Interscalene brachial plexus anesthesia and analgesia for open shoulder surgery: a randomized, double-blinded comparison between levobupivacaine and ropivacaine

Comparison of the onset time between 0.375% ropivacaine and 0.25% levobupivacaine for ultrasound-guided infraclavicular brachial plexus block: a randomized-controlled trial

At centers with pressure on rapid operating room turnover, onset time is one of the important considerations for choosing a local anesthetic drug. To hasten the onset of the block, higher concentrations of local anesthetics are sometimes used. However, the use of diluted local anesthetics may be safer. Therefore, we aimed to compare the onset times of equipotential levobupivacaine and ropivacaine at low concentrations for infraclavicular brachial plexus block. Adult patients undergoing upper extremity surgery under ultrasound-guided infraclavicular brachial plexus block at our center were randomly allocated to the levobupivacaine and ropivacaine groups. Infraclavicular brachial plexus block was induced with 0.25% levobupivacaine or 0.375% ropivacaine depending on the assigned group. The degrees of sensory and motor blockade were assessed for 40 min after the administration of local anesthetics. A total of 46 patients were included in the analysis. Infraclavicular brachial plexus block with 0.25% levobupivacaine and 0.375% ropivacaine provided sufficient surgical anesthesia. The sensory onset time of 0.375% ropivacaine was shorter than that of 0.25% levobupivacaine (group R, 15 [15.0–22.5] min; group L, 30 [17.5–35.0] min, p = 0.001). There were no significant differences in other block characteristics and clinical outcomes between the two groups. Thus, when a quicker block onset is required, 0.375% ropivacaine is a better choice than 0.25% levobupivacaine.

Trial registration ClinicalTrials.gov (NCT03679897).

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.

Ropivacaine versus levobupivacaine in peripheral nerve block: A PRISMA-compliant meta-analysis of randomized controlled trials

BACKGROUND

To determine which is more potent in peripheral nerve block between ropivacaine and levobupivacaine.

METHODS

A literature search was performed in the EMBASE, Medline, the Cochrane Library, and the Web of Science. The trials that were found were then evaluated for eligibility. The Cochrane Collaboration's Review Manager software was used to perform the meta-analyses.

RESULTS

Twelve studies including 556 patients were included for final analysis. No statistically significant difference was observed between the 2 drugs with respect to onset time of surgical anesthesia, onset time of sensory block, onset time of motor block, duration of motor block, and patients overall satisfaction. Levobupivacaine provided more long-term anesthesia (weighted mean difference [WMD], -2.94; 95% confidence interval [CI], -5.56 to -0.32; I = 93%) and significantly lower incidence of postoperative rescue analgesia (odds ratio [OR], 2.11; 95% CI 1.18-3.74; I = 21%) than ropivacaine. There was a trend toward greater duration of sensory block in the levobupivacaine group (WMD, -1.16; 95% CI, -1.89 to -0.43; I = 14%).

CONCLUSION

Levobupivacaine is more potent than ropivacaine in peripheral nerve block to some extent. Otherwise, more rigorous randomized control trials are required in the future.

Postoperative analgesia comparing levobupivacaine and ropivacaine for brachial plexus block: A randomized prospective trial

BACKGROUND

On a pharmacologic basis, levobupivacaine is expected to last longer than ropivacaine. However, most reports of these anesthetics for brachial plexus block do not suggest a difference in analgesic effect. The aim of this study is to compare the postoperative analgesic effects of levobupivacaine and ropivacaine when used for treating ultrasound-guided brachial plexus block.

METHODS

A total of 62 patients undergoing orthopedic surgery procedures were prospectively enrolled and randomized to receive levobupivacaine (group L, N = 31) or ropivacaine (group R, N = 31). The duration of analgesia, offset time of motor block, need for rescue analgesics, and sleep disturbance on the night of surgery were recorded. Pain score was recorded on the day of surgery, and on postoperative days 1 and 2.

RESULTS

There was no difference in the time interval until the first request for pain medication comparing the two groups (group L: 15.6 [11.4, 16.8] hours; group R: 12.5 [9.4, 16.0] hours, P = 0.32). There was no difference in the duration of motor block (group L: 12.2 [7.6, 14.4] hours; group R: 9.4 [7.9, 13.2] hours, P = 0.44), pain score (P = 0.92), need for rescue analgesics (group L: 55%; group R: 65%, P = 0.6), or rate of sleep disturbance (group L: 61%, group R: 58%, P = 1.0) on comparing the two groups.

CONCLUSIONS

There was no difference in postoperative analgesia comparing levobupivacaine and ropivacaine when used for brachial plexus block.

Blind suprascapular and axillary nerve block for post-operative pain in arthroscopic rotator cuff surgery

PURPOSE

The goal of the study was to evaluate the efficacy of additional axillary nerve block (ANB) with suprascapular nerve block (SSNB) and patient-controlled anaesthesia (PCA) with no device assistance after arthroscopic rotator cuff repair. The hypothesis is that patients with intravenous (IV) PCA and the blockade of the two main nerves (SSNB + ANB) experienced lesser pain than patients with IV PCA or IV PCA + SSNB.

METHODS

The 114 patients undergoing arthroscopic rotator cuff repair were allocated randomly to three groups as follows: group I, intravenous PCA pumps (only PCA); group II, IV PCA + SSNB using a blind technique (PCA + SSNB); and group III, IV PCA + SSNB + ANB using a blind technique (PCA + SSNB + ANB). Pain visual analogue scale (VAS) scores were evaluated at 1, 6, 12, 24, 36, and 48 post-operative hours. Furthermore, the degree of pain was compared according to cuff tear size.

RESULTS

The pain VAS score of group III was lower than that of the other two groups and was significantly lower at post-operative hours 1, 6, and 12. In addition, the larger cuff tear tended to be indicative of greater pain. However, all groups experienced rebound pain.

CONCLUSION

PCA + SSNB + ANB using a blind technique is a better pain control method than PCA + SSNB and only PCA during the initial 12 post-operative hours. PCA + SSNB + ANB is a cost-effective, time-saving, and easily performed method for post-operative pain control as an axis of multimodal pain control strategy.

LEVEL OF EVIDENCE

II.

Which is your choice for prolonging the analgesic duration of single-shot interscalene brachial blocks for arthroscopic shoulder surgery? intravenous dexamethasone 5 mg vs. perineural dexamethasone 5 mg randomized, controlled, clinical trial

The aim of this study was to compare the effect of intravenous (I.V.) dexamethasone with that of perineural dexamethasone on the prolongation of analgesic duration of single-shot interscalene brachial plexus blocks (SISB) in patients undergoing arthroscopic shoulder surgery. We performed a prospective, randomized, double-blind, placebo-controlled study. Patients undergoing elective arthroscopic shoulder surgery with ultrasound-guided SISB were enrolled and randomized into 2 groups. A total volume of 12 mL of the study drug was prepared with a final concentration of 0.5% ropivacaine. In the I.V. group, patients received SISB using ropivacaine 5 mg mL with normal saline (control) with dexamethasone 5 mg I.V. injection. In the perineural group, patients received SISB using ropivacaine 5 mg mL with dexamethasone 5 mg, with normal saline 1 mL I.V. injection. The primary outcome was the time to the first analgesic request, defined as the time between the end of the operation and the first request of analgesics by the patient. The secondary outcomes included patient satisfaction scores, side effects, and neurological symptoms. Patients were randomly assigned to 1 of the 2 groups using a computer-generated randomization table. An anesthesiologist blinded to the group assignments prepared the solutions for injection. The patients and the investigator participating in the study were also blinded to the group assignments. One hundred patients were randomized. Data were analyzed for 99 patients. One case in the I.V. group was converted to open surgery and was therefore not included in the study. Perineural dexamethasone significantly prolonged analgesic duration (median, standard error: 1080 minutes, 117.5 minutes) compared with I.V. dexamethasone (810 minutes, 48.1 minutes) (P = 0.02). There were no significant differences in side effects, neurological symptoms, or changes in blood glucose values between the 2 groups. Our results show that perineural dexamethasone 5 mg is more effective than I.V. dexamethasone 5 mg with regard to analgesic duration of SISB for arthroscopic shoulder surgery.

Efficacy and safety of 1% ropivacaine for postoperative analgesia after lower third molar surgery: a prospective, randomized, double-blinded clinical study

OBJECTIVES

The purpose of this study was to investigate postoperative analgesic effect of ropivacaine administered as main or supplemental injection for the inferior alveolar nerve block (IANB) in patients undergoing lower third molar surgery.

MATERIALS AND METHODS

The double-blind randomized study comprised 72 healthy patients. All patients received two blocks, the IANB for surgical procedure + IANB after surgery for postoperative pain control, and were divided into three groups: (1) 2 % lidocaine/epinephrine + 1 % ropivacaine, (2) 2 % lidocaine/epinephrine + saline, and (3) 1 % ropivacaine + saline. The occurrence of postoperative pain, pain intensity and analgesic requirements were recorded. Data were statistically analyzed using chi-square, Fisher, and Kruskal-Wallis tests and analysis of variance (ANOVA) with Bonferroni and Tukey correction.

RESULTS

Ropivacaine was more successful than lidocaine/epinephrine in obtaining duration of postoperative analgesia, reduction of pain, and analgesic requirements whether ropivacaine was used for surgical block or administered as a supplemental injection after surgery.

CONCLUSIONS

Ropivacaine (1 %, 2 ml) resulted in effective postoperative analgesia after lower third molar surgery.

CLINICAL RELEVANCE

Since pain control related to third molar surgery requires the effective surgical anesthesia and postoperative analgesia, the use of 1 % ropivacaine could be clinically relevant in a selection of appropriate pain control regimen for both surgical procedure and early postsurgical treatment.

Update on the clinical utility and practical use of ropivacaine in Chinese patients

We reviewed the Chinese and English literature for efficacy and tolerability data as well as pharmacological properties of ropivacaine in Chinese patients. Ropivacaine is a long-acting amide local anesthetic agent that elicits nerve block via reversible inhibition of sodium ion influx in nerve fibers. The available evidence in the literature on anesthesia practice indicates that ropivacaine produces equally surgical sensory block and postoperative and obstetrics analgesia with good maternal and fetal outcome to those of bupivacaine or levobupivacaine. It appears to be associated with comparable onset, quality, and duration of sensory block, but with a lower incidence or grade of motor block, compared to bupivacaine. The satisfaction of both patients and surgeons is high when ropivacaine is used. Thus, ropivacaine appears to be an important option for regional anesthesia and for the management of postoperative and labor pain, with its enhanced sensorimotor differentiation blockage at lower concentrations and enhanced safety at higher concentrations.

Low-dose ropivacaine for supraclavicular brachial plexus block combined with general anesthesia for successful postoperative analgesia: A case series

Background:

Ropivacaine, a long-acting local anesthetic agent, has been used for postoperative analgesia in brachial plexus block (BPB) at high doses. However, use of lower doses would reduce the occurrence of adverse effects.

Methods:

We applied BPB with low-dose ropivacaine (10 mL of 0.375% ropivacaine) after induction of general anesthesia for surgery of the upper extremities in 62 patients at our hospital. Ropivacaine was administered via a fluoroscopy-guided supraclavicular method. Analgesic effects during surgery, visual analog scale pain scores, skin sensation, muscle strength, and postoperative patient satisfaction indices were evaluated.

Results:

Fifty-six patients (90.3%) did not require supplemental analgesics during surgery. The remaining six patients were administered fentanyl due to the insufficient analgesic effects of the nerve block. Some adverse effects, including numbness and delayed motor and sensory recovery of the upper extremities, were observed. The mean postoperative patient-evaluated visual satisfaction scale was 94.1.

Conclusions:

Our results suggest that low-dose ropivacaine is clinically acceptable for BPB under general anesthesia.

Clinical comparisons of 0.5% and 0.375% levobupivacaine for ultrasound-guided axillary brachial plexus block with nerve stimulation

Background

In an axillary brachial plexus block (ABPB), where relatively large doses of local anesthetics are administered, levobupivacaine is preferred due to a greater margin of safety. However, the efficacy of levobupivacaine in ABPB has not been studied much. We performed a prospective, double-blinded study to compare the clinical effect of 0.375% levobupivacaine with 0.5% levobupivacaine for ultrasound (US)-guided ABPB with nerve stimulation.

Methods

Forty patients undergoing elective upper limb surgery were randomized into two groups: Group I (0.375% levobupivacaine) and Group II (0.5% levobupivacaine). All four main terminal nerves of the brachial plexus were blocked separately with 7 ml of levobupivacaine using US guidance with nerve stimulation according to study group. A blinded observer recorded the onset time for sensory and motor block, elapsed time to be ready for surgery, recovery time for sensory and motor block, quality of anesthesia, patient satisfaction and complications.

Results

There were no significant differences in the time to find nerve locations, time to perform block and number of skin punctures between groups. Insufficient block was reported in one patient of Group I, but no failed block was reported in either group. There were no differences in the onset time for sensory and motor block, elapsed time to be ready for surgery, patient satisfaction and complications.

Conclusions

0.375% levobupivacaine produced adequate anesthesia for ABPB using US guidance with nerve stimulation, without any clinically significant differences compared to 0.5% levobupivacaine.

Update on local anesthetics: focus on levobupivacaine

In recent years levobupivacaine, the pure S (−)-enantiomer of bupivacaine, emerged as a safer alternative for regional anesthesia than its racemic parent. It demonstrated less affinity and strength of depressant effects onto myocardial and central nervous vital centers in pharmacodynamic studies, and a superior pharmacokinetic profile. Clinically, levobupivacaine is well tolerated in a variety of regional anesthesia techniques both after bolus administration and continuous postoperative infusion. Reports of toxicity with levobupivacaine are scarce and occasional toxic symptoms are usually reversible with minimal treatment with no fatal outcome. Yet, levobupivacaine has not entirely replaced bupivacaine in clinical practice. In anesthesia and analgesia practice, levobupivacaine and bupivacaine produce comparable surgical sensory block with similar adverse side effects, and equal labor pain control with comparable maternal and fetal outcome. The equipotency of the two drugs has been recently questioned, prompting clinicians to increase the dose of levobupivacaine in an attempt to ensure adequate anesthesia and analgesia and offsetting, therefore, the advantages of less motor block with levobupivacaine. In this review we aim to discuss the pharmacological essentials of the safer profile of levobupivacaine, and analyze the evidence regarding the current clinical indications.

Ropivacaine: A review of its pharmacology and clinical use

Ropivacaine is a long-acting amide local anaesthetic agent and first produced as a pure enantiomer. It produces effects similar to other local anaesthetics via reversible inhibition of sodium ion influx in nerve fibres. Ropivacaine is less lipophilic than bupivacaine and is less likely to penetrate large myelinated motor fibres, resulting in a relatively reduced motor blockade. Thus, ropivacaine has a greater degree of motor sensory differentiation, which could be useful when motor blockade is undesirable. The reduced lipophilicity is also associated with decreased potential for central nervous system toxicity and cardiotoxicity. The drug displays linear and dose proportional pharmacokinetics (up to 80 mg administered intravenously). It is metabolised extensively in the liver and excreted in urine. The present article details the clinical applications of ropivacaine and its current place as a local anaesthetic in the group.

Comparison of 0.25% levobupivacaine and 0.25% bupivacaine for posterior approach interscalene brachial plexus block

PURPOSE

This study compares the onset time and quality of posterior approach interscalene brachial plexus block produced by 0.25% levobupivacaine and 0.25% bupivacaine.

METHODS

Sixty adult patients undergoing open or closed shoulder surgery were enrolled in this double-blind, randomized study, and they were randomly allocated to receive 40 ml of 0.25% levobupivacaine (Group L, n = 30) or 0.25% bupivacaine (Group B, n = 30). The patients were assessed at 5 min intervals after local anesthetic injection in order to determine loss of shoulder abduction and loss of pinprick sensation in the C(5-6) dermatomes. The mean onset time of motor and sensory block and onset time of complete motor and sensory block were documented in both groups.

RESULTS

In both groups, mean onset time of sensory block was <5 min and mean onset time of complete sensory block was <25 min. The onset times for sensory block and complete sensory block were not statistically different between the groups (P > 0.05). In both groups, mean onset time of motor block was <10 min but the mean onset time of complete motor block was <30 min. The onset times of motor block and complete motor block were not statistically different among the groups (P > 0.05). After the injection of the local anesthetic, 27% of Group L and 87% of Group B had complete motor block. Four patients in Group L had no motor block.

CONCLUSION

We conclude that 0.25% levobupivacaine and 0.25% bupivacaine have similar motor and sensory block onset times and qualities when used in posterior approach interscalene brachial plexus block, and provide comfortable anesthesia and analgesia for shoulder surgery.

Effects of local anesthetic concentration and dose on continuous interscalene nerve blocks: a dual-center, randomized, observer-masked, controlled study

BACKGROUND AND OBJECTIVES

It is currently unknown if the primary determinant of continuous peripheral nerve block effects is simply total drug dose, or whether local anesthetic concentration and/or volume have an influence. We therefore tested the null hypothesis that providing ropivacaine at different concentrations and rates--but at an equal total basal dose--produces similar effects when used in a continuous interscalene nerve block.

METHODS

Preoperatively, an anterolateral interscalene perineural catheter was inserted using the anterolateral approach in patients undergoing moderately painful shoulder surgery. Subjects were randomly assigned to receive a postoperative perineural infusion of either 0.2% ropivacaine (basal 8 mL/h, bolus 4 mL) or 0.4% ropivacaine (basal 4 mL/h, bolus 2 mL) through the second postoperative day. Our primary endpoint was the incidence of an insensate hand/finger during the 24 hours beginning the morning following surgery.

RESULTS

The incidence of an insensate hand/finger did not differ between the treatment groups (n = 50) to a statistically significant degree (0.2% ropivacaine, mean [SD] of 0.8 [1.3] times; 0.4% ropivacaine, mean 0.3 [0.6] times; estimated difference = 0.5 episodes, 95% confidence interval, -0.1 to 1.1 episodes; P = .080). However, this is statistically inconclusive given the confidence interval. In contrast, pain (P = .020) and dissatisfaction (P = .011) were greater in patients given 0.4% ropivacaine.

CONCLUSIONS

For continuous interscalene nerve blocks, given the statistically inconclusive primary endpoint results and design limitations of the current study, further research on this topic is warranted. In contrast, providing a lower concentration of local anesthetic at a higher basal rate provided superior analgesia.

Upper extremity regional anesthesia: essentials of our current understanding, 2008

Brachial plexus blockade is the cornerstone of the peripheral nerve regional anesthesia practice of most anesthesiologists. As part of the American Society of Regional Anesthesia and Pain Medicine's commitment to providing intensive evidence-based education related to regional anesthesia and analgesia, this article is a complete update of our 2002 comprehensive review of upper extremity anesthesia. The text of the review focuses on (1) pertinent anatomy, (2) approaches to the brachial plexus and techniques that optimize block quality, (4) local anesthetic and adjuvant pharmacology, (5) complications, (6) perioperative issues, and (6) challenges for future research.

Interscalene brachial plexus block for outpatient shoulder arthroplasty: Postoperative analgesia, patient satisfaction and complications

BACKGROUND

Shoulder arthroplasty procedures are seldom performed on an ambulatory basis. Our objective was to examine postoperative analgesia, nausea and vomiting, patient satisfaction and complications of ambulatory shoulder arthroplasty performed using interscalene brachial plexus block (ISB).

MATERIALS AND METHODS

We prospectively examined 82 consecutive patients undergoing total and hemi-shoulder arthroplasty under ISB. Eighty-nine per cent (n=73) of patients received a continuous ISB; 11% (n=9) received a single-injection ISB. The blocks were performed using a nerve stimulator technique. Thirty to 40 mL of 0.5% ropivacaine with 1:400,000 epinephrine was injected perineurally after appropriate muscle twitches were elicited at a current of less than 0.5% mA. Data were collected in the preoperative holding area, intraoperatively and postoperatively including the postanesthesia care unit (PACU), at 24h and at seven days.

RESULTS

Mean postoperative pain scores at rest were 0.8 ± 2.3 in PACU (with movement, 0.9 ± 2.5), 2.5 ± 3.1 at 24h and 2.8 ± 2.1 at seven days. Mean postoperative nausea and vomiting (PONV) scores were 0.2 ± 1.2 in the PACU and 0.4 ± 1.4 at 24h. Satisfaction scores were 4.8 ± 0.6 and 4.8 ± 0.7, respectively, at 24h and seven days. Minimal complications were noted postoperatively at 30 days.

CONCLUSIONS

Regional anesthesia offers sufficient analgesia during the hospital stay for shoulder arthroplasty procedures while adhering to high patient comfort and satisfaction, with low complications.

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.

The postoperative analgesic effects of intra-articular levobupivacaine in elective day-case arthroscopy of the knee: a prospective, randomized, double-blind clinical study

PURPOSE

Pain and emesis are the two major complaints after day surgery. Local anesthesia has become an important part of optimizing perioperative pain treatment. The aim of the present study was to study two different concentrations of levobupivacaine's effect on postoperative pain following elective arthroscopy of the knee with lidocaine 10 mg/ml with adrenaline as active control.

TYPE OF STUDY

Prospective, randomized double-blind study with lidocaine as active control but without placebo.

METHODS

One hundred and twenty patients were studied comparing levobupivacaine 2.5 mg/ml, levobupivacaine 5 mg/ml, and lidocaine 10 mg/ml with adrenaline given intra-articularly at the end of day-case operative elective arthroscopy of the knee done in light general anesthesia. Primary study endpoint was the need for any analgesics during the first 24 postoperative hours.

RESULTS

Levobupivacaine 5 mg/ml was associated with a reduced need for any analgesia during the entire 24-h study period (p = 0.013) as compared to both 2.5 mg/ml levobupivacaine and lidocaine with adrenaline. Levobupivacine 2.5 mg/ml was inferior to lidocaine with regard to pain relief with an increase in need for oral analgesia already during stay in the recovery unit (p < 0.001).

CONCLUSIONS

Levobupivacaine 5 mg/ml was found to be an effective local anesthetic in day-case operative arthroscopy of the knee providing superior postoperative analgesia as compared to lidocaine with adrenaline or a lower concentration of levobupivacaine.

LEVEL OF EVIDENCE

Level I: Prospective, randomized double-blind study without placebo.

[Levobupivacaine for regional anesthesia. A systematic review]

Levobupivacaine [S(-)bupivacaine], the levorotatory S-enantiomer of racemic bupivacaine, is commercially available in the U.S. and in most European countries. We performed a systematic review (MEDLINE database) and identified 88 articles on the clinical application of levobupivacaine in more than 3,000 patients. The use of levobupivacaine is described for epidural, caudal, and spinal anesthesia, for peripheral nerve blocks, for ophthalmic and dental anesthesia, for different pediatric indications and for intravenous regional anesthesia. In these regional techniques, levobupivacaine was used for all common indications in a wide range of clinical settings. Epidural levobupivacaine was combined with fentanyl, morphine, sufentanil, epinephrine, and clonidine, spinal levobupivacaine was combined with sufentanil, fentanyl, and epinephrine. In most studies, levobupivacaine was compared to bupivacaine and/or ropivacaine.

Levobupivacaine 0.2% or 0.125% for Continuous Sciatic Nerve Block: A Prospective, Randomized, Double-Blind Comparison with 0.2% Ropivacaine

In 60 patients receiving elective hallux valgus repair, we compared the efficacy of continuous popliteal sciatic nerve block produced with 0.2% ropivacaine (n = 20), 0.2% levobupivacaine (n = 20), or 0.125% levobupivacaine (n = 20) infused with a patient-controlled system starting 3 h after a 30-mL bolus of the 0.5% concentration of the study drug and for 48 h (baseline infusion rate, 6 mL/h; incremental dose, 2 mL; lockout time, 15 min; maximum incremental doses per hour, 3). No differences were reported in the intraoperative efficacy of the nerve block. The degree of pain was similar in the three groups throughout the study period, both at rest and during motion. Total consumption of local anesthetic solution during the first 24 h was 148 mL (range, 144-228 mL) with 0.2% ropivacaine, 150 mL (range, 144-200 mL) with 0.2% levobupivacaine, and 148 mL (range, 144-164 mL) with 0.125% levobupivacaine (P = 0.59). The volume of local anesthetic consumed during the second postoperative day was 150 mL (range, 144-164 mL) with 0.2% ropivacaine, 154 mL (range, 144-176 mL) with 0.2% levobupivacaine, and 151 mL (range, 144-216 mL) with 0.125% levobupivacaine (P = 0.14). A smaller proportion of patients receiving 0.2% levobupivacaine showed complete recovery of foot motor function as compared with 0.2% ropivacaine and 0.125% levobupivacaine, both at 24 h (35% vs 85% and 95%; P = 0.0005) and at 48 h (60% vs 100% and 100%; P = 0.001). We conclude that sciatic infusion with both 0.125% and 0.2% levobupivacaine provides adequate postoperative analgesia after hallux valgus repair, clinically similar to that provided by 0.2% ropivacaine; however, the 0.125% concentration is preferred if early mobilization of the operated foot is required.

Lidocaine versus ropivacaine for continuous interscalene brachial plexus block after open shoulder surgery

BACKGROUND

This study compared the postoperative infusion of 1% lidocaine and 0.2% ropivacaine for continuous interscalene analgesia in patients undergoing open shoulder surgery.

METHODS

Forty patients undergoing open shoulder surgery received an interscalene brachial plexus block with 30 ml of either 1.5% lidocaine (n = 20) or 0.5% ropivacaine (n = 20), followed by a continuous patient-controlled interscalene analgesia with 1% lidocaine or 0.2% ropivacaine, respectively. A blinded observer recorded the quality of analgesia and recovery of motor function during the first 24 h of infusion.

RESULTS

Onset of the block occurred after 7.5 (5-40) min with lidocaine and 30 (10-60) min with ropivacaine (P = 0.0005). Postoperative pain intensity was higher with lidocaine than ropivacaine for the first 8 h of infusion. The ratio between boluses given and demanded from the pump was 0.5 (0.13-0.7) with lidocaine and 0.7 (0.4-1.0) with ropivacaine (P = 0.005). Rescue IV tramadol was required during the first 24 h of infusion by 16 patients of the lidocaine group (84%) and eight patients of the ropivacaine group (46%) (P = 0.05). At the 16 h and 24 h observation times a larger proportion of patients receiving ropivacaine had complete regression of motor block (70% and 95%) than patients receiving lidocaine (50% and 55%) (P = 0.05 and P = 0.013, respectively).

CONCLUSIONS

Although 1% lidocaine can be effectively used for postoperative patient-controlled interscalene analgesia, 0.2% ropivacaine provides better pain relief and motor function.