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*Corresponding Author: Krishna Prasad T, Professor, Dept of Anaesthesiology, Shri Sathya Sai Medical College and RI, Ammapettai, Deemed University, Kanchipuram Dt- 603108. India.
Citation: Sheik Abdulla, Krishna prasad T, Manahoor Jaffar, Soundarya Priyadharsini K., (2024), Levobupivacaine -Safe and Effective Drug In Daycare Ophthalmic Surgery, J Clinical Research and Reports, 16(3); DOI:10.31579/2690-1919/396
Copyright: © 2024, Krishna Prasad T. K. This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
Received: 10 July 2024 | Accepted: 30 July 2024 | Published: 12 August 2024
Keywords: levobupivacaine; peribulbar block; akinesia
A new local anesthetic, levobupivacaine, is the levorotatory isomer of bupivacaine and therefore meets all safety requirements. Out of 120 articles, ten articles similar to the current study objectives were included in the study and analyzed. Keywords used in the search include medical education and geriatrics. : in view of the above studies reviewed, we conclude levobupivacaine given in ophthalmic blocks is effective and safe for daycare surgeries. Levobupivacaine's lower risk of adverse effects may be especially helpful for the elderly cataract extraction, useful in daycare with the benefits of good preservation of sensory and motor block postoperatively. Less pain compared to lignocaine in the intraoperative and postoperative periods. We suggest drugs and agents which are appropriately suitable for clinical use in peribulbar anesthesia for cataract surgery.
Levobupivacaine has lower arrhythmogenic potential, and the central nervous system has less depressing action. The current trend in anesthetic techniques for cataract surgery is towards less invasive methods that ensure the safety of surgical interventions and rapid recovery. It is known that the ideal anesthetic should have low systemic toxicity and be non-harmful or permanent with a rapid onset of action and sufficient duration of anesthetic effect to perform the procedure with a short recovery period. A recent local anesthetic, levobupivacaine, is the levorotatory isomer of bupivacaine and thus satisfies sufficient safety criteria.
An extensive search of all materials related to the topic was carried out in the PubMed and Google Scholar search engines. Relevant research articles focusing on levobupivacaine -safe and effective drug in daycare ophthalmic surgery published in the period of 2000-2020 were included in the review. Out of 120 articles, ten articles similar to the current study objectives were included in the study and analyzed. Keywords used in the search include medical education and geriatrics
Fifty patients were assigned randomly to receive either 0.75 percent levobupivacaine or 0.75 percent racemic bupivacaine for peribulbar anesthesia prior to intraocular surgery. When comparing levobupivacaine and racemic bupivacaine, there were no statistically significant differences in the mean (SD) volume of anesthetic used (11 (2.7) ml vs. 10 (2.6) ml), the time to satisfactory block (levobupivacaine-13 (5.6) min vs. racemic bupivacaine-11 (4.4) min), peri-operative pain scores, or the frequency of adverse events. Levobupivacaine's lower risk of adverse effects may be especially helpful for the elderly cataract extraction patient population, where multiple medical conditions are common.[1]
A study looked into 203 people who had phacoemulsification surgery for cataracts. Two groups received either lidocaine (4% concentration) or levobupivacaine (0.75% concentration), with allocation determined by chance. It was determined when the sensory block began and when it ended. Patients used a verbal pain score to report their experience of pain during the application process, during surgery, and afterward. Both the surgeon's and the patient's opinions on the procedure's success and any complications that arose were documented. The levobupivacaine group had significantly longer mean sensory onset and offset times (P 0.01). Levobupivacaine patients reported significantly less pain than lidocaine patients throughout the study (P 0.01). Levobupivacaine also showed statistically significant increases in both the patient and surgeon satisfaction mean scores (P 0.01). There were no statistically significant variations in the occurrence of complications or the need for additional anesthesia. Compared to lidocaine, which is typically used in phacoemulsification for cataract surgery, topical levobupivacaine 0.75 percent was found to be equally effective and safe. Satisfaction rates between surgeons and patients were high, suggesting a successful block. There is now a new, safe, and effective option for topical anesthesia during cataract surgery: levobupivacaine (0.75%). [2]
Over the course of the study, 105 patients undergoing peribulbar anesthesia for cataract surgery were randomly divided into three groups of 35 patients each and given 5 ml of either a 1: 1 mixture of bupivacaine 0.5% and lidocaine 2% (group 1), levobupivacaine 0.75% (group 2), or ropivacaine 1% (group 3). (Group 3). At 2, 4-, 6-, 8-, and 10 minutes post-injection, ocular movement scores were analyzed. Verbal pain scores were used to assess the effectiveness of intraoperative and postoperative analgesia. The duration of the operation, the use of any supplementary anesthetics, the hemodynamic parameters, and the occurrence of any complications during the procedure were all noted. As a result, group 1 had significantly less ocular movement than group 2 did in minute 2. The second and third groups were not distinguishable from one another. Groups 1 and 2 had considerably lower ocular movement scores at minutes 4 and 6 compared to group 3. At 8 and 10 minutes, statistical difference was barely substantial in ocular movement scores between groups. Verbal discomfort scores in postoperative hour 4 were highest in group 3, but scores for the intraoperative period and postoperative hours 1 and 2 were alike among the groups. There was no difference in surgical time or hemodynamic values between the groups. We settle that all agents are appropriately suitable for clinical use in peribulbar anesthesia for cataract surgery. There was no clinical significance to the fact that the ropivacaine group had better ocular movement totals at minutes 4 and 6, despite the fact that they were significantly higher than the other groups.[3]
The study included 135 patients undergoing local anesthesia for vitreoretinal surgery. Patients were randomly allocated to one of three groups. For retrobulbar anesthesia, patients in Group LB were given 5 mL of 0.5% levobupivacaine, patients in Group L were given 5 mL of 2% lidocaine, and patients in Group B were given 5 mL of 0.5% bupivacaine injected in the inferotemporal space. Recordings of sensory and motor block times were made. A verbal pain scale was used to evaluate both during and after surgery. Point scales were used to evaluate the success of the anesthetic, the level of satisfaction felt by both the patient and the surgeon, and the extent to which akinesia developed. Symptoms and hematological readings were tracked. There were no significant differences between the groups in terms of patient demographics, surgical duration, or hemodynamic data. Motor and sensory blockade lasted longer in the levobupivacaine and bupivacaine groups than in the lidocaine group. There was a statistically significant (p0.05) increase in the incidence of injection-related pain in Groups L and B compared to Group LB. The intra-operative pain was less in the levobupivacaine group compared to the lidocaine and bupivacaine groups, and surgeon and patient satisfaction was higher. When used for retrobulbar anesthesia in vitreoretinal surgery, levobupivacaine outperforms lidocaine and bupivacaine in terms of motor and sensory block duration as well as surgeon and patient satisfaction.[4]
The purpose of this study was to draw a comparison between the value and effectiveness of Peribulbar blockade for superficial extraconal anesthesia using levobupivacaine 0.5% versus bupivacaine 0.5% combined with lidocaine 2% in patients undergoing phacoemulsification. One hundred fifty patients were randomly assigned to receive either a Peribulbar block (PB) with a mixture of levobupivacaine 0.5% and lidocaine 2% or a PB with a mixture of bupivacaine 0.5% and lidocaine 2% in this prospective, double-blind study. A 15-millimeter needle was inserted into infra-temporal space, just above the inferior orbital notch, to create the block. Each solution was injected in increments of 6.9 ml until the upper eyelids drooped completely. We measured akinesia at 2-, 5-, and 10-minutes post-block. A verbal rating scale was used to assess pain levels instantly after the block, at the end of the surgery, and 4 hours later. Post-operatively, both patients and doctors were polled on their preferences for the block's effectiveness. Akinesia scores at 2, 5, and 10 minutes were not significantly different between groups (P = 0.2), nor were the numbers of supplemental injections needed (P = 0.84), or the volumes of local anesthetics needed initially or altogether (P = 0.80 and 0.81, respectively). Surgeon and patient satisfaction were equally high across both groups (P = 0.53 and P = 0.74, respectively). Similarly, there were no statistically significant differences between the groups on any of the three occasions when verbal rating scales were administered. Both groups required the same amount of intra-operative topical anesthetic. (P = 0.69). Similar block quality and efficacy can be achieved when administering a combination of levobupivacaine 0.5% and lidocaine 2% for a superficial extra-conal block, as can be achieved when administering a combination of bupivacaine 0.5% and lidocaine 2%.[5]
The low cardiovascular and neurological toxicity of levobupivacaine has managed to be administered as a local anesthetic in an extensive variety of specialist applications including peribulbar block for cataract surgery. The aim of this research was to assess the efficacy of levobupivacaine 0.5% and to compare block quality vs. ropivacaine 0.75% in peribulbar anesthesia. Methods: We considered 208 patients who underwent phacoemulsification for cataracts and randomly assigned them to receive either levobupivacaine (0.5%) or ropivacaine (0.75%) for peribulbar block, both of which contained hyaluronidase. Injections of 6 mL of the anesthetic mixture were made into the inferotemporal and superonasa regions to produce a nerve block.
After 24 hours to assess the block's efficacy, the following were measured- Time of motor and sensory onset, Akinesia score, Time of motor and sensory offset, and Patient and surgeon satisfaction. Pre-block, post-block, and postoperative intraocular pressure as well as the duration of surgical intervention was also determined. The results showed that, compared to ropivacaine, levobupivacaine significantly delayed the onset of motor and sensory function on average (P 0.001). The akinesia score was significantly higher (P 0.01), as were the mean motor and sensory offset times (P 0.001). There were no significant differences between the two groups in terms of average intervention times or patient/surgeon satisfaction. Levobupivacaine (0.5%) has better anesthetic properties with respect to 0.75% ropivacaine and is well-suited for a peribulbar block in cataract surgery.[6]
As compared with racemic bupivacaine, ropivacaine also showed the clinically relevant advantage of a stronger differentiation between sensory and motor blocks, which is particularly useful when early mobilization is important to accelerate postoperative recovery. Ropivacaine is 40-50% less potent than bupivacaine and levobupivacaine because of its lower lipid solubility; reduced potency does not imply that this agent is less effective than the other two, and using an equipotency ratio of 1.5: 1 between ropivacaine and the two other drugs results in a substantially similar clinical profile with good preservation of motor function. In conclusion, the reduced toxic potential of both levobupivacaine and ropivacaine should be carefully considered when choosing the local anesthetic for regional anesthesia techniques requiring large volumes and infusion rates, such as for epidural anesthesia/analgesia, peripheral nerve blocks, and local infiltration. [7]
It is possible to provide labor analgesia with either combined spinal-epidural or purely epidural block. There is a minimum local dose of levobupivacaine and ropivacaine shown in various studies for intrathecal as 2.73-3.16 mg for levobupivacaine and 3.33-3.96 mg for ropivacaine. An improved sensory block and less motor block are provided by the addition of opioids. The use of ropivacaine and levobupivacaine has been encouraged because of relative safety. At least 0.1% is required for satisfactory analgesia for the analgesic efficacy to be dependent on its concentration.
The sub-Tenon’s block has become the most commonly used block in ophthalmic regional anesthesia practice in the UK. Given the lower incidence of serious sight-threatening complications with the sub-Tenon technique2, this study may be seen as less relevant to current practice. However, globe rupture, optic nerve injection, and optic muscle damage have all been reported following sub-Tenon’s block15. The sub-Tenon’s block is also not suitable for all patients; it should be avoided in patients with the thin sclera, scleral scarring, or chronic eye inflammation and in situations where chemosis, conjunctival hematoma, or disruption are undesirable. [9]
The peribulbar block is used to obtain anesthesia and akinesia of the eye by injecting a local anesthetic around the muscle cone. A patient scheduled for cataract surgery received a peribulbar block with 6 mL of 2% lidocaine hydrochloride. Following the injection, confusion, hypotension, and dilatation of the contralateral pupil rapidly progressed to loss of consciousness and respiratory arrest. The patient was intubated and mechanically ventilated for 30 min. The patient regained her consciousness, was extubated, and transferred to the intensive care unit for further follow-up. Although brainstem anesthesia because of the peribulbar block is very rare, this procedure should be performed with complete monitorisation and resuscitation equipment. In view of the above studies reviewed, we conclude levobupivacaine given in ophthalmic blocks is effective and safe for daycare surgeries. [10]
Based on the above reviews, we suggest the drug Levobupivacaine is a suitable anesthetic in terms of its limited neurotoxicity and low cardiotoxicity, which represents a valid reason for use of levobupivacaine with good preservation of motor blocks. We suggest this drug for day care surgeries
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