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Li X, Li J, Zhang P, Deng H, Yang M, He H, Wang R. The minimum effective concentration (MEC90) of ropivacaine for ultrasound-guided caudal block in anorectal surgery. A dose finding study. PLoS One 2021; 16:e0257283. [PMID: 34534232 PMCID: PMC8448308 DOI: 10.1371/journal.pone.0257283] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2020] [Accepted: 07/13/2021] [Indexed: 02/05/2023] Open
Abstract
Background Caudal epidural block (CEB) provides reliable anesthesia for adults undergoing anorectal surgery. Despite the widely utilization, the minimum effective concentration for 90% patients (MEC90) of ropivacaine for CEB remains unknown. Objective To estimate MEC of ropivacaine for CEB in anorectal surgery. Design A prospective dose-finding study using biased coin design up-and-down sequential method. Setting Operating room and postoperative recovery area of Chengdu Shangjin Nanfu Hospital, from October 2019 to January 2020. Patients 50 males and 51 females scheduled for anorectal surgery. Interventions We conducted two independent biased coin design up-and down trials by genders. The concentration of ropivacaine administered to the first patient of male and female were 0.25% with fixed volume of 14ml for male and 12ml for female patients based on our previous study. In case of failure, the concentration was increased by 0.05% in the next subject. Otherwise, the next subject was randomized to a concentration 0.05% less with a probability of 0.11, or the same concentration with a probability of 0.89. Success was defined as complete sensory blockade of perineal area 15 min after the block evidenced by the presence of a lax anal sphincter and pain-free surgery. Main outcome measures The MEC of ropivacaine to achieve a successful CEB in 90%(MEC90) of the patients. Results The MEC90 of ropivacaine for CEB were estimated to be 0.35% (95% CI 0.29 to 0.4%) for male and 0.353% (95%CI 0.22 to 0.4%) for female. By extrapolation to MEC in 99% of subjects (MEC99) and pooled adjacent violators algorithm (PAVA) adjusted responses, it would be optimal to choose 0.4% ropivacaine with a volume of 14ml for male and 12ml for female. Conclusions A concentration of 0.35% ropivacaine with a volume of 14ml provided a successful CEB in 90% of the male patients, while 0.353% ropivacaine with a volume of 12ml provided a successful CEB in 90% of the female patients. A concentration of 0.4% and a volume of 14ml for male and 12 ml for female would be successful in 99% of the patients. Trial registration Chictr.org.cn identifier: No. ChiCTR 1900024315.
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Affiliation(s)
- Xuehan Li
- Department of Anesthesiology, and Laboratory of Anesthesia and Intensive Care Medicine, West China Hospital of Sichuan University, Chengdu, Sichuan, China
| | - Jun Li
- Department of Anesthesiology, and Laboratory of Anesthesia and Intensive Care Medicine, West China Hospital of Sichuan University, Chengdu, Sichuan, China
| | - Pei Zhang
- Department of Anesthesiology, and Laboratory of Anesthesia and Intensive Care Medicine, West China Hospital of Sichuan University, Chengdu, Sichuan, China
| | - Huifei Deng
- Department of Anesthesiology, and Laboratory of Anesthesia and Intensive Care Medicine, West China Hospital of Sichuan University, Chengdu, Sichuan, China
| | - Mingan Yang
- Division of Biostatistics & Epidemiology, School of Public Health, San Diego State University, San Diego, CA, United States of America
| | - Hongbo He
- Benign Coloproctological Diseases Center, West China Hospital of Sichuan University, Chengdu, Sichuan, China
| | - Rurong Wang
- Department of Anesthesiology, and Laboratory of Anesthesia and Intensive Care Medicine, West China Hospital of Sichuan University, Chengdu, Sichuan, China
- * E-mail:
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Wang HZ, Wang LY, Liang HH, Fan YT, Song XR, She YJ. Effect of caudal ketamine on minimum local anesthetic concentration of ropivacaine in children: a prospective randomized trial. BMC Anesthesiol 2020; 20:144. [PMID: 32513111 PMCID: PMC7278144 DOI: 10.1186/s12871-020-01058-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2019] [Accepted: 05/27/2020] [Indexed: 12/31/2022] Open
Abstract
Background Caudal ketamine has been shown to provide an effective and prolonged post-operative analgesia with few adverse effects. However, the effect of caudal ketamine on the minimum local anesthetic concentration (MLAC) of ropivacaine for intra-operative analgesia is unclear. Methods One hundred and sixty-nine children were randomized to five groups: Group C (caudal ropivacaine only), Group K0.25 (caudal ropivacaine plus 0.25 mg/kg ketamine), Group K0.5 (caudal ropivacaine plus 0.5 mg/kg ketamine), Group K0.75 (caudal ropivacaine plus 0.75 mg/kg ketamine), and Group K1.0 (caudal ropivacaine plus 1.0 mg/kg ketamine). The primary outcome was the MLAC values of ropivacaine with/without ketamine for caudal block. Results The MLAC values of ropivacaine were 0.128% (0.028%) in the control group, 0.112% (0.021%) in Group K0.25, 0.112% (0.018%) in Group K0.5, 0.110% (0.019%) in Group K0.75, and 0.110% (0.020%) in Group K1.0. There were no significant differences among the five groups for the MLAC values (p = 0.11). During the post-operative period the mean durations of analgesia were 270, 381, 430, 494, and 591 min in the control, K0.25, K0. 5, K0.75, and K1.0 groups respectively, which shown that control group is significantly different from all ketamine groups. Also there were significant differences between K0.25 and K0.75 groups, and between K1.0 groups and the other ketamine groups. Conclusions Adding caudal ketamine to ropivacaine prolong the duration of post-operative analgesia; however, it does not decrease the MLAC of caudal ropivacaine for intra-operative analgesia in children. Clinical trial registration ChiCTR-TRC-13003492. Registered on 13 August 2013.
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Affiliation(s)
- Huai-Zhen Wang
- Department of Anesthesiology and Perioperative Medicine, Guangzhou Women and Children's Medical Center, Guangzhou Medical University, 9# Jinsui Road, Guangzhou, 510623, China
| | - Ling-Yu Wang
- Department of Anesthesiology and Perioperative Medicine, Guangzhou Women and Children's Medical Center, Guangzhou Medical University, 9# Jinsui Road, Guangzhou, 510623, China
| | - Hui-Hong Liang
- Department of Anesthesiology and Perioperative Medicine, Guangzhou Women and Children's Medical Center, Guangzhou Medical University, 9# Jinsui Road, Guangzhou, 510623, China
| | - Yan-Ting Fan
- Department of Anesthesiology and Perioperative Medicine, Guangzhou Women and Children's Medical Center, Guangzhou Medical University, 9# Jinsui Road, Guangzhou, 510623, China
| | - Xing-Rong Song
- Department of Anesthesiology and Perioperative Medicine, Guangzhou Women and Children's Medical Center, Guangzhou Medical University, 9# Jinsui Road, Guangzhou, 510623, China
| | - Ying-Jun She
- Department of Anesthesiology and Perioperative Medicine, Guangzhou Women and Children's Medical Center, Guangzhou Medical University, 9# Jinsui Road, Guangzhou, 510623, China.
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Vittinghoff M, Lönnqvist PA, Mossetti V, Heschl S, Simic D, Colovic V, Dmytriiev D, Hölzle M, Zielinska M, Kubica-Cielinska A, Lorraine-Lichtenstein E, Budić I, Karisik M, Maria BDJ, Smedile F, Morton NS. Postoperative pain management in children: Guidance from the pain committee of the European Society for Paediatric Anaesthesiology (ESPA Pain Management Ladder Initiative). Paediatr Anaesth 2018; 28:493-506. [PMID: 29635764 DOI: 10.1111/pan.13373] [Citation(s) in RCA: 61] [Impact Index Per Article: 10.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/14/2018] [Indexed: 12/21/2022]
Abstract
The main remit of the European Society for Paediatric Anaesthesiology (ESPA) Pain Committee is to improve the quality of pain management in children. The ESPA Pain Management Ladder is a clinical practice advisory based upon expert consensus to help to ensure a basic standard of perioperative pain management for all children. Further steps are suggested to improve pain management once a basic standard has been achieved. The guidance is grouped by the type of surgical procedure and layered to suggest basic, intermediate, and advanced pain management methods. The committee members are aware that there are marked differences in financial and personal resources in different institutions and countries and also considerable variations in the availability of analgesic drugs across Europe. We recommend that the guidance should be used as a framework to guide best practice.
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Affiliation(s)
- Maria Vittinghoff
- Department of Anesthesiology and Intensive Care Medicine, Medical University of Graz, Graz, Austria
| | - Per-Arne Lönnqvist
- Paediatric Anaesthesia & Intensive Care, Section of Anaesthesiology & Intensive Care, Department of Physiology & Pharmacology, Karolinska Institutet, Stockholm, Sweden
| | - Valeria Mossetti
- Department of Anesthesia and Intensive Care, Regina Margherita Children's Hospital, Torino, Italy
| | - Stefan Heschl
- Department of Anesthesiology and Intensive Care Medicine, Medical University of Graz, Graz, Austria
| | - Dusica Simic
- University Children's Hospital, Medical Faculty University of Belgrade, Serbia
| | - Vesna Colovic
- Royal Manchester Children's Hospital, Central Manchester University Hospitals, Manchester, UK
| | - Dmytro Dmytriiev
- Department of Anesthesiology and Intensive Care, Vinnitsa National Medical University, Vinnitsa, Ukraine
| | - Martin Hölzle
- Section of Paediatric Anaesthesia, Department of Anaesthesia, Luzerner Kantonsspital, Luzern, Switzerland
| | - Marzena Zielinska
- Department of Paediatric Anaesthesiology and Intensive Care, Wroclaw Medical University, Wroclaw, Poland
| | - Anna Kubica-Cielinska
- Department of Paediatric Anaesthesiology and Intensive Care, Wroclaw Medical University, Wroclaw, Poland
| | | | - Ivana Budić
- Centre for Anesthesiology and Resuscitation, Clinical Centre Nis Department of Anesthesiology, Medical Faculty, University of Nis, Nis, Serbia
| | - Marijana Karisik
- Institute for Children Diseases, Department of Anaesthesiology, Clinical Centre of Montenegro, Podgorica, Montenegro
| | - Belen De Josè Maria
- Department of Pediatric Anesthesia, Hospital Sant Joan de Deu, University of Barcelona, Barcelona, Spain
| | - Francesco Smedile
- Department of Pediatric Anesthesiology, Bambino Gesù Children's Hospital, Rome, Italy
| | - Neil S Morton
- Paediatric Anaesthesia and Pain Management, University of Glasgow, Glasgow, UK
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Malav K, Singariya G, Mohammed S, Kamal M, Sangwan P, Paliwal B. Comparison of 0.5% Ropivacaine and 0.5% Levobupivacaine for Sciatic Nerve Block Using Labat Approach in Foot and Ankle Surgery. Turk J Anaesthesiol Reanim 2017; 46:15-20. [PMID: 30140496 DOI: 10.5152/tjar.2017.03411] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2017] [Accepted: 07/28/2017] [Indexed: 11/22/2022] Open
Abstract
Objective Compared to ropivacaine, levobupivacaine is more lipophilic and a more potent vasoconstrictor. The study was conducted to compare the effect of 0.5% ropivacaine and 0.5% levobupivacaine in sciatic nerve block using conventional Labat approach in foot and ankle surgery. Methods A prospective double-blind, randomised study was carried out in 100 patients of either sex, aged between 20 to 60 years, and American Society of Anesthesiologist (ASA) grades I and II. Patients were randomly allocated into groups R and L of 50 each with 0.5% ropivacaine and 0.5% levobupivacaine, respectively, for sciatic nerve block using the Labat approach. We assessed the onset and duration of sensory and motor block, duration of analgesia, consumption of analgesic, and any untoward effect over 24 hours. Results Both the groups were comparable with regard to demographic variables and onset of sensory and motor block (p>0.05). Group L compared to group R had significantly longer median (95% confidence interval) duration of sensory block (647.50 min [624.99-674.41] vs. 535 min [524.77-559.83], respectively; p<0.0001) as well as motor block (1065.0 min [1054.5-1068.90] and 945 min [947.13-1013.30], respectively; p<0.0001). Postoperative analgesia also lasted significantly longer in group L compared to group R (1320 min [1273.4-1321.8] vs. 840 min [759.23-812.77]; p<0.0001]). Patients in group L had significantly better visual analogue scale (VAS) score and lesser consumption of analgesics (p<0.0001). None of the groups developed any adverse effect over the observation period. Conclusion Levobupivacaine provides prolonged postoperative analgesia in sciatic nerve block with reduction in postoperative analgesic consumption.
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Affiliation(s)
- Khushboo Malav
- Department of Anaesthesiology and Critical Care, Dr. S.N. Medical College, Jodhpur, India
| | - Geeta Singariya
- Department of Anaesthesiology and Critical Care, Dr. S.N. Medical College, Jodhpur, India
| | - Sadik Mohammed
- Department of Anaesthesiology and Critical Care, All India Institute of Medical Sciences, Jodhpur, India
| | - Manoj Kamal
- Department of Anaesthesiology and Critical Care, All India Institute of Medical Sciences, Jodhpur, India
| | - Pushpender Sangwan
- Department of Anaesthesiology and Critical Care, Dr. S.N. Medical College, Jodhpur, India
| | - Bharat Paliwal
- Department of Anaesthesiology and Critical Care, All India Institute of Medical Sciences, Jodhpur, India
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She YJ, Zhang ZY, Song XR. Caudal dexmedetomidine decreases the required concentration of levobupivacaine for caudal block in pediatric patients: a randomized trial. Paediatr Anaesth 2013; 23:1205-12. [PMID: 24383602 DOI: 10.1111/pan.12278] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/09/2013] [Indexed: 12/19/2022]
Abstract
BACKGROUND AND OBJECTIVES Dexmedetomidine (D) can prolong the duration of local anesthetics, but the effect of caudal dexmedetomidine on the potency of levobupivacaine (L) for caudal block has not been investigated. This study was designed to determine the effect of caudal dexmedetomidine on levobupivacaine for caudal block in pediatric patients. METHODS Eighty-nine children scheduled for elective inguinal hernia repair or hydrocele were randomly assigned to one of the three groups: Group L (caudal levobupivacaine), Group LD1 (levobupivacaine plus 1 μg·kg(-1) dexmedetomidine), or Group LD2 (levobupivacaine plus 2 μg·kg(-1) dexmedetomidine). The primary endpoint was the minimum local anesthetic concentration (MLAC), which was determined using the Dixon up-and-down method. The secondary endpoints were the duration of analgesia and sedation. RESULTS The MLAC values (sd) of caudal levobupivacaine were 0.103 (0.01)%, 0.068 (0.02)%, and 0.055 (0.03)% in Groups L, LD1, and LD2, respectively. The values of EC50 and EC95 (95% CI) of caudal levobupivacaine from logistic regression analysis were 0.094 (0.083-0.105)% and 0.129 (0.1-0.159)%, 0.058 (0.044-0.072)% and 0.106 (0.067-0.144)%, and 0.046 (0.033-0.059)% and 0.091 (0.055-0.127)% in Groups L, LD1, and LD2, respectively. The mean durations of analgesia in the postoperative period were 141, 378, and 412 min in Groups L, LD1, and LD2, respectively (L vs LD1 or LD2, P < 0.001). The mean durations of sedation in both Groups LD1 and LD2 also were significantly prolonged, compared with Group L (P < 0.01). CONCLUSIONS Caudal dexmedetomidine reduces the MLAC values of levobupivacaine and improves postoperative analgesia in children without any neurological side effects.
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Affiliation(s)
- Ying-Jun She
- Department of Anesthesiology, Guangzhou Women and Children Medical Center, Guangzhou Medical University affiliated Women and Children Medical Center, Guangzhou, China
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Marhofer P, Ivani G, Suresh S, Melman E, Zaragoza G, Bosenberg A. Everyday regional anesthesia in children. Paediatr Anaesth 2012; 22:995-1001. [PMID: 22967158 DOI: 10.1111/pan.12003] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
Regional anesthesia in children is an evolving technique with many advantages in perioperative management. Although most regional anesthesia techniques are sufficiently described in the literature, the implementation of these techniques into daily clinical practice is still lacking. The main problems associated with pediatric regional anesthesia (PRA) include the appropriate selection of blockade, the management around the block, and how to teach these techniques in an optimal manner. This review article provides an overview of these 'hot' topics in PRA.
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Affiliation(s)
- Peter Marhofer
- Department of Anaesthesia, Intensive Care Medicine and Pain Therapy, Medical University of Vienna, Vienna, Austria.
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Makkar JK, Wig J. ED50 of levobupivacaine with clonidine: is the starting dose right? Paediatr Anaesth 2011; 21:908-9. [PMID: 21718382 DOI: 10.1111/j.1460-9592.2011.03557.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Disma N, Frawley G, Mameli L, Pistorio A, Alberighi ODC, Montobbio G, Tuo P. Effect of epidural clonidine on minimum local anesthetic concentration (ED50) of levobupivacaine for caudal block in children. Paediatr Anaesth 2011; 21:128-35. [PMID: 21159021 DOI: 10.1111/j.1460-9592.2010.03478.x] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Abstract
BACKGROUND Clonidine has the potential to significantly prolong the duration of caudal epidural anesthesia. We investigated the effect of the addition of clonidine to the MLAC of levobupivacaine in a randomized controlled dose-response trial. METHODS A group of 120 children aged <6 years of age received caudal anesthesia with levobupivacaine and 1, 2, or 3 μg·kg(-1) of clonidine. The MLAC was determined according to a Dixon-Massey protocol. The primary outcome was effective surgical anesthesia. Secondary outcomes were the duration of postoperative analgesia, postoperative pain scores, clonidine side effects, and time to hospital discharge. RESULTS The MLAC of caudal levobupivacaine was 0.106%, 0.077%, and 0.035% with 1, 2, and 3 μg·kg(-1) of clonidine, respectively. There were significant dose-dependent increases in median duration of analgesia. The incidence of delayed discharge, somnolence, and PONV was significantly increased in the 3 μg·kg(-1) of clonidine group. CONCLUSIONS Clonidine produces a local anesthetic sparing effect with a dose-dependent decrease in levobupivacaine MLAC for caudal anesthesia. In addition, there is a dose-dependent prolongation of postoperative analgesia following lower abdominal surgery in children. A dose of 2 μg·kg(-1) of clonidine provides the optimum balance between improved analgesia and minimal side effects.
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Affiliation(s)
- Nicola Disma
- Department of Anaesthesia, IRCCS Gaslini Children's Hospital, Genoa, Italy
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Deng XM, Xiao WJ, Tang GZ, Luo MP, Xu KL. Minimum local analgesic concentration of ropivacaine for intra-operative caudal analgesia in pre-school and school age children. Anaesthesia 2011; 65:991-5. [PMID: 20659102 DOI: 10.1111/j.1365-2044.2010.06454.x] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
We compared the minimum local analgesia concentration of ropivacaine for intra-operative caudal analgesia in pre-school and school age children. Fifty-one boys, undergoing hypospadius repair surgery, were stratified into pre-school or school age groups. After induction of anaesthesia, caudal block was performed with ropivacaine 1 ml.kg⁻¹ of the desired concentration. The first child in each group received ropivacaine 0.125%, and subsequent concentrations were determined by the analgesic response of the previous patient using Dixon's up-and-down method. Under general anaesthesia with 0.7 minimum alveolar concentration of sevoflurane, the minimum local analgesia concentration of ropivacaine for intra-operative caudal block was 34% greater in school age than in pre-school age boys (0.143% (95% CI 0.132-0.157%) vs 0.107% (95% CI 0.089-0.122%), respectively; p < 0.001). This study indicates that a higher concentration of ropivacaine is needed for school age than pre-school age children to provide intra-operative caudal analgesia when combined with general anaesthesia.
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Affiliation(s)
- X M Deng
- Department of Anaesthesiology, Plastic Surgery Hospital, Beijing, China
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Evidence-based clinical update: Which local anesthetic drug for pediatric caudal block provides optimal efficacy with the fewest side effects? Can J Anaesth 2010; 57:1102-10. [DOI: 10.1007/s12630-010-9386-1] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2010] [Accepted: 09/01/2010] [Indexed: 10/19/2022] Open
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Fournier R, Faust A, Chassot O, Gamulin Z. Levobupivacaine 0.5% provides longer analgesia after sciatic nerve block using the Labat approach than the same dose of ropivacaine in foot and ankle surgery. Anesth Analg 2010; 110:1486-9. [PMID: 20304982 DOI: 10.1213/ane.0b013e3181d3e80b] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
BACKGROUND Levobupivacaine and ropivacaine are 2 left enantiomeric molecules frequently used for peripheral nerve blocks because of their safe clinical profile. Levobupivacaine is more lipophilic and theoretically more potent than ropivacaine, but clinical studies show conflicting results in terms of anesthetic and analgesic characteristics. We hypothesized that the pure S-enantiomer of bupivacaine provides longer-lasting analgesia than ropivacaine. METHODS We compared the analgesic characteristics of 20 mL levobupivacaine versus 20 mL ropivacaine 0.5% in a posterior sciatic nerve block (Labat approach) for foot and ankle surgery. In a double-blind, randomized, prospective design, 80 patients received either substance. We assessed the onset, duration, and success of the block, and the need for rescue analgesia and technical or neurologic complications over 24 hours. RESULTS The onset of sensory block (minutes) and the success rate were similar in levobupivacaine and ropivacaine groups (onset, 15 minutes [5-40 minutes] vs 15 minutes [5-60 minutes], respectively; success rate, 90% vs 92.5%). The average time for the first request of pain medication provided by 20 mL levobupivacaine 0.5% was significantly longer than with ropivacaine (1605 minutes [575-2400 minutes] vs 1035 minutes [590-1500 minutes], P < 0.001). The need for postoperative rescue analgesia was higher in the ropivacaine group (37 of 40 [92.5%] vs 30 of 40 [75%], P < 0.034). No complications were noted in either group at 24 hours. CONCLUSION Twenty milliliters levobupivacaine 0.5% in posterior gluteal (Labat) sciatic nerve block provided longer-lasting analgesia after foot and ankle surgery compared with the same dose of ropivacaine.
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Affiliation(s)
- Roxane Fournier
- Department of Anesthesiology, University Hospital of Geneva, Geneva, Switzerland.
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