Levobupivacaine

Impact of superior hypogastric nerve block during uterine fibroid embolisation on pain scores, opioid requirements, and same-day discharge: a case-control study

AIM

To assess the safety and efficacy of superior hypogastric nerve block (SHNB) in managing periprocedural pain associated with uterine fibroid embolisation (UFE) and in facilitating same-day discharge.

MATERIALS AND METHODS

Prospectively enrolled case-control study with retrospective analysis comprising 119 eligible patients who underwent UFE for symptomatic fibroids was undertaken at a UK teaching hospital between January 2016 and September 2022. SHNB was administered to 62 participants in addition to systemic analgesia; 57 participants received systemic analgesia alone. SHNB was performed mid-UFE using 20 ml of 0.25% levobupivacaine. Pain scores were assessed using an 11-point (0-10) verbal numerical rating scale (NRS). The study received research and ethics committee approval. Statistical analysis was performed using the chi-square and independent t-test or Mann-Whitney U-test. A p-value of <0.05 defined significance.

RESULTS

Participants who received SHNB experienced significantly less pain during the first 6 h post-procedure (averaged median pain score 2.6 versus 3.8, p=0.031). SHNB reduced the proportion of participants requiring post-procedural anti-emetics (45% versus 63%, p<0.05). For participants entered on the day-case pathway (SHNB = 34, no-SHNB = 16), those who received SHNB had a higher rate of successful same-day discharge (62% versus 31%, p=0.044). This SHNB group required significantly less opioids for periprocedural pain relief (median oral morphine equivalents; 44 mg versus 80 mg, p=0.020). No SHNB-related adverse events occurred.

CONCLUSION

SHNB is safe and effective in reducing perioperative pain, opioid requirements, and anti-emetic use in patients undergoing UFE for symptomatic fibroids. SHNB, as an adjunct to analgesic optimisation, facilitates same-day discharge, which is often limited by severe post-embolisation pain.

In vitro chondrotoxicity of bupivacaine, levobupivacaine and ropivacaine and their effects on caspase activity in cultured canine articular chondrocytes

Bupivacaine, levobupivacaine and ropivacaine are potent, long acting, amide-type local anesthetics that have several clinical applications including intra-articular administration. The objectives of this study were to evaluate their in vitro effects on cell viability and caspase activity to elucidate whether they activate the extrinsic or intrinsic pathways of apoptosis in canine articular chondrocytes. Chondrocytes in monolayer culture were treated with culture medium as the control, or with 0.062% (0.62 mg/mL) bupivacaine, 0.062% levobupivacaine, and 0.062% ropivacaine for 24 hr. Cell viability was evaluated using the live/dead, 3-(4,5-dimehylthiazolyl-2)-2,5-diphenyltetrazolium bromide (MTT), and Cell Counting Kit-8 (CCK-8) assays. Evaluation of caspase-3, caspase-8, and caspase-9 activity was performed using colorimetric assays. The MTT and CCK-8 assays were used to evaluate the effect of caspase inhibitors on local anesthetic chondrotoxicity. All three local anesthetics decreased chondrocyte viability after 24 hr (P<0.001). Apoptosis was induced through both the extrinsic and intrinsic pathways. Bupivacaine increased caspase-3, caspase-8, and caspase-9 activity (P<0.001). Levobupivacaine increased caspase-3 (P=0.03) while ropivacaine did not significantly upregulate activity for all three caspases. Caspase inhibition did not suppress bupivacaine chondrotoxicity whereas inhibition of caspase-8 and caspase-9 decreased ropivacaine chondrotoxicity and mildly attenuated levobupivacaine chondrotoxicity. In summary, the level of chondrotoxicity, the type of caspase activated, the level of caspase activation, and the response to caspase inhibitors was dependent on the type of local anesthetic. Therefore, ropivacaine may be a safer choice for intra-articular administration compared to levobupivacaine and bupivacaine.

The pharmacokinetics of levobupivacaine 0.5% after infraorbital or inferior alveolar block in anesthetized dogs

Introduction

Data are lacking on the pharmacokinetic profile and safety of levobupivacaine (LB) used for regional anesthesia of the maxilla and mandibles in dogs.

Methods

Infraorbital block (n = 10), inferior alveolar block (n = 10) or both infraorbital and inferior alveolar blocks (n = 10) were administered to dogs undergoing dental surgery under isoflurane anesthesia. The dose of LB was calculated as 0.11 ml/kg^2/3 for the infraorbital block and 0.18 ml/kg^2/3 for the inferior alveolar block. Blood samples were collected before and immediately after administration of the oral blocks, and 3, 4, 7, 12, 17, 32, 47, 62, 92, and 122 min thereafter. Quantification of LB in plasma was performed by LC-MS/MS.

Results and discussion

The results are presented as median and interquartile range. In dogs in which all four quadrants of the oral cavity were desensitized with LB, the C _max was 1,335 (1,030-1,929) ng/ml, the T _max was 7 (4-9.5) min, and the AUC_{(0 → 120)} was 57,976 (44,954-96,224) ng min/ml. Plasma concentrations of LB were several times lower than the reported toxic concentrations, and no signs of cardiovascular depression or neurotoxicity were observed in any of the dogs, suggesting that the occurrence of severe adverse effects after administration of LB at the doses used in this study is unlikely.

A Comparison Between Intrathecal Levobupivacaine and Bupivacaine for Quality and Safety During Infraumbilical Surgeries

Background

Levobupivacaine toxicity reports are rare, and when they do occur, toxic symptoms are frequently treatable with minimal morbidity and mortality. However, levobupivacaine has not entirely replaced bupivacaine in clinical practice. Moreover, the experience of intrathecal anesthesia with levobupivacaine is not well documented. Hence, the purpose of this study is to assess the quality and duration of sensory and motor blockade of levobupivacaine and its side effects, if any, compared to intrathecal bupivacaine during infraumbilical surgeries.

Methods

After approval by the Institutional Ethical Committee of Kurunji Venkatramana Gowda (KVG) Medical College and Hospital, Sullia, 90 patients aged between 18 and 65 years, of either sex, who were scheduled for elective abdominoperineal, urological, or lower limb surgeries under intrathecal anesthesia were enrolled in this prospective study from January 2013 to June 2014. The selected patients were randomly assigned to three groups of 30 each: group HB (3 mL of 0.5% hyperbaric bupivacaine), group IB (3 mL of 0.5% isobaric bupivacaine), and group IL (3 mL of 0.5% isobaric levobupivacaine). Motor blockade was assessed using the modified Bromage scale. Intergroup comparison was done using Tukey’s post hoc test. The incidence of adverse effects was analyzed using a chi-squared test. Significance was defined as P<0.05.

Results

In our study, the mean age of patients in the three groups was comparable (P>0.05), i.e., group IB was 39.23±11.78 years, group HB was 43.63±11.33 years, and group IL was 39.8±12.07 years. The time of onset of sensory block was 6.57±1.794 minutes in group IB, 2.30±1.343 minutes in group HB, and 4.57±1.960 minutes in group IL, and this variation was statistically highly significant (P<0.001). A total of 15 patients suffered hypotension intraoperatively, of which eight belonged to group HB, four to group IB, and the rest to group IL. Intraoperative or postoperative nausea/vomiting was seen in five patients in group IB, two patients in group HB, and one patient in group IL. In the postoperative period, the mean heart rate (HR) was 77.47±4.88/minute in group IB, 68.78±7.88/minute in group HB, and 72.15±8.83/minute in group IL. The data was statistically highly significant (P<0.001).

Conclusion

Our study revealed that 15 mg of isobaric levobupivacaine (3 mL of 0.5%), the new racemic isomer of bupivacaine, was intermediate in its anesthetic properties when compared to isobaric bupivacaine and hyperbaric bupivacaine. The onset of sensory and motor blockade is slower than hyperbaric bupivacaine but faster than isobaric bupivacaine with a higher level of maximum sensory block.

Cardiopulmonary Effects and Pharmacokinetics of Dexmedetomidine Used as an Adjunctive Analgesic to Regional Anesthesia of the Oral Cavity with Levobupivacaine in Dogs

This study investigated the cardiopulmonary effects and pharmacokinetics of dexmedetomidine (DEX) used as an adjunctive analgesic for regional anesthesia of the oral cavity with levobupivacaine in anesthetized dogs. Forty dogs were randomly assigned to four groups of 10 dogs. All dogs received levobupivacaine (4 blocks) with DEX IO (infraorbital block, n = 10) or IA (inferior alveolar block, n = 10) or placebo (PLC; n = 10) or DEX (n = 10) was injected intravenously (IV) after administration of levobupivacaine. The dose of DEX was always 0.5 µg/kg. Cardiopulmonary parameters were recorded, and blood was drawn for the quantification of DEX in plasma using LC-MS/MS. Heart rate was lower in all LB + DEX groups, while mean arterial pressure (MAP) was higher in the LB + DEX IV and LB + DEX IA groups compared to the LB + PLC IV group. Compared to DEX IV, IO and IA administration resulted in lower MAP up to 2 min after application. Absorption of DEX was faster at IO administration (Cmax and Tmax were 0.47 ± 0.08 ng/mL and 7.22 ± 1.28 min and 0.76 ± 0.09 ng/mL and 7.50 ± 1.63 min for the IO and IA block, respectively). The IA administration resulted in better bioavailability and faster elimination (t1/2 was 63.44 ± 24.15 min and 23.78 ± 3.78 min for the IO and IA block, respectively). Perineural administration of DEX may be preferable because of the less pronounced cardiovascular response compared to IV administration.

Prolonged blockade of the cervical sympathetic nerve by stellate ganglion block accelerates therapeutic efficacy in trigeminal neuropathy

PURPOSE

Stellate ganglion block (SGB) is effective in treating head and neck pain and neuropathic diseases by increasing tissue blood flow through its sympatholytic effect. This study aimed to investigate the relationship between duration of cervical sympathetic nerve block by SGB and its therapeutic efficacy against trigeminal neuropathy after orthognathic surgery.

METHODS

Twenty-eight patients with trigeminal neuropathy were randomly assigned to two groups (mepivacaine and levobupivacaine) according to the drug used for SGB. Increased blood flow, which is a symptom of sympathetic blockade, was recorded for 180 min after SGB. Current perception threshold, warm or cool detection threshold, and tactile detection threshold were measured preoperatively, postoperatively, on day 10 after initiation of SGB, and 3 months postoperatively to compare therapeutic efficacy between the groups.

RESULTS

The levobupivacaine group had a significantly longer duration of increased blood flow compared with the mepivacaine group. Values of current perception threshold, warm and cool detection threshold, and tactile detection threshold significantly improved in the levobupivacaine group on day 10 after initiation of SGB and 3 months postoperatively.

CONCLUSION

A prolonged increase in blood flow due to long-term sympatholytic effects accelerates the therapeutic efficacy of SGB in trigeminal neuropathy.

A Review of Regional Anesthesia in Infants

Regional anesthesia provides effective anesthesia and pain relief in infants with age-specific data attesting to safety and efficacy. Regional anesthesia decreases exposure to opioids and general anesthetic agents and associated adverse drug effects, suppresses the stress response, and provides better hemodynamic stability compared to general anesthesia. Regional anesthesia can prevent long-term behavioral responses to pain. As a result, the overall number and variety of nerve blocks being used in infants is increasing. While neuraxial blocks are the most common blocks performed in infants, the introduction of ultrasound imaging and a better safety profile has advanced the use of peripheral nerve blocks. Infant-specific pharmacokinetic and pharmacodynamic data of local anesthetic medications are reviewed including risk factors for the accumulation of high serum levels of unbound, pharmacologically active drug. Bupivacaine accumulates with continuous infusion and 2-chloroprocaine can be used as an alternative. Local anesthetic systemic toxicity has the highest incidence in infants less than 6 months of age and is associated with bolus dosing and penile nerve blocks. Local anesthetic toxicity is treated by securing the airway, suppression of seizure activity and implementation of cardiopulmonary resuscitation. Administration of intralipid (intravenous lipid emulsion) is initiated at the first sign of toxicity. A high level of expertise in regional anesthesia is needed when treating infants due to their unique development.

Population Pharmacokinetics of Levobupivacaine During Transversus Abdominis Plane Block in Children

BACKGROUND

Levobupivacaine is commonly used during transversus abdominis plane (TAP) block in pediatric patients. However, the dosing regimen is still empirical, and the pharmacokinetic properties of levobupivacaine are not considered. Here, the pharmacokinetics of levobupivacaine during an ultrasound-guided TAP block were evaluated to optimize dosing regimen, regarding the between-subject variability (BSV) and the volume of levobupivacaine injected.

METHOD

The clinical trial (prospective, randomized, double-blind study protocol) was conducted in 40 children aged 1-5 years, who were scheduled for inguinal surgery. Each patient received 0.4 mg/kg of levobupivacaine with a volume of local anesthesia solution adjusted to 0.2 mL/kg of 0.2% or 0.4 mL/kg of 0.1% levobupivacaine. Blood samples were collected at 5, 15, 20, 25, 30, 45, 60, and 75 minutes after the block injection. The population pharmacokinetic analysis was performed using the NONMEM software.

RESULTS

From the pharmacokinetic parameters obtained, median Cmax, tmax,, and area under the concentration versus time curve were 0.315 mg/L, 17 minutes, and 41 mg/L·min, respectively. BSV of clearance was explained by weight. At the dose regimen of 0.4 mg/kg, none of the infants showed signs of toxicity, but in 13 patients, TAP block failed. After analysis, BSV for absorption rate constant, distribution volume, and clearance were 81%, 47%, and 41%, respectively. Residual unexplained variability was estimated to be 14%.

CONCLUSIONS

For improved efficiency in the pediatric population, the dose of levobupivacaine should be greater than 0.4 mg/kg. Children's weight should be considered to anticipate any risk of toxicity.

Ultrasound-guided adductor canal block using levobupivacaine versus periarticular levobupivacaine infiltration after totalknee arthroplasty: a randomized clinical trial

BACKGROUND

Both postoperative pain control and range of motion are important in total knee arthroplasty (TKA). However, in the literature, there is little comparison of peripheral nerve blocks and periarticular infiltration techniques using levobupivacaine. The aim of our study was to measure pain with visual analogue scale (VAS) and knee range of motion (ROM) between in patients undergoing adductor canal block (ACB) for TKA using levobupivacaine compared to periarticular levobupivacaine infiltration (PAI-L).

DESIGN AND SETTING

Prospective randomized clinical trial in a university hospital.

METHODS

Patients aged 40-85 years who underwent unilateral TKA were included; 39 were treated withperiarticular infiltration using 40 ml (0.125 mg) of levobupivacaine (PAI-L group); and 40 were treated with ACB using 20 ml of 0.25% levobupivacaine (ACB-L group). Postoperative pain scores at rest and during active physical therapy were assessed using a VAS, along with knee ROM in flexion and extension. In addition, 100-foot walking time results, total morphine consumption and time of first analgesia requirement were recorded postoperatively.

RESULTS

VAS scores at rest and during active physical therapy and the total amount of morphine consumed were lower in the ACB-L group than in the PAI-L group (P < 0.05). In contrast, knee ROM in flexion and extension and 100-foot walking times were greater in the PAI-L group than in the ACB-L group (P < 0.05).

CONCLUSION

ACB-L was superior to PAI-L regarding pain treatment after TKA; however, PAI-L was superior to ACB-L regarding postoperative ROM and walking ability.

CLINICAL TRIAL REGISTRY

ACTRN-12618000438257.

Levobupivacaine versus Racemic Bupivacaine in Spinal Anaesthesia for Urological Surgery

Racemic bupivacaine is the most common local anaesthetic used intrathecally. This prospective, randomized, double-blind study compared the clinical efficacy and motor block of 0.5% levobupivacaine with 0.5% racemic bupivacaine in spinal anaesthesia for urological surgery. The surgery required an upper level of sensory block of at least the tenth thoracic dermatome. Fifty patients were recruited (levobupivacaine group n=24; bupivacaine group n=26). Spinal anaesthesia was achieved with 2.6 ml of study solution injected in the subarachnoid space at the lumbar 3/4 interspace. One patient from the levobupivacaine group was excluded due to technical failure. There were no significant differences between the two groups in the quality of sensory and motor block or in haemodynamic change. Anaesthesia was adequate and patient satisfaction good in all cases.

We conclude that 0.5% levobupivacaine can be used as an alternative to 0.5% racemic bupivacaine in spinal anaesthesia for surgery when a sensory block to at least T10 is required.

Effective concentration of levobupivacaine and ropivacaine in 80% of patients receiving epidural analgesia (EC80) in the first stage of labour: A study using the Continual Reassessment Method

BACKGROUND

A comparison of the effective dose in 50% of patients (ED50) has suggested that the potency of levobupivacaine lies between that of bupivacaine and ropivacaine. However, for clinical purposes, knowledge and use of doses close to the ED95 are more relevant. This study was designed to determine the EC80 (effective concentration) for both epidural levobupivacaine and ropivacaine using the Continual Reassessment Method (CRM) during obstetric analgesia.

METHODS

In this double-blind randomised study, term parturients were included by cohorts of 6 if cervical dilatation was≤5cm and visual analogue pain score (VAPS)>30mm. Efficacy was defined by a decrease of VAPS to a value≤10, thirty minutes after epidural injection of 20mL of levobupivacaine or ropivacaine. The first cohort received the lowest dose. Every next cohort received a dose according to the response's probability calculated using a Bayesian method, incorporating data from all consecutive previous patients. In addition, a logistic equation was fitted a posteriori to the whole data set to determine the whole dose-probability curve.

RESULTS

Fifty-four patients were enrolled. Levobupivacaine 0.17% and ropivacaine 0.2% gave probabilities of success of 82% and 72% respectively. By fitting the logistic model to the data, the concentration leading to a probability of 0.8 (EC80) was 0.14% for levobupivacaine and 0.24% for ropivacaine while the EC50 were 0.09% for levobupivacaine and 0.17% for ropivacaine, respectively.

CONCLUSION

This study suggests that epidural levobupivacaine used as the sole drug for labour analgesia has an EC80 lower than that of ropivacaine.

The effect of addition of dexamethasone to levobupivacaine in parturients receiving combined spinal-epidural for analgesia for vaginal delivery

Background and Aims:

Regional analgesia is commonly used for the relief of labour pain, Prolongation of analgesia can be achieved by adjuvant medications. The aim of this randomised controlled trial was to evaluate the efficacy of intrathecal levobupivacaine with dexamethasone for labour analgesia.

Methods:

A total of 80 females were included in this study, all were primigravidas undergoing vaginal delivery with cervical dilatation ≥4 cm and 50% or more effacement. Forty females were included randomly in either Group L (received intrathecal levobupivacaine 0.25% in 2 mL) or Group LD (received intrathecal levobupivacaine 0.25% combined with dexamethasone 4 mg in 2 mL). The primary outcome was the duration of spinal analgesia. Secondary outcomes included the total dose of epidural local anaesthetic given, time to delivery, neonatal outcome and adverse effects.

Results:

The duration of spinal analgesia was significantly longer in the LD group compared with L group (80.5 ± 12.4 min vs. 57.1 ± 11.5 min, respectively; P < 0.001). In Group LD compared with Group L, time from spinal analgesia to delivery was significantly lower (317.4 ± 98.9 min vs. 372.4 ± 118.8 min, respectively; P = 0.027), and total epidural levobupivacaine consumption was significantly lower (102.4 ± 34.8 mg vs. 120.1 ± 41.9 mg, respectively; P = 0.027). The two groups were comparable with respect to characteristics of sensory and motor block, haemodynamic parameters, pain scores, neonatal outcome and frequency of adverse effects.

Conclusion:

Intrathecal dexamethasone plus levobupivacaine prolongs the duration of spinal analgesia during combined spinal-epidural CSE for labour analgesia.

The Efficacy of Levobupivacaine Hydrochloride-Dexamethasone Infiltration for Post-Tonsillectomy Pain in Adults

OBJECTIVE

The aim of the study is to evaluate the efficacy of peritonsillar infiltration of a levobupivacaine hydrochloride and dexamethasone combination for post-tonsillectomy pain in adult patients.

METHODS

A total of 40 patients were included in this double-blind, randomized, and placebo-controlled study. The patients were equally randomized into 2 groups by means of sealed envelopes. The study group (SG) received peritonsillar levobupivacaine hydrochloride and dexamethasone infiltration and the control group (CG) received peritonsillar saline infiltration. Pain scores at the second, fourth, eighth, 12th, 16th, and 24th hours and the second to seventh days after operation were recorded by the patients in each group using a visual analog scale. Duration of surgery and the total amount of blood loss during the surgery were also recorded for each patient.

RESULTS

All pain scores in the SG were lower than those in the CG; however, the difference was significant at the second, 12th, and 16th hours, and the second and third day (P < 0.05). Postoperative morbidity parameters, including otalgia, nausea, vomiting, fever, halitosis, and bleeding were similar between the 2 groups. Total amount of analgesic consumption in the SG was significantly lower than in the CG on each day of the week after tonsillectomy.

CONCLUSIONS

Peritonsillar infiltration of a levobupivacaine hydrochloride and dexamethasone combination may provide pain reduction and decrease analgesic consumption in the postoperative period after adult tonsillectomy.

Evaluation of levobupivacaine passage to breast milk following epidural anesthesia for cesarean delivery

BACKGROUND

Following maternal administration, local anesthetics pass into breast milk. In the present study, we aimed to compare the passage of levobupivacaine and bupivacaine into breast milk following epidural anesthesia for cesarean delivery.

METHODS

A total of 20 women undergoing elective cesarean delivery under epidural anesthesia were randomized to receive either 0.5% levobupivacaine or 0.5% racemic bupivacaine via an epidural catheter. Immediately before and 30min, 1h, 2h, 6h, 12h and 24h after administration of epidural local anesthetic, maternal blood and breast milk samples were taken simultaneously. Drug concentrations in plasma and milk were determined via high-performance liquid chromatography. The infant's drug exposure was determined by calculating milk/plasma ratios of levobupivacaine and bupivacaine.

RESULTS

Both levobupivacaine and bupivacaine were detected in breast milk 30min after epidural administration. Concentrations of both agents showed constant and similar decreases in milk and plasma and were nearly undetectable at 24h. The milk/plasma ratios were 0.34±0.13 for levobupivacaine and 0.37±0.14 for bupivacaine.

CONCLUSIONS

Both levobupivacaine and bupivacaine pass into breast milk following epidural administration. The concentration of both drugs was approximately three times lower in breast milk than in maternal plasma.

Intrathecal bupivacaine or levobupivacaine: which should be used for elderly patients?

OBJECTIVES

To compare two intrathecal anaesthetics, bupivacaine and levobupivacaine, for their effects on motor and sensory blockade and haemodynamics in patients aged ≥ 65 years undergoing transurethral resection of the prostate (TUR-P) or transurethral resection of the urinary bladder (TUR-M).

METHODS

Patients scheduled to undergo TUR-P or TUR-M were randomized to receive either 3 ml (15 mg) 0.5% isobaric levobupivacaine (group L) or 3 ml (15 mg) of 0.5% hyperbaric bupivacaine (group B) for spinal anaesthesia. The onset time, maximum level and time to reach the maximum level of sensory and motor blockade were recorded. Changes to haemodynamic parameters were also recorded.

RESULTS

The study randomized 100 patients: 57 to group L and 43 to group B. Levobupivacaine did not cause any significant changes in haemodynamic parameters, including systolic blood pressure, and showed a similar sensory block onset time compared with bupivacaine, but it had a significantly longer motor block onset time compared with bupivacaine.

CONCLUSION

These current findings suggest that levobupivacaine can be used as a substitute for bupivacaine for spinal anaesthesia in elderly patients ≥ 65 years of age undergoing elective TUR-P or TUR-M operations.

Clinical profile of levobupivacaine in regional anesthesia: A systematic review

The quest for searching newer and safer anesthetic agents has always been one of the primary needs in anesthesiology practice. Levobupivacaine, the pure S (−)-enantiomer of bupivacaine, has strongly emerged as a safer alternative for regional anesthesia than its racemic sibling, bupivacaine. Levobupivacaine has been found to be equally efficacious as bupivacaine, but with a superior pharmacokinetic profile. Clinically, levobupivacaine has been observed to be well-tolerated in regional anesthesia techniques both after bolus administration and continuous post-operative infusion. The incidence of adverse drug reactions (ADRs) is rare when it is administered correctly. Most ADRs are related to faulty administration technique (resulting in systemic exposure) or pharmacological effects of anesthesia; however, allergic reactions can also occur rarely. The available literary evidence in anesthesia practice indicates that levobupivacaine and bupivacaine produce comparable surgical sensory block, similar adverse side effects and provision of similar labor analgesia with good comparable maternal and fetal outcome. The present review aims to discuss the pharmacokinetic and pharmacological essentials of the safer profile of levobupivacaine as well as to discuss the scope and indications of levobupivacaine based on current clinical evidence.

The comparison of levobupivacaine in continuous or single dose spinal anesthesia for transurethral resection of prostate surgery

BACKGROUND

The aim of the study is to compare the efficacy of levobupivacaine induced continuous spinal anesthesia (CSA) versus single dose spinal anesthesia (SDSA) in patients who are planned to undergo transurethral prostate resection.

METHODS

Sixty years or older, ASA I-II or III, 50 patients were included in the study. 12.5mg 0.5% levobupivacaine were administered intrathecally in SDSA group. In CSA group, initially 2mL of 0.25% levobupivacaine were administered through spinal catheter. In order to achieve sensory block level at T10 dermatome, additional 1mL of 0.25% levobupivacaine were administered through the catheter in every 10min. Hemodynamic parameters and block characteristics were recorded. Preoperative and postoperative blood samples of the patients were drawn to determine plasma cortisone and plasma epinephrine levels.

RESULTS

CSA technique provided better hemodynamic stability compared to SDSA technique particularly 90min after intrathecal administration. The rise in sensory block level was rapid and the time to reach surgical anesthesia was shorter in SDSA group. Motor block developed faster in SDSA group. In CSA group, similar anesthesia level was achieved by using lower levobupivacaine dose and which was related to faster recovery. Although, both techniques were effective in preventing surgical stress respond, postoperative cortisone levels were suppressed more in SDSA group.

CONCLUSION

CSA technique with 0.25% levobupivacaine can be used as a regional anesthesia method for elderly patients planned to have TUR-P operation.

Levobupivacaine vs. bupivacaine for third molar surgery: quality of anaesthesia, postoperative analgesia and local vascular effects

OBJECTIVES

The main purpose of this prospective, double-blind, randomized study was to evaluate anaesthetic parameters, postoperative analgesia and vasoactive properties of levobupivacaine and bupivacaine for lower third molar surgery.

MATERIAL AND METHODS

Sixty patients (ASA I) were scheduled for lower third molar surgery under inferior alveolar nerve block, lingual nerve block and buccal nerve block (mandibular nerve blocks) obtained with 3 ml of 0.5 % levobupivacaine and 3 ml of 0.5 % bupivacaine. Success rate, onset and duration of three nerve bocks were evaluated by electrical pulp testing, pinprick testing and signs of soft tissue anaesthesia (patient-reported numbness). Intensity of intraoperative anaesthesia and postoperative analgesia were measured with visual analogue scale (VAS) and numeric rating scale (NRS). The time of first postoperative pain reported and analgesic consumption were also recorded. The laser Doppler flowmetry was used for the measurement of the first premolar pulpal blood flow.

RESULTS

There were no differences between levobupivacaine and bupivacaine regarding the success rate, onset and duration of mandibular nerve blocks as well as intensity of postoperative analgesia and analgesic consumption. Intensity of intraoperative anaesthesia and duration of postoperative analgesia were significantly higher in the levobupivacaine than in the bupivacaine group. Both anaesthetics showed similar biphasic vasoactive effect.

CONCLUSIONS

Levobupivacaine 0.5 % achieved superiority over bupivacaine 0.5 % in the intensity of intraoperative anaesthesia and duration of postoperative analgesia for lower third molar surgery under the mandibular nerve blocks.

CLINICAL RELEVANCE

It seems that the plain levobupivacaine (0.5 %) could be an effective alternative to plain bupivacaine (0.5 %) in those dental procedures which require profound bone and soft tissue anaesthesia.

What the phlebologist should know about local anesthetics

An increasing number of phlebological interventions are performed under local and tumescent anesthesia. Although the modern local anesthetic agents are generally perceived as being effective and safe drugs, the administration of these drugs may be associated with a number of adverse events. It is therefore mandatory that everyone who uses these compounds has insight into the pharmacological actions of these drugs and is capable of recognizing and adequately treating potential adverse events. The present narrative review summarizes the current knowledge on mechanisms of action of the most important local anesthetic drugs and reviews the potential adverse effects as well as their treatment.

[Contribution to post-caesarean analgesia of ultrasound-guided transversus abdominis plane block]

OBJECTIVE

The aim of this study was to evaluate the contribution made by ultrasound-guided transversus abdominis plane block (TAP) to the quality of the analgesia with intrathecal opioids obtained in patients undergoing elective caesarean delivery.

MATERIAL AND METHODS

A prospective, randomized study in patients submitted to elective caesarean section with spinal anaesthesia with 0.5% hyperbaric bupivacaine. The patients were randomized into 3 groups according to the added complementary drug for analgesia: group A morphine 0.1mg; group B fentanyl 10 μg; group C 10 μg fentanyl+bilateral TAP block. The TAP block with 20 ml of 0.5% levobupivacaine on each side, after surgery. Groups A and B, were injected with 20 ml of saline. Postoperative analgesia was performed with morphine bolus through a system of patient-controlled analgesia (PCA). We studied the pain on a visual analogue scale at 12 and 24h at rest and movement, the time elapsed to require the first bolus, and morphine bolus in 24h. Secondary effects such as nausea, vomiting, pruritus, and drowsiness, were also evaluated. The level of patient satisfaction was also recorded.

RESULTS

A total of 90 patients were included. At rest the 12/24h VAS score was: group A, at 12h 2.1 ± 1.2, at 24h 4.7 ± 1.6; group B at 12h 4.3 ± 2.9, at 24h 4.8 ± 2; group C at 12h 1.9 ± 1.09, at 24h 2.3 ± 1.2 (P<.05). Walking improved analgesia more in group C (P ≤.02). The time of asking for the first bolus was lower in group B: group A 9.3 ± 4.9h (P=.02 compared to group C), in group B 2 ± 1.8h (P<.001 compared to group C) and group C 13.2 ± 2.1h. The number of bolus in 24h in group B was 38 ± 5, in group A 10 ± 2 (P<.05), group C 5 ± 2 (P<.001). Delayed nausea was increased in group B (36.6%) and pruritus was greater in group A (36.6%).

CONCLUSIONS

Ultrasound (US)-guided TAP block improves spinal opioid analgesia, with a decrease in VAS scores in the first 24h, and reduces opioid requirement and secondary effects after caesarean delivery.

The effects of tramadol and levobupivacaine infiltration on postoperative analgesia in functional endoscopic sinus surgery and septorhinoplasty

OBJECTIVE

The aim of this prospective, randomized, double-blind study was to investigate the postoperative analgesic effects of levobupivacaine or tramadol infiltration administered prior to surgery in septorhinoplasty (SRP) or endoscopic sinus surgery (ESS).

MATERIAL AND METHODS

Sixty ASA class I-III adult patients electively undergoing SRP or ESC were included the study. Induction of anesthesia was performed with propofol 2-2.5 mg/kg, rocuronium bromide 0.6 mg/kg and fentanyl 1 μg/kg i.v. Sevoflurane 2% with an N2O/O2 mixture (FiO2: 35%) was used for maintenance. Tramadol 0.5 mg/kg (Group T: n=20), levobupivacaine 0.25% (Group L: n=20) and lidocaine 1% (Group C: n=20) in a 1/200,000 adrenaline solution was infiltrated into the surgical area 10 min before the operation (5 mL for ESS and 10 mL for SRP). All patients received fentanyl (bolus dose: 15 μg and lockout interval: 10 min) with a patient-controlled analgesia device during the postoperative period. Pain was assessed using an 11-point visual analogue scale (VAS) every 4 h for the first 24 h. Analgesic requirements, opioid consumption and side effects in the postoperative period were recorded.

RESULTS

There was a statistically significant decrease in postoperative fentanyl demand and consumption in patients receiving tramadol. Fentanyl doses in the 24 h period were 345.2±168.8 μg, 221.1±120.6 μg and 184.1±130.3 μg (p=0.002) for the Groups C, L and T, respectively. There were statistically significant differences in fentanyl requirements between the tramadol and control groups at the 16, 20 and 24 h time points (p=0.012, p=0.004 and p=0.002, respectively). The side effect profiles were similar.

CONCLUSIONS

Our study indicates that the preemptive tramadol infiltration technique is an efficient, practical and safe alternative to levobupivacaine in ESS or SRP operations.

The effects of levobupivacaine infiltration on post-tonsillectomy pain relief in adults: a single-blinded, randomized, and controlled clinical study

The aim of this prospective single-blinded and controlled study is to evaluate the efficacy of levobupivacaine infiltration on post-tonsillectomy pain relief in adults. The study was conducted with 40 adult patients who underwent tonsillectomy. These patients were randomized in either study group (SG) who received levobupivacaine infiltration to peritonsillary fossae prior to surgery or control group (CG) with no medication. After surgery, all the patients were queried for pain scores by visual analog scale. In addition, the volume of intraoperative bleeding, the duration of operation, the severity of postoperative complications, and the amount of analgesic requirement were the other outcome measures of this study. There were significant differences between groups regarding pain scores for the first 24 h in favor of SG. The analgesic requirement was also significantly lower in SG (p = 0.009). Although there was a sustained decrement at pain score during first 24 h for SG, however, the change from baseline score (immediate score) for each time interval revealed no significance compared to CG. In addition, the duration of operation and the volume of intraoperative bleeding were similar (p = 0.64 and p = 0.165). In conclusion, preincisional infiltration of levobupivacaine is a safe and reliable method for post-tonsillectomy pain reduction in adults. However, more in-depth, double-blinded and placebo controlled studies are required to elucidate its long term benefits.

Levobupivacaine-induced contraction of isolated rat aorta is calcium dependent

Levobupivacaine is a long-acting local anesthetic that intrinsically produces vasoconstriction in isolated vessels. The goals of this study were to investigate the calcium-dependent mechanism underlying levobupivacaine-induced contraction of isolated rat aorta in vitro and to elucidate the pathway responsible for the endothelium-dependent attenuation of levobupivacaine-induced contraction. Isolated rat aortic rings were suspended to record isometric tension. Cumulative levobupivacaine concentration-response curves were generated in either the presence or absence of the antagonists verapamil, nifedipine, SKF-96365, 2-aminoethoxydiphenylborate, Gd(3+), N(W)-nitro-l-arginine methyl ester (L-NAME), 1H-[1,2,4]oxadiazolo[4,3-a]quinoxalin-1-one (ODQ), and methylene blue, either alone or in combination. Verapamil, nifedipine, SKF-96365, 2-aminoethoxydiphenylborate, low calcium concentrations, and calcium-free Krebs solution attenuated levobupivacaine-induced contraction. Gd(3+) had no effect on levobupivacaine-induced contraction. Levobupivacaine increased intracellular calcium levels in vascular smooth muscle cells. L-NAME, ODQ, and methylene blue increased levobupivacaine-induced contraction in endothelium-intact aorta. SKF-96365 attenuated calcium-induced contraction in a previously calcium-free isotonic depolarizing solution containing 100 mmol/L KCl. Levobupivacaine-induced contraction of rat aortic smooth muscle is mediated primarily by calcium influx from the extracellular space mainly via voltage-operated calcium channels and, in part, by inositol 1,4,5-trisphosphate receptor-mediated release of calcium from the sarcoplasmic reticulum. The nitric oxide - cyclic guanosine monophosphate pathway is involved in the endothelium-dependent attenuation of levobupivacaine-induced contraction.

Comparison of peritonsillar levobupivacaine and bupivacaine infiltration for post-tonsillectomy pain relief in children: placebo-controlled clinical study

OBJECTIVES

To compare the effects of preincisional peritonsillar infiltration of levobupivacaine and bupivacaine on post-tonsillectomy pain in children.

METHODS

Sixty children undergoing elective tonsillectomy or adenotonsillectomy were randomly allocated into three groups before tonsillectomy: peritonsillar infiltrations with 0.25% levobupivacaine with 1:200,000 epinephrine (group levobupivacaine, n=20), 0.25% bupivacaine with 1:200,000 epinephrine (group bupivacaine, n=20), and normal saline (group saline, n=20) were applied. Pain was evaluated by using a modified Children's Hospital of Eastern Ontario Pain Scale (mCHEOPS). Choice of additional analgesic was acetaminophen for all patients.

RESULTS

mCHEOPS values at 0th (immediately) and 30th minute after arrival the PACU were lower in both the local anesthetics groups than the saline group (p<0.001, p<0.01 for the group levobupivacaine; p<0.001, p<0.05 for the group bupivacaine, respectively). In addition, mCHEOPS values at 1st hour in the ward was lower in the group bupivacaine when compared to the group saline (p<0.05). Analgesic requirements and the time to first analgesia required, were also significantly different between the local anesthetic and saline groups (p<0.05 for both local anesthetics groups). Time to first mobilization was shorter in both local anesthetic groups when compared to the saline group (p<0.05 for both local anesthetic groups).

CONCLUSION

Preincisional peritonsillar infiltration with levobupivacaine or bupivacaine before tonsillectomy, are effective than saline, in reducing early post-tonsillectomy pain, where as bupivacaine had slightly longer effect. Compared to saline, with both anesthetic infiltrations, lesser medication for analgesia is required. The clinical trial registration number (Research Ethics Committee of Medical Faculty, Uludag University): 2008-4/36, 19 February 2008.

Transient neurological symptoms after spinal anaesthesia with levobupivacaine 5 mg/ml or lidocaine 20 mg/ml

BACKGROUND

Transient neurological symptoms (TNS) after spinal anaesthesia have been reported most commonly in association with lidocaine, but have been observed with other local anaesthetics. The aim of this prospective, randomized, double-blind study was to investigate the incidence of TNS after spinal anaesthesia with either levobupivacaine or lidocaine.

METHODS

Patients undergoing inguinal hernia, appendectomy, varicose vein or minor orthopaedic operations were included in the study (60 patients; 47 male, 13 female, overall mean age 30 years). All patients had an American Society of Anesthesiologists score of I or II. The patients were randomly assigned to receive spinal anaesthesia with either 20 mg isobaric levobupivacaine (5 mg/ml) or 80 mg isobaric lidocaine (20 mg/ml). Onset of sensory and motor block and side effects were recorded. On post-operative days 1, 2, and 3, patients were interviewed by an investigator blinded to the spinal anaesthetic used. The patients were classified as having TNS if, following recovery from anaesthesia, there was pain in the buttocks, thighs and/or lower limbs.

RESULTS

In the levobupivacaine group, one patient (3.33%) experienced TNS, whereas in the lidocaine group, eight (26.6%) experienced TNS (P=0.002). Maximum times to arrival of sensory blocks were shorter with lidocaine (P<0.001). The levobupivacaine and lidocaine groups did not differ significantly in terms of the highest dermatome included in sensory block or motor block grade.

CONCLUSION

After spinal anaesthesia with levobupivacaine, the incidence of TNS was much less than after lidocaine. However, it appears that TNS may occur in association with levobupivacaine.

The effects of topical levobupivacaine on morbidity in pediatric tonsillectomy patients

OBJECTIVE

To reduce the post-tonsillectomy morbidity by swab soaked with 5 ml levobupivacaine hydroclorur (25 mg/10 ml).

STUDY DESIGN

A double-blind prospective randomized controlled clinical study.

METHODS

In this randomized double-blind study in group I (30 children, mean age 7.5+/-2.6) we tightly packed swab soaked with 5 ml levobupivacaine hydroclorur (25mg/10 ml) and in group II (21 children, mean age 7.9+/-3.7) we used 5 ml saline swabs into each of the two tonsillar fossae after tonsillectomy for 5 min. We used McGrath's face scale to compare the two groups in respect of pain control.

RESULTS

There was statistically significant pain relieving effect in the levobupivacaine group in the first 24h (p<0.05). But after 24h pain relieving effect of levobupivacaine was not significant (p>0.05). We did not see any serious complications for both groups. Postoperative morbidity mean results (nausea, vomiting, fever, bleeding, halitosis and ear pain) were not statistically different between the two groups (p>0.05).

CONCLUSION

Topical levobupivacaine seems to be a safe and easy medication for postoperative pain control in pediatric tonsillectomy patients.

Epidural analgesia practices for labour: results of a 2005 national survey in Ireland

BACKGROUND AND OBJECTIVE

The last 25 years have seen changes in the management of epidural analgesia for labour, including the advent of low-dose epidural analgesia, the development of new local anaesthetic agents, various regimes for maintaining epidural analgesia and the practice of combined spinal-epidural analgesia. We conducted a survey of Irish obstetric anaesthetists to obtain information regarding the conduct and management of obstetric epidural analgesia in Ireland in 2005. The specific objective of this survey was to discover whether new developments in obstetric anaesthesia have been incorporated into clinical practice.

METHODS

A postal survey was sent to all anaesthetists with a clinical commitment for obstetric anaesthesia in the sites approved for training by the College of Anaesthetists, Ireland.

RESULTS

Fifty-three per cent of anaesthetists surveyed responded. The majority of anaesthetists (98%) use low-dose epidural analgesia for the maintenance of analgesia. Only 11% use it for test-dosing and 32% for the induction of analgesia. The combined spinal-epidural analgesia method is used by 49%, but two-thirds of those who use it perform fewer than five per month. Patient-controlled epidural analgesia was in use at only one site.

CONCLUSION

It appears that Irish obstetric anaesthetists have adopted the low-dose epidural analgesia trend for the maintenance of labour analgesia. This practice is not as widespread, however, for test dosing, the induction of analgesia dose or in the administration of intermittent epidural boluses to maintain analgesia when higher concentrations are used. Since its introduction in 2000, levobupivacaine has become the most popular local anaesthetic agent.

A comparison of the inhibitory effects of bupivacaine and levobupivacaine on isolated human pregnant myometrium contractility

BACKGROUND

Epidural analgesia with levobupivacaine and bupivacaine is a common and effective method of labor pain relief. However, its use is associated with an increased instrumental delivery rate. One of the mechanisms postulated to account for this unwanted effect is the direct effect of local anesthetics on myometrial contractility. We determined the effects of bupivacaine and levobupivacaine on the amplitude and frequency of contractions of human term myometrium.

METHODS

Uterine specimens were obtained from nonlaboring parturients scheduled for elective lower-segment cesarean delivery at term. Longitudinal muscle strips were prepared and mounted vertically in tissue chambers, and changes in the amplitude (peak force) and the frequency of contractions were recorded. Spontaneous contractions commenced after a period of application of 1 g (9.81 mN) of tension to the myometrial strips. No uterotonic drugs were used. The muscle strips were then exposed to cumulative concentrations of bupivacaine and levobupivacaine and dose-response curves were generated.

RESULTS

Both bupivacaine and levobupivacaine decreased the amplitude of contractions in human myometrium in a concentration-dependent manner, reaching significance at 1x10(-4) M for both bupivacaine and levobupivacaine compared with the internal control amplitude. With both drugs, the decrease in amplitude was accompanied by an increase in the frequency of contractions reaching significance at 3x10(-5) M for both bupivacaine and levobupivacaine compared with the internal control frequency.

CONCLUSIONS

The concentrations required for the effects on amplitude are much higher (33 fold) than the clinically relevant plasma concentrations of these drugs after epidural administration, and are unlikely to be significant in the setting of low-dose epidural analgesia in labor.