A Prospective Double Blind Comparative study of Epidural Anaesthesia with Bupivacaine (0.5%) 15 ml...

ISSN: 2055-530X International Journal of Latest Trends in Engineering, Science and Technology

Volume 2, Issue 1

A Prospective Randomized Double Blind comparative study of Epidural Anesthesia with

Bupivacaine (0.5%) 15ml and Levobupivacaine (0.5%) 15ml in Patients undergoing

Elective Lower Abdominal Surgery.

Dr. Syed Akram Moin

Resident, Kakatiya Medical College, Warangal, DRNTRUHS, India.

Dr. Praveen Kumar Devulapalli

Associate Professor of Anesthesiology, Kakatiya Medical College, Warangal, DRNTRUHS,

[email protected]

DR. S. Muneeruddin Ahmed

Professor and HOD of ENT, Mamatha Medical College, Khammam, DRNTRUHS, India,

[email protected].

Abstract

INTRODUCTION: Importance of regional

anesthesia is increasing in recent years and

becoming a vital part of the clinical practice

of anesthesiologist. However drug toxicity

issues in regional anesthesia continues to be

an important consideration. Bupivacaine

has emerged as the most commonly used

drug for central neuraxial blockade in spite

of prolonged post operative motor blockade,

and cardio toxicity. levobupivacaine has the

advantages low cardiovascular toxicity and

a relatively low motor nerve fiber

penetration and block, thereby a decreased

post operative motor blockade helping in

early ambulation of the patients. AIM: To

evaluate and compare clinically the

pharmacological effects between 0.5%

levobupivacaine and 0.5% bupivacaine for

epidural anesthesia in lower abdominal

surgeries. OBJECTIVES: to observe the

clinical parameters after administration of

the drug such as time for onset and duration

of sensory and motor blockade, and

Duration of analgesia. RESULTS:

Levobupivacaine gave profound and

prolonged motor blockade and also a

prolonged duration of sensory blockade

with negligible adverse effects.

KEY WORDS: Epidural anesthesia,

Levobupivacaine, Bupivacaine, Clinical

parameters, Local anesthetics, Motor

blockade and sensory blockade.

INTRODUCTION: In Anesthesiology

practice search for safe and newer drugs

remains the primary need especially in

regional anesthesia. Over the last two

decades regional anesthesia underwent many

modifications with advent of newer drugs

like bupivacaine and its two forms. They are

racemic mixture (50:50) of its two

enantiomer, levobupivacaine, S (−) isomer

and dextro bupivacaine, R (+) isomer.

Accidental injection of R (+) isomer of

bupivacaine resulting in severe CNS and

CVS adverse reactions is reported in the

literature whereas the Levorotatory forms

have shown safer pharmacological profile (¹,

²). This is attributed to its faster protein

binding nature (³). It also has lesser CNS and

CVS adverse effects (4, 5). Levobupivacaine

has been recently introduced into Indian

market and is being widely used in various

health set-ups (6). Such an increased usage

mandates documentation of evidence based

literature with regards to risk and safety

concerns as well as clinical issues related to

levobupivacaine (6). Levobupivacaine

produces less motor blockade compared to

Levobupivacaine and enantiomer excess

mailto:[email protected]

mailto:[email protected]


Volume 2, Issue 1

bupivacaine when used in epidural

anesthesia (7). The present study includes a

similar attempt to study the clinical

parameters to understand the range of

clinical safety in day to day usage in a tertiary Hospital set up.

MATERIALS AND METHODS: A

study entitled “Prospective randomized

double blind comparative study of

epidural anesthesia with Levobupivacaine

0.5% 15 ml and Bupivacaine 0.5% 15 ml

for elective lower abdominal surgeries”

was undertaken in Mahatma Gandhi

Memorial Hospital attached to Kakatiya

Medical College Warangal, during the

period between January 2013 to June

2014. The study was undertaken after

obtaining ethical committee clearance

as well as informed consent from all

the patients. Sixty patients, scheduled for

elective lower abdominal surgeries were

included in the study. The study

population was randomly divided

using computer generated randomization

numbers into two groups with 30 patients

in each group. Group L (n=30) – received

15 ml of 0.5% injection

Levobupivacaine (Levo bupivacaine 0.5%

preservative free 0.5% 20 ml ampoules).

Group B (n=30) – received 15 ml of

0.5% injection Bupivacaine

(Bupivacaine 0.5% preservative free 0.5%

20 ml vials). Inclusion criteria: 1. Adult

patients aged between 18 to 55 years of

both sex. 2. Patients belonging to ASA

class I and II posted for elective lower

abdominal surgery. Exclusion criteria: 1.

Patient refusal 2. Patients belonging to

ASA class III, IV and V. 3. Patients with

co morbid diseases like hypertension,

diabetes mellitus and ischemic heart

disease. 4. Pregnant patients. 5. Patients

posted for Emergency surgeries. 6. Obese

patient with BMI > 30. 7. Patients whose

height less than 150 Cms and more than

180 Cms. 8. Patients having: raised

intracranial pressure, severe hypo volemic,

bleeding coagulopathy, local infection. All

the patients underwent pre-anesthetic

examination on the evening before

surgery, assessing history and general

condition of the patient, airway assessment

by Mallampati grading. Nutritional status,

height and weight of the patient, a detailed

examination of the Cardio vascular

system, Respiratory system and Central

nervous system under taken. Examination

of the spine was also done. The following

investigations were done in all patients:

Hemoglobin estimation, Urine

examination for albumin, sugar and

microscopy, Standard 12-lead

electrocardiogram, Random blood sugar,

Blood urea and Serum creatinine. The

patients were g i v e n premedication

with tablet Alprazolam 0.5 mg and

tablet Ranitidine 150 mg orally at bed

time on the previous night before surgery.

They were kept nil orally 10 pm onwards

on the previous night. On the day of

surgery, patient’s basal pulse rate and

blood pressure were recorded. A

peripheral intravenous line with 18 gauge

cannula was secured in one of the upper

limbs. All the patients were preloaded

with 500 ml of Ringer lactate 30

minutes prior to the epidural procedure and

pre medicated with injection midazolam 1

mg i. v. before epidural anesthesia. Multi

parameter monitor was connected which

records heart rate, non-invasive

measurement of systolic blood pressure

(SBP), diastolic blood pressure (DBP),

mean arterial pressure(MAP), continuous

electrocardiogram (ECG) monitoring and

oxygen saturation (SPO2). With the

patients in sitting position under aseptic

precautions, epidural space was identified

by loss of resistance technique using 18G

Tuohy needle via the midline approach at

either L3-4 or L2-3 inter spinous


Volume 2, Issue 1

space. An epidural catheter was

threaded and fixed at 3 Cms inside the

epidural space. A test dose of 3 ml of

2% lignocaine with 1:200000

adrenaline was injected through the

catheter after aspiration. After ruling out

intrathecal and intravascular placement of

the tip of the catheter, study drug was

injected in increments of 5 ml with first 5

ml given in sitting position. The patients

were shifted to supine position after 1 min

and remaining 10 ml of study drug was

injected. The study drugs were prepared

and loaded in three 5 ml sterile syringes

and given by another anesthesiologist

who is not involved with the study.

Thus the observers as well as the patients

were blinded for the study of drugs.

Assessment of sensory and motor

blockade were done at the end of each

minute with the patient in supine position

after completion of the injection of 15 ml

of the study drug, which was taken as the

starting time. The onset time and the

time for maximum motor and sensory

block and the maximum level of sensory

and motor block were recorded. Sensory

blockade was assessed using a short

bevel 22 gauge needle and was tested in

the mid clavicular line on the chest, trunk

and lower limbs on either side. Motor

blockade in the lower limbs was

assessed using modified Bromage scale:

0 – Able to perform a full straight leg raise

over the bed for 5 sec. 1– Unable to

perform the leg raise but can flex the leg

on the knee articulation. 2 – Unable to flex

the knee but can flex the ankle. 3 – Unable

to flex ankle but can move the toes. 4 –

Unable to move toes (total paralysis).

Measurements of blood pressure, heart

rate, respiratory rate and oxygen

saturation were obtained at 0, 2, 5, 10

mins after epidural anesthesia and every

10 mins thereafter. Intra operatively and

postoperatively complications like fall in

blood pressure, variation in heart rate were

noted, treated and tabulated. Hypotension

is defined as reduction of systolic blood

pressure more than 30% from basal

systolic blood pressure or SBP less than

90 mmHg and is treated with increased

rate of intravenous fluids and if needed

injection mephentermine 3 mg (I.V) given

in increments. Bradycardia (<60

beats/min) was treated with injection

Atropine 0.6 mg (I.V). Postoperatively,

duration of analgesia was assessed till the

patients complained of pain at the surgical

site. Epidural top up was given once the

patient complained of pain. Time taken for

complete recovery of motor power was

also noted. Onset of sensory blockade:

Was taken as the time from the

completion of the injection of the study

drug till the patient does not feel the

pin prick at L1 level on the dependent

side. Time for maximum sensory

blockade: is defined as the time from the


drug to the maximum sensory blockade

attained. Onset of motor blockade: is

taken from the completion of the injection

of study drug till the patient develops

modified Bromage scale grade 1 motor

blockade. Time for maximum motor

blockade: is defined as the time from the


drug to the maximum motor blockade

attained. Duration of motor block: is

taken from the time of injection till the

patient attains complete motor recovery

(Bromage 0). Duration of analgesia: is

taken from the time of injection till the

patient complains of pain at the site of

surgery. The results of the study were

statistically analyzed between the two

groups.

STATISTICAL METHOD APPLIED:

Statistical analysis was done using SPSS

version 13.0. Descriptive statistics was


Volume 2, Issue 1

done by calculating mean, standard

deviation, range and proportion

appropriately. The inferential statistics

(test of significance) was done using

unpaired t-test two-way repeated measure

ANOVA and chi-square test. P-value: it

is the probability rate at 0.05 level of

significance for corresponding degree of

freedom. p>0.05 is not significant, P<0.05

is significant, P<0.01 is significant.

RESULTS: 60 patients were divided into

two groups L and B each with 30 patients.

The youngest patient was aged 18 years

and the eldest was 55 years. The mean age

was 32.23 in group L and 33.40 in group B.

The Standard deviation for group L was

9.46 and for group B was 7.89. Both the

groups were similar with respect to age

distribution. In group L 26 (86.67%) were

males and 4 (13.33%) were females. In

group B 24 (80%) patients were male and

6 (20%) were females. The mean body

weight in group L was 59.40 ± 5.86 kgs

and group B is 62.77± 7.18 kgs. There was

no significant difference in the body

weight of patients between the two groups.

The mean height in group L is 170 cm

and group B is 169.03 cm. The mean

duration of surgery was 96.83 ± 27.49

mins in group L and 0.83 ± 23.12 mins

in group B. The mean time of onset of

sensory blockade in group L is 1.73±1.4

mins and in group B it was 1.60±1.3mins.

There was no statistical significant

difference between the groups (p=0.7).

The mean time taken for attaining

the maximum sensory blockade was

23.77±10.5 mins in group L and

23.23±7.8 mins in group B. There was no

statistical significant difference between

the two groups (P-0.3). Fourteen patients

(46.66%) in group L and 12 (40%)

patients in group B attained block above

T6 and this was statistically not significant.

The mean time taken for the onset of

motor blockade is 6.1±4.1 mins in group

N Group Group

L

Group

B

P-

value

1 Mean

Age

SD

32.23

± 9.46

33.40 ±

7.89

--

2 Sex

%

Male:

59.40

Female

13.33

Male:

80

Female:

20

--

3 Height

(Cms)

170 169.03

4 Body

Weight

(Kgs)

59.40±

5.86

62.77±

7.18

5 Mean

sensory

block-

onset

1.73 ±

1.4

1.60 ±

1.3

0.7

6 Mean

sensory

block-

maxima

23.77 ±

10.5

21.23 ±

7.8

0.3

7 Level of

Sensory

Block>6

14 12 0.1

8 Mean

motor

block-

onset

6.1 ±

4.1 5.53

2.6

0.6

9 Motor

grade-4

16 5 0.001

10 Mean

time Max

Motor

blockade

32.53 22 0.001

11 Analgesia

& Motor

blockade

duration

235.4 ±

61.8

215 ±

174.6

197.3 ±

34.5

54.1 ±

34.6

0.001

0.001

Table 1 Showing the demographic data

and observations of clinical parameters

(n=2X30=60).


Volume 2, Issue 1

L and 5.53±2.6 mins in group B. There

was no statistical significant difference

between the two groups (P- 0.6) - (Table

1). The number of patients with Bromage

2 were 5 (16.66%) in group L and

19(63.33%) in group B. Patients with

Bromage 4 were 16 (53.33%) in group L

and 5 (16.66%) in group B. More intense

motor blockade of Bromage 3 and 4 was

found in 25 (83.33%) patients in group L,

compared to 11(36.66%) patients in group

B, the P value was 0.001 (taking P<0.05 as

significant) is significant. The mean

timetaken for attaining maximum motor

blockade was 32.53±14.1 mins in group L

and 22±9.7 mins in group B. There was

statistically highly significant difference

between the t w o groups (P-0.001 out

19 out of 30 patients in group B attained

Bromage grade 2 earlier as more

number of patients 25 out of 30 in

group L attained Bromage grade 3 and

4 and hence took a longer time to

achieve the maximum motor blockade.

The mean duration of analgesia is


197.3±34.5 mins in group B. There

was statistically significant difference

between the two groups (P-0.005). The

mean duration of motor blockade was


174.6±34.6 mins in group B. There

was statistically highly significant

difference between the group (p=0.001).

There was no statistically significant

difference in the mean heart rate between

groups at various intervals. None of

the patients in both the groups

developed Bradycardia (Table 2).

Time Gr-L Gr-B P

Basa 90.53±15.8

89.17±15.2

HR-

0

95.93±13.1

95.00±13.7

2

min

95.53±12.2

92.57±15.0

5

min

95.30±13.1

89.93±14.2

10

min

93.27±14.4

86.03±15.3

20

min

87.13±12.1

83.57±11.9

30

min

87.07±13.3

83.17±11.8

0.8

40

min

85.87±13.9

81.57±10.2

50

min

83.60±13.5

80.93±9.5

60

min

83.93±12.7

80.77±18.3

70

min

84.93±15.2

79.37±17.3

80

min

85.37±14.6

82.50±19.1

90

min

86.33±14.6

82.70±19.1

Table 2: Showing the variation in Mean

Heart rate during the blockade

(n=2X30=60).


difference in systolic blood pressure

between both the groups. Seven patients

in group L and 4 patients in group B

developed hypotension which was

treated with intravenous fluids and

injection mephentermine (Table 3).


Volume 2, Issue 1

Tim

e

Gr-L Gr-B P

SBP 125.82±8.5

126.93±10.2

SBP

0

125.46±12

123.18±9.5

2

min

126.96±10.5

122.89±10.9

5

min

124.79±10.4

123.14±12.0

10

min

125.82±12.5

120.50±11.0

20

min

122.04±12.9

119.32±10.1

0.8

30

min

122.54±11.5

120.96±11.1

40

min

121.68±12.3

120.11±10.9

50

min

123.32±11.5

120.82±9.7

60

min

124.21±9.8

122.89±11.4

70

min

123.61±9.4

117.21±23.7

80

min

123.57±9.8

122.96±10.5

90

min

121.64±10.5

124.00±10.2

Table 3: Mean SBP in mmHg at various

intervals during the blockade

(n=2X30=60).


difference in diastolic blood pressure

between both the groups (table 4). There is

no statistically significant difference in

mean arterial pressure between both the

two groups (Table 5).

Tim

e

Gr-L Gr-B P

DBP 84.77±9.2

82.83±9.8

SBP

0

79.97±12.4

79.00±9.8

2

min

78.27±11.4

77.33±9.9

5

min

77.40±10.2

76.43±13.3

10

min

77.57±12.2

73.33±9.6

20

min

76.80±11.5

74.17±8.8

30

min

78.50±13.6

76.07±8.6

0.4

40

min

79.43±12.5

75.23±8.7

50

min

78.90±11.3

74.47±9.6

60

min

77.90±11.0

73.43±17.6

70

min

78.10±11.6

71.27±21.6

80

min

74.37±22.5

73.20±22.4

90

min

72.93±22.3

73.80±22.5

Table 4: Showing the Mean DBP in

mmHg at various time intervals during

the blockade (n=2X30=60).

DISCUSSION: The present Study was

undertaken in MGM Hospital attached to

Kakatiya medical College, Warangal to

evaluate the sensory and motor blocking

properties of Levobupivacaine 0.5%

compared with 0.5% bupivacaine.


Volume 2, Issue 1

Tim

e

Gr-L Gr-B P

MAP 96.07±10.5

95.07±12.0

MAP

0

min

89.33±20.4

91.17±9.8

2

min

91.10±11.3

89.93±10.7

5

min

90.07±10.9

89.23±14.1

10

min

88.80±11.3

86.90±9.9

20

min

89.87±13.5

87.10±10.1

30

min

90.37±12.4

87.93±10.2

0.4

40

min

91.10±12.4

87.13±9.8

50

min

90.80±12.8

87.33±8.9

60

min

89.30±11.9

85.23±19.4

70

min

91.97±12.4

82.23±24.8

80

min

86.47±25.9

85.20±25.7

90

min

84.37±25.6

85.30±25.5

Table 5: Showing the Mean arterial

Pressure in mmHg at different time

intervals (n=2X30=60).

This is a Prospective double blind

randomized comparative study of epidural

anesthesia with Levobupivacaine 0.5% 15

ml and bupivacaine 0.5% 15ml for elective

Abdominal surgeries. After informed

consent 60 patients of ASA class I and II,

posted for various elective lower Abdominal

surgeries were grouped randomly into either

bupivacaine (B) group or Levobupivacaine

(L) group. After identification of epidural

space with loss of resistance technique and

introduction of epidural catheter, 3 ml of

lignocaine 2% with adrenaline test dose,

later 15 ml of the study drug was injected

and various parameters were studied. In this

study, the drugs selected for epidural

anesthesia were bupivacaine and

Levobupivacaine. Bupivacaine is used for

epidural anesthesia for lower abdominal

surgeries in this hospital. Levobupivacaine

another local anesthetic with structural

similarity to bupivacaine without its cardio

toxic effects has been introduced to Indian

market recently, was found to be equally

effective as bupivacaine for epidural

anesthesia by various authors. Few studies

have compared bupivacaine and

Levobupivacaine for epidural anesthesia in

India. Hence Levobupivacaine was selected

for the present study to compare with

routinely used bupivacaine. Dose of the

drugs selected: The volume 0.5%

bupivacaine used regularly for lower limb

orthopedic surgeries in is hospital for

epidural anesthesia is 15 ml after using 3 ml

of 2% lidocaine with adrenaline as test dose;

the total dose being 18 ml. This is calculated

as 1ml/segment up to 150 Cms of height,

and adding 0.1ml/segment for every 5 Cms

of increasing height (8), the mean height in

the present study were 170 Cms in both the

groups. Nerve block up to T10 (13

segments) was required for lower limb

surgeries, total volume required would be 18

ml. Hence in both the groups 15 ml was

selected as the volume of the study drug in

addition to test dose. Demographic data:

Demographic data comparing age, sex,

weight, height showed no statistically

significant difference between the two

groups. In the present study the mean time

for onset of sensory block is 1.73±1.4 mins

in group L and 1.60±1.3 mins in group B.

There is no statistically significant difference

in the onset of sensory blockade between the

two groups. Similarly the study conducted

by Casati A et al (9) comparing epidural


Volume 2, Issue 1

anesthesia with Bupivacaine and

Levobupivacaine did not find any statistical

difference in onset of sensory block. In our

study the maximum level of sensory

blockade was T4 (n=5) in both the groups.

The range of block was very wide in both

the groups (T12-T4). In a similar study by

Jaffrey A Katz et al (10) the maximum level

of sensory blockade with 0.5% bupivacaine

was also T4. The mean time for maximum

sensory level in our study was 23.77±10.5

mins in Levobupivacaine group vs.

21.23±7.8 mins in bupivacaine group with

no statistical difference. It is in correlation

with the studies conducted by Kopacz DJ,

Allen HW, and Thomson GE (11).

In our

study the duration of analgesia is longer with

Levobupivacaine group compared with

bupivacaine group. It is 235.46±1.8 mins

with Levobupivacaine 0.5% vs. 197.33±4.5

mins with bupivacaine. This is statistically

significant. This study concurs with the

study conducted by Kopacz DJ et al (11

) who

observed the mean duration of analgesia to

be 360 mins with Levobupivacaine 0.5% and

300 mins with bupivacaine 0.5% which is

significant. Three patients of

Levobupivacaine group required

supplemental analgesics intra-operatively as

they had inadequate block where as 5

patients in bupivacaine group required

supplemental analgesics. There was no

statistical significant difference in the

requirement of supplemental analgesics. The

onset of motor blockade was 6.1±4.1 min in

group L and 5.53±2.6 mins in group B.

There was no statistical significance in the

motor onset between the two groups. In the

present study motor blockade was checked

by using Bromage scale and onset was taken

as soon as the patient developed grade 1

motor blockade. In a similar conducted by

Casati A, Aldegheri G¹² onset of motor

block was 26±25 min with Levobupivacaine

0.5% and 16±9 mins with bupivacaine 0.5%

and not statistically significant. In this study

it was found that Levobupivacaine 0.5%

produces more intense motor blockade than

bupivacaine 0.5%. In Levobupivacaine

group number of patients with grade 4 motor

blockades was 16 compared with only 5

patients in bupivacaine group. This is

statistically significant. Hence the present

study agrees with study conducted by Casati

A, Santorsola R, Aldegheri G et al (13)

regarding degree of motor blockade. The

mean time for maximum motor blockade

in group L is 32.53±14.1 and 22±9.7 min

in group B. There is statistically significant

difference between the two groups in the

time taken for maximum motor blockade.

This could possibly be due to more

number of patients with maximum motor

blockade of grade 2 in group B compared

to grade 4 in group L. The time taken to

attain grade 2 blockades will be shorter

than to attain grade 4. In a similar study

conducted by Kopacz DJ, Allen HW,

Thomson GE (¹¹) the time for maximum

motor block was with 0.5%

Levobupivacaine-47±29 mins and 0.5%

bupivacaine was 32±17 mins which concurs

with present study. The duration of motor

blockade in group L is 215.3±54.1 mins

compared to 174.6±34.6 mins in group B.

The duration with Levobupivacaine is

more prolonged than with bupivacaine

0.5% which is statistically highly

significant. Our study agrees with study

conducted by Tanaka PP, Ogleari M, and

Val Morbida P (7) regarding duration of

motor blockade. There is no statistically

significant difference in the heart rate

between the two groups at various time

intervals. No patients in either group

developed significant Bradycardia. The

above result is consistent with the study

conducted by Koch T, Fischtner A,

Schwmmer U (13) wherein there was no

statistically significant difference in the

heart rate with bupivacaine 0.5%. There

was no statistically significant difference


Volume 2, Issue 1

in SBP, DBP, MAP monitored at various

intervals between the two groups as there

was no statistically significant difference

in the level of sensory block in both the

groups. However 7 patients in group

R and 4 patients in group B

developed hypotension which was

treated with intravenous fluids and

injection mephentermine. However 7

patients in group L and 4 patients in group

B developed hypotension which was

treated with intravenous fluid8 and inj

mephentermine. Similar findings were also

presented in the studies conducted by

Bergamaschi F, Balle VR, Gomes ME (14)

where more number of patients with 0.5%

Levobupivacaine developed hypotension.

CONCLUSIONS: There was no

statistically significant difference in the

onset of sensory and motor blockade and

maximum level of analgesia between

Levobupivacaine 0.5% and bupivacaine

0.5%. Ropivacaine 0.5% produced more

intense motor blockade than bupivacaine

0.5%. The time taken for maximum motor

blockade was longer with Levobupivacaine

0.5% compared to bupivacaine 0.5%.

Duration of analgesia is prolonged with

Levobupivacaine 0.5% compared to

bupivacaine 0.5%. Duration of motor

blockade is also prolonged with 0.5%

Levobupivacaine compared to 0.5%

bupivacaine. Hence it can be concluded

that Levobupivacaine 0.5% 15 ml given

epidural route produces a profound and

prolonged motor blockade and also a

prolonged duration of sensory blockade.

Levobupivacaine 0.5% can be a safe and

effective local anesthetic for epidural

blockade in lower abdominal surgeries.

REFERENCES:

1. McLeod GA, Burke D.

Levobupivacaine. Anaesthesia. 2001;

56:331–41.

2. Casati A, Baciarello M. Enantiomeric

local anesthetics: Can Ropivacaine and

levobupivacaine improve our practice? Curr

Drug Ther. 2006;1: 85–9.

3. Burm AG, van der Meer AD, van Kleef

JW, Zeijlmans PW, Groen K.

Pharmacokinetics of the enantiomers of

bupivacaine following intravenous

administration of the racemate. Br J Clin

Pharmacol.1994; 38:125–9.

4.Huang YF, Pryor ME, Mather LE, Veering

BT. Cardiovascular and central nervous

system effects of intravenous

levobupivacaine and bupivacaine in

sheep. Anesth Analg. 1998; 86:797–804.

5. Morrison SG, Dominguez JJ, Frascarolo

P, Reiz S. A comparison of the

electrocardiographic cardiotoxic effects of

racemic bupivacaine, levobupivacaine, and

ropivacaine in anesthetized swine. Anesth

Analg.2000;90: 1308–14.

6. Sukhminder Jit Singh Bajwa and Jasleen

Kaur, Clinical profile of levobupivacaine in

regional anesthesia: A systematic review,J

Anaesthesiol Clin Pharmacol. 2013 Oct-

Dec; 29(4): 530–539.

7. TanakaPP, Ogleari M, valmorbida P, Et

al. Revista Brasileria De anaesthesiologia

01/2006;55(6); 597-605.

8. W and Graf BM. Benefit-risk assesment

of Levobupivacaine in the management of

postoperative pain. Drug Safety 2004-

27(14):1093-1114.

9.Casati, Santorsola R, Aldegheri G, Ravasi

F, Fanelli G, Berti M, Fraschini G, Torn G,

et al. J.Clinical Anaesthesia 2003 March 15th

(2); 126-131

10.S Shaikh, K Rohini, Comparison Of

Epidural Bupivacaine 0.5% With Epidural

Ropivacaine 0.75% For Lower Limb

http://www.ncbi.nlm.nih.gov/pubmed/?term=Bajwa%20SJ%5Bauth%5D

http://www.ncbi.nlm.nih.gov/pubmed/?term=Kaur%20J%5Bauth%5D

http://www.ncbi.nlm.nih.gov/pubmed/?term=Kaur%20J%5Bauth%5D

https://ispub.com/IJA/30/2/14010




Volume 2, Issue 1

Orthopedic Procedures. Internet journal of

anesthesiology. 2012. 30(2); 14010.

11.Kopascz DJ, Allen HW, Thomson GE, et

al, Anaesth analg. 2000 March; 90(3) 642-

648.

12.Casati, Santorsola R, Aldegheri G,

Ravasi F, Fanelli G, Berti M, Fraschini G,

Torn G, et al. J.Clinical Anaesthesia 2003

March 15th

(2); 126-131.

13.Koch T, Fishtner A, Schwemmer U, et al.

Anasthetist. 2008 May; 57 (5); 475-482.

14..Bergamaschi F, Balle VR, Gomes ME,

et al. Rev.Bras anaestesiol 2005; 55;6;606-

613.


A Prospective Double Blind Comparative study of Epidural Anaesthesia with Bupivacaine (0.5%) 15 ml...

Documents

Transcript of A Prospective Double Blind Comparative study of Epidural Anaesthesia with Bupivacaine (0.5%) 15 ml...