Drugs and Clinical Pharmacology of Central Blocks in Infants and Children

Part of the Anesthesia, Intensive Care and Pain in Neonates and Children book series (AICPNC)

Abstract

Even though more than 100 years have passed since the first description of the use of central blocks in children (Bier, 1899, Tyrell-Gray, 1909), there are still new and important things to learn within this particular field of anesthesia. Therefore, to perform safe and effective regional anesthesia in infants and children, a solid knowledge of the age-related pharmacology of both local anesthetics and their adjuncts is an absolute prerequisite. Although not as extensive as in adults, the published literature within the field of clinical pharmacology of local anesthetics and their adjuncts in infants and children is quite substantial at this point in time.

Keywords

Human Serum Albumin Local Anesthetic Complex Regional Pain Syndrome Brugada Syndrome Epidural Block 
These keywords were added by machine and not by the authors. This process is experimental and the keywords may be updated as the learning algorithm improves.

References

  1. 1.
    Lönnqvist PA (2012) Toxicity of local anesthetic drugs: a pediatric perspective. Paediatr Anaesth 22:39–43PubMedCrossRefGoogle Scholar
  2. 2.
    Walker SM, Westin BD, Deumens R et al. (2010) Effects of Intrathecal Ketamine in the Neonatal Rat: Evaluation of Apoptosis and Long-term Functional Outcome. Anesthesiology 113:147159CrossRefGoogle Scholar
  3. 3.
    Westin BD, Walker SM, Deumens R et al. (2010) Validation of a Preclinical Spinal Safety Model: Effects of Intrathecal Morphine in the Neonatal Rat. Anesthesiology 113:183–199PubMedCrossRefGoogle Scholar
  4. 4.
    Walker SM, Grafe M, Yaksh TL (2012) Intrathecal clonidine in the neonatal rat: dose-dependent analgesia and evaluation of spinal apoptosis and toxicity. Anest Analg 2012; in pressGoogle Scholar
  5. 5.
    Lonnqvist PA, Walker SM (2012) Ketamine as an adjunct to caudal blockade in neonates and infants: is it time to re-evaluate? Br J Anaesth 2012; in pressGoogle Scholar
  6. 6.
    Lonnqvist PA, Ivani G, Moriarty T (2002) Use of caudal-epidural opioids in children: still state of the art or the beginning of the end? Paediatr Anaesth 12:747–749.PubMedCrossRefGoogle Scholar
  7. 7.
    Lonnqvist PA (2012) Alpha-2 adrenoceptor agonists as adjuncts to Peripheral Nerve Blocks in Children-is there a mechanism of action and should we use them? Paediatr Anaesth 22:421–424PubMedCrossRefGoogle Scholar
  8. 8.
    Lonnqvist PA(2005) Adjuncts to caudal block in children — Quo vadis? Br J Anaesth 95:431–433PubMedCrossRefGoogle Scholar

References of the Review Article

  1. 1.
    Catterall WA (2002) Molecular mechanisms of gating and drug block of sodium channels. Novartis Found Symp 241:206–218PubMedCrossRefGoogle Scholar
  2. 2.
    Mazoit JX, Dalens BJ (2004) Pharmacokinetics of local anaesthetics in infants and children. Clin Pharmacokinet 43:17–32PubMedCrossRefGoogle Scholar
  3. 3.
    Nau C, Strichartz GR (2002) Drug chirality in anesthesia. Anesthesiology 97:497–502PubMedCrossRefGoogle Scholar
  4. 4.
    Cartwright PD, Fyhr P (1988) The manufacture and storage of local anesthetics. Reg Anesth 13:1–12Google Scholar
  5. 5.
    Mazoit JX, Denson DD, Samii K (1988) Pharmacokinetics of bupivacaine following caudal anesthesia in infants. Anesthesiology 68:387–391PubMedCrossRefGoogle Scholar
  6. 6.
    Mazoit JX, Denson DD, Samii K (1996) Pharmaisolated albumin and isolated alpha-1-acid glycoprotein. Differences between the two enantiomers are partly due to cooperativity. J Pharmacol Exp Ther 276:109–115Google Scholar
  7. 7.
    Meunier JF, Goujard E, Dubousset AM et al. (2001) Pharmacokinetics of bupivacaine after continuous epidural infusion in infants with and without biliary atresia. Anesthesiology 95:87–95PubMedCrossRefGoogle Scholar
  8. 8.
    Sitbon P, Laffon M, Lesage V et al. (1997) Lidocaine plasma concentrations in pediatric patients after providing airway topical anesthesia from a calibrated device. Anesth Russell SC, Doyle E. A risk-benefit assessment of topical percutaneous local anaesthetics in children. Drug Saf 16:279–287CrossRefGoogle Scholar
  9. 9.
    Taddio A, Ohlsson A, Einarson TR et al. (1998) A systematic review of lidocaine-prilocaine cream (EMLA) in the treatment of acute pain in neonates. Pediatrics 101:E1PubMedCrossRefGoogle Scholar
  10. 10.
    Russell SC, Doyle E (1997) A risk-benefit assessment of topical percutaneous local anaesthetics in children. Drug Saf 16:279–287PubMedCrossRefGoogle Scholar
  11. 11.
    Burm AGL (1989) Clinical pharmacokinetics of epidural and spinal anesthesia. Clin Pharmacokinet 16:283–311PubMedCrossRefGoogle Scholar
  12. 12.
    Ecoffey C, Desparmet J, Berdeaux A et al. (1984) Pharmacokinetics of lidocaine in children following caudal anaesthesia. Br J Anaesth 56:1399–1402PubMedCrossRefGoogle Scholar
  13. 13.
    Ecoffey C, Desparmet J, Berdeaux A et al. (2004) Bupivacaine in children: pharmacokinetics children under 2 years of age. Br J Anaesth 92:218–222CrossRefGoogle Scholar
  14. 14.
    Chalkiadis GA, Eyres RL, Cranswick N et al. (2004) Pharmacokinetics of levobupivacaine 0.25% following caudal administration in children under 2 years of age. Br J Anaesth 92:218–222PubMedCrossRefGoogle Scholar
  15. 15.
    Cortinez LI, Fuentes R, Solari S et al. (2008) Pharmacokinetics of levobupivacaine (2.5 mg/kg) after caudal administration in children younger than 3 years. Anesth Analg 107:11821184Google Scholar
  16. 16.
    Desparmet J, Meistelman C, Barre J et al. (1987) Continuous epidural infusion of bupiva- caine for postoperative pain relief in children. Anesthesiology 67:108–110PubMedCrossRefGoogle Scholar
  17. 17.
    Lerman J, Nolan J, Eyres R et al. (2003) Efficacy, safety, and pharmacokinetics of levobupivacaine with and without fentanyl after continuous epidural infusion in children: a multicenter trial. Anesthesiology 99:1166–1174PubMedCrossRefGoogle Scholar
  18. 18.
    Ala-Kokko TI, Partanen A, Karinen J et al. (2000) Pharmacokinetics of 0.2% ropivacaine and 0.2% bupivacaine following caudal blocks in children. Acta Anaesthesiol Scand 44:1099–1102PubMedCrossRefGoogle Scholar
  19. 19.
    Lonnqvist PA, Westrin P, Larsson BA et al. (2000) Ropivacaine pharmacokinetics after caudal block in 1–8 year old children. Br J Anaesth 85:506–511PubMedCrossRefGoogle Scholar
  20. 20.
    Emanuelsson BM, Persson J, Sandin S et al. (1997) Intraindividual and interindividual variability in the disposition of the local anesthetic ropivacaine in healthy subjects. Ther Drug Monit 19:126–131PubMedCrossRefGoogle Scholar
  21. 21.
    Hansen TG, Ilett KF, Reid C et al. (2001) Caudal ropivacaine in infants: population phar- macokinetics and plasma concentrations. Anesthesiology 94:579–584PubMedCrossRefGoogle Scholar
  22. 22.
    McCann ME, Sethna NF, Mazoit JX et al. (2001) The pharmacokinetics of epidural ropiva- caine in infants and young children. Anesth Analg 93:893–897PubMedCrossRefGoogle Scholar
  23. 23.
    Bosenberg AT, Thomas J, Cronje L et al. (1998) Pharmacokinetics and efficacy of ropi- vavoxamine and ketoconazole as in vivo inhibitors. Clin Pharmacol Ther 64:484–491CrossRefGoogle Scholar
  24. 24.
    Rapp HJ, Molnar V, Austin S et al. (2004) Ropivacaine in neonates and infants: a population pharmacokinetic evaluation following single caudal block. Pediatr Anesth 14:724–732CrossRefGoogle Scholar
  25. 25.
    Berde CB, Yaster M, Meretoja O et al. (2008) Stable plasma concentrations of unbound ropi- vacaine during postoperative epidural infusion for 24–72 hours in children. Eur J Anaesthe- siol 25:410–417CrossRefGoogle Scholar
  26. 26.
    Dalens B, Ecoffey C, Joly A et al. (2001) Pharmacokinetics and analgesic effect of ropivacaine following ilioinguinal/iliohypogastric nerve block in children. Paediatr Anaesth 11:415–420PubMedCrossRefGoogle Scholar
  27. 27.
    Arlander E, Ekstrom G, Alm C et al. (1998) Metabolism of ropivacaine in humans is mediated by CYP1A2 and to a minor extent by CYP3A4: an interaction study with fluvoxamine and ketoconazole as in vivo inhibitors. Clin Pharmacol Ther 64:484–491PubMedCrossRefGoogle Scholar
  28. 28.
    Gantenbein M, Attolini L, Bruguerolle B et al. (2000) Oxidative metabolism of bupivacaine into pipecolylxylidine in humans is mainly catalyzed by CYP3A. Drug Metab Dispos 28:383–385PubMedGoogle Scholar
  29. 29.
    Burm AG, van der Meer AD, van Kleef JW et al. (1994) Pharmacokinetics of the enantiomers of bupivacaine following intravenous administration of the racemate. Br J Clin Pharmacol 38:125–129PubMedCrossRefGoogle Scholar
  30. 30.
    Burm AGL, Vermeulen NPE, Van Kleef JW et al. (1987) Pharmacokinetics of lidocaine and bupivacaine in surgical patients following epidural administration. Simultaneous investigation of absorption and disposition kinetics using stable isotopes. Clin Pharmacokinet 13:191–203Google Scholar
  31. 31.
    Burm AG, Stienstra R, Brouwer RP et al. (2000) Epidural infusion of ropivacaine for postoperative analgesia after major orthopedic surgery: pharmacokinetic evaluation. Anesthesi- ology 93:395–403CrossRefGoogle Scholar
  32. 32.
    Scott DB, Lee A, Fagan D et al. (1989) Acute toxic ity of ropivacaine compared with that of bupivacaine. Anesth Analg 69:563–569PubMedGoogle Scholar
  33. 33.
    Knudsen K, Beckman Suurküla M, Blomberg S et al. (1997) Central nervous and cardiovascular effects of i.v. infusions of ropivacaine, bupivacaine and placebo in volunteers. Br J Anaesth 78:507–514PubMedCrossRefGoogle Scholar
  34. 34.
    Bardsley H, Gristwood R, Baker H et al. (1998) A comparison of the cardiovascular effects of levobupivacaine and rac-bupivacaine following intravenous administration to healthy volunteers. Br J Clin Pharmacol 46:245–249PubMedCrossRefGoogle Scholar
  35. 35.
    Stewart J, Kellett N, Castro D (1995) The central nervous system and cardiovascular effects of levobupivacaine and ropivacaine in healthy tricular myocytes. Circulation 92:3014–3024CrossRefGoogle Scholar
  36. 36.
    Maxwell LG, Martin LD, Yaster M (1994) Bupivacaine-induced cardiac toxicity in neonates:successful treatment with intravenous phenytoin. Anesthesiology 80:682–686PubMedCrossRefGoogle Scholar
  37. 37.
    Hubler M, Gabler R, Ehm B et al. (2010) Successful resuscitation following opivacaine-in- duced systemic toxicity in a neonate. Anaesthesia 65:1137–1140PubMedCrossRefGoogle Scholar
  38. 38.
    Longobardo M, Delpon E, Caballero R et al. (1998) Structural determinants of potency and stereoselective block of hKv1.5 channels induced by local anesthetics. Mol Pharmacol 54:162–169PubMedGoogle Scholar
  39. 39.
    Gonzalez T, Arias C, Caballero R et al. (2002) Effects of levobupivacaine, ropivacaine and bupivacaine on HERG channels: stereoselective bupivacaine block. Br J Pharmacol 137:1269–1279PubMedCrossRefGoogle Scholar
  40. 40.
    Valenzuela C, Snyders DJ, Bennett PB et al. (1995) Stereoselective block of cardiac sodium channels by bupivacaine in guinea pig ventricular myocytes. Circulation 92:3014–3024PubMedCrossRefGoogle Scholar
  41. 41.
    Komai H, Lokuta AJ (1999) Interaction of bupivacaine and tetracaine with the sarcoplasmic reticulum Ca2+ release channel of skeletal and cardiac muscles. Anesthesi- ology 90:835–843CrossRefGoogle Scholar
  42. 42.
    Zapata-Sudo G, Trachez MM, Sudo RT et al. (2001) Is comparative cardiotoxicity of S()) and R(+) bupivacaine related to enantio- mer-selective inhibition of L-type Ca(2+) channels? Anesth Analg 92:496–501PubMedCrossRefGoogle Scholar
  43. 43.
    Raymond SA, Thalhammer JG, Strichartz GR (1989) Axonal excitability: endogenous and exogenous modulation, in Dimitrijevic Ed Altered sensation and Pain. Recent Achievement in Restorative Neurology, Vol 3, Karger Basel 1990, cited by Raymond SA and Strichartz GR. The long and short of differential block (Editorial). Anesthesiology 70:725–728PubMedCrossRefGoogle Scholar
  44. 44.
    Vabnick I, Novakovic SD, Levinson SR et al. (1996) The clustering of axonal sodium channels during development of the peripheral nervous system. J Neurosci 16:4914–4922PubMedGoogle Scholar
  45. 45.
    Rasband MN, Trimmer JS (2001) Developmental clustering of ion channels at and near the node of Ranvier. Dev Biol 236:5–16PubMedCrossRefGoogle Scholar
  46. 46.
    Kohane DS, Sankar WN, Shubina M et al. (1998) Sciatic nerve blockade in infant, adolescent, and adult rats: a comparison of ropivacaine with bupivacaine. Anesthesiology 89:1199–1208PubMedCrossRefGoogle Scholar
  47. 47.
    Greitz D, Hannerz J (1996) A proposed model of cerebrospinal fluid circulation: observations with radionuclide cisternography. AJNR Am J Neuroradiol 17:431–438PubMedGoogle Scholar
  48. 48.
    Wachi A, Kudo S, Sato K (1989) Characteristics of cerebrospinal fluid circulation in infants as detected with MR velocity imaging. Acta Anaesthesiol Scand 33:385–388CrossRefGoogle Scholar
  49. 49.
    Booth D, Evans DJ (2004) Anticonvulsants for neonates with seizures. Cochrane Database Syst Rev 4:CD004218PubMedGoogle Scholar
  50. 50.
    de La Coussaye J, Brugada J, Allessie MA (1992) Electrophysiologic and arrhythmogenic- effects of bupivacaine. A study with high-resolution ventricular epicardial mapping in rabbit hearts. Anesthesiology 77:32–41Google Scholar
  51. 51.
    Mazoit JX, Decaux A, Bouaziz H et al. (2000) Comparative ventricular electrophysiologic effect of racemic bupivacaine, levobupivacaine, and ropivacaine on the isolated rabbit heart. Anesthesiology 93:784–792PubMedCrossRefGoogle Scholar
  52. 52.
    Simon L, Kariya N, Edouard A et al. (2004) Effect of bupivacaine on the isolated rabbit heart: developmental aspect on ventricular conduction and contractility. Anesthesiology 101:937–944PubMedCrossRefGoogle Scholar
  53. 53.
    Odoom JA, Sturk A, Dokter PWC et al. (1989) The effects of bupivacaine and pipecoloxy- lidide on platelet function in vitro. Acta Anaesthesiol Scand 33:385–388PubMedCrossRefGoogle Scholar
  54. 54.
    Hollmann MW, Gross A, Jelacin N et al. (2001) Local anesthetic effects on priming and activation of human neutrophils. Anesthesiology 95:113–122PubMedCrossRefGoogle Scholar
  55. 55.
    Beloeil H, Asehnoune K, Moine P et al. (2005) Bupivacaine’s action on the carrageenan induced inflammatory response in mice: cytokine production by leukocytes after ex-vivo stimulation. Anesth Analg 100:1081–1086PubMedCrossRefGoogle Scholar
  56. 56.
    Leduc C, Gentili ME, Estèbe JP et al. (2002) Inhibition of peroxydation by local anesthetic in an inflammatory rat model with carrageenan. Anesth Analg 95:992–996PubMedGoogle Scholar
  57. 57.
    Rowbotham MC, Reisner-Keller LA, Fields HL (1991) Both intravenous lidocaine and morphine reduce the pain of postherpetic neuralgia. Neurology 41:1024–1028PubMedCrossRefGoogle Scholar
  58. 58.
    Marret E, Rolin M, Beaussier M et al. (2008) Meta-analysis of intravenous lidocaine and postoperative recovery after abdominal surgery. Br J Surg 95:1331–1338PubMedCrossRefGoogle Scholar
  59. 59.
    Linchitz RM, Raheb JC (1999) Subcutaneous infusion of lidocaine provides effective pain relief for CRPS patients. Clin J Pain 15:67–72PubMedCrossRefGoogle Scholar
  60. 60.
    Dadure C, Motais F, Ricard C et al. (2005) Con enantiomers on intracellular Ca2+ regulation in murine skeletal muscle fibers. Anesthesiology 102:793–798CrossRefGoogle Scholar
  61. 61.
    Popitz-Bergez FA, Leeson S, Strichartz GR et al. (1995) Relation between functional deficit and intraneural local anesthetic during peripheral nerve block. A study in the rat sciatic nerve. Anesthesiology 83:583–592Google Scholar
  62. 62.
    Zink W, Missler G, Sinner B et al. (2005) Differential effects of bupivacaine and ropivacaine enantiomers on intracellular Ca2+ regulation in murine skeletal muscle fibers. Anesthesiology 102:793–798PubMedCrossRefGoogle Scholar
  63. 63.
    Nouette-Gaulain K, Sirvent P, Canal-Raffin M et al. (2007) Effects of intermittent femoral nerve injections of bupivacaine, levobupivacaine, and ropivacaine on mitochondrial energy metabolism and intracellular calcium homeostasis in rat psoas muscle. Anesthesiology 106:1026–1034PubMedCrossRefGoogle Scholar
  64. 64.
    Brown DL, Ransom DM, Hall JA et al. (1995) Regional anesthesia and local anesthetic induced systemic toxicity: seizure frequency and accompanying cardiovascular changes. Anesth Analg 81:321–328PubMedGoogle Scholar
  65. 65.
    Di Gregorio G, Neal JM, Rosenquist RW et al. (2010) Clinical presentation of local anesthetic systemic toxicity: a review of published cases, 1979 to 2009. Reg Anesth Pain Med 35:181–187PubMedCrossRefGoogle Scholar
  66. 66.
    Weinberg GL (2010) Treatment of local anesthetic systemic toxicity (LAST). Reg Anesth Pain Med 35:188–193PubMedCrossRefGoogle Scholar
  67. 67.
    Rosenblatt MA, Abel M, Fischer GW et al. (2006) Successful use of a 20% lipid emulsion to resuscitate a patient after a presumed bupivacaine-related cardiac arrest. Anesthesiology 105:217–218PubMedCrossRefGoogle Scholar
  68. 68.
    Litz RJ, Popp M, Stehr SN et al. (2009) Successful lipid emulsions. Anesthesiology 110:380–386Google Scholar
  69. 69.
    Ludot H, Tharin JY, Belouadah M et al. (2008) Successful resuscitation after ropivacaine and lidocaine-induced ventricular arrhythmia following posterior lumbar plexus block in a child. Anesth Analg 106:1572–1574PubMedCrossRefGoogle Scholar
  70. 70.
    Mazoit JX, Le Guen R, Beloeil H et al. (2009) Binding of long-lasting local anesthetics to lipid emulsions. Anesthesiology 110:380–386PubMedGoogle Scholar
  71. 71.
    Flandin-Bléty C, Barrier G (1995) Accidents following extradural analgesia in children. The results of a retrospective study. Paediatr Anaesth 5:41–46PubMedCrossRefGoogle Scholar
  72. 72.
    Jamali S, Monin S, Begon C et al. (1994) Clonidine in pediatric caudal anesthesia. Anesth Analg 78:663–666PubMedCrossRefGoogle Scholar
  73. 73.
    Hansen TG, Henneberg SW, Walther Larsen S et al. (2004) Caudal bupivacaine supplemented with caudal or intravenous clonidine in children undergoing hypospadias repair: a doubleblind study. Br J Anaesth 92:223–227PubMedCrossRefGoogle Scholar
  74. 74.
    De Negri P, Ivani G, Visconti C et al. (2001) How to prolong postoperative analgesia after caudal anaesthesia with ropivacaine in children: S-ketamine versus clonidine. Paediatr Anaesth 11:679–683PubMedCrossRefGoogle Scholar
  75. 75.
    Braun S, Gaza N, Werdehausen R et al. (2010) Ketamine induces apoptosis via the mitochondrial pathway in human lymphocytes and neuronal cells. Br J Anaesth 105:347–354PubMedCrossRefGoogle Scholar
  76. 76.
    Eisenach JC, Yaksh TL (2003) Epidural ketamine in healthy children - what is the point? Anesth Analg 96:626PubMedGoogle Scholar
  77. 77.
    Lejus C, Surbled M, Schwoerer D et al. (2001) Postoperative epidural analgesia with bupi- vacaine and fentanyl: hourly pain assessment in 348 paediatric cases. Paediatr Anaesth 11:327–332PubMedCrossRefGoogle Scholar
  78. 78.
    Luz G, Innerhofer I, Bachmann B et al. (1996) Bupivacaine plasma concentrations during continuous epidural anesthesia in infants and children. Anesth Analg 82:231–234PubMedGoogle Scholar

Copyright information

© Springer-Verlag Italia 2013

Authors and Affiliations

  1. 1.Department of Physiology and Pharmacology, Section of Anesthesiology and Intensive CareThe Karolinska InstituteStockholmSweden

Personalised recommendations