A double-blind randomised comparison of ropivacaine 0.5%, bupivacaine 0.375% - lidocaine 1% and ropivacaine 0.5% - lidocaine 1% mixtures for cataract surgery

Evaluation of efficacy of peribulbar block with the combination of 2% lidocaine and 0.5% bupivacaine in comparison with 2% lidocaine and 0.75% ropivacaine in cataract surgery

Introduction

Cataract surgery is performed under peribulbar or retrobulbar block. Majority of the patients posted for cataract have some form of medical diseases like diabetes, hypertension, angina, ischaemic heart disease etc. Lidocaine and bupivacaine are the most commonly used local anesthetic for the block procedure. Here we compare the efficacy of peribulbar block in cataract surgery using the combination of 1:1 mixture of 2% lidocaine with 0.5% bupivacaine and 1:1 mixture of 2% lidocaine with 0.75% ropivacaine.

Materials and Methods

It is a prospective, randomized, double blinded study including 60 patients were devided into two groups of 30 each, Group-R received 8 ml of 1:1 mixture of 4 ml of 2% lidocaine, 4 ml of 0.75% ropivacaine and 15 IU/ml of hyaluronidase and group-B received 8 ml of 1:1 mixture of 4 ml of 2% lidocaine, 4 ml of 0. 5% bubivacaineand 15 IU/ml of hyaluronidase. Peribulbar block was performed as per Bloomberg's modification of the Davis and Mandel technique where 5 ml of local anesthetic was injected in the infero temporal region and 3 ml of drug was injected in the superi nasal area. Patients were assessed for sensory block, eyelid and occular movements at an interval of 2 minutes. Systolic, diastolic and mean arterial pressures, heart rate, oxygen saturation, ECG were monitored non invasively at 1,3,5,8,10,15 and then every 10 minutes till the end of the surgery.

Observation and Discussion

Mean time for the onset of sensory blockade was 2.70 ± 6.5 minutes in Group B and 2.63 ± 0.57 minutes in group R with P-value 0.671, showing no significant difference in the onset of sensory blockade. Onset of motor blockade was 6.53 ± 1.81 minutes in group B, and 7.57 ± 1.46 minutes in the group R, the P-value being 0.018 was statistically significant. Regarding the duration of analgesia, our study showed mean time for analgesia lasted for 295 ± 54.63 minutes in group B and 414.67 ± 99.47 in group R with P value 0.001 showing statistically significant prolongation of duration of analgesia with group R. We observed a significant increase of mean IOP in bupivacaine group from 13.333 ± 1.582 mm Hg to 21.966 ± 2.697 mm Hg, whereas in ropivacaine group it increased from 12.766 ± 1.222 mm Hg to 13.0 ± 1.341 mm Hg after peribulbar anaesthesia.

Comparing Efficacy and Safety of Intracameral Injection of Marcaine and Lidocaine on Postoperative Pain and Recovery After Cataract Surgery

Background: Various topical (intracameral) analgesics are used to relieve postoperative pain after cataract surgery. Objectives: We decided to compare the effects of intracameral Marcaine and lidocaine on pain intensity after the cataract operation. Methods: In this double-blind, randomized clinical trial, 64 patients who were candidates for cataract surgery were randomly assigned to either anesthesia with lidocaine or bupivacaine (Marcaine) by intracameral injection. Study endpoints included pain score, hemodynamic status, patient satisfaction, and recovery duration. Results: The Marcaine group experienced a shorter recovery than another group (P = 0.001). The mean pain score at the different time points after the operation was significantly lower in the group receiving Marcaine than those receiving lidocaine (P < 0.001). Our study showed a higher level of patients’ satisfaction with Marcaine as compared to the lidocaine group (P = 0.026). However, postoperative hemodynamic status was similar in both groups. Conclusions: Compared with lidocaine, intracameral injection of Marcaine results in a shorter postoperative recovery period, reduced pain intensity, and higher satisfaction among patients after cataract surgery.

Efficacy of ropivacaine versus bupivacaine in preventing peribulbar block failure: A meta-analysis

PURPOSE

Peribulbar block is considered a standard of care in ophthalmological practice due to its easy execution and minor complications. There is a paucity of studies confirming efficacy between ropivacaine and bupivacaine for this specific technique. We evaluated the efficacy of ropivacaine or bupivacaine in preventing total or partial peribulbar block failure in ophthalmic surgeries.

METHODS

Meta-analysis of randomized clinical trials, comparing patients submitted to ophthalmic surgeries under peribulbar anesthesia with ropivacaine and bupivacaine. We searched in different databases for articles published until March, 2018. Data on patients, anesthesia, procedures and akinesia were tabulated. After calculating the chi-square of heterogeneity, we adopted a random-effects model with DerSimonian-Laird test, as well as an odds ratio and a 95% confidence interval.

RESULTS

From the 310 articles identified, 21 studies were selected. The use of ropivacaine was considered a protective factor for ocular akinesia failure in peribulbar block when compared to bupivacaine (OR = 0.53, 95% CI = 0.35-0.81 and p value = 0.003).

CONCLUSIONS

In ophthalmic surgeries, ropivacaine in peribulbar anesthesia is associated with lower rate of block failure when compared to bupivacaine.

A prospective comparison of the efficacy of 0.5% bupivacaine vs 0.75% ropivacaine in peribulbar anesthesia for vitreoretinal surgery

Purpose:

To date, there is no information on the comparison of the effect of 0.5% bupivacaine with 0.75% ropivacaine solution for vitreoretinal surgery. The aim of the study was to compare the efficacy of 0.5% bupivacaine with 0.75% ropivacaine in peribulbar anesthesia for vitreoretinal surgery. This was a prospective randomized double-blinded observational study in a hospital setting. Sixty patients planned for vitreoretinal surgery were randomized into two groups based on the peribulbar injection administered either with 0.5% bupivacaine or 0.75% ropivacaine solution, as Group B (n = 30) and Group R (n = 30), respectively. Time of onset of analgesia, akinesia, and the need for supplemental anesthesia were noted. Student's t-test or Mann-Whitney U test were used for comparing continuous variables and Chi-square or a Fischer exact test were used as appropriate for comparing two proportions.

Results:

The patients in Group R showed an earlier onset of both, analgesia (1.97 min vs. 2.10 min, P = 0.002) and akinesia (2.77 min vs. 4.20 min, P < 0.001) compared with the patients in Group B. The efficacy of the block attained was Grade 5 (adequate anesthesia and akinesia without supplementation) in about 97% of the patients in Group R while only 90% in Group B. However, the differences between the groups for the efficacy of the block were not statistically significant (P = 0.301) neither for Grades 5 nor for Grade 4 and 3 (P = 1.00 for both). The onset of postoperative pain was similar for both groups (P = 1.00).

Conclusion:

We concluded that 0.75% ropivacaine is a better choice of local anesthetic solution for patients undergoing primary vitreoretinal surgery compared with 0.5% bupivacaine.

The quest for effective pain control during suture adjustment after strabismus surgery: a study evaluating supplementation of 2% lidocaine with 0.4% ropivacaine

Purpose

To determine whether the addition of 0.4% ropivacaine to the standard 2% lidocaine peribulbar anesthetic block improves pain scores during suture adjustment in patients undergoing strabismus surgery with adjustable sutures.

Methods

Prospective, double-blind study of 30 adult patients aged 21–84 years scheduled for elective strabismus surgery with adjustable sutures. Patients were divided into two groups of 15 patients each based on the local anesthetic. Group A received 2% lidocaine and Group B received 2% lidocaine/0.4% ropivacaine. Pain was assessed using the visual analog scale (VAS) preoperatively and at 2, 4, and 6 hours postoperatively. The Lancaster red-green test was used to measure ocular motility at the same time points.

Results

The pain scores in the two groups were low and similar at all measurement intervals. The VAS for Group A versus Group B at 2 hours (1.7 versus 2.4, P=0.5) and 4 hours (3.5 versus 3.7, P=0.8) showed no benefit from the addition of ropivacaine. At 6 hours, the VAS (3.7 versus 2.7) was not statistically significant, but the 95% confidence interval indicated that ropivacaine may provide some benefit. A repeated measures ANOVA did not find a statistically significant difference in VAS scores over time (P=0.9). In addition, the duration of akinesia was comparable in both groups (P=0.7).

Conclusion

We conclude that the 50:50 mixture of 2% lidocaine with 0.4% ropivacaine as compared to 2% lidocaine in peribulbar anesthetic blocks in adjustable-suture strabismus surgery does not produce significant improvements in pain control during the postoperative and adjustment phases. In addition, ropivacaine did not impair return of full ocular motility at 6 hours, which is advantageous in adjustable-suture strabismus surgery.

Preemptive analgesia with ropivacaine for pars plana vitrectomy: randomized controlled trial on efficacy and required dose

BACKGROUND

The rationale of preemptive analgesia in ocular surgery is avoiding central sensitization because of nociceptive stimuli. The applicability in clinical practice has been argued because evidence for a relevant effect is missing. The present study attempts to demonstrate a clinically relevant pain reduction by preemptive peribulbar ropivacaine injection.

METHODS

Sixty patients scheduled for vitrectomy under general anesthesia between March and June 2007 were randomly assigned to receive 0.75% ropivacaine with 75 IU of hyaluronidase as peribulbar injection of 1, 3, or 5 mL before or 5 mL after surgery. Control subjects were 30 patients without any additional analgesic treatment. Groups were compared regarding procedure duration, consumed amount of analgesics during and after surgery, and pain 1, 3, and 24 hours postoperatively.

RESULTS

Postoperative pain was most marked in control subjects and in the group that received the injection after surgery. Before surgery, the dose of 5 mL of ropivacaine was most effective (postoperative pain median = 0), whereas patients who had received 1 mL or 3 mL reported some pain.

CONCLUSION

The study highlights the benefit of the concept of preemptive analgesia in general: the peribulbar injection of 5 mL of 0.75% ropivacaine before surgery provides a substantial benefit in terms of analgesic demand and postoperative discomfort.

Ropivacaine: a review of its use in regional anaesthesia and acute pain management

Ropivacaine (Naropin) is the pure S(-)-enantiomer of propivacaine, and is a long-acting amide local anaesthetic agent, eliciting nerve block via reversible inhibition of sodium ion influx in nerve fibres. Ropivacaine is a well tolerated regional anaesthetic effective for surgical anaesthesia as well as the relief of postoperative and labour pain. The efficacy of ropivacaine is similar to that of bupivacaine and levobupivacaine for peripheral nerve blocks and, although it may be slightly less potent than bupivacaine when administered epidurally or intrathecally, equi-effective doses have been established. Clinically adequate doses of ropivacaine appear to be associated with a lower incidence or grade of motor block than bupivacaine. Thus ropivacaine, with its efficacy, lower propensity for motor block and reduced potential for CNS toxicity and cardiotoxicity, appears to be an important option for regional anaesthesia and for the management of postoperative and labour pain.

Intraocular pressure and quality of blockade in peribulbar anesthesia using ropivacaine or lidocaine with adrenaline: a double-blind randomized study

The aim of this study was to compare the effects of ropivacaine with those of lidocaine on the intraocular pressure (IOP) and the quality of the blockade in peribulbar anesthesia for cataract surgery. Fifty patients were allocated randomly into two groups and received 7-10 ml of 0.75% ropivacaine or 2% lidocaine with adrenaline, though the peribulbar two-point injection. The quality of the blockade was assessed by ocular and eyelid akinesia, pain during the peribulbar injection, and surgical satisfaction. The duration of the motor block was also evaluated after surgery. The IOP was measured using a Tonopen before the blockade (control) and at 1, 5, and 10 min after injection of the anesthetic. Lidocaine induced significantly lower akinesia scores at 6, 8, and 10 min post-injection than did ropivacaine. The mean IOP (mmHg) was significantly lower with respect to the baseline level at 10 min after blockade in the ropivacaine group compared with the lidocaine group. Ropivacaine also caused less pain on injection. There was no difference in surgical satisfaction between the groups. The duration of the motor block obtained with ropivacaine was longer than that obtained with lidocaine. Our data indicate that ropivacaine has efficacy similar to lidocaine, with slightly longer onset and duration of the motor blockade. In addition, ropivacaine (0.75%) induces lower IOP and less pain on injection than does lidocaine (2%) when used in peribulbar anesthesia for cataract surgery.

A prospective, randomized, double-blinded comparison of ropivacaine 0.5%, 0.75%, and 1% ropivacaine for peribulbar block

STUDY OBJECTIVE

To evaluate the efficacy of three different concentrations of ropivacaine (0.5%, 0.75%, and 1%) together with a single concentration of hyaluronidase administered for peribulbar block.

DESIGN

Prospective, randomized, double-blind study.

SETTING

Anesthesia department of a university teaching hospital.

PATIENTS

68 ASA physical status I, II, and III patients undergoing elective cataract surgery.

INTERVENTIONS

Patients were randomly allocated to receive peribulbar block with 6.5 mL of either 0.5% (Group Ropi-5; n = 22), 0.75% (Group Ropi-7.5; n = 22), or 1% ropivacaine (Group Ropi-10; n = 24). In all patients, 0.5 mL of hyaluronidase was added to the local anesthetic solution.

MEASUREMENTS AND MAIN RESULTS

A larger proportion of patients in Groups Ropi-7.5 (82%) and Ropi-10 (83%) showed complete motor block 15 minutes after injection compared with Group Ropi-5 (55%;p = 0.05, andp = 0.03, respectively). Hypotension (reduction of systolic blood pressure by 30% or more from baseline) was observed in two Group Ropi-5 patients (9%), and two Group Ropi-7.5 patients (9%;p = 0.31), whereas bradycardia (reduction in heart rate < or = 50 bpm) was observed in one Group Ropi-5 patient (4%), and three Group Ropi-10 patients (12%;p = 0.18). Seven hours after surgery, a smaller proportion of Group Ropi-10 patients (64%) showed complete recovery of sensory function as compared with both Group Ropi-5 (94%) and Group Ropi-7.5 (90%;p = 0.03 and p = 0.03, respectively). Complete recovery of motor function 1 hour after surgery was more frequent in Group Ropi-5 (37%) than in Group Ropi-7.5 (5%) or Group Ropi-10 (9%;p = 0.05 and p = 0.05, respectively); however, no other differences in recovery of motor function were observed at any other observation times, with complete recovery in all patients 7 hours after surgery.

CONCLUSIONS

While confirming that ropivacaine is a good option for peribulbar anesthesia, this study demonstrated that the use of 0.75% or 1% concentrations are preferred in that they produce quick and deep sensory and motor block of the operated eye. If recovery of normal motor function is important after surgery, the 0.75% concentration probably represents the best compromise.

Transient neurological syndrome: does it really exist?

PURPOSE OF REVIEW

Subarachnoid injection of local anesthetics has been related to the appearance of transient neurological symptoms (called transient neurologic syndrome), as reflected by a number of clinical reports showing their incidence in clinical practice. However, the etiology of this syndrome is virtually unknown, as is the number of factors implicated in its development. This review will attempt to clarify this entity and its relationship with spinal anesthesia.

RECENT FINDINGS

Intrathecal administration of local anesthetics is known to increase glutamate concentration in cerebrospinal fluid and histopathologic changes of motor neurons in the lumbar spinal cord, suggesting damage of dorsal and ventral roots. In-vitro studies of cultured neurons exposed to different concentrations of local anesthetics have shown changes in growth of cones and neurites, which may be related to transient neurologic syndrome.

SUMMARY

The latest studies show biochemical and anatomopathologic changes that support the structural basis of the existence of transient neurologic syndrome. In the authors' view, transient neurologic syndrome could represent the lower end of a spectrum of local anesthetic toxicity. Recent findings demonstrate that nerve membrane damage induced by highly concentrated local anesthetics such as lidocaine, tetracaine, dibucaine and procaine may generate irreversible neural injury. Still further studies are needed to establish the relationship between morphological changes induced in vitro and the occurrence of clinical symptoms.

Ophthalmic regional anaesthesia

PURPOSE OF REVIEW

To summarize recent knowledge concerning ophthalmic regional anaesthesia.

RECENT FINDINGS

Ophthalmic regional anaesthesia has changed considerably over the past few years. Alternatives to retrobulbar anaesthesia have been proposed to reduce the number of complications without detriment to efficiency. Finally new local anaesthetics have been adopted and the indications have broadened, especially in vitroretineal surgery.

SUMMARY

New developments in ophthalmic regional anaesthesia are presented in this review. Different methods, indications and side effects are described in order to facilitate the clinician's choice, without any claim to single out an ideal technique.

Intraoperative single-shot "3-in-1" femoral nerve block with ropivacaine 0.25%, ropivacaine 0.5% or bupivacaine 0.25% provides comparable 48-hr analgesia after unilateral total knee replacement

PURPOSE

To compare analgesia after intraoperative single shot "3-in-1" femoral nerve block (FNB) in combination with general anesthesia using ropivacaine 0.25%, ropivacaine 0.5% with bupivacaine 0.25% for total knee replacement (TKR).

METHODS

We performed a randomized, double-blind study in 48 patients for elective TKR under general anesthesia. Patients were randomized to one of four groups (C: sham block, R1: "3-in-1" FNB using 30 mL of ropivacaine 0.25%, R2: "3-in-1" FNB using 30 mL of ropivacaine 0.5%, B: "3-in-1" FNB using 30 mL of bupivacaine 0.25%). Verbal pain score (VPS) both at rest and movement were assessed for 48 hr after TKR (0=none; 1=mild; 2=moderate; 3=severe). Total morphine consumption and its associated side effects, duration of hospitalization after operation were also compared.

RESULTS

There were no differences in patients' physical characteristics, intraoperative morphine usage, operation time, tourniquet time or length of hospitalization between the four groups. When compared with group C, the VPS was significantly lower in groups R1, R2 and B at one, four, eight, 24 and 48 hr after TKR (P <0.05). The morphine requirement of groups R1, R2 and B were also significantly lower when comparing with group C up to 48 hr postoperatively (P <0.05). There were no significant differences in VPS and postoperative morphine requirement at any time between groups R1, R2 and B.

CONCLUSION

"3-in-1" FNB with ropivacaine provided analgesia that was clinically comparable to that of bupivacaine up to 48 hr after TKR. Increasing the concentration of ropivacaine from 0.25% to 0.5% failed to improve the postoperative analgesia of "3-in-1" FNB.

Comparison of lignocaine 2% with adrenaline, bupivacaine 0.5% with or without hyaluronidase and a mixture of bupivacaine, lignocaine and hyaluronidase for peribulbar block analgesia

PURPOSE

Each of the freely available local analgesic agents may be used, alone or in combination, with or without hyaluronidase, epinephrine and sodium bicarbonate for peribulbar block analgesia (PBA). A prospective audit of four solutions was undertaken to rationalize choice of local analgesic agent for PBA.

METHODS

A randomized, prospective study on 200 middle-aged to elderly patients undergoing cataract extraction was undertaken to compare the efficacy of: (1) bupivacaine 0.5% (bup 0.5% plain); (2) bupivacaine 0.5% plus hyaluronidase 100 i.u. ml-1 (bup 0.5% hyalase); (3) lidocaine 2% plus epinephrine 1:200 000 (lido 2% epi); or (4) a mixture of lidocaine 2% and bupivacaine 0.5% (2:3 volume per volume mix) containing hyaluronidase 25 i.u. ml-1 (lido/bup/hyalase). A standardized deep peribulbar block technique, akinesia scoring system (each 5 minx4), and supplemental protocol was followed. Onset of block and supplementation rates to achieve akinesia were recorded by a blinded observer; the requirement for augmentation with topical oxybuprocaine or subconjunctival lidocaine during surgery and the time from first PBA injection to the completion of surgery (the duration of surgical access) were also recorded.

RESULTS

Groups (N=50) were comparable. Akinesia scores were similar after each agent at 5 min, better with lido 2% epi compared with bup 0.5% plain at 10 min (P<0.05), and better with bup 0.5% hyalase, lido 2% epi, and lido/bup/hyalase, than with bup 0.5% plain at 15 min (P<0.01, <0.01, <0.05, respectively) and at 20 min (P<0.05, <0.05, <0.025, respectively). The supplementation rate at 5 min was least with lido 2% epi, greater with bup 0.5% plain (P<0.01) and bup 0.5% hyalase (P<0.0005) and greatest with lido/bup/hyalase (P<0.0005), but similar in each group at 10, 15 and 20 min. Overall, those given lido 2% epi required the least number of supplemental injections to achieve globe akinesia. Mean supplemental injectate volumes, augmentation rates during surgery and the durations of surgical access provided by each agent were similar.

CONCLUSION

All four agents provided adequate analgesia during cataract extraction lasting approximately 95-100 min after PBA injection. Lido 2% epi demonstrated most rapid onset and required least number of injections to establish block. A hyaluronidase effect was evident only after 15 min in the bup 0.5% hyalase and lido/bup/hyalase groups. Bup 0.5% plain was overall the least satisfactory, and the greatest supplementation rate occurred with lido/bup/hyalase, suggesting that either lido 2% epi or bup 0.5% hyalase are the most suitable of the agents tested for this type of surgery.