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• W2110489715 abstract "I read with interest the article by Marret et al.1Marret E. Gentili M. Bonnet M.P. Bonnet F. Intra-articular ropivacaine 0.75% and bupivacaine 0.50% for analgesia after arthroscopic knee surgery A randomized prospective study.Arthroscopy. 2005; 21: 313-316Abstract Full Text Full Text PDF PubMed Scopus (38) Google Scholar in which they reported on their randomized prospective study comparing intra-articular ropivacaine 0.75% and bupivacaine 0.5%. Although I agree with the authors that ropivacaine has a lower toxic effect than bupivacaine, it occurred to me that there were some points that would add to this discussion. The authors stipulate that the maximum recommended dose of bupivacaine is 150 mg. Accordingly, they believe that ropivacaine doses of 200 mg and even higher can be administered to patients without producing any toxic symptoms. Recommendations for a single dose of local anesthetic that do not take into account the site of injection are of little value.2Rosenberg P.H. Veering B.T. Urmey W.F. Maximum recommended doses of local anesthetics A multifactorial concept.Reg Anesth Pain Med. 2004; 29: 564-575PubMed Google Scholar There is some variation in the officially recommended highest doses of local anesthetics in different countries; the range for bupivacaine is 150 to 175 mg and for ropivacaine is 200 to 225 mg.2Rosenberg P.H. Veering B.T. Urmey W.F. Maximum recommended doses of local anesthetics A multifactorial concept.Reg Anesth Pain Med. 2004; 29: 564-575PubMed Google Scholar This recommended maximum dose is not evidence based, but more likely based on experience.2Rosenberg P.H. Veering B.T. Urmey W.F. Maximum recommended doses of local anesthetics A multifactorial concept.Reg Anesth Pain Med. 2004; 29: 564-575PubMed Google Scholar The pharmacokinetic profile of local anesthetics is influenced by the site of administration and, to my knowledge, plasma levels after administration of intra-articular local anesthetics are still not well known. The authors reported that doses of bupivacaine exceeding 150 mg may lead to a high risk of systemic toxicity. They based this on 2 case reports.3Liguori G.A. Chimento G.F. Borow L. Figgie M. Possible bupivacaine toxicity after intraarticular injection for postarthroscopic analgesia of the knee Implications of the surgical procedure.Anesth Analg. 2002; 94: 1010-1013Crossref PubMed Scopus (28) Google Scholar, 4Sullivan S.G. Abbott Jr, P.J. Cardiovascular toxicity associated with intraarticular bupivacaine.Anesth Analg. 1994; 79: 591-593Crossref PubMed Scopus (23) Google Scholar Nevertheless, direct intravascular injection is the most probable cause of the systemic toxicity in these case reports, because symptoms happened during or immediately after the injection. Accordingly, 225 mg of ropivacaine could have induced similar systemic toxicity if injected directly in a blood vessel, and nobody can predict the patient’s outcome even if ropivacaine has a lower toxic effect.Although the authors used the maximum recommended doses of both local anesthetics, I still wonder why bupivacaine in this study was no more effective than placebo, and by which mechanism ropivacaine—a similar amide-linked local anesthetic—was more effective. In my opinion, from a clinical and not a statistical point of view there was no significant difference between ropivacaine and bupivacaine, and VAS scores at rest and movement were almost identical at 2, 6, and 24 hours. Furthermore, because many factors influence pain scoring during anesthesia recovery, I believe that VAS scores at 15 minutes do not reflect the real pain status of the patient. This work raises the interesting question about the real analgesic effect of intra-articular local anesthetics, especially ropivacaine, and about the benefit/risk ratio of this technique.In conclusion, intra-articular administration of local anesthetics provides short-term analgesia or no analgesia at all. For this reason I believe that other analgesia techniques, especially peripheral nerve blocks, are safer and provide better pain relief of longer duration. I read with interest the article by Marret et al.1Marret E. Gentili M. Bonnet M.P. Bonnet F. Intra-articular ropivacaine 0.75% and bupivacaine 0.50% for analgesia after arthroscopic knee surgery A randomized prospective study.Arthroscopy. 2005; 21: 313-316Abstract Full Text Full Text PDF PubMed Scopus (38) Google Scholar in which they reported on their randomized prospective study comparing intra-articular ropivacaine 0.75% and bupivacaine 0.5%. Although I agree with the authors that ropivacaine has a lower toxic effect than bupivacaine, it occurred to me that there were some points that would add to this discussion. The authors stipulate that the maximum recommended dose of bupivacaine is 150 mg. Accordingly, they believe that ropivacaine doses of 200 mg and even higher can be administered to patients without producing any toxic symptoms. Recommendations for a single dose of local anesthetic that do not take into account the site of injection are of little value.2Rosenberg P.H. Veering B.T. Urmey W.F. Maximum recommended doses of local anesthetics A multifactorial concept.Reg Anesth Pain Med. 2004; 29: 564-575PubMed Google Scholar There is some variation in the officially recommended highest doses of local anesthetics in different countries; the range for bupivacaine is 150 to 175 mg and for ropivacaine is 200 to 225 mg.2Rosenberg P.H. Veering B.T. Urmey W.F. Maximum recommended doses of local anesthetics A multifactorial concept.Reg Anesth Pain Med. 2004; 29: 564-575PubMed Google Scholar This recommended maximum dose is not evidence based, but more likely based on experience.2Rosenberg P.H. Veering B.T. Urmey W.F. Maximum recommended doses of local anesthetics A multifactorial concept.Reg Anesth Pain Med. 2004; 29: 564-575PubMed Google Scholar The pharmacokinetic profile of local anesthetics is influenced by the site of administration and, to my knowledge, plasma levels after administration of intra-articular local anesthetics are still not well known. The authors reported that doses of bupivacaine exceeding 150 mg may lead to a high risk of systemic toxicity. They based this on 2 case reports.3Liguori G.A. Chimento G.F. Borow L. Figgie M. Possible bupivacaine toxicity after intraarticular injection for postarthroscopic analgesia of the knee Implications of the surgical procedure.Anesth Analg. 2002; 94: 1010-1013Crossref PubMed Scopus (28) Google Scholar, 4Sullivan S.G. Abbott Jr, P.J. Cardiovascular toxicity associated with intraarticular bupivacaine.Anesth Analg. 1994; 79: 591-593Crossref PubMed Scopus (23) Google Scholar Nevertheless, direct intravascular injection is the most probable cause of the systemic toxicity in these case reports, because symptoms happened during or immediately after the injection. Accordingly, 225 mg of ropivacaine could have induced similar systemic toxicity if injected directly in a blood vessel, and nobody can predict the patient’s outcome even if ropivacaine has a lower toxic effect. Although the authors used the maximum recommended doses of both local anesthetics, I still wonder why bupivacaine in this study was no more effective than placebo, and by which mechanism ropivacaine—a similar amide-linked local anesthetic—was more effective. In my opinion, from a clinical and not a statistical point of view there was no significant difference between ropivacaine and bupivacaine, and VAS scores at rest and movement were almost identical at 2, 6, and 24 hours. Furthermore, because many factors influence pain scoring during anesthesia recovery, I believe that VAS scores at 15 minutes do not reflect the real pain status of the patient. This work raises the interesting question about the real analgesic effect of intra-articular local anesthetics, especially ropivacaine, and about the benefit/risk ratio of this technique. In conclusion, intra-articular administration of local anesthetics provides short-term analgesia or no analgesia at all. For this reason I believe that other analgesia techniques, especially peripheral nerve blocks, are safer and provide better pain relief of longer duration. Intra-articular ropivacaine 0.75% and bupivacaine 0.50% for analgesia after arthroscopic knee surgery: A randomized prospective studyArthroscopyVol. 21Issue 3PreviewPurpose: Intra-articular administration of local anesthetic solution provides analgesia after arthroscopic knee surgery. Bupivacaine is considered the gold standard local anesthetic in this indication, but ropivacaine, which is less toxic than bupivacaine, can consequently be administered in higher doses, potentially increasing the duration of analgesia. We compared the analgesic effect of intra-articular injection of ropivacaine 225 mg and bupivacaine 150 mg in patients undergoing arthroscopic surgery. Full-Text PDF Author’s ReplyArthroscopyVol. 21Issue 11PreviewWe thank Dr. Al-Nasser for his comments on our article concerning the comparison of intra-articular bupivacaine and ropivacaine. Dr. Al-Nasser questions the maximum recommended dose of bupivacaine and ropivacaine according to the fact that the toxic threshold depends on the site of injection and on the features of each patient. We agree that plasma absorption of local anesthetics depends on the site of injection and that plasma concentrations below toxic threshold have been measured after intra-articular injection of bupivacaine, probably related to a limited or slow absorption. Full-Text PDF" @default.
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• W2110489715 title "Clinical significance of intra-articular local anesthetics" @default.
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