Ropivacaine and dexamethasone: a potentially dangerous combination for therapeutic pain injections
Ropivacaine and dexamethasone: a potentially dangerous combination for therapeutic pain injections
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DOI：
10.1111/1754-9485.12333
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发表时间：
2015-10-01
影响因子：
1.6
通讯作者：
Coucher, John Richard
中科院分区：
文献类型：
--
作者：
Watkins, Trevor William;Dupre, Simon;Coucher, John Richard
在特定的患者群体中，靶向脊髓类固醇注射在减轻背痛方面是有效的，并且具有显著不良神经预后的小风险。最近的建议是在所有脊髓注射中使用非颗粒类固醇药物，以降低神经血管栓塞不良事件的风险。许多注射剂使用局部麻醉剂和类固醇的组合。在我们的机构，我们最近观察到罗哌卡因和地塞米松组合之间的相互作用，归因于前者与碱性溶液不相容，导致快速结晶。本研究进一步研究了常用的局部麻醉剂和类固醇联合使用，以确定这种沉淀效应是否更广泛。方法：对常用局麻药（利多卡因、布比卡因、罗哌卡因）和非颗粒类固醇地塞米松磷酸钠联合用药进行宏观、微观评价，并测定pH值。在观察结晶析出率和晶体尺寸的地方。同时还对盐酸碳酸氢钠溶液对罗哌卡因的污染进行了评价。评价颗粒类固醇剂醋酸倍他米松的颗粒大小作为比较。结果：所有罗哌卡因和非颗粒地塞米松磷酸钠的混合物评估显示溶液的ph依赖性结晶。地塞米松与利多卡因或布比卡因联合使用无沉淀。空气净化后，拔针中残留的碳酸氢钠污染罗哌卡因具有沉淀效应。结论：我们描述了结晶作用与罗哌卡因和非颗粒类固醇，地塞米松磷酸钠的组合，一种混合物，已在文献中用于靶向疼痛注射。由于这可能被认为是一种非颗粒类固醇/麻醉注射剂，如果在靶向脊髓注射期间发生无意的血管内注射，就像颗粒类固醇药物所描述的那样，这可能会增加风险。这是由于地塞米松的pH值升高和罗哌卡因与碱性溶液不相容所致。
Introduction: Targeted spinal steroid injections are effective in reducing back pain in selected patient populations and carry a small risk of significant adverse neurological outcomes. Recent recommendations are for the use of non-particulate steroid agents for all spinal injections to reduce the risk of neurovascular embolic adverse events. Many injections have used a combination of local anaesthetic agent with the steroid. At our institutions, we have recently observed interactions between ropivacaine and dexamethasone combinations ascribed to the incompatibility of the former with alkaline solutions, resulting in rapid crystallisation. This study has further investigated the combinations of commonly used local anaesthetic and steroid combinations to determine if such precipitation effects are more widespread.Methods: The commonly used local anaesthetics (lignocaine, bupivacaine, ropivacaine) and the non-particulate steroid dexamethasone sodium phosphate combinations were evaluated macroscopically, microscopically, and pH values measured. Where crystallisation was observed the rate of precipitation and crystal size was measured. Contamination of ropivacaine with sodium bicarbonate solution was also evaluated. Particulate size of the particulate steroid agent betamethasone acetate was evaluated as a comparison.Results: All mixtures of ropivacaine and the non-particulate dexamethasone sodium phosphate assessed demonstrated a pH-dependent crystallisation of the solution. No precipitation was demonstrated with the combinations of dexamethasone and lignocaine or bupivacaine. Contamination of ropivacaine with residual sodium bicarbonate in a drawing up needle following air clearing had a precipitation effect.Conclusion: We describe the effect of crystallisation with the combination of ropivacaine and the non-particulate steroid, dexamethasone sodium phosphate, a mixture that has been used in the literature for targeted pain injections. As this may be considered a non-particulate steroid/anaesthetic injectate, this would potentially carry increased risk if inadvertent intravascular injection occurred during a targeted spinal injection, as has been described with particulate steroid agents. This is due to the elevated pH of dexamethasone and the incompatibility of ropivacaine with alkaline solutions.