title: Intraoperative epidural anesthesia and postoperative analgesia with levobupivacaine for major orthopedic surgery: a double-blind, randomized comparison of racemic bupivacaine and ropivacaine.
abstract: OBJECTIVE
  To compare the onset time and duration of epidural anesthesia, and the quality of postoperative analgesia produced by levobupivacaine, racemic bupivacaine, and ropivacaine.
  
  
  METHODS
  Prospective, randomized, double-blinded study.
  
  
  METHODS
  Inpatient anesthesia at a University Hospital.
  
  
  METHODS
  45 ASA physical status I, II, and III patients, undergoing elective total hip replacement.
  
  
  METHODS
  After standard intravenous midazolam premedication and infusion of 500 mL of Ringer's acetate solution, patients were randomly allocated to receive epidural block with 0.5% levobupivacaine (n = 15), 0.5% bupivacaine (n = 15), or 0.5% ropivacaine (n = 15). Postoperatively, after pinprick sensation recovered at T(t), a patient-controlled epidural infusion was provided with 0.125% levobupivacaine, 0.125% bupivacaine, or 0.2% ropivacaine, respectively (baseline infusion rate 5 mL/hr; incremental bolus 2 mL, lockout time: 20 min). Intravenous ketoprofen was also available for rescue analgesia if required.
  
  
  RESULTS
  The onset time of sensory block was 31 +/- 16 minutes with levobupivacaine, 25 +/- 19 minutes with bupivacaine, and 30 +/- 24 minutes with ropivacaine (p = 0.98), after a median (range) volume of 15 (10-18) mL in Group Levobupivacaine, 14 (10-18) mL in Group Bupivacaine, and 15 (10-18) mL in Group Ropivacaine (p = 0.85). Six patients in the ropivacaine group (40%) showed an intraoperative Bromage score <2 as compared with only three patients of Group Levobupivacaine (20%) and no patient of Group Bupivacaine (p = 0.02). Recovery of pinprick sensation at T(t) occurred after 214 +/- 61 minutes with levobupivacaine, 213 +/- 53 minutes with bupivacaine, and 233 +/- 34 minutes with ropivacaine (p = 0.26). A similar degree of pain relief was observed in the three groups without differences in local anesthetic consumption and need for rescue analgesia. Motor blockade progressively resolved without differences among the three groups.
  
  
  CONCLUSIONS
  Levobupivacaine 0.5% produces an epidural block of similar onset, quality, and duration as the one produced by the same volume of 0.5% bupivacaine, with a motor block deeper than that produced by 0.5% ropivacaine. When prolonging the block for the first 12 hours after surgery with a patient-controlled epidural infusion, 0.125% levobupivacaine provides adequate pain relief after major orthopedic surgery, with similar recovery of motor function as compared with 0.125% bupivacaine and 0.2% ropivacaine.
authors.affiliation: Vita-Salute University of Milano-Department of Anesthesiology, IRCCS H San Raffaele, Milan, Italy. casati.andrea@hsr.it
authors.forename: Andrea
authors.initials: A
authors.lastname: Casati
authors.forename: Roberta
authors.initials: R
authors.lastname: Santorsola
authors.forename: Giorgio
authors.initials: G
authors.lastname: Aldegheri
authors.forename: Flavio
authors.initials: F
authors.lastname: Ravasi
authors.forename: Guido
authors.initials: G
authors.lastname: Fanelli
authors.forename: Marco
authors.initials: M
authors.lastname: Berti
authors.forename: Gianfranco
authors.initials: G
authors.lastname: Fraschini
authors.forename: Giorgio
authors.initials: G
authors.lastname: Torri
mesh_terms: D000368:Aged; D000577:Amides; D016058:Analgesia, Patient-Controlled; D000767:Anesthesia, Epidural; D000779:Anesthetics, Local / Q000737:chemistry; D019644:Arthroplasty, Replacement, Hip; D002045:Bupivacaine / Q000737:chemistry; D004311:Double-Blind Method; D005260:Female; D006801:Humans; D008297:Male; D009407:Nerve Block; D010147:Pain Measurement; D010149:Postoperative Pain / Q000188:drug therapy / Q000517:prevention & control*; D011446:Prospective Studies; D000077212:Ropivacaine; D013237:Stereoisomerism
chemical_list: D000577:Amides; D000779:Anesthetics, Local; D000077212:Ropivacaine; D002045:Bupivacaine