|Year : 2019 | Volume
| Issue : 1 | Page : 44-49
A comparative study between the effect of intrathecal hyperbaric bupivacaine with fentanyl and hyperbaric levobupivacaine with fentanyl for knee arthroscopy
Ayman Esmail Hussien, Mohamed Adel Gawad Abdel Halim
Department of Anesthesiology and Intensive Care, Faculty of Medicine, Al-Azhar University, Cairo, Egypt
|Date of Submission||21-Sep-2018|
|Date of Acceptance||10-Mar-2019|
|Date of Web Publication||3-Jun-2019|
Ayman Esmail Hussien
Source of Support: None, Conflict of Interest: None
Background The use of levobupivacaine as a pure S (−) enantiomer of bupivacaine was progressively increased due to lower cardiotoxicity and neurotoxicity and shorter motor block duration. The aim of this work was to compare the effectiveness of lower-dose local anesthetics’ use together with higher opioid dose to decrease the side effects of drugs. We compared sensorial, motor block levels and side effects of equal doses of hyperbaric bupivacaine and levobupivacaine with intrathecal fentanyl addition in knee arthroscopy.
Patients and methods After hospital ethics committee approval and getting written informed consent from patients, 100 patients with American Society of Anesthesiologists grade I–II, aged 18–40 years were included in the study. They were randomized to either group A receiving 7.5 mg (1.5 ml) hyperbaric levobupivacaine with 25 μg (0.5 ml) fentanyl, or group B receiving 7.5 mg (1.5 ml) hyperbaric bupivacaine with 25 μg (0.5 ml) fentanyl.
Results Hemodynamic parameters such as the 45th minute mean arterial pressure of group B was found to be lower (P<0.05). In group A, maximum sensorial block level and postoperative visual analog scale scores were higher (P<0.05). Onset of motor block time, time to maximum motor block, time to sensorial block, reversal of two dermatome and first analgesic need were similar in both groups.
Conclusion Intrathecal hyperbaric levobupivacaine–fentanyl combination is a better and good alternative to bupivacaine–fentanyl combination in knee arthroscopy, as it maintains hemodynamic stability.
Keywords: fentanyl, hyperbaric bupivacaine, hyperbaric levobupivacaine, knee arthroscopy, motor block, sensory block, spinal anesthesia
|How to cite this article:|
Hussien AE, Abdel Halim MG. A comparative study between the effect of intrathecal hyperbaric bupivacaine with fentanyl and hyperbaric levobupivacaine with fentanyl for knee arthroscopy. Sci J Al-Azhar Med Fac Girls 2019;3:44-9
|How to cite this URL:|
Hussien AE, Abdel Halim MG. A comparative study between the effect of intrathecal hyperbaric bupivacaine with fentanyl and hyperbaric levobupivacaine with fentanyl for knee arthroscopy. Sci J Al-Azhar Med Fac Girls [serial online] 2019 [cited 2019 Aug 24];3:44-9. Available from: http://www.sjamf.eg.net/text.asp?2019/3/1/44/259530
| Introduction|| |
For the local anesthetic selection, it is known that the agent onset and duration of action, sensorial block level to motor block level and cardiac toxicity should be considered. An overall 0.5% heavy bupivacaine is more commonly used for spinal anesthesia for knee arthroscopy . Levobupivacaine, being the S enantiomer of bupivacaine, is less cardiotoxic and less neurotoxic in cases of accidental intravascular injection and has a shorter duration of motor block than racemic bupivacaine; its use has increased progressively ,. There is the clinical profile of potency for motor block for the pipecolylxlidines when administered spinally: low, intermediate, and high for ropivacaine, levobupivacaine, and bupivacaine, respectively ,.
The use of low doses of anesthetics and opioids in spinal anesthesia was reported to have advantages such as faster onset of action, better efficacy with minimum toxic effect and selective sensorial block . Fentanyl can be combined with local anesthetics for spinal anesthesia, and, when used in this way, it prolongs the duration of action and spread of sensory block as well . Fentanyl has been combined with bupivacaine for lower limb surgery and also for inguinal herniorrhaphy and cesarean section ,,,. We planned to compare the onset and duration of action, sensorial and motor block levels, and side effects of equal doses of hyperbaric bupivacaine and levobupivacaine with intrathecal fentanyl addition in spinal technique in knee arthroscopy.
| Aim of work|| |
The aim of this work was to compare the effectiveness of low-dose levobupivacaine and bupivacaine with fentanyl in unilateral block for knee arthroscopy.
| Patients and methods|| |
This study across sectional comparative study was carried out after approval of the hospital ethical committee in Al-Azhar University Hospitals and informed consent was obtained in all patients; this study was carried out during the period spanning from 20/10/2017 to 20/10/2018.
One hundred patients aged between 18 and 40 years, classified as American Society of Anesthesiologists grades I–II of both sexes undergoing knee arthroscopy surgery were included in the study. Patients with a history of allergy to any drug of the study and with any contraindication to regional anesthesia were excluded. Patients were divided equally into the two groups by a randomized table created by a computer software program using sealed envelopes:
Group A received 7.5 mg (1.5 ml) hyperbaric levobupivacaine and 25 μg (0.5 ml) fentanyl. Group B received 7.5 mg (1.5 ml) hyperbaric bupivacaine and 25 μg (0.5 ml) fentanyl.
The primary outcomes
The primary outcome of the study was the intensity of block as regards the onset and duration of sensory and motor blockade.
The secondary outcomes
The secondary outcomes of the study were the hemodynamic changes, postoperative analgesia, and incidence of complications.
All patients were evaluated by medical history and a complete physical examination. No premedication was administered. Hemodynamic parameters were recorded with ECG, systolic and diastolic blood pressure, heart rate and oxygen saturation (SpO2). Intravenous prehydration with 500 ml of 0.9% isotonic NaCl infusion was administered. Hypotension, defined as a decrease of systolic blood pressure more than 20% from baseline or a fall below 90 mmHg, was treated with incremental intravenous doses of 3 mg of ephedrine and intravenous fluid as required, and bradycardia, defined as a heart rate below 50 beats/min, was treated with 0.3–0.6 mg of intravenous atropine.
Patients were placed on the operation table in the sitting position and were administered 3 ml (60 mg) 2% lidocaine infiltration anesthesia through L3–4 after sterilization with antiseptic solution (povidone iodine). The intrathecal space was reached with a 27 G spinal needle (Standard Quincke Babcock, Cutting Sharp Bevel). After intrathecal injection of anesthetic drugs, patients were placed in the lateral position for 10 min to achieve unilateral block and then returned to the supine position.
The ice cubes were used for sensorial block evaluation (onset, offset) and sensorial block reversal time. The time of the first analgesic need was recorded as first analgesia time.
Bromage scale was used for assessment of the intensity of motor block. In the Bromage scale, the intensity of motor block is assessed by the patient’s ability to move their lower extremities as follows: 0=free movement of legs and feet; 1=just able to flex knees with free movement of feet; 2=unable to flex knees, but with free movement of feet; and 3=unable to move legs or feet.
‘Onset of motor block’ is recorded as when Bromage scale is ‘1’ after administration of local anesthetics, and ‘onset of highest motor block’ is recorded as time to reach the highest scale of motor block. ‘Operation duration’ is recorded as time until end of operation after administration of local anesthetics.
Pain intensity was recorded during skin incision, 2 and 4 h postoperatively by visual analog scale (VAS). Before operation, VAS was explained to patients as ‘0’ no pain and ‘10’ intolerable pain. During operation, in cases where analgesia was insufficient (VAS: 3–4), patients were excluded from the study in both groups.
The hemodynamic parameters [systolic, diastolic blood pressure, heart rate and oxygen saturation (SpO2)] were recorded at 0, third, and fifth minutes and every 5 min after injection of local anesthesia. Sensorial and motor block was recorded at the first, third, and fifth minutes, and it was recorded every 15 min until reversal of motor block.
Side effects such as pruritus, nausea, vomiting, anxiety, and respiratory depressions were followed-up 24 h postoperatively ([Figure 1]).
Statistical analysis was performed by statistical package for the social sciences for Windows 17.0 program Version 22.0 (SPSS Inc., Chicago, Illinois, USA). All data were expressed as means, SD, and frequency. Statistical significance was accepted as P value less than 0.05. The comparison between groups was tested using the independent t test. The comparisons within groups were tested using Fisher’s exact test and χ2 test.
| Results|| |
Demographic data of study
A total of 100 patients were included in the study. However, in 20 patients, due to insufficient regional anesthesia, additional local anesthetics were given, and the patients were excluded from the study, as the doses were changed.
Statistically nonsignificant differences were detected among the groups with respect to age, weight, and height ([Table 1]).
Anesthesia determination parameters
There was statistically no significant difference between groups at the first minute motor block level; however, the third and fifth minute motor block levels were significantly different between groups ([Table 2]). The Bromage score at the third minute in group A was ‘1’, and it was ‘2’ in group B. The Bromage score at the fifth minute was ‘2’ in group A and ‘3’ in group B.
Maximum motor block level and time to end of motor block were found to be higher in the bupivacaine group B (P<0.05).
The onset of motor block time, time to maximum motor block, time to sensorial block, reversal of two dermatome, and first analgesic need were similar in both groups ([Table 3]). Reversal of motor block was statistically significantly different between groups, and the mean value of group B was statistically significantly higher than that of group A.
The basal heart rate of group A was 93.10±14.14 beats/min and 89.21±12.78 beats/min in group B. There was a statistically significant difference between the heart rate of groups ([Table 4]).
Preoperative mean arterial pressure (MAP) of group A was 94.20±14.33 mmHg, and MAP of group B was 91.68±09.27 mmHg. There was a statistically significant difference between MAP of groups at the 40th minute (P<0.05); the MAP of group A (86.30±8.80 mmHg) was statistically significantly higher than that of group B (79.32±08.90 mmHg). At other time measurements, there was a statistically nonsignificant difference between the MAP of groups ([Table 5]).
Visual analog scale
Postoperative VAS was found to be higher in the levobupivacaine group (group A) (P<0.05). There was a significantly nonsignificant difference between VAS scores of both groups at skin incision. However, postoperative 30th and 60th minute VAS distribution of groups was statistically significantly different ([Figure 2]).
Side effects of groups
There was a statistically significant difference in the incidence of side effects between groups ([Table 6]) (P<0.05).
| Discussion|| |
There was increased popularity of regional anesthesia among anesthetists in knee arthroscopy. Regional anesthesia has some risks; deaths are primarily related to excessive high regional blocks and toxicity of local anesthetics. Reduction in doses and improvement in technique to avoid higher block levels and heightened awareness of the toxicity of local anesthetics have contributed to the reduction of complications related to regional anesthesia .
Over the last decade, spinal anesthesia has been refined with the addition of opioids to local anesthetic solutions. It was reported that use of only local anesthetics in knee arthroscopy operation under spinal anesthesia is not sufficient in the prevention of pain during manipulation, has a short duration of action, and has disadvantages such as the early need for analgesia ,,. The addition of morphine significantly prolongs postoperative analgesia to 18–24 h, whereas the more lipophilic opioids such as sufentanil and fentanyl improve and prolong intraoperative analgesia and reduce the amount of local anesthetics required to perform sufficient block intensity necessary for knee arthroscopy. By adding opioids to spinal anesthesia, a reduction in local anesthetic dose is possible. This reduction in local anesthetic requirements reduces the intensity and duration of motor blockade and allows patients to ambulate faster. Initial reports on low-dose spinal anesthesia suggest that this may also reduce hypotension .
Heavy bupivacaine 0.5% is most commonly used for spinal anesthesia for knee arthroscopy. Many studies have claimed successful anesthesia with very low doses of intrathecal bupivacaine (5–9 mg) when coadministered with opioids . Kim and Moneta  advocated the use of 7.5 mg bupivacaine for knee arthroscopy, as this dose was associated with a decreased incidence of hypotension, but, again, a large number of patients rated the analgesic quality as poor. Ginosar et al. , reported ED50 and ED95 of hyperbaric bupivacaine in cesarean section with combined spinal epidural technique were 7.6 and 11.2 mg, respectively. In our study, anesthesia was successful with 25 μg fentanyl added to 7.5 mg hyperbaric bupivacaine. Only in 20 patients, it was not sufficient, and local anesthetics were administered.
Because of the lower cardiovascular side effect and central nervous system toxicity, the use of levobupivacaine as the pure S (−) enantiomer of bupivacaine has progressively increased ,. Epidural levobupivacaine has the advantage of decreased cardiotoxicity in cases of accidental intravascular injection . Parpaglioni et al.  reported the minimum intrathecal levobupivacaine dose to be 10.58 mg. Alley et al.  evaluated three intrathecal doses of levobupivacaine and bupivacaine (4, 6, and 8 mg) in healthy volunteers and found no differences in the clinical profile of sensory and motor blocks and recovery from spinal anesthesia. In some studies, levobupivacaine and racemic bupivacaine showed an undistinguishable clinical profile in spinal anesthesia ,.
In the selection of local anesthetics, it is desired that the agent’s onset of action is short, the duration of action is longer and sensorial block level to motor block level is higher. Camorcia et al.  reported that intrathecal 0.5% levobupivacaine had weaker motor block potency than 0.5% bupivacaine in CSE anesthesia technique. In our study, levobupivacaine had lesser motor potency. Bromage score at the third and fifth minutes was one to two in levobupivacaine and two to three in bupivacaine. In contrast, maximum sensorial block level was found to be higher in the levobupivacaine group.In our study, preoperative VAS scores were similar in both groups, whereas postoperative 2 and 4 h VAS scores were lower in the bupivacaine group than in the other group.
Intrathecal opioid administration has side effects in both groups, such as nausea, vomiting, pruritus, respiratory depression, and urinary retention . Highly lipid soluble opioids cause temporary pruritus, whereas intrathecal morphine causes long-acting and intensive pruritus .
In the study by Bremerich and colleagues, fixed doses of intrathecal hypertonic levobupivacaine 0.5% (10 mg) and bupivacaine 0.5% (10 mg) combined with either intrathecal fentanyl (10 and 20 μg) or sufentanil (5 μg) were compared in terms of sensory and motor block characteristics. However, we compared the lesser 7.5 mg hyperbaric levobupivacaine and 7.5 mg bupivacaine combined with higher fentanyl dose (25 μg) than that used in the study by Bremerich et al. . Moreover, in the study of Gautier et al. , different doses than that of our study were used.
Intrathecal 7.5 mg hyperbaric levobupivacaine and 25 μg fentanyl combination is a good alternative to 7.5 mg bupivacaine 25 μg fentanyl combination in knee arthroscopy, as it maintains hemodynamic stability at higher sensorial block levels.
| Conclusion|| |
Intrathecal hyperbaric low-dose levobupivacaine–fentanyl combination is a better and good alternative to bupivacaine–fentanyl combination in knee arthroscopy, as it maintains hemodynamic stability.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Liu SS, Ware PD, Allen HW, Neal JM, Pollock JE. Dose response characteristics of spinal bupivacaine in volunteers. Clinical applications for ambulatory anesthesia. Anesthesiology 1996; 85:729–736.
Pittoni G, Teffeletto F, Calcarella G, Zanette G, Giron GP. et al.
.. Spinal anesthesia in outpatient knee surgery: 22-gauge versus 25-gauge Sprotte needle. Anesth Analg 1995; 81:73–79.
Ben-David B, Solomon E, Levin H, Admoni H, Goldik Z, Vaida S. Spinal bupivacaine in ambulatory surgery: the effect of saline dilution. Anesth Analg 1996; 83:716–720.
White PF. Outpatient anesthesia. In: Miller RD, ed. Anesthesia. 3rd ed. New York: Churchill Livingston e; 1990. 2025–2059
Akerman B, Helberg B, Trossvik C. Primary evaluation of the local anesthetic properties of the amino amide agent ropivacaine (LEA 103). Acta Anesthesiol Scand 1988; 32:571–578.
Gupta A, Axelsson K, Thörn SE, Matthiessen P, Larsson LG.
Low-dose bupivacine plus fentanyl for spinal anesthesia during ambulatory inguinal herniorrhapy: a comparison between 6 mg and 7.5 mg of bupivacaine. Acta Anesthesiol Scand 2003; 47:13–19.
Ben-David B, Solomon E, Levin H et al.
Intrathecal fentanyl with small dose dilute bupivacaine: better anesthesia without prolonging recovery. Anesth Analg 1997; 85:560–565.
Barkshire K, Russell R, Burry J, Popat M. A comparison of bupivacaine-fentanyl-morphine with bupivacaine-fentanyl-diamorphine for Cesarean section under spinal anesthesia. Int J Obst Anesthesia 2001; 10:4–10.
Casimiro C, Rodrigo J, Mendiola MA, Rey F, Barrios A, Gilsanz F. Levobupivacaine plus fentanyl versus racemic bupivacaine plus fentanyl in epidural anesthesia for lower limb surgery. Minerva Anesthesiol 2008; 74:381–391.
Albright GA, Ferguson JE, Joyce TH, Stevenson DK. Anesthesia in obstetrics: maternal, fetal and neonatal aspects. 2d ed. Boston, MA: Butterworths 1986. 622.
Bogra J, Arora N, Srivastava P. Synergistic effect of intrathecal fentanyl and bupivacaine in spinal anesthesia for cesarean section. BMC Anesthesiol 2005; 5:5.
Hamber EA, Viscomi CM. Intrathecal lipophilic opioids as adjuncts to surgical spinal anesthesia. Reg Anesth Pain Med 1999; 24:255–263.
Kim KC, Moneta MD. Unilateral spinal anesthesia can be obtained with low dose bupivacaine. Anesthesiology 1992; 77:A803.
Ginosar J, Mirikatani E, Drover DR, Cohen SE, Riley ET. ED50 and ED95 of intrathecal hyperbaric bupivacaine co administered with opioids for cesarean delivery. Anesthesiology 2004; 100:676–682.
Glaser C, Marhofer P, Zimpfer G, Heinz MT, Sitzwohl C, Kapral S, Schindler I. Levobupivacaine versus racemic bupivacaine for spinal anesthesia. Anesth Analg 2002; 94:194–198.
Kopacz DJ, Allen HW. Accidental intravenous levobupivacaine. Anesth Analg 1999; 89:1027–1029.
Parpaglioni R, Frigo MG, Lemma A, Sebastiani M, Barbati G. Minimum local anesthetic dose (MLAD) of intrathecal levobupivacaine and ropivacaine for cesarean section. Anesthesia 2006; 61:110–115.
Alley EA, Kopacz DJ, McDonalds SB, Liu SS. Hyperbaric spinal levobupivacaine: a comparison to racemic bupivacaine in volunteers. Anesth Analg 2002; 94:188–193.
Lee YY, Muchhal K, Chan CK. Levobupivacaine versus racemic bupivacaine in spinal anesthesia for urological surgery. Anesth Intensive Care 2003; 31:637–641.
Gautier P, de Kock M, Huberty L, Demir T, Izydorczic M.
Comparison of the effects of intrathecal ropivacaine, levobupivacaine, and bupivacaine for cesarean section. Br J Anesth 2003; 91:684–689.
Camorcia M, Capogna G, Beritta C, Columb MO. The relative potencies for motor block after intrathecal ropivacaine, levobupivavacaine, and bupivacaine. Anesth Analg 2007; 104:904–907.
Dahl JB, Jeppesen IS, Jorgensen H, Wetterslev J, Moiniche S. Intraoperative and postoperative analgesic efficacy and adverse effects of intrathecal opioids in patients undergoing cesarean section with spinal anesthesia: a qualitative and quantitative systematic review of randomized controlled trials. Anesthesiology 1999; 91:1919–1927.
Bremerich DH, Fetsch N, Zwissler BC, Meininger D, Gogarten W, Byhahn C.Comparison of intrathecal bupivacaine and levobupivacaine combined with opioids for Cesarean section. Curr Med Res Opin 2007; 23:3047–3054.
[Figure 1], [Figure 2]
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6]