Levobupivacaine vs Ropivacaine for Brachial Plexus Block

Levobupivacaine and ropivacaine show similar analgesic effects postoperatively after brachial plexus block, according to a study recently published in Medicine.¹

Both levobupivacaine and ropivacaine are commonly used to provide long-lasting analgesia after peripheral nerve block. Levobupivacaine however, presents several advantages over ropivacaine, with greater lipophilic properties,² longer-lasting analgesia from epidural and spinal injections,^3,4 and a more potent analgesic effect postoperatively.

Here, using a randomized prospective trial, researchers sought to determine whether levobupivacaine could provide longer-lasting analgesia than ropivacaine after brachial plexus block, as was found in just 1 study.⁵

The study was conducted on 62 patients undergoing orthopedic surgery, consisting of open reduction and internal fixation of fractures, who were randomly assigned in a double-blind manner to receive levobupivacaine (group L; n=31; mean age, 67 years; 58% women) or ropivacaine (group R; n=31; mean age, 68 years; 64.5% women) for brachial plexus nerve block. Nerve block was achieved using an interscalene approach for humerus (n=9 in group R, n=10 in group L) and elbow (n=4 in group R, n=3 in group L) fractures, or an axillary approach for wrist fractures (n=18 in both groups).

Group L was injected with 20 mL 0.375% levobupivacaine in saline, and group R with 20 mL 0.375% ropivacaine in saline. Peripheral nerve blocks guided by ultrasound and combined with nerve stimulation (using a 6-13-Hz linear probe and a 22-g needle) were performed in patients under general anesthesia by anesthesiologists experienced in the technique. Oral lornoxicam (4 mg) was administered after each meal, from postoperative days 1 to 5, and patients could request analgesics at any time after surgery (25 mg per rectum diclofenac as first-line, and 15 mg intravenous pentazocine as second-line therapy).

No difference was found between groups R and L for the “time interval until the first request for pain medicine” (P =.32); the duration of the motor block assessed with a 0 to 6 modified Lovett rating scale (P =.44); pain scores, evaluated with a 0 to 5 verbal rating scale, at any point after surgery (P =.92); need for rescue analgesics (P =.6); or rate of sleep disturbance (P =1.0). 

The researchers conclude that levobupivacaine and ropivacaine display similar analgesic effects after brachial plexus blocks.

Summary and Clinical Applicability

“This study shows that the analgesic effects of levobupivacaine and ropivacaine are not statistically significant when used for ultrasound guided brachial plexus block. This unexpected result may be explained by the pharmacodynamics of local anesthetics used for brachial plexus blocks,” conclude the study’s authors.

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References

1. Watanabe K, Tokumine J, Lefor AK, et al. Postoperative analgesia comparing levobupivacaine and ropivacaine for brachial plexus block: A randomized prospective trial. Medicine (Baltimore). 2017;96(12):e6457. doi: 10.1097/MD.0000000000006457
2. Leone S, Di cianni S, Casati A, Fanelli G. Pharmacology, toxicology, and clinical use of new long acting local anesthetics, ropivacaine and levobupivacaine. Acta Biomed. 2008;79(2):92-105.
3. Sia AT, Goy RW, Lim Y, Ocampo CE. A comparison of median effective doses of intrathecal levobupivacaine and ropivacaine for labor analgesia. Anesthesiology. 2005;102(3):651-656.
4. Egashira T, Fukasaki M, Araki H, et al. Comparative efficacy of levobupivacaine and ropivacaine for epidural block in outpatients with degenerative spinal disease. Pain Physician. 2014;17(6):525-529.
5. 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(5):339-345.