Extending low-dose epidural analgesia for emergency Caesarean section using ropivacaine 0.75%

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

OBJECTIVES

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

MATERIALS AND METHODS

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

RESULTS

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

CONCLUSIONS

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

CLINICAL RELEVANCE

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

Comparison of ropivacaine with levobupivacaine under epidural anesthesia in the lower limb orthopedic surgeries: A randomized study

Context:

Epidural anesthesia is nowadays considered as the gold standard anesthetic technique for lower limb orthopedic surgeries, and the present study was conducted to evaluate the efficacy of levobupivacaine and ropivacaine in terms of onset, duration of sensory and motor block with duration of postoperative analgesia in patients undergoing lower limb orthopedic surgeries under epidural anesthesia.

Aims:

To compare the efficacy of 15 mL of levobupivacaine 0.5% with that of 15 mL of ropivacaine 0.75% in patients undergoing lower limb orthopedic surgeries under epidural anesthesia and to determine the better of the two agents with respect to onset, duration of sensory and motor blockade, postoperative analgesia, and adverse effects; if any.

Settings and Design:

A double-blind randomized study.

Subjects and Methods:

A total of seventy patients planned to undergo elective lower limb orthopedic surgeries fulfilling the criteria were enrolled in the study. Group I (n = 35): Received 15 mL 0.5% levobupivacaine epidurally. Group II (n = 35): Received 15 mL 0.75% ropivacaine epidurally.

Statistical Analysis:

Statistical Analysis was done by Statistical Package for Social Sciences (SPSS Version 15.0) statistical analysis software. The values were represented in number (%) and mean ± standard deviation.

Results:

Time to achieve sensory onset and motor onset were significantly lower in Group II (17.86 ± 2.51 and 23.14 ± 2.73) as compared to Group I (26.14 ± 2.45 and 31.43 ± 2.59) while the duration of sensory block was significantly higher in Group II (173.29 ± 6.29 min) as compared to Group I (156.71 ± 6.96 min). Although motor block duration of Group I (142.43 ± 8.43 min) was higher than that of Group II (141.43 ± 12.81 min), but this difference was not found to be statistically significant.

Conclusions:

The inference drawn from this discussion, in general, indicated that both the drugs are comparable for block onset, quality, and duration along with similar hemodynamic profile when given in same concentration. However, relatively better response of ropivacaine for block onset and duration as obtained in the present study coupled with higher but statistically.

Anaesthesia for urgent (grade 1) caesarean section

PURPOSE OF REVIEW

We describe the different possible anaesthetic techniques for an emergency caesarean section. To choose the right method of anaesthesia may have major implications for mother, child and all involved personnel. The major controversy is whether one have other or better alternatives or both than general anaesthesia, with a rapid sequence induction technique, when the foetus is compromised.

RECENT FINDINGS

Recently published studies indicate that a top-up of a well functioning labour epidural is as fast as general anaesthesia, and that the top-up can be performed during preparation and transport. Spinal anaesthesia, when performed by skilled anaesthetists, is as fast or almost as fast as general anaesthesia with a very low failure rate. Combined spinal/epidural may have advantages, especially in high-risk cardiac patients, but is too time-consuming. General anaesthesia still seems to be the method of choice for most anaesthetists in extremely urgent settings. The major disadvantage with general anaesthesia is the risk of failure and the dramatic consequences of a 'cannot intubate, cannot ventilate' situation. Awareness is another concern, and the incidence varies from 0.26 to 1% in recent literature.

SUMMARY

Regional anaesthesia techniques such as a single-shot spinal or a top-up of a well functioning labour epidural analgesia are good alternatives to general anaesthesia in an emergency caesarean setting.

Comparison of 2% Lignocaine with Adrenaline and Fentanyl, 0.75% Ropivacaine and 0.5% Levobupivacaine for Extension of Epidural Analgesia for Urgent Caesarean Section after Low Dose Epidural Infusion during Labour

Low dose local anaesthetic and fentanyl epidural solutions are commonly ‘topped-up’ for urgent caesarean section. However, the block characteristics associated with newer local anaesthetics such as ropivacaine 0.75% and levobupivacaine 0.5% have not been fully determined. In a randomised double-blinded controlled clinical trial, we compared 2% lignocaine with adrenaline and fentanyl (LAF), 0.75% ropivacaine and 0.5% levobupivacaine for extension of low dose epidural analgesia for urgent caesarean section in 90 Asian parturients.

There was no significant difference in the median, interquartile range, time to T4 loss of sensation to cold between LAF (9.5, 7.0 to 13.3 minutes), 0.75% ropivacaine (10.0, 7.0 to 15.0 minutes) and 0.5% levobupivacaine (10.0, 7.0 to 15.0 minutes). No woman required conversion to general anaesthesia. The supplementation rate did not differ between groups. Levobupivacaine provided a longer duration of sensory block compared to LAF, but a similar duration to 0.75% ropivacaine.

Under the conditions of this study there was no significant difference in time to surgical readiness (defined as loss of sensation to cold to T4) between LAF, 0.75% ropivacaine and 0.5% levobupivacaine groups. Ropivacaine and levobupivacaine are suitable alternatives for extending epidural analgesia for urgent caesarean section.

Epidural lidocaine-bicarbonate-adrenaline vs levobupivacaine for emergency Caesarean section: a randomised controlled trial

Epidural mixtures containing lidocaine with or without additives are commonly used to convert epidural analgesia in labour to anaesthesia for emergency Caesarean section, but direct comparisons with alternative, single agents in this situation are few. In a prospective double-blinded trial, we compared a freshly prepared lidocaine-bicarbonate-adrenaline mixture (final concentrations 1.8%, 0.76% and 1:200,000, respectively) with our standard agent, levobupivacaine 0.5%, for extending epidural blockade for emergency Caesarean section. Using a sequential analysis technique, with data analysed in blocks of 40, women receiving epidural analgesia in labour who required top-up for Caesarean section were randomly assigned to receive 20 ml of epidural solution over 3 min. The first analysis (n = 40) indicated that the study should be stopped, as significant differences were found in our primary outcome data. Median (IQR [range]) times to reach a block to touch to T5 and cold to T4 were, respectively, 7 (6-9 [5-17]) min and 7 (5-8 [4-17]) min for lidocaine-bicarbonate-adrenaline, and 14 (10 -17 [9-31]) min and 11 (9-14 [6-30]) min for levobupivacaine (p = 0.00004 and 0.001, respectively). Pre- and intra-operative supplementation/pain, maternal side-effects and neonatal outcomes (excluding five women who underwent instrumental delivery) were similar between the groups. Intra-operative maternal sedation (scored by the mother on a 10-point scale) was greater with lidocaine-bicarbonate-adrenaline (4.5 (3-8 [1-9])) than with levobupivacaine (3 (1-4 [1-7])), but not significantly so (p = 0.07). We conclude that epidural lidocaine-bicarbonate-adrenaline halves the onset time when extending epidural analgesia for Caesarean section although there is a possibility of increased maternal sedation.

Extending low-dose epidural analgesia in labour for emergency Caesarean section ? a comparison of levobupivacaine with or without fentanyl

Women in labour receiving epidural analgesia with 15 ml bupivacaine 0.1% and 2 microg.ml(-1) fentanyl followed by 10-15-ml top-ups as required, who needed Caesarean section, were randomly allocated to receive 20 ml levobupivacaine 0.5% over 3 min with either 75 microg fentanyl (1.5 ml) or 1.5 ml saline. Further top-ups or inhaled or intravenous supplementation were given for breakthrough pain. Time to onset (loss of cold sensation to T4 and touch sensation to T5 bilaterally), quality of analgesia and side-effects were recorded. The study was stopped after 112 patients had been randomly assigned, due to a unit protocol change, from midwife-administered top-ups to patient-controlled epidural analgesia. Data from 51 patients given fentanyl and 54 given saline were available for analysis. There were no significant differences in onset times or supplementation between the groups, but there was more intra-operative nausea/vomiting with fentanyl (53%) than with saline (18%; p = 0.004). We found no advantage of adding fentanyl to epidural levobupivacaine when extending epidural analgesia in women already receiving epidural fentanyl during labour and there was an increased incidence of intra-operative nausea and vomiting. Power analysis suggested the same conclusion even had the study proceeded to completion.

A randomised comparison of 0.5% bupivacaine with a lidocaine/epinephrine/fentanyl mixture for epidural top-up for emergency caesarean section after "low dose" epidural for labour

BACKGROUND

When extending a fentanyl-containing, low-dose labour epidural for emergency caesarean section it has been shown that there is no difference in time to surgical readiness between plain bupivacaine 0.5% and mixtures of lidocaine/epinephrine or lidocaine/bupivacaine/epinephrine. However, it is not known whether adding fentanyl to the lidocaine/epinephrine mixture would increase speed of onset or improve the efficacy of the mixture when topping up for an emergency caesarean section.

METHODS

In a prospective, single blind study we compared plain 0.5% bupivacaine with a lidocaine/epinephrine/fentanyl mixture for extending previous low-dose epidural analgesia for emergency caesarean section in 68 patients.

RESULTS

There was a significantly longer median preparation time for the mixture than for the single drug (3.0 v 1.25 min: P < 0.0005). The median onset time for block of T7 to touch from the start of the top-up was 13.8 min for the mixture and 17.5 min for plain bupivacaine. This difference was not statistically significant and was offset by the longer preparation time. No general anaesthetics were required for poor blocks and the need for other intraoperative supplementation was not significantly different between the groups (bupivacaine 5/34, lidocaine mixture 2/26).

CONCLUSIONS

The use of a lidocaine/epinephrine/fentanyl mixture conferred no clear statistically significant benefit over the use of plain 0.5% bupivacaine when used to extend fentanyl containing low-dose labour epidural analgesia for emergency caesarean section, but the lidocaine solution is cheaper and less toxic than the alternatives.