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Levobupivacaine for postoperative epidural analgesia in orthopaedic surgery

Afaf AA, Liu CY, Joanna OS

Clin Ter, 2013;164(2):91-5.
PMID: 23698199 DOI: 10.7417/CT.2013.1524

Levobupivacaine is the S(-)enantiomer of bupivacaine, a long acting amino-ester local anaesthetic agent. Cocktail mixture of levobupivacaine and fentanyl infusion is commonly given via epidural for post-operative analgesia. The concentration of levobupivacaine for optimal pain relief with least side effects remained uncertain.

Matched MeSH terms: Bupivacaine/analogs & derivatives*
Fulltext Comparison of 0.5% ropivacaine and 0.5% levobupivacaine for infraclavicular brachial plexus block

Mageswaran R, Choy YC

Med J Malaysia, 2010 Dec;65(4):300-3.
PMID: 21901950

A prospective randomized double-blind study was conducted which involved, 60 ASA 1-2, aged 18-65 years patients, who had elective or emergency orthopaedic surgeries of the upper limbs. They were randomly divided into two groups: Group I received 30 mls of 0.5% ropivacaine; and Group II received 0.5% levobupivacaine for infraclavicular brachial plexus block based on the coracoid approach. The onset time required for sensory block of all required dermatomes (C5-T1) and the onset time of motor block were documented. Based on the Visual Analogue Score, pain scores were recorded every 30 minutes during surgery and at the 6th hour. The mean onset time (SD) for sensory block with ropivacaine was 13.5 +/- 2.9 minutes compared to levobupivacaine at 11.1 +/- 2.6 minutes (p = 0.003). The onset time for motor block was 19.0 +/- 2.7 minutes in Group I compared to 17.1 +/- 2.6 minutes (p = 0.013) in Group II. Patients in both groups experienced both mild to moderate pain at the 6th hour. In conclusion, there were statistically significant differences in the onset-time for sensory and motor block. However, there was no statistically significant difference in terms of effectiveness of analgesia at the 6th hour. Although the clinical advantage of levobupivacine is not substantial, its safety profile becomes a major consideration in the choice of local anaesthetic for brachial plexus block where a large volume is required for an effective result.

Matched MeSH terms: Bupivacaine/analogs & derivatives
Levobupivacaine vs racemic bupivacaine in spinal anesthesia for sequential bilateral total knee arthroplasty: a retrospective cohort study

Chen CK, Lau FC, Lee WG, Phui VE

J Clin Anesth, 2016 Sep;33:75-80.
PMID: 27555137 DOI: 10.1016/j.jclinane.2016.03.007

STUDY OBJECTIVES: To compare the anesthetic potency and safety of spinal anesthesia with higher dosages of levobupivacaine and bupivacaine in patients for bilateral sequential for total knee arthroplasty (TKA).
DESIGN: Retrospective cohort study.
SETTING: Operation theater with postoperative inpatient follow-up.
PATIENTS: The medical records of 315 patients who underwent sequential bilateral TKA were reviewed.
INTERVENTIONS: Patients who received intrathecal levobupicavaine 0.5% were compared with patients who received hyperbaric bupivacaine 0.5% with fentanyl 25 μg for spinal anesthesia.
MEASUREMENTS: The primary outcome was the use of rescue analgesia (systemic opioids, conversion to general anesthesia) during surgery for both groups. Secondary outcomes included adverse effects of local anesthetics (hypotension and bradycardia) during surgery and morbidity related to spinal anesthesia (postoperative nausea, vomiting, and bleeding) during hospital stay.
MAIN RESULTS: One hundred fifty patients who received intrathecal levobupivacaine 0.5% (group L) were compared with 90 patients given hyperbaric bupivacaine 0.5% with fentanyl 25 μg (group B). The mean volume of levobupivacaine administered was 5.8 mL (range, 5.0-6.0 mL), and that of bupivacaine was 3.8 mL (range, 3.5-4.0 mL). Both groups achieved similar maximal sensory level of block (T6). The time to maximal height of sensory block was significantly shorter in group B than group L, 18.2 ± 4.5 vs 23.9 ± 3.8 minutes (P< .001). The time to motor block of Bromage 3 was also shorter in group B (8.7 ± 4.1 minutes) than group L (16.0 ± 4.5 minutes) (P< .001). Patients in group B required more anesthetic supplement than group L (P< .001). Hypotension and postoperative bleeding were significantly less common in group L than group B.
CONCLUSION: Levobupivacaine at a higher dosage provided longer duration of spinal anesthesia with better safety profile in sequential bilateral TKA.

Matched MeSH terms: Bupivacaine/analogs & derivatives*
Near fatal error in management of postoperative epidural analgesia

Wan Mat WR, Yahya N, Izaham A, Abdul Rahman R, Abdul Manap N, Md Zain J

Int J Risk Saf Med, 2014;26(2):57-60.
PMID: 24902502 DOI: 10.3233/JRS-140611

Acute pain service (APS) ensures provision of effective and safe postoperative pain relief. The following cases describe a potentially fatal error in managing patients who receive epidural analgesia postoperatively.

Matched MeSH terms: Bupivacaine/analogs & derivatives
The effectiveness of patient-controlled epidural analgesia with ropivacaine 0.165% with fentanyl 2.0 miroc g/ml or levobupivacaine 0.125% with fentanyl 2.0 micro g/ml as a method of postoperative analgesia after major orthopaedic surgery

Misiran KB, Yahaya LS

Middle East J Anaesthesiol, 2013 Feb;22(1):59-64.
PMID: 23833852

This prospective randomized single-blinded study was conducted to determine whether there were differences in consumption, demand dosing and postoperative analgesia quality between PCEA using ropivacaine and levobupivacaine. Seventy patients with ASA classification I and II aged 18 to 80 years old scheduled for elective total knee replacement or total hip replacement were studied. All patients received CSE and then were randomly allocated to receive either ropivacaine 0.165% (Group A) or levobupivacaine 0.125% (Group B) both added with fentanyl 2.0 mcro g/ml via epidural route. PCEA regime was offered for 48 hours with additional standard orthopaedic practice of oral analgesia (etoricoxib 120 mg OD and paracetamol 1.0 gm QID) on the second postoperative day. Basal infusion of PCEA was at 3.0 ml/hour and discontinued after 24 hours following started of PCEA. The consumption of local anaesthetics used within the first 24 hours (basal + demand) and 48 hours (total basal + total demand) were recorded. The VAS pain score, sedation score, side effects and vital signs (blood pressure, heart rate and respiratory rate) were also recorded every four hours for 48 hours. This study showed that the total volume of drug used was significantly higher in Group A (163.31+/- 29.01 ml) than Group B (142.69 +/- 30.93ml) (p<0. 01). The mean dose of Group A for the first 48 hours after surgery was 251.43 +/- 70.02mg and was significantly greater than the mean dose of Group B (178.91 +/-42.33 mg) (p<0.01). The numbers of PCEA boluses delivered (D) and PCEA attempts (A) were higher in the Group A (22.37 +/-7.32 and 27.66 +/- 9.12) in contrast to Group B (17.63 +/- 7.71 and 24.40 +/- 11.51) but the differences were not statistically significant. The ratio D/A showed significantly higher in Group A (0.83 +/- 0.13) than Group B (0.74 +/- 0.15) (p<0. 02). The VAS pain score was similar for both groups. One patient in Group B had vomiting and there was no sedation, hypotension, pruritus or motor block recorded in both groups. In conclusion this study showed that both PCEA using ropivacaine 0.165% with fentanyl 2.0 micro g/ml and levobupivacaine 0.125% with fentanyl 2.0 micro g/ml provided effective postoperative analgesia within the first 48 hours of major lower limb orthopaedic surgery despite clinically significant dose difference. There was no hypotension, pruritus, sedation or motor block recorded in both groups.

Matched MeSH terms: Bupivacaine/analogs & derivatives
Pre-emptive intraperitoneal local anaesthesia: an effective method in immediate post-operative pain management and metabolic stress response in laparoscopic appendicectomy, a randomized, double-blinded, placebo-controlled study

Thanapal MR, Tata MD, Tan AJ, Subramaniam T, Tong JM, Palayan K, et al.

ANZ J Surg, 2014 Jan-Feb;84(1-2):47-51.
PMID: 23057502 DOI: 10.1111/j.1445-2197.2012.06210.x

Although laparoscopic surgeries are associated with reduced surgical stress response and shortened post-operative recovery, intense pain and high analgesia requirements in the immediate post-operative period are often the chief complaints.

Matched MeSH terms: Bupivacaine/analogs & derivatives