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ORIGINAL ARTICLE
Year : 2020  |  Volume : 4  |  Issue : 3  |  Page : 115-117

Evaluation of postoperative analgesic effects of infraorbital nerve block by levobupivacaine vs. Ropivacaine after cleft palate surgery: A double-blinded randomized trial


1 Department of Anesthesiology, AIIMS, Rishikesh, Uttarakhand, India
2 Department of Burns and Plastic Surgery, AIIMS, Rishikesh, Uttarakhand, India
3 Department of Transfusion Medicine, AIIMS, Rishikesh, Uttarakhand, India

Date of Submission17-Mar-2020
Date of Decision19-Mar-2020
Date of Acceptance02-Apr-2020
Date of Web Publication18-Jul-2020

Correspondence Address:
Dr. Vijay Adabala
Department of Anesthesiology, AIIMS, Rishikesh - 249 201, Uttarakhand
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/BJOA.BJOA_15_20

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  Abstract 


Background: Both ropivacaine and levobupivacaine have been used for the peripheral block in children for surgical pain. The present study is aimed to compare the effectiveness of 0.375% levobupivacaine and 0.375% ropivacaine in the infraorbital block for cleft palate surgery. Patients and Methods: Eighty patients between the age group of 2–12 years planned for elective surgery for cleft palate were included in the study. The solution for Group L was a mixture of 0.375% levobupivacaine and the solution for Group R was a mixture of 0.375% ropivacaine. Infraorbital nerve blocks were conducted by landmark-guided technique. We used the Verbal Rating Scale (VRS) to assess the postoperative pain. Results: There was a statistically significant difference in the time interval until the first request for pain medication was made by the participants in the two groups (10.6 [8.4, 12.8] vs. 8.5 [6.1, 10.8] h, P = 0.002). There were differences in pain scores calculated at regular intervals after surgery comparing the two groups (2.7 ± 0.3 vs. 3.6 ± 0.3, P = 0.01). There were differences in the need for rescue analgesics comparing the two groups. Conclusion: The analgesic effects of levobupivacaine are statistically better than ropivacaine in the infraorbital block in children who underwent cleft palate surgery.

Keywords: Levobupivacaine, pain, regional anesthesia, ropivacaine


How to cite this article:
Adabala V, Kumar A, Tandon S, Chattopadhyay D, Prasad E. Evaluation of postoperative analgesic effects of infraorbital nerve block by levobupivacaine vs. Ropivacaine after cleft palate surgery: A double-blinded randomized trial. Bali J Anaesthesiol 2020;4:115-7

How to cite this URL:
Adabala V, Kumar A, Tandon S, Chattopadhyay D, Prasad E. Evaluation of postoperative analgesic effects of infraorbital nerve block by levobupivacaine vs. Ropivacaine after cleft palate surgery: A double-blinded randomized trial. Bali J Anaesthesiol [serial online] 2020 [cited 2020 Aug 6];4:115-7. Available from: http://www.bjoaonline.com/text.asp?2020/4/3/115/290082




  Introduction Top


Cleft palate repair is one of the head-and-neck procedures done in children. As such, children with cleft palate tend to have a compromised airway due to associated congenital anomalies such as Pierre Robin sequence and  Treacher Collins syndrome More Details. Postoperative respiratory complications, such as narrowed airway, increased secretions, pain, and bleeding, are expected in these surgeries.[1],[2] Hence, regional anesthesia becomes a good option in this surgery.

The supremacy of bilateral infraorbital block using levobupivacaine over intravenous fentanyl as well as over peri-incisional infiltration has been shown. Levobupivacaine was developed after ropivacaine was noted to be associated with fewer adverse events. Both ropivacaine and levobupivacaine have been used for the peripheral block in children for surgical pain. However, no studies have established the supremacy of these drugs over each other in cleft palate surgeries.[3],[4],[5] Hence, the present study is aimed to compare the effectiveness of 0.375% levobupivacaine and 0.375% ropivacaine in the infraorbital block for cleft palate surgery.


  Patients and Methods Top


The study was performed at AIIMS Rishikesh after taking ethical approval from the institute ethical committee. Forty patients in each group were included in the study. The children between the age group of 2–12-years planned for elective surgery for cleft palate were included after taking informed written consent from their respective parents or guardians. Patients who refused to give consent, known allergic to local anesthetics, on anticoagulants or bleeding disorder, and underlying other significant systemic diseases were excluded from the study. The participants were randomly selected into Groups L or R using a computer-assisted block randomization technique.

The solution for Group L was a mixture of 7.5 ml of 0.5% levobupivacaine and 2.5 ml of saline (final concentration of the mixture was 0.375%). The solution for Group R was a mixture of 5 mL of 0.75% ropivacaine and 5 mL of saline (final concentration was 0.375%), of which 2–3 ml of these drugs are given in each group of patients by landmark technique.

We used 2 mg/kg propofol and 2 mcg/kg fentanyl for induction. A Ring-Adair-Elwyn south-facing endotracheal tube was used, and anesthesia was maintained with 2%–4% sevoflurane. A bilateral infraorbital block is performed using 2–3 mL of 0.375% levobupivacaine (Group L) or ropivacaine (Group R). Ephedrine and phenylephrine were administered to maintain appropriate hemodynamics as necessary. At the end of the surgery, 2 mg/kg diclofenac sodium is routinely administered intravenously. The verbal rating scale (VRS), classified as 0 equals no pain and 5 equals the severest pain, was used to assess the pain. Parents/guardians were enquired regarding the pain if the child is not able to express. Nurses were educated before the study regarding the assessment of pain scores and neurologic evaluation.

We used the Statistical Package for the Social Sciences (IBM SPSS Statistics for Windows, Armonk, NY, USA) version 20.0 in the data analysis. Normally distributed continuous variables were presented as a mean ± standard deviation and analyzed using unpaired Student's t-test. For categorical variables, Chi-square or Fisher's exact test was used to assess the difference between the groups. A value of P < 0.05 was considered statistically significant.


  Results Top


A total of 80 patients were enrolled in this study. We found no significant differences in demographic data of the two groups [Table 1]. We experienced no difficulty in performing the infraorbital block in both groups.
Table 1: Demographic data

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There was a significant difference in the time interval until the first request for pain medication was made by the participants in the two groups (10.6 {8.4, 12.8} vs. 8.5 {6.1, 10.8} h, P = 0.002). There were differences in pain scores calculated at regular intervals after the surgery comparing the two groups (2.7 ± 0.3 vs. 3.6 ± 0.3, P = 0.01) [Table 2]. There were differences in the need for rescue analgesics comparing the two groups.
Table 2: Comparison between the groups

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  Discussion Top


Regional Anesthesia is preferred in cleft lip and palate surgeries to avoid postoperative pain and to avoid the side effects of opioids[6]. Most appropriate local anesthetics are chosen for peripheral nerve block. Levobupivacaine is considered more lipophilic compared to ropivacaine. Levobupivacaine is more potent than ropivacaine concerning postoperative analgesia and cardiac side effects. In comparison, levobupivacaine was found to produce more extended analgesia than ropivacaine.

This prospective, randomized, double-blind study was conducted to provide data of clinical use of 0.37% levobupivacaine and 0.37% ropivacaine for infraorbital nerve block using landmark technique for cleft palate surgeries. We found that 0.375% levobupivacaine provided longer postoperative analgesia when compared to 0.375% ropivacaine.

The efficacy of levobupivacaine over ropivacaine in terms of postoperative analgesia was proved in the study conducted by Fournier et al.[7] In their study, a total of 40 patients were enrolled and received equal volume and concentration of both rugs for sciatic nerve block. The median postoperative analgesia provided by levobupivacaine was longer (1605 min) than that provided by ropivacaine (1035 min).

Cline et al.[8] compared 40 mL 0.5% levobupivacaine to 40 ml 0.5% ropivacaine in axillary brachial plexus block and found a significantly longer duration of analgesia with levobupivacaine compared to ropivacaine (P = 0.013). The observed difference in the postoperative analgesia provided by levobupivacaine and ropivacaine was only 3 h in their study, while it was 8 h in our study. This shows that the duration of blockade may depend on regional techniques. Cacciapuoti et al.[9] found that 1 mg/kg 0.5% levobupivacaine provides 3.5 h longer duration of analgesia compared to 1.45 mg/kg 0.5% ropivacaine in axillary plexus block. The study results are in accordance with the results of these studies.

Other studies have reported that the duration of analgesia when using levobupivacaine for brachial plexus block was the same as that when using ropivacaine and the same pain level at 6 h after the operation.[10],[11] The reason could be due to the age and the site of the block in the body where blood supply differs.

Limitations for our study were limited participants, and that we used the landmark-guided technique for the block. In the landmark-guided technique, the exact site of the block was unconfirmed, and it could have brought some difference. No postoperative complications were noted in both groups.


  Conclusion Top


The analgesic effects of levobupivacaine are statistically better than ropivacaine in the infraorbital block in children who underwent cleft palate surgery.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Senapathi TG, Widnyana MG, Ryalino C, Junaedi MD. A preliminary study on the pectoralis block II as a part of multimodal analgesia for intra and postoperative pain management in modified radical mastectomy. Bali J Anesth 2018;2:105-8.  Back to cited text no. 1
    
2.
Singh P, Kapur A, Gupta SK. Comparative evaluation of low-dose levobupivacaine and ropivacaine in patients undergoing inguinal herniorrhaphy under walking spinal anaesthesia as daycare surgery. Bali Journal of Anesth 2019;3:111-7.  Back to cited text no. 2
    
3.
Prabhu KP, Wig J, Grewal S. Bilateral infraorbital nerve block is superior to peri-incisional infiltration for analgesia after repair of cleft lip. Scand J Plast Reconstr Surg Hand Surg 1999;33:83-7.  Back to cited text no. 3
    
4.
Rajamani A, Kamat V, Rajavel VP, Murthy J, Hussain SA. A comparison of bilateral infraorbital nerve block with intravenous fentanyl for analgesia following cleft lip repair in children. Paedatr Anaesth 2007;17;133-9.  Back to cited text no. 4
    
5.
Coban YK, Senoglu N, Oksuz H. Effects of preoperative local ropivacaine infiltration on postoperative pain scores in infants and small children undergoing elective cleft palate repair. J Craniofac Surg 2008;19:1221-4.  Back to cited text no. 5
    
6.
Mesnil M, Dadure C, Captier G, Raux O, Rochette A, Canaud N, et al. A new approach for peri-operative analgesia of cleft palate repair in infants: the bilateral suprazygomatic maxillary nerve block. Paediatr Anaesth 2010;20:343-9.  Back to cited text no. 6
    
7.
Fournier R, Faust A, Chassot O, Gamulin Z. Levobupivacaine 0.5% provides longer analgesia after sciatic nerve block using the labat approach than the same dose of Ropivacaine in foot and ankle surgery. Anesth Analg 2010;110:1486-9.  Back to cited text no. 7
    
8.
Cline E, Franz D, Polley RD, Maye J, Burkard J, Pellegrini J. Analgesia and effectiveness of levobupivacaine compared with ropivacaine in patients undergoing an axillary brachial plexus block. AANA J 2004;72:339-46.  Back to cited text no. 8
    
9.
Cacciapuoti A, Castello G, Francesco A. Levobupivacaina, bupivacaina racemica e ropivacaina nel blocco del plesso brachiale. Minerva Anestesiologica. 2002;68:599-605.  Back to cited text no. 9
    
10.
Mageswaran R, Choy YC. Comparison of 0.5% ropivacaine and 0.5% levobupivacaine for infraclavicular brachial plexus block. Med J Malaysia 2010;65:300-3.  Back to cited text no. 10
    
11.
Liisanantti O, Luukkonen J, Rosenberg PH. High-dose bupivacaine, levobupivacaine and ropivacaine in axillary brachial plexus block. Acta Anaesthesiol Scand 2004;48:601-6.  Back to cited text no. 11
    



 
 
    Tables

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Abstract
Introduction
Patients and Methods
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