Comparitive study between levobupivacaine versus bubivacaine in spinal anesthesia for cesarean sections

Esraa H Abd-El Wahab; Sohair M Soliman; Sabry M Amen; Sameh R El-Shehdwy

doi:10.4103/tmj.tmj_34_17

ORIGINAL ARTICLE

Year : 2018 | Volume : 46 | Issue : 3 | Page : 232-238

Comparitive study between levobupivacaine versus bubivacaine in spinal anesthesia for cesarean sections

Esraa H Abd-El Wahab, Sohair M Soliman, Sabry M Amen, Sameh R El-Shehdwy
Department of Anesthesiology and Surgical ICU, Faculty of Medicine, Tanta University, Tanta, El-Gharbia, Egypt

Date of Submission	28-Mar-2017
Date of Acceptance	18-Jul-2017
Date of Web Publication	28-Feb-2019

Correspondence Address:
Esraa H Abd-El Wahab
El-Gharbia, Tanta, Elazhria Region, 31511
Egypt

Source of Support: None, Conflict of Interest: None

Check

DOI: 10.4103/tmj.tmj_34_17

Abstract

Background Levobupivacaine showed a lower risk of cardiovascular and central nervous system toxicity than bupivacaine, which is the most popular local anesthetic agent in obstetric practice. The aim of this study was to investigate the clinical efficacy of levobupivacaine 0.5% compared with bupivacaine 0.5% for spinal anesthesia for cesarean sections.
Aim The aim of this study was to compare the efficacy of levobupivacaine 0.5% versus bupivacaine 0.5% in spinal anesthesia for cesarean section.
Patients and methods A total of 60 pregnant women in American Society of Anesthesiologists I–II group scheduled to have an elective cesarean operation were allocated into the study. Patients were randomly divided into two groups (30 patients in each group). Group I (bupivacaine group): in this group, patients received 2.5 ml bupivacaine 0.5%. Group II (levobupivacaine group): in this group, patients received 2.5 ml levobupivacaine 0.5%. Heart rate and mean arterial blood pressure were recorded intraoperatively. The onset time of sensory block and postoperative pain were assessed by visual analogue scale; time of postoperative first rescue of analgesia and duration of motor blockade were assessed by the Bromage score postoperatively.
Results There was no significant difference between both groups as regards hemodynamics (heart rate and mean arterial pressure), two-segment regression of sensory block, time of first feeling of pain, total dose of consumption of analgesia, and visual analogue score. There was a significant decrease in the time to reach maximum sensory and motor block in group II compared with group I. Time of two-segment regression of motor block was significantly lower in group II than in group I.
Conclusion Adequate surgical anesthesia can be achieved with both levobupivacaine and hyperbaric bupivacaine, as tested by the loss of pinprick sensation in both groups. Levobupivacaine given intrathecally can provide a safe and effective analgesic choice for parturients undergoing elective cesarean section, as the incidence of side effects with its use was significantly lower in comparison with hyperbaric bupivacaine.

Keywords: bupivacaine, cesarean section, intrathecal, levobupivacaine

How to cite this article:
Abd-El Wahab EH, Soliman SM, Amen SM, El-Shehdwy SR. Comparitive study between levobupivacaine versus bubivacaine in spinal anesthesia for cesarean sections. Tanta Med J 2018;46:232-8

How to cite this URL:
Abd-El Wahab EH, Soliman SM, Amen SM, El-Shehdwy SR. Comparitive study between levobupivacaine versus bubivacaine in spinal anesthesia for cesarean sections. Tanta Med J [serial online] 2018 [cited 2023 Nov 30];46:232-8. Available from: http://www.tdj.eg.net/text.asp?2018/46/3/232/253201

Introduction

Spinal anesthesia for cesarean section has become increasingly popular, and, in the recent decade, it has been the preferred technique for the majority of anesthesiologists. This is primarily due to increased maternal morbidity with general anesthesia and benefits conveyed to the mother [1].

Bupivacaine is an aminoamide local anesthetic with high potency and long duration and differential sensorial-motor blockade. It is presented as a racemic mixture composed of 50% of the S isomer and 50% of the R isomer (S50–R50) [2].Clinical studies demonstrated that a large proportion of bupivacaine toxicity is due to its dextrorotatory isomer R (+) [3].

Concerns with regard to this compound’s adverse cardiac effects motivated researchers to investigate the mechanisms underlying local anesthetic-induced toxicity and to develop new, safer compounds as a result of these efforts; (S-) bupivacaine (levobupivacaine) has been recognized as the lesser toxic of this compound’s two enantiomers [4].

The toxicity of levobupivacaine will be reassessed to determine its potential benefits for clinical use [5]. Its decrease of cardiovascular and central nervous system toxicity will make levobupivacaine a less toxic substitute in spinal anesthesia [6],[7]. However, levobupivacaine (the S enantiomer of racemic bupivacaine), when compared with bupivacaine, has similar efficacy with enhanced safety profile than bupivacaine, and this provided a major advantage in regional anesthesia.

Levobupivacaine has low cardiotoxicity and less undesired effects on the central nervous system, and, because of its significantly low side effects, levobupivacaine seems to be an attractive alternative to bupivacaine. Hence, it can be used as a proper alternative local anesthetic for spinal anesthesia in patients with coexisting systemic disease (cardiopulmonary problems) [8].

Aim and objectives

The aim of the study was to compare the efficacy of levobupivacaine 0.5% versus bupivacaine 0.5% in spinal anesthesia for cesarean sections.

Patients and methods

After obtaining the research ethics committee approval code and the informed and written consent from patients, 60 women scheduled for elective cesarean delivery, American Society of Anesthesiologists (ASA) physical status class I or II, were enrolled into this prospective randomized, double-blind study at Tanta University Hospital in the Obstetrics Department.

Patients refusing regional anesthesia, having contraindications to spinal anesthesia such as coagulopathy, local infection, or anatomic malformation at the site of the block, known systemic diseases (renal, hepatic, respiratory, cardiac) or neurological disease and history of allergy to local anesthetics were excluded from the study.

Following application of routine monitors (noninvasive blood pressure measurement, ECG, and pulse oximetry) and insertion of a peripheral 20 G intravenous cannula, a rapid infusion of lactated Ringer’s solution 10 ml/kg was administered. Baseline systolic blood pressure and heart rate were calculated as the mean of the three recordings. Patients were placed in the sitting position. After disinfecting the skin and infiltrating with 2% lidocaine, lumbar puncture was performed at the L3–4 interspace using a 25-G Quincke point needle. Patients were randomly divided into two equal groups by using a sealed opaque envelope (30 patients in each group) according to the local anesthetic used: Group I (bupivacaine group): patients in this group received 2.5 ml bupivacaine 0.5% within ∼2 min and group II (levobupivacaine group): patients in this group received 2.5 ml levobupivacaine 0.5% within ∼2 min.

ECG and oxygen saturation were monitored continuously, and arterial blood pressure was measured every 2 min until 20 min, then every 5 min until the end of the operation.

Sensory testing was assessed by loss of pinprick sensation to a 23 G hypodermic needle, and dermatomal levels were tested every 2 min until the highest level had stabilized.

Motor testing was assessed by Bromage score (0: no motor loss, 1: inability to flex the hip, 2: inability to flex the knee joint, 3: inability to flex the ankle).

Testing was continued after completion of surgery or regain of sensory and motor power.

Measurements

Mean arterial blood pressure and heart rate values were recorded, and then after 5, 10, 15, 20, 30, 40, 50, and 60 min after the procedure. Duration of the surgery was recorded.

The onset of sensory block was defined as the time from the end of the injection until the loss of response to painful stimuli by pinprick method.

The maximum sensory (T6) level achieved.

Duration of sensory block was defined as the time interval from the establishment of the complete sensory block to two-segment regression of sensory block by pinprick method.

The onset of motor block was defined as the time from the end of the injection until the loss of motor power.

Duration of complete motor block was defined as the time from establishment of the maximum motor block to earliest sign of recovery of motor block, as evidenced by the decrease of bromage score.

Time to rescue analgesia was defined as the time between administration of a spinal anesthetic drug to the time of administration of first rescue analgesia.

The total dose of rescue analgesia in 6 h was given as follows: postoperative analgesia was given according to visual analogue scale (VAS) between 0 and 10 (0=no pain, 10=most severe pain). If VAS less than 4, NSAIDs were given; if VAS more than 4, a pethidine dose of 1 mg/kg was given intravenously. [Figure 1] represented patients flowchart that summarizing enrollment, allocation, follow-up, and analysis in the study protocol.

Figure 1 Patient flowchart summarizing enrollment, allocation, follow-up, and analysis in the study protocol.

Click here to view

Statistical analysis

Statistical presentation and analysis of the present study was conducted, using mean and SD. Value of P less than 0.05 was considered significant.

Results

With regard to the demographic data ([Table 1]) such as age, height, and weight, duration of surgery, VAS and time of postoperative first rescue of analgesia (h), there was no significant difference between both groups.

Table 1 Demographic data, height, duration of surgery, and time of postoperative first rescue of analgesia in both groups

Click here to view

As regards hemodynamics (heart rate and mean arterial pressure), there was no significant difference between both groups.

The time of onset of sensory block was significantly short in group II when compared with group I (P=0.01, [Table 2]).

Table 2 Characteristics of sensory blocks

Click here to view

The time of maximum sensory level was significantly short in group II when compared with group I (P=0.03). The time of sensory regression was insignificant when compared with each other.

The time of onset of motor block was significantly short in group II when compared with group I (P=0.03, [Table 3]).

Table 3 Characteristics of motor blocks

Click here to view

The time of maximum motor level in was significantly short in group II when compared with group I (P=0.001, [Table 3]).

The time of motor regression was significantly short in group II when compared with group I (P=0.001, [Table 3]).

Discussion

The frequency of cesarean delivery has increased markedly. Anesthetic techniques currently available for cesarean delivery are general and regional anesthesia. Regional anesthetic techniques are the gold standard for cesarean section [9]. General anesthesia is performed in cases of contraindication to regional anesthesia and failure of regional technique, as general anesthesia is associated with airway-related adverse outcome, aspiration risk, intraoperative awareness, and increased uterine atony leading to higher blood loss [10].

Regional anesthesia for cesarean section includes three techniques − spinal, epidural, and combined spinal epidural anesthesia. Spinal anesthesia is the most preferred of regional anesthesia for lower segment cesarean section (LSCS), as it provides easy and rapid induction (in contrast to an epidural block), is reliable, and has the advantages of allowing the mother to be awake during delivery, not needing airway manipulation, mintaining the mother’s airway reflexes, minimizing the hazards of aspiration, decreasing blood loss, reducing the risk of drug-induced fetal depression, providing effective sensory and motor blockade and carrying the need for analgesia over to the postoperative stage [11].

Local anesthetics remain the most commonly used drugs in RA, via the neuraxial or peripheral route, by a single shot or continuous infusion. Bupivacaine is a widely used, long-acting amide local anesthetic. It has the longest time of onset of action among all local anesthetics and a tendency to produce sensory block and motor block at low concentrations. These qualities have made bupivacaine a popular intrathecal drug for anesthesia [12].

Levobupivacaine, the pure S (−) enantiomer of bupivacaine, has strongly emerged as a safer alternative for regional anesthesia than its racemic sibling [13], bupivacaine. Levobupivacaine has been found to be equally efficacious as bupivacaine, but with a superior pharmacokinetic profile [14].

As regards onset time of sensory block and time to complete sensory block, it was significantly shorter in group II when compared with group I.

In agreement with our study, Guler et al. [15], in their study compared 10 mg levobupivacaine with fentanyl with 10 mg bupivacaine with fentanyl in 60 patients scheduled for elective cesarean section and concluded that levobupivacaine could be a good alternative to bupivacaine in cesarean section, as it provided sufficient sensory block level.

In contrast to our study, Turkmen et al. [16], in their study of 50 patients who were scheduled for cesarean section and who were divided into bupivacaine+fentanyl group (group B; n=25), 7.5 mg of 0.5% bupivacaine+15 μg fentanyl intrathecally and levobupivacaine+fentanyl group (group L; n=25), 7.5 mg of 0.5% levobupivacaine+15 μg fentanyl intrathecally, found that onset of sensory block was shorter in the bupivacaine+fentanyl group, which may be due to the small dose of drugs.

Moreover, Vanna et al. [5], compared 2.5 ml of isobaric levobupivacaine with 2.5 ml hyperbaric bupivacaine in70 patients scheduled for endoscopic transurethral surgery and reported similar onset of sensory block with both drugs. This may be due to the surgery being different to our surgery.

In addition, Fattorini et al [17], reported that they did not observe a significant difference in the sensory block characteristics of levobupivacaine and bupivacaine among 60 patients who underwent major orthopedic surgery under spinal anesthesia. Patients received 3 ml of isobaric bupivacaine in group I and 3 ml of isobaric levobupivacaine in group II.

As regards the onset of motor block and time to complete motor block, it was significantly shorter in group II when compared with group I.

In agreement with our study, Duggal et al. [9] in their study of 60 patients, who were divided into the levobupivacaine group (2 ml) and bupivacaine group (2 ml) for elective cesarean section, found that the onset of motor block was faster in parturients who received levobupivacaine, and the difference was statistically significant.

In contrast to our study, Turkmen et al. [16], found that the time of maximum motor block was shorter in the bupivacaine+fentanyl group, which may be due to the small dose of drugs.

Furthermore, Fattorini et al. [17], reported that they did not observe a significant difference in the motor block characteristics of levobupivacine and bupivacaine among 60 patients who underwent major orthopedic surgery under spinal anesthesia.

As regards the time of two-segment regression of sensory and motor block, in the present study, there were no significant differences in the time of two-segment regression of sensory block between two groups, and there was a significant decrease in the time of two-segment regression of motor block in group II when compared with group I.

In agreement to our study, Camorcia et al. [18] reported that intrathecal 7.5 mg hyperbaric levobupivacaine 0.5% and 25 μg fentanyl had weaker motor block potency than intrathecal 7.5 mg hyperbaric bupivacaine 0.5% in 80 patients scheduled for elective cesarean section.

In addition, Vercauteren et al. [19], performed a study on patients who received 0.125% levobupivacaine and 0.125% racemic bupivacaine and found that levobupivacaine led to less motor impairment compared with racemic bupivacaine in intrathecal labor analgesia.

Moroever Bremerich et al. [20],[21], noted that 7.5 mg/10 mg/12 mg levobupivacaine showed significantly shorter and less pronounced motor blockade when compared with same doses of bupivacaine in parturients undergoing elective cesarean section with spinal anesthesia.

In contrast to our study, Alley et al. [4], evaluated three intrathecal doses of levobupivacaine and bupivacaine (4, 6, and 8 mg) in healthy volunteers and found no differences in the clinical profile of sensory and motor blocks and recovery from spinal anesthesia, which may be due to the different dose from our study.

Futhermore, Fattorini et al. [17], reported that they did not observe a significant difference in the sensory and motor block characteristics of levobupivacaine and bupivacaine.

As regards heart rate and mean arterial blood pressure, our study found that it was insignificant statistically when both groups were compared with each other.

In agreement with our study, Vanna et al. [5], demonstrated that 2.5 ml of 0.5% isobaric levobupivacaine, the pure S (−) enantiomer of racemic bupivacaine, is as effective as 2.5 ml of 0.5% hyperbaric bupivacaine for spinal anesthesia in transurethral endoscopic urological surgery, and the hemodynamics are similar to those obtained with racemic bupivacaine.

In addition, Glaser et al. [1], compared 3.5 ml of isobaric levobupivacaine to 3.5 ml of isobaric bupivacaine in patients scheduled for elective hip replacement and found it to be equally effective with no intergroup difference in hemodynamic characteristics.

Moreover, Burlacu and Buggy [3] reported that 2.6 ml 0.5% racemic bupivacaine and levobupivacaine in a dose-effect study comparing racemic bupivacaine and levobupivacaine in patients undergoing urological surgery have a nearly equivalent clinical profile and hemodynamic effects.

On the contrary, Guler et al. [15], conducted a study on 60 pregnant women in ASA I–II group scheduled to have elective cesarean operation, in which the patients were randomly divided into two groups. The following combinations were used in the two groups: 10 mg levobupivacaine (0.5%)+fentanyl (15 μg) for group LF (n=30) patients and 10 mg hyperbaric bupivacaine (0.5%)+fentanyl (15 μg) for BF (n=30). They reported that the rate of occurrence of hypotension was 36.6% in the group that was administered spinal anesthesia with 10 mg 0.5% bupivacaine. The incidence of hypotension was significantly reduced to 16.6% in the doses used in the levobupivacaine. This study was different from our study in doses of the drug and addition of narcotics.

Furthermore, Bano and Firdous [22], found that intrathecal 7.5 mg hyperbaric levobupivacaine and 25 μg fentanyl combination is a good alternative to 7.5 mg bupivacaine and 25 μg fentanyl combination in 80 patients scedeuled for elective cesarean surgery, as it maintains hemodynamic stability at higher sensorial block levels.

Furthermore, Duggal et al. [9], in their study of patients sceduled for elective cesarean section were allocated into two groups of 20 each. Group B received 8.75 mg of 0.5% hyperbaric bupivacaine with 12.5 μg of fentanyl. Group L received 8.75 mg of 0.5% isobaric levobupivacaine with 12.5 μg of fentanyl. They found that the incidence of hypotension and the need for bolus doses of vasopressor was significantly lesser in group levobupivacaine who received 8.75 mg of 0.5% levobupivacaine with 12.5 μg of fentanyl.

In our study, the incidence of nausea and vomiting was insignificant between two groups when compared with each other.

In regional anesthesia for cesarean sections, nausea and vomiting can occur due to different factors. The most important reason is that cerebral blood flow decreases as a consequence of hypotension (hypotension is the most common complication in the spinal anesthesia [23]. It is known that besides its effects on the mother, it causes acidosis by altering uteroplacental perfusion). Other reasons are related to the level where the block reaches. It may as well occur because of an increase in the block level, or because of the fact that structures are related to peritoneal stretch during the operation due to an inadequate block level.

In contrast to our study, Guler et al. [15], conducted a study on 60 pregnant women in ASA I–II group scheduled to have an elective cesarean operation, in which the patients were randomly divided into two groups. The combinations were as follows: 10 mg levobupivacaine (0.5%)+fentanyl (15 μg) for group LF (n=30) patients and 10 mg hyperbaric bupivacaine (0.5%)+fentanyl (15 μg) for BF (n=30). They showed that nausea and vomiting was less while using levobupivacaine than bupivacaine, which may be due to the lower dose than the dose in our study.

Moreover, Duggal et al. [9], conducted a study on 60 patients who were divided in two groups: levobupivacaine group (2 ml) and bupivacaine group (2 ml) for elective cesarean section, and they showed that nausea and vomiting were less while using levobupivacaine compared with bupivacaine.

Conclusion

Levobupivacaine had a faster onset of action, provided effective surgical anesthesia for elective cesarean section and lesser duration of motor block when compared with bupivacaine. On the basis of this study, we conclude that levobupivacine is a good alternative to bupivacaine in cesarean section.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

References

1.	Glaser C, Marhofer P, Zimpfer G, Heinz MT, Sitzwohl C, Kapral S et al. Levobupivacaine versus racemic bupivacaine for spinal anesthesia. Anesth Analg 2002; 94:194–198.
2.	Nogueira CS, Lima LC, Paris VC, Neiva PM, Otani ET, Couceiro RO et al. A comparative study between bupivacaine (S75-R25) and ropivacaine in spinal anesthesia for labor analgesia. Rev Brasil Anestesiol 2010; 60:484–494.
3.	Burlacu CL, Buggy DJ. Update on local anesthetics: focus on levobupivacaine. Ther Clin Risk Manag 2008; 4:381–392.
4.	Alley EA, Kopacz DJ, McDonald SB, Liu SS. Hyperbaric spinal levobupivacaine: a comparison to racemic bupivacaine in volunteers. Anesth Analg 2002; 94:188–193.
5.	Vanna O, Chumsang L, Thongmee S. Levobupivacaine and bupivacaine in spinal anesthesia for transurethral endoscopic surgery. J Med Assoc Thai 2006; 89:1133–1139.
6.	Akcaboy EY, Akcaboy ZN, Gogus N. Low dose levobupivacaine 0.5% with fentanyl in spinal anaesthesia for transurethral resection of prostate surgery. J Res Med Sci 2011; 16:68.
7.	Akan B, Yagan O, Bilal B, Erdem D, Gogus N. Comparison of levobupivacaine alone and in combination with fentanyl and sufentanil in patients undergoing transurethral resection of the prostate. J Res Med Sci 2013; 18:378.
8.	Cuvas O, Basar H, Yeygel A, Turkyilmaz E, Sunay M. Spinal anesthesia for transurethral resection operations: levobupivacaine with or without fentanyl. Middle East J Anaesthesiol 2010; 20:547–552.
9.	Duggal R, Kapoor R, Moyal G. A comparison of intrathecal levobupivacaine with hyperbaric bupivacaine for elective cesarean section: a prospective randomized double-blind study. J Obstet Anaesth Crit Care 2015; 5:78. [Full text]
10.	Wong C. General anesthesia is unacceptable for elective cesarean section. Int J Obstet Anesth 2010; 19:209–212.
11.	Kan R, Lew E, Yeo S, Thomas E. General anesthesia for cesarean section in a Singapore maternity hospital: a retrospective survey. Int J Obstet Anesth 2004; 13:221–226.
12.	Mukherjee S. Rising cesarean section rate. J Obstet Gynecol India 2006; 56:298–300.
13.	Freise H, Meissner A, Lauer S, Ellger B, Radke R, Ellger B et al. Thoracic epidural analgesia with low concentration of bupivacaine induces thoracic and lumbar sympathetic block: a randomized, double-blind clinical trial. J Am Soc Anesthesiol 2008; 109:1107–1112.
14.	Bajwa SJS, Kaur J. Clinical profile of levobupivacaine in regional anesthesia: a systematic review. J Anaesthesiol Clin Pharmacol 2013; 29:530.
15.	Guler G, Cakir G, Ulgey A, Ugur F, Bicer C, Gunes I, Boyaci A. A comparison of spinal anesthesia with levobupivacaine and hyperbaric bupivacaine for cesarean sections: a randomized trial. Erciyes University 2012; 2:84–89.
16.	Turkmen A, Moralar D, Ali A, Altan A. Comparison of the anesthetic effects of intrathecal levobupivacaine+ fentanyl and bupivacaine+ fentanyl during caesarean section. Middle East J Anaesthesiol 2012; 21:577–582.
17.	Fattorini F, Ricci Z, Rocco A, Romano R, Pascarella MA, Pinto G. Levobupivacaine versus racemic bupivacaine for spinal anaesthesia in orthopaedic major surgery. Minerva Anestesiol 2005; 72:637–644.
18.	Camorcia M, Capogna G, Berritta C, Columb MO. The relative potencies for motor block after intrathecal ropivacaine, levobupivacaine, and bupivacaine. Anesth Analg 2007; 104:904–907.
19.	Vercauteren MP, Hans G, De Decker K, Adriaensen HA. Levobupivacaine combined with sufentanil and epinephrine for intrathecal labor analgesia: a comparison with racemic bupivacaine. Anesth Analg 2001; 93:996–1000.
20.	Bremerich DH, Fetsch N, Zwissler BC, Meininger D, Gogarten W, Byhahn C. Comparison of intrathecal bupivacaine and levobupivacaine combined with opioids for caesarean section. Curr Med Res Opin 2007; 23:3047–3054.
21.	Bremerich DH, Kuschel S, Fetsch N, Zwissler B, Byhahn C, Meininger D. Levobupivacaine for parturients undergoing elective caesarean delivery. A dose-finding investigation. Der Anaesthesist 2007; 56: 772–779.
22.	Bano N, Firdous R. Effects of intrathecal hyperbaric versus isobaric bupivacaine in elective caesarean section. Faisalabad:Punjab Medical College; 2015.
23.	Yorozu T, Morisaki H, Kondoh M, Zenfuku M, Shigematsu T. Comparative effect of 6% hydroxyethyl starch (containing 1% dextrose) and lactated Ringer’s solution for cesarean section under spinal anesthesia. J Anesth 2002; 16:203–206.