Case Series of Adaptive Changes in Clinical Practice and Trainee Education for Cesarean Delivery due to Drug Shortages of 0.75% Hyperbaric Bupivacaine in 2018.

Hyperbaric bupivacaine, the local anesthetic routinely selected for single-injection spinal anesthesia for cesarean delivery (CD), was in short supply in 2018. Hospital stocks were significantly less than before and after the shortage period. We developed a contingency plan to communicate with pharmacy and retrieve, restrict, and reallocate remaining stocks of drug to continue performing CD under neuraxial anesthesia, specifically spinal anesthesia for emergency CD, when time appropriate. Retrospective chart review revealed that elective and emergency CDs were performed without delays or increase in rate of general anesthesia during this period. However, trainees had fewer opportunities to perform spinal anesthesia for CD.

Considerations for Management of Bupivacaine Formulation Shortage Affecting Obstetric Anesthesia Services.

Healthcare facilities across North America are experiencing a shortage of several formulations of bupivacaine affecting analgesia and anesthesia care, particularly for obstetric services. This editorial will discuss evidence-based considerations to address the bupivacaine shortage including interprofessional team engagement for planning, alternative anesthetic and analgesic management strategies for the obstetrical patient, and safe drug preparation. As leaders in healthcare, nurse anesthetists are encouraged to work closely with their anesthesia, pharmacy, obstetric, and facility leadership to develop best alternative solutions during this drug shortage to provide safe analgesic and anesthetic care.

Análisis de la regresión temporal en el ensanchamiento del intervalo QRS inducido por bupivacaína con la administración de Intralipid. Estudio en un modelo experimental porcino / Analysis of the temporal regression of the QRS widening induced by bupivacaine after Intralipid administration. Study in an experimental porcine model

Objetivo: La toxicidad cardiaca inducida por la bupivacaína (B) se relaciona con el bloqueo de los canales de sodio, que se traduce por un ensanchamiento del intervalo QRS. Estudios experimentales recientes, sugieren que el Intralipid (IL) es eficaz en revertir la toxicidad cardiaca de la B. Nuestro objetivo fue analizar la evolución temporal del ensanchamiento del QRS inducido por la B con la administración de IL. Material y método: Doce cerdos fueron anestesiados con tiopental sódico, 5 mg kg−1, y sevoflurano a concentración alveolar mínima de 2,6%. Tras la instrumentalización se administró un bolo de B de 4-6 mg kg−1 con el objetivo de inducir un aumento de 150% en la duración del QRS. El grupo IL recibió 1,5 mL kg−1 de IL seguido de 0,25 mL kg min−1; el grupo control (C) recibió salino. Se registraron los parámetros electrocardiográficos tras la infusión de B y a 1, 5,10 y 30 min de la administración de Intralipid/salino. Resultados: La administración de B (4,33°æ 0,81 mg/kg en el grupo IL y 4,66°æ 1,15 mg/kg en el grupo C) indujo cambios electrocardiográficos similares en ambos grupos; el porcentaje medio de incremento máximo en el QRS fue de 184°æ 62% en el grupo IL, y de 230°æ 56% en el grupo C. El IL revirtió el ensanchamiento del QRS inducido por la B, a los 10 min de su administración el intervalo QRS disminuyó 132°æ 56% vs. 15°æ 76%, en relación al máximo incremento inducido por la B, en el grupo IL y grupo C respectivamente. Conclusión: El IL revirtió eficazmente el ensanchamiento del intervalo QRS inducido por la B. El tiempo hasta la normalización de los parámetros electrocardiográficos puede prolongarse más de 10 min. Mientras persistan los fenómenos de toxicidad cardíaca, las medidas de resucitación y monitorización deben continuarse hasta que los parámetros de conducción cardíaca se hayan restaurado de forma adecuada (AU)

Objective: The principal mechanism of cardiac toxicity of bupivacaine relates to the blockade of myocardial sodium channels, which leads to an increase in the QRS duration. Recently, experimental studies suggest that lipid emulsion is effective in reversing bupivacaine cardiac toxicity. We aimed to evaluate the temporal evolution of the QRS widening induced by bupivacaine with the administration of Intralipid. Material and methods: Twelve pigs were anesthetized with intravenous sodium thiopental 5 mg kg−1 and sevoflurane 1 MAC (2.6%). Femoral artery and vein were canalized for invasive monitoring, analysis of blood gases and determination of bupivacaine levels. After instrumentation and monitoring, a bupivacaine bolus of 4-6 mg kg−1 was administered in order to induce a 150% increase in QRS duration (defined as the toxic point). The pigs were randomized into two groups of six individuals. Intralipid group (IL) received 1.5 mL kg−1of IL over one minute, followed by an infusion of 0.25 mL kg min−1. Control group (C) received the same volume of a saline solution. The electrocardiographic parameters were recorded, and blood samples were taken after bupivacaine and 1, 5, 10 and 30 minutes after Intralipid/saline administration. Results: Bupivacaine (4.33°æ 0.81 mg/kg in IL group and 4.66°æ 1.15 mg/kg in C group) induced similar electrocardiographic changes in both groups; mean maximal percent increase in QRS interval was 184°æ 62% in IL group, and 230°æ 56% in control group (NS). Lipid administration reversed the QRS widening previously impaired by bupivacaine. After ten minutes of the administration of IL, the mean QRS interval decreased to 132°æ 56% vs. 15°æ 76% relative to the maximum widening induced by bupivacaine, in IL and C group, respectively. Conclusion: Intralipid reversed the lengthening of QRS interval induced by the injection of bupivacaine. Time to normalization of electrocardiographic parameters can last more than 10 minutes. While the phenomena of cardiac toxicity persist, resuscitation measures and adequate monitoring should be continued until adequate heart conduction parameters are restored (AU)

The effect of pH buffering on reducing the pain associated with subcutaneous infiltration of bupivicaine.

The authors propose that pH buffering of bupivicaine with sodium bicarbonate reduces the pain associated with its local subcutaneous infiltration. In a double-blind, prospective study, 62 healthy adult volunteers received a 0.5 mL subcutaneous infiltration of 0.5% buffered bupivicaine into the dorsum of a randomly chosen hand. The pH was adjusted to 7.0 by adding 0.05 mL of sodium bicarbonate (1 mEq/L [corrected]) to 10 mL vials of commercially available bupivicaine (1:200 dilution). The control hand was injected with the same amount of unbuffered agent. Pain was scored after each infiltration using a nonsegmented visual analogue scale. Student's t-test for paired measurements was used to analyze intergroup pain score differences. Forty-three subjects (69%) reported less pain with buffered bupivicaine and only 17 (27%) noted a modest increase: two subjects (3%) reported no difference. The mean pain score for the buffered agent was 22 mm compared with 30 mm for the control. The mean difference (control-experimental) was 8 mm (t = 4.64, df = 61, P less than .001). The authors conclude that the addition of sodium bicarbonate to bupivicaine reduces the pain associated with its local infiltration.