No significant changes in vitals. Minimal bradycardia and fall in BP observed in a few patients.  No significant events like Nausea, Vomiting, Shivering, Pruritus, Sedation, Respiratory distress etc.  No need for rescue analgesia in 30 patients (75%)  Rescue analgesia given in 10 patients (25%)

1. REGIONAL
&
NEURAXIAL BLOCKADE

2. Dr. Mridul M. Panditrao
Consultant
Department of Anesthesiology
& Intensive care
Rand Memorial Hospital
Freeport, Bahamas

3. Formerly:
PROFESSOR & HEAD
Department of Anaesthesiology &
Critical Care
Padmashree Dr. D.Y. Patil Medical
College
Pimpri, Pune

4. History: It all started with cocaine
 Incas in South Americas chewed coca leaves as a euphoriant,
dating back to 3000 B.C. (Erythroxylum coca, Coca Plant)
 Numbness of tongue was considered as a temporary side-effect
 1860: cocaine isolated coca leaves by Paolo Mantegazza, who
tested it on himself.
 1860: cocaine formulated into “Dr. Mariani's French Tonic”, for
which Dr. Mariani received a gold medal from Pope Leo XIII.
 1884: cocaine used for topical ophthalmic anesthesia by Carl
Koller (at the suggestion of Freud).

5. 1885 Advertisement !

6. History: more cocaine
 1884: cocaine used for peripheral nerve block
(Halstead)
 1886: John S. Pemberton invented Coca Cola,
combining cocaine with Cola nitida extract (kola
nut).
 1898: cocaine first for spinal anesthetic
(Karl Gustav August Bier)
 Personally developed PDPH, which he correctly diagnosed!

7. Modern local anesthetics
 1932: Tetracaine
 1943: Lignocaine (Lofgven and Lundquist)
 1957: Mepivacaine
 1960: Prilocaine
 1963: Bupivacaine
 1972: Etidocaine discovered
 1973: Etidocaine lost
 1996: Ropivacaine
 1999: Levobupivacaine

8. Two types of linkages give rise to 2 chemical
classes of local anesthetics.
ESTER LINKAGE (1 EYE!) AMIDE LINKAGE (2 EYES!!)
PROCAINE LIGNOCAINE
procaine (Novocaine) lignocaine (Xylocaine)
tetracaine mepivacaine (Carbocaine)
(Pontocaine)
bupivacaine (Anavin)
benzocaine
etidocaine (Duranest)
cocaine
ropivacaine (Ropin)

9. Lignocaine (Lignocaine)
O
N
N
Amide Linkage

10. SELECTIVE PHARMACOLOGICAL PROPERTIES
OF SOME AMIDE - type LAAs
 LIGNOCAINE
 Most widely used LA
 Effective by all routes.
 Faster onset, more intense, longer lasting, than
procaine.
 Good alternative for those allergic to ester type
 More potent than procaine but about equal toxicity
 More sedative than others

11. Bupivacaine (Anawin)
N
*
N N N
*
O O
S Bupivacaine R Bupivacaine
Enantiomer: levobupivacaine, Chirocaine
Equipotent, but less cardiotoxic than bupivacaine

12. SELECTIVE PHARMACOLOGICAL PROPERTIES
OF SOME AMIDE - type LAAs
 Bupivacaine
 No topical effect
 Slower onset and one of longer duration agents
 Unique property of sensory and motor dissociation
can provide sensory analgesia with minimal motor
block
 has been popular drug for analgesia during labor
 More cardiotoxic than other LA

13. Acute Toxicity
 Main concern is CNS and Cardiac toxicity
 CNS
 Tinnitus, dizziness, lightheadedness are early signs
 Anxiety disorientation loss of consciousness
seizures respiratory arrest
 Cardiac
 Hypotension
 All local anesthetics are negative inotropes
 PVC wide QRS Multiform vtach vfib, or
 Pattern with bupivacaine
 Bradycardia asystole
 Pattern with bupivacaine + lignocaine

14. Acute Toxicity
 With most drugs like Lignocaine, CNS toxicity
precedes cardiac toxicity, providing a warning of
impending disaster.
 With bupivacaine, acute toxicity rapidly
progresses to cardiovascular collapse.
 Pregnancy enhances the risk of cardiac toxicity.

15. Neurotoxicity
 Lignocaine
 Initially seen with formulation in 10% dextrose
 Now seen with all formulations
 No longer recommended for spinal anesthesia
 Bupivacaine appears free of neurotoxicity

16. Treatment of overdose
 Airway:
 100% oxygen
 Intubate if necessary to ventilate
 CNS:
 Break seizure with propofol, thiopental, or midazolam
 Cardiovascular
 Amiodarone has demonstrated efficacy. Use 300 mg
 Lidocaine would be a particularly poor choice!
 Resuscitation difficult with bupivacaine, more
frequently successful in animal studies following
ropivacaine and levobupivacaine overdose.

17. Dosing Guidelines
(nerve block)
Drug Onset Per Package Insert Local custom Duration
Maximum With epinephrine
Amides
Lidocaine Rapid 4.5 mg/kg 7 mg/kg 900 mg with epi 1-2 h
Mepivacaine Medium 6 mg/kg not given 750 mg 2-3 h
Etidociaine Rapid 6 mg/kg 8 mg/kg N/A 4-8h
Prilocine Medium 8 mg/kg 8 mg/kg N/A 1-2 h
Bupivacaine Slow 2.5 mg/kg 3 mg/kg 200 mg 4 - 12 h
Ropivacaine Slow 4 mg/kg No effect N/A 4-9h
Levobupivacaine Slow 2 mg/kg (!) not given 300 mg 4-8h
Esters
Procaine Rapid 10 mg/kg 15 mg/kg N/A 15-30 min
Chloroprocaine Very rapid 10 mg/kg 15 mg/kg 10 mg/kg 30-60 min
Tetracaine Slow 1.5 mg/kg 2.5 mg/kg N/A 3h

18. What is Ropivacaine Hydrochloride?
 Ropivacaine is a long-acting, local anesthetic with both
anesthetic and analgesic effects. At high doses it produces
surgical anesthesia and at lower doses it produces
analgesia (sensory block) with limited motor block..
 0.75% is indicated for surgical anesthesia
 0.2% is indicated for postoperative pain relief .

21. Ropivacaine (Ropin) ®
N
N *
O S
bupivacaine
N
Only available as pure S isomer *
N
Causes vasoconstriction
Less motor block than bupivacaine O
Otherwise, equipotent anesthesia, but less
cardiotoxic

22. SELECTIVE PHARMACOLOGICAL PROPERTIES
OF SOME AMIDE - type LA
 Ropivacaine
 Enantiomer of propivacaine (S stereoisomer)
 Structurally very similar to bupivacaine
 No topical effectiveness
 Clinically ~ equivalent to bupivacaine
 Similar sensory versus motor selectivity as bupivacaine
with significantly less CV toxicity (allegedly)

23. PHARMACOLOGY OF ROPIVACAINE
 Ropivacaine is less lipid soluble
 Less penetration in nerve fibers
 Less motor block
 Early mobilization
 Early recovery

24. PHARMACOLOGY OF ROPIVACAINE
cardio toxicity
 Less toxic effects to CVS
 Does not cause arrhythmias
 Does not cause ECG Changes
neurotoxicity
 Less toxic effects to CNS
 Ropivacaine will not cause seizures, convulsions
 Visual and hearing disturbances, paraesthesia rarely

25. Comparison of LA characteristics
Relative Relative onset pKa Local vasodilation Plasma
lipid potency duration protein
solubility binding
lignocaine 4 4 rapid 7.9 moderate +++ 55%
bupivacaine 130 16 slow 8.1 long + 90%
ropivacaine N/A 12 rapid 8.1 long ± 94%
Ropivacaine
Plasma protein binding may be used as an indirect measure of tissue binding tendencies

26. L A As in Sub- Arachnoid Block ?
Name Concen Onset Durati Reco pH Uses Toxicity
tration (min.) on mmen (pKa)
(%) (min.) ded
Max.
dose
Lignocaine 5 1-5 30-90 100 5.0-7.0 No More Neuro
With mg (7.9) longer than Cardiac
dextrose used
Bupivacaine 0.5 1-15 75-200 20 4.0-6.5 Drug of More cardiac
With mg (8.1) choice than Neuro
dextrose at
present
Ropivacaine 0.75 ???? ???? ???? N.D. Epi/infi ?????
In epi. (8.1) ltration
4mg/k
g

30. Ropivacaine intrathecally ???
 To find out the efficacy of 0.75%
Ropivacaine isobaric given
intrathecally for lower abdominal
& lower limb surgeries : A
prospective feasibility study

31. Aims & Objectives :
 To study the efficacy of 0.75% isobaric
ropivacaine in sub-arachnoid block
 To observe any side- effects of 0.75% isobaric
ropivacaine in sub-arachnoid block

32. MATERIALS & METHODS
Stringent Inclusion & Exclusion Criteria
 Age Range of 20 - 75 years
 Informed Consent
 ASA I- II
 Lower Limb/Abdominal & Gynaecological Surgeries
 Proper Pre-op. evaluation & preparation
&
 I E C Approval

33. MATERIALS & METHODS
 NBM overnight
 All Monitoring Devices
 Pre-loading with Lactated Ringer – 10 ml/kg (nearly
500ml.) 15 min. prior
 All aseptic Precautions
 L2-L3 / L3- L4 space
 26 Gz. Quinke’s Spinal needle
 Sitting or Lateral Position
 Midline intra-thecal approach

34. MATERIALS & METHODS
 3.0 ml of Ropivacaine 0.75% isobaric
 after free flow of C S F
 Supine with 10°-15° Head Down
 A pillow under the head
 Pulse/ NIBP/ SpO2 X 5 min. for first 30 min.
 No interference by surgeons permitted till the
desired level is achieved
 Infusion of R/L continued as per the requirement

35. MATERIALS & METHODS
Assessment of Neuraxial Blockade
 Sensory Block: Pin-Prick test
 Observed till T5- T6 level is achieved
 Then permitted for surgical intervention
 Motor Block: Bromage Scale
Grade Criteria Degree of block
I Free movement of legs and feet Nil (0%)
Just able to flex knees with free movement of
II Partial (33%)
feet
Unable to flex knees, but with free movement of
III Almost complete (66%)
feet
IV Unable to move legs or feet Complete (100%)
Bromage PR. Philadelphia: WB Saunders; 1978: 144

36. MATERIALS & METHODS
Intra-operative Management
 Continuous Monitoring
 Intake according to Blood loss/ Urinary output
 Side effects: N/V, Pain, Shivering, Pruritus, Sedation,
Respiratory discomfort, Sensorium etc....,if any
 Residual neuraxial/ Wearing off of blockade noted
 Visual Analog Scoring (VAS)
 VAS More than 7 ….. Rescue Analgesia...
Inj. Diclofenac Na 75mg I.M.

37. MATERIALS & METHODS
 Readings of Blockade : Observations
To Time of Giving Spinal Analgesia
T1 Time of Onset of Sensory Blockade
T2 Time of Onset of Motor Blockade
T3 Time to reach Maximum Sensory level
T4 Time to two segment regression of sensory block
T5 Time of Wearing off of Sensory Block
T6 Time of Wearing off of Motor Block
T7 First dose of rescue Analgesia

38. MATERIALS & METHODS
Optimal Surgical Conditions Score (self-devised)
Conditions 2 1 0
No.
1 Intra-operative Muscle relaxation Pronounced Minimal Nil
2 Intra-operative Bleeding Minimum Moderate Excessive
3 Post-operative Bleeding Minimum Moderate Excessive

39. Results
 Total Number of ASA I-II patients (N) = 40
 Age Range = 23- 72 yrs.
 Sex : M = 26, F= 14
 Specialty wise distribution:
Gen. Surg.= 15, Ortho.=14 , Gyne. = 6, Uro.= 5

40. Results
NO. Parameter Range Value Mean ± SD
1 Onset of Sensory block 10-300sec 69.9 ± 69.8 sec
2 Onset of Motor block 10-660sec 165.8 ± 161.7 sec
3 Peak of Sensory block 120-1320 sec 578.2± 298.0 sec
4 2 Segment Regression 60-177min 132.6 ± 36.97 min
5 Wearing off of Sensory block 62-180min 135.8 ± 34.63 min
6 Wearing off of Motor block 45-346min 118.8 ± 46.81 min
7 Time from Spinal to Rescue (1st 110-525min 255.32 ± 88.54 min
Dose of Rescue)

41. Results
 Onset of Sensory block = 1.5 min. average
 Onset of Motor block = 3.5 min. average
 Peak of Sensory block = 10min. average
 2 Segment Regression = nearly 2hrs. 30min.
 Wearing off of Sensory block = nearly 2hrs. 30min.
 Wearing off of Motor block = nearly 2hrs.
st
 Time from Spinal to Rescue (1 Dose of Rescue) =
nearly 4.5 hrs.

42. Results
Intra-operative Vitals Profile & Events
 Pulse = minimal bradycardia ,< 2 - 5% of baseline
 NIBP = minimal Fall, < 3.5- 6.8% of baseline
 SpO2 = 100% , No change, either on room air or on
O2 1 - 2 liters /min.
 No extra Fluid requirement
 No Pharmacological support required
 No specific side effects attributable to Spinal/ drug
 No sedation & comfort level of patients = adequate
 Optimal Surgical Conditions Score = 5 - 6

43. Results
Post-operative Follow-up
 No Problems specific to Spinal/ Drug in
first 24 hrs,
next 72 hrs. or
till the patients were discharged!
 On Follow-ups : No Complaints till now!

44. Results
Encouraged by these observations & results
 Used In Lower Segment Caesarian sections (LSCS)
 Specific Modification in Protocol was:
2.0 ml of intra-thecal injection
 Strict watch was kept on APGAR of the neonate
 No fall in scores have been observed till now!

45. Discussion
Comparative with other LAA
Parameter Lignocaine Ropivacaine Bupivacaine
Onset of Sensory block 1 - 5 min. 0.6 - 5 min. 1 – 15 min.
Onset of Motor block 2 - 6 min. 0.6 - 11 min 3 – 20 min
Peak of Sensory block 2 – 8 min. 2 - 22 min. 3 – 30 min
2 Segment Regression 30 -90 min. 60 - 180 min 75 – 200 min.
Wearing off of Sensory block 35 - 105 min. 60 - 180 min 80 - 210 min.
Wearing off of Motor block 45 – 120 min. 45 - 346 min 80 – 240 min.
Time from Spinal to Rescue 45 – 135 min. 110 - 525 min. 130 – 700 min.
(1st Dose of Rescue)

46. Discussion
 Ropivacaine as Ropin® is available in 0.75%, 20 & 4 ml.
 Ropivacaine as Ropin® is available in 0.2%, 20 ml.
 Has been used for Peripherral Nerve Blocks & Epidurally ＊
 Has been used for Labour Analgesia epidurally ＊
 Proven to have a very wide safety margin and safety profile＊
＊
Emanuelsson B.M. Ekblom A. Olofsson C. Reventlid H.: Ropivacaine 7.5 mg/ml for elective Caesarean section. A clinical and
pharmacokinetic comparison of 150 mg and 187.5 mg. Acta anaesthesiologica scandinavica 1997, 41, 9, . 1149-1156 ;
Kanai.A, Kinoshita S., Suzuki A., Okamoto H., Hoka S Advantage of ropivacaine for postoperative epidural analgesia following leg
orthopedic surgery [Article in Japanese] . Masui. 2005 Jan;54(1):8-13.
Turner, G.; Blake, D.; Buckland, M. Continuous Extradural Infusion of Ropivacaine for Prevention of Postoperative Pain
After,Major Orthopedic surgery :; Survey of Anesthesiology:Regional Anestheisa and Pain Control, 1997, 44, 4, 213-219
Emmanuel A, Fabienne B:Patient-Controlled Epidural Analgesia Versus Continuous Epidural Infusion with Ropivacaine for
Postoperative Analgesia in Children, Anesth Analg 2003;97:1608–11

47. Discussion
 SDERTEaL J E , Article: AstraZeneca's Local Anaesthetic
Naropin Announced an Additional Approval for a New Route
of Administration, Intrathecal (Spinal) use in the European
Union (EU). http://www.highbeam.com/doc/1G1-
113834425.html, Jan-Mar 2004
 Simpson D, Curran M, Oldfield V, Keating G : Ropivacaine
A Review of its Use in Regional Anaesthesia and Acute
Pain Management, Drugs 2005; 65 (18): 2675-2717

48. Conclusion
Ropivacaine Intra-thecally : A feasibility study
 3.0 ml. appears to be a safe dose
 Useful in all types of surgical procedures
 Onset of Sensory Block comparable to that of Lignocaine
 Onset of Motor Block comparable to that of Bupivacaine
 Peak of Sensory Block comparable to that of Bupivacaine
 2 segment regression & Wearing of Sensory and Motor
Block, Intermediate between both the drugs!
 Motor Recovery appears to be earlier than Sensory
recovery
 Safety Profile appears to be adequate

49. Conclusion
 Ropivacaine has All the Advantages of both Lignocaine and
Bupivacaine combined
 Although structurally it is similar to bupivacaine, some of the
actions are like Lignocaine
 Being a Chiral Drug (S-enantiomer) there is definitely no Cardio-
vascular toxicity
 Lesser Motor and Autonomic blocking action
 Provides Excellent Intra-operative conditions for both Surgeon as
well as Anaesthesiologist
 Appears to be safe for both Mother as well as Newborn

50. Conclusion
 Post-operative course- early, intermediate as well as
late : appears to be smooth, uneventful and adequate!
 No neurological, both short term as well as long term
problems seem to have happened till now in any of
the nearly 80 patients , we have studied (as confirmed
by the follow up!)
 The dose of 3.0 ml used may be slightly on lower side!
 Peculiarly Motor block wears off earlier than Sensory!

51. Take Home Message !
 We recommend 0.75% isobaric Ropivacaine
for intra-thecal use, with all proper
precautions & patient selection, in-depth &
vigilant intra-operative monitoring and
sincere post-operative follow-up, of short as
well as long term!