What are the risks of hypotension with bupivacaine (local anesthetic) erector spinae block and how can it be managed?

From the Guidelines

Bupivacaine erector spinae block can cause hypotension, although it is a relatively uncommon risk, and its management is crucial to prevent morbidity and mortality. The risk of hypotension with bupivacaine erector spinae block is primarily due to sympathetic blockade if the local anesthetic spreads to the paravertebral space. According to the study by Yao et al. 1, the use of local anesthetics like ropivacaine in erector spinae plane blocks can reduce pain scores and opioid consumption, but the study does not directly address the risk of hypotension with bupivacaine.

To manage the risk of hypotension, the following strategies can be employed:

• Using appropriate bupivacaine concentrations (0.25-0.5%) and volumes (20-30 mL per side for adults)
• Avoiding inadvertent intravascular injection through careful aspiration and incremental injection technique
• Monitoring patients for at least 30 minutes post-procedure with vital sign checks
• Positioning the patient supine with legs elevated if hypotension occurs
• Administering IV fluids (500-1000 mL crystalloid bolus) and, if needed, vasopressors such as ephedrine (5-10 mg IV) or phenylephrine (50-100 mcg IV)

It is essential to note that patients with cardiovascular disease, hypovolemia, or those taking antihypertensive medications are at higher risk and may require more cautious dosing and closer monitoring. The study by Shim et al. 1 also highlights the importance of careful patient selection and monitoring in the context of erector spinae plane blocks. Overall, the key to managing hypotension risk with bupivacaine erector spinae block is careful patient selection, appropriate technique, and vigilant monitoring.

From the FDA Drug Label

Local anesthetics produce vasodilation by blocking sympathetic nerves. Elevating the patient's legs and positioning her on her left side will help prevent decreases in blood pressure. Patients over 65 years, particularly those with hypertension, may be at increased risk for developing hypotension while undergoing anesthesia with Bupivacaine Hydrochloride Also, hypotension due to loss of sympathetic tone and respiratory paralysis or underventilation due to cephalad extension of the motor level of anesthesia may occur.

Hypotension Risk with Bupivacaine Erector Spinae Block:

• Bupivacaine can cause hypotension due to vasodilation from blocking sympathetic nerves.
• Patients over 65 years, especially those with hypertension, are at increased risk of hypotension.
• Preventive measures include elevating the patient's legs and positioning on the left side.
• Management: Monitor blood pressure closely, and consider preventive measures to minimize the risk of hypotension 2, 2.

From the Research

Risks of Hypotension with Bupivacaine Erector Spinae Block

• Bupivacaine erector spinae block can cause hypotension, although the risk may be lower compared to other types of regional anesthesia 3, 4.
• The use of bupivacaine in erector spinae plane blocks has been shown to result in low peak plasma concentrations of total and free bupivacaine, which may reduce the risk of hypotension 5.
• However, hypotension can still occur, especially if high doses of bupivacaine are used or if the patient has underlying medical conditions that increase the risk of hypotension 6.

Management of Hypotension

• Hypotension caused by bupivacaine erector spinae block can be managed with vasopressors, such as ephedrine or phenylephrine 3, 4.
• The use of lower doses of bupivacaine or the addition of other medications, such as sufentanil, may also help to reduce the risk of hypotension 3.
• Close monitoring of the patient's blood pressure and heart rate is essential to quickly identify and manage any hypotensive episodes 4, 6.

Factors Influencing the Risk of Hypotension

• The speed of injection of bupivacaine can influence the risk of hypotension, with faster injection speeds resulting in higher usage of vasopressors 4.
• The dose of bupivacaine used can also impact the risk of hypotension, with higher doses increasing the risk of hypotension 3, 5.
• Patient factors, such as age and underlying medical conditions, can also influence the risk of hypotension 3, 6.