ERAS has gained so much popularity in orthopedic surgery as we all know that standardized ERAS program has shown to reduce postoperative morbidity and length of hospital stay (LOS). Lately, in our facility, we have been emphasizing early ambulation and physical therapy for the patients right after surgery. Surgeons want patients to have patient’s motor function back quickly after surgery so that patients can participate in the physical therapy after total knee/hip replacement. Bupivacaine is gold standard for spinal block. Bupivacaine causes more motor block compared to ropivacaine. In addition, bupivacaine is more cardiotoxic than ropivacaine. Recent studies have shown that ropivacaine provides effective spinal anesthesia for lower limb and hip surgeries. Hence one may postulate that the use of ropivacaine in spinal block may be a better choice for the ERAS patients.
Bhat et al. compared efficacy of ropivacaine vs bupivacaine among 70 patients who had lower limb and abdominal surgeries. Group A received 3 ml of (0.5%) isobaric bupivacaine (15 mg) and Group B 3 ml of (0.75%) isobaric ropivacaine (22.5 mg). He found that onset of motor blockade was comparable in both the groups but duration of motor blockade was significantly shorter in ropivacaine group. Although the study may have its drawback such as the dosage of ropivacaine is not the same as bupivacaine, but even with higher dosage of ropivacaine, the motor blockade was shorter. In addition, hemodynamically, ropivacaine group was more stable as shown below.
PF Fentanyl often used as an adjuvant to improve the quality of spinal block. In a study by Jagtap et al. intrathecal 15 mg 0.5% ropivacaine with 25 mcg fentanyl (Group RF) or 15 mg 0.5% bupivacaine with 25 mcg fentanyl (Group BF) were used to compared the onset, duration, spread of sensory and motor block. Similarly to the other study’s finding, they found that the ropivacaine group provided similar sensory but shorter duration of motor block compared to bupivacaine group. This is desirable for early ambulation and participating physical therapy for the total hip/knee patients.
In another study by Dar et al. intrathecal injection of 3 ml of ropivacaine 0.5% and 3 ml of bupivacaine 0.5% were used to compare the onset and duration of motor block, the onset of sensory block (6 ± 1.3 min vs. 3 ± 1.1 min) and motor block (13 ± 1.6 min vs. 9 ± 1.3 min; P < 0.05) was significantly slower in ropivacaine group as compared to bupivacaine group. The total duration of sensory block was significantly shorter in the ropivacaine group (160 ± 12.9 min) than in the bupivacaine group (260 ± 16.1 min; P < 0.05). The duration of motor block was also shorter in the ropivacaine group compared to bupivacaine group (126 ± 9.2 min vs. 174 ± 12.6 min).
So as we can see from the above 3 studies, if for the routine TKR, 3ml 0.5ml ropivacaine should suffice for the need of surgery. For hip surgery, PF fentanyl may be needed to improve the quality of the ropivacaine block but it would not delay the return of the motor function. For revision of the hip or knee, more ropivacaine may be needed for the dosing of spinal which would give longer duration of sensory block as needed for the surgery.
Let me know what your thoughts on this and if you have used ropivacaine in your practice, please share your experience with us.
Have a great week!
Jagtap S, Chhabra A, Dawoodi S, Jain A.Comparison of intrathecal ropivacaine-fentanyl and bupivacaine-fentanyl for major lower limb orthopaedic surgery: A randomised double-blind study. Indian J Anaesth. 2014 Jul;58(4):442-6.
Bhat SN1, Himaldev1, Upadya M1. Comparison of efficacy and safety of ropivacaine with bupivacaine for intrathecal anesthesia for lower abdominal and lower limb surgeries.Anesth Essays Res. 2013 Sep-Dec;7(3):381-5. doi: 10.4103/0259-1162.123252.
Dar FA1, Mushtaq MB1, Khan UM1. Hyperbaric spinal ropivacaine in lower limb and hip surgery: A comparison with hyperbaric bupivacaine. J Anaesthesiol Clin Pharmacol. 2015 Oct-Dec;31(4):466-70. doi: 10.4103/0970-9185.169064.