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Local anesthetic dosing and toxicity of adult truncal catheters: a narrative review of published practice
  1. Brittani Bungart1,2,
  2. Lana Joudeh1,2 and
  3. Michael Fettiplace1,2
  1. 1Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
  2. 2Department of Anaesthesia, Harvard Medical School, Boston, Massachusetts, USA
  1. Correspondence to Dr Michael Fettiplace, Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, Massachusetts 02114, USA; fettiplace{at}


Background/importance Anesthesiologists frequently use truncal catheters for postoperative pain control but with limited characterization of dosing and toxicity.

Objective We reviewed the published literature to characterize local anesthetic dosing and toxicity of paravertebral and transversus abdominis plane catheters in adults.

Evidence review We searched the literature for bupivacaine or ropivacaine infusions in the paravertebral or transversus abdominis space in humans dosed for 24 hours. We evaluated bolus dosing, infusion dosing and cumulative 24-hour dosing in adults. We also identified cases of local anesthetic systemic toxicity and toxic blood levels.

Findings Following screening, we extracted data from 121 and 108 papers for ropivacaine and bupivacaine respectively with a total of 6802 patients. For ropivacaine and bupivacaine, respectively, bolus dose was 1.4 mg/kg (95% CI 0.4 to 3.0, n=2978) and 1.0 mg/kg (95% CI 0.18 to 2.1, n=2724); infusion dose was 0.26 mg/kg/hour (95% CI 0.06 to 0.63, n=3579) and 0.2 mg/kg/hour (95% CI 0.06 to 0.5, n=3199); 24-hour dose was 7.75 mg/kg (95% CI 2.1 to 15.7, n=3579) and 6.0 mg/kg (95% CI 2.1 to 13.6, n=3223). Twenty-four hour doses exceeded the package insert recommended upper limit in 28% (range: 17%–40% based on maximum and minimum patient weights) of ropivacaine infusions and 51% (range: 45%–71%) of bupivacaine infusions. Toxicity occurred in 30 patients and was associated with high 24-hour dose, bilateral catheters, cardiac surgery, cytochrome P-450 inhibitors and hypoalbuminemia.

Conclusion Practitioners frequently administer ropivacaine and bupivacaine above the package insert limits, at doses associated with toxicity. Patient safety would benefit from more specific recommendations to limit excessive dose and risk of toxicity.

  • Drug-Related Side Effects and Adverse Reactions
  • Nerve Block
  • Pain, Postoperative
  • Postoperative Complications

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  • BB and LJ are joint first authors.

  • Twitter @BrittaniBungart, @mfettiplace

  • BB and LJ contributed equally.

  • Contributors MF conceived the project and designed the extraction. BB, LJ and MF all contributed to literature screening, data extraction, data preparation, manuscript drafting and manuscript editing.

  • Funding MF is supported by an NIH T32 training grant 5T32GM007592-42.

  • Competing interests None declared.

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.