A comparison of levobupivacaine 0.125%, fentanyl 4 mu g/mL, or their combination for patient-controlled epidural analgesia after major orthopedic surgery

Levobupivacaine, the isolated S(-) isomer of bupivacaine, is less cardiotox ic than racemic bupivacaine in animal studies. We studied the effectiveness of patient-controlled epidural analgesia (PCEA) with either levobupivacain e 0.125% or fentanyl 4 mu g/mL alone, or a combination of levobupivacaine a nd fentanyl in 65 patients after total joint arthroplasty in a prospective, random, double-blinded fashion. Intraoperatively, all patients received 20 mt of 0.75% levobupivacaine. Study medication was infused at an initial ra te of 4 mL/h, with additional medication available on patient demand (2 mL/ 10 min). The combination of levobupivacaine and fentanyl produced better an algesia (longer time to first PCEA request; P = 0.007 combination versus fe ntanyl and P = 0.006 combination versus levobupivacaine) than either drug a lone. Patients in the levobupivacaine groups had appreciable sensory blocka de to pinprick with minimal motor impairment. Resting and dynamic visual an alog scale pain scores were lower in the combination group than in the plai n fentanyl group at 6 (P = 0.022 and 0.036) and 12 h (P = 0.002 and 0.001). The 24-h overall patient- and investigator-rated visual analog scale pain scores were also lower in the combination group (resting P = 0.007, dynamic P = 0.005). There was no significant difference among the groups in the in cidence of postoperative nausea (26.2%), pruritus (9.2%), hypotension (23.1 %), or sedation (0%). We conclude that the analgesic effects of levobupivac aine 0.125% and fentanyl (4 mu g/mL) are additive and beneficial for the ma nagement of orthopedic surgical pain by the PCEA method. Patients in this s tudy began demand-dosing later, reported lower pain scores, and had no grea ter risk of adverse events than those who were given either levobupivacaine or fentanyl alone. Implications: We demonstrated a significant additive ef fect of the combination of levobupivacaine (0.125%) and fentanyl (4 mu g/mL ), compared with either drug alone, when using patient-controlled epidural analgesia in patients after total joint arthroplasty.