Ropivacaine

Article Author:
Ashley George
Article Editor:
Mark Liu
Updated:
10/17/2019 1:49:02 PM
PubMed Link:
Ropivacaine

Indications

Ropivacaine is FDA-approved for surgical anesthesia and acute pain management. It is used in an epidural block for surgery—such as cesarean sections. It is also used in major nerve blocks and local infiltration. In acute pain management, ropivacaine is used in epidurals (continuous infusion or intermittent bolus) for postoperative or labor pain control. More recently, ropivacaine’s use in chronic pain management has also been evaluated.

In epidural administration for cesarean section, clinical trials show that ropivacaine (0.75% or 0.5%) has a clinically similar onset of sensory and motor block to bupivacaine 0.5%. The median duration of analgesia that ropivacaine supplied to the T6-S3 dermatomes is similar to bupivacaine, but with a much shorter duration of motor block (0.9 hrs vs. 2.5 hrs). For intrathecal administration, hyperbaric solutions of ropivacaine are faster in onset and recovery than isobaric ropivacaine, but the spread and duration of the hyperbaric ropivacaine block are very variable. Co-administration with opioids reduces the amount of local anesthetic needed and prolongs analgesia without lengthening the period of the motor block.

 An outpatient study looking at bupivacaine and ropivacaine in managing chronic low back pain found there were no significant differences in analgesia, motor blockade, or hemodynamic changes between bupivacaine 0.125% and ropivacaine 0.2%. Ropivacaine was also found to be effective for severe refractory migraine through trigger point inactivation.[1][2][3]

Mechanism of Action

Ropivacaine is a long-acting amide local anesthetic. It exhibits a similar mechanism of action to other local anesthetics in that it reversibly inhibits sodium ion influx in nerve fibers. Amides preferentially bind and inactivate sodium channels in the open state—thereby blocking propagation of action potentials. The dose-dependent inhibition of potassium channels potentiates this action.

Ropivacaine has a few properties that make it unique. Ropivacaine is less lipophilic than other local anesthetics, such as bupivacaine, and is less likely to penetrate large myelinated motor fibers. It therefore selectively acts on the nociceptive A, B, and C fibers over the AB (motor) fibers. Ropivacaine is also manufactured as a pure S(-) enantiomer; the S(-) enantiomer has significantly less cardiotoxicity and neurotoxicity.[4][5]

Administration

Ropivacaine is administered in incremental doses. Factors that affect the dosing of any administered local anesthetic include the area to be anesthetized, the vascularity of tissues, the number of neuronal segments to be blocked, and the depth and duration of anesthesia required.

An adequate test dose of 3-5 mL of short-acting local anesthetic with epinephrine should be used before the induction of the complete block. A repeat of the test dose should be given if the patient is moved in such a way that displacement epidural catheter may have occurred.

For lumbar surgery epidural blocks, the ropivacaine doses considered necessary to produce a successful block are 15-30 mL of 0.5% solution, 15-25 mL of 0.75% solution, 15-20 mL of 1% solution.

When used in lumbar epidural blocks for cesarean section, the doses for ropivacaine are 20-30 mL of 0.5% solution and 15-20 mL of 0.75% solution.

Dosages of ropivacaine when performing thoracic epidural blocks for surgical anesthesia are 5-15% mL dose of 0.5% solution and 5-15 mL of 0.75% solution.

When performing major nerve blocks, the dosages are 35-50 mL of 0.5% solution and 10-40 mL of 0.75% solution

For field blocks (e.g., minor nerve blocks and infiltration), ropivacaine is dosed at 1-40 mL dose of 0.5% solution.

When managing post-operative pain, peripheral nerve blocks are continuously infused at a dose of 5-10 mL/hr of 0.2% solution. For pain management through lumbar or thoracic epidurals, the continuous infusion dose of ropivacaine is at 6-14 mL/hr of 0.2% solution.

In prolonged blocks, there should be consideration of the risks of reaching a toxic plasma concentration or inducing local neural injury. A 24-hour cumulative dose of up to 770 mg ropivacaine is generally well tolerated in adults for postoperative pain management. Ropivacaine should be used with caution when administering it to debilitated patients for more than 70 hours.[6][7][8][9]

Adverse Effects

Ropivacaine is generally well tolerated. A pooled analysis from controlled clinical trials (n=1,661), in which patients received ropivacaine 0.125-1% for nerve blocks, indicates that the most common adverse reactions are hypotension (32%), nausea (17%), vomiting (7%), bradycardia (6%), and headache (7%). A similar side effect profile occurred in patients who received bupivacaine 0.25-0.75%.

Patients 61 years or older who received epidural ropivacaine 1% had a higher incidence of bradycardia than patients aged 41-60 years (58% vs. 15%); they also had a higher incidence of hypotension than patients aged 18-40 years old (74% vs. 20%).

The overall incidence of adverse reactions in children one month to 15 months is low; the most common adverse effects of ropivacaine in this age group were nausea and or vomiting.

The most common fetal or neonatal adverse reactions, following the use of ropivacaine in women undergoing cesarean section or labor, were fetal bradycardia (12%), neonatal jaundice (8%), and unspecified neonatal complications (7%).[10]

Contraindications

The only absolute contraindication to ropivacaine is in patients with a known hypersensitivity to ropivacaine or any amide-type local anesthetic.

Monitoring

Attention should be paid to vital signs (heart rate, blood pressure, oxygen saturation) after administration of a test dose to ensure that the local anesthetic is not intravascular. Cardiovascular and respiratory vital signs should be monitored after each local anesthetic injection. Restlessness, anxiety, perioral paresthesias, metallic taste, tinnitus, tremors, and blurred vision are a few of the early signs of central nervous system toxicity.

Toxicity

Local anesthetic system toxicity (LAST) primarily affects the central nervous system (CNS) and cardiovascular system. Local anesthetics can be assigned a cardiovascular collapse (CC) to CNS ratio, which is the ratio of the drug required to cause cardiovascular collapse compared to the drug dose required to produce seizures. Ropivacaine has a higher CC to CNS ratio (indicating a higher margin of safety) than bupivacaine and levobupivacaine. Ropivacaine has a greater arrhythmogenic cardiac effect, and less of an effect on contractility.[11]]

Enhancing Healthcare Team Outcomes

Multimodal analgesia involves the use of medications that act on different sites and pathways in an additive or synergistic manner to give pain relief with minimal or no opiate use. Opioids are associated with adverse effects such as nausea, vomiting, respiratory depression, and drug addiction. Local anesthetics play a large role in multimodal analgesia. Regional anesthesia can significantly reduce post-operative pain frequency and improve overall patient satisfaction (Level I). Ropivacaine has additional benefits compared to other local anesthetics because it is less cardiotoxic. This characteristic makes it a safer option for patients to be sent home with post-operatively. Administration of ropivacaine often requires a team of health professionals, including physicians, pharmacists, nursing, and home health.[12][13]


References

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[2] Casati A,Vinciguerra F, Intrathecal anesthesia. Current opinion in anaesthesiology. 2002 Oct     [PubMed PMID: 17019252]
[3] Wulf H,Peters C,Behnke H, The pharmacokinetics of caudal ropivacaine 0.2% in children. A study of infants aged less than 1 year and toddlers aged 1-5 years undergoing inguinal hernia repair. Anaesthesia. 2000 Aug     [PubMed PMID: 10947688]
[4] Aberg G, Toxicological and local anaesthetic effects of optically active isomers of two local anaesthetic compounds. Acta pharmacologica et toxicologica. 1972     [PubMed PMID: 4678027]
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[6] Chung CJ,Yun SH,Hwang GB,Park JS,Chin YJ, Intrathecal fentanyl added to hyperbaric ropivacaine for cesarean delivery. Regional anesthesia and pain medicine. 2002 Nov-Dec     [PubMed PMID: 12430112]
[7] Crosby E,Sandler A,Finucane B,Writer D,Reid D,McKenna J,Friedlander M,Miller A,O'Callaghan-Enright S,Muir H,Shukla R, Comparison of epidural anaesthesia with ropivacaine 0.5% and bupivacaine 0.5% for caesarean section. Canadian journal of anaesthesia = Journal canadien d'anesthesie. 1998 Nov     [PubMed PMID: 10021954]
[8] García-Leiva JM,Hidalgo J,Rico-Villademoros F,Moreno V,Calandre EP, Effectiveness of ropivacaine trigger points inactivation in the prophylactic management of patients with severe migraine. Pain medicine (Malden, Mass.). 2007 Jan-Feb     [PubMed PMID: 17244105]
[9] Lierz P,Gustorff B,Markow G,Felleiter P, Comparison between bupivacaine 0.125% and ropivacaine 0.2% for epidural administration to outpatients with chronic low back pain. European journal of anaesthesiology. 2004 Jan     [PubMed PMID: 14768921]
[10] Simon MJ,Veering BT,Stienstra R,van Kleef JW,Burm AG, The effects of age on neural blockade and hemodynamic changes after epidural anesthesia with ropivacaine. Anesthesia and analgesia. 2002 May     [PubMed PMID: 11973214]
[11] Corcoran W,Butterworth J,Weller RS,Beck JC,Gerancher JC,Houle TT,Groban L, Local anesthetic-induced cardiac toxicity: a survey of contemporary practice strategies among academic anesthesiology departments. Anesthesia and analgesia. 2006 Nov     [PubMed PMID: 17056977]
[12] Beverly A,Kaye AD,Ljungqvist O,Urman RD, Essential Elements of Multimodal Analgesia in Enhanced Recovery After Surgery (ERAS) Guidelines. Anesthesiology clinics. 2017 Jun     [PubMed PMID: 28526156]
[13] Zhou J,Fan Y,Zhong J,Wen X,Chen H, Efficacy and safety of multimodal analgesic techniques for preventing chronic postsurgery pain under different surgical categories: a meta-analysis. Scientific reports. 2017 Apr 6     [PubMed PMID: 28386070]