Ropivacaine - Fentanyl an Alternative to
Bupivacaine - Fentanyl for Major Lower Limb and Lower Abdominal Surgeries - A Comparative Study
Shilpashri AM*, Keerthana DS and Priya R
Department of Anesthesiology, JJM Medical College, India
Submission: February 01, 2019; Published: February 06, 2019
*Corresponding author: Shilpashri AM, Department of Anesthesiology, JJM Medical College, Davangere, Karnataka, 577004, India
How to cite this article: Shilpashri A, Keerthana D, Priya R. Ropivacaine - Fentanyl an Alternative to Bupivacaine - Fentanyl for Major Lower Limb and
Lower Abdominal Surgeries - A Comparative Study. J Anest & Inten Care Med. 2019; 8(3): 555736. DOI: 10.19080/JAICM.2019.08.555736
Background: Spinal anesthesia is the most convenient anesthetic technique that offers many advantages over general anesthesia, including reduced stress response and improved post-operative pain relief. The administration of local anesthetics in combination with opioids intrathecally is an excellent technique for managing postoperative pain following abdominal, pelvic, orthopedic procedures on lower extremities. Ropivacaine, a newer amide local anesthetic produces similar sensory block to that of an equivalent dose of bupivacaine, with a reduced degree of motor block. It has an improved safety profile over bupivacaine with reduced central nervous system and cardiotoxic potential and hence is gaining favor.
Objective: To compare the clinical effects of intrathecal ropivacaine-fentanyl with bupivacaine-fentanyl for major lower limb and lower abdominal surgeries.
Methods: 100 patients belonging to ASA physical status I & II scheduled for lower abdominal and lower limb surgeries were randomly selected for the study and were divided into two groups of 50 each. Group RF patients received 2ml of 0.75% isobaric (15mg) ropivacaine +0.5ml (25 mcg) fentanyl+ 1ml of 25% dextrose intrathecally. Group BF patients received 3ml of 0.5% hyperbaric (15mg) bupivacaine + 0.5 ml (25 mcg) fentanyl intrathecally. The following parameters were monitored - onset and duration of sensory block, onset and duration of motor block, height of sensory block, hemodynamic parameters and adverse effects.
Results: Both the groups were similar in demographic attributes. Both the groups had almost similar onset of peak sensory block, and maximum sensory height. Duration of sensory and motor block were significantly less in RF group. Quality of intraoperative analgesia, hemodynamic parameters were comparable in both groups, incidence of side effects were higher with group BF.
Conclusion: Ropivacaine can be used successfully as an alternative to Bupivacaine for surgeries of lower abdomen and lower limb where early ambulation, decreased hospital stays, and decreased morbidity are appreciated.
Central neuraxial blockade in the form of spinal/epidural is very popular for lower abdominal and lower limb surgeries as these techniques avoid the disadvantages associated with general Anaesthesia like airway manipulation, poly pharmacy and other untoward effects like postoperative nausea, vomiting, need for supplemental intravenous analgesics. Presently the most widely used drug Bupivacaine 0.5% is cardiotoxic and also produces motor blockade of prolonged duration.
Ropivacaine is a relatively newer amide (s-enantiomer) local anesthetic with high pka and low lipid solubility, and it is considered to block sensory nerves to greater degree than motor nerves and has similar local anesthetic properties and chemical structure to that of bupivacaine . The newer drug
ropivacaine being comparatively less cardiotoxic, also produces minimal motor blockade of shorter duration  which relieves the psychological distress of being immobile for a longer period of time after surgery compared to intrathecal bupivacaine during lower abdominal and lower limb surgeries . Intrathecal opioids are commonly combined with local anesthetics to improve the onset time of block, duration and quality of analgesia both intraoperatively and postoperatively. Fentanyl being the latest, is hundred times more potent than morphine has been the latest tool in the armory of modern-day anesthesiologists . Hence this study is designed to assess the onset and duration of sensory and motor blockade of Ropivacaine- Fentanyl and side effects if any compared to intrathecal Bupivacaine -Fentanyl during lower abdominal and lower limb surgeries.
This clinical study was conducted on hundred adult patients
of ASA physical status I & II in the age group of 18 to 65 years, of
either sex, posted for elective major lower limb & lower abdominal
surgeries under spinal Anaesthesia after taking informed consent
at Chigateri General Hospital, Woman and Children Hospital, and
Bapuji Hospital attached to J.J.M. Medical College, Davangere
After institutional committee approval and written informed
consent, a comparative study was carried out on hundred adult
patients. Patients were randomly divided on an alternative basis
into two groups of fifty each. Group RF (Ropivacaine – Fentanyl):
Received 2ml of 0.75% Isobaric Ropivacaine(15mg) + 0.5ml
Fentanyl(25mcg) + 1ml 25% dextrose and Group BF (Bupivacaine
- Fentanyl): Received 3ml of 0.5% Hyperbaric Bupivacaine(15mg)
+ 0.5ml Fentanyl (25mcg).
A detailed history, general physical examination, systemic
examination, airway assessment and spine examination were
done. Routine laboratory investigations like complete blood
picture, bleeding and clotting time, serological status for HIV and
Hepatitis B were done.
a) Inclusion criteria
i. Age: 18 - 65years.
ii. Gender: Males and Females.
iii. A patient who fits into American society of
anesthesiologists (ASA) physical status criteria I and II scheduled
for elective major lower limb and lower abdominal surgery under
iv. Patients who are willing and able to give informed
v. Concomitant medications: The patient can take relevant
medication for concomitant diseases like diabetes, hypertension
b) Exclusion criteria
i. Patient refusal.
ii. Age> 65 years or <18 years.
iii. ASA Grade III or IV.
iv. Patient with pre-existing neurological and spine
v. Pregnant women and lactating mother.
vi. Patients allergic to Local Anesthetics and Opioids.
vii. Patient on anticoagulants/known coagulation disorder.
viii. Local infection at the site of proposed puncture for
Patient was shifted onto the OT table. ECG, non-invasive
blood pressure, pulse oximeter monitors were attached, and
baseline parameters was recorded. Lactated Ringer’s solution
8-10ml/kg was infused intravenously before the block. With the
patient in sitting or left lateral position, under aseptic precautions
subarachnoid block was performed by midline approach using 23
G Quinke Babcock spinal needle at L3-L4 intervertebral space and
the patient received one of the two study drugs
Sensory blockade was assessed as the loss of pin-prick
sensation at the site of surgical incision. Onset and duration of
motor blockade was assessed using modified bromage scale.
Highest level of sensory block and duration of analgesia (sensory
block) which is the time from onset of analgesia to time of
request for rescue analgesics were noted. Complications such as
bradycardia, hypotension, nausea & vomiting, pruritis, shivering,
if any were noted intra operatively. Postoperatively, monitoring of
vital signs was continued every 30 minutes upto 6 hours.
Descriptive and inferential statistical analysis has been carried
out in the present study. Results on continuous measurements are
presented on Mean ± SD (Min-Max) and results on categorical
measurements are presented in Number (%). Significance is
assessed at 5 % level of significance. Student t test (two tailed,
independent) has been used to find the significance of study
parameters on continuous scale between two groups (Inter group
analysis) on metric parameters. Chi-square/Fisher Exact test
has been used to find the significance of study parameters on
categorical scale between two or more groups.
The Statistical software namely SAS 9.2, SPSS 15.0, Stata 10.1,
Med Calc 9.0.1, Systat 12.0 and R environment ver.2.11.1 were
used for the analysis of the data and Microsoft word and Excel
have been used to generate graphs, tables etc.
100 patients completed the study. 50 of them received 0.75%
Isobaric Ropivacaine with Fentanyl 25mcg and 1ml 25% dextrose.
50 of them received 0.5% Hyperbaric Bupivacaine with Fentanyl
25mcg. Demographic data such as age, height, weight between two groups were comparable (Table 1). 84% of the patients in
group BF and 80% of the patients in group RF achieved a sensory
block of T6. 12% of patients in group BF and 16% of patients in
group RF achieved a sensory block of upto T8. 4% of patients in
both groups achieved a sensory block upto T10. These findings
were clinically and statistically not significant. Complete motor
blockade was observed in all patients in Group BF and 94% of
patients in Group RF. The mean value for duration of sensory
block was 309.82±31.09 minutes in Group BF and 203.08±29.36
minutes in Group RF with p value <0.001.
76% of patients in Group BF and 88% of patients in Group
RF had a duration of motor block ranging from 120–180 minutes.
The average duration of motor blockade was 180.50±50.84
minutes in Group BF and 158.82±24.55 minutes in Group RF
with p value 0.008. There was no significant change in heart rate
following subarachnoid block in both groups. The heart rates
were comparable in both groups without any clinical or statistical
significance (Figure 1). There was fall in systolic blood pressure
following spinal Anaesthesia in both groups. The magnitude of
fall was more in group BF compared to group RF. There was fall
in diastolic blood pressure following spinal Anaesthesia in both
groups. The magnitude of fall was similar in both groups and it
was not clinically or statistically significant.
Hypotension was seen in 14% of patients in group BF and 4%
of patients in Group RF. Bradycardia was seen in 10% of patients
in Group BF and 4% of patients in Group RF. Shivering was seen in
4% of patients in group BF and not seen in group RF. Nausea and
vomiting was seen in 2% of patients in group RF and not seen in
Group BF. Pruritis was seen in 6% of patients in group BF and not
seen in group RF.
In our study the demographic details profile and the type of
surgeries were kept identical in both groups to avoid variations in
intraoperative and postoperative outcome of patients
The mean time for onset of sensory block in group RF was
1.75±0.25 minutes and in group BF was 1.63±0.69 minutes, with
p value 0.201. The mean time for onset of motor blockade in group
RF was 2.63±0.55 minutes and in group BF was 2.54±0.58 minutes
with a p value of 0.417. Both the above values are statistically
insignificant. There is no significant difference in onset of sensory
and motor block. This observation was comparable to a study done
by Koltka et al. , who compared equipotent doses of ropivacaine
- fentanyl and bupivacaine – fentanyl for spinal Anaesthesia for
lower abdominal surgery found no significant difference in onset
of sensory and motor block. In another study done by Luck et al.
, who compared hyperbaric solutions of racemic bupivacaine,
levobupivacaine, and ropivacaine for spinal Anaesthesia, they
concluded that there was no significant difference between the
groups with regard to mean time to onset of sensory and motor
block. Malinovsky et al.  found that onset of motor blockade was
similar in the two groups receiving ropivacaine and bupivacaine
intrathecally. Helena Kallio et al.  & Mc Namee et al.  also
found similar time to onset of complete motor block.
80 % of patients in group BF and 84 % of patients in group
RF achieved a sensory block up to T6 level. 16 % of patients in
group BF and 12 % of patients in group RF achieved a sensory
block up to T8, and 4% of patients in both groups achieved a level
up to T10 which was comparable. In a study conducted by Lee et
al. , who conducted a randomized double-blind comparison
of ropivacaine-fentanyl and bupivacaine-fentanyl for spinal
Anaesthesia noted both groups attained similar level of sensory
94 % of patients in group RF and 100 % of patients in group
BF developed complete motor block. Chan Jong Chung et al.  observed complete motor block in all patients receiving either
bupivacaine or ropivacaine for caesarean section. N Boztug 
and others observed complete motor blockade in 88 % of patients
receiving ropivacaine and 100 % patients receiving bupivacaine
Chung et al. , studied the effects of addition of intrathecal
fentanyl to hyperbaric ropivacaine and concluded that duration
of sensory block was prolonged when an opioid was added to
the local anesthetic. According to a study by Marret et al. 
in comparison to bupivacaine, ropivacaine produced a shorter
duration of sensory block when given intrathecally. In our study
duration of sensory blockade in group BF was 309.82±31.09
minutes which was longer than duration of sensory blockade in
group RF which was 203.08±29.36 minutes which is statistically
Koltka et al. , compared equipotent doses of isobaric
ropivacaine and bupivacaine, both with fentanyl for the
subarachnoid block and found that the RF group is associated
with a shorter duration of motor block of 90 minutes versus 130
minutes in group BF. In our study, the duration of motor block
in group RF was 158.82±24.55 minutes and was shorter than
group BF with motor block of 180.50±50.84 minutes which is
In another study by Lee et al. , equal doses of intrathecal
ropivacaine and bupivacaine with fentanyl were used for urology
surgeries, and it was reported that ropivacaine provided shorter
duration of motor block of 126 minutes compared to bupivacaine
with 189 minutes. Boztug et al.  also stated that ropivacaine
-fentanyl group had a shorter duration of motor block. Because
of this differential blockade, ropivacaine with fentanyl is found to
be favorable for surgeries which prevents morbidities related to
bladder catheterization and early ambulation prevents deep vein
The hemodynamic parameters heart rate, systolic blood
pressure, diastolic blood pressure was comparable between both
the groups and no significant hemodynamic alteration was seen in
the two groups. Group RF is haemodynamically more stable than
group BF. This correlates with the study done by Mc Namee et al.
In a study conducted by Sheetal et al.  incidence of
hypotension was 3.3 % of patients in group RF, and 10 % of
patients in group BF which correlates with our study. Hypotension
occurred in 4 % of the cases in the RF group and 14 % of cases
in group BF in our study and was easily managed by ephedrine
boluses. 6% of patients in the BF group and none in the RF group
experienced pruritis. This incidence is much lower compared to
the incidence reported by Patra et al.  (46%) and Khanna &
Singh  (20%) who also used fentanyl as adjuvant intrathecally
Intrathecal Ropivacaine -Fentanyl is similar to Bupivacaine
- Fentanyl in onset of sensory and motor block, degree of motor
block, height of sensory block. Ropivacaine - Fentanyl group is
hemodynamically more stable than Bupivacaine - Fentanyl group.
But there is a shorter duration of sensory and motor block with
Ropivacaine compared to Bupivacaine. Hence, Ropivacaine can be
used successfully as an alternative to Bupivacaine for surgeries of
lower abdomen and lower limb where early ambulation, decreased
hospital stays, and decreased morbidity are appreciated.