Pregnancy Category: B
ClassificationTherapeutic: epidural local anesthetics
Local or regional anesthesia for surgery.Acute pain management.
Local anesthetics inhibit initiation and conduction of sensory nerve impulses by altering the influx of sodium and efflux of potassium in neurons, slowing or stopping pain transmission.
Decreased pain or induction of anesthesia; low doses have minimal effect on sensory or motor function; higher doses may produce complete motor blockade.
Absorption: Systemic absorption follows epidural administration, but amount absorbed depends on dose.
Distribution: If systemic absorption occurs, this agent is widely distributed and crosses the placenta.
Metabolism and Excretion: Small amounts that may reach systemic circulation are mostly metabolized by the liver; < 1% excreted unchanged in the urine.
Half-life: 4.2 hr (after epidural use).
Time/action profile (analgesia)
|Epidural||10–30 min||unknown||2–8 hr†|
Contraindicated in: Hypersensitivity; cross-sensitivity with other amide local anesthetics may occur (bupivacaine, lidocaine, mepivacaine, prilocaine).
Use Cautiously in: Concurrent use of other local anesthetics; Liver disease; Concurrent use of anticoagulants (including low-dose heparin and low-molecular-weight heparins/heparinoids) ↑ the risk of spinal/epidural hematomas; Pediatric: Safety not established.
Adverse Reactions/Side Effects
Central nervous system
- seizures (life-threatening)
- cardiovascular collapse (life-threatening)
- chest pain
- hypotension (most frequent)
- urinary retention
Fluid and Electrolyte
- metabolic acidosis
- circumoral tingling/numbness
- allergic reactions
Drug-Drug interactionAdditive toxicity may occur with concurrent use of other amide localanesthetics (includinglidocaine, mepivacaine, and prilocaine ).Fluvoxamine, amiodarone, ciprofloxacin, and propofol may ↑ the effects of ropivacaine.
Epidural (Adults) Lumbar epidural—15–30 mL of 0.5% solution or 15–25 mL of 0.75% solution or 15–20 mL of 1% solution; Lumbar epidural for cesarean section—20–30 mL of 0.5% solution or 15–20 mL of 0.75% solution; Thoracic epidural—5–15 mL of 0.5–0.75% solution.
Major nerve block: (Adults) 35–50 mL of 0.5% solution or 10–40 mL of 0.75% solution.
Field block: (Adults) 1–40 mL of 0.5% solution.Labor Pain
Epidural (Adults) Lumbar epidural—10–20 mL of 0.2% solution initially, then continuous infusion of 6–14 mL/hr of 0.2% solution with incremental injection of 10–15 mL/hr of 0.2% solution.Postoperative Pain
Epidural (Adults) Lumbar or thoracic epidural—Continuous infusion of 6–14 mL/hr of 0.2% solution.
Infiltration (minor nerve block): (Adults) 1–100 mL of 0.2% solution or 1–40 mL of 0.5% solution.
Availability (generic available)
Solution for injection (preservative-free): 0.2%, 0.5%, 0.75%, 1%
- Monitor for sensation during procedure and return of sensation after procedure.
- Systemic Toxicity: Assess for systemic toxicity (circumoral tingling and numbness, ringing in ears, metallic taste, dizziness, blurred vision, tremors, slow speech, irritability, twitching, seizures, cardiac dysrhythmias). Report to anesthesiologist.
- Orthostatic Hypotension: Monitor BP, heart rate, and respiratory rate continuously while patient is receiving this medication. Mild hypotension is common because of the effect of local anesthetic block of nerve fibers on the sympathetic nervous system, causing vasodilation. Significant hypotension and bradycardia may occur, especially when rising from a prone position or following large dose increases or boluses. Treatment of unresolved hypotension may include hydration, decreasing the epidural infusion rate, and/or removal of local anesthetic from analgesic solution.
- Unwanted Motor and Sensory Deficit: Low-dose local anesthetics are added to epidural opioids for pain management to provide analgesia, not to produce anesthesia. Patients should be able to ambulate if their condition allows; epidural analgesic should not hamper ambulation. Location of epidural catheter, local anesthetic dose, and variability in patient response, can result in unwanted motor and sensory deficits. Pain is the first sensation lost, followed by temperature, touch, proprioception, and skeletal muscle tone.
- Assess for sensory deficit every shift. Ask patient to point to numb and tingling skin areas (numbness and tingling at the incision site is common and usually normal). Notify health care professional of unwanted motor and sensory deficits.
- Unwanted motor and sensory deficits often can be corrected;a change in position may relieve temporary sensory loss in an extremity, minor extremity muscle weakness is often treated by decreasing the epidural infusion rate and keeping the patient in bed until the weakness resolves. Sometimes removing local anesthetic from the analgesic solution is necessary, such as when signs of local anesthetic toxicity are detected or when treatment of motor and sensory deficits has been unsuccessful.
Potential Nursing DiagnosesAcute pain, acute (Indications)
Impaired physical mobility
- See Route and Dosage section.
- Instruct patient to notify nurse if signs or symptoms of systemic toxicity occur.
- Advise patient to request assistance during ambulation until orthostatic hypotension and motor deficits are ruled out.
- Decrease in postoperative pain without unwanted sensory or motor deficits.
Naropin®Ropivacaine Neurology A long-acting anesthetic for obstetrics, locoregional anesthesia, post-op pain, surgical anesthesia, acute pain management
NaropinA brand name for ROPIVACAINE.
ropivacaine; Naropin local anaesthetic agent of long duration of action; has same range of cautions, interactions and contraindications as lidocaine (lignocaine); contraindicated by certain selective serotonin reuptake inhibitor antidepressant agents (see Table 1, Table 2, Table 3 and Table 4)
|Type of local anaesthetic||Onset time||Offset time|
|Lidocaine||5 minutes||30-90 minutes|
|Bupivacaine||20 minutes||6-8 hours|
|Prilocaine||5-10 minutes||2-4 hours|
|Mepivacaine||5-10 minutes||2-4 hours|
|Levo-bupivacaine||20-30 minutes||6-8 hours|
|Ropivacaine||5-10 minutes||2-4 hours|
|Local anaesthetic agent Proprietary name||Principal drug interactions||Effect of interaction|
|Increased myocardial depression|
Increased risk of ventricular arrhythmias if lidocaine is given with quinpristin/dalfopristin
Increased risk of ventricular arrhythmias if lidocaine is given with any drug that prolongs the QT interval of the cardiac cycle
Plasma concentration of lidocaine increased by amprenavir, atazanavir and lopinavir
Increased myocardial depression
Increased risk of lidocaine toxicity when given with propranolol
The action of lidocaine is antagonized by the hypokalaemia caused by acetazolamide, loop diuretics or thiazide and related diuretics (i.e. a greater dose of lidocaine would be required to achieve anaesthesia)
Increased risk of ventricular arrhythmia if lidocaine is given with dolasetron
Plasma concentration of lidocaine increased when given with cimetidine; risk of lidocaine toxicity increased with cimetidine
|Beta-blockers||Increased risk of bupivacaine toxicity when given with propranolol|
Increased risk of myocardial depression if given with other antiarrhythmic agents
|Increased risk of myocardial depression if given with antiarrhythmic agents|
Increased risk of methaemoglobinaemia if given with sulphonamide antibacterial agents
|Antidepressants||Metabolism of ropivacaine is inhibited by fluvoxamine, thereby enhancing the risk of ropivacaine toxicity|
|Drug not listed in the British National Formulary|
|Main presenting complaint||9-year-old girl presents with 3-week history consisting of pain in the medial (tibial) sulcus of the left hallux since 'picking' nail|
Otherwise fit (i.e. no other significant medical history; no regular medications)
Advised to contact you by GP
|Examination||Local tenderness, inflammation and swelling at medial area of left hallux; no signs of obvious infection; medial side of nail plate very ragged as a result of onychotillomania|
Vascular examination: normal
Neurological examination: normal
Dermatological examination: mild hyperhidrosis in both feet
Biomechanical assessment: fully compensated rearfoot varus; no joint pathologies
Social assessment: dance and gymnastics twice a week
Footwear assessment: trainers (one size too small); laces not tied
|Diagnostic tests||None indicated|
|Management plan|| Short-term plan |
Explanation of likely cause of current problem (picking nails, hyperhidrotic skin, short, unlaced shoes, excess pronation)
1. Immediate treatment: exploration of both sides of both first toenails, and reduction of ragged edges with Black's file + LA is necessary, with patient/parental consent. Advise regime of daily warm saline foot baths and demonstration to mother on how to pack affected sulcus with cotton wool. Review in 7 days (or SOS)
Exercise advice: no gym/sport/dance before next appointment
Shoe advice (give leaflet) - needs a larger trainer, and needs to tie laces so that rearfoot is retained in the heel cup of the shoe
Skin care advice (treatment/avoidance of hyperhidrosis) - give leaflet
3. Temporary insole with medial felt (cobra) pad to minimize hallux trauma due to excess compensatory pronation/foot lengthening on weight-bearing
4. Letter to GP informing of action to date (copy to notes)
Explanation of details of other treatments that may be necessary after next visit
1. Further clearance of medial side of first nail or removal of spike of nail under LA or removal of medial section of first nail under LA and phenolization of exposed pocket of nail matrix + dressings (94% cure rate) + details of aftercare regimes for this range of options
2. Biomechanical and gait evaluation, with provision of bespoke antipronatory orthoses
3. Review patient every 4 months to monitor biomechanical, skin and nail function
LA, local anaesthetic.
|Agent (brand name)||Maximum safe dose (70-kg adult)||Dose per kg of body mass|