Wound infiltration and drain lavage with ropivacaine after major shoulder surgery

Subcutaneous infiltration and wound lavage with ropivacaine is an alternative to opioids after major shoulder surgery. However, the efficacy and potential toxicity of this method remain unclear. We therefore evaluated plasma ropivacaine concentrations after shoulder infiltration and wound lavage. We subsequently quantified the efficacy of two ropivacaine concentrations. Patients undergoing major shoulder surgery were anesthetized with alfentanil and propofol. The initial patients (n = 18) received ropivacaine 7.5 mg/mL and ropivacaine plasma concentrations were measured in 15-min intervals. The subsequent 45 patients were randomly assigned to: 1) isotonic saline, 2) 3.75 mg/mL ropivacaine, or 3) 7.5 mg/mL ropivacaine. Ten milliliters of each solution was administered subcutaneously and 20 mL was injected into the wound drain which was clamped for 10 min. Supplemental postoperative pain relief was provided by patient-controlled anesthesia using the opioid piritramid (3.5-mg boluses, 6-min lock-out). Postoperative pain scores were recorded on a 100-mm visual analog scale for 4 h in the initial patients and for 10 h in the second part of the study. Unbound ropivacaine plasma concentrations peaked after 15 min at 0.08+/-0.09 microg/mL; the maximum was 0.30 microg/mL, compared with a toxic threshold of 0.6 microg/mL. In the second part of the study, pain scores were significantly lower after 3.75 mg/mL (20+/-15 mm) or 7.5 mg/mL (10+/-9 mm) ropivacaine than saline (35+/-10 mm). Piritramid requirements differed significantly in the three groups, being highest with saline and lowest with ropivacaine 7.5 mg/mL. We conclude that wound infiltration and lavage with 30 mL ropivacaine 7.5 mg/mL after major shoulder surgery resulted in very low pain scores and opioid requirement. IMPLICATIONS: Wound infiltration and lavage with 30 mL ropivacaine 7.5 mg/mL after major shoulder surgery resulted in very low pain scores and opioid requirement.     

The dose-sparing effect of clonidine added to ropivacaine for labor epidural analgesia

To determine the effects of clonidine with ropivacaine during epidural labor analgesia, we studied 66 nulliparous women in early active labor. Women were randomized to receive ropivacaine 0.1% 8 mL plus 75 microg of clonidine (Group 1), ropivacaine 0.2% 8 mL plus 0.5 mL of NaCl 0.9% (Group 2), or ropivacaine 0.2% 8 mL plus 75 microg of clonidine (Group 3) 5 min after a bupivacaine 7.5 mg with epinephrine 15 microg test dose. Upon request, additional analgesia with ropivacaine 0.1% 8 mL followed by ropivacaine 0.2% 8 mL/h was administered. With clonidine, duration of analgesia was increased (132 +/- 48 min [Group 1] and 154 +/- 42 min [Group 3] versus 91 +/- 44 min [Group 2]; P < 0.05), and total ropivacaine dose over the first 4 h was significantly reduced (40.5 +/- 15 mg [Group 1] and 47.0 +/- 16 mg [Group 3] versus 72.5 +/- 18 mg [Group 2]; P < 0.01). The incidence of more profound motor block was more frequent in Group 2 (P < 0.05). Although there was a trend for more women receiving clonidine to require ephedrine for treatment of hypotension, this did not seem to have an impact on fetal outcome or incidence of cesarean deliveries for nonreassuring fetal heart rate tracings. This study demonstrates the dose-sparing effect of clonidine when added to ropivacaine. IMPLICATIONS: The effect of adding 75 microg of clonidine to ropivacaine for epidural labor analgesia was studied. Clonidine increased analgesia duration and produced dose sparing compared with ropivacaine alone. Despite a tendency for hypotension in women receiving clonidine, there was no apparent effect on delivery mode or neonatal outcome.     

Ropivacaine 2 mg/mL vs. bupivacaine 1.25 mg/mL with sufentanil using patient-controlled epidural analgesia in labour

BACKGROUND: In recent studies, minimum local analgesic concentrations have been defined as 0.93 mg/mL for bupivacaine and 1.56 mg/mL for ropivacaine for epidural analgesia for the first stage of labour, resulting in an analgesic potency ratio of 1 : 0.6. In the current study we compared ropivacaine and bupivacaine in a PCEA system (combined with sufentanil) taking this potency ratio into account but administering drug doses providing sufficient analgesia for all stages of labour. METHODS: In a prospective, double-blinded study 114 parturients were randomised to receive either ropivacaine 2 mg/mL with sufentanil 0.75 microg/mL or bupivacaine 1.25 mg/with sufentanil 0.75 microg/mL. After epidural catheter placement, PCEA was available with boluses of 4 mL, a lock-out time of 20 min and no basal infusion rate. We evaluated pain intensity during contractions, sensory and motor function, duration of labour, mode of delivery and neonatal outcome. Consumption of local anaesthetic and opioid drugs and PCEA system variables were recorded. RESULTS: Mean total consumption as well as mean hourly drug consumption was significantly increased in the ropivacaine-sufentanil group. No differences in analgesic quality, sensory or motor blocking potencies or neonatal outcome variables between groups were detected. Frequency of instrumental deliveries was significantly increased in the ropivacaine-sufentanil group. CONCLUSIONS: The results support the findings of previously published studies postulating ropivacaine to be 40-50% less potent for labour epidural analgesia compared to bupivacaine. However, we observed an increased frequency of instrumental deliveries with ropivacaine. To evaluate the clinical relevance of these findings, further investigations are warranted.     

Continuous interscalene analgesia with ropivacaine 2 mg/ml after major shoulder surgery

BACKGROUND: In this open, randomized study, the pharmacokinetics, clinical efficacy, and safety of a 48-h continuous interscalene infusion of 2 mg/ml ropivacaine for postoperative pain relief were investigated in patients undergoing open major shoulder surgery. METHODS: An initial interscalene block with 30 ml ropivacaine, 7.5 mg/ml (225 mg), was performed. After completion of interscalene block, all patients (n = 24) received general anesthesia, and 6 h after interscalene block, a 48-h continuous interscalene infusion of 12 or 18 mg/h using 2 mg/ml ropivacaine was started. Total and unbound plasma concentrations of ropivacaine and 2.6-pipecoloxylidide (PPX; a major active metabolite) were determined during and up to 6 h after the interscalene infusion. Postoperative pain at rest was assessed by a visual analog scale. Supplementary analgesics and adverse events were recorded. RESULTS: Plasma concentrations of total and unbound ropivacaine were proportional to the total dose. At the end of the interscalene infusion of 9 ml/h, the mean +/- SD plasma concentrations of total and unbound ropivacaine were 1.40 +/- 0.54 and 0.03 +/- 0.01 mg/l, respectively, and of total and unbound PPX were 0.70 +/- 0.38 and 0.30 +/- 0.20 mg/l, respectively. Plasma concentrations of unbound ropivacaine and unbound PPX, added together, remained well below threshold levels for systemic central nervous system toxicity. There were no significant differences between the groups for postoperative pain (median maximum of about 20 mm on the visual analog scale in both groups), analgesic consumption, or quality of pain relief assessed by the patient. No signs or symptoms of systemic local anesthetic toxicity were observed. CONCLUSION: A 48-h continuous interscalene infusion of 6 or 9 ml/h ropivacaine, 2 mg/ml, started 6 h after an initial interscalene block of 30 ml ropivacaine, 7.5 mg/ml, provided satisfactory postoperative pain relief after major shoulder surgery and was well tolerated. Unbound plasma concentrations of ropivacaine and PPX remained well below threshold levels for systemic central nervous toxicity.     

Caudal ropivacaine and neostigmine in pediatric surgery

BACKGROUND: Neostigmine has been added to local anesthetics for different nerve blocks. This study was conducted to evaluate effects of neostigmine when added to ropivacaine for caudal anesthesia. METHODS: We studied children, aged 1-5 yr, undergoing inguinal hernia and hypospadias surgery. After standard induction of anesthesia, Group I received 0.2% ropivacaine 0.5 ml/kg and Group II received 0.2% ropivacaine 0.5 ml/kg with 2 microg/kg neostigmine via the caudal route. Heart rate, mean arterial pressure, and pulse oximetry were recorded before induction, after induction, and then every 10 min after caudal anesthesia. Hemodynamic, Toddler-Preschooler Postoperative Pain Scale pain score, and sedation score values were recorded 30 min after extubation and at hours 2, 4, 6, 12, and 24. A pain score greater than 3/10 resulted in administration of rectal paracetamol. RESULTS: There were no differences between the groups in demographic and hemodynamic data, duration of surgery and anesthesia, time to extubation, or sedation scores. The pain scores were significantly lower in Group II at 6 and 12 h (P < 0.05). Time to first analgesic requirement was statistically prolonged in Group II (19.2 +/- 5.5h) when compared with Group I (7.1 +/- 5.7 h) (P < 0.05). Total analgesic consumption was statistically larger in Group I (174 +/- 96 mg) when compared with Group II (80 +/- 85.5 mg) (P < 0.05). The incidence of vomiting (3 patients in Group II and 1 patient in Group I) was not statistically significantly different. CONCLUSIONS: The authors found that a single caudal injection of neostigmine when added to ropivacaine offers an advantage over ropivacaine alone for postoperative pain relief in children undergoing genitourinary surgery.     

Continuous Interscalene Analgesia with Ropivacaine 2 mg/ml after Major Shoulder Surgery

Background: In this open, randomized study, the pharmacokinetics, clinical efficacy, and safety of a 48-h continuous interscalene infusion of 2 mg/ml ropivacaine for postoperative pain relief were investigated in patients undergoing open major shoulder surgery.

Methods: An initial interscalene block with 30 ml ropivacaine, 7.5 mg/ml (225 mg), was performed. After completion of interscalene block, all patients (n = 24) received general anesthesia, and 6 h after interscalene block, a 48-h continuous interscalene infusion of 12 or 18 mg/h using 2 mg/ml ropivacaine was started. Total and unbound plasma concentrations of ropivacaine and 2.6-pipecoloxylidide (PPX; a major active metabolite) were determined during and up to 6 h after the interscalene infusion. Postoperative pain at rest was assessed by a visual analog scale. Supplementary analgesics and adverse events were recorded.

Results: Plasma concentrations of total and unbound ropivacaine were proportional to the total dose. At the end of the interscalene infusion of 9 ml/h, the mean +/- SD plasma concentrations of total and unbound ropivacaine were 1.40 +/- 0.54 and 0.03 +/- 0.01 mg/l, respectively, and of total and unbound PPX were 0.70 +/- 0.38 and 0.30 +/- 0.20 mg/l, respectively. Plasma concentrations of unbound ropivacaine and unbound PPX, added together, remained well below threshold levels for systemic central nervous system toxicity. There were no significant differences between the groups for postoperative pain (median maximum of about 20 mm on the visual analog scale in both groups), analgesic consumption, or quality of pain relief assessed by the patient. No signs or symptoms of systemic local anesthetic toxicity were observed.     

Evaluation of efficacy and plasma concentrations of ropivacaine in continuous axillary brachial plexus block: high dose for surgical anesthesia and low dose for postoperative analgesia

BACKGROUND AND OBJECTIVES: Ropivacaine is a potent local anesthetic that, experimentally at low concentrations, produces an effective block of pain conducting nerve fibers. Therefore, it was hypothesized that 0.1% and 0.2% ropivacaine would provide clinically adequate postoperative analgesia in continuous axillary plexus block. METHODS: Sixty patients (ASA I-II) scheduled for elective hand or forearm surgery received 5 mg/kg of 0.75% ropivacaine for axillary block using nerve stimulator technique. One hour later, in random order, a continuous infusion of either 0.1% ropivacaine (0.125 mg/kg/h), 0.2% ropivacaine (0.25 mg/kg/h) or saline 6 to 11 mL/h was started. RESULTS: The mean total ropivacaine dose for the surgical block was 5.1 to 5.2 mg/kg with the supplementation. All patients were pain free for the first 12 to 15 hours after the block. The need for postoperative analgesics during the infusion was similar in all groups. After the initial block, the maximum plasma concentrations (mean 2.5 microg/mL) were measured at 45 or 60 minutes after injection. The highest individual plasma concentration was 4.2 microg/mL. Despite the high venous peak concentration, no toxic reactions were observed. The mean peak plasma concentration (Cmax) was 2.2+/-0.5 microg/mL for saline, 2.6+/-0.8 microg/mL for 0.1% ropivacaine, and 2.6+/-0.7 microg/mL for 0.2% ropivacaine. During the continuous infusion of 24 hours, the ropivacaine concentration declined steadily. CONCLUSIONS: Ropivacaine is safe and effective for axillary brachial plexus block. The continuous infusion of 0.1% or 0.2% ropivacaine was no more beneficial than an infusion of saline in relieving postoperative pain in patients having elective hand surgery. None of the infusions were sufficient to adequately treat the patients' pain without the addition of adjunct agents.     

A comparison of epidural ropivacaine infusion alone and in combination with 1, 2, and 4 microg/mL fentanyl for seventy-two hours of postoperative analgesia after major abdominal surgery

Our aim in this prospective, randomized, double-blinded study was to compare the analgesic effectiveness and side effects of epidural infusions with ropivacaine 2 mg/mL alone (Group R; n = 60) and in combination with fentanyl 1 microg/mL (R1F; n = 59), 2 microg/mL (R2F; n = 62), and 4 microg/mL (R4F; n = 63) for up to 72 h after major abdominal surgery. Effective epidural neural blockade was established before surgery; postoperatively, the infusion rate was titrated to a maximum of 14 mL/h for analgesia. No additional analgesics other than acetaminophen were permitted during the infusion. The median of individual visual analog scale score with coughing were <20 mm for all groups (0 = no pain, 100 = worst pain) and was significantly lower (P < 0.01) for Group R4F at rest and with coughing (compared with Group R). Infusions were discontinued due to inability to control pain in significantly fewer patients in Group R4F (16%) than the other groups (34% to 39%; P < 0.01). For all groups, >90% of patients had no detectable motor block after 24 h. Hypotension, nausea, and pruritus were more common with the larger dose of fentanyl. We conclude that, after major abdominal surgery, an epidural infusion of ropivacaine 2 mg/mL with fentanyl 4 microg/mL provided significantly more effective pain relief over a 3-day period than ropivacaine alone or ropivacaine with lower concentrations of fentanyl. Implications: Postoperative epidural analgesic infusions are widely used, but there is little information regarding optimal strengths of opioid with local anesthetic. In this blinded, prospective study, we compared four different epidural infusion solutions for efficacy and side effects over a clinically useful postoperative period and conclude that an epidural infusion of ropivacaine 2 mg/mL with fentanyl 4 microg/mL was most effective.     

Ropivacaine 3.75 mg/ml, 5 mg/ml, or 7.5 mg/ml for cervical plexus block during carotid endarterectomy

OBJECTIVE: To examine the effect of 225 mg (7.5 mg/mL), 150 mg (5 mg/mL), and 112.5 mg (3.75 mg/mL) ropivacaine on quality of cervical plexus block during carotid endarterectomy. METHODS: Patients (n = 93) scheduled for carotid endarterectomy were randomized to receive a cervical plexus block with deep infiltration of 10 mL and superficial infiltration of 20-mL volumes of ropivacaine 7.5, 5.0, or 3.75 mg/mL. Pain, coughing, hemodynamic consequences of the block, postoperative visual analog scores, and pain satisfaction index were recorded. If necessary, anesthesia supplements with aliquots of 3 mL lidocaine 1% were given during surgery. RESULTS: Incidences of coughing and hoarseness were similar in all groups. More local anesthetic infiltrations were required in the ropivacaine 3.75-mg/mL and 5-mg/mL groups. Postoperatively, no intragroup differences were observed. A trend toward better pain satisfaction was observed in the ropivacaine 7.5-mg/mL group. CONCLUSION: The best quality of cervical plexus block associated with the smallest incidence of pain for patients undergoing carotid endarterectomy was obtained with 30 mL of 225 mg and 150 mg of ropivacaine, respectively.     

Epinephrine does not prolong the analgesia of 20 mL ropivacaine 0.5% or 0.2% in a femoral three-in-one block.

We tested the effect of epinephrine added to 20 mL ropivacaine 0.5% and 0.2% on postoperative analgesia via a femoral catheter after total knee replacement. Forty-one patients undergoing total knee replacement under combined peripheral block/general anesthesia were randomly allocated to two groups. After insertion of a femoral catheter, 21 patients in the Ropivacaine-Epinephrine (ROPI-EPI) group received 20 mL ropivacaine 0.5% plus epinephrine 1:200,000, whereas 20 patients in the Ropivacaine group (ROPI) received 20 mL plain ropivacaine 0.5%. Thereafter, a sciatic block with 30 mL bupivacaine 0.5% plus epinephrine 1:200,000 was performed in all patients, followed by general anesthesia. After surgery, patient-controlled analgesia (PCA) with ropivacaine 0.2% plus epinephrine 1:200,000 for Group ROPI-EPI and plain ropivacaine 0.2% for Group ROPI was available via the femoral catheter (200 mL ropivacaine 0.2% +/- epinephrine, bolus 20 mL, lockout 120 min). The patients were instructed to use PCA when the knee pain score was >3 cm. The interval between the initial ropivacaine injection and the first PCA injection determined the duration of 20 mL ropivacaine 0.5% +/- epinephrine, whereas the interval between the first and second PCA injection determined the duration of 20 mL ropivacaine 0.2% +/- epinephrine. The average duration of ropivacaine 0.5% was 657 +/- 345 min for the ROPI-EPI group and 718 +/- 423 min for the ROPI group (NS), whereas for ropivacaine 0.2%, the average duration was 409 +/- 245 min for the ROPI-EPI group and 419 +/- 339 min for the ROPI group (not significant). We conclude that epinephrine does not influence the duration of analgesia of the ropivacaine concentrations investigated. IMPLICATIONS: We evaluated the effect of epinephrine on the duration of analgesia of 20 mL ropivacaine 0.5% or 0.2% injected in femoral three-in-one block for pain relief after total knee replacement. Our results show that epinephrine does not alter the duration of analgesia of the two solutions investigated.     

The effect of the addition of epinephrine on early systemic absorption of epidural ropivacaine in humans

The addition of epinephrine to ropivacaine has not been recommended because ropivacaine has intrinsic vasoconstrictor properties. However, few pharmacokinetic data are available on the addition of epinephrine to epidural ropivacaine in humans. In this prospective, double-blinded study, we randomized patients having elective abdominal hysterectomy to receive epidural ropivacaine 1.5 mg/kg, diluted in 15 mL, either with (epinephrine group, n = 12) or without (plain group, n = 12) epinephrine 5 microg/mL and then measured arterial and venous plasma concentrations of ropivacaine at intervals up to 180 min. We found that arterial and venous plasma ropivacaine concentrations were smaller in the epinephrine group compared with the plain group in the first 60 min after the drug administration (P < 0.01). Mean (+/- SD) maximum total plasma ropivacaine concentration was smaller in the epinephrine group (arterial, 0.92 +/- 0.32 microg/mL; venous, 0.82 +/- 0.33 microg/mL) compared with the plain group (1.31 +/- 0.39 microg/mL and 1.31 +/- 0.50 microg/mL, respectively; P = 0.01). Time to maximum total plasma ropivacaine concentration was not significantly different between groups (mean +/- SD; arterial, 16 +/- 2 min; venous, 23 +/- 2 min in the epinephrine group versus 9 +/- 2 min and 12 +/- 3 min, respectively, in the plain group; P = 0.08). Arterial plasma ropivacaine concentrations were larger than venous concentrations during the first hour (P < 0.01); the arterio-venous difference decreased exponentially, and the rate and magnitude of this decrease was unaffected by epinephrine. We conclude that the addition of epinephrine 5 microg/mL to ropivacaine reduced the early systemic plasma concentrations of ropivacaine after epidural injection and may be useful for decreasing the risk of toxicity from systemic absorption of epidural ropivacaine. IMPLICATIONS: The addition of epinephrine 5 microg/mL to epidural ropivacaine reduced the systemic arterial and venous plasma concentrations of ropivacaine in the first hour and the maximum plasma concentration of ropivacaine. Epinephrine may be a useful additive for reducing the risk of systemic toxicity when large doses of ropivacaine are given epidurally.     

Caudal Ropivacaine and Neostigmine in Pediatric Surgery

Background: Neostigmine has been added to local anesthetics for different nerve blocks. This study was conducted to evaluate effects of neostigmine when added to ropivacaine for caudal anesthesia.

Methods: We studied children, aged 1-5 yr, undergoing inguinal hernia and hypospadias surgery. After standard induction of anesthesia, Group I received 0.2% ropivacaine 0.5 ml/kg and Group II received 0.2% ropivacaine 0.5 ml/kg with 2 [mu]g/kg neostigmine via the caudal route. Heart rate, mean arterial pressure, and pulse oximetry were recorded before induction, after induction, and then every 10 min after caudal anesthesia. Hemodynamic, Toddler-Preschooler Postoperative Pain Scale pain score, and sedation score values were recorded 30 min after extubation and at hours 2, 4, 6, 12, and 24. A pain score greater than 3/10 resulted in administration of rectal paracetamol.

Results: There were no differences between the groups in demographic and hemodynamic data, duration of surgery and anesthesia, time to extubation, or sedation scores. The pain scores were significantly lower in Group II at 6 and 12 h (P < 0.05). Time to first analgesic requirement was statistically prolonged in Group II (19.2 +/- 5.5h) when compared with Group I (7.1 +/- 5.7 h) (P < 0.05). Total analgesic consumption was statistically larger in Group I (174 +/- 96 mg) when compared with Group II (80 +/- 85.5 mg) (P < 0.05). The incidence of vomiting (3 patients in Group II and 1 patient in Group I) was not statistically significantly different.     

The analgesic efficacy of bilateral combined superficial and deep cervical plexus block administered before thyroid surgery under general anesthesia

In this study we evaluated the analgesic efficacy of combined deep and superficial cervical plexus block in patients undergoing thyroidectomy under general anesthesia. For this purpose, 39 patients undergoing elective thyroid surgery were randomized to receive a bilateral combined deep and superficial cervical block (14 mL per side) with saline (Group 1; n = 13), ropivacaine 0.5% (Group 2; n = 13), or ropivacaine 0.5% plus clonidine 7.5 microg/mL (Group 3; n = 13). Deep cervical plexus block was performed with a single injection (8 mL) at the C3 level. Superficial cervical plexus block consisted of a subcutaneous injection (6 mL) behind the lateral border of the sternocleidomastoid muscle. During surgery, the number of additional alfentanil boluses was significantly reduced in Groups 2 and 3 compared with Group 1 (1.3 +/- 1.0 and 1.1 +/- 1.0 vs 2.6 +/- 1.0; P < 0.05). After surgery, the opioid and non-opioid analgesic requirements were also significantly reduced in Groups 2 and 3 (P < 0.05) during the first 24 h. Except for one patient in Group 3, who experienced transient anesthesia of the brachial plexus, no side effect was noted in any group. We conclude that combined deep and superficial cervical plexus block is an effective technique to alleviate pain during and immediately after thyroidectomy. IMPLICATIONS: Combined deep and superficial cervical plexus block is an effective technique to reduce opioid requirements during and after thyroid surgery.     

Ropivacaine epidural anesthesia and analgesia versus general anesthesia and intravenous patient-controlled analgesia with morphine in the perioperative management of hip replacement. Ropivacaine Hip Replacement Multicenter Study Group.

The aim of our study was to compare epidural anesthesia and analgesia (EDA) with ropivacaine versus general anesthesia followed by IV patient-controlled analgesia with morphine (GA/PCA) after hip replacement regarding pain, side effects, and discharge from the postanesthesia care unit. After ethics committee approval, randomization, and informed consent, 90 patients were enrolled. In Group EDA, epidural anesthesia (ropivacaine 10 mg/mL, 15-25 mL) was followed by an epidural infusion (2 mg/mL, 4-6 mL/h for 24 h, plus top-up doses of 6-10 mL for 48 h). GA/PCA patients received general anesthesia (isoflurane/N2O/fentanyl) followed by IV patient-controlled analgesia with morphine postoperatively. Pain was assessed by using visual analog scales (0-100 mm) at rest and during physiotherapy. Pain at rest was less in the EDA (n = 43) group than in the GA/PCA (n = 45) group (at 10 h: 11.8+/-12.9 vs. 28.4+/-17.1 [P< 0.001]; at 24 h: 14.3+/-11.7 vs. 24.0+/-17 [P<0.01]; in 48 h: 14.3+/-9.3 vs. 21.1+/-17.4 [P = 0.1]). Whereas EDA patients were deemed ready for discharge from the postanesthesia care unit earlier than GA/PCA patients (5.6+/-8.9 vs. 39.7+/-41.5 min), the actual discharge time was comparable. The median time for first passage of flatus was shorter in the EDA group than in the GA/PCA group (26 vs. 47 h). Nausea and vomiting were more common in the GA/PCA group than in the EDA group (16% vs. 28% and 11% vs. 22%, respectively), whereas hypotension (11% vs. 4%) and bradycardia (14% vs. 2%) were less frequent. Under the conditions of the present study, EDA with ropivacaine provided pain control after hip replacement superior to that provided by IV patient-controlled analgesia with morphine, particularly during the first 24 h. Both approaches to pain management were equally safe. IMPLICATIONS: Compared with general anesthesia and postoperative IV patient-controlled analgesia with morphine, epidural anesthesia and analgesia with the new local anesthetic ropivacaine enables patients to be discharged sooner from a postanesthesia care unit and provides superior pain relief during the first 24 h after hip replacement.     

The number of injections does not influence local anesthetic absorption after paravertebral blockade

PURPOSE: The aims of this study are to determine if the injection of a single large dose of local anesthetics into the paravertebral space increases the risks of inducing toxicity compared with multiple small injections and to describe ropivacaine plasma concentrations resulting from paravertebral blockade. METHODS: Paravertebral blockade was performed using a solution of 10 mL ropivacaine 0.75%, 10 mL lidocaine CO2 2% plus 0.1 mL epinephrine 1:1000 either by a single injection at T3 or T4 (Group S, n = 6) or by five injections of 4 mL each at T2 to T6 (Group M, n = 8). Blood samples were taken at zero, five, ten, 15, 20, 30, 45, 60 and 90 min and at two, three, four, five, six and eight hours. Ropivacaine and lidocaine plasma concentrations were measured by high performance liquid chromatography. RESULTS: Maximal plasma concentrations were comparable for lidocaine: 2.6 +/- 1.3 (S) vs 2.6 +/- 0.8 microg x mL(-1) (M) and for ropivacaine: 1.3 +/- 0.2 (S) vs 1.3 +/- 0.1 microg x mL(-1) (M). Area under the plasma concentration-time curve was higher in Group M for lidocaine: 577.6 +/- 146.1 vs 401.7 +/- 53.2 mg x min(-1) x mL(-1) (P = 0.04) but similar for ropivacaine: 381.1 +/- 95.4 (M) vs 363.1 +/- 85.3 mg x min(-1) x L(-1) (S). CONCLUSIONS: The injection of a single large bolus of local anesthetics into the paravertebral space does not increase its absorption. Maximal ropivacaine plasma concentrations resulting from paravertebral blockade are similar to those reported with equivalent doses of bupivacaine.     

The clinical efficacy and pharmacokinetics of intraperitoneal ropivacaine for laparoscopic cholecystectomy.

Postoperative pain after laparoscopic surgery is less than after laparotomy, and patients may benefit from an intraperitoneal injection of local anesthetic. Thirty-seven ASA physical status I or II patients received in double-blinded fashion 20 mL of 0.9% saline solution (placebo), ropivacaine 0.25% (Rop 0.25%), or ropivacaine 0.75% (Rop 0.75%) immediately after trocar placement and at the end of surgery. We measured pain and morphine consumption until 20 h after surgery. Plasma ropivacaine concentrations were measured. The three groups were comparable for shoulder pain, parietal pain, and incidence of side effects. Visceral pain at rest, during cough, and on movement and total consumption of morphine were significantly smaller in Groups Rop 0.25% and Rop 0.75% when compared with Placebo. Although no adverse effect occurred in any patient, the largest dose led to large plasma concentrations of ropivacaine (2.93 +/- 2.46 microg/mL and 3.76 +/- 3.01 microg/mL after the first and second injection, respectively). We conclude that intraperitoneal administration of ropivacaine before and after surgery significantly decreases postoperative pain. Because the smaller dosage (2 x 50 mg) provided similar analgesia and was associated with significantly smaller plasma concentrations than the larger dosage (2 x 150 mg), this smaller dosage seems more appropriate. IMPLICATIONS: Intraperitoneal ropivacaine 100 mg injected during laparoscopic cholecystectomy significantly decreased postoperative pain when compared with injection of intraperitoneal placebo. At this dose, plasma concentrations remained in the nontoxic range,     

Plasma concentrations and analgesic effects of ropivacaine 3.75 mg/ml during long-term extrapleural analgesia after thoracotomy

BACKGROUND AND OBJECTIVES: Fourteen patients received long-term extrapleural analgesia with ropivacaine for postoperative pain relief after posterolateral thoracotomy. We determined plasma concentrations of ropivacaine as well as pain scores and opioid consumption to assess the analgesic effect. METHODS: In this prospective study, an extrapleural catheter was placed with its tip near the third rib before chest closure. The extrapleural block started with 10 mL of 7.5 mg/mL of ropivacaine followed 30 minutes later by an infusion of 3.75 mg/mL of ropivacaine at a fixed rate of 0.1 mL/kg/h for 71.5 hours. RESULTS: Mean total and free ropivacaine concentrations increased until day 1, reached similar values on day 2, and subsequently decreased. In 13 patients, free drug levels did not exceed 0.14 mg/L. Coincidence of above-average total ropivacaine concentrations up to 4.8 mg/L and low plasma binding resulted in free drug concentrations up to 0.31 mg/L in 1 patient. An impaired ropivacaine plasma binding was observed in 2 patients after major surgical blood loss, in 3 patients in a state of a moderate postoperative acidosis, and in 1 patient after intravenous administration of clindamycin. All free ropivacaine concentrations measured were below the toxic threshold, and we observed no clinical signs of ropivacaine-related toxicity. The magnitude of pain scores and the opioid consumption pointed out a sufficient postoperative analgesia. CONCLUSIONS: A dose of 0.375 mg/kg/h of ropivacaine can safely be administered for long-term extrapleural analgesia after thoracotomy.     

Addition of epinephrine to epidural ropivacaine during labour--effects on onset and duration of action, efficacy, and systemic absorption of ropivacaine

Addition of epinephrine to epidural anaesthetic solutions may enhance efficacy and duration of analgesia. We postulated that addition of epinephrine 5 microg.mL(-1) to epidural ropivacaine would improve efficacy, decrease systemic absorption and reduce neonatal effects. Twenty-one multiparous women were studied. An initial dose of ropivacaine 30 mg followed by an infusion of ropivacaine 10 mg.h(-1) was given via a lumbar epidural catheter. According to random allocation, epinephrine 5 microg.mL(-1) was added to ropivacaine. Ropivacaine concentrations were measured in maternal venous plasma after one hour of infusion and in both umbilical venous and maternal plasma at delivery. Neonatal neurologic and adaptive capacity score (NACS) tests were performed at 2 and 24 h postpartum. All women delivered vaginally. The groups had similar ropivacaine dose requirements, epidural-delivery intervals and satisfaction scores. Bromage scores for motor block were greater in the epinephrine group (2; range: 1-3) than controls (1; range: 0-2). Mean plasma ropivacaine concentrations (+/-SD) were less in the epinephrine group (0.17 +/- 0.05 mg.L(-1), n = 10) than controls (0.31 +/- 0.14 mg.L(-1), n = 11; P < 0.05) after one h of infusion but not at delivery. UV ropivacaine concentrations and NACS scores were similar in the two groups. The addition of epinephrine to ropivacaine decreases maternal plasma concentrations after one h of epidural infusion but also increases motor block.     

Postoperative extradural analgesia with morphine and ropivacaine. A double-blind comparison between placebo and ropivacaine 10 mg/h or 16 mg/h

BACKGROUND: Some controversy exists in the literature on the benefit of epidurals compared to patient-controlled intravenous analgesia (PCA). Also, the dose of ropivacaine for epidural analgesia when combined with morphine remains uncertain. The aim of this study was to compare the epidural vs. PCA technique and high-dose vs. low-dose ropivacaine combined with morphine during knee replacement surgery. METHODS: In this prospective, randomized, double-blind study, postoperative pain relief with a combination of epidural ropivacaine (Group L: 10 mg h-1, Group H: 16 mg h-1) and morphine (0.16 mg h-1) was evaluated in 30 patients. A placebo group (Group PL) of 15 patients having PCA morphine served as the control. Visual analog pain (VAS), morphine consumption, sensory and motor block and side-effects were recorded during 48 h. RESULTS: VAS scores at rest were significantly lower in Groups L and H compared to Group PL. On movement, Group H had lower VAS scores than Group PL during 3-27 h (P<0.05) and Group L during 4-9 h (P<0.05), while Group L had lower a VAS than Group PL during 9-18 h (P<0.05). Morphine consumption after 48 h was greater in Group PL (64.6+/-36.3 mg) vs. Group L (23.3+/-33.9 mg) (P<0.001) and Group H (4.3+/-9.6 mg) (P<0.0001). Mild motor block was seen in Group H in 20% and 14% patients at 24 h and 48 h, respectively, but time to mobilization was similar between the groups. Pruritus was more common in the ropivacaine groups (P<0.05). CONCLUSION: Lumbar epidural analgesia using a combination of ropivacaine (16 mg h-1) and morphine (0.16 mg h-1) provides superior analgesia compared to the PCA technique or ropivacaine (10 mg h-1) and morphine (0.16 mg h-1). Although this resulted in a mild motor block during the first 12 h, patient mobilization was similar in all groups.     

Ropivacaine undergoes slower systemic absorption from the caudal epidural space in children than bupivacaine.

We compared the systemic absorption of ropivacaine and bupivacaine after caudal epidural administration in children. Twenty ASA physical status I or II children aged 1-7 yr undergoing elective hypospadias repair were randomized after the induction of general anesthesia to receive a single caudal epidural injection of 2 mg/kg of either ropivacaine 0.2% (R) or bupivacaine 0.2% (B) in a double-blinded fashion. Peripheral venous blood samples (1 mL) were obtained before and 1, 5, 10, 15, 20, 30, 40, 50, 60, 70, 80, 90, and 120 min after the caudal injection. The total R and B concentration was measured in plasma by using high-performance liquid chromatography. All blocks were successful, and there were no complications. The peak plasma concentration (mean +/- SD) (R = 0.67 +/- 0.16 and B = 0.73 +/- 0.23 microg/mL) and the area under the plasma concentration curve (R = 61.9 +/- 20.6 and B = 62.7 +/- 18.2 microg x mL(-1) x min(-1)) were comparable between the two study groups. The median (range) time to attain peak plasma concentration was significantly slower in children who received ropivacaine (R = 65 [10-120] min and B = 20 [15-50] min, P < 0.05). We conclude that ropivacaine undergoes slower systemic absorption from the caudal epidural space in children than does bupivacaine. IMPLICATIONS: We compared the systemic absorption of ropivacaine (0.2%) and bupivacaine (0.2%) after caudal epidural injection of 2 mg/kg in children aged 1-7 yr. Our results show that ropivacaine undergoes slower systemic absorption from the caudal epidural space in children than does bupivacaine.