Levobupivacaine or ropivacaine: A randomised double blind controlled trial using equipotent doses in spinal anaesthesia

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SBP: Systolic Blood Pressure." ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "Diana Bolaños-Arboleda, Nelson Javier Fonseca-Ruiz, Nury Isabel Socha-García, Edward García-Peñuela, Germán Monsalve-Mejía" "autores" => array:5 [ 0 => array:2 [ "nombre" => "Diana" "apellidos" => "Bolaños-Arboleda" ] 1 => array:2 [ "nombre" => "Nelson Javier" "apellidos" => "Fonseca-Ruiz" ] 2 => array:2 [ "nombre" => "Nury Isabel" "apellidos" => "Socha-García" ] 3 => array:2 [ "nombre" => "Edward" "apellidos" => "García-Peñuela" ] 4 => array:2 [ "nombre" => "Germán" "apellidos" => "Monsalve-Mejía" ] ] ] ] ] "idiomaDefecto" => "en" "Traduccion" => array:1 [ "es" => array:9 [ "pii" => "S0120334716300077" "doi" => "10.1016/j.rca.2016.01.008" "estado" => "S300" "subdocumento" => "" "abierto" => array:3 [ "ES" => true "ES2" => true "LATM" => true ] "gratuito" => true "lecturas" => array:1 [ "total" => 0 ] "idiomaDefecto" => "es" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S0120334716300077?idApp=UINPBA00004N" ] ] "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2256208716300037?idApp=UINPBA00004N" "url" => "/22562087/0000004400000002/v1_201604260026/S2256208716300037/v1_201604260026/en/main.assets" ] "en" => array:20 [ "idiomaDefecto" => true "cabecera" => "Scientific and Technological Research" "titulo" => "Levobupivacaine or ropivacaine: A randomised double blind controlled trial using equipotent doses in spinal anaesthesia" "tieneTextoCompleto" => true "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "97" "paginaFinal" => "104" ] ] "autores" => array:1 [ 0 => array:4 [ "autoresLista" => "Manazir Athar, Syed Moied Ahmed, Shahna Ali, Kashmiri Doley, Ankur Varshney, Mohd. Masood Hussain Siddiqi" "autores" => array:6 [ 0 => array:2 [ "nombre" => "Manazir" "apellidos" => "Athar" ] 1 => array:4 [ "nombre" => "Syed Moied" "apellidos" => "Ahmed" "email" => array:1 [ 0 => "sma99@rediffmail.com" ] "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "*" "identificador" => "cor0005" ] ] ] 2 => array:2 [ "nombre" => "Shahna" "apellidos" => "Ali" ] 3 => array:2 [ "nombre" => "Kashmiri" "apellidos" => "Doley" ] 4 => array:2 [ "nombre" => "Ankur" "apellidos" => "Varshney" ] 5 => array:2 [ "nombre" => "Mohd. Masood Hussain" "apellidos" => "Siddiqi" ] ] "afiliaciones" => array:1 [ 0 => array:2 [ "entidad" => "Department of Anaesthesiology and Critical Care, Jawaharlal Nehru Medical College, Aligarh Muslim University, UP, India" "identificador" => "aff0005" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author at: Department of Anaesthesiology and Critical Care, Jawaharlal Nehru Medical College, Aligarh Muslim University, 202002, Uttar Pradesh, India." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Levobupivacaína o ropivacaína: un ensayo aleatorio doble ciego controlado con dosis equipotentes en la anestesia espinal" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:8 [ "identificador" => "fig0025" "etiqueta" => "Fig. 3" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "fuente" => "Source: Authors." "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr3.jpeg" "Alto" => 948 "Ancho" => 1578 "Tamanyo" => 96594 ] ] "descripcion" => array:1 [ "en" => "Block characteristics." ] ] ] "textoCompleto" => "IntroductionTraditionally, bupivacaine has been the drug of choice for the subarachnoid block. However, significantly long duration of action delays recovery of motor function and prolongs post-anaesthesia care unit stay. In addition, several studies have shown that bupivacaine produces higher neurological and cardiac toxicity compared to other local anaesthetics.<a class="elsevierStyleCrossRef" href="#bib0185">1</a> The problems associated with the toxicity of racemic bupivacaine triggered the development of alternative suitable ‘single enantiomeric’ local anaesthetic agents with low cardiac and CNS toxicity. Levobupivacaine and Ropivacaine are two relatively new amide local anaesthetic agents that have been produced in order to address the issues of bupivacaine toxicity.Levobupivacaine is a high potency, long-acting local anaesthetic with a relatively slow onset of action.<a class="elsevierStyleCrossRef" href="#bib0190">2</a> It has a lower propensity to block inactivated sodium and potassium channels along with faster rate of dissociation compared to its racemic form.<a class="elsevierStyleCrossRef" href="#bib0195">3</a> The majority of in vitro, in vivo and human pharmacodynamic studies of nerve block indicate that levobupivacaine has similar potency, yet lower risk of cardiovascular and CNS toxicity than bupivacaine.<a class="elsevierStyleCrossRef" href="#bib0200">4</a> So, having a higher threshold for cardiac and neurotoxicity compared to racemic bupivacaine, anaesthetists feel safer working with levobupivacaine<a class="elsevierStyleCrossRef" href="#bib0205">5</a> and has the potential to replace bupivacaine as the standard drug.<a class="elsevierStyleCrossRef" href="#bib0210">6</a>Ropivacaine is the ‘S’ isomer of the propyl analogue of bupivacaine with longer duration of action, low lipid solubility, low potency and low cardiovascular and CNS toxicity.<a class="elsevierStyleCrossRef" href="#bib0215">7</a> Ropivacaine blocks nerve fibres involved in pain transmission (Aδ and C fibres) to a greater degree than those controlling motor function (Aβ fibres).<a class="elsevierStyleCrossRef" href="#bib0220">8</a> Therefore, ropivacaine has been found to induce less intense motor blockade than bupivacaine. Hence, its comparatively shorter duration, faster recovery of motor function and lower toxicity profile have been identified as a potential benefit for surgery of intermediate duration as well as for ambulatory surgery in day care surgical units.In the present era of evidence-based medicine, each step of our management is thoroughly evaluated by properly controlled, peer-reviewed medical research, and subarachnoid block is not an exception. The concept of a single shot with bupivacaine can do all is now questioned and necessitate the judicious use of safer substitutes. As of Casati et al.<a class="elsevierStyleCrossRef" href="#bib0225">9</a> theoretical as well as experimental differences do exist in toxicology and clinical profiles due to different anaesthetic potencies of these isomeric forms of bupivacaine, but reflections of these characteristics into clinical practice have not been evident so far. So, we have to explore the typical characteristics and potential uses of these newer drugs. Many studies have been done to compare various forms of bupivacaine, ropivacaine and levobupivacaine. However, most of them have used low doses which may be inadequate for hip surgeries.<a class="elsevierStyleCrossRef" href="#bib0230">10</a> Furthermore, they have generally used hyperbaric forms<a class="elsevierStyleCrossRefs" href="#bib0235">11,12</a> and potency ratio between levobupivacaine and ropivacaine was not taken into consideration.<a class="elsevierStyleCrossRef" href="#bib0245">13</a>Therefore, this study was conducted to compare the efficacy and characteristics of isobaric forms of intrathecal levobupivacaine 0.5% with ropivacaine 0.75% in equipotent doses for lower limb orthopaedic surgery.MethodologyFollowing approval by the Institutional Ethics Committee [(Ref. No. D1303/FM) and Clinical Trial Registry No. (<a id="intr0015" class="elsevierStyleInterRef" href="https://clinicaltrials.gov/NCT02201784">NCT02201784</a>)] and written informed consent, this prospective, randomised, double-blind, controlled, equivalence trial was conducted on sixty ASA grade I/II patients of either sex, aged between 18 and 60 years undergoing spinal anaesthesia for lower limb orthopaedic surgery. Patients with contraindication for spinal anaesthesia, known allergy to local anaesthetic drugs and patients having h/o diabetes, neurological or musculoskeletal diseases that could make our technique difficult were excluded. The patients were randomly divided into two groups of 30 each (group L and group R) by computer-generated randomisation (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>). Patients in group L received 3ml levobupivacaine 5mg/ml (15mg of LEVO-ANAWIN® 0.5% Neon Laboratories Ltd.) while in group R received 3ml ropivacaine 7.5mg/ml (22.5mg of ROPIN® 0.75% Neon Laboratories Ltd.). All drugs were loaded by an anaesthetist who did not have any involvement in further patient assessment while another anaesthetist administered anaesthesia and assessed all patients. Patients had standard monitoring including electrocardiography, pulse oximetry and non-invasive blood pressure monitoring (NIBP). Baseline heart rate (HR), NIBP and arterial oxygen saturation (SpO2) were measured. All patients received oxygen via Hudson mask at the rate of 6l/min until the surgery ends. Intravenous (IV) access was secured, patients were premedicated with i.v. ondansetron 0.1mg/kg body weight and preloading done with lactated Ringer's (LR) solution 15ml/kg body weight. Under strict aseptic precautions, skin was infiltrated with lidocaine 2% and lumbar puncture was performed in the sitting position with a 25-G Quincke spinal needle (Becton Dickinson, Madrid, Spain), using a midline approach at the L3–4 intervertebral space. Correct needle placement was identified by free flow of CSF and confirmed by aspiration and reinjection of CSF before and after the administration of the study drug solution. The study drug was injected over 20s. After the injection of the spinal medication, the patients were placed supine immediately, the time of which was recorded as ‘zero’. The level of sensory block was assessed every 5min till the loss of sensation to pinprick, using a 22-guage hypodermic needle with 2mm protrusion through the guard. Assessments continued at 30min intervals following the completion of surgery until normal sensation returned. After confirming the loss of sensation at T10 dermatome in comparison to C5–6 dermatome, patients were given i.v. midazolam 0.03mg/kg body weight and surgeons were allowed to proceed for the surgery. Inability to achieve T10 sensory level within 30min was considered as ‘Failure’. These patients were administered general anaesthesia. They were not included for analysis but only reported as total number of failures according to per protocol analysis. Motor block in the lower limbs was graded according to the modified Bromage scale<a class="elsevierStyleCrossRef" href="#bib0250">14</a> (Grade 0=No motor block, Grade 1=Inability to raise extended leg, able to move knees and feet, Grade 2=Inability to raise extended leg and move knee, able to move feet, Grade 3=Complete motor block of the lower limbs). Thereafter, it was performed every 5min till the attainment of MB grade 3 followed by every 30min until complete recovery (MB grade 0). HR, NIBP and SpO2 was recorded before induction, every 3min till 15min, then, every 15min until discharge from the recovery room. Hypotension was defined as systolic BP<90mmHg and was treated with inj. mephenteramine of 6mg i.v bolus and fluids. Bradycardia was defined as HR<50beats/min and treated with i.v. atropine of 0.5mg, if symptomatic. For assessment of the onset of anaesthesia, the time for sensory block to develop to T10, maximum block height and time to achieve maximum height were noted. To assess the duration of the sensory block, time for regression to L1 and duration of analgesia (primary outcome) were compared. Time to achieve maximum motor block, duration of motor block along with any side effects were also noted.<elsevierMultimedia ident="fig0005"></elsevierMultimedia>Statistical analysisPower analysis estimated that a sample size of 30 patients per group would yield 95% power for testing the hypothesis at equivalence margin of 30-min difference in mean time to first analgesic requirement (PS Power and Sample Size Calculator-Version 3.0.43; Dupont WD, Plummer WD). The Type I error probability associated with this test, for the null hypothesis that levobupivacaine and ropivacaine in equipotent doses are similar in terms of duration of analgesia was α=0.05 (<a class="elsevierStyleCrossRef" href="#fig0015">Fig. 2</a>). Statistical analysis was performed using Excel 2013 (Microsoft, Redmond, VA), SPSS software (Version 19, SPSS Inc., USA) and Graph Pad Prism 5.00 (Graph Pad Software, San Diego, CA). Data are presented as mean (±SD), median (range), or frequencies (%) as appropriate. Group demographic data and adverse events were compared using unpaired t-test or chi-square (χ2) test, whichever applicable. Comparison of block characteristics, duration of analgesia and haemodynamics were made using unpaired t-test. To compare intragroup variations from baseline, one-way ANOVA with Dunnett's multiple comparisons tests was used. A p-value of <0.05 was considered statistically significant.<elsevierMultimedia ident="fig0015"></elsevierMultimedia>ResultsThere were no significant differences between the two groups with respect to age, sex, weight, ASA grade or duration of surgery (<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>). Anaesthesia was successful in all patients except two failures in group L. Onset of anaesthesia to T10 was 7.33±2.49min in group R and 13.50±4.86min in group L (p<0.0001). The median (range) maximum height achieved in terms of dermatomes in group R was T7 (T5–T10) while in group L was T7 (T4–T10). The time to reach maximum height was shorter in group R (13.17±3.02min) as compared to group L (20.33±5.31min) with a p<0.0001 (<a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>, <a class="elsevierStyleCrossRef" href="#fig0025">Fig. 3</a>).<elsevierMultimedia ident="tbl0005"></elsevierMultimedia><elsevierMultimedia ident="tbl0010"></elsevierMultimedia><elsevierMultimedia ident="fig0025"></elsevierMultimedia>The time to modified Bromage 3 (MB-3) grade was 7.83±2.84min in group R and 12.17±4.09min in group L with p<0.0001. Levobupivacaine produced significantly longer duration of motor block (290.50±34.67min) compared to ropivacaine (222.50±23.00min), p<0.0001. Time for regression of sensory block to L1 was longer in the group L than group R (251.50±33.12min versus 191.50±22.86min; p<0.0001). Duration of analgesia was also significantly longer in group L (309.83±36.45) than group R (249.50±22.83), p<0.0001.Baseline haemodynamic parameters were comparable in both the groups. The mean MAP decreased significantly in both the groups compared to baseline/preoperative values (p<0.05) but overall incidence of hypotension was not significantly different (<a class="elsevierStyleCrossRef" href="#fig0035">Fig. 4</a>a). Furthermore, it was transient (30min) in ropivacaine group compared to levobupivacaine which was sustained (100min). There were no significant differences between the two groups with respect to PR and SpO2 (p>0.05) (<a class="elsevierStyleCrossRef" href="#fig0035">Fig. 4</a>b and c).<elsevierMultimedia ident="fig0035"></elsevierMultimedia>No incidence of Post Dural Puncture Headache (PDPH) or any other significant adverse effect was observed in either group (<a class="elsevierStyleCrossRef" href="#tbl0015">Table 3</a>). Hypotension was the most common side effect seen in both the groups, however, total amount of mephentermine used was significantly not different (p>0.05). Bradycardia occurred during intra-op period in 2 patients of each group.<elsevierMultimedia ident="tbl0015"></elsevierMultimedia>DiscussionIn our study isobaric levobupivacaine showed significantly slower onset of sensory and motor block but with prolonged duration of analgesia compared to ropivacaine.No significant differences in patient characteristics and baseline haemodynamic parameters were observed between the two groups.Levobupivacaine and ropivacaine have been produced in order to address the issues of bupivacaine toxicity.<a class="elsevierStyleCrossRefs" href="#bib0185">1,15</a> Several studies have been undertaken in the past to evaluate the clinical efficacy and toxicology of these local anaesthetics in different dosage and baricity. Most of these clinical studies suggested that levobupivacaine was slightly less potent than bupivacaine but more potent than ropivacaine.<a class="elsevierStyleCrossRef" href="#bib0260">16</a> Higher potency of levobupivacaine than ropivacaine could partly be explained by its greater lipid solubility and formulation<a class="elsevierStyleCrossRef" href="#bib0265">17</a> which underestimates the active molecules by 12.6% than its racemate.<a class="elsevierStyleCrossRef" href="#bib0270">18</a> However, many recent studies<a class="elsevierStyleCrossRefs" href="#bib0275">19,20</a> have found greater than 30% difference in potency which implies that levobupivacaine is actually more potent than ropivacaine. Its potency compared to ropivacaine remained inconsistent and varied from 1 to 1.67.<a class="elsevierStyleCrossRef" href="#bib0265">17</a> So, based on the above facts and various previous studies,<a class="elsevierStyleCrossRefs" href="#bib0215">7,19,21,22</a> we assumed levobupivacaine to be 1.5 times more potent than ropivacaine.Previous authors have used different doses (5–17.5mg) of levobupivacaine.<a class="elsevierStyleCrossRefs" href="#bib0235">11,12,23,24</a> Taking into consideration the previous studies,<a class="elsevierStyleCrossRefs" href="#bib0235">11–13</a> MLAC and potency ratio we have used levobupivacaine 15mg (5mgml−1) to compare ropivacaine 22.5mg (7.5mgml−1), so as to achieve adequate sensory and motor block for most of the orthopaedic procedures.There is gross variation in the findings of various authors regarding sensory block onset time. According to some authors, there is no significant difference in onset time.<a class="elsevierStyleCrossRefs" href="#bib0235">11–13,24</a> Contrary to this, some are of the opinion that there is significant difference in the onset time of two drugs.<a class="elsevierStyleCrossRefs" href="#bib0295">23,25,26</a> However, in the present study, ropivacaine achieved sensory level of T10 significantly faster than levobupivacaine consistent with the past researches.<a class="elsevierStyleCrossRefs" href="#bib0295">23,25,26</a> The variations in the finding of these studies could be due to sample size, demographic profile, methodology, drug dose and baricity. Cuvas et al.<a class="elsevierStyleCrossRef" href="#bib0315">27</a> has only taken elderly (>60 yrs) males while Sananslip et al.<a class="elsevierStyleCrossRef" href="#bib0320">28</a> recruited females posted for gynaecological surgery.In the present study, both groups achieved the median dermatomal height of T7 but levobupivacaine took longer time to achieve maximum block level than ropivacaine. Furthermore, levobupivacaine (T4–T10) showed slightly greater variability compared to ropivacaine (T5–T10). According to most of the authors,<a class="elsevierStyleCrossRefs" href="#bib0240">12,21,23,26–29</a> median height attained was in the range of T8–T9 with similar dosing and technique. Nevertheless, few authors<a class="elsevierStyleCrossRefs" href="#bib0235">11,12</a> obtained varied results which may be attributed to different doses and baricity of the ropivacaine used in their study.Similar to the sensory blockade, ropivacaine also showed faster onset of motor blockade compared to levobupivacaine. However, Khaw et al.<a class="elsevierStyleCrossRef" href="#bib0330">30</a> used a measured isobaric preparation of ropivacaine for spinal anaesthesia in right lateral position administered over 60s did not find any significant difference. As we have not measured the specific gravity of the drug in our study, taking into consideration the fact that bupivacaine and ropivacaine are hypobaric at 37°C,<a class="elsevierStyleCrossRef" href="#bib0335">31</a> it can be assumed that the hypobaric nature of our drug, sitting position<a class="elsevierStyleCrossRefs" href="#bib0340">32,33</a> and comparatively faster rate of injection<a class="elsevierStyleCrossRef" href="#bib0325">29</a> has resulted in quicker onset of motor blockade.In our study, sensory (L1) and motor regression of ropivacaine was comparatively faster than levobupivacaine. Various authors in the past obtained similar results with ropivacaine showing faster sensory<a class="elsevierStyleCrossRefs" href="#bib0235">11,24,25</a> and motor recovery.<a class="elsevierStyleCrossRefs" href="#bib0245">13,23,27</a>Ropivacaine and levobupivacaine, apart from being slightly different in potencies, are assumed to be almost similar in clinical hands.<a class="elsevierStyleCrossRef" href="#bib0225">9</a> But the present study showed that even at equipotent doses of 1.5:1 (Ropi:Levo), ropivacaine offer significantly shorter duration of analgesia compared to levobupivacaine. This was similar to the findings of previous authors who showed early regression of ropivacaine as compared to levobupivacaine.<a class="elsevierStyleCrossRefs" href="#bib0240">12,23,34</a> However, Gautier et al.<a class="elsevierStyleCrossRef" href="#bib0355">35</a> documented no difference while comparing 12mg ropivacaine with 8mg levobupivacaine in Caesarean section. Different pharmacodynamic response due to lower dose and different study population seems to be the most reasonable explanation for this discrepancy.Decrease in MAP and PR are two most frequently encountered complications of neuraxial blocks. In our study, it was observed that fall in BP was transient in ropivacaine group but sustained in levobupivacaine group. In spite of this, there was no significant difference in the overall incidence of hypotension and these were promptly treated without any serious consequences. Further, the total mephentermine dose required in both the groups were comparable (p>0.05). However, the higher incidence of transient hypotension seen with ropivacaine could arise due to quicker attainment of maximum height of block in comparison to levobupivacaine resulting in fall blood pressure. This was in accordance with the opinion of Carpenter et al.<a class="elsevierStyleCrossRef" href="#bib0360">36</a>Extreme care and vigilance were taken to avoid biases by making the study randomised and double blind. However, biases and limitations often creep during research and this study is not an exception. Study design might have led certain degree of biases to sneak in as we used per protocol analysis. An important limitation of our study was that we did not measure the specific gravity of either of the drug. Maintenance of temperature could be a problem in tropical countries which could have influenced the overall results.<a class="elsevierStyleCrossRef" href="#bib0330">30</a> Besides, higher sodium concentration and osmolality of levobupivacaine further increases its density. The quality of anaesthesia was also not measured in the study.ConclusionWe, therefore, conclude that isobaric levobupivacaine and ropivacaine doses used in the study produce adequate anaesthesia and analgesia for lower limb orthopaedic surgery without any serious side effects. Levobupivacaine produces significantly longer duration of analgesia than ropivacaine when used in a ratio of 0.6:1. Hence, drugs should be used taking into consideration the condition of patient, nature and duration of surgery. Efficacy, toxicity and haemodynamic profile make ropivacaine suitable agent for day care and other surgeries with low threshold for hypotension, while levobupivacaine can be a suitable agent for prolonged surgeries.FundingNone.Conflicts of interestNone declared." "textoCompletoSecciones" => array:1 [ "secciones" => array:13 [ 0 => array:3 [ "identificador" => "xres631174" "titulo" => "Abstract" "secciones" => array:5 [ 0 => array:2 [ "identificador" => "abst0005" "titulo" => "Introduction" ] 1 => array:2 [ "identificador" => "abst0010" "titulo" => "Objective" ] 2 => array:2 [ "identificador" => "abst0015" "titulo" => "Methodology" ] 3 => array:2 [ "identificador" => "abst0020" "titulo" => "Results" ] 4 => array:2 [ "identificador" => "abst0025" "titulo" => "Conclusion" ] ] ] 1 => array:2 [ "identificador" => "xpalclavsec644027" "titulo" => "Keywords" ] 2 => array:3 [ "identificador" => "xres631173" "titulo" => "Resumen" "secciones" => array:5 [ 0 => array:2 [ "identificador" => "abst0030" "titulo" => "Introducción" ] 1 => array:2 [ "identificador" => "abst0035" "titulo" => "Objetivo" ] 2 => array:2 [ "identificador" => "abst0040" "titulo" => "Metodología" ] 3 => array:2 [ "identificador" => "abst0045" "titulo" => "Resultados" ] 4 => array:2 [ "identificador" => "abst0050" "titulo" => "Conclusión" ] ] ] 3 => array:2 [ "identificador" => "xpalclavsec644026" "titulo" => "Palabras clave" ] 4 => array:2 [ "identificador" => "sec0005" "titulo" => "Introduction" ] 5 => array:2 [ "identificador" => "sec0010" "titulo" => "Methodology" ] 6 => array:2 [ "identificador" => "sec0015" "titulo" => "Statistical analysis" ] 7 => array:2 [ "identificador" => "sec0020" "titulo" => "Results" ] 8 => array:2 [ "identificador" => "sec0025" "titulo" => "Discussion" ] 9 => array:2 [ "identificador" => "sec0030" "titulo" => "Conclusion" ] 10 => array:2 [ "identificador" => "sec0035" "titulo" => "Funding" ] 11 => array:2 [ "identificador" => "sec0040" "titulo" => "Conflicts of interest" ] 12 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2015-07-05" "fechaAceptado" => "2016-01-28" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec644027" "palabras" => array:5 [ 0 => "Anesthesia, spinal" 1 => "Anesthetics, local" 2 => "Hemodynamics" 3 => "Bupivacaine" 4 => "Anesthesia" ] ] ] "es" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec644026" "palabras" => array:5 [ 0 => "Anestesia espinal" 1 => "Anestésicos locales" 2 => "Hemodinámica" 3 => "Bupivacaina" 4 => "Anestesia" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:3 [ "titulo" => "Abstract" "resumen" => "IntroductionLevobupivacaine and ropivacaine are relatively new local anaesthetics developed in order to address the issue of bupivacaine toxicity. Although certain differences do exist between their pharmacological profiles, its clinical relevance at equipotent doses is not evident so far. ObjectiveTo compare the efficacy and characteristics of equipotent doses of intrathecal levobupivacaine with ropivacaine. MethodologySixty ASA grade I/II patients of 18–60 years, either sex posted for lower limb orthopaedic surgery under spinal anaesthesia were randomly given either 15mg levobupivacaine or 22.5mg ropivacaine. Sensory and motor block, haemodynamic characteristics, as well as any side effects, were recorded. ResultsOnset of sensory block to T10 was more rapid in group R than group L, p<0.0001. The median (range) height achieved in group R was T7 (T5–T10) while in group L was T7 (T4–T10). Time to reach maximum height and time to modified Bromage grade 3 was shorter in group R as compared to group L, p<0.0001. Levobupivacaine produced significantly longer (290.50±34.67) duration of motor block compared to ropivacaine (222.50±23.00). Duration of analgesia was significantly longer in group L (309.83±36.45) than group R (249.50±22.83). No serious adverse effects were recorded. ConclusionLevobupivacaine produces significantly longer duration of analgesia than ropivacaine when used in a ratio of 0.6:1. Efficacy, toxicity and haemodynamic profile make ropivacaine suitable agent for surgeries with low threshold for hypotension." "secciones" => array:5 [ 0 => array:2 [ "identificador" => "abst0005" "titulo" => "Introduction" ] 1 => array:2 [ "identificador" => "abst0010" "titulo" => "Objective" ] 2 => array:2 [ "identificador" => "abst0015" "titulo" => "Methodology" ] 3 => array:2 [ "identificador" => "abst0020" "titulo" => "Results" ] 4 => array:2 [ "identificador" => "abst0025" "titulo" => "Conclusion" ] ] ] "es" => array:3 [ "titulo" => "Resumen" "resumen" => "IntroducciónLa levobupivacaína y la ropivacaína son anestésicos locales relativamente nuevos, desarrollados con el fin de abordar la cuestión de la toxicidad de la bupivacaína. Aunque existen ciertas diferencias entre sus perfiles farmacológicos, su relevancia clínica en dosis equipotentes no es evidente hasta ahora. ObjetivoComparar la eficacia y las características de las dosis equipotentes de levobupivacaína por vía intratecal con las de ropivacaína. MetodologíaA Sesenta pacientes de grado ASA I/II de 18 a 60 años y de ambos sexos, programados para cirugía ortopédica del miembro inferior bajo anestesia espinal, se les dio al azar o bien 15mg de levobupivacaína o 22,5mg de ropivacaína. El bloqueo motor, el bloqueo sensorial, las características hemodinámicas y cualquier otro efecto secundario fueron registrados. ResultadosEl inicio del bloqueo sensorial en T10 fue más rápido en el grupo R que en el grupo L, p<0,0001. El nivel mediano (rango) alcanzado en el grupo R fue T7 (T5-T10), mientras en el grupo L fue T7 (T4-T10). El tiempo para alcanzar el nivel máximo y para alcanzar un grado 3 en la escala de Bromage fue más breve en el grupo R en comparación con el grupo L, p<0,0001. La levobupivacaína produce una duración significativamente más larga (290.50±34.67) del bloqueo motor que la ropivacaína (222.50±23.00). La duración de la analgesia fue significativamente más larga en el grupo L (309.83±36.45) que en el grupo R. No se registraron efectos adversos graves. ConclusiónLa levobupivacaína produce una duración de la analgesia significativamente más larga que la ropivacaína cuando se utiliza en una proporción de 0,6:1. La eficacia, toxicidad y perfil hemodinámico hacen de la ropivacaína un agente adecuado para cirugías con un umbral bajo de hipotensión." "secciones" => array:5 [ 0 => array:2 [ "identificador" => "abst0030" "titulo" => "Introducción" ] 1 => array:2 [ "identificador" => "abst0035" "titulo" => "Objetivo" ] 2 => array:2 [ "identificador" => "abst0040" "titulo" => "Metodología" ] 3 => array:2 [ "identificador" => "abst0045" "titulo" => "Resultados" ] 4 => array:2 [ "identificador" => "abst0050" "titulo" => "Conclusión" ] ] ] ] "NotaPie" => array:2 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "Please cite this article as: Athar M, Ahmed SM, Ali S, Doley K, Varshney A, Siddiqi MMH. Levobupivacaína o ropivacaína: un ensayo aleatorio doble ciego controlado con dosis equipotentes en la anestesia espinal. Rev Colomb Anestesiol. 2016;44:97–104." ] 1 => array:2 [ "etiqueta" => "☆☆" "nota" => "Clinical Trial Registry Number: <a class="elsevierStyleInterRef" id="intr0010" href="ctgov:NCT02201784">NCT02201784</a>." ] ] "multimedia" => array:7 [ 0 => array:8 [ "identificador" => "fig0005" "etiqueta" => "Fig. 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "fuente" => "Source: Authors." "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1669 "Ancho" => 2353 "Tamanyo" => 168013 ] ] "descripcion" => array:1 [ "en" => "CONSORT flow diagram." ] ] 1 => array:8 [ "identificador" => "fig0015" "etiqueta" => "Fig. 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "fuente" => "Source: Authors." "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 693 "Ancho" => 1590 "Tamanyo" => 77615 ] ] "descripcion" => array:1 [ "en" => "Sample size versus power graph for the study." ] ] 2 => array:8 [ "identificador" => "fig0025" "etiqueta" => "Fig. 3" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "fuente" => "Source: Authors." "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr3.jpeg" "Alto" => 948 "Ancho" => 1578 "Tamanyo" => 96594 ] ] "descripcion" => array:1 [ "en" => "Block characteristics." ] ] 3 => array:8 [ "identificador" => "fig0035" "etiqueta" => "Fig. 4" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "fuente" => "Source: Authors." "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr4.jpeg" "Alto" => 2913 "Ancho" => 1569 "Tamanyo" => 259758 ] ] "descripcion" => array:1 [ "en" => "(a) Mean arterial pressure variation with time. (b) Pulse rate variation with time. (c) SpO2 variation with time." ] ] 4 => array:8 [ "identificador" => "tbl0005" "etiqueta" => "Table 1" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at1" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:2 [ "leyenda" => "n, number of patients; M:F, male:female; min, minutes; p≤0.05 is considered significant.Source: Authors." "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Variable \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="center" valign="top" scope="col" style="border-bottom: 2px solid black">Group L (n) \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="center" valign="top" scope="col" style="border-bottom: 2px solid black">Group R (n) \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="center" valign="top" scope="col" style="border-bottom: 2px solid black">p value \t\t\t\t\t\t\n \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Age (years) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">38±17 (30) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">35±16 (30) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.51 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Sex (M:F) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">24:6 (30) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">23:7 (30) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.99 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Weight \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">53.83±9.44 (30) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">57.17±6.65 (30) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.12 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">ASA grade I/II \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">24/6 (30) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">24/6 (30) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1.00 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Duration of surgery (min) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">108±39.47 (28) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">93±25.35 (30) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.09 \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab1035466.png" ] ] ] ] "descripcion" => array:1 [ "en" => "Patient characteristics." ] ] 5 => array:8 [ "identificador" => "tbl0010" "etiqueta" => "Table 2" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at2" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:2 [ "leyenda" => "n, number of patients; “T” is dermatomal level; min, minutes; data are expressed as mean±SD or median (range); p-value <0.05 is considered significant.Source: Authors." "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Variable \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="center" valign="top" scope="col" style="border-bottom: 2px solid black">Group L (n=28) \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="center" valign="top" scope="col" style="border-bottom: 2px solid black">Group R (n=30) \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="center" valign="top" scope="col" style="border-bottom: 2px solid black">p value \t\t\t\t\t\t\n \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Time to achieve sensory block at T10 (min) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">13.50±4.94 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">7.33±2.54 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top"><0.0001 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Median maximum level of sensory blockade (range) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">T7 (T4–T10) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">T7 (T5–T10) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">– \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Time to maximum cephalic spread of sensory block (min) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">20.33±5.31 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">13.17±3.02 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top"><0.0001 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Recovery to L1 (min) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">251.50±33.12 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">191.50±22.86 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top"><0.0001 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Duration of analgesia (min) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">309.83±36.45 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">249.50±22.83 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top"><0.0001 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Onset of motor block to Bromage 3 (min) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">12.17±4.09 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">7.83±2.84 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top"><0.0001 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Duration of motor block (min) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">290.50±34.67 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">222.50±23.00 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top"><0.0001 \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab1035464.png" ] ] ] ] "descripcion" => array:1 [ "en" => "Block characteristics." ] ] 6 => array:8 [ "identificador" => "tbl0015" "etiqueta" => "Table 3" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at3" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:2 [ "leyenda" => "n, number of patients; p≤0.05 is considered significant.Source: Authors." "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Variable \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="center" valign="top" scope="col" style="border-bottom: 2px solid black">Group L (n=28) \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="center" valign="top" scope="col" style="border-bottom: 2px solid black">Group R (n=30) \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="center" valign="top" scope="col" style="border-bottom: 2px solid black">p value \t\t\t\t\t\t\n \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Nausea/vomiting \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">4/0 (14/%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">2/0 (7%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.42 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Hypotension \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">7 (25%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">10 (33%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.57 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Bradycardia \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">2 (7%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">2 (7%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.99 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Shivering \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">3 (11%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">5 (17%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.71 \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab1035465.png" ] ] ] ] "descripcion" => array:1 [ "en" => "Adverse effects." ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:36 [ 0 => array:3 [ "identificador" => "bib0185" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "The comparative toxicity of ropivacaine and bupivacaine at equipotent doses in rats" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "P. 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Statistics

Scientific and Technological Research

Levobupivacaína o ropivacaína: un ensayo aleatorio doble ciego controlado con dosis equipotentes en la anestesia espinal

Manazir Athar, Syed Moied Ahmed

Corresponding author

sma99@rediffmail.com

Corresponding author at: Department of Anaesthesiology and Critical Care, Jawaharlal Nehru Medical College, Aligarh Muslim University, 202002, Uttar Pradesh, India.

, Shahna Ali, Kashmiri Doley, Ankur Varshney, Mohd. Masood Hussain Siddiqi

Department of Anaesthesiology and Critical Care, Jawaharlal Nehru Medical College, Aligarh Muslim University, UP, India

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long-acting local anaesthetic with a relatively slow onset of action&#46;<a class="elsevierStyleCrossRef" href="#bib0190"><span class="elsevierStyleSup">2</span></a> It has a lower propensity to block inactivated sodium and potassium channels along with faster rate of dissociation compared to its racemic form&#46;<a class="elsevierStyleCrossRef" href="#bib0195"><span class="elsevierStyleSup">3</span></a> The majority of in vitro&#44; in vivo and human pharmacodynamic studies of nerve block indicate that levobupivacaine has similar potency&#44; yet lower risk of cardiovascular and CNS toxicity than bupivacaine&#46;<a class="elsevierStyleCrossRef" href="#bib0200"><span class="elsevierStyleSup">4</span></a> So&#44; having a higher threshold for cardiac and neurotoxicity compared to racemic bupivacaine&#44; anaesthetists feel safer working with levobupivacaine<a class="elsevierStyleCrossRef" href="#bib0205"><span class="elsevierStyleSup">5</span></a> and has the potential to replace bupivacaine as the standard drug&#46;<a class="elsevierStyleCrossRef" href="#bib0210"><span class="elsevierStyleSup">6</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">Ropivacaine is the &#8216;S&#8217; isomer of the propyl analogue of bupivacaine with longer duration of action&#44; low lipid solubility&#44; low potency and low cardiovascular and CNS toxicity&#46;<a class="elsevierStyleCrossRef" href="#bib0215"><span class="elsevierStyleSup">7</span></a> Ropivacaine blocks nerve fibres involved in pain transmission &#40;A&#948; and C fibres&#41; to a greater degree than those controlling motor function &#40;A&#946; fibres&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0220"><span class="elsevierStyleSup">8</span></a> Therefore&#44; ropivacaine has been found to induce less intense motor blockade than bupivacaine&#46; Hence&#44; its comparatively shorter duration&#44; faster recovery of motor function and lower toxicity profile have been identified as a potential benefit for surgery of intermediate duration as well as for ambulatory surgery in day care surgical units&#46;</p><p id="par0020" class="elsevierStylePara elsevierViewall">In the present era of evidence-based medicine&#44; each step of our management is thoroughly evaluated by properly controlled&#44; peer-reviewed medical research&#44; and subarachnoid block is not an exception&#46; The concept of a single shot with bupivacaine can do all is now questioned and necessitate the judicious use of safer substitutes&#46; As of Casati et al&#46;<a class="elsevierStyleCrossRef" href="#bib0225"><span class="elsevierStyleSup">9</span></a> theoretical as well as experimental differences do exist in toxicology and clinical profiles due to different anaesthetic potencies of these isomeric forms of bupivacaine&#44; but reflections of these characteristics into clinical practice have not been evident so far&#46; So&#44; we have to explore the typical characteristics and potential uses of these newer drugs&#46; Many studies have been done to compare various forms of bupivacaine&#44; ropivacaine and levobupivacaine&#46; However&#44; most of them have used low doses which may be inadequate for hip surgeries&#46;<a class="elsevierStyleCrossRef" href="#bib0230"><span class="elsevierStyleSup">10</span></a> Furthermore&#44; they have generally used hyperbaric forms<a class="elsevierStyleCrossRefs" href="#bib0235"><span class="elsevierStyleSup">11&#44;12</span></a> and potency ratio between levobupivacaine and ropivacaine was not taken into consideration&#46;<a class="elsevierStyleCrossRef" href="#bib0245"><span class="elsevierStyleSup">13</span></a></p><p id="par0025" class="elsevierStylePara elsevierViewall">Therefore&#44; this study was conducted to compare the efficacy and characteristics of isobaric forms of intrathecal levobupivacaine 0&#46;5&#37; with ropivacaine 0&#46;75&#37; in equipotent doses for lower limb orthopaedic surgery&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Methodology</span><p id="par0030" class="elsevierStylePara elsevierViewall">Following approval by the Institutional Ethics Committee &#91;&#40;Ref&#46; No&#46; D1303&#47;FM&#41; and Clinical Trial Registry No&#46; &#40;<a id="intr0015" class="elsevierStyleInterRef" href="https://clinicaltrials.gov/NCT02201784">NCT02201784</a>&#41;&#93; and written informed consent&#44; this prospective&#44; randomised&#44; double-blind&#44; controlled&#44; equivalence trial was conducted on sixty ASA grade I&#47;II patients of either sex&#44; aged between 18 and 60 years undergoing spinal anaesthesia for lower limb orthopaedic surgery&#46; Patients with contraindication for spinal anaesthesia&#44; known allergy to local anaesthetic drugs and patients having h&#47;o diabetes&#44; neurological or musculoskeletal diseases that could make our technique difficult were excluded&#46; The patients were randomly divided into two groups of 30 each &#40;group L and group R&#41; by computer-generated randomisation &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>&#41;&#46; Patients in group L received 3<span class="elsevierStyleHsp" style=""></span>ml levobupivacaine 5<span class="elsevierStyleHsp" style=""></span>mg&#47;ml &#40;15<span class="elsevierStyleHsp" style=""></span>mg of LEVO-ANAWIN<span class="elsevierStyleSup">&#174;</span> 0&#46;5&#37; Neon Laboratories Ltd&#46;&#41; while in group R received 3<span class="elsevierStyleHsp" style=""></span>ml ropivacaine 7&#46;5<span class="elsevierStyleHsp" style=""></span>mg&#47;ml &#40;22&#46;5<span class="elsevierStyleHsp" style=""></span>mg of ROPIN<span class="elsevierStyleSup">&#174;</span> 0&#46;75&#37; Neon Laboratories Ltd&#46;&#41;&#46; All drugs were loaded by an anaesthetist who did not have any involvement in further patient assessment while another anaesthetist administered anaesthesia and assessed all patients&#46; Patients had standard monitoring including electrocardiography&#44; pulse oximetry and non-invasive blood pressure monitoring &#40;NIBP&#41;&#46; Baseline heart rate &#40;HR&#41;&#44; NIBP and arterial oxygen saturation &#40;SpO<span class="elsevierStyleInf">2</span>&#41; were measured&#46; All patients received oxygen via Hudson mask at the rate of 6<span class="elsevierStyleHsp" style=""></span>l&#47;min until the surgery ends&#46; Intravenous &#40;IV&#41; access was secured&#44; patients were premedicated with i&#46;v&#46; ondansetron 0&#46;1<span class="elsevierStyleHsp" style=""></span>mg&#47;kg body weight and preloading done with lactated Ringer&#39;s &#40;LR&#41; solution 15<span class="elsevierStyleHsp" style=""></span>ml&#47;kg body weight&#46; Under strict aseptic precautions&#44; skin was infiltrated with lidocaine 2&#37; and lumbar puncture was performed in the sitting position with a 25-G Quincke spinal needle &#40;Becton Dickinson&#44; Madrid&#44; Spain&#41;&#44; using a midline approach at the L<span class="elsevierStyleInf">3&#8211;4</span> intervertebral space&#46; Correct needle placement was identified by free flow of CSF and confirmed by aspiration and reinjection of CSF before and after the administration of the study drug solution&#46; The study drug was injected over 20<span class="elsevierStyleHsp" style=""></span>s&#46; After the injection of the spinal medication&#44; the patients were placed supine immediately&#44; the time of which was recorded as &#8216;zero&#8217;&#46; The level of sensory block was assessed every 5<span class="elsevierStyleHsp" style=""></span>min till the loss of sensation to pinprick&#44; using a 22-guage hypodermic needle with 2<span class="elsevierStyleHsp" style=""></span>mm protrusion through the guard&#46; Assessments continued at 30<span class="elsevierStyleHsp" style=""></span>min intervals following the completion of surgery until normal sensation returned&#46; After confirming the loss of sensation at T<span class="elsevierStyleInf">10</span> dermatome in comparison to C<span class="elsevierStyleInf">5&#8211;6</span> dermatome&#44; patients were given i&#46;v&#46; midazolam 0&#46;03<span class="elsevierStyleHsp" style=""></span>mg&#47;kg body weight and surgeons were allowed to proceed for the surgery&#46; Inability to achieve T<span class="elsevierStyleInf">10</span> sensory level within 30<span class="elsevierStyleHsp" style=""></span>min was considered as &#8216;Failure&#8217;&#46; These patients were administered general anaesthesia&#46; They were not included for analysis but only reported as total number of failures according to per protocol analysis&#46; Motor block in the lower limbs was graded according to the modified Bromage scale<a class="elsevierStyleCrossRef" href="#bib0250"><span class="elsevierStyleSup">14</span></a> &#40;Grade 0<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>No motor block&#44; Grade 1<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>Inability to raise extended leg&#44; able to move knees and feet&#44; Grade 2<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>Inability to raise extended leg and move knee&#44; able to move feet&#44; Grade 3<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>Complete motor block of the lower limbs&#41;&#46; Thereafter&#44; it was performed every 5<span class="elsevierStyleHsp" style=""></span>min till the attainment of MB grade 3 followed by every 30<span class="elsevierStyleHsp" style=""></span>min until complete recovery &#40;MB grade 0&#41;&#46; HR&#44; NIBP and SpO<span class="elsevierStyleInf">2</span> was recorded before induction&#44; every 3<span class="elsevierStyleHsp" style=""></span>min till 15<span class="elsevierStyleHsp" style=""></span>min&#44; then&#44; every 15<span class="elsevierStyleHsp" style=""></span>min until discharge from the recovery room&#46; Hypotension was defined as systolic BP<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>90<span class="elsevierStyleHsp" style=""></span>mmHg and was treated with inj&#46; mephenteramine of 6<span class="elsevierStyleHsp" style=""></span>mg i&#46;v bolus and fluids&#46; Bradycardia was defined as HR<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>50<span class="elsevierStyleHsp" style=""></span>beats&#47;min and treated with i&#46;v&#46; atropine of 0&#46;5<span class="elsevierStyleHsp" style=""></span>mg&#44; if symptomatic&#46; For assessment of the onset of anaesthesia&#44; the time for sensory block to develop to T<span class="elsevierStyleInf">10</span>&#44; maximum block height and time to achieve maximum height were noted&#46; To assess the duration of the sensory block&#44; time for regression to L<span class="elsevierStyleInf">1</span> and duration of analgesia &#40;primary outcome&#41; were compared&#46; Time to achieve maximum motor block&#44; duration of motor block along with any side effects were also noted&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Statistical analysis</span><p id="par0035" class="elsevierStylePara elsevierViewall">Power analysis estimated that a sample size of 30 patients per group would yield 95&#37; power for testing the hypothesis at equivalence margin of 30-min difference in mean time to first analgesic requirement &#40;PS Power and Sample Size Calculator-Version 3&#46;0&#46;43&#59; Dupont WD&#44; Plummer WD&#41;&#46; The Type I error probability associated with this test&#44; for the null hypothesis that levobupivacaine and ropivacaine in equipotent doses are similar in terms of duration of analgesia was <span class="elsevierStyleItalic">&#945;</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;05 &#40;<a class="elsevierStyleCrossRef" href="#fig0015">Fig&#46; 2</a>&#41;&#46; Statistical analysis was performed using Excel 2013 &#40;Microsoft&#44; Redmond&#44; VA&#41;&#44; SPSS software &#40;Version 19&#44; SPSS Inc&#46;&#44; USA&#41; and Graph Pad Prism 5&#46;00 &#40;Graph Pad Software&#44; San Diego&#44; CA&#41;&#46; Data are presented as mean &#40;&#177;SD&#41;&#44; median &#40;range&#41;&#44; or frequencies &#40;&#37;&#41; as appropriate&#46; Group demographic data and adverse events were compared using unpaired <span class="elsevierStyleItalic">t</span>-test or chi-square &#40;<span class="elsevierStyleItalic">&#967;</span><span class="elsevierStyleSup">2</span>&#41; test&#44; whichever applicable&#46; Comparison of block characteristics&#44; duration of analgesia and haemodynamics were made using unpaired <span class="elsevierStyleItalic">t</span>-test&#46; To compare intragroup variations from baseline&#44; one-way ANOVA with Dunnett&#39;s multiple comparisons tests was used&#46; A <span class="elsevierStyleItalic">p</span>-value of &#60;0&#46;05 was considered statistically significant&#46;</p><elsevierMultimedia ident="fig0015"></elsevierMultimedia></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Results</span><p id="par0040" class="elsevierStylePara elsevierViewall">There were no significant differences between the two groups with respect to age&#44; sex&#44; weight&#44; ASA grade or duration of surgery &#40;<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#41;&#46; Anaesthesia was successful in all patients except two failures in group L&#46; Onset of anaesthesia to T<span class="elsevierStyleInf">10</span> was 7&#46;33<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>2&#46;49<span class="elsevierStyleHsp" style=""></span>min in group R and 13&#46;50<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>4&#46;86<span class="elsevierStyleHsp" style=""></span>min in group L &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#46;0001&#41;&#46; The median &#40;range&#41; maximum height achieved in terms of dermatomes in group R was T<span class="elsevierStyleInf">7</span> &#40;T<span class="elsevierStyleInf">5</span>&#8211;T<span class="elsevierStyleInf">10</span>&#41; while in group L was T<span class="elsevierStyleInf">7</span> &#40;T<span class="elsevierStyleInf">4</span>&#8211;T<span class="elsevierStyleInf">10</span>&#41;&#46; The time to reach maximum height was shorter in group R &#40;13&#46;17<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>3&#46;02<span class="elsevierStyleHsp" style=""></span>min&#41; as compared to group L &#40;20&#46;33<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>5&#46;31<span class="elsevierStyleHsp" style=""></span>min&#41; with a <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#46;0001 &#40;<a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>&#44; <a class="elsevierStyleCrossRef" href="#fig0025">Fig&#46; 3</a>&#41;&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><elsevierMultimedia ident="tbl0010"></elsevierMultimedia><elsevierMultimedia ident="fig0025"></elsevierMultimedia><p id="par0045" class="elsevierStylePara elsevierViewall">The time to modified Bromage 3 &#40;MB-3&#41; grade was 7&#46;83<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>2&#46;84<span class="elsevierStyleHsp" style=""></span>min in group R and 12&#46;17<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>4&#46;09<span class="elsevierStyleHsp" style=""></span>min in group L with <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#46;0001&#46; Levobupivacaine produced significantly longer duration of motor block &#40;290&#46;50<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>34&#46;67<span class="elsevierStyleHsp" style=""></span>min&#41; compared to ropivacaine &#40;222&#46;50<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>23&#46;00<span class="elsevierStyleHsp" style=""></span>min&#41;&#44; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#46;0001&#46; Time for regression of sensory block to L1 was longer in the group L than group R &#40;251&#46;50<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>33&#46;12<span class="elsevierStyleHsp" style=""></span>min versus 191&#46;50<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>22&#46;86<span class="elsevierStyleHsp" style=""></span>min&#59; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#46;0001&#41;&#46; Duration of analgesia was also significantly longer in group L &#40;309&#46;83<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>36&#46;45&#41; than group R &#40;249&#46;50<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>22&#46;83&#41;&#44; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#46;0001&#46;</p><p id="par0050" class="elsevierStylePara elsevierViewall">Baseline haemodynamic parameters were comparable in both the groups&#46; The mean MAP decreased significantly in both the groups compared to baseline&#47;preoperative values &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#46;05&#41; but overall incidence of hypotension was not significantly different &#40;<a class="elsevierStyleCrossRef" href="#fig0035">Fig&#46; 4</a>a&#41;&#46; Furthermore&#44; it was transient &#40;30<span class="elsevierStyleHsp" style=""></span>min&#41; in ropivacaine group compared to levobupivacaine which was sustained &#40;100<span class="elsevierStyleHsp" style=""></span>min&#41;&#46; There were no significant differences between the two groups with respect to PR and SpO<span class="elsevierStyleInf">2</span> &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#62;<span class="elsevierStyleHsp" style=""></span>0&#46;05&#41; &#40;<a class="elsevierStyleCrossRef" href="#fig0035">Fig&#46; 4</a>b and c&#41;&#46;</p><elsevierMultimedia ident="fig0035"></elsevierMultimedia><p id="par0055" class="elsevierStylePara elsevierViewall">No incidence of Post Dural Puncture Headache &#40;PDPH&#41; or any other significant adverse effect was observed in either group &#40;<a class="elsevierStyleCrossRef" href="#tbl0015">Table 3</a>&#41;&#46; Hypotension was the most common side effect seen in both the groups&#44; however&#44; total amount of mephentermine used was significantly not different &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#62;<span class="elsevierStyleHsp" style=""></span>0&#46;05&#41;&#46; Bradycardia occurred during intra-op period in 2 patients of each group&#46;</p><elsevierMultimedia ident="tbl0015"></elsevierMultimedia></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0095">Discussion</span><p id="par0060" class="elsevierStylePara elsevierViewall">In our study isobaric levobupivacaine showed significantly slower onset of sensory and motor block but with prolonged duration of analgesia compared to ropivacaine&#46;</p><p id="par0065" class="elsevierStylePara elsevierViewall">No significant differences in patient characteristics and baseline haemodynamic parameters were observed between the two groups&#46;</p><p id="par0070" class="elsevierStylePara elsevierViewall">Levobupivacaine and ropivacaine have been produced in order to address the issues of bupivacaine toxicity&#46;<a class="elsevierStyleCrossRefs" href="#bib0185"><span class="elsevierStyleSup">1&#44;15</span></a> Several studies have been undertaken in the past to evaluate the clinical efficacy and toxicology of these local anaesthetics in different dosage and baricity&#46; Most of these clinical studies suggested that levobupivacaine was slightly less potent than bupivacaine but more potent than ropivacaine&#46;<a class="elsevierStyleCrossRef" href="#bib0260"><span class="elsevierStyleSup">16</span></a> Higher potency of levobupivacaine than ropivacaine could partly be explained by its greater lipid solubility and formulation<a class="elsevierStyleCrossRef" href="#bib0265"><span class="elsevierStyleSup">17</span></a> which underestimates the active molecules by 12&#46;6&#37; than its racemate&#46;<a class="elsevierStyleCrossRef" href="#bib0270"><span class="elsevierStyleSup">18</span></a> However&#44; many recent studies<a class="elsevierStyleCrossRefs" href="#bib0275"><span class="elsevierStyleSup">19&#44;20</span></a> have found greater than 30&#37; difference in potency which implies that levobupivacaine is actually more potent than ropivacaine&#46; Its potency compared to ropivacaine remained inconsistent and varied from 1 to 1&#46;67&#46;<a class="elsevierStyleCrossRef" href="#bib0265"><span class="elsevierStyleSup">17</span></a> So&#44; based on the above facts and various previous studies&#44;<a class="elsevierStyleCrossRefs" href="#bib0215"><span class="elsevierStyleSup">7&#44;19&#44;21&#44;22</span></a> we assumed levobupivacaine to be 1&#46;5 times more potent than ropivacaine&#46;</p><p id="par0075" class="elsevierStylePara elsevierViewall">Previous authors have used different doses &#40;5&#8211;17&#46;5<span class="elsevierStyleHsp" style=""></span>mg&#41; of levobupivacaine&#46;<a class="elsevierStyleCrossRefs" href="#bib0235"><span class="elsevierStyleSup">11&#44;12&#44;23&#44;24</span></a> Taking into consideration the previous studies&#44;<a class="elsevierStyleCrossRefs" href="#bib0235"><span class="elsevierStyleSup">11&#8211;13</span></a> MLAC and potency ratio we have used levobupivacaine 15<span class="elsevierStyleHsp" style=""></span>mg &#40;5<span class="elsevierStyleHsp" style=""></span>mg<span class="elsevierStyleHsp" style=""></span>ml<span class="elsevierStyleSup">&#8722;1</span>&#41; to compare ropivacaine 22&#46;5<span class="elsevierStyleHsp" style=""></span>mg &#40;7&#46;5<span class="elsevierStyleHsp" style=""></span>mg<span class="elsevierStyleHsp" style=""></span>ml<span class="elsevierStyleSup">&#8722;1</span>&#41;&#44; so as to achieve adequate sensory and motor block for most of the orthopaedic procedures&#46;</p><p id="par0080" class="elsevierStylePara elsevierViewall">There is gross variation in the findings of various authors regarding sensory block onset time&#46; According to some authors&#44; there is no significant difference in onset time&#46;<a class="elsevierStyleCrossRefs" href="#bib0235"><span class="elsevierStyleSup">11&#8211;13&#44;24</span></a> Contrary to this&#44; some are of the opinion that there is significant difference in the onset time of two drugs&#46;<a class="elsevierStyleCrossRefs" href="#bib0295"><span class="elsevierStyleSup">23&#44;25&#44;26</span></a> However&#44; in the present study&#44; ropivacaine achieved sensory level of T<span class="elsevierStyleInf">10</span> significantly faster than levobupivacaine consistent with the past researches&#46;<a class="elsevierStyleCrossRefs" href="#bib0295"><span class="elsevierStyleSup">23&#44;25&#44;26</span></a> The variations in the finding of these studies could be due to sample size&#44; demographic profile&#44; methodology&#44; drug dose and baricity&#46; Cuvas et al&#46;<a class="elsevierStyleCrossRef" href="#bib0315"><span class="elsevierStyleSup">27</span></a> has only taken elderly &#40;&#62;60 yrs&#41; males while Sananslip et al&#46;<a class="elsevierStyleCrossRef" href="#bib0320"><span class="elsevierStyleSup">28</span></a> recruited females posted for gynaecological surgery&#46;</p><p id="par0085" class="elsevierStylePara elsevierViewall">In the present study&#44; both groups achieved the median dermatomal height of T<span class="elsevierStyleInf">7</span> but levobupivacaine took longer time to achieve maximum block level than ropivacaine&#46; Furthermore&#44; levobupivacaine &#40;T<span class="elsevierStyleInf">4</span>&#8211;T<span class="elsevierStyleInf">10</span>&#41; showed slightly greater variability compared to ropivacaine &#40;T<span class="elsevierStyleInf">5</span>&#8211;T<span class="elsevierStyleInf">10</span>&#41;&#46; According to most of the authors&#44;<a class="elsevierStyleCrossRefs" href="#bib0240"><span class="elsevierStyleSup">12&#44;21&#44;23&#44;26&#8211;29</span></a> median height attained was in the range of T<span class="elsevierStyleInf">8</span>&#8211;T<span class="elsevierStyleInf">9</span> with similar dosing and technique&#46; Nevertheless&#44; few authors<a class="elsevierStyleCrossRefs" href="#bib0235"><span class="elsevierStyleSup">11&#44;12</span></a> obtained varied results which may be attributed to different doses and baricity of the ropivacaine used in their study&#46;</p><p id="par0090" class="elsevierStylePara elsevierViewall">Similar to the sensory blockade&#44; ropivacaine also showed faster onset of motor blockade compared to levobupivacaine&#46; However&#44; Khaw et al&#46;<a class="elsevierStyleCrossRef" href="#bib0330"><span class="elsevierStyleSup">30</span></a> used a measured isobaric preparation of ropivacaine for spinal anaesthesia in right lateral position administered over 60<span class="elsevierStyleHsp" style=""></span>s did not find any significant difference&#46; As we have not measured the specific gravity of the drug in our study&#44; taking into consideration the fact that bupivacaine and ropivacaine are hypobaric at 37<span class="elsevierStyleHsp" style=""></span>&#176;C&#44;<a class="elsevierStyleCrossRef" href="#bib0335"><span class="elsevierStyleSup">31</span></a> it can be assumed that the hypobaric nature of our drug&#44; sitting position<a class="elsevierStyleCrossRefs" href="#bib0340"><span class="elsevierStyleSup">32&#44;33</span></a> and comparatively faster rate of injection<a class="elsevierStyleCrossRef" href="#bib0325"><span class="elsevierStyleSup">29</span></a> has resulted in quicker onset of motor blockade&#46;</p><p id="par0095" class="elsevierStylePara elsevierViewall">In our study&#44; sensory &#40;L<span class="elsevierStyleInf">1</span>&#41; and motor regression of ropivacaine was comparatively faster than levobupivacaine&#46; Various authors in the past obtained similar results with ropivacaine showing faster sensory<a class="elsevierStyleCrossRefs" href="#bib0235"><span class="elsevierStyleSup">11&#44;24&#44;25</span></a> and motor recovery&#46;<a class="elsevierStyleCrossRefs" href="#bib0245"><span class="elsevierStyleSup">13&#44;23&#44;27</span></a></p><p id="par0100" class="elsevierStylePara elsevierViewall">Ropivacaine and levobupivacaine&#44; apart from being slightly different in potencies&#44; are assumed to be almost similar in clinical hands&#46;<a class="elsevierStyleCrossRef" href="#bib0225"><span class="elsevierStyleSup">9</span></a> But the present study showed that even at equipotent doses of 1&#46;5&#58;1 &#40;Ropi&#58;Levo&#41;&#44; ropivacaine offer significantly shorter duration of analgesia compared to levobupivacaine&#46; This was similar to the findings of previous authors who showed early regression of ropivacaine as compared to levobupivacaine&#46;<a class="elsevierStyleCrossRefs" href="#bib0240"><span class="elsevierStyleSup">12&#44;23&#44;34</span></a> However&#44; Gautier et al&#46;<a class="elsevierStyleCrossRef" href="#bib0355"><span class="elsevierStyleSup">35</span></a> documented no difference while comparing 12<span class="elsevierStyleHsp" style=""></span>mg ropivacaine with 8<span class="elsevierStyleHsp" style=""></span>mg levobupivacaine in Caesarean section&#46; Different pharmacodynamic response due to lower dose and different study population seems to be the most reasonable explanation for this discrepancy&#46;</p><p id="par0105" class="elsevierStylePara elsevierViewall">Decrease in MAP and PR are two most frequently encountered complications of neuraxial blocks&#46; In our study&#44; it was observed that fall in BP was transient in ropivacaine group but sustained in levobupivacaine group&#46; In spite of this&#44; there was no significant difference in the overall incidence of hypotension and these were promptly treated without any serious consequences&#46; Further&#44; the total mephentermine dose required in both the groups were comparable &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#62;<span class="elsevierStyleHsp" style=""></span>0&#46;05&#41;&#46; However&#44; the higher incidence of transient hypotension seen with ropivacaine could arise due to quicker attainment of maximum height of block in comparison to levobupivacaine resulting in fall blood pressure&#46; This was in accordance with the opinion of Carpenter et al&#46;<a class="elsevierStyleCrossRef" href="#bib0360"><span class="elsevierStyleSup">36</span></a></p><p id="par0110" class="elsevierStylePara elsevierViewall">Extreme care and vigilance were taken to avoid biases by making the study randomised and double blind&#46; However&#44; biases and limitations often creep during research and this study is not an exception&#46; Study design might have led certain degree of biases to sneak in as we used per protocol analysis&#46; An important limitation of our study was that we did not measure the specific gravity of either of the drug&#46; Maintenance of temperature could be a problem in tropical countries which could have influenced the overall results&#46;<a class="elsevierStyleCrossRef" href="#bib0330"><span class="elsevierStyleSup">30</span></a> Besides&#44; higher sodium concentration and osmolality of levobupivacaine further increases its density&#46; The quality of anaesthesia was also not measured in the study&#46;</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0100">Conclusion</span><p id="par0115" class="elsevierStylePara elsevierViewall">We&#44; therefore&#44; conclude that isobaric levobupivacaine and ropivacaine doses used in the study produce adequate anaesthesia and analgesia for lower limb orthopaedic surgery without any serious side effects&#46; Levobupivacaine produces significantly longer duration of analgesia than ropivacaine when used in a ratio of 0&#46;6&#58;1&#46; Hence&#44; drugs should be used taking into consideration the condition of patient&#44; nature and duration of surgery&#46; Efficacy&#44; toxicity and haemodynamic profile make ropivacaine suitable agent for day care and other surgeries with low threshold for hypotension&#44; while levobupivacaine can be a suitable agent for prolonged surgeries&#46;</p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0105">Funding</span><p id="par0120" class="elsevierStylePara elsevierViewall">None&#46;</p></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0110">Conflicts of interest</span><p id="par0125" class="elsevierStylePara elsevierViewall">None declared&#46;</p></span></span>"
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        "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Introduction</span><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Levobupivacaine and ropivacaine are relatively new local anaesthetics developed in order to address the issue of bupivacaine toxicity&#46; Although certain differences do exist between their pharmacological profiles&#44; its clinical relevance at equipotent doses is not evident so far&#46;</p></span> <span id="abst0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Objective</span><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">To compare the efficacy and characteristics of equipotent doses of intrathecal levobupivacaine with ropivacaine&#46;</p></span> <span id="abst0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Methodology</span><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Sixty ASA grade I&#47;II patients of 18&#8211;60 years&#44; either sex posted for lower limb orthopaedic surgery under spinal anaesthesia were randomly given either 15<span class="elsevierStyleHsp" style=""></span>mg levobupivacaine or 22&#46;5<span class="elsevierStyleHsp" style=""></span>mg ropivacaine&#46; Sensory and motor block&#44; haemodynamic characteristics&#44; as well as any side effects&#44; were recorded&#46;</p></span> <span id="abst0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Results</span><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Onset of sensory block to T<span class="elsevierStyleInf">10</span> was more rapid in group R than group L&#44; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#46;0001&#46; The median &#40;range&#41; height achieved in group R was T7 &#40;T5&#8211;T10&#41; while in group L was T7 &#40;T4&#8211;T10&#41;&#46; Time to reach maximum height and time to modified Bromage grade 3 was shorter in group R as compared to group L&#44; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#46;0001&#46; Levobupivacaine produced significantly longer &#40;290&#46;50<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>34&#46;67&#41; duration of motor block compared to ropivacaine &#40;222&#46;50<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>23&#46;00&#41;&#46; Duration of analgesia was significantly longer in group L &#40;309&#46;83<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>36&#46;45&#41; than group R &#40;249&#46;50<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>22&#46;83&#41;&#46; No serious adverse effects were recorded&#46;</p></span> <span id="abst0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Conclusion</span><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">Levobupivacaine produces significantly longer duration of analgesia than ropivacaine when used in a ratio of 0&#46;6&#58;1&#46; Efficacy&#44; toxicity and haemodynamic profile make ropivacaine suitable agent for surgeries with low threshold for hypotension&#46;</p></span>"
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        "resumen" => "<span id="abst0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Introducci&#243;n</span><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">La levobupivaca&#237;na y la ropivaca&#237;na son anest&#233;sicos locales relativamente nuevos&#44; desarrollados con el fin de abordar la cuesti&#243;n de la toxicidad de la bupivaca&#237;na&#46; Aunque existen ciertas diferencias entre sus perfiles farmacol&#243;gicos&#44; su relevancia cl&#237;nica en dosis equipotentes no es evidente hasta ahora&#46;</p></span> <span id="abst0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Objetivo</span><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">Comparar la eficacia y las caracter&#237;sticas de las dosis equipotentes de levobupivaca&#237;na por v&#237;a intratecal con las de ropivaca&#237;na&#46;</p></span> <span id="abst0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Metodolog&#237;a</span><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">A Sesenta pacientes de grado ASA I&#47;II de 18 a 60 a&#241;os y de ambos sexos&#44; programados para cirug&#237;a ortop&#233;dica del miembro inferior bajo anestesia espinal&#44; se les dio al azar o bien 15<span class="elsevierStyleHsp" style=""></span>mg de levobupivaca&#237;na o 22&#44;5<span class="elsevierStyleHsp" style=""></span>mg de ropivaca&#237;na&#46; El bloqueo motor&#44; el bloqueo sensorial&#44; las caracter&#237;sticas hemodin&#225;micas y cualquier otro efecto secundario fueron registrados&#46;</p></span> <span id="abst0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0055">Resultados</span><p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">El inicio del bloqueo sensorial en T10 fue m&#225;s r&#225;pido en el grupo R que en el grupo L&#44; p<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#44;0001&#46; El nivel mediano &#40;rango&#41; alcanzado en el grupo R fue T7 &#40;T5-T10&#41;&#44; mientras en el grupo L fue T7 &#40;T4-T10&#41;&#46; El tiempo para alcanzar el nivel m&#225;ximo y para alcanzar un grado 3 en la escala de Bromage fue m&#225;s breve en el grupo R en comparaci&#243;n con el grupo L&#44; p<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#44;0001&#46; La levobupivaca&#237;na produce una duraci&#243;n significativamente m&#225;s larga &#40;290&#46;50<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>34&#46;67&#41; del bloqueo motor que la ropivaca&#237;na &#40;222&#46;50<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>23&#46;00&#41;&#46; La duraci&#243;n de la analgesia fue significativamente m&#225;s larga en el grupo L &#40;309&#46;83<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>36&#46;45&#41; que en el grupo R&#46; No se registraron efectos adversos graves&#46;</p></span> <span id="abst0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0060">Conclusi&#243;n</span><p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">La levobupivaca&#237;na produce una duraci&#243;n de la analgesia significativamente m&#225;s larga que la ropivaca&#237;na cuando se utiliza en una proporci&#243;n de 0&#44;6&#58;1&#46; La eficacia&#44; toxicidad y perfil hemodin&#225;mico hacen de la ropivaca&#237;na un agente adecuado para cirug&#237;as con un umbral bajo de hipotensi&#243;n&#46;</p></span>"
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        "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as&#58; Athar M&#44; Ahmed SM&#44; Ali S&#44; Doley K&#44; Varshney A&#44; Siddiqi MMH&#46; Levobupivaca&#237;na o ropivaca&#237;na&#58; un ensayo aleatorio doble ciego controlado con dosis equipotentes en la anestesia espinal&#46; Rev Colomb Anestesiol&#46; 2016&#59;44&#58;97&#8211;104&#46;</p>"
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                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Sex &#40;M&#58;F&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">24&#58;6 &#40;30&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">23&#58;7 &#40;30&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;99&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Weight&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">53&#46;83<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>9&#46;44 &#40;30&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">57&#46;17<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>6&#46;65 &#40;30&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;12&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">ASA grade I&#47;II&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">24&#47;6 &#40;30&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">24&#47;6 &#40;30&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">1&#46;00&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Duration of surgery &#40;min&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">108<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>39&#46;47 &#40;28&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">93<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>25&#46;35 &#40;30&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;09&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
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          "leyenda" => "<p id="spar0090" class="elsevierStyleSimplePara elsevierViewall"><span class="elsevierStyleItalic">n</span>&#44; number of patients&#59; &#8220;T&#8221; is dermatomal level&#59; min&#44; minutes&#59; data are expressed as mean<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>SD or median &#40;range&#41;&#59; <span class="elsevierStyleItalic">p</span>-value &#60;0&#46;05 is considered significant&#46;</p><p id="spar0110" class="elsevierStyleSimplePara elsevierViewall"><span class="elsevierStyleItalic">Source</span>&#58; Authors&#46;</p>"
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                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Variable&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="center" valign="top" scope="col" style="border-bottom: 2px solid black">Group L &#40;<span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>28&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="center" valign="top" scope="col" style="border-bottom: 2px solid black">Group R &#40;<span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>30&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="center" valign="top" scope="col" style="border-bottom: 2px solid black"><span class="elsevierStyleItalic">p</span> value&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">13&#46;50<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>4&#46;94&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">7&#46;33<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>2&#46;54&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">&#60;0&#46;0001&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Median maximum level of sensory blockade &#40;range&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">T<span class="elsevierStyleInf">7</span> &#40;T<span class="elsevierStyleInf">4</span>&#8211;T<span class="elsevierStyleInf">10</span>&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">T<span class="elsevierStyleInf">7</span> &#40;T<span class="elsevierStyleInf">5</span>&#8211;T<span class="elsevierStyleInf">10</span>&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">&#8211;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Time to maximum cephalic spread of sensory block &#40;min&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">20&#46;33<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>5&#46;31&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">13&#46;17<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>3&#46;02&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">&#60;0&#46;0001&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Recovery to L<span class="elsevierStyleInf">1</span> &#40;min&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">251&#46;50<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>33&#46;12&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">191&#46;50<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>22&#46;86&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">&#60;0&#46;0001&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Duration of analgesia &#40;min&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">309&#46;83<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>36&#46;45&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">249&#46;50<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>22&#46;83&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">&#60;0&#46;0001&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Onset of motor block to Bromage 3 &#40;min&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">12&#46;17<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>4&#46;09&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">7&#46;83<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>2&#46;84&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">&#60;0&#46;0001&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Duration of motor block &#40;min&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">290&#46;50<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>34&#46;67&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">222&#46;50<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>23&#46;00&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">&#60;0&#46;0001&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
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          "en" => "<p id="spar0085" class="elsevierStyleSimplePara elsevierViewall">Block characteristics&#46;</p>"
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        "etiqueta" => "Table 3"
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            "identificador" => "at3"
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          "leyenda" => "<p id="spar0100" class="elsevierStyleSimplePara elsevierViewall"><span class="elsevierStyleItalic">n</span>&#44; number of patients&#59; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#8804;<span class="elsevierStyleHsp" style=""></span>0&#46;05 is considered significant&#46;</p><p id="spar0115" class="elsevierStyleSimplePara elsevierViewall"><span class="elsevierStyleItalic">Source</span>&#58; Authors&#46;</p>"
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                  <table border="0" frame="\n
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                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Variable&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="center" valign="top" scope="col" style="border-bottom: 2px solid black">Group L &#40;<span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>28&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">4&#47;0 &#40;14&#47;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">2&#47;0 &#40;7&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;42&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Hypotension&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">7 &#40;25&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">10 &#40;33&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;57&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Bradycardia&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">2 &#40;7&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">2 &#40;7&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;99&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Shivering&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">3 &#40;11&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">5 &#40;17&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;71&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
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        ]
        "descripcion" => array:1 [
          "en" => "<p id="spar0095" class="elsevierStyleSimplePara elsevierViewall">Adverse effects&#46;</p>"
        ]
      ]
    ]
    "bibliografia" => array:2 [
      "titulo" => "References"
      "seccion" => array:1 [
        0 => array:2 [
          "identificador" => "bibs0005"
          "bibliografiaReferencia" => array:36 [
            0 => array:3 [
              "identificador" => "bib0185"
              "etiqueta" => "1"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "The comparative toxicity of ropivacaine and bupivacaine at equipotent doses in rats"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:6 [
                            0 => "P&#46; Dony"
                            1 => "V&#46; Dewinde"
                            2 => "B&#46; Vanderick"
                            3 => "O&#46; Cuignet"
                            4 => "P&#46; Gautier"
                            5 => "E&#46; Legrand"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:6 [
                        "tituloSerie" => "Anesth Analg"
                        "fecha" => "2000"
                        "volumen" => "91"
                        "paginaInicial" => "1489"
                        "paginaFinal" => "1492"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/11094006"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            1 => array:3 [
              "identificador" => "bib0190"
              "etiqueta" => "2"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Anaesthetic agents for advanced regional anaesthesia&#58; a North American perspective"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:2 [
                            0 => "C&#46;C&#46; Buckenmaier 3rd"
                            1 => "L&#46;L&#46; Bleckner"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:6 [
                        "tituloSerie" => "Drugs"
                        "fecha" => "2005"
                        "volumen" => "65"
                        "paginaInicial" => "745"
                        "paginaFinal" => "759"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/15819588"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            2 => array:3 [
              "identificador" => "bib0195"
              "etiqueta" => "3"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Mechanism for bupivacaine depression of cardiac conduction&#58; fast block of sodium channels during the action potential with slow recovery from block during diastole"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:2 [
                            0 => "C&#46;W&#46; Clarkson"
                            1 => "L&#46;M&#46; Hondeghem"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:6 [
                        "tituloSerie" => "Anesthesiology"
                        "fecha" => "1985"
                        "volumen" => "62"
                        "paginaInicial" => "396"
                        "paginaFinal" => "405"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/2580463"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            3 => array:3 [
              "identificador" => "bib0200"
              "etiqueta" => "4"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Levobupivacaine&#58; a review of its pharmacology and use as a local anaesthetic"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:2 [
                            0 => "R&#46;H&#46; Foster"
                            1 => "A&#46; Markham"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:6 [
                        "tituloSerie" => "Drugs"
                        "fecha" => "2000"
                        "volumen" => "59"
                        "paginaInicial" => "551"
                        "paginaFinal" => "579"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/10776835"
                            "web" => "Medline"
                          ]
                        ]
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Article information

ISSN: 22562087
Original language: English

DOI:10.1016/j.rcae.2016.02.012

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2024 October	95	7	102
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2024 August	90	5	95
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2024 June	100	14	114
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2024 March	89	15	104
2024 February	102	12	114
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2023 November	101	18	119
2023 October	106	15	121
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2023 August	43	4	47
2023 July	48	7	55
2023 June	63	10	73
2023 May	105	9	114
2023 April	57	10	67
2023 March	56	11	67
2023 February	48	18	66
2023 January	35	10	45
2022 December	38	5	43
2022 November	37	4	41
2022 October	42	11	53
2022 September	28	21	49
2022 August	38	13	51
2022 July	37	14	51
2022 June	40	18	58
2022 May	25	13	38
2022 April	44	15	59
2022 March	34	11	45
2022 February	16	9	25
2022 January	24	13	37
2021 December	20	12	32
2021 November	16	20	36
2021 October	46	12	58
2021 September	59	23	82
2021 August	56	21	77
2021 July	30	16	46
2021 June	32	16	48
2021 May	31	11	42
2021 April	40	12	52
2021 March	23	5	28
2021 February	14	10	24
2021 January	14	11	25
2020 December	10	10	20
2020 November	10	10	20
2020 October	9	9	18
2020 September	13	6	19
2020 August	14	10	24
2020 July	16	11	27
2020 June	5	6	11
2020 May	8	6	14
2020 April	6	4	10
2020 March	4	4	8
2020 February	9	2	11
2020 January	8	3	11
2019 December	12	9	21
2019 November	4	2	6
2019 October	5	2	7
2019 September	2	3	5
2019 July	1	3	4
2019 June	2	3	5
2019 May	0	13	13
2019 April	1	0	1
2019 January	1	0	1
2018 September	1	0	1
2018 June	3	3	6
2018 May	26	10	36
2018 April	36	6	42
2018 March	26	10	36
2018 February	16	5	21
2018 January	23	8	31
2017 December	23	6	29
2017 November	17	7	24
2017 October	18	12	30
2017 September	22	4	26
2017 August	10	8	18
2017 July	23	5	28
2017 June	26	16	42
2017 May	36	12	48
2017 April	35	9	44
2017 March	12	8	20
2017 February	11	2	13
2017 January	14	3	17
2016 December	40	9	49
2016 November	25	6	31
2016 October	45	5	50
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2016 August	28	7	35
2016 July	28	9	37
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