Epidural Infusion Of Ropivacaine Research Articles

Perioperative Ultrasound-Guided Continuous Caudal Epidural Analgesia in Newborns: A Case Series in a Tertiary Medical Center.

Background Caudal epidural anesthesia technique is a relevant method for postoperative analgesia in newborns, allowing for the reduction of drug-induced respiratory depression. The threading of a catheter is, however, uncommon in clinical practice. Our main purpose was to describe our experience regarding caudally inserted epidural catheters in neonates undergoing major abdominal surgery. Methods We included every full-term neonate undergoing surgery under combined caudal epidural-general anesthesia from 2017 to 2022 in our institution. After induction of general anesthesia, an ultrasound-guided caudal epidural injection was performed, and an epidural catheter was inserted for perioperative analgesia. An epidural bolus of ropivacaine was administered to every patient before the surgical incision, and an epidural infusion of ropivacaine 0.05% was administered for 24 hours. Results Retrospectively obtained data included six full-term neonates with American Society of Anesthesiologists (ASA) physical status II to IV. Intraoperatively, good analgesia was achieved without hemodynamic instability or need for additional systemic opioids after induction. At the end of surgery, five of the six neonates were extubated without adverse respiratory events. Postoperatively, effective analgesia was achieved in four cases with an epidural infusion of ropivacaine 0.05%, at a rate between 0.2 and 0.4 mg/kg/h, and intravenous paracetamol. Epidural pain control was not successful in one neonate, and thus an intravenous fentanyl infusion was added. The sixth neonate remained intubated for prolonged mechanical ventilation due to surgical complications, and thus an intravenous fentanyl infusion was introduced for sedation in the neonatal intensive care unit (NICU), not allowing to evaluate the effectiveness of the epidural infusion alone. No other complications related to the epidural catheters were reported. Conclusion Continuous caudal epidural analgesia may be a valuable technique with a low risk of complications, decreasing the incidence of respiratory adverse events in this patient population. Although more cases are needed for a stronger conclusion, it has become a useful analgesic strategy for major abdominal surgery in neonates in our institution.

Multimodal approach to pain management in thoracic surgery

The American Cancer Society estimated that 68,820,000 men and 61,360,000 women in the United States of America would die from lung and bronchial cancer in 2022, which is equal to 21% of all cancer deaths. Patients who undergo thoracotomy have a higher risk of postoperative complications due to the severe pain syndrome that typically develops after surgery. Even though there has been extensive research on the advantages and disadvantages of various perioperative analgesia techniques, the search for the best and safest still continues.
 Objective — to improve the results of perioperative anesthesia in patients undergoing thoracotomy by choosing the optimal method of analgesia.
 Materials and methods. A total of 59 patients with lung cancer who underwent thoracotomy at the communal non‑profit enterprise «Kyiv City Clinical Hospital No 17» from 2018 to 2020 were included in an open‑label noncommercial randomized controlled clinical trial. Patients were divided into 2 groups: the multimodal analgesia (MA) group (32 patients) and the epidural analgesia (EA) group (27 patients). According to the concept of preemptive analgesia, patients in the MA group received 1000 mg of paracetamol and 50 mg of dexketoprofen intravenously 1 hour before surgery. In the postoperative period, dexketoprofen and paracetamol were administered every 8 hours in combination with epidural analgesia. During postoperative epidural analgesia, patients received 40 mg of a 2% lidocaine solution through a catheter inserted into the epidural space (Th5—Th6) and a ropivacaine 2 mg/mL (3—14 mL/h) infusion. Patients in the EA group received only epidural analgesia in the postoperative period. After placement of an epidural catheter in the epidural space (Th5—Th6), they had an injection of 40 mg of a 2% lidocaine solution and an epidural infusion of ropivacaine 2 mg/ml (3—14 mL/h).
 Results. The study groups did not demonstrate a statistically significant difference in terms of age, hight, weight, a grade of anesthesiological risk (ASA), blood loss, surgery duration, and surgical volume (р >0,05). The level of analgesia was assessed using the numerological rating scale (NRS) after 3, 6, 24, and 32 hours after surgery. Every research stage revealed a significant difference in the level of pain syndrome between the study groups (p<0.05). Patients in the EA group experienced more severe pain syndrome than those in the MA group. Consequently, 7 patients (26%) in the EA group were anesthetized with morphine 10 mg intramuscularly compared to 3 patients (9%) in the MA group.
 Conclusions. In patients undergoing thoracic surgery, a multimodal analgesic approach, which includes the use of COX‑2 and COX‑3 inhibitors in combination with epidural analgesia, has been shown to produce better analgesia compared to epidural anesthesia alone. The beneficial effect of multimodal analgesia was seen in a significant difference (p<0.05) in the intensity of pain syndrome between the study groups in the early postoperative period after thoracotomy.

Intravenous Morphine Infusion versus Thoracic Epidural Infusion of Ropivacaine with Fentanyl after the Ravitch Procedure-A Single-Center Cohort Study.

Objective. To compare the efficacy of analgesia with intravenous infusion of morphine and thoracic epidural infusion of ropivacaine with fentanyl in pediatric patients after the Ravitch procedure. Methods. Postoperative analgesia was achieved by intravenous morphine infusion with a dose of 0.02–0.06 mg/kg per hour (intravenous group, n = 56) or thoracic epidural infusion of 0.2% ropivacaine and fentanyl 5 µg/mL with a flow rate of 0.1 mL/kg per hour (epidural group, n = 40). Furthermore, the multimodal pain management protocol included paracetamol, non-steroidal anti-inflammatory drugs, and metamizole as a rescue drug. The primary outcomes included pain scores (according to the Numerical Rating Scale, range 0–10), while the secondary outcomes included consumption of the rescue drug, anxiety, postoperative side effects, and patient satisfaction. The observation period lasted from postoperative day 0 to postoperative day 3. Results. Median average and maximal pain scores at rest, during deep breathing, and coughing were significantly lower in the intravenous group compared to the epidural group (p < 0.05). The effect size was medium (Cohen’s d ranged from 0.5 to 0.7). Patients receiving morphine required significantly lower numbers of metamizole doses than in the epidural group (median 1 vs. 3; p = 0.003; Cohen’s d = 0.6). Anxiety, postoperative side effects, and patient satisfaction were similar in both groups (p > 0.05). Conclusions. An intravenous infusion of morphine may offer better postoperative analgesia than a thoracic epidural infusion of ropivacaine with fentanyl.

Pain levels and patient comfort after lower limb arthroplasty comparing i.v. patient-controlled analgesia, continuous peripheral nerve block and neuraxial analgesia: a retrospective cohort analysis of clinical routine data

BackgroundInsufficient pain control after lower limb arthroplasty results in delayed recovery and increased risk for pain chronicization. The ideal kind of analgesia is still discussed controversially. We conducted a retrospective analysis of single-center routine data from a German university hospital, including patients receiving either total hip (THA) or knee arthroplasty (TKA).MethodsAll patients received general anesthesia. Patients undergoing THA received either continuous epidural ropivacaine infusion (0.133%, Epi) or patient-controlled analgesia (PCA) with the Wurzburg Pain Drip (tramadol, metamizole and droperidol, WPD) or with piritramide (Pir). After TKA, patients received either continuous femoral nerve block (ropivacaine 0.2%, PNB) or Pir.ResultsThe analyzed cohort comprised 769 cases. Use of WPD after THA (n = 333) resulted in significantly reduced Numeric Rating Scale (NRS) values at rest, compared to Epi (n = 48) and Pir (n = 72) (.75 [IQR 1.14] vs. 1.17 [1.5], p = .02 vs. 1.47 [1.33], p < .0001) as well as maximum NRS scores (2.4 [1.7] vs. 3.29 [1.94], p < .001 vs. 3.32 [1.76], p < .0001). Positive feedback during follow-up visits was significantly increased in patients with a WPD PCA (p < .0001), while negative feedback (senso-motoric weakness/technical problems/nausea/dizziness/constipation) was particularly increased in Epi patients and lowest in those with WPD (p < .0001). After TKA, Pir (n = 131) resulted in significantly reduced NRS values at rest, compared to PNB (n = 185) (1.4 [1.4] vs. 1.6 [1.68], p = .02). Positive feedback was increased in patients with a Pir PCA in comparison with PNB (p = .04), while negative feedback was increased in PNB patients (p = .04). Overall, WPD presented with the lowest rate of any complications (8.7%), followed by Pir (20.2%), PNB (27.6%) and Epi (31.3%) (p < .001).ConclusionsIn the assessed population, the use of a WPD PCA after THA offered better pain control and patient comfort in comparison with continuous epidural or piritramide-based analgesia. After TKA, the use of a Pir PCA provided superior analgesia and a lower complication rate compared to continuous PNB.

Complete atrioventricular block under epidural ropivacaine infusion in a patient with first-degree atrioventricular block and myasthenia gravis: a case report

BackgroundFirst-degree atrioventricular block (AVB) may lead to complete AVB. Herein, we present a case of a complete AVB under thoracic epidural catheter infusion of ropivacaine with fentanyl in a patient with first-degree AVB and myasthenia gravis.Case presentationA 74-year-old woman with first-degree AVB underwent thymectomy for myasthenia gravis. Continuous thoracic epidural catheter infusion of 0.2% ropivacaine with fentanyl was initiated at 15 min before the end of the surgery. At 9 h postoperatively, the electrocardiogram showed a 10-s-long pause due to complete AVB. Thus, a temporary pacemaker was implanted, and at 19 h postoperatively on postoperative day 1, cardiac pacing was initiated and lasted approximately 30 s. After catheter removal, she had no further episodes of complete AVB.ConclusionFirst-degree AVB may lead to complete AVB under the influence of thoracic epidural infusion of ropivacaine in patients with myasthenia gravis.

A Randomised Blinded Comparison of Epidural Infusion of Ropivacaine, Ropivacaine with Fentanyl for PONV and Sedation in Elective Lower Abdominal Oncosurgeries

Introduction: Epidural analgesia is one of the preferred and convenient mode of perioperative management. Neuraxial opioids augment local anaesthetic effect, thus reducing their requirement for analgesia. The addition of fentanyl may cause side-effects like Postoperative Nausea and Vomiting (PONV), sedation which results in patient discomfort, thus effecting postoperative recovery. Aim: To estimate the incidence, compare the requirement of rescue antiemetics for PONV and Ramsay Sedation Scores within first 24 hours of postoperative period in patients undergoing elective lower abdominal oncological sugeries. Materials and Methods: The present study was a randomised study which was carried out from September 2016 to May 2018, in 70 patients of American Society of Anesthesiologists (ASA) 1 and 2, scheduled for elective lower abdominal oncological surgeries. The study population was divided into group R, comprising of patients receiving epidural infusion of 0.2% ropivacaine and group RF with patients receiving epidural infusion of 0.2% ropivacaine with 2 μg/mL fentanyl. The incidence of PONV, rescue antiemetics for PONV and the incidence of sedation using Ramsay sedation score were evaluated in each group and compared. All data was statistically analysed and compared using Student's t-test, Chi-square. The p-value &lt;0.05 was considered to be statistically significant. Results: Groups were comparable with regard to demographic data. The incidence of PONV in group R was 37.1% and in group RF was 28.6%. The requirement of rescue antiemetic for PONV were comparable in the study groups. However, this was not statistically significant. Patients in group RF had higher mean Ramsay sedation scores at 0, 1, 2, 4, 6, 12, 18 and 24 hours but the observed difference in both the groups was statistically significant p&lt;0.05 except at 0 and 2nd hours which were not statistically significant (p&gt;0.05). Conclusion: This study concludes that the patients receiving epidural infusion of ropivacaine with fentanyl should be given prophylactic antiemetic to minimise patient’s discomfort. Also, these patients when compared to patients receiving epidural infusion of ropivacaine alone require monitoring for sedation during the postoperative period.

Positive Impact of Intraoperative Epidural Ropivacaine Infusion on Oncologic Outcomes in Pancreatic Cancer Patients Undergoing Pancreatectomy: A Retrospective Cohort Study.

Background: Previous literatures have demonstrated that regional anesthesia such as epidural anesthesia may affect long-term survival of cancer patients. In the present study, we conducted a retrospective cohort study to investigate the survival impact of intraoperatively epidural ropivacaine infusion on pancreatic ductal adenocarcinoma (PDAC) patients.Methods: PDAC patients who underwent pancreatic surgery in Zhongshan Hospital Fudan University from January, 2015 to June, 2018 were included. The surgical procedure was performed under combined endotracheal general anesthesia and thoracic epidural anesthesia, and patient-controlled epidural analgesia (PCEA) with 0.12% ropivacaine was given after surgery for further pain control. Patients were divided into two groups according to their intraoperative epidural ropivacaine concentration: high (0.375%-0.5%) and low (0.15%-0.25%). Survival outcome was compared between groups.Results: A total of 215 patients were enrolled and their baseline characteristics were balanced between groups, except that patients with high concentration ropivacaine received higher total dose opioid and had longer operative time. Resected PDAC patients who were administrated with high concentration ropivacaine through epidural catheter intraoperatively had improved overall survival (median overall survival, mOS, high VS low, 37.6 VS 23.7 months, p=0.04). High epidural ropivacaine concentration was an independent prognostic factor (hazard ratio [HR]=0.65, 95% confidence interval [CI], 0.44-0.94; p=0.03). Subgroups analyses shown that T3M0 PDAC patients with preoperative CA 19-9 higher than 200 U/ml, negative resection margin, and those without tumor deposit and adjuvant radiotherapy could benefit from high concentration of ropivacaine.Conclusion: Intraoperatively epidural infusion with high concentration of ropivacaine was associated with improved OS in PDAC patients undergoing pancreatectomy.

Remission of Pain From Frostbite and Erythromelalgia With Epidural Infusion of Ropivacaine: Results of a Two-Year Follow-Up.

Remission of Pain From Frostbite and Erythromelalgia With Epidural Infusion of Ropivacaine: Results of a Two-Year Follow-Up.

Case Report and Literature Review: Interventional Management of Erythromelalgia.

Erythromelalgia is a rare and very difficult to treat pain syndrome that usually presents as severe bilateral burning pain in the extremities. Here we present a case of a 34-year-old female with erythromelalgia who we treated successfully with a lumbar epidural infusion of ropivacaine and fentanyl. The patient had complete relief shortly after the epidural infusion, and she remained stable with only minor pain two weeks and nine months later. With this case, we have reviewed the interventional treatments of erythromelalgia. We suggest epidural infusion as the first line interventional management, followed by sympathetic block. Spinal cord stimulation can be considered if other interventional managements fail.

Efficacy of preemptive analgesia on acute postoperative pain in children undergoing major orthopedic surgery of the lower extremities.

BackgroundChildren undergoing major orthopedic surgery of the lower extremities can experience severe postoperative pain; yet, the ideal postoperative pain management strategy is unknown. Thus, in this patient population, we investigated the effect of intraoperative epidural infusion of local anesthetic on acute postoperative pain and analgesic consumption.Patients and methodsPatients (N=50, 3–12 years) randomly received either ropivacaine 0.15% (preemptive group) or normal saline (control group) as an initial bolus of 0.2 mL/kg, followed by continuous infusion of 0.15 mL/kg/h throughout surgery. Following surgery, patient-controlled epidural analgesia with ropivacaine 0.1% was provided. The main study outcomes were the revised Face, Legs, Activity, Cry, and Consolability pain scores, epidural ropivacaine consumption, and additional analgesic requirements during the first 48 hours postoperatively.ResultsForty-seven patients completed the study, 23 in the preemptive group and 24 in the control group, respectively. The revised Face, Legs, Activity, Cry, and Consolability pain scores were significantly lower in the preemptive group only at 30 minutes after postanesthesia care unit arrival and 6 hours after surgery (median difference −1.0, 95% CI −2.0 to −1.0, P=0.001 and median difference −2.0, 95% CI −3.0 to −1.0, P=0.005, respectively). However, they were not significantly different between the groups at 12, 24, and 48 hours postoperatively. Epidural ropivacaine consumption and additional analgesic requirements throughout 48 hours postoperatively were not significantly different between the groups.ConclusionIntraoperative epidural infusion of ropivacaine did not demonstrate preemptive analgesic efficacy within 48 hours postoperatively in children undergoing extensive lower limb orthopedic surgery.

Comparative Evaluation of Ropivacaine and Fentanyl Versus Ropivacaine and Fentanyl with Clonidine for Postoperative Epidural Analgesia in Total Knee Replacement Surgery.

Clonidine an alpha 2 adrenoceptor agonist possesses analgesic properties and has been used as an adjuvant in epidural analgesia. The addition of clonidine to other analgesics may result in enhanced analgesia through additive mechanisms or synergistic mechanisms. The enhanced analgesia may lead to a decrease in the dosage of analgesic drugs along with reduction of side effects. The purpose of this study was to evaluate the effect of adding clonidine to epidural ropivacaine and fentanyl mixture in terms of quality of analgesia and side effects in patients of total knee replacement surgery. A prospective randomised double blind study was conducted on 60 patients of ASA physical status I, II and III who underwent unilateral total knee replacement surgery under combined spinal epidural anaesthesia. Patients were divided into two Groups A and B randomly. Postoperatively Group A received continuous epidural infusion of ropivacaine 2 mg.ml -1 and fentanyl 2 μg.ml -1 along with clonidine 2 μg.ml-1 in the range of 3-7 ml.hr-1 while Group B received the ropivacaine and fentanyl epidural solution. The postoperative VAS scores, haemodynamic parameters, motor block, sedation, nausea, vomiting and any other significant side effects were noted. The two groups were compared with student's t-test, Pearson's Chi square test and t-test using SPSS statistical software. Visual analog scale scores were lower in Group A (3.38) than in Group B (3.72). The average infusion rate was lower in Group A (4.7 ± 0.7 ml.hr -1) than in Group B (5.5 ± 0.7 ml.hr-1). Patients in Group A required less dosage of rescue pain medication Paracetamol (1g i.v.), diastolic pressure and heart rate were lower in Group A. The groups were comparable in terms of sedation, motor block and nausea vomiting. Clonidine added to a ropivacaine and fentanyl mixture augmented the postoperative epidural analgesia without significant side effects.

A prospective randomized comparative study of postoperative pain control using an epidural catheter in patients undergoing posterior lumbar interbody fusion.

To assess the efficacy of continuous epidural infusion analgesia (ED) with 0.2% Ropivacaine versus IV PCA (Fentanyl) in spinal fusion surgery patients. A prospective randomized comparative clinical trial. Patients were randomized into one of two groups-the epidural group (ED-51 patients) and the IV PCA group (IV-43 patients). The epidural catheter tip was placed one level cephalad to the level of the PLIF in patients in the ED group. Patients were assessed by determining the pain score, cumulative opioid requirement, adverse effects, and satisfaction. Pain score comparisons between the ED group and the IV group, respectively, were as follows: immediate postoperative status: 2.1±1.5 vs. 7.2±2.1, p=0.01; postoperative day 1: 2.3±1.9 vs. 6.8±2.3, p=0.02; postoperative day 2: 1.9±1.8 vs. 5.4±2.1, p=0.02; postoperative day 3: 1.5±1.6 vs. 3.9±1.9, p=0.03; postoperative day 4: 3.8±2.1 vs. 3.1±1.9, p=0.4. Lower levels of opioids were required in the ED group, and fewer opioid-related complications developed in the patients in this group. Complications related to the use of epidural catheters were comparable between the two groups. Patient satisfaction with postoperative pain control was higher in the ED group. In comparison with the use of IV PCA only, continuous epidural infusion of Ropivacaine resulted in lower pain scores and opioid consumption and higher patient satisfaction levels after posterior lumbar interbody fusion.

Intrathecal morphine versus epidural ropivacaine infusion for analgesia after Cesarean section: a retrospective study.

BackgroundAnalgesia after Cesarean delivery (CD) requires early ambulation to prevent thromboembolic disease and to facilitate baby care. We retrospectively reviewed anesthesia charts and medical records of patients who underwent CD to compare the efficacy of spinal anesthesia supplemented with intrathecal morphine hydrochloride (ITM) and combined spinal–epidural anesthesia followed by opioid-free epidural analgesia (CSEA-EDA).FindingsAll subjects underwent CD at Nagaoka Chuo General Hospital between February 2012 and January 2013. Patient characteristics, time to first analgesic rescue after CD, and analgesic use after CD were examined. Incidences of postural hypotension, lower extremity numbness/weakness, postoperative nausea/vomiting (PONV), and pruritus were also examined for 48 h after CD. Average time to first analgesic use after CD (ITM 25.13 ± 16.07 h, CSEA-EDA 22.42 ± 16.27 h, p = 0.521) and cumulative probability of rescue analgesic use (p = 0.139 by log-rank test) were comparable between groups. However, average analgesic use within 24 h was lower in the ITM group (0.75 ± 1.05 times) than in the CSEA-EDA group (1.52 ± 1.72 times, p = 0.0497). Numbness or motor weakness in lower extremities only occurred in the CSEA-EDA group, and pruritus only occurred in the ITM group.ConclusionsThe results of this study suggest that ITM is better than CSEA-EDA for anesthesia following CD with regard to pain control. Also, ITM would be advantageous for early ambulation following CD because of lower incidence of numbness and motor weakness in lower extremities compared to CSEA-EDA.

A comparison of the analgesic efficacy and safety of epidural bupivacaine with fentanyl and ropivacaine with fentanyl in abdominal surgery

Context Epidural bupivacaine remains the most widely used local anesthetic for postoperative pain relief, but ropivacaine is increasingly being used as it has less cardiac toxicity. Aim To compare the analgesic efficacy and safety of epidural bupivacaine with fentanyl versus ropivacaine with fentanyl during abdominal surgery and in the immediate postoperative period. Materials and methods One hundred patients undergoing abdominal surgeries under general anesthesia with supplementary epidural analgesia were studied. Group B received an epidural infusion of 0.2% bupivacaine with fentanyl 2 mcg/ml at 6 ml/h intraoperatively and 0.1% bupivacaine with fentanyl 2 mcg/ml at 6 ml/h postoperatively. Group R received an epidural infusion of 0.2% ropivacaine with fentanyl 2 mcg/ml at 6 ml/h intraoperatively and 0.1% ropivacaine with fentanyl 2 mcg/ml at 6 ml/h postoperatively. Results Intraoperative and postoperative heart rate and mean arterial pressure in both groups were comparable. Pain scores were significantly higher in group B postoperatively up to 24 h. The number of epidural topups required was comparable intraoperatively, but in the postoperative period, group B needed significantly more number of epidural topups. The requirement of rescue analgesia showed no significant difference intraoperatively and postoperatively between groups. Conclusion An epidural infusion of ropivacaine 0.2% with fentanyl provides better intraoperative and postoperative analgesia compared with bupivacaine 0.2% with fentanyl.

A comparison of epidural infusion of 0.2, 0.25, and 0.3% ropivacaine with fentanyl after unilateral total knee arthroplasty

A comparison of epidural infusion of 0.2, 0.25, and 0.3% ropivacaine with fentanyl after unilateral total knee arthroplasty

Efficacy of Thoracic Epidural Analgesia With or Without Intercostal Nerve Cryoanalgesia for Postthoracotomy Pain

We evaluated effects of thoracic epidural analgesia combined with intercostal nerve cryoanalgesia or epidural analgesia alone on acute and long-term pain after posterolateral thoracotomy. Forty-two elective thoracotomy patients were randomly assigned to two groups, epidural combined with cryoanalgesia or epidural alone. A thoracic epidural catheter was inserted before induction of anesthesia. At the end of the operation, cryoanalgesia was performed to 3 intercostals nerves: 1 at the level of the incision, 1 caudal, and 1 cranial. Cryoanalgesia was blinded to the investigating anesthetists and patients. To avoid impingement of intercostal nerves, chest closure in all patients was performed using intracostal sutures through drilled holes in adjacent ribs. In the postanesthesia care unit, epidural infusion of ropivacaine (1 mg/mL) with fentanyl (5 μg/mL) was started and continued 3 days. Thereafter, pain was treated with oral strong or weak opioids combined with nonsteroidal antiinflammatory drugs or acetaminophen. Pain was assessed with the verbal pain scale or visual analog scale. Patients visited a local pain clinic at 8 weeks and at 6 months postoperatively. The cryoanalgesia group had more neuropathic-type pain compared with the epidural-alone group 8 weeks after operation (p < 0.05). The cryoanalgesia group had also more pain on normal daily activities 8 weeks after the operation (p < 0.05). After 6 months, there were no statistically significant differences between groups. Intercostal cryoanalgesia seems to increase the incidence of long-term pain after thoracotomy.

Ropivacaine: A review of its pharmacology and clinical use

Ropivacaine is a long-acting amide local anaesthetic agent and first produced as a pure enantiomer. It produces effects similar to other local anaesthetics via reversible inhibition of sodium ion influx in nerve fibres. Ropivacaine is less lipophilic than bupivacaine and is less likely to penetrate large myelinated motor fibres, resulting in a relatively reduced motor blockade. Thus, ropivacaine has a greater degree of motor sensory differentiation, which could be useful when motor blockade is undesirable. The reduced lipophilicity is also associated with decreased potential for central nervous system toxicity and cardiotoxicity. The drug displays linear and dose proportional pharmacokinetics (up to 80 mg administered intravenously). It is metabolised extensively in the liver and excreted in urine. The present article details the clinical applications of ropivacaine and its current place as a local anaesthetic in the group.

Flip-flop kinetics of ropivacaine during continuous epidural infusion influences its accumulation rate

Ropivacaine has an optimal toxicity profile for epidural anesthesia in adults, but there are currently no studies concerning its pharmacokinetics during continuous infusion. The primary objective of this study was to evaluate the pharmacokinetics and safety of ropivacaine in adults during a 48-h continuous epidural infusion. We enrolled 43 adults (ASA I-II) scheduled for major abdominal or urologic surgery with postoperative continuous epidural analgesia with ropivacaine 0.2% (5 mL/h) and sufentanil 0.75 μg/mL for 48 h. Ropivacaine blood samples were collected during continuous epidural infusion before the bolus and 3, 6, 12, 24, 48, 54, 60 h after the bolus; plasma concentrations were measured on HPLC-UV. The concentration-time relationship of ropivacaine levels was analyzed using a population pharmacokinetic method based on a mixed-effect-model approach (P-PHARM software). Mean plasma concentration of ropivacaine at the end of epidural infusion (C(48 h)) was 1.69 μg/mL (0.21-3.8 μg/mL). Mean (range) C(max) was 1.82 μg/mL (0.61-4.0 μg/mL); the area under the plasma concentration curve, AUC ((0-60)), was 67.48 ± 30.60 μg·h/mL. Total plasma ropivacaine concentrations fell mainly within (84%) or below (12%) the range reported to be safe in adults (1.0-3.0 μg/mL). Only two patients (5%) reached ropivacaine plasma levels higher than 3 μg/mL, namely 3.8 and 4.0 μg/mL at 48 and 54 h, respectively. Total ropivacaine concentrations up to 4.0 μg/mL were tolerated during long-term epidural ropivacaine infusion. Mean clearance for total ropivacaine was 5.33 L/h. Age was the only covariable to significantly reduce clearance variability: CL (L/h)=15.04-0.148 × age (years). The volume of distribution (Vd) was 92.15 L. The infusion dosing period half-life (t(1/2,DP)=0.693 × Vd/CL) was 10.8 h. Exposure to ropivacaine during epidural infusion is highly variable. The apparent infusion dosing half-life t(1/2,DP) is the most appropriate parameter to predict drug accumulation upon epidural infusion since it appears to better reflect the interplay interference between volume distribution and absorption rate during the accumulation phase. Prediction of ropivacaine accumulation can be improved by considering patient age.

Comparison of Automated Intermittent Low Volume Bolus with Continuous Infusion for Labour Epidural Analgesia

Delivery of local anaesthetics via automated intermittent bolus has been shown to improve epidural analgesia compared to delivery via continuous epidural infusion. However the optimal bolus volume has not been investigated. This randomised, double-blind study compared the analgesic efficacy of automated intermittent bolus (volume 2.5 ml every 15 minutes) with that of a continuous epidural infusion (10 ml/hour) for the maintenance of labour epidural analgesia, to determine whether the advantages previously demonstrated for automated intermittent bolus over continuous epidural infusion are retained at this low bolus volume. With the approval of the Hospital Ethics Committee, we recruited 50 parturients who received combined spinal epidural analgesia with intrathecal ropivacaine 2 mg and fentanyl 15 microg. For epidural maintenance, participants were randomised to either the automated intermittent bolus group (2.5 ml automated intermittent epidural boluses of ropivacaine 0.1% plus fentanyl 2 microg/ml delivered over a two-minute period every 15 minutes) or the continuous epidural infusion group (continuous epidural infusion of ropivacaine 0.1% plus fentanyl 2 microg/ml at 10 ml/hour). The primary study outcome was the incidence of pain during labour that required management with supplemental epidural analgesia. There were no significant differences between the two regimens in terms of breakthrough pain (automated intermittent bolus 36% [9/25] vs continuous epidural infusion 32% [8/25], P = 0.77). At the doses used in this study, maintenance of labour analgesia using automated intermittent bolus at a bolus volume of 2.5 ml every 15 minutes does not decrease the incidence of breakthrough pain or improve analgesic efficacy compared to continuous epidural infusion.

Choice of a Perioperative Analgesia Mode during Hip Joint Replacement

Objective: to evaluate the efficiency and safety of various perioperative analgesia modes during total hip joint replacement (THR). Subjects and methods. A randomized controlled trial enrolled 90 patients who were divided into 3 groups according to the choice of a perioperative analgesia mode on day 1: general sevofluorane anesthesia, by switching to intravenous patient-controlled analgesia with fentanyl (PCA, GA group), a combination of general and spinal bupiva-caine anesthesia, by switching to PCA with fentanyl (SA group), a combination of general and epidural ropivacaine anesthesia with continuous postoperative epidural ropivacaine infusion (EA group). All the patients received non-opi-oid analgesics after surgery. Results. Prolonged epidural block ensures better postoperative analgesia at rest and during mobilization and a less need for opioids than other analgesia modes (p<0.05). With neuroaxial block, the preoperative need for sympatomimetics is much higher than that in the GA group (p<0.05). There is also a trend toward a higher incidence of cardiac arrhythmias and postoperative nausea and vomiting in the SA and EA groups. There are no differences in the frequency of hemotransfusion and postoperative complications and the length of hospital stay. Conclusion. Prolonged epidural block provides excellent perioperative analgesia during THR, but the risk-benefit ratio needs to be carefully assessed when an analgesia mode is chosen.