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Table of Contents
ORIGINAL ARTICLE
Year : 2020  |  Volume : 4  |  Issue : 3  |  Page : 95-98

Comparison of epidural levobupivacaine and bupivacaine in lower abdominal and lower limb surgeries


1 Department of Critical Care Medicine, RIMS, Ranchi, Jharkhand, India
2 Department of Anaesthesia, Vydehi Institute of Medical Sciences and Research Centre, Bengaluru, Karnataka, India
3 Department of Intensive Care Medicine, RIMS, Ranchi, Jharkhand, India
4 Department of Superspeciality Anaesthesia, RIMS, Ranchi, Jharkhand, India
5 Department of Pathology, CCL, Ranchi, Jharkhand, India

Date of Submission06-Mar-2020
Date of Decision14-Mar-2020
Date of Acceptance23-Mar-2020
Date of Web Publication18-Jul-2020

Correspondence Address:
Dr. J Prashanth Prabhu
Department of Anaesthesia, Vydehi Institute of Medical Sciences and Research Centre, Bengaluru - 560 066, Karnataka
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/BJOA.BJOA_21_20

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  Abstract 


Background: Bupivacaine, the most commonly used drug for a central neuraxial blockade, also carries undesirable effects like a prolonged postoperative motor blockade. The objective of the study was to compare the intensity of sensory and motor blockade, hemodynamic effects, and adverse effects, if any, between the two drugs. Patients and Methods: A randomized, double-blind study was carried out on 100 patients. Patients were divided into two groups of 50 patients each. Group L received 20 ml of 0.5% levobupivacaine epidurally, and Group B received 20 ml of 0.5% bupivacaine epidurally. We observed the characteristics of the sensory and motor blockade in both groups. Results: The hemodynamic effects of both drugs were statistically and clinically comparable. The total duration of the sensory blockade with levobupivacaine was 366.60 ± 29.25 min compared to 370.80 ± 37.73 min with bupivacaine (P = 0.535). The total duration of the motor blockade with levobupivacaine was 139.20 ± 27.15 min compared to 172.80 ± 26.77 min (P < 0.001) with bupivacaine. Conclusion: Levobupivacaine produces shorter motor blockade, which may provide early ambulation of patients in day care surgeries. In surgical procedures requiring extensive motor blockade, epidural levobupivacaine may not be an appropriate choice.

Keywords: Epidural, levobupivacaine, motor blockade, sensory blockade


How to cite this article:
Prakash J, Prabhu J P, Kharwar RK, Priye S, Singh D, Saran K. Comparison of epidural levobupivacaine and bupivacaine in lower abdominal and lower limb surgeries. Bali J Anaesthesiol 2020;4:95-8

How to cite this URL:
Prakash J, Prabhu J P, Kharwar RK, Priye S, Singh D, Saran K. Comparison of epidural levobupivacaine and bupivacaine in lower abdominal and lower limb surgeries. Bali J Anaesthesiol [serial online] 2020 [cited 2020 Sep 30];4:95-8. Available from: http://www.bjoaonline.com/text.asp?2020/4/3/95/290086




  Introduction Top


Regional anesthesia means the interruption of impulse conduction in the nerves using specific, reversibly acting drugs (local anesthetics).[1] Lower abdominal and lower extremity surgeries can be carried out both under general anesthesia as well as under central neuraxial block. Epidural block results in the sympathetic blockade, sensory analgesia or anesthesia, and motor blockade, depending on the dose, concentration, or volume of local anesthetic.[2] Epidural anesthesia is a widely used technique and has the added advantage over general anesthesia of providing both intraoperative and postoperative pain relief with an epidural catheter, thereby decreasing the morbidity and reduces the intraoperative blood loss.

The first described the placement of a lumbar epidural catheter was performed by Manuel Martínez Curbelo in 1947,[3] a Cuban anesthesiologist who introduced a 16G Tuohy needle and through this needle, he introduced a 3.5 Fr ureteral catheter made of elastic silk into the lumbar epidural space and through the catheter in place and repeatedly injected local anesthetic to achieve anesthesia. Conventionally, amide local anesthetics have been used in regional anesthetic techniques, and bupivacaine has emerged as the most commonly used drug for the central neuraxial blockade. Nevertheless, it also carries undesirable effects such as a prolonged postoperative motor blockade and cardiotoxicity. Ropivacaine, on the other hand, is a weaker drug as it has a shorter duration of action, limiting its use in longer duration surgeries.[2]

Keeping these factors in mind, long-acting amide local anesthetic, S(−) enantiomer of bupivacaine, levobupivacaine has been developed. The advantages of levobupivacaine over bupivacaine are decreased cardiovascular toxicity and there is also a relatively decreased motor nerve fiber penetration and block, and thereby, a decreased postoperative motor blockade and thus early ambulation of the patients can be achieved.[2],[3],[4]

The objective of the present study was to compare the intensity of sensory and motor blockade, hemodynamic effects, and adverse effects between the 0.5% levobupivacaine and 0.5% bupivacaine.


  Patients and Methods Top


This is a double-blind, randomized study that was conducted on 100 patients. Inclusion criteria include the American Society of Anesthesiologists (ASA) physical status Grade I and II, aged between 18 and 70 years who underwent elective lower abdominal, and lower limb surgeries under epidural anesthesia were selected. The study protocol was approved by the institutional review board. The study conformed to the Helsinki Declaration. All patients provided written informed consent to be included in this study.

Patients with a known case of hypersensitive reactions to local anesthetics, unwilling patients, and emergency surgeries; patients with medical complications such as anemia, heart disease, severe hypovolemia, shock, septicemia, and hypertension; patients with coagulation disorders or on anticoagulant therapy, local infection at the site of proposed puncture for epidural anesthesia; and patients requiring intraoperative top-up of local anesthetic due to prolonged surgery were excluded from the study.

The study population was randomly divided into two groups, with 50 patients in each group and informed written consent taken. The selected drug was sealed within an envelope, which was randomly picked. The drug was then administered by anesthesiologists unrelated to the study.

Group L received 20 ml of 0.5% levobupivacaine epidurally, and Group B received 20 ml of 0.5% bupivacaine epidurally. Preanesthetic checkup was done 1 day before the surgery. A general physical examination along with proper systemic examination, assessment of airway, and local examination of the lumbar spine were done. Relevant investigations were reviewed. Patients were asked to restrict solids and fluids orally 8 h before the surgery. Oral premedication with 0.25 mg of alprazolam was given orally previous night with sips of water along with ranitidine 50 mg and ondansetron 4 mg given orally previous night and early morning with sips of water.

On the day of surgery, the patient shifted to the operation theater. Following the placement of standard monitors, electrocardiogram, pulse oximeter, noninvasive blood pressure (BP), and oxygen saturation (SpO2), intravenous (IV) line with 18G cannula was secured, and patients were preloaded with IV fluids (500 ml of crystalloid solution).

The midline approach was used in all cases. Under aseptic precautions, local infiltration using 2% xylocaine was given. The epidural needle was inserted into L2 to L3 space in midline perpendicular to the skin with the bevel facing upward. The Tuohy needle is then advanced slowly until epidural space was identified by the loss of resistance technique. The bevel of the needle was directed toward cephalad, and the epidural catheter was inserted.

After the administration of a test dose, a single shot of the study drug (either 20 ml of 0.5% levobupivacaine or 20 ml of 0.5% bupivacaine) was injected into the epidural space following parameters were monitored: hemodynamic changes of pulse rate, systolic BP, diastolic BP, mean arterial pressure, and peripheral SpO2 were recorded.

All observations and particulars of each patient were recorded in the pro forma. Cases with an inadequate level of analgesia and inadequate muscle relaxation were excluded from the study, and this inadequacy was attributed to the technical mistakes in performing the epidural block.

Descriptive and inferential statistical analysis has been carried out in the present study. Student's t-test (two-tailed and independent) has been used to find the significance of study parameters on a continuous scale between two groups (intergroup analysis) on metric parameters. Chi-square or Fisher's exact test was used to find the significance of study parameters on a categorical scale between two or more groups. We used Statistical Package for the Social Sciences 25 (IBM Corp. Released 2017. IBM SPSS Statistics for Windows, version 25.0 Armonk, NY, USA: IBM Corp.) for the statistical data analysis. P < 0.05 was considered statistically significant.


  Results Top


Both groups were comparable for demographic characteristics in the present study, as shown in [Table 1]. There were no significant differences between the two groups in terms of age, sex, weight, height, and duration of surgery. There were no significant differences between the two groups concerning the type of surgery and baseline hemodynamic parameters. There was no significant fall in SpO2 and statistically comparable between both the groups at all the time.
Table 1: Demographic characteristics of the patients

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In Group L and B patients, the mean time needed for the sensory level onset to reach the T10 level was 20.52 ± 5.85 min and 20.80 ± 6.43 min, respectively (P = 0.820). The total duration of sensory block was 366.60 ± 29.25 min and 370.80 ± 37.73 min, respectively (P = 0.535). The time needed for two-segment regression in groups L and B varied were 85.30 ± 21.44 min and 94.50 ± 16.26 min, respectively (P = 0.017), as shown in [Table 2].
Table 2: Sensory and motor block duration (min) presented as mean±standard deviation

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In this study, the side effect events were classified into cardiovascular (hypotension and bradycardia) and postoperative nausea and vomiting. The difference in side effect events between the two groups was statistically insignificant. Treatment of hypotension (ephedrine 6 mg) was required in one patient in Group L and three patients in Group B. Treatment of bradycardia (atropine 0.6 mg) was required in three patients in Group B. Hypotension was observed in 20% of patients of Group B compared to 10% of patients in Group L [Table 3].
Table 3: Side effects comparison between the two groups

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  Discussion Top


Levobupivacaine is a relatively new long-acting local anesthetic, with a pharmacological activity closely to that of racemic bupivacaine but less cardiotoxic and neurotoxic in comparison to racemic bupivacaine.[5],[6],[7] Bupivacaine (1-butyl-2,6-pipecoloxylidide) was synthesized by Ekenstam et al. 1957 and was first introduced into clinical use in 1963.[8] Bupivacaine is the most commonly used drug for the central neuraxial blockade. Bupivacaine is a racemic mixture of equal amounts of the optic isomers levobupivacaine and dextrobupivacaine, which is known as S(−) and R(+) enantiomers.[9]

Based on demonstrations that racemic bupivacaine cardiotoxicity is enantioselective that is more pronounced with R(+) enantiomer. It also carries undesirable effects such as prolonged postoperative motor blockade and cardiotoxicity. Hence, levobupivacaine, S(−) enantiomer of bupivacaine has been developed with a decreased postoperative motor blockade and thus early ambulation of the patient.[10] Hence, we compared epidural levobupivacaine and bupivacaine in lower abdominal and lower limb surgeries using 20 ml of single-shot 0.5% isobaric solution in 100 patients of ASA grade I and II. In this discussion, we are comparing with other studies about dosage, the concentration of the drug, sensory block, motor block, complications, and side effects.

Cox et al.[11] reported that the durations of motor block of 0.5% levobupivacaine and 0.5% bupivacaine were 185–205 and 185–192 min, respectively. They observed more time consumed in the onset of a motor block with levobupivacaine compared to bupivacaine, which was similar to our observation. He also observed that the overall satisfactory block was less in the levobupivacaine group.

Kopacz et al.[12] reported that the duration of sensory block in levobupivacaine and bupivacaine were 550.6 ± 87.6 and 505.9 ± 71 min, respectively. They also observed that 82% of patients receiving levobupivacaine, and 61% of patients receiving bupivacaine patients reported adverse effects. This could be because of a higher concentration of drugs used (20 ml of 0.75%) compared to ours (20 ml of 0.5%).

Bergamaschi et al.[13] observed a slower onset of the motor blockade with levobupivacaine compared to bupivacaine, which was similar to our findings. He also observed hypotension in 66.7% of levobupivacaine patients and 43.5% of bupivacaine patients. This could be due to his study population, where the study patients were parturient posted for a lower segment cesarean section.

De Negri et al.[14] concluded that bupivacaine had significantly higher motor block compared to the levobupivacaine and ropivacaine groups. Locatelli et al.[15] also showed higher motor blockade in the bupivacaine group compared to levobupivacaine, unlike our study. Casati et al.[16] conducted a double-blind study and observed that the onset time of sensory block and two-segment regressions in his study drugs were similar to the observations in our study.


  Conclusion Top


Levobupivacaine produces shorter motor blockade, which may provide early ambulation of patients in day care surgeries. In surgical procedures requiring extensive motor blockade, epidural levobupivacaine may not be an appropriate choice.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Jankovic D. Regional Nerve Blocks and Infiltration Therapy. 3rd ed. Malden: Blackwell publishing; 2004. p. 305-26.  Back to cited text no. 1
    
2.
Miller RD, Eriksson LI, Fleisher LA, Wiener-Kronish JP, Young WL. In: Miller's Anesthesia. 7th ed. London: Churchill Livingstone/Elsevier; 2010. p. 1611-38.  Back to cited text no. 2
    
3.
Aldrete JA, Cabrera HS, Wright AJ. Manuel Martinez Curbelo and continuous lumbar epidural anesthesia. Bull Anesth Hist 2004;22:1, 4-8.  Back to cited text no. 3
    
4.
Tanaka PP, Ogleari M, Valmorbida P, Tanaka MA. Levobupivacaine 0.5%, 50% enantiomeric excess bupivacaine and racemic bupivacaine in epidural anesthesia for lower abdominal procedures. Comparative study. Rev Bras Anestesiol 2005;55:597-605.  Back to cited text no. 4
    
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Burlacu CL, Buggy DJ. Update on local anesthetics: Focus on levobupivacaine. Ther Clin Risk Manag 2008;4:381-92.  Back to cited text no. 5
    
6.
Bajwa SJ, Kaur J. Clinical profile of levobupivacaine in regional anesthesia: A systematic review. J Anaesthesiol Clin Pharmacol 2013;29:530-9.  Back to cited text no. 6
[PUBMED]  [Full text]  
7.
Sathitkarnmanee T, Thongrong C, Tribuddharat S, Bn MT, Bn KP, Bn RK. A comparison of spinal isobaric levobupivacaine and racemic bupivacaine for lower abdominal and lower extremity surgery. J Med Assoc Thai 2011;94:716-20.  Back to cited text no. 7
    
8.
Ekenstam BA, Egner B, Pettersson G. N-alkyl-pyrrolidine and N-alkyl piperidine carboxylic acid amides. Acta Chem Scand 1957;11:1183-90.  Back to cited text no. 8
    
9.
Lyons G, Columb M, Wilson RC, Johnson RV. Epidural pain relief in labour: Potencies of levobupivacaine and racemic bupivacaine. Br J Anaesth 1998;81:899-901.  Back to cited text no. 9
    
10.
Foster RH, Markham A. Levobupivacaine: A review of its pharmacology and use as a local anaesthetic. Drugs 2000;59:551-79.  Back to cited text no. 10
    
11.
Cox CR, Faccenda KA, Gilhooly C, Bannister J, Scott NB, Morrison LM. Extradural S(-)-bupivacaine: Comparison with racemic RS-bupivacaine. Br J Anaesth 1998;80:289-93.  Back to cited text no. 11
    
12.
Kopacz DJ, Allen HW, Thompson GE. A comparison of epidural levobupivacaine 0.75% with racemic bupivacaine for lower abdominal surgery. Anesth Analg 2000;90:642-8.  Back to cited text no. 12
    
13.
Bergamaschi F, Balle VR, Gomes ME, Machado SB, Mendes FF. Levobupivacaine versus bupivacaine in epidural anesthesia for cesarean section. Comparative study. Rev Bras Anestesiol 2005;55:606-13.  Back to cited text no. 13
    
14.
De Negri P, Ivani G, Tirri T, Modano P, Reato C, Eksborg S, et al. A comparison of epidural bupivacaine, levobupivacaine, and ropivacaine on postoperative analgesia and motor blockade. Anesth Analg 2004;99:45-8.  Back to cited text no. 14
    
15.
Locatelli B, Ingelmo P, Sonzogni V, Zanella A, Gatti V, Spotti A, et al. Randomized, double-blind, phase III, controlled trial comparing levobupivacaine 0.25%, ropivacaine 0.25% and bupivacaine 0.25% by the caudal route in children. Br J Anaesth 2005;94:366-71.  Back to cited text no. 15
    
16.
Casati A, Santorsola R, Aldegheri G, Ravasi F, Fanelli G, Berti M, et al. Intraoperative epidural anesthesia and postoperative analgesia with levobupivacaine for major orthopedic surgery: a double-blind, randomized comparison of racemic bupivacaine and ropivacaine. J Clin Anesth. 2003;15:126-31.  Back to cited text no. 16
    



 
 
    Tables

  [Table 1], [Table 2], [Table 3]



 

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