Measurement of bupivacaine induced myotoxicity in interfascial plane blocks: A randomised controlled trial

Vasundhara Rakhi, Sonali Kaushal, Surinder Singh, Vasundhara Rakhi, Sonali Kaushal, Surinder Singh

Abstract

Background and aims: Recent reports of local-anaesthetic induced myotoxicity after peripheral nerve blocks have increased interest in this less commonly known complication. Although the morphological, physiological and biochemical changes in muscle after injection of clinically used concentration of bupivacaine have been studied in animals, little research has been conducted on human subjects, especially in relation to fascial plane blocks. We conducted a study to examine the changes in circulating creatine phosphokinase (CPK) levels in patients undergoing modified radical mastectomy (MRM) or mesh hernioplasty (MH) with or without peripheral nerve blocks. The study explored local anaesthetic (bupivacaine) induced myotoxicity by measuring changes in serum CPK levels following transversus abdominis plane block (TAP) or pectoral nerve block-II (PEC- II) in patients undergoing MH or MRM, respectively.

Methods: The study was a randomised, controlled open-label trial. Patients undergoing MH who were randomised to the intervention group received TAP block whereas those undergoing MRM received PEC-II block. Blood samples were drawn at baseline, 6 and 24 hours after surgery for serum CPK measurements. Changes in serum CPK levels between the control and intervention groups were compared using repeated-measures analysis of variance.

Results: Baseline serum CPK levels were similar between the groups. There was a significant difference in the change in serum CPK levels between the groups. It significantly rose in the intervention group as compared to the control group (p < 0.001).

Conclusion: The study shows that serum CPK levels significantly increase at 24 hours after interfascial plane block thereby indirectly indicating myotoxicity. Further research is needed to ascertain its clinical impact.

Keywords: Bupivacaine; creatine kinase; local anaesthetics; myotoxicity; nerve block; neurotoxicity; peripheral nerve.

Conflict of interest statement

There are no conflicts of interest.

Copyright: © Indian Journal of Anaesthesia.

Figures

Figure 1
Figure 1
Patient enrolment and follow up in the study
Figure 2
Figure 2
Change in serum creatine phosphokinase (CPK) levels (IU/L) between groups (Group A: Intervention, Group B: Control), P < 0.001 for comparison between groups

References

    1. Hussain N, McCartney CJL, Neal JM, Chippor J, Banfield L, Abdallah FW. Local anaesthetic-induced myotoxicity in regional anaesthesia: A systematic review and empirical analysis. Br J Anaesth. 2018;121:822–41.
    1. Zink W, Graf BM. Local anesthetic myotoxicity. Reg Anesth Pain Med. 2004;29:333–40.
    1. Brun A. Effect of procaine, carbocain and xylocaine on cutaneous muscle in rabbits and mice. Acta Anaesthesiol Scand. 1959;3:59–73.
    1. Neal JM, Salinas FV, Choi DS. Local anesthetic-induced myotoxicity after continuous adductor canal block. Reg Anesth Pain Med. 2016;41:723–7.
    1. Nosaka K, Sakamoto K. Changes in plasma enzyme activity after intramuscular injection of bupivacaine into the human biceps brachii. Acta Physiol Scand. 1999;167:259–65.
    1. Foster AH, Carlson BM. Myotoxicity of local anesthetics and regeneration of the damaged muscle fibers. Anesth Analg. 1980;59:727–36.
    1. Benoit PW, Belt WD. Some effects of local anesthetic agents on skeletal muscle. Exp Neurol. 1972;34:264–78.
    1. Gomez-Arnau JI, Yanguela J, Gonzalez A, Andrés Y, García del Valle S, Gili P, et al. Anaesthesia-related diplopia after cataract surgery. Br J Anaesth. 2003;90:189–93.
    1. Nouette-Gaulain K, Jose C, Capdevila X, Rossignol R. From analgesia to myopathy: When local anesthetics impair the mitochondrion. Int J Biochem Cell Biol. 2011;43:14–9.
    1. Zink W, Seif C, Bohl JRE, Hacke N, Braun PM, Sinner B, et al. The acute myotoxic effects of bupivacaine and ropivacaine after continuous peripheral nerve blockades. Anesth Analg. 2003;97:1173–9.
    1. Dorado-Velasco FC, Loaiza-Ruiz DM, Llinás-Hernández PJ, Herrera Huependo GA. Bupivacaine-induced myotoxicity during a continuous perineural femoral block: Case report. Col J Anest. 2020;48:169–73.
    1. Holm B, Kristensen MT, Bencke J, Husted H, Kehlet H, Bandholm T. Loss of knee-extension strength is related to knee swelling after total knee arthroplasty. Arch Phys Med Rehabil. 2010;91:1770–6.
    1. Cereda CM, Tofoli GR, Maturana LG, Pierucci A, Nunes LA, Franz-Montan M, et al. Local neurotoxicity and myotoxicity evaluation of cyclodextrin complexes of bupivacaine and ropivacaine. Anesth Analg. 2012;115:1234–41.
    1. Cherng CH, Wong CS, Wu CT, Yeh CC. Intramuscular bupivacaine injection dose-dependently increases glutamate release and muscle injury in rats. Acta Anaesthesiol Taiwan. 2010;48:8–14.
    1. Steiness E, Rasmussen F, Svendsen O, Nielsen P. A comparative study of serum creatine phosphokinase (CPK) activity in rabbits, pigs and humans after intramuscular injection of local damaging drugs. Acta Pharmacol Toxicol (Copenh) 1978;42:357–64.
    1. Hogan Q, Dotson R, Erickson S, Kettler R, Hogan K. Local anesthetic myotoxicity: A case and review. Anesthesiology. 1994;80:942–7.
    1. Kaushal S, Singh S, Sharma A. A randomised study comparing the extent of block produced by spinal column height and body weight-based formulae for paediatric caudal analgesia. Indian J Anaesth. 2020;64:477–82.
    1. Chakraborty A, Khemka R, Datta T. Ultrasound-guided truncal blocks: A new frontier in regional anaesthesia. Indian J Anaesth. 2016;60:703–11.
    1. Wahal C, Kumar A, Pyati S. Advances in regional anaesthesia: A review of current practice, newer techniques and outcomes. Indian J Anaesth. 2018;62:94.
    1. Nouette-Gaulain K, Bellance N, Prévost B, Passerieux E, Pertuiset C, Galbes O, et al. Erythropoietin protects against local anesthetic myotoxicity during continuous regional Analgesia. Anesthesiology. 2009;110:648–59.
    1. Galbes O, Bourret A, Nouette-Gaulain K, Pillard F, Matecki S, Py G, et al. N -Acetylcysteine protects against bupivacaine-induced myotoxicity caused by oxidative and sarcoplasmic reticulum stress in human skeletal myotubes. Anesthesiology. 2010;113:560–9.

Source: PubMed

Sponsor e collaboratori

Condizioni mediche

Interventi farmacologici

3
Sottoscrivi