The transversus abdominis plane block is an interfascial block intended to target nerves supplying the abdominal wall. It has been shown to reduce pain and postoperative opioids in abdominal surgeries. We present the case of a high-risk patient in whom bilateral continuous lumbar transversus abdominis plane blocks provided effective postoperative analgesia following infraumbilical midline laparotomy. A 59-yr-old woman with coronary artery disease, severe peripheral vascular disease, and mild to moderate obstructive sleep apnea underwent a total abdominal hysterectomy, bilateral salpingo-oophorectomy, and pelvic lymph node dissection via an infraumbilical midline laparotomy. Bilateral ultrasound-guided lumbar transversus abdominis plane blocks with catheters were sited intraoperatively. Using only a continuous local anesthetic infusion in the postoperative period, the patient required no systemic opioids or acetaminophen for 81 hr. A sensory block level of T6-L1, higher than that reported following a single-shot technique, remained for 24 hr following infusion discontinuation and finally normalized after 33 hr. Lumbar transversus abdominis plane blocks with continuous infusions may offer an effective alternative to epidural blockade and systemic opioids in high-risk patients. Additionally, given the extensive somatosensory block, this technique may have an analgesic role following abdominal incisions involving not only the infraumbilical region but also supraumbilical sites. Le bloc du plan transverse de l’abdomen est un bloc interfascial qui cible les nerfs innervant la paroi abdominale. Il a été démontré qu’il réduisait la douleur et les besoins postopératoires en opioïdes lors d’une chirurgie abdominale. Nous présentons le cas d’une patiente à risque élevé chez qui des blocs lombaires continus du plan transverse de l’abdomen ont procuré une analgésie postopératoire efficace après une laparotomie sous-ombilicale médiane. Une femme de 59 ans souffrant de maladie coronarienne, de maladie vasculaire périphérique grave et d’apnée du sommeil obstructive légère à modérée a subi une hystérectomie abdominale totale, une salpingo-ovariectomie et un évidement ganglionnaire pelvien par laparotomie sous-ombilicale médiane. Des blocs bilatéraux lombaires échoguidés du plan transverse de l’abdomen ont été positionnés pendant l’opération. En utilisant seulement une perfusion d’anesthésique local en période postopératoire, la patiente n’a pas eu besoin d’opioïdes systémiques ou d’acétaminophène pendant 81 h. Un bloc sensitif au niveau T6-L1, plus haut que celui rapporté après une technique à injection unique, s’est maintenu pendant 24 h après l’interruption de la perfusion, puis s’est finalement normalisé après 33 h. Les blocs lombaires du plan transverse de l’abdomen suivis de perfusions continues pourraient constituer une alternative efficace aux blocs périduraux et aux opioïdes systémiques chez les patients à risque élevé. En outre, étant donné l’étendue importante du bloc somatosensoriel, cette technique pourrait jouer un rôle analgésique après des incisions abdominales réalisées non seulement dans la région sous-ombilicale, mais également dans les zones sus-ombilicales.

Objectives: There are concerns about the potency of epinephrine (EPI), norepinephrine (NE), and phenylephrine (PE) stored in syringes for later infusions in clinical care. The objective of our study was to optimize a liquid chromatography-tandem mass spectrometry (LC-MS/MS) method to determine the concentrations EPI, NE, and PE dissolved in normal saline and stored in 50 mL 3-part Becton Dickinson syringes. Methods: Medications were diluted in normal saline to 80 μg/mL for EPI and NE, and 100 μg/mL for PE. The solutions were stored in syringes for 0 (fresh), 3, and 7 days in a medical refrigerator. United States Pharmacopeia grade EPI, NE, and PE and their deuterium-labeled analogs were used as calibration standards. Stored samples and standards were diluted and analyzed by LC-MS/MS operated in selected reaction monitoring mode. Results: The calculated limit of quantification for EPI, NE and PE were well below the concentrations used in clinical practice. The coefficient of variation remained below 12 % for all samples. The standard linear calibration regressions for EPI, NE, and PE had r ² values of between 0.96 and 0.98 (p < 0.001). EPI and NE stored in the refrigerator remained within 10 % of the of their initial concentrations at all time points. The concentration of PE in syringe decreased by 19.85 % at 3 days, with no further decrease at 7 days, compared to fresh PE. Conclusions: The sample preparation steps and optimized LC-MS/MS method allowed simple and reliable measurements of EPI, NE, and PE.

Objectives: To compare effectiveness and safety of rescue therapy approach with recombinant Factor VII activated (rFVIIa) for refractory bleeding in cardiac surgery compared with a propensity-score-matched control group at a single academic institution. Methods: In total, 8860 adult patients had cardiac surgery with cardiopulmonary bypass between 2009 and 2019. Ninety-seven patients (1.1%) received rFVIIa; 81 (83.5%) of rFVIIa cases were propensity score matched 1:1 with controls using pre- and intraoperative variables. Effectiveness was assessed with coagulation tests, chest tube drainage, and reoperation for bleeding. Safety was assessed with morbi-mortality. Results: The median dose of rFVIIa was 55.6 μg/kg (IQR, 37.4-80.0 μg/kg). The first dose after CPB was given at a Median time of 176 min (IQR, 131-232 min). Postoperative INR was lower in the rFVIIa group (Median, 0.8; IQR, 0.7-0.9) versus control (Median, 1.4; IQR 1.3-1.6; P <.0001). Other coagulation tests, chest tube drainage, and reoperation for bleeding were no different. Mortality and thrombo-embolism were higher in the rFVIIa—OR, 3.17 (95% CI, 1.41-7.14; P = .0054) and OR, 10.50 (95% CI, 1.64-117.5; P = .0196). Stroke (OR, 1.82; 95% CI, 0.51-6.48; P = .35) and renal failure (OR, 1.31, 95% CI, 0.69-2.48, P = .41) were not statistically different. RFVIIa group received 4.4 (95% CI, 3.28-5.91, P = .0001) and 1.97 (95% CI, 1.18-3.30; P = .02) times more blood products volume intra- and postoperatively. Conclusions: Rescue therapy with rFVIIa seems to effectively control bleeding. However, we observed an association with increased mortality, thromboembolism, and transfusion. We did not find rFVIIa association with risk of stroke or renal failure.

Hypotensive states commonly require intravenous infusions of inopressors such as epinephrine, norepinephrine, and phenylephrine.1 Traditionally, these high-alert medications were prepared in plastic bags at “standard” concentrations and administered using high-volume infusion pumps. Several studies have documented the stability of these medications in plastic bags for infusions, supporting compounded pharmacy and industry preparations.2–4 The introduction of smart syringe infusion pumps has allowed for accurate lower infusion rates and decreased volume load but with a requirement of higher medication concentrations.The U.S. Food and Drug Administration recommends against storing compounded medications in syringes after multiple reports of decreasing concentration (up to 70%) of multiple medications stored in Becton Dickinson syringes.5 Other factors affecting the stability of compounded sympathomimetics include interactions with air, light, elevated temperature, heavy metals, and alkaline pH, which favor oxidative degradation. Previous sympathomimetics stability studies report a variety of experimental conditions, thus limiting comparisons.6 For those reasons, our current institutional practice is to prepare syringe infusions at the point of care for immediate use. However, due to safety concerns about point-of-care intravenous medications prepared by health professionals, multiple organizations recommend abandoning this practice in favor of preparation by pharmacy or industry.7,8To address some of these concerns, this study aimed to assess the stability of epinephrine, norepinephrine, and phenylephrine, when diluted in 0.9% isotonic sodium chloride solution, refrigerated (5 to 8°C), protected from light exposure, and stored in 50-ml syringes of three commercial brands—Becton Dickinson (USA), Covidien (USA), and Terumo (Philippines)—for 14 days using high-performance liquid chromatography–mass spectrometry (HPLC-MS/MS).The Institutional Research Ethics Board waived approval for this study. A previous study optimized the methods of measurement of these medications using HPLC-MS/MS and determined a sample size of four syringes of each branch at each time interval.9 Detailed methods can be found in Supplemental Digital Content 1 (https://links.lww.com/ALN/D464). United States Pharmacopeial grade (purity greater than 99.9%) epinephrine, norepinephrine, and phenylephrine and their corresponding labeled isotopologues were used as standards for the calibration curves. The area under the curve of each drug was obtained by HPLC-MS/MS using a custom-developed selected reaction monitoring method. For calibration purposes, four points were used for each medication: the expected concentration (which was 80 μg/ml for epinephrine and norepinephrine and 100 μg/ml for phenylephrine), 10 μg/ml above the expected concentration, and 10 and 20 μg/ml below the expected concentration. The calibration standards were measured in quadruplicate pre- and post-testing the syringe samples. The eight data points from the pre- and post-calibration standards were used for the linear regression analysis.Pharmaceutical presentations diluted in 0.9% isotonic sodium chloride solution were used to prepare batches of 12 syringes, 4 of each syringe brand: Becton Dickinson, Covidien, and Terumo. The batches were prepared fresh (less than 4 h before testing) and 3, 7, and 14 days before testing. The syringes were prepared aseptically, protected from ultraviolet radiation with amber plastic bags, labeled with a computer generated random number blocked by date, and stored in a medical fridge (5 to 8°C). Laboratory personnel were blinded to both preparation time and syringe brand.The experimental design is a fractional factorial design. The factors examined were syringe type (Becton Dickinson, Covidien, and Terumo), storage time (0, 3, 7, and 14 days), and medication concentration (epinephrine, 80 μg/ml; norepinephrine, 80 μg/ml; and phenylephrine, 100 μg/ml). Each factor combination was replicated four times; that is, four different syringes per brand (total of 12 syringes), per medication, per time period, measured once. Linear regression was used to estimate the effect of medication with 95% CI on the concentration standards. Comparison of pre- and posttesting calibration readings, the effect of syringe type and time interval on the medications’ concentration, and the effect of pH were performed using ANOVA. Tukey’s test was used for correcting for multiple comparisons. A P value less than 0.05 was considered significant. Statistical analyses were performed with the Rstudio 2021.09.0 + 351 software.Medication calibration curves had a coefficient of determination of R2 = 0.88, 0.92, and 0.97, for epinephrine, norepinephrine, and phenylephrine, respectively (Supplemental Digital Content 2, https://links.lww.com/ALN/D465). Quadratic regressions on concentration were estimated, but ANOVA indicated that the quadratic terms were not significant (P = 0.289, 0.815, and 0.66 for epinephrine, norepinephrine, and phenylephrine, respectively). ANOVA indicated that pre- and postreading calibration concentration standards were not statistically different. Syringes’ mean medication concentrations were 82 SD ± 5.05 μg/ml, 77 SD ± 5.39 μg/ml, and 92 SD ± 3.56 μg/ml for epinephrine, norepinephrine, and phenylephrine respectively. There were no significant differences between syringe brands, storage time, or their interactions for epinephrine and norepinephrine. There was a significant effect of day (P = 0.03) for phenylephrine (fig. 1), as concentration on day 7 was significantly higher (93.34 μg/ml, SD ± 4.18 μg/ml) than on day 14 (89.9 μg/ml, SD ± 4.05 μg/ml). However, it was not considered clinically relevant as the concentrations were not less than 10% of the fresh preparations....