Levobupivacaine Thermogel for Long-acting Analgesia.

The adequate management of analgesia, by pharmacological methods or not, is a great challenge. Local anesthetics are used for pain relief, mainly by parenteral, intramuscular, catheter, and other routes of administration. The use of in situ forming systems becomes an alternative for the control of pain. The present research investigates development of thermogels containing poloxamer and levobupivacaine. All formulations were prepared by the cold method; the compatibilities of the excipients were evaluated by DSC, rheology and viscosities, transition temperature, syringeability, release kinetics, and permeation. The compatibility of the tested excipients with the drug was initially observed; all formulations had a viscosity increase at 37°C. Different delivery rates were observed in both the release and permeation studies. The developed systems maintained the in vitro release of the drug for a long period, likely decreasing side effects in vivo and avoiding the need for supplementary analgesia by other routes.

The effect of intra-articular levobupivacaine on shoulder cartilage at different doses - experimental study / O efeito de levobupivacaína intra-articular na cartilagem do ombro em doses diferentes-estudo experimental

Abstract Background and objectives: In this study it was aimed to examine the histological and morphometric effects on cartilage structure of intra-articular application of levobupivacaine to the shoulder joint. Methods: In twenty New Zealand adult male rabbits, 35 shoulders were used for the study and prepared in 5 groups of 7. These groups were defined as Groups L1, L2, L3 and L4 which were right shoulders administered with 0.25% and 0.5% levobupivacaine, Group C which were left shoulders as the control group and Groups S1 and S2 which were left shoulders administered with 0.9% saline. On the 2nd and 15th days the animals were killed, the glenohumeral joints were evaluated macroscopically then cartilage samples were taken. These samples were evaluated with Mankin score, and histomorphometrically by measuring the thickness of the cartilage between the superficial cartilage layer and the tidemark and the thickness of calcified cartilage between the tidemark and the subchondral bone. Results: Macroscopically, on the 15th day the joint fluid was seen to have reduced in all the groups. After microscopic evaluation, the highest Mankin score (mean: 3.14 ± 2.1/14) was in the L4 group (15th day 0.5% levobupivacaine) and was found to be statistically significant (p < 0.05). No statistically significant difference was determined between the other groups. Conclusions: Histologically, as the highest Mankin score was in the L4 group, this indicates that in a single intra-articular injection of levobupivacaine a low concentration should be selected. Level of evidence: Level 5, animal study.

Resumo Justificativa e objetivo: Neste estudo o objetivo foi examinar os efeitos histológicos e morfométricos sobre a estrutura da cartilagem da aplicação intra-articular de levobupivacaína em articulação do ombro. Métodos: Trinta e cinco ombros de 20 coelhos New Zealand, machos e adultos, foram usados para o estudo e divididos em cinco grupos de sete. Os grupos foram definidos como L1, L2, L3 e L4, consistiram em ombros direitos nos quais levobupivacaína a 0,25% e 0,5% foi administrada; o Grupo C, que consistiu em ombros esquerdos, foi o grupo controle; os grupos S1 e S2, que consistiram em ombros esquerdos, receberam solução salina a 0,9%. Os animais foram sacrificados no segundo e no 15º dia; as articulações glenoumerais foram avaliadas macroscopicamente e, em seguida, amostras de cartilagem foram coletadas. As amostras foram avaliadas com o escore de Mankin e histomorfometricamente. Mediu-se a espessura da cartilagem entre a camada superficial e a "linha de maré" (tidemark) e a espessura da cartilagem calcificada entre a tidemark e o osso subcondral. Resultados: Macroscopicamente, observou-se no 15º dia que o líquido articular havia reduzido em todos os grupos. Após a avaliação microscópica, o maior escore de Mankin (média: 3,14 ± 2,1/14) foi observado no grupo L4 (15º dia levobupivacaína a 0,5%), considerado estatisticamente significativo (p < 0,05). Nenhuma diferença estatisticamente significativa foi determinada entre os outros grupos. Conclusões: Histologicamente, como o maior escore de Mankin foi observado no Grupo L4, isso indica que em uma única injeção intra-articular de levobupivacaína uma concentração baixa deve ser selecionada. Nível de evidência: Nível 5, estudo em animais.

The effect of intra-articular levobupivacaine on shoulder cartilage at different doses-experimental study.

BACKGROUND AND OBJECTIVES: In this study it was aimed to examine the histological and morphometric effects on cartilage structure of intra-articular application of levobupivacaine to the shoulder joint. METHODS: In twenty New Zealand adult male rabbits, 35 shoulders were used for the study and prepared in 5 groups of 7. These groups were defined as Groups L1, L2, L3 and L4 which were right shoulders administered with 0.25% and 0.5% levobupivacaine, Group C which were left shoulders as the control group and Groups S1 and S2 which were left shoulders administered with 0.9% saline. On the 2nd and 15th days the animals were killed, the glenohumeral joints were evaluated macroscopically then cartilage samples were taken. These samples were evaluated with Mankin score, and histomorphometrically by measuring the thickness of the cartilage between the superficial cartilage layer and the tidemark and the thickness of calcified cartilage between the tidemark and the subchondral bone. RESULTS: Macroscopically, on the 15th day the joint fluid was seen to have reduced in all the groups. After microscopic evaluation, the highest Mankin score (mean: 3.14±2.1/14) was in the L4 group (15th day 0.5% levobupivacaine) and was found to be statistically significant (p<0.05). No statistically significant difference was determined between the other groups. CONCLUSIONS: Histologically, as the highest Mankin score was in the L4 group, this indicates that in a single intra-articular injection of levobupivacaine a low concentration should be selected. LEVEL OF EVIDENCE: Level 5, animal study.

Bilateral greater occipital nerve block for treatment of post-dural puncture headache after caesarean operations / Bloqueio bilateral do nervo occipital maior para tratamento de cefaleia pós-punção dural após cesarianas

Abstract Background: Post-dural puncture headache (PDPH) is an important complication of neuroaxial anesthesia and more frequently noted in pregnant women. The pain is described as severe, disturbing and its location is usually fronto-occipital. The conservative treatment of PDPH consists of bed rest, fluid theraphy, analgesics and caffeine. Epidural blood patch is gold standard theraphy but it is an invasive method. The greater occipital nerve (GON) is formed of sensory fibers that originate in the C2 and C3 segments of the spinal cord and it is the main sensory nerve of the occipital region. GON blockage has been used for the treatment of many kinds of headache. The aim of this retrospective study is to present the results of PDPH treated with GON block over 1 year period in our institute. Methods: 16 patients who had been diagnosed to have PDPH, and performed GON block after caesarean operations were included in the study. GON blocks were performed as the first treatment directly after diagnose of the PDPH with levobupivacaine and dexamethasone. Results: The mean VAS score of the patients was 8.75 (±0.93) before the block; 3.87 (±1.78) 10 min after the block; 1.18 (±2.04) 2 h after the block and 2.13 (±1.64) 24 h after the block. No adverse effects were observed. Conclusions: Treatment of PDPH with GON block seems to be a minimal invasive, easy and effective method especially after caesarean operations. A GON block may be considered before the application of a blood patch.

Resumo Justificativa: A cefaleia pós-punção dural (CPPD) é uma complicação importante da anestesia neuroaxial e mais frequentemente observada em grávidas. A dor é descrita como intensa, perturbadora, e sua localização é geralmente fronto-occipital. O tratamento conservador da CPPD consiste em repouso no leito, fluidoterapia, analgésicos e cafeína. O tampão sanguíneo peridural é o padrão ouro de tratamento, mas é um método invasivo. O nervo occipital maior (NOM) é formado por fibras sensoriais com origem nos segmentos C2 e C3 da medula espinhal e é o principal nervo sensorial da região occipital. O bloqueio do NOM tem sido usado para o tratamento de muitos tipos de dor de cabeça. O objetivo deste estudo retrospectivo foi apresentar os resultados de CPPD tratada com bloqueio do NOM no período de um ano em nosso instituto. Métodos: Foram incluídas no estudo 16 pacientes diagnosticadas com CPPD e submetidas a bloqueio de NOM após cesariana. Os bloqueios do NOM foram feitos com levobupivacaína e dexametasona como o primeiro tratamento imediatamente após o diagnóstico de CPPD. Resultados: A média dos escores EVA das pacientes foi de 8,75 (±0,93) antes do bloqueio; 3,87 (±1,78) 10 minutos após o bloqueio; 1,18 (±2,04) duas horas após o bloqueio e 2,13 (±1,64) 24 horas após o bloqueio. Efeitos adversos não foram observados. Conclusões: O tratamento da CPPD com bloqueio do NOM parece ser um método minimamente invasivo, fácil e eficaz, especialmente após cesarianas. O bloqueio do NOM pode ser considerado antes da aplicação de um tampão sanguíneo peridural.

Bilateral greater occipital nerve block for treatment of post-dural puncture headache after caesarean operations.

BACKGROUND: Post-dural puncture headache (PDPH) is an important complication of neuroaxial anesthesia and more frequently noted in pregnant women. The pain is described as severe, disturbing and its location is usually fronto-occipital. The conservative treatment of PDPH consists of bed rest, fluid theraphy, analgesics and caffeine. Epidural blood patch is gold standard theraphy but it is an invasive method. The greater occipital nerve (GON) is formed of sensory fibers that originate in the C2 and C3 segments of the spinal cord and it is the main sensory nerve of the occipital region. GON blockage has been used for the treatment of many kinds of headache. The aim of this retrospective study is to present the results of PDPH treated with GON block over 1 year period in our institute. METHODS: 16 patients who had been diagnosed to have PDPH, and performed GON block after caesarean operations were included in the study. GON blocks were performed as the first treatment directly after diagnose of the PDPH with levobupivacaine and dexamethasone. RESULTS: The mean VAS score of the patients was 8.75 (±0.93) before the block; 3.87 (±1.78) 10min after the block; 1.18 (±2.04) 2h after the block and 2.13 (±1.64) 24h after the block. No adverse effects were observed. CONCLUSIONS: Treatment of PDPH with GON block seems to be a minimal invasive, easy and effective method especially after caesarean operations. A GON block may be considered before the application of a blood patch.

Association between levobupivacaine and pancuronium. Interference in neuromuscular transmission and blockade in rats.

PURPOSE: To evaluate the effects of levobupivacaine on neuromuscular transmission and neuromuscular blockade produced by pancuronium in vitro. METHODS: Thirty rats were distributed into groups (n = 5) according to the drug used alone or in combination: Group I - levobupivacaine (5 µg.mL-1); Group II - pancuronium (2 µg.mL-1); Group III - pancuronium (2 µg.mL-1) + levobupivacaine (5µg.mL-1). The following parameters were evaluated: 1) amplitude of diaphragmatic response to indirect stimulation, before and 60 minutes after the addition of levobupivacaine and pancuronium alone, and after the addition of levobupivacaine combined with pancuronium; 2) membrane potentials (MP) and miniature endplate potentials (MEPP). RESULTS: Levobupivacaine alone did not alter the amplitude of muscle response and MP. In preparations previoulsy exposed to levobupivacaine, the block with pancuronium was significantly denser (90.2 ± 15.2%), showing a significant difference (p=0.031) in comparison to the block produced by pancuronium alone (48.9% ± 9.8%). There was a decrease in the frequency and amplitude of MEPPs. CONCLUSION: Levobupivacaine potentiated the neuromuscular blockade produced by pancuronium, confirming a presynaptic action by a decrease in miniature endplate potentials.

Levobupivacaine absorption pharmacokinetics with and without epinephrine during TAP block: analysis of doses based on the associated risk of local anaesthetic toxicity.

PURPOSE: Cases of local anaesthetic systemic toxicity (LAST) periodically occur following transversus abdominal plane (TAP) blocks. The aim of this study was to characterize levobupivacaine absorption pharmacokinetics, with and without epinephrine, and estimate the risk of LAST, based on a previously reported toxic threshold. METHODS: Previously reported data from 11 volunteers receiving ultrasound-guided TAP blocks with and without epinephrine on two independent occasions were analysed. Serial venous concentrations were measured for 90 min. A pharmacokinetic analysis was performed using the NONMEM statistical programme. The use of epinephrine in the solution was included in the analysis of covariates. The associated risk of LAST symptoms associated with different levobupivacaine dose schemes with and without epinephrine was estimated in 1000 simulated subjects. RESULTS: A one-compartment first-order input and elimination model adequately fit the levobupivacaine data. Epinephrine prolonged the levobupivacaine absorption half-life {4.22 [95 % confidence interval (CI) 2.53-6.50] vs. 7.02 [95 % CI 3.74-14.1]; p < 0.05} and reduced its relative bioavailability (0.84; 95 % CI 0.72-0.97; p < 0.05) The derived model predicts that levobupivacaine dose schemes should be halved from 3 mg kg(-1) body weight with epinephrine to 1.5 mg kg(-1) without epinephrine to obtain a comparable risk of anaesthetic toxicity symptoms of approximately 0.1 %. CONCLUSIONS: Our results strongly support the addition of epinephrine to the local anaesthetic solution, especially when doses of levobupivacaine of >1.5 mg kg(-1) are required. Recommendations regarding the maximum allowable doses of local anaesthetics should consider population analysis to determine safer dosage ranges.

Association between levobupivacaine and pancuronium. Interference in neuromuscular transmission and blockade in rats

ABSTRACT PURPOSE: To evaluate the effects of levobupivacaine on neuromuscular transmission and neuromuscular blockade produced by pancuronium in vitro. METHODS: Thirty rats were distributed into groups (n = 5) according to the drug used alone or in combination: Group I - levobupivacaine (5 µg.mL-1); Group II - pancuronium (2 µg.mL-1); Group III - pancuronium (2 µg.mL-1) + levobupivacaine (5µg.mL-1). The following parameters were evaluated: 1) amplitude of diaphragmatic response to indirect stimulation, before and 60 minutes after the addition of levobupivacaine and pancuronium alone, and after the addition of levobupivacaine combined with pancuronium; 2) membrane potentials (MP) and miniature endplate potentials (MEPP). RESULTS: Levobupivacaine alone did not alter the amplitude of muscle response and MP. In preparations previoulsy exposed to levobupivacaine, the block with pancuronium was significantly denser (90.2 ± 15.2%), showing a significant difference (p=0.031) in comparison to the block produced by pancuronium alone (48.9% ± 9.8%). There was a decrease in the frequency and amplitude of MEPPs. CONCLUSION: Levobupivacaine potentiated the neuromuscular blockade produced by pancuronium, confirming a presynaptic action by a decrease in miniature endplate potentials.

Evaluation of sciatic nerve damage following intraneural injection of bupivacaine, levobupivacaine and lidocaine in rats / Avaliação da lesão do nervo ciático após injeção intraneural de bupivacaína, levobupivacaína e lidocaína em ratos

ABSTRACT OBJECTIVE: The local anesthetics may cause neurotoxicity. We aimed to compare the neurotoxic potential of different local anesthetics, local anesthetic induced nerve damage and pathological changes of a peripheral nerve. METHODS: Sixty Wistar rats weighing 200-350 g were studied. Rats were assigned into 3 groups and 26-gauge needle was inserted under magnification into the left sciatic nerve and 0.2 mL of 0.5% bupivacaine, 5% levobupivacaine, and 2% lidocaine were injected intraneurally. An individual who was blind to the specifics of the injection monitored the neurologic function on postoperative 1st day, and daily thereafter. Neurologic examination included assessment for the presence and severity of nociception and grasping reflexes. At the 7th day sciatic nerve specimen was taken for evaluation of histopathologic changes. RESULTS: There was no statistical difference detected among groups regarding grasping reflex and histopathologic evaluation. Two cases in bupivacaine group, 1 case in levobupivacaine group and 2 cases in lidocaine group had slight grasping, while 1 case in lidocaine group had no grasping reflex on the seventh day. Severe axonal degeneration was observed in all groups, respectively in bupivacaine group 4 (20%), levobupivacaine group 3 (15%), and lidocaine group 6 (30%). CONCLUSION: In all groups, histopathological damage frequency and severity were more than the motor deficiency.

RESUMO OBJETIVO: Os anestésicos locais podem causar neurotoxicidade. Nosso objetivo foi comparar o potencial neurotóxico de diferentes anestésicos locais, os danos induzidos aos nervos e as alterações patológicas de um nervo periférico. MÉTODOS: Foram estudados 60 ratos Whistler com 200-350 g. Os ratos foram divididos em três grupos, uma agulha de calibre 26 foi inserida no nervo ciático esquerdo, com o uso de ampliação, e 0,2 mL de bupivacaína a 0,5%, levobupivacaína a 5% e lidocaína a 2% foram injetados por via intraneural. Um colaborador, cego para os conteúdos das injeções, monitorou a função neurológica no primeiro dia de pós-operatório e depois diariamente. O exame neurológico incluiu a avaliação da presença e da gravidade da nocicepção e dos reflexos de agarrar. No sétimo dia, uma amostra do nervo ciático foi colhida para avaliar as alterações histopatológicas. RESULTADOS: Não houve diferença estatística entre os grupos em relação ao reflexo de agarrar e à avaliação histopatológica. Dois casos no grupo bupivacaína, um no grupo levobupivacaína e dois no grupo lidocaína apresentaram um leve reflexo de agarrar; também no grupo lidocaína, um caso não apresentou reflexo de agarrar no sétimo dia. Degeneração axonal grave foi observada em todos os grupos: quatro casos no grupo bupivacaína (20%), três no grupo levobupivacaína 3 (15%) e seis no grupo lidocaína (30%). CONCLUSÃO: Em todos os grupos, a frequência de dano histopatológico e de gravidade foi maior do que a deficiência motora.

Evaluation of sciatic nerve damage following intraneural injection of bupivacaine, levobupivacaine and lidocaine in rats.

OBJECTIVE: The local anesthetics may cause neurotoxicity. We aimed to compare the neurotoxic potential of different local anesthetics, local anesthetic induced nerve damage and pathological changes of a peripheral nerve. METHODS: Sixty Wistar rats weighing 200-350g were studied. Rats were assigned into 3 groups and 26-gauge needle was inserted under magnification into the left sciatic nerve and 0.2mL of 0.5% bupivacaine, 5% levobupivacaine, and 2% lidocaine were injected intraneurally. An individual who was blind to the specifics of the injection monitored the neurologic function on postoperative 1st day, and daily thereafter. Neurologic examination included assessment for the presence and severity of nociception and grasping reflexes. At the 7th day sciatic nerve specimen was taken for evaluation of histopathologic changes. RESULTS: There was no statistical difference detected among groups regarding grasping reflex and histopathologic evaluation. Two cases in bupivacaine group, 1 case in levobupivacaine group and 2 cases in lidocaine group had slight grasping, while 1 case in lidocaine group had no grasping reflex on the seventh day. Severe axonal degeneration was observed in all groups, respectively in bupivacaine group 4 (20%), levobupivacaine group 3 (15%), and lidocaine group 6 (30%). CONCLUSION: In all groups, histopathological damage frequency and severity were more than the motor deficiency.

A comparison of different densities of levobupivacaine solutions for unilateral spinal anaesthesia / Uma comparação das diferentes densidades das soluções de levobupivacaína para raquianestesia unilateral

ABSTRACT BACKGROUND AND OBJECTIVES: The aim of the study was to compare the block characteristics and clinical effects of dextrose added to levobupivacaine solutions at different concentrations to provide unilateral spinal anaesthesia in lower extremity surgery. METHODS: This prospective, randomised, double-blind study comprised 75 ASA I-II risk patients for whom unilateral total knee arthroscopy was planned. The patients were assigned to three groups: in Group I, 60 mg dextrose was added to 7.5 mg of 0.5% levobupivacaine, in Group II, 80 mg and in Group III, 100 mg. Spinal anaesthesia was applied to the patient in the lateral decubitus position with the operated side below and the patient was kept in position for 10 min. RESULTS: The time for the sensorial block to achieve T12 level was slower in Group I than in Groups II and III (p < 0.05, p< 0.00). The time to full recovery of the sensorial block was 136 min in Group I, 154 min in Group II and 170 min in Group III. The differences were statistically significant (p < 0.05). The mean duration of the motor block was 88 min in Group I, 105 min in Group II, and 139 min in Group III and the differences were statistically significant (p < 0.05). The time to urination in Group I was statistically significantly shorter than in the other groups (p < 0.00). CONCLUSIONS: The results of the study showed that together with an increase in density, the sensory and motor block duration was lengthened. It can be concluded that 30 mg mL-1 concentration of dextrose added to 7.5 mg levobupivacaine is sufficient to provide unilateral spinal anaesthesia in day-case arthroscopic knee surgery.

RESUMO JUSTIFICATIVA E OBJETIVOS: Comparar as características do bloqueio e os efeitos clínicos da adição de dextrose às soluções de levobupivacaína em diferentes concentrações para proporcionar raquianestesia unilateral em cirurgia de extremidade inferior. MÉTODOS: Estudo prospectivo, randômico e duplo-cego conduzido com 75 pacientes, estado físico ASA I-II, programados para artroplastia unilateral total do joelho. Os pacientes foram divididos em três grupos: no Grupo-I, 60 mg de dextrose foram adicionados a 7,5 mg de levobupivacaína a 0,5%; no Grupo II, 80 mg e no Grupo III, 100 mg. A raquianestesia foi aplicada ao paciente posicionado em decúbito lateral, com o lado operado abaixo, e o paciente foi mantido em posição durante 10 minutos. RESULTADOS: O tempo para o bloqueio sensorial atingir o nível T12 foi mais lento no Grupo-I do que nos grupos II e III (p < 0,05,p < 0,00). O tempo de recuperação total do bloqueio sensorial foi de 136 minutos no Grupo-I, 154 minutos no Grupo-II e 170 minutos no Grupo III. As diferenças foram estatisticamente significativas (p < 0,05). A média da duração do bloqueio motor foi de 88 minutos no Grupo-I, 105 minutos no Grupo-II e 139 minutos no Grupo-III e as diferenças foram estatisticamente significativas (p< 0,05). O tempo de micção foi significativamente menor no Grupo-I do que nos outros grupos (p < 0,00). CONCLUSÕES: Os resultados do estudo mostraram que, junto com um aumento da densidade, a duração dos bloqueios sensorial e motor foi prolongada. Pode-se concluir que uma concentração 30 mg mL-1 de dextrose adicionada a 7,5 mg de levobupivacaína é suficiente para proporcionar raquianestesia unilateral para artroscopia do joelho em regime ambulatorial.

A comparison of different densities of levobupivacaine solutions for unilateral spinal anaesthesia.

BACKGROUND AND OBJECTIVES: The aim of the study was to compare the block characteristics and clinical effects of dextrose added to levobupivacaine solutions at different concentrations to provide unilateral spinal anaesthesia in lower extremity surgery. METHODS: This prospective, randomised, double-blind study comprised 75 ASA I-II risk patients for whom unilateral total knee arthroscopy was planned. The patients were assigned to three groups: in Group I, 60mg dextrose was added to 7.5mg of 0.5% levobupivacaine, in Group II, 80mg and in Group III, 100mg. Spinal anaesthesia was applied to the patient in the lateral decubitus position with the operated side below and the patient was kept in position for 10min. RESULTS: The time for the sensorial block to achieve T12 level was slower in Group I than in Groups II and III (p<0.05, p<0.00). The time to full recovery of the sensorial block was 136min in Group I, 154min in Group II and 170min in Group III. The differences were statistically significant (p<0.05). The mean duration of the motor block was 88min in Group I, 105min in Group II, and 139min in Group III and the differences were statistically significant (p<0.05). The time to urination in Group I was statistically significantly shorter than in the other groups (p<0.00). CONCLUSIONS: The results of the study showed that together with an increase in density, the sensory and motor block duration was lengthened. It can be concluded that 30mg mL(-1) concentration of dextrose added to 7.5mg levobupivacaine is sufficient to provide unilateral spinal anaesthesia in day-case arthroscopic knee surgery.

Comparison of lidocaine, levobupivacaine or ropivacaine for distal paravertebral thoracolumbar anesthesia in ewes.

OBJECTIVE: To compare the effects of lidocaine, levobupivacaine, or ropivacaine on the onset time and duration of anesthesia of the flank of ewes, using the distal paravertebral thoracolumbar approach. STUDY DESIGN: Randomized experimental study. ANIMALS: Twenty-six healthy mixed-breed ewes (46 ± 3.1 kg). METHODS: Thoracolumbar paravertebral nerve blocks were performed using the distal approach in sheep for ruminal fistulation. The 13th thoracic (T13), first lumbar (L1) and second lumbar (L2) nerves were infiltrated with 2% lidocaine (group GLI, n = 9), 0.5% levobupivacaine (group GLE, n = 8) or 0.5% ropivacaine (group GRO, n = 9); 1.5 mL on the dorsal branch and 2.5 mL on the ventral branch, total volume of 12 mL per ewe. Anesthesia onset time and duration were assessed by application of superficial and deep pin pricks, and skin clamping with a hemostat. Heart rate, respiratory rate, rectal temperature and systemic arterial pressures were recorded prior to nerve block (T0), after the anesthetic agent injection and onset time (T1) and predetermined time points during the surgical procedure (T2-T6). RESULTS: Incomplete nerve blocks were present in five of the 26 ewes enrolled in the study and they were not included in the statistical analyzes. Onset times in GLI, GLE and GRO were 1.5 ± 0.5, 3.1 ± 1.5 and 2.1 ± 0.8 minutes, respectively, with GLE significantly longer than GLI. The durations of anesthesia for GLI, GLE and GRO were 80 ± 27, 649 ± 68 and 590 ± 40 minutes, respectively, with the duration of GLI significantly shorter than GLE and GRO. There were no clinically important changes in cardiopulmonary variables. CONCLUSION AND CLINICAL RELEVANCE: Administration of levobupivacaine and ropivacaine at the distal paravertebral site to block nerves T13, L1 and L2 produced a longer duration of anesthesia of the ewe's flanks compared with lidocaine.

Low-dose levobupivacaine plus fentanyl combination for spinal anesthesia in anorectal surgery / Combinação de levobupivacaína em dose baixa e fentanil para raquianestesia em cirurgia anorretal

BACKGROUND: the aim of this study was to investigate the effects of spinal anesthesia using two different doses of fentanyl combined with low-dose levobupivacaine in anorectal surgery. METHODS: in this prospective, double-blind study, 52 American Society of Anaesthesiologists I-II patients scheduled for elective anorectal surgery were randomized into two groups. The patients in group I received intrathecal 2.5 mg hyperbaric levobupivacaine plus 12.5 µg fentanyl and in group II received intrathecal 2.5 mg hyperbaric levobupivacaine plus 25 µg fentanyl. All the patients remained in the seated position for 5 min after completion of the spinal anesthesia. Sensory block was evaluated with pin-prick test and motor block was evaluated with a modified Bromage scale. RESULTS: motor block was not observed in both of the groups. The sensory block was limited to the S2 level in group I, and S1 level in group II. None of the patients required additional analgesics during the operation. Time to two-segment regression was shorter in group I compared with group II (p < 0.01). One patient in group I and 5 patients in group II had pruritus. Hemodynamic parameters were stable during the operation in both of the groups. CONCLUSION: spinal saddle block using hyperbaric levobupivacaine with both 12.5 µg and 25 µg fentanyl provided good quality of anesthesia without motor block for anorectal surgery in the prone position.

JUSTIFICATIVA: O objetivo deste estudo foi investigar os efeitos da raquianestesia com o uso de duas doses diferentes de fentanil em combinação com dose baixa de levobupivacaína em cirurgia anorretal. MÉTODOS: Neste estudo prospectivo e duplo-cego, 52 pacientes com estado físico ASA I-II, programados para cirurgia eletiva anorretal, foram randomicamente alocados em dois grupos. Os pacientes do Grupo I receberam 2,5 mg de levobupivacaína hiperbárica mais 12,5 µg de fentanil por via intratecal e os do Grupo II receberam 2,5 mg de levobupivacaína hiperbárica mais 25 µg de fentanil por via intratecal. Todos permaneceram em posição sentada por cinco minutos após o término da raquianestesia. O bloqueio sensorial foi avaliado com o teste da picada de agulha e o bloqueio motor com a escala modificada de Bromage. RESULTADOS: O bloqueio motor não foi observado em ambos os grupos. O bloqueio sensorial limitou-se ao nível S2 no Grupo I e S1 no Grupo II. Nenhum dos pacientes precisou de analgésico suplementar durante a operação. O tempo de regressão de dois seguimentos foi menor no Grupo I em comparação com o Grupo II (p < 0,01). Um paciente do Grupo I e cinco do Grupo II apresentaram prurido. Os parâmetros hemodinâmicos permaneceram estáveis durante a cirurgia em ambos os grupos. CONCLUSÃO: O bloqueio espinhal em sela com o uso de levobupivacaína hiperbárica, tanto com 12,5 µg quanto com 25 µg de fentanil, proporciona boa qualidade de anestesia sem bloqueio motor para cirurgia anorretal em decúbito ventral.

Low-dose levobupivacaine plus fentanyl combination for spinal anesthesia in anorectal surgery.

BACKGROUND: the aim of this study was to investigate the effects of spinal anesthesia using two different doses of fentanyl combined with low-dose levobupivacaine in anorectal surgery. METHODS: in this prospective, double-blind study, 52 American Society of Anaesthesiologists I-II patients scheduled for elective anorectal surgery were randomized into two groups. The patients in group I received intrathecal 2.5mg hyperbaric levobupivacaine plus 12.5 µg fentanyl and in group II received intrathecal 2.5mg hyperbaric levobupivacaine plus 25 µg fentanyl. All the patients remained in the seated position for 5 min after completion of the spinal anesthesia. Sensory block was evaluated with pin-prick test and motor block was evaluated with a modified Bromage scale. RESULTS: motor block was not observed in both of the groups. The sensory block was limited to the S2 level in group I, and S1 level in group II. None of the patients required additional analgesics during the operation. Time to two-segment regression was shorter in group I compared with group II (p<0.01). One patient in group I and 5 patients in group II had pruritus. Hemodynamic parameters were stable during the operation in both of the groups. CONCLUSION: spinal saddle block using hyperbaric levobupivacaine with both 12.5 µg and 25 µg fentanyl provided good quality of anesthesia without motor block for anorectal surgery in the prone position.

Comparison of different postoperative pain managements in patients submitted to transperitoneal laparoscopic renal and adrenal surgery.

PURPOSE: We compared the effects of local levobupivacaine infiltration, intravenous paracetamol, intravenous lornoxicam treatments on postoperative analgesia in patients submitted to transperitoneal laparoscopic renal and adrenal surgery. MATERIALS AND METHODS: Sixty adult patients 26 and 70 years who underwent laparoscopic renal and adrenal surgery were randomized into three groups with 20 patients each: Group 1 received local 20 mL of levobupivacaine 0.25% infiltration to the trocar incisions before skin closure. In group 2, 1g paracetamol was given to the patients intravenously 30 minutes before extubation and 5 g paracetamol was given intravenously in the 24 postoperative period. In group 3, 8 mg lornoxicam i.v. was given 30 minutes before extubation and 8 mg lornoxicam i.v. was given in the 24 postoperative period. In the postoperative period, pain scores, cumulative tramadol, and additional pethidine consumption were evaluated. RESULTS: Postoperative pain scores significantly reduced in each group (p < 0.05). Although pain levels of the groups were not significantly different at 1, 2, 4, 8, 12 and 24 hours postoperatively, cumulative tramadol consumptions were higher in group 1 than the others. (Group 1 = 370.6 ± 121.6 mg, Group 2: 220.9 ± 92.5mg, Group 3 = 240.7 ± 100.4 mg.) (p < 0.005). The average dose of pethidine administered was significantly lower in groups 2 and 3 compared with group 1 (Group 1: 145 mg, Group 2: 100mg, Group 3: 100mg) (p = 0.024). CONCLUSIONS: Levobupivacaine treated group required significantly more intravenous tramadol when compared with paracetamol and lornoxicam groups in patients submitted to transperitoneal laparoscopic renal and adrenal surgery.

Comparison of different postoperative paın managements in patients submitted to transperitoneal laparoscopic renal and adrenal surgery

ABSTRACTPurpose:We compared the effects of local levobupivacaine infiltration, intravenous paracetamol, intravenous lornoxicam treatments on postoperative analgesia in patients submitted to transperitoneal laparoscopic renal and adrenal surgery.Materials and Methods:Sixty adult patients 26 and 70 years who underwent laparoscopic renal and adrenal surgery were randomized into three groups with 20 patients each: Group 1 received local 20mL of levobupivacaine 0.25% infiltration to the trocar incisions before skin closure. In group 2, 1g paracetamol was given to the patients intravenously 30 minutes before extubation and 5g paracetamol was given intravenoulsy in the 24 postoperative period. In group 3, 8mg lornoxicam i.v. was given 30 minutes before extubation and 8mg lornoxicam i.v. was given in the 24 postoperative period. In the postoperative period, pain scores, cumulative tramadol, and additional pethidine consumption were evaluated.Results:Postoperative pain scores significantly reduced in each group (p < 0.05). Although pain levels of the groups were not significantly different at 1, 2, 4, 8, 12 and 24 hours postoperatively, cumulative tramadol consumptions were higher in group 1 than the others. (Group 1 = 370.6 ± 121.6mg, Group 2: 220.9 ± 92.5mg, Group 3 = 240.7 ± 100.4mg.) (p < 0.005). The average dose of pethidine administered was significantly lower in groups 2 and 3 compared with group 1 (Group 1: 145mg, Group 2: 100mg, Group 3: 100mg) (p = 0.024).Conclusions:Levobupivacaine treated group required significantly more intravenous tramadol when compared with paracetamol and lornoxicam groups in patients submitted to transperitoneal laparoscopic renal and adrenal surgery.

Deaths from homicides: a historical series / Mortes por homicídios: série histórica / Muertes por homicidios: serie histórica

OBJECTIVE: to describe mortality from homicides in Itabuna, in the State of Bahia. METHOD: study with hybrid, ecological and time-trend design. The mortality coefficients per 1,000 inhabitants, adjusted by the direct technique, proportional mortality by sex and age range, and Potential Years of Life Lost were all calculated. RESULTS: since 2005, the external causes have moved from third to second most-common cause of death, with homicides being responsible for the increase. In the 13 years analyzed, homicides have risen 203%, with 94% of these deaths occurring among the male population. Within this group, the growth occurred mainly in the age range from 15 to 29 years of age. It was ascertained that 83% of the deaths were caused by firearms; 57.2% occurred in public thoroughfares; and 98.4% in the urban zone. In 2012, the 173 homicides resulted in 7,837 potential years of life lost, with each death causing, on average, the loss of 45.3 years. CONCLUSIONS: mortality by homicide in a medium-sized city in Bahia reaches levels observed in the big cities of Brazil in the 1980s, evidencing that the phenomenon of criminality - formerly predominant only in the big urban centers - is advancing into the rural area of Brazil, causing changes in the map of violent homicide in Brazil. .

OBJETIVO: descrever a mortalidade por homicídios em Itabuna, Bahia. MÉTODO: estudo com delineamento híbrido, ecológico e de tendência temporal. Foram calculados os coeficientes de mortalidade por 1.000 habitantes, ajustados pela técnica direta, mortalidade proporcional segundo sexo e faixa etária e anos potenciais de vida perdidos. RESULTADOS: desde 2005 as causas externas passaram de terceira para segunda causa de morte, sendo os homicídios responsáveis pelo incremento. Nos 13 anos analisados, os homicídios ascenderam 203%, com 94% desses óbitos incidindo na população masculina. Entre essa, o crescimento se deu principalmente na faixa etária de 15 a 29 anos de idade. Apurou-se que 83% das mortes foram por arma de fogo, 57,2% ocorreram em via pública e 98,4% na zona urbana. Em 2012, os 173 homicídios ocasionaram 7.837 anos potenciais de vida perdidos, com cada óbito provocando, em média, a perda de 45,3 anos. CONCLUSÕES: a mortalidade por homicídios em uma cidade de médio porte, na Bahia, atinge índices observados nas grandes metrópoles do país na década 1980, evidenciando que o fenômeno da criminalidade violenta - antes predominante apenas nos grandes centros urbanos - avança para o interior, provocando mudanças no mapa da violência homicida do país. .

OBJETIVO: describir la mortalidad por homicidios en Itabuna-Bahía. MÉTODO: estudio con delineamiento híbrido, ecológico y de tendencia temporal. Fueron calculados los coeficientes de mortalidad por 1.000 habitantes ajustados por la técnica directa, la mortalidad proporcional según sexo e intervalo de edad y los Años Potenciales de Vida Perdidos. RESULTADOS: desde 2005 las causas externas pasaron de la tercera para la segunda causa de muerte, siendo los homicidios responsables por el incremento. En los 13 años analizados, los homicidios ascendieron 203%, con 94% de esas muertes ocurriendo en la población masculina. Entre esta, el crecimiento sucedió principalmente en el intervalo de edad de 15 a 29 años de edad. Se encontró que 83% de las muertes fueron por arma de fuego; 57,2% ocurrieron en la vía pública; y 98,4% en la zona urbana. En 2012, los 173 homicidios ocasionaron 7.837 años potenciales de vida perdidos, con cada muerte provocando, en promedio, la pérdida de 45,3 años. CONCLUSIONES: la mortalidad por homicidios en una ciudad de porte medio en Bahía alcanza índices observados en las grandes metrópolis del país en la década de 1980, evidenciando que el fenómeno de la criminalidad violenta - antes predominante apenas en los grandes centros urbanos - avanza para el interior provocando cambios en el mapa de la violencia homicida del país. .