Comparison of intrathecal ropivacaine-fentanyl and bupivacaine-fentanyl for major lower limb orthopaedic surgery: A randomised double-blind study

Intrathecal ropivacaine versus bupivacaine in a non-obstetric population- A meta-analysis and trial sequential analysis

Background and Aims

Intrathecal bupivacaine is used for anaesthesia and analgesia but is associated with hypotension. Ropivacaine is an alternative drug that may have fewer cardiotoxic and neurotoxic events. This meta-analysis investigated whether intrathecal ropivacaine is associated with reduced hypotension as compared to bupivacaine.

Methods

The meta-analysis is registered in the International Prospective Register of Systematic Reviews (PROSPERO). The databases PubMed, Cinahl Plus, Google Scholar, and Scopus were searched, and papers from January 1980 to January 2023 were deemed eligible and filtered using predetermined inclusion and exclusion criteria. The primary outcome was the incidence of hypotension. Secondary outcomes were the duration of sensory block, duration of motor block, incidence of bradycardia, ephedrine usage, and duration of analgesia. Jadad scores were used to evaluate the quality of the papers. RevMan statistical software® utilised inverse variance and a random effect model to calculate the standardised mean difference with 95% confidence intervals for continuous variables and the Mantel-Haenszel test and the random effect model to calculate the odds ratio for dichotomous variables.

Results

Thirty-three papers, including 2475 patients in total, were included. The Jadad score was between 1 and 5. The incidence of hypotension was significantly higher with intrathecal bupivacaine than with ropivacaine (P = 0.02). The duration of sensory block (P < 0.001) and motor block (P < 0.001) was prolonged with intrathecal bupivacaine. The duration of analgesia favoured intrathecal bupivacaine (P = 0.003).

Conclusion

Intrathecal ropivacaine has a reduced incidence of hypotension and a reduced duration of sensory block compared to bupivacaine.

Effect of dexmedetomidine and fentanyl on hemodynamic changes and block profile following spinal anesthesia with ropivacaine among patients with femoral fractures undergoing lower limb surgery

The aim of this study was to compare the effect of dexmedetomidine and fentanyl on hemodynamic changes and block characteristics following spinal anesthesia with ropivacaine among patients with femoral fractures undergoing lower limb surgery. In this double-blind clinical trial, 64 patients who were candidates for lower limb surgery. Patients were divided into two groups based on the block pattern. In the first group, dexmedetomidine was prescribed. In the second group, fentanyl with ropivacaine was prescribed. Sensory and motor blocks at or above the T8 dermatome in each group were measured. Furthermore, the sensory block was evaluated every 1 minute after anesthesia with a needle (pin prick method) and also the motor block was evaluated every 5 minutes by the bromage scale. There was a statistically significant difference between the two groups in terms of the time for achieving sensory block to T8 or higher dermatome (p = 0.0001). The time elapsed until the onset of motor block was shorter in the dexmedetomidine group, and dexmedetomidine had a shorter time for achieving sensory block to T8 or higher dermatome than fentanyl. A statistically significant difference was found in terms of the time elapsed until the motor block and the time for achieving sensory block to the T8 dermatome or higher (p <0.05). The time elapsed until the onset of motor block was shorter in the dexmedetomidine group, and dexmedetomidine had a shorter time for achieving sensory block to T8 or higher dermatome than fentanyl. Our findings revealed a statistically significant difference in terms of the duration of sensory block for reaching the T12 to L1 dermatome and the duration of obtaining bromide scores 0 and 1 (p = 0.0001). The time for achieving sensory block to dermatome T12 to L1 and the time of obtaining bromage scales of 0 and 1 were longer in dexmedetomidine group (p = 0.0001). Pain in dexmedetomidine group was less than fentanyl group in 2 to 8 hours after surgery (p <0.05). The duration of analgesia was longer in the dexmedetomidine group (p = 0.001). In summary, it can be suggested that adding dexmedetomidine to the anesthetic ropivacaine may be beneficial.

The Comparison of Intrathecal Ropivacaine with Bupivacaine for Knee Arthroscopy: A Meta-analysis of Randomized Controlled Trials

The comparison of intrathecal ropivacaine with bupivacaine for knee arthroscopy remains controversial. We conduct a systematic review and meta-analysis to explore the efficacy of intrathecal ropivacaine versus bupivacaine for knee arthroscopy. We search PubMed, EMbase, Web of science, EBSCO, and Cochrane library databases through August 2019 for randomized controlled trials (RCTs) assessing the effect of intrathecal ropivacaine versus bupivacaine for knee arthroscopy. This meta-analysis is performed using the random effects model. Five RCTs are included in the meta-analysis. Overall, compared with intrathecal bupivacaine for knee arthroscopy, intrathecal ropivacaine is associated with increased onset time of motor block (mean difference [MD] = 2.05, 95% CI: 1.43-2.67, p < 0.00001) and decreased duration of sensory block (MD = -26.82, 95% CI: -31.96 to -21.67, p < 0.00001) but shows no remarkable influence on onset time of sensory block (MD = -0.09; 95% CI: -1.89 to 1.70, p = 0.92), duration of motor block (MD = -59.76; 95% CI: -124.44 to 4.91, p = 0.07), time to maximum block (MD = 2.35; 95% CI: -0.16 to 4.86, p = 0.07), first urination time (MD = -26.42, 95% CI: -57.34 to 4.51, p = 0.09), or first ambulation time (MD = 3.63, 95% CI: -25.20 to 32.47, p = 0.80).Intrathecal ropivacaine can substantially increase onset time of motor block and decrease the duration of sensory block than intrathecal bupivacaine for knee arthroscopy.

First Evaluation Switching From Ropivacaine to Highly Concentrated Bupivacaine in Intrathecal Mixtures for Cancer Pain

BACKGROUND

Intrathecal drug delivery is widely used for intractable cancer pain treatment. A combination of drugs with morphine and bupivacaine is recommended in first line therapy. In France, we use ropivacaine 10 mg/mL instead of bupivacaine 5 mg/mL, the only concentration available. Bupivacaine 40 mg/mL has been available in France only since July 2020 under temporary authorization of use.

OBJECTIVES

The main objective of the study was to evaluate the safety, efficacy by pain assessment, to analyze drug dosage changes, to report adverse events (AEs) and conversion ratios switching from ropivacaine to bupivacaine. Secondary objective was to evaluate costs differences.

MATERIALS AND METHODS

We conducted this retrospective follow-up monocentric study within the Institut de Cancérologie de l'Ouest (ICO) Pain Department in Angers, France. We included 14 patients aged 18 years and above, implanted with an Intrathecal Drug Delivery Systems (IDDS) for cancer pain treatment and followed up at ICO from July 2020 to February 2021 after switching from ropivacaine to bupivacaine. We used a continuous infusion mode and Bolus could be added through Personal Therapy Manager (PTM).

RESULTS

The median conversion ratio between ropivacaine and bupivacaine was 0.68 (0.65; 0.69) and resulted in no significant change in numeric rating scale evaluation (p = 0.10). We observed moderate and rapidly reversible AEs such as clinical hypotension (29%) and motor block after bolus (21%). The estimated median hospital cost per day was significantly lower (p = 0.05) for the bupivacaine refills than for the last ropivacaine pump refill, decreasing from US$ 61.7 (49.6; 70.5) to US$ 50.4 (45.9; 60.4). The median reimbursement per day from the National Health Insurance (NHI) was three times lower for bupivacaine pump refill when compared to the last ropivacaine pump refill (p < 0.01), decreasing from US$ 179.10 (156.79; 182.91) to US$ 64.59 (59.85; 71.89).

CONCLUSION

Switching from ropivacaine to bupivacaine in IDDS appears more efficacious while remaining just as secure, and at lower cost.

The effect of post-operative ultrasound-guided transmuscular quadratus lumborum block on post-operative analgesia after hip arthroplasty in elderly patients: A randomised controlled double-blind study

Background and Aim

The best analgesic technique after hip surgeries is a matter of debate. This clinical trial aimed to assess the effect of transmuscular ultrasound-guided quadratus lumborum (QL) block on post-operative analgesic consumption after hip arthroplasty in elderly patients.

Methods

This prospective randomised double-blind study was carried out on 60 patients aged 60-80 years presented for total hip replacement under unilateral spinal anaesthesia. Patients were randomly allocated to one of two groups: A control group, receiving sham transmuscular QL block (QLB) (1 ml of normal saline), and a QL group, receiving real transmuscular QLB (30 ml of plain bupivacaine 0.25%). Post-operative morphine consumption (primary outcome), post-operative pain score (secondary outcome), time to the first request of rescue analgesia, patient's satisfaction and the occurrence of post-operative complications were measured.

Results

Compared to the control group, the use of QLB in the second group significantly decreased intravenous morphine consumption postoperatively from 8.50 ± 3.06 mg to 5.60 ± 3.22 mg (P = 0.0007) with a significant prolongation of the time to the first call for analgesia (P < 0.0001). It also decreased the post-operative visual analogue score 4 h, 6 h and 8 h postoperatively (P < 0.05). However, there was no difference between both the groups regarding patient's satisfaction and the occurrence of complications (P > 0.05).

Conclusion

The use of transmuscular QLB in patients undergoing total hip replacement decreased post-operative analgesic consumption and post-operative pain score and prolonged post-operative analgesia. It did not affect patients' satisfaction and occurrence of post-operative complications.

Comparing Effects of Intrathecal Adjuvants Fentanyl and Dexmedetomidine with Hyperbaric Ropivacaine in Patients Undergoing Elective Infraumbilical Surgeries: A Prospective, Double-Blind, Clinical Study

Background:

Spinal anesthesia is most commonly used anesthesia technique for infraumbilical surgeries, and it is cost-effective with decreased hospital stay. Intrathecal isobaric ropivacaine has shorter duration of anesthesia than bupivacaine. By making, ropivacaine hyperbaric will help to achieve dense block with good postoperative analgesia.

Materials and Methods:

Ninety patients with American Society of Anesthesiologists physical status Classes I and II, aged between 18 and 60 years of either sex, undergoing for elective infraumbilical surgeries were randomly allocated into three groups 30 each (n = 30). Group Ropivacaine + Dexmedetomidine (RD) received 2.5 ml of 0.5% hyperbaric ropivacaine (15 mg) + dexmedetomidine 10 μg (0.5 ml), Group Ropivacaine + Fentanyl (RF) received 2.5 ml of 0.5% hyperbaric ropivacaine (15 mg) + fentanyl 25 μg (0.5 ml), and Group Ropivacaine + Normal saline (RC) received 2.5 ml of 0.5% hyperbaric ropivacaine (15 mg) +0.5 ml of normal saline. The onset, extent, and duration of sensory and motor block, duration of rescue analgesia, hemodynamic parameters, and side effects such as nausea, vomiting, pruritus, and shivering were recorded.

Results:

Time of onset early in RD (1.673 ± 0.567), in RF (1.73 ± 0.520), and in RC (1.763 ± 0.420) min (P = 0.783). Time to achieve maximum level of sensory block in RD (5.94 ± 1.88), in RF (3.86 ± 1.22), and RC (5.99 ± 0.46) min (P < 0.001). The total duration of analgesia in Group RD (356.67 ± 63.022), in RF (255.10 ± 35.626), and in RC (197.67 ± 37.605) min (P < 0.001). The time onset and duration of motor block in Group RD (1.59 ± 0.59, 319.57 ± 64.752), Group RF (1.59 ± 0.53, 236.83 ± 33.797), and Group RC (2.07 ± 0.20, 183.93 ± 35.252) min both are statistically highly significant (P < 0.001).

Conclusion:

Addition of glucose to ropivacaine makes the block dense. Addition of adjuvants such as dexmedetomidine and fentanyl further hastens the onset; prolong the postoperative analgesia with minimal hemodynamic and other side effects.

Comparison of the Efficacy of Intrathecal Isobaric Ropivacaine and Bupivacaine in Day Care Knee Arthroscopy: A Randomized Controlled Trial

Background:

The primary goal of ambulatory anesthesia is a rapid recovery with minimal side effects. Ropivacaine, due to its property of sensory-motor dissociation, maybe a useful agent when equivalent spinal anesthesia and quicker recovery of motor function is desirable.

Aim:

The aim of this study is to compare the efficacy of intrathecal isobaric ropivacaine with bupivacaine and to assess their postoperative recovery profile in patients undergoing arthroscopic knee surgery.

Setting and Design:

This randomized controlled study was conducted at a tertiary care hospital.

Materials and Methods:

A total of 90 adult American Society of Anaesthesiologist physical status Classes 1 and 2 patients were randomized into two groups to receive 2 ml plain solution of either 0.5% bupivacaine (Group B) or 0.75% ropivacaine (Group R). In the intraoperative period, onset, efficacy, duration, and regression of sensory and motor block were noted in both the groups at regular intervals. Postoperatively, the groups were compared for pain score, recovery profile, analgesic requirement, and complications.

Statistical Analysis:

Data analysis was performed using Chi-square test and Student's t-test.

Results:

The mean onset time of sensory block at L1 was significantly less (P = 0.025) and duration of sensory and motor block was significantly more (P = 0.001) with bupivacaine as compared to ropivacaine. The analgesic requirement on the 1^st postoperative day (P = 0.011) and incidence of delayed voiding of urine (P = 0.022) were significantly more with ropivacaine. The postoperative recovery profile and discharge times were similar between the groups.

Conclusion:

Isobaric ropivacaine was associated with a longer onset and shorter duration of sensory and motor block, increased postoperative analgesic requirement, higher complication rate, and similar discharge times as compared with bupivacaine. Therefore, isobaric bupivacaine may be preferred over isobaric ropivacaine for day care knee arthroscopy, especially in cases with an anticipated longer duration of surgery.

Comparison of Efficacy of Epidural Ropivacaine versus Bupivacaine for Postoperative Pain Relief in Total Knee Replacement Surgeries

Background:

Epidural analgesia has become the standard of care for knee replacement surgeries worldwide. Bupivacaine has been used successfully for many years. Epidural ropivacaine is now being used increasingly and seems to have benefits other than just pain relief, in terms of a better safety profile.

Aim:

To compare the efficacy of bupivacaine 0.125% (Group B) versus two concentrations of ropivacaine 0.1% (Group R1) and 0.2% (Group R2), in terms of pain scores, requirement of rescue analgesia, related adverse effects, and duration of postoperative (PO) hospital stay.

Materials and Methods:

A retrospective study was conducted from the acute pain service data of patients who underwent joint replacement surgeries in one or both limbs, over a span of 6 months. Patients were allocated to and analyzed under one of the three groups based on the drug concentration used postoperatively by epidural infusion. Data retrieved were demographic data, daily average visual analog scale (VAS) pain scores, rescue analgesia given, adverse effects, and PO hospital stay days for all three groups.

Results:

Demographic data were comparable between the three groups. Daily average VAS pain scores on days 1 and 2 were significantly higher in Group R1. Groups B and R2 were comparable. There was significantly more requirement of rescue analgesia in Group R1 on day 1. Day 2 showed no significant difference in rescue analgesic requirement in all three groups. Days of PO hospital stay were significantly higher in Group R1. Adverse effects such as hypotension and delayed motor block were higher in Group B.

Conclusion:

Ropivacaine 0.2% and bupivacaine 0.125% were equally efficacious in terms of VAS pain scores, rescue analgesic requirement, and duration of PO hospital stay, but ropivacaine had a better safety profile in terms of less hypotension and lesser motor block.

Comparison of the Efficacy and Safety of Morphine and Fentanyl as Adjuvants to Bupivacaine in Providing Operative Anesthesia and Postoperative Analgesia in Subumblical Surgeries Using Combined Spinal Epidural Technique

Introduction:

The combined spinal epidural (CSE) technique involves intentional subarachnoid blockade and epidural catheter placement during the same procedure to combine their individual best features, to reduce the total drug dosage and avoid their respective disadvantages. The addition of opioids to local anesthetics (bupivacaine) for CSE anesthesia (CSEA) is increasingly common to enhance the block. Neuraxial fentanyl is more potent and has shorter duration of action than morphine which provides prolonged anesthesia and analgesia, however at the cost of increased incidence of adverse effects like delayed respiratory depression.

Aims and Objectives:

The aim is to compare the efficacy and safety of morphine and fentanyl as adjuvants to bupivacaine in subumblical surgeries using CSE technique. The characteristics of sensory and motor block, intergroup variations in pain, cardiorespiratory parameters, and adverse effects were compared between the two groups.

Materials and Methods:

A total of 60 patients belonging to physical status American Society of Anesthesiologists Classes I and II, aged 18–60 years were randomized into two groups: Group A (n = 30) received intrathecal 0.5% heavy bupivacaine 12.5 mg and morphine 2.85 μg/kg; Epidural Anesthetic bolus (when required/T11Regression) 8 ml 0.25% isobaric bupivacaine and 0.04 mg/kg morphine; Epidural Analgesic bolus (postoperative visual analog scale [VAS] score >30) 5 ml 0.125% isobaric bupivacaine and 0.04 mg/kg morphine and Group B (n = 30) received intrathecal 0.5% heavy bupivacaine 12.5 mg and fentanyl 0.35 μg/kg; Epidural Anesthetic bolus (when required/T11Regression) 8 ml 0.25% isobaric bupivacaine and 0.7 μg/kg fentanyl; Epidural Analgesic bolus (postoperative VAS score >30) 5 ml 0.125% isobaric bupivacaine and 0.7 μg/kg fentanyl.

Results and Conclusion:

Group A had significantly prolonged two segment regression time, T11 regression time, lower mean VAS score, prolonged effective analgesia, and required lesser number of epidural boluses in 24 h as compared to Group B (P < 0.001). There were no significant differences between the groups considering onset of sensory block, duration of motor block, median maximum sensory block level achieved after spinal component (T6), median highest sensory block level achieved after epidural anesthetic bolus (T7-4seg enhancement after regression to T11), cardiorespiratory parameters and adverse effects. None of the patients had respiratory depression nor was there any failure of spinal/epidural component of CSEA. Thus, addition of morphine to bupivacaine in CSEA produced prolonged effective anesthesia and postoperative analgesia compared to addition of fentanyl to bupivacaine without producing undue adverse effects.

Comparison of Dexmedetomidine and Magnesium Sulfate as Adjuvants with Ropivacaine for Spinal Anesthesia in Infraumbilical Surgeries and Postoperative Analgesia

Introduction:

Postoperative pain is a major cause of fear and anxiety in hospitalized patients and so if patients remain pain-free during this period, they can cooperate with the circumstances well, leading to early recovery. Over the last two decades, there has been considerable revival of interest in the use of regional anesthesia techniques for surgery and pain management. As very few studies have been conducted using ropivacaine with dexmedetomidine and magnesium sulfate (MgSO₄) as adjuvants, the present study was undertaken with primary aims to compare the hemodynamic stability, onset and duration of sensory and motor block and with secondary aims of the postoperative analgesic effect of dexmedetomidine and MgSO₄ along with ropivacaine.

Materials and Methods:

After getting the Institutional Ethics Committee approval, this study was conducted on fifty patients of the American Society of Anesthesiologists physical Status I and II aged between 20 and 65 years of either sex and scheduled to undergo infraumbilical surgeries under spinal anesthesia. They were divided into two groups of 25 each. Group D patients received 3 ml of 0.75% isobaric ropivacaine hydrochloride with 10 μg of dexmedetomidine whereas Group M patients received 75 mg of MgSO₄ in the place of dexmedetomidine. The quality of surgical analgesia and quality of intraoperative muscle relaxation were assessed and graded.

Results:

We found out that onset of sensory and motor block was earlier in Group D in comparison to Group M. There was a significant reduction in the time to the first rescue analgesia in group receiving intrathecal dexmedetomidine.

Conclusion:

It is concluded from our study that ropivacaine plus dexmedetomidine group are better than ropivacaine plus MgSO₄ in providing early onset of sensory and motor block as well as in providing postoperative analgesia.

Comparison of clonidine and fentanyl as adjuvant to ropivacaine in spinal anesthesia in lower abdominal surgeries

Background:

Ropivacaine, a newer local anesthetic, is gaining increased acceptance due to its improved safety profile over bupivacaine and lignocaine. Analgesic adjuvants have proved to be valuable in improving the quality of anesthesia and duration of analgesia.

Aim:

To compare the efficacy of clonidine and fentanyl as adjuvants to ropivacaine in spinal anesthesia in lower abdominal surgeries.

Materials and Methods:

A randomized, double-blind control study was carried out in 100 patients who were randomly divided into two groups. Ropivacaine-clonidine group (RC) received 30 μg of clonidine with 18.75 mg of 0.75% isobaric ropivacaine, Ropivacaine-fentanyl group (RF) received 25 μg of fentanyl with 18.75 mg of 0.75% isobaric ropivacaine intrathecally. The onset and duration of sensory and motor block, hemodynamic parameters, quality of surgical analgesia, total analgesia time, sedation score, and side effects were statistically analyzed using SPSS statistical package, paired and unpaired t-tests and Chi-square test.

Results:

The duration of sensory block in RC (240.00 ± 20.99), RF (196.80 ± 18.34), and motor block in RC (192.20 ± 17.36), RF (139.20 ± 17.93) outlasted the duration of surgery. In clonidine group, there was significant prolongation of sensory block, motor block and the total analgesia time. Hypotension and bradycardia occurred more commonly in RC group, whereas pruritus was more in RF group.

Conclusion:

Ropivacaine when combined with either clonidine or fentanyl provided an adequate subarachnoid block for lower abdominal surgeries. As an adjuvant, clonidine has advantage over fentanyl as it increased the duration of the subarachnoid block and the postoperative analgesia.

A Randomized Double Blinded Comparison of Epidural Infusion of Bupivacaine, Ropivacaine, Bupivacaine-Fentanyl, Ropivacaine-Fentanyl for Postoperative Pain Relief in Lower Limb Surgeries

BACKGROUND

Continuous epidural infusion of Bupivacaine and Ropivacaine with or without the addition of Fentanyl has been evaluated by various researchers for effective postoperative pain relief. Studies however, depict significant variability in their results with regard to analgesic efficacy and adverse effects like hypotension, motor blockade etc.

AIM

To comparatively evaluate postoperative analgesic efficacy, motor sparing effect, postoperative haemodynamic variations and total postoperative analgesic consumption in first 24 hours.

MATERIALS AND METHODS

A randomised double blind study was conducted on 100 adult, ASA grade I and II patients, of either sex who had undergone elective lower limb surgery under spinal anaesthesia. According to the group allocated, patients were started on epidural infusion after completion of surgery. Group I (0.2% Ropivacaine), Group II (0.1% Ropivacaine + 2μg/ml Fentanyl), Group III (0.2% Bupivacaine), Group IV (0.1% Bupivacaine + 2μg/ml Fentanyl) at the rate of 6 ml/hour. VAS scores, epidural consumption, supplemental epidural boluses, rescue analgesics, haemodynamics, motor block, sensory block regression, sedation, nausea and pruritis were recorded by a blinded observer for 24 hours.

RESULTS

The haemodynamic parameters were stable in all the groups. Side effects including the motor block were negligible and comparable in all groups. Group I patients had significantly lower VAS scores, mean total epidural consumption, supplemental epidural bolus requirement and rescue analgesic requirement among all groups.

CONCLUSION

It can be concluded that epidural analgesia using Ropivacaine 0.2% infusion is more effective than other study groups when used for postoperative pain relief in lower limb surgeries.