title: [Combined "3-in-1"/sciatic nerve block. Block effectiveness, serum level and side effects using 700 mg mepivacaine 1% without and with adrenaline and prilocaine 1%].
abstract: A high dose of local anaesthetic is necessary for the combined "3-in-1"/sciatic nerve block. Prilocaine is recommended for its low toxicity. However, in some patients prilocaine results in pronounced methaemoglobin formation due to toludine. Little has been known hitherto about the use of high-dose mepivacaine for the combined 3-1/sciatic nerve block. This study was undertaken to compare the use of 700 mg mepivacaine 1% and of 700 mg prilocaine 1%.
  
  
  METHODS
  The study was approved by the ethics committee of our hospital. Once their informed consent had been obtained in writing 3 x 20 patients (ASA 1-2) undergoing planned surgery on the foot or ankle joint were enrolled in the study. The patients were randomized to the following three groups on a double-blind basis: group 1,700 mg mepivacaine without epinephrine; group 2,700 mg mepivacaine with 0.2 mg epinephrine (1:350,000); group 3,700 mg prilocaine 1%. Arterial blood samples for determination of local anaesthetic serum levels were collected over a 120-min period. We determined methaemoglobin and oxygen saturation before and 120 min after the blockade and continued these measurements for 6 h in group 3. At 15-min intervals, all patients were questioned about early signs of toxicity. The perioperative monitoring including blood pressure, ECG and pulse oximetry. Data were analysed using ANOVA and Student's t-test, P < 0.05 considered statistically significant.
  
  
  RESULTS
  The blocking efficacy did not differ among the groups (groups 1, 2, 3:90%, 95%, 90%). The maximum mepivacaine serum level in group 1 was 3.91 micrograms/ml +/- 0.95 and 2.94 micrograms/ml +/- 0.58 in group 2 (Fig. 2). Over the entire observation period the addition of epinephrine resulted in a significant reduction of the serum level (between 60.3% at t = 15 min and 19.7% at t = 120 min). In the prilocaine group the maximum serum level was 2.07 micrograms/ml +/- 0.56, significantly less than in either mepivacaine group. No patient showed signs or symptoms of local anaesthetic toxicity. In the prilocaine group there was wide variation in methaemoglobin formation among the patient, with a median of 10.1% (Fig. 3, Table 3). Three patients showed a maximum methaemoglobinemia between 16% and 17%. Five patients were still cyanotic after 6 h when they were transferred to the ward. The fractional SaO2 values amounted to 88% (median) with a minimum of 80.3%.
  
  
  CONCLUSIONS
  Both mepivacaine 1% and prilocaine 1% are appropriate local anaesthetics for the combined 3-in-1/sciatic nerve block at a dose of 700 mg. There was no difference in the blocking efficacy. No patient showed clinical signs or symptoms of a local anaesthetic toxicity. Following prilocaine we are sometimes faced with high methaemoglobinemia, which may necessitate prolonged monitoring.
authors.affiliation: Klinik für Anästhesiologie, Universitätsklinik Ulm.
authors.forename: B
authors.initials: B
authors.lastname: Eifert
authors.forename: R
authors.initials: R
authors.lastname: Hahn
authors.forename: B
authors.initials: B
authors.lastname: Maier
authors.forename: F
authors.initials: F
authors.lastname: Konrad
authors.forename: M
authors.initials: M
authors.lastname: Georgieff
mesh_terms: D000328:Adult; D000779:Anesthetics, Local / Q000008:administration & dosage / Q000009:adverse effects / Q000493:pharmacokinetics; D000842:Ankle / Q000601:surgery; D004305:Dose-Response Relationship, Drug; D004311:Double-Blind Method; D004837:Epinephrine / Q000008:administration & dosage / Q000009:adverse effects / Q000493:pharmacokinetics; D005260:Female; D005528:Foot / Q000601:surgery; D006801:Humans; D008297:Male; D008619:Mepivacaine / Q000008:administration & dosage / Q000009:adverse effects / Q000493:pharmacokinetics; D008657:Metabolic Clearance Rate / Q000502:physiology; D008708:Methemoglobinemia / Q000097:blood / Q000139:chemically induced; D008875:Middle Aged; D009407:Nerve Block / Q000379:methods*; D011318:Prilocaine / Q000008:administration & dosage / Q000009:adverse effects / Q000493:pharmacokinetics; D012584:Sciatic Nerve / Q000187:drug effects*
chemical_list: D000779:Anesthetics, Local; D011318:Prilocaine; D008619:Mepivacaine; D004837:Epinephrine
vernacular_title: Die kombinierte "3-in-1"/Ischiadicus-Blockade. Blockadeerfolg, Serumspiegel und Nebenwirkungen bei Einsatz von je 700 mg Mepivacain 1% ohne und mit Adrenalin sowie Prilocain 1%.