intravenous (IV) midazolam and endotracheal intubation. Unforhmately the patient succumbed to aspiration pneumonitis and acute respiratory distress syndrome 3 days later in the intensive care xmit. 

Another clinical consideration is the abiUty of local anesthetic agents to effect differential blockade of sensory and motor fibers. In surgical procedures such as obstetrics or postoperative pain rehef, an agent which produces profound sensory block accompanied by minimal motor block is desirable. On the other hand some procedures such as limb surgery require both deep sensory and motor blockade. In clinical practice, bupivacaine ( 22,... 

Clinical use Because of its long duration of action, bupivacaine is indicated for long surgical anesthesia where a considerable amount of postoperative pain is expected such as dental and oral surgeries. Infiltration using a 0.25 % solution of bupivacaine produces sensory anesthesia with an onset of 2 to 5 min and a duration of 2 to 4 h or greater (Tetzlaff, 2000). A nerve conduction block with a duration of between 4 to 8 h and occasionally up to 24 h is achieved with injection of 0.5 to 0.75 %... 

The addition of droperidol 2.5 mg to fentanyl 0.4 mg in 40 ml of 0.125% bupivacaine lowered the incidence of postoperative nausea and vomiting compared with a solution without droperidol or with butorphanol added instead in patients undergoing anorectal surgery in a prospective randomized, single-blind study (28). 

A 26-year-old woman with a history of multiple substance abuse required emergency caesarean section at 30 weeks of gestation as a result of crack cocaine-induced placental abruption and fetal distress (251). Her admission blood pressure was 145/95 mmHg, heart rate 95/minute and respiratory rate 20/minute. The fetal heart rate was 130/minute and non-reactive, with late and variable decelerations and no response to maternal oxygen administration. Spinal block with bupivacaine, fentanyl, and morphine was performed with the patient in a sitting position. No maternal or neonatal postoperative complications were reported. 

In a randomized, double-blind study, 64 patients undergoing total knee arthroplasty received either intrathecal morphine 0.3 mg or intrathecal diamorphine, 0.3 mg in 0.3 ml, with 2-2.5 ml of 0.5% heavy spinal bupivacaine (3). The patients given morphine had significantly greater analgesia at 4, 8, and 12 hours postoperatively. The incidence of opioid-related adverse effects was not significantly different between the groups. 

Gopinathan C, Sockalingham I, Fung MA, Peat S, Hanna MH. A comparative study of patient-controlled epidural diamorphine, subcutaneous diamorphine and an epidural diamorphine/bupivacaine combination for postoperative pain. Eur J Anaesthesiol 2000 17(3) 189-96. 

Cataract patients, in general, have relatively little immediate postoperative pain. This absence of pain is, at least in part, due to the long duration of action (up to 12 hours) of bupivacaine used in retrobulbar anesthesia. Some practitioners recommend the use of oral analgesics, such as acetaminophen or ibuprofen, as needed, if the patient experiences minor discomfort in the immediate postsur-gical period.Topical NSAIDs are also reported to decrease immediate postoperative pain. Significant or persistent postoperative pain is considered to be abnormal and may be a symptom of such complications as corneal abrasion, bullous keratopathy, high lOP, or endophthalmitis. 

A 53-year-old woman received postoperative epidural analgesia by nurse-administered bolus doses after a total knee replacement (16). She received her first epidural bolus of 0.25% bupivacaine 6 ml with morphine 2 mg 2 hours after the operation, with good effect. Six hours later she was accidentally given a second top-up dose intravenously. She became distressed and complained of tinnitus, palpitation, and dizziness. She was able to cooperate and was in sinus rhythm with a tachycardia of 120/minute. She was observed overnight on ICU and made a full recovery. 

Effective postoperative pain relief can be obtained with a mixture of fentanyl and bupivacaine, which not only provides better analgesia than either drug alone, but also fewer adverse effects. There have been several studies of the efficacy of this mixture, using different doses and routes of administration, the addition of clonidine, and in comparison with morphine. 

Transdermal fentanyl was the cause of an opioid overdose when a 77-year-old man with a history of severe arthritis developed respiratory failure after starting epidural diamorphine-bupivacaine mixture for postoperative pain (50). The fentanyl patch was removed, the epidural infusion was stopped, and naloxone was given to counteract the excessive opioid effects. 

SUvasti M, Pitkanen M. Continnous epidural analgesia with bupivacaine-fentanyl versus patient-controlled analgesia with i.v. morphine for postoperative pain relief after knee ligament surgery. Acta Anaesthesiol Scand 2000 44(1) 37 2. 

During a study of 104 adults to compare the efficacy and safety of 40 ml of 0.75% ropivacaine (300 mg) and 40 ml of 0.5% bupivacaine (200 mg) for axillary plexus block, significantly more patients reported postoperative dizziness in the ropivacaine group (5 versus 0) (63). However, this occurred 4-5 hours after the injection in two patients and the day after in the other three, and was therefore unlikely to have been due to high serum concentrations. One patient developed dizziness, dysarthria, and unconsciousness, with convulsions shortly after an injection of ropivacaine, indicating an intravenous injection. 

In a study in 60 anesthetized children undergoing minor subumbilical surgery caudal blocks, 0.2% ropivacaine, 0.25% racemic bupivacaine, and 0.25% levobupivacaine (all 1 ml/kg) were compared (81). All the blocks were successful in terms of intraoperative and early postoperative analgesia. Ropivacaine, but not levobupivacaine, was associated with less motor block during the first postoperative hour compared with racemic bupivacaine. However, the lower concentration of ropivacaine will have biased this result. 

Caudal block with bupivacaine in children provides adequate analgesia in the early postoperative period, but additional analgesia is often required as the block wears off. Two studies have looked at adjuvants to prolong the analgesic effect. 

In 165 children receiving caudal anesthesia with fenta-nyl 1 mg/kg and bupivacaine 4 mg/kg, there were adverse effects in only six, two of whom required postoperative ventilation. This was felt to be due to their pathology and not the anesthetic. However, there was no comment on the presence or absence of specific local anesthetic adverse effects, and an unusually high dose of... 

A former preterm infant had two awake caudal anesthetics for herniotomy within 3 weeks (84). The first was uneventful with bupivacaine 0.25% at 35 weeks of age. At 38 weeks, the baby had intraoperative and postoperative bouts of apnea after inadvertent administration of bupivacaine 0.125% plus clonidine. 

An epidural infusion of 0.2% ropivacaine plus sufentanil has been compared with 0.175% bupivacaine plus sufentanil in 86 patients postoperatively after major gastrointestinal surgery there was no statistically significant difference in the incidence of adverse effects (respiratory depression, sedation, nausea, vomiting, pruritus, and motor blockade), but those given ropivacaine mobilized more quickly (114). 

Severe burning pain in the bnttocks, thighs, and calves has been described in a 5-year-old boy who was given 0.25% bupivacaine and morphine epidnrally for perioperative and postoperative analgesia (135). 

Occasionally orthopedic patients have developed compartment syndrome postoperatively during epidural infusions of bupivacaine/fentanyl mixtures. However, although aggressive analgesia was blamed for the resulting disasters, there seems to have been a remarkable lack of adequate pressure area care, correct positioning, and regular review of both patients and splints (SEDA-22,136). 

In a comparison of intrathecal bupivacaine 10 mg and bupivacaine 7.5 mg combined with ketamine 25 mg, in 30 healthy women there was no extension of postoperative analgesia or reduction in postoperative analgesic requirements in those given ketamine (176). Those given ketamine had a shorter duration of motor blockade, but had an increased incidence of adverse effects, and the study was abandoned after 30 patients. 

A cluster of 25 cases of transient or permanent diplopia occurred after 13 retrobulbar blocks, 10 peribulbar blocks, and two unknown techniques, possibly related to the non-availability of hyaluronidase, highhghting the likely importance of hyaluronidase in preventing anesthetic-related myopathy in the extraocular muscles (290). Other reports of 21 cases of persistent postoperative diplopia following the peribulbar technique (291) and 4 cases foUowing the retrobulbar technique during the period of non-availabihty of hyaluronidase support this theory (292). Bupivacaine and lidocaine may be contraindicated for peribulbar or retrobulbar injections without hyaluronidase. 

Post-thoracotomy pain can be treated with thoracic epidural or thoracic paravertebral blockade. In 100 adult patients allocated to receive one of these treatments with preoperative bolus doses of bupivacaine followed by a continuous infusion there was less postoperative respiratory morbidity and significantly better arterial oxygenation in the paravertebral group nausea (10 versus 2), vomiting (7 versus 2), and hypotension (7 versus 0) were more problematic in the epidural group (346). 

Opioids potentiate the analgesic effect of neuraxial local anesthetics, with minimal adverse effects (SEDA-18,141) (SEDA-20, 121) (SEDA-22, 135), as shown in several studies with clonidine, fentanyl, morphine, or pethidine as the systemic or neuraxial analgesic, and bupivacaine, lidocaine, and ropivacaine as the local anesthetic. The benefits have been shown in relief of long-term pain and postoperative pain, in adults and children (SEDA-18, 141) (SEDA-18,146). 

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