Anesth Analg 2001;92:720-724
© 2001 International Anesthesia Research Society
REGIONAL ANESTHESIA AND PAIN MEDICINE
A Comparison of Ropivacaine and Bupivacaine for Cervical Plexus Block
Ariane Junca, MD*,
Emmanuel Marret, MD*,
Georges Goursot, MD
,
Xavier Mazoit, MD, PhD
, and
Francis Bonnet, MD*
*Service d’Anesthésie-Réanimation, Hôpital Tenon, Assistance Publique-Hôpitaux de Paris; Hôpital Saint-Michel, Paris; and Laboratoire d’Anesthésie, Université de Paris Sud, Faculté de Médecine, Le Kremlin Bicêtre, France
Address correspondence and reprint requests to Francis Bonnet, Service d’Anesthésie, Hôpital Tenon, 4 rue de la Chine, 75970 Paris CEDEX. Address e-mail to francis.bonnet{at}tnn.ap-hop-paris.fr
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Abstract
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We compared bupivacaine 0.5% and ropivacaine 0.75% for cervical plexus block (CB). Forty patients scheduled for carotid artery surgery were allocated randomly to undergo superficial and deep CB with 30 mL of one of the two anesthetic solutions. We evaluated the onset of anesthetic block; the requirement for supplementation during the surgery; the patients’ satisfaction; postoperative pain on a visual analog scale at 1, 2, and 3 h; and the use of paracetamol as a rescue analgesic medication. Arterial blood was sampled immediately and 1, 3, 5, 10, 15, 30, 45, and 60 min after CB for measurements of bupivacaine or ropivacaine concentrations. Patients in both groups had equivalent onset of CB, local infiltration with lidocaine during surgery, and satisfaction scores. In the Bupivacaine group, visual analog scale scores were lower at 2 and 3 h, and the delay before paracetamol administration was prolonged. Observed peak concentrations were larger in the Ropivacaine group (4.25 [2.07–6.59 mg/L] vs 3.02 [0.98–5.82 mg/L]), but time to reach peak concentrations was comparable (5 [1–15 min] vs 5 [0–45 min] in the Ropivacaine and Bupivacaine groups, respectively). We conclude that ropivacaine has no advantage over bupivacaine for CB.
Implications: Compared with bupivacaine (150 mg), a larger dose of ropivacaine (225 mg) produces comparable features of cervical plexus block but less postoperative analgesia and larger plasma concentrations. There is no reason to favor ropivacaine in such a case.
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Introduction
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Carotid surgery can be performed under cervical plexus block to accurately monitor the neurological status of the patients during the surgical procedure (1,2). Both lidocaine and bupivacaine have been used for cervical plexus block. Bupivacaine 0.5% provides more than 3 h of anesthesia and analgesia (3). A high level of vascular absorption of local anesthetics has been documented after cervical plexus block (4,5). Symptoms of toxicity, such as drowsiness, slurring of the speech, or confusion, are occasionally observed, and seizures have also been reported at a rate of 0.3% (6). The risk of such events limits the administration of large doses of local anesthetics, especially bupivacaine. Ropivacaine is considered less toxic than bupivacaine (6,7), although it is considered a long-acting local anesthetic. In addition, ropivacaine produces vasoconstriction, which could limit its vascular absorption (8–10). Thus, ropivacaine could be administered at a larger dose than bupivacaine and could be an attractive alternative to bupivacaine for cervical plexus block. We therefore designed a study to compare those two anesthetics and to measure their plasma absorption after cervical plexus block.
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Methods
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Forty ASA I–III patients scheduled for carotid surgery under cervical block were included in this prospective, double-blinded study, which was performed in two centers after written informed consent and approval of the institutional ethical committee (Comité Consultatif Pour La protection Des Personnes Dans La Recherche Biomédicale Ile De France-Paris-St. Antoine). On the morning of surgery, patients were allocated randomly into two groups by opening a sealed envelope containing a number indicative of the group assignment and determined from a table of randomized numbers. In both groups, the cervical block was performed with 30 mL of the local anesthetic solution (ropivacaine 0.75% or bupivacaine 0.5%), which was blinded as to the investigator performing the block.
After premedication with hydroxyzine 1 mg/kg, lactated Ringer’s solution was infused into a peripheral vein. Heart rate, arterial pressure, and arterial oxygen saturation were monitored while patients were breathing oxygen 4 L/min via a face mask. A short catheter was placed in a radial artery for arterial blood sampling. The cervical plexus block consisted of both a deep and superficial block. A single injection of 15 mL of the local anesthetic solution was performed at C4 onto the cervical transverse process, 2–3 cm deep on the skin and 1 cm posterior to the posterior border of the sternocleidomastoid, with a 25-mm short-bevel needle. The block was completed by a subcutaneous injection of the remaining 15 mL of the solution along the posterior border of the sternocleidomastoid. Before any injection, the absence of blood in the needle hub was checked by aspiration.
Sensory blockade was tested every 5 min for 20 min by pinprick along the neck and the upper part of the thorax corresponding to the segmental distribution from C2 to C4. During surgery, whenever the patients complained of pain, regional anesthesia was supplemented by injection of lidocaine 1% by the surgeon.
Pain was evaluated after surgery on a visual analog scale (VAS) graded from 0 (no pain) to 100 (the worse pain imaginable). Pain measurements were performed in the recovery room and 1, 2, and 3 h after the end of surgery. When they complained of pain and when the VAS score was >30, patients received on demand 2 g of IV propacetamol (Pro-Dafalgan®; UPSA, Rueil-Malmaison, France). In the recovery room, patients were also asked to quote their degree of comfort during the surgical procedure on a VAS (0 = absolutely uncomfortable during surgery, 100 = very comfortable and satisfied by the anesthetic technique).
Arterial blood samples were withdrawn for measurements of local anesthetic plasma concentrations immediately at the end of injection of the first 15 mL for the deep cervical block and at 1, 3, 5, 10, 15, 30, 45, and 60 min after the end of the superficial block. Plasma was separated within 1 h of collection, frozen immediately, and stored at -20°C. Total plasma bupivacaine and ropivacaine concentrations were measured by gas chromatography, with mepivacaine as an internal standard. The limit of detection was 0.01 µg/mL. The within-day and between-days coefficients of variation were 8% and 12% at 0.02 µg/mL and 5% and 7% at 0.2 µg/mL, respectively.
Group size (20 patients per group) was selected by using proportions samples size estimates (power = 80%, 
= 0.05) to detect a 30% difference in VAS scores that we expected to be the advantage of ropivacaine. A Mann-Whitney U-test was used for comparison of demographics, patient satisfaction, delay before the administration of analgesic rescue medication, and observed peak concentration (Cmax) and time to reach Cmax (Tmax). Statistical analysis used a two-way analysis of variance for VAS scores; when a difference was documented, a post hoc Scheffé F test was performed for intergroup comparisons. Kaplan-Meyer curves were performed for the time of first request for rescue paracetamol. The two groups were compared in this setting by using a log-rank test. Categorical variables were analyzed with a 
2 test. Values are reported as medians and extremes.
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Results
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Forty patients were included in this study: 13 men and 7 women in the Ropivacaine group and 15 men and 5 women in the Bupivacaine group. The two groups were comparable for weight (68 [41–85] kg and 69 [50–100] kg in the Bupivacaine and Ropivacaine groups, respectively) and height (163 [155–177] cm and 165 [151–174] cm in the Bupivacaine and Ropivacaine groups, respectively). Median age was 70 [47–78] yr in the Bupivacaine group and 76 [59–88] yr in the Ropivacaine group (P < 0.05).
The onset of sensory blockade was 8.3 (3–14.2) min in the bupivacaine and 5.8 (1.7–13.3) min in the Ropivacaine group (not significant).
The two groups were comparable for the median duration of surgery (125 [60–181] min and 95 [53–162] min in the Bupivacaine and Ropivacaine groups, respectively). In both groups, 14 of the 20 patients required a complementary infiltration of the surgical field with lidocaine. After surgery the satisfaction score was 80 (0–100) in the Bupivacaine group and 80 (30–100) in the Ropivacaine group (not significant).
VAS scores were higher in the Ropivacaine group at 2 and 3 h ( Table 1). The median value of the delay between the block completion and the first administration of propacetamol was 10.5 (2.6–24.0) h in the Bupivacaine group and 6.0 (2.6–24.0) h in the Ropivacaine group (not significant). During the first 12 h, 44% of the patients (n = 8) did not require any supplemental analgesic in the Bupivacaine group versus 16% (n = 3) in the Ropivacaine group (P = 0.06). The Kaplan-Meyer curves for the time of first request for rescue paracetamol documented a significant difference (P < 0.05) between bupivacaine and ropivacaine ( Fig. 1).
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Figure 1. Kaplan-Meyer curves for the time of first request for rescue analgesic medication (paracetamol). The Bupivacaine group is significantly different from the Ropivacaine group (P < 0.05).
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Individual and mean values of arterial plasma concentrations are reported in Figures 2 and 3. Plasma samples were available for measurement of local anesthetic concentrations in 19 patients in each group. Cmax was higher in the Ropivacaine Group than in the Bupivacaine group (4.25 [2.07–6.59] mg/L vs 3.02 [0.98–5.82] mg/L). Values higher than 5 µg/mL were measured in six patients in the Ropivacaine group and in two in the Bupivacaine group. Tmax was comparable and occurred shortly after the end of the local anesthetic administration (5 [1–15] min vs 5 [0–45] min in the Ropivacaine and Bupivacaine groups, respectively). None of the patients developed any signs or symptoms of local anesthetic toxicity.
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Figure 2. Individual arterial plasma concentrations of bupivacaine and mean values of these concentrations, expressed in µg/mL.
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Figure 3. Individual arterial plasma concentrations of ropivacaine and mean values of these concentrations, expressed in µg/mL.
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Discussion
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In this study, the effectiveness of cervical plexus block was comparable for carotid surgery when using bupivacaine or ropivacaine, despite the administration of a larger dose of the latter drug (150 vs 225 milligrams). Moreover, the duration of analgesia provided by the block was longer for bupivacaine than for ropivacaine. Previous studies comparing 0.5% bupivacaine and ropivacaine for epidural anesthesia concluded that sensory blockade was comparable but motor blockade was weaker with ropivacaine (11,12). At smaller concentrations in obstetrics, epidural ropivacaine was also found to be a less potent analgesic (13). These findings were confirmed when using ropivacaine for peripheral nerve or plexus blocks. Several studies (14,15), although not all (16–18), have indeed documented a shorter duration of anesthesia and analgesia for ropivacaine when compared with bupivacaine. Moreover, in the negative studies, sensory block or pain assessment was often not prolonged enough to allow detection of a difference in the duration of blockade (16–18). Finally, the comparison of 100 milligrams of bupivacaine and 300 milligrams of ropivacaine for local infiltration after inguinal hernia repair failed to document any difference; the duration of analgesia also suggested that ropivacaine was less potent than bupivacaine (19). This study is thus in agreement with the findings of a less potent anesthetic and analgesic effect of ropivacaine. Although the duration of the ropivacaine block was long enough to allow completion of surgery without any problem, and although the postoperative course of carotid surgery is not extremely painful, it can be concluded that ropivacaine gives no special advantage over bupivacaine for pain control in this setting.
We gave to this series of patients the maximum recommended dose of bupivacaine (150 mg) and a dose slightly smaller than the maximum recommended dose of ropivacaine (225 mg). Cervical plexus block leads to a rapid and high plasma absorption of local anesthetics (5). Tissot et al. (5) measured a mean Tmax at 10 minutes after injection of a mixture of lidocaine and bupivacaine for deep and superficial cervical plexus block, and the median value for Tmax was also 10 minutes in another study (20). Because we performed earlier arterial blood sampling in this study, we documented an even shorter Tmax for ropivacaine and bupivacaine as well. Arterial concentrations of local anesthetics are larger than venous concentrations, especially in the first hour after administration (21,22); thus, comparisons of the concentrations measured in this study are restricted to those studies in which arterial samples were also performed. Knudsen et al. (22) reported that the maximum tolerated arterial plasma total concentration of ropivacaine was 4.3 mg/L in healthy volunteers. In a few patients of this study, values of Cmax of ropivacaine were larger than those known to induce minor symptoms of toxicity in volunteers, although we did not observe such symptoms. Because the dose of bupivacaine administered was smaller, the median value of Cmax of bupivacaine was also smaller than that of ropivacaine, but it was above the toxic threshold defined by Knudsen et al. (22) in two patients, suggesting that high plasma absorption occurs whatever the type of local anesthetic. In agreement, in a series of 15 patients who underwent a cervical plexus block, Tissot et al. (5) noticed that peak arterial plasma concentrations were larger than the toxic threshold of lidocaine in six patients and larger than that of bupivacaine in two patients, with minor symptoms of toxicity in only one patient. Similar data were reported more recently (20). Finally, Dawson et al. (4) documented that large peak concentrations were achieved, even after injection of epinephrine-containing lidocaine solution, questioning the preventive effect of epinephrine on vascular absorption at this site of administration. Convulsions have occasionally been noticed after cervical plexus block (sometimes also because of injection in the vertebral artery) (2), and ropivacaine induces such a complication after interscalene block (23) and sciatic nerve block (24). Because ropivacaine was thought to induce vasoconstriction (8,10), one might have expected that this could limit its vascular absorption and favor the prolongation of its effect. The results of this study do not confirm such a hypothesis, leading to the conclusion that there is no reason to favor the use of ropivacaine for cervical plexus block.
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Acknowledgments
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This work was supported by a grant from laboratoires ASTRA France, Groupe Pharmaceutique ASTRA Suède, Reuil-Malmaison, France, for insurance legally required to conduct the study.
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Footnotes
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Presented in part at the 8th European Society of Anaesthesiologists annual meeting in Vienna. The abstract has been published in a supplemental issue of the European Journal of Anaesthesiology (2000;17:A324).
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Accepted for publication November 7, 2000.
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Abstract
Introduction
