On paediatric regional anaesthesia : The use of paravertebral blockade, aspects on plasma protein binding, and systemic toxicity of local anaesthetics
Author: Lönnqvist, PA
Date: 1996-05-15
Location: Lars Leksells auditorium, Medicinhistoriska museet
Time: 9.00
Abstract
Paediatric regional anaesthesia has gained widespread popularity during
recent yearsbecause of an excellent potential for intra- and
postoperative pain relief and reduction of thesurgically induced stress
response. The aim of the present thesis was to adapt and develop
thetechnique of paravertebral blockade (PVB) for the safe use in
paediatric patients and also toinvestigate aspects on plasma protein
binding and toxicity of local anaesthetic drugs whichmight be of
importance in the special settings of paediatric anaesthesia. The optimal
landmarks for puncture of the thoracic paravertebral space (PVS) was
derivedfrom computed tomography and clinical measurements and were found
to correlate well withpatient weight (r = 0.94-0.95). The lateral
distance from the spinous process and the depthfrom the skin to the PVS
can be calculated from the equations: lateral distance (mm) = 0.12kg +
10.2 and depth (mm) = 0.53 kg + 21.2. Retrospective data indicate that
the PVB iscapable of providing similar postoperative pain relief in
children undergoing renal surgery withan unilateral incision compared to
lumbar epidural blocks. In a prospective multi-centre studythe failure
rate and complications associated with PVB were studied in a mixed
population ofadult and paediatric patients and PVB was found comparable
in these aspects to otherestablished alternative regional techniques.
Plasma concentrations of lidocaine after bolusinjection (5 mg . kg-1 )
and subsequent infusion (2.5 mg .kg-1 h-1 ) of lidocaine with
adrenalineinto the PVS were found to be well below the levels associated
with side effects or toxicity. In vitro studies of the effects of
hypothermia and haemodilution on the plasma proteinbinding (PPB) of
lidocaine, assessed by ultrafiltration, were carried out on blood
collectedfrom healthy, medication free, adult volunteers. A significant
reduction in PPB could beobserved between 37 and 24 ¡C but a further
decrease in temperature did not cause anyaddition reduction in PPB. Even
moderate degrees of dilution of the plasma phase of the bloodwill cause a
decrease in PPB but the PPB was not found to be affected by changes
inhaemotocrit. In order to confirm a clinical impression of side effects
or even early signs ofcentral nervous system toxicity in ex-premature
infants undergoing awake caudal anaesthesia,unblinded assessments of
behavioural changes before and twenty minutes after the performanceof a
caudal block with bupivacaine (3.1 mg . kg-1) were compared with blinded
evaluations ofsimultaneously performed EEG recordings. An integrated
evaluation of the findings supportthe occurrence of systemic side effects
and signs of early CNS toxicity at plasma concentra-tions of bupivacaine
within the 0.56-1.62 . mg ml-1 range.The current thesis delineate the use
of paravertebral blockade in paediatric patients and hasalso elucidated
some aspects of plasma protein binding and toxicity of local anaesthetic
drugsthat are of special interest in paediatric regional anaesthesia.Key
words: Anesthesia, regional, paravertebral; Children, infants; Local
anesthetics,bupivacaine, lidocaine; Pharmacokinetics; Plasma protein
binding; Side effects; Toxicity.PA Lönnqvist: On paediatric regional
anaesthesia: The use of paravertebral blockade, aspectson plasma protein
binding, and systemic toxicity of local anaesthetics. Stockholm 1996.ISBN
91-628-1974-7
Issue date: 1996-04-24
Publication year: 1996
ISBN: 91-628-1974-7
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