• Daniel Katz, Jia Song, Matthew Carangelo, Timothy Bergsma, Roy Winston, and Ruth Landau.
• Icahn School of Medicine at Mount Sinai, New York, NY, 1 Gustave L. Levy Place, New York, NY 10029, United States of America. Electronic address: daniel.katz@mountsinai.org.
• J Clin Anesth. 2024 Sep 21; 99: 111589111589.

Study ObjectiveTo simulate bupivacaine pharmacokinetics in scenarios of labor epidural analgesia (LEA) extended for intrapartum cesarean delivery (CD) with epidural or intrathecal boluses, followed by transversus abdominis plane (TAP) block with liposomal bupivacaine (LB) for postcesarean analgesia.DesignBupivacaine plasma concentrations were simulated using a 2-compartment distribution model fit to previous study data.SettingVirtual pharmacokinetic simulations.PatientsVirtual individuals (1000, each scenario) had uniform weight (80 kg) but varying absorption parameters.InterventionsThe 6 scenarios varied in LEA infusion duration (6 or 24 h), local anesthetic used for bolus to extend LEA (epidural lidocaine or intrathecal bupivacaine), TAP block regimen, and time between bolus and TAP block.MeasurementsScenario outcomes included geometric mean (GM) peak bupivacaine plasma concentration (Cmax) with 95% prediction interval (PI), median (range) Cmax, and number of virtual individuals (per 1000) with Cmax reaching estimated toxicity thresholds (neurotoxicity: 2000 μg/L; cardiotoxicity: 4000 μg/L).Main ResultsIn simulated scenarios of LEA infusion for 24 h with an epidural bolus of lidocaine 400 mg for CD followed 1 h later by TAP block, the GM Cmax for the scenarios with TAP blocks including either LB 266 mg plus bupivacaine hydrochloride 52 mg or bupivacaine hydrochloride 104 mg was 1860 (95% PI, 1107-3124) and 1851 (95% PI, 1085-3157) μg/L, respectively. Among 1000 virtual individuals for each scenario, 404 and 401 had Cmax reaching 2000 μg/L, respectively; 1 and 0 had Cmax reaching 4000 μg/L, respectively. For other scenarios, GM Cmax remained <1000 μg/L.ConclusionsAcross 6 different simulations of TAP blocks for intrapartum CD analgesia, LEA with bupivacaine (with or without boluses for extension and including a conservative modeling of lidocaine without epinephrine), followed by TAP block with LB and/or bupivacaine hydrochloride 0, 1, or 2 h after CD, is unlikely to result in bupivacaine plasma concentrations reaching local anesthetic systemic toxicity thresholds in healthy patients.Copyright © 2024 The Authors. Published by Elsevier Inc. All rights reserved.

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