ropivicane vs marcaine

[bostonblaz]

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first, how long are you guys getting on your blocks. I came from a place that only used marcaine and using 0.5% approx 100 mg and 1:200k epi and getting 18-24 hrs, and now am using 0.5% ropivicane and getting 12 hrs at best. does this sound correct to you? using ultrasound and no other change in technique.

 

[seinfeld]

sounds about right, although i am getting 12-18hrs. i always think of 0.5% ropiv = 0.25% bupivaicaine and 0.75% ropiv = 0.5% bupiv

 

[BLADEMDA]

Here is my view: N> 5,000

0.5% ropivacaine will last just as long as 0.75% ropivacaine in terms of narcotic consumption/time to sensation.

0.5% Marcaine will last LONGER than 0.5% or 0.75% ropivacaine in terms of narcotic consumption/time to sensation. I agree that Marcaine will give you 4-6 more hours of pain relief.

That said, here is some data (peer reviewed):

http://www.anesthesia-analgesia.org/cgi/reprint/87/6/1316.pdf

http://www.ncbi.nlm.nih.gov/pubmed/...nkpos=3&log$=relatedarticles&logdbfrom=pubmed


http://www.ncbi.nlm.nih.gov/pubmed/19151302?dopt=AbstractPlus


http://www.ncbi.nlm.nih.gov/pubmed/...nkpos=2&log$=relatedarticles&logdbfrom=pubmed

 

[BLADEMDA]

1: Reg Anesth Pain Med. 1999 Nov-Dec;24(6):514-8. Links

Comment in: Reg Anesth Pain Med. 2000 Nov-Dec;25(6):659. 0.75% and 0.5% ropivacaine for axillary brachial plexus block: a clinical comparison with 0.5% bupivacaine.

Bertini L, Tagariello V, Mancini S, Ciaschi A, Posteraro CM, Di Benedetto P, Martini O.
Department of Anesthesia, Centro Traumatologico Ortopedico, Rome, Italy.
BACKGROUND AND OBJECTIVES: Although ropivacaine has been extensively studied for epidural anesthesia, very few reports exist on brachial plexus block. We therefore decided to investigate the clinical features of axillary brachial plexus anesthesia with two different concentrations of ropivacaine (0.5% and 0.75%) and to compare the results with those obtained with 0.5% bupivacaine. METHODS: Three groups of patients were randomized and prospectively studied. They received, in a double-blind fashion, 32 mL of the local anesthetic solution into the midaxilla, by a nerve-stimulator technique. Onset time in each of the stimulated nerves was recorded both for the sensory and motor block. Peak time (ready to surgery), rate of supplemental blocks, need for intraoperative opioids, duration of sensory and motor block, postoperative analgesic requirements, and patient satisfaction were also recorded. RESULTS: The rate of complete sensory and motor block observed with both ropivacaine groups was higher at 10, 15, and 20 minutes postinjection (P < .001). The mean peak time was shorter with ropivacaine than with bupivacaine (R50 = 16.37 minutes, R75 = 14.7 minutes, B = 22.3 minutes, P < .05). The quality of the anesthesia was higher with ropivacaine, as measured by the intraoperative needs for opioids and the overall patient's satisfaction (P < .05). No significant differences were noted with all the other studied parameters. CONCLUSION: Ropivacaine showed advantages over bupivacaine for axillary brachial plexus block. Because no statistical differences were found between the two ropivacaine groups, we therefore conclude that 0.75% does not add benefit and that 0.5% ropivacaine should be used to perform axillary brachial plexus blocks.

 

[Narcotized]

.

 

[BLADEMDA]

No, something sounds very odd about that. I did a ton of blocks with .5% ropivicaine as a resident and might get 12 hours at the worst. More typical was wearing out sometime in the middle of the night, around 18 hours, and not uncommon was what we nicknamed a "superblock," that being on 24 hour followup they were still blocked.

Post residency I use .5% bupivicaine and don't notice much of a difference.

"Duration of sensory blockade was longer in the bupivacaine group, 17 +/- 3 hr, than in the ropivacaine group, 13 +/- 2 hr (P < 0.0001). CONCLUSION: We conclude that bupivacaine 0.5% and ropivacaine 0.5% have a similar onset of motor and sensory blockade when used for lumbar plexus and sciatic nerve block. Analgesic duration from bupivacaine 0.5% was prolonged by four hours compared with an equal volume of ropivacaine 0.5%"

 

[USAnesthesiaDoc]

I agree that sensory blockade seems to last longer with 0.5% bupi. I've been out of residency over 4 years and do 10-20 blocks a week, with ultrasound for almost 2 years now, and with nerve stim for the years prior. Tried 0.5% ropi and 0.75% ropi and added epi, got 18 hours at best (I know this because I called patients at home the next day and saw them in the hospital on POD#1); however, frequently only got 12 hours. 0.5% bupi with epi can get you to 24 hours, sometimes. This has been my clinical experience.

 

[coprolalia]

Marcaine is also a lot cheaper than Naropin. Just better have the lipid rescue sitting nearby... (probably for the ropivacaine too, actually).

-copro

 

[BLADEMDA]

I agree that sensory blockade seems to last longer with 0.5% bupi. I've been out of residency over 4 years and do 10-20 blocks a week, with ultrasound for almost 2 years now, and with nerve stim for the years prior. Tried 0.5% ropi and 0.75% ropi and added epi, got 18 hours at best (I know this because I called patients at home the next day and saw them in the hospital on POD#1); however, frequently only got 12 hours. 0.5% bupi with epi can get you to 24 hours, sometimes. This has been my clinical experience.

We agree. My N is > 5,000 and Bupivacaine is much more reliable in getting 18-20 hours of good post op pain relief. Ropivacaine, which is an excellent drug with a better safety profile, gives a 12-18 hour block.

 

[Narcotized]

I did read that study. I also read:

"IN CONCLUSION, there was no clinical difference in onset and duration among .5% bupivicaine, .5% ropivacaine, and .75% ropivacaine when injected in equal volumes for interscalene brachial plexus blocks.... seems to be the same efficacy between equal concentrations of ropivacaine and bupivicaine."

Different experiences between different providers.

 

[Licoricestick]

Marcaine is also a lot cheaper than Naropin. Just better have the lipid rescue sitting nearby... (probably for the ropivacaine too, actually).

-copro

Levobupivacaine anyone? It's the generally preferred agent where I am, we like that we get the same duration (~18hrs) as racemic bupiv, but the hospital likes it's safety margin (racemic bupivacaine is generally disapproved of for peripheral blocks).

 

[Pilot Doc]

Levobupivacaine anyone? It's the generally preferred agent where I am, we like that we get the same duration (~18hrs) as racemic bupiv, but the hospital likes it's safety margin (racemic bupivacaine is generally disapproved of for peripheral blocks).

I don't think levobupivicaine is available in the US. "Racemic bupivicaine", aka bupivicaine, is very widely used for peripheral blocks.

 

[BLADEMDA]

I did read that study. I also read:

"IN CONCLUSION, there was no clinical difference in onset and duration among .5% bupivicaine, .5% ropivacaine, and .75% ropivacaine when injected in equal volumes for interscalene brachial plexus blocks.... seems to be the same efficacy between equal concentrations of ropivacaine and bupivicaine."

Different experiences between different providers.

You need a bigger "N" to make statements. I spoke with the authors of the study you just quoted several years ago at the ASA. They admitted to me that while the duration of Rop and BUP were the same in their study the BUP patients were much more CONSISTENT in the duration of the block. In other words, more ROP patients seemed to have shorter blocks than BUP patients.

Thus, my personal opinion about duration of analgesia is based on THOUDANDS of patients and not 60 in each group. BUP will give you a consistently longer duration of analgesia than ROP over a large number of patients. ROP is an excellent local with a great safety profile so I prefer it for lumbar plexus and sciatic blocks. But, for a long acting single shot interscalene or Femoral block BUP may be the better choice.

That said, SAFETY comes first and many will give up a few hours of analgesia for a better safety margin. Perhaps, Rop is the better choice in the ASA 4 patient?

Blade

 

[Narcotized]

Getting back to the original comment, I find 12 hours to be the bare minimal block we were getting with .5% ropivacaine in our program, not the maximal. Collectively we did thousands of blocks and I took an extreme interest in regional and gathered experiences from other residents. When I use ultrasound it is very thorough. I don't just locate the nerve. I adjust the needle usually at least one or more times and the nerve is completely surrounded and soaked in anesthetic. I have not compared exact numbers, but the ropivacaine blocks were rather lengthy and I have not found a noticably difference with bupivicaine at this time, but I haven't measured it in an exact manner either.

Many potential variables exist. For example, maybe stimulator only blocks which aren't necessarily right on the nerve do better with bupivicaine while more exact ultrasound guided blocks completely dousing the nerve don't measure an appreciable difference. Whatever the answer is, I can this for sure, a 12 hour block where I trained was a pretty poor result with .5% ropivacaine, and definitely far from best result (which as I stated went over 24 hours not infrequently).

 

[Narcotized]

I agree with Narcotized.

Dream, what drugs and doses do you use, and how long are your blocks lasting?

 

[BLADEMDA]

I did read that study. I also read:

"IN CONCLUSION, there was no clinical difference in onset and duration among .5% bupivicaine, .5% ropivacaine, and .75% ropivacaine when injected in equal volumes for interscalene brachial plexus blocks.... seems to be the same efficacy between equal concentrations of ropivacaine and bupivicaine."

Different experiences between different providers.

Please do an EXTENSIVE literature search and speak with the GURUS at Academia. Even with your U/S 0.5% BUP gives a RELIABLY longer block than 0.5% Rop. Yes, that ONE study showed BUP and ROP were similar but I spoke with the LEAD author and he personally agreed that BUP is more reliable for a longer duration of analgesia.

Bup is CHEAPER and lasts LONGER than ROP. How much longer? Probably just a few hours (4?) so SAFETY is paramount when choosing a local.